Our Scores are Bad Because of Our Patients

When you work in patient experience, you hear a lot of excuses for why scores are low:

  • We were under construction and the noise was bad
  • We had a lot of turnover and new staff wasn’t properly trained
  • We just merged with another big health system and there’s a lot of uncertainty
  • We’re here to save our patients’ asses, not kiss them 
  • Our hospital isn’t as fancy as the one down the street, we need a makeover, we need private rooms, we need valet parking, we need… 
  • We were focused on getting ready for The Joint Commission visit
  • Change takes time, we’re getting there

As much as I’ve heard these used as valid reasons, they are things that we have some control over and can work to mitigate. Much of it has to do with communication, whether it’s internal to the employees to set behavioral standards or external to the patients to help them understand what’s happening and why. 

So what really gets me is when we blame the patients, themselves, for our inability to provide an acceptable experience for them:

  • We have a really bad payor mix; they’re all uninsured and homeless
  • Our patients are all drug-seekers; they’re mad we don’t give them what they want

So it’s their fault?

Hey, I know there are people out there who can be pretty unreasonable and difficult to please, but that doesn’t mean we shouldn’t try. I’ve seen far too many staff members immediately take an aggressive stance as soon as they realize their patient is uninsured, experiencing homelessness, or trying to manage chronic pain. They make assumptions and treat these patients a certain way and then wonder why they return an unfavorable survey.  That’s just not acceptable.

And, incidentally, wealthier patients don’t always make for happier ones. Years ago, I worked in a very fancy hospital in a very affluent area and found that those patients had much higher standards. They seemed far less tolerant when things didn’t go as planned and much harder to please.  But that doesn’t mean we didn’t try. 

The bottom line is it doesn’t matter what socioeconomic class of patient we’re seeing. We should be doing our absolute best every time when it comes to serving our patients. And instead of blaming them for not having a good experience, we should be looking at ways we can better reach them. If we find our scores are low in a given demographic, it’s on us to figure out how to improve.

Oh, there was one excuse in the top section that’s actually true. Change takes time. You’ll get there.

Two Trips to the Urgent Care

This past week, I found myself in the throws of one of the worst head colds I’ve had in quite some time. I don’t get sick easily; all the years of working in hospitals has made my immune system pretty tough, so when I do get sick, it’s usually something major. I had been a little congested for a few days, but woke up one morning with an excruciating sore throat that made it nearly impossible to swallow. My primary care physician didn’t have an opening for me that day and I simply couldn’t wait to get some relief so off I went to the local urgent care clinic in town. 

I got in almost immediately and saw the nurse practitioner. She was great. Very kind, very thorough, and very sympathetic to my pain. My rapid strep test came back negative (surprisingly) as did the influenza test, so she didn’t want to prescribe antibiotics but, rather, manage my symptoms. That made sense to me. All I really wanted was some relief from the throat pain.

I picked up the prescription for viscous lidocaine, which did help the sore throat but tasted like motor oil, and stayed in bed for the next two days. 

I started to feel like I was getting better but three days later, not only was my sore throat back with a vengeance, but now my right ear felt like someone was sticking knives in it. My husband said I turned an eerie shade of white and insisted we get back to the urgent care right away. I didn’t argue.

We arrived 10 minutes prior to closing time and the receptionist told us they weren’t taking any more patients. I told her I had been there a few days ago and my symptoms had gotten worse. She apologized and said we could either come back in the morning or go to the Emergency Department tonight. The ED for a sore throat? No way.

I was contemplating how many boxes of popsicles to buy to hold me over to the morning when my husband suggested the urgent care about a half an hour away, which was open later. As much as I’m a fan of continuity of care, I knew there weren’t enough popsicles in the whole town to get me through the night so off we went.

The other urgent care center doesn’t look like much from the road, but inside it’s quite lovely. The receptionist was very nice, as was the tech who took my vitals, but the real star was the nurse practitioner. Her main concern was getting me some immediate relief, especially after she learned that I’d been suffering for nearly a week. She gave me a steroid, decadron, along with an antibiotic for the ear infection I’d developed. By the time I picked up a box of popsicles at the grocery down the street, I was feeling 100% better. 

