Service Fanatics

by James Merlino

  This global grab bag of comments demonstrates the challenge: if the patient experience can mean anything, then how do you define it as an organization and, more important, how do you fix it? Patients have widely varying perspectives, and it is unreasonable to hold patients to a single definition of how they think about the patient experience. The patient experience can mean anything, can differ from patient to patient, and is highly perspective- and experience-based. A patient will define the experience from his or her unique vantage point, which is often determined by a single good or bad event. This is what patients remember.

  Professional Definitions of the Patient Experience

  Harley Manning of Forrester Research, who focuses on understanding and enhancing customer experience in a variety of industries across the world, including healthcare, defines customer experience simply as “How customers perceive their interactions with your company.”5 Patients are our customers, and they can define their experience any way they want. An astute observer once remarked to me that the patient experience is what patients say it is to their family and friends when they are out of your healthcare environment.

  Merriam-Webster’s Collegiate Dictionary has several definitions of the word experience, but the one that fits most appropriately in this context is, “the act or process of directly perceiving events or reality.” An additional definition is, “something personally encountered, undergone, or lived through.”6

  There are consultant reviews and reports that try to explain it, but consultants may have a bias and the tendency to wrap their definition around their services. In a 2009 white paper published by Deloitte Consulting LLP, the authors state, “The patient experience refers to the quality and value of all of the interactions—direct and indirect, clinical and nonclinical—spanning the entire duration of the patient/provider relationship.”7

  Gallup’s definition centers on engagement and the need to fulfill psychological elements of confidence, integrity, pride, and passion, combined with providing top-of-line medical care.8 This definition’s central component, engagement, certainly is an element of delivering a great patient experience. Patient engagement is a major focus of Gallup’s healthcare consulting business.

  Further, there are definitions built around consensus statements and surveys from healthcare leaders. The Beryl Institute, an industry-sponsored organization that works to synthesize thought leadership in the field of patient experience, composed a work group of health professionals to tease out a consensus statement that defined the patient experience as “The sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care.”9 I believe consensus statements are compromises, as they amalgamate a variety of ideas. There is the risk that something truly important is missing. Our own retreat demonstrated this observation.

  Healthcare’s inability to articulate a concise definition of the patient experience, in conjunction with our individual beliefs regarding what we think it means and how to fix it, makes fixing it very difficult. I realized early on that if Cleveland Clinic was going to improve the patient experience, we first needed to define it. Ultimate success in our efforts to improve would mean controlling the perspective on the “elephant.”

  Additionally, fixing the patient experience has an impact on hospital operations, an element that cannot be managed by consensus. The problem with definition lies not only with frontline people but with the very people who are trying to drive and manage change. We all want to do the right thing for the organization. But without clear leadership and direction, there develops a meandering definition of the patient experience: each person has an idea of what the patient experience means, and everyone has individualized thoughts regarding how to improve it, which leads to decision-making paralysis and ineffective change.

  Early in my role as CXO, I believed that the patient experience was all about patient perception and that there was little we could do to affect it. Many still have this belief, and while perception may drive how patients view their experiences, providers and systems have tremendous power to set and manage those perceptions.

  An interesting study examined whether patients’ recollections of past events could affect their perceptions of an experience.10 Two groups of patients underwent colonoscopy. In one group, patients had procedures done according to normal practices. In the other group, the scope was kept in the patients longer before it was completely removed. The researchers theorized that the longer procedure would be viewed as more favorable. This hypothesis seems counterintuitive, as one would believe the shorter procedure would be perceived as better. Patients tended to zero in on the part of the procedure where they had the least amount of discomfort—which was at the end, where the scope was in longer, but not really doing anything clinically significant. That last part of the procedure defined the patients’ perception of the experience.

  This study suggests that there are critical events in a procedure that define the patient’s perception of how that procedure was performed. The study also suggests that the entire experience can be influenced by the provider. There are critical touch points that define the patient experience, and we have the ability to influence those touch points. Imagine if we knew where the critical points were for every patient’s journey—the interactions that were really meaningful. Our efforts and resources could be targeted to ensure that those were exceptional points of contact. Having seamless processes and aligning our efforts around those touch points is achievable. This not only will have impact on patients’ perceptions of their experience, but will improve the way we deliver care.

