Remzi provides Dana with medical advice and treatment, but he also helps guide her and her family through the right decisions. Dana’s mother describes Remzi as one of the most compassionate and caring people she has ever met, saying, “His empathy is real!” The family’s trust and confidence in Remzi’s medical ability is bolstered by his concern for Dana as a person, not just as a patient.
Is it truly possible to expect both high professional competency and compassionate care with a human connection? I had the honor of being a guest speaker at an advanced executive leadership course at Harvard Business School when we discussed this very question as part of a Cleveland Clinic case study. We were considering the patient experience, how it factored into the treatment of patients and whether there could be a financial return on investment to help drive these concepts across an organization. I posed a dilemma to the students: You’re a patient needing heart surgery and have the choice of two surgeons. One is absolutely the best in the world by every measurable objective outcome, but she is mean and doesn’t communicate well with patients or their families. She’s a true technocrat who has no empathy or humanism. Your other choice is a surgeon renowned for compassion and empathy, but his outcomes, while within the standard of care, by reputation are not quite as good as the other surgeon’s. Whom would you want to do your surgery?
Interestingly, the students were about equally divided in their choice. Some said they didn’t care whether the surgeon ever talked to them, as long as the operation was a success with a great outcome. Others took what I call the more “humanistic” perspective: they wanted someone to care for them as a person as well as perform a competent operation, arguing that if the compassionate surgeon’s outcomes were within the standard of care, that was good enough.
As a surgeon who has seen excellent, marginal, and poor surgeons up close, I used to believe that technical proficiency was the most important element of surgical care and that if I ever needed an operation, I would surely choose technical prowess over everything else, including whether the doctor talked to me. I have seen very nice and empathetic but technically challenged surgeons navigate terrible complications and avert liability by building strong connections with patients and families. This illustrates a fact that’s often revealed in malpractice litigation: Doctors don’t get sued because they are incompetent. They get sued because they don’t communicate or build relationships with patients and families.
I wonder how the Harvard students would have responded if my colleague Shannon Philips, Cleveland Clinic’s quality and safety officer, had first educated them about the culture of safety. Technically proficient but disruptive physicians actually create an environment that is unsafe and stifle other caregivers from stepping forward to protect patients. These physicians can actually have worse outcomes because they foster a culture of fear. I suspect the students who favored the technocrat might have reconsidered.
Being on the other side of healthcare, both as a patient and as a family member of a patient, changed my beliefs about what I want from a physician. Patients deserve—and should demand—a physician who is medically competent as well as empathetic and compassionate. I also believe that as healthcare leaders responsible for safeguarding quality medical delivery, we should work hard to ensure that we provide both.
Brian Bolwell, chair of Cleveland Clinic Taussig Cancer Institute, is, like Remzi, among the smartest physicians I know, and also a caring and compassionate human being. I was in his office one day, and he seemed subdued. I asked what was wrong, and he said, “A young woman I took care of for a long time just died. It’s impossible not to be sad.” She was not merely a patient to him; he knew about her life, shared a journey with her, and cared about her. If I am ever diagnosed with a terrible disease, I want physicians like Remzi and Bolwell to care for me. I want to have a connection with the persons treating me. I want to know that they care about me personally, that they are as invested in my recovery as I am. Yes, I demand that they be competent and objective, but I want to know that they will be there with me and for me. I don’t want some brilliant technocrat to just perform a procedure and walk away without an afterthought as to how I will get back to my life. I want my doctors to know something about me as a person, listen to what I think, and understand that outside the hospital I have a life, a family, and friends. Why is this important? I want my doctors and other caregivers invested personally in my outcome.
Empathetic care that transcends the human condition is what I aim to provide to my patients and is the standard we should all expect for ourselves as patients. A personal investment in empathy and compassion by all caregivers is the foundation of the future for healthcare. We must align our organizations and people around patients and how we deliver care to them.
A focus on the patient experience has become a differentiator for Cleveland Clinic. Dana travels 2,000 miles for high-quality care and high-quality caring at our institution. Our alignment around the patient impacts everything we do, not only improving patient satisfaction, but ultimately enhancing our delivery of safe, high-quality care and high value. Any healthcare system in the world can and should adopt putting patients first as its primary purpose.
When we began our patient experience journey, there was no textbook or playbook telling us how to start. The healthcare scholarship doesn’t often consider the competency of how to deliver care. Trial and error became our modus operandi. We created our own strategies and tactics, adopted some from others, and applied lessons from businesses outside healthcare. Our approach has been based on living the challenges at the front lines of a diversified and heterogeneous healthcare system with incredible patient needs and demands. Our physician champions, including me, still see patients. Our nurse champions are at the patients’ bedside. This frontline involvement and commitment is one of the reasons we’ve been successful. You cannot fix the patient experience from a 50,000-foot strategic perspective; most of the work must be operationalized at the patient touch points and carried out by frontline caregivers.
