Let’s follow the course of a typical hospital patient.  The family is in the hospital waiting room, filling out the same exact forms that they have completed many times before.  They must endure long waits for doctors that often don’t show up on time.  On the other hand, if the patient is even a few minutes late, their appointment can be cancelled and sometimes they are fined.  Frightened families endure siloed care with physicians and departments that don’t talk with one another.  They have poor access to their own health information. They are given poor directions to different areas of the hospital that end up impossible to find while in hospital gowns that are humiliating and uncomfortable.  They are given cold and tasteless food by cafeteria workers that act even colder.  Sleep is constantly interrupted by blood draws and vital signs timed in the middle of the night to be available for the doctor’s morning rounds and by nurses laughing and shouting so loud they can’t hear the call bell of a patient needing to go to the toilet but unable to do so on his/her own.  Or maybe they don’t sleep because they are a nervous wreck after the physician didn’t adequately explain the major surgery scheduled for the next morning.

Bad experiences like these are the rule rather than the exception.  Hospital have realized they must do better.  For many years, service industries other than healthcare have competed on how well they can deliberately manage their customer’s experience. Healthcare only dreams of providing the same elite customer experience of a 5 star hotel, famous restaurant or a first class trip on a full-service airline.  The cost of a hospital stay is more than all three of those events combined, so the comparison is tempting and spurs on ideas for how we should improve (hire a patient care navigator, serve better food, train staff on service excellence, provide 5 star amenities, enforce quiet times at night, etc.).  Most notable about these ideas is that there is no common theme.  Any time there is no clear priority for how to act, it means the root cause is not fully understood.  As Thoreau said: “There are a thousand hacking at the branches of evil to one who is striking at the root.”  The ideas described above, although creative, are merely branches.  The root of the problem is poor nurse engagement.

To understand the impact of the bedside nurse, just look at the data.  The goal of excellent patient experience is their loyalty (i.e. their likelihood to recommend).  Surveys from Gallup polls and Press Ganey show patient loyalty is driven by two issues: 1) how well did nurses communicate and respond to their needs? 2) how effective was teamwork?  The importance of this is not new.  Florence Nightingale described communication, responsiveness and teamwork as the basic tenets of excellent nursing care 180 yrs ago.  The key point is that other issues that play a role in the patient experience take a back seat to the nurse.  How well the physician communicates is important, but patients always double check things a physician says with nurses.  Patients find nurses more approachable than those in positions of authority like a physician.  Gallup polling done over the last several decades has shown that patients trust nurses more than doctors and the gap has been widening over time. If patients don’t get good information from the nurse, they blame poor communication and teamwork with the doctor.  There is some evidence that hospital amenities influence patient choice in hospitals, but probably because nicer hospitals lead to happier and more engaged nurses.  There are many examples of hospitals with first class amenities that went bankrupt without a strong nursing culture, like Century City Doctors hospital in Beverly Hills.  On the other hand, some hospitals are in tents in Afghanistan, and their patients have wonderful experiences.

It is no secret that many nurses accept responsibility for the patient experience with reluctance and cynicism.  Past failed initiatives to improve patient satisfaction have induced a resistance to this idea.  Some see it as a political ploy to distract from the underlying systems issues that are more responsible for patient dissatisfaction (e.g. poor nursing ratios).

Regardless who feels responsible, every time a patient endures mistreatment our culture erodes a bit more.  Systems drive culture.  It is impossible to have a powerful service culture with a system that is sets us up to fail.  There is no quick fix for this.  One hospital executive who came from the hotel industry said that it would be easier to send customer service staff to nursing schools rather than train nurses in the art of customer service. That was a powerful way to make a point.  The main point being that this former hotel executive (now hospital CEO) has never talked to a bedside nurse.  How about sending that executive to nursing school?  Then he would realize the clinical impact of replacing all your experienced nurses with customer service “artists” fresh out of nursing school.  Patients won’t be happy when their complication rates go up because of inexperienced nurses.

Those of us that aren’t nurses should start by being curious as to what makes them resist their role in the first place.  Those that I’ve talked to say that the retail model – the approaches and standards used in other service industries (e.g. “the customer is always right”) – does not work when caring for the sick.  Nurses must set boundaries for behavior of upset patients and families.  Like flight attendants, we trust nurses at the end of the day that they will keep the priorities straight.  Patients must remain safe at whatever the cost–even to the point of angering patients and family members.

The Ritz-Carlton mindset is not only futile, but can have unintended consequences.  The opioid crisis is in part due to overprescribing narcotics in the pursuit of better patient satisfaction scores.  Interestingly, the highest ranked nurses have patients with the lowest level of pain, even without giving them more narcotics.  Nurses often need to push family members to participate in a patient’s care.  This is exactly what they need to do to avoid a hospital readmission but definitely not an effective tactic to improve their satisfaction.

Another problem is that its hard to get nurses to create optimal experiences when they have chronic concerns about patient safety and aren’t able to speak up about that (see prior post: “Sophie’s Choice”).  Worrying about a patient’s experience before their safety is not just putting the cart before the horse, its more like trying to extract golden eggs from a goose on life support.  Nurses employ superficial tools like the Press Ganey’s AIDET (acknowledge, introduce…) to improve their bedside manner.  When used in the context of a poor safety culture and a feeling that their work is undervalued, use of AIDET mandates a form of emotional labor known as “surface acting”. At best, this type of acting yields interactions that are far from spontaneous and authentic and it risks cognitive dissonance, undue job stress and burnout.  At worst, it is viewed as a form of doublespeak that prompts nurses to question the integrity of the organization and become actively disengaged.  Either reaction can backfire and reduce patient satisfaction.

