Swiss Cheese (or The Holy Cow)


“Here is your data for the Press Ganey Surveys under Patient Safety.” She slid a piece of paper in front of me, watching intently for my reaction.

I glanced down at the paper for a second. There was my name in the red section. Whatever that means. Good? Bad? I was not going to ask. 

Quickly, I ticked through a mental check list: Do I wash my hands between patients? Yes. In fact my hands burn and are chapped from it. Do we clean each room after each use? Yes. Is the clinic neat and orderly? Yes. Garbage left about? No.

I don’t really care about the numbers.

“So we recommend that you say, ‘For your safety, I am going to clean my hands now.’ Then you should foam your hands. Using those words will trigger people to remember it when they see the survey. That way they will score you higher.”

I guess that means the score was not good?

So there you have it, folks. Washing my hands is no longer enough. I have to use parlor tricks, too. Trick people into thinking I am cleaner than I already am. You know. For their safety. Because filling out a survey saves lives.


Feels like we are missing the point.


131 thoughts on “Swiss Cheese (or The Holy Cow)

  1. …I will say that when I was at my former eye doctor and saw a bottle of Drano next to his sink, I was grossed out. But, really???? I had to pull ploys like that in the classroom at the end, too. “The reason I write on the board in cursive is because I’m dyslexic and if I start printing two things will happen. First, I’ll transpose letters and you’ll think I’m stupid. Second, it is too slow.” I was very happy when I began using the computer and projector to present a lecture. I could type perfectly and achieve the same dynamic presentation, but then I had to say, “I’m giving my lecture this way so I can save it to your Blackboard site and you can review it later, OK?”

    Liked by 1 person

  2. I had minor surgery in the spring. I had a great bone doc, maybe early 50s. He was personable and knowledgeable and I was happy with him. At the end of my initial visit, he asked (almost begged) me to log onto their patient portal because they get points for that. I did it for him, not because I needed information from it. I wanted him “to get credit.” I will also say that he responded very promptly to an email I send him a couple weeks after surgery when I didn’t know if something was going south. I was sure to go back on and give him a good review. All this stuff is crazy. In the old days, good doctors had more returning patients and that was a good indicator of customer satisfaction. Guess it doesn’t work that way anymore.

    Liked by 1 person

  3. Since I began reading you, I always fill out the surveys and mail them back.

    I still hang up on urgent care phone call surveys though. They do not have “press one to hold this call” or “press 2 to call back at your convenience” options. I am just not that dedicated.

    Liked by 1 person

    • Nope. Never. Not to say that we should not try to treat our patients with humanity and respect and compassion. Some of that can be measured by survey. But the emphasis to this degree is crazy and not in patients’ best interest.

      Liked by 1 person

  4. UGH. People are always saying crappy variations of, “Perception is reality.” No. No, it’s not. It’s the people who think and say that who degrade the ability to distinguish perception from reality!

    I thought of you yesterday when thinking I ought write a 500-star review of my sons’ pediatrician. In this objective reality, where reality is reality, I am grateful-inexpressibly grateful–she is taking such amazing care of my sons. I wish that were the standard by which you were judged.

    Liked by 1 person

  5. I had a market research agency for many years. Done with that now thank God, but I’m still “interested” by surveys. The thing is, “clients” (mine) are becoming hysterical about it. I call American Express, I get a survey to evaluate the executive. They don’t sample. Every transaction is “surveyed” which is useless, makes me waste time as a customer, and creates a climate of fear on the executives. That is just one example of many situations where organizations start “surveying” every action of their key people. Part of Uber’s success is the “review” system. But, come on! Are we going towards Uber-Doctors?

    Liked by 1 person

  6. it sounds like symbolism over substance like when the feds decided to put braille on the ATM machines years ago to make us feel like they were accessible.

    A true story, I actually was in a car with a friend

    who pulled up so that the ATM machine was on the passenger side of the car so I could use it. I guess that since he saw that the numbers were brailed, he thought I could use it. It took me forever and it was a weird experience and it almost made me late to a coffee shop gig I had to play that night.

    some sighted people, I just don’t understand.

    Liked by 1 person

  7. I had the same problem with teaching–getting evaluations from students who weren’t qualified to understand pedagogical practice (like, I don’t know, why we couldn’t just watch a movie every day in class).

    Performance feedback, when done anonymously, generally skews negative. And that’s a problem. Teachers should be evaluated by other credible teachers; doctors by other credible doctors, not necessarily by those being taught or treated, because they don’t understand the job from behind the scenes.

    (And I say this as someone who loved and was very much devoted to my students and who generally did well on my course evaluations.)