I slept better that night than I had in several days and the pain in my throat never returned. It was amazing. That shot of decadron may have been slightly outside the usual course of treatment, but it was exactly what I needed. 

I’m not saying anything bad about the nurse practitioner at the first center; she did exactly what she should have. No antibiotics for a virus, I get it. But when it comes to relieving suffering, the second center knew just what to do.

Incidentally, I asked them how close to closing time they stop seeing patients. The tech said they don’t turn anyone away if they get there before 7pm. Even if it’s 6:59, if they need care, they get it that night. Admittedly, it can get a little tough on staff who are eager to get home after a 10-hour day, but the mission, the reason they’re there, is what keeps them going. They know they are there to help. And they did.

Yes, We Survey the Angry People

Last time, I wrote about patient experience scores, the percentile rankings, the distribution of responses, and how staff are almost always surprised when they see that it isn’t just the angry people who fill out surveys. One thing that inevitably gets asked whenever I present this kind of data is, “Can we filter out the people who leave here ticked off so they don’t get a survey?”  

I used to laugh when they’d ask that, but quickly realized they weren’t joking. They’d really like us to exclude dissatisfied people. But it doesn’t work that way.

Let’s start with the obvious. Really? You really want us to not get feedback from people unless they’re happy? Does any company have that luxury? With Yelp just a click away, every business is subject to ratings, good and bad. I can rate everything from my dinner at the four-star restaurant to the Uber driver who took me there. If they want good reviews, they need to do a good job, not cherry pick the satisfied customers. That’s not just dishonest, it’s silly, as it sets a completely unrealistic set of expectations. It would be even more disappointing to have a bad experience because, according to the reviews, no one has ever had a bad experience. 

But more importantly, we learn more from our unhappy patients than we do from our happy ones. As much as I tend to focus on the positive, there are often ideas or suggestions from patients who wanted something more from us that are really constructive and useful. 

For example, at one hospital, we added some simple signage in our parking garage to more clearly point out the entrance for day-surgery patients. At another, we created scripting for our medical assistants that let patients know they could skip the checkout desk unless they needed a follow-up appointment. These were things that were easy to address but, had it not been for the surveys, we wouldn’t have realized were dissatisfiers.

And most of us have a blind spot about our own words and actions. I’ve known plenty of people (myself included) who say things with the best of intentions, not realizing they’re annoying or downright offensive to some people. This is especially true in healthcare settings where people tend to be a bit more sensitive. But how else would we know if we didn’t receive the feedback?

Let me quick to say that it’s equally important to celebrate and recognize the positive comments that come through on those surveys. People love to know that their hard work doesn’t go unnoticed or unappreciated, and it’s a great way to improve your organization’s culture. But it’s a mistake to not look at ways you can make things even better.

Yes, it’s discouraging to see negative comments, especially when you remember that patient and you remember doing everything you could to try and make their visit a pleasant one. But any organization (or individual for that matter) that wants to improve needs to hear some honest feedback, even if it’s tough to take. Surrounding yourself with people who never complain or offer some constructive criticism won’t help you get any better.

What Does This Score Mean?

I’ve worked in patient experience for many years in several organizations in different parts of the country and, while there are differences between health systems, there’s one thing I’ve seen in every one of them: a firm belief that only the angry people fill out surveys. 

It simply isn’t true.

And it makes me sad because it tells me that no one has taken the time to really explain these scores. 

Typically, when scores are posted, staff only see their percentile ranking. This is how your hospital compares to the rest of the hospitals in the database. It’s important because this is how CMS determines your reimbursement, but it doesn’t tell the whole story.

One of the best things you can do, especially in an under-performing hospital, is to break down the percentage of patients’ ratings for each question. If you’re scoring low when you look at the percentile ranking, look instead at how you’re actually being rated. 

For example, in answer to the question “Would you recommend this hospital to your friends and family?” your hospital’s responses are:

Definitely Yes 66%

Probably Yes 23%

Probably No  8%

Definitely No  3%

Does that look like only the angry people are filling out surveys? 89% of patients would recommend you. That looks pretty good, right?

Here’s the thing: CMS is only looking at the percentage of patients that gave you the highest, or Top Box, response. If it isn’t Definitely Yes, it doesn’t count. And, they’re comparing you to the other hospitals in the country and right now, 66% only puts you at about the 35th percentile. 

