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The term “patient experience” is all the rage.

Many associate the term with amenities and customer service. While those things are certainly part of it, the patient experience encompasses more than friendliness and frills. The patient experience is the unique combination of everything and everyone a patient interacts with and that person’s resulting feelings, emotions, and perceptions. Improvement initiatives targeting the patient experience might include: improving parking, ensuring more timely x-rays, practicing Studer’s “key words at key times,” employing new communication tactics to gain patient trust, smiling, and much more. These improvements never happen in a vacuum. Everything in healthcare is interrelated, so an improvement to one aspect of care is likely to affect another aspect of care. Quality improvements are more like bowling and less like sharp shooting. An improvement in teamwork between doctors, nurses, and staff might impact patient perceptions, employee satisfaction, clinical outcomes, and length of stay. There’s a reason why there’s been recent focus on the patient experience. We don’t refer to the patient transaction. Effective, patient-centered healthcare that reaps loyal patients requires us to move beyond transactions to experiences. Starbucks succeeded, in part, because they took a simple transaction (buying and drinking coffee) and transformed it into an experience – sipping gourmet coffee while visiting with friends and listening to Rat Pack tunes. Buying a cup of coffee is no longer about the product, it’s about the experience and the feelings that experience gives a person (i.e. comfort, sense of community, relaxation, etc.). Pine and Gilmore, authors of The Experience Economy: Work is Theater and Every Business a Stage (1999) argue even a simple, every-day transaction or interaction can be turned into a memorable experience and a valuable win. For example, most of our employees probably greet patients when they approach the desk. Consistently doing something is a great beginning, but we become excellent when our interactions are genuine and connect with patients. How are patients greeted when they approach the desk? Are our employees smiling? Are they making eye contact? Are they authentic? Seemingly small parts of how we do something can mean the difference between providing transactions and providing experiences. To transform mundane into memorable, we must focus on more than the what; we must focus on the how. As Maya Angelou tells us, “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”

Contributor: Teira Gunlock, PRC Client Education Consultant

It’s nice to be recognized and rewarded – especially when we think others don’t notice the effort we put into our work. But recognition events can be costly. Here are a few ways to recognize and reward your employees – without breaking the bank. 

1. Celebrate employees’ anniversaries. Send a Happy Anniversary card and a hand written note thanking them for their service. Make sure to be detailed on the thanks – mention specific events, actions, etc.
2. On-The-Spot rewards. Hand out little items when you catch employees doing things right. Examples are candy, tickets to be entered into a monthly drawing or a gift card to be redeemed at the cafeteria
3. Thanks picnic. Invite employees and their families for a picnic that includes fun for all (bounce houses for the kids, entertainment, etc.).
4. Holiday party. Be sure to include carolers, gifts, holiday treats, etc.
5. On Thanksgiving, Christmas, Easter, and Independence Day all employees receive a complimentary meal in the cafeteria.
6. Celebrate Nurse’s Day. Decorate the cafeteria in a 50’s diner theme, complete with an Elvis impersonator.
7. The stars come out at night. Don’t forget the night shift! Host events to thank them for all they do.
8. Celebrate every holiday with fun.  For Halloween, host a pumpkin carving contest.  Celebrate caring on Valentine’s Day with an essay contest about caring staff. Memorial Day is the perfect time to honor employees and patients who have served in the military – ask employees to bring in pictures of family members who have/are serving. Don’t forget the International Day of Laughter and Talk Like a Pirate Day!
9. Impromptu party. For those units who are increasing their patient/employee/medical staff survey scores, throw an impromptu party, complete with things that go “up” – popcorn, helium balloons and graphs of their scores.
10. Random acts of appreciation. Be creative and provide a department with homemade cookies and heartfelt thanks, decorate a unit with streamers and banners or stop by for an impromptu skit thanking a department for all they do. 

I recently read Gretchen Rubin’s The Happiness Project (2009), which recounts wisdom and lessons learned while tackling resolutions in various arenas of her life (energy, mindfulness, marriage, etc.). She writes, “To be happy, I need to think about feeling good, feeling bad, and feeling right, in an atmosphere of growth” (pg 67). I like to think of creating a service excellence culture – one that provides memorable experiences to patients, employees, and physicians – in similar four-part terms. To create a culture of service excellence, we need to fix what doesn’t work, replicate what does work, connect to “why,” and continually improve.

