Service Fanatics

by James Merlino

  You will experience failure; have no regrets. I’m fortunate to have a boss who doesn’t dwell on failures but wants to know about the next good idea. This leadership style is important. At Cleveland Clinic, administrative failure is expected, innovation is encouraged, and not trying or giving up is unacceptable. When I was writing a Harvard Business Review article about the patient experience, the editor asked me what I’d change if I could go back in time. I replied “nothing” and added that our progress was the net effect of success and failure and that everything we have done has contributed in some way to our accomplishments. Not everything we’ve tried has worked, but we persist in picking ourselves up off the ground and trying new things. For every couple of failures, there are home runs that ignite and propel us forward, including the Cleveland Clinic Experience Program, the empathy video, our summits, and the physician communication program, among others. Learn from the failures, but celebrate the successes.

  Everyone must be on the bus. As our strategic initiative to implement the caregiver label reinforces, everyone is important, and likewise, no one is exempt. I refer specifically to physicians. I once heard a healthcare consulting executive counsel that physicians are busy, they will get it, and just make sure everyone else is leading it. Wrong! Physicians must not only “get it”; they must be involved in leading and managing the patient experience. Without their adoption and participation, we fail.

  Take care of your people. Our people—caregivers—are our most important asset. Delivering care for patients is hard work, and we have to make certain that we look out for our caregivers. Hospitals are dangerous places; we kill people every year. We don’t intend to, but accidents and errors in healthcare delivery are well documented, and everyone at the front lines understands the risks. Our caregivers must come to what they do every day engaged and in the moment. We must not let them face a dangerous environment, uncertainty, anxiety, harassment, or bullying. We must adopt a zero-tolerance policy against treating people badly. Most of us cannot imagine what it’s like to drive to work every day in fear of interacting with a bullying coworker. Or what it’s like to be at home on a Sunday, fretful about facing a terrible, unfriendly, toxic, or dangerous work environment. But I know what that feels like, and there are people reading this book who also know what that feels like. We must do better, our people deserve better, and our patients require it.

  Do things that people say won’t work. If I had a nickel for every time someone said, “It won’t work,” I would be retired and counting waves on a beach somewhere. And if I had listened, we would have done nothing. A host of our best successes were at one time in jeopardy because people spoke against them. Instincts in this business are important. Take the time to learn your organization and know your people and leaders. Understand what’s important to them and make allies in your efforts. Once you have a solid footing and have identified a group of supporters, engage them to help you and push forward with new ideas. There will be times when a strong personality registers an objection to a new idea. There will be the long-time administrator who has seen and done it all, and there will be the experienced administrator who knows from all previous jobs that something like this simply won’t work. Don’t be afraid to buck conventional wisdom. It takes courage and the willingness to occasionally make enemies. But the risk is worth it for the potential organizational impact.

  Move quickly. While most improvement efforts take time and decisions must be made thoughtfully, sometimes a good idea just needs to be launched. I must drive my team members crazy when I come in at the start of the week and throw out an idea for a new initiative. They look at me like I’m some kind of disorganized nutcase. Please don’t misunderstand what I’m saying. Good leadership and operations management require careful planning and execution—most of the time. But don’t get mired in the mindset that every good idea and project needs a comprehensive business plan and PERT2 chart. Some of our strongest successes came from good ideas that we just started implementing. We had C-suite executives from a large East Coast hospital system make two site visits to Cleveland Clinic to hear about our patient experience strategy and leadership rounding. They wanted to visit again, “To see one more time how you do it.” I refused and advised the hospital to just start the rounding and work out the kinks as they went along.

  As long as you’re mindful of scale, not going too fast with something too big—not going to enterprise scale immediately—there’s something to be said about just starting a project to see where it leads. In today’s healthcare environment, where change is rapid and the future uncertain, speed to adopt can be critical.

  Take risks, be vulnerable, and have a little courage. I think one of the best compliments any of my colleagues ever paid me was when I asked him to describe my leadership style; he said, “courageous.” I wasn’t sure what that meant at the time, but he told me: “You took on something you knew nothing about, improving the patient experience. You challenged the conventional thinking and were not afraid to offer something disruptive: the Cleveland Clinic Experience Program. You never give up!” In retrospect, I understand today much better what that meant. Healthcare delivery and hospital operations are locked in legacy and tradition. They needs to be shaken up a little—executing on improving the patient experience required courage to do just that. It also requires relentless effort to keep trying and working at improving even when things don’t seem to be going your way. Beth E. Mooney, chairman and CEO of KeyCorp, and the chairperson of our safety, quality, and patient experience board of directors committee, describes it as “relentless incrementalism.”3

  It also requires vulnerability, a willingness to be uncomfortable. I believe we become too entrenched in the status quo. We worry more about job preservation, colleague happiness, and decorum. If you are not willing to take risks—and that includes your own job security—you will never truly push the envelope on transformational change. Taking a risk requires courage and a willingness to embrace vulnerability.