    Liked by 1 person

  8. Haha! Reminds me of a joke about owning a dog…all of a sudden you need to show your hands like a magician after a trick just so they see there is nothing in your hands! Maybe you should think of doing that with your next patient – “look Mrs so-and-so, no germs!” 😂😂

    Liked by 1 person

  9. Ahhh, are we MBA bashing again? Tsk, Tsk. Now listen up plebes, you will address all MBA’s as Your Highness or Your Majesty; you will bring offerings to placate your asters; you will obediently partake of every task assigned you by your MBA. Failure to do any of these could result severe disciplinary action by your most high MBA.


    Sigh. In all honesty Victo, there are positives to using customer feedback at least in part for purposes of assessing employee effectiveness and/or customer satisfaction. This is an improvement on the old system where the old boys club made all the decisions. An MBA will always tell you “If you can’t measure it, you can’t manage it.” Which is true – just how it is measured is the trick. Now comes the annoying part – if you are going to use patient observations as a part of that assessment, then it is important that the patient know what they are looking at. In your case that may very well mean pointing out to the patient that you are cleaning your hands. Not only does that make them aware but it also reassures them that you are taking all the necessary precautions and are willing to take the time to make that clear to them. It serves both purposes.

    I know this is annoying but it is a function of the structured operating environment and is very typical for most corporate jobs. In the case of corporations, the employee has to make their accomplishments known to their bosses and the management. No one is paid to watch you or anyone else for that matter, any more – as there used to be. You have to blow your own horn, so to speak. Just as you have to communicate to your patients Victo because, in part, they are doing your appraisal -so to the corporate employee has to communicate up the chain in order to satisfy their appraisal.

    That may all seem a waste of time but the structure that demands it, in turn bestows many benefits upon the employees and patients. It is the price to be paid and actually there is some small benefit to the patient.

    Liked by 2 people

      • Hmmm, I’ve seen MBA’s doused in other liquids, like water, and they seem to actually get crispier – if losing their sense of humor qualifies as getting crispy. 😀

        Liked by 1 person

    • The question is not whether or not I am washing my hands. It is that I am supposed to use condescending words to call attention to that fact in order to manipulate numbers. It is insulting to patients. It dumbs down the profession. I want to treat my patients with respect, not treat them like four year olds. Show me where using those words saves lives, fine. I will do it. But simply padding my numbers by using that kind of verbiage upsets me.

      Liked by 1 person

      • First of all you are not “padding”your numbers – you are getting the metrics to match the reality. Perhaps the metrics are poorly chosen – that is not yours to determine. The intent behind the metrics is to honestly measure service impact. You are taking it personally and getting your hackles up – it is not directed at you- it is , perhaps poorly, designed to help.

        How can it hurt to make your patients aware that you are washing your hands? It may very well reassure them. It is not talking down to them. Perhaps there is another way to communicate to the patients about the hand-washing- be inventive. Maybe a one page flyer given to each patient that emphasizes the importance of cleanliness and pointing out that you and your staff wash your hands before touching any patient. Then you could make an effort to wash your hands in their sight to emphasis that you are doing your part. This could easily have a positive (albeit small) impact on the health of your patients and communicate that you are doing your part. A single page two-color handout would be minimal in cost. You now the reinforcement for your patients would be good – It scares me the number of men I see in public washrooms who do not wash their hands after using the facilities.

        Be a role model Victo. Remember they lookup to you and some will mimic your behaviour.

        Liked by 1 person

  10. I just had a crazy urge to wash my hands after reading, and then an intense debate with myself if I should do it before or after writing my comment. So I did both. I hope the overlords will record your influence in this matter. 🙂

    Liked by 1 person

  11. I am one of the “aholes” you speak of who collect the data and put it on a monthly dashboard. I usually do not pull surveys on individual clinicians unless I get a crappy survey back and I start looking into what happened. You have two sides to every story. I do not think the survey is a waste. It is a tool but should not be used just punitively. It is a scorecard, a snap shot of on going and for trending issues. I can tell when we were short of visiting staff because our numbers reflect it. When employees are unhappy, the care changes and the patients will say so.
    We too use a discharge checklist with similar language to the survey that is supposed to help the patient remember how things were during our tenure with them. It helps them to prepare and know what to do with the envelope when it comes. Most toss it out. The average of good reviews to bad breaks the statistic that only disgruntled people fill them out as we get great feedback and have many happy patients, who tell others how good our care was….and that is the best marketing. If I can turn a patient around who had a bad experience and expressed it in a survey, that too is good business.
    When I get a great review, and I can determine the clinician, I will send it on them as a kudos.
    If you want to be pissed, be pissed at the government that is going to hold these scores as part of how they are going to pay practitioners and agencies for providing service. That is what is wrong and why your pencil pushing geek came at you.
    And what is the ratio of acid to alkaline they put in that soap? Its terrible.

