Seemingly modest, unintentional words or actions can trigger people to be upset. While I’m very informal, and most of my patients call me Jim instead of Dr. Merlino, I would never want them to address me by some pet name. I find being called “sweetie” or “honey” distasteful. We certainly can’t predict how people like to be addressed, and we also can’t read minds to understand whether certain words may irritate people. But we don’t need to do either, because we can train people to consistently employ a framework that will avoid such triggers. If we don’t know the name of the patient or what he or she wishes to be called, the appropriate form of address is “sir” or “ma’am.” Using appropriate generic salutations will ensure that we don’t get this simple expectation wrong. If we know the patient’s name or preferred form of address, that should be our standard. It is also not wrong and very easy to simply ask the patient, “How would you like me to address you?” The interaction between the dying black veteran and our physical therapist illustrates how a service excellence program and behavioral standards can help.
How We Apologize Is Also Important
Service recovery, or how we apologize and make amends, is also an essential component of a service excellence strategy. Recognizing when mistakes are made, apologizing for their occurrence, and doing something to make it better are critical to good customer service. In the hospitality industry, a typical example of service recovery is receiving an apology and a free dessert for a hair in the soup or a round of drinks on the house for waiting too long for a table. However, in reality, the theory and mechanics of service recovery are much more sophisticated. In healthcare, we cannot offer a “service bribe” to make people better. Our only recourse is to try to correct the problem and make people feel like we care by doing so. It’s not just about saying you’re sorry.
When we experience a service failure, we get angry. The degree of anger is proportional to the event. We will be more angry when we are sitting in the airport waiting for our flight and it is suddenly cancelled and less angry when we order a specific coffee and discover down the street that the barista gave us the wrong one. But in both cases, we experience some level of discontent. That discontent or anger rises abruptly and, as time progresses, starts to level off. It reaches a plateau and eventually subsides. This is not to suggest that we forget the event and just let bygones be bygones, but generally our heightened anger is not sustained. Evidence suggests that if we apologize as that discontent is rising or at its highest point, usually immediately after the inciting event occurs, then there’s a tendency for the apology to be dismissed, as the person delivering it gives the impression of not really listening. However, if we do something to acknowledge the mistake—show empathy and apologize—the service recovery is believed to be much more effective and meaningful and tends to be accepted by the customer as sincere. This is referred to as the anger-hostility curve (Figure 10.1).4
Figure 10.1 The anger-hostility curve (adapted from Timm).
Having a robust service recovery strategy is not only the right thing to do; it also helps protect the brand. Paige Hall, CEO of AboutFace, actually suggests that when service failures occur, if they are appropriately recovered, customers report a higher level of satisfaction with the organization.5 A critical component of service recovery is not just apologizing, but taking appropriate action to fix the problem.
This is especially important in healthcare, because any patient complaint involving medical care is defined as a grievance by Medicare and can affect a hospital’s Medicare credentialing. Such complaints must be recorded and available for audit by Medicare. However, there’s a caveat: if the problem is fixed immediately, then it does not need to be recorded as a grievance.
For instance, if a patient’s intravenous line (IV) is causing pain, the patient reports it to the nurse, and the nurse takes care of the problem, it’s not a grievance. However, if the patient complain, the problem is ignored, and it requires supervisor involvement to address the problem, then this is a grievance. Medicare’s policy is common sense. The opportunity is nearly unlimited for mistakes and complaints in a hospital. Giving frontline people the opportunity to immediately address them and apologize is common sense. Medicare’s policy focuses on monitoring really outrageous problems and those that don’t get addressed. There are a few exceptions, where the complaint may fall into specific categories such as abuse, neglect, or fraud. But in general, providing immediate recognition and resolution of a patient complaint eliminates the need for grievance reporting. So having a good service recovery strategy and training every caregiver how to apply it is good for patients and the business.
Communicate with H.E.A.R.T.
The legendary service culture found in organizations such as The Ritz-Carlton hotel company and Walt Disney Company is the product of strategic intent and comprehensive tactics, including a training and development program all employees are required to attend regularly. We knew that Cleveland Clinic needed a service excellence strategy, tactics, and training program, but we faced several challenges and requirements. First, we wanted a program tailored to the healthcare environment and for healthcare workers to accommodate the nuance that the healthcare customer is not always right. Second, there were sporadic efforts to implement similar strategies in the past that failed because there was no program to sustain them, and we wanted to rectify this. Third, we wanted a program “developed by us, for us” to accommodate our culture. Finally, the tactics needed to support a solid approach to service recovery to avoid the escalation of complaints to grievances.
