Service Fanatics

by James Merlino

  Figure 5.1 A caregiver culture would allow us to achieve our enterprise goals.

  Under Cosgrove’s leadership, our organization had laid significant groundwork to strengthen our organization’s human capital. We modernized our HR infrastructure, focused on development of our people, and started to change how we referred to each other to take us back to our roots. We had reinforced our mission, strengthened our vision, and added critical components to our values. Next would come the daunting task of actually getting people aligned.

  Here are critical steps for success in considering culture revitalization:

  1. Define or refresh a unifying organizational mission, vision, and values. It is important that the M/V/V fit the organization in its current form. If the enterprise is made up of different business units, the M/V/V should be standardized.

  2. Don’t try to change your culture. People don’t like to be changed, and organizations represent the net value of their successes and failures, good and bad. This is especially true for organizations with a long legacy of success. Ask what you want the organization to become or what it will be in the future, and then shape a strategy to identify what you are in your current form and what you need to do to achieve what you want to be.

  3. Leverage your organization’s legacy to drive your efforts. Every organization has a story to tell. Organizational history is likely what drove the mission and can be an important starting point for discussions about culture development. Use your organization’s history to ignite passion and frame the road map for the future.

  4. Recognize that the key to your success is your people. Great organizations invest heavily in their people. Make sure that you treat your employees well. Their engagement will drive the organization’s success and enterprise goals.

  5. Implement a talent management strategy that includes the following vital elements:

  Find the right people. Not everyone should work in healthcare. The goal is to ensure that they are the right cultural fit for the organization.

  Onboard employees extensively about their new role, goals, and the organizational expectations, not just for whatever they are being hired to do but for cultural alignment.

  Provide development opportunities so that your employees have a career trajectory.

  Measure engagement to keep a handle on the “pulse” of the organization.

  Recognize and reward people to validate their worth to the organization and call out achievements. Employees want to know that management is paying attention to the good work that they are doing to support the organization.

  Off-board people who don’t belong. One disengaged employee who does not support the organization or the mission can have negative consequences for an entire department. The hardworking and engaged employees will resent these people being around.

  6. Promote the concept of teamwork: “We are all in this together.” For healthcare, “We are all caregivers.” It does not matter what an individual’s job is in an organization, but each must support the mission. Everyone owns the “customer” experience, and beyond that, everyone needs to own the delivery of whatever it is your company does for customers.

  Chapter 6

  Cultural Alignment: The Cleveland Clinic Experience

  Since the introduction of the Patients First motto, there had been discussions about how to instill that purpose more strongly into the culture of the organization. Creating the motto, making patient experience a strategic priority, revamping the mission, vision, and values, and appointing a chief experience officer proved not to be enough. And while we could point to a number of success stories in improving the patient experience in the units and in addressing physician communication, caregivers were not aligned and did not live the patient experience. It became increasing clear that we needed to do something so that everyone would comprehend the importance of the patient experience. We needed to shock the system. We needed an all-hands-on-deck training program.

  Although we had little granular patient experience research at the time, we all knew anecdotally that patients paid attention to virtually everything. It didn’t matter how good the medical care was or whether every safety contingency was covered. If a phlebotomist was rude when awakening the patient, a nurse seemed preoccupied, or a doctor didn’t explain things completely, the patient left with a negative perception. We needed to evoke something dramatic to get everyone wrapped around the patient.

  The why was pretty clear. Despite our early efforts, we still had terrible patient experience scores. Patients were continually complaining, often about simple things like rude behavior, not knowing what was going on with their care, and poor coordination between caregivers. The pressure on the culture was mounting for all of us to change.

  We were relatively new at patient-centered thinking, and no one in our organization had experience with culture-change initiatives on the scale of the entire Cleveland Clinic. At our strategy session in late 2009, we had committed to develop a culture of “engaged and satisfied” caregivers for the purpose of achieving enterprise goals. This obviously meant alignment around the patient. Cosgrove had talked about it for years, but we hadn’t done anything yet to achieve that change. We were behind, and he was frustrated.

  We Learned from Others

  To get started on building our cultural alignment training program, several members of the patient experience team and others from HR benchmarked organizations known for great service delivery. We looked at healthcare organizations but also wanted to learn from outside industries. Natural targets were hospitality companies and other service leaders.

  The InterContinental Hotels Group manages Cleveland Clinic’s hotel properties, and Campbell Black, regional director and general manager, graciously allowed us to spend a day with his senior leadership. They gave us a behind-the-scenes look at how they developed employees and sustained their excellent service culture. Black made several very important points, highlighting the need for ongoing training and constant individual recognition of great work. He also underscored how InterContinental aligns everything around the customer and holds employees accountable to the organization’s values.