    Liked by 3 people

    • Those soaps and foams are a dermatological nightmare. As for surveys, I agree they can be helpful. That’s why I don’t say get rid of them. But using the data in this way is not helping patients one bit. If you are manipulating the language to get certain results you are gaming the system and those results are not valid.


      • Yes and no to the gaming. We do not tell them how to answer. When we are doing the last couple of visits and discharging, we say, do you remember how we made your home safer when we first came out? Do you remember how we talked about the side effects of your medications? On the form is reminders and other information to help keep them safe. It is not word for word to the survey.
        A big fault with the survey is that we teach patients to rate their pain on a 1 to 10 scale, 10 being the worse. Then the survey comes along and says that 10 is the best answer. It is all very confusing, especially to our older generation.
        I imagine it can be difficult because your survey is personal. But we all know your great! The little geek is just trying to follow the rules.

        Liked by 1 person

  12. You can always ask for a fish license for your imaginary goldfish.

    Then ask the surveying person to survey your capability to have a fish license to keep a goldfish as a pet (imaginary or not is not relevant!) and wait for the response.

    When they give you a weird look you can tell them to “find the fish” because something about the meaning of life is fishy. If you are lucky you meet a Monty Python fan. Sometimes you have to fight useless with silly and exchange fish slappings. Bring the bigger fish…

    Liked by 1 person

  13. Your patients might not realize you are washing your hands because you are probably engaging in interesting and/or IMPORTANT conversation while your are washing your hands. Maybe if you didn’t talk while you were washing your hands, they’d notice more. Because it would be really stupid to say, I’m washing my hands for your safety….. But you’re probably trying to save time by talking about how they are doing, building rapport, etc, so if you didn’t talk at all that would be weird and, God forbid, your time per visit might increase, and then you’d be deemed “less productive.” Maybe just have a brief moment of silence to begin the hand washing ceremony. Make sure you turn around and face them while you dry your hands, so they can’t help but notice. 😉 Oh, never mind, really. You are an excellent doctor.

    Liked by 2 people

    • We are supposed to foam which takes two seconds. I wash with soap and water in front of them after a pelvic exam or procedure. Often, I wipe down my stethoscope with an alcohol swab (they are supposed to be terribly filthy) in front of patients. Sigh. As you point out, there are better things to do with that time than use silly phrases.

      Liked by 1 person

  14. People are cronic complainers. They do it for attention. Also for favors when they give good ratings. I knoe people who do this all the time. They even mention it to be seen earlier! Good luck your place is loosing it’s humanity.

    Liked by 1 person

    • It is so silly. The question is not even about washing my hands. It is about patient safety. But I don’t know how it is exactly worded and I don’t know if it was just someone who was upset about something else or did not understand the survey that brought that score down. I just don’t pay attention to them. I am debating if I should care enough about this to have my office manager take a closer look at the data? I am thinking there are better things to focus on.

      Liked by 1 person

  15. We ran out of thread (above) which is very sweet for me as a newcomer to your most entertaining and educational pages, but in answer to your most important question – your poor Chapped Hands PawPaw Ointment. I am not sure what country you are in yet but my daughter sends it to me (in the midwest) from Australia (we are both from New Zealand). I have it in a reasonable sized tub and it lasts for AGES! If you cannot find it let me know.. The other one that might be easier to find for you is The Body Shop Hemp Hand Protector. Have a gorgeous day! c

    Liked by 1 person

  16. It is like with speaking. You must tell them what you are going to tell them. Then you tell them. Then you tell them what they told them. It is how we remember. So telling them you are going to wash your hands for their safety, you drawing their attention to the act. They witness you doing it. And during the exam they appreciate your thoughtfulness. It is just how people remember things.

    Liked by 1 person

    • You are absolutely right, but this is not what I want them to remember. I want them to remember what I said about their medications, their disease, their lab work. Washing my hands and filling out surveys is not the take home message. At least it shouldn’t be.


      • I get a printed report, and take notes. People have gotten the message about hand washing, and people are watching everyone in the medical setting to make sure they do wash up. Plus we all carry hand sanitizer.

        Liked by 1 person

  17. Oh wow. This makes me glad that I don’t have to do surveys for my doctor. Instead, if patients give them thank you cards, they can turn them in for points through an internal system or something.

    Liked by 1 person

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