As part of the effort to create the Cleveland Clinic Experience, an employee focus group discussed best-practice behaviors in addressing our patients. The focus group also considered behaviors and actions we should use with each other. The resulting formula reflected important elements of service excellence:
1. Introduce yourself and your role when you meet someone.
2. Use the 10/4 Rule: At 10 feet, make eye contact and smile. At 4 feet, maintain eye contact and greet warmly.
3. Use sir or ma’am when you don’t know a patient’s name.
4. Use a person’s preferred name when known.
5. Clearly communicate expectations: “I am here to …”
6. Offer to resolve concerns or forward them to the appropriate person.
7. Use active listening. Pay full attention to the person speaking. Reword the message to ensure understanding.
8. Show empathy. Try to put yourself in the patient’s place.
9. Use common courtesy. Say please and thank you and open doors for others.
10. Anticipate needs, and offer to help without being asked.
11. Thank people.
These 11 points are neither unique nor original to Cleveland Clinic, but they summarize what our employees thought was important to display with patients and each other. The items on the list represent commonsense, everyday behaviors for civilized society. Can anyone disagree that we should employ them when interacting with patients or fellow caregivers?
A module of the Cleveland Clinic Experience program introduced our 43,000 caregivers to the expected service excellence behaviors. We subsequently summarized and packaged them into our S.T.A.R.T. with Heart customer service training program:
S Smile and greet warmly (use sir/ma’am or preferred name).
T Tell your name, role, and what to expect.
A Actively listen, show empathy, and assist.
R Rapport and relationship-build.
T Thank the person.
The Clinic had already been using a complementary service recovery module, Respond with H.E.A.R.T. that had previously been developed by Cleveland Clinic caregivers:
H Hear the story.
E Empathize.
A Apologize.
R Respond.
T Thank the patient.
All employees are trained on the behaviors when they participate in the Cleveland Clinic Experience, and the service excellence program is self-sustaining. Yo
u can’t put people through training and expect the behaviors to be present forever. Rather than refresher courses, we wanted to create a culture of service excellence in which employees would support and police the actions of each other. The Coach with H.E.A.R.T. program teaches select caregivers to look out for H.E.A.R.T. behaviors and service recovery, compliment people doing a good job, and help those struggling. A coach can be anyone, not necessarily a manager or leader, but merely a coworker with expanded interest in doing the right thing and helping develop a highly performing service culture.
An important element of the Coach with H.E.A.R.T. program is providing developmental support without being negative or degrading. We also did not want to create an environment where failure to use the tactics became punitive. Service excellence requires training and maintenance, and the coaching program was developed to help reinforce doing and saying the right things. We want our people to use their natural enthusiasm and commitment to their jobs and for the entire organization to be wrapped around our framework. Immediately disciplining an employee for not using service standards was not an acceptable course of action. Everyone occasionally has a bad day, may not feel well, or may be provoked by the actions or words of a patient and pushed off a high-performing game. We wanted to create an environment where people can help, support, and learn from each other. The coaching program helps to build that environment.
Collectively, S.T.A.R.T. with Heart, Respond with H.E.A.R.T., and Coach with H.E.A.R.T. make up our Communicate with H.E.A.R.T. service excellence suite of programs. It is a service excellence program developed by healthcare workers for healthcare workers in a healthcare environment. Over 45,000 present and past caregivers at all of our sites throughout the world have been trained on the H.E.A.R.T. program. We have successfully adopted it for use in our Middle Eastern operations and have implemented the program in more than 15 other healthcare organizations, to public employees in a small city, in two Las Vegas casinos, and at a home health agency, and we’ve begun deploying it successfully with employees of the Cleveland Metropolitan School District. The different perspectives obtained from working with organizations outside healthcare have strengthened the model. It has also helped validate our work by demonstrating that the approach is scalable and works in other environments.
We offer a similar program for our contract workers. Patients and families don’t know that food-service workers or parking attendants don’t work for Cleveland Clinic. Employees of the companies delivering these services are seen as Cleveland Clinic caregivers just as much as anyone directly receiving a paycheck from our organization. These workers must be aligned around our organizational priorities and trained in service excellence just like anyone else. Each year, William M. Peacock III, our chief of operations, holds a seminar for leaders of our suppliers. Part of the seminar includes discussion of our Patients First philosophy and the expectations we hold for our business partners.