  Never forget where you came from or who helped get you there. I don’t think this one needs a lot of explaining. It is something my father told me. I have seen people quickly excel into leadership positions and then tend to lose sight of their team who helped get them there.

  Our Passion Is What Sustains Our Charge

  We’re all part of a healthcare ecosystem. What binds us together—whether you serve in healthcare, are employed by an organization that supports healthcare, or work in any other industry—is that someday, everyone will be a patient, even you. Healthcare providers consider themselves among an elite group; someday, everyone will need what we deliver.

  When Pat Ryan took over as CEO of Press Ganey in 2012, he came to Cleveland Clinic to talk about his goals for the company and how he believed he could help improve healthcare delivery. I was struck by his word choice; his emphasis was less on his company and more on his personal passion to better a system he felt had terrible flaws that adversely affected patients. In an early conversation, he described coordinating care for a sister who lived out of state because she could not get through to her provider. He discussed his aggravation while trying to help his sister navigate care. He shared her anxiety of not being able to connect with her caregivers. Over the years, he’s peppered many of our business conversations with personal and family stories that impact his thinking on ways his company could improve healthcare. He recently announced that the responsibility, the very purpose of Press Ganey, is to help healthcare organizations work to reduce patient suffering, a far cry from an organization that collects and distributes data. His experiences and insights drive his business acumen to improve an organization that impacts healthcare for many.

  Robert H. Bazemore, former president of Janssen BioTech, Inc., now president of strategic marketing for Johnson & Johnson, spoke at the 2012 annual patient experience summit about how the pharmaceutical industry could partner with healthcare providers to take better care of patients. He stunned the audience when he admitted to being
a cancer survivor whose life was saved by a drug his company produces. You could have heard a pin drop in the auditorium. He talked about “living on the other side of healthcare” as a patient and how his experience, his empathy, drives the way he leads his company every day.

  Larry Ruvo, senior managing director of Southern Wines & Spirits of Nevada, is a passionate supporter of the patient experience and advocate for the important role of nonmedical family caregivers in managing chronic disease. Ruvo was the primary caregiver for his father, Louis, who suffered from Alzheimer’s disease. Larry invested millions in brain disease research through his Keep Memory Alive Foundation and support of the Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas.

  Ruvo conducted a touching interview with Siegfried Fischbacher, the lifelong partner and current caregiver of Roy Horn, who was tragically injured during their Siegfried & Roy show at the Mirage Hotel and Casino in Las Vegas in 2003.4 On video link from the Lou Ruvo Center for Brain Health, Ruvo interviewed Fischbacher about his experience as a caregiver. The interview was intense, poignant, and revealing. Fischbacher was candid and vulnerable about his love for Horn and the challenges of helping him through a long and very difficult recovery. The rock-star-famous entertainer, emotionally sharing the challenges of caring for a loved one, demonstrated the other side of the patient experience, the caregiver experience.

  Three people, three very different stories, all in a position to impact healthcare. Their stories also help you quickly understand how the patient experience touches all of us in a very personal way.

  Like Ryan, Bazemore, Ruvo, and many others mentioned in this book with whom I’ve had the pleasure to work, my passion to improve is rooted in personal experience, from being on the other side and working on the frontline to care for patients. This is empathy at its very core: understanding what patients go through and appreciating what caregivers experience in delivering great care. It’s extremely helpful when leaders in important places have been on the other side and know what it’s like. Take time to understand what this means. Whether putting yourself in the place of patients in healthcare or customers in another industry, you’ll gain great insights, more finely honed senses, and a keener understanding of what you and your organization need to do to deliver a great experience.

  Cleveland Clinic Is an Amazing Place

  The organization is what it is today because of its long history of innovation, leadership, vision, and the hard work of a lot of people. You may read parts of my story here and think that Cleveland Clinic before Cosgrove was a driven, unfriendly machine that cared only about clinical work and not patients. Nothing could be further from the truth. Patients not only were provided high-quality care, but were, for the most part, treated with respect, compassion, and dignity. I’m confident that for every terrible story like mine, there were dozens of remarkable examples that paint a very different picture.

  However, Cleveland Clinic was inconsistent. The organization did not have a singular patient-centered focus, and that needed to change. Cosgrove pointed the ship in the direction of patients, and we haven’t looked back since. This book tells you how we sailed, smooth waters and otherwise.

  Some might contend that it’s acceptable for customer experiences to follow a typical bell-shaped distribution, with some terrible, most good, and a few extraordinary. In healthcare, however, the way we treat our customers—patients—should not be arrayed on a bell curve. We cannot accept anything less than the consistent delivery of safe, high-quality, compassionate, and empathetic care. Who would want to be the patient or family at the bottom of a bell-shaped experience curve? As I can tell you from personal experience, no one. And if my family was at the bottom, so were many others.

