Creating Accountability for Patient Experience

This article appears in the February 2012 issue of HealthLeaders magazine.

Any story that attempts to discuss ways to improve the patient experience should attempt to define it, because there is ample confusion in healthcare, even among otherwise highly competent leaders, about what patient experience actually is.

It isn't providing excellent quality healthcare—at least not totally. A basic assumption by patients is that when they receive a medical intervention, the actual medical care will be excellent. Rather, patient experience is much more comprehensive, even encompassing patients' feelings about the hospital brand and their "stickiness," that is, their loyalty.

Our own HealthLeaders Media survey on patient experience in 2009 showed how difficult it was for hospital and health system senior leaders to define the term: 34% chose "patient-centered care," 29% selected "an orchestrated set of activities that is meaningfully customized for each patient," and 23% said it involved "providing excellent customer service."

The rest agreed that the patient experience meant "creating a healing environment," was "consistent with what's measured by HCAHPS," or was something "other" than the aforementioned options.

Sounds like patient experience encompasses just about everything except, possibly, the clinical care itself.

That's just about right, says James Merlino, MD, Cleveland Clinic's chief experience officer. The wide-ranging view of what constitutes patient experience used to be perplexing, he says, but the correct answer for him and for many others who are looking to improve is that it's "all of the above."

"When I took over this role, we suffered from the same problem as everyone else. In order to fix it, you have to define it," he says. Rather than defining patient experience success as performing well on standardized measures such as HCAHPS or other metrics, Merlino and the Cleveland Clinic leadership team went the other way.

"We made it more abstract. The idea being, let's just tell our people that anything that affects the patient outside the delivery of medical care is patient experience."

Not that they don't strive to do well on metrics like HCAHPS and other patient experience measures, but Merlino says he wants to avoid a "teaching to the test" mentality that may result from an exclusive focus on how the hospital system performs on measures that might affect reimbursement.

Rather, a more holistic approach is needed to fully incorporate the core idea of patient experience—that one bad experience can ruin the whole effort. By focusing exclusively on measures that are on the HCAHPS survey, essentially, you're missing both the ethical obligation to do best for the patient at all times, as well as the potential long-term benefits of patient loyalty.

"One bad interaction can define the impression," he says. "This is well documented in retail and other service businesses."

So how does one begin to incorporate accountability and responsibility for a patient's experience throughout the institution?

In stages, he says.

HCAHPS' focusing role
At the beginning, despite his misgivings, Merlino did focus on HCAHPS scores. He explains: "We chose HCAHPS initially not because we're chasing numbers, but because it was the only thing that had leverage. If you don't do it well, you will be penalized financially. We had started on this journey for the right reason before HCAHPS, but needed something to focus on."

But more important was to get the message to everyone who works in the hospital that each of them is responsible for patient experience.

"You can talk to anyone at our main campus and ask them about patient experience. They will say it's important and they are part of it," Merlino says.

Merlino says Cleveland Clinic faced an interesting challenge culturally, because it had always been thought of as an organization founded by doctors, for doctors. Instead, it's for patients, Merlino says, and the rest of the employees, whether they regularly encounter patients or not, have at least as important a role to play in patient experience.

Cleveland Clinic took a big risk to deliver that message to the entire staff of 42,000 employees by taking them offline over a period of months in small group sessions that lasted a half day. Everyone spent valuable time, from neurosurgeons to housekeeping staff, discussing why it was important, how everyone is in this together, and service excellence standards and how to improve.

In tables of eight to 10 people, including a facilitator, Merlino and his staff talked to the randomly assigned groups about patient experience using theoretical situations and a visual learning map, encouraging them to develop a collegial atmosphere. It cost $11 million to do the project, says Merlino, but it was well worth it.

"It was a leveling experience that got everyone to realize that patient experience isn't the responsibility of one group," he says.

Rather, it is a team effort, and the organization succeeds or fails on patient experience as a team.
"A highly engaged workforce is a big driver of satisfaction," he says. "We needed a culture of engaged and satisfied caregivers. If we don't get that, we don't get to any other level. Any Fortune 100 company understands that."

And patient experience is a journey that never ends, he says.

While Merlino says Cleveland Clinic is "nowhere near where we want to be," its patient satisfaction scores, after 2009, when this intensive training was initiated, jumped 15% in one year, from 2010 to 2011.

"We attribute it to our work on this program," Merlino says.

Driving accountability
But a one-day retreat for employees wasn't going to get the job done in and of itself, Merlino realized. Sustainability was critical, so patient experience measurement and metrics needed to be implemented by the management staff, a group 2,200 strong, and they needed to know it was one of the most critical factors by which their performance would be judged going forward. And it had to have full support from Toby Cosgrove, MD, Cleveland Clinic's CEO.

