Improving Healthcare Blog

The Hidden Program of Care

Bradley R. Fulton, PhD, Researcher, Press Ganey Associates — Wed, 09 May 2012 12:00:00 GMT

After graduating from my doctoral program, I obtained a two-year post-doctoral fellowship in “environmental psychology.” Yes, I know it sounds like I was going to study the effects of climate change on mental health. In actuality, I was about to begin working with an architect.

Environmental psychology is a curious area of psychology that focuses on the interrelationship of environments and human behavior and mental processes. Thus, although studying the effects of nature, or climate change, on our mental health certainly falls within the purview of environmental psychology, my intent was to study the “built” environment; that is, environments that have been built by humans.

At the time, my research focused on gerontology – my focus is more properly referred to as environmental gerontology. Specifically, I was interested in on the quality of life of persons with dementia. Studying the built environment was an important aspect of my research, as many persons with dementia are cared for in built environments. Traditional models of nursing homes were (and still are) beginning to be replaced with more advanced models that are informed by an understanding of how humans interact with their environments. These models are more home-like and less institutional, reducing the often upsetting transition from living in one’s own home to living in an aging community. They take advantage of colors, smells, sounds, and other sensory stimuli to create an engaging environment. Many of the design features are intended to make “way-finding” easy. They are designed to promote “aging in place” rather than the constant moving to progressively more sophisticated care environments often associated with dementia care. The overall focus is to exercise and enhance the residents’ abilities, rather than protect them from their disabilities.

As I proceeded through my studies I was introduced to the concept of the “hidden program.” This is an important concept to the study of environmental psychology. Essentially, the hidden program is comprised of the implied expectations of a built environment. The best way to understand the hidden program is through an exercise. Consider the waiting room of a primary care practice. A typical waiting room has chairs in various arrangements, magazines, windows, a television, perhaps an aquarium and some toys for children, and a door through which a nurse will appear and call our name. The general construction of that room, its features, and the arrangements of the various amenities speak loudly. They inform people how to think and how to behave within that setting. What is a person expected to do? Generally, a person is expected to wait. And while they wait they can watch television, read a magazine, look at the pretty fish, or play with some toys. Nowhere are these behaviors written down – they are implied and expected. What also is implied is what we are expected not to do there. What would happen if I walked in with a sleeping bag and pillow, laid it out on the floor, and took a nap while I waited? That might be a bit unexpected. (So much so that I may be asked to either leave or make an appointment with a psychologist.) Or what if I brought in my two daughters and a bunch of blankets, and started re-arranging the chairs into a “fort” while I waited. No written rules against that.

Take a moment and reflect on the environment, or “place,” you are currently in, whether it be a small private room, a common area within a building, or somewhere outdoors. Seriously, consider for a moment what you are expected to do there? What are you not expected to do there, and why? What changes would you like to make to that place, and why? What would you like to do there? Why don’t you do that? How do others use that place? How does that differ from how you use it, and why?

As I moved beyond gerontology, and began research in other care settings, the hidden program revealed itself to me as an important organizing construct, one that certainly has implications well beyond environmental psychology.

See the figure below, a simple Donabedian-type health quality model. On the left are the care elements, the inputs of the system. These inputs are filtered through the care practice, which basically consists of the attitudes and behaviors of the various players. Finally, there are outcomes: clinical, financial, and satisfaction. But perhaps the most important aspect of this model is the arrows, which represent the program. The light color is meant to emphasize the many “hidden” aspects of this program. In the phrase the hidden program, the “program” refers to the behaviors and attitudes the structure of the care elements afford, and how these, in turn, affect care outcomes. Not all elements of the program are hidden, of course. We know what our incentives are. We are aware of evidence-based care and how that impacts our care practice. But many elements are hidden to us. Thus, the word “hidden” suggests that we often do not (or cannot) consider many of the relationships among these three constructs.

A Model of the Hidden Program of Care

Now pretend that you had the ability to “un-hide” all aspects of the program. How important would that be to your practice of care? Consider the ability to fully understand patient expectations, and what is driving those expectations. Consider completely knowing physician and staff attitudes, how those interact and influence their behaviors, and how those behaviors influence the client. What if we could reveal the full impact of care practice elements on care outcomes? Would that be helpful in structuring the care elements in such a way as to positively impact care practice and through it care outcomes?

Now, finally, consider measurement. This is precisely what we are doing when we obtain and consider operational, clinical, financial, satisfaction and other metrics. We are “un-hiding” the hidden program. We are doing this when we analyze these data and uncover relationships. When we engage in quality improvement, we use these metrics to introduce changes to the structure of care elements that will lead to improved care outcomes:

What is your hidden program of care?
What steps are you taking to “un-hide it?”
What aspects remain hidden to you and what can you do to un-hide them further?

The more our program of care remains hidden to us, the less control we have over it, and the less control we have over care outcomes. The foundation of effective quality improvement is un-hiding and understanding our program of care.

My Top 10 List of Reasons to Attend a Symposium

Deb Stargardt, MBA, Improvement Manager, Press Ganey Associates — Wed, 25 Apr 2012 12:00:00 GMT

I’ve just returned from an inspiring two days in San Francisco. No, I wasn’t touring the wine country – although that doesn’t sound like a bad idea. Actually, I was attending the Press Ganey Regional Education Symposium. Before you roll your eyes at my use of the word “inspiring” to describe a symposium, let me explain. Did you know that the word inspire comes from the Latin verb spirare meaning “to breathe?” Inspiration literally means to breathe into. Along with the fantastic spring air in San Francisco, I was able to breathe in some fresh ideas and perspectives. It felt good to inhale the positive energy and exhale discouraging thoughts.

At the same time, if you’re like me, it takes more than one colleague’s suggestion to persuade me that an activity is worthwhile. I couldn’t get David Letterman on the phone, but here is my version of the Top Ten Reasons to Attend a Press Ganey Regional Education Symposium:

10. “You don’t know what you don’t know.” It’s trite, but true. One of the realities of our nation’s economic crisis is businesses having their best and brightest workers stepping up to wear many different hats. If you are a star, you know this to be true. Your organization depends on you for that “one more thing.” Perhaps your most recent responsibility is patient satisfaction. Regardless of how you have prioritized the myriad of duties you face, Press Ganey has anticipated the questions you might have.

9. “You’re not alone.” This comment appears regularly on the symposium evaluation forms. Attendees remark that, “It’s reassuring to know that other hospitals are on a similar journey to ours.” There is safety in numbers, and many health care professionals are dealing with challenges similar to yours.

8. “Ignorance isn’t bliss.” We’ve all heard that expression, “Ignorance is no excuse in the eyes of the law.” Try telling CMS you didn’t know about the HCAHPS survey requirements! The symposium offers real-time knowledge in clinical quality and efficiency; employee and physician engagement; medical practice; and service excellence – knowledge that translates to monetary gain in a pay-for-performance world.

