Service Fanatics

by James Merlino

  It’s hard to walk into a room of 12 people and say they’re losing their jobs. In January 2011, we shut down the service navigator program. For two months I sat on pins and needles awaiting the first complete set of HCAHPS numbers without the navigator program. I was definitely feeling pressure, but I held fast to the results of our study. Our decision was validated: for three months, we tracked each floor that previously had a navigator, and there was no degradation in scores. In fact, some scores increased. The service navigator program was an expensive one everyone believed had significant impact on the patient experience, but in reality there was no correlation.

  The experience taught me three important lessons about patient experience tactical implementation. First, preserve scarce enterprise resources for strategic initiatives. The navigators had taken on a variety of other roles to help drive patient experience improvement in their units. Many of these tasks were not part of the enterprise vision for patient experience improvement but were activities the local units considered important, and the navigator was a resource. This ties back to the elephant description challenge I laid out earlier. I would never tell someone his or her idea to improve the patient experience was bad, but I would not deploy limited enterprise resources to implement a nonstrategic initiative. We used the HCAHPS data as a broad measure for the program, but we did not incorporate a process metric to monitor whether the navigators were effective.

  The second important lesson is that practices must be carefully examined before broader rollout. The service navigators pilot had shown tremendous promise; however, when reevaluated under more rigorous circumstances, the program did not perform as thought.

  Third, while not proved by data, this experiment validated for me the meaning of the patient experience. Processes and operations must function effectively. Patients may have liked having someone around to fill in the gaps and attend to little things. But the navigators were never an acceptable alternative to effective care delivery. They essentially became a crutch to support a bad or failed process. Patients may have appreciated the navigator calling a physician who failed to round, but this didn’t prevent them from giving the physician an unacceptable HCAHPS score for not communicating. Likewise, if the room was dirty and the navigator got EVS to clean the room immediately, this was no substitute for the room being cleaned in the first place. The patients were correctly using the survey to rate their perceived experiences based on what happened before the navigator intervened. In essence, the navigator became a work-around for processes that should have functioned appropriately to begin with.

  There are many tactics that impact the patient experience. Every tactic should be a best practice, be easily understood, have clear process metrics that permit managers to monitor adoption and usage, and have sustainable impact on a particular outcome. It’s also important to realize that, as the saying goes, the way to boil an ocean is one cup at a time. Not all new programs can immediately be implemented on an enterprise scale. Not only is this challenging to do in large organizations, but the cost of failure can be extraordinary. Test something first on a small, frontline unit, and if it works, establish whether it’s transferable to the rest of the organization, and then determine how to scale it.

  Finding early partners is critical. Just because you’re in charge of the patient experience will not mean you can order people to implement something. The Cleveland Clinic patient experience would not be as successful without the assistance and early partnership of Hancock. She was not in charge of all of nursing then, but she commanded tremendous respect and knew nursing operations better than anyone else I knew.

  Improvement isn’t always just big structural change; often, it’s paying attention to the little things. The pilot with one of our worst-performing units taught us that endoscopy scheduling and basic caregiver communication have significant impact on the patient experience. It’s critical to examine the impact of everyday processes.

  Effective Execution Requires Metrics

  Tactics alone aren’t sufficient to compel an institution like Cleveland Clinic to embrace the importance of achieving a consistently great patient experience. We are a data-driven healthcare organization. If something is a strategic priority, metrics need to support and sustain it. In the beginning, few of us were paying any attention to our data about the patient experience. Good execution required that we disseminate the patient experience data we collect to all levels of management.

  We had plenty of data along the care continuum, and we needed to make sure that it was driven vertically down through management (Figure 9.4). Data needed to impact strategic decision making, support implementation of tactical best practices, and touch individuals at the front line who were operationalizing the change. Strategic data became the overall enterprise goal that all senior leaders needed to understand and follow. Ultimately, they would be held accountable for their performance. Supporting best practices, such as nurse hourly rounding, is tactical data. This information is disseminated across units throughout the enterprise for managers to follow and share with their frontline nurses. Regularly distributing communication scores to the physicians is an example of sharing operational data. It is used for individual performance improvement.

  Figure 9.4 Driving data down vertically through management.

  Driving transformational performance improvement in patient experience requires that an organization establish a strategic priority, set goals, and provide metrics and data to every manager. Because they are accountable for driving patient experience improvement, managers need to understand how their role relates to the organizational goal. Driving data to every manager also ensures that we have a standard to recognize and by which we hold people accountable for their work.

  Given that resources for implementing new tactics will continue to contract, we must be smarter about our approach to problems. Cleveland Clinic is mapping high-level patient flow through our system to better understand where to target improvements for maximal impact. We must select projects that impact multiple areas and performance measures. For example, we’ve used HCAHPS scores as targets for improvement, while many of the programs we’ve implemented have impact beyond the inpatient environment. Improving physician communication broadly impacts inpatient and outpatient communication, as well as coordination with nurses and other caregivers. If we wander too far into the weeds chasing a single metric, we’ll lose the ability to transform care more broadly.

