Service Fanatics

by James Merlino

  This prompted a deep dive into the data and patient comments. What we found is that getting the appointment when wanted was less important than the conduct of the appointment staff and the encounter with the physician. If appointment staff were helpful and courteous, patients rated the overall experience very high. Likewise, if patient-physician interactions were positive, that defined the overall rating of the encounter. “Appointment when wanted” did not accurately capture what was truly important to patients. It wasn’t when the appointment occurred, but the positive experience with the appointment staff and physician that were important.

  There are ample occurrences along the healthcare continuum that can result in a bad experience or make patients unhappy. But there are many things we can do that have great impact on enhancing the patient experience and delivering high-quality care. This was an example. We were measuring something that really did not matter to patients. The root of what was important was the interaction with the staff at all touch points. Using data to better understand such nuances, ascertaining we are employing appropriate metrics, and testing the validity of those metrics are all vital to ensuring that we regard the right information.

  The single best way to find out what is important to patients is to just ask them! Don’t be afraid of the answers. Each patient suggestion or comment may lead to significant and meaningful improvements in your organization. Cleveland Clinic uses a variety of other tactics to better understand what’s important to patients. Several years ago, we established Voice of the Patient Advisory Councils (VPACs). An emerging trend and not unique to us, VPACs allow patients to provide feedback that helps tailor activities. Because of our sizable main campus hospital, we formed VPACs for most large institutes.

  Groups like these also help validate our understanding of what’s important to patients and amend our views when our thinking is off-track. We’ve used VPAC input to help redesign the look and feel of selected waiting rooms and to develop a new patient-friendly admission guide. Group members helped confirm why our “hospital quiet at night” scores were so low. We suspected it was less about being interrupted from sleep and more about hallway ruckus and noisy neighbors, and the VPACs confirmed this.

  I recall listening to a Digestive Disease Institute VPAC discuss bathrooms, which are very important to such patients. Several floors suffered poor cleanliness scores, and we supposed this was overall room cleanliness. But the actual problem was bathroom appearance. While the bathrooms were not dirty, VPAC members criticized low levels of light and untidy urinal storage, which made the bathrooms appear dirty and cluttered. We changed the lighting and urinal organization, and cleanliness scores improved.

  We don’t let just anyone sit on a VPAC. Patients are nominated by clinical staff and interviewed, and there are minimal participation requirements. While any ideas and suggestions are welcome, we ensure that participants can work with others and channel their individual perspectives into constructive group feedback. We also have parameters on discussion topics; obviously, we’re running a forum for improvement, not airing individual grievances. Additionally, we discourage suggestions unlikely to be implemented. We need to “rebuild the hospital so everyone has a private room” is simply not practical or constructive.

  Success of VPACs also requires commitment from the organization and its leadership. John J. Fung, liver transplant surgeon and chair of the Digestive Disease Institute, leads all its VPAC meetings. Such visible commitment demonstrates to patients that leadership cares about their input and that feedback will be considered at the highest levels.

  Pragmatism

  We’re relentless in pursuing patient-centeredness and trying to understand what patients want, but we also must be pragmatic about the challenges we face in healthcare. At our organization and in healthcare in general, the pendulum of patient-centered care had swung too far in the wrong direction. Now that it’s swinging back, we must ensure that it doesn’t go too far in the other direction. While always keeping the patient as our true north and taking into account our patient experience strategic priority, we must also be mindful of the realities and difficulties of delivering effective care and weigh those against what patients tell us they want.

  Excessive surveying doesn’t necessary equate to better patient-centered care. We can become distracted by things that are simply unreasonable or lack significant improvement value against the costs of implementation. For instance, is it reasonable to expect that hospitals are quiet at night, an emblematic question from the HCAHPS survey? Hospitals, especially large academic centers, have difficulty achieving top metrics in this area. We simply don’t know what patients expect regarding quiet. Does it mean minimal interruptions? Do they expect a good night’s sleep? We have to recognize that hospitals are simply not quiet. Hospital patients should not expect to get a good night’s sleep.

  Similarly, there’s a national push to essentially eliminate visiting hours—patients and families want unrestricted access to their loved ones—and few would disagree. However, are unrestricted visiting hours at night reasonable for the privacy and comfort of patients in semiprivate rooms? One of the top patient complaints about noise relates to having a roommate. I have heard estimates that more than 60 percent of U.S. hospital rooms are semiprivate. Certainly, we aren’t going to demolish all the hospitals with semiprivate rooms and rebuild them so that patients can have private rooms. We allow unrestricted visiting hours, permitting patients to have family members and friends with them around the clock. Then we ask whether the hospital room was quiet. This reflects a lack of systems thinking. One good idea, unrestricted visiting hours, can lead to noisy hospital rooms at night, and therefore this is probably a bad question to ask patients on a survey.

