For example, J. Michael Henderson, MD, our chief quality officer, recalls locking a lab door to prevent physicians from using substandard equipment. They were analyzing patient urine samples there and not sending them to the lab for evaluation. This practice had been in place for decades, but it no longer met national quality standards. Henderson tried to change their behavior, and when the physicians would not comply, he removed the equipment and locked the door.11
Because we have been successful in cascading the patient experience message, everyone owns responsibility for driving it. All leaders, whether managing huge operational divisions with a thousand people or supervising just a couple of employees, must lead it in their areas. For customer-centric organizations to be highly successful, every leader in the organization must own and lead the customer focus.
One of healthcare’s challenges is that patient-centeredness can appear to be the responsibility of only the people who deal directly with patients. Nothing can be further from the truth. For hospitals to be successful, all clinical and nonclinical leaders must align around the patient. Failure will cause the patient experience messaging cascade to stop.
The patient experience, like any other major organizational initiative, requires visionary leaders who own the strategy, talk about it, and have the ability to occasionally take charge and execute a tactic. Persistence is required to prevent the patient experience from becoming a “flavor of the month.” Every leader and manager must be made to understand why it is important and how he or she is critical to its success. Accountability must be present for those who don’t believe it and don’t want to adopt it as an organizational priority. Leaders also must be willing to try new things and challenge others around organizational dogma.
In summary:
1. The top person at the organization must own improving the patient experience as his or her priority. If the leader is not talking about it, people will not pay attention and it will not get the consideration it deserves. Likewise, since the patient experience is inherently comprehensive, the only leader with the authority to impact such a broad scope is the CEO.
2. While the top person owns the issue and messaging, a C-suite executive who reports directly to the CEO is necessary to execute for meaningful operational effectiveness. Improving the patient experience will require resources, management of data, and specific tactics. There must be a person who is responsible for day-to-day operational improvement.
3. Just telling people in the organization that the patient experience is a priority will not fix it. Every leader and manager in the organization must understand the burning platform, know that it is a priority from leadership, and take responsibility for implementing it. This includes nonclinical leaders as well as clinical leaders.
4. Leadership rounding is an easy tactic that can be implemented immediately in any healthcare environment. It’s a way to drive executive-level visibility to caregivers and patients and identify important issues that can impact operations.
Chapter 4
Describing the Elephant: Defining the Patient Experience and Strategy
A solid definition of the patient experience is elusive. But before we can improve it, we need to have a working definition of how to think about it. There are two reasons why a concise definition is critical. First, we must define the patient experience for patients regarding what is important; otherwise patients will define it for us. Generally, patients are unsophisticated healthcare consumers. A particular experience equates to quality in a patient’s mind. Patients often use proxies to judge our effectiveness. These proxies are things they do understand and can easily relate to their personal experience. We need to make sure that they pick the right proxies or at least understand their environment as it relates to their proxies.
Second, before you can improve an organization’s patient experience, it must be clearly defined so that everyone in that organization—every caregiver—knows how it relates to his or her job and what must be done to improve it. If you cannot clearly communicate to caregivers the patient experience definition and expectations, it will be impossible for them to understand how to frame improvement tactics. Caregivers will not be sure what they are improving. Successful change management requires that all personnel in an organization, at every level—from the receptionist scheduling the appointment to the director of supply chain—understand exactly what the initiative means to them and what it is that you want them to do. Not having a unifying definition creates confusion for leaders and managers trying to affect it, as well as for frontline caregivers who are trying to deliver on it.
The definition also must account for the clinical realities of hospital operations and everyday patient care. People must understand how the definition fits into the overall scheme of what they do every day. Nurses, doctors, and other caregivers must go about the business of delivering care to patients. These professionals are very busy, and they don’t have time to study and understand a definition. There can be no room for interpretation. Getting people to understand the definition quickly will make it practical and drive rapid adoption. Adoption will also improve if the framework naturally fits with what people do every day.
A concise definition of the patient experience must factor into other hospital programs that are well established and critical to the functioning of a healthcare system, namely safety and quality. Patient experience cannot be viewed as a stand-alone hospital initiative. Patient experience, safety, and quality are inextricably linked, and tactics that improve the patient experience, such as cultural development, certainly impact safety and quality as well. An effective definition must align these links. If we define the patient experience too narrowly, such as related to patient perceptions or satisfaction, then we run the risk of marginalizing more important issues, such as patient safety.