  In summary:

  1. Talking about improving the patient experience is important, but ultimately success will be defined by the ability to execute. Actually getting something done and showing improvement in a defined outcome measure will demonstrate that the patient experience initiative is more than just a marketing campaign.

  2. Operational success requires coalition building with critical stakeholders. The patient experience touches everything in the organization; remember, our goal is organizational alignment around the patient (the customer). Successful execution will require support from leaders across the organization, and your ability to build a strong team of willing stakeholders will help improve the execution of new processes. Gain broad support for new initiatives, but use your proximity to the boss and get leaders to mandate when necessary.

  3. Fix broken basic hospital processes first. Creating new processes or implementing new tactics as a work-around for a broken system is wasteful and will not fix the problem. We have a tendency to assume that everything is already working well and that the only way to improve is to implement something new. That is not the case.

  4. Whether your system comprises 1 hospital or 100 hospitals, start with small projects that can create early wins. Ignore the pressure to “enterprise” something immediately. There is no company research and development office in the world that doesn’t experiment before it rolls something new out. This is no different. Figure out if something is going to work on a small scale, measure its effectiveness by determining if it improved an outcome, see if the proce
ss can be sustained for a defined period of time—say, three months—and then determine how to scale it.

  5. Identify best practices. Do not waste time and money on programs or tactics until you have investigated and trialed best practices that have been demonstrated to work in other hospital environments. Everyone has his or her own definition of the patient experience and his or her own ideas on how to improve it. Do not let that get in the way of using things that we already know work. There are programs that work and work well, such as nurse hourly rounding. This is a best practice that should be mandated for every hospital in the world.

  6. Learn from others. Big, successful organizations like Cleveland Clinic have a tendency to believe that the only good ideas come from within. Wrong! My CEO has a saying: “We need to stop breathing our own exhaust fumes.” We have learned a great deal from hospitals much smaller than we are and from businesses in completely different industries. Look around; there are good ideas out there.

  7. Have the courage to divest a good idea that doesn’t measure up. It is hard to shut down a program: leaders and managers become emotionally attached to their “baby,” employees may lose their jobs, and shutting down something is sometimes harder than building it. Some holdout supporters will also manipulate data to demonstrate success when there is nothing but failure. Be objective and critical in your program evaluations, and be steadfast in your need to terminate something when it is clear that it is not effective.

  Chapter 10

  Healthcare Requires Service Excellence

  How often have you stood at a service counter in a retail business or patronized a restaurant where it seems everyone ignores you? Recently I was at the checkout of a large electronic consumer products store. Nearly every employee I passed while browsing stopped to ask whether I needed anything. When I got to the cashier, the young woman behind the counter was typing on her smart phone, while I stood right in front of her with my purchase. She finished typing, put the phone down, and rang me up, without acknowledging me or even looking at me. As she was executing my transaction, another employee arrived at work and walked behind me, and she yelled out to him, “Hey, Ron! Where you been? What’s up?” She finally looked at me and asked whether I would like to pay with cash or credit.

  It’s critical that everyone in our organization acknowledge and, when needed, try to help our customers. These interactions create an important first impression, and subsequent positive impressions, that convey we care. I’ve stated previously that you don’t need to be a medical professional to be a caregiver. You also don’t have to be a medical professional to be nice to patients or help them find their way around the hospital. Needing healthcare services is stressful enough without that stress being compounded by bad interactions with our people or organization.

  Like many major medical centers and large hospital complexes, navigating the halls of Cleveland Clinic can be difficult. In 2008, shortly after we opened the latest addition to our main hospital, the Sydell and Arnold Miller Family Pavilion, we created a program called the Red Coats. These men and woman have a strong predilection for customer service and are stationed throughout the main campus simply to help people navigate. If you are lost or have questions about where to find something, the Red Coats can help you. The program has been immensely popular with patients and our employees, and we frequently receive comments about how the Red Coats have established lasting relationships with some of our patients. It has greatly enhanced way-finding in our organization.

  Having a group of specially trained greeters has been effective, but one of our goals is to have every caregiver greet and assist every patient and the patient’s accompanying friends and family members wherever they are in our facilities. You can station only so many Red Coats throughout the campus, so we need alignment among everyone to help. Each caregiver has the opportunity to create a positive, lasting impression for patients.

