Category: Culture

As of this writing, most of us are sheltering in place and working from home due to COVID-19. Non-clinical hospital leaders, including the patient experience professionals, may be coming to the hospital a couple of days a week, but we’re doing most of our work from our living rooms over Zoom. So without being there, how do we know things are getting done?

Early in my career, I worked under several bosses who felt they needed to micromanage everything my colleagues and I did. Every moment between 8:30am and 5:00pm had to be accounted for or the assumption was we were slacking off. I always had a pretty good work ethic and wasn’t motivated to work out of fear. I did the job because I enjoyed the job and wanted to keep learning. I realize not everyone thinks that way.

But those colleagues of mine who didn’t have that same attitude didn’t do great work under that kind of micromanaging. They found ways to game the system and make it look like they were working. And they mostly got away with it. At some point, they might have gotten found out but that only brought the hammer down harder. I had to ask myself why they didn’t just let them go? Why spend your whole day surveilling your staff when you could be doing more important things?

When I came into leadership, one of the best things I did was hire people who appeared to have a work ethic like mine. People who got the job done without having to be watched like a hawk. People who had a passion for the work and who wanted to keep getting better at it. People I knew I didn’t need to micromanage.

And guess what – work got done. I had a great team who understood the expectations, had the tools they needed, knew they could come to me with questions, and were recognized and celebrated for doing a good job. I could spend my time setting the strategic direction of the department instead of yelling at them for coming in ten minutes late.   

And now that I’m not physically in the hospital, watching to be sure leader rounds are happening and staff are using AIDET in every interaction, I have to trust that they’re doing it because they know it’s the right thing to do, not because they’ll get in trouble if they don’t. 

For those managers who came up thinking that they always had to be looking over their employees’ shoulders, always there monitoring their every move lest they start goofing off, this new normal should be proof positive that that style of leadership doesn’t work. It never has. Anyone can get compliance, what matters is commitment. 

I don’t know what work will look like when this is over, but working remotely has forced micro-managers to trust their employees and change their style of leadership. It’s about time. I’m sorry it took a pandemic to do it.

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

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

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

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

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

So it’s their fault?

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

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

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

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

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.

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?

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?

How do you create lasting change in an organization? What’s the ‘secret sauce’ when it comes to delivering on – and sustaining – exceptional patient experience?

By now, you know that I’ve worked in a lot of different hospitals and health systems. I’ve been fortunate to have worked for some really high performing organizations that were firing on all cylinders, and I’ve worked for some incredibly dysfunctional places that just couldn’t get out of their own way.

I’ve seen the same tactics rolled out over and over again: hourly rounding, bedside shift report, sit a bit, it takes two rounding, AIDET, multidisciplinary rounds, updated whiteboard, and on and on. For those of you who aren’t familiar with these terms, it doesn’t really matter. These were things that were dreamed up with the very best of intentions, designed to improve the patient experience. And, when done correctly, really do have a positive impact.

Here’s the thing.

Not one of these things is going to work without relationship. Not relationship between nurses and patients, as you might think, but relationship between nurses and leadership.

When tactics like these are rolled out as edicts, without leadership soliciting any input from staff or developing any kind of dialogue about why these things are important, they become check-the-box exercises. They’re done because they have to be done, but there’s no real connection or meaning behind it. That defeats the whole purpose.

If I am brand new to an organization and I walk up and introduce myself to a unit manager by saying, “Hi, I’m the new patient experience director and I’m here to make sure you and your staff are doing hourly rounds. Can I see your rounding logs, please?”, do you think I’m going to make a new friend? Is this nurse manager going to see me as a person who is there to support her or a person who is there to monitor her?

I’m not the rounding police. I don’t care if she and her staff have checked the box and rounded on every patient. I care that she and her staff have connected in a meaningful way with those patients, but I won’t be able to support her in those efforts if we are not in right relationship. It’s up to me to help her connect the dots between hourly rounding and delivering an exceptional experience. She needs to know that she can count on me to help remove the barriers that may be keeping her staff from spending quality time with patients.

How do I do it? Be visible, accessible, approachable, open, curious. Develop and maintain a relationship. Listen. Be open about what I can and cannot do. Deliver on what I promise. That’s it. That’s the secret sauce.

Somewhere along the road, front line staff came to distrust leadership. As leaders, it’s up to us to build that trust back up. When staff know that we care about them and what they’re dealing with, they are far more likely to do the things we’re asking of them. Sure, we could take a ‘crack the whip’ approach and demand that they do these things or be fired, but that’s not what’s going to move the needle on patient experience. Not over the long-term, anyway.

The patient experience is a reflection of your culture. Don’t focus on the scores, focus on the people.

Some years ago when I first started working in patient experience, I was with an organization that wanted to, among other things, change its culture. The Director of Human Resources was concerned about the low employee engagement scores and high turnover. She approached the CEO about making some changes designed to improve our patient satisfaction scores and make staff enjoy coming to work.

As the newly-minted Manager of Patient Experience, I was brought in on the team to help lead the change. I had just come from a healthcare system that had engaged the Studer Group and I saw some great successes there with the Studer model.