7. “It feels good to get away.” These are stressful times in health care, and we should all take a moment to renew now and then. The symposium is a great way to get away from cell phones, pagers, email and putting out fires and sit down with fellow professionals to simply talk about how to make health care better.

6. “Free therapy.” Seriously. We all have a story and it is therapeutic to tell it to empathetic listeners. Some of the best discussions come from sharing an incident or patient comment. The keynote speakers at the symposium are very special people sharing their talent in reaching into the complexities of health care and pulling out heartfelt compassion and enthusiasm.

5. “Registration is less than gourmet coffee.” If you can spend $4 a day on a soy latte, you have a great head start toward the cost of a Press Ganey Regional Education Symposium.

4. “Education teaches you how to spell experience.” It’s like the chicken and the egg when we talk about the value of education and experience. The truth is that it takes both to be successful in life. The symposium environment offers new leaders the opportunity to learn from tenured leaders.

3. “You meet lots of patients.” Think about it. Are there any of us who have not had a personal experience in health care? The sessions are designed to keep the focus on the patient. Participants are able to explore different “what-if” solutions and scenarios to determine how they might be perceived by patients rather than caregivers.

2. “Adults are slow learners.” There are lots of reasons for this – none of them negative. Adults have established ways of doing things. They are preoccupied and need to know the relevance and immediate application of new information. It’s hardly a surprise that many adult educational endeavors fail. The Press Ganey Regional Education Symposium is designed for adult learners. Attention is given to examples that convey authentic problems and best practice solutions.

1. And the top reason for attending a Press Ganey Regional Education Symposium? “You can get to ‘always’ from here.” The upcoming symposium destinations of Houston, Boston, Atlanta and Chicago are really just way stations on your journey to “always” on your surveys. Many organizations are looking for a back road or shortcut to take them to their goals. Your major highway may appear congested with stop and go traffic – scores that go one way for a while, and then a dogleg takes you off in another direction. The symposium will get you back on track and help you set a compass that will take your organization to always.

It’s not too late to sign up for one of the remaining Regional Education Symposiums. If you are reading this post, you’re just the kind of knowledge-seeker we are hoping to attract. Come share your unique insights with other Press Ganey clients. It’s a wonderful experience just waiting to happen.

Overcoming Our Instincts on Price and Quality

Wed, 18 Apr 2012 12:00:00 GMT

Most of us believe that when we pay more for a name brand product, we are getting more for our money. Some do this even knowing that some companies jack up prices to build a sense of exclusivity for the brand. In fact, marketing research shows that in the absence of evidence of higher quality, consumers still think, “It’s expensive, so it must be good.”

And yet, a casual glance at any issue of Consumer Reports shows that in many cases the price-quality correlation is spurious; many higher-quality products can be bought at bargain prices. This general relationship holds true for health care.

The mantra of payment reform is to move from paying for volume of service provided to payment for value. Value is the relationship of cost and quality. In order to get to value-based payment, we need metrics to prove quality and cost-effectiveness. Great strides have been made as far as the quality measure piece of the equation is concerned; not so much for the cost component.

The Hospital Inpatient Value-based Purchasing Program for fiscal year 2013 includes clinical process and satisfaction measures. For fiscal 2014 outcomes measures were added, including survival measures for acute myocardial infarction, heart failure and pneumonia. This month, we are expecting the proposed rule for fiscal year 2015 to be issued by the Centers for Medicare and Medicaid Services (CMS). It is expected that a proposed measure that was dropped in the final 2014 rule will be resurrected in the 2015 proposal – Medicare spending per beneficiary. This measure assesses Medicare Part A and Part B payments for services provided to a beneficiary during a care episode running from three days prior to an inpatient hospital admission to 30 days post-discharge. The payments included in this measure are price-standardized and risk-adjusted to remove sources of variation not directly related to a hospital’s decisions in providing care. CMS said it would post hospital-specific performance on the measure in April, so things are heating up.

Posting value scorecards such as this on a government website is supposed to drive patient choices of where to seek care. Of course, there are risks. Providers may try to game their ratings, for example, by avoiding care of patients with high-risk or costly conditions. The public may misinterpret what the reported measure scores really say about quality, cost and the interrelationship of the two. Attribution poses another huge challenge; a cost-measure spanning pre- and post-discharge leaves a valid question of how to hold the right providers accountable for high costs. For now the approach appears to be making the hospital responsible, leaving it to find a way to make it work. It’s the same approach CMS is taking with readmission measures, which ding a hospital for a readmitted patient even if the second admission occurs at another hospital.

Judith Hibbard from the University of Oregon just published fascinating results in Health Affairs of an experiment that tried to test how to best display quality and cost results together so that consumers could make choices based on overall value. I found it intriguing but unsurprising that a substantial portion of consumers in the study avoided lower-cost providers. So it isn’t only Mercedes and Prada and Apple that leave consumers starry-eyed; even consumers who pay a larger portion of their health care costs out of pocket tend to associate high cost with high quality.

An overwhelming amount of research into the cost-quality relationship in health care has found no substance to the assumption that high cost means high quality. If we want to break the vicious cycle of increasing cost of health care, consumers have to play a crucial role in making informed decisions where to seek care, and value should be an integral part of the decision-making process.

So are we doomed because of our beliefs? The results Hibbard and colleagues uncovered have a silver lining: When cost data were displayed together with easy-to-interpret quality metrics and high-value options, consumers were more likely to overcome the association between high cost and high quality and more often selected the high-value providers. Since consumers tend to be more interested in the quality of health care than in its cost, it will be crucial that public reports are designed to make it easy for consumers to understand the factors that drive value.

Health care providers and those of us who support performance measurement and improvement should embrace this kind of transparency. As coverage expands (if the Supreme Court doesn’t stop it) let’s welcome the new generation of value-savvy patients with open arms, ensuring that it has the most relevant and valid data to help choose the providers of high-quality and cost-effective care. In the long run, it will be best for all of us.

To Cure the Patient, Treat the Whole Person

Patrick T. Ryan, CEO, Press Ganey Associates — Mon, 02 Apr 2012 12:00:00 GMT

Starting in October, scores from a government-mandated patient satisfaction survey will determine a portion of hospitals’ Medicare payments, and many organizations are worried about the financial fallout. A recent study published in the prestigious Archives of Internal Medicine posited that higher patient satisfaction scores correlate with greater use of hospital services and higher mortality. Some healthcare professionals have jumped on that assertion as proof that because good clinical treatment can be painful and traumatic, patient satisfaction is ipso facto a faulty gauge of who gets the best care.