  When we started our work, most of our frontline workforce, nurses and especially physicians, had no idea that our patient satisfaction was quantifiably inconsistent or even being measured. Many had never heard of the HCAHPS survey. Our inpatient satisfaction scores were among the lowest in the country. We were in the 5th percentile for the cleanliness of our hospital rooms. For how quiet our rooms were at night, we weren’t much better, in the 5th percentile. Probably most disturbing of all, we were in the 14th and 16th percentile, respectively, for how well our physicians and nurses communicated with patients. Aggregating our scores, Cleveland Clinic was in the 16th percentile for all of the nearly 5,000 U.S. hospitals reporting data. In another external evaluation, the University HealthSystem Consortium (UHC) benchmark for patient-centeredness, we ranked 51 out of the 98 hospitals reporting at the time. For an organization perceived as a top medical center in the world and deemed a top hospital by U.S. News & World Report, having scores this low was bad for our patients and incompatible with our brand. Something had to be done.

  Today, as a result of our patient experience initiative and other efforts, we have virtually transformed our organization, as shown in Figures 13.1 through 13.6. Our collective HCAHPS scores have moved from 16th to approximately the 66th percentile. Our individual domain scores in nurse and physician communication are at the 79th and 67th percentiles, respectively. Our reputation scores (overall rating) are above the 92nd percentile. We lead most HCAHPS domains against chief competitive peer groups, including the top five U.S. News & World Report hospitals and the largest academic health centers with 1,000 or more beds at a single site. Out of more than 400 participating hospitals, we now rank third in the UHC benchmark for patient-centeredness.

  Figure 13.1 HCAHPS overall rating—main campus.

  Figure 13.2 HCAHPS nurse communication rating—main campus.

  Figure 13.3 HCAHPS cleanliness rating—main campus.

  Figure 13.4 HCAHPS pain management rating—main campus.

  Figure 13.5 HCAHPS doctor communication rating—main campus.

  Figure 13.6 HCAHPS discharge rating—main campus.

  Beyond the data, the improvement is palpable. Daily, we hear stories from patients or family members about how Cleveland Clinic has changed. Cosgrove often says that when he became CEO, more people complained than complimented him about Cleveland Clinic. Today, that’s reversed. While improving the patient experience is a journey that never ends, with no final destination, we clearly have done much more than many believed possible to transform a major, tradition-steeped academic medical center into a patient- and family-centered environment.

  At the beginning of the book, I asked you to think about medicine a hundred years ago. Now envision what medicine will be like a hundred years from today. There may be machines that can scan patients and instantly eradicate disease! But will the emotional and spiritual needs of humans change? Will patients seek treatment and cure irrespective of compassion, caring, and empathy, wanting only that their problems be fixed? I hope that the role of compassion, humanism, and empathy will still be strong.

  The 360 continuum of patient experience must receive our constant attention. Processes and tactics require continual measurement and adjustment. We must strive to remind all those in our business that they count and that a high-performing culture with patients at the center requires us to be attentive to developing our caregivers. One slip back to the mindset of doing a job and not driving a passion can engender a dangerous event in safety, a lapse in quality, or a failure in service.

  We also must make sure that we’re listening to customers and responding to their needs. We tend to believe we know what’s best for people, which frequently leads us to talk more and listen less. We must ensure that we understand patients as people and address their emotional and spiritual needs as well as their medical needs. Reciprocal to making sure we understand our patients is ensuring that our patients understand us. We’re in the ultimate service business where the customer is not always right. We have an obligation to help patients and their families understand what’s going to happen to them every step along the journey, but patients and their families must be good partners to us as well.

  Twenty years ago, if you had talked to me about the patient experience,
I would have wondered what you were talking about. Ten years ago, if you had said I would be leading efforts to improve the patient experience at Cleveland Clinic, I’d have laughed. Five years ago, a reporter challenged me to prove we were making a difference. Today, we have transformed an organization and are helping to lead an industry. In 2013 that reporter’s company, HealthLeaders Media, picked me as one of 20 people who make healthcare better,5 an amazing turn of events.

  I know that an absolute focus on the patient and the family is the right thing to do, and it should be the default setting for everyone in this business. I’m fortunate to work in one of the world’s best healthcare organizations, but even we can do better. The work is hard, and sustaining it requires constant attention. The letters I receive from patients, family members, and caregivers continue to fuel me to improve the patient experience. They remind me why we’re here, and I challenge everyone reading this book who works in or around healthcare to use affecting patient stories to drive you as well.

  Improving the experience for our patients is not a destination, but a journey. Success comes in incremental steps achieved by paying attention to the little things, holding people accountable, and pushing the strategy forward. The patient experience is not about making patients happy; it’s about how we deliver care. Someday I hope that the patient experience is not a process or strategy that needs to be led by an executive, but simply a state of being for healthcare delivery across the world. This may be unrealistic or idealistic. But our focus must always be on improving care and how we deliver it, providing the safest and highest-quality medicine possible!