The Customer is NEVER Right - A Nurse Practitioner's Perspective
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After Action Review: Transforming Healthcare: A Pathway to Nursing Excellence (Hawaii)

My own After Action Review (AAR), as there were no attendee evaluations, for the conference presentation titled “The Customer is NEVER Right” in Hawaii (13 Jan 2017):

What was supposed to happen (GOAL)?
1. Bring Awareness 
2. Recruit Companions 
3. Arouse Change

What was the plan to achieve this? 60-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. Unlike previous presentations of the same content I added the following words at the end of this presentation, “To those interested, I will send you a PDF copy of the book if you ‘LIKE’ the book’s Facebook page.” Words with the intent of getting eyes to the Facebook page, the blog and the book.

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 the presentation, which keeps me from making changes on the fly. But with 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. On a separate note, the conference organizer’s equipment did not support a video within the slides. However, because of similar experience with the same conference organization, the contingency plan was to explain the video. And because presenters before my presentation had the same problem when it happened to my presentation it was not as awkward.

What actually happened? I delivered the presentation as intended and within the allotted time. When the video did not play the video’s content was explained. As to the audience, from my perspective it appears the presentation was well received. However, that reception was not appreciated until finished and the audience shared a few reassuring comments and asked a number of questions that were encouraging. Because, otherwise, during the presentation, like previous, I did not notice any reassuring nods or smiles but instead mostly saw blank facial expressions from where I was standing. Except, and a big except, for moments of comic relief that were purposely injected into the presentation as suggest by someone who had heard the presentation two other times before. That person suggesting the comic relief was notably missing from the first to the second presentation. Other than that all I saw were blank faces. But than, once again, I am not able to decipher the meaning of blank faces. And why, again, like previous presentations, I have no idea how it went or what actually happened, as it is hard for me to assess the audience’s reaction. That said, like previous presentations, one thing is for certain the presentation does capture the attention of the audience despite their blank faces.

This AAR, as previous, is without anyone’s input but my own as no input is available from those who attended the session. The audience had 15-20 people, as before, I expected/hoped for more. At this conference my presentation was not competing with any other session as in other conferences thus the low attendance was more a reflection of the conference than of my presentation.

At the end of the presentation a number of encouraging questions were asked, which is always good, and none of the questions were negative or challenging, which is even better. Also, like in previous presentations, a few persons came by after the presentation to give additional positive feedback, which is always good as well.

One of those who I had an encouraging conversation with during the questions portion of the presentation and afterwards as well was a previous administrator. However, differently from previous administrators I thought this administrator was more receptive to the presentation than previous administrators who have heard the presentation. I spoke with the same administrator after the presentation as well. Unfortunately, I lack the gift of gap and may have missed an opportunity to recruit a companion. However, I did ask the administrator the question I point out in the presentation that administrators have difficulty answering, “What benefit has chasing satisfaction scores brought to healthcare, other than customer retention and profits?” This administrator’s answer, “[paraphrasing] Rating healthcare gives patients an opportunity to tell us how we [healthcare workers] are doing.” Which I agreed. However, I would not consider such claim as a benefit to healthcare. But if it is a benefit it seems like a lot of money, time and energy wasted, not to mention all the collateral damage left behind just to find out how we are doing. Interestingly, this administrator could NOT mention any other benefits from rating healthcare despite 30+ years of rating healthcare and all the money, time and energy waste to do so.

“What benefit has chasing satisfaction scores brought to healthcare, other than customer retention and profits?”

Lastly as to what actually happened, this presentation did bring awareness, one of the intended goals, but as for recruitment of companions or arousing change I doubt any influence as with presentations before. However, I am beginning to believe that the latter two are a lot to ask from others. That said, yes, awareness was made, however, with little, if any, impact. As for the more significant goal of recruitment and change nothing was accomplished.

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. 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 point made during the presentation and an unsolicited point made by the administrator I spoke with as well. That said, because of those, especially the fact no one wants to be unemployed, and who can blame them, I realize that I am asking a lot for anyone to cross to my side and help to push back. However, this audience seemed to be significantly more receptive than groups before but I am not sure why as the presentation content was the same as previous and I doubt it VERY much the extra enthusiasm was because we were in Hawaii.

What worked and why? With regard to the goals only awareness was made. However, other than that I would say not much more was accomplished. As for the other two goals, recruitment and change, MOST definitely nothing was accomplished.

Interestingly, as mentioned above, at the suggestion of someone I added comic relief to this presentation after it was removed from the first presentation, it was a big hit and will be part of future presentations as well.

One person took up the offer of a PDF copy of the book after I made the offer during the presentation that anyone who “Liked” the book’s Facebook page I would send them such copy. Despite it was one of 20+, one is better than none and hopefully that person will pass it on to others, both the PDF copy and the suggestion to “Like” the Facebook page. To that I will add, that is an idea I intent to extend to anyone who “Likes” the Facebook page regardless if they have heard the presentation or not.

Once again, as every time before, the tablet to read from helped with staying on time and message thus that too stays. Other than the tablet and the humor being effective nothing else, like the content and context of the presentation, worked with regard to reaching the goals of awareness, recruitment and change. However, I truly believe both the content and context are the right path.

