Comments

Quality is free. All at the expense of having to stay an extra hour at work or you can choose not doing the mandated charting expected of frontline health care workers. I began my own efforts because despite my high work ethic and committment to quality, I left feeling like my patients deserved more then they received. Quality requires engagement and someone needs to see what is occuring on this frontline.

Posted by Kellyann Curnayn at May 4, 2009 4:08 PM

This doesn’t surprise me one iota Tom. When we go to see the doctor or the nurse as patients we expect them to know their job. We take as read their technical qualifications. What makes the real difference is more often how patients are ‘treated’ in a non clinical sense. I deliver customer training workshops for front line health care staff for a large part of my time. I constantly tell these folks they are customer care professionals. Kellyann rightly points out that to understand quality at the front line managers need to ‘be there’ at least now and again. Healthcare managers who remain in the warmth and comfort of their office will never ‘get it.’

Posted by Trevor Gay at May 4, 2009 5:06 PM

Great post. Doesn't just apply the medical world. In the technical support world a good engineer can score higher customer satisfaction even when they can't solve the customer's problem than a poor engineer who solves the problem quickly.

Despite the fact we deal with large, corporate customers, I repeat the mantra the your job is to deal with the teachnical AND emotional needs of the customer.

Posted by PaulH at May 5, 2009 2:07 AM

Does this also apply to teenagers at school? Educational policy emphasizes outcomes (No Child Left Behind), but teenagers emphasize the process (drop-out rate). If school was an experience that teenagers enjoyed, then the outcomes would take care of themselves.

Posted by Mike L. at May 5, 2009 3:18 AM

Many organisations try to take the "process route" to ensuring supportive interactions with customers. Processes do help to a certain extent, but keeping staff happy is the real "secret" of customer-centric organisations. Thank you Tom for driving the point home (again) with research data!

Posted by Subir Ghosh at May 5, 2009 4:31 AM

I do have a concern about the conclusion that the patient's health outcome isn't a Top 15 satisfaction issue. The question I would ask is: did the survey ask this?

It mightn't be the same survey but I saw something on Press Ganey’s website stating that their regular surveys, "...consists of 38 standard questions organized into 10 sections: Admission, Room, Meals, Nurses, Tests and Treatments, Visitors and Family, Physician, Discharge, Personal Issues, and Overall Assessment." In other words, nothing obvious about outcomes.

Personally, I'm in no doubt that I'd rather be treated by Dr. House and cured than be treated by the most polite staff in the world and not cured. So if there was a question about outcome, it'd be interesting to see how that correlated to overall satisfaction.

[I don't for a minute doubt that motivated staff being polite to patients in clean, well run hospitals is great. Or that it helps to create an environment in which it's easier for the givers and receivers of treatment to get things right first time. But I am also very surprised that getting the basic service offering right isn't ranked higher.]

Posted by Mark JF at May 5, 2009 4:49 AM

Hi Mark – You raise an interesting and very relevant issue. Like you, if I needed a life saving operation the best surgeon can frankly have the bedside manner of Basil Fawlty on a bad night as far as I’m concerned, I just want the best. Dr Harold Shipman (who murdered at least 200 of his patients) would have scored very well on traditional patient feedback. From all that I've read Dr Shipman was a very popular doctor with patients. We need to assess the whole ‘patient experience’ as well as patient ‘satisfaction.’ This means as well as asking patients (I would say the patients opinion is the most important variable) we need to measure outcome using objective measures including peer review, comparison and 360 degree assessment. Subjectively my gut instinct tells me that if scores are high on all other variables the chances are the outcome will also score high …but there are exceptions – ’Trust Me I’m a Doctor’ is not good enough when along comes Dr Shipman. There are a million and one anecdotes/stories about this whole subject. One story I use is the female patient in Australia who was suing her Gynaecologist for a procedure that went wrong. At the 11th hour before the court case her lawyer informed her there had been a mistake and the error in her treatment was in fact made by her GP (Family Doctor) and not the Gynaecologist. She immediately withdrew her complaint explaining that she liked her GP and was not prepared to sue him. We should never underestimate the soft skills.

Posted by Trevor Gay at May 5, 2009 7:27 AM

Mark JF,

Like my colleague, Trevor, I spent years in health care administration, my years being in CQI/Risk Management. I can directly vouch for what Tom is saying here. There are a ton of different companies out there (all functionally similar to Press Ganey) that build on a "core" set of measures and add customized measures for organizations. I know first-hand that what Tom is repeating in this post is on the money.

I did part of the training with all new orientees to the hospital system, and one of the things I told them in very direct, straightforward language is that it has been proven that you are less likely to be sued for malpractice if you treat the patient with dignity and respect, the way you would want to be treated, or for your wife/husband/mother/father/child, etc. to be treated.

