Service Fanatics

by James Merlino

  After years of training under these conditions, we stopped seeing patients as people. The patient-centered experience I had during my first two years of medical school was gone. Patients were not people; they were diseases that needed to be treated. They became “the small bowel obstruction in the emergency department,” or the “SWM with the gunshot wound.” Patients and family members who asked too many questions were annoying, and anyone who challenged us was met with aggression. We didn’t see our colleagues as people, either. Instead of wanting to work as a team or help each other improve, we mocked what we thought was others’ incompetence. On pediatric surgery during the fourth month of my internship, my chief resident informed me, “If you don’t make a pediatrician cry during this rotation, you won’t pass.” I was told by attending physicians that if I could not get a patient’s diagnosis in three questions or less, I was stupid.

  Did my medical training change me? It certainly did! In my drive to become an exceptional surgeon, I had partially forgotten the reason I went into medicine in the first place, which was to care for and help people. My fellowship year at Cleveland Clinic was a searing reminder and rousing wake-up call that I needed to change course.

  A Pioneer in the Patient Experience

  At the conclusion of my fellowship, determined to follow a more patient-centered approach, I began my practice at MetroHealth Medical Center, the public hospital for Cuyahoga County in northeastern Ohio. I made sure I got to know all of my patients personally. I made it a practice in follow-up conversations to ask for an update about something I remembered about my patients as individuals. I routinely rounded on them twice a day and called when I was unable to do so. I called family members when we missed seeing one another at the hospital. Half of my patients were on Medicaid or uninsured, but everyone got my cell phone number. These were practices that many of the doctors at Metro followed.

  I was the only colorectal-trained surgeon in my group. When you’re responsible for finding your own patients, you learn very quickly the power of relationships and the fact that they are often driven by the experience you provide to referring physicians and patients. High-quality care isn’t much of a competitive differentiator when you’re in the backyard of an organization perceived as among the premier institutions in the world. But being superior at providing the care around the care—improving the patient experience—was a critical differentiator for me in competing against the giant Cleveland Clinic.

  I also leveraged the “other” customer in the market, physicians. Federal law prohibits financially incentivizing referrals, but I “incentivized” them by providing better service. There’s an old adage in private practice that physicians get more patients by being affable, available, and accessible, and I strove to be all three. I visited providers in the community to ensure they knew who I was and the type of care I would give their patients, and I communicated comprehensively with them about their patients. My volume of new colorectal surgery patients tripled, as word of mouth drove more referrals—referrals that likely would have gone to Cleveland Clinic. The county hospital was successfully differentiating experience against one of the top colorectal programs in the world.

  Cleveland Clinic Gets a New Leader

  For the next several years, I stayed in close touch with my fellowship clinical mentor, Feza Remzi. He kept me regularly informed about changes at Cleveland Clinic, and he often remarked how the organization was transforming itself for the better under the leadership of Delos M. “Toby” Cosgrove, who assumed the position of president and CEO midway through my 2004 fellowship year. Cosgrove had identified patient-centeredness as one of his strategic priorities and launched an effort to march Cleveland Clinic in that direction. I remember his initial efforts during my fellowship: He had the organization adopt a “Patients First” motto. He later established an Office of Patient Experience and hired a C-level executive, the chief experience officer (CXO), to lead it. Fledgling patient-centered programs were begun.

  Cleveland Clinic Gets a Second Chance

  In 2008, when I had been at Metro for almost three years, Remzi called to say he was going to apply for the chairmanship of colorectal surgery, recently vacated by Fazio, who had been named chairman of the Digestive Disease Institute. Remzi asked me to help him prepare for the search committee presentation, saying that if he were successful, he would hope to recruit me back to Cleveland Clinic.

  Remzi was aware of what I had been doing at Metro to build my practice by focusing on relationships. He had a similar vision: to differentiate Cleveland Clinic’s colorectal surgery department with service to patients and their physician partners in the community. Historically, the department had been successful because referring physicians simply sent over patients. Remzi wanted to build and improve relationships with physician practices all over the state and country to differentiate on service. He was my mentor and friend, so of course I agreed to help him prepare to secure the chairmanship. But I said I would never come back to Cleveland Clinic.

  The chairmanship search took eight months, and Remzi and I talked nearly every week. He reiterated his recruitment pitch to me multiple times, and I always declined. But I was becoming intrigued. Remzi is a passionate and compassionate doctor and human being. I could not completely dismiss and ignore the perspectives he was sharing about the changes at Cleveland Clinic because I knew we had similar beliefs regarding a patient-centered medical practice. And Remzi was truly energized about what was growing possible under Cosgrove’s leadership.

  When Remzi called to tell me that he had been selected as chairman, he offered me one more chance to come back. He pledged a culture of service and respect and unwavering support of the patient-centered initiatives that I believed important. With that promise in hand, I said yes.

