Service Fanatics

by James Merlino

  I left work that night feeling that the success of the entire patient experience initiative was in the balance. The organization had invested heavily in developing the learning map program, and I had staked my reputation on it. We needed to walk out of that meeting with concurrence to proceed. I went home and started on my presentation. I decided to take the story from the beginning, talk about why we were doing it, how we would measure success, and how we would implement. I proposed a pilot with small groups, working up to a single institute to test effectiveness. We would pilot in the Digestive Disease Institute, my home base, where I felt the most comfortable with the subculture and thought we could successfully navigate the politics. I stayed up all night honing the message. I was on the phone with Brion from Root multiple times until very late, absorbing all I could about the learning map tactic, reexamining evidence of its effectiveness, and reviewing testimonials from Fortune 500 leaders who had deployed it. I studied the evidence we had assembled regarding how people learn and what makes culture change initiatives fail. At the heart of the discussion would be the how to do this, not the why, and whether doctors should be required to participate. Were the learning map and small-group discussions the best way to align our culture?

  The next morning arrived, and I made my best pitch. After setting up the why, going over our benchmarks, and explaining the how, I clicked up a summary slide entitled current state, saying, “Here are the tactics we currently have in place to develop and maintain our culture.” The slide was blank. I moved on to the next topic, adding, “We have nothing!” It was a shocker, and frankly, I was nervous, being in my position and a member of the group for only four months. But the statement was true, and I challenged the room to dispute it. Hahn looked at me and said, “You have a lot of balls to say that!” He was acknowledging my willingness to call it out, not scolding me. No one challenged me on the statement; everyone knew it was true that there was no program in place. I finished the presentation proposing that we conduct a pilot and see what happened. We had come a long way, and it was worth a shot to see whether this could help us.

  Then the fun began. All the concerns regarding cost and productivity were raised again, and there was vigorous debate about physician participation—from the physicians. Cosgrove was silent, letting others be heard, and I was having difficulty reading him and the room. Finally, he smacked the table and declared, “Enough. We’ll never know the cost, but what will be the cost of not doing this? Five years ago, we wouldn’t have been ready, but today we’re a different organization, and we have to try it.” He felt that if doctors didn’t participate, there would be no point in doing it. Cosgrove gave us the green light to pilot the program in the Digestive Disease Institute with about 1,000 people. But he wanted two things before we proceeded with an enterprise rollout. First, he wanted to be certain of physician support and requested that another group of physicians he selected test it to ensure it resonated. Second, Cosgrove was very concerned about whether we could sustain the program and wanted evidence of sustainability.

  We assembled a group of 10 physicians to review the map and test the process. Cosgrove recommended some of the most skeptical physicians on staff to ensure honest, tough feedback. Zabell assembled them in a room, and before we revealed the map, I presented what we were seeking to achieve and why. Then we turned the map over, and Zabell, Vernon, and I talked through the program. I didn’t know many of these physicians personally and had no idea how it would go. To our surprise, they all were incredibly supportive. They provided excellent suggestions on how to engage the medical staff, including messaging to physicians deeming them opinion leaders whose participation was essential to demonstrate the program’s importance. The pilot physicians also made it clear we had to spell out the why to the entire organization. One longtime physician said, “The organization really needs to do something like this.” The meeting finally convinced me the program would work.

  However, no one on the team was convinced we had checked the box on Cosgrove’s sustainability requirement. We decided to delay the Digestive Disease Institute pilot and reexamine sustainability. While we championed the fact that we had built the program without consultants, we decided to bring one in for an independent assessment. It was a very expensive two-day engagement, in which we had him watch focus groups of the learning map in progress. At the end of the second day, he still had given us nothing. Seated next to me, he finally turned and exclaimed, “The managers! The managers are the key to sustaining the program, and they will make it successful.” There were about 2,200 managers in the organization. Effectively touching each manager would touch every employee. Our team quickly went back to the drawing board and developed two more pieces to the program that would be required for all managers (Figure 6.2). The first, “Leading the Way,” would be a half-day managers’ retreat laying out exactly what the Cleveland Clinic Experience learning map exercise was meant to accomplish, setting managers’ expectations, and seeking their help in transforming the organization. The second session, “Coaching for Outstanding Performance,” would be a full-day course given after groups had completed the learning map exercise. The course would reiterate the goals, discuss engagement strategies, and provide ways to sustain change. These manager retreats were a prelude to the important leadership forums we continue to have today.

  Figure 6.2 Process flow for the Cleveland Clinic Experience.

