Service Fanatics
Page 26
We Must Teach People How to Be Patients
We healthcare professionals spend enormous time educating patients about their disease and its treatment. But we spend little or no time talking to patients about what it means to be a patient and what to expect during hospitalization. The anxiety, fear, and confusion inherent in all hospital patients is exacerbated by them not knowing what’s going on and being unable to anticipate what will be happening.
To address this healthcare communication loophole, in 2011 Cleveland Clinic worked with an outside technology company to develop an online engagement module about being a better hospital patient. The program helps patients understand key processes and interactions that will define their experience, including how to partner with our healthcare team to make the hospital stay more satisfying. Our hypothesis was that if we discussed with patients what to expect during their hospitalization, we could level-set expectations against the reality of the environment, enhance patients’ comfort level with the hospital encounter, and drive improvement in inpatient satisfaction scores.
Structuring information around the HCAHPS domains, we educated patients regarding what to expect during hospitalization and suggested tactics that might improve the healthcare experience. We informed patients that the average inpatient nurse cares for four to five patients and may not be able to answer a call button immediately due to caring for another patient, but the team would respond immediately in an emergency. We informed patients that hospitals are not quiet, and while we work hard to create a healing environment, it may be noisy and there may be interruptions. We informed patients that pain is very difficult to completely eliminate and could be a very real part of their experience. We let them know we would do everything to try to make them comfortable and they should let us know when we were not successful, but it was possible that we could not completely take the pain away.
Regarding the most important part of the hospital environment, communication, we asked patients to be partners with the healthcare team and to write down their questions to be well prepared. We also asked patients to empower their families and friends to serve as surrogate communicators and advocates.
We tested the effectiveness of the program by comparing two groups of patients undergoing similar procedures. When patients were informed that nurses come as soon as they can when the call button is pressed, satisfaction with response rates was higher. When we helped patients ask better questions of their care team, satisfaction with communication was better. When patients were educated about the hospital environment, they were more forgiving of interruptions and their perception of quietness was higher. We found that patients’ expectations could be set to a level that was realistic. The group that received the “what to expect education” scored us higher in every HCAHPS domain.
Cleveland Clinic is doing other things as well to address the expectation-experience mismatch. Our service excellence program, Communicate with H.E.A.R.T., has built-in training modules to help caregivers appreciate that everyone has a role in setting expectations for patients. Every patient-provider encounter should be wrapped in a conversation about what to expect, beginning from the patient’s point of access and through the clinical areas when care is discussed. What we provide to patients before they even arrive on campus can include information about parking, navigation, their healthcare team, or the philosophy of care delivery.
An old adage in medical training is that discharge planning begins at admission. We often say that, but we typically don’t design our processes to support it. Care delivery is a longitudinal journey. In 2013 when we redesigned our hospital admission guide, we worked with our care teams to ensure that we provide patients and families with information to help plan discharge. We provide a patient and family member checklist that includes reminding them to think about things such as who will assist the patient when he or she leaves the hospital, who will schedule follow-up doctor visits, and so on. This helps patients and family members better prepare for transitioning care to the home environment.
Healthcare reform and the emergence of accountable-care organizations and population health-management strategies have brought the concept of patient partnership to prime time. Healthcare organizations will be subject to increased pressure to manage decreasing resources more effectively. One strategy to reduce waste and improve care delivery is to shift payments from volume-based care, or getting paid for doing things, to value-based care, or being paid for delivering care better. Incumbent upon this strategy is the incorporation of tactics to engage, or activate, patients. Healthcare organizations are developing programs to enable patients to do more; however, the focus cannot be unidirectional. The risk and responsibility must not be solely on the provider; patients must play a role as well. We can call patients to remind them to take medications and ensure they have follow-up visits scheduled. We can even go to their homes and check on them and bring them to their visits. But we cannot force them to eat properly, take their medications, or avoid unhealthy habits such as smoking. Promoting wellness, managing health, and curing disease require a 100 percent effort, not only from the provider, but from the patient and family members as well.
Growing consumerism, driven by the increasing availability of information, as well as rising insurance premiums and deductibles, is making the patient a much more important player in healthcare decision making. Patients today have access to incredible amounts of healthcare information. The Internet provides a wealth of information, including access to scientific findings, hospital and provider ratings, marketing content, and, increasingly, cost data. Additionally, the explosion of social media is making the exchange of opinions and ratings much more accessible for patients seeking to understand their various treatment options. Social media is also a great “leveler” for patients, as it is giving them a powerful forum to get the attention of healthcare workers and organizations.