1. Many quickly associate the term “service excellence” with “service recovery.” Every organization suffers from a few service breakdowns – where we fail to meet patients’ expectations. Breakdowns in service produce a pall over the entire experience. We have to create strategies that prevent these errors from occurring and strategies that cope with the errors when they inevitably do. After all, healthcare is a business where human interactions are vital, so the potential for problems is always there. Though effective error prevention and service recovery are paramount to being a high-functioning organization in the eyes of patients, we must also remember that only focusing on breakdowns does not necessarily improve the care the majority of our patients receive. Service recovery is a part of service excellence, not its entirety.
2. Exploring our bright spots and replicating what works is valuable because it reveals creative tactics for creating excellent patient experiences, motivates employees to improve, and utilizes our unique strengths to create customized solutions. Harnessing our creative power is necessary to innovate ways to “wow” patients and deliver memorable experiences. If we want employees to go above and beyond, we need them to stay positive – easily done when we’re examining achievements. Furthermore, by studying what we already do well within our organizations or departments, we create solutions that capitalize on OUR strengths and address OUR needs.
3. When we are connected to purpose, work is more rewarding. What kind of organization are we? What do we believe in? Why do we do what we do? These are important, sometimes difficult, questions to answer. In order for us to connect to our purpose, we must first define it. We have to build a collective identity that states who we are and who we strive to be. This is more than writing a mission statement. Every day is an opportunity to connect to why we do what we do. We aim to provide compassionate and personalized care to thousands of patients. Supporting physicians so they can treat our patients efficiently is why we come to work each day. Every patient deserves to feel she had excellent care. We may articulate our individual or collective identity in a variety of ways, but the important thing is to see it not as words, but as a way of being – a practice. A culture that can articulate and consistently connect to its purpose – its why – promotes engaged employees and physicians that give our patients great stories to tell.
4. Continual improvement is the only way to keep pace with continually swelling patient expectations. Patient perceptions have been on an upward trend for several years. In most PRC comparison or normative groups, it takes more patients to respond “excellent” this year than it did last year to be at the 90^th (or another) percentile, it took more last year to respond “excellent” than the year before, and so on. With increasing levels of satisfaction come higher expectations that we have to exceed in order to deliver excellent care. By recognizing and rewarding all of the improvement that occurs, big or small, we can ensure a culture of improvement that does not rest. Service excellence is a moving target. We have to move with it.

Contributor: Teira Gunlock, Client Education Consultant

Think about your children’s first trip on an airplane. As a parent, you probably did not warn, “We will have to wait in line for a very long time. The food is bad. Your ears might hurt.” Instead, you likely said, “We’re going somewhere new and exciting!” Or, “We’re going on an adventure!” Framing affects perceptions. The first impression most patients have about our healthcare organizations comes from us.

“Managing up” occurs when we highlight positive aspects of our service or organization. Many organizations are faced with challenges, from old facilities to high turnover rates, so they hesitate to use this approach for improving perceptions. These same organizations forget they still have many aspects of excellence – experienced nursing staff, caring physicians, or dedicated volunteers. Talking about these areas of special value puts patients’ minds at ease.

When this concept is presented, some agree that they should stop complaining. Managing up is more than not managing down. Consider these examples:

• Managing Down: “It’s going to be another 20 minutes. Dr. Jones is always late.”
• Better: “I’m sorry it’s going to be another 20 minutes. Is there anything I can do for you while you wait?”
• Managing Up: “I’m sorry it’s going to be another 20 minutes. Dr. Jones is a very thorough physician who will provide you the same great care as soon as she is available.  Is there anything I can do for you while you wait?”

Whether patients are in our care for a minor outpatient procedure or a long inpatient stay, they are in a foreign environment. Not every healthcare encounter involves patients shaking with fear, but it likely involves patients in unfamiliar territory. We can help patients acclimate to foreign environments by providing information in a positive way.

