by Thomas H Lee
Empathy as Essential to Excellence
When care is not empathic and clinicians realize it, they have a common response: they cringe. That is not the way they want to see themselves. But when clinicians think of quality, they tend to focus on technical issues (“Do we have the latest equipment?”) or their reliability in complying with evidence-based guidelines. In fact, as individuals and as teams, clinicians have much more reliability in delivering evidence-based care than in delivering empathetic care even though compassion is at the core of their self-images.
The irony is that clinicians tend to take for granted that care is going to be compassionate, whereas patients take for granted that care is going to be technically excellent. Both are important, of course, but it is risky to assume that either will naturally occur if good people just work hard. They both take disciplined management, and improvement on one does not guarantee improvement on the other. The healthcare organizations that rank highest for clinical care in the annual surveys conducted by U.S. News & World Report don’t always get comparable scores in patient satisfaction surveys.
Cleveland Clinic provides a great case in point. In 2008, the first year Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) results were publicly released, the hospital, which was fourth in the U.S. News rankings, was barely in the top half of hospitals in patient satisfaction. Only 72 percent of Cleveland Clinic doctors and 62 percent of nurses scored high in the ability to communicate.
The HCAHPS data came as a wake-up call to Toby Cosgrove, the CEO of Cleveland Clinic. As James Merlino recounts in Service Fanatics, Cosgrove set out to improve the patient experience at every turn. He appointed Merlino as chief experience officer (CXO), and they decided that the foundation of the makeover should be to inject empathy into every facet of the patient experience, just as service at every point in a customer’s stay is the key to the success of world-class hotels such as the Ritz-Carlton. To communicate the idea that the staff and the patients were part of a single organism, they instituted regular training in emotional intelligence for their 2,200 managers.
Merlino also commissioned a video, Empathy: The Human Connection to Patient Care, to underscore the human commonalities of hospital staff and patients. The video, which has no dialogue, follows several people as they walk through the hospital, with only brief captions to indicate what they are experiencing. A patient tethered to IVs and tubes is identified as “10,000 miles from home,” and an ICU physician as “ending a 12-hour shift.” In one particularly moving sequence, a young girl pets a therapy dog; her caption reads “Visiting dad for the last time.” The video ends with the words “If you could stand in someone’s shoes. See what they see. Feel what they feel. Would you treat them differently?” The video, which was intended for internal use, went viral on YouTube, garnering more than 2 million views.
The message that the leadership at Cleveland Clinic sent to their colleagues is increasingly widespread. Technical excellence is not enough. Safety is not enough. Efficiency is not enough. Clinicians have to be reliable in every way, including delivery of care that is empathic. Excellence means consistency in delivering care the way it should be—for every patient every time.
What’s the path to empathic care? Acting and short courses in empathy can provide a jump-start, but empathy deepens with practice. As Larson and Yao (see note 4) put it, “Empathy, considered by many an art, cannot be achieved simply through explicit teaching and mimicking. … This is a slow immersion process that can be likened to the maturing of a fine wine.” Transforming an organization from a technocracy to one powered by empathy won’t happen overnight. To drive that change and sustain improvement, the next key step to master is measurement.
CHAPTER
4 Measurement
WE HAVE THE will, but we only partially understand the way. We know the problem: the chaos of modern medicine and the destructive impact it can have on coordination and empathy. We understand the strategic imperative to improve patient-centered care, and we have pretty clear ideas about what we need to do: deliver compassionate, coordinated care. However, our knowledge of the science to support these critical steps—what to measure to assess our progress, how to collect the data, how to analyze them, and how to use them to create change—is far from perfect and often is a subject of controversy.
To drive improvement—sustained improvement—we need measures, we need data, and we need wisdom about how to use them. Measures and data give providers insight into how they are doing compared with others and where opportunities to improve may exist. The real goal is not to rank providers on their empathy but to help them improve. Organizations want them to deliver their best possible care to the next patient they see, and the patient after that, and the patient after that. Performance improvement is really about changing the future, but it requires honest and rigorous assessment of the present and the past.
This is where many efforts to improve empathy in care have stalled. If healthcare is to be organized around meeting patients’ needs, it seems obvious that patients must be the ultimate judges of providers’ success. However, providers traditionally have had deep reservations about whether data from patients can be used to judge the quality of healthcare. This chapter will review and address the most common reservations and describe the rapid evolution and state of the science for the collection and use of data. First, to provide the context for the current and likely future states, we need to understand where we have come from.
A Brief History of Patient Experience Measurement
The field of patient experience measurement is burgeoning, but it is a relatively new business function, and when the field first developed, its goals were different from what they are today.
