An Epidemic of Empathy in Healthcare

by Thomas H Lee

  When I learned of this cultural standard at Mayo Clinic, I began asking physicians there, “What happens if you don’t answer right away?” Some looked genuinely puzzled, as if I had suggested truly deviant behavior. One said, “Well, you won’t do well here.” Another said, “The last thing you want is for people to say, ‘He’s the kind of guy who doesn’t answer his page right away.’”

  There are other aspects of the Mayo Way, of course, including the expectation that the first physician who sees a patient will take care of that patient even if the patient’s issues turn out to fall outside that physician’s area of expertise. There is also a dress code. The message is clear: “There is a Mayo way of doing things. Don’t come here if you don’t want to adopt it—completely.” The standards translate into high-quality, well-coordinated care that is a source of pride throughout the Rochester area and that patients willingly travel long distances to access.

  To use the tradition lever, organizations must be ready to part company with personnel who are unwilling or unable to adhere to the norms and work with their colleagues toward their shared purpose. In the past, hospitals often welcomed almost any decent physician who would bring patients and therefore revenue to the institution. Physicians rarely lost their credentials or were fired. That still does not happen often, but when it does, colleagues usually ask, “What took so long?”

  Providing Examples

  Max Weber’s models provide motivation to drive an epidemic of empathy, but clinicians also need examples, as was described in Chapter 5. The bad apple approach is not enough; clinicians need to be able to learn from their colleagues who have developed empathic care patterns over the years and made certain actions routine in their practices.

  The apprenticeship approach still has its place in medicine, and the level of detail at which learning occurs can be quite minute. For example, I have made some questions I learned from admired colleagues part of my routine patient care visits. I had one of my patients come back from a consultation with the cardiologist Dale Adler and say how impressed he was when Dale said, “Tell me what your life is like.” Now I ask that of virtually every patient, knowing that the open-ended format allows patients to talk about what is most important to them while giving me information about their physical and psychological status.

  Similarly, from my own primary care physician, Charles Morris, MD, I learned to say to patients, “Help me understand what I can do to help you.” I use that near the end of almost all complicated visits both to get patients’ hopes right out on the table and to make clear that I consider it my job to help them.

  I learned those two questions by accident, but many organizations aren’t relying on chance encounters between clinicians. They are taking steps to celebrate clinical champions and spread their best practices systematically. They are having large-scale meetings at which physicians and nurses share their tips and assigning individual clinicians to work directly with such champions in some cases. These steps send the message that empathic care is important to the organization but also that it is possible and that it does not conflict with overall clinical excellence. In fact, empathic care is at the core of clinical excellence.

  One valuable lesson from the social network research of Christakis and others is that the impact of these positive examples can be augmented if they are concentrated and presented in a group. That grouping transmits the message that the organization is not just focusing on one exceptional individual but that a norm is in development. As was described in Chapter 5, groups tend to tip when a critical mass (e.g., three or four clinicians) has adopted a new and better way of delivering care.

  Providing the Tools

  There is still work to be done even after motivating clinicians to provide more empathic care and giving them models. For example, communication skills come naturally to some but not all clinicians. Some organizations are requiring that all clinicians undergo training in communication with patients. At the very least, training should be made available to those for whom patient data suggest substantial opportunities to improve. Another way to identify clinicians for whom such training would be useful is to have trained observers sit in on a sample of patient interactions.

  An outstanding description of the tools that have proved most useful to providers can be found in the book Service Fanatics by my colleague James Merlino, MD, the former chief experience officer at Cleveland Clinic. This book not only describes tools such as communication training in detail but also places them in the context of the journey of an organization from disappointing to excellent performance. A deeper and valuable description of that communication training program can be found in the book by two of Merlino’s former physician colleagues at Cleveland Clinic, Adrienne Boissy and Timothy Gilligan, Communication the Cleveland Clinic Way: How to Drive a Relationship-Centered Strategy for Exceptional Patient Experience.

  The Role of Governing Boards

  Using any of Weber’s four levers is challenging and disruptive to frontline healthcare providers. These approaches are the kinds of measures that sound better when they are part of a speech, article, or book than they do when you are a busy clinician trying to get through your day. For that reason, the very good people in healthcare often push back on steps that will improve it.

  Great healthcare organizations tend to have great leaders and great boards behind those leaders. They have directors/trustees/overseers who understand the meaning of strategy, who remind management to focus not just on the rocks in the water but on the horizon as well. They track metrics that reflect progress toward goals and help management through the tough choices that must be made when change is the imperative.

