Speaker 1: I want to start with a who question. This is the who section. Who does not seem to belong in this group? W. Edwards Deming, the father of quality measurement, PDCA 6 Sigma. What about Walt Disney, father of animation and theme parks? What about Hans Selye, the father of psychoneuroimmunology? Or Mother Teresa, icon of compassion? Well, if you look at this group, most people would say the odd one in the group is Walt Disney. These three at least have had some things to say about clinical measurement, about the immune system and prevention, and of course about healing when we cannot cure. It's hard to see Walt Disney fitting into the kind of things we've talked about today. And there was a time when I would have said impossible, not logical, improbable. But you see, innovation is making connections that are unusual connections for most people. Two economists wrote a book called The Experience Economy. In this book, they said that instead of three sectors of the economy like we are used to, commodities, goods and services, there's actually four sectors. Now of course when I was in the hospital business in the 1980s, we saw ourselves a new frontier was service excellence. And we were going to learn from all the service industries how to have great service. And the way we went about it, of course, was to take all of their scripts and standardize them for our staff and tell them this is what you say, introduce yourself, tell the patient why you're here and what you're going to do. And when you leave the room you say, is there anything else I can do for you? Just like a waitress. That was my thinking. But then I read this book and there was a shift that took place because this book said that there's a whole nother sector completely different than service. And it's when you buy essentially an emotional experience. Nobody comes out of a movie and talks about the service they got. Nobody comes out of Disneyland and talks about the service they got. They talk about the experience they had. And after today, I would say to you, nobody will come out of here talking about the service they got, but most of us will talk about the experience we had. That's completely different. Service is labor done for me. I would otherwise do for myself. Clean my own house. Paint the house. Change the oil in my car. Cook me some food. But an experience is quite different. And of course, in this book, which really grabbed me, was Walt Disney, the quintessential example of the service economy according to these two economists. Well, I got to thinking about it. And I got to thinking, now we're not in the entertainment business, so that doesn't quite fit. But then it began to dawn on me that not all experiences are fun. Theater is about not only the things that make us laugh and have fun. What else is theater about? If it's about the entire human experience, then it also has tragedy. Tom Hanks, as Woody in the movie Toy Story, was certainly entertaining. But Tom Hanks, dying of AIDS, in what movie? Philadelphia. That was not entertaining. This E word is not entertainment. It is experience. Could I say that I had a profound experience watching Tom Hanks with AIDS? Yes, it's an experience. Could I also say I had a great experience watching Tom Hanks or listening to his voice in the little character Woody in Toy Story? Vastly different experiences. But I believe that, like Simon Sinek said today, that in the 80s, we were like this. And then we began to diverge into the service economy. And we thought patient satisfaction and patient satisfaction scores and all of those things would lead us to the same things that service does in the service industry. And I began to see something is vastly missing from the service industry when it comes to the bedside of a patient. And I decided that the breakthrough that we talked about earlier, although small, some people will say, oh the difference is insignificant. But wait a minute. I thought today we just said that when your routine changes even slightly, it can have a profound impact on your thinking, on your behaving. And when you're thinking and behavior changes, you get a different world. So let's look at this. Are we in the same sector as Disney, only offering a different experience? Well, Disney is in the business of meeting the emotional needs of a family to have fun together. Well, that's not us. But we in hospitals are in the rule, the job of meeting the people's needs, who are a family especially, who are going through pain, anxiety, fear, and even tragedy together. So we could say that a hospital without compassion that meets the needs of those in pain would be like a trip to Disney that was no fun. Deming said something that most people who quote Deming never quote. When most people quote Deming, they say if you can't measure it, you can't improve it. And yet Deming also said the most important figures for management are unknown and unknowable. And he goes on to give the example of how do you measure the multiplying effect of going from good to great in a patient's perceptions? How do you measure that multiplying effect of that? And yet that could be the single greatest thing we could focus on next to safety. Let's take an illustration. We'll go about this in two different ways. We'll start in the service industry. I'm in the hospital bed. Smiling face comes in the room and says, good morning, Mr. Lee. My name is Sherry. I'm here to draw your blood today. We'll probably be drawing your blood every day to check on your progress. And I say, well, good morning, Sherry. But you see, now she's finished with her script. And she has nothing left to say until she says, is there anything else you need at the end? And so for the next seven minutes, we have complete silence. Does that begin to feel awkward? Well, silence is not only awkward, but just before an invasive procedure, and I have deliberately taken the least invasive, least painful, least anxiety-producing experience patients could possibly have and still call it invasive, to make my point. In silence, where does the patient's mind go? Just before a procedure that's invasive. To everything that can go wrong, you can't help it if you try. Well, how many things can go wrong with a blood draw? You say, well, not that much. Well, you're all professionals in healthcare. You can discount this. But when I was nine years old, my mother told me they could put a bubble up your arm, go right to your heart, and kill you. Did you ever hear that? It could kill you with a bubble. Yeah. What else could go wrong? Did you know they could blow out your vein? Yeah, think about that next time. They could blow out your vein. Bleed out underneath. Big, big bruise on there. Hurts to bend your arm for a week. I know because it happened to my son. You know what they say when they blow out your vein? Oops. There's a reassuring word. Oops. And then they say, give me your other arm. I want to say, bring me another phlebotomist. Well, if I'm having all these thoughts, oh, by the way, how many sticks? There's one that you worry about. Ow, ow, ow, ow, ow. Yeah. If I'm having these kinds of thoughts, what happens to my heart rate? Goes up. What happens to my blood pressure? Goes up. When your heart rate and blood pressure goes up, what happens to your pain threshold? Goes down. Everything hurts more than it should. So when she puts that little inner, that little bicycle inner tube or whatever it is, around my arm and tights a knot in there, she catches some of my skin and it hurts. And I look down there and I think, you know what?