Patient satisfaction became a topic of interest to hospitals in the 1980s, which, although just a few decades ago, was a qualitatively different era in healthcare. In fact, throughout most of the twentieth century the conventional wisdom held that our healthcare was generally excellent—and beyond measurement. In the years leading up to the millennium, there had been so much medical progress that there was some uncertainty about whether new tests and treatments were being used wisely, and guidelines had been developed to try to prevent overuse and underuse. The preservation of physicians’ autonomy to do what they judged best for patients was often invoked as the first principle of high-quality healthcare.
As was noted in Chapter 2, the publication of two groundbreaking Institute of Medicine (IOM) reports—To Err Is Human in 2000 and Crossing the Quality Chasm in 2001—revealed deficits in safety, reliability, and patients’ overall experience. This did not come as a complete surprise to healthcare providers, of course. There had been growing concern that healthcare might not be as safe as many assumed, and researchers had begun to collect data on how often patients were injured by their care. The series of studies in New York State and elsewhere by Troyen Brennan and his Harvard colleagues showed that potentially preventable injuries were surprisingly common and that they had little relationship to the medical malpractice system.1 This research ultimately created the context for the first IOM report, with its vivid image of a 747 crashing every day to capture the toll of medical injuries on patients in the United States. Although that image was considered sensational by many, it was effective in driving change and helped create the patient safety movement in healthcare.
Patient safety was not the only dimension of quality that was recognized as problematic. Crossing the Quality Chasm also highlighted five other aims: care should be effective, patient-centered, timely, efficient, and equitable. In its recommendations, the IOM defined goals, including the following:
• That healthcare should be responsive to patients’ needs at all times (24 hours a day every day)
• That the care system should be designed to meet the most common types of needs but flexible enough to accommodate the needs and values of individuals
• That patients be the source of control and have the necessary information
and the opportunity to exercise as much control as they wanted over healthcare decisions that affect them
• That clinicians and patients communicate effectively and share information
• That the health system anticipate patients’ needs, not just respond to events
• That clinicians and organizations cooperate, communicate, and coordinate their efforts
These goals are at the core of strategy for most healthcare organizations today, but they were not on the radar of many hospitals and other provider organizations in the 1980s, when the management of these organizations first started talking about patient satisfaction. At that time, hospital leaders were interested in addressing and preventing patient complaints and were seeking ways to improve “service” as a way of competing for market share. Since hospital leaders assumed that the actual clinical care they were providing was excellent—or at least just fine—they believed that they needed to differentiate themselves by providing “wow experiences” such as beautiful settings, smiling and friendly personnel, excellent food, musicians in the lobby, artwork on the walls, and easy parking. Doctors and nurses weren’t opposed to those efforts but did not think they were critical to actual patient care and mustered only modest enthusiasm. Clinicians felt, “This is what administrators do, not what we do.”
This orientation toward “hotel functions” was not a reflection of naiveté on the part of healthcare providers. As was described in Chapter 2, in that era patients could generally go to any provider they chose without any difference in their personal costs. Hospitals could thrive if they got patients in the door, into their beds, and into their procedure rooms. With enough market share, hospitals would be indispensable to health insurance companies and could negotiate “cost-plus” contracts that covered their expenses for all their populations—including the uninsured or underinsured—and still provide a financial margin. Thus, the focus for hospital leaders was improving their brand.
Today, the driver of the healthcare marketplace is becoming competition on value: meeting patients’ needs as efficiently as possible. To improve value, organizations need to measure and make progress on the types of issues that were the focus of Crossing the Quality Chasm. But when the patient satisfaction business emerged in the 1980s, it was oriented toward brand, not value. Indeed, patient satisfaction was the prevailing term used for measuring patient views of care because it reflected the notion of the patient as a consumer who must be satisfied to be retained.
Irwin Press, PhD, a Notre Dame professor who taught a course on medical anthropology, took time during the early 1980s to observe the complexities of patient care in the multicultural environment of the University of Miami’s Jackson Memorial Hospital. His original research focused on the experience of individuals whose cultural beliefs about health and wellness differed from those of Western medicine. He quickly realized, however, that medical treatment felt foreign to pretty much everyone, not just to non-Westerners. Most patients, whatever their cultural backgrounds, felt that they were on unfamiliar turf when they found themselves in a land of experts who had their own procedures, language, and social mores.
Toward the end of his stay at Jackson Memorial, Press mentioned to an administrator that if patients were more satisfied with their experience of care, they might be less likely to sue the hospital for real or imagined errors. That notion was enticing to the administrator, who let Press review malpractice claims against the hospital. Press found what Brennan and his colleagues would later document in New York State: an enormous proportion of claims had little or nothing to do with problems in technical quality. What seemed to be driving many of the legal actions was the fact that patients and their families had become angry and upset.
