We have made an effort to wrap physicians around everything we do in the patient experience. We have physicians involved in our unit teams, consulting with the ombudsman department, and teaching communication skills. As frequently as possible, with anything related to the patient experience, we use physicians to help lead and drive a program and carry the message to others across the organization about why this is important. This is not something that my office developed; it’s a best practice that our organization follows for most important initiatives. At Cleveland Clinic, we have integrated physicians into every facet of decision making. The tally of the number of physicians involved in leadership positions totals more than 300, nearly 10 percent of the medical staff. But even involving this many physicians doesn’t guarantee there will be universal buy-in of new programs and strategic initiatives. It takes time, transparency of decision making, and authentic leadership. Having physicians at the table is not enough. They must be participating in the debate and integral to key decisions.
As a group, physicians are intelligent, assertive, motivated, driven, data- and goal-oriented, and focused on doing what’s right for patients. Few enter the field of medicine and take the Hippocratic oath without the absolute desire to care for people. Physicians are lifelong learners, with insatiable curiosity.
As I applied to medical school, an experienced physician offered his counsel. He advised me to prepare for a never-ending journey of exploration and discovery—one that would continually fascinate me, make me better at what I did, and have the added benefit of helping others. It sounded like I was about to embark on an epic adventure. The patient experience has been that adventure.
It strikes me that as physicians mature in practice, they continue on their lifelong quest for medical knowledge but often fail to develop their interpersonal relationship and patient-interaction skills. I make this statement based upon several observations. There is a dearth of professional development curriculum offerings compared to the number of offerings on medical science. Also, there is generally no requirement for interpersonal or patient-practice assessment in any regulatory or professional certification, although this situation is evolving. Further, when one looks at national HCAHPS data for the physician communication domain, an 80-percent score on inpatient satisfaction falls in the 50th percentile. This means that half of physicians who are ranked with HCAHPS scores achieve a score of “C” or worse from patients when they’re asked whether their physicians always communicated appropriately. Should we accept this? Many believe that doctors just aren’t able to improve. Cleveland Clinic’s data, and that of other organizations, disproves the point.
Getting physicians and physician leaders to understand the importance of the patient experience takes time, recurrent and consistent education, and consensus building. If you ask any member of our medical staff today, overwhelmingly most will attest to the importance we place on the patient experience. Some may not have bought in 100 percent, but most will agree that it’s the right thing to do, and all will know that the patient experience is very important to the organization.
The uncertainty about how the future of healthcare will impact hospitals today is also directly affecting physicians. Robert Coulton, executive director of professional staff affairs at Cleveland Clinic, has been managing the physician group practice for over two decades. He has had a ringside seat to many changes in healthcare and observes, “It is tough for doctors right now. There are a lot of things that are dramatically impacting how they practice.” Tremendous disruption is occurring in the physician world, creating anxiety and insecurity. But we cannot drive cultural development in healthcare and lead changes to improve patient-centered care unless our physicians are fully committed colleagues helping to lead through the opportunities. Many observe that there has never been a better time than this difficult era to elevate physicians to help lead.
In summary, for nonphysician leaders:
1. Ask physicians for their help and give them clear suggestions on what they can do to help. Don’t just assume that they should be a part of something; often, they may not know how to engage or will not feel valued for their involvement in nonmedical programs. Engage them in the “noble purpose” of helping to improve the way we deliver the patient experience.
2. Create a burning platform by educating physicians about the environment. There are numerous factors that impact doctors today as never before: increasing regulatory burden, transparency, and personal accountability. These are important for improving medicine but challenging for doctors because they do not know how to manage through them and many have no idea how these changes will affect them personally. Educate physicians and help them understand the business side of medicine and how to manage these changes.
3. Leverage your data. Provide doctors with as much information about their safety, quality, and patient satisfaction data as you have. Give physicians every verbatim comment from patients. Doctors should know what patients think and say about them. Leverage the data transparently by making it available to all of the medical staff. This is the future of medicine, and the sooner physicians are exposed to it, the more prepared they will be to accommodate an increasingly transparent healthcare environment.
4. Make physicians your partners: ask them to help set your strategies, goals, and agendas. Merely inviting physicians to a meeting does not check the box on engagement. Make sure they’re involved in decision making and have access to as much of the raw information as you do.
5. Recognize the challenges physicians face in participating in administrative functions and endeavor to accommodate them. Administrators have a great deal of flexibility in their schedules (I can say that because I am one). Physicians need to practice medicine, but we need their meaningful involvement, so accommodate their schedules. Private practice physicians lose money when they don’t directly participate in patient care; be willing to buy some of their time. Employed physicians are burdened by productivity standards; give them protected administrative time.