  Around the country, boards of forward-looking healthcare organizations are adapting to the challenges of the new era. Here are a few noteworthy examples:

  • Some organizations start board meetings with the presentation of an actual patient case, often one in which the outcome was poor. Sometimes the patient is brought into the room to drive home the message that the issue under discussion has had a real impact on a real human being. The board and management discuss what went wrong and why and review what is being done to reduce the chances that the patient’s adverse outcome will ever happen again.

  • Many boards are devoting part of every meeting’s agenda to reviewing quality data, often deliberately placing this agenda item before financial reports so that time is available and energy is high when quality data are being discussed. This reverses a traditional dynamic of putting quality data after financial discussions and often running out of time for topics such as patient experience and safety.

  • Some boards have quality committees that meet with senior management to review performance so that data can be explored in greater depth than is possible at a meeting of the full board. These committees are considered the counterparts of board finance committees.

  • Some boards are making sustained explicit efforts to get members out of their chairs and into patient care settings. University of Utah Health Care’s board assigns each member to a patient-care unit. Board members visit the unit monthly, meeting staff and interviewing patients. Utah also has had board members go through an exercise in which they were told they had a disease (e.g., heart failure) and had to search for information and explore decisions that a patient with that condition would have to make.

  Holding management accountable is impossible without good data and in ample amounts. That means a measurement/analytic/accountability strategy that goes beyond small samples of patients. Organizations need enough data so that worrisome trends cannot be dismissed as meaningless and individual patient-care units and clinicians themselves can feel the pressure to improve and identify role models. The data will never be perfect, but boards should not allow management to be paralyzed by the inevitable imperfections. After all, paralysis is the worst possible strategy for any healthcare organization.

  Boards should be looking at an array of quality data that include but also go beyond patient
experience at every meeting, including the following:

  • Mortality. Expected versus observed mortality is readily calculated for the overall patient population and for specific conditions that are the focus of government value-based purchasing programs (acute myocardial infarction, pneumonia, and heart failure). Boards should place mortality data in perspective, however, and know that they are important yet are not the sole relevant measure of quality. It is not realistic to expect providers to be statistically better than expected for mortality, as the biggest determinant of mortality is the burden of disease in individual patients. However, if mortality is worse than expected, it should be considered an organizational crisis.

  • Clinical metrics that are the focus of value-based purchasing initiatives. Examples include readmission rates for acute myocardial infarction, heart failure, pneumonia, chronic obstructive lung disease, and major total joint replacement. These metrics are, of course, important to patients with these conditions and are increasingly available publicly. They therefore help shape the organization’s brand. More important, board focus on these measures encourages management to organize teams that can improve these condition-specific outcomes.

  • Metrics that are drivers of market share, such as patient experience data. These metrics are the most direct measure of the organization’s overall effectiveness in meeting patients’ needs and giving them peace of mind that their clinicians are working well together on their behalf. Analyses in every patient setting—inpatient, outpatient, emergency department, and so on—show that what patients value most are the competency, empathy, and communication skills of clinicians and the coordination of care. Patients are not that interested in amenities such as food and parking, and boards should not be distracted by them either.

  • Measures of effectiveness of care for condition-specific subsets. An example would be patient reported outcome measures (PROMs). These measures are different from the process measures that are used in value-based purchasing initiatives, as they cannot be calculated by analyzing insurance claims; they require asking patients about their outcomes and whether their needs have been met. Relatively few organizations collect such data yet, but boards should encourage management to move down this path because hospitals and physician groups are important but limited units of analysis and improvement. When subsets of patients with similar shared needs can be identified and teams can be organized to meet those needs, major gains in effectiveness and efficiency can be achieved. These teams need data to guide their efforts to improve, and only patients can provide information on the outcomes that matter to them. Boards should not allow management to assert that their organizations are delivering world-class care without measuring actual outcomes.

  • Engagement of clinicians and other employees. Organizations need a workforce that takes pride in delivering excellent care and doing so as efficiently as possible. Organizations with better engagement data have lower turnover rates and better financial and quality performance.

  With the right governance, the right leadership, and the right management, healthcare organizations can achieve clarity on their goals, use incentives wisely, and drive an epidemic of empathy.

  CHAPTER

  7 Ten Key Steps Toward Higher-Value Empathic Healthcare

  RECOGNIZING THE INFORMATION overload we all face today and the many mandates, strategic imperatives, and recommendations that compete for top priority among providers of healthcare, here are 10 key steps that I hope will be useful in creating the context for and driving an epidemic of empathy in healthcare. I will start by being broad and strategic and get specific and tactical as the list goes on. The perspective may seem optimistic, but I believe the steps are grounded in reality and are consistent with the basic values of people who deliver, fund, and use healthcare.

