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.

Is a Service Failure as Serious as a Quality Failure?

One of the unfortunate realities of working in healthcare is that bad things happen. There are wrong-site surgeries,  medication errors, and unexpected deaths, to name a few. Thankfully, they don’t happen often; we work hard to keep people safe, so when things like this happen, we do a lot of investigation.

Often, these things aren’t one person’s fault; they’re a combination of processes that failed or actions not taken, so we do something we call an RCA, or root cause analysis. It’s designed to not place the blame on an individual, but to look at processes and where we can improve. 

We create a timeline of events, gather the people who were involved, outline the contributing factors, and discuss what we knew when we knew it. It’s easy to fall into hindsight, but we have to keep in mind that certain details weren’t known at the time. We also come up with ideas for preventing this from happening again. 

RCAs are good things. They always result in change, improvement, learning, and the chance for the staff to come to terms with what is usually an emotional situation. 

It occured to me that we don’t have the same kind of analysis after a service failure. 

When it comes to patient complaints and, to a large degree, patient grievances, we apologize, maybe take some money off the bill, talk to the person against whom the complaint was made, do a little coaching, and that’s about it. We don’t do nearly the amount of problem-solving that we do with quality and safety events.

Why is that?

For starters, I think we still believe that good service is a nice-to-have, not a have-to-have in healthcare. There are still plenty of clinicians who feel that if you didn’t die, you’ve got no reason to complain. 

I think the bigger issue, though, is that it’s just harder to measure. It’s easy to know when something that is never supposed to happen happens. Quality issues are black and white; did you end the surgery with the same number of sponges you started with? Was the right dose of medication delivered at the right time and by the right route? These are yes-no questions. It happened or it didn’t.

Service isn’t so simple. They’ve tried to make it black and white with checklists that contain all the steps in AIDET and all the evidence-based practices we strive to do. Did you knock before entering the patient’s room? Check. Did you round on the patient every hour? Check. Did you manage-up the previous nurse who’s going home for the day? Check. 

All of these are good, but they don’t guarantee the patient will have a good experience. Sometimes we do these things but in a manner that comes off as insincere. It happened, but the patient didn’t feel it. How do you measure that?

Patient experience is a gray area in an industry that prefers black and white. When the patient complains, we say,”She was just crabby, We did everything we could do and we still couldn’t make her happy. That’s just how some people are.” And that’s that. We shrug our shoulders and say, “Oh well,” and put her in the They’ll-Never-Be-Satisfied bucket. No real investigation, no problem solving, no improvement plan. 

We just don’t see service events as being as serious as quality ones. And until we do, we will continue to have them. 

Can you imagine how things would change if we did an RCA on every patient complaint? It feels impossible and overwhelming now but, if we did them consistently, we’d have fewer and fewer of them.

Does your health system treat them differently?

Communication Styles in Action

Last time, I wrote about the company retreat I helped facilitate that focused on empathy, kindness and communication styles. As a person who is very focused on caring for people, it was interesting to me to talk with those who focus on the action of fixing the problem, not so much the feelings of the people involved. 

Timing is everything. Just a few days later, I got a phone call from one of our hospitalist physicians asking for my help. There was a patient on our med/surg unit who was very unhappy. This physician had done his best to make things better, but the patient really wanted to complain to someone in administration. “I’m on my way.” 

I got off the elevator and made my way to the nurses’ station where he was waiting for me, and along with him was the director of the unit. He had been telling her about this unhappy patient and when I said I was going in to speak with him, she offered to come, too.

“Let’s do this together,” she said. “I don’t do the touchy-feely stuff, that’s not really what I’m good at.” “Sometimes, that’s not what’s needed,” I answered, remembering what we had covered in that retreat the week before. “Maybe he’s not a touchy-feely type. Let’s see what he says.”