What didn’t work and why? Much more difficult to assess on my own, however, here are some questions. Is it The Knitted Brow or the “matter of fact” and/or the inflammatory delivery that shocks the audience and a hindrance to the goals? Or is the shock because of healthcare’s submissive nature? Or is it the VERY REAL risk of being unemployed that I did not gain any companions or meet any goals, as the needle did not move again? Or are there other variables that I am not able to appreciate as to what isn’t working or why? Obviously, I see what I am doing as right but that is not to say anything I have done thus far is in the right direction, except for a few who have commented that I am a voice for many. Of course, that challenged by those who have described the content and context as inappropriate.

Nonetheless, the day after numbers: -Facebook New Likes: ONE (For the first time of the five presentation thus far and specifically to this presentation, and not unrelated, as the person who liked the page replied, “The presentation resonated with us.” The comment after receiving a PDF copy of the book as offered during the presentation). -LinkedIn Profile views: ZERO -Website views: No change from previous trends thus ZERO impact as well. -Amazon: No activity (no books sold—not the goal but another metric) -Hearts and Minds changed: Hard to assess but looks like NONE! Although those numbers paint a disappointing picture I am sure an accurate one of NOTHING accomplished. However, and a big however, despite those numbers I would say the most rewarding presentation thus far and even encouraging.

Because although a self-AAR does not permit an appropriate evaluation of the differences between the intent, what happened, why what worked or didn't work the numbers are still the numbers. And the numbers are NOT encouraging.

What could have gone better? I believe the message is the right message and despite those who agree are scarce they are more in numbers than those who have expressed dissent. That feedback, both positive and negative, is the fuel that I am on the right path of a VERY LONG haphazard mountainous road of exhausting climbs and sudden drops. Not pleasurable in any sense but rather tiring and punishing in its climb. Yet having to be traveled in order to get to the goal, which waits at the top. However, despite that encouragement, without the input from others it is hard to access if any of this is correct or not or even worth anything.

Thus far, the only ones who have told me to tone down the message have been healthcare administrators, despite they agreed with the message. However, the one administrator I spoke to at this conference not only agreed with the message but there was NO mention of toning the message down, actually made no comment with regard to the message’s tone.

As mentioned in other AAR’s, with regard to the message’s tone, I get it. But it is hard NOT to point out that the root problems of ALL of this chaos in healthcare are healthcare administrators who have sold their soul to outsiders. That said, I know the spokesperson for this message could be better and should be better than what I can deliver but for right now, unfortunately, there is no one but me. Believe me when I say no one is asking for a better spokesperson than I as I rather not be in front of anyone.

On top of that, could more time to make the point be what is missing as this is a very large and complicated problem which requires a complicated multifaceted solution? Hard to tell, however, not much was gained from presentations that were of similar times, 60-minutes, either. That said, after cropping the 60-minute presentations to 15-minute presentations I learned that 15-minutes is more than enough time to get someone to look in your direction if they are interested.

Granted the 60-minute presentations have allowed for more elaboration of pertinent and convincing information and even generated more post-presentation conversation. However, it is hard to discern if the post-presentation conversation was from the longer time versus the venue milieu, as all three 60-minute presentations have been with the same conference company and more-or-less the same milieu in different locations. And although the longer time brought greater awareness, one of the goals, none of them brought change or companions.

On that note, prior to this presentation I had thought and even considered developing a 6-8 hour program to present as Continued Medical Education (CME). However, that is a huge project as far as I am concerned and I am not sure I am up for it as these presentations already take up enormous amounts of free time for which I am not compensated. And although ALL of this began as a means to channel my frustration with the current healthcare system as related to chasing satisfaction scores it has not accomplished anything for any one else, myself included, and much less for healthcare. The one ABSOLUTE accomplishment it has made is burn LOTS and LOTS of my free time and the free time of those around me!

Interestingly, and something that caught my attention before, although none were present at this conference but mentioned in previous AAR, a poster exhibition rather the podium presentation. As mentioned before, as well, I have considered submitting a poster but reconsidered due to unsure what that entails. Better yet, 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. That said, I am sure a poster can be fabricated with the intent to overcome the book’s stagnation of bringing awareness, recruitment and change. However, I am not sure that is a good vehicle either but the wheels are in motion with regard to trying a poster, as well. Not sure the idea of a 6-8 hour class program is either not to mention both seem like a LOT of work, to get where.

One other thing, I left my business cards to share with anyone who even hinted to as much as a smidgen of interest, like the administrator. However, I forgot them, again, but NO one asked for them either, as before, again, so maybe not a game changer either.

That said, I did share a PDF copy with the one person who showed interest by “Liking” the book’s Facebook page. However, I have done that before as well without any feedback. But only time will tell where that will lead as well. That said, I did not have any books to share but I have shared a number of books (50-60) thus far as well without feedback.

