The Customer is NEVER Right - A Nurse Practitioner's Perspective
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Presentation After Action Review

My own After Action Review (AAR) as there were no attendee evaluations:
What was supposed to happen (GOAL)? 1. Bring Awareness 2. Recruit Companions 3. Arouse Change
What was the plan to achieve this? 20-minute podium presentation followed by questions and answers. Presentation slides included links to the book’s web and Facebook pages, to include at the end of the presentation a slide that directs those interested to follow-up via those page links.
How did the plan change as it progressed? There was no change to the plan during its execution. Because of my inability to talk off the cuff I must read which keeps me from making changes on the fly. By reading not only do I stay within the allotted time but it ensures I do not leave out vital points from a conversation that matters.
What actually happened? I delivered the presentation as intended. Other than that I have no idea how it went or what actually happened, as it is hard for me to assess the audience’s reaction and there were no attendee evaluations. Thus, this AAR is without anyone’s input but my own as there were no evaluations from those who attended the session. The audience had 20-25 people, I expected/hoped for more. However, the session was competing with seven other sessions, three of them workshops. One thing is for certain, as with previous presentations, the presentation does capture the attention of the audience. Other than that, unlike previous presentations, I did not notice any reassuring nods or smiles. Additionally, and it just might be my perception, what I saw most in the audience were somewhat blank facial expressions. However, I noticed those somewhat unemotional faces during the presentations of others as well. So not sure what any of that means.
There was a single question from the audience, yes, just one, who asked, “Who is we?” Not sure where, when, or why in the presentation I mentioned “we” my brain replied to the question asked, “What does that mean?” My mouth instead replied, “We is healthcare.”
After my reply the person injected, “The U.S. is so centric.” What? I thought. But after a short pause I was able to focus that this was an international conference outside the U.S.A. and most of the participants were from Europe where healthcare is primarily provided by the government and not privately as is in the U.S.A..
The person elaborating, “Who in healthcare? Nurses? Doctors? Administrators?” Again, still unable to recall where, when, or why I mentioned we, my brain yelled, “What!?!” Still not knowing where all this was going or in what content I had mentioned “we” my mouth said, “We is all the above. Nurses. Doctors. Administrators. Clerks. Everyone in healthcare, as no one in healthcare deserves any kind of violence projected at them.”
The same person injecting, “How does this apply to the rest of us?” What? You are asking me who is “we” but then ask how it applies to “us”? What? If not those I mentioned in healthcare then who is us? I wanted to ask this person. Because, isn't "us" the objective 1st plural noun and "we" the subjective 1st plural noun. Essentially they are the same except one is the objective noun and the other the subjective noun. Isn’t it? Where have I landed? The same person adding, “We (What? Did you just say FREAKING WE!?! and you are asking me who I meant by “we”) serve in the National Healthcare System (NHS) where no one is fired for a patient complaint.” I choose not to answer that. However, I did point out, “But everyone is here [at the conference] because of healthcare directed violence.”
The moderator, who was from the U.S.A. as well, then took over the conversation pointing out that in the U.S.A. not only can someone be fired because of customer complaints but organizations lose reimbursement because of low satisfaction scores as well. However, I am not sure the NHS person understood the moderator’s explanation either causing me to believe either my presentation was lost in translation or the concept of satisfaction scores was unimaginable to someone who works in NHS. Except, another NHS person (different country, maybe, but not sure) tried to explain my point. Unsure the first NHS person understood the second NHS person said to me, “Jose, you should come work with us (NHS). You will love it.” Interestingly, that would be the second time a NHS person would invite me to work in their system where I guess no one gets fired because of patient complaints. The other time was at a conference in Jamaica and a Canadian working in NHS invited me to work in Canada.
Another U.S.A. person jumped into the conversation from the audience pointing out what the moderator had already explained. Nonetheless, I do not believe any of us moved the conversation nor did any of us answer who “we” was for the person who asked, other than we were ALL healthcare workers.
Other than that interaction there were no other questions or comments even after the moderator asked if there were any. That said the other two presenters I shared the session with each got 3-4 questions. However, I am not sure what not getting questions means but my guesses are two possibilities (1) the message was either clear thus no questions needed (my wishful thinking) and (2) the audience was too shell-shocked at what I had delivered to ask any questions. However, unlike previous presentations, no one at this conference came by to comment on the presentation, except for the moderator who made positive comments.
The end point, did I bring awareness, recruit companions, or arouse change? Awareness was most definitely made, as it was the theme of the conference, however with little, if any, impact. Recruitment and change, most definitely NOT!
Why were the differences between the intent and what happened? I set out to bring awareness and change to this silent national crisis knowing one person can do neither and why I need companions. However, since writing the book, I did so by jumping into this without any idea on how any of that gets done and how time consuming it has been. I realize my Knitted Brow and my “matter of fact” and inflammatory delivery are not the best but right now there is no one else. And healthcare’s submissive nature does not help. That is not redirecting blame or an excuse but just pointing out the battles are going to be tough and long with only one of two choices, keep trying or cease. Not to mention, and likely the single most significant factor in all of this, who wants to be unemployed, a conversation I had with the moderator when he presented during a different session. That said, because of those, especially the latter, I realize that I am asking a lot for anyone to cross to my side and help to push back when they have so much to lose.
What worked and why? With regard to the goals, awareness, recruitment and change, very little if anything worked or was accomplished at this conference. About the only thing that worked was using the tablet to read from which helped with staying on time and message. Other than the tablet being effective nothing else worked. As even the presentation's title, which I would say is an attention-getter, did not work as it lacked the ability to attract others to the presentation. Not to mention, I considered the conference attendees as a group that would be the most interested as a whole as my presentation was not only specific to their passion, healthcare directed violence, but my presentation also points to a likely cause for all the research many of them have been conducting. That cause being the obsession of customer satisfaction scores as a catalyst to healthcare directed violence. But no connection, I guess, another epic example of what happens when one assumes.
What didn’t work and why? Much more difficult to assess on my own. Is it the Knitted Brow or the “matter of fact” and/or the inflammatory delivery that shocks the audience or keeps them from asking questions? Or is it healthcare’s submissive nature or the VERY REAL risk of being unemployed that I did not gain any companions, as the needle did not move?

