Physicians, nurses, and other healthcare professionals spend many hours every year improving their knowledge of disease and how to treat illness. Yet how much time do we spend thinking about better ways to deliver that knowledge to patients? The fact is we spend little time. Physicians in training are instructed to deliver care by modeling their teachers and mentors. They learn their communication styles, interaction styles, and overall approach to patients by mimicking the people that are teaching them. While we are beginning to spend more time with medical students and house staff teaching basic things like communication skills, we spend very little time teaching them how to interact with patients. Furthermore, we spend very little or no time, nor is there significant coursework offered, in teaching physicians better ways to interact with patients. Providing a clear, concise definition of how to think about the patient experience allows every caregiver in the organization to clearly understand our expectations of them.
Putting It All Together
Once you have defined the patient experience, the next important element is to operationalize the improvement. My Harvard colleagues invited me to present with them at the 2012 Production and Operations Management Society annual conference in Chicago. I was asked to describe how we execute on improving the patient experience. I talked about setting the patient as true north, the importance of making the patient experience a strategic priority, how we define the patient experience for caregivers, and the consequences of effective and accountable leadership.
I then discussed how we frame execution. If we accept that managing the experience requires us to think about the “360,” then we can unwind that 360 into a linear journey, with an arrow representing direction to consider how everything we deliver to patients is connected along that flow (see Figure 4.3). Our challenge is to manage everything we do across that continuum in a consistent, reproducible manner, whether related to safety, quality, or the patient experience. Every patient touch point must be consistent and the continuum seamless. Indeed, for any organization as complex as ours, everything we do for customers must be done consistently across the continuum. This is the foundation of systems thinking. When we solve problems with a systems mindset, we are always thinking about how changes or improvements will impact other processes downstream.
Figure 4.3 Cleveland Clinic’s definition of the patient experience in the 360 continuum.
To successfully manage seamless continuum flow requires bucketing execution into three critical elements: process, people, and patients, which I call managing the 3Ps (see Figure 4.4). Process is the first P. Hospitals are replete with processes, and the first priority must be to ensure that basic hospital processes function efficiently and effectively. Then you can consider what additional processes or tactics will directly improve what you’re already doing. People, the caregivers who are foundational to the organization, are the second P. This represents everything done to manage, invest in, and develop caregivers in a service-oriented culture aligned around and focused on the patient. The final P is for patients. There is likely no business that requires development of more and stronger customer partnerships than healthcare. We are in the business of helping people, but we also need those people to help us. We cannot do it alone, and how we educate, engage, and activate patients and their families, as well as manage their expectations, is critical to achieving the collective goal of a great patient experience. As you contemplate improvement strategies and tactics and consider how to budget resources, understand how they fit into the 3Ps framework to help structure your thinking and execution.
Figure 4.4 The 3Ps framework for executing a great patient experience.
The patient experience is paramount, but it is more than making patients happy. The definition must provide healthcare leaders and employees with a framework to prioritize their thinking. Just as in the airline industry, we must never compromise what is the most important element, which is delivering a safe product. If we lose sight of what is important, our efforts to improve the experience and patient satisfaction will become irrelevant. Along with providing a clear definition, we must deliver a framework to think about execution. As you continue to read this book, consider how every strategy and tactic discussed helps to drive safety, quality, satisfaction, and all that we do in healthcare.
In summary:
1. The patient experience is about how we deliver care, not whether we can make patients happy. Questions and domains on standardized surveys are designed to evaluate the process of care delivery by nurses, physicians, and others involved in healthcare. If the patient experience were just about satisfaction, we would not need to evaluate as many patient touch points.
2. The patient experience can mean anything to patients. The patient experience includes everything patients see, touch, feel, hear, and think about regarding their interactions with the processes and the people in the organization during their journey through medical care. Our challenge is to get them in, deliver what they need, and return them to where they started, which we affectionately label “managing the 360.”
3. Cleveland Clinic defines and manages the patient experience as processes that deliver safe care, high-quality care, and maximum patient satisfaction in an environment of high value. Healthcare delivery is the ultimate service business, but we must ensure that the most important elements of healthcare—safety and quality—are prioritized above service. This is necessary to ensure that all of the elements are linked and the organization can message the priorities to employees and caregivers clearly.
4. Employees need a clear definition of what the patient experience means and what you want patients to do. Patients also need help framing how to think about their experience so that they understand why things are happening. Failure to set and manage appropriate expectations will result in patients evaluating your performance based on their understanding of the environment.
5. Improving the patient experience, or our ability to execute on a strategy, requires a framework to operationalize what we do. Using the 3Ps of process, people, and patients helps managers and leaders understand how different tactics fit into an enterprise strategy. The framework also allows organizations to better understand how their patient experience strategy fits into the overall strategy of the organization.