  Another organization we visited was Houston Methodist, which puts considerable effort into constant culture development. A program called the Houston Methodist Experience, an ongoing training and development effort, begins at an employee’s onboarding and lasts throughout his or her entire career at the organization. As president Marc Boom describes, “It starts from our board and goes all the way through our organization.”1 The Houston Methodist Experience is centered on a concept called I CARE, which stands for Integrity, Compassion, Accountability, Respect, and Excellence. Each employee is expected to embody the I CARE values in all that he or she does for the organization.2 The Houston Methodist Experience is meant to instill these concepts in all employees.

  From our benchmarking and discussions with service-sector leaders across the country, it became clear that organizational culture is an enterprise asset. And like any other major asset, it must be developed, maintained, and leveraged as a tool to achieve organizational goals. Organizations that did this well created a culture of ownership we desired. We also found that adherence to a set of values was a recurring theme. In addition, we learned that efforts at cultural alignment are not successful unless sustainability is addressed early and becomes part of the developmental effort. All the programs we benchmarked had long-term operational sustainability elements to ensure ongoing success. Tactics included consistent enterprise messaging and regular manager meetings. Other critical sustainability components included engagement measurement and a rewards and recognition program, important HR infrastructure that we were rapidly developing.

  The Delivery Tactic Is Key

  In designing our program, it was imperative to deliver information so that it would be remembered by employees and change their behavior. Learning research demonstrates that people retain about 10 percent of what they read.3 Traditional didactic instruction
increases retention to 50 percent. But with learner interaction and engagement in small-group activity—displaying material visually, allowing for one-on-one interchange, sharing stories, making it fun and relevant—people can retain up to 95 percent and will adopt the behaviors you’re seeking. Our culture-training program needed to be meaningful and interactive, and our goal was not only to learn new concepts but to adopt new ways of doing things.

  The team had recommended building our program around a visual delivery tool called a learning map. A learning map is a visual representation of content and has been demonstrated to be a useful tool for stimulating small-group dialogue. The learning map idea was championed by senior HR executive Reggie Stover, who had been recruited from PepsiCo, where he had used similar tactics. He had begun working on the development of the learning map before I became the CXO.

  When the learning map concept was first introduced to me, I admit I was skeptical. I knew nothing about culture change tactics, but I recall worrying that if this was the best we had, we were in trouble. After the program was described to me, I didn’t completely understand how it would work. I thought there was no way people would agree to do it, let alone believe it could develop our culture. My predecessor had nearly torpedoed the idea by branding it a “board game,” and I secretly agreed with her (see Figure 6.1). Advising Cosgrove that we should give 43,000 people a half-day off work to sit around a table and talk about Patients First using something that resembled a board game seemed preposterous!

  Figure 6.1 Learning map.

  I started to change my mind about the learning map concept when I met Arden Brion, managing director of Root, Inc., a pioneer in learning map technology, who had used this tactic with great success at other companies, including several of the Fortune 500. Brion explained the concept and galvanized for me the importance of using a visual tool to drive small-group discussion, explaining that the interactivity of learning map exercises is one of the reasons they are successful. He also discussed the importance of having Cleveland Clinic people populate the content on the map so that it becomes theirs. This was my introduction to the concept of “by us, for us.” We settled on the learning map tool because it was interactive and would engage caregivers in developing what is important for the organization and discussing tactics that would help achieve our enterprise goals.

  To proceed in developing the training program, we formed a team jointly led by my office and HR. Donna J. Zabell, a member of my team who had been the longtime nurse manager of the cardiac operating rooms under Cosgrove, and Thomas Vernon, an HR executive with organizational learning and development experience, would colead the project.

  Root’s team elicited input from several key executives to decide what strategic themes the map would include and how the information would be “bucketed.” Cosgrove immediately zeroed in on making sure everyone understood why we put patients first. We also wanted to include service excellence education and some practical skill training. After we determined the key elements, we assembled focus groups of employees from across the organization. Brion’s team from Root facilitated discussions to determine how the content of the “buckets” would best be messaged and represented in the map. Designers from his company drew the map in real time during the focus groups. Participation from the employees was critical. Not only did they frame how the messages should be delivered; they elevated a number of important issues, such as how we would discuss defining and measuring the patient experience, why it’s important, and how it relates to the key themes.

  The focus-group exercise also taught me an important lesson about executive presence and sponsorship. At first, I was not scheduled to attend meetings; I was still settling into my role and frankly did not think I was needed. Zabell said that if I didn’t attend, no one would come. She said, “No one will take it seriously. You have to tell them it’s important.” We argued about it, because I was still not sure I was taking it seriously. Zabell politely told me that we really had nothing else and needed to try to make it work. So I agreed, and it was an incredible process to watch. There were a variety of people in the room, from high-level executive leaders, hospital presidents, and nurse leaders to frontline caregivers. Many were skeptical at first, but you could see the conversation and input intensify as the map was drawn in real time. People were engaged and energized, and the most common emotion was passion for wanting to get this right for the organization.

