Service Fanatics

by James Merlino

  In the world of patient complaints, we say there are always three sides to every story. The patient’s side, the organization’s side, and what really happened. Sorting out the truth can sometimes be a little tricky. In this case, our organization’s side of the story was very different from the patient’s and likely closer to the truth. His medical record read like a legal brief from caregivers who were trying to protect themselves and the organization. He had a long history of noncompliance, missed appointments, and threats against staff. What he said about his condition was true, but the treatment had been delayed because of him, not us. He was scheduled for surgery but had missed an appointment with his surgeon two days before the lobby incident, and then came in on this particular day and demanded that the surgeon see him immediately. But the surgeon was out. The patient also neglected to tell us that he had threatened the surgeon’s team and the anesthesiologist with physical violence if anything happened during surgery. The surgeon called me and said there was no way he could operate on this patient. He was very upset, didn’t believe he could think straight, and worried about how this patient would behave in the hospital.

  Under these circumstances, with threats of physical violence against caregivers, the hospital is well within its right to fire the patient. It’s hard to argue that the members of the surgeon’s team would not have been in fear for their safety, as well as preoccupied by the patient’s potential behavior. As our team calmed the patient, let everyone cool off, and contemplated our actions, the surgeon called me back and said, “There is no way we can fire this guy. If we do, he will die. He needs surgery, and we are the best people to do it for him. We will get it done.” That surgeon’s call summed up what we are all about: putting patients first and delivering world-class care. The patient had his surgery at our organization, and he had a successful outcome. There was nothing more important than making sure we helped this person in need, despite the fact that he would likely never perceive that we treated him with dignity and respect and say so on his survey.

  People do not realize what a tough business healthcare delivery can be. Healthcare professionals are screamed at, threatened, and occasionally physically abused every day across the world. This tends to happen more frequently in psychiatric units and emergency departments. When I was a resident, I was once kicked in the chest by a drunken trauma patient. My colorectal surgery colleague had a patient throw a cell phone at her head, causing a laceration on her face. A nurse on one of our psychiatric units had her face clawed by a patient. These terrible things happen every day in the process of delivering care to people, so we have to recognize that despite our desire to constantly deliver patient-centered care, at times it is simply not possible.

  We Must Talk About Empathy

  Teaching service excellence may be easy, but sustaining the behaviors is challenging for any organization. People must be constantly reminded, and given some of the complexities we deal with every day, as illustrated by the previous examples, it can be emotionally challenging for healthcare workers to be consistent. One thing that helps is talking about empathy. We are no different from the people we serve.

  From the very beginning of Cleveland Clinic’s efforts to improve the patient experience, even those predating me as CXO, we’ve always endeavored to express empathy more broadly across the organization.

  Empathy can be a difficult concept to grasp, but most in healthcare understand that it’s important. The term can mean different things to different people, and while there are standard definitions used by people who study it, it is not universally understood. Empathy is an example of a latent construct, meaning it is believed to exist and people can validate it when they encounter it, but they often have difficulty describing exactly what it is or means. There is also a constant debate regarding whether it is innate, can be learned, or is some combination of both.

  Empathy is probably one of the most misunderstood terms in the world of healthcare. It’s also one of the most overused. As healthcare leaders, we want all of our caregivers to have and express empathy. We’re always talking about that. But the vast majority of healthcare workers have never been exposed to it. We have placed considerable focus on empathy at Cleveland Clinic since Cosgrove’s pivotal interaction with Harvard Business School student Kara Medoff Barnett (see Chapter 3). You could say she kick-started our conversation. Our challenges have been how to better message empathy, how to teach it, and how to get all of our caregivers to be more empathetic.

  To be empathetic, you must have insight into your own personality. Cosgrove has long subscribed to the emotional intelligence concept pioneered by Daniel Goleman.7 He argues that a critical element of leadership success is not intellect or hard work but the ability to understand how one’s actions and beliefs impact decision making and interactions. To continue our efforts to extend empathy across the organization, our caregivers need to have an understanding of emotional intelligence and how it applies to their interactions with patients and fellow caregivers.

  We decided that the focus of one of our manager training forums would be that emotional intelligence is necessary for empathy, which gives us the ability to drive more compassionate care. Two to three times a year we pull all of our managers—approximately 2,200 people—together for a training session. We open each forum with a video and wanted one that demonstrated empathy to properly kick off the discussion. I’ve seen a lot of materials that attempt to portray empathy, including many videos. One particularly caught my attention—a Chick-fil-A employee training video shown at an innovation conference I attended in Chicago. Chick-fil-A has a reputation for superior customer satisfaction and a strong commitment to values. It takes tremendous organizational commitment to stay closed on arguably one of the busiest retail days of the week, Sunday, so that employees can spend time with their families. The company produced a video shot in one of its stores highlighting the personal situations of customers and employees. The point, and title of the video, is Every Life Has a Story. The video demonstrates to employees that most customers and fellow employees are fighting some kind of battle and “Everyone we interact with is a chance to create a remarkable experience.”8

  The concept grabbed me immediately; the video was essentially demonstrating empathy. I walked away wondering whether we could use a similar approach to capture patient and caregiver stories. Wouldn’t the life events of patients and the people taking care of them be that much more powerful? I started showing the Chick-fil-A video to others on my team and across Cleveland Clinic, and at first, many people did not agree with my interpretation or perspective. They couldn’t make the connection, and some thought the video was too dark. This was my thought exactly! We’re not in a field where it’s always about happiness and joy.