We entered his room and introduced ourselves. He proceeded to tell us all about the things he was unhappy with. We listened intently. Everything he complained about, she wrote down and when he was finished, she immediately sprang into action. She told him all the things she was going to do and how long she’d be gone and then went off to get started. I stayed behind.

He told me how much he appreciated people like her. It was clear that she cared and was going to do everything she could to fix the issues, but to him, what was done was done. 

Rather than feel powerless, I decided to go after the touchy-feely. I’d noticed a Happy Birthday balloon in the corner of the room and asked if it was his birthday. “Yesterday. My daughter brought me that.”

“You had to celebrate your birthday in the hospital? I’m so sorry to hear that. That’s not a fun way to spend your birthday!” 

“Yeah, well I don’t know how many more I’m going to have so I’m happy to spend them anywhere,” he said. The tone of the room changed and his face went from serious to sad. “I don’t mean to be one of those patients who complains about everything,” he said. “I just want people to care, to do a good job, to deliver what they promise. You have people here who just don’t seem to care. This director, she cares. You can tell things matter to her. Look, she solved my problem in two seconds. But others… they’re just sleepwalking.”

I told him how sorry I was that this was how he had experienced us. “That’s not who we are,” I said. “That’s not how we want you to think of us.” He reached for my hand. “Thank you. I know you two are doing your best.” He sort of half smiled and closed his eyes. 

At that point, the director came back in and told him what she had done to fix his complaint. He thanked her, smiled at me, and closed his eyes again. 

The two of us walked back to the elevator, happy that she was able to address the action items and I was able to address the touchy-feely part. 

The whole time, I kept thinking about what I’d experienced in that retreat and how important it is to work with people who fill in your holes, who can do the things that you can’t. Instead of seeing another’s strengths as better than or inferior to yours, think of them as complementary to yours. Instead of competing, try collaborating.

It’s probably the best thing you can do for your patients.

What’s Your Approach to Problems?

One of the cool things I get to do within my health system is co-facilitate half-day retreats focused on kindness and empathy. These retreats are designed to reiterate our values with staff after they’ve been us for 3 to 4 months. We talk about ways they’ve seen these values play out along with ways they, themselves, can make their hospitals better places to work.

One of the exercises explores communication styles and how we deal with patient complaints. We boil it down to 4 main types: 

  • The how: these people are process-driven and want to understand how things unfolded as they did and how we can make changes so they don’t happen that way again.
  • The why: these are the visionaries. They are future-focused and imagine the possibilities of designing a system that supports the people and the process.
  • The who: the people-people.Their main concern is taking care of people’s feelings. They can’t change what happened so they focus on caring for the people involved.
  • The what: these folks take action. They’ll make a list of the issues, rank them in order of importance and get busy fixing them.. 

As a facilitator, I’m supposed to remain dispassionate and espouse the virtues of each group, but it’s plain to see that I’m a ‘who’ person. I am fully invested in the people and how they feel. It’s not better or worse than any other group, but it’s clearly me. 

I spent a few moments with each group, helping them through the exercise and facilitating the discussion. The group I found most interesting was the ‘what’ group. These are the action-oriented people who want to get to the business of fixing things as quickly as possible. 

They acknowledged they can be seen as cold by the ‘who’ people but they felt they were the most helpful; they’re going to fix the problem. And isn’t that why people complain in the first place, to get things fixed? It’s not a therapy session, it’s a grievance. 

Now I understand why some families roll their eyes at me when I say things like, “I can’t imagine how difficult this must have been for you,” or “I see your frustration, I’m sure I’d feel the same way if this had happened to me.”  They aren’t about the feelings. They want it fixed. 

I get it. 

And that’s what the real point of the exercise was: we are all different in how we approach problems so we all need to work together to fix them. We can miss things when we work alone but working together gives us a more complete solution. 

This part of the retreat is often the most highly-rated section. It helps the participants appreciate other people’s communication styles and understand the limits of their own. It’s a nice example of teamwork and being part of something bigger than yourself. I’m so glad I get to be a part of it.

