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James I. Merlino is a colorectal surgeon and the chief experience officer at the Cleveland Clinic. Ananth Raman is the UPS Foundation Professor of Business Logistics at Harvard Business School. HEALTH CARE'S SERVICE FANATICS How the Cleveland Clinic leaped to the top of patient-satisfaction surveys by James I. Merlino and Ananth Raman THE CLEVELAND CLINIC has long had a reputation for medical excel- lence and for holding dov^in costs. But in 2009 Delos "Toby" Cos- grove, the CEO, examined its performance relative to that of other hospitals and admitted to himself that inpatients did not think much of their experience at its flagship medical center or its eight community hospitals—and decided something had to be done. Over the next three years the Clinic transformed itself. Its overall ranking in the Centers for Medicare & Medicaid Services (CMS) sur- vey of patient satisfaction jumped from about average to among the top 8% of the roughly 4,600 hospitals included. Hospital executives from all over the world now flock to Cleveland to study the Clinic's practices and to leam how it changed. The Clinic's journey also holds lessons for organizations outside health care—ones that until now have not had to compete by cre- ating a superior experience for customers. Such enterprises often have workforces that were not hired with customer satisfaction in mind. Can they improve the customer experience without jeopar- dizing their traditional strengths? The Clinic's success suggests that they can. The Cleveland Clinic's transformation involved actions any organization can take. Cosgrove made improving the patient ex- perience a strategic priority, ultimately appointing James Merlino, a prominent colorectal surgeon (and a coauthor of this piece), to io8 Harvard Business Review May 2013

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Page 1: HEALTH CARE'S SERVICE FANATICS - UW Dept of Surgery Cares Serv… · io8 Harvard Business Review May 2013. n. HEALTH CARE'S SERVICE FANATICS lead the efiFort. ... number of breakthrough

James I. Merlino is acolorectal surgeon and thechief experience officer atthe Cleveland Clinic.

Ananth Raman is the UPSFoundation Professor ofBusiness Logistics at HarvardBusiness School.

HEALTH CARE'SSERVICE FANATICS

How the Cleveland Clinic leaped tothe top of patient-satisfaction surveysby James I. Merlino and Ananth Raman

THE CLEVELAND CLINIC has long had a reputation for medical excel-lence and for holding dov in costs. But in 2009 Delos "Toby" Cos-grove, the CEO, examined its performance relative to that of otherhospitals and admitted to himself that inpatients did not thinkmuch of their experience at its flagship medical center or its eightcommunity hospitals—and decided something had to be done.Over the next three years the Clinic transformed itself. Its overallranking in the Centers for Medicare & Medicaid Services (CMS) sur-vey of patient satisfaction jumped from about average to among thetop 8% of the roughly 4,600 hospitals included. Hospital executivesfrom all over the world now flock to Cleveland to study the Clinic'spractices and to leam how it changed.

The Clinic's journey also holds lessons for organizations outsidehealth care—ones that until now have not had to compete by cre-ating a superior experience for customers. Such enterprises oftenhave workforces that were not hired with customer satisfaction inmind. Can they improve the customer experience without jeopar-dizing their traditional strengths? The Clinic's success suggests thatthey can.

The Cleveland Clinic's transformation involved actions anyorganization can take. Cosgrove made improving the patient ex-perience a strategic priority, ultimately appointing James Merlino,a prominent colorectal surgeon (and a coauthor of this piece), to

io8 Harvard Business Review May 2013

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lead the efiFort. By spelling out the problems in a sys-tematic, sustained fashion. Merlino got everyone inthe enterprise—including physicians who thoughtthat only medical outcomes mattered—to recognizethat patient dissatisfaction was a significant issueand that all employees, even administrators andjanitors, were "caregivers" who should play a role infixing it. By conducting surveys and studies and so-liciting patients' input, the Clinic developed a deepunderstanding of patients' needs. It gave MerUno adedicated staff and an ample budget with which tochange mind-sets, develop and implement processes,create metrics, aind monitor performance so that theorganization could continually improve. And it com-municated intensively with prospective patients toset realistic expectations for what their time in thehospital would be like.

These steps were not rocket science, but theychanged the organization very quickly. What's more,fears expressed by some physicians that the initia-tive might conflict with efforts to maintain high qual-ity and safety standards and to further reduce coststurned out to be unfounded. During the transforma-tion the Clinic rose dramatically in the UniversityHealthSystem Consortium's rankings of 97 academicmedical centers on quality and safety. Its efficiency indelivering care improved as well.

