What Are We Celebrating?

Not long ago, I was at a patient experience conference and decided to sit in on a breakout session given by a hospital that had recently received an award for raising their H-CAHPS scores. We’re all looking for the secret sauce and I was interested in hearing how they did it.

The two presenters talked about how they took a specific question from the survey and made that their focus. They conducted huddles on that question at the start and end of every shift, they measured and posted results in every unit, the unit managers and charge nurses socialized it throughout the day every day, and individual coaching was given to everyone who wasn’t performing as expected for that particular question. 

The results were impressive. The whole time this was in place, scores went up considerably and patient comments reflected that the practice was being done. It was great.

And then…

And then they focused on another question. And guess what happened to the first question.  Did those results sustain? Did they continue to do those things they’d been drilled on for weeks before? Nope. They fell off like Humpty Dumpty.

The results for the question they were now focused on were great, just like the first one had been. But those didn’t last either. Whatever had the intense focus performed well. Nothing else did.

So I raised my hand and asked, “Can you speak a little about sustainability? When do these behaviors you’re coaching for become just part of a normal day, ‘this is how we do things here’? Can you explain why they weren’t sustained over the long-term?”

They looked at each other for a moment and one of them said, “Well, you know, we ask an awful lot of our nurses. They have so many things they have to focus on; we think we can only ask so much. One thing at a time.” 

I’m sorry… you got an award for this?

This, in my opinion, is what’s wrong with so many hospitals’ approaches to improving patient experience. Unless it’s part of your culture, unless it’s what employees commit to, unless it’s “this is how we do things here,” you don’t have real improvement. You have compliance, but not commitment. 

I was so disappointed when I left that session. Any one of us could have given that very same presentation. We have all done that very method of performance improvement and gotten the same results. Why do we keep doing it that way? 

It seems that’s exactly what so many leadership teams want. They want a spike in improvement that they can show to their bosses. Are we all really that short-sighted? Really? We’re celebrating a blip on a spreadsheet. That’s just not how I do things. Whenever you have a huge spike, you will have a huge fall. Patient experience is a culture, not a program, and it takes time. 

It’s time we start rewarding those hospitals that put in the work over the long haul and sustained those improvements over months and years. Let’s do it the right way and feature them at the patient experience conferences. 

What is your leadership team celebrating?

Yes, We Survey the Angry People

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

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

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

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

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

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

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

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

What Does This Score Mean?

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

It simply isn’t true.

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

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

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

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

Definitely Yes 66%

Probably Yes 23%

Probably No  8%

Definitely No  3%

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

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

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

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

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

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

Always 70%

Usually 24%

Sometimes 4%

Never 2%

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

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

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

Patient Experience over the Holidays

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

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

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

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

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

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

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

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

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. 

The No Pass Zone Pitfall

In every hospital I’ve ever worked, we’ve observed something called the No Pass Zone. The No Pass Zone means that when a call light is on outside a patient’s room, whoever is nearby, no matter what their job title, stops and answers the light. We go in, we tell the patient we saw the call light was on, and we ask what we can do to help.

No exceptions. You do not walk past a patient room when a light is on. Ever.

We drill this like crazy at new employee orientation. We tell clinical and non-clinical staff alike, “Do not walk past a room if there’s a light on. It doesn’t matter if that’s not your patient or you’re not an RN, or you’re in a hurry. If a light is on, you go in.” It’s crystal clear.

So what could possibly go wrong?

I was on my way up to the 3rd floor one Thursday morning to do my daily patient rounds. Each of us on the leadership team has an assignment of four patient rooms to round on. We ask questions about their stay, like which staff member can we recognize for doing a great job, what can we be doing differently to make your stay with us a little better, and some focus questions about a specific topic we’re trying to measure, like quiet and restfulness or RN Communication.

I got off the elevator with my rounding questions all ready to go when the very first room down the corridor had its call light on.

My eyes locked in on that soft white glow hanging from the ceiling. I could see nothing else. This was it. This was my moment. I was going to answer a call light. My mother, an RN of nearly 50 years, would be so proud.

I went into the room and saw a face that was familiar to me. He was a patient from a few weeks ago who had been in one of my assigned rooms for several days; I’d gotten to know him a bit. He looked different today.

“Hi!” I said. “I remember you! I saw your light on, how can I help you?”

“I need my nurse,” he cried. “My stomach is in so much pain and I just pooped myself and I called the nurse and I need help!”

“Oh my… okay… I’ll find your nurse… hang on… I’ll get some help.”

I ran out into the hallway and saw the manager of the unit. “Hey,” I said, “I answered the call light in room 301. The patient said he pooped himself and needs his nurse.”

