Service Fanatics

by James Merlino

  One of my primary responsibilities as CXO is ensuring there is plenty of gasoline around to fuel the fire, continually stoking the importance of staying focused on the patient as our alignment, purpose, and strategy. My associates may tire of hearing it, but Patients First is our reason for existence, and I’m determined to keep that fire alive. Adopting a Patients First or customers-first platform is also a no-lose proposition. In healthcare, it’s impossible to argue against something successfully framed as right for patients.

  Cleveland Clinic Became an Early Pioneer in Patient Experience

  Cosgrove introduced Patients First and set a strategic goal of improving the patient experience for Cleveland Clinic before the topic came in vogue for most hospitals or was elevated in importance through the Medicare Hospital Value-Based Purchasing Program. With passage of the 2010 Patient Protection and Affordable Care Act, hospitals and physicians are required to pay attention to improving the patient experience or risk both financial penalties linked to reimbursement and damaged reputations. But should we need “sticks” to drive hospitals to a more patient-centered focus? Cleveland Clinic started this because it was the right thing to do, but quite frankly, we needed to do this because we had a reputation risk that patients would see a connection between how they felt treated as individuals and how they perceived their quality of care.

  One might believe hospitals make it a priority to put patients at the center, but they don’t typically frame their strategies this way. Hospitals are in the business of taking care of patients. It’s the most important thing they do. Customers in healthcare enter the system not as consumers in the traditional definition of the word, but as patients. A patient is a sick individual who needs medical attention. Patients are anxious, confused, and fearful and have a significant information disadvantage about their condition and what to expect during care. Whatever brings them to the hospital is enough to worry about. Patients don’t want to be in the hospital, and we have an obligation to treat them in the very best possible way we can.

  Framing it from a purely business perspective, we also need patients to be successful. Patients have a choice, and we should be thankful they chose us. We have an obligation to ensure that our organizations are aligned around them so that every employee or caregiver has the patient in mind and ensures that all services and deliverables are wrapped around the patient.

  When I became CXO, I said the goal of Cleveland Clinic was to become the world leader in the patient experience. I specifically used the word become because I knew it was not a destination, but a journey we would always be on. In 2013, I employed tactics that I had used while observing Disney and the Mirage in our main campus hospital in Cleveland. I randomly asked 10 employees, “Why are you here?” Eight of them gave an answer related to our Patients First philosophy. This is a “B” grade, demonstrating we are just above average and still have a lot of work to do.

  Cleveland Clinic has directed significant resources toward understanding how to deliver to patients the ultimate healthcare experience. This is not our imperative solely because it’s the right thing to do; it also defines our brand and industry. Ranking as a provider of top-rated specialty care, including being the world’s number one heart center, carries with it a responsibility to deliver an exceptional patient experience.

  One of our most important accomplishments has been successfully introducing Patients First and aligning our people around it. Healthcare organizations—or those in any other industry, for that matter—that want to start a transformation program that is centered on the customer should begin with these steps:

  1. Set your customer as the true north of the organization. Help your people understand that they exist to serve the customer and that the organizational strategy and operational processes must support that.

  2. Define your purpose, and message it simply to everyone as the reason you exist. Having a mission statement is important, but employees often do not remember it or know what it truly means. Having a succinct purpose will allow you to more clearly articulate what it is that your organization does. Your employees will also remember it.

  3. Set the platform on fire and fuel it with gasoline. Healthcare organizations do not typically provide an excellent experience. Use your organization’s data and tell patient stories to get people to pay attention to this issue. Constantly reminding employees why they come to work and what it is that the organization does will help keep the focus on the customer.

  4. Make improving the customer experience a top strategic priority. Simply introducing a purpose will not improve the organization; it must be top-of-mind for all leaders and managers. Ensure that it drives the strategy of the organization.

  Chapter 3

  Leading for Change

  Cleveland Clinic has made significant improvements in the patient experience, not because there is a CXO or an Office of Patient Experience, but because our president and CEO owns the patient experience as a strategic initiative. Our success in transformation occurred because the top person in the organization led the way.

  When I confer with senior hospital leaders having responsibility for managing the patient experience, I often find their CEOs have little hand in leading or messaging it. Others tell me the CEO occasionally says it’s important, but holds no one accountable for improvement. This is confirmed in a HealthLeaders Media survey finding that 48 percent of hospital leaders think the patient experience is a top strategic priority,1 but only 15 percent identify the CEO as owner of the initiative.2 Patient experience improvement is often seen as “just another thing we have to do,” with responsibility relegated to nursing, quality, or hospital operations.

