Service Fanatics

by James Merlino

  The purpose of Cleveland Clinic’s motto and focus is not about care delivery, nor is it about making patients happy. It’s about alignment: getting everyone to put patients at the center of everything we do, always thinking about what is right for the patients—and their families.

  Initially, many Cleveland Clinic employees viewed the Patients First initiative as a superficial marketing ploy. But our rejection and mocking of the concept illustrated Cleveland Clinic’s failures as an organization and reinforced the need for transformation. If we could not understand or take seriously the importance of a patient-centered focus, regardless of whether or not we felt the CEO believed it, what was the point of being in the business of taking care of people? In healthcare, adopting a Patients First alignment should be a mandatory part of your brand. It is not a gimmick or a marketing ploy; it is a cultural underpinning.

  Recently, someone asked me to defend my position on “customer first” versus “employee first,” arguing that we should put employees—instead of customers—at the center of what we do because they are the ones who deliver on customer centricity. I disagree. Alignment around the customer is an organizational strategy that articulates why the company exists and gives everyone working for the organization a common purpose—the reason for coming to work every day—which is to serve the customer. Are employees important? Absolutely! An organization must take care of its people. But the primary purpose of any service business, especially in healthcare, is to keep the customer (the patient) at the center of the organizational strategy. Organizations don’t exist for their employees. They exist for their customers.

  It was not until I left Cleveland Clinic after my fellowship and started treating patients on my own that I recognized the true meaning of employees aligning around patients. I quickly learned that there are numerous factors that affect a patient’s perception of care.

  At MetroHealth, I had a patient who vomited in his bed, soiling his sheets. He asked the nurse on multiple occasions if he could get his bed changed, and no one helped him. Finally, a cleaning person came into the patient’s room, and he asked for help changing the sheets. The cleaning person came back with a fresh set of sheets, but instead of changing the patient’s sheets, the individual merely placed the folded sheets on the edge of the bed and walked out. Apparently in this person’s mind, he or she had helped the patient, but now it was up to the patient to change the sheets. Frustrated, the patient went ahead and changed his own sheets. He did not want to complain. As he explained to me, “I see these people every day. I don’t want to make them mad.” Fortunately, he was a nice guy with a great sense of humor, and he did not want to make a big deal about it. But after he was discharged, he told everyone he knew the “sheets story.”

  Patients First as Purpose: Why We Exist

  While healthcare organizations often fail to grasp the importance of customer centricity, other industries provide exemplar models. Contrast the “sheets story” with the employee alignment around the customer I observed when visiting Walt Disney World Resort in Orlando, Florida. Early in my career as CXO, I was interested in understanding how Disney delivers great customer service. I received an overview from one of its executives regarding how the Walt Disney Company frames its organizational culture, spending enormous amounts of time and resources teaching employees, known as cast members, about the organization’s mission and how members are to portray it. Each cast member is expected to live the six cultural values of innovation, quality, community, storytelling, optimism, and decency.7

  I was given a behind-the-scenes tour of parts of the resort. I certainly knew Disney’s reputation for great service, but I was a little skeptical and a bit cynical that an organization with nearly 70,000 employees in Orlando alone could get everyone to recite the organization’s values upon demand. To poke fun at my host, I performed a little test. As he was giving me the tour, I asked every cast member whom we encountered to recite for me the six Disney values. Initially, it was a little embarrassing to my host because none of the people we met could recite the full list, even with coaching. But it was amazing that each cast member could articulate that he or she felt part of something big and important, something truly magical with a higher purpose, much more than just a job. They all believed their mission was to “deliver happiness” to people. It was an eye-opening experience for me, and I was captivated by these interactions. Delivering happiness is Disney’s Patients First motto, their organizational purpose, and everyone we encountered seemed to live it. My colleague from Disney was grinning (mouse) ear-to-ear. The idea of organizational purpose is not new. Patients First is not just a motto; it is a purpose.

  Alan Siegel, the CEO of Siegelvision, a premier international branding firm whose mantra is Clarity Above All, says that organizations must use the concept of simplicity in defining their purpose.8 Siegel was the genius behind the design of the IRS 1040EZ one-page tax form. He successfully took a very complicated process (filing taxes) and simplified it to a single page. Siegel believes that our goal as leaders is to devise a simple message or a single purpose that frames what our organizations are about. It should not be something people need to think about; it should be something people understand intuitively. Siegel argues that this is the best way to effectively and powerfully communicate a common reason for existing. For organizations involved in healthcare, what simple phrase communicates purpose better than Patients First?

  I observed another great nonhealthcare manifestation of a customers-first purpose when I stayed at the Trump International Hotel & Tower while attending a conference in Chicago. The constant proselytizing “The Donald” makes about quality was evident from the moment I arrived. One would expect a customer-centric and quality focus from an organization in the hospitality business, but I have stayed at many top hotels throughout the world and never quite experienced what I encountered at Trump’s hotel. From the attendant opening the door when I arrived, to the time I departed when the valet put my bags in the taxi, everyone and everything I encountered in between was a seamless representation of high quality. Everyone embodied the organization’s purpose perfectly. While there were numerous contributors to this exceptional experience, a few details really stood out, making it personal and special.

