An Epidemic of Empathy in Healthcare

by Thomas H Lee

  In the past, hospitals and doctors would take care of Medicare patients, but from a financial perspective they were better off when commercial patients filled hospital beds and office-visit schedules. The providers could negotiate higher payments from the commercial insurers and use the profits to cover their losses from taking care of Medicare patients. That dynamic worked well for many providers until recently.

  Now commercial insurers are responding to pressures to control costs from employers and are refusing to raise payments enough to allow providers to do business as usual. In fact, many insurers are demanding cuts in their payments to providers. Unable to cross-subsidize the care of Medicare patients, hospitals and doctor groups could decide to take fewer elderly patients. However, without Medicare beneficiaries, they wouldn’t have the critical mass of patients they need for either high quality or efficiency. Providers have realized that they need to hold on to their elderly patients and also figure out how to care for them efficiently so that they can at least break even if they accept Medicare’s levels of payment.

  The first step in retaining or increasing their market share of the elderly is to mount focused efforts to meet the needs of that population. As one hospital leader told me, “I wake up every day wondering how I can get elderly patients—who have a hard time getting around to begin with—to drive past a hospital near their home and come to me. The only way to make that happen is to do a great job for them.”

  Sarasota Memorial Hospital has reached out to seniors by creating an outlet in a major mall. Although no medical care is delivered there, the hospital sponsors guided walks through the mall, followed by educational sessions. Sarasota Memorial is attracting and serving elderly patients by meeting their needs for information and exercise. It is being rewarded by an increasing market share because many of the elderly who take mall walks are deciding to seek care from Sarasota Memorial clinicians.

  This dynamic, in which providers first compete for patients by meeting their needs and then work to lower costs enough to earn a margin, is good for society but stressful for providers. Even though healthcare providers in general and physicians in particular tend to be competitive (they all want to be “the best”), they don’t enjoy waiting to see whether their hard work is going to be rewarded. Nevertheless, the alternatives to a marketplace driven by competition—for example, shifting costs to patients or trying to use government regulation to control costs and ensure quality—are not pretty for patients or providers.

  Accordingly, many providers are changing the way they work in preparation for a marketplace driven by competition. For example, Cleveland Clinic publishes its clinical outcomes for a widening array of medical and surgical conditions, and University of Utah Healthcare publishes online all of its patients’ comments—good, bad, and ugly. In the old marketplace, where reputation was what mattered most, why would any healthcare organization publish anything negative about its care? In the new one, where providers are starting to compete on value for patients, organizations such as Cleveland Clinic and the University of Utah have figured out that they gain an advantage by putting their results before the public, thus motivating their own personnel to improve the care they provide.

  Real competition challenges some of the traditional ways in which clinicians think about what constitutes excellence. In many organizations around the country, I have met good, hardworking doctors who take justifiable pride in quality metrics such as the reliability with which they deliver evidence-based medicine, for example, whether they give beta blockers to a patient after acute myocardial infarction or how long it takes them to get a patient with a heart attack from the emergency department to the cardiac catheterization laboratory.

  The work needed to make progress on such measures should not be trivialized, but the fact is that patients assume that providers are going to be reliable in delivering evidence-based processes. They are not particularly interested in the difference between 97 percent reliability and 99 percent reliability in the performance of such processes, and they should not be. Instead, they base their choices about where to go on what is different among providers, and these traditional quality metrics are often all too similar.

  Providers facing competition need a competitive differentiator, and that requires the development of a real strategy.

  The Strategic Imperative: Improving Value for Patients

  What does strategy really mean? As Michael Porter and I wrote in the New England Journal of Medicine, strategy is something fundamentally different from operational effectiveness. Operational effectiveness means working hard, embracing best practices, and burnishing reputations that attract both patients and talent. Those good management practices remain absolutely essential; in fact, they are the table stakes for providers. Even if they have the most brilliant strategy in the world, they will not be successful without excellent operational effectiveness.

  But these days, operational effectiveness is no longer a guarantee of success. To thrive, providers today also need strategy, which is about making the choices necessary to distinguish an organization in meeting customers’ needs. Choices are painful; they anger constituents who feel that they are losing out. To make choices, providers need to address some challenging issues.

  The first and most fundamental question, as we wrote in our New England Journal of Medicine paper, is “What is our goal?” Strategy begins with clarity on this most basic question. The answer must be understood throughout the organization and used to guide all decision making. There is no goal that serves healthcare organizations as well as does improving value for patients. It is the one aim that all stakeholders embrace.3

  Why is clarity on this seemingly obvious point important? First, many healthcare organizations have evolved with multiple missions in mind, such as serving their communities, teaching, and doing research. Individually, every one of these goals is laudable and important. Collectively, they constitute a mishmash in which it is difficult or impossible to make decisions about how scarce resources are allocated. To guide decision making in a time of turmoil, we think one goal—improving value for patients—must be the clear top priority. The other goals should be pursued but be subordinated to value for patients.