  Disparity between what top leaders say about the patient experience and where it resides organizationally is a key reason why there isn’t sufficient traction to drive meaningful change. Improving the patient experience is all-encompassing; it requires every person and every process to be aligned around the patient. No one in the organization can singly achieve that alignment unless the top person is leading the charge. Because everything the patient experience encompasses is inherently comprehensive, only the top leader can effectively impact such a broad scope. In organizations where the CEO owns the patient experience, including Cleveland Clinic, Children’s National Medical Center, Houston Methodist, and UCLA Health System, among others, you quickly recognize the impact of senior leadership.

  At the beginning of Cleveland Clinic’s efforts to improve the patient experience, Cosgrove set the strategy, as well as managed the change. Within a couple of years of becoming CEO, he launched a variety of major initiatives to help improve patient-centered care.

  For example, Cleveland Clinic became the first U.S. healthcare system to change the way medicine was organized. Traditional academic medicine is structured around major departments, such as the Department of Surgery or the Department of Medicine. All subspecialties related to surgery or medicine were within these departments.

  While surgeons and medical specialists in many of the major service lines, such as cardiac and digestive diseases, were already very good at working closely together, Cleveland Clinic was founded on the model of physicians working together as a unit. Cosgrove felt very strongly that formalizing this model and integrating it across the organization for all specialties would greatly enhance patient care. So our radical institute model was born. The entire enterprise was reorganized around new institutes, a significant restructuring of how care is delivered and how patients interact with the system.

  There are no longer departments of medicine or surgery; there are institutes organized around disease and organ systems. The Sydell and Arnold Miller Family Heart & Vascular Institute includes all the medicine and surgical specialties necessary to treat any heart or vascular condition. Physicians and services are colocated so patients do not have to travel to multiple locations. And there is a common leadership team for each institute consisting of a clinical physician chairperson, a nursing leader, and an administrative oper
ations expert. The idea was to reorient care delivery around the patient.

  Cosgrove introduced other important but less dramatic ideas as well. In 2005, he established a comprehensive wellness initiative for employees and hired Dr. Michael Roizen, the first chief wellness officer. Cosgrove was always bothered by how hospital gowns undermined patient dignity and determined to change this. He engaged Diane von Furstenberg, designer of the legendary wrap dress, to create a new patient gown, which debuted in 2010 after years of research and development and has become famous. Convinced that art could be therapeutic for patients and families, in 2004, he created the Arts and Medicine Institute and hired a physician, Iva Fattorini, to chair it.

  While Cosgrove was doing a lot to improve the patient experience, it was unclear whether his efforts were having any impact. Relatively flat patient experience scores persisted, and he continued to receive negative patient experience anecdotes.

  One of the most important catalysts that reinforced Cosgrove’s convictions and motivated him to redouble his efforts came in 2006, when he was invited to speak to Harvard Business School MBA students, who were analyzing a case about Cleveland Clinic’s model of care. At the conclusion of Cosgrove’s remarks, student Kara Medoff Barnett raised her hand. “Dr. Cosgrove, my father needed mitral valve surgery. We knew about Cleveland Clinic and the excellent results you have. But we decided not to go there because we heard that you had no empathy. We went to another hospital instead, even though it wasn’t as highly ranked as yours. Dr. Cosgrove, do you teach empathy at Cleveland Clinic?”3

  Taken aback, Cosgrove had no choice but to admit the truth, that Cleveland Clinic did not teach empathy to its physicians. In one anecdote, Medoff Barnett had very successfully framed financial ROI for the patient experience. For an organization whose brand was incredibly important in attracting patients, she demonstrated the significance of differentiating on the patient experience.

  Nearly half of Cleveland Clinic’s heart business comes from outside our primary service area. When the demographics of those patients are analyzed, it’s clear they had a choice; they could go wherever they wanted for care. The student’s father, also a physician, recognized that from a quality standpoint, he would probably be fine at any of the top U.S. medical centers.4 But he and his family were more concerned about how they would be treated as people, not just as patients. The family differentiated on the experience the patient would have, not the reputation for quality. And because of that, Cleveland Clinic lost his business.

  Another galvanizing incident occurred 10 days later, when Cosgrove attended the dedication of King Saud Medical City in Riyadh, Saudi Arabia. The hospital president was addressing what the new medical center would bring to the kingdom and the importance of attending to patients’ and families’ emotional and spiritual, as well as medical, needs. The speaker continued that providing medical care was scarcely enough; there must be a focus on the human condition. Cosgrove noticed that the king and other members of the audience were weeping. Cosgrove was moved by the impact of these words and began to realize he was missing something. He needed to do more and invest more.

  A C-Suite Executive Leads and Manages Day to Day

  Cosgrove recognized that while it was critical for him as CEO to maintain engagement and to message the importance of the patient experience, an organization as large as Cleveland Clinic needed management of day-to-day patient experience operations. This would ensure that the patient experience received appropriate focus and attention from all key stakeholders, including physicians, nurses, and employees in all operations. The person responsible would report to Cosgrove and, he reasoned, would also need to be a physician.

