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 Doctor-Patient Relationship

The relationship you have with your primary care physician can mean the difference between life and death.

How’s that for an opening statement?

My parents had my eldest brother, Chris, in 1959, then 14 months later had my other brother, Andrew, and 18 months later had my sister, Mary. It was just the three of them in this tight cluster until 7 years later when I came along. Those two were full of energy, into everything, and had non-stop energy. She, on the other hand, was an introverted sensitive soul.

She also had a weight problem. For as long as I could remember she was extremely self-conscious about it. My brothers were skinny, especially Chris, and poor Mary got picked on. A lot.

It didn’t help that our primary care physician was a scary looking old man who spoke in a thick German accent and used to tease her about her weight every year at her annual school physical. She dreaded those visits and even as an adult hated going to the doctor for fear that they’d say something unkind.

Those early pediatrician visits made a big impression on her. She thought every doctor was an old man who said things like, “Vell younk lady, you ah putting on some veight, again, yah? You haff to shtop eating so many cookies.” And always in front of my brothers, giving them plenty of ammunition for teasing.

She never got over it. This was a woman who, in her late 30s, refused to go to a doctor when she clearly and unmistakably had gallstones. Incredibly painful gallstones which she insisted on treating with over the counter tylenol. They either resolved on their own or she just adjusted her pain tolerance, I’m not sure which. But it infuriated my mom who was a nurse and me who worked at a hospital. We begged her to go to a doctor but she absolutely refused. She told us didn’t want to go because she was sure they’d get on her case about her weight. Exasperated, Mom and I finally gave up.

Fast forward to the fall of 2012. Mary was suffering from some insanely horrible back pain. Nothing over the counter could touch it. She’d gone to a chiropractor, a massage therapist, and an acupuncturist, but got no relief at all. I remember her telling me that driving over railroad tracks made her see stars.

Finally, I said, “That’s it. I’m getting you an appointment to see a doctor. We have GOT to get this looked at.” A few days later, I was able to get her in to an internal medicine physician with the medical group I worked with. Although I turned my head when he asked her to take her shirt off, there was no way not to notice the giant lump she had on her breast. It was huge. Softball size huge. I couldn’t believe my eyes.

A few imaging tests later and it was confirmed. The pain in her back wasn’t a bulging disc or muscle spasms. It was stage 4 breast cancer with compression fractures in her spine. The cancer had spread from her breast, through her rib cage and into her back. There was nothing they could do. They gave her six months.

I was as supportive as I knew how to be but I had to ask why she didn’t go see a doctor as soon as she found the lump. It all came down to her fear of ridicule. She truly thought that her doctor would spend more time chastising her about her weight than addressing the lump in her breast.

Now I’m not going to blame my sister’s death on her childhood physician; at some point, we all have to grow up and do the right thing. But she was truly traumatized as little kid and those scars stayed with her well into adulthood.

Sometimes we say things and we don’t mean anything by it. We’re joking, we’re trying to inject humor in an uncomfortable situation, or we’re just not thinking about how the other person is hearing it. Whatever the reason – it matters. Doctors, believe me, we listen to what our physicians say to us. It may be a throwaway comment to you, but it’s gospel to us. Venn you vant to make a shatement about your patient’s veight, pause. Think about how that may impact their relationship to the medical field.

I loved my old PCP. There was nothing he could have advised me to do that I wouldn’t have done. And not because it was good advice; other doctors gave me the same advice, it was because I liked him. Liking him made me much more inclined to do what he asked. When he addressed issues about my weight, it was always with compassion and sensitivity

Doctors, you’re more than just the treating physician. Inspiring behavioral change doesn’t really happen without relationship. Get to know your patients. Be kind when you have to deliver some unpopular or sensitive news like needing to lose weight. The words you choose can make all the difference.

When Your Husband is the Patient

“Honey. Honey, wake up. We have to go to the hospital right now.”

My husband has had his share of health problems, but I’ll never get used to being awakened from a sound sleep to those words.

I somehow managed to get myself out of bed, brush my teeth, and throw on some clothes before braving the several feet of snow and merciless winter wind to get to the car. As he was doubled over in pain in the passenger seat, I pulled out of the driveway, into the dark and headed toward the local emergency department.

Walking in the front door toward the registration desk, I took notice of everything around us. Having worked at my share of hospitals, I was on high alert. Was the person at the desk looking up as we walked in? Was the waiting area clean? Were there signs telling us where to go and what we needed to do? I noticed everything.

It’s funny how we’re so much more vigilant when it’s a loved one as opposed to ourselves.

I got him over to the front desk and smiled when the woman told us her name and said she was going to walk us through the registration process. She was patient while he took a few extra moments to pull his wallet from his back pocket. The pain in his stomach made it hard for him to straighten up but she didn’t seem to mind.