  The physician focus group and the decision to leverage the managers for sustainability also gave the team important insights into how to communicate the program to the organization. We wanted everyone to know what we were seeking to accomplish and why. Messaging would be targeted for three groups: physicians, managers, and all other caregivers. Following the focus-group physicians’ advice, we sent letters to every staff member explaining what we were doing and reinforcing that the other caregivers across the organization viewed them as leaders. To managers, we messaged that they were essential to building the organization needed for future success. For the entire organization, our marketing team, led by Paul Matsen, chief marketing and communications officer, created a “brand book” that explained the role of the caregiver and how difficult, yet imperative, it is to the organization.

  Something to Align the Culture

  After extensive piloting, in late 2010, we introduced the Cleveland Clinic Experience program to our organization. The brand book was delivered in advance to all the employees, recognizing the important work they do and ensuring they understood the why. Each manager attended a “Leading the Way” session. Finally, each employee attended a four-hour exercise designed specifically to align our entire population to the organizational priority of Patients First. The program explained why Patients First is our guiding principle and described how every person who works for Cleveland Clinic is a caregiver regardless of role. There were exercises introducing expected service behaviors and our service recovery program, Respond with H.E.A.R.T., and there was a discussion of organizational values. Employees were asked to pick one of the values and tell the group why it was important to them in their role at the Clinic. At the end of the exercise, participants graduated and received a special caregiver name-badge backer. Next came the capstone training course, “Coaching for Outstanding Performance,” again for all of the managers.

  The Cleveland Clinic Experience became the instrument to internalize the concept that we are all caregivers and to begin the sustainability effort. It took a little more than a year to put everyone through the exercise across all of our sites. While the design and execution expense was relatively minimal, the cost in salary and wages alone was an estimated $11 million. This doesn’t include the opportunity cost of lost physician productivity, such as forestalling a surgeon from performing operations.

  While we agreed in advance that there would not be an immediate impact on outcome measures such as patient experience, complaints, and employee engagement, we did survey caregivers to judge their satisfaction with the program. The surveys were anonymo
us, and nearly half of attendants completed them, with the following results:

  In addition, we wanted to capture visually what we were hearing anecdotally, so the team designed large posters with columns headed Skeptical, Neutral, and Believer for the walls where we hosted the Cleveland Clinic Experience. We asked arriving participants to put a blue sticker in the column that most indicated their frame of mind about the experience. At the end, they did the same with a green sticker. Most were skeptical or neutral at the start, but most were believers at the end (Figure 6.3). It was a great visual to demonstrate that people “got it” and were in agreement.

  Figure 6.3 Participants’ frame of mind before (gray) and after (black) the experience.

  There were thousands of positive anecdotes from our caregivers about how much they liked the program and how supportive they were of Patients First. One of the most common observations was about physician participation: “I can’t believe the doctors are doing this, too!” or “I have been here 32 years and have never done anything with one of the doctors.” Employees were thrilled to see physicians participating with them to help improve their organization. Nearly all of the physicians participated with gentle appeals and words of encouragement. We had “gotten to” mandatory without “making it” mandatory.” I’m a realist and never would have contended that all physicians would like it. Prior to the sessions, most were skeptical and, in some cases, resistant. But their support afterward was quite surprising.

  In October 2010, we received our surprise, but anticipated, visit from the Joint Commission for recertification of our main campus hospital. During the executive debrief at the end of the visit, the lead surveyor said, “You have beautiful buildings, high-tech equipment, and intensely complex patients, but it’s your people who are your greatest asset. They are engaged, passionate, and compassionate. Congratulations! You have world-class care here because you have world-class people!”4 Nearly all of the main campus caregivers had just completed the Cleveland Clinic Experience. It was by far the greatest single validation of what we were doing!

  Accomplishing the Impossible

  The Cleveland Clinic Experience became our program to modify our culture. We successfully took all of our 43,000 employees, including our physicians, offline for a half-day to align them around Patients First, as well as other critical organizational priorities, such as service excellence. I believe we’re the largest company, and certainly the first in healthcare, to take such a bold action to align culture in one fell swoop! People I talk with often express surprise about the project’s scale and scope: “You put all employees through it?” Yes, everyone! From healthcare leaders, I’m always asked, “And the doctors did it?” Yes, the doctors did it!

  Sustainability has been robust and consistent. Each new employee, including every new physician, goes through the Cleveland Clinic Experience as part of on-boarding. We continually refer to our employees as caregivers in conversation, meetings, and publications. Our service excellence program, Communicate with H.E.A.R.T., was developed to reinforce the expected service behaviors explained in the Cleveland Clinic Experience and is now part of every caregiver’s workflow. Patient experience, service excellence, and our values are incorporated into everyone’s annual performance review.

