URGENT MESSAGE: Over time, urgent care operators become desensitized by what they see and hear every day—a serious challenge to continual improvement and, therefore, success. In this second installment of her guest blog on “blinders,” Lou Ellen Horwitz describes how what is said in an urgent care center influences patient perceptions. She provides practical suggestions on coaching staff to be mindful of their words, volume, and audience when engaging in business and nonbusiness conversation.

Lou Ellen Horwitz is Director of Learning at Seattle-based Immediate Clinic. She has also served as Executive Director of the Urgent Care Association of America.

Blinders—they’re not just for your eyes. It’s a classic misstep in healthcare that operators and providers find themselves wearing auditory blinders and working under the mythical “cone of silence.” If you were a fan of the TV show Get Smart (or the recent movie versions), you know that the cone of silence—a device intended to render the conversations within eavesdrop-proof—never worked properly. Even so, there seems to be a belief in healthcare that the CoS not only exists, but works perfectly and somehow renders patients and others unable to hear what staff are saying.

For example, I was in a hospital outpatient area recently, sitting in the waiting room. Multiple groups of scrub-wearing staff strolled through the area (which was a transition between different treatment areas), talking loudly about their weekends, or their schedule, or their kids, or where they were going for lunch. You’ve probably experienced this as well, because it’s become the norm in healthcare.

Now, think back to a time when you were in a nice hotel at a meeting, or even in the lobby. Do you ever see similar behavior? Not on your life. If there are conversations in your view between the hotel staff, they are very, very discreet. Usually those staff are fully “on stage” while in public areas and will be making eye contact with guests and giving them a big smile. Ignoring the guests around them and having casual personal conversations that can be heard by everyone is just not done.

The difficulty with this in healthcare is that the division between public areas and private areas is not so neat. If you go into the “back of the house” in a hotel, it’s plenty casual and noisy, because it’s not somewhere guests are supposed to be and staff can behave naturally. When they pass through those doors though, they are on stage again. There’s a very clear division between those behaviors. In healthcare—and especially in urgent care—there are few, if any true, areas where patients never go.

So, does this mean staff have to be “on stage” 100% of the time? Is it even fair to ask that of someone working a 12-hour day in a stressful, busy urgent care when their true breaks are few and far between?

To address this properly, you must do three things.
The first is to listen. Just sit quietly in your office with the door open, and listen for a little while, maybe 10 minutes. Consider doing it again from your version of the nurse’s station, depending on the size of your clinic. Generally, the lobby is not a problem (because your people think of it as a public area), but if you have a hunch it might be, do a third listening test there. Pay attention, also, to the volume of conversations over the telephone and seeping out from the breakroom.

What did you hear? “Oh my God the system just kicked me out again!” “Our grass is getting so long because it keeps raining, but when it’s sunny my husband wants to go and play golf so I guess I’m just going to have to do it.” “Hi. This message is for Peter Simpson. This is the urgent care center calling back with his test results. Can you please call us back right away?” “I am so hungover—did you guys get to go to the game?” “Ugh! I keep forgetting to use that new hand sanitizer!”
No, I’m not making those up.

The second thing you must do is talk to your staff about it. Having specific examples like the above is very powerful, so take notes while you are listening and use them in your talk. It probably won’t take long to get a good list. One way to have it really hit home is to tell them you’ve been out secret shopping “some clinics” and want to tell them what you heard. If you have really good examples, you’ll get some laughs—until you drop the bomb that all of this came from your clinics. It should get pretty quiet after that.

It is almost impossible to change people’s behavior in sharing information. We are a social species, and talking to one another is how we build relationships and share our lives. You want your team to have and grow those relationships, so stifling conversation is probably too militaristic an approach. The better option is to just lower the volume. The trick is how to get it down and keep it down.

Consequently, the third thing you must do is engage your team in figuring out how to minimize patient exposure to casual conversations, because you will need more work than just raising awareness of it. Tools to consider include:
A “watchword”—This is a word or phrase that staff can say to each other if they notice they are getting too loud or inappropriate in a conversation. Since it’s very hard to self-monitor, staff can help each other. The watchword should be something that a patient wouldn’t recognize as a watchword—a term that sounds clinical would do nicely, but it shouldn’t be a term we would typically use in urgent care so it will be clear to staff that it really means “sssshhhhh!!!”

For example, “We have a 10-42, guys, just wanted to make sure you knew.” You could also use it to reinforce something you want your patients to think, in case they do hear it. “I sent you our quality numbers just now.”

  1. Visual reminders—A button on uniforms or signs in hidden areas can also help to “launch” your efforts. These will need to change over time, however, as they will blend into the scenery after a while if you don’t rotate them. Staff could also use a hand signal.
  2. Appoint a monitor—The receptionist is often the perfect person to be the conversation volume monitor. If a conversation can be heard at the front desk, it is too loud. Ideally, the receptionist has a simple signal he or she can use—even if it’s just a flag to wave (literally)—so they aren’t having to constantly run back to quiet teammates.
  3. Go digital—There are several free smartphone apps (Decibel 10th is one) that can measure volume levels. If you have a spare tablet in your office, it could be a good early experiment to leave it on for a day where your staff can see it spike. Some of them will give you a history over a certain period of time, so if you use measurements for motivation, this is great data.

The most important aspect of which tools you use is that you get buy-in from the staff—remember, you are engaging them in the solution so it will stick! They will have an opinion on which approaches will work best for them, and will probably come up with even better ones.

Auditory blinders are almost always harder to manage than visual blinders, because it’s a matter of constant awareness until new habits are created—a good 30 days of careful modulation, at least. And it gets out of hand quickly, leaving no residual evidence like a pileup of papers or supplies would leave behind. So it’s very hard to measure whether a clinic is improving or not. Constant vigilance is really the best weapon. Over time, the “norm” will change and it will get easier to keep the volume down.

If you need more motivation, consider the HIPAA violations you are indirectly addressing by lowering your volume. It’s virtually impossible not to talk about patients inside the clinic. Lowering the volume of that talk helps avoid incidental PHI exposure.

If you had to choose between your clinic sounding like Grand Central Station or a luxury hotel, you’d probably go with luxury hotel. If your patients got to pick the environment they’d rather be sick or hurt in, there’s no question which they’d pick.

Take the Blinders Off Your Eyes—and Ears

Lou Ellen Horwitz, MA

Director of Staff Development & Communication at MultiCare Retail Health & Community-Based Care, Chief Operating Officer at the Urgent Care Association
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