  I rejoined Cleveland Clinic as a colorectal surgeon in 2009 with trepidation, but hope. In honor of my father and our family’s experience, I’d give it another try. I came back with the aspiration to evangelize other doctors in our department with what I’d learned in my patient-centered private practice. I came back the son who could not make a difference in the care of his father, but who would try his utmost to make a difference for future Cleveland Clinic patients and their families. Little did I know where that decision would lead.

  I busied myself with patient care while launching some patient experience–related programs within the department and then across our Digestive Disease Institute. In 2010, seven months after I returned, I was recommended as a possible candidate for the position of CXO. I had had no idea that the position had become vacant, and I was initially not interested. When I was contacted for an interview, I assumed that the organization had already picked a successor and that it was just going through the motions.

  During my interview with Cosgrove, he asked why I thought the patient experience was important. I told him the story of my father and said that I did not think anyone else should die in our hospital believing it is the worst place in the world for patients. He was stunned—but it was the truth. He asked me how we should improve, and I said I wasn’t quite sure. I asked him the same question, and he had a similar answer. We agreed to figure it out together.

  Chapter 2

  Patients First as True North

  Imagine the practice of medicine a hundred years ago: a time before antibiotics, complicated imaging, and the advent of miracle drugs that cure disease or at least significantly alter its course. There’s a picture I use in presentations of a solo practitioner walking through a farmyard carrying the iconic black medical bag. Most of the medical miracles of a hundred years ago were contained in that black bag, but most of the healing that doctors did rested in the hands that carried the bag and the relationships and interactions that the physician had with patients and families.

  As the leading early-twentieth-century physician, researcher, teacher, and humanitarian Francis Weld Peabody observed to a group of Harvard University medical students in 1927, “The good physician knows his patients through an
d through, and his knowledge is bought dearly. Time, sympathy, and understanding must be lavishly dispensed, but the reward is to be found in that personal bond.”1 Physicians and nurses of that day would deliver whatever medicine they had and dispense whatever care they could, but for the most part, they were providing comfort and compassion. They talked with patients and families, and they touched people, giving them reassurance and hope when there may have been little.

  When I consider how we deliver medicine today, I think of my operating room or an intensive care unit. Both are filled with teams of highly trained professionals working with the best medical technology on the planet: the practice of medicine has evolved from an individual pursuit to a team sport. When I was an intern, patients who had an inguinal hernia repair often stayed overnight in the hospital. Today they spend a few hours in the postanesthesia care unit. Inpatients today are older and sicker and have multiple medical problems. We often note that large tertiary-care hospitals around the country are becoming gargantuan intensive care units.

  Patients First as Founding Principle

  Cleveland Clinic was founded close to a hundred years ago, when four solo practitioners with their black bags determined to form a unit to care for patients. Beginning with its unique group practice model in 1921, the organization differentiated itself on innovation, one of the key drivers of Cleveland Clinic’s success today. Coronary angiography was invented here in 1958, and it revolutionized the treatment of heart disease. This was soon followed by the first cardiac bypass surgery in 1967. These and other innovations helped Cleveland Clinic grow in size and renown, bringing patients from all over the world and driving a high volume of procedures that further enhanced its reputation as a clinical and academic powerhouse. Today, 14 medical and surgical specialties rank in the top 1, and the hospital overall is ranked number four in the country according to U.S. News & World Report. The organization’s focus on clinical excellence and its unique model of medicine have brought it to the ranks of greatness.

  But over the years, Cleveland Clinic’s singular concentration on clinical outcomes caused it to lose its way from the tenets of its founders, who believed that the patient was the most important part of the organization. While very good at medical care, the organization had lost some of its caring. Missing in the orchestration of complexity and high-pitched care was often the human touch. Cleveland Clinic was recognized for clinical excellence, but it was not known as a place to be cared for as a human being. Nor was it known for being a collegial unit as the founders had envisioned. My own experience was testament to that. Something needed to change.

  Patients First as New CEO Motto

  That change process began when Cosgrove became CEO in 2004. One of his first efforts was to immerse himself in what he describes as “CEO school.”2 He consulted and spent time with business experts such as Jack Welch, past chairman and CEO of General Electric; Michael E. Porter, the Bishop William Lawrence University Professor at the Institute for Strategy and Competitiveness at Harvard Business School; and others. Among the compelling issues that Cosgrove identified through this schooling was the need for healthcare to return the customer—the patient—to chief focus.

  Shortly thereafter, Cosgrove introduced the “Patients First” motto. His visionary goal was simple: for everyone in the organization to have a clear understanding why they come to work every day and why Cleveland Clinic exists. The single most successful move in transforming the patient experience at Cleveland Clinic was to align the organization around Patients First.