Think of it this way: if I got a 66% on a math test in a class full of smart kids who all got 90% and my teacher grades on a curve, I just failed. But if I’m in a class full of knuckleheads who all got 30%, I got an A. It’s all about your compare group. And you can’t control your compare group.

For a hospital that’s low in the percentile rankings, I find it’s best to break out each of the responses and focus on moving the second-highest scores to the Top Box scores. 

Here’s another example: your score for courtesy and respect for nursing is in the 12th percentile. Sounds terrible, right? But if you break it out, it might look something like this:

“During this hospital stay, how often did the nurses treat you with courtesy and respect?”

Always 70%

Usually 24%

Sometimes 4%

Never 2%

94% of patients gave positive responses; the key is in moving people from Usually to Always. 

When I took this approach and broke it down to the staff, a huge lightbulb went on and suddenly, it all started to make sense. Now, they weren’t feeling defeated being in the 12th percentile. Now, they knew they had to move a few Usually responses to Always responses and they didn’t have that far to go.

I still would want to investigate the 2% of patients who said Never, but the message to the staff, the way to keep them engaged and excited is to show them they’re not doing nearly as bad as they think. It isn’t only the angry people who fill out surveys.

Patient Experience over the Holidays

I recently traveled back to my hometown of Chicago for a family wedding and made plans to extend my trip a few days to visit with old friends, eat that amazing food, and see the lights along Michigan Avenue and Lake Shore Drive. There’s nothing quite like Chicago at Christmastime and seeing my dearest friends did my heart a world of good.

As I was enjoying brunch with one of them, she reminded me that it was five years ago since she had her kidney removed and she’d been cancer-free ever since. I was so happy for her. I don’t know a lot of cancer survivors. As a child I’d lost three of my four grandparents to cancer. More recently, I lost my mom to cancer in 2010, my dad to cancer in 2011, and my sister to cancer in 2013. In 2014, this friend of nearly 20 years told me she had cancer. I remember not being able to breathe for several seconds, frightened that I would lose her, too.

A few days before Christmas, she underwent surgery intending to remove just the cancerous section, but once the surgeon was inside, he realized he needed to remove the entire kidney. It was difficult for her to receive that news, but well worth it knowing that it meant a greater chance of her being healthy for years to come. 

I really wanted to visit her in the hospital, which wasn’t easy with all the craziness of the holiday season, but it turned out that I was able to break away for a bit on Christmas Day. As I pulled into the parking lot that Thursday morning and noticed how many cars weren’t there, it struck me that the people who were there as patients must be miserable. Who wants to spend Christmas in the hospital? Even the people working would likely rather be home with their families, right?

She and I had a lovely visit. She didn’t look too bad for only being a couple of days post-op, and her spirits were good. I spent about an hour or so with her, until her mom arrived, but was struck at how quiet the hospital was. It was definitely a skeleton crew of clinical staff and not an administrator in sight. 

Why would they not have patient advocates or volunteers visiting people that day?

Of course I know why. People don’t want to work on holidays and employers don’t want to pay hourly employees time-and-a-half to come in. But wouldn’t that be a wonderful and meaningful thing to do for patients? 

Having a visitor on Christmas Day meant the world to my friend. I think I know what I need to design in my next patient experience director role. Does your hospital have a program like that?

The RCA Gone Wrong

I’ve written before about Root Cause Analysis, those things hospitals do when there’s a serious safety event. A good RCA will include a description of the event, a timeline of everything that happened leading up to the event, all of the people involved, an investigative team, a report out that focuses on process, not people, and asks ‘why’ until you get to the root of the issue, and plans for corrective action. 

They’re good things to do. When done well, the participants leave with a better understanding of where the process broke down and what steps they can take to improve it. Staff who had been struggling with guilt or regret often feel much better afterwards because they had a chance to see how other factors contributed to the event. Silos are broken down as a result of people from many departments coming together and examining how their individual efforts affected the outcome. 

Staff feel supported by leadership and empowered to make changes when RCAs are done well.

But what if they’re not?

I participated in an RCA a few years ago that ended up doing more harm than good because of a poor facilitator and a misdirected leader. 