Tom has oft quote Leland Kaiser's question to friends after a hospital stay: "Did you have a good time?" This sounds totally bizarre to people who DON'T understand the nature of the health care business. Think about what we are talking about...

Do we use the term "Heath Outcome Industry?" No, we call it the "Heath CARE Industry."

We MUST, HAVE TO, (and damn well can't afford NOT TO) see the word "CARE" as a verb and not a noun. It is a process. It is NOT something you peel open a sterile pack and dump out on a tray. It is an ongoing, concerted effort by a lot of people that had damn well better emphasize "caring" in everything they do. Caring for the patient, and caring for their fellow workers. I also emphasize caring about the community in which they and the hospital function, because people need hospitals. It is those people ultimately (their tax dollars and insurance premiums, etc.) that keep the doors open. Forget that you are accountable to them to do an excellent job and do it in a fiscally responsible way and you have failed them. Hello, unemployment line.

You want to know the funny thing about all this? I can't "prove it" with some fancy, high-dollar, specific study. But "mother-in-law" evidence supports my contention highly, as does information (coincidence? pattern?) such as mentioned above:

Hospitals staffed by people who emphasize the "high touch" (a.k.a. "CARING") aspect of care at least equally as much as the "high tech" and "outcomes" portions of the equation actually DO tend to have better outcomes. A lot of that has to do with the sense of comes from people talking to one another and working toward the same objectives. One thing I can't stand (and I seriously get livid over it) is when the "health care workers" forget that the patient IS the center of the "health care team." They forget that 99% of the time the most valuable information for diagnostic and prognostic purposes doesn't come out of any machine, it comes of the patient's own mouths (and perhaps the looks on their faces.)

As Paul and Sabir above (thank you, neighbors) brought out above, these ideas are universal. Put people first (genuinely, sincerely, with heart and -- dare I say "passion") and the outcomes will improve as a result.

Why is it so hard for people to grasp this?

Posted by Dan Gunter at May 5, 2009 7:55 AM

P.S. Sorry about the appearance of the word "heath" instead of "health". My "" key is sticking at times. As you can quite we see. My apoogies. I just can't figure out what the he to do about it.

;-)

Posted by Dan Gunter at May 5, 2009 8:03 AM

Dan - as I said in my comment, I fully appreciate the point about treating people with politely and so forth. It should be a no-brainer in any service industry and Jack Welch said - not always a popular figure but this was great - even "manufacturing" companies are in the service industry. I'm just so surprised that being better than when you went in isn't a key determinant of patient satisfaction. Hence my question about the methodology and whether the question was asked. Of course, it might be that the unsatisfied patients all died before they could fill in the questionaire...!

But my point is this: I think you've got to get the basic, fundamental service right or else no ammount of customer care will sustain the enterprise. I appreciate we're in a kind of circular argument here and I agree with Tom's points 2 and 3 but who'd go cheerily into a hospital that was rated the cleanest, most caring in the world if it was bottom quartile on outcomes?

[And I appreciate that outcomes aren't always comparable accross hospitals with different specialities and in different socio-economic areas, but by the same token was that factored into the original survey?]

BTW, sounds like your keyboard needs a Healthy Keyboard Checkup at the local clinic!

Posted by Mark JF at May 5, 2009 9:22 AM

Mark JF,

That keyboard was officially terminated a few moments ago. One too many drops of condensation from the iced tea glass -- frequent problem here in the South.

One of the things to keep in mind is that hospitals do address this issue. However, you must also keep in mind that "outcome" in health care terms is still a somewhat subjective measure, largely dependent upon who is looking at it and how.

Let's say I go into the hospital with gallbladder disease. They remove it. Problem fixed. But in the process, I'm naturally going to have a few bruises from injections, tenderness at the site where the laparoscope (or scalpel) went in, post-anesthesia weakness, possible nausea, etc. etc. etc. So, I'm not feeling 100% when I leave. Can you rate this as a 100% successful outcome because I no longer have gallbladder disease or stones? Or do we compare how many venipuncture bruises I have? Can we factor in a rating of my post-op tenderness compared to some non-existent "standard?" Every patient is unique. Every treatment plan is unique. Every outcome is unique.

To some it would be a 100% successful surgery if the gallbladder was removed and I didn't die of surgical complications. But what if I contract nosocomial (hospital acquired) pneumonia (or swine flu) while I'm there? Maybe they keep me an extra couple of days to treat the hospital acquired infection? Would you rate that a "successful" outcome?

In the hospital setting, these things actually are measured and tracked, but in ways that a patient can't simply answer because the answer ISN'T that simple. There are factors such as "Length of Stay" for patients with the same disease or injury. Post-up complications. Recovery times. Literally hundreds.

Patients don't expect to feel 100% when they get discharged from the hospital. They expect some recovery time. So "outcome" psychologically turns out not to be the big issue in their minds. It unfailingly turns out to be matters of personal touch, respect, courtesy, dignity, and such that they weigh in their own minds to decide for themselves whether or not it was a good experience.

