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. 

Some Positive Thoughts on Positivity

Earlier this morning as I was doing my daily patient rounding, one of the nurses I’d said ‘good morning’ to smiled and told me how much she enjoyed seeing me every day. “You always have such a positive energy around you,” she said. “It really brings the mood up when you come and talk to patients and to us. I really appreciate you.”

Wow. What a lovely thing to hear.

I sort of blushed and said thank you but what I really wanted to tell her was that it was a very deliberate decision every morning to show up with a smile. 

We patient experience directors have to walk a tricky line. On the one hand, we’re trying to dispel the outdated thinking that patient experience is ‘fluff stuff’ led by a bunch of vapid do-gooders who have no clue about real life. And at the same time, we can’t appear jaded and cynical or give in to all the forces that tell us that other things are more important.

I’ve taken a bit of heat in my career trying to be positive. I’ve encountered plenty of eye rolls, arms folded firmly across chests, sarcasm, and open hostility. I’ve been dismissed from meetings with a flick of the wrist, interrupted, had my data challenged in every conceivable way, and told ‘that’s nice, but we have real work to do.’

I’ve even had patients tell me to leave when I’ve come to round on them after learning I wasn’t a physician or a nurse. If I can’t give them pain meds then what good am I?

I have to choose to be positive. But honestly, why would I choose to be anything else? 

I’ve been angry, frustrated, outspoken, sarcastic, and cynical myself and you know where it got me? No further than being positive. Being positive just makes me feel better. Noticing the good, recognizing when something goes well, celebrating people who give a little extra… these things make me happy. And knowing that by doing them I can make someone else happy makes me even more happy. 

Staff perform better when the culture is positive. The world has enough desk pounders, enough cynics, enough people who are eager to rain on your parade. If I expect staff to be supportive and friendly and caring to patients, how can I not be that way to them?

So yes, when I walk in the front door, step off the elevator, and onto a med/surg unit, I am smiling. I am positive. Even if I have to fake it for a few minutes. Fluff stuff? No way. I’m changing healthcare.

More Thoughts on Appreciative Coaching

Last time, I wrote about appreciate coaching and how it’s more effective for people to improve and learn. Well, this past week, quite by accident, I stumbled upon an article from the Harvard Business Review entitled “Why Feedback Fails.” In studying how people learn, thrive, and excel, they point to three core evidence-based learning theory tenets:

1.       Telling people what we think of their performance doesn’t help them thrive and excel, and telling people how we think they should improve actually hinders learning;

2.       Humans are highly unreliable raters of other humans. The feedback you give is more about you than the person receiving feedback;

3.       The only realm in which humans are an unimpeachable source of truth is that of their own feelings and experiences.

People tend to perform better by being given goals and results to achieve, when they receive positive feedback about what they are doing well, and by watching other people excel and receive validation for their excellence. The article went so far as to give examples on how to more effectively communicate with teams to elicit these principles:

Instead of:                                                            Try:

Can I give you some feedback?Here’s my reaction
Good job!Here are three things that really worked for me. What was going through your mind when you did them?
Here’s what you should doHere’s what I would do
Here’s where you need to improveHere’s what worked best for me and why
That didn’t really workWhen you did (x) I felt (y)  -or- That didn’t really work for me
You need to improve your communication skillsHere’s exactly where you started to lose me
You need to be more responsiveWhen I don’t hear from you, I worry we’re not on the same page
You lack strategic thinkingI’m struggling to understand your plan
You should do ____   (in response to being asked for advice)What do you feel you’re struggling with and what have you done in a similar situation? 

You might find that you’ve done a few things in the left column. That’s okay. We all have. But now we know better. Modelling and recognizing excellence is more effective in helping teams provide excellent care, everytime.

Reference: Marcus Buckingdall and Ashley Goodall. “The Feedback Fallacy.” Harvard Business Review, March-April 2019 edition. https://hbr.org/2019/03/the-feedback-fallacy

Appreciative Coaching

What’s the best way to help people improve? How do we work with staff members who do a good job and help them get even better?

Many of us came into leadership positions at a time when we focused on the gaps: what our employees needed to work on and where they were weakest. During annual evaluations, we centered the discussion around mistakes and weaknesses.

There’s a better way.

Appreciative coaching focuses on what people are doing well. It allows them to determine where they’d like to improve.

For example, when watching a nurse do hourly rounding, we might say, “I observed your interaction with Mrs. Jones. How do you think it went? I saw you do __ and __ really well, great job! What do you think could have gone better? Okay, how can I help you with that?”

When we use appreciative coaching, four things happen:

  • We build a road to improvement. Employees are more likely to make improvements when they identify the things they want to do better. We tend to follow through on things when they’re our own ideas.
  • We make it ‘safe’ to not be perfect as long as we’re still trying. Employees do better when they’re supported, not criticized. 
  • We foster a culture of recognition and appreciation. When we tell employees what they’re good at and how important those skills are, they do them more often and even better than before.
  • As leaders, we start to see our staff differently. When we look for the good, we tend to see more good. 

Of course, if there are some serious performance issues, that’s an entirely different conversation. But for your high-performing staff, try a little appreciative coaching. 

The Patient Experience Nurse

Earlier this month, we celebrated Nurse’s Week. Our Chief Nurse Executive had a whole week of wonderful things planned for the department including massages, root beer floats, a homemade meatball contest, and an awards ceremony. She had a few different categories but the one that caught my attention was the Patient Experience Award given to the nurse that consistently exemplified excellent patient experience.

The winner was someone I knew. I had spoken with him a time or two when I did patient rounds on his floor and had heard his name a lot as someone patients absolutely loved. The next time I saw him, I pulled him aside to congratulate him and I asked him what it was he did that earned him this award.

“I just talk to them.”

“Come on,” I said. “Lots of nurses talk to patients. What are you doing that’s making such a difference?”

His answer was not what I was expecting. I thought he’d go into some big thing about how he always does AIDET when he’s in a patient room and he always calls them by the name they wish to be called and he always manages up the other staff… Nope.

“I think it’s my job to help them understand their disease so they can better manage it,” he said. “Most of them don’t connect the dots between what they do and how they feel. If I can help them see how doing this thing makes them sick, they’re less likely to do that thing. If they understand that their health is something they can control, they usually do. But, too often, they come in, they get some meds, they go home, and then they’re right back here again in few weeks. I talk to them. I work with them. I encourage them. I help them.”

“Wow,” I answered. “That was not what I thought you were going to say.”

“I can see myself in everyone here. You got your life together? Great, me too. You got problems? Things in your life went sideways? I get it. I was there, too. You can’t judge people. If you judge, you can’t understand. If you understand, you can’t judge. You just talk to them so they know you’re on their side, you’re rooting for them. I think that’s what I do.”

I thanked him and left feeling so good that we had someone like that working at our hospital. Someone who connects with, roots for, and educates patients. Someone who doesn’t judge, but listens, informs, cares.

Maybe that’s the secret sauce.