Patients are no longer just patients, consumers, or customers; appropriately, they are our partners. We need them to help us by taking care of themselves and understanding not only their disease but the environment in which they are treated. We need them to be advocates and challenge us. There has never been a better time or more tools to help meet deBronkard’s goal of creating empowered, equipped, educated, engaged, and expert patients, or Gleason’s goal of making sure patients are heard.
In summary:
1. Patient care is complicated, and patients and families can help ensure safe, high-quality care by becoming our partners, which means taking more responsibility for their care by asking questions, learning about their disease, understanding their behaviors that can negatively impact their health, ensuring compliance with recommended treatments, and knowing what it means to be a patient beyond just their disease.
2. Providers have to remember that patients and their families are relatively unsophisticated consumers of healthcare who fall into a very submissive relationship with healthcare professionals. This combined with the fact that health literacy in the United States is generally very low requires us to actively work on strategies and tactics to help raise the level of patients’ participation so that they are better partners in their care. We should embrace patient activism and recognize that it is a powerful tool to help us do our work more effectively.
3. Providers have a responsibility to go beyond educating, engaging, and activating patients and ensure that they understand the treatment environment and set the expectations of what patients will encounter. We spend a great deal of time speaking with patients and families about disease and disease management; we also need to talk to them about what to expect in the hospital and at other points in their healthcare journey. This will help prevent the expectation-experience mismatch that so many patients experience. Imagine the impact on safety if every patient and family member would help watch out for errors and felt empowered to speak up when they suspect something is wrong or just have the courage to question us.
Chapter 13
Getting It Done Has
Defined Our Success
Our greatest patient experience achievement has been our ability to execute the work, an achievement I owe to my mentor and friend from Harvard Business School, Ananth Raman. He helped me understand the importance of how to operationalize the change.
Execution has taken our patient experience improvement from aspirational goal to operational reality, gained the respect of leaders across Cleveland Clinic, and drawn the attention of healthcare institutions around the world. The success of our execution is palpable. Our organizational metrics are improved, our caregivers live the patient experience, our leaders drive it, and most important, our patients feel it. The challenge going forward is to sustain and improve upon what we’ve done. It’s easy to fix something broken; it’s much harder to take something successful and make it better. While our strategy will evolve and tactics will come and go, the navigational focus of patients as our true north and our fundamental alignment around the patient must never waver.
In January 2014, I spoke to a group of physicians from Hillcrest Medical Center in Tulsa, Oklahoma. The Medical Group’s CMO, Jeffrey Galles,1 e-mailed me after the meeting and observed that his senior hospital leadership often says, “We can’t all be Cleveland Clinic.” My response was, “Yes, you can!” It’s about leadership mindset and how the organization aligns around a Patients First philosophy and sets the patient experience as a strategic priority. And while it’s true that initially we invested materially in our patient experience initiative, today we know better how to achieve success without spending a lot. Setting a patient experience strategy and developing and executing tactics need not be expensive. Implementing nurse hourly rounding does not require infrastructure or special technology; it requires leadership, training, and accountability. Distributing physician-specific scores to doctors and teaching them communications skills require are efforts that the courage to start, leadership, and accountability. You see the common threads here. Leadership rounding is another great example: it could be started tomorrow by every hospital CEO throughout the world, for low cost and high payoff.
Personal Learnings
I’ve read many books and articles on organizational transformation and leadership, and they’re all very good at describing what and how things were done. Few have addressed the leadership missteps or learning opportunities in the struggle to be successful. I didn’t enter medicine to be a healthcare organization leader but fell into the role. The information in this book represents the work of numerous people, many much smarter and more capable than I. The results are neatly organized and presented here, which does not do justice to our trial-and-error process. When I talk about what we’ve accomplished, I often tease audiences that they’re seeing the “sausage,” which tastes great, but is the end product of a very bloody factory that we have long since closed down. Even with the many people dedicated to Cleveland Clinic’s initiative, it’s hard work and takes time. My own experience on this journey has taught me several very important, yet sometimes difficult, lessons:
Don’t expect results overnight. Think long term. I remember day one of my new role as CXO being ready to change the world and Cleveland Clinic along with it. However, this doesn’t happen fast. Enthusiasm and excitement are important, but thoughtful decision making with a long-term perspective is critical. As I have said multiple times, we also have to be considerate of how our decisions impact the system. One small improvement, when not considered appropriately against the system, can have unintended negative consequences on other areas of the organization. Looking for instant gratification in this work can lead to dangerous mistakes that negatively affect people and the organization. Cosgrove began his patient experience journey in November 2004. My journey started in July 2009. We’re both still very much on the ride, with a lot of work to do. Recognize that you’re taking on organizational transformation. Healthcare is not used to this type of patient-centered focus or change. If there is anything you take away from reading this book, let it be that patient experience improvement is a multiyear proposition. Be patient, but be persistent.
