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Investing in Patient Experience Protects Hospital Revenue

May 19, 2014

Patient experience is not a nicety, but a quantifiable score that can decrease revenue. Learn from Cleveland Clinic's lessons: focus on culture, quickly; get physicians on board, despite their recalcitrance; and just get started.


James Merlino, MD
Chief Experience Officer at Cleveland Clinic

Many of the hospital and health system executives I speak with say the patient is at the center of everything their organization does. That had better be true given that hard dollars are now on the line, depending on how satisfied patients are with their care.

Under the Centers for Medicare & Medicaid Services' Hospital Value-Based Purchasing program, hospitals can either lose or gain up to 1.25% of their Medicare payments in fiscal year 2014 based in part on their HCAHPS scores. CMS will up the ante over the next few years, with 2% of reimbursement dollars ultimately being at risk by fiscal year 2017.

Aligning Organizational Culture
Truly building a patient-centered environment often means changing an organizational culture that may be mired in internal politics or focused on processes and workflows that are designed for the convenience of staff and clinicians rather than the patient.

The first step to redefining the workplace culture around the patient is to get employees on board, James Merlino, MD, chief experience officer at healthcare giant Cleveland Clinic, recently told me.

"It's so important to get people within the organization aligned," Merlino says. "If you don't have the right people with the right mindset, you won't be successful."

Cleveland Clinic established its Office of Patient Experience in 2007, and Merlino has held the CXO title since July 2009. He says providing the best possible patient experience is a "strategic initiative" for the 4,450-bed institution.

"Our CEO wanted to demonstrate that we have a serious commitment to elevating the level of importance of the patient experience. … Healthcare doesn't exist without the patient," Merlino says.

Cleveland Clinic's "Patients First" philosophy affirms patient care, comfort, and communication as fundamental values throughout the organization.

"Everyone comes to work focused on the mission that everything we do is for the patient," Merlino says.

Engaging All Employees
One of the health system's most successful patient-centered initiatives is a half-day training program called Cleveland Clinic Experience, Merlino says.

"Employees are randomly assigned to sit in groups of eight or 10 people to talk about Cleveland Clinic's values, service excellence, and what it means to put the patient at the center of everything the organization does," he says.

The program works, Merlino believes, because it mixes employees from all areas of the organization to engage in the dialog. Physicians and nurses sit with environmental services workers and valet attendants to discuss culture and core values.

"It became very powerful because it was a leveling exercise," he says. "The toughest stakeholder group to get engaged was the docs. Many went into it kicking and screaming, but most walked away saying it was a good experience. And the most common anecdote was from employees saying they couldn't believe the docs were doing this, too."

So far, 43,000 employees have gone through the class since it was launched in 2010, and the results speak for themselves, Merlino says. "We have seen the highest rise in patient satisfaction, the highest rise in employee satisfaction, and the steepest decline in patient complaints [since beginning the program]."

Mandating Physician Communication Training
Cleveland Clinic also requires its doctors to attend a day-long physician communications course. About 40 physicians representing different specialties and age groups have been trained to teach the class to their peers. Having physicians lead the discussion encourages engagement and increases the value of the course, Merlino says.

"When we piloted the program with about 200 physicians, the results demonstrated that patient satisfaction improved, but, interestingly, the physicians felt it was very valuable as well," he says.

"We made the course very practical," he adds. "It is small groups, which is how adults learn best. Some of it is standardized, but it is very free-flowing so we are not giving people scenarios. We are asking people to bring their personal scenarios to the session, and we are not limiting it to difficult communication challenges in medicine. We are asking people to share personal communication challenges."

Calculating the ROI
Providing these training classes to such a large workforce isn't cheap. For example, Cleveland Clinic has budgeted $800,000 for the physician communication course in 2014, which does not include the opportunity cost of keeping physicians from providing patient care for a day. However, the return on investment is significant if viewed in terms of the culture shift and increased patient satisfaction, Merlino says.

"If you are nailing it down for a business case and defining the ROI, it's about your brand. You want patients to come to your organization and leave feeling like they were cared for and that is what we are trying to accomplish. That is what patients want," he says.

Better HCAHPS scores also protect revenue from value-based purchasing penalties, he adds. "Certainly, there could be a government penalty, and we could potentially lose money. With high patient satisfaction, we don't have to give money back."

'Just Do Something'
Many provider organizations delay efforts to adjust their culture because it is daunting work and they don't know where to begin, Merlino says.

"Just do something and get started," he advises. "I think the first lesson is to start somewhere, because a lot of hospitals tend to spin their wheels and not go anywhere. People spend a lot of time thinking about where to start but don't actually get going."

"Changing a culture isn't quick. It takes time," he adds. "We've been at this for a long time, and it doesn't happen overnight. Starting early on your culture is important. If I could go back and change one thing, I would focus on culture earlier."

While making the shift to putting the patient first may not be an easy task, it's increasingly important. Patients are becoming more demanding healthcare consumers and payers are less willing to reward care that doesn't meet patients' needs—both of which will take an economic toll on organizations that don't get their priorities straight.

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