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Quality: It's All About the Bike

Morley Robbins, for HealthLeaders Media, November 20, 2008

Clinical excellence is assumed

Now the more calloused (or more cavalier) reader may respond, "Why all the fuss about service? It simply doesn't matter how nice we are to the patient—we're still going to get paid, and they're still going to come to our hospital." And truth be known, that's absolutely right—for the time being. But there are two principle reasons why more attention needs to be paid to this other wheel—one is more universal, and the other is clearly financial.

A colleague who recently had an extended interaction with several hospitals put a sharp point to this universal issue. As she explained it, the healthcare encounter is all about instilling confidence in the patient interaction—and that requires emotional intelligence, not clinical intelligence. Lay people simply don't have the requisite skills or criteria to assess clinical expertise. But they can certainly judge whether the caregiver "cares" about them and whether by their actions and their compassion they instill a sense of confidence. And she noted, without that confidence factor, the patient enters a very negative spiral, and begins to wonder: "Will I ever get out of here, and more importantly, will I get out of here alive?"

And what is it that patients remember following a hospital stay? It's not the clinical stuff—research consistently documents that patients assume they will receive excellent clinical care. However, what patients do remember, and what they share with friends and family members, is how they were treated (i.e. how well the staff responded to their needs, how well their questions were answered, to what extent did the staff demonstrate compassion, etc.). This is the "soft" stuff that doesn't matter in healthcare—or so we're led to believe.

And if that doesn't spark a response, then the emergence of pay for performance should. Starting in the fall of 2010, as much as 4% to 5% of your Medicare revenue will be at stake for both your clinical performance as well as your service performance, the latter being measured by your HCAHPS scores. There are, in fact, 10 factors that will be used to judge hospitals, but the key metric is to determine patient loyalty is:

  • Percent of patients who reported yes, they would definitely recommend the hospital.

This question is a powerful predictor to assess the patient's overall experience.

So now let's return to our symbolic bicycle. Have you decided yet which wheel is "clinical" and which is "service?" A colleague recently asked two simple questions to clarify this issue: "Which is the wheel the patient sees? And which is the wheel that determines the 'direction' the patient experience will ultimately take?" It's very clear to me which wheel is which.

Let's explore this further. The back wheel is "out of sight," it is far more technical and infinitely more complicated, in large part because of the gears, the shifting mechanism, the rear axle design, etc. And doesn't this begin to mirror the clinical side of healthcare? But if my front wheel is not properly aligned, doesn't have sufficient air or inadvertently gets turned the wrong way, it doesn't matter how sophisticated the gearing mechanism is on my bike, I'm certain to have a bad experience. And yes, I ultimately need both wheels to have a quality riding experience—just as a patient needs peak performance on both the clinical and service dimensions to have a quality patient outcome.

So what to do?

There's quite a lot that healthcare leaders and clinical staff members can do to immediately address this redefined concept of quality as a symbiotic bicycle. Contact me at the e-mail address below and I'll send a dozen steps and initiatives that will bring balance and symmetry to the quality quotient in your hospital—literally overnight. They are categorized along three dimensions designed to materially enhance the patients' experience: demonstrate commitment, refresh your perspective, and apply reward and recognition.

So now we've come full circle.

It all starts and ends with the patient. But how we see them is strongly influenced by the lens through which we process the world. I fully endorse the need to keep relentless pressure on maintaining the clinical caliber of our healthcare institutions. But I feel equally as strongly that the pursuit of excellence in "quality" demands a bilateral focus on both clinical and service performance. Anything short of that is either a very bumpy ride or an unnecessarily sterile experience for the patient.

So grab a bike helmet, take an objective ride through your own institution, and see how you would capitalize on this analogy.


Morley Robbins is a principal with Health Planning Source, a healthcare strategy consulting firm in Durham, NC. He can be reached at morleyrobbins@healthplanningsource.com


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