As Press spoke about his observations, the idea that patients might be less likely to sue doctors and hospitals if they were more satisfied with their care caught the attention of healthcare managers nationally. The number and cost of suits were rising, creating the sense of a malpractice crisis. In addition, healthcare was beginning to feel the early impact of cost pressures, and managed care insurance plans were starting to steer patients toward some hospitals and away from others. Fearful of losing market share, hospitals sought expertise from other business sectors, including service industries such as resorts, hotels, and amusement parks.
In this context, the patient satisfaction business was born, with the two major drivers being concern about complaints that might turn into malpractice suits and fear of potential loss of market share. Press teamed with a Notre Dame colleague, Rod Ganey, PhD, an expert in statistics and survey methods, and in 1985 they founded Press Ganey, the company I joined in 2013. In addition to measuring patients’ overall satisfaction and willingness to recommend an organization, the company measured the evaluation of care that patients received in terms of the clarity of communication, the efficiency of processes, the extent to which care was responsive and personalized, and the empathy of the care providers.
Press Ganey started measuring patient satisfaction with surveys mailed to samples of patients after their hospitalization. Growing interest in the results of patient satisfaction surveys attracted several other companies, including National Research Corporation (NRC), Gallup, HealthStream, Professional Research Consultants, Inc. (PRC), and Avatar, to the field. The Joint Commission, the leading accreditation agency for hospitals, added a requirement that hospitals measure patient satisfaction in some format to obtain accreditation. The settings of care for which data were sought expanded to include outpatient care, emergency departments, and ambulatory surgery, among others. Consulting companies started to offer advice on how to improve satisfaction.
In the wake of the IOM reports, the federal government became actively interested in patient experience. The Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ) worked with researchers to develop the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a standardized instrument that is administered to randomly selected patients after discharge from the hospital. The HCAHPS survey was approved by the National Quality Forum in 2005 and implemented by CMS in 2006, and the first voluntary public reporting of HCAHPS results began in 2008.
HCAHPS went from being voluntary to being a fact of life for hospitals during the next few years. Hospitals received a financial incentive for participating in HCAHPS (“pay for reporting”), and eligible participation increased to nearly 95 percent. With the Affordable Care Act of 2010, portions of hospital Medicare reimbursement were tied to performance on HCAHPS, beginning with hospital discharges in 2012.
These same broad trends are playing out in other sectors of healthcare delivery. In sum, the trends are as follow:
• Standardized tools are being developed, tested, and then implemented with the suffix CAHPS (e.g., CG-CAHPS, or Clinician and Groups CAHPS, which is designed to drive improvement in care in doctors’ offices).
• These tools are used on a voluntary basis at first, and then implementation is greatly enhanced through the use of financial incentives for reporting.
• Eventually, the tools become mandatory as financial incentives are tied to actual performance.
• As the tools are used, performance improves. Providers that stand still—that is, do nothing and have the same performance year after year—start to fall behind their competition (see Figure 4.1).
Figure 4.1 National HCAHPS “Rate This Hospital” average top box percentage trend since inception
Patient Satisfaction Versus Patient Experience
Another important change occurred in the years after the IOM reports: the term patient satisfaction began to give way to patient experience. This change seems a semantic nuance to many but is actually of historical significance. The IOM reports had revealed that there were important quality problems that needed to be addressed in healthcare. The challenges for clinicians and administrators amounted to something much more important than soothing ruffled feathers or attr
acting patients with wow experiences. There were basic issues related to providers’ ability to meet patients’ needs with reliability, efficiency, and safety that needed to be addressed.
Providers started to realize that patients do not come to hospitals or physician offices because they want to be pampered or have a recreational experience. Patients seek healthcare because they are worried, anxious, frightened, or in pain. They want relief from suffering, including prevention of anticipated suffering. As was described in Chapter 2, they want good clinicians who work well together and listen to patients’ concerns. They want to be able to trust those clinicians. They want peace of mind that things are as good as they can be in light of the cards they have been dealt. They hope that their care will be safe, compassionate, and coordinated.
If patient satisfaction reflects whether the care conforms to patients’ expectations, patient experience reflects everything that directly or indirectly affects patients across the continuum of care, including the expectations that patients bring to their healthcare encounters. Everything means every single thing: not just the care and the service that patients receive but also the relief of their suffering, physical discomfort, and anxiety. It is not defined completely by the responses to a series of yes-or-no questions about whether an important step such as receiving an explanation of test results occurred.
Think of patient satisfaction as an interim measure: “I am satisfied that what was supposed to happen with my care actually happened.” Think of patient experience as the more critical outcome measure: “I have peace of mind that everyone worked well together to meet my needs as fully as possible.” The latter is a deeper and more holistic measure, and it presents a tougher challenge: clinicians must be involved and engaged if there is to be improvement.