Two years ago my 89-year-old father had minor surgery on his leg to remove a cancerous growth. The dermatologist had to scrape so many layers before eliminating diseased tissue that he recommended my father visit the wound care center to speed healing. In this organization, wound care was part of the Physical Therapy department on the lower level. My father and I made our way down, and scheduled two appointments per week, Tuesday and Friday, for what would be a total of six weeks. Then we transitioned to only once per week as the wound healed.

My father would wait only a minute or two before being called back. Richard and Mark took turns applying topical anesthetic, debriding the wound, and wrapping up gradually diminishing wounds on my father’s leg. This took about 15 or 20 minutes, and I’d bide my time in the waiting room.

It didn’t take long for me to recognize the regulars. Despite my best efforts to pass the time checking e-mails, the stock market, and my never-ending Scrabble matches, I couldn’t help but to glance around whenever there was action in the reception area or waiting room. I made mental notes of the patients I saw most often.

The young college-aged soccer player on crutches and her equally blonde mother who have permanent grins as if to convey the temporary nature of their predicament.

The knitter who waits with unwavering patience for her appointment time, only to abandon her knitting most willingly once she hears her name.

The burly older Polish man with the thick accent who brings plastic bags and the newspaper every time he visits. He sorts through the paper, separating the wanted from the unwanted, throwing away or sometimes leaving behind the inserts, ads, and undesirable sections. The staff knew to circle back after he left to check for trash.

The elderly gentleman with the walker, who without exception goes to the men’s room just before his therapist comes to call for him. And his wife who always rolls her eyes to the therapist, which is enough said.

The older couple who graduated from the university at which I teach, who one time engaged me in discussion about my affiliation based on my logoed sweatshirt. Since then, they haven’t even met my glance; perhaps time has diminished their recognition of me, particularly since I haven’t worn identifying clothing since then.

I’ve also observed the staff, both the ones who are affiliated with the department and those who pass through. I began to notice an almost metronomic tendency for actions to repeat themselves. The employees, who walk and talk through the waiting area as if there was no silence; who wait for the elevator as if no one will get off when the doors open; who whisk past and stare at the floor while listening to music through ear buds; who call everyone who checks in or out “sweetie” or “honey”; who listen to various iterations of almost scripted check-out conversation (“be gentle with the bill, I’m sore…”) and then feign interest and laughter. Initially annoying, it became familiarly amusing after a while.

Physical therapy and radiology share a common check-in desk, long enough to spread from one patient entry to the other. There are always more PT patients than radiology patients, so PT knows to check for their patients in waiting room chairs on both sides. And radiology knows not to question anyone wandering over to their circle of chairs that doesn’t look over. The PT patients are recognized and instantly checked in upon emerging from the elevator. On the other hand, for every eight or so PT patients, there is one radiology patient who pops out of the elevator, pauses to read the signs, and then nervously walks over to the receptionist.

Most of these patients are one-and-done; a simply x-ray or sonogram to eliminate something from the list of potential diagnoses. On a rare occasion there is a patient who walks in emitting stress and angst to suggest that she is in the midst of a life-changing event. The mother who pushes a stroller with a baby who wears a mask; the middle-aged woman who checks in for an MRI of her chest; the elderly woman and her daughter who are silent except for the simple word or two of direction from the daughter. These are the cases I noticed the most, for they are a brief glimpse into the potentially horrible world that is theirs alone to inhabit.

After all the trips, and time spent, and weather tolerated, I’m glad my father’s leg has healed. I’m also grateful that I don’t have to make the time to pick him up from his apartment at his independent living facility and drive him to and from the clinic. However, I’ll miss seeing him so frequently, even though I see him at least once a week. Surprisingly, I’ll also miss the observation, the regulars, (some of) the staff, and the routine. It seems that the wound care clinic transformed from a treatment facility to a Cheers-like venue where I expected the next man out of the elevator to be greeted with a chorus of “Norm!”.

Learning #3: Improving the patient and family experience cannot be distinguished from clinical care.

Patient experience, safety, and quality are categories of care constructed by organizations which often serve to separate rather than to integrate processes. They are inter-related; we cannot affect one without impacting the other two.