  When I entered my guest room, on the bed was a personalized letter signed by Donald Trump. It acknowledged me as a customer and thanked me for coming, set my expectations by highlighting why my stay would be an exceptional experience, and let me know that the staff, his people, were there for me. Communications kept coming. When I returned from my meeting, there was a card from whoever had turned down my bed: “We wish you a pleasant stay and hope you have a wonderful evening. Please let me know if you need anything.” I had a drink at the bar that night, and the server was present but never intrusive. He seemed to anticipate my every need.

  As a service-industry leader responsible for customer centricity, I know some of the activities and devices that set appropriate expectations and drive a positive experience. But what impressed me most about this property was that, at every step, my experience was exceptional. The hotel had very successfully discerned the touch points critical to customers. The things I cared about were all covered, with additional enhancements.

  Hospitality industry companies, especially the top brands, are well known for delivering a great experience. But there is a great experience, and there is making someone feel special. My experience at the Trump property impressed me, and I walked away feeling special. Making the customer feel special was clearly the organizational purpose. I still have that letter.

  No one really believed that one simple motto, Patients First, would transform Cleveland Clinic. But that motto did something I’m not sure anyone recognized at the time: it started a cultural alignment of the workforce around the patient and began to define the organization’s purpose.

  I think most people in the organization today understand the importance of this simple purpose. Several years into Cleveland Clinic�
�s Patients First transformation, and after I had become CXO, I received very powerful patient proof. I was sitting by the pool after attending a meeting in Florida when I learned that an out-of-state patient was trying to reach me. At the time, Felix Rappaport was president and COO of the Mirage Hotel and Casino in Las Vegas, part of MGM Resorts International. I had no idea who he was or why he wanted to talk. Rappaport and I connected, and he told me what a wonderful patient experience he had at Cleveland Clinic. While his organization was dedicated to achieving great customer service, he thought we—a hospital—did a better job.

  I asked Rappaport to tell me what in particular about the experience was special. He observed that all the people he encountered, from the attendant who parked his car to the employee transporting him around the hospital, seemed as though they were all there for him and no one else. Everyone worked together, as if the entire organization was focused on making his experience exceptional. Over and over, Rappaport described feeling he was the focal point of everyone in the hospital. He described what I believe is one of the greatest achievements we have made as an organization.

  At Rappaport’s invitation, I visited the Mirage. It is an amazing property, and I was intrigued to test his observation that Cleveland Clinic delivers better service. Similar to my visit to Walt Disney World, from the moment I was picked up at the airport to the time I was driven back, I asked every Mirage employee, “Do you like working at the Mirage, and why are you here?” Incredibly, all the employees I encountered loved working there. They all had a story to tell about their jobs: The limousine driver had a sick child and remarked how the leadership went the extra mile to take care of him and his family. The desk clerk appreciated the environment and flexible hours so she could finish school. The person who managed the hotel’s iconic volcano attraction thought he had the “coolest job in the world” and was proud to tell his friends and family what he did. The energy and job satisfaction from the employees I encountered was admirable.

  The next day, I spoke to the Mirage’s senior leadership, explaining Cleveland Clinic’s Patients First philosophy and how I thought the concept might apply to their organization. I was pretty certain they understood the concept’s relationship to healthcare, but I wasn’t convinced they believed customer centricity affected all businesses. After conveying accolades about the employees I had encountered, I hit my audience with a bombshell. While observing that employees were happy and satisfied in their jobs—making a personal connection to the organization is an essential tactic for employee engagement—I did not perceive a high level of engagement around the customer: me. For example, when I came off the escalator at the airport, instead of seeing the limousine driver waiting with a sign with my name on it, I had to search for him. I described how there were several burned-out lightbulbs and a nonfunctioning television remote control in my guest room.

  I asked my audience to imagine everyone in the organization completely focused on the customer. There would be a synergy of productivity: the organization would have satisfied employees performing their jobs well, and employees would always look out for the customer. The limousine driver would know to meet me at the bottom of the escalator closest to my gate. The housekeeper, whose job it is to clean the room, would check light switches to make sure all the lamps were working. All employees would go out of their way to think one step beyond what they do to what is important to the customer. This is the difference between job satisfaction and job engagement.

  You can do a great job taking care of your employees and keeping them satisfied, and they can perform well in their jobs, but the idea of alignment around the customer is something that elevates service to the next level. I’m sure some of the Mirage managers viewed my anecdotes just as process breakdown. But with engaged employees aligned around a common purpose, the culture could compensate for process failures.