  I sat down with Sue Andrella, our senior director of media production, and we started a conversation about using video to capture people’s stories. Andrella leads a team of talented creatives who produce tremendously powerful patient stories that we use at a variety of leadership events. I showed her the Chick-fil-A video and gave her my thoughts, and interestingly, while she had never seen this video, she had exactly the same thoughts as I had and had already been thinking about ways to use video to demonstrate empathy. Her team went to work. She reviewed several scripts with me, and we haggled over the types of stories and how they would be filmed, and we wrestled with how to link powerful patient stories in a very complex and sprawling hospital system. Should we use real patients or actors? Do we put patients and caregivers together? Do they need to be connected? What score should we use? Should there be a voice-over? Finally, Andrella, a couple of members of her team, and I met for a final script review before filming. I quickly read the script, pushed it back across the table, and said, “Let’s just start.” There’s not a creative bone in my body, and I was having trouble visualizing from the script. I was familiar with her team’s work and knew that once Andrella and her team got started, they would put together an amazing piece. After filming and editi
ng for several weeks, Andrella called to say the rough cut was done. I insisted on seeing what they had completed and went to the studio. While some minor technical finishes were still needed, the team had scored. My gut was wrenched, and I sat captivated and silent as the rough cut played. When I saw the little girl pet the therapy dog and the caption came up, “visiting Dad for the last time,” I could no longer hold my emotions, and tears came to my eyes. I realized while watching the images that I wasn’t feeling sorry for people: I was feeling what they were feeling and felt empathy for most of the situations. It was uncanny! I believed we had developed a tool that could get people to relate.

  As we prepared for the January forum, I had a rough cut of the video in my office, and Cosgrove walked in. He knew about the project, and I asked whether he wanted a preview. Clearly moved after seeing it, he sat silent for several seconds, and said, “Wow, that’s powerful!” He decided to show it at his annual “State of Cleveland Clinic” address.

  Today, our Empathy: The Human Connection to Patient Care video sits in the public domain on YouTube and a variety of other social media and Internet sites. We have permitted its use to anyone as long as he or she doesn’t alter it or use it for commercial purposes. To date, more than 2 million people have viewed it, and over 500 businesses, including hospitals, have let us know they are using it for onboarding and employee training programs. Nearly every week, I receive notification that another hospital is using it for training. In 2014 I spoke at the Association of Professional Chaplains meeting in Anaheim, California, to a group of about 500 professional chaplains. I showed the video at the beginning of my presentation, and at the end one of the attendees went up to the microphone and said, “Dr. Merlino, we are all familiar with this video, and on behalf of all of us here, I want to thank Cleveland Clinic and thank you for producing it; it will make healthcare better!” I was speechless. What we produced and anticipated to be a simple video for internal training to help our people better empathize has turned into a worldwide healthcare phenomenon, something none of us ever considered. In 2014, Sue, her team, and I received the CEO Award of Excellence for our work on the video. This award is given once a year to a team that demonstrates outstanding work to advance the values of Cleveland Clinic. The video is powerful because its message is simple: There are a lot of things in the lives of our patients and coworkers and in our own lives that impact what we do. Recognizing our personal impact and having empathy for others allows us to be our best in taking care of patients.

  We produced a follow-up video that I affectionately call Empathy II, officially titled Patients: Afraid and Vulnerable. It attempts to take the empathy exposure to a deeper level by examining caregivers from our organization who have had serious encounters with healthcare, caregivers as patients. This video is also posted on YouTube.

  Service excellence and empathy have applications to any business with customers. Take time to understand customers’ perspectives, and make sure that interactions are professional, respectful, and courteous. This is a “lizard’s brain” function that should be second nature to everyone in the organization. The stresses associated with delivering healthcare are unique and require each of us to understand what we bring to our roles every day. Emotional intelligence is a relatively new discipline but a skill essential to truly understanding our intrinsic bias and to putting ourselves aside to empathize with what our patients or customers are going through. Can we teach emotional intelligence and empathy to our caregivers? It’s really not an option, but a requirement.

  To summarize:

  1. All service industries should implement a robust service excellence strategy. It does not matter if you are responsible for delivering products or services to patients, consumers, or other business customers, service excellence will ensure that your customers are treated with courtesy and respect and are well served. Good service excellence is not just about smiling and saying thank you, and it is also not about scripting. It is a robust framework of tactics to ensure your people are consistently delivering the service and building the relationships you need to make your organization successful.

  2. Service excellence strategies must include service recovery tactics. There is a science behind saying, “I’m sorry.” Service recovery tactics in hospitals are not only good to have; they can also help to reduce the number of hospital complaints and grievances. Every employee in a hospital should know the appropriate framework to recover service and apologize.

