Service Fanatics

by James Merlino

  Shortly after I got the job, Cosgrove said, “So you’re going to be in charge of the patient experience.” I laughed and replied, “If you want me to be in charge of it, then you have the wrong person, because the reality is that we’re all in charge of it.” While key strategic priorities of any organization must be set by its top leaders for operationalization by others, effective change management requires that everyone—leaders, managers, and employees across the organization—buy into the initiative. If all leaders in the organization did not “get” that the patient experience was important and that they needed to be part of fixing it, there was no way we were going to be successful.

  I had this conversation with Marc Boom, MD, president and CEO of Houston Methodist, when I interviewed him about leadership in the patient experience for an article for the Association of Patient Experience.8 He believes that the top person needs to drive it, because otherwise organizations won’t be successful, but acknowledges that it’s everyone’s responsibility to ensure that it becomes a reality.

  One of Cosgrove’s leadership attributes that really helped kick-start our success in the patient experience is his ability to think at a very strategic level but get tactical when necessary. Leaders certainly must be the visionaries who drive innovation. Equally important, however, is the ability to get into the weeds. Transformational change happens because leaders can get into the detail when needed and start fires to ignite processes to support change. This helps to ground and activate change initiatives at the front line.

  Some early tactics that we deployed were Cosgrove’s ideas. As leader of the heart center, he was tasked with consolidating a collection of heart practices throughout northeastern Ohio. One of his first moves was to distribute unblinded program and physician-specific performance data. He correctly believed that communicating this data to all physicians would help drive improvement, as no one wanted to be at the bottom of the list. So another of the early patient experience improvement projects initiated by Cosgrove was to rank and distribute physician scores. He reasoned that physicians needed to know how they were judged and what patients were saying about them.

  Cosgrove also routinely made decisions that were important for patients but not very popular internally. Marketing and complaint data revealed that patients often viewed Cleveland Clinic as difficult to access. One patient commented, “The Clinic takes only rich people or rulers from Arab countries,” for example. Cosgrove felt this misperception had to be attacked head-on, and in 2010, Cleveland Clinic mandated the offering of same-day appointments. Any patient calling Cleveland Clinic is offered to be seen that day—by a generalist or a specialist. We embarked upon a major marketing campaign, “The Power of Today,” running television, radio, and print advertising that states, “Call today for an appointment today.”

  It was an unpopular decision, not universally supported by the medical staff; many physicians were unhappy and voiced concerns. Offering same-day appointments created some schedule bottlenecks and quickly revealed a few areas where capacity was lacking, such as dermatology. Imagine the number of parents calling for appointments in pediatric dermatology in June right after school lets out and public pools open: offering a same-day appointment to every parent calling became a challenge and did not quite achieve the success we desired. However, for every patient that we could not accommodate for a rash, there were incredible success stories, such as a young woman with rectal bleeding who needed to be seen by a doctor. She called for a same-day appointment and, within 24 hours, had a colonoscopy that diagnosed colon cancer. She was seen by a colorectal surgeon, and a plan of care was developed that same day to treat her cancer.

  Same-day access was groundbreaking in healthcare. As far as we could tell, there was no other U.S. tertiary-care hospital so bold as to implement a similar program. New-patient encounters jumped 20 percent the first year, and now Cleveland Clinic records approximately one million same-day appointments annually. We meet 96 percent of same-day requests.

  Some criticize CEOs like Cosgrove for being too much in the weeds. We occasionally tease him about asking during an executive committee meeting how much sidewalk salt we use in winter. But we really mean it as a compliment, not a criticism. Many of our early successes came because of his direct involvement. His deep understanding of hospital operations, coupled with his vision for healthcare, helps to make our change efforts both practical and successful.

  David T. Feinberg, MD, the CEO of UCLA Hospital System, is not unlike Cosgrove in this regard. To help combat the problem with pressure ulcers, Feinberg demands that their incidence be reported to him personally any time of the day or night. He says, “I want to know when patients are harmed—it is unacceptable.”9 Contrast this with other organizations in which the CEO is not engaged or where top leaders don’t walk the patient experience talk.

  Cosgrove’s decisions and his unwavering support of our implementation helped thoroughly ground the Patients First philosophy in Cleveland Clinic’s culture. His leadership demonstrated that we were not just talking about improving the patient experience; we were serious and willing to make difficult decisions to dramatically change our practice of medicine. Seeing Cosgrove in the weeds proved his commitment and got the organization thinking about change.

  It is incumbent upon leaders not just to be visionary but to have the capability to execute, the ability to go from a 50,000-foot strategic perspective to a 5-foot tactical one instantly. That talent is not micromanagement; it’s called knowing your organization.

  Cosgrove also recognizes when collaboration is warranted versus a “command and control” approach. Moving from the old academic department model to the new institutes structure was disruptive innovation in healthcare, and he knew it would require collaboration with physician leadership for acceptance. However, with same-day appointments, he decided it was important for patients, so he leveraged his CEO prerogative and mandated it.