While we were all sitting around the big conference room table trying to come up with ideas, I brought up one of the things that stuck with me and still does to this day: if you see a piece of trash on the floor, pick it up. It may seem like a small thing but it speaks to the overall sense of ownership and pride an employee feels by working there. It’s not ‘someone else’s job’. I work here. It’s my job. When I see things that are wrong, I take action and make them right.

My suggestion was met with deafening silence. The COO finally spoke up and said, “If this doesn’t directly make patient experience scores go up, I don’t want to invest one minute of energy into it.”  

It was then I knew we had a problem.

Sometimes, when you’re trying to change a culture, you do things that appear to be insignificant or even silly, but they’re things that build on an idea. When you pick trash up off the floor, you’re not only reinforcing the idea of accountability, you’re demonstrating that no job is ‘beneath’ you. It’s not someone else’s job to pick up trash, it’s not someone else’s job to answer that call light, and it’s not someone else’s job to handle this angry patient. If you see something, you do something.

When employees are empowered to step outside their job description and fix something that needs fixing, it strengthens their sense of pride, commitment, and feeling of belonging within an organization. To this day, I can’t walk down the halls of a hospital and not pick up trash when I see it. And when others see me model that behavior, they do it, too.

What seemingly insignificant behaviors are you encouraging your employees to do?

One of the great things about having a long career in a single industry is being able to see all the changes and improvements that are made over the years. I’ve been in non-clinical healthcare roles for the better part of 20 years, always with a focus on patients and their families.

Early on, it was all about quality and safety. We wanted better than expected outcomes and zero harm for our patients, which are wonderful goals, don’t get me wrong. But there was very little, if any, thought given to patient experience or employee engagement. We used to think that patients would be happy simply because we cured whatever illness they had or performed a successful surgery. “Hey, you didn’t die. Be happy we saved your life.” And we weren’t all that interested in how staff was doing either. “Hey, this is just part of the job. Be happy you have a job.” A former boss actually said that to me once after a particularly difficult case. Seriously.

These days, it’s so inspiring and affirming to see the industry putting these four domains: safety, quality, patient experience, and staff engagement, on the same plane. There is undeniable evidence that, according to the 2018 Strategic Blueprint for Transformational Change from Press Ganey, “…performance in each domain does not take place in a silo, but rather, drives and is driven by performance in the others.”

Just about every hospital I know has a daily safety huddle, where people in all departments come together for a few minutes every day to discuss safety issues and potential risks. More and more, they’re adding patient experience to the mix and identifying areas where they need to implement service recovery or proactively get out and address an issue before it becomes a bigger problem.

And at national healthcare conferences, I see more and more breakout and keynote sessions about addressing employee engagement and preventing staff burnout. It’s wonderful to see these changes and I’m so encouraged to see how far we’ve come over the years.

Safety, quality, patient experience and staff engagement. When the goals of all four are aligned, integrated, and given equal weight, all kinds of wonderful things begin to happen: patients start to experience what they want and expect from us and we are reconnected to our purpose of having chosen to work in healthcare. It’s an exciting time, one I’m glad to be able to experience.

The work of culture change, whether it’s within a hospital or any other organization, is tough. It starts out with a lot of excitement and energy; there are meetings about mission statements, brainstorming exercises on behaviors, and several iterations of the training program in power point before unveiling the final product. The training sessions are the easy part. We design them to be fun, participatory, and a re-positioning of what most of us learned as children: be nice to your coworkers, treat customers well, and don’t let your mood dictate your manners.

Sustainability, well, that’s the hard part.

No matter how much you involve front-line staff in the development of the program, there will always be people who resist. Plenty of books have been written about the importance of leaders holding their teams accountable to the new behavioral standards. We’ve been taught how to have those conversations with low performers and helping them either move up or move on. We know about using behavioral-based interviewing to hire the right people. We have no shortage of books to help leaders lead.

What if the issue isn’t front-line staff?

Your organization is full of directors and vice presidents who moved into those positions under the ‘old’ way of doing things, before your culture change program came to town. And they’re very invested in remaining in those positions. So, while they’ll give your program lip-service and convince the president they’re on board, they may be the ones who are really struggling with this new way of doing things.

They may feel very threatened by all the change but they know they have to get behind it if they want to stay in those roles. So rather than attack the program, they may attack you. I hear it all the time from my friends who do this kind of consulting work. When things get too unsettling for middle management, the conversation shifts and the focus moves from the product to the person. It becomes more about how unlikable that consultant is and less about the content of the material.

Be patient with these people. They have a lot invested in their jobs and they’re used to doing things a certain way. Plus, the pressure is on them when it comes to holding their teams accountable. They’re under a microscope, much more than the front line, when it comes to sustaining change. They’re nervous. They’re threatened. They’re human.

Don’t take it personally. Their attacks aren’t as much about you as they are about them. You keep doing the work you know you were meant to do. Keep trying to make the world a better place, one organization at a time. Some people aren’t ready to make the change. But don’t let them slow you down.