  Like any other business, healthcare institutions exist for their customers. As one of Cleveland Clinic’s founders, William E. Lower, said, “A patient is the most important person in the organization.”3 Without patients, there would be no hospitals, no healthcare jobs, and nothing for us to do.

  We in healthcare might not like to refer to our patients as customers, but patients are indeed customers before they become patients. And patients don’t just need our services. They come to us at their most vulnerable and often at the most frightening time in their lives, and they put those lives in our hands. Patients expect us to provide comfort and healing in a compassionate environment, to be concerned for their emotional and spiritual needs as well as their medical care.

  Is there any more intensely focused service industry than healthcare? Every decision in the organization must first consider what is best for patients. This is the idea behind the Patients First motto and the reason Cosgrove chose it. Introducing a motto as a first step may appear to be superficial. However, it was neither simple nor insignificant. By introducing the Patients First motto, Cosgrove created an important early talking point and simple strategic statement of why the organization exists.

  Patients First would provide the rallying point to align the organization’s culture, to set the organization’s purpose, to serve as a burning platform for change, and to be a strategic imperative. Patients First would become our “true north,” our reason for existing as an organization, our navigational reckoning.

  I remember when the new motto was introduced. Cosgrove had been CEO for just a couple of months, and an internal campaign was launched around the concept of Patients First. Everyone in the organization was issued Patients First lapel pins, which we all wore as dutiful employees. Patients First was widely communicated across the organization, and it became part of our branding. We still wear the lapel pins.

  At first, a lot of people were skeptical. I recall walking with a colleague down one of the skyways that connect our buildings, joking that the new motto was superfluous. “We are doctors. When do we not put the interests of our patients first?” In our sleep-deprived and overworked state, we ridiculed the motto. And we were not the only ones poking fun; many frontline employees mocked the new motto as well. Every time something didn’t work or a patient ran afoul of a hospital process, people would blurt out “Patients First.” I’m not sure anyone truly believed this was an important effort that would revolutionize Cleveland Clinic.

  Many staff members and physicians even poked fun at what they perceived as Cosgrove’s hypocrisy. People would make comments such as, “Have you ever met the guy? He’s far from Patients First.” They talked about Cosgrove’s own behavior as a physician and how he often would not see patients after surgery, relying on his team members, who would make excuses for why he was not in the postoperative environment. One of his patients, a physician from another hospital system, remarked to me several years later that he actually got to meet Cosgrove after his operation. He relayed this excitedly, having heard that Cosgrove never rounded on patients after surgery.

  Although Cosgrove didn’t routinely appear to be patient-centered does not mean that he didn’t care about patients. Quality technical care was his patient focus. He recalled, “During my training, 10 percent of patients were dying during heart surgery. I focused on fine-tuning what I was doing in order to bring down the mortality rate. I didn’t spend much time talking to patients or thinking about their feelings. I didn’t think about society, the whole patient, or how an organization works. All I did was heart surgery—all day, every day. I spent my life in pursuit of technical excellence.”

  He shared a story with me about when he was in training as a resident. “Our goal was to keep people alive. Patients were happy if they even survived heart surgery, let alone thinking about how they were treated as human beings. … Imagine our perspective—we were around death every day. During my time at Boston Children’s, five children died in one day! … Do you think we didn’t develop a coping mechanism that shut off our emotional side of care delivery?”4

  Patients accepted his remoteness as a trade-off for his expert surgical skills and anticipated high-quality outcomes. These are facts that Cosgrove freely admits today—and adamantly states are not the right way to practice medicine. Introducing the Patients First motto launched an incredible transformation, not just for Cleveland Clinic, but for the new CEO as well.

  Patients First as Or
ganizational Alignment

  It might seem intuitive that service-oriented businesses, especially in healthcare, would understand the need to put customers at the center of everything they do and even message it with a motto, but this is not the case. We’ve all experienced service failures, when it felt like we were the least important part of the equation. Think about the service businesses in your daily interactions. How many demonstrate the importance of customers?

  An ongoing study by Watermark Consulting illustrates the point.5 Each year, the firm analyzes total returns for two model stock portfolios composed of the best and worst publicly traded companies in Forrester Research’s annual Customer Experience Index.6 Watermark calls the top 10 companies customer experience leaders and the bottom 10 customer experience laggards. Similar to Cleveland Clinic’s Patients First philosophy, everything that the leaders do is aligned around the customer. Customer experience laggards are the opposite. Since 2007, Watermark has analyzed the stock performance of the leaders and laggards against the S&P 500 Index. On average, the leaders generated a total return three times higher. They also performed more than five times better than the laggards. The conclusion is simple: companies with alignment around customers create greater shareholder value.

  It would seem logical that all hospitals share a common patient focus, but most do not. Alignment around patients is discussed or even bragged about, but often there is no accountability or management, and if you evaluate these hospitals’ operations, there is no evidence of alignment around the patient.