Founded in 1921 with a single site, the ClevelandClinic has long been one of the most prestigious

From Mediocreto Top TierIn a U.S. government survey, the proportionof patients who gave the Cleveland Clinic'sflagship center the highest possible score foroverall satisfaction has jumped in recent years.It no\N ranks in the 92nd percentile among theroughly 4,600 hospitals surveyed.

OVERALLSATISFACTIONCLEVELAND CLINIC'SPERCENriLE RANKING

2008 2009 2010 2011 2012

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medical centers in the United States. It has pioneeredmany procedures (including cardiac catheterization,open-heart bypass, face transplant, and deep-brainstimulation for psychiatric disorders) and made anumber of breakthrough discoveries (identifyinggenes linked to juvenile macular degeneration andto coronary artery disease, for example). It expandedaggressively in the late 1990s and is now one of thelargest nonprofit health care providers in the UnitedStates. In addirion to its 1,200-bed main hospitaland its community hospitals, it has 18 family healthcenters throughout northeastern Ohio; a tertiary-care hospital in Weston, Florida; a brain treatmentcenter in Las Vegas; and operations in Canada, AbuDhabi, and Saudi Arabia. In 2012 its 43,000 employ-ees treated 1.3 million people, including more than50,000 inpatients at the main campus.

For most of the Clinic's history, providing patientswith an excellent overall experience—in areas suchas making appointments, offering a pleasant physi-cal environment, addressing their fears and concernsduring their stays, and providing clear discharge in-structions—was not a priority. Like most hospitals,especially prestigious ones, the Clinic focused almostsolely on medical outcomes. It took great pride thatU.S. News & World Report repeatedly ranked it amongthe top five U.S. hospitals for overall quality of careand listed its heart program as number one.

In 2007 the Clinic adopted a new care model in aneffort to improve collaboration and thereby increasequality and efficiency and reduce costs. It abandonedthe traditional hospital structure, in which a depart-ment of medicine supervises specialties such as car-diology, pulmonology, and gastroenterology whilea department of surgery oversees general surgeryalong with cardiac, transplant, and other specialtyprocedures. Instead it created institutes in whichmultidisciplinary teams treat all the conditions af-fecting a particular organ system. Its heart and vascu-lar institute, for example, includes everything havingto do with the heari and circulatory systems (cardiacsurgery, cardiology, vascular surgery, and vascularmedicine), and cardiologists and surgeons see pa-tients together. The new model had positive effectsnot only on quality and costs but also on the patientexperience.

Certain developments, though, soon led theClinic's leadership to realize that these changes andaccomplishments would not suffice. In 2008, to helpconsumers make more-informed choices and to en-courage hospitals to improve care, the CMS began

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Organizations that havenot had to compete byoffering great customerservice but suddenly findthat they must do sooften face a challenge:They have a culture, em-ployees, and processesill-suited to the task.

But the Cleveland Clinic's

success in transforming itself

shows that it can be done. In

just a few years the Clinic went

from having mediocre patient-

satisfaction scores to rising

to the upper echelons of U.S.

hospitals.

Its CEO made improving pa-

tients' experiences a strategic

priority. He appointed a promi-

nent physician—an insider who

commanded the respect of

other physicians (a key interest

group)—to lead the effort and

gave him ample resources:

a staff that now numbers 112

people.

The initiative, which is still

under way, is having an addi-

tional benefit: helping the Clinic

improve quality, safety, and

efficiency.

making the scores in its satisfaction survey and com-parative data on the quality of care publicly availableonline. It Einnounced that starting in 2013, roughly$1 billion in Medicare payments to hospitals wouldbe contingent on performance in these areas, and theamount at risk would double by 2017.

CMS satisfaction scores are based on randomlyselected patients' postdischarge responses to ques-tions about how well doctors and nurses communi-cated with them, whether caregivers treated themwith courtesy and respect, the staff's responsivenessto the call button, how well their pain was controlled,and the cleanliness of the room and bathroom,among other things. Patients are also asked to givethe hospital an overall rating and to say whether theywould recommend it to friends and family (see theexhibit "From Mediocre to Top Tier").

