Surprised and Delighted

Saturday, December 5, 2015

idea_bulbs_pop_up_150_wht_16515Quality is subjective. It is in the head and the heart of the beholder.

We feel quality when our experience exceeds our expectation.

And this simple definition of quality has some profound implications.


The first is that to measure quality we need to know both parts of the quality equation … we need to know both the expectation and the experience.

Why is that?

One reason is because we can set expectation much more easily than we can set the experience.

Example:  Suppose I am a hospital and I am interested in the perceived quality of the service that I provide to patients.  So I implement a quality survey and I ask the patients one question as they leave.  I ask “Were you satisfied?” The exit poll data is assiduously collected, processed and presented at the monthly Quality Committee meeting. If our average satisfaction score this month is better than last month we “high five” and if it is less then we “deep dive”.

Q1: What is the relationship between the satisfaction score and the actual experience?
A1: Satisfied means that experience equals expectation. That’s all.

Q2: What is the easier way to improve satisfaction scores? Improve experience or reduce expectation?
A2: Reduce expectation.

And that is what we do. We take the path of low resistance to improving satisfaction. We set low expectations. We talk only about what might go wrong. Never about what will go right.


The message here is that to understand quality we have to measure both expectation and experience.  And when harvesting feedback we need to ask both questions.

Compare these two alternatives:
Q: Were you satisfied with the service you received in outpatients today?
A: Yes.

Q: What did you experience in outpatients today and what was your expectation?
A: I struggled to find a parking place and I was a bit worried that I would be late for my appointment, but I ended up waiting over two hours anyway. I did not know how long the wait would be and I was then worried that I had not put enough time on the parking ticket. But it is what I expected because the appointment letter said that I need to allow up to three hours. My appointment took ten minutes and the doctor was nice.


We assume that because we usually experience queues and delays then it would be much more difficult to improve patient satisfaction by actually improving their experience … in other words … eliminating the avoidable root causes of the queues and delays.

So we don’t bother trying. We just reinforce the low expectation.


Another reason we need to know both expectation and experience is because it is our expectation that drives our decision.

If we expect a poor experience we are much less likely to choose that option.

Here is how we learn this avoidance behavior:
Step 1. We start with a reasonable expectation and no experience.
Step 2. We have a poor experience, we feel disappointed, and we lower our expectation.
Step 3. If we have a choice then we avoid the experience. If we have no choice then we accept it.
Step 4. We experience what we expected (but at least have avoided further disappointment).

But are we actually satisfied? Or are we just resigned to the fact that is all we can hope to expect.

Have we learned to become helpless, skeptical or even cynical?


Knowing the patient expectation provides a goldmine of opportunity for a healthcare organization that wants to improve the quality of its service.

Engagement in change does not follow from disappointment – it follows from delight – or more specifically delight accompanied by surprise.

We feel surprised and delighted when we experience something that exceeds our expectation.


So recall the story of the satisfied outpatient with the sense of resigned acceptance.

Then read the feedback below that was shared with me this week … feedback from a doctor in training who has just completed the Foundations of Improvement Science in Healthcare (FISH) course … the free offer.

“To be honest, I was very surprised with the content of the course … in a  good way – so much so that I sat and completed it over two days! 

I was fully expecting a generic online management course filled with the usual buzz words and with no real substance or learning point to take away from it (I’m generally very sceptical of such things as I feel many courses are primarily money making exercises with little real value as the developers are well aware that healthcare professionals need to tick off the management box at their appraisals).

What I actually found was a course that presented the problems of a chaotic department (that I’m all too familiar with as a radiologist) and actually broke down the problem into its root causes and fundamental components in a logical way with simple and effective strategies to improve a service. Considering each process in terms of a series of streams and stages and presenting these functions as a Gantt chart is brilliantly simple, demystifies what actually happens in a process, and is a simple way of identifying all the faff that goes on around the real value work that we – something that I was all to aware of prior to the course but didn’t really know how to tackle. What I have learned is definitely a valuable foundation in managing the various processes of a department such as my own and I will certainly make use of these tools in the future.”

Does that sound like a surprised-and-delighted reaction?