With over 30 years of experience working with physicians and nurses in organizations that provide direct care to patients and having recently joined Press Ganey, an organization with over 25 years of experience in measuring, reporting and driving improvement in the patient experience of care, my company and I hold a far different point of view. There exists a large and long-established body of research, published in equally prestigious journals, that finds patients are actually quite accurate judges of health care quality. The skeptics also forget that it was hospitals that first began surveying patients on their care experiences back in the 1970s. Hospital leaders knew back then – as thousands of medical providers know today – that respected and empowered patients are more willing to be active participants in their care and also have better outcomes.

Before addressing the skeptics’ arguments, let’s set aside the straw man in the debate: Those who advocate for service excellence in medical care are not talking about making the experience akin to that of a hotel, but rather about removing defects in care that lead to avoidable suffering. Survey questions that ask the patient to evaluate time spent with clinicians, the frequency of communication and care coordination among nurses and doctors, and the safety and cleanliness of the care setting, are all about evaluating quality of care.

Now, on to the Archives of Internal Medicine study, conducted by a research team at the University of California-Davis. The study finding – that higher patient satisfaction scores correlate with higher costs and more patient deaths – was more than surprising to those who passionately advocate for patients. That’s because it was 180 degrees away from previous research, including:

A Duke University study, published in the American Journal of Managed Care last year, found that higher hospital patient satisfaction scores were strongly associated with lower 30-day hospital readmission rates for heart attacks and pneumonia. An earlier report by the same team of a smaller cohort of hospitals found a correlation between higher patient satisfaction and lower inpatient mortality rates for the same conditions.
A major study in the New England Journal of Medicine in 2008 of clinical data from 2,429 hospitals found a strong positive correlation between patient overall satisfaction and clinical performance.
A 2007 analysis of data from the Pennsylvania Health Care Cost Containment Council and my company found that facilities in that state with higher patient satisfaction scores on room cleanliness, technicians’ blood-drawing skills and nurse responsiveness to patient concerns tended to have lower rates of infections and infection mortality.
Three research articles published from 1996 to 2002 in the Journal of Pain and Symptom Management showed that patients are satisfied with their care even though they are in pain.

Those and other studies led us to look more closely at the recent UC-Davis research. We found its conclusions and inferences controversial. It only examined patient evaluations of physicians, rather than hospitals, which made the link between satisfaction and hospital deaths not credible.

The patient satisfaction survey tool used by the UC-Davis team asked patients to rate their primary care physician over an entire year as well as the care they received from all providers in all settings. A more accurate means of establishing a relationship between patient satisfaction and care quality is obtained through surveys that are sent to patients within 12 weeks of discharge asking the specifics of each encounter.

Put into everyday language, these findings tell us that that there is a difference between simply doing something – treating the condition – and doing it in a way that meets the other needs of the patient, such as being treated as a person, acknowledging pain and letting the patient know everything possible is being done to help. Health care providers are expected to cure the illness; they excel when they also treat the patient as a human being.

How Far Have We Really Come on Patient-Centered Care?

Lisa Cone-Swartz, Vice President, Product Management, Press Ganey Associates — Wed, 28 Mar 2012 19:22:00 GMT

Across the country, there is a shift from paying for volume of health care to paying for quality and efficiency. Patient-centered care – defined by the Institute of Medicine as “care that is respectful of and responsive to individual patient preferences, needs, and values” – is one of the key ingredients of care quality. Patient-centered care also can help lower medical costs and reduce the need for some health care services, according to research by the University of California-Davis Health System.

So if patient-centered care results in higher quality care at a lower cost, it makes sense that this concept would be widely adopted. It turns out, if you look closely, we really haven’t come very far. The British psychoanalyst Enid Balint is credited with coining the term “patient-centered medicine” in 1969, yet on a 2012 patient-to-patient online forum, I find the following post: “I have the most basic question – how do I find a good specialist who also welcomes an engaged patient? I have a very competent doctor who scoffs at my efforts to self-educate and discounts my findings, yet doesn’t communicate even the basics, only dictates what I should do next.” Numerous people responded to this post to share their own experience with a provider that did not exhibit a “patient-centered” approach.

The topic is highlighted in a recent article in the March 1 issue of the New England Journal of Medicine, “Shared Decision Making – The Pinnacle of Patient-Centered Care.” The authors write: “Caring and compassion were once often the only ‘treatment’ available to clinicians. Over time, advances in medical science have provided new options that, although often improving outcomes, have inadvertently distanced physicians from their patients. The result is a health care environment in which patients and their families are often excluded from important discussions and left feeling in the dark about how their problems are being managed and how to navigate the overwhelming array of diagnostic and treatment options available to them.”

To address this “inadvertent distancing of physicians from their patients,” many are focused on the concept of patient engagement. Christine Bechtel of the National Partnership for Women and Families wrote in a forward to Transforming Patient Engagement: Health IT in the Patient Centered Medical Home: “The bottom line is this: You can’t be patient-centered without both patient engagement and patient involvement in the way care is provided.”

Transforming Patient Engagement, a 2010 publication of The Patient Centered Primary Care Collaborative, can be used as a resource for providers looking to focus on providing patient-centered care. It contains a dozen papers and two dozen case examples that touch on many facets of patient engagement. The papers include everything from one-on-one strategies for engagement, such as motivational interviewing and shared decision-making, to practice structural changes, including team-based care and intensive chronic disease management.

While it would be beneficial to have a gauge of how engaged a patient is, most providers report that they lack systematic collection or discrete reporting of a profile of their patients’ level of engagement in their own care. Recognizing this gap, Press Ganey and the American Medical Group Association recently announced the launch of a unique survey tool, the Coordinated Care Survey, which asks patients to assess their own behaviors and beliefs, not just their perspective on the providers’ performance.

Moving from traditional passivity to active, informed engagement will be an unexpected challenge for many patients. Those who are unable or unwilling to participate actively and knowledgeably in their care are more likely to suffer preventable illness, receive less effective care, pay more out-of-pocket costs, experience poor outcomes and suffer a diminished quality of life.

Moving from a patriarchal role to a partner role will be a challenge for many providers. Those who are unable or unwilling to actively practice “patient-centered care” may lose out on compensation or bonus payments that are based on quality care, lose out on favorable reimbursement terms or even lose their job.

The shift to patient-centered care may be full of challenges, but the stakes are too high for all of us to let another few decades pass before “patient-centered medicine” is the norm.

Want to Improve Morale? Try Getting Around

Wed, 21 Mar 2012 12:00:00 GMT

We at Press Ganey get a lot of questions from critical access hospital executives wanting to know what they can do to improve employee relations. It’s a key concern, especially because poor staff morale has a proven link with lower patient satisfaction scores, employee retention and recruitment. It also affects a hospital’s reputation in smaller communities, where people tend to know others who work in the facility.

