Leadership helps ensure patient needs are consistently met across complex organizations
Upheaval in health care isn't just transforming traditional C-suite positions in hospitals. Growing accountability for clinical and patient satisfaction outcomes across the care continuum is creating a need for new leadership roles. The chief patient experience officer — or CXO — is one such emerging position.
The CXO is responsible for making sure every aspect of a complex delivery system consistently meets basic patient and human needs. While payment models that reward patient satisfaction are the most obvious driver, the need goes far deeper, says Anthony Cirillo, who heads Fast Forward, a patient experience and health care marketing firm.
With the rise of accountable care organizations, patient loyalty could mean the difference between success and failure, making satisfaction an organizational strategic imperative. "Word of mouth is the best marketing and that comes down to patient experience," Cirillo says. "So shouldn't you have a senior executive concentrating specifically on that?"
Even more fundamentally, delivering a positive patient experience is essential to achieve the core mission of health care organizations, and to fulfill the aspirations of every professional, support person and manager on staff. "Every employee is a CXO and every employee is a CMO. Care is delivered on the front line," Cirillo says.
Creating an environment that promotes positive patient experience starts at the top — with the CEO getting in touch with his or her own motivation and vision for the organization, says Tom Voccola, who heads CEO2, a firm specializing in revitalizing organizations by empowering managers and employees. "When we get back to why we are here, we do our jobs because we can, not because we should."
The CXO plays a crucial role in operationalizing the patient experience mission by orienting and coaching employees and medical staff, and providing tools to identify and act on opportunities to improve, Cirillo says. Just as important, the CXO supports hospital staff healing, which is essential to maintaining compassion and reducing burnout and turnover.
CEOs across the country understand the strategic importance of systematically improving the patient experience, says Tim Morgan, chief operating officer at executive recruiting firm B.E Smith. But there's no real consensus on how to go about it. "Many are using executives who already oversee clinical operations, such as chief nursing officers or vice presidents of patient care. Often, they have [staff from] more than one function reporting to them," Morgan says. Quality reporting frequently is involved as documenting satisfaction becomes increasingly data-driven. And other senior executives, such as chief financial officers, are getting involved because patient satisfaction scores now directly affect payment.
Many organizations are not large enough to justify a separate executive dedicated to the patient experience, Morgan acknowledges, but that could change as successful models emerge. "Talking to hospitals that have implemented the role will be very helpful."
James Merlino, M.D. | chief experience officer, Cleveland Clinic | A practicing colorectal surgeon, Merlino was appointed CXO in 2009, and now spends about 80 percent of his time leading the clinic's patient experience efforts and referring-physician relations. One of the nation's largest integrated health care delivery systems and a perennial international quality leader in many clinical fields, Cleveland Clinic was one of the first to dedicate a C-suite executive to patient experience.
We made patient experience a strategic focus when Dr. Delos "Toby" Cosgrove took over in 2004. He remarks on a couple of experiences he had in full-time practice. Once when he was speaking at Harvard Business School, a young woman told him her father had mitral valve surgery, but he went to the Mayo Clinic even though the Cleveland Clinic was the No. 1 heart center in the United States. She said, "You don't teach your physicians empathy." He was silenced by that and answered the only way he could: "You're right, we don't."
Toby realized that patients were coming to the clinic for clinical excellence, but they didn't like us very much. That was unacceptable. He wanted to pay more attention to the emotional, physical and spiritual environment around health care. The first thing he did was adopt a "patients first" philosophy. We also became the first health care system to have a chief experience officer that is analogous to the chief customer service officer at many other service companies.
We adopted a very aggressive program to improve the patient experience. One area we focused on was how caregivers communicate with patients. We adopted best practices, like hourly nurse rounding. We established a physician committee with transparent measures and a manual of best practices for how to talk better with patients. We developed a service excellence program that taught caregivers how to interact with patients, and how to perform service recovery — the right way to apologize.
We relabeled all of our employees as caregivers — it doesn't matter what you do for the organization, if you support the mission you support the caring of patients. To change the culture we sat all of our staff down in small groups for three hours to talk about service excellence and what it means to be a caregiver. We asked them to pick a value in their job and tell us what it means. To do it with 43,000 caregivers, we trained 400 employee-facilitators to lead the discussions. We regularly take 2,500 managers offline to talk about skill building and to reinforce our patients-first principles.
There's no question it changed the culture and our performance. Three years ago we were at the bottom in patient satisfaction of the 17 largest health systems. Now we are at the top in all but two domains.