That's why use of an X-Y matrix (satisfaction with the measure vs. perceived importance) is one of the handiest graphical analysis tools in the health care industry.

I will reiterate my firm, staunch belief that the hospitals that go so far as to actually work hard -- very, very hard -- to address the "courtesies" that patients find so important are also the hospitals that on average have MUCH better outcomes as determined by a plethora of technical and statistical measures regarding actual medical treatment/procedure quality.

By and large, it's more likely that the hospital that takes time to "do all the right things" will "do all things right" than the other way around.

It starts with a "patient first attitude." I have a name. It's on my chart. It's on my door. It's on my wrist. Read it. Use it. My birth certificate and driver's license don't read: "The hot appendix in room 207." My stance: Real Health CARE Teams Don't Treat Illnesses and Injuries -- They Treat People." Those people just happen to have illnesses and injuries.

Did I mention "Always put the patient first?"

And the cherry on top of my health care quality sundae is this:

BENCHMARKING SUCKS! It is one of the absolute worst "mediocrity inducing" weapons of self-destruction ever to befall the health care industry. I have nothing against knowing what other people are looking at qualitatively or quantitatively. But trying to be "as good as" is as good as saying "We want to be average." It fails to push you to the higher levels. All but one hospital in the measurement group is trying to be "as good as the "top dog." If and when a hospital takes over that coveted slot, they tend to stop improving.

Measure this: How are WE doing? Better than before? If not, WHY not?

CONTINUOUS - quality - improvement. Emphasis on continuous.

I'm as entertained by "House" as anybody. Love the show. I think I may have worked with several doctors that the show was scripted based on. Funny thing: rarely did they keep their patients on their roles.

And in closing, the most important thought:

PATIENT FIRST.

Posted by Dan Gunter at May 5, 2009 10:17 AM

Software and Healthcare are similar? (that is scary - just wished someone had debugged me before release!)

In software satisfied customers pay their maintenance (support annual fee) successful customers buy more.

I remember a while back I tried to talk internally about the idea of promoting customer success rather than customer satisfaction. Of course all that happened was that the measurement of Customer Satisfaction was renamed Customer Success.....

Posted by PaulH at May 5, 2009 10:30 AM

PaulH,

Funny you mention software as an example and raise the issue of similarity.

I switched antivirus/firewall programs on all my computers about four years ago from one MAJOR producer to another MAJOR producer (I'll be polite and not "name names" here.) Want to know why?

Well, they both cost about the same. That wasn't the issue. They both pretty much stay up to date with the latest virus definitions. So, that wasn't the reason. But an interesting thing happened.

I had a question about site licensing to run it on more than one machine. Not a technical problem, just a question. I called up the manufacturer of the software. I was told all representatives were busy and was asked to leave my name and telephone number on a voice mail system. When did they return my call?

They didn't.

Two days later, I waltzed right into the nearest software retailer and bought the competitor's product. And I've been using it since. When Vista came along, I had total fits with it not getting along with Vista's security settings. Technical problem? "Customer SUCCESS" issue? Yes. But they answered my call to tech support -- a real, live, friendly human being. They spent something like THREE OR FOUR HOURS using remote access to one of my machines to make it work right.

Did I get mad and abandon them for another software company? Nope. And I just renewed the subscription with them on three machines a couple of months ago.

Technical problems... ($%*@) happens now and then. Sometimes BIG problems. Show me you're genuinely working on the problem... MY problem, and I'm most likely a customer for life. Drop the ball on customer service and I don't care how flawlessly your software, or widget, or even doctors perform, I'm a "done tater" as we say here in the South. I figure if you don't care about customer service, sooner or later your product's technical quality will follow suit. Fool me once, shame on you. Fool me twice, shame on me.

Posted by Dan Gunter at May 5, 2009 10:54 AM

Mr. Dan Gunter
That's why use of an X-Y matrix (satisfaction with the measure vs. perceived importance) is one of the handiest graphical analysis tools in the health care industry.

Having a kind,loving,patient person waiting on you will always make the perceived experience better that applies to all and every service industry. But that is not what anyone is really talking about. The real question is why aren't people kind,gentle(loving a little to much)and patient. It requires a person to rise above themselves to see the needs of other first. I propose most enter the health care industry with those virtues in tow but.....It is virtues that if tested to far will fall off the radar.
Outcomes should not even be an area of debate. Basic care improves outcomes and the lack of basic care is what I perceive is contributing to the dismal quality profile of America.
Measure:
Urinary tract infection
blood borne pathogens
central line infections
hospital aquired pneumonias
All of these things require BASIC very non technical approaches to having 100% success rate. On the bottom of the triage list is
1. Getting your patient out of bed (pnuemonia)
2. Giving patients a bath (not just a basin)
3. Oral care on an intubated patient. (every two hours)
4. Wash your hand often and effectively.