I usually tell executives to focus on these two things: Active listening to employees and recognizing jobs well done.

On the first solution, establish and keep up places where you can go to hear employees’ suggestions, requests, concerns and ideas – a listening post such as a coffee club or a leadership round. One of the key drivers of morale in health care organizations is satisfying staffers’ need to have influence on things that affect their jobs and feeling as though leaders listen to them. If a leader does nothing else, he or she should sit down and develop five key listening posts that cover all aspects of their employee base regularly – and make sure to attend these events rigorously. So, if each week one of the leaders hosts a “coffee club” with employees, make sure it is held no matter what, even if the department of health is at the front door.

Of course, you also need to respond to employee input. Have a regular means of follow-up communication, either through a newsletter, a manager or in person, describing the action taken based on employee concerns.

Then there is genuine recognition. I don’t mean sending out an email that says “thank you for what you do.” I mean leaders and managers genuinely reaching out to individuals and acknowledging that what they are doing is making a difference. If you notice an employee holding the door open for a visitor, go out of your way to mention that at a department meeting.

Both of these steps require that leaders and managers do two things: Get out of the offices and walk around and look and listen. Keep your eyes wide open and ears even more so, and close the loop by making sure employees know they have been heard.

You don’t need always need survey data to help you decide what to do.

Value-based Purchasing Solutions are Often Hidden Beneath the Surface

Thu, 01 Mar 2012 13:00:00 GMT

In my spare time I teach nursing leadership and management at Missouri State University. During a recent course I was helping the students review and prepare for an exam when I realized there was so much content that they really were unsure of where to start. We took a time out to review, and I’m happy to report that the students did very well on their exam.

It occurred to me that this is very much like what hospital executives are facing today. There is so much coming at them from regulatory agencies, patients, physicians, their colleagues and the local market that it may feel overwhelming to determine where the highest and best priorities lie. Quality and safety of the care provided in the hospital have been on the front burner for many years, as has patient experience. Pay for reporting, core measures and patient safety goals have been priorities for at least a decade. Now, the challenges are exploding, the result of value-based payment (VBP), new quality metrics, the need to partner with other providers and much more.

As a staff nurse in the 1980s I was expected to respond to patient satisfaction surveys. However, reaction and accountability for patient satisfaction (and quality too) was very department specific based on the survey data. Today, there is no room for silos. Under value-based purchasing, those responsible for patient satisfaction, core measures and clinical outcomes will have to work together to ensure full reimbursement and maintain market share. It isn’t just about meeting reporting rules; it is about improving care quality across the board. In addition, our reimbursement is as much tied to how others are performing as it is to how the individual hospital is performing. When you begin comparing anything to anyone else, everyone begins to get better. That makes it even harder to continue that improvement. With VBP, we also know that when a measure is “topped out” – meaning the majority of organizations are scoring at the highest level – that measure is removed and another takes its place.

How does a hospital executive determine how best to meet these challenges? As I realized with my nursing students, sometimes the solution to the challenge that the executive thinks will work best, may not be the right solution for sustainable improvement and success within VBP. HCAHPS is a great example. The hospital might be scoring low on the nurse communication domain, and the executive may appropriately say that this means the nurses are not communicating as well with the patients as they need to be. The suggested solutions may be more training, goal setting and accountability for nurse communications. But what if it’s not the nurses’ communication skills that are the problem? You’ve trained them well, you’ve established goals and accountability but still it only gets better for a short time. What’s missing is the root cause for why those nurses may not be communicating well (and the physicians too!).

It is important to remember that you cannot separate the patient experience from what we do to the patient. Do nurses have time to establish relationships with patients? Do we have mechanisms in place that look at staffing not only for the midnight census but also recognizing what happens throughout the day on the busy inpatient units, where beds may actually be “turned over” twice to reduce length of stay and assure observation patients are discharged appropriately? Or are we also incorporating acuity into our staffing algorithms? Have we assured that we aren’t creating a situation where the post-anesthesia care unit or the emergency department bolus patients to the inpatient units because either the elective schedule for the operating room has too many peaks and valleys or the ED must wait for admission orders from the hospitalist? That hospitalist may be the only one on duty; he or she may want all patients held in the ED so that he/she can come see all the patients and write the orders for admission in one visit. These issues must be factored into the solution to improve the HCAHPS domain of nurse communication.

This is just one example of making sure that the solution we think is best to address an issue is really the right solution and the issue is really what we think it is. This kind of root-cause analysis that has worked so well to reduce risk and improve quality should be employed with our core measures and patient experience metrics. A Band-Aid for the immediate situation may help in the short term, but what solution will offer the best sustainable improvement and success? Sometimes it’s not necessarily the ripple we see on the surface but the iceberg under the waterline that is the real concern.

Cultural Competence and Biomedicine

Robert Wolosin, PhD, Research and Analytics, Press Ganey Associates — Thu, 23 Feb 2012 13:00:00 GMT

For many, culture has come to mean “the way we do things around here,” but that’s not quite right. More correctly put, it is “what we take for granted around here.” In other words, practices that are incorporated so deeply into a group’s way of life so as not to require conscious thought are parts of that group’s culture. For instance, no one questions why we speak English in America (although in “My Fair Lady,” it is noted that America was one place where English completely disappeared!) We are born into a society of English speakers; we learn it at home and school. We use it in the course of everyday life. (If you are beginning to tire of this list, it just proves my point: English is an element of American culture that doesn’t have to be explained.)

When commentators talk about cultural competence, they generally refer to the ability of a medical provider to relate to patients from different cultures. Thus, Anglo providers are encouraged to become familiar with Hispanic or Russian or Hmong culture and language, presumably so as to be better able to get along with, understand and treat such patients. (An Internet search for “medical Spanish” yielded 22 million hits, including an ad for a smartphone app.) Medical students and residents are warned about cultural faux pas when dealing with representatives of non-Anglo cultures. In the medical encounter, one such faux pas is the direct approach of a Hispanic woman without getting “permission” from her husband or father.

But what about the culture of medicine itself? The way medicine is practiced in this country is a culture unto itself, with its own values, myths, practices and ideologies. Some of the values are rationality, measurement and scientific method. Elements of biomedical ideology include a hierarchy in which other workers are subordinate to physicians and their decisions, as well as framing the participants in medical encounters as knowledgeable experts treating ignorant patients, so as to justify the expectation that patients will follow “doctors’ orders.”

The transparency of this culture to its providers makes it difficult for them to transcend it in any encounter, not just encounters with representatives of non-mainstream cultures. Speaking “medicalese” is merely the tip of the iceberg. Doctors who neglect the culture of medicine may perpetuate practices learned in training without considering whether or not they are in the patient’s best interest. Instead, such cultural practices (such as tonsillectomy for persistent childhood sore throat) may result in much mischief.