  This was an important inflection point in Cleveland Clinic’s efforts to improve the patient experience. While the CEO led the initiative, appointing a separate senior executive responsible for the patient experience became important to ensure successful, consistent execution.

  Many service organizations have one person, such as a chief customer officer, responsible for managing the customer experience, and while the position is not new to industry, it is new to healthcare. Forrester Research published a report evaluating the role of senior executives who lead customer service.5 In a review of 155 positions across several industries, Forrester found that these leaders typically sit on the company’s executive team and more than half report directly to the CEO. Many may have a small staff and limited budget, but because of strategic scope and reporting relationships, these executives have influence over the entire organization and huge resources. Some serve in a strictly advisory position with no operational areas, while others have large operations with thousands reporting to them.

  Hospitals often have numerous people managing pieces of the patient experience process. Their proximity to senior leadership is frequently unclear, making progress difficult. HealthLeaders magazine6 published an interview of four individuals leading and managing the patient experience. The article sought insights regarding why healthcare is unable to move this important initiative as quickly and as successfully as the leaders think necessary. The interviews included four different roles: a director of inpatient services, a chief nursing officer, a director of quality and risk management, and a director of operations. The diversity of these roles and their reporting relationships, in some cases multiple steps away from the CEO or senior leadership, helps illustrate the challenges of a cohesive approach to managing patient experience strategy. Each person was knowledgeable and passionately committed, and each presented a slightly different perspective of challenges in improving the patient experience.

  Cosgrove decided to create a new C-suite position, that of chief experience officer (CXO). He read the article “The New CEO—Chief Experience Officer,”7 which discussed how this role could impact healthcare organizations. The new CXO would report to him and would be responsible for managing day-to-day execution of the strategy.

  Bridget Duffy became Cleveland Clinic’s first CXO, the first such position at a major U.S. healthcare organization. Duffy fit the profile perfectly. She was a physician who had been serving in a similar role for Medtronic, Inc. An early leader in this new field, Duffy was passionate about the patient experience and possessed the insight to strengthen Cleveland Clinic’s strategy.

  The role of CXO began as a consultative function, and Duffy became an important change agent. She further developed the infrastructure necessary to drive organizational change. She initiated better messaging about the patient experience and helped people across the organization understand what the patient experience was about and why it was important. She formed the Office of Patient Experience and with Cosgrove’s support assembled what they felt were appropriate resources to make it successful. She also helped to elevate Cleveland Clinic’s brand in this space, as news of Cosgrove’s seriousness at driving improvement became more well known nationally.

  I first met Duffy shortly after moving my practice to Cleveland Clinic in 2009. I was struck by her passion and clarity of thought on the importance of the patient experience. I shared with her the story of my father, and she immediately empathized and articulated the challenges the organization needed to overcome to move toward greater patient-centeredness. I remember walking out of her office knowing that I had made the right decision to come back to Cleveland Clinic.

  Duffy served as CXO for two years before deciding to move back to California, just a few months after I returned. While she was successful in introducing the concept of the patient experience, raising its level of importance, and expanding the infrastructure, she was burdened in executing on the strategy, partly because she was inhibited by Cleveland Clinic’s culture. While she was a physician, she was viewed as an outsider by the medical staff because she did not practice in Cleveland Clinic’s environment. She had difficulty changing an entrenched culture. Duffy continues to be a highly regarded and respected thought leader in the patient experience space.

  After Duffy left, Cosgrove decided to seek intern
al candidates to fill the CXO role. He wanted to find a practicing physician who “came from the culture” to lead it. Knowing that physicians would be the toughest stakeholder group to change, he wanted an established clinician to lead it.

  Shortly after taking the CXO role, I quickly realized the reality on the ground. The cultural tides of the organization were strong and not aligned. I recognized there would be no honeymoon. Duffy had messaged the change, but now we needed to figure out how to execute. I met with a respected elder surgical statesman who told me that many people believed the patient experience was just lip service and no one really felt that Cosgrove was serious or committed to changing the culture four years after the program had begun. I was also cautioned that the patient experience would not just improve on its own. “Just because Cosgrove talks about it and there is a CXO does not mean anyone is going to pay attention to it,” the elder statesman said. His point was that it would take real engagement of the frontline nursing staff and physicians to truly make a difference.

  This was a sentiment echoed by many physicians. Practically all of the administrative leaders I met with were 100 percent behind the strategy, and nearly every physician I spoke with questioned what it meant and how it would be successful. This is not to suggest the physicians were against it; it demonstrates that physicians were giving us a more honest answer. I recognized that the patient experience would improve only when our leaders recognized its importance and led the change, not because I had an impressive title and Cosgrove and I told them the patient experience was important. I decided that the patient experience implementation needed to go underground. The change would have to come from the bottom up, not the top down.