Make the right promises, then keep them
The secret to excellence in care
In our last post, we touched briefly on what makes healthcare so challenging: The Primary Chaos of the human body and its sundry diseases, obscured by the Secondary Complexity of allocating limited healthcare resources toward an ever shifting set of priorities. Nevertheless, we still get sick and we still need care, so what should we do?
Fortunately, medical science is making great advances in resolving Primary Chaos. We know much more this year than we did 10, 20 or 40 years ago. The best strategy may be to stay alive long enough for medicine to catch up. Even with advances in the diagnosis and treatment of disease, our research apparatus is primarily centered around products (medicines, devices, diagnostics) and tends to have limited ability to study the delivery of those products in the form of services. Health services research is a very real thing, but its methodologies are still somewhat “drug-like” in approach with randomized trials, intention to treat, and similar concepts that make less sense when studying a protean service.
Similarly, advances in financial technology and insurance policy allow us to make some progress on payment and resource allocation that plagues Secondary Complexity. It is easier than ever (but still not very easy) to move money between patients, families, providers and payors. Most of the limitations that exist are policy challenges rather than technical ones, except the “list of names” problem. Rules such as ICHRA and programs like the GUIDE model and VBID signal hope that we can move past the one beneficiary/one year mentality that limits modern insurance’s ability to get meaningful things covered.
All things considered, the future is pretty bright, but as a provider of healthcare services today, what should you do to ensure successful navigation of Scylla and Charybdis?
Make the right promises, then keep them.
Earth shattering, I know. There is more than meets the eye, so let’s break it all down:
“Promises, seriously?”
Yes. A promise is defined as anything that leaves another with an expectation. Deceptively simple, massively pervasive. In healthcare, we make and almost immediately break promises all the time. How many times have you either heard (or said), “someone will be with you shortly” only to be left waiting for minutes to hours? Although it seems minor, this incredibly common, well-intentioned statement builds on a mountain of broken service promises that leave experienced patients simply unable to trust us at all. Promise making starts with a prospective patient’s FIRST interaction with your service–marketing materials, the phone answering tree, website, etc. By the time they actually see a clinician, they are likely 25 promises deep.
When we clinicians fail to keep our promises, patients have two ways to interpret these failings as outlined by Hanlon’s razor: “Never attribute to malice that which is adequately explained by stupidity.” Now, raise your hand if you want a stupid clinician? Moreover, the litany of broken promises would suggest that nearly every clinician ever has been stupid. So rather than extending the benefit of the doubt, which is warranted because systems of care are pretty stupid, broken promises are instead attributed to malice. Clinicians do not keep our promises because they do not care.
And therein lies the problem. How would you treat someone who actively demonstrates that they do not care about you? Would you tell them the truth? Would you trust their advice? Maybe in an emergency, but about chronic behavioral changes such as diet, exercise, medicine adherence and substance avoidance? Probably not. Would you let that person try multiple times to help you or would they get one, high-pressure-and-therefore-likely-to-fail attempt to fix your problems? Without trust, sharing the truth or a chance to iterate toward a successful outcome, patients set clinicians up for failure, and the vicious cycle continues.
Imagine an alternative scenario, where kept promises lead to trust. That trust leads to the truth, elusive in most clinical encounters because of overwhelm, mistrust, shame, and/or a desire to please the clinician before you. Furthermore, that trust leads to repeat interactions, allowing more chances for the truth to surface, and more chances to make fewer, small changes, putting time on your side allowing for watchful waiting, also known as the body having enough time to heal. Kind of sounds like agile development, doesn’t it?
As a medical student visiting the Special Care Center, the precursor to Iora’s practices, I encountered a gentleman with diabetes, who swore he was taking his insulin regularly but his blood sugars remained frustratingly elevated. Fortunately he had a relationship with his health coach, who through great systematic design, had a history of keeping her promises. He trusted her enough to share that he was not taking his insulin because he was afraid of bottoming out. He was ashamed of this and did not want to let me down. Through his trusting relationship with his coach, we moved his insulin dosing before breakfast, his only reliable meal. Without her, we would have uselessly or dangerously increased his insulin dose. Physiologically the approach was probably neutral, but his confidence helped ensure one of the basic tenets of medicine, “it is helpful to get the medicine in the patient.”