"The top person  has to say it's critical," Merlino says. "If you don't have that, you're not successful."
Those 2,200 managers underwent two sessions to discuss measurement protocols, accountability, engagement, and developing unity of purpose.

"These managers sustain it," says Merlino. "Managers must be razor-focused on the goals; you have to give them mechanisms to track them and you have to hold them accountable. They will then hold their employees accountable. Toby drives it to the executive leadership team, we drive it to our management, and management drives it to the employees. In a way, what we're doing is enforcing basic management techniques. It's not rocket science."

UCLA's reason for being
If Merlino sees patient experience as a critical part of the care process, David Feinberg, MD, sees it simply as the reason for being for Ronald Reagan UCLA Medical Center, for which he is the CEO.

Put simply, Feinberg is a believer that if patient experience is excellent, most everything else that's a priority for the hospital or health system will fall into place. Which is why he is self-deprecating about UCLA's achievement of 99th percentile in HCAHPS scores.

"Our HCAHPS scores are good, but we're not doing well in patient satisfaction," he says. "We've had a meteoric rise from 38% to 99th percentile. We perform at the very top regarding HCAHPS questions. That being said, we're terrible because to get to 99th percentile, you have to get 85 out of 100 people to give you that answer on their survey. That means we've failed even though we're the best, because we've failed with 15 people out of the last 100."

He says, with no hint of guile, that the scores need to be 100 out of 100 before he can boast that they've gotten anywhere.

Yet his hospital represents the top 1%, in a manner of speaking, meaning it must be doing something right.

His biggest challenge, he says, was instilling a team spirit about patient care throughout the organization.

One of the guiding philosophies is that it's not just about the people who touch patients. "Whether you're in IT, or billing and collections, or frontline nurses, docs—wherever you fit—you're part of a healing team."

That's fine for a major academic medical center in one of the nation's largest cities, which has far more resources than the average community hospital, but Feinberg takes care to mention that much of the work is commonsensical and that being attentive to the customer's needs doesn't cost much, if anything, and often leads to better, more coordinated care, and thus, a lower ultimate cost of care.

Anyone in a leadership position should be able to start with culture, anyway, says Steve Whitehurst, chief customer and strategy officer with BerylHealth, which consults with hospitals on patient experience.

"Of course, it all starts with the culture and leadership engagement," he says. "CEOs may talk about the patient experience, but if they don't drive this message down into the organization, it doesn't work."

He says that's a great way to begin a discussion about HCAHPS not being the final arbiter of patient experience or quality, "because it's a great measure of 'always.' If my mom was getting care, do I want her to say that someone ‘always' did this or that—whatever question is being asked—or that her nurse was compassionate and took good care of her?"

He says he sees a lot of working to the test and toward obtaining the "always" answer.

"When you put them to a test that requires an ‘always' answer, it doesn't give them any opportunity to impact the patient experience," he says. "I don't believe a lot of hospitals are going past HCAHPS scores. About 20% are doing it because there's a penalty associated with it, and most of the rest are lagging and not doing anything about it."

UCLA's Feinberg says, without a hint of hyperbole, that from a leadership standpoint, patient experience is his "singular focus."

He practices what he preaches by rounding on patients for a couple of hours each day, and he makes it clear that he expects his management team to do so as well, if not to his extent from a time standpoint. He insists that everything else should be subordinate to what he calls a "laser focus on making sure the next patient gets that best care."

When others, including patients, see examples of great care through actions or patient referral, he makes a point of celebrating it, making sure the individual who exceeded expectations gets the credit.

"When we fail, we share that broadly as well," he adds. He encourages the staff—anyone who comes in contact with a patient—to probe patients and their families to "see where we messed up," he says. "I give out meal coupons and Starbucks coupons. We're pretty service minded."

He says service recovery, in the form of responding when things go wrong, is key to retaining patients over the long term, and that's what he's most concerned about—test scores are only one way of measuring how well they are meeting that goal.

"We're clearly far from perfect, but when those things happen, we're aggressive in seeing if we can make amends," he says.

Every unit, every shift, huddles around metrics and reviews handwritten notes as well as current HCAHPS scores and core measures scores. That kind of daily reinforcement helps tie workers more closely not only to how to recover from mistakes, but also to the patient's needs, refocusing them on what's most important.

"The best thing we've ever done to improve employee satisfaction is not to focus on it. Rather, we've focused on patient satisfaction," says Feinberg. "People here want to take care of others. If we're doing that, they're more satisfied in their jobs. I don't care if we ever become an employer of choice. We want to be a place that patients choose. If you get it right for the patient, your employees are happy, because their job is easier and you've tapped into their purpose."

This article appears in the February 2012 issue of HealthLeaders magazine.