Our service excellence program is not about scripting. Consumers are not fooled by the mechanical mannerisms that scripts create; those interactions are robotic and insincere. Instead, we provide our people with a framework from which to create their interactions. When we introduce employees to H.E.A.R.T., we ask them to imagine how they would want someone to use the framework with them and how they would want to see it delivered. We also believe that the program is not yet complete or comprehensive. Every year, we find new environments in which to use Communicate with H.E.A.R.T. to strengthen the model and improve the program. We are trying to create that “lizard’s brain” in every one of our people so that the behaviors become innate and reflexive.
Successful service excellence does not happen in a vacuum. It requires people who are passionate, compassionate, and committed to helping others, including both patients and coworkers. Successful implementation of our service excellence program requires the entire talent management infrastructure I addressed earlier in the book. Finding the right people, screening them for our values, and holding people accountable for actions and behavior are all critical for a service excellence endeavor to be successful.
For cross-training and evaluation, we’ve created a mystery shopping component to the program, Shop for H.E.A.R.T. In large organizations with many different sites, it’s easy to deploy employees who don’t know or have never been seen by colleagues in another area. We train managers and other leaders how to conduct mystery shopping and send them to experience frontline staff interaction. The mystery shoppers use a checklist for S.T.A.R.T. with Heart behaviors, immediately score the frontline staff, and offer valuable feedback to their managers. This approach helps managers observe the framework deployed in different environments and offers valuable perspectives on the range of delivery techniques employees use with patients. We also have started an employee mystery shopping program, where our caregivers can provide direct feedback about their experiences. It’s hard for anonymous mystery shoppers to penetrate the front desks of healthcare, but employees who are also patients are able to relay their personal experiences. We encourage them to document and report both the good and the bad, and we provide this feedback to managers and the front line.
Service Excellence Requires Accountability
A robust service excellence strategy encompasses not only a tactical framework for caregiver behavior, but coaching and mystery shopping components that are necessary to ensure consistency and reliability. I tend to fly a single major airline and am very familiar with its efforts to try to ensure great customer service. But the employees fail at consistency. If you fly frequently, you notice the variation. Sometimes the flight attendants are friendly, sometimes they aren’t. Generally, the pilots make a brief introduction before takeoff and offer a “welcome aboard” once airborne, but sometimes they don’t. I’m a rather nervous flyer, so when pilots fail to make these announcements, what else do they fail to do on their checklists? Just training people in service excellence standards isn’t enough; there must be tactics to ensure consistency and sustain reliability.
Service failure can have a long-lasting negative impact. Repeated service failures may lead patients to believe that organizations can’t or don’t want to improve.6 A robust service excellence strategy is not typically utilized in healthcare settings. However, service excellence is a low-cost, easily implemented program that can have significant impact on how patients view the organization and may also help reduce the number of reportable Medicare grievances.
Patients Are Not Always Right
A healthcare service excellence strategy must also accommodate the times when we cannot make a patient happy. Healthcare is the ultimate service business, but the customer is not always right. Cosgrove was out shopping one day when a person approached him and asked, “Why am I unable to schedule an appointment at Cleveland Clinic?” He was certainly befuddled and apologized to the person and promised to look into it and have someone respond. What this person did not reveal was her diagnosis of Munchausen syndrome by proxy. This is a mental illness and form of child abuse in which a primary caregiver exaggerates or fabricates illness or symptoms in a child to get attention. These are very difficult cases that require careful supervision, and when a minor is involved, there is usually court-ordered supervision. This is the ugly side of the patient experience, the side that doesn’t get attention and celebration. But there are many patients who have supervised access to medical care or who have been “fired” from healthcare organizations and are no longer permitted to utilize services there.
Limiting patient access to healthcare or firing patients and preventing access is not something that is done hurriedly or easily. Such actions can be done only by the Ombudsman/Patient Relations Department, and there are strict guidelines to protect the patient and organization. We make every effort to do the right thing for patients and place the burden on the organization to ensure this. These challenging patients often can raise their voices and become threatening. A comprehensive service excellence training program teaches employees how to re
main calm under very difficult situations and to always treat the patient with consistent communication, dignity, and respect.
When seeing patients in my clinic one day, my assistant alerted me to a patient in the lobby of the executive offices yelling at the top of his lungs and threatening to remove his clothing, so I needed to get there as soon as possible. At first, I chuckled in disbelief, wondering why there was no one else who could take care of this. Just another day in the patient experience! By the time I arrived, one of my administrative colleagues and five police officers had intercepted him. The patient was screaming that Cleveland Clinic was trying to kill him and demanded to speak with someone “important” immediately. We were able to deescalate the situation and eventually guide him to the office of the ombudsman to determine the best way to help. He said that he had a life-threatening need for surgery, and it had been delayed. He did not understand why and believed his doctors had discriminated against him because he did not have insurance.
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