Implications: Watch what you say, and how you say it. Artificially dichotomizing “care” and “cure” does nothing to help your patients and their families in recovery. All it does is feed those in the organization who don’t want “patient satisfaction programs” to impact what they do. When you look at care experiences from the patient’s point of view, everything is everything. Patients want to feel safe and secure, to perceive that they are getting the best possible care, to be assured that they know what is happening and will happen, and to be heard.

How can any of these be pigeon-holed into safety, clinical quality, or experience alone? Doesn’t active listening directly impact shared decision making? And doesn’t timely and proper communication directly impact safety (falls, medication errors, etc.)? Doesn’t discharge planning, discussions about home and social support systems, and clear instructions on new medications and follow-up visits directly impact readmissions? So why should one aspect be distinguished from the others?

For example, many organizations will show a near-100% compliance providing discharge instructions to patients and families. However, patient surveys such as HCAHPS reveal a significantly lower percentage of patients recall this information. Some organizations interpret this disparity as the patient’s fault: “We checked the item, so it must have happened. It’s not our fault that the patient can’t remember.” If an organization receives 70% top-box scores for discharge information, 30% of patients don’t recall critical information designed to improve safety, outcome, compliance, and to reduce no-show appointments and readmissions. Instead of attributing the source of blame, an organization would do well to assess why 30% of their discharged patients can’t recall discharge information. Are there language issues? Is the discharge process confusing or too technical for some patients to recall? Can your organization better involve family members and other caregivers in the discharge process?

The best organizations discuss all aspects of care together – for instance, the impact on quality and patient experience when safety protocols are redesigned, the impact of new quality guidelines on safety, costs, and patient perceptions of care, etc. You may consider appointing one person in every meeting to provide feedback on every strategic initiative from the patient’s point of view. This way, the patient’s voice is continually infused into planning and tactics.

In October of last year, I had the honor of delivering a keynote address for the 2015 PFCC VisionQuest in Pittsburgh, PA. I structured my talk around four key points that I’ve learned over the years as I’ve engaged with healthcare organizations regarding Patient Experience and culture change.

Since I delivered my talk, I’ve come to realize that providing learnings is not enough. Those in attendance may have found inspiration from my talk, but I could have done more to provide them with sufficient detail to do something differently!

Over the next 6 weeks, I’d like to follow up on my talk with reminders of the four points I made, coupled with behaviors and tactics that naturally follow from these learnings. This week’s takeaway focuses on patient satisfaction.

Learning #1: Patient satisfaction should not be the goal of a healthcare organization.

The objects and measures of success for a healthcare organization should extend past patient satisfaction and should include patient activation, patient engagement, and patient loyalty. Patient satisfaction may be fleeting and an insufficient driver of lasting effects.

Implications: Engage patients and their families in shared decision making. This may take the form of providing decision aids; involving a variety of personnel to spend time with patients discussing their condition, prognosis, and options; and, using evolving technologies to continue discussions outside of clinical appointment times. Caregiver-patient interactions should focus on identifying patients’ goals, not lecturing patients about the goals identified by guidelines. What is realistic for a given patient? What is attainable? What is unacceptable from a clinical perspective? How can a patient goal (e.g., wanting to attend a loved one’s wedding or graduation) provide inspiration and continued motivation for attaining clinically meaningful goals? Caregivers should document patient goals, distribute them among members of the organization, and ensure that subsequent communication refocuses activities on achieving them.

Reframing discussions of patient satisfaction to patient engagement and understanding what patients and their families experience while under you care helps to move away from objections and stalemates. We’ve all heard “We’ve tried this and that,” “We have a long history of patient satisfaction programs,” and “I’m here to save their ass, now I have to kiss their ass too?” Some organizations have too long of an organizational memory, such that it inhibits the ability to move forward and to effect lasting change. Thus, move the discussion away from patient satisfaction, which has fleeting associations with behavioral changes, to engagement and activation. These are the terms that will connect patient experience initiatives to safety, clinical outcomes, costs, and other metrics to align your efforts with others in your organization.