  To refresh our Patients First theme and reinforce our values, about every four months, all our 2,200 managers attend a leadership forum designed to develop organizational competencies. These are traits we expect everyone in the enterprise to have. Every manager should be familiar with the organizational competencies and cascade them to his or her direct reports. At these forums, we’ve covered engagement, emotional intelligence, culture of safety, culture of continuous improvement, value-based care, and change management. Each session links to our culture story and thoroughly incorporates the themes introduced through the Cleveland Clinic Experience.

  The Cleveland Clinic Experience, along with its associated sustainability tactics, is in my mind the single most important thing we’ve done to improve our organization. It directly targeted the culture, which is the most important element necessary to achieve patient-centeredness, and it has translated into improved patient satisfaction and enhanced safety and quality as well. The program has been successful because it had absolute organizational leadership and commitment: Cosgrove got behind it and stayed behind it. It also allowed us to reset, not change, our culture by demonstrating to everyone why we’re here—for the patient—and aligning us and everything we do around the patient. The great leveling exercise became the springboard for our messaging and development tactics moving forward.

  When implementing a cultural exercise, consider the following:

  1. What are you trying to achieve, and how does it relate to the enterprise strategy? Our program was designed nearly exclusively for organizational alignment around the customer, with a focus on improving patient satisfaction. At the time, this was the appropriate focus. Our new working definition of the patient experience, which includes safety, quality, and satisfaction, could have been incorporated into the program to directly address those as well as culture and service. Understand what your long-term strategic needs are to adjust your culture first, and then build your program around those needs.

  2. Decide if your goal is to inform or to change behavior. If you are going to get people to adopt new behaviors, your tactics need to consist of interactive small-group exercises. People remember what they discuss with other people more than what they learn in a classroom. It is a costly proposition in terms of time and commitment, but one that we believe pays off.

  3. Deciding to put your organization through a major exercise will cause people to ask, “How do we know this will work?” The answer is there is no guarantee it will and there is no direct metric to measure that. Our metrics of success lagged behind the effort by a year, if not longer. These programs can be an expensive leap of faith, but if they are carefully constructed, well thought out, and successfully executed, as we and others have demonstrated, then they can be highly successful.

  4. The sustainability of the program and the messaging must be determined before you start the program. This is where most efforts fail and are at risk of becoming just the “flavor of the month.” If your organization is not going to invest to sustain the change, then don’t invest in the program to begin with because it will not work.

  5. Big organizations are culture-centric. This means that they tend to reject outsiders and consultants. Our program, the content, and the execution were all developed and accomplished by our own people. We used outsiders to help us think it through and design the learning map, but the program was ours: “designed by us, for us!” This is a powerful statement to the organization that we are leading this for our people.

  6. Everyone must participate. There was a lot of pushback from some about requiring doctors to participate. This program would have failed if they had not, and I would not have recommended we proceed. Programs like this cannot exclude important and powerful stakeholder groups. What is the point of an alignment exercise if the group that is viewed to have the most power does not actively engage?

  Chapter 7

  Physician Involvement Is Vital

  Growing up, I always wanted to be a doctor. I had my black doctor’s bag, and I played doctor in the neighborhood. My collection of stuffed animals had so many stitched-up surgical scars that the toys could barely contain their stuffing. I saw the family doctor virtually every month, needing shots for bad allergies, and I was in awe of him, his tools, and his book-filled office! I remember marveling that there was no way I would ever be able to read that many books. There were no physicians in my blue-collar family, and we were conditioned to believe that doctors were all-knowing and deserved nearly unequivocal respect.

  Doctors have incredible responsibility. They take care of people at the worst times of their lives. Physicians weigh an enormous amount of information and make decisions that impact patients’ health and welfare, and patients place immense
trust in their doctors to do the right thing. In some cases, doctor-patient interactions involve violating the patient in the most personal way possible. When patients go under general anesthesia, they trust the physicians and entire operative team to bring them back to consciousness. There are few ways to risk more personally violating individuals—or having greater responsibility toward them—than when exercising our sacred duty to ensure patients emerge safely from anesthesia and successfully from their surgeries. This is a profound, frequently challenging, and very stressful responsibility.

  Doctors work very hard and train a long time to be able to practice medicine. I was in medical school for four years, residency for seven years—which included two years of research—and one year of fellowship. That was 12 years of training before I was able to see a patient independently. It also requires huge personal sacrifice: surgical residency involves long, grueling hours of work. In addition, there is substantial opportunity cost; I could have been doing something else over the course of those 12 years. Finally, there’s the educational debt. I graduated from medical school with more than $200,000 of debt, and my wife and I both still pay student loans. The average physician incurs almost $170,000 in medical education debt, with nearly 20 percent of graduates having more than $250,000.1