  By posing too many questions, or asking questions that capture the wrong information, we may be driving unintended consequences. In 2013, Cleveland Clinic partnered with the Ohio State Medical Association to survey Ohio physicians regarding their views on pain management. Of the 1,100 physicians surveyed, 98 percent believe they are under increasing pressure from employers to improve patient satisfaction scores for pain treatment. Seventy-four percent agree that, in general, U.S. physicians overprescribe controlled substances to treat pain specifically to increase patient-satisfaction scores. These are troubling findings, and the consequences can be dangerous for patients. There is emerging evidence that heroin abuse is linked to prescription narcotic abuse. Americans constitute 4.6 percent of the world’s population and already consume 80 percent of the world’s opioid supply. We’ve set an expectation in this country that pain will always be treated, and it may be wrong to ask patients how their providers performed in treating pain.

  Patient satisfaction surveys also measure patient perception. As I’ve said, patients define their perception of the experience relative to their personal situation. Many of the standardized surveys we are required to use are not well adjusted for important patient factors, such as the severity of a patient’s chronic disease or presence of depression; both are important elements that can define patients’ perception of their care. One study estimated that up to 30 percent of chronic medical patients who are hospitalized have elements of depression.8 At Cleveland Clinic, we analyzed our HCAHPS data relative to a patient’s severity of illness and self-reported depression. When compared to more healthy patients without chronic disease or depression, patients with chronic disease and/or depression gave significantly lower HCAHPS scores across all domains, an important finding that impacts how we interpret this data and the assumptions we make about our facilities and their ability to deliver patient-centered care.

  Tell Patient Stories

  Every patient has a story, and we need to take the time to listen. We’ll be more insightful as we help patients navigate a very difficult time. Marc Boom of Houston Methodist Hospital opens board meetings by reading a patient letter—a patient’s story. “It helps remind us why we’re here, and we learn things about our organization,” he says. This is why I keep
that letter and photo on my desk.

  As healthcare professionals, we’re very good at persuading ourselves we know exactly what patients want. After all, we are the professionals, and in many cases, we have been patients. Both perspectives tend to convince us we know best. But using feedback and data analytics is vital to true understanding.

  Do your people know what customers think? Do you have insights on frontline issues? Do you distribute that information so everyone knows it? Satisfaction surveys provide important data, and organizations should use them to measure specific areas of interest. However, direct visibility and discussions with frontline customers, in our case patients, are crucial to accurately understand what’s occurring. Cleveland Clinic has made significant strategy changes and meaningful organizational improvements by paying attention to the data.

  Important elements to consider:

  1. Get over the bias that because healthcare professionals are both leaders and consumers of healthcare we know what’s best for patients. Often we really don’t understand what it means to be on the other side, and the only way to be sure that we get it right is to ask our patients and understand what is important to them.

  2. There is more to what patients think than what standardized surveys reveal. Patient anecdotes can be very powerful statements about opportunities that organizations have to improve. Take the time to ask patients and their families what is important.

  3. Establish a voice of the patient council that meets regularly to keep the “pulse of the consumer” and understand what patients are thinking about. Ensure that it is well represented and attended by senior leadership, and empower patients’ activism by implementing some of their suggestions. Patients deserve to have a direct window to the top of the organization.

  4. Remember that patients do not want to be our customers. They come to us often at the worst time in their lives. Because patients are not sophisticated healthcare consumers, they use proxies to rate us. The little things matter to patients, and they will use these details to judge our effectiveness at care delivery.

  5. Every patient has a story, and telling these stories to caregivers across the organization is a powerful way to remind people why they work in healthcare. Share patient letters and stories frequently across the organization. Open meetings with a story, and make sure that the information goes all the way up to the board of directors, who work to support the mission and, therefore, are caregivers as well.

  Chapter 9

  Execution Is Everything

  Shortly after becoming CXO, I learned a hard lesson in humility and the difference between talking about strategy and having the ability to execute on strategy. I read a hospital trade journal article about the emerging patient experience field—an article that did not mention Cleveland Clinic. I was surprised. We were the first U.S. hospital to have a CXO, with the first department focused on the patient experience. I thought we were well on our way to success. My arrogance led me to believe there must be something newsworthy we could offer the publication. After all, we were Cleveland Clinic—people should want to know what we were doing.

  I called the reporter and inquired whether we could participate in another article covering some of our initiatives in progress. She provided a stiff dose of reality: “I know of Cleveland Clinic and your office. So you are the CXO? What have you done that actually improved the patient experience?” I described our strategy and how we were thinking about the patient experience, but it was all anecdotal. She pushed right back, “You have terrible scores! Why would anyone want to read about what you’re doing? Call me when things get better!” She was absolutely right, and it taught me a valuable lesson on the importance of having something that was working. Brand recognition, the correct strategy, and good ideas get you nothing if you don’t execute successfully.