Chapter 5
Culture Is Critical
The entrance to our old executive offices was across from the elevators to the main hospital. One day I was walking in the lobby about to get on one of the elevators when I noticed a puddle on the floor. I immediately went to find something to wipe it up. As I was returning to the lobby with my paper towels, I stopped and observed all of the people that were either avoiding or stepping over the puddle. People were taking appropriate evasive action, but no one did anything to take care of it. Many were our employees—doctors, nurses, other staff—who were ignoring a problem that could have caused harm to a patient.
I’m often asked what I might have done differently along our patient experience journey. While quick to admit the trial-and-error process that’s collectively led to our success, I unequivocally respond “the culture”—turning our attention to aligning and developing it earlier. Culture in healthcare is critical!
Culture impacts safety, quality, and satisfaction, everything in healthcare—or in any organization, for that matter. Human talent is our most important asset, responsible for delivering everything we do. But it would have been difficult, having just taken over the patient experience initiative, for me to raise the specter of culture change. How could a relative neophyte challenge the culture that has made Cleveland Clinic highly successful since its foundation in 1921? It wouldn’t have been a credible first step.
Cleveland Clinic was founded by four physicians who were friends and colleagues in Cleveland, Ohio. Three of the four served together on the battlefields of Western Europe in World War I, where teams of physicians worked closely to care for patients. Back home in the United States, the practice of medicine was very competitive and
independent, with no incentives for teamwork. Believing there was a better way, these men founded Cleveland Clinic “to act as a unit” in the group practice of medicine.
Over the years, while it was generally true that our physicians collaborated closely on patient care, many felt the founders’ ideal had faded as the organization grew. We started as a small, single-location, tertiary-care specialty referral center. Today we are big and growing: an enormous organization with some 43,000 people throughout the globe. We have more than 3,000 physicians and scientists. Those still here after more than a quarter century talk about how different it was when there were only 150 physicians on the medical staff. While our culture supported physician teamwork, the concept of team has been eroded by our size, and there certainly wasn’t a workforce uniformly focused on patients.
The organization also didn’t have a reputation for being particularly nice to employees or patients, confirmed by engagement and satisfaction studies at the time I assumed the role of CXO. At a recent executive leadership retreat, I asked my colleagues to select adjectives to describe Cleveland Clinic before Cosgrove became CEO. A longtime physician didn’t hesitate to say “mean” and “vindictive,” not a very conducive culture for patient-centered teamwork! We provided excellent medical care, but we were not excellent at caring or treating patients with empathy. Nor were we consistent in treating our own people with respect, something I experienced firsthand during my fellowship.
Cosgrove often joked in speeches that patients came to us for clinical excellence but did not like us very much. One of my patients, also a Cleveland Clinic financial supporter, ribbed me about our culture every time I saw him. He’d had heart, prostate, and back surgeries with us. He said he came to Cleveland Clinic for surgery because of our master technicians but went to his primary-care physician, employed by our chief regional competitor, when he wanted to be cared for as a person.
There were two strong elements of our culture: one, the physicians, employed in a large group practice, and two, everyone else. You would often hear nonphysicians joke that Cleveland Clinic was all about the doctors—a hospital founded by doctors, for doctors, and because of doctors. Within the “everyone else” group, there were large, defining stakeholder subcultures, such as nursing, which made up about a third of it. But in general, doctors were perceived as the proverbial king of the hill. One early patient experience initiative was to reserve for patients all parking spaces close to our buildings, forcing doctors to park farther away. One angry physician cried, “What does Patients First really mean? Doctors last?” Cosgrove’s comeback was “Yes!”
We had drifted away from what our founders believed necessary for delivery of great care, namely, high-performing teams. I’m sure they didn’t use the words “high-performing teams” back in 1921. But a review of our history and founders’ statements leaves little doubt what they hoped to create.1 They espoused the importance of teamwork: your role didn’t matter, but your contribution to the overall goal did. Cosgrove often emphasizes that one of his most important priorities is to protect this ideal.
In addition to our “us-them” challenge, the other main obstacle to alignment around our founders’ vision was that we were no longer just one hospital. We were a heterogeneous healthcare system functioning as a holding company. We had nine community hospitals across northeastern Ohio; each had been a stand-alone hospital or system with its own culture. We had hospital operations in Florida and Canada, and we managed hospitals in the United Arab Emirates. We had lost the small-town feel as we grew into a vast healthcare system. One of Cosgrove’s top priorities when he became CEO was to transform our holding company into a healthcare operating company, integrating services and operations across all sites—truly creating one Cleveland Clinic. And part of this integration task was cultural alignment.