What is needed is a thoroughgoing self-consciousness on the part of providers so as to take the differences between biomedical and lay culture into account, and when appropriate, transcend medical culture to adopt a more personal perspective.

When providers examine their own culture and step out of it to deal with patients as persons (and not simply bearers of broken machinery) they may rediscover the joy of genuine, healing human connections that prompted a medical career in the first place. And patients may be happier and more willing to follow through with recommendations.

A Patient’s Experience and a Dream

Thu, 16 Feb 2012 13:00:00 GMT

Last fall I conducted an alumni interview of a high school senior who was seeking early admission to my alma mater. Among a dozen or so standard questions, I asked, “So what do you want to be when you grow up?” Without hesitating, she said, “pediatric endocrinologist.” “Huh?” came my eloquent reply.

I have always been interested in how people choose – or end up in – their careers. For many, it is a series of chance occurrences to which they apply a grown-up version of “eeny, meeny, miny, moe” at the appropriate time. But despite all that, somehow most people seem to end up where they belong. Or perhaps they simply take a liking to one of the things they stumble upon and stick around long enough to make a career of it.

But when it comes to health care providers, one hears different stories altogether. So many of the caregivers I meet report that they always knew they would become a nurse or a doctor. Sometimes it runs in the family (“I come from a long line of nurses”). Sometimes the family runs it (“My mother always said I’d be a great doctor”). Sometimes it’s an urge from the gut (“I always wanted to help people”). But there’s a common thread in their stories: knowing from an early age that they were destined to be caregivers. They didn’t choose it as much as it chose them.

In the case of my interviewee, I heard an interesting variation on this theme. While she was saying “pediatric endocrinologist,” I was thinking that most medical students haven’t a clue what specialty they will practice; how could this high school senior know with such certainty? But it turns out that this young woman has had far more exposure to the health care system than most medical students—exposure that has shaped her life in immeasurable ways. Diagnosed at a young age with a complex chronic condition, she has spent nearly a third of her life as an inpatient. Given that context, the precision of her reply is easier to fathom.

What particularly fascinated me was the primary reason she gave for wanting to pursue a career in medicine in general and in pediatric endocrinology in particular. While it was her “amazing caregivers” who first inspired her to consider a career in medicine, the thing that really drives her ambition is her experience as a patient and her desire to improve the patient experience.

Having spent a cumulative six years in acute care beds at several different hospitals, this young woman truly has seen it all – the good, bad, beautiful and (sometimes) downright ugly. Generally, she had extremely positive things to say about the health care system and about her caregivers. But the extent of her exposure gave her plenty of time to think about how her experience might have been different and how future patients’ experiences will be different as additional knowledge is amassed – here she referred in particular to additional understanding around creating healing environments for patients.

Without criticizing or complaining – and with a clear appreciation for the complexity of hospital operations – she speaks eloquently and candidly about communication between caregivers and patients, the challenges of pain management, how her emotional needs were met (or not) and the impact of all of these factors on her own experience.

We had a particularly interesting discussion about the use of alternative therapies for pain management and doctors’ reluctance to use such approaches on pediatric patients. “Their hearts were always in the right place; they wanted to relieve my pain. But I was more interested in learning how to cope with my pain – an idea I had a hard time getting across to my doctors.”

I have reflected on this fascinating conversation many times since it took place – not only because it was an opportunity to spend time with an extraordinary young woman who truly has persevered against all odds, but because it crystalized for me the value of the voice of the patient. It served as a clear reminder of the importance of our work and how much we can learn from the very person we ultimately hope to help: the patient.

I am so very hopeful that this young woman – who is healthy now and who was just accepted early decision to my alma mater – will indeed become a doctor. We all know the old adage that doctors make the worst patients. I came away from this conversation thinking that patients might just make the best doctors.

Developing Stage Presence in Health Care

Sandy Myerson, RN, MBA/MS, Managing Consultant, Press Ganey Associates — Wed, 08 Feb 2012 13:00:00 GMT

Stage actors, movie stars and dancers have it. Musicians and rock stars have it. Newscasters and national lecturers have it. What do they have that health care providers could benefit from incorporating into their daily work? Stage presence! It’s not just actors, musicians and dancers who need it today. Doctors and nurses can use the tools of the theater to connect with patients, resulting in greater understanding of treatment and reduced anxiety.

Many in health care disagree. “I went to nursing school so I could help people, not to learn how to be an actor,” sums up this attitude.

The Oxford English Dictionary defines stage presence as the ability to command the attention of an audience by the impressiveness of one’s manner or appearance. Presence is derived from the word “present”; therefore stage presence means focus and attention on the interaction at hand – to be in the moment. Health care providers are often distracted, prioritizing simultaneous requests for their attention, yet they need to establish immediate rapport with patients. Stage presence means the ability to set aside distractions, giving undivided attention during interactions with patients and family members and using effective communication to establish that immediate connection.

There is more pressure than ever to improve patient satisfaction scores and waiting times in the emergency department. Hospitals are now reporting data regarding average length of stay in the ED, with the expectation that the data will soon be publicly available. Additionally, hospitals will feel the impact of achievement in value-based purchasing measures this spring; studies have shown that the experience patients have in the ED sets the stage for how satisfied they are with their inpatient stay as reflected in scores on the Hospital Consumer Assessment of Healthcare Providers and Systems survey. Reducing waiting times and the average length of stay are not sufficient to improve the patient experience; staff members and physicians must also communicate with care and compassion. EDs that rank in the top decile for patient satisfaction have not only implemented strategies to improve patient flow, they also have a culture in which all members of the care team have learned to use certain phrases and words during patient interactions and transitions along the ED visit, embracing the elements of stage presence.

That requires all staff members to “act” a certain way, at all times, regardless of any stress they might be experiencing in their personal lives. Additionally, much of the work performed in an ED is done in view of patients, so staff members are always on-stage – they need to leave the work area to be off-stage. Finally, work becomes routine for staff members and physicians – it is just another day in the office. Yet for the patient, the visit to the ED is anything but routine. For many, it is the first encounter with the hospital; they’re not feeling well, don’t know what to expect and are anxiety-ridden. Often, patients fear the worst. “Is this cancer?” “Am I having a heart attack?” “My father died when he was the age I am now.” Keeping in mind the patient’s perspective will help staff members treat the “routine” patient complaint with the level of attention and focus required so that the patient feels valued.