It was a terribly sad case; a patient came in with a seemingly minor issue requiring some routine surgery but suffered an arrest in the operating room and didn’t survive. In the days that followed, there was a lot of finger pointing. Rumors were swirling throughout the whole hospital. The staff who were involved were feeling terrible about the outcome and unsupported by their leader. It was a very messy situation. 

The Vice President of Patient Safety and Risk scheduled the RCA as he always did and included everyone who had been involved but this time, something was different; the president wanted to attend. He hadn’t had any involvement in the case but wanted to see and hear what was discussed at the RCA. If this had been a president who was visible, approachable, and often involved in the day-to-day activities at the hospital, this might not have been a bad thing. But this president was none of those things. Having him there inhibited the participants and made them feel even more like they were under attack. 

When we started talking about how things broke down and began to ask those “why” questions, the president chimed in and asked, “Why, if that was your responsibility, did you not do it?” The VP tried to jump in and bring the focus back to the process, not the person, but the president wouldn’t let it go. It was easy to scapegoat this particular nurse, but if you took a step back, you could see there was a bigger issue here. Many things were going on at that moment and we, as the investigators, have to see it from the perspective of what was happening as it was happening, not from the benefit of hindsight. 

The RCA continued in much the same way, with the president asking very pointed questions to the people in the room about their personal responsibility for the outcome instead of looking at  the many different ways the process failed. As much as the VP tried to keep things on track, he simply couldn’t get control of the meeting. It was a disaster. We left the room feeling worse than we did when we entered with no real resolution or plan for corrective action. 

I can’t speak for the president but I suspect he left feeling very satisfied that he got to what he thought was the issue: a bad nurse. I can’t begin to describe what a huge step backwards this RCA was, not only for staff morale but for patient safety. When staff feels that they will be blamed for every mistake and there is no tolerance for error, they don’t perform better, they perform far worse. 

A culture of safety is so much more than zero harm. It’s staff who are empowered to speak up when they see something wrong. It’s channels that make it easy to report an issue or a near-miss, along with a feedback loop so employees know that action is being taken. It’s processes in place with several steps along the way to catch mistakes before they reach a patient. It’s leaders who don’t set out to find a scapegoat when things do go wrong. It’s providing safe spaces for staff to talk through events once they’ve occurred. It’s staff working across their departments, together, to keep patients safe. It’s everyone working together, focused on patient safety throughout the continuum of care. 

I’ve participated in many more RCAs since this one and am happy to say they go well much more often than they go wrong. But when they go wrong, it takes a very long time to recover.

Do You Need a Director?

If your hospital is part of a larger health system with many hospitals in several states, should there be a Director of Patient Experience in each of them? Do you need a director-level position if the overall vision and program strategy is done at a regional or national level or could you do just fine with a coordinator or a specialist managing the day-to-day drivers of improvement? If you have a dedicated person inside the walls of each hospital, does patient experience become that person’s job instead of everyone’s?

When I’ve held the director-level position, it was primarily at independent hospitals, those not tied to a larger health system. I, along with the local executive team, set the strategy, created the training tools, selected the vendors for our electronic rounding programs, and structured the accountability standards. In a larger system, all of those things are done at the national or regional level, with very little room for variability at the local level. 

When all of those decisions are being made at a higher level, do you need a director at each hospital? You could make the argument that a director who sits on the operational leadership team has more influence and will be able to more effectively lead culture change within the walls of the hospital than a specialist-level would. You could say that it sends a message to staff that patient experience is important and that’s why there’s a director in charge of it.

But when there’s a high level person in that role, it often becomes solely his or her responsibility. Staff can more easily say, “This is a patient experience issue. It’s not my job, call her,” when the reality is, of course, it’s everyone’s job.

Staff understand that everyone has a role to play when it comes to safety and quality, but patient experience is often seen as one person’s job. That can be especially true when there’s a director on site. If it were a coordinator or a specialist, you can more easily make the argument that the directors over each unit and department have to take ownership of patient experience results. The specialist can offer support and assistance by providing data, offering training, and assisting in service recovery, but the directors have the ultimate responsibility of ensuring that staff deliver on the promise of an exceptional experience. 

And specialists aren’t in charge of setting the strategic direction. They get the tools from the national or regional level and are charged with executing on those tools. It’s difficult for a director to act on a prepackaged toolkit about which they had no input, especially if they’ve had that responsibility previously. 

