The Minnesota Supreme Court is weighing whether to hear a court case in which a doctor is suing the son of one of his patients for criticisms on a rate-your-doctor website. This case highlights the growing role of social media in medical practice: Patients and relatives of patients now have an unprecedented ability to publicly express dissatisfaction with patient care, and they can affect the reputations of doctors and hospitals.


Medicare's tying reimbursement to patient satisfaction scores (Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS, and pay for performance) is having real consequences for hospitals. Many hospitals are at immediate risk of a significant decrease in reimbursements if they don't improve their patient satisfaction scores. As Medicare is expected to add more than 20 million new patients in the next few years, hospitals must improve their patient satisfaction quotient to be financially successful.

While there is considerable debate about the validity of social media reviews and patient satisfaction scores, there is little doubt that patient satisfaction matters. This issue is complicated by the many factors that drive patient satisfaction, such as physician interaction, nursing support, admissions procedures, outpatient clinical experiences, billing administration and many others. Patient satisfaction is driven more by a hospital's core culture than by any other influence.

Changing Hospital Cultures

Hospital leaders increasingly recognize the connection between their cultures and patient satisfaction, and realize that many roles and people in their organizations are not inherently patient-centric. Some medical specialists, for instance, deliberately objectify patients' conditions, thereby reducing their emotional involvement with the patient. They may believe that objectifying promotes better treatment decisions and protects physicians from the stress of making incorrect decisions or being unable to help a patient. Similarly, administrators have so many processes and procedures to follow that they might feel compelled to focus more on paperwork than on serving patients. There are many elements in hospitals that steer employees away from patient-centric attitudes and behaviors.

Changing hospitals to be more patient-centric requires a significant cultural change, made more difficult by the depth of current attitudes and behaviors and the complexity of hospital processes and financial pressures. For example, physicians are educated to think of themselves as experts in their specialties and are, therefore, often reluctant to adopt new attitudes and behaviors. Changing a hospital's culture is a difficult task.

While many hospital leaders have a long history of effective administration, the challenges of the culture change caused by the pressures for patient satisfaction frequently lie outside their experience. Few are experts on leading significant culture change, and fewer still are aware of the emerging science of cultural change.

New Science of Cultural Change

There are several research breakthroughs in the understanding of organizational and individual learning that have revolutionized leaders' ability to change organizational culture. This science has led to the development of a simple change methodology based on the Four Positives, which have been used effectively for culture change in many other industries and in hospital emergency departments:

  • positive deviance
  • positive images
  • positive practice
  • positive reflection

Positive Deviance

Defining a clear, compelling image of the desired attitudes and behaviors is critical to cultural change. Positive deviants, those few people in a hospital who best exemplify the patient-centric culture, have the expertise needed to define the compelling purpose of patient satisfaction and the operational excellence to achieve the desired outcome.

Action: Identify your positive deviants by asking: "Who are the people I most respect for their ability to satisfy patients while delivering excellent outcomes?" Statistical analysis has shown that the personnel identified by this question are models of the most desirable attitudes and behaviors. You can discover their expertise by asking them why they love their job and what they do that directly supports their love for the job. Their answer to the first question is almost always about achieving a greater social good (their reason for being patient-centric); their answer to the second question is about building operational excellence (their path to mastery for achieving patient satisfaction).

Positive Images

Motivating people to embrace the positive deviant attitudes and behaviors as their own is the next step in changing a culture. The neuroscience of positive images shows that people working in groups who read and discuss the positive deviants' compelling purpose and path to mastery release neurotransmitters that promote increased openness to new ideas and speed learning of new attitudes and behaviors. In addition, if the participants write down their ideas during this discussion, neural resources are shifted from portions of the brain associated with fear and resistance to those associated with a sense of empowerment and control.

Action: Guide hospital work groups to read, discuss and write about the positive deviants' purpose and path to mastery, which generates a groundswell of interest and acceptance. A feeling of grassroots-driven, patient-centric cultural change can be created.

Positive Practice

Positive practice is performing a function with a conscious effort to do so as defined by the positive deviants. Every function of the job is practiced frequently, in the right way, each time it is performed. Cultural change involves specific changes to behaviors and business processes that are learned by practicing a desired function correctly. The positive deviant definition of operational excellence describes how to perform the function for the most positive results, and in ways that align with the desired new culture.

For example, a physician, nurse or administrator may have an exercise that guides him or her to record a comment about the emotional state of a patient during an interaction. This assignment requires the learner to listen carefully to a patient; observe body, voice and language cues; and process the information to form a conclusion about the patient's emotional state. This exercise, combined with many similar exercises, teaches listening skills, and a foundation for empathy is established.

Action: Have hospital work groups use the positive deviant patient satisfaction expertise to define a program on how to learn. The program should have exercises that apply small aspects of the operational excellence in real situations for no more than an hour each week.

Positive Reflection

Cultures change one person at a time, and the most important driver of this type of change is personal reflection. The neuroscience of learning indicates that time spent thinking about performing a function is as important as trying the new attitudes and behaviors. The positive practice produces rich experiences that can be a great source of reflection about the new culture.

Action: Establish an expectation and a process, using focused time in standard weekly staff meetings, to discuss the results of the positive practices. Guide the work groups to discuss what they learned when they tried each positive practice. In addition, establish a process for having people record what they learned from both their personal practice and from the experiences of their colleagues. These reflections on patient satisfaction will drive personal adoption of patient-centric attitudes and behaviors. When enough people are functioning in the desired way, such attitudes and behaviors will result in a patient-centric culture.

The Power of the Four Positives

Regardless of the medical community's range of perspectives on the appropriateness or value of rate-the-doctor social media or the Medicare pay-for-performance policy, both forces will put significant pressure on hospitals for the foreseeable future. The Four Positives can change hospital cultures quickly and effectively to improve patient satisfaction.

William Seidman, Ph.D., is the CEO of Cerebyte Inc., Lake Oswego, Ore. Rick Grbavac, M.B.A, is the vice president of account management at Cerebyte Inc.