When Things Don’t Go Right

mans arm with iv

Writing all of these blogs on Service Recovery and what happens when things don’t go right made me reflect on a missed opportunity I experienced recently. I had a special person in my life who needed to have surgery. This was one of those situations where I’d made sure that my special person went for their surgery at “my hospital”: the one where I’d had my babies and worked for many years. The day of the surgery, everything was going well through pre-op.  While I was waiting, they kept me very well informed throughout the process. When I finally got to the inpatient floor and were reunited with my special person, I knew immediately that something was wrong. My special  person kept it together until the admitting nurse left the room. Then, the person called me to the bedside, held my hand, and burst into tears.

At first, I thought he was in pain, grateful to be alive or something. But no, it was anger. My special person had had a significant and horrible experience with the PACU nurse who had been taking care of them for the past 2 hours. I mistakenly thought that my special person was confused having just come out of the anesthesia, etc. But, they knew the time that they got to recovery, the name of the person who they had been with for those two hours, the name of the nurse who took over for the difficult nurse, and at what time the shift change took place.

As my special person was recounting his story,  an unsuspecting charge nurse walked into the room to do her Nurse Leader Rounding. I was trying to let everything play out naturally, but finally I had to stop her and let her know that he had only gotten to the room a few moments ago and there was no way that he knew the plan of care, etc. But, I also told her I was so glad she was there because, boy could she help us! I encouraged my special person to speak about his experience which he did. The charge nurse took it all down, said she’d send an email to her manager, and ask that the manager to talk to the leader of PACU, etc.

Now, my special person was going to be discharged the next day. I knew how email and communication like that can work and decided to lob the organization a softball. I got up early the next morning and left the manager of the PACU  a voicemail at 6 a.m. (surgery people start early!) I told him that this patient was being discharged by 11 and that all they needed was for someone from the PACU to go up and hear their story. If someone could apologize, I was convinced that was all they needed to recover the experience.

Not wanting to interfere too much further, I went on about my morning trusting the next steps to the organization. I didn’t think anything else of it until my phone rang at about 12:30. I recognized the number from the hospital and thought it was strange since I’d just talked to my special person and knew they were discharged and waiting for their ride downstairs to go home. Believe it or not, the incoming call was the manager of the PACU calling to tell me that they tried to follow up with my special person but had gone up to the room at 12:15 and had just missed them! Their attitude was like “Aww shucks…” like they were surprised that they just missed talking to my special person!

Now, I called at 6 a.m. and told them there was a window to resolve this in person. However, they didn’t try until 6 hours later, well after the stated discharge time and organizational goal of 11 a.m. The manager and assistant manager wanted to talk to me about it all and I just directed them back to my special person. Later that evening someone phoned the special person at home, but by then it was too late to really make a difference in my special person’s experience. And sadly, for this organization, my special person can’t tell their story of their experience at that hospital, albeit with an amazing clinical outcome, without telling this part of the PACU stay that didn’t go well.

There’s something about an apology in the moment that makes all the difference in the world. After a patient has left the environment, it now takes more than an apology to make that experience better.  We all want to provide the best care possible.  That’s important in the preventative moments to make sure things don’t go wrong, but it’s also equally or more important when things don’t go well.

I’m curious to hear, what have you found that works best in your organization for service recovery? What would you tell the manager and assistant manager in this situation if you were coaching them? How have you handled situations like this after the person has left the organization? I’d welcome your thoughts and suggestions as I certainly have my own and have shared them with the organization where my special person had their care!

Janiece Gray

Janiece Gray

I began my career as a social worker and later, with my Master of Health Administration (MHA), directed operations at Allina Health in Minnesota. I later directed patient experience at Allina. My background and experience give me strengths in approaching healthcare opportunities and challenges through a systems lens – with unique strengths, challenges and activation points. My experience is also informed by leadership roles leading performance improvement in patient-centered care and patient experience departments. Working in the client role with healthcare consulting firms inspired me to address some unmet needs in the industry, and to co-found DTA Associates. I have a Lean Six Sigma Black Belt, and find that the discipline of practice translates to healthcare work very well.

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