Every employee should know something about their organization or area of service that puts patients at ease. Many employees, however, are not practiced to speak up in this manner. A few activities can help prepare employees to manage up:

• Activity #1: Think of positive ways to describe your co-workers that would help patients relax and manage up the care they receive. Write down descriptions. Share with the group.
• Activity #2: Think of positive ways to describe the best aspect of your job that would help patients relax and manage up the care they receive. Write down descriptions. Share with the group.

These activities prepare employees for speaking positively about their organization, but also build teamwork and a sense of pride in their service and organization. By managing up, we can all go somewhere new – a place where employees and physicians choose to work and patients choose to be treated.

Contributor: Teira Gunlock, Client Education Consultant

After I present the benefits of engaging staff in discussions about creative ways to wow patients and provide excellent experiences, I’m often greeted with “…that’s great…but just tell me what to do.” The problem is there is no one-size-fits-all solution to becoming an organization that consistently provides patients great stories to tell. As the authors of The Power of Positive Deviance: How Unlikely Innovators Solve the World’s Toughest Problems (2010) write, “Discoveries from one community cannot be repackaged and provided to another as a silver bullet” (Pascale, Sternin, Sternin, p. 112).

            Executing the best strategy to improve our patients’ experiences requires us to start from within. This does not mean we can discount successful strategies others have used. No matter the source, there are plenty of process lessons we can learn from others. The best lessons, however, are often found within the walls of our organizations. The “positive deviance” approach to problem solving asks, “What are we doing right?” and “How can we replicate success?” It is a communal approach to improvement that employs open discussion, critical thinking, and creativity.

Uncovering our bright spots and analyzing our specific situation is a rigorous process, but with great payoff. When we choose to learn from our positive deviants – those people and units showing great success – we equip our employees with messages of motivation. We have created excellent patient experiences. We can create more excellent patient experiences. We are quick to turn to consulting companies, national conferences, and world-renowned hospitals for guidance, bypassing the teachable moments in our institutions. Often, we already hold the keys to excellence. We simply have to find them. When it comes to problem solving, let us begin by looking within.

Proust advises us, “We do not receive wisdom, we must discover it for ourselves, after a journey through the wilderness which no one can make for us, which no one else can spare us.” In the spirit of self-discovery, some questions are listed below to guide discussions and uncover our bright spots worth replicating.

What is the problem we are trying to overcome?  

How many of our patients rate their quality of care as “excellent?” How many say “very good?” How many say “good?” When we peel the onion to our patient perception data, we find the biggest problem we have in our organizations is that too many patients like us and not enough love us. The problem we are trying to overcome is not dissatisfaction, but mere satisfaction. We don’t want patients to be simply “satisfied” or “ok” with their care, we want patients to believe they had excellent care. We want patients to leave our institutions with stories to tell of our caring staff, impeccable teamwork, and consistent communication.

Who has overcome this problem? How?

 Every unit has obstacles: tight budgets, turnover, low volume, high volume, old facilities, cramped quarters, etc. Yet in every hospital, some units overcome these obstacles to provide consistently compassionate care that connects with patients. Our goal is to uncover these high performers – these positive deviants – and to study what it is they do differently from those struggling to be a high performer. What do they do for patients that they don’t have to do? What do they do that exceeds patients’ expectations? Answers to these and similar questions can light our unique path to excellence.

When patients pay us compliments, what aspects of care do they recognize?

            To tackle the problem of increasing the patients who are impressed with our care and service, we have to investigate how impressive experiences look and feel. What “wows” patients may differ from what we might guess – patients and caregivers approach care from a distinctly different perspective. Reading patient letters and listening to PRC Voices^® is a great place to start when trying to figure out what is behind a positive experience worth talking about (i.e. timeliness, ease of scheduling, bubbly technician, etc.). Most units, departments, and hospitals do a decent job of sharing positive comments from patients. While a pat on the back is certainly warranted in these instances, we are missing an opportunity if that is the only action that’s taken. We have to use these comments as an opportunity to ask more questions: What was distinct about this patient’s care that triggered such a positive response? How can we deliver more experiences like this?

What are our best shifts/days/weeks like?