There are a few key words and phrases health care providers can deliver to patients using stage presence to help ease anxiety and demonstrate compassion and concern. When patients present to the ED, clinicians always ask, “What brings you in today?” They should also ask, “What are you most concerned about?” Responses to the latter question give physicians and nurses important information that will enable them to address patients’ concerns directly, resulting in a higher level of patient satisfaction. Another key phrase clinicians can use to connect with patients is to say, “I’m so sorry you’re not feeling well.” This immediately communicates a sense of empathy. When followed with, “We’re going to do everything we can to help you feel better,” patients often breathe a sigh of relief, knowing that you take their concern seriously.

When care providers connect with patients in a caring and compassionate manner, patients’ anxiety diminishes. When doctors and nurses focus on the patient, listen actively and respond accordingly, rapport and trust develop. These approaches, when combined with efficient ED processes, result in a higher-quality patient experience.

Stage presence isn’t just for actors anymore.

Listening with Purpose

Deb Stargardt, MBA, Improvement Manager, Press Ganey Associates — Wed, 01 Feb 2012 13:00:00 GMT

I’ve been an apprentice of servant leadership for several years now, having once been in the role of teaching its principles to health care leaders. In his classic essay, “The Servant as Leader,” Robert K. Greenleaf said that “only a true natural servant automatically responds to any problem by listening first.” As caregivers, we may not be able to take away all of the pain, sadness, disappointment or anger that an illness provokes, but we can listen. As a hospital services improvement manager at Press Ganey, I’ve noted just how granular a patient’s perceptions of this can be. How is it that a nurse or physician can demonstrate service excellence by “always” treating patients with courtesy and respect and explaining medications and so many other aspects of care, but struggle with the patient’s perception of “how often did doctors/nurses listen carefully to you?” I’ve decided to put my servant heart to the test on this dilemma.

First and foremost, the use of the word “carefully” is intentional. Listening should be intentional – with purpose. A case in point is the way I sometimes respond to my sons when they walk into a room while I’m busy at work. Priding myself as an above average multi-tasker, I lend only a partial ear, offering little more than an occasional nod and “uh huh” here and there, relying on my filter for hot words to alert me when more attention may be required – words such as police, flunk, insurance, etc. What would I need to do differently or more often for my child to tell his friends, “My mom always listens carefully to me.” I’m reminded of some effective communication techniques I’ve discovered through the years – all of which promote engagement in the listening process:

Restating – repeating what you hear the person say, but in your words. “Let’s see if I’m clear – you had your purse on the chair and now it’s gone?”
Summarizing – bringing the pieces of the conversation together to verify understanding. “It sounds like you may have trouble getting a ride home from the hospital tomorrow; is that correct?”
Prompting – using brief, positive prompts to keep the conversation going. “Oh…and then…?”
Reflecting – introducing your perceptions and feelings into the person’s words. “This seems really important to you.”
Offering feedback – sharing your initial thoughts on the situation, providing pertinent information, observations, insights or experiences. “It’s not uncommon to be nervous before surgery. I’ve cared for many surgical patients. What specific things are bothering you?”
Emotion labeling – using a descriptive word to restate a patient’s feelings may help the person see things more objectively. “You appear frustrated this morning; what can I do to help?”
Probing – drawing the person out to explore the deeper meaning to what he is saying. “What do you think might happen if you are unable to stay on this new diet?”
Validation – acknowledging the problem, issue or feeling while remaining open and empathetic in your responses. “I appreciate your willingness to talk about such a difficult issue.”
Pausing – deliberately pausing at key points for emphasis. “Your medication may cause dizziness… (pause) … do not attempt to get out of the bed unassisted.”
Silence – allowing for comfortable silences to slow down the interaction offers the person time to think as well as talk. Silence can also be very helpful in diffusing an unproductive interaction.
“I” messages – (not to be confused with iPhone, iPad or iPod) putting the focus on the discussion, not the person, by bringing yourself into the conversation. “I would really like to talk some more, but I need to step away for a bit. Could we continue our conversation when I return to check on you in an hour?”
Redirecting – diffusing an escalation in aggressiveness, agitation or anger by gently changing the topic of discussion. “You mentioned your granddaughter may come visit you tomorrow. That sounds wonderful.”
Consequences – providing a “reality check” as part of the feedback loop. “What happened the last time you stopped taking the medicine your doctor prescribed?”

Self-awareness is another important tenet of servant leadership that facilitates effective listening. When I think about body language and that earlier example of communicating with my sons, it occurs to me that folded arms or a wandering gaze may be sending the wrong signal – impatience, indifference, intolerance, etc. Without realizing it, I might discourage them from speaking openly and honestly – the last thing I would want to do! Pulling out the imaginary mirror, we can get up front and personal with how others perceive us – our demeanor, mannerisms and facial giveaways – exaggerations that only a caricature artist could love. Or perhaps we’ve allowed marvels of technology like COW’s and smartphones to become the focal point during bedside interactions. Experience has provided some insights for enhancing body language and minimizing distractions from the listening process.

Sitting down – assuming that the other person is seated or reclined, getting on the same level opens the dialogue while conveying, “I am taking time for you.”
Eye contact – maintaining eye contact reinforces where your attention lies and conveys “I am interested in what you have to say.”
Touch – reaching out to people with a gentle touch reinforces the human connection and conveys caring. Touching a person’s arm or shoulder lightly while validating their concerns is very powerful. “I can see that you are anxious about going home.”
Hands-free – stopping whatever it is you are doing – if only briefly – communicates “I am giving your words, your thoughts, your feelings my full attention.”
Smiling – a smile in an invitation, encouraging the individual to share thoughts with you while saying “I am here because I want to be.”

The Greek philosopher Epictetus, who spent a portion of his life as a slave, is credited with saying, “Nature hath given men one tongue but two ears, that we may hear from others twice as much as we speak.” I think of it this way – hearing is to listening as data is to information. Absent the ability to translate spoken words into meaningful expressions of human feelings and thoughts, the voice of our patient, customer, colleague or family member simply falls on deaf ears.

Lessons for Health Care from Home Renovation

Lisa M. Daul, MBA, Principal Consultant, Press Ganey Associates — Tue, 24 Jan 2012 13:00:00 GMT

My mother thinks I missed my calling, and my father can’t quite believe the things I actually take on. It’s my passion outside of work – my hidden talent. It all has to do with neglected houses and my desire to make them shine again. I get so much enjoyment and fulfillment out of taking a real “handywoman special” and turning it into something so improved that it isn’t recognizable (with help from my spouse, of course). I once thought this activity to be wildly different from my professional career in quality improvement, but upon examination it is quite similar.

Buying a run-down property takes vision. You have to look past the cracked walls, orange shag carpet and outdated kitchen, and create an image of a new home. Some (typically my husband) may not see the future state as I do, so I have to sell my vision.

Quality improvement initiatives require vision, too. Like dilapidated houses, there are so many processes in health care facilities that could be improved. We know what they are; they usually have been issues for a quite a while. They go unaddressed until someone comes along with a vision for a better future state and generates enthusiasm by selling that vision to others.