If the goal of the large multi-site health system is consistency across the enterprise, it will do just fine to set the strategy, create the training, design the toolkit, and analyze the data at the system level. Create some director positions at the regional level to serve as consultants for lower performing hospitals and then have a specialist or coordinator at each hospital to keep things running smoothly.  

How does your hospital manage its patient experience efforts?

Thoughts from the Night Shift

A few years ago, I was working at a large medical center and decided to go out on the floors in an effort to connect with the night shift. As part of the leadership team I know it’s important to get out and talk with the direct-care staff, and it’s especially important to visit with the often overlooked night shift. 

My alarm went off at an hour when most college students are just going to bed. It was a time of night I haven’t seen in decades and I couldn’t imagine how anyone could be awake, let alone work. I dragged myself into the shower hoping the steady stream of hot water would bring me back into consciousness. It worked. I got dressed, put my face on, and headed out into the dark.

When I got to the hospital, I discovered one of the few perks of working nights: plenty of parking. Plus, it’s really quiet. That’s something we never experience during the day.

While I was able to get through most of the hospital, I spent the majority of my time in two different med/surg units and the differences between them were startling. In the first one, the nurses seemed genuinely happy to see someone from administration. When I walked up to them, they smiled and were very eager to talk about what they liked about working there. They had some suggestions about what could be improved but overall they were very positive. As I was leaving, I thanked them for taking time out of their very busy shift to talk to me. “No problem,” they answered. “We like seeing you guys up here. Thanks for not forgetting the night nurses.”

I walked toward the elevator smiling. “Wow,” I thought. “This is great. This is going to be a really good night.”

The other unit was completely different. I approached the small group of nurses at the desk and introduced myself. “Hi, my name’s Kate. I’m the director of patient experience and I’m out tonight visiting the units to…” 

“Ambush us?” said the tall one.

“Oh my goodness, no,” I said. “Is that what you think?” She shrugged and said, “Well, we never see you guys here. Something must be up.”

I spent the next several minutes trying to reassure her and the others that this was something the leadership team was committed to doing: getting out on the floors and talking to the people who are caring for patients, both days and nights. They seemed unconvinced. 

After some gentle prodding, they opened up a bit about what it’s like to work nights. The thing they liked best, they said, was the teamwork. They don’t have the same resources as the day shift so they pull together and help each other out. And while they complain that they never see anyone from administration, they like that they never see anyone from administration.

They said they feel more free to just be nurses without having management looking over their shoulder every minute. 

That struck a nerve. Free to be nurses without management looking over their shoulder? Wow. What had we done to make them feel this way?

I asked them to tell me more about that and, essentially, it all boiled down to one thing: their manager acted more like a taskmaster than a supporter. The relationship was less about re-engaging great nurses to continue doing great work and more about pointing out all the things they were doing wrong. We do ask a lot of our direct-care staff, that’s true, and for good reason: we want patients to be safe and feel well cared for. But there’s a way to ensure that all of those required steps – like asking a patient’s name and birthdate before giving a medication or foaming in and out of patient rooms – are done without it coming across as punitive.  

Until we give our leaders the right training on how to get the job done while still serving as an ally, a resource, a champion for the staff, we will hear things like I heard: just let us be nurses.

When Leaders Round on Staff

It was still dark when my alarm went off. I got out of bed, stumbled into the shower, managed to find clothes that matched, and headed to the hospital to round on some staff members in the middle of the night.

One of the things my health system does is get leadership to get out on the floors, into all the departments, and talk to staff. Our goal is to find out what’s working well, what we can be doing better to support them in their work, be visible, approachable, and make connections.

I got to the hospital and was struck by how quiet it was. Usually when I get to work there’s a lot going on, people everywhere, visitors trying to find patient rooms, lots of commotion. Now, it was quiet and I didn’t see anyone as I came in through the employee entrance and made my way to my office to drop off my things.

I headed up to one of the nursing units I visit on a daily basis. I know just about everyone on the day shift and look forward to seeing them each day. Tonight, I met people I’d never met before. People who were incredibly dedicated to their jobs. People who had worked here for more than 25 years. People who truly believed in our mission.