Speaker 2: If you can't see the skin in the knot, how will you ever find my vein? We're talking patient

Speaker 1: perceptions. I look at her face when she's looking for a vein. It has a frown on it. What does a frown tell you when somebody is looking for something? Well, it means they can't find it. So imagine my surprise when she pulls up the needle and she starts to thinking, I want to say, hold it, hold

Speaker 2: it. I could get you a vein. Let me pump, pump this out for you. You know, they're quick. Of course, I

Speaker 1: don't do that. It's not very manly. This is more of the manly pose. Help yourself. There's my arm. I'm brave. I can take anything. Put two or three bubbles up there. I'll show you. Blow it out. You try that on me. I can take anything. 17 sticks, no problem. Of course, I'm like this and my pain threshold is way down here. When she puts the needle in, oh, how big a needle is that? Look, she got it. First stick. How lucky was that? Now, if you draw blood, do you want to be thought of as lucky or good? Patient perception. Nothing about her made me think that she would ever get that vein except by pure luck. Of course, I'm glad. She stands up and her script kicks in and she says, now then, Mr. Lee, is there anything else I can do for you? And I say, no, thank you, Sherry. Do you really have to put me through this again tomorrow? I'm afraid you do, Mr. Lee. And she's out the door and down the hall. In any way you can measure what she did, it was perfect. Perfect clinically, perfect for service, perfect for courtesy, but was she great? You can't improve on it and you can't ask the patient how to improve it because the patient doesn't know. Good morning, Mr. Lee. My name is Sherry. I'm here to draw your blood today. And I say, well, good morning, Sherry. She says, by the way, do you live around here or are you from out of town? I said, well, no, I live around here. I raised two kids here. You see, she sensed that I was a little tense and she decides to distract me. I don't know what she might say, but I tell her about my two kids a little bit. Her son's a Macintosh computer technician. My daughter's an artist. And while I'm telling her this, she's already put a tourniquet around my arm and pinched some of my skin. But did I notice? Not much. I'm trying to talk about my kids. She starts feeling for a vein and I get focused real fast. My heart rate starts to do this. And I think, oh, here it comes. And she looks up and she says, by the way, you have a nice vein here, Mr. Lee. I should have no trouble with this one. What did that do to my heart rate? What did it do to my pain threshold? And then she goes on and said, by the way, beginners can be a little rough, but I have done this for 10 years. When they're trying to find somebody that can get a vein, they usually call the lab and say, is Gentle Sherry down there? And I say, they call you Gentle Sherry? Now, you see, once in a while somebody will go, tsk, when I say that, which of course means too much Disney for this group. We're not going to call each other Tinkerbell or Gentle Sherry. I don't think so. Too much Disney or too American for us. But I got that from clinical trials. Gallup reports them in the book First Break All the Rules. They would go to a hospital, ask for the best nurses. They were doing a placebo experiment with a shot. Then they would ask for average nurses. Best nurses are those nurses that get lots of compliments from patients. Average nurses get no compliments and no complaints. They each give a subject. They all are randomized. So this double blind study, they asked the subject after each shot, the different subjects and the different nurses, did we get a pain rating by saying on a scale of 1 to 10, how much did that hurt? After they take away the double blind, they suddenly discover that your best nurses have lower pain ratings than your average nurses. And you say, well, how can that be? There it is on the videotape. The best nurses tend to say, this might sting a little bit, Mr. Lee, but I'll be as gentle as I can. What does the

Speaker 2: word gentle do to a person's anxiety? A little bit of fear. If I can say this for a blood draw, how much more important would this be for every other procedure that we do? But it are the passionate,

Speaker 1: compassionate, caring people that do this because it has to be done from the heart. You can't fake it. These authors say that experiences occur whenever an individual has been engaged in a personal or memorable way. The difference between these two Cherries is that one engaged me in a personal memorable way. And when she got up and said, is there anything else I could do for you? I will say not right now, but if I have to have my blood drawn tomorrow, will you please be the one who comes back? Don't be sending rough Rudy up here. I want gentle Sherry again. And Deming

Speaker 2: says that difference between being perfectly satisfied and wanting the person back again

Speaker 1: cannot be measured, scripted, reduced variation, or standardized. It comes only from the heart. It can be physical, emotional. Australia pointed out that compassion can actually affect the immune system. If you believe compassion can reduce stress in a patient. Mother Teresa said, we cannot, we can do no great thing. We can only do great small things with great love. Thank you very much.