The day after numbers: -Facebook New Likes: ZERO (actually two Likes were lost although not likely related). -LinkedIn Profile views: ZERO -Website views: No change from previous trends thus ZERO impact as well. -Amazon: No activity (no book sold—not the goal but another metric) -Presentation download requested ZERO. -Hearts and Minds changed: Hard to assess but looks like NONE! Although those numbers paint a disappointing picture I am sure an accurate one. Because although a self-AAR does not permit an appropriate evaluation of the differences between the intent and what happened, and why what worked or didn't work, the numbers are still the numbers.
What could have gone better? I know the heart is in the right place and I believe the message is the right one. However, without the input from others it is hard to access if that is correct or not. That said, in Florida I recall a healthcare executive telling me the message was right on but that it had to be toned down. I get it. But it is hard not to point out that the root problem of all this are healthcare administrators who have sold their soul to outsiders. With that said, I know the spokesperson could be better choice other than myself but for right now, unfortunately, there is no one but me. Believe me no one is asking for a better spokesperson than I as I rather not be in front of anyone.

Could more time to make the point be what is missing? Hard to tell as in Jamaica and in Florida the allotted time was 60 minutes without much gained either. Granted the longer time allows for more elaboration of pertinent and convincing information. However, although the longer time brought greater awareness, one of the goals, it brought no change or companions. On that note, after cropping those presentations from 60-minutes to 15-minutes for Indianapolis, I learned that 15 minutes is more than enough time to get someone to look in your direction if they are interested.
Interestingly, and something that caught my attention, there were a number of poster presentations, likewise at other conferences as well. However, this time, maybe, just maybe, the thought of a poster might be another vehicle. I considered submitting a poster before but reconsidered after not sure what that entails either. Not to mention, how do I go about creating a poster as most posters, if not all, are about research and have somewhat of a template that is not consistent with the book’s methodology. Not to mention, other than intended on bringing awareness that is about all the book has in common with research. That said, I am sure a poster can be fabricated with the intent to overcome the presentation's stagnation of bringing awareness, recruitment and change. The wheels are turning with regard to trying a poster as another vehicle but only time will tell if the wheels are moving forward or just in place.
One more thing, I forgot my business cards at home and was not able to share them with anyone who even hinted to as much as a smidgen of interest. Like the session moderator and a different session moderator who liked a question I proposed to a presenter. However, the conference provided us with a list of emails to everyone who presented so I intent to email those to persons a PDF copy of the book—I have nothing to loose and everything to gain.
On that note, I did share a PDF copy with one presenter who showed interest, however, the person’s interest was how our views with regard to patients being customers were at opposite ends. Imagine that.
Interestingly, I did bring with me a single copy of the book to share with a cited author in the book who was presenting at the conference. Unfortunately, that person’s presentation and mine were at the same time making it impossible to attend the other presentation. Nonetheless, I emailed the person before our scheduled presentations but never heard back. While going through the email list I recognized a second cited author from the book and provided him the book after his presentation.
Despite that fortunate outcome I am not holding my breath as the latter cited author’s work is largely in healthcare directed violence and not the main theme of the book. And although there is some mention in “The Customer is NEVER Right” about healthcare directed violence it is still a book about customer service in healthcare which is not only another animal but an animal most stay away from. The same for the moderators and presenter mentioned, their focus is healthcare directed violence and not customer service. I can only hope if they read the book that a light comes on pointing out the book’s significant to their passion.