They didn’t know me, but they opened up to me, told me what they loved about working here, what they wished we would change, what we as leaders could do to help them be more effective. It was eye-opening, amazing, and humbling. 

I met an RN who told me that “Christmas came early” because we approved a position that gave him additional support overnight and relieved him of the stress he’d been feeling. I spoke to a nursing assistant who said she felt like this was a second home to her because of her fabulous teammates. 

And I never would have met them had I not signed up to do leader rounding. 

Leader rounding is an evidence-based practice that increases not only direct-care staff engagement but leader engagement, as well.

When we get out from behind our desks and talk to people, it improves staff morale and helps us feel more a part of things. Talking to people you don’t normally talk to or even see is a great way to understand what’s really going on. 

If you’re a leader, get out there and round. If you’re a direct-care worker, talk to the leaders when they come to your unit or department. Tell them what you love and what you wish they’d improve. We’re listening. 

All It Takes is One

A few years ago, I was in charge of reviewing all of the social media posts about our hospital. I sifted through everything on Facebook, Yelp, Google +, and the like and added those comments to our tracking and trending forms of what was being said about us. That, along with our comments from the surveys, helped us determine which areas were doing great and which needed a little extra assistance.

One comment that stands out in my memory was a 5-star Yelp review from a woman who was over the moon about the great care she’d gotten in our Emergency Department. She’d written several paragraphs, each one more glowing than the last, about all the wonderful people who had cared for her, how quickly she’d been seen, and how this was her hospital of choice, despite living closer to our competitor. 


She had a list of nurses’ and physicians’ names and showered praise over each of them, likening them to gods and angels. It was quite a review.

I remember sending it to the team; the ED wasn’t accustomed to hearing good news. More often than not, when people post on social media it’s to complain and trash-talk (often anonymously). So I was happy in this case to send over something to brighten their day.

Not 72 hours later, she posted again, this time calling us THE WORST HOSPITAL EVER (emphasis hers) and warning people to never go there. EVER. She got my attention.

I took a walk over to the ED and asked what had happened at her last visit, why she had gone from our #1 fan to our biggest hater.

As it turns out, there was one person with whom she’d interacted and it didn’t go well. It wasn’t so much a negative interaction as it was a just-not-quite-as-good-as-the-previous-ones kind of interaction. We’d done such an impressive job earlier, that we set the bar pretty high. This staff member wasn’t quite as attentive and it set us back. A lot. 

I thought long and hard about how to handle this. She’d left her name, so it wouldn’t have been inappropriate for us to contact her. Should I call her? Should the manager of the ED call her? Should the person she’d complained about call her? 

Ultimately, I did. I was used to these kind of conversations and it was certainly in my job description to follow up on reviews, positive or negative. I braced myself and dialed her number. 

She picked up on the first ring and, after I introduced myself, went into a tirade about how completely awful and disappointing we were. I listened, didn’t interrupt or try to apologize at first. Just let her talk. And talk she did.

“It sounds like this visit was very different from the others,” were my first words after she’d finished. “I’m so sorry. I can hear how disappointed you are.”

“You’re damn right I am,” she continued. I let her continue. She said mostly the same things she’d said before, but it clearly mattered to her that I heard them. 

“Gloria (not her real name), I’m so sorry we let you down. You came to expect a certain level of care and service from us and we didn’t deliver this time. I’m sorry we missed the mark the other day. What can we do moving forward?”

After a few seconds of silence she said, “Nothing. It’s in the past. But I’m glad you called.” 

“Gloria, I hope it’s not any time soon, but if you ever need to go to an emergency department again, whether it’s here or another hospital, I hope you receive the level of care you expected from us.”

“Well, I know you guys can do it. You did it before, you can do it again.” She paused. “I love your hospital. I don’t want to go anywhere else. But you have to do better, okay? I know you can do better. Promise me you’ll do better.”

I thanked her for talking with me and she thanked me for calling her. I was glad I did. Until that call, I don’t think I realized that people really do form relationships with their hospitals. This was her hospital. It was familiar. She felt safe there. We needed to reassure her that this one bad experience was not going to be the new normal.

All it takes is one bad interaction. It can completely undo all the goodwill you’ve built up with your community. If you’re lucky enough to get the opportunity to apologize, don’t pass it up.