  Owning Change at All Levels

  Our most successful move was to align the organization around Patients First. Our second most successful move was getting people to own leading this change. Just as Cosgrove has done it for Cleveland Clinic overall, the physician staff has done it for our more than two dozen institutes. Institute chairs are leaders in their fields and understand what they do better than most in the world. Incorporating the patient experience as a competency is making the same impact on their areas that Cosgrove made on the enterprise as a whole.

  I once was told that successful leaders develop strategy and ways to implement it and then motivate people to adopt it as their own and carry it out. We ignited a “burning platform” to focus people on improving the patient experience, and I am most proud of our success in inspiring others to own and drive the improvement. Cosgrove’s responsibility is to keep the patient experience top of mind. My responsibility is to ensure there is plenty of gasoline to throw on the burning platform. But it’s everyone’s responsibility to own and drive the change. Leaders in our organization who were initially reticent now drive it with incredible passion and believe that it is absolutely the right thing to do.

  I first met Joseph Iannotti, chair of the Orthopaedic and Rheumatologic Institute, shortly after I became CXO. Iannotti is a world-renowned surgeon and researcher and a hard-core, outcomes-based thinker who probably didn’t give much consideration to the patient experience during his training and early career. He was of the mindset that “It’s about the quality of what we do and nothing else.” When I went to his office as part of my early institute-chair “meet and greets,” I observed that his office furnishings were colorful and stood out from the typical Cleveland Clinic doctor’s office. I’m sure I offered some sarcastic comment about his decor, and he remarked, “This is about the physician experience.”

  Iannotti was courteous and complimentary when discussing the patient experience. Of course, no one criticized it, knowing it was Cosgrove’s baby. But I quickly sensed he was not convinced of the importance, and questioned whether he
would spend any time focusing on it. I clearly remember walking away from that meeting thinking this was going to be very hard. If we could not convince the top leaders beyond the C-suite, especially clinical leadership, this endeavor would never be successful.

  Iannotti came to understand that the patient experience has national urgency and is a differentiator in healthcare. He embraced the patient experience as a priority for his institute and leads it at his level. Today, his institute has among the highest patient experience scores in the organization. Each physician and staff member knows the patient experience priority, and while some may still not believe it to be important, they drive it because they know they will be held accountable for it.

  Four years after that meet and greet, Iannotti remarked, “You have really fixed the patient experience here.” I laughed and said that it wasn’t me, it was people like him. His institute does well because he owns the issue.

  I recently received a call from the chairman of orthopedics at a major academic center, one of the country’s largest orthopedic programs. Referred by Iannotti, he opened the conversation saying, “Our patient experience is really bad, and Joe says you can help me fix it.” We discussed a variety of tactics, but eventually I pointed him right back to Iannotti. The patient experience is tops in our orthopedic department because of its chairperson’s leadership. To be similarly successful, my caller needed to start there too.

  Leadership Can Change a Hospital

  Lutheran Hospital is a small, 125-bed hospital located in Cleveland’s historic Ohio City neighborhood. A stalwart example of a local community hospital, Lutheran was an important anchor to neighborhood economic viability. This institution was acquired by Cleveland Clinic in 1997. For years, its overall HCAHPS scores were low, with very little change. In January 2012, a new leader, Brian Donley, was appointed president of the hospital. Donley was vice chairperson of the orthopedics department and headed Cleveland Clinic’s foot and ankle center. It was his first time in a major leadership role, but he quickly set key organizational priorities. While the patient experience was already a strategic initiative for the enterprise, Donley immediately renewed its emphasis as a top priority for Lutheran.

  Donley increased his visibility by rounding on patients and talking to caregivers throughout the hospital. He made physician engagement a top priority and started hosting small dinner meetings with physicians. Early on, he was challenged by a senior staff member who declared that a lot of patient experience programs had been trialed at Lutheran and hadn’t worked. Donley pushed back and said the hospital would continue to pursue improvement in the patient experience. The new president also needed new resources to assist him in the transformation. I hired a patient experience director for the hospital, and K. Kelly Hancock, executive chief nursing officer of the Clinic System, hired a new chief nursing officer for the hospital.

  In the early quarters under Lutheran’s new leadership team, the hospital achieved some of the highest single improvements in patient satisfaction across the entire enterprise. After one year, every HCAHPS domain jumped nearly 40 percentile points. If you asked Donley how he made such incredible improvements so rapidly, he would attribute it to the great people working at the hospital—leaders, managers, and every caregiver. The metrics improved because of his leadership and his team driving the improvement. He recognized the importance of the patient experience as a hospital priority, and as president, he owned it, messaged it, and sent a clear signal to everyone that improvement was essential.

  It’s not just the clinical leadership that has to drive patient experience improvement. Steven C. Glass is our CFO, and if there’s a nonclinical executive who really gets the clinical side of what we do, he’s the one. Well before we started enterprise leadership rounding, Glass rounded on hospital patient floors. He visited patients, talked to staff, and sought to truly understand our frontline work. Rounding in clinical units is a leadership competency he has cascaded to his entire team.