Shortly after I became CXO, the chief nursing officer and I convened an enterprise retreat on the patient experience. We wanted to involve as many key stakeholder leaders from across the organization as possible early in our change process. We invited a variety of C-suite members, physician leaders, nurse leaders, and operations leaders from all across the enterprise, including our main campus, community hospitals, and ambulatory centers. At the opening of the retreat, we asked the 60 attendees to break up into small groups and discuss a vision for the future state of the patient experience at Cleveland Clinic. In essence, we asked them to define the perfect patient experience. Results ran the gamut from free parking, happy caregivers, more smiles, quality medical care, and new and clean facilities to improved communication with patients.
I liken the patient experience “definition challenge” to the parable of the blind men and the elephant.1 In this tale, six blind men touching different parts of an elephant are asked to describe the animal. The man who touches the leg observes that the elephant is like a pillar, while the man touching the tail describes the elephant as a rope. The fellow who touches the ear says the beast is like a large hand fan. Each man recounts something different because none of the men can see the elephant as a whole. They could not agree on what the elephant was like, despite all of them correctly describing a feature of the animal.
Our early enterprise retreat validated that the parable was an apt analogy. Everyone knew that the patient experience was important, everyone knew that it needed to be improved, and everyone wanted to help. But everyone had a different idea of what the patient experience meant and how to fix it.
A survey conducted by HealthLeaders Media2 found that U.S. hospital leaders believe the patient experience to be the number one strategic priority for their organizations. Yet I find that few C-suite hospital leaders agree on the definition of patient experience. Nor do they concur on how to organize and lead patient experience improvement efforts. When I speak with leaders at all levels, I find that patient experience improvement efforts are disorganized and inconsistent across U.S. hospitals.
Part of the challenge is that the patient experience as a focus area is relativel
y new. Traditionally, it has been defined as patient satisfaction, and responsibility for measurement and management of improvement efforts was relegated to the marketing department. The Affordable Care Act and Medicare have now linked inpatient reimbursement to hospitals’ performance on HCAHPS scores. Medicare is also working to expand patient experience measurement tools in the ambulatory, pediatric, and emergency department environments. Other payers have followed Medicare’s lead, with many private health plans now negotiating with hospitals to link a portion of payments to patient experience performance metrics.
Data transparency and its link to reimbursement are also driving increased consumerism. Patients have a choice, and they are using publicly reported data to exercise their options regarding where to go for care. These external pressures are forcing hospital leaders to pay attention and determine what the patient experience means to their organizations and how to improve it.
Why Definition Is Difficult
If you ask any healthcare worker if the patient experience is important, most everyone will say, “Yes, absolutely!” It’s hard to disagree with the need to provide a great experience for patients. Our enterprise patient experience retreat discussions certainly validated that. While everyone agreed on the importance of outstanding patient experience, few could actually define what it means or how to achieve it. We also faced definitional challenges because we all believed we knew what was important.
What fascinated me most from our retreat was not only the group’s passion about why the patient experience was important, but our collective belief that we were better able to define it because we have the benefit of experience both as caregivers and as patients ourselves.
Part of the problem of gaining universal adoption of the patient experience as a top priority is directly related to difficulty in defining precisely what the patient experience means and how it fits into everything else of concern to healthcare organizations. As a 2010 Gallup Business Journal states in an article on the patient experience, “After all, if you can’t define it, you can’t provide it.”3
To achieve organizational adoption of a new concept like the patient experience, you must define the what, the why, and the how.
When I first started talking about the patient experience, people would often ask me, “But what does it mean?” and “How do you define it?” and “Why is it important?” I remember the feeling of helplessness as I tried to message what it was, what we were doing, and why. Giving presentations to our individual medical departments, I saw blank stares from the audience members. No one grasped what I was trying to say, and as I rambled off lists of different things that I thought were important to patients, I was unsure myself.
After my appointment as CXO, one of the people I met during initial meet and greets with senior leaders across our organization was the president of our regional hospitals. At the time, these hospitals had terrible patient experience scores. He was very supportive of the importance of the patient experience, and we discussed the overall strategy and what might make a difference. Our conversation then veered off into specific tactics we might implement. In retrospect, I recognize that we were jumbling emotional conviction regarding the importance of improving the patient experience with ideas for strategy and tactics. He pledged his support and committed to do whatever was necessary to fix it. We were both on the emotional “can’t disagree with the importance of the patient experience” bandwagon without really knowing the scope or definition of what we were talking about.
The early days of my career as CXO were peppered with conversations like that, repeated across the enterprise. Everyone agreed that it was important and pledged to help—but no one knew exactly what it meant or how to fix it. Everyone was committed to it, everyone wanted to share his or her ideas and thoughts on tactics, and some were running out in front trying to implement things they were convinced would make a difference.