There are a lot of ways to do something right and a few ways to do something wrong. Be flexible on what you choose as right. From a senior position in enterprise leadership, it’s tempting to issue mandates that everyone do something the enterprise way. But healthcare delivery is highly nuanced, and bedside care is not an assembly line or one size fits all. The hospitals in our system range from a world-prominent, 1,200-bed specialty facility focused on high-acuity tertiary care to small community facilities. We have adopted the concept of “One Cleveland Clinic” to ensure that we standardize critical strategies and tactics. But failure to recognize and accept that each facility has its own local culture and individual needs will lead to certain failure. It works best when leaders and managers are permitted to tailor the implementation and delivery. Such local ownership drives more effective adoption, because we’re putting faith in local skills to execute. Nurse hourly rounding is a best practice that should be implemented in every unit of every hospital across the world. But as long as there’s documentable process performance, how hourly nurse rounding is implemented should be driven by the local environment. Not every patient door must have a checklist to prove compliance. Another good example is plan of care communication between physicians and frontline nurses, also a best practice that everyone should implement. But whether that communication happens at the bedside, after the physician rounds, or via physicians reporting to the nurse manager should be an issue of local control reflecting what works best for the individual practice environment. Assuming that we know how everything should apply to every care environment is wrong, and it’s a mistake we tend to make when we do not consider the entire organization.
Recognize that you will make people mad. To this day, I’m sure there are people who would like to see my position, our department, and the effort we’ve all put into improving the patient experience disappear off the face of the planet. Not everyone is on the bus, and not everyone will appreciate what you’re endeavoring to do. Some will be against the concept, some will be against the leader, and some will be both. Our challenge is to transform the halfhearted 10 percent of the organization and get rid of the 5 percent who are employed in healthcare for the wrong reasons. Determination in the patient experience field is important, but resilience is critical. Both chief of staff Joseph F. Hahn and clinical services CAO Cynthia Hundorfean remind me continually to “do what’s right, and the rest will take care of itself,” which is sage advice. When dealing with resistance, it’s important to be respectful and act with integrity, but ultimately, when you take the side of the patient, you’ll never lose. I’ve contended many times with people who dislike me personally, but that’s OK as long as we agree that improving the patient experience is the right thing to do.
Committees are important, but don’t use them as a substitute for leadership. I have watched hospitals, ours included, get bogged down in committee-think. Sometimes it seems that every major initiative and decision needs to be vetted by a committee, subcommittee, or task force. This is probably a phenomenon more commonly seen in healthcare because of its multiple stakeholder groups and legacy governance structures. But some of our best decisions that have had tremendous impact on the organization were made by command-and-control leadership because someone took responsibility to lead. I have occasionally been criticized for this approach, but I think our results speak volumes about our methods. I am not advocating that we make decisions without consultation and vetting, but sometimes decisions need to be made. We can save people a lot of time and the organization a lot of money by not using a committee for every initiative. Cleveland Clinic does not have a patient experience advisory committee. It has a leader, me, and a strong partner, the executive chief nursing officer, who lead our enterprise efforts. We consult extensively with each other as well as with others across the enterprise, but we are held accountable for the work; therefore we make decisions and we operationalize them.
We are in the ultimate service business where the customer is not always right. Often there’s less science and more emotion when it comes to managing patient perceptions of care. Empathy goes both ways; just as we must take care of patients, we also have a responsibility to protect our people, because taking care of patients is not easy work. As I have said, when patients complain, there are always three sides to the story: what the patient said happened, what our caregivers think happened, and what really happened. It’s easy to get carried away with anecdotes and jump to conclusions—something I term “anecdotal assassination.” But our responsibility is to ensure we understand the facts before we act, as we have as much responsibility to our caregivers as we do to our patients. Do some patients fabricate information to manipulate the system in their favor? Perhaps their explanation of what happened may not be the accurate interpretation of reality. Be cautious about taking an anecdote as a burning platform for change. We have an obligation to make sure that we understand the context of the anecdote and don’t unjustly assume that our caregiver did something wrong. In some organizations, a carefully placed anecdote or collection of anecdotes can successfully kill a career. We have responsibility as leaders to ensure that our judgments about people are based on evidence and trends of actions, not stories or isolated incidents.