From a practical standpoint, improvement required us to frame a strategy concisely and then focus on key elements that allowed us to implement it. Everything patients—and their families—see, do, and touch is considered by us as the patient experience.
This book focuses on how to think about the patient experience, how to define it, and the factors we feel are critical to enhance it. Improving patient-centeredness also impacts how we deliver safety and quality. These are important not just for patients, but for caregivers as well.
In the subsequent chapters, I describe how Cleveland Clinic’s leadership determined to make the patient experience a priority, defined it, and set a strategy for improving it. I discuss the foundational elements of culture, physician involvement, and understanding patients. I share our execution successes and failures, including how we organize, recruit, train, and measure for service excellence; how Cleveland Clinic has evolved its culture and aligned its workforce around Patients First; and how we improved the critical element of physician communication. I convey my beliefs and experiences regarding cutting-edge issues such as making patients our partners in ensuring a quality experience and sharing approaches with caregivers worldwide so that patients everywhere can hope to receive better care.
I have written about Cleveland Clinic’s journey because we have made a difference and our approach is working. It is just one of many possible approaches, and you may find that it can help your organization. And just as we have learned from a variety of different businesses outside of healthcare, I believe that our strategy and many tactics hold lessons for other businesses as well. Aligning a workforce around the customer is applicable to any business that has customers, which is every business.
No doubt some reading this book will look at parts of our organization and say that our approach is not functioning as well as we think. Improving the patient experience is hard work, and we still have a lot to do. But just as Cleveland Clinic historically has had relentless
focus on medical excellence, there’s no question that we now pair that with a relentless focus on improving the patient experience. We have gone from being among the lowest-rated hospitals in the country for patient experience metrics to among the highest.
This book is not meant to be a comprehensive resource for every patient experience tool available or a technical manual of all that we do. I discuss our strategy and many of our tactics, and I describe some of the roadblocks we encountered. If you peer under the hood of our organization, we look like most other healthcare systems—perhaps even like yours. We have the same needs and challenges, and we all face an uncertain future.
There are some elements unique to our journey that have granted us unusual success. Cleveland Clinic’s appetite for innovation allowed this program to gain hold and flourish, giving us a head start. But at the time we began, external pressures were not as intense. Today, the forces pushing hospitals to get better are much stronger, so this should help others gain the foothold they need to climb the path of improvement.
It’s my hope that you will find something in this book that can help your organization. Perhaps the book will reinforce that you are on the right path and provide you with a reassuring pat on the back. My goal is simple. If you deliver healthcare, you must think about how to align your organization around the patient. In such an environment, Remzi, Bolwell, and millions of other caregivers throughout the world can deliver high professional competency and compassionate care with a human connection. It is what patients like Dana Bernstein want. It is the right thing to do, and it should be the focus of healthcare. It is what you would want for yourself and your family.
Acknowledgments
I would not be the person I am today without what my patients have given me since I started this journey called medicine. From the very first patient I saw as a medical student to the ones I treat today, they teach me, inspire me, and challenge me to think differently and to care more. They have taught me the gift of empathy, and it is an honor to have been a part of their lives in such a personal way. The same is true for the incredible people, my caregiver colleagues across healthcare, who share the profound responsibility of delivering care for people.
I would not be successful personally or professionally without the support and encouragement of my wife and best friend, Amy. She was at my side when this patient-centered epiphany occurred, and has supported me during my journey at Cleveland Clinic. Writing a book like this requires the sacrifice of nights and weekends; they were her sacrifices as well.
My father’s name was Carmen, and I owe who I am to my family: my mother, Shirley, and my siblings, Sue and Tom.
Toby Cosgrove, CEO and president, and Joe Hahn, chief of staff of Cleveland Clinic, have given me this awesome opportunity to help shape an organization and start a movement. Toby’s vision to drive the patient experience was a disruptive innovation in healthcare at a time when no one else was talking about it. Together, Toby and Joe have taken the Clinic to heights many thought not possible. They have never wavered in their support, and there is nothing I will ever be able to do to thank them.
Kelly Hancock, our executive chief nursing officer, has been my friend, confidant, and an early and critical ally in all our efforts to improve the patient experience at Cleveland Clinic. Our success belongs as much to her as it does to me. We would not have achieved what we have without her passion, support, determination, and keen instincts. She is an incredibly gifted leader highly respected not only in our organization, but in healthcare across the United States.
Feza Remzi is my clinical mentor, my friend, and the department chair of colorectal surgery. My first rotation during my fellowship was with him. He taught me the value of a personal connection with patients and is a role model for compassion and humanism. He got me back on track after my father died, and he was the first to enchant me with what Cleveland Clinic is about. I am at Cleveland Clinic because of him, and I will be forever in his debt.