Having a CXO has helped to elevate the issue. Patient experience doesn't just belong to nurses or doctors or operations — everyone is responsible for it, and senior leadership in all areas needs to lead it. Support from the CEO allows this to be successful with key stakeholders who can drive change.
Sven Gierlinger | vice president, hospitality and service culture, Henry Ford Health System | Denise Beaudoin | vice president, customer engagement, Henry Ford Health System | Beaudoin and Gierlinger share responsibility for managing patient satisfaction and experience, including monitoring outcomes and assisting departments in improving performance, at the five acute care hospitals and one inpatient psychiatric unit, a 1,200-physician medical group, a 1,700-physician medical network, 32l outpatient clinics and a managed care plan serving 648,000 members. Gierlinger's background is in hotel and hospitality management and he directs service quality for the system. Beaudoin has been at Henry Ford for 24 years in marketing. She oversees its Internet outreach strategy including patient and employee portals and service line websites, and she launched the organization's customer relations strategy in 2004. In 2011, Henry Ford won a Malcolm Baldrige national quality award.
Gierlinger: With value-based purchasing, service isn't just a nice thing to have anymore, it is now a necessity; it is an essential part of overall quality. We were working toward the Baldrige award for several years, with Denise leading Category 3, Customer Focus, while we opened a new facility at West Bloomfield that was our service innovation lab, staffed with leaders from the hotel and restaurant industry. So right out of the gate, our Press Ganey scores were in the top decile and we have remained there. Part of the process was to create a corporate department to systematize the best practices developed at Bloomfield and lead culture change across the organization. What works at a 193-bed suburban facility may not work at an 800-bed tertiary referral center downtown. You have to pick what can be deployed and drive improvement from within. We are a diverse system and the challenges are different in each area.
Beaudoin: We are accountable to senior leadership to share best practices across the organization, but they are not implemented the same everywhere. For example, leadership rounding is done in every facility, but the tactics in the units are a little different. Some use managers and above, some use supervisors and above; some are weekly, some are twice a month. But the goals and strategies are the same.
Gierlinger: As part of best-practice searching, we benchmarked our operations against UCLA [Health System]. We invited its CEO, Dr. David Feinberg, to speak at a retreat where he addressed 1,200 leaders across the system. Later we visited UCLA and adopted its model of rounding, but created our own version.
Beaudoin: External benchmarking has helped us improve. Before, we had seen improvement in satisfaction scores, but they plateaued. With VBP we don't want to stand still, we need to keep moving forward. What a CXO does is set aggressive targets for the organization and provide tools and support to help individual units achieve them.
Kurt Knoth | vice president of performance improvement and patient affairs, Spectrum Health, Grand Rapids, Mich. | Knoth joined Spectrum last year as head of performance improvement and then took on patient satisfaction and experience operations for the system's nine hospitals, 1,500 physicians and extensive long-term care, home care and clinic services across western Michigan. Prior to joining Spectrum, Knoth was a health care consultant.
I truly believe that if we do not view process improvement and performance improvement through the lens of patient experience, we are missing the point of why we are here. Based on where health care is going, it makes sense to have an executive focus on patient experience as is done with clinical quality and safety. It is not just ACOs and reform, it plays into reimbursement. Every other industry in the world is judged on customer satisfaction, so why shouldn't health care?
When you think about the kinds of things that drive patients crazy, it makes sense to have a process improvement guy in charge of patient affairs. It is kind of a complaint department, handling everything from "I fell and got injured" to "gosh, I don't like the selection of coffee flavors in the cafeteria." We have five RNs working in the hospitals monitoring complaints on a day-to-day basis and it all feeds back systematically to the process improvement department. Having clinical people involved in the process helps, because they know the clinical standards and can ensure they are followed, as well as provide education to the patient and family.
On the other side, we have the center for exceptional experience, which has internal consultants who are also nurses. They work with operational leaders based on Press Ganey and HCAHPS patient experience data. They work with units that fall below our standards, helping them to improve. Sometimes it is scripting for how patients are greeted. In health care we do many things that may make sense clinically, yet are confusing, scary or overwhelming to patients and families. The team works to help leaders and teams communicate what they are doing and why. Things like excessive wait times get kicked to process improvement, where we figure out what can be done to improve patient flow.
It couldn't be done without top management's support. Changing culture requires changing behavior. Our senior system leaders preach patient experience all the time, and down one level, the hospital presidents are totally on board.