  The other reason for achieving clarity on the goal is that many organizations have misconceptions about what strategy really means. For example, achieving a specific financial margin target such as 3 percent is not a strategy. Growing or merging with other organizations is not a strategy. Adding the infrastructure for new technologies is not a strategy. These decisions and results may flow from strategy, but they are not strategy itself. They do not directly define what the organization is trying to do for whom.

  Providers that understand that their goal is to improve value for patients can then organize themselves to meet patients’ needs and become more efficient in doing so. This strategy will be robust regardless of whether they are being paid a fee for service or are reimbursed according to some other model. Providers are going to be living with a mixed payment model forever, and this means that their strategy—their core understanding of what they are trying to do for whom—must transcend the payment model.

  Improving value for patients fills the bill. Contracting is important, of course, on a year-to-year basis, but over the long haul the success of providers will be determined by their ability to improve value for patients. If providers can produce better outcomes, they will attract more patients. Greater efficiency will improve financial margins. Just as important, they will be more successful in retaining personnel, who are always influenced by the extent to which they feel pride in their place of work.

  The Business Imperative: Patient Loyalty and Market Share

  If the strategic imperative for healthcare organizations is to meet patients’ needs effectively and efficiently, just what are those needs? As a practicing physician, I know that I have good insight—often the best insight—into the medical needs of my patients, such as what tests they need to screen for disease and what
treatments may help them the most. As important as those clinical issues may be, however, they do not constitute the totality of healthcare. Other factors are important in determining where patients are going to go for their care and influence whether they will stay there.

  Not so long ago, patient loyalty was a nice-to-have for healthcare providers. Today, it is fast becoming a life-or-death issue. In last century’s version of the fee-for-service system, whether patients returned for care did not really matter financially as long as there were other patients to take their place. Of course, no hospital or doctor wanted to disappoint patients, but if a practice had a long waiting list for appointments or if a hospital’s bed occupancy was high, no one worried too much if some patients decided to get their care elsewhere.

  That casual perspective toward patient loyalty changed with the passage of the Affordable Care Act in 2010. For more and more Americans each year, insurance products provide incentives to obtain care from limited networks of providers. Many patients are pausing to weigh their loyalty to their current physicians or hospitals against the impact on their household budgets of staying with those providers. Some are changing providers as a result.

  Many providers are participating in accountable care organization (ACO) contracts, in which they bear responsibility for the total cost of care of a patient population. For ACO providers, it is important to hold on to all patients, healthy as well as sick, and to keep those patients’ care within their organization. To do so, they need to meet their patients’ needs and give them peace of mind that those needs are being met.

  What, besides out-of-pocket costs, is likely to influence patients as they choose where to get healthcare? They want providers to work together and work with them to help them live lives that are as long and healthy as possible. They want peace of mind that their outcomes are as good as they can be even though they may fall short of perfect health.

  These concerns are reflected in Figure 2.1, which summarizes an analysis of nearly a million surveys of patients, identifying factors that separate patients into groups with different levels of commitment to their clinicians and their medical practices. In this analysis, “Recommendation Failure Rate” is the percentage of patients who did not give a top rating on a 5-point scale when asked how likely they were to recommend either the provider or the practice (15 percent overall). The likelihood of recommending a practice is a reasonable (and probably the best available) reflection of the extent to which patients have peace of mind that their care is optimizing their outcomes.

  Figure 2.1 What drives patient loyalty

  The most important single variable in driving the likelihood to recommend is the patient’s confidence in the clinician. But even when that confidence is high (see the right side of the decision tree), the Recommendation Failure Rate rises to 11 percent if patients did not think that everyone was working well together on their behalf and to 22.3 percent if they felt that the care provider team was not deeply concerned about their issues (bottom row, fourth box from the right). The algorithm can be used to compare physicians on the percentages of their patients who fall into high-, medium-, low-, and very low risk groups.

  This analysis is interesting not just for what is included but also for the factors that were not included after taking the variables in the decision tree into account. Variables that did not add statistically important information included waiting time, convenience, and amenities. Naturally, patients do not want to wait longer than necessary, but what is most important in influencing their likelihood of recommending physician practices is having good clinicians who listen to their issues and work well together.

  The same themes emerge from analyses of patient-experience data from people who have been hospitalized, which demonstrate that coordination of care and communication are most important in driving patients’ likelihood of recommending an institution. The single most important driver is nursing communication with the patient; this makes sense because nurses do so much of the actual work with patients during their hospitalizations and play an enormous role in conveying to patients what is happening and what will happen next. Variables such as food and parking rank at the very bottom of virtually all analyses of what drives patients’ likelihood to recommend hospitals.