I always refer to the patients name and I'm the minority. The doctor will always ask "do you have room 352" and I respond "you mean my dear patient Mr. Smith."
Department of Health estimates it spends (Medicare dollars) 20 Billion a year on Hospital Aquired Infections.

Posted by Kellyann Curnayn at May 5, 2009 11:19 AM

Anyone survey patients with really bad outcomes?
It would be difficult since they are dead.
Airlines are safe - planes might be late, crowded,
impersonal etc, but they get safer every year. Customer service and safety mught be related and they might not be. It can be safely said that customer service and safety in the commercial airline industry have nothing to do with each other.

Posted by dan at May 5, 2009 11:27 AM

I was the person who had to formulate a plan and head up a team to address every single problem or bad outcome and see to it that it didn't happen again if AT ALL avoidable. This involved digging far deeper than the surface problem. Just like caring for the patient, it was my mission to find that actual disease (root cause) that caused the symptom (bad outcome.) And I can tell you unequivocally, without flinching or batting an eye that it was very, very, rarely a problem with someone not knowing what they were doing. Almost every time it was due to someone not really CARING about what was being done (or how.) In cases that SEEMED like an equipment malfunction or failure, it was almost always traceable back to a human error (lack of proper maintenance, etc.)

Software? Computer programs don't make mistakes. They are executable code that functions as a human programmer designed it to. Quality in such a case often goes back to "How thoroughly did the company test it? What possible scenarios did they use and under what conditions?" What would make a company go the extra mile and test to more demanding standards? Perhaps an attitude that says we want our customers to be REALLY happy with the experience of using our software, as opposed to "Well, we can always try to fix it later."

If the F.A.A. allows an airline's planes to continue flying, I think it a reasonable assumption that the planes are considered safe by people who know airline safety far better than I. If one of them crashes (pretty much THE ultimate "indicator" that says "we had a problem") and the F.A.A. says "this airline does not perform proper preventative maintenance" they ground them. Maybe I'm the oddball in that if I'm going to fly somewhere, I don't spend hours or days reviewing the safety ratings of every airline carrier. And none of my friends hear me asking "What's the safest airline you've flown with?" Instead, the conversation usually runs more like "Have you had more problems booking flights with...? How did they handle it if there was a delay? Did they lose your luggage?"

But I wonder if anyone has the "safety" numbers on ,oh, let's say Virgin airlines compared to other carriers? And I wonder if anyone has actually compared those safety numbers to the customer service ratings and rankings.

I would not be at ALL surprised to see a strong correlation. Perhaps not DIRECT causality. I've flown multiple times, been treated by different doctors, owned numerous products, and paid for numerous services in my lifetime. My belief that the company/provider that offers the best customer service will tend to have the best technical quality -- at least in the long run -- has not failed me yet. At least it hasn't killed me.

Maybe that's not scientific, but it has held up okay for me.

I don't care how much you know 'til I know how much you care.

You could flip the whole issue and look at another way, and here's what I'll bet you WON'T find: a hospital with frequent very bad patient outcomes that has HIGH "customer satisfaction" scores.

If someone in the software industry, airlines, automobiles, lawn care, whatever... thinks that customer service and technical outcomes (including safety) aren't related somewhere down the line, I respectfully suggest considering the fact that just because two things are separated by considerable time and space, it doesn't mean they aren't related.

If they are both affected by the attitudes of management and every team member: "We want Excellence" (quality in terms of everything we do) it will show in every area of the business/product/service. On the other hand, half-hearted focus on Excellence results in "Well, we're great at this (safe) but it's okay if we suck over here (handling customers upset over a delay)." You can trace performance in every Excellence and Quality measure (and I dare say EVERY Excellence and Quality measure) all the way back to a driving source and to some key decision makers, if you work at it long enough and hard enough. And if I see a CEO, Board Member, Manager, flight attendant, doctor, nurse, programmer, pilot that's willing to "settle" in one area, I'll bet you he's willing to settle in another. I'd bet Richard Branson never said "It's okay if they crash, just make sure you keep the customers smiling all the way to terra firma."

Does YOUR company's mission and vision statement say "We strive to provide the best (insert product/service description) ... but we don't really care if we are the world's worst at customer service" ???

If it does, I want a copy. I love a good laugh. And I'll also keep your competitor's phone number and web address handy. I'll be calling them soon.

Posted by Dan Gunter at May 5, 2009 12:24 PM

The reason customer service is discussed so much it that is can be discussed so much. Everyone understands good customer service and knows when it is bad or good. Everyone is actually an expert on these kinds of things. Few people are experts on analyzing something like an airplane crash or a hospital operation going bad. Relatively few people would know how to analyze data associated with these things. Almost no one would want to listen to someone with power point slides explaining the nitty gritty details of this type of data analysis. Conversation about good customer service does interest lots of people - it bit like conversations about the weather or sports or politics.
By the way, quality is not free until some time after it has been invested in.