What advice would you give yourself if you were to go back to where you were at the start of the project? I am not the right spokesperson, I realize that, and honestly believe a different spokesperson would be a significant game changer but right now there is no one else. Can the tone, especially with regard to administrators, be minimized? I find it hard to convince myself of minimizing the tone directed at healthcare administrators and outsiders as I fully blame them for where we are in healthcare today. It is healthcare’s altruistic, submissive and accommodating culture which has allowed others to not only walk all over us but to wipe their feet on us as well. Because of that I am not convinced lowering the tone will get us to taking healthcare back or make healthcare great again. I truly believe that pulling back on the tone only takes the heat off of those who have taken us down the wrong tracks, which is why administrators have been the only ones to point the tone out. That said, I believe a more articulate spokesperson could deliver the message better despite the tone.

I have watched LOTS of TedTalks presentations, LOTS of them, including Fred Lee, and many others speak but I cannot find myself among those individuals. And much less, I do not possess their talent to deliver their message, whatever that message is, so effortlessly. I just am not a spokesperson. But, again, there is no one else. And, again, as pointed out so many more times before, I have but two choices. One, continue on until a better spokesperson appears or, two, cease in trying to bring awareness, recruitment and change that is so desperately needed.

Having said all the above and despite the already manifested likeliness of a poster presentation and/or a 6-8 hour program being a big waste of time and effort, just keeping it honest, there is honest consideration for both of those as to continued determination. And, although already integrated, reaching out to Senator McCain incorporating greater perseverance. And although not interested in the politics reaching out to the new Secretary of Human and Health Services (HHS) as there might be a chance of gaining some traction with the incoming administration.

Lastly, my life [wife] and another great friend, both huge supporters who been to three of the five presentations, did have some advice relating to the content of specific slides for this presentation. However, although I will consider their advice I do not see their advice as a game changer to the overall goals.

What are the key lessons to share with others? (1) The heart is in the right place. (2) The message is the right one. Can the tone be changed? Hard to say (admit). (3) The spokesperson is not the best choice. (4) Comic relief is effective.

What next? Another abstract submission is pending approval and another one or two are likely to be submitted. However, again, when it comes to submitting more abstracts time is a huge lost luxury. Nonetheless, the intent continues to be the same: awareness, recruitment and change. And as mentioned in previous AARs, more, in many forms, is needed under the belt to get the foot in the right doors thus submitting more abstracts, despite most have been rejected and a huge loss of time, will continue to be submitted. At least until I tire.

As already mentioned other vehicles to consider would be a poster and/or a class presentation despite neither appealing to me in regards to time wasted. And of course continue to reach out to Senator John McCain’s (AZ) and now the new HHS Secretary as well with greater perseverance with regard to abolishing HCAHPS, as either in our corner will MOST definitely turn heads.

What should be expected in a year from now? Hard to say, as the book has now been out for 4 years and this the fifth attempt to gain companions without gaining any, again. Although getting Senator McCain’s the new HHS Secretary’s attention would be a HUGE game changer it is more a fantasy than obtainable and the same goes for trying a class of the same theme/intent. But willing to try despite another side of me is convinced that if by the book’s 5th year the needle has not moved it is time to move on. But only time will tell.

Any personal lessons? I never thought this was going to be easy. But I never thought it was going to be so frustrating either. And again, after not moving the needle, like so many of times before I considered putting down the guidon (flag). However, at this conference I was given some energy to press on. In the past I have had to remind myself this is not about me but about healthcare. And if not me who? My bridges 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 LOTS of something else especially since at the moment I am currently unemployed and this time finding a new job has been very challenging, for a number of reasons. However, none of those reasons are what any of this is about.

In the past, and again, 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 here either. However, I truly want to take healthcare back and make healthcare great again.

However, the bottom line is time. And does it take a lot of time. It does! Time during which I could be doing, as already said so many times before, LOTS of other things! Additionally at some point I might realize “what is the point?” But until then I will continue to submit abstracts and pursue the others mentioned hoping that 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 have been the healthcare executive who asked me to tone down the message and it’s delivery. That said, Nelson Mandela told us, “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. That said, aside being my own harshest critic I am also my own biggest hindrance as well.

That aside, the criticism of myself or from others I can handle but finding another spokesperson is going to be quite the challenge and the former administrator at this conference remained me of that by telling me, “No one wants to be without a job.” Yes! I get it. But then a little voice inside my head reminds me, “Warriors are not the ones who always win, but the ones that always fight.” -Unknown

Again, a lot of time and effort goes into these presentations for nothing to be accomplished. Also as already mentioned, the book has been out for four years now and I realize my writing sucks but the intent, taking healthcare back to make healthcare great again, is still the only message and goal of the book and ALL of this yet neither have gone anywhere.

I realize Florence Nightingale didn’t change nursing over night either. And before the emails, in NO manner am I comparing myself to Florence, oh no, but instead just reminding myself that change is never accepted or so easy. And why the underlying message is to press on! The more exposure the more exposure, I guess. Most definitely, reaching out to Senator McCain and the new HHS Secretary although a fantasy a HUGE game changer and nothing to lose by doing so but more time.

THANK YOU to everyone who attended the presentation, especially that ONE person who “Liked” the book’s Facebook page and those who encourage me to press on!

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