The Clinic's overall score was just average thatyear, and its performance in some areas was down-right dismal: It ranked in the bottom 4% for staff re-sponsiveness and room cleanliness, 5% for whetherthe area near a patient's room was quiet at night,14% for doctors' communication skills, and 16% fornurses' communication skills. "Patients were comingto us for the clinical excellence, but they did not likeus very much," Cosgrove says. And from stories he'dheard from patients and their families and consumerresearch he had read, he realized that he couldn'tcount on medical excellence to continue attractingpatients—for many people choosing a hospital, theanticipated patient experience trumped medical ex-cellence. He decided to make improving the patientexperience an enterprisewide priority.

Leading the ChangeCosgrove understood that to achieve that goal, theClinic would need to significantly change how it op-erated. Getting employees to modify their mind-setsand behaviors wouldn't be easy. In recent years cost

pressures had forced hospitals to cut support staffeven as medical complexity and regulatory demandsincreased. Launching an initiarive that would add tothe burden would be challenging. Obtaining buy-infrom physicians would be especially difficult. TheClinic differs from many hospitals in that its physi-cians are employees, but they wield more power thanemployees often do. Many are superstars in their spe-cialties; they are a major reason—maybe the reason-patients choose the Clinic. Cosgrove couldn't expectto issue an edict and have them salute and obey.

For all those reasons, he decided to create a newposition, chief experience officer. He initially ap-pointed an outsider who was not a practicing physi-cian. She left after 24 months. He then decided to callon a senior physician from inside the organization—someone who would fiilly understand the challengesof delivering a great patient experience while alsofocusing on medical outcomes and who would haveimmediate credibility. He chose Merlino.

Merlino had recently moved his practice from theMetroHealth Medical Center, a large county hospitalin Cleveland, to the Clinic, where he'd held a fellow-ship earlier in his career. He was already working onmaking the digestive disease institute a "patient-centered" organization. Before building his surgicalpractice, he had worked in government administra-tion and in political public-opinion research and hadserved on a community hospital's board.

During his interview with Cosgrove, Merlino tolda story about his father, who had been a patient atthe Clinic several years earlier. That experience hadbeen terrible: Among other things, his father feltthat the nurses had been unresponsive, and his phy-sician had not always seen him daily. He had died inthe hospital thinking it was the worst place in theworld. "Nobody else should die here believing that,"Merlino said. Both men admitted they didn't knowwhat accomplishing that goal would take. "We will

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need to figure it out together," Merlino told the CEO.Twenty minutes after the interview, Cosgrove's chiefof staff called Merlino to offer him the job, askinghim to devote 50% ofhis time to the initiative (henow devotes 80%).

To help carry out the mandate, Cosgrove gaveMerlino the Office of Parient Experience, which cur-rently has a $9.2 million annual budget and 112 peo-ple, including project managers, data experts, andservice excellence trainers. Its responsibilities in-clude conducting and analyzing patient surveys, in-terpreting patients' complaints, administering "voiceof the patient" advisory councils, training employees,and working with units to identify and fix problems.

Publicly Acknowledging the ProblemGetting employees to take the new mandate seri-ously was a considerable challenge. Doctors and

nurses typically focus on performing procedures andtreatments and often fail to explain them fully and interms patients can understand. The Clinic's caregiv-ers were no different.

Ignorance and cost pressures presented twoother obstacles. Employees at most hospitals areunaware of CMS scores or don't believe they mat-ter all that much, and they don't understand how toimprove the patient experience. Some executivesbelieve incorrectly that amenities like better foodand bigger TVs are the key, and others are reluctantto invest scarce funds in a major change program. Inthese areas, too, the Clinic was no exception.

One of the OPE's first projects under Merlinowas to broadly publicize the detailed results of theCMS survey—both for the Clinic as a whole and forindividual units. This was Cosgrove's idea. Beforebecoming CEO, Cosgrove had led the departmentof cardiothoracic surgery, and he had been taskedwith improving the department's surgical outcomes.One method he'd found efifective was releasing out-comes data on every surgeon and program so thatall could see how their performance compared withthat of others. He hoped that publicizing the CMSdata would have a similar effect. In one sense, itdid: Employees were shocked by the scores and un-derstood that the problem was important. But theywere confused about what they could do personallyto raise them.

Understanding Patients' NeedsMerlino recognized that to drive meaningful change,he had to create a strategy and a plan for executingit. To measure progress, he decided to rely on themetrics used in the CMS satisfaction surveys—theHospital Consumer Assessment of Healthcare Pro-viders and Systems. This was an easy choice: TheCMS data had credibility, they were available onlineto consumers, and hospitals' Medicare reimburse-ments would soon be affected by them. But theindustry's understanding of why patients gradedhospitals as they did—of what patients' underlyingneeds were—was limited.

