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.

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.