  3. Talking about and teaching empathy are important to help employees understand what it means to be on the other side of what we do. Empathy is critically important in healthcare because of the stress and anxiety patients experience, but empathy can apply to any business that has customers. Better understanding what your customers are experiencing will help you deliver better services.

  4. Patients are not always right and don’t always act appropriately. We have to try to help people as best we can, but sometimes that is never enough. Recognize that what patients complain about may not have occurred exactly the way they believe it did. Investigate patient complaints carefully to get all sides of a story and ensure you have the full picture.

  5. Teach emotional intelligence. It is an important concept. Being aware of how you react and respond to situations and understanding how others react and respond not only will help create a better work environment, but is critical for delivering empathetic and compassionate care.

  Chapter 11

  Doctors Need to Communicate Better

  Osbourne Bodden lives in the Cayman Islands. For most of his career, he worked in the financial services industry, including two of the top four U.S. accounting firms. He had recently retired and was now running a small business that he had inherited from his mother. The night before I opened the fourth annual Cayman Islands Healthcare Conference, I was invited to a small dinner with a group of business-people to discuss patient experience. I had the pleasure of sitting next to Mr. Bodden and his wife. He shared with me the story of his mother who had recently passed away. He described her as a “tough old bird,” someone who had opinions and “took care of business.” He explained how she had raised her child and suffered through hardships. She started and managed a successful small business in 1955, becoming one of the first female business owners in the Cayman Islands, and she had lived to the grand age of 86. He went on to tell me about her healthcare experience. He had been very close to his mother and was responsible for taking care of her. Together, they had discussed her frail health, as well as her wishes and expectations. When she became ill, she feared the diagnosis of cancer and expressed this to her son. He had taken her to see a physician, and he asked the physician to broach the topic gingerly so that his mother could adapt and “warm up to the idea.” Unfortunately, the physician did not listen and blurted out to his mother, “You have cancer, and we have to start treatment immediately.”1

  Bodden describes the interaction: “My mother just shut down. She did not want to hear it, and left the hospital and never came back.” His mother went to Cuba for care. She felt that she was treated more like a person by her Cuban doctors than the ones she had seen in the United States. She continued her care at Baptist Hospital in Miami, and then came back to the Islands, where she spent her final days.

  Mr. Bodden is not just any small businessman in the Cayman Islands; he is also the Honorable Minister Bodden, the Minister of Health, Sports, Youth, and Culture—a leader in a position to change things! As he continued to describe to me at dinner: “We lose sight—in healthcare—that we are dealing with people and families, that we are required to treat the soul as much as we have to treat the disease.” This story is unique because it was relayed to me during a random dinner conversation in a foreign country and because the first doctor he described worked for us in our Weston, Florida, facility, but the theme is common, and it plays out every day in healthcare across the globe.

  There’s an important, significant disconnect between how we as providers think we comm
unicate with patients and how patients rate our ability to communicate. As a profession, we do a poor job of communicating with patients. If you ask physicians to rate themselves on patient communication, they’ll say they are excellent and further espouse that they have excellent patient relationships. While true for many, and perhaps even most, this certainly does not extend universally.

  We evaluated three months of written patient comments at our main campus. Almost half of the 540 comments about physicians were negative, and nearly three-quarters of the negative comments related to how physicians communicated (see Figure 11.1). Common themes were lack of compassion, inadequate explanations, poor listening, and poor coordination and communication with nurses and other caregivers. Most disturbing was the theme of “bad attitude.”

  Figure 11.1 Comments and the opportunity for improvement.

  If over a span of three months, half of the comments made by patients were negative, how does this reconcile with physicians’ belief that they are great communicators? It’s partly because physicians seldom receive direct feedback from patients about their experience with them. Most hospitals and practices don’t provide this information directly to doctors. It’s also because physicians in general doubt that effective communication skills are a valued part of their responsibility. For a variety of other reasons, including fear of reprisal and concern for hurt feelings, patients often won’t provide direct negative feedback to their physicians. However, when patients are in the comfort and, more important, the anonymity of their homes, that reluctance evaporates and patients are forthright.

  Observing physicians in the office environment provides insights into these communication challenges. When patients first enter the doctor’s office, they are often anxious to describe their condition. When a physician solicits the patient’s agenda, or allows patients to open with the “chief complaint,” patients feel more empowered and believe the physician is paying greater attention. A study published in the Journal of the American Medical Association2 demonstrates part of the problem. The authors reviewed 264 patient-physician interviews from 29 board-certified primary-care physicians. Physicians solicited the patient’s chief complaint in only 75 percent of the interviews, and the patient was allowed to complete an opening answer in only 28 percent of interactions. For patients not allowed to complete an opening answer, the physician interrupted after an average of 23 seconds. The patient would have needed on average only six additional seconds to complete the answer. Soliciting the chief complaint or, as the authors describe it, the patient’s agenda, is the first step in the physician-patient communication interaction. In primary care, an area perhaps considered more patient-centric than other specialties, doctors were not meeting the mark.