Posted by dan at May 5, 2009 12:49 PM

"I don't care how much you know 'til I know how much you care." Well stated Dan Gunter
You were in charge of the team who had the responsibility of doing the root cause analysis.(interesting)
Every severe error and root cause analysis that I was privy to resulted in creating a new charting process or checklist for Nurses. So the reality is I now have less hands on time because of a tedious time consuming process. How do we enforce caring behaviors? I have a few ideas.

Yes of course yes, not caring produces bad outcomes. That is the premise of everything I've been saying. Yet no one will hold there employees accountable for NOT caring behaviors.

If I didn't care I wouldn't be blogging. If you've seen my website I'm not trying to make any money. . The kids are waiting at the bus stop and my husband wants to know what I do all day. I'm out of here.

Posted by Kellyann Curnayn at May 5, 2009 12:49 PM

P.S., especially to Mark JF,

You are right in that this IS indeed a "circular argument" of sorts. I prefer to think of it as an exploration, as opposed to argument. I totally understand your point of view. And I respect it. But my point of view is that "circular" is the key word in this discussion AND many of our business and "life problems." Much more than many readers of Tom's blogs might realize.

Our finite human capabilities, vision, understanding, etc. limit our view at times. We humans tend to want to see clear, straight, linear connections between things or we tend to dismiss them as unrelated. But the issues we're tossing on the table here are related -- and I am convinced of this beyond anyone being able to convince me otherwise. It may be in a circular fashion, with lots of factors, in between, but they are related. If the circles were smaller, maybe we could see them better.

We just have to back up sometimes and take in the view of the whole mountain. Each stone and pebble that makes up that mountain is related to every other stone and pebble. If one is lying on one side of the mountain and the other on the opposite side, I can't see them both, unless I fly over the mountain to a vantage point that lets me see them both.

I love seeking that vantage point. Only then do I realize the significance and interrelatedness of it all. And it can be breathtaking.

I agree that if you ignore the "basic" service/outcome issue, no amount of "nice gestures" will fix that.

Take a "Total Excellence" and Quality approach, and NEITHER will be ignored. And you will more than likely score better in each individual area. It's all about an overall mindset.

Thanks to everyone for the thought provoking comments. Hope I haven't bored anyone to death.

Posted by Dan Gunter at May 5, 2009 12:51 PM

Dan - I'm definitely not bored - just fascinated by the discussion – congratulations for expressing your passionately held views so well. When I worked as a complaints manager in healthcare for two years the vast majority of complaints were about communication - the soft stuff - rather than technical competence of doctors and nurses. I recall Tom saying many years that doctors who care for you with kindness don’t get sued. Patients will judge ther experience with healthcare professionals on many measures but ‘liking the clinician’ and their ‘bedside manner’ will always be high on the patient’s criteria to judge the relationship.

Posted by Trevor Gay at May 5, 2009 1:25 PM

Mike L,

BRAVO! If you haven't already read it, get a copy of "Orbiting the Giant Hairball. A Corporate Fool's Guide to Surviving With Grace." It's by Gordon MacKenzie. I think you'll appreciate it.

Propoganda vs. Education: propoganda teaches you WHAT to think. Education teaches you HOW to think. Yes, our next generation should know how to add, subtract, multiply, divide, and write a coherent sentence; however, our children are not motivated to learn, and they CERTAINLY are not being INSPIRED to learn.

We beat the facts into them so that we can beat them out of them at test time.

I wouldn't want to spend six to eight hours of my day in a place like that, even if it was called a "job" and I was getting paid a grotesquely large salary.

Education should include facts AND intellectual stimulation.

Posted by Dan Gunter at May 5, 2009 1:32 PM

Trevor,

I'm going to try and find the info (I admit to losing track of it somewhere.) But one of the major institutions of higher learning was involved in a study of "high tech vs. high touch" and whether it had an effect on litigation against the hospitals and doctors.

Their finding: your BEST defense against lawsuits is to be honest with the patient. Own up to the problem and fix it. I'm paraphrasing, but the premise is on track.

The reaction from the hospitals and doctors they tried to convince to actually IMPLEMENT it: predominantly... "WHAT? No way! They'll sue us if we tell them we did something wrong."

You buy them book and buy them books...