  Similarly, in analyses of survey responses from emergency department patients, the most important factors driving patients’ likelihood of recommending the facility are whether they feel that the staff cares about them, whether they feel the staff has kept them informed about delays and what is happening, and whether they feel they have been treated with courtesy. Issues such as pain control and actual waiting time were not statistically important after taking into account whether the clinicians demonstrated empathy and communicated well with patients.

  The same themes emerge in analyses of the pediatric population and every other segment of patients where my colleagues and I have looked. Patients want good clinicians who are working well together and are listening to them. Those themes make sense to clinicians and certainly do not clash with what drew them to healthcare. The bottom line is that healthcare is in the fortunate position of having a business imperative that resonates well with the values of its personnel.

  The Clinical Imperative: Reliability and Improvement

  The strategic imperative for healthcare providers in this new era of value-driven competition is to meet patients’ needs as effectively and efficiently as possible. The business imperative that logically flows from meeting patients’ needs is to provide care that inspires confidence in clinicians as individuals but is also coordinated and empathic. That all sounds good, but what do these imperatives translate into for doctors, nurses, and other frontline caregivers?

  Imperatives are far from welcome to many clinicians and other personnel who are already under considerable duress. As is true in every business sector, healthcare personnel are struggling with constant pressures to do more and do it better with fewer resources. These pressures are especially daunting in healthcare because of its complexity: there are so many issues to address and so many definitions of “better.”

  The result of the complexity of healthcare is that dozens, even hundreds, of metrics are being used to evaluate healthcare providers, and their cumulative weight can be overwhelming. The performance report cards in many organizations are literally hundreds of pages long, with data on mortality, complications, compliance with clinical guidelines, safety events, patient experience, and financial issues. In many organizations dozens of personnel are employed just to collect, analyze, and report these data.

  The many different performance metrics can, paradoxically, impede improvement. Measurement overload is a common complaint. “Just tell me three things you want me to do, and I’ll do them,” one physician said to me recently. “But if you tell me twenty-five things, it is going to be hard for me to pay attention to any of them.”

  In fact, there are really just two things healthcare providers need to focus on: The first is to be reliable in delivering care the way it should be delivered, which means excellent technical quality, coordination, empathy, and efficiency. The second is making improvement a perpetual focus. Providers should never be satisfied with their care as it is. There are always ways in which they can improve; no one should ever consider himself or herself the best or even good enough.

  Performance measurement is still fairly new in healthcare. For simplicity’s sake, the cultural history of healthcare performance improvement can be divided into the eras before and after the 2000 publication of To Err Is Human by the Institute of Medicine (IOM).4 Before the report, the conventional wisdom was that the quality of healthcare in the United States was generally excellent but difficult to measure. Guidelines had been developed for some topics, but in the absence of alternatives, the preservation of physicians’ autonomy to do what they judged best for patients was often invoked as the first principle of high-quality healthcare.

  In truth, most healthcare providers knew well before 1999 that hea
lthcare often fell short of what it could and should have been. But To Err Is Human and its 2001 successor, Crossing the Quality Chasm,5 drew attention to gaps in safety, reliability, efficiency, and the overall experience of care. At many institutions, the work of improving healthcare quality and efficiency was broken down into various subcategories, leading to several new roles and an abundance of new metrics. New titles included chief quality officer, chief safety officer, chief patient experience officer, chief population management officer, and chief value officer. Inevitably, complaints about measurement fatigue and skepticism about performance measurement emerged.6

  Research and experience in subsequent years have shown that all these streams of work are important and none can be ignored. The implication is that it is time to reintegrate the various streams of quality that emerged after the IOM reports: reliability in adherence to guidelines, safety, patient experience, and efficiency. The basic challenge for healthcare providers is nothing less than to be reliably excellent in all of them.

  The unsurprising reality is that no one is the best at everything and everyone has room for improvement on something. No institution can rest on its laurels because it has a fabulous reputation. We cannot assume that a hospital that is excellent on guideline compliance metrics is also excellent in patient safety. All the dimensions of quality are separate yet intertwined, and they combine to determine the outcomes and costs of care.

  An important implication is that providers have to measure actual outcomes. Traditionally, clinicians have been leery of putting too much weight on patient outcomes such as mortality, other clinical outcomes, or patient experience because of difficulties with risk adjustment and the impact of clinical and socioeconomic factors beyond their control. That said, the real issue in healthcare is how patients are doing, not the reliability of providers. It is hard to improve if the focus is not on the real target.