Some Positive Thoughts on Positivity

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

Wow. What a lovely thing to hear.

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

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 On the one hand, we’re trying to dispel the outdated thinking that patient experience is ‘fluff stuff’ led by a bunch of vapid do-gooders who have no clue about real life.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

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

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

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

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

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

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

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.

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.

Surprise and Delight

I recently came across a book called The Power of Moments: Why Certain Experiences Have Extraordinary Impact by Chip and Dan Heath. If you haven’t read it, I strongly suggest you do. Once I picked it up, I couldn’t put it down and it completely changed the way I approach my work in patient experience and employee engagement.

In healthcare, we talk a lot about Evidence-Based Best Practices, things that have been tested and shown to be effective. We work tirelessly to implement and measure best practices and then we wonder why our patient experience scores are so low. It’s frustrating.

I took a look at our comments on our surveys and the responses we get on our discharge follow-up phone calls. They largely consist of, “Everything was fine.” Ugh. Fine. I hate fine. Fine is the kiss of death.

Turns out, these best practices, things like introducing yourself to patients, explaining what the next steps are in the plan of care, or describing the possible side effects of their medications are things patients have come to expect from us. We’re not going to get outstanding surveys if we only give them what’s expected. It’s like buying a car with air conditioning. We’re not going to wow people with the awesome air conditioning package; they expect it. They didn’t always. I can still remember cars without air conditioning but it’s unthinkable now. Same with these best practices. Patients notice when we don’t do them.

So how do we create a hospital stay memorable enough for patients to even bother filling out a survey and then to describe their stay as exceptional?

This is where Dan and Chip’s book changed my whole perspective. They dive into the science behind what makes things memorable and offer real-life, practical examples of what staff can do to create those peak moments that patients will remember more than anything else. They don’t have to be expensive or labor-intensive or time consuming. They can be quiet moments of connection or surprising moments of responsiveness. And they not only delight the patients, they can touch the other staff, re-engage them, reconnect them to their passion and have a ripple effect across departments.

Best practices are important, they’re the minimum level of service we should be providing every time, and they’re not going to get you anything but middle-of-the-pack results. If you want to deliver a truly exceptional experience, surprise and delight.

The other piece is knowing that, as leaders, we are very good at solving problems. We know how to smooth out the potholes but we probably don’t know how to create peak moments for patients. You know who does? Your front line staff, that’s who. Let them drive this. Don’t roll out some ‘moment making’ program in which administration tells the staff exactly what they are to do to delight patients. Empower them to come up with those ideas and deliver them.

And while they’re out there pouring their hearts into this, you’d better be doing everything you can as a leader to surprise and delight them. Fill their cups, do a few unexpected things to show your support and appreciation of them. Don’t expect them to create any moments for patients that you wouldn’t also create for them. Watch how fast your culture changes, how happy your staff members are, and how infrequently you hear the words, “Everything was fine,” in your discharge follow up phone calls.