If Disney Ran Your Hospital – An Interview with Free Lee

Fred Lee is an American Author who is a nationally recognised expert and consultant in patient relations and service excellence.  His book ‘If Disney Ran Your Hospital: 9 ½ Things You Would Do Differently’ was awarded the 2005 Book of the Year from American College of Healthcare Executives.  Here he talks to us about the differences between patient service and patient experience…

What is the similarity between hospitals and Disney?
I did not see the similarity myself in the beginning. The book that enlightened me was a book by two economists called, The Experience Economy, Where Work is Theater and Every Business a Stage. Their hypothesis is, that we need to add one more economic sector to commodities, goods and services. When we buy a ticket to a theater or a holiday destination, we are not looking for something tangible like commodities, goods or services, but an intrinsic memorable emotional experience or story to tell. They write:

“All prior economic offerings (commodities, goods and services) remain at arms-length, outside the buyer, while experiences are inherently personal. They actually occur within any individual who has been engaged on an emotional level. The result? No two people can have the same experience—period.”

In other words, commodities, goods and services are extrinsic and temporary, but experiences are by definition intrinsic and leave an emotional imprint on one’s memory that may last a lifetime. That is a world of difference from picking up your dry cleaning or getting the oil changed in your car, or ordering pizza, or dropping by the market to pick up a loaf of bread.

Hospitals and Disney are both in the Experience business, not just the Service business. Nobody comes out of a theater and talks about the service they received. They talk about how the experience made them feel. Theater, however, is about all the emotional experiences of human beings from the things that make us laugh to the things that make us cry—the two icons of theater. Tom Hanks was the voice of Woody in Disney’s Toy Story, because Disney is primarily all about comedy. But Tom Hanks also played a person dying of Aids in the movie, Philadelphia, which was a tragedy. Hospitals are on the tragedy end of the experience continuum, not the comedy end.

So Disney tries to meet the emotional needs of a family to have fun together. Hospitals, on the other hand, are dealing with emotional needs of a family going through, fear, anxiety, pain and loss together. Both are emotional at the core, even though the emotions are vastly different. So I could say: “A hospital without compassion would be like Disney without fun.”

Why is patient perception so important?
Surely I do not need to convince anyone in medicine of the importance of the patient’s state of mind in the healing processes of the body. Patient perceptions are the basis of their emotions and state of mind. Ever since biological science discovered, first in animals and then in humans, the profound relationship between emotional distress and disease outcomes, there has been an explosion of clinical studies that prove the negative link between distress, fear, and anxiety, and immune function.

Almost every major University Medical Center is now doing their own research in Psychoneuroimmunology, which is the study of the effect of a patent’s state of mind (perceptions) on their immune system. You can easily find studies which show, based on objective physiological markers, that empathetic connection between clinician and patient can affect better outcomes in wound healing, infection fighting, diabetes control, readmission to hospital, hypertension, open heart surgery, complications, and a host of others. Even insurance companies have shown that 72% of all medical malpractice claims could have been prevented by a better doctor patient relationship.

The great psychiatrist, Harry A. Wilmore, wrote, “The failure to empathize is the basis of most of the unhappy doctor patient relationships.”

Can you give a few examples of what hospitals can learn from Disney?
• Focus on the whole family, not just the patient
• Do everything possible to meet people’s emotional needs, not just their physical needs.
• Make courtesy and compassion more important than efficiency.
• Use the power of imagination to put yourself in the guest’s shoes. Or, “What must this person be feeling?”
• Use the theater metaphor instead service as your guide. Like:
“In this scene, what do we want the audience (patient) to see, hear and feel?”
• Co-design processes with actual users (patients)

How exactly can hospitals bridge the gap between ‘good’ and ‘great’?
We need to define the terms. For me, “good” means meeting universal service expectations like courtesy and respect.

But, “great” means exceeding universal service expectations by assessing and responding to a patient’s emotional state of mind, reducing their fear and stress, by listening to their story, empathizing with them, and instilling hope and trust with assurance.

Can you give a few tools/advice?
We cannot operationalize compassion like we can courtesy behaviors, because we cannot script it. It must come from the heart. People don’t need tools for compassion. Clinicians simply need to be persuaded of its importance in the human healing process. What we need are managers who call their staff “caregivers” instead of employees, and explain the WHY of caring, and talk about its importance every day.

After all, the word “patient” comes from the root word “pathos”, which means “one who suffers.” And the word “nurse,” comes from same root as “nurture” which is how we minister to one who suffers. And the word “compassion” means to enter into another person’s pathos with kindness and understanding.

It concerns me that we seem to be losing these long held traditional values in medicine–what we once called the “art of medicine” as opposed to just the “science of medicine.”

I do not buy the notion that some people have the ability to empathize or be kind, and others do not. It’s a human innate ability. It only needs to be stimulated and inspired every day by great managers. That’s the purpose of my book, which contains at least fifty suggestions and stories designed to inspire more caring from our caregivers.

Is it possible to measure patient perception? And if yes: how?
The answer is NO. But we can still get feedback.

For instance, we can aggregate and quantify the percentage of patients who answered “yes” or “no” to objective questions like, “Did the doctor explain things in words you could understand?” Or, “Did you have to wait more than a week for an appointment?” Or, “Were you treated with courtesy and respect?”

But how do you measure how a person “felt” about the way they were treated during their stay, especially since they may have interacted with 80 or more different people during that time.

W. Edward Deming, the father of TQM (Total Quality Management), Six Sigma, Lean, and PDSA, which are all about what can be measured, wrote in his most influential book, Out of the Crisis.

“The most important numbers for management are unknown and unknowable. What is the value, for instance, of the multiplying effect of a happy customer and the opposite effect of an unhappy customer?”

So Deming would assert that patient perceptions cannot be objectively measured or quantified.

When we use the term “good to great” we are alluding to a book by that name written by Jim Collins. Here is Jim Collins on things that cannot be measured:

“Some leaders try to insist, “The only acceptable goals are measurable,” but that’s actually an undisciplined statement. Lots of goals—(like positive attitude, love, compassion, trust, loyalty, quality of life and motivation)—are worthy but not quantifiable. But you do have to be able to tell if you’re making progress.”

I agree. However, if we accept the importance of qualitative information, we can certainly understand patient perceptions through their stories, comments, complaints, and fan mail. I encourage hospital leaders to start their journey to patient engagement by making a list of all the adjectives and adverbs in fan mail from patients. This will provide an accurate qualitative guide to what makes the difference between good and great. My wife, Aura, did this when she was the Chief Nursing Officer at a 300 bed hospital. By far the most common words used by a fan were: Caring, Cared, Cares, Compassion, Kindness, Warm, Concerned, Comforting, Listened, Reassuring, Tender, Loving, etc. I doubt it would be much different in The Netherlands.

This is not a new thing. The limitations of objective measurement have given rise to major disciplines like:
Narrative Medicine
Experience Based Design (NBD)
Empathic Design
User co-design
Empathy based improvement

My book belongs on the same shelf as the many books and articles that have been published in these disciplines.

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