  Service Excellence Is Not Just Smiling

  I hate when people say hospitals need to be like hotels. Hospitals are not hotels. I have never stayed at a hotel where people come into your room at three o’clock in the morning and do things to hurt you, like draw your blood. I also generally stay in hotels when I am happy, like on vacation. People are generally not happy to be in a hospital. We also simply cannot add more amenities to make patients happy when often we have to do things they will not like. But as Micah Solomon, a patient experience consultant, points out, healthcare should be “healing with hospitality.”1 Solomon goes on to say that the healthcare industry has an “insular nature, which makes the status quo self-reinforcing … in other words, healthcare providers and institutions compare themselves to each other,” which makes learning from others more difficult. There is no reason why we cannot learn from other industries such as the hospitality industry to improve what we do.

  I enjoy staying at The Ritz-Carlton hotels. They’re a bit pricey, but I like how the employees smile and say hello when we pass in the hallway. If I’m standing alone looking lost, someone always stops to ask whether I need assistance. Like most males, I prefer never to admit I’m lost or need help, so it’s a tad annoying, but I still find it a nice touch. At a Ritz-Carlton, I’m never lost, I never wonder where the restroom is, and I never want for anything. Because I’m not a billionaire, that kind of service and attention is cool.

  The Ritz-Carlton and other great service organizations excel at having every employee acknowledge and help customers. This is called service excellence. It’s a little hard to define, but a very good start is the opening line of a paper by the late Robert Johnston, professor of operations management at Warwick Business School in the United Kingdom: “Service excellence is both obtrusive and elusive. We know when we have received it and, rather more frequently, we know when we have not.”2

  For healthcare, this service excellence definition better aligns our thinking: “the ability of the provider to consistently meet and manage patient expectations. Clinical excellence must be the number one priority for any healthcare system. However, the best healthcare systems combine professional (clinical) service excellence with outstanding personal service.”3

  Cleveland Clinic has the clinical excellence; now we must build and sustain the service excellence. Successful service excellence programs don’t require perfect delivery of scripted phrases or behaviors at every customer touch point. What is required is a framework for everyone in the organization to understand and consistently deliver a basic set of behavioral standards at every touch point. For instance, we don’t need every person in the organization asking patients or their families if they’re lost and offering directions. But teaching caregivers to pay attention to how our patients and families behave—so if, for instance, they look lost, the caregiver will offer assistance—is part of the framework. We don’t want to oblige everyone to walk around smiling and saying hello to all our patients. But we want our caregivers to acknowledge people when they pass in the hallways. A friend introduced me to the concept of the “lizard’s brain”—when behavior and actions are reflexive and innate. Service excellence should be that.

  A good service excellence strategy is also essential to meet patient expectations. Patients come into the hospital with anxiety, fear, and an expectation that we will be there and take care of them. When a service failure allows the patient to form the impression that we don’t care, or the patient forms the impression that we aren’t compassionate, we’ve failed to deliver to the standard the patient is expecting. The interaction can potentially define us. What we delivered as an experience did not meet expectation.

  One day on leadership rounds, Cosgrove and two other members of our executive team walked into a patient’s room and asked how everything was going. All of the patient’s responses to Cosgrove’s questions about care were positive. Our chief nurse, part of the team that day, thought the patient was holding back and asked him if something was bothering him. The patient looked at Cosgrove and said, “You know, Dr. Cosgrove, I’m a Vietnam veteran,
and I’m dying of cancer. You would think someone in my circumstances would be treated with a little more respect than being called ‘sunshine.’ And by the way, Dr. Cosgrove, if you hadn’t noticed, I’m black, and to me, being called sunshine is a racial slur!”

  Needless to say, Cosgrove was shocked and immediately apologized. As a fellow Vietnam veteran, Cosgrove had immediate empathy for the patient and his need for respect. This patient’s expectation was that he be referred to by his name or by “sir.” Is this too much to ask? His experience was obviously something entirely different.

  When we discussed the situation with the offending physical therapist and reviewed her performance with her supervisor, we found that the employee was actually exceptional. “Bubbly” is how one nurse described her. “Someone you would want taking care of your family.” We discovered that the word sunshine was just part of this employee’s regular patter and that she used it frequently. There was no ill intent on the part of the employee, but what this interaction created was a very typical expectation-experience mismatch. The patient wanted one thing, he received another, and it made him quite upset. It also illustrates that care can be going perfectly, but a minor interaction may lead patients to define our organization as a place that makes them feel uncomfortable and disrespected.

  Some reading this may consider the patient holding us accountable for the word sunshine to be minor and that hospitals and other organizations should not be judged on such interactions. I don’t disagree, and certainly delivering high-quality care is more important than remembering how to refer to someone. However, if we accept that a patient’s state of mind is important to his or her overall well-being, then we should be concerned about the little things. We should eliminate things that could cause the patient to be upset or more uncomfortable in an environment that is already stressful. It should not be up to us to judge what is or isn’t right for the patient. This patient wanted to be treated with dignity, not only because he served our country, but more important, because he expected us to be culturally sensitive to his race. It’s the least we can do for a man of distinction (a veteran) and a fellow human being dying of cancer.