            We’ve all had bad days, good days, and great days. The positive deviance approach seeks to find what’s behind the great days. How do these great days begin? How do they end? Who is working? What qualities do they possess? How do we instill processes that make these great days the rule and not the exception? We all have unique strengths, and by exploring them we can create innovative ways to improve the patient experience.  

All the adversity I’ve had in my life, all my troubles and obstacles have strengthened me. . . You may not realize it when it happens, but a kick in the teeth may be the best thing in the world for you – Walt Disney

When I look back on my life and on the amazing things I have seen and accomplished, one thing becomes clear to me. I am a lucky man.  When I started my journey from Cuba to America at age 17, there is no way I could have imagined a life better than the one I’ve lived thus far.  Many of you have heard my story, but for those who have not, suffice it to say that Nebraska is a long way from the streets of Havana.

Coming here in 1962 with my mother and siblings was an uncertain and harrowing adventure. We came ashore in Miami, Florida on July 4 (Independence Day in more ways than one!).  We were eventually relocated to Burwell, Nebraska where I spent my teen years and graduated high school. Culture shock cannot begin to describe what we experienced that first winter in Nebraska, and I’m not just referring to the obvious differences in climate. To this day, I continue to hone my “Nebraska accent” and I have never forgotten the sacrifices it took for my mother (who turned 90 this year) to bring her children to this new home called America.

A man should never neglect his family for business—Walt Disney

As I prepare this letter, I am in the midst of enjoying a rare few days away with my family.  While many may find the central Florida attraction (yes, the one with the ears) to be tiresome, I can honestly say I’ve never grown too old to appreciate its allure.  This will hopefully explain why I have “Mickey on my mind” at the moment. Once here, it is hard to escape the influence of the little mouse. In gas stations and restaurants, on t-shirts and apparel items, on road signs and even water towers—Disney’s original California dream is so blatantly evident it becomes commonplace. Cheesy?  Perhaps so, but my wife, Joyce, and I try to visit as often as we can.

While working to grow PRC into a successful business, there were years when time away was few and far between. This has been a hard lesson for me to learn but, as I get older, I realize the importance of making the time to put work aside and spend quality time with my family. Seeing Disney again through the eyes of our grandchildren is definitely something I would not want to miss.  Where I once may have been hesitant to spend $20 on a mouse-shaped balloon, I don’t even flinch now when I get to buy four of them and see the delight in their eyes.

Disneyland is a work of love. We didn’t go into Disneyland just with the idea of making money—Walt Disney

It is hard to ignore the obvious effort that has gone into making this destination “the happiest place on earth.”  A man with a mathmatical mind like mine tries to fathom the details it must have taken to create this billion-dollar Disney empire (did you know that 8 million cubic yards of earth were moved to build the Magic Kingdom?!). It was clearly much more than a desire to make money that drove Disney; if financial gain was the ultimate goal, there were a lot of business endeavors that would have been easier and more rapidly lucrative than moving swampland.

When I think about the 30 plus years that PRC has been in existence, I can honestly say that profits were never of highest importance to my partners and me. It is true that Joyce and I, along with our partners Ken Livingston and Tom Schleff, have been fortunate to build a successful business; however, our primary focus was always working to find ways to deliver quality research, to innovate, and to provide excellent customer service for our clients. The pleasure we derived from collaborating together with our many talented associates was better than any monetary dividend.

Of all the things I’ve done, the most vital is coordinating those who work with me and aiming their efforts at a certain goal—Walt Disney

This past year, our talented associates worked together to create many enhancements to PRC EasyView.com® (a robust HCAHPS Scorecard, HCAHPS Compliance Trending, and a Value-Based Purchasing Calculator) to mention a few. They’ve also developed a new online service for our Community Health Needs Assessment clients called HealthForecast.net™ where communities can publicly share information gathered from needs assessment research and prioritize plans to improve the health of areas in which they live. Our interviewing teams have completed more surveys than ever before and our survey options have expanded to meet the needs of the evolving marketplace and our customers.