Sensitive

Ever since I was a little kid, I remember my parents telling me I was too sensitive. When I was in 2nd grade, my Brownie troop took a trip to the movies where we saw “For The Love of Benji.” For those of you unfamiliar, Benji, the family dog, gets lost when they all take a trip to Greece and they spend the whole movie trying to find him. 

I cried and cried. Poor Benji, he’s lost in a foreign country and can’t find his way back to his family… it was more than my 7-year-old heart could take. The Brownie troop leader had to take me out to the lobby and sit with me until I could pull myself together. The other Brownies had no idea why I was so upset.

My tender heart got a little tougher as I got older but I still find myself being the only one in my family moved to tears at a rescue shelter, a Broadway show, or even a home-for-the-holidays-themed commercial. In the family reunion of my stoic, stiff upper lip northern European relatives, I’m a sensitive soul. 

I’ve learned, though, that sensitive doesn’t just mean cries at the drop of a hat. Sensitive also means I pick up on things that others often miss, and it has served me well in this line of work.  

When I’m talking with an upset family, I scan the room and notice everything. From the personal belongings in the patient room to the amount of eye contact the family members make with one another, I take it all in and use it to help me better understand and connect with them. Even with my colleagues, I’m usually the first to notice when someone is not quite themselves and I’m quick to change my communication style to suit the tone of the meeting. I’m sensitive. I notice.

Not everyone does. There have been plenty of meetings after which I left feeling emotionally drained while everyone else was just fine, unaffected, oblivious to the tension in the room.

True, it’s not always easy. It’s hard to be in tune with how other people feel and then take on those feelings, myself. But if I’m going to convey kindness, compassion, and empathy in my work, I need to. It seems only natural. If I can’t understand why they’re so upset, how can I be moved to action to make it better? So many people will listen to a complaint, say all the right things, promise to make some improvements, then simply walk away and do nothing more. When you feel what they feel and understand how important it is, you do something. 

Sensitive, to me, doesn’t mean touchy, emotional, or weepy. It means I see things that some other people don’t. I pick up on things that others may not notice. I feel things more deeply than others. I’ve found it valuable in patient experience work. Not so much at the Benji movie.

Clear is Kind, part 2

Last time, I wrote about Brene Brown and how she stresses that clear is kind. I related it to my own experiences surrounding death and dying and, while using language like passed on to a better place may feel more comfortable, it isn’t clear. And it isn’t kind.

Thinking about all that reminded me of another incident in which being clear would have been much kinder.

I was working at a smaller community hospital, not a large trauma or academic medical center, when a patient who’d had multiple cardiac arrests on the floor was moved to the Intensive Care Unit with a significant decrease in brain function. The family was understandably upset and wanted answers about how this happened. 

We needed to have a family conference but there were no conference rooms available at that moment. We did the next best thing and gathered in the empty patient room next to his while the team of physicians and nurses spoke with the family about what had happened and what the plan was, moving forward.  

In hindsight, it’s easy now to see where we went wrong. We allowed to family to remain in that empty patient room after the conference. We thought we were being sensitive and accommodating, but over the next several days, they had multiple family members round the clock, sleeping in sleeping bags on the floor of that room. They brought in coolers filled with water and juice and even plugged in a crock pot for pulled pork sandwiches. 

We thought that by not setting any boundaries, we were being nice but it was the worst thing we could have done. By not telling them at 9pm that it was time to go home, we gave them the message that they shouldn’t leave. They stayed and didn’t get the rest they needed. They even asked if they could use the patient showers so they could clean up. 

It also put an undue burden on the staff. There was a window between the two rooms so anytime a nurse went into his room to provide care, the family was watching. It was very hard for the nurses to focus  and concentrate, knowing that there were people looking at them. People who, quite frankly, didn’t really know what they were looking at. 