Posted by Dan Gunter at May 5, 2009 1:38 PM

"The reason customer service is discussed so much it that is can be discussed so much. Everyone understands good customer service and knows when it is bad or good. Everyone is actually an expert on these kinds of things. Few people are experts on analyzing something like an airplane crash or a hospital operation going bad. Relatively few people would know how to analyze data associated with these things. Almost no one would want to listen to someone with power point slides explaining the nitty gritty details of this type of data analysis. Conversation about good customer service does interest lots of people - it bit like conversations about the weather or sports or politics.
By the way, quality is not free until some time after it has been invested in."

dan - I appreciate your entire comment--much appreciated. There's a lot there, some irreverant and some reverential. The question for me is the significance of either. For example, does discussion lessen the act of actually doing? Or, does deciphering the reasons planes crash via a powerpoint presentation as opposed to a discussion of customer service nullify the other? Perhaps it's about the audience being reached and not about which is more relevant or even why it is so.

Posted by Judith Ellis at May 5, 2009 1:49 PM

It can't hurt to discuss customer service. Just be aware of the fact that it is fun to talk about and my not necessarily be important beyond the fact that it is fun. (of couse, fun is important) But if we are talking about airplanes for example, what's good customer service?
I vote for arriving alive unhurt and not afraid to take another trip. Getting that done requires an immense amount of engineering talent. Yet we get all excited when a crew member sings the safety instructions in the form of a rap song. That's very cool, but its not why people fly. People fly because its very fast and very safe. No one would fly if it was only as safe as taking a automobile. So the big giant leap in aviation was making the whole trip very save which requires an immense amount of specialized knowledge. But this is never praised and marveled at. We complain about the seats or grumpy attendants or we praise the 'front line personnel' when none of this stuff would work what so ever without people make flying extremely safe. In order to whip hospitals into shape, we need to look at it in the same was that the FAA looks at aviation. If it turns out that cheerful attentive staff reduces hospital deaths in a big way (not anecdotal evidence such as cited in the post, but real scientific studies backed by data) I'm all for it. But lets just find out. Of just have fun. Or both.

Posted by dan at May 5, 2009 2:48 PM

dan,

There are actually lots of people tracking outcomes for hospitals. Everyone from state health departments, to insurance companies, to Health & Human Services. In that respect, there are TONS of people trying to "whip" hospitals into shape. They have been trying to for decades. There have been great improvements in the industry as a whole and within particular hospitals. But they seem to keep running up against performance improvement barriers that are difficult to pinpoint specific technical causes for. I dealt with this repeatedly in my work.

Like yourself, I'd love to see more "concrete" data that can show the "direct link" or causality between the outcomes and the patient "service" experience. Not everyone agrees with my firm belief that the link is there. It may not be a direct link, but rather a common causality for the two measures.

It's really a "culture" issue (again, my opinion, shared by some, disagreed with by a few, even.) Tom seeded this whole dialog by pointing out studies that showed that "outcomes" were not a major factor patients considered in rating their satisfaction with hospitals. A few people seemed very surprised. I wasn't. I found that out a long time ago.

Indeed, people come to the hospital to "get well." Fixing something that's broken or removing something that's diseased or sending someone home that wasn't expected to survive is indeed why a hospital exists. On the other hand, many people DO have a choice in which hospital they use. Not every patient is simply a captive audience.

Do both, definitely: fix the problem AND make the experience enjoyable. Statistics HAVE proven that having a "pleasant" hospital stay reduces patient stress during and after hospitalization, which is proven to reduce healing and recovery times and increase patient compliance with treatment regimens. Those are in turn proven to improve outcomes (beyond the patient merely living through the hospital stay.)

BETTER "SERVICE" => REDUCED STRESS => BETTER/FASTER RECOVERY => BETTER OUTCOMES.

Maybe the circle isn't quite as big or complex as I once thought. My mistake.

Customer service is not just something that's "fun to talk about." It can and does impact a patient's physical well being.

And as for the guy "rapping" the safety instructions on the plane... what if we turned on the news next week and someone who'd survived a crash was being interviewed and said "As many times as I'd flown, I'd never really paid attention to the safety instructions, but that guy's singing saved my life"... would we even be having this discussion?

Far fetched? Maybe. Let's just hope we don't have to answer that question.

Agreed. Let's shoot for great outcomes AND have fun in the process. Certainly nothing wrong with doing both.

Posted by Dan Gunter at May 5, 2009 3:21 PM

My cousin's life was recently saved by an advanced lung machine used to clean out his longs of toxic material.
He got the toxic material while he was in the hospital for a gallbladder operation. When the operation was over, the staff was removing a tube that had been sent into his stomach through his mouth. This is a routine procedure in surgery. When they removed the tube, material leaked out of the tube and went into his lungs - hence the toxic material in his lungs. He was put into an induced comma for six weeks while the lung machine cleaned out his lungs. He would not have noticed cheerful happy staff. If the operation had been done corectly, we wouldn't even have been over night in the hospital. Grumpy staff would have mattered very little.

If a story ever comes up of a 'rapping flight attendant' saving someones life, I'd be surprised.
But we would still be having this discussion, because planes don't crash, so the people behind the scenes are in a sense,saving lives every day in a very undramatic, boring way.