2011 was a landmark year for PRC in many ways. Like many other businesses we were concerned about the economy and the ever-changing healthcare environment.  Our associates are used to working a little harder, tightening our belts, and staying true to our mission and values. Because of this, we are well positioned for the future. We have quality people and proven procedures in place to make sure our clients not only receive accurate research results, but also have the tools and support to use them to make positive improvements. I am extremely proud of our associates and the manner in which we continue to excel even during these challenging times.

 “All our dreams can come true – if we have the courage to pursue them” –Walt Disney

I am certainly no Walt Disney, but I can relate to his desire to build and create things that make a difference. In Disney’s case, it was entertaining and inspiring guests. For me, it has always been research and the ways it can support positive change in healthcare organizations.  As we progress through 2012, I wish each of you the satisfaction I feel every day when I come to work, and the pleasure of knowing you are doing an important job that makes a difference in the lives of others.

For now, I have Kingdoms to conquer and Worlds to explore (the Magic Kingdom and EPCOT’s World Showcase) and those grandchildren won’t wait much longer. I wish each of you a prosperous and Happy New Year!

Dr. Joe M. Inguanzo, Ph.D.
President and CEO, PRC

Hospitals are not Lake Woebegon, Garrison Keillor’s fictional town where “all the women are strong, all the men are good looking, and all the children are above average.” There are high, middle, and low performing units at most hospitals. The question is – which units get more attention from leadership? Are low performers asked to explain their disappointing scores from patient perception surveys? Or are high performers asked to explain their success? When a unit has months of high achievement and months of mediocrity, which months are subjects of conversation?

A culture of service excellence focuses on what’s going right and tries to replicate that success. It asks “What are our top performing units doing?” and “What did an employee do that he didn’t have to do?” Answers to these and similar questions reveal behaviors worth noticing and repeating. When so much of each day is spent on what went wrong, practicing service excellence means turning our attention to what went right. Here are some simple tactics organizations have used to instill a culture of service excellence and focus on the bright side: 

• Begin meetings with “3 stories of excellence.” Story telling is a fun and engaging way to learn. When stories are focused on excellence, they encourage everyone to solve the real problem – getting more patients to love us.
• Start each week by reading a letter from a happy patient. Letters are an important way to connect to patients’ experiences. Those written detailing bad experiences obviously deserve attention, but so do those written detailing fabulous experiences. Nobody wants to come to work on Monday and hear about their failings, so beginning each week with a story of success is a great tool to keep morale intact and inspire employees to always be at their best.
• Celebrate any success. No matter how big or small, we reward the behavior we want to see repeated. Whether it’s through an old-fashioned thank you note, public recognition, or something else creative and personal, we can’t let moments that deserve praise go unnoticed.

Contributor: Teira Gunlock, PRC Client Education Consultant

To achieve long-term sustainability, organizations should seek patient loyalty through providing extraordinary patient experiences. The hurdle to loyalty in most organizations is not the large presence of dissatisfied patients; the problem is the large presence of merely satisfied patients. These merely satisfied patients likely didn’t experience problems, but they also didn’t experience moments of “wow.” They had a plain bagel experience. Plain bagels are fine; there’s nothing wrong with them. If they are the only flavor available, you’ll take one, but you’d rather have any other flavor. Patients need flavor for their experience to be memorable. 

Improving patient perceptions is difficult, in part because patients cannot tell us how to flavor their experience to make it excellent. They can tell us when something goes wrong, even when something goes exceptionally well. Often, however, patients cannot identify the reason why an experience was not excellent. They simply know it when they see it.

“Magical Express” is a system used at Walt Disney Resorts. Instead of having to wait on your bags at baggage claim, the resort identifies your bags with special tags and has them delivered to your room. This allows you to get off the plane and right down to having fun and relaxing. It’s unlikely a customer said, “If you had picked up my bags for me and delivered them to the room, the experience would have been excellent.” It takes something innovative, creative, and new to deliver a “wow” to customers. Replicating others’ successful tactics is paramount to improvement, but we also need to creatively design new ways to make the patient experience more compassionate, personalized, and memorable.

Source: http://disneyworld.disney.go.com/planning-guides/in-depth-advice/airport-service/

Contributor: Teira Gunlock, Client Education Consultant