  That night Rappaport invited me to dinner with another MGM senior executive, Renee West, president and COO of the Excalibur Hotel & Casino and Luxor Las Vegas properties. My companions wanted to try a new restaurant at Caesars Palace Las Vegas, a competing resort. We met at the restaurant, and I chatted with West about my talk, the importance of cultural alignment, and our Patients First philosophy. I was excited to continue my test of employee responses to the question, “Why are you here?” so when our server returned to the table, I asked her, “Why do you work at Caesars?” Immediately, she said, “I am here for you. You are the most important person in our business, and we want you to come back.” It was like putting a quarter in a slot machine and hitting the jackpot. In one line, this waitress, who had no idea she was serving leaders of three of the strip’s most prominent properties, immediately articulated the concept of cultural alignment with the customer at the center of her responsibilities. It was a true “customers-first moment,” and I could see in West’s expression how struck she was by the response. We offered the waitress no more explanation or discussion, and we went on with the dinner. Her service was excellent.

  The need for customer centricity extends beyond consumer-services companies to include business-to-business enterprises as well. Cisco Systems, Inc., is a world-renowned technology innovator. Its longstanding chairman and CEO, John T. Chambers, met with our executive team and shared personal leadership insights when he appeared in our Ideas for Tomorrow lecture series in 2012.9 Part of Cisco’s success comes from its merger and acquisition activities. We asked Chambers what key attributes he seeks when considering an acquisition. He responded that a critical component is an absolute focus on the customer.

  Customer focus is an essential ingredient for success in any industry. It doesn’t matter whether you serve consumers or businesses. Ensuring that your organization is focused on the customer is an essential ingredient to successfully move your product or service against competitors. Organizations must place their customers at the center and ensure alignment around them. Employees, managers, and leaders must clearly understand that the customer is the organization’s purpose. As Forrester Research’s Harley Manning, vice president and research director serving customer experience professionals, put it, “Customers don’t need you. You need them,” and “Everybody wants your customers.”10

  Patients First as Both “Burning Platform” and Strategic Priority

  In addition to Cleveland Clinic’s alignment and purpose, Patients First has also become our “burning platform” for change. The metaphor of the burning platform is about a sense of urgency in motivating change: if you find yourself on a burning oil-drilling platform, you must jump off or die.11 In his highly regarded article “The 8-Step Process for Leading Change,” Harvard Business School professor John P. Kotter, PhD, cites creating a sense of urgency as the first step.12

  When I started as CXO, our patient experience scores, as measured by the Centers for Medicare and Medicaid Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, were terrible. Our institution scored near the bottom of all hospitals reporting in 2008. How could a hospital ranked as one of America’s best by U.S. News & World Report be among the lowest performers with regard to the patient experience? It was inconsistent with our reputation and brand. Here was quantitative evidence that we were not putting patients first, and we used it to light the platform on fire.

  Burning platforms can also be used to take an organization beyond just average, as Radboud University Medical Center, a 1,000-bed hospital located about 75 miles southeast of Amsterdam in the Netherlands, learned. In 2005, the government closed Radboud’s heart program because of poor quality metrics. I had the opportunity to sit with Radboud’s chairman of the executive board, Melvin Samsom, and Lucien Engelen, director of its REshape & Innovation Center.13 According to Samsom, who was appointed as the chief medical officer after the crisis and later became the CEO, it “was a huge shock on the system.” If the heart program was so bad that the government had to shut it down to protect patients, where else was the hospital deficient? This crisis became Radboud’s burnin
g platform. “We were determined to not just fix the program, but to become the best,” Samsom said. “Quality is measured on a bell-shaped curve. We were at the bottom or far left of the curve. Most organizations sit in the middle. We wanted to use this crisis as our burning platform to propel us to the top or far right of the curve.” They have been successful, and today Radboud’s heart program, as well as many of its other clinical programs, is rated among the best in the Netherlands. Samsom persists in using the shutdown of its heart program to beat the drum for staying focused on quality.

  The mandated closing of an important service line such as cardiac care at Radboud University Medical Center certainly grabs attention. But identifying a burning platform and creating a new motto are not enough to drive an important effort to improve service. Simply creating a new motto and talking about patient complaints puts the effort at risk of becoming just another “flavor of the month.” New initiatives like this can easily be swept under the rug as insignificant and ineffectual. When Patients First was introduced, I imagine some employees were anticipating that the new initiative would go away, speculating that it would eventually lose steam and Cosgrove would forget about it. But Cosgrove did not forget about it, and his early steps were critical to ensuring its success.

  We had no playbook for organizational transformation; we had no next steps or pages of well-described tactics ready for deployment. However, one of Cosgrove’s early actions was to set improving the patient experience as a top strategic priority for the organization. He recognized that mottoes and anecdotes don’t change organizations. If Patients First was going to work, it would need to be a topic that stayed on every leader’s and manager’s agenda. Patients First and the patient experience improvements were here to stay. Setting Patients First as a strategic priority meant there would be an organizational goal to improve patients’ experiences, metrics would be identified and made available, and leaders and managers would be held accountable.