She looked at me and said very calmly, “Okay, Kate, I’ll get his nurse. You know you were just in a room with a patient who has C-diff, right?”

I stopped dead in my tracks. “What?” C.-diff is clostridium difficile, a nasty little bug that wreaks havoc on your colon.

“Kate, go wash your hands with soap and water. Didn’t you see the signs on the door about contact precautions or notice the cart with all the PPE on it?”

Actually, no. I hadn’t.

Right outside the room there was a cart with PPE – personal protective equipment –  gowns, gloves, and masks and a big sign warning that we needed to take precautions before entering. I was so fixated on the call light, I never saw them.   

Thankfully, I hadn’t actually touched anything in the room, but I still felt like I had cooties all over me. I washed my hands for what seemed like an hour.

Here’s the thing: depending on our lens, we tend to fixate on certain things. As the patient experience director and a non-nurse, when I saw a call light, all I could think to do was answer it. Immediately. Someone needs help. Go help.

What we can’t forget to do is pause and take a look around. Notice the big red signs on the door. As you walk around the giant cart of PPE to get to the door, stop for a second and ask yourself why it’s there. Don’t get so caught up in your own forest that you can’t see the other trees.

More About the Checklist

Last time, I wrote about management by checklist. I stressed the importance of relationships and helping your team connect to the ‘why’ behind the directives.

This time I’d like to expand on that and talk about the number of things that are on that checklist.

A few years ago, I was working at a hospital that really wanted to improve their patient experience scores (their words, not mine) so they decided to make a list of all the things that have been shown to do so: AIDET, hourly nurse rounding, bedside shift report, MD-RN rounds, leader rounds, empathy statements, in-the-moment coaching, physician shadowing… the list went on and on. At the end of the exercise, I think there were 28 things they wanted to implement.

I asked them what they wanted to start with. “We’re doing them all!”

“All?” I asked. “We’re starting with all of them?”

“Yep, we’re going to shake things up all across the board,” they answered. “We’ve designed checklists to ensure that everyone is doing these things and we’re going to see an amazing jump in our scores, just you watch.”

The next week our nurse leaders were presented with a list of 28 things they needed to start doing and monitoring. Some of those things were already in place but happening inconsistently, others were new. We didn’t leave a lot of time for training; most of the instructions were given verbally at the time of the rollout.

There was a blitz, with many units trying hard to do everything on the list, but after just a few weeks, they ran out of steam. Too many plates spinning, too many things falling off, and too many opportunities to fail.

Had we just gone with one or two at a time, given them time to become a habit, and let them see some success before adding another, I think we would have had a very different outcome.

When we give our teams too many things to accomplish, they end up accomplishing nothing.

Management by Checklist

In the world of patient experience, we have a lot of evidence-based best practices that we’re constantly measuring: bedside shift report, hourly nurse rounding, MD-RN team rounds, leader rounding, and more. We spend a lot of time checking off boxes on the checklist to be sure all of those things are being done.

It’s important that we do these things. But how do we get people not only to do these things but do them well?

I’ve seen far too many managers send out communications that outline a process and direct people to action but few that have been all that compelling. That may be management but it’s not leadership.

The thing that moves people to action isn’t always a directive. And even if they do start moving, there’s no guarantee they’ll be moving effectively.

We make lasting change through relationships. People are far more likely to make a change when they understand the reason behind it and trust the person leading the change.

When we spend time with staff, understand what drives them, recognize the challenges they face, and get to know them as people, we begin to earn their trust. I’m far more likely to get behind a leader who knows me than one I’ve never even seen.

The checklists aren’t enough. Help your team connect to the why. When leaders lead with trust, mutual respect and connection, they create teams who not only make the change but do it well, with intention and purpose.

The Case for Leader Rounding

They call it sacred time. That hour between 9 and 10am where the leaders of the hospital go into their assigned rooms out on the floors and talk to patients and their families. It’s an hour when no meetings are to be scheduled. It’s protected time, dedicated solely to patient rounds.  

Sometimes it’s a social visit: how are things going, is there anything we can do to improve your stay, do you need anything, etc. Sometimes, it’s a focus on a particular issue: is it quiet at night, are you able to get enough rest, what kind of noise is keeping you awake, is it equipment, staff, other patients?

After rounding, there’s a huddle to review any big issues that need escalation and recognize any staff that patients said provided outstanding care and service. It becomes very apparent at those huddles who is doing those rounds and who is phoning it in. When day after day, a person says, “My patients were sleeping,” or “My patients said everything was fine,” we know there’s not a whole lot of rounding going on.