Culture Is Hard to Define
There are two critical elements that compose culture: first, the people who make up the organization and, second, how intensely those people are committed to what they do. Do they come to work to perform a task and collect a paycheck? Or do they believe they are part of something special, working for an organization with a compelling vision and mission and giving everything they have to make that organization great? Some would call this engagement; others would call it creating a culture of ownership.
Many employees go to work, perform their job, go home, and start the cycle all over again the next morning. They know what is defined in their job description, and they do it, and do it well. But in healthcare, that is not enough. A. Marc Harrison, MD, chief executive officer of Cleveland Clinic Abu Dhabi, points out, “I want people to come to their job every day like they are owners of the company, personally invested in our success.”2
Owners live their mission, vision, and values. They care and are passionate about what they do, but they go the extra mile to understand everything around their environment. They hold themselves accountable to a higher standard. It’s a culture that chief quality officer J. Michael Henderson, MD, says is necessary to achieve high levels of safety and quality, as well as patient experience. A successful culture of ownership would have everyone stopping to take care of that spill by the elevator. Developing that culture of ownership is a challenge all healthcare organizations face.
I don’t claim to be an organizational culture expert, whether at defining, measuring, or changing it. I even challenge the notion of experts in this field. When you review the “culture” scholarship, the “experts” don’t even agree about the definition of culture or how to measure it. There are also different types of “experts,” including those who study culture and those in leadership positions who write about how they’ve developed their organizations’ cultures. One finding I believe is certain; the top person must protect and define the culture. Joseph M. Scaminace, chairman and CEO of OM Group, Inc., and vice chairman of Cleveland Clinic’s board of trustees, once told me that when he became CEO, his first act was to get rid of the external organizational development consultants. “I know how to lead, and our team will define the culture we need to be successful.”3
Large nonhospital corporations tend to be driven strictly in a top-down fashion; the CEO is responsible for minding the mission and managing the culture. In academia, there are unique and powerful stakeholder groups to be considered. A university faculty tends to function independently, cannot be underestimated, and must be consulted about culture change.
Hospitals do not fit the corporate authoritarian leadership model and are more analogous to academia, owing to large, influential physician and nursing stakeholder groups. Community-hospital structures are classically defined by a triangle, with each tip representing a key stakeholder group, including administration, trustees, and medical staff. With the evolving importance of nursing, some might suggest that the classic triangle has become a square.
So what cultural framework should Cleveland Clinic have? There are unique cultural attributes from the original group practice model and hospital, now joined by community hospitals and other units with their own historical identities and cultures. We have large physician and nursing stakeholder groups and competing identities, such as clinical excellence, education, and research. How exactly would we frame a culture-change program, and what would we want that culture to be?
I don’t like the expression “change the culture.” The messaging of everything we’re doing in the patient experience is very important, but no one wants or likes to be changed. Cleveland Clinic was immensely successful at the time we started thinking about culture vis-à-vis the patient experience. We needed to celebrate who we were and what got us there. There would be people, especially longtime physicians who had joined the organization when there were only 150 doctors, telling us that the culture was just fine and we didn’t need to change anything.
Coming out aggressively that we were going to “change the culture” had the potential to send shivers down our collective spine and likely result in no support for the initiative. T
here’s a terrific Harvard Business Review piece about “organizational immunology” that compares an organization attacking change to the immune system attacking disease.4 Recalling the cliché “culture eats strategy for breakfast,” I was concerned that our strategy to change the culture would be eaten by the culture that existed at Cleveland Clinic.
Culture in its present, prechange state is what I call the organization’s bedrock. I could never define the totality of Cleveland Clinic’s culture. However, I could cite several specific elements, such as innovation and high quality. Our culture is the amalgamation of nearly a century of layered success and failure that led to the rise of a highly successful organization. We would take that foundation and layer on what we needed to enhance it, rather than change it.
A practical and much more understandable alternative to changing culture is to seek what elements to add to it. Or what elements to modify because we don’t like them. Or how to collectively develop culture to where we want it to be. I recognize this is wordplay in a sense, that modify and develop also mean change. But this represents a much more subtle tactic than change the culture. Our organization’s culture is foundationally solid. We don’t want to change what we are but to determine what we want to be and develop to that level. This is the approach we have taken. I’ve joked with Melvin Samsom of Radboud University Medical Center about the nuances of cultural change and the importance of respecting the past while building the future state. He agreed about overtly avoiding the word change and has coined the phrase “culture change in stealth mode,”5 which is exactly what we were considering at Cleveland Clinic.
The problem with developing the culture is very similar to that of improving the patient experience: few can actually define or impact it. There are multiple definitions of culture. One of our leaders used to say that culture is “how we do things around here.” This always seemed too simplistic. Is it how we deliver food, wash gowns, or inject medications? Those are the types of things we do in a hospital, and if culture encompasses all that, then where do you start?
Service Fanatics Page 10