We got back to the treatment area almost immediately and I noticed that everyone we passed on the way to his room acknowledged us in some way, whether it was a smile, a hello, or just eye contact. I started to relax. A little.

It wasn’t long before the physician came in and asked one simple open-ended question, “Hello, Mr. Kalthoff. What brings you in tonight?”

Anyone who knows my husband knows he can’t ever answer a question with a simple answer. If you ask him what time it is, you’ll learn all about the history of watchmaking.

I watched this doctor’s face as he relayed his entire medical history and that of his father’s and was truly impressed that she didn’t interrupt. She asked very focused questions to get him back on track but it never came off as rude or impatient. I could use some of that, especially when I ask what he’d like for dinner.

She got to the heart of the medical issue that brought him to the ER and in no time he was back in imaging getting a CT scan. They even let me go back with him, which I didn’t expect, and told us it would be about an hour before we’d get some results. I looked at the clock and started the countdown.

While we waited, several people came in to check on him, including a student who had anticipatory service down to an art. Without having to ask, he brought me a glass of water and a pillow for the uncomfortable chair I’d been sitting in and an extra blanket for my husband. I was impressed. He was oblivious. The pain meds had kicked in.

Which brings me to the point. Often, patients don’t notice the things family members notice. And even if they do, they’re less likely to be upset by them. I can make excuses for doctors and nurses all day if I’m the patient, but if it’s my family, that protective instinct kicks in and I’m ready for battle.

Thankfully, that night in the emergency department, there was no need for battle. Everyone was marvelous. The CT results came back sooner than expected and his condition was explained in a way we both could understand. We left feeling much better than we did when we came in and I happily filled out the survey when it came a few days later in the mail.

When we talk about patient experience, we cannot forget the people who are with them. They notice everything. They worry more. They have more questions. They listen closely to how their loved one is spoken to or spoken about. We have to remember to include them in the discussion and address their needs, as well.

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.

The Family Conference

I hadn’t been involved in the case. I didn’t know anything about why the family was upset, only that their father had died and they had questions about what had happened.

I met the patient’s two adult daughters in the hospital lobby and escorted them back to our conference room where several staff members, including the hospitalist physician who had cared for him, were waiting. After we’d gone around the table and introduced ourselves, I asked the daughters to tell us about their concerns.

As they told their story, I looked around the table and took note of how we were sitting, where our hands were, what kinds of expressions were on our faces. Most of us were sitting forward in our chairs, hands together, eyes on the sisters, while periodically nodding our heads or pursing our lips as they spoke. One of us sat back in his chair, arms folded across his chest, looking mostly at the table. The sisters noticed.

“Why can’t you look at me?” one of them demanded. “I’ve been asking questions about what happened and all you can do is stare down at the papers in front of you.”

He looked startled. “I just want to be sure I’m answering your questions accurately. I printed parts of his record so I don’t say anything incorrect.”

I could appreciate where he was coming from; he came to the family conference prepared to answer medical questions about what had happened. He didn’t come prepared to address their feelings about what had happened.

The woman continued, “All of you at this table have offered an apology and I believe everyone here feels genuinely sorry. Except you.” I shifted uncomfortably in my chair as she pointed at him.

“Maybe you do feel bad. Maybe you do have some empathy for me and my sister but you need to learn how to make people see that. I don’t believe for one second that you care at all and I really hope I’m wrong. If you really do care, then don’t just say you’re sorry. Show it.”

I was starting to feel really bad for him. Here he was in a room with several staff members, including the Chief Medical Officer, getting raked over the coals for a death that really wasn’t his fault. And that’s where he was stuck – it wasn’t my fault.

I’ve said before that patients and their families don’t care whose fault something is. They just want to know you heard them, you’re sorry, and you’ll do your best to be sure it doesn’t happen again. In this case, the patient’s daughters wanted medical answers, yes, but they also wanted all of us to understand how difficult things had been and to take steps to improve. This poor guy was stuck.

As uncomfortable as this family conference was at times, I’m very glad we had it. It gave all of us at the table a chance to hear directly from the family how scary, confusing, and frustrating it can be when loved ones are in our care. We forget sometimes that treating a patient also means caring for a family, and showing genuine empathy involves more than simply saying you’re sorry.

For the Non-Clinical PX Leader

Last time, I asked the question: “Do you have to be a nurse to be a good patient experience professional?”

I know a lot of great patient experience leaders who are nurses but I don’t think an RN is a prerequisite. Sure, being a nurse gives you some street cred when you first walk onto a unit and nurses might be a little more inclined to listen to you because they know you know what their job is like. But it’s not everything.