Darlene Cox | administrator, patient care services at Hackensack University Medical Center, N.J. | Cox took over in January as head of patient experience activities at HUMC, a 775-bed academic facility with 2,200 affiliated physicians. She is a former chief nursing officer and CEO of a community hospital and an academic medical center, and was a White House Fellow in 1991–92.
We have not only a fiscal imperative on quality and safety, we have a relationship imperative as well. Patient experience strategy, with HCAHPS as a reference, must be aligned with clinical quality and patient safety strategies to ensure not only that patients will refer others to us, but also will return themselves.
I work with the CMO, COO, CNO and the chief strategy officer to ensure that their operations and strategies are aligned with a service agenda. The entire organization is expected to engage with the patient experience objective, and I work with everyone from the board to middle managers to make that happen. I present and work with clinical departments and physicians, but also support departments including environmental services, transport, nutrition and dietary, guest services, telecommunications, business office — everyone who touches the patient.
It is all data-driven. We use the Press Ganey priority index to identify the best opportunities for improvement. Every department is expected to develop an action plan and report on it. It helps us to identify areas that are not getting the outcomes we need, so we can redouble our efforts in coaching and helping them define strategies to get there.
This is also about improving clinical outcomes. You have a designated time with patients, and you make the biggest impact by being clear about their problems, what they can expect from you as a provider, what they need to do to help themselves, and how to navigate the system after they leave the hospital or office. This can help prevent relapses and readmissions. Improving the patient experience also improves care, patient safety and clinical and financial outcomes. That is the real agenda — pulling together with the patient to make the best possible experience, not just subjectively, but objectively.
Diane Stover | chief patient experience and marketing officer, Beacon Health System, South Bend, Ind. | Stover directs marketing and patient experience strategy for two hospitals operating 1,000 beds, 1,000 affiliated physicians and health care facilities in north central Indiana and south Michigan. She is a certified experience economy expert and worked as chief innovation officer at Memorial Health System, one of Beacon's predecessors. She is co-author, with Memorial CEO Phil Newbold, of Wake Up and Smell the Innovation! Stirring up a Return on Imagination (Networlding Publishing, 2011).
We don't want satisfied patients, we want raving fans. So we have developed a strategy around exceptional experience. I developed the first draft, then got input from clinical people and took it back to the C-suite, and they approved it. I take it to the departments and they make plans to fulfill it.
I make recommendations based on experience and insight, but it takes input from everyone, even for things that seem simple. In reviewing our obstetrics program, we asked our valet parkers what they say to new parents leaving the hospital with their baby. They are the last employees the patient sees. Some said, "Drive safe, take care of that baby," but one said, "See you in nine months." No one ever told them what to say, so they made it up.
We decided to write a script. After going back and forth, we came up with "Take care of that beautiful baby." But a nurse said, if you say "beautiful" and the baby has a cleft palate, they might think you are being sarcastic. So we changed it to "Take care of that precious baby." Drilling down helped them understand how important they are and how powerful their words can be. Everyone needs to be involved in creating a positive patient experience.
Nine steps to superior patient experience
1. Hire and retain exceptional staff.
Look at hiring prospects through a patient experience lens. If you hire someone who is not capable of providing a good experience, it can be hard to get rid of that employee.
2. Create clear expectations for exceptional service.
In areas covered by surveys, goals may be quite clear. In others, concrete performance measures should be developed and tracked.
3. Provide access to materials to help staff understand the science and tools of creating exceptional experience.
These may include in-house facilitators and consultants as well as books and online resources from such sources as authors B. Joseph Pine and James H. Gilmore.
4. Recognize and benchmark successful departments.
It will encourage continued excellence and enable others to benefit from in-house expertise.
5. Coach and provide resources to struggling departments.
Use people familiar with experience improvement science. Lay out the issues honestly and make a correction plan. Hold workshops and reward performance gains.
6. Gather customer insights through multiple channels.
Use focus groups, community advisory groups and monitor complaints made directly to the organization or indirectly through social media or reviews.
7. Commit to never walking past an unsafe situation or unsatisfactory patient service.
Apply your own experience to judge if what you're seeing qualifies as excellent treatment, and speak up if it doesn't.
8. Review policies and procedures to ensure they are patient-friendly.
For example, one hospital began closing its cashier window early on weekends to save money, and missed a patient looking to settle a $17,000 account in cash.
9. Learn from industries outside health care.
Many are far ahead in customer service.
Source: Diane Stover, chief patient experience and marketing officer, Beacon Health System