If I have a healthcare-related resolution for 2013, its to be a champion and protector of empathy. As a member of the leadership team of a health system, that means making room for empathy in how we deliver care. Or, put more simply, valuing the time our providers spend with patients over raw productivity or efficiency metrics. As a blowhard healthcare blogger, it means advancing the cause to anyone else who is able to make room for empathy in patient care. Unfortunatly, while we often pay lip service to patient engagement, we usually measure and pay providers on exactly the opposite. Patient-centered communication rockstar Steve Wilkins wrote a great piece on his blog this week: The 10 Commandments of Patient Engagement. In the post, Steve lists 10 actionable steps providers can take to more meaningfully engage with patients during a visit. I agree with every single one of them.
I’m willing to bet most providers - nurses, mid-levels and physicians - would all say the things on Steve’s Top 10 List are things they do, or want to do. Then they’ll sigh and say something like: “but there’s now way we can be expected to strike up a conversation just for kicks, not with the productivity standards we are held to.” If they are self-employed, the later part of that dismay might instead be: “and still pay my bills on today’s lousy reimbursement.”
That’s where I see a very important role for leaders in healthcare organizations - making room for empathy.
Doctors are, generally, paid on a productivity basis. This usually comes in the form of a base salary plus a portion based on something called a worked relative value unit, or WRVU (often called an RVU too). Suffice it to say, it means the more cases a provider sees, or the more complex the case they see are, the more they get paid. Nurses, mid-levels and physicians are all, with increasing frequency, being held to productivity standards. Productivity is often is expressed simply, usually as a number of patients per day. If, on average, a primary care doctor can see patients in 10 minutes, and they have 6 hours of patient time allotted on their schedules per day, that means to be 100% productive they need to see 36 patients per day.
Now, most of us can recognize that’s a pretty lofty goal and one which doesn’t leave much room for longer, more complex patients. It certainly leaves very little room for meaningful interactions. And, even in a more relaxed model of say 20 patients per day, explains why doctors are so often running behind schedule.
The problem for us administrative types is that 20 patients per day looks pretty good on a spreadsheet. And, there are a lot of sources and third parties to back up high efficiency models of productivity. So we push for it. We write productivity goals into contracts, we push nurses to work faster, and we take away any time for empathetic patient relationships.
Then we try and shoehorn empathy in. We coach staff on smiling and key phrases. “Is there anything else I can do for you?” We say we value and even demand the kinds of things Steve Wilkins is asking of providers. But, in reality, we are grading and paying providers on exactly the opposite.
Here’s another example, this time pertaining to nursing. Many of Steve’s commandments are often part of the nursing intake function. So, the graphic below depicts a very simplified flow map of a nursing intake procedure:
In the image above, each step of the process is shown along with it’s approximate time. Some steps, such as listening to the chief complaint may take anywhere from 1–3 minutes. If you add up all the minimal times, this flow takes 8 & 1/2 minutes. If the steps take their maximum amount of time, the process takes over 15 minutes.
If a nurse is being held to a productivity measure which requires they complete this process in the minimum time, what gets cut? Regrettably, all too often, its the part of the process we as patients would say is the most critical - the human interaction.
So, when I write about making room for empathy, I believe we have to look carefully at two key things: our metrics and processes. In terms of metrics, we have to ask ourselves: are the goals we hold staff to consistent with what we are asking of them? In other words, does it work to script customer service phrases while paying bonuses based on productivity? We have to look at processes to see where we can make time.
I understand the need to do more with less, and to better use our resources. But patients are increasingly voting with their feet. If we want to remain viable, we have to make patient engagement a top priority. That means making room for engagment in the patient process flow.
The best way to make room for empathy is to find steps which do not add value. For instance, in the flow image above, would it make more sense for someone else to pull the chart, take the height and weight and room the patient? If we took 3 minutes out of the nursing flow, but kept the expectation at an 8–15 minute process, then we’ve added 3 minutes of face time. It doesn’t sound like much, but we know from studies as little as one extra minute of meaningful, heartfelt interaction can make a huge difference in a patient’s relationship with their provider. By the way, this same process map / time protecting idea works for physicians.
As we head in to 2013, here are my challenges to fellow leaders, administrators and health system executives:
- Make a PDF of Steve’s 10 Commandments
- Map out your current patient process flow, record times for each step, average them together
- Use a LEAN process flow calculator or your own best judgement to find steps which don’t add value to the critical path. This isn’t as tricky as it sounds, it means looking at each step and asking could I cut this out or find someone else to do it and, in doing so, make room for empathy?
- Remove the steps which don’t add value, or find someone else to do them. Yep, that may mean a hire, but cost today is better than a loss due to poor patient satisfaction. But I think most of us will find there is enough waste in our flows to more than allow for patient engagement.
- Implement one of Steve’s commandments for everything you cut out
- Measure marketshare, patient satisfaction and, I argue most importantly, staff satisfaction - all will improve.