6. Respect the influence that physicians have over patients and recognize physicians as different, but remind them that they are not any more important than other members of the healthcare team. Because of the tremendous influence they have on patients and families, we have an obligation to hold them to a higher standard of behavior and professionalism.
In summary, for physician leaders:
1. It’s true. It can’t be done without your participation, but that is not license to try to control, obstruct, or change something just because you don’t like it. Exercise emotional intelligence, and practice listening more than talking. Develop your team and business skills so you can relate.
2. You are not necessarily the smartest person in the room. Nurse leaders and nonclinical leaders who are professionals in their respective fields are just as smart and important as you are. Respect them for who they are and the years of training and education they have, and recognize that many hold you in esteem because you are a doctor. Do not abuse this perception. Instead, mitigate it. Ensure that your opinions jibe with the system, not just the doctors. And by the way, just because you completed your MBA doesn’t make you a business professional. It took you over a decade of education and training to practice medicine. It took your chief financial officer the same amount of time to attain his or her professional status as well.
3. You’re not in Kansas anymore. Real change in healthcare is here, and many of these changes will impact you personally. The only way to thrive is to work closely with your colleagues from nursing and other professions.
4. Help police yourselves. You know where the problems exist. Bullying is unacceptable and must stop. We also know the physicians we would never send our family members to see. Ask yourself why. Should they be seeing members of the public? Ensure that your colleagues are using their influence over patients appropriately.
5. Physicians in administrative positions are not sellouts. The job is difficult. Give them respect.
Chapte
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Want to Know What Patients Think? Ask!
In December 2010, I received a letter from the husband of a deceased patient who said the Clinic had failed his wife. Enclosed was a photograph of the couple at their daughter’s wedding. My heart sank. Looking at the beautiful picture, I immediately feared that we had missed something, that there had been a terrible medical error causing a treatment failure that led to her death. His wife had been diagnosed with breast cancer; she was successfully treated and cured. Several years later she had a recurrence, which was treated and controlled. She subsequently developed a final recurrence, and despite aggressive treatment, the disease won the war. She began palliative treatment and was sent home on hospice. She was readmitted to the hospital for dehydration and died after four days.
Her last wish had been to die peacefully at home, with her family at her side. We had failed at helping her realize this last wish. She did not need to be in the hospital the last three days of her life. The patient and her husband told everyone who would listen that they needed to get home. No one could help them. They talked to doctors, nurses, case managers, social workers. No one could make the appropriate arrangements to have her discharged. Furthermore, no one was coordinating her care. She had no hope from further medical treatment; she wanted to be with her family at home. We did not fail in her medical treatment; we failed in her treatment as a person. Our organization was unable to integrate the emotional and spiritual elements of this patient’s care with her medical care. We failed her because no one was listening to the patient or the family. Everyone was focused on his or her “job,” and collectively they ignored the primary purpose of why we are here, which is to put the patient first.
Today that letter and photograph sit on my desk as a constant reminder that treating patients is about more than just treating disease, and that to be successful, we need an organization where the patient is at the center of everything we do. It is a reminder of why we are here and the purpose of what we do every day for patients.
I have heard it said that up to 90 percent of service businesses say they know exactly what their customers want, but only 10 percent actually take the time and invest the resources to be sure they are right. This is an interesting but shocking statistic. Most people leading service businesses would say they understand their markets and customers. I’m sure many can point to robust market share and sales growth. Imagine how much more successful these companies could be with research to intimately target customer needs.
Healthcare providers—doctors, nurses, and administrators—are guilty of this phenomenon as well. We think we know exactly what’s important for patients. We stand at their bedside and tell patients exactly what they need to know and what we think they want to hear. This sounds a little extreme, and I certainly don’t mean in a literal sense that we dictate to patients without interaction, but think about it: for the most part, physicians are in tight control of the healthcare environment, and patients are poorly equipped to challenge what we tell them.
Most caregivers perform their functions every day with a marked sense of determination and precision. Nurses flow in and out of patients’ rooms constantly, taking vital signs, delivering medications, doing rounds; it’s amazing to watch. They are efficient, fast, complete, almost fluid in their delivery.
The way we interact with patients is primarily a function of our training, and the requirement to be efficient and collect a lot of information quickly makes us forget that we are interacting with people. We don’t listen very well to what patients really want or what they think is important. Patient-centeredness is about encompassing the “quality of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient.”1 We frequently fail to remember or even realize that delivery of medical care is not just about medicine; it’s also about spiritual and emotional care. It’s about addressing the patient’s needs holistically.