  Setting Patients First as true north and adding the patient experience to an already long list of strategic priorities was easy, but getting down to business and making it happen was another matter entirely. We had a burning platform, passionate people, and agreement on what was important, but I had no idea where or how to start. I had no mentor, no role model, and no coach. There were no textbooks and no real articles about tactics and execution. We had not yet teased out the concept of the three Ps: process, people, and patients.

  When I speak to healthcare audiences, they strongly identify with this conundrum. They see the need for adopting a more patient- and family-centric environment but frequently express frustration about getting going. The most frequently asked questions when I speak to other hospital systems are “Where do we begin?” and “How do we start?”

  A running joke in medicine is that surgeons are not trained to think but to do. So I felt like I wasn’t living up to my training. Successful execution is worshipped in any industry. This was an important lesson instilled by my colleague and friend Ananth Raman, UPS Foundation Professor of Business Logistics at Harvard Business School. I was first introduced to Ananth shortly after becoming chief experience officer. He is a passionate believer in the importance of the patient experience and was studying the Clinic’s efforts to improve. He spent his career studying factory operations and how processes are more efficient when you take the human element out of production.

  Ananth recognized that healthcare was a business that required humans to make the product—healthcare delivery—more efficient and caring. We had long conversations about what the patient experience meant and its value to the organization. We discussed how important it was for patients and how improving it would be transformative for healthcare. And he always pushed me hard about how we would execute: “Jim, how do you fix it? How do you improve it? What are the tactics? Everyone agrees it’s important, but how do you execute?”

  It’s challenging to answer, in part, because those assigned to lead patient experience initiatives frequently lack operational experience and have little control over operations. They’re figureheads, given an important responsibility to transform an organization but few resources to do it. This is a difficult but not impossible task, and effectiveness is largely determined by skill in building coalitions of operational leaders. The ability to begin and move projects forward requires consensus and buy-in. It sounds difficult, and it is. But remember that the purpose is to put patients first. Getting people on the bus to do something is much easier when the goal is to improve the way we take care of people.

  This is exactly where I found myself when I took over the patient experience for Cleveland Clinic. I had a handful of employees and a mandate to change an organization of 43,000, including powerful physician, nursing, and human resources stakeholder groups. If I wanted to do something at the bedside, I had to negotiate with nursing. If I wanted to address training or culture, I had to confer with human resources. If something affected a patient operational area, such as food service, parking, or cleaning, that was the purview of operations. Each leader had ideas regarding priorities and how to frame the problem. This is one reason why midlevel operational leaders have difficulty moving a patient experience agenda and why it’s critical to select the right leader for the initiative. If a nurse leads the patient experience, a strong physician partner is essential. Similarly, a physician leader needs a nurse partner. Nonclinical operations leaders need both.

  When I first became CXO, we could not articulate what a successful execution would look like, let alone discuss tactics to drive it. And just as everyone had a different patient experience definition, there was an equal number of ideas on improvement. Some felt we needed to start a smile campaign. Others believed we needed more nonclinical people visiting patients daily. The ideas came nonstop, multiple, free-flowing, and overwhelming. I was almost paralyzed, not knowing where to start or what to try. And there were conversations about the “low-hanging fruit,” a phrase I detest, and queries about “the easy, quick wins” and “gaining some early successes.” Everyone looked at me, asking essentially, “What are you doing? What are you trying? And how can we help
you?” The expectations to improve were intense.

  Cleveland Clinic was also in the midst of a major organizational integration effort. We were essentially a hospital holding company working to integrate various pieces of our organization into a hospital operating company and an integrated health system. It was impossible to suggest ideas without being challenged about how they would impact and be implemented across the “enterprise.” If you forgot to use the word enterprise in every proposition, people regarded you as failing to grasp what enterprise meant. A colleague on the executive committee took a very public shot at me, “Jim, you just don’t understand what strategy in an integrated health system is all about.”

  It was a recipe for disaster: the pressure to try something, coupled with not really controlling anything and having to negotiate with powerful colleagues who had rigid ideas about what was important. The first few months of my new job were exhausting. Fortunately, my boss was the consummate CEO. “I have your back, Jim. Take your time to figure it out,” Cosgrove told me. I was grateful for the breathing room.

  I thought the best way to start was to go small, to try modest projects without enterprise implications to see whether they worked. If we got something to work in a microenvironment like a single unit or department, we could scale it up to the enterprise. (Enterprise be damned; the patient experience is driven at the local level!) We also needed to better understand what was happening at the unit level before we attempted something enterprise-wide.

  So our start was this: We identified one of our worst HCAHPS-performing units and assembled a team consisting of the nurse manager, a representative from the Office of Patient Experience, a physician champion, the supervisor from environmental services, and others involved in care coordination, such as the social worker and case manager. This team met weekly for about an hour to identify problems contributing to patient dissatisfaction. The team reviewed HCAHPS data and talked to patients and staff. The goals were to collect real-time data, identify opportunities, and, when possible, solve identified problems quickly.