The Clinic had tried to make itself more appeal-ing to patients by doing things like having greetersat the door, redesigning its gowns, and improvingfood services. But these amenities were superficialefforts—and shots in the dark. It was unclear which,if any, affected the CMS scores.

MerUno saw that if the patient experience was go-ing to be a strategic priority, employees had to under-

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Stand exactly what it meant and what each person'sresponsibility for delivering it entailed. He crafted abroad, holistic definition: The patient experience waseveryone and everything people encountered fromthe time they decided to go to the Clinic until theywere discharged. The effort to improve it becameknown as "managing the 360."

Although institutions talk a lot about the impor-tance of empathy in delivering good care, they actu-ally have little knowledge of what patients experi-ence as they navigate health care, except for theirinteractions with doctors and nurses. So Merlinocommissioned two studies. The first involved a ran-domly selected group of former patients who hadtaken the CMS survey by phone. Researchers fol-lowed up with them, asking why they'd answeredeach question the way they had. The second was ananthropological examination of a nursing unit thathad received some of the Clinic's worst scores in theCMS survey. Researchers observed interactions be-tween parients and employees and questioned bothparties about things that happened.

The studies produced a number of findings. Al-though several problem areas were not especiallysurprising, it was clear that employees did not alwayskeep them in mind. Patients did not want to be in thehospital. They were afraid, sometimes terrified, oftenconfused, and always anxious. They wanted reassur-ance that the people taking care of them really under-stood what it was like to be a patient. Their familiesfelt the same way.

Patients also wanted better communication: Theywanted information about what was going on in theirenvironment and about the plan of care; they wantedto be kept up-to-date even on minute activities. Andthey wanted better coordination of their care. Whennurses and doctors did not communicate with oneanother, patients were left feeling that no one wastaking responsibility for them.

The studies also revealed that patients often usedproxies in their ratings: If the room was dirty, for ex-ample, they might take it as a sign that the hospitaldelivered poor care. Another striking finding wasthe importance of doctors' and nurses' demeanor.Patients tended to be more satisfied when their care-givers were happy. It wasn't that they craved interac-tions with happy employees; rather, they believedthat if their caregivers were unhappy, it meant eitherthat the patient was doing something to make themfeel that way or that something was going on thatthey did not want to reveal.

Making Everyone a CaregiverAt most hospitals the primary relationship is consid-ered to be between the doctor and the patient; therest of the staff members see themselves in support-ing roles. But in the eyes of patients, all their interac-tions are important.

To understand how many people a patient typi-cally encounters. Merlino asked one patient—awoman undergoing an uncomplicated colorectalsurgery—to keep a journal of everyone who caredfor her during her five-day stay. It turned out thatthere were eight doctors, 60 nurses, and so manyothers (phlebotomists, environmental service work-ers, transporters, food workers, and house staff) thatthe patient lost track. Few of her 120 hours at theClinic were spent with physicians. Moreover, herjoumal did not even take into account employees innondinical areas, such as billing, marketing, parking,and food operations—people who did not interactdirectly with her but might have had a big impacton her stay. Merlino realized that all employees arecaregivers, and that the doctor-centric relationshipshould be replaced by a caregiver-centric one.

To get everyone in the organization to start think-ing and acting accordingly. Merlino proposed hav-ing all 43,000 employees participate in a half-dayexercise. Randomly assembled groups of eight to10 people would meet around a table with a trainedfacilitator—a janitor might be seated between aneurosurgeon and a nurse. All would participate ascaregivers, sharing stories about what they did—andwhat they could do better—to put the patient firstand to help the Clinic deliver world-class care. Theywould also be trained in basic behaviors practiced byworkers at exemplary service organizations: smil-ing; telling patients and other staff members theirnames, roles, and what to expect during the activityin question; actively listening to and assisting pa-tients; building rapport by learning something per-sonal about them; and thanking them. The cost of thehalf-day program, including the employees' salaries,would be $11 million.