Posted by dan at May 5, 2009 3:44 PM

dan,

I hate to hear about anyone going through something like that. I hope he is recovering well. I also hope that the hospital staff treated your cousin and the rest of your family with genuine caring, politeness, and courtesy throughout the experience. As a very staunch patient advocate, it always saddens me to no end to hear of a bad patient outcome. But nothing infuriates me more than to hear of a bad outcome AND indifference or rudeness by hospital staff. Despite how it might seem, I don't rank "courtesies" as being above "outcomes." BOTH should be high on the agenda for any hospital. There is NO REASON for a hospital to see this as an either/or matter.

I wish your cousin and you well.

Posted by Dan Gunter at May 5, 2009 4:08 PM

dan - With regards to your second comment, there is still this division of what is most essential. There is no doubt that the engineering talent is most essential, as without it we would not be talking about airlines safety or healthcare regulations, as both require specialized skill. But I think where what you have written becomes problematic is the somewhat despairing view of customer service. Both are needed, even though the technical aspect is perhaps not praised as often. But every time a life is saved or business done more efficiently, I am reminded of it actually.

I was just watching a video of Arianna Huffington interviewing Richard Branson yesterday on one his flights from San Francisco to southern California. The whole experience from the ticket purchase to the flight itself looked so fun, so inviting. While it is obvious that it is the technology that enables the plane to be suspended WHILE moving in mid air, the reason why people probably fly Virgin as opposed to other airlines is for the customer service and fun. Technology and customer service are both necessary for business because of the people aspect. In fact, both are done in order to affect what's important to us.

Regarding the mundane that saves lives and creates spark in our society even when we do not openly appreciate it, I remain grateful. Personally, I love engineers and scientists. As out there as I usually am, I typically gravitate to these. :-)

All the best to your cousin, dan.

Posted by Judith Ellis at May 5, 2009 5:36 PM

It seems like my cousin will be OK. But this is not a rare event. 100,000 people die each year due to mistakes in hospitals. Think of how much money was 'wasted' on my cousin because of a mistake. How do we get as serious about mistakes in hospitals as we would about airplanes crashing?
I also think you are missing my point. I think we actually need to know the factors involved in these mistakes. If customer service is a big factor, then it needs to be part of the solution. But then again, it would need to be enforced. Why do airlines tell us where all the exit doors are and so forth before each flight? Because its the law and someone will catch them if they don't do it. What the FAA does in partnership with the airlines works. This is a government/business partnership that works very well. My point is that in at least one area, the government can do something very right. We should be able to do this in fixing hospitals.

Posted by dan at May 5, 2009 6:00 PM

OK, dan. Good point about the government/business partnership and how it could be such in fixing hospitals. But the customer service factor here remains not so clear. If I am an airline stewardess, why must I also become the engineer or be more valued or less than because of this? This is what I took from your distinction between the engineer that uses PowerPoint presentations as opposed to someone who does so in relation to customer service. One seemed to be devalued or less significant. Problems can be addressed at various angles and positions based on skill sets and proclivities. Did I misread your comment completely?

Posted by Judith Ellis at May 5, 2009 6:40 PM

dan,

Although when an unfortunate event such as this with your cousin occurs it may not seem like it, there are many guidelines hospitals must follow, all intended to decrease the likelihood of bad outcomes. From infection control measures (to prevent the spread of nosocomial (hospital acquired) infections such as staph, pneumonia, etc.), surgical oversights (such as "sponge" and "instrument counts" before completing a surgical procedure, proper use of sharps containers to reduce accidental needle sticks, monitoring of post-up complications to watch for increases or trends, medication error reporting... the list goes on forever. Do they completely eliminate mishaps? Unfortunately, no, they don't.

Similarly, all the safety measures, testing, maintenance procedures, pre-flight checklists, passenger safety demonstrations, etc. do not keep planes from crashing, either.

If hospital personnel do not adhere to the mandated guidelines (as set forth by everyone from Health & Human Services, O.S.H.A., state health departments, J.C.A.H.O., Medicare and Medicaid agencies, etc.), they can expect to pay penalties ranging from losing reimbursement all the way to having their doors closed.

In my work, one of the biggest and scariest words among hospital personnel and administrative folks was "COBRA." COBRA is a set of guidelines set forth to essentially make sure that no patient was denied treatment or given substandard treatment based on inability to pay. It covers a lot more than that. But a COBRA violation is the kiss of death for a hospital. Even an "alleged" violation can cause so much administrative grief that it can still do severe damage and cost a hospital more than most people would ever imagine.

At the risk of sounding like I'm disagreeing with you, and I suppose in a friendly and well intended way, I am, there are, indeed, many standards, mechanisms, and laws in place to help safeguard patients from bad events.