It was a source of frustration for me, trying to make those leaders understand the importance of connecting with patients. After all, this was our opportunity to see the hospital through their eyes and find out what’s working well, what’s not, and what’s important to them so we could make things better. Why wouldn’t they make time for that?

Pleading and begging and even data about how leader rounds improves patient experience scores didn’t appear to be having much of an impact. Turns out, nothing is as compelling as a real-life story.

Doug was in charge of facilities, a no nonsense kind of guy who made sure all the engineering, heating and cooling, and equipment was humming. I never would have guessed he’d be so passionate about patient care.

He was in a room one morning trying to have a conversation with the patient and his family members and needed an interpreter. We had interpreter services with an outside company and, while reaching those individuals was sometimes a chore, it was necessary. After connecting with them, it was clear the family was in the dark about what was happening when the physicians and nurses came in.

Doug hung in there. He stayed with them, wanting to know if they knew what the patient’s condition was, if they understood what the medications were for, if they’d had a chance to ask questions, and on and on. He reassured them, told them he’d get them the answers they needed and left to find the manager of the unit.

She, too, did some digging and identified each of the nurses who had been caring for this family. Of the six or seven, only one had documented in the chart the she had used the language assistance program.

From that moment on, everything changed with this family. No one went into that patient’s room without the interpreter service and no one left without checking with the family that all of their questions were answered.

We likely never would have known any of this without the leader rounding program and for Doug’s persistence. He could have reported that the patient wasn’t English speaking and the interpreter services weren’t working. He could have reported that the family said everything was fine. He could have skipped the room altogether and just said the patient was sleeping, But he didn’t. He went in, took the time, and helped this family get answers.

I can only imagine what they must have been feeling up until Doug stepped in.

Some hospitals don’t do leader rounding because they think it’s too much work or they don’t want the nurses to think they’re checking up on them. We do it because we feel that leaders are part of the care team. We bring a different perspective in with us and we’re another set of eyes making sure patients and their families are receiving the best possible care and service.

Doug’s story was just what we needed to light a fire under some of the leaders and help them see just how important it is. I hope it does the same for you.

The Elephant in the Emergency Department

I am a big fan of Liz Jazwiec and her 2009 book Eat That Cookie! Make Workplace Positivity Pay Off for Individuals, Teams and Organizations. In it, she talks of her time as the manager of a busy Chicago emergency department where the motto seemed to be “I’m here to save your ass, not kiss it.”

I first heard of Liz when the hospital I was working for at the time hired her to give a talk to our managers and directors. She had been a patient experience cynic who thought the whole thing was ridiculous. The president of her hospital told her she had to get her patient experience scores up or she’d be looking for another job. At first, she resisted but soon realized he was serious.

Like so many nurse managers I’ve met, she thought patient experience was fluff stuff and had no place in healthcare, especially a busy ED where things were quite literally life and death. She sneered at the smile police who told her to “just be nice” while she was working hard to bring people back from the brink of death.

To Liz, many of her patients were cranky, ungrateful whiners who were tough to deal with. But as she started being nicer, she was surprised that they started being less cranky, showed some appreciation, and were easier to deal with.

Eventually, Liz not only got her patient experience scores up, she became a believer in the patient experience movement, even becoming a coach for The Studer Group. I love her story and if you haven’t read her book, you really should.

Something else to consider when it comes to the ED is throughput and the effect it has on the nurses.

Much of the dissatisfaction in the ED comes from waiting too long with no idea of what’s happening and why. Staff can certainly help by keeping patients informed but when things are backed up, staff start feeling the pressure, too. When there’s no available bed on the floor, an ED nurse has to now be a telemetry nurse, something they don’t particularly enjoy.

ED nurses are trained to stabilize and either discharge or admit. Once the decision has been made, the ED nurse moves on to the next patient. To have a bunch of patients on gurneys lining the hallway needing ongoing care makes ED nurses anxious. They want the patients to get up to the floors as much as the patients do.

Additionally, there are patients in the ED who need specialized care that the hospital may or may not provide. Sometimes, getting a surgeon or psychiatrist to come in can be a challenge and getting a patient transferred to another facility can take hours. These situations, too, can make staff anxious; they have to manage the questions and complaints but they’re powerless to actually fix them.  

Without efficient discharge processes on the floors, patients can end up staying a day or two longer than needed and that means longer waits in the emergency department for patients who need an inpatient bed. Case managers, social workers, hospitalists, attending physicians, and house supervisors all play a role that affects wait times, and, subsequently, patient experience in the ED.

Nothing can take the place of a warm greeting, staff that meet and even anticipate your needs, and physicians that explain things in a way you can understand. But when it comes to patient satisfaction in the ED, you have to include throughput and inpatient discharge processes in your efforts or you’re only solving part of the problem.