So what should we non-clinical patient experience leaders do?

  1. Listen to and support the clinical staff. This is the most important part of the job. Happy nurses make for happy patients.
  2. Never immediately assume that the patient is telling you the whole story. The patient is telling you the story as he sees it. ALWAYS get the story from the nurse, too.
  3. Remove ridiculous and repetitive work. As an administrator, you have the power to make things easier for nurses. Ask them to tell you what makes their work difficult and then do everything you can to get rid of those things.
  4. Recognize and reward. Tell them, show them, do whatever you need to do to demonstrate how much you appreciate them.
  5. Hold them accountable for bad behavior. Let’s be honest, every now and again people are going to say or do something they shouldn’t but make your expectations clear and hold them to that standard. We should never meet rudeness with rudeness.
  6. Keep what’s best for the patient as your “True North” when faced with a difficult decision. It’s not about making them happy, it’s about doing what’s best for them.
  7. Spend some time on the floors shadowing a nurse. If you really want to know what it’s like, schedule a few hours out there with them. It’s an eye-opener.
  8. Talk to clinical staff as partners, not subordinates. After all, you can’t do the work yourself. All those ideas you have about improving things for patients, they are the ones that are going to be carrying those out. Talk with them, not at them.
  9. Recognize the science behind good service. Positive patient experience is in fact tied to better clinical outcomes. Be sure your clinical staff understands that.
  10. Keep learning. Consider getting certified. The exam for the CPXP designation isn’t easy. Demonstrate your commitment by continuing to keep up with the research.

The days of patient experience being a “nice to have” but not “have to have” are over. This is no longer fluff stuff; there’s actual science behind a better experience leading to better clinical outcomes.

A good patient experience leader can’t be just a pollyanna, always spreading sunshine and roses (although those don’t hurt). We have to know how to inspire, how to engage hearts and minds, and how to stay positive through difficult times. We have to be able to meet people – patients and staff – where they are and make a connection.

Do You Need to be a Nurse?

“Are you a nurse?” It’s a question I get asked a lot, mostly by nurses, and I wonder sometimes if it would have made a difference in my career.

When it comes to patient experience, the service trainings and other improvement efforts we spearhead are geared primarily toward nurses. Nurses comprise the largest percentage of the workforce in hospitals and they are typically the ones patients remember, even more than physicians. Of course we have training for ancillary staff and non-clinical teams but most of our conversations about patient experience involve nurses.

I’m sure if I had RN after my name it would change my perspective. I’d be a lot more comfortable on the floors, going in and out of patient rooms, and knowing what to do in case of a medical emergency. I’d have a much better understanding of what it’s like to work on a med-surg floor, trying to manage the many demands of patients, their families, and physicians, not to mention entering everything into the electronic medical record and the countless other things nurses have to do for 8-12 hours straight.

Am I really qualified to tell them how to deliver better care and service?

You might think not, but more and more, the people we’re hearing from in the patient experience conversation these days are the patients, themselves. We read their comments from the surveys and bring them in to tell their stories of what it was like when they were lying helpless in a hospital bed.

Many keynote speakers at Patient Experience conferences are not nurses, but patients, who talk about how frightened they were and how much they needed the hospital staff to show them more compassion and kindness. Patient and Family Advisory Councils and Focus Groups are widely used to suggest changes and improvements to the way care is delivered. And you know what? Nurses listen.

So I ask the question: do you need to be a nurse to be a good patient experience leader?

My opinion, of course, is no. While being an RN would give me a different perspective, it wouldn’t necessarily give me a better one. When you’re a hammer, everything tends to look like a nail and patient experience is more than nursing care.

I work with physicians, housekeepers, billers and coders, security guards, registrars, telephone operators, and many others, all of whom are involved in patient experience efforts. While I need to understand their perspective, I don’t need to have lived it, myself. I’ve never been a server in a restaurant but I know good service from bad.

I think what’s at the root of the question, “Are you a nurse?” is that nurses want to know that we understand how difficult their job can be. I think they’re worried that some administrative pencil pusher is going to try to tell them they how to do their job.

That is not my style.

I think what makes for a good patient experience professional has less to do with the initials after your name and more to do with the love inside your heart.

  • Can you stay calm when people are yelling?
  • Can you listen to criticism without getting defensive?
  • Can you de-escalate a tense situation?
  • Can you resolve a problem without throwing another person or department under the bus?
  • Can you inspire people to action around a common goal?
  • Can you figure out a way to present dry, dull data in an engaging way?
  • Can you genuinely connect with another person, especially one in some kind of pain, and convey sincere kindness and caring?

I believe that’s what makes for a good patient experience professional, nurse or not.