No matter how many laws or standards or regulations are in place, the bottom line is that health care is provided by human beings, not machines. Just as the pilot in the cockpit of that plane can make one mistake and end the lives of many, or a flock of geese can result in the unthinkable failure of both of a plane's engines, so, too, can things go wrong in health care.

We depend on human beings to do things right and do the right things. I suppose my contention is that a team of people who cares enough to stop and think about details such as how they interact with patients and make the patient "feel" during their stay is more likely to be a team that will pay attention to the technical details that can mean life or death for a patient.

From experience, I can tell you that more often than not, it is the rude, insensitive, arrogant medical person (be that a doctor, nurse, tech, clerk, housekeeper, whatever) that will be most likely to make a serious mistake. That is not true 100% of the time. But it has been proven accurate enough -- scientific data or not -- in the laboratory of the human mind to cause people to get their guard up and expect mistakes by the folks with poor bedside manner, and meanwhile often forgive the mistakes of those who are respectful and honest enough to go so far as to say "I made a mistake, I am sorry, and we are doing everything possible to take care of it."

You can technically train someone to the point they can conduct a medical task to perfection. What you CAN'T "train" into someone is genuine caring and conscientious behavior. You can grow those over time through good examples, coaching, and reinforcement. But they are still human behaviors.

No law, regulation, or standard can "make" a plane flight or hospital stay safe. People understanding the real purpose of such laws, regulations, and standards and complying with (or better yet, exceeding them because it is the right thing to do and not just for CYA purposes) is who I want flying my plane and caring for me in the hospital.

Even then, each time we board a plane, walk into a hospital, or even drive a car, we are taking a risk.

I just feel better being surrounded by people who seem to give a damn about doing the right thing. I don't know how well my pilot or doctor is trained, beyond the fact he has been "cleared to go" by meeting some MINIMAL standards. I don't want minimal. Taking time to greet and say hello, to answer my questions, to show respect... those indicate that maybe -- just maybe -- I'm placing my trust in hands that are operated by a more than "minimal" attitude.

Posted by Dan Gunter at May 5, 2009 6:41 PM

Dan - would you agree with me that to 'recruit for attitude train for skills' rather than the reverse can go some way to reducing errors in healthcare?

Posted by Trevor Gay at May 5, 2009 6:47 PM

Trevor,

I would respectfully disagree with you and qualify it: I wouldn't say it could go "some way," I would say it would go a "LONG WAY."

LOL. For real, you're on the money, there, Trevor.

Unfortunately (and I risk pissing off a doctor or two when I say this, but they probably realize this better than me), some (not ALL, but SOME) doctors became doctors because they wanted the sense of power and autonomy... "I want to be the BOSS." They had problems with authority.

You think that's the person who's going to be "legislated" into providing better care? Hmmm... I don't think so.

There are nurses and other medical personnel with similar issues. So I'm not just picking on doctors, here.

But take a person who really wants to take good care of people because they love people and train him in medicine, nursing, flying planes, whatever (and don't drain the common sense out of them along the way) and you've got one helluva doctor, nurse, or pilot.

Posted by Dan Gunter at May 5, 2009 7:04 PM

Cheers Dan - my best friend who is a doctor gave me this one day - I think you will appreciate it :-)

"The man arrived at the Pearly Gates and found a queue a mile long and took his place at the back. The day was hot and tempers were getting frayed as the delay lengthened. After a while an old man dressed in a long white coat, sporting a long white beard and carrying a black bag marched to the front of the queue through the Pearly Gates and into heaven. The Angel whose job was to guide the queue calmed everyone’s rising anger by explaining; "Don’t worry - that's just God, sometimes he thinks he is a doctor!”

Posted by Trevor Gay at May 5, 2009 7:15 PM

OK, Dan. patrick has been on me religiously about my long comments. As I look at your mulitiple ones, back to back, they are a bit annoying. I must also admit to not even reading them. (I get it patrick--finally! :-)) But as anyone who has been reading TP's posts know, I've been there--though maybe not what I see here. (Have I?) Anyway, I concur with patrick after having seen such that it can be quite annoying and laborious to even look at indeed--tiring. patrick must be smiling the biggest smile right now! :-)

Posted by Judith Ellis at May 8, 2009 9:38 AM

I will try to respond to the above comment when I have more time. Might take a couple of hours to type. Need to do an outline and a couple of drafts. And call up my editor.

Posted by Dan Gunter at May 10, 2009 7:45 PM

As I waded through this sea of comments - and I admittedly barely read any in their entirety - I am curious about the survey itself. Being one who has faced surgery way too many times (long, sad story...snore), I find it very hard to believe that a positive health outome did not make the top 15. Maybe the outcome question was not asked. I agree patients absolutely care about the process (happy, efficient staff, etc.), but they endure the process looking and praying for a favorable outcome. Otherwise, it would be like rating car makers that build cars that don't run.

Posted by Dave Conrad at June 8, 2009 1:32 PM