  Cleveland Clinic’s Definition of the Patient Experience

  I have devoted considerable thought to what the patient experience actually means and how it can be improved. It is pretty clear that everything has impact upon patient perceptions; therefore everything is the patient experience. It is everything patients see, touch, feel, hear, and think about their interactions with the organization. When asked how I think about the patient experience, I always start out by showing a slide displaying a box labeled “The Episode,” as shown in Figure 4.1. Arrows around the box indicate a direction of movement. The arrows represent the patient’s journey through and around the medical care. The patient experience encompasses everything before the patient becomes a patient, such as perceptions of the organization and the ease of access. The patient experience includes what happens while patients are receiving inpatient or outpatient care. The patient experience also includes getting patients back to the starting point, encompassing discharge, follow-up, and so on. I call this the patient experience “360.” Managing this 360 is our challenge.

  Figure 4.1 The patient experience 360.

  How the definition is used and messaged differs depending upon whether you assume the provider or the patient perspective. The definition is critical to both the inward-facing (provider) and outward-facing (patient) perspectives.

  For an inward-facing definition to help drive organizational improvement by focusing strategies and tactics, it must be easy to understand and applicable to the ways hospitals think about and lead their operations. The definition must account for a variety of different priorities in healthcare and help employees understand how to think about the patient experience.

  Because for patients the experience can be anything they perceive it to be, the actual outward-facing definition is less relevant and can be less precise. Patients’ experience is driven by perception, and their tendency is to define it based upon an in-the-moment experience. They will use this lens to filter everything they see and experience. We need a consistent definition that helps patients understand how to think about their experience. We define the patient experience for them to assist them in focusing that lens on what is important.

  If the patient experience is everything, let’s contemplate what we want the patient to see and experience. To understand how this concept works and consider how to make improvements, we place ourselves in
the role of the patient and ask, “What would we want to experience?” Think about how patients transition through a healthcare encounter and include in that flow their feelings and needs. We did this in several of our areas using patient focus groups and voice of the patient advisory councils. For an effective patient experience, the flow must be seamless and must generally meet the expectations of the patient.

  In the 360 concept, patient movement is generally longitudinal. Patients enter on one side, interface with a variety of touch points, whether administrative or medical, and exit on the other side. This basic flow is similar whether describing an ambulatory or inpatient encounter. The ideal experience for the patient is for each touch point to be effective and each transition seamless.

  To illustrate, consider something that happens every night on the Las Vegas strip. As I mentioned previously, in front of the Mirage Hotel and Casino is a volcano attraction. For 15 minutes every night at 5 p.m. and every hour on the hour until 11 p.m., lights, music, drama, and fire coalesce and build to a crescendo of anticipation and excitement that ends in a fiery explosion. The visitor sees magic, unaware of the hundreds of processes and multitude of people working behind the scenes. The day after I first watched this unique entertainment, I was given a behind-the-scenes, under-the-volcano tour of the operation. Management pulled back the Wizard of Oz’s curtain to reveal multiple hidden processes that when combined deliver a consistent, reproducible experience for viewers. The Mirage volcano is a model of seamless execution designed to deliver a friendly and fascinating user experience.

  Taking care of patients is much more complicated than making that volcano erupt; nevertheless, the point is the same. We should ensure that patients never see or experience the complex support that drives the flow—whether processes, information technology, or human beings. Too much behind-the-scenes exposure can erode patient confidence in our system, as it may appear disjointed and uncoordinated. Creating the ideal patient experience requires a multitude of caregivers from a variety of disciplines employing complex processes that work together to deliver what meets the patient perception of the ultimate. For the patient, the process should be akin to hearing a well-conducted orchestra performing together to create a harmony of experience and ensure consistency, superior execution, and seamless transition. The combination of consistency and accuracy in what we do not only secures the optimal patient experience but also upholds safety and quality.

  To understand how we would like our employees to think about the patient experience, let’s look at aviation. I have had opportunities to fly on private jets and sit up front with flight crews and better understand how they perform their tasks. On one such flight, just after completing the preflight checklist and right before we took off, one of the pilots informed me that there were times I could not talk to them, specifically during takeoff and landing and during selected events in the air. Once we were airborne, I asked why these sterile cockpit rules existed. The pilot told me that takeoff and landing are the most dangerous times for pilots, and they have to be completely focused and cannot be distracted. Furthermore, when the plane encounters certain types of events in the air, such as heavy turbulence, the same is true. Pilots focus on flying the plane rather than conversing with passengers. I often get nervous during periods of heavy turbulence and wonder why pilots don’t immediately announce that everything is OK. It is because my satisfaction is not their priority; it’s ensuring that the plane is safe.

  Airlines have hundreds of thousands of employees around the world, and their leaders must balance the same elements: seamless execution from the customer experience standpoint, safety, and high quality. Airlines have achieved remarkable safety records partly because of the way they prioritize how they want their people to think about what they do every day. Airlines prioritize safety above everything else, and then comes quality, followed by the customer experience. In the airline industry, safe travel is when landings equal takeoffs. High-quality airline travel is landing and taking off on time. You can personally define the airline customer experience.