In home renovation, the fun begins after you buy the dilapidated structure and are unlocking the door. Enthusiasm is high; you can’t wait to roll up your sleeves and get in to start improving. Soon, you start to encounter unexpected issues such as rotted floors under that orange shag carpet. You end up addressing more issues than originally expected. The progress slows a little, but you stick to your vision and push forward.

In health care, you’ve sold your vision and your quality improvement team is chartered. You hold your first meeting. Everyone is hyped to make changes and finally address this issue once and for all. The team rolls up its collective sleeves and gets to work. You soon discover the process is more complex than expected. You’re slowed due to garnering buy-in from departments you didn’t even realize were a part of the process. But you have a vision and you push forward.

In home renovation, you’ve been working on your property for quite some time now. You begin to focus on all the things that still need to be fixed or updated, and you’re beginning to doubt the prudence of your purchase. You’re feeling overwhelmed, and the vision is fading fast. This is where you pause and pull out the pictures of the property when it was first purchased. You see the tremendous amount of progress that has been made and you take time to celebrate, even though the ultimate vision has yet to be realized. You go back to work on the property with renewed enthusiasm.

In health care, your team has been meeting for what seems like forever. Progress is slow, and some team members begin to miss meetings. You begin to question whether this process will ever be improved. The vision is fading. As the team leader, you realize how necessary it is to pause, see where progress has been achieved and celebrate accomplishments with the team.

In rehabbing properties, sometimes you need a break to reinvigorate. This works for health care teams, too. You don’t abandon the project; you just take a short hiatus. It does wonders to re-energize, refocus, and then drive forward again toward the vision.

In both worlds, sometimes you need to call in experts to help with an aspect of the project. Know when you’re in over your head and don’t be ashamed to get help to achieve the vision.

It’s true that health care is vastly more complex than home renovation, and sometimes the complexity seems overwhelming. I think it helps make it less daunting to think about a care process as an older home, one needing group ownership, hard work and tender loving care to transform it into something that really works for everyone.

Accounting for Accountability

Mary Beth Lee, MS, RN, Client Improvement Manager, Press Ganey Associates — Fri, 13 Jan 2012 13:00:00 GMT

Sit in any meeting of health care executives and you are bound to hear the term “accountability” thrown around. This is especially true today. Under health reform, so many of the needed changes depend on leaders, physicians and frontline staff delivering measurable results. We are told that hospitals and physician groups are being held accountable for patient outcomes and nurses are being held accountable for exceeding patient expectations. In reality, however, accountability is exactly what seems to be what is lacking in many organizations. It’s worth examining why this is so hard to achieve.

Accountability is often used synonymously with such concepts as responsibility, answerability, blameworthiness, liability and other terms. Loosely translated, it means the buck stops with everyone.

Every organization’s bottom line depends on all executives and employees feeling responsibility to their jobs, colleagues and patients. When is accountability an issue that needs to be addressed? One hint might be when an organization finds itself dealing with the same issues in the same manner, again and again. For example, putting hourly rounding into practice includes meeting specific objectives, but often rounding is taken for granted, as something to be done if no other needs arise. When an organization fails to achieve objectives and cannot identify why a practice such as hourly rounding is not succeeding as planned, it has an accountability problem.

The following are a few ideas on how to ensure that each employee has a sense of ownership that extends beyond a paycheck:

Start at the top. Creating a culture of accountability is a job that starts with the highest level of leaders. One of the biggest failures is to begin a process and not follow through with it. This causes the employee to lose respect for the process and to question a leader’s commitment, which can undermine any initiative. When I was a nursing director, I would drop everything to answer a call light or assist a visitor. No matter how busy I was, I was cognizant that I needed to send the message to my staff that these behaviors were always expected.
Define success. The employees must understand what the initiative is trying to achieve. Employees need to know what they are being held accountable for. How do they know when they have succeeded or fallen short? Setting clear standards and goals gives them something to target.
Seek feedback and listen. If you want accountability from employees, you have to be willing to listen to their advice – and then take it. Service excellence initiative decisions are often made without asking those frontline workers who probably know their customers best. Provide formal channels for employee feedback on implementation, and be sure to communicate your actions back down the chain.
Evaluate the results. How do you know if employees are actually being accountable to the new practice, and how do they know? Spend time sharing objective criteria such as call light volumes and patient satisfaction data. Also use input from patients and employees to find a balance between productivity and customer satisfaction.

Holding employees accountable to clear and high standards is a benefit to everyone. When you expect more from your employees, they perform better and feel good about their jobs. When employees have tools to identify and track their performance, they know exactly where and how to improve, which boosts productivity. All of these factors lead to higher staff satisfaction and patient satisfaction, which for managers and executives is the ultimate accountability metric.

Of Survey Data and Human Biases

Bradley R. Fulton, PhD, Researcher, Press Ganey Associates — Wed, 04 Jan 2012 13:00:00 GMT

“I just spoke with three patients last week who told me how much they love the care I provide. This week, two other patients told me this is the highest quality care they have ever had. I don’t understand why my Press Ganey scores aren’t better! I don’t think the data are valid.”

When I speak with physicians, and hear the above argument, I understand their confusion and frustration, and why this would lead them to question the accuracy of the data. The data are valid, but the reactions are natural.

Humans aren’t computers; we are social animals. Human brains are designed to allow large amounts of social information to be encoded, stored, and retrieved in an efficient and useful manner. These highly developed processes, however, are not without their drawbacks. Making a judgment, for example, is a highly complex process. To be accurate, the person making the judgment needs to consider all relevant information. A physician making a statement about his/her patients’ satisfaction needs to consider the viewpoint of all (or a representative sample) of his/her patients. Moreover, the physician would need to consider all of the various facets of those patients’ satisfaction. Finally, he/she would need to develop some method of summarizing the data so that it is actionable – or at least understandable.

Because we literally cannot do this, the human brain has developed shortcuts. All people use these shortcuts, but very few are actually aware of them. For example, the availability bias is the tendency to make a judgment based on information that is readily available in memory. For example, when patients give a doctor high praise, he/she is likely to remember this. Later, when the doctor is making a judgment about patient ratings of care, he/she is likely to easily recall this information and base judgments on it.

A doctor might argue that we are equally likely to easily recall patients’ criticisms. But consider the availability bias in conjunction with the confirmation bias, which is the tendency to search for information that confirms one’s preconceptions. Even if patients’ criticisms are as equally available in memory as patients’ praise, physicians, without realizing, are more likely to seek information from patients that confirms his/her belief of being a good physician (patients’ praise).