  1. Embrace value for patients as the overarching goal of healthcare. Value means meeting the needs of patients as efficiently as possible. It is the only goal that resonates with all stakeholders. Clinicians who do not want to think about efficiency are ceding that responsibility to others; this is likely to lead to adverse consequences for patients and a worse professional environment for providers.

  Accepting responsibility for quality and cost is the smart and right thing for providers to do. Embracing this goal means plunging in and making it the top priority with which everything else must be aligned.

  2. Embrace market forces as drivers of a new healthcare marketplace. Providers are unnerved about unintended consequences and potentially perverse outcomes if patients are regarded as consumers who shop for care that they can afford and that meets their needs. However, the reality is that middle-class families cannot afford the full costs of the status quo: health insurance plans with access to any provider and providers who can charge whatever they believe is needed to cover their costs plus a modest margin.

  The inevitable consequences of this tension are already playing out. Individual patients/consumers are picking insurance plans that they can afford at open enrollment or on the exchanges, and many of those plans do not include all providers. Employers and payers are starting to steer patients toward providers that accept bundled prices for the care of chronic and acute conditions. Only a small percentage of patients are changing where they get their care as a result of these forces at this point, but it takes only small shifts in volume to destabilize a provider organization that relies on the old model of care.

  The implication is that market forces are arriving as real drivers, and providers should do more than accept this reality. Here again, the alternatives are worse for patients and worse for providers. The organizations that will be most successful will be the ones that embrace market forces and look for opportunities to use them to increase their market share by improving their efficiency and the way they meet patients’ needs.

  3. Recognize that competition is the secret sauce for a better healthcare system. If you accept the idea that market forces are the best option for driving healthcare, plunge into competition on the right things. If you don’t accept market forces as the best driver, consider carefully the alternatives and their implications. Every path forward has potentially adverse unintended consequences; competition is the only one that offers the potential for major improvements too. Competition in every other business sector leads to better quality at lower cost, and there is no reason that it cannot and will not do the same thing in healthcare.

  That is the good news. The tough news is that competition is stressful. It virtually always demands improvement, and improvement requires change. Change is miserable for good hardworking people who are already overwhelmed by their work. (One of my colleagues likes to say, “All change is bad, including change for the better.”) However, inability to change is a losing game plan in a competitive environment, and change for the better can win market share, improve margins, and enhance professional pride.

  Forward-looking organizations should recognize the opportunity in competition. If they see that opportunity and respond to it before their competitors do, they will have an advantage in organizing their personnel to thrive in the new marketplace. The goal, of course, is not to separate providers into winners and losers but to drive improvement, and competition does a much better job of driving improvement than setting some floor of minimum performance that is sufficient to avoid penalties.

  4. Embrace empathic, coordinated care as a core component of high-value healthcare. The hard clinical outcomes such as mortality and complications matter most, and providers must be reliably excellent in following guidelines and delivering evidence-based medicine, but that is not enough. Providers have to be tuned in to other types of outcomes that matter to patients, including the disutility of care: the anxiety, the confusion, and the uncertainty about what is happening next. Clinicians know that these issues matter. When the clinicians themselves are ill or their friends or family members require care, they do all they can to ensure that these issues are addressed.

  Recognizing patient suffering an
d anticipating, mitigating, and preventing it are acts consistent with the highest professional values of clinicians. Empathy is thus a core element of excellence. One cannot have high-value healthcare that does not address these types of outcomes. Providers are unlikely to be able to hold on to their market share or gain the trust of more patients without making empathic care part of their strategic vision.

  5. Measure the outcomes that matter to patients. Peace of mind and trust are difficult to measure, but there are reasonable markers available; likelihood to recommend may be the best. Clinicians should get over their concern that patients cannot judge quality as well as can those with clinical training. Likelihood of recommending and other patient experience variables reflect the extent to which patients believe that their needs are being met. If patients do not believe their needs are being met, it is hard to argue that providers have met them.

  The measures will never be perfect. The data will never be perfect. The analytic methods will never be perfect. But collectively, providers and the organizations that help them measure these outcomes should use what is available to improve while also working to improve measurement. Perfection should not be the enemy of the good, and collecting more data can help reduce the chances of being misled by the data. Then the data should be used with wisdom and humility.

  6. Organize patients and providers to improve those outcomes and do so efficiently. The reason to measure performance is to improve it, and that is not likely to happen if clinicians are pushed to work harder as individuals. What can lead to marked improvement is segmenting patients into groups with similar needs and organizing multidisciplinary teams to meet those needs. Those teams are most likely to be effective if patient volume is concentrated on them and if the key team members are consolidated at one site so that they really know one another, learn to trust one another, and send the same messages to patients. If those teams are rewarded for better performance, whether financially or otherwise, they can often create remarkable improvements in both quality and efficiency.