After fumbling through what I thought the patient experience meant, most conversations got worse, with the inevitable follow-up question, “OK, great, so how do we fix it?” Shortly after my meeting with the president of our regional hospitals, he gave all of his COOs a mandate: “Fix the patient experience.” One of them called to tell me about it, and then asked, “Jim, tell me how to define the patient experience. What is the scope?” At that moment, I finally realized it was imperative to nail down a definition that people could grasp. Here was an operational leader ready to execute, but we hadn’t identified what he should be executing.
Nationally among hospital leaders and healthcare providers, the words patient experience carry an unfavorable association. The definition has been hijacked, and the patient experience is frequently considered synonymous with making patients “happy.” A 2014 article in Forbes reported that an emergency medical department with poor patient satisfaction rankings began offering “Vicodin goody bags to discharged patients in order to improve their ratings.”4 The article went on to suggest that if patients don’t get what they want, they will not be happy and, therefore, will rate their providers poorly. That “more of what they want” includes expensive diagnostic tests that may not be beneficial. Similarly, when patients seek antibiotics for themselves or their children, if the physician believes the drugs are not warranted and does not comply with the request, poor ratings may follow. These suggestions are preposterous and dangerous.
Patient Perceptions of the Experience
Patients’ definition of their own experience is quite divergent as well. We ask patients for feedback, and the results are fascinating. We’ve found that patients often use the word experience in their comments: “I can’t believe how the experience in this hospital was.” “This place is amazing—everyone is so friendly and caring.” A patient remarked to our CEO on one of his leadership rounds, “Where do you find all of these angels to take care of patients?” Occasionally, patient comments are less complimentary: “My experience was terrible!” Patients tend to define their experience based on an “in-the-moment” encounter or a specific significant occurrence. Regardless of the quality of the entire journey, it will be the one or two great—or bad—events that will define a particular patient’s experience.
Patients’ perceptions, and, therefore, their patient experience definitions, are also influenced by the people around them. Once, when he was chairman of the Department of Thoracic and Cardiovascular Surgery before becoming CEO, Cosgrove was summoned urgently to a patient’s room after surgery. The operation had gone well, and he believed the patient to be recovering without incident. Concerned, he ran to the room, finding the patient visiting with family and doing fine. A family member implored Cosgrove to look under the bed, where she pointed out dust bunnies. She asked the world-renowned surgeon, “How can this hospital provide top care if you can’t even clean the floors?” Cosgrove was stunned. Why were the family members evaluating the organization’s quality on dust bunnies when their loved one had a successful outcome from a difficult operation? He was getting firsthand insight into how patients judge our overall effectiveness based upon seemingly minor things that they readily understand.
I once rounded on one of my patients, and in the room were several family members. They knew of my role in patient experience and immediately wanted to relay a terrible experience they had had in our hospital cafeteria. They went on to describe, “We waited at the counter and the employees just ignored us. People down there were not helping us. The cashier person was rude. She was too busy talking to her partner.” The patient, who had not even been in the cafeteria with his family members, piled on, “Yeah, that is no way for a hospital cafeteria to function.” I thought this patient’s experience so far had been very positive. He had a good medical outcome, the nurses and I were attentive, and he was happy with our interactions. Does the bad experience of a family member in the cafeteria impact the patient’s perception of his experience while in the hospital? I am not sure anyone knows the answer for certain. However, to ignore the possibility would be to diminish
the impact of family dynamics on perceptions and opinions. We must assume that occasionally the patient’s personal and family experience in the hospital environment outside of the patient’s room will impact survey results.
There may also be a disconnect between patients’ perceptions and how care was delivered. One patient wrote to our organization, “Your hospital is really bad. They hurt me.” Those are tough words for a healthcare professional to hear. Yet often, when we review a dissatisfied patient’s medical record and discuss the experience with the team that took care of him or her, we discover that, in fact, the outcome was very good, it met our standards of medical care, and all the members of the team thought that they were going above and beyond what was required to ensure that the patient and family experience was exceptional. When I asked this particular patient what he meant by “hurt,” he expressed disappointment at having to undergo treatment in the first place. We were not being judged on the care or the caring; we were being evaluated on the patient having the disease—a battle we could never win, but a very important illustration of how some patients think. Often patients’ definition of “quality” is not our definition of quality. Patients relate to things they understand, and that drives their perceptions.
Patients frequently use their experience with service quality to define their perception of the healthcare they received. If you ask patients to tell you “What is it about your stay that made the experience great,” they often zero in on a specific item such as “The doctors explained things well and were very nice,” “The nurses were very attentive,” or “The building is new and clean.”
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