Initiatives to improve patient experience that ignore nursing’s cynicism never ring true and are dead on arrival.  We must develop a genuinely shared mission for how to proceed, a mission that draws on the hospital’s very soul, reflecting and reinforcing what its staff care about and what makes them come to work in the morning. Hospitals wanting to be admired by their patients first need to gain the admiration of those who know them best–the bedside nurse.  When just a single nurse becomes truly engaged in such a mission, it will be contagious.  Collaboration with nurses on important hospital initiatives is often ignored, which is why this internal marketing effort will have tremendous power. Nurses are starving for it, will be inspired and engaged by being included in the development of a shared mission. Once it comes to fruition, they will go the extra mile and their patients will take notice by giving us their loyalty.  Our common mission will be a north star on which all service decisions can be developed.

So, what is the magical shared mission?   For the answer, let’s look at the master of the magical customer experience: Walt Disney.  Here is a direct quote from their training website: “Safety is always the number one concern and priority—everything else, including Courtesy, falls in line after it.”  Specifically, they teach their employees (i.e. castmembers) very sophisticated concepts of safety – such as the need to speak up to ensure safety and the importance of situational awareness.

Patients, Disney guests and airline passengers assume safety.  No one gives us credit for safety.  They only notice when safety didn’t happen.  However (and this is the key point), employees always know if safety is happening and their engagement depends on it.  A culture where nurses are not fully engaged blocks any other initiative we might want to do. When safety is not prioritized and/or there is a fear of speaking up about it, we put nurses in the dilemma of Sophie’s choice and make it impossible to become engaged. If Disney prioritizes safety, with a risk to their customers that is several orders of magnitude less, shouldn’t hospitals?

You might ask why Disney prioritizes something that seems to be so peripheral to profits.  The explanation comes from Paul O’Neil, the CEO of Alcoa.  He found that emphasizing safety promotes certain keystone habits.  These habits include employee assertiveness, developing a culture where people feel free to speak up, excellent communication skills, and a disciplined attitude of continuous improvement.  Managers in a high reliability organization (the gold standard for safety) are more engaged with their employees.  They ask for their feedback about how to improve, educate and train their teams more often, and conduct thorough debriefs when safety events or near misses happen. They are also not afraid to make hard decisions, far different than the standard “wimpy” managers that don’t weed out problem actors.

The benefit of such keystone habits is that they don’t just increase safety, they are also  the same behaviors that drive accountability and improve the financial bottom line.  The learning environment it promotes will prepare the organization for any potential crisis it might face.  It improves HR costs in part by allowing nurses to decompress from their emotional labor.  It increases efficiency by improving cross functional teamwork which breaks down silos between departments. In the end, it reveals an important paradox about safety.  Focusing on costs over safety leads to dissatisfied staff and lack of teamwork, which ultimately drives up costs.  Changing the focus to safety leads to staff engagement, more discretionary effort and responsiveness and greater cost efficiency.

There is another common theme of safety and service – both thrive in a decentralized organization.  Top level managers and leaders talk about safety and service using abstract buzzwords – “we need transparency, accountability, engagement, empowerment, alignment, to invest in culture,” etc.  Those on the front lines (the ones that actually cause success or failure) understand it in far more specific terms.  It is about how you respond to the “moments of truth”, those times when a patient is in trouble either clinically or emotionally.  Do nurses respond in the best possible way knowing that managers and administrators will show support, respect and trust their actions?  That as long as they tried their best, nothing bad will happen to the nurse even if something goes wrong?  The job of everyone in the organization is to make sure the answer is always “yes”. If the answer is ever “no”, you can forget about delegating responsibility to frontline people. Why should anybody take on any risks or any responsibilities if there is a fearful environment and there is a penalty from a mistake?  Autonomy and decision making are keys to retaining excellent staff.  Without it the dominos start to fall.  Burnout comes from having no control over a bad outcome. Lack of support leads to paralysis – no one feels they can make a decision.

A manager of an award-winning hotel was asked about his secret to success.  He said that he has not given the authority to our frontline people to say “no” to our customers.  He only gave them the authority to say “yes” to their demands and requests. If they, for any reason have to say “no”, they have to ask for permission from their managers.  High reliability organizations that are preoccupied with achieving zero errors also provide this same authority to those on the front lines and give them the resources to act in the best way possible.

It takes courage for any hospital administration to break ranks and delegate this level of authority.  They must take risks by providing the staff with time off of clinical duties to learn and debrief cases that had complications or near misses.  They must participate in team meetings with clinicians so they can understand and correct systems issues that commonly plague the team’s efforts.  They must create a just culture that blocks the influence of politics on medical staff peer review.  All of this drives a profound customer experience and zero harm.

Let’s come back to a key point – wanting the staff to feel supported and making it happen are two vastly different things. An administrator that just “wants it”, uses big picture, abstract concepts to describe great things.  Someone who “makes it happen” knows to help solve the little things.  As Mother Teresa famously said, “Not all of us can do great things. But we can do small things with great love.”  The small things take care of the goose so we get a lot more great golden eggs.