Now consider both of these in light of the self-serving bias, which is the tendency to take credit for successes and deny responsibility for failures. Thus – again, without realizing – a physician will have the tendency to take credit for the patient’s successes and deny responsibility for failures. “I explained it to him a thousand times; he just never listens.” So, put altogether, the physician will tend to deny failures, seek information confirming successes, and make judgments based on this information, which will likely be readily available in memory. Re-read the quote at the beginning of this post with those biases in mind.

Remember there are two members of this dyad – the physician and the patient. The patient is also susceptible to biases. Consider expectancy effects, which occur when someone subtly communicates to another the kind of behavior he/she expects to find, thereby creating the expected reaction. The manner in which a physician asks the patient a question, for example, can create an expectancy effect. “Do you feel satisfied with your visit today?” This is a simple question, but how do you think the patient will respond? The patient knows very well the physician wants a “yes” response. And unless the patient wants to be considered negatively by the care provider and spend extra time explaining issues, the patient will say yes.

Consider the following question as an alternative: “How could I have made your visit better?” What expectancy effect does this question create?

Another issue is the tendency of patients to reply in a manner that will be viewed favorably by their physicians. This is called the social desirability bias. Patients lie to avoid negative outcomes. “Have you been keeping on your exercise routine?” “Why yes, doctor.” “You’ve been taking your medicine regularly, right?” “Yep, haven’t missed a dose.” “Do you have any questions that I haven’t answered?” “Nope.” “Do you understand the plan for your new diet and exercise routine?” “Yep, I got it.” “Overall, are you satisfied with your visit today?” “Oh absolutely!”

Environmental effects occur when the physical environment affects feelings, thoughts, or behavior or impacts people in other ways. Many people are intimidated by the sheer presence of a physician. Being in a medical environment – with physicians, nurses, medical equipment, other patients, etc. – can be overwhelming to some. Many patients will feel anxiety about being in the situation and will do whatever they can to minimize that anxiety. So, put altogether, the patient is in an intimidating environment, is well aware of what the physician is expecting him/her to say/do, and has a tendency to lie to reduce anxiety and negative consequences. On top of that, the physician will tend to deny failures, seek information confirming successes, and make judgments based on this information which will likely be readily available in memory. Again, re-read the quote at the top of the page keeping this in mind.

These are just a few of the many human cognitive biases; many others are at play. This is why the physician-patient interaction is so complex – much more complex than most people realize. This is also why Press Ganey employs sound survey development techniques, and sound research methods like random sampling, to avoid these types of biases. Without a doubt the data are not perfect; there is error in all data.

However, considering all of this, which would you consider a more valid, unbiased measure of patient satisfaction – survey data or physicians’ opinions?

Holiday Tips from a Frequent Flier

Teresa Roberts, MA, MSA, Principal Consultant, Press Ganey Consulting Group — Wed, 14 Dec 2011 13:00:00 GMT

Since this is a season not just to be jolly but also to hit the road, I thought I’d break with precedent for this health care blog and simply share a few tips for making holiday journeys a little more pleasant.

First, my credentials: I travel a lot. I’m about to hit “platinum” airline status, passing silver and gold along the way. Being a consultant means spending a lot of time with far-flung clients, which means being up in the air most weeks.

Now, some tips.

Make sure you have a designated seat. At most airport gates, there are electronic boards with lists of stand-by passengers hoping to get aboard. Who’s most likely to get bumped? Travel lore is that it’s those who paid the least through a discount online site. Clue: Do you have a specific seat listed? If not, call that airline now and ask for one. If you’re traveling with children, tell them that, too. No airline wants cranky, crying children hanging around at airport gates for hours. If the airline won’t budge, find out the flights departing shortly after yours and be ready to act quickly if you’re way too low on that stand-by list.

Pack light, send ahead, carry on. Any reason you can’t send those packages ahead to your destination instead of trying to lug or check them all? If you’ve checked luggage, you are at the mercy of the airlines as to when you can get on a later flight or a connecting flight. That’s why a smart business traveler who absolutely must get to a destination on time never checks a bag.

When a flight’s been canceled ... Check the flight boards for the next plane to your destination and swing into action (before leaving home download an airline or travel app such as FlightTrack to your smartphone). Can you go through Cincinnati instead of Detroit to get there? Before you call the airline or talk to a gate agent, know your options. If you’ve hustled directly to the gate for the next flight, the first thing the agent will ask is, “Did you check any bags”?

Going once, going twice … I keep my own, non-statistically valid tally of how often a flight actually goes when it’s been delayed more than twice. Ask the gate personnel if the plane is in the air, and if they say yes, double check via phone or app. If the flight still hasn’t taken off from New York LaGuardia, the odds of it arriving at Atlanta Hartsfield in the next half hour are not optimal. Ask if there is an available crew. If the flight’s been delayed too long, the crew may hit the limit of how long it can work that day. No flight attendants, no flight.

The odds of a flight happening plummet no matter what they tell you about it being just another hour or “waiting until maintenance looks at it.” When a flight I’m on has been delayed twice, I start looking for any later flight, train or car rental available.

Really do remember 3-1-1. As in assembling holiday toys, it pays to follow the Transportation Security Administration rules. Last week I watched a TSA inspector dump an entire plastic bin of water bottles, pop cans, cosmetics and other liquids. Have I ever forgotten a Not-So-Smart Water in my carry-on? Yes. But it’s painful when the security line is held up while someone argues about giving up their bottle of cologne or that a 6-ounce container is only half full, so why can’t it count as 3 ounces of liquid? When the TSA says 3-1-1, it means business. (No liquid container larger than 3 ounces, all containers in a one-quart, zip-lock bag, one bag per flier.)

The wise men and women and the overheads. The holidays mean full flights and loads of carry-ons. (Did I mention shipping those packages and maybe some clothes ahead?) Too many bags mean too many bag checks at the gate, which means a late takeoff. Often folks at the back of the plane are early boarders. The right place to stow your bag is near you, not in the first overhead bin you see. Why? Because when all the spots at the front are taken, later boarders have to head down the aisles, bumping into others, to find a space. And when it’s time to de-plane, all the folks at the front have to claw their way back to get their bags, making everyone’s exodus tougher.

Show goodwill to those with close connections. In the crowded skies of the holidays, making a flight can mean making it home to a waiting family … or not. If a flight attendant asks you to let those with close connections come down the aisle first, please smile and let them zip by.

Gratitude for those who serve. At the holidays, there are many men and women in the armed services who are traveling home for a brief respite with their loved ones. They serve us in often brutal circumstances. Whenever a flight attendant announces that we have someone in the military on board, other passengers often applaud. In the Minneapolis airport, I saw scores of people clap as four uniformed servicemen walked through together. They stood a little straighter and walked a little prouder. A simple “Thank you for your service!” is a great holiday greeting on the road.

Happy and safe holiday travels to you all!