  Everyone Must Participate, Even the Doctors

  We decided early on that to be successful, every employee—including each physician—would be required to participate. Employees would arrive at the event, sign in, and be randomly assigned to a table with 8 to 10 others. Random assignments ensured that everyone encountered fresh faces and different roles. We wanted employees sharing stories and discussing their experiences and reactions with a range of people, not just those they knew or were comfortable with because they worked in similar careers or units. Around a table could be a neurosurgeon, a parking valet, a nurse, and a cleaning person. I often referred to the Cleveland Clinic Experience as the “great leveling exercise.” It did not matter what you did for the organization—for half a day, you were just a caregiver who works for Cleveland Clinic and supports our mission.

  The team decided to have a facilitator at each table responsible for managing content flow and ensuring that every critical element of the exercise was covered. For three and a half hours, the facilitators would guide discussion around each of the components in Figure 6.1. Facilitators also were responsible for leveling the emotional intelligence disparities among table participants, toning down the overly talkative and drawing in quieter people, critical to achieving effective group participation. Finding a sufficient number of facilitators would be an enormous task. At first, the facilitators included the planning group and others from the Office of Patient Experience and the Office of Learning and Performance Development. We considered hiring contract facilitators but wanted to stay true to the belief this had to be “our people teaching our people.” As we gradually rolled out the program, we observed participants to identify additional facilitators. We ultimately trained more than 400 facilitators from a variety of different disciplines and careers. One facilitator was a painter from operations whom we affectionately referred to as “Joe the painter.” He became the poster child for the program being designed and implemented by only Cleveland Clinic people.

  There had been several discussions about cost, including one rather heated exchange at an executive team meeting. Our nursing leadership was very concerned about lost productivity. In the usual sense of the measure, there would be lost productivity by taking a half-day of each employee’s time. The investment of time could impact patient care if nurses were 100 percent productive 100 percent of the time they’re on the clock, but they aren’t. This reasoning applies to most employees across the organization, including the doctors. Surgeons, for instance, do not operate every day. For employees like cashiers or police officers, whose efficacy is measured by the number of hours they stand at their posts, then yes, their shifts would need to be covered. But taking most people off station for four hours would likely have a minimal effect on operations and productivity. Managing participation in the exercise would require thoughtfulness and collaboration, but we believed it could be done without negatively impacting operations. And in fact, it didn’t. The year we ran 43,000 employees through the Cleveland Clinic Experience, we recorded one of our best years in patient volumes and financial performance. Some lingering critics might argue that the year would have been even better had we not done the exercise. I would argue that the year was as good as it was because we did the Cleveland Clinic Experience. Who is to judge?

  There also was considerable discussion about how to evaluate the program’s success. How do you measure culture change (or development, as I say)? Obviously, this would be very tough. With the items we were attempting to impact, patient experience, complaints, and employee engagement, it could take a year
or more to see a difference. There are also no direct outcome metrics to tell you that the culture has been modified. So clearly there was a gamble. We were embarking on a very expensive program that did not have a real ROI measure. There was definitely an element of this being a “leap of faith,” with our gut telling us it was the right thing to do. We ultimately determined to define success by how participants viewed the program: did employees consider it effective? We would wait for the longer-term impacts on patient experience, complaints, and employee engagement. Anyone embarking on a cultural development program like this will have to contend with finance, which will want to know the ROI. There just isn’t one to defend the expenditure in the short term. Our leap of faith was guided in part by the successes that had been achieved in previous years by organizations conducting similar activities.

  You Must Convince People It’s the Right Thing to Do

  Making the argument that doctors should participate was easy; convincing people the argument is right is a whole different story. When the learning map was first proposed, before I became CXO, there was the assumption that doctors would participate in this program. The nondoctors who were advocating, developing, and leading the initiative could not understand why doctors should not be included. There were no doctors involved in the discussions, however, until I came into the picture. As we got closer to implementation, the issue of physician participation moved to the forefront. Some leaders in the office that oversees the group practice were vigorously opposed. They argued that the doctors were different, and it would have a very serious effect on productivity. I took the matter to chief of staff Joseph Hahn, reasoning that, “What would be the purpose of trying to align the culture if we excluded the group considered the most important element?” We agreed to take the issue to the executive team meeting the next day; this would be our go/no-go decision point. About half the team was composed of physicians. If we could convince them, we would likely get the go-ahead.