  Now let’s think about how to discuss the patient experience definition with the people who drive the experience, our caregivers. If we accept that everything that touches the patient constitutes the patient experience, then how do we help our people think about it? How do we further define it so that we can begin to understand ways to make it better and also make certain that it fits with everything else we do to ensure great care for patients? At Cleveland Clinic, the patient experience does not equate to patient satisfaction. Rather, we define the patient experience, or our Patients First culture, as, first, providing safe care; second, delivering high-quality care; third, in an environment of exceptional patient satisfaction; and, finally, in a value-conscious environment, or as I like to say, “everything else we do” (see Figure 4.2).

  Figure 4.2 The Patients First culture.

  Think about why this definition is important. Healthcare is the ultimate service-delivery business. There’s nothing more high touch and personal than how we deliver care to our patients. However, a major problem is that we are in the ultimate service-delivery business in which our customer is not always right. When I operate on a patient and go to her room the next morning, I inform her that she will be getting out of bed and walking. The day after major abdominal surgery, patients are exhausted, have pain, and generally do not want to move. Often they will say that they cannot do it. This is simply not an option. I don’t say “OK, I’ll come back tomorrow, and then we’ll see how you feel.” I tell her that she will be getting out of bed and that the nurses will help her.

  This is when patients generally get annoyed with me. And if I don’t explain why walking is important, they will then define their experience and perception of me based upon the belief that I was mean and made them get out of bed when they were in pain. But when I inform patients that it is critical to ambulate to avoid complications and that it is a safety and quality issue, they are more willing to comply. I have set an expectation and guided them regarding how to define my care and their experience. I don’t let them define me based upon their being upset. I help them understand—and define their experience—based on my looking out for their safety.

  While patient advocates may bristle at my suggestion that we help patients understand how to define their experience, I see this as an opportunity to increase the level of patients’ engagement in their healthcare. Everything we do for patients is important, but I want them to be able to prioritize the most important elements of their experience. Safety trumps satisfaction every time, and when we ask patients to do things that they may not like or that make them unhappy, it’s important that they understand why.

  Having a definition that prioritizes how we think about satisfaction relative to safety and quality is also important for our caregivers. I often talk to physicians who are reluctant to get on board, suspicious of our efforts to improve the patient experience. I regularly hear sarcastic remarks from colleagues who accuse me of caring more about “smiling” and “making patients happy” than quality. I refer these individuals to Cleveland Clinic’s definition of what is important in a Patients First culture and note that our first priority is not quality. It’s actually providing safe care, followed by quality, then ensuring patient satisfaction. Those are the elements of high-value care.

  If a world-class surgeon forgets to administer a drug to prevent blood clots after surgery, and the patient subsequently develops a fatal pulmonary embolism, the world-class operation that the world-class surgeon just performed is irrelevant.

  The way we’ve taught our caregivers to define and think about the patient experience is similar to how Medicare wants the public to think about it. When you examine the HCAHPS, you realize very quickly that the complexity and granularity of the questions relate to issues much more important than just whether patients were happy. There are nine questions regarding patient communication, including how nurses communicate, how physicians communicate, and how w
e communicate about medications. Certainly, if measuring the patient experience were just about whether patients were happy, we would not need nine questions about communication. That’s because the patient experience is more about how we actually deliver care.

  It’s been demonstrated that when nurses communicate better at the bedside, medication errors, pressure ulcers, and falls decrease.11 So improving nurse communication at the bedside directly impacts how well we ensure patient safety. When physicians communicate more effectively with patients and families, treatment compliance increases, and when physicians communicate and coordinate better with nurses, there is an overall improvement in the quality of care. There’s no question that when all caregivers communicate better with patients, they are more satisfied, and this obviously has direct impact upon the patient experience. And when we affect safety, quality, and satisfaction, we also impact the value of healthcare. That’s the point: improving the experience of care—the way we deliver care to patients—not only impacts safety, quality, and patient satisfaction; it drives higher effectiveness, efficiency, and, ultimately, value in healthcare.

  As Leah Binder, the CEO of The Leapfrog Group, pointed out in a blog post, “Many providers still do not grasp that improving the patient experience requires something more than studying the issue and implementing a few new policies. It requires a paradigm shift in the way they think about their role in the patient’s life and the fundamentals of their practice.”12 Her statement grasps the complexity of and difficulty in developing a unifying definition. Her comments further reinforce that this is about not just satisfying patients or affecting patient’s perceptions, but also how we actually transform the interaction, which is about care delivery.