PDF Summary:Patients Come Second, by Paul Spiegelman and Britt Berrett

Most healthcare organizations claim to put patients first, but Paul Spiegelman and Britt Berrett argue this approach misses a crucial step. In Patients Come Second, they contend that exceptional patient care starts with prioritizing employees. When healthcare workers feel valued and engaged, they provide better care, which leads to improved patient experiences and stronger business outcomes.

The authors explain how to build a culture that supports this philosophy through transformative leadership, personalized recognition programs, and community engagement. They also discuss measurement strategies for tracking employee engagement and patient satisfaction, showing how these metrics can guide organizational improvements. By creating a cycle where engaged employees lead to satisfied patients and business growth, healthcare organizations can achieve better results for everyone involved.

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(Shortform note: Tailoring recognition programs and consistently acknowledging employees in a personal way keeps your workforce from disengaging because it continually satisfies their basic psychological needs. According to Marylène Gagné and Edward L. Deci, when employees’ needs for autonomy, competence, and relatedness are met, they internalize organizational goals, display more self-determined motivation, and show greater persistence, performance, and psychological well-being over time.)

Following that, let's look at internal and external engagement strategies.

Internal Engagement Strategies

Spiegelman and Berrett say that recognizing and rewarding employees is key to cultivating engagement. If workers sense that they're valued, they’re more likely to be committed to the company. Recognition should be sincere, unexpected, and tailored to individual preferences. Additionally, it must be inclusive, ensuring that all employees feel appreciated for their contributions.

The authors suggest developing creative and personalized programs that recognize and impact everyone in the company. Find ways to reward people for extra efforts, such as organizing a bake sale for a sick coworker or noticing little things like garbage in the corridors. Recognize what matters to employees beyond their work, such as giving them time off to volunteer in their community.

(Shortform note: While recognizing and rewarding employees can boost engagement, it can also have unintended consequences. According to Edward L. Deci, Richard Koestner, and Richard M. Ryan, when rewards become highly salient or expected, they can undermine intrinsic motivation. When employees begin to expect recognition for every extra effort, their internal drive to perform well can diminish. This means they may only engage deeply in their work when they anticipate recognition, rather than because they find the work itself meaningful.)

External & Community Engagement

According to Spiegelman and Berrett, engaging with the broader community boosts workers' commitment and benefits the organization. Community encompasses the built environment of your home and workplace, plus the individuals living and working in those places.

Engaging with the community is a win-win-win: It makes employees feel positive about contributing, increases employee engagement, and benefits the community. It also dismantles internal obstacles as employees from various departments collaborate. Additionally, the community supports your organization and your cause.

However, you should also prioritize looking after your internal group. You can’t ask employees to contribute to the community if they are in distress. Assisting each other must precede assisting the community.

(Shortform note: Engaging with the broader community can backfire if it’s perceived as self-serving. If the community feels that your organization is more interested in advancing its own interests than in genuinely addressing community needs, it can lead to cynicism and distrust. This can erode long-term trust in your institution. To avoid this, ensure that your community engagement efforts are driven by a genuine desire to serve and are responsive to the community’s own definitions of its needs.)

Measuring Impact & Linking to Outcomes

Spiegelman and Berrett note that healthcare executives are currently prioritizing patients' experiences. The government limits compensation for providers by requiring good patient reviews and keeping readmission rates low. Providing an outstanding patient experience may determine whether healthcare providers succeed or fail financially in the near future. The authors reiterate that patients' experience encompasses every interaction and is influenced by an organization's culture, which affects how patients perceive care over its full course.

(Shortform note: In the UK, the National Health Service (NHS) is funded by taxes, and hospitals receive budgets from the government. This means that hospitals' compensation isn't directly tied to patient reviews or readmission rates. Instead, the government allocates funds based on population needs and overall service demand. While patient feedback and quality metrics are important for improving care, they don't directly impact how much money hospitals receive. This system aims to ensure that healthcare is provided based on need rather than financial incentives tied to specific performance indicators.)

To establish a connection with patients, it's important that each interaction healthcare providers have with them is meaningful. Given how anxious and exposed patients usually are when engaging with their healthcare providers, having someone greet them or take an extra moment to ensure they’re okay can often be more impactful than their experience of the actual treatment. Spiegelman and Berrett point out that, according to industry standard estimates, the typical person visits a hospital only once every seventeen years and an emergency room every three years. This means there aren't many opportunities to do it correctly.

The Importance of Consistency for Frequent Patients

While the average person may not visit a hospital or emergency room often, some patients are admitted to the hospital or visit the emergency room multiple times a year. For these patients, the consistency of care and coordination between healthcare providers may be more important than a single warm greeting or check-in. For example, a patient with a chronic illness who is admitted to the hospital multiple times a year may value having a consistent care team that knows their medical history and can provide personalized care. Similarly, a patient who visits the emergency room frequently may appreciate having a care coordinator who can help them navigate the healthcare system and ensure they receive appropriate follow-up care.

Afterward, we'll examine measurement frameworks and improvement cycles that can help you track progress and implement strategic adjustments.

Measurement Frameworks

Spiegelman and Berrett suggest using metrics to track progress and implement strategic adjustments. It's crucial to use metrics to review your performance history. They also serve as an early alert, so if you start veering off track, you can fix your path before you really lose your way. Organizations can implement strategic changes in almost any desired area by starting to measure the change they wish to achieve.

The Dangers of Metric Fixation

In The Tyranny of Metrics, historian Jerry Z. Muller argues that an overreliance on metrics can be detrimental to organizations. He contends that when organizations succumb to what he calls “metric fixation”—the obsessive belief that the best way to manage is to focus on and reward targets based on standardized numerical indicators—they invite pervasive gaming of the numbers, a displacement of attention from their real mission to what is being measured, and a host of unintended consequences that can ultimately make performance worse rather than better.

The authors also recommend regularly conducting employee engagement surveys to assess organizational momentum. This feedback helps you determine whether your staff are engaged with the work they're doing and whether they're collaborating effectively. By consistently carrying out such assessments, you can study the trends that arise and focus on improving your weakest areas.

(Shortform note: Conducting employee engagement surveys over time is important because it allows you to track changes in your workplace that you might not otherwise notice. For example, you might not realize that your employees are becoming less engaged with their work until you see a downward trend in your survey results. These surveys provide a quantitative record of how your workplace is functioning, which can reveal patterns and trends that might not be apparent through casual conversations.)

Actionable Insights & Improvement Cycles

Spiegelman and Berrett advise creating structured programs to facilitate idea generation and improvement. These programs unite workers to exchange their thoughts, facilitate communication, and empower employees to express themselves. They also provide an organized framework for implementing fresh initiatives.

(Shortform note: The idea of structured programs for idea generation and improvement has a long history. In 1986, Masaaki Imai described how Toyota’s kaizen suggestion system formalized the process of submitting improvement ideas and tied them to rewards.)

The authors also suggest routinely assessing staff involvement and devising plans of action. This vital practice helps you assess if you're staying on the correct track. It affirms all your efforts and provides organizational reassurance that you're on the correct path.

(Shortform note: In The Fearless Organization, Amy C. Edmondson argues that when employees lack psychological safety, they avoid the interpersonal risks of speaking up by staying silent or by telling leaders what they think they want to hear. This means that meetings, surveys, and other formal mechanisms can generate reassuring but deeply misleading signals of alignment and engagement, because the quiet you observe is produced by fear, not by the absence of problems or disagreement.)