A common mistake made by those endorsing this humanistic, relational side of care is that relationship building takes long periods of time, much of it spent chatting about pets and children. Given that physician time is one of the most squandered, expensive resources in the world, promise-keeping is a much more effective, faster alternative. For further reading, check out SERVQUAL and the emphasis on reliability as the primary predictor of customer experience.
“So, how do you actually keep your promises?”
First, be aware when you have made a promise. Call when you say you will with lab results. The corollary is to NOT make promises if you cannot keep them. We will cover this more in the “right promises” section. Resist the people-pleasing temptation to just say yes that probably got you into human services in the first place. Rather than saying no, make a relevant promise you believe you can keep. This is harder than it looks, as it requires understanding your current capability performance. In simpler terms, don’t tell someone you will call them in two weeks if you are going to be on vacation in two weeks. But if you do, you better call them.
Second, gear your entire service operation toward promise keeping. Remain disciplined and thoughtful about making new promises: Measure your current performance, observe your people, live or recorded, performing your service, eliminate friction through design, staffing, technology and job aids, and train up or remove promise breakers.
If this all seems to be too much for your size, scale and current reality, then start by simply remembering and writing down all the promises you make, as you make them. “There are two types of Internal Medicine interns– those who write things down and those who forget.”
Did you know that most doctors write “to-do” lists at the bottom of our visit notes? There our to-dos pile up, as unstructured text, unaggregated across patients, unable to be sorted, tracked, prioritized and delegated. And we wonder why the ball constantly gets dropped?
A simple “promise” tracking system e.g. to do lists, Trello boards, etc. shared amongst your team will make promises visible, increasing the probability of those promises being kept. Additionally, you will all get much more annoyed if someone is making bonehead promises. Fear not when this happens, as continuous improvement is required in the face of chaos. Furthermore, broken promises due to failed operations or entirely missing capabilities are actually clues on how to prioritize your improvement efforts. For those of you keeping score at home, I am fundamentally alluding to the Three Ways of DevOps.
“Wait, what are the right promises?”
So you’ve built your continuously improving operations, or at least you’ve started writing down the promises you’ve made in some trackable format. Well done! But how do you know if you are making the right promises? Ultimately patient progress is the best measure of promise quality. Some surrogate measures include continued engagement, patient retention, or simply making promises that can be kept.
The right promises stem from the union of: possible, clinically appropriate and patient-specific. Thus ensuring that the potential benefit of your care outweighs the potential harm, while creating a plan that a patient can and will actually follow.
A possible promise (what you CAN do) is one that you can keep with confidence. You should make these all the time, as kept promises in rapid succession are the basis of trust. Be on time, give accurate directions, have great signage, if you ask the patient to fill out paperwork, read it. Start setting expectations about your actual service (not your ideal service) immediately. A word of warning, never attempt to force excellence by committing to a promise you cannot keep. You will both fail in your delivery AND undermine your team simultaneously. You cannot shortcut discipline or excellence.
A clinically appropriate promise (what you SHOULD do) stems from your clinical knowledge – evidence, guidelines, relevant clinical data. It is what all the schooling, training, continuous education, decision support tools, guidelines and technology are there to do. Wherever possible, build clinical knowledge into your tools and technology to reinforce your providers, lest you roll the dice on idiosyncratic interpretation and recall. As with everything, track the clinical appropriateness and outcome of your approaches and improve them over time.
A patient-specific promise (what this NEEDS) is perhaps the most challenging and rewarding part of all of this. You have to combine what you can and should do with the clinical, personal and idiosyncratic knowledge you have earned through a relationship based on kept promises. It is how you know to move insulin dosing rather than increase the dose. Knowing patients allows you to make recommendations that will work for them. It is the essence of both cultural competence and individual patient-centeredness. Without this knowledge, which can only be gained in a trusting relationship, you are effectively shooting in the dark.
And there you have it: Make clinically-appropriate, patient-centered promises that you can keep. Keep track of the promises you’ve made so that you actually keep them, every single one. Continuously improve your ability to keep current promises and then make new ones. Then enjoy the fruit of your hard labor: your clinical service will improves the lives of those it serves and those who deliver it. You will retain patients who you can care for efficiently and effectively. They will in turn recommend others, growing your service. And all will be well, until all the growth drives you to start breaking your promises. Fear not, you now know how to get back on track.