  I am often invited to speak to our various finance departments about the patient experience. Many finance executives spend time rounding with me and our clinical leaders. Once, I drove back to Cleveland Clinic with Glass after we visited another health system. He shared with me his thoughts on leadership as a CFO. “Jim, I am not just someone who manages the finances. I see myself as an executive with a role in the organization’s strategy. I don’t set strategy, but if I am not participating, what good am I to our mission of serving patients? Everything I do from a finance perspective directly impacts our ability to deliver care to patients.”10

  Finance in general and Glass in particular have received a lot of undeserved criticism in our organization because many feel that finance “runs the ship.” Nothing could be further from the truth. Glass and his team do what no one else likes to think or talk about: they manage the budget. Glass has worked exhaustively to help senior and frontline leaders understand hospital finances. He has involved physicians in his department, created a standing budget committee that includes doctors, and integrated other clinical leaders into nearly every level of the finance function.

  This type of leadership perspective is important. Many are capable of managing healthcare organization finance, but we should not see that as solely adequate. We should look for people who “get it,” who understand that it’s not just about leading one silo; it’s about understanding how that silo supports the mission of patient care.

  The Impact of Leadership Rounds

  Senior leadership visibility is critical to improving the patient experience. Leadership rounding is one of the tactics Glass and many other leaders regularly employ to better understand what is going on at the front lines. This important tactic gives leaders visibility to both caregivers and patients, and those interactions help them to better understand how their decision making affects the organization.

  In 2011, I visited David Feinberg at UCLA Health System. He told me that he occasionally will hold meetings with people while rounding in the hospital. “Time is short. I can accomplish two things at once: conduct a meeting and see our patients and employees,” he said. Rounding has a reciprocal effect, demonstrating to frontline caregivers that senior leaders are engaged about what the staff does every day.

  My visit to UCLA coincided with a day when Feinberg’s hospital was doing what it calls executive rounding, and he invited me to attend. We started in an auditorium, with about 60 senior leaders. The meeting opened with stories about the great work two employees had done for patients. Smaller groups of three or four were then deployed to various areas of the hospital. For about an hour, each group talked to patients and caregivers and evaluated the environment. The group reassembled in the auditorium to discuss patient stories and organizational opportunities. I immediately was impressed and told Feinberg that leadership rounding was something we were going to implement at Cleveland Clinic. I remember asking whether I could “steal” his idea. He laughed and said of course, but for full transparency, that he got the idea from another hospital.

  Today we conduct leadership rounds once a month. We follow the same format as UCLA, with a few enhancements. We use three checklists: one for patients, one for caregivers, and one for the environment. We collate the information and distribute it to every manager and leader. As a result, we have made very significant process improvements, including completely changing the way we deliver and maintain supplies in the nursing units and developing a new process to inventory and deliver patient IV pumps. Both problems were tremendous nursing dissatisfiers.

  We also have started group recognition at our leadership rounds. In addition to calling out two outstanding caregivers, we recognize an entire group of caregivers who are critical to the mission but frequently have little exposure to our leadership. We have recognized the police force, environmental-service workers, pharmacists, and case managers. In medicine, doctors and nurses are commonly identified as heroes, but we send a message that there are heroes in different roles across the organization and th
at everyone is important.

  Leadership rounding has been a great tool for finding areas of opportunity, but using it for leadership visibility has been the most important benefit. Leadership rounding is also easy to do and can be started right away. If you are a president and CEO of a hospital, or any company for that matter, how often do you get to the front lines and talk to employees and customers? How often does your senior team do it? Start today!

  Rounding across the organization keeps our leaders grounded in the reality of what the organization does every day for patients. Cosgrove was rounding with our executive chief nursing officer, K. Kelly Hancock, and they walked into a room where the patient was obviously delirious and trying to get out of bed. They immediately attended to the patient, and a third person, Eileen Sheil, executive director, corporate communications, who was also rounding with them, went for help. It was right after morning shift change. The first nurse Sheil encountered said that it was not her patient and she could not help. The second nurse encountered said she had just signed out and was going home. Sheil went back into the patient’s room and told Hancock what had happened, and she immediately got someone to help. The point is that while we work very hard to manage an effective, efficient organization, there are little things that happen every day—whether process or people related—that lead to significant difficulty in achieving our goals. Having top leaders at the front lines exposes them to the real world of what we do, but also sends the message that we are visible and engaged with what is happening.

  To be successful in improving the patient experience, we must get people to help us lead the change. We cannot be successful trying to do it ourselves. At Cleveland Clinic, we’ve created a broad coalition of leaders who understand that the patient experience is important and take responsibility for driving its improvement. Having the patient experience as a top strategic priority allowed us to discover people who recognized the significance of the initiative. We started with these early adopters, people who understood immediately why the patient experience was important, and slowly worked to convince others.