Cosgrove embraced the idea, but some membersof the executive team were skeptical. Physicians onthe team believed that doctors would never go alongwith the plan and should not have to take time fromtheir busy schedules. The head of nursing at the timeworried about the impact on productivity of takingnurses away from the floor and questioned whetherit could be justified without a quantifiable ROI. Cos-grove listened to the discussion in silence and then

HOW THE CLEVELANDCLINIC STACKS UPTHE CLINIC'S PERCENTILERANKING AMONG HOSPITALSSURVEYED FOR THE PROPORTIONOF PATIENTS WHO GAVE THEIRINSTITUTION THE HIGHESTPOSSIBLE SCORE

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HOW THE CLEVELANDCLINIC STACKS UPTHE CLINIC'S PERCENTILERANKING AMONG HOSPITALSSURVEYED FOR THE PROPORTIONOF PATIENTS WHO GAVE THEIRINSTITUTION THE HIGHESTPOSSIBLE SCORE

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spoke. Making any exceptions, he said, would un-dermine one of the program's main aims: to elimi-nate the divide between doctors and the rest of thestaff and create a unified culture in which everyoneworked together to do what was best for the patients.And yes, the ROI was unclear. "But what will be thecost [for patients and the organization] of not pro-ceeding?" he asked. The executive team acquiesced.

The program was launched in late 2010. It tooka full year for everyone to go through it. A handfulof physicians asked to be excused but were refused.As hoped, the program had a profound impact. Non-physician employees were amazed by the experienceof sitting with doctors and discussing how they, too,were caregivers. Participants shared frustrationsabout not always being able to provide a nurturingenvironment. Even doctors who had been skepticalabout the exercise felt it was worthwhile.

Embedding ChangesTo continue to drive change and to permanently al-ter how people performed their jobs, the Glinic insti-tuted a number of other measures:

Identifying problems. Merhno put in placesystems to track and analyze patients' attitudes andcomplaints and to determine and address the rootcauses of problems. Like many hospitals, the Glinichad used a similar approach to improve safety. Ap-plying the methodology to issues like dirty rooms,noisy environments, and patient-caregiver commu-nication was not a big leap. In addition, the Clinic'sbusiness intelligence department set up electronicdashboards that displayed real-time data availablefor all managers to view.

Establishing processes and norms. Merlinocreated a "best practices" department within theOPE to identify, implement, promote, and monitorapproaches used by top performers in the CMS sur-vey. In many cases it tested practices in pilot projectsbefore rolling them out broadly.

Some efforts were relatively simple. For example,one program reinforced the basic behaviors taught inthe half-day exercise. As part of the program, man-agers monitored their employees and coached thosewho were falling short.

A related initiative tEirgeted prospective patients-people deciding where to go for care. A commoncomplaint of potential patients who'd opted to goelsewhere was that the Clinic was too big and wasdifficult to access; people needed a special connec-tion—"to know someone"—to get an appointment.

So Cosgrove mandated that all patients have the op-tion of getting an appointment the same day theycalled, making the Clinic the first major U.S. pro-vider to offer this service. It created a single phonenumber for booking appointments, and centralizedscheduling across the enterprise. When patientscalled the dedicated number, operators were trainedto say, "Thank you for calling the Cleveland Clinic.Would you like to be seen today?" A television andradio advertising campaign, "Today," promoted thenew service and sent a clear message that the Clinicwould help patients with anything they needed, notjust complicated conditions. The campaign was anovernight success: During the first year, visits bynew patients increased by 20%. Same-day appoint-ments now account for more than one million pa-tient visits a year.

Another common complaint was that despite thecreation of the multidisciplinary institutes, caregiv-ers did not communicate or coordinate well with oneanother. Merlino decided to begin addressing thisproblem by testing a process to determine the rootcauses of communication breakdowns in each unit;remedies would then be devised on a case-by-casebasis. He commissioned a study of the weekly hud-dles of critical floor leaders, selecting for the pilot afloor with one of the hospital's worst scores in theCMS survey. A team consisting of the floor's nursemanager; its assistant nurse manager; a physicianfrom the specialty that had the most patients on thefloor; the environmental services supervisor (whooversaw housekeeping); the case manager respon-sible for discharge, insurance, and at-home needs; asocial worker; and a representative from the Ofliceof Patient Experience began meeting each week todiscuss patient complaints and concems.

It quickly identified several problems. First, thesocial worker and the case manager—employeescritical to ensuring a smooth discharge process-did not like each other and never talked. The floor,which conducted a large volume of gastroenterol-ogy and radiology procedures, constantly ran be-hind schedule. Patients ordered to have no food ordrink before a procedure might go hungry all day ifthe procedure was delayed; even worse, procedureswere sometimes postponed until the next day with-out the patient's being informed—leaving him or hernot just hungry but confused. Finally, doctors didnot always communicate with nurses after rounds,so nurses were often unaware of the