Brian Bolwell, chair of Cleveland Clinic Taussig Cancer Institute, is likely more responsible than anyone else for my holding the position of chief experience officer, encouraging me to persevere during the search process. He is a remarkable leader from whom I learned never to fear speaking up for what’s right, especially when it concerns the patient.
Ananth Raman has been my mentor, friend, and, more important, patient experience soul mate from the beginning. He has tutored me in the nuances of execution and continually challenges me to think differently regarding opportunities we face so we may find success in what we do. He has been a constant and consistent navigational beacon in this journey.
David Longworth began his career at Cleveland Clinic and, after 10 years at the Clinic, joined a Boston health system. He returned to Cleveland Clinic 10 years later as chair of medicine. He is my barometer of the “before and after” comparison, constantly reassuring me that where we stand today is better than where we stood yesterday. David has a great mind and has been my muse for many ideas about the patient experience.
Adrienne Boissy has been by my side on this journey from day one. She is passionate, committed, and driven to provide what is needed and right for patients. Her incredible work has enhanced our physician culture and likely will effect meaningful change in the practice of medicine worldwide.
Cindy Hundorfean, our chief administrative officer, is responsible for leading the clinical enterprise. This is the engine of Cleveland Clinic, and there are few people whom I have ever met who can boil down such an enormous operation into something manageable. Cindy has been an important mentor from the beginning. If I owe Brian Bolwell the credit for keeping me in the race for the job, I owe Cindy credit for keeping me in the job. She has been an important source of encouragement, guidance, and support throughout this journey.
Linda McHugh, executive administrator to the CEO and Board of Governors, has been at Cleveland Clinic her entire career, most of it at Toby Cosgrove’s side. She knows the organization’s history well and has lived through and assisted in leading our tremendous growth and success, including helping to propel the heart institute to the number one position in the world. Through my years as chief experience officer, she has been a guide, mentor, and friend. I am indebted to her for reading the entire manuscript and providing her historical, candid, and objective advice.
Beth Mooney, chairman and CEO of KeyCorp, is a member of Cleveland Clinic’s Board of Directors and chairman of its Safety, Quality, and Patient Experience Committee. She is an incredible leader who rose to the top in part by differentiating on the customer experience. She taught me how to think and act like a professional and, from the very beginning, guided me in framing our capability, enhancing it for short-term success, and innovating to drive long-term differentiation. I am indebted to her for her critical review of the manuscript and for writing the wonderful Foreword to this book.
We developed our international patient experience footprint with Bill Peacock, Jim Benedict, Rob Stall, and the late Bill Ruschhaupt, MD, from operations. They taught me volumes about international healthcare and challenged us to think out of the box to meet the needs of other cultures.
Marc Harrison and I both started in the Clinic’s C-suite at about the same time; he with much more healthcare leadership experience than I. He is a smart and gifted leader who personally knows the other side of healthcare better than most. He was a beacon in the early fog and has taught me the importance of skepticism, healthy debate, accountability, and integrity.
Tom Graham serves as our chair of innovations. He has a brilliant mind that brings unmatched business acumen to the world of medicine, and he and his team have taught us how to take our success and push it into the market.
I find it a little amusing to tell people “I have an editor.” Casey Ebro from McGraw-Hill has shepherded this work from the beginning. Her incredible mind and engaging and inquiring personality match no one I have met. She has made me smarter and this book better.
Writing was never my st
rength in school, and there was always something attractive to me about the unintelligibility of a doctor’s handwriting. Beth Brumbaugh shaped my words and made this book readable. I am indebted to her for taking this work and making it concise for all to understand. She is extremely talented, and from her, I have become better as well.
A colleague of mine often remarks that leaders are not successful without a great team of people to support them, and my work in the patient experience is no exception. I have been successful because the people around me are gifted and exponentially smarter than I: Jennifer Fragapane, Carmen Kestranek, Stacie Pallotta, Mary Linda Rivera, Tom Vernon, and Donna Zabell.
We become better leaders through a variety of methods, but the best way is to acquire the skills and attributes of those around us whom we respect and admire. I am honored and fortunate to work with some of the brightest and most talented leaders in healthcare, including my colleagues on the Clinic’s executive team, our medical and nursing leadership, and our administrative leaders across the organization. From you, I have learned much, and together we have created success.
There are many people who have worked very hard to transform this organization around the patient and create a world-class patient experience; I cannot possibly list and thank everyone individually. But this book is about you, and the tremendous achievement we have accomplished is your achievement—thank you!
Finally, Toby often talks about the incredible platform that is Cleveland Clinic—meaning that bright, innovative people working in this incredible organization create synergies that allow success beyond what any one person can bring on his or her own. Toby is right! Anyone who believes that what happens here is the result of one person is mistaken. The Clinic provides a unique, innovative platform to drive collective success; it is an intangible that is hard to describe, but one that produces results that are real!
Service Fanatics Page 2