Imagine you are home on a Sunday afternoon doing whatever it is you like to do—playing with your children, watching a sporting event, preparing dinner—when suddenly you get a headache and start to feel dizzy. The headache momentarily subsides, but as you are walking over to sit down, the dizziness gets worse and you nearly pass out. You feel better the rest of the day, but first thing Monday morning, you call your doctor. She schedules an appointment for the next day, although at this point, you feel fine and consider cancelling. On Tuesday, your doctor examines you and can’t find anything wrong. But to be safe, she orders a CT scan of your brain. Wednesday, you get the scan and go back to work. Wednesday afternoon, you get a call from the doctor’s office because she would like to see you to discuss the test. In the doctor’s office Thursday morning, she reports that the test is abnormal, and there is a mass in your brain. Your life freezes. You experience a sudden visceral reaction; you feel sick; you are confused. “Mass in my brain? What does that mean?” Your doctor says it might mean you have brain cancer.
On Friday, you see a neurosurgeon, who schedules a biopsy for the following Monday. Over the weekend, all you can think about is dying of brain cancer. But you hold out a sliver of hope that it will be one of the more benign diagnoses your doctor talked about. Monday comes, you get the biopsy, and you wake up in recovery. Your spouse is there, looking anguished and scared. You are in pain and confused. A couple of hours later, your surgeon comes in and tells you that the diagnosis is glioblastoma multiforme, the most lethal form of brain cancer. Your life is forever changed. In one week, you went from “normal” to a new “normal” that will redefine everything you do, everything you think about, and everything you experience. You move to a single focus: survival.
This has nothing to do with patient feedback. But it has a lot to do with listening and understanding. In this terrible situation, what would you be thinking about? Sitting at home, in the car, or in the hospital, every day as the world revolves, all you would think about is the cancer. That is what occurs with patients. It drives their behaviors, reactions, and interactions. Yet we fail to comprehend what’s going on in their minds.
Cleveland Clinic collects patient feedback from a variety of comprehensive surveys conducted in six critical environments: inpatient, ambulatory, emergency, psychiatry, pediatrics, and home health. Two of these surveys are standardized instruments developed by the Agency for Healthcare Research and Quality and are part of the HVBP: the HCAHPS and the Home Health Care CAHPS. A third, the Clinician and Group CAHPS survey, is a standard tool used in the ambulatory environment, currently mandated only for physicians participating in accountable care organizations.
Extensive testing went into development of the CAHPS instruments, including validation by Rand Corporation.2 In 2005, the HCAHPS instrument was endorsed by the National Quality Forum.3 The Centers for Medicare & Medicaid (CMS) established three broad goals for the HCAHPS tool:
First, the survey is designed to produce data about patients’ perspectives of care that allow objective and meaningful comparisons of hospitals on topics that are important to consumers. Second, public reporting of the survey results creates new incentives for hospitals to improve quality of care. Third, public reporting serves to enhance accountability in healthcare by increasing transparency of the quality of hospital care provided in return for the public investment. With these goals in mind, the CMS and the HCAHPS Project Team have taken substantial steps to assure that the survey is credible, useful, and practical.4
The CAHPS instruments are not perfect, and there has been criticism that they prevent hospitals from obtaining the granular data necessary to drive improvement processes. In addition, the surveys measure patient experience perceptions without providing real insight into what’s important to patients.
The HCAHPS surveys also lack a robust adjustment process to segment patient medical risk that may bias results. Cleveland Clinic substantiated that when patients are stratified by severity of illness, survey results change significantly. Patients with higher documented severity of i
llness tend to score the inpatient environment more poorly. Hospitals that have sicker patients may have lower scores and greater difficulty determining what impacts patient perceptions.
Studies have demonstrated that certain groups of patients score hospitals differently; for instance, those admitted for exacerbation of chronic conditions have worse perceptions of inpatient experience than those admitted for elective surgical procedures.5,6 This is also the reason why the HCAHPS survey methodology adjusts many of the domains down for surveys received from surgical admissions.7 While the instruments are not perfect, they are evolving; and despite some of these limitations, the instruments and data in fact can be effectively used to drive and monitor performance improvement, as our organization has clearly demonstrated.
Patients have a strong tendency to judge their experience based on their personality, values, and expectations. Healthcare is a very emotional and personal experience, so how can our emotions and personality not impact our perceptions? I was at dinner with a friend who recently went through a healthcare crisis and was extolling her doctor. She emphasized how good this physician was and that she believed he was very talented. I asked how she knew. She described how he was very matter of fact, to the point, efficient, and took time to clearly explain things.
Service Fanatics Page 16
