This article appears in the July/August issue of HealthLeaders magazine.
"Real change begins to happen when physicians, nurses, and staff hear the voice of the customer, the voice of the patient."
"It's really about cultural change and maintaining that, which is probably twice as hard as getting to cultural change."
"Patient experience is not a campaign. It's an actual, critical part of culture."
"If anything makes physicians act, it's not being the best, and wanting to be."
"It was horrible. When I pressed the call button, I couldn't get anyone to answer. I could hear other patients crying in their room and the nurses weren't attending to them."
Those comments were part of a six-sentence paragraph described by a patient during a telephone survey after a three-week hospital stay in October 2012. It's something no hospital wants to believe is happening, but the reality is that scenes like the one above play out in patients' hospital rooms across the country.
That feedback is hard to read, but even harder to hear says Kevin Gwin, vice president of communications for Nashville-based Ardent Health Services, parent company of the hospital where the incident occurred. Gwin is providing new insight into how patient experience scores can be improved at Ardent Health and believes that the voice of the patient is the most effective change agent. The C-suite at each Ardent hospital is in charge of patient experience, but Gwin is in charge of getting patient experience scores up. That's why he asks nurses to read this patient's comments in full and out loud at staff meetings.
"Nurses become emotional when they hear a comment like this," says Gwin. "But that's how you change behavior. We're going to read it in a voice that makes the comment come alive."
Patient experience and satisfaction is the No. 1 priority for healthcare executives, according to the HealthLeaders Media Industry Survey 2013—above clinical quality, cost reduction, and many other burning issues. Yet there is little consensus about how to measure, improve, and incorporate patient experience into hospital processes.
One reason patient experience is ambiguous for hospitals is because it is a close relative of patient satisfaction, which is measured through HCAHPS, says Patrick T. Ryan, CEO of Press Ganey, a South Bend, Ind.–based company that works with healthcare organizations to measure and improve patient experience through surveys and consulting. In fact, according to this month's HealthLeaders Media Intelligence Report on Patient Experience, most respondents surveyed said the No. 1 goal of their patient experience efforts is to improve HCAHPS scores. Patient satisfaction and experience are closely tied together, but they are not the same, says Ryan.
"It's much more than patient satisfaction," he says. "The confusion that some folks come into the industry with is that patient satisfaction is about keeping people happy, but it couldn't be further from that because when people enter the health system, they're coming in at one of the most complex and stressful times in their life. And what they want most from the experience is communication and understanding of what their condition is, the path to the best possible health they can achieve, and a way in which to coordinate that with their clinicians and staff to ensure that they get there."
Measuring patient loyalty
How hospitals and health systems approach patient experience varies widely. Some are adopting measures from retailing, financial services, and other industries that depend heavily on loyal customers because, with growing healthcare consumerism, hospitals want to be seen as a reliable health partner throughout a patient's life instead of the place where patients go when they are sick. Ardent Health—a for-profit system that owns 13 hospitals, a multispecialty physician group, a health plan, and retail pharmacies in New Mexico, Oklahoma, and Texas—is using Net Promoter Score as it aggressively works to change its culture.
"Real change begins to happen when physicians, nurses, and staff hear the voice of the customer, the voice of the patient," says Gwin, who believes NPS gives a clearer view of how the patient perceives experience at the time and place of care.
NPS, developed by the Boston-based global strategy consulting firm Bain & Co. in 2003, has been catching on in the healthcare industry as a way to measure patient experience. Besides Ardent Health, St. Louis–based Ascension Health, which has operations in 21 states and reported $16.6 billion in total operating revenue in 2012, also uses NPS.
The key difference from HCAHPS is that NPS measures loyalty by asking customers to assign a number, on a scale of 0 to 10, to the question "How likely is it that you would recommend to a friend or colleague?" A patient who chooses 0–6 is labeled a detractor and is likely to negatively talk about the experience. Scores of 7 or 8 mean the patient is passive—satisfied but "unenthusiastic, and vulnerable" to competition. The jackpot is a 9 or 10. Either of those means the patient is loyal and is extremely likely to promote the organization to friends and family members.
To calculate the NPS, it's a simple math equation: Subtract the percentage of detractors from the percentage of promoters, and that is the score. The NPS recommendation question is similar to the HCAHPS survey, specifically question 22, but Gwin believes an NPS score is a better measurement of patient experience and loyalty because the data is raw, relevant, and returned quickly. Ardent uses an outside vendor to conduct an NPS survey with a representative sample of patients who are discharged weekly. When the surveys are returned, the scores are pushed out to each hospital's C-suite team.
Gwin says leaders in Ardent Health hospitals are empowered to manage their own NPS scores; the data is to help them make decisions, but there is a corporatewide standard of calling back a patient who was surveyed and turned out to be a detractor. He says hospital leaders are the ones who make the calls because he believes the most effective and meaningful way to change culture is to hear—really hear—from the patient what the experience was like.