What advice would you give yourself if you were to go back to where you were at the start of the project? Again, I took on this journey not knowing what I was getting into, what was involved, and how time consuming it has been. That said, I know that I am not the right spokesperson. I realize that from the onset. However, there is no one else but me. Can the tone, especially with regard to administrators, be minimized? I find it hard to be convinced of minimizing the tone. That said, I have watched TedTalks, lots of them, especially Fred Lee, but I cannot find myself. I just am not a spokesperson. But, again, there is no one else. Again, leaving with two choices, continue on until a better spokesperson appears or cease in trying to bring awareness and/or change.
What are the two or three key lessons to share with others? (1) The heart is in the right place. That is without question. (2) The message is the right one. That is without question as well. Can the tone be changed/minimized? Hard to say and much harder to admit. (3) The spokesperson is not the best choice. That too is without question.
What next? On to Hawaii for a similar presentation but more so about customer satisfaction rather specific to healthcare directed violence. Nonetheless, the intent is the same: awareness, recruitment and change. And as mentioned in previous AARs, more is needed under the belt to get the foot in the right doors thus submitting more abstracts, despite most have been rejected, and maybe a poster presentation. And of course, continue to reach out to Senator John McCain’s (AZ) interest with regard to abolishing HCAHPS—that alone will turn heads.
What should be expected in a year from now? Hard to say, as the book has been out for four years now and this was the fourth attempt, of more than ten abstracts submitted as most have been rejected, to gain companions without gaining any. And of all the previous this was an audience I was sure would be interested but NOPE. Although getting Senator McCain’s attention would be a HUGE game changer it is more a fantasy than imaginable let alone obtainable. But will try.
Any personal lessons? I never thought this was going to be easy. But I never thought it was going to be so frustrating either. Not to mention, in front of an audience whom I thought was on the same sheet of music and nothing. And again, after not moving the needle, like so many of times before I considered putting down the guidon (flag). In the past I reminded myself this is not about me but about healthcare. But if not me to push forward than who? My bridges in healthcare are already burned thus I have nothing to lose other than time, and a LOT of time it is. Time during which I could be doing something else. Times before I have mentioned of finding encouragement in Thomas A. Edison’s words, “Many of life’s failures are people who did not realize how close they were to success when they gave up.” As encouraging those words might be there is nothing for me to gain by succeeding either. So then why press on?
That said this was the 5 International Conference of Violence in the Health Sector. Ten years have gone by since the first one and they are still finding the same results in their research, year after year and country after country. Yet they continue.
Does it take a lot of time? ABSOFREAKINGLUTELY! it does. Time during which I could be doing other things?! At some point I might realize “what is the point?” But until then I will continue to submit abstracts hoping at some point I will capture someone’s attention. Until then!
Conclusion: Other than myself being my harshest critic I would have to say the second biggest critic was the healthcare executive who asked me to tone down the message and it’s delivery. That said, Nelson Mandela told us, which I learned at this conference, “You don’t make peace by talking to your friends (the choir); you have to make peace with enemies.” Got it. Just not convinced it’s the same for taking healthcare back.
Aside being my own harshest critic I am also my own biggest hindrance as well. The criticism of myself or from others I can handle but finding another spokesperson is going to be quite the challenge. Again, despite those a lot of time and effort goes into these presentations for nothing to be accomplished. Also as mentioned, the book has been out for four years now and I realize my writing sucks but the intent, taking healthcare back, is clearly in the book yet it has gone nowhere as well. I realize Florence Nightingale didn’t change nursing over night either. Before the emails, in NO manner am I comparing myself to Florence, oh no, but instead just reminding myself that change is never accepted so easily. Press on! The more exposure the more exposure, I guess. Most definitely, reaching out to Senator McCain, although a fantasy a HUGE game changer and nothing to lose by doing so but more time.

THANK YOU to the moderator, those who attended the presentation and those who encourage me to press on!

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