This went on for over a week before the patient was transferred to a hospital that could offer a higher level of care. That place, I knew, had very clear boundaries about how many visitors could be there at any given time, very clear visiting hours, and a very strict no crock pot policy. 

It’s important to remember that the things we say or do when we try to be sensitive or accommodating aren’t always the kindest. Families need to know it’s okay to go home. To sleep in their own bed. To shower in their own bathroom. Or if they live out of town, at least at a hotel. Somewhere that isn’t the hospital so they can recharge, refresh, and be ready to support the patient and each other. 

This is where being a patient experience professional can get a little tricky. For those of us who have a hard time saying no, saying yes to every request seems like the kind thing to do. It isn’t. Not always. We have to stress the importance of downtime, of rest, and we have to be sure we’ve earned their trust, so they know they can leave the room and their loved one will still be safe. 
I wish we’d done things differently for that family. I wish I’d known of Brene Brown and her clear is kind message at that point in my career. It would have been a much kinder situation for everyone.

Clear is Kind

I read a lot of Brene Brown’s work. Her book, The Gifts of Imperfection, made a huge impact on me and I’ve been a fan of hers ever since it came out in 2010. I’ve started reading her most recent work, Dare to Lead, and in it, she talks about how being clear is kind.

It made me think back to when I was working in organ donation and transplantation. I was not on the recipient side, where the person who has been sick for so long finally gets that life-saving transplant. I was on the donor side, where a family who has just suffered a sudden tragedy is asked to make the ultimate selfless decision and donate their loved one’s organs. 

Since most Americans hate to think of death, we tend to use phrases like ‘passed on,’ ‘is no longer with us,’ or ‘is in a better place.’ They told us on day one of orientation NOT to use euphemisms. Say ‘dead’ or ‘died.’ It may be uncomfortable for you as the bearer of bad news, but it’s the kindest thing you can do. Families will appreciate it.

I said it a lot. I got used to saying it and I got used to hearing it.

Fast-forward a few years to when my husband and I were throwing a party at my house around the 4th of July. All of our friends and family were there, including my very best friend. It was well into the evening and many of us had had a few too many drinks, so when her phone rang and I saw all the color drain from her face, I didn’t know what had happened. 

I’d heard her say her brother’s name. I’d heard hospital. I thought I’d heard accident, but I wasn’t sure. I looked to my other friend in the room. “Wait… what happened? Is he okay?”

“He’s fine now,” she said. 

“Oh, thank God,” I answered. “Something happened but he’s okay?”

“He’s much better now. He’s out of pain.”

“Wait. Is he okay or is he not okay?” I struggled to read her face and make some sense of the situation. My friend had run out of the room crying and saying she had to get to the hospital, but my other friend was calmly telling me he was better. I had no idea what to think and those moments of uncertainty were horrible.

Finally, my husband who thankfully doesn’t drink, said, “He died, Kate. We have to get her to the hospital so she can be with the rest of her family. Let’s go. I’m driving.”

And at that moment, I understood. As horrible and unthinkable as that news was, I was almost relieved to know what we were dealing with. The next few days were a terrible blur for all of us, but I kept going back to those first moments when everything was so confusing.

I suppose it’s easier to deal with being mad at the one being unclear than it is to deal with your feelings about a friend dying. But when you’re faced with a sudden, unexpected, and tragic loss, what you need is information. Clarity. 

I know when Brene Brown says “clear is kind” she’s talking about instructions, feedback, expectations, generally between co-workers or bosses and employees. But it’s also true in painful situations like death. While we may want to soften the blow and use those phrases we think are helpful, it really only makes things worse. 

When I’m talking to an angry patient and trying to do some service recovery, the very best thing I can do besides apologize is be very clear about what happened and what we’re going to do about it. Patients want answers and as uncomfortable as it can be for me, it doesn’t pay to use fluffy language to try and soften things up.

Clear is kind.