The Hidden Patient Experience

How well-meaning and clinically unimportant actions can make or break the patient experience, and how leaders at Cleveland Clinic and Mount Sinai Health System are refocusing efforts.

During her hospital's monthly executive leadership rounds, Cleveland Clinic's executive chief nursing officer, K. Kelly Hancock, MSN, RN, NE-BC, met a patient who didn't seem quite happy, despite his insistence that everything was OK.

"We could just tell that he was a bit hesitant in his answers," Hancock says. So before she and her fellow executives left him, they probed a little more, asking, "Are you sure there's nothing else we could do to make your experience better?"

Actually, something was bothering him. Someone had come in to change his gown, and instead of addressing him by name, such as Mr. Smith, they called him "honey" and "sweetie."

"For him, he was offended," Hancock says.

It may have seemed like a small thing, but it really rubbed him the wrong way, and totally colored his experience as a patient. It was clear that it had been bothering him for quite some time.

"You've really got to dig when you're with the patients and the families," Hancock says. "What's important to that patient [is something] you may miss."

Clinicians might check off all of the important clinical boxes when caring for a patient, but it's often the small—perhaps nearly imperceptible—nonclinical elements of a hospital stay that most affect whether a patient has a good experience.

"I think that patients come to us expecting to get really good clinical care," agrees Sandra Myerson, MBA, MS, BSN, RN, senior vice president and chief patient experience officer at New York's Mount Sinai Health System. "The only way they can really judge us is on the rest of it."

With all the effort, money, and attention that's currently being paid to the patient experience, it's important for clinicians to understand how to get to the real heart of how a patient is feeling, and to do it in real-time.

Digging in
Beginning this year, Cleveland Clinic will be starting a program in which providers, such as nurses and physicians, will actually shadow patients during their inpatient stay or outpatient visit to better understand "what their experience is through their lens." Hancock says she's "really excited" about the program and can't wait to start it, adding that they think that "it's important enough that it's clearly worth the investment to take those caregivers offline."

"We know the best feedback is from the patient," Hancock says. "We think it really will lend itself to some great feedback to develop stronger interventions."

Shadowing could also help clinicians develop the empathy they need to really understand what patients are going through, and therefore, what they care about. Hancock says compassionate care is about being present, empathetic, and listening for key words that a patient uses that might clue clinicians into their emotions, and ultimately, their experience.

Use the right language
Hancock says it's important to meet patients where they are, and the shadowing project will very literally do that. By asking something as simple as "What's important to you during this stay?" clinicians might find out that the patient really wants his hair washed or face to be shaved. They're small things that can go a long way in providing dignity and comfort, but that may not be "important" clinically.

"We have to pay attention to those things that are concerning to the patient that we might not even think they should be concerned about," Myerson says. "We tend to be really task oriented."

Hancock says providing a template for talking about these nonclinical topics can help staff drill down into what's really important or worrying to the patient. In addition, engaging in role-playing exercises can help staff ensure that such conversations with patients happen naturally and without sounding scripted.

Myerson adds that training managers and other clinicians to ask certain open-ended questions, rather than yes-or-no questions, can elicit better responses. For instance, clinicians might ask "How did you sleep?" or "What got in the way of you sleeping well?" instead of "Did you sleep well?"

Another question that could be useful, especially if a patient is suffering, is "What's the worst part of this for you?" according to a new essay in JAMA. Asking such a question and "turning toward" suffering, the authors write, helps not only with the patient experience in the moment, but with overall, long-term healing in a way that straightforward diagnosis and treatment may not. It acknowledges that patients are whole human beings. It's also important to remember that clinicians are whole humans, too, and that these non-clinically focused interactions doesn't always come naturally. That's why they need training.

"We're spending a lot of time and effort around coaching people to be really effective communicators because it's not something that we learned in school," Myerson echoes. "It's about the human experience."

Be visible and open
Myerson says patients aren't always comfortable expressing their concerns during their hospital stay, especially if they're unhappy with a particular clinician. Patients may also not know who to complain to in the first place. That's why nurse managers have to be visible and available to patients.

"What we like to do is have the nurse manger round on every patient every day. It is a really great way for the patient know who's in charge of the unit," she says. "At the end of the day the nurse manager is really the CEO for their unit."

Nurse managers at Mt. Sinai also hand out postcards with their name, photo, and contact information—in English on one side, and Spanish on the other—so patients have it handy if they need to get in touch. Nurse managers at Cleveland Clinic also round on new patients and distribute business cards.

"If I know who's in charge I can go right to the boss," Myerson says.

But it's not only the boss who has a role to play in listening to the patient. For instance, Myerson says some of their housekeepers have a great, natural ability to interact and connect with patients, and sometimes patients will confide things in them. When that happens, they're instructed to tell either the charge nurse, nurse manager, or their own supervisor.

In fact, everyone on the nonclinical teams receive education about making eye contact with patients, smiling, and introducing themselves. Myerson adds that building services team members have huddles before each shift, and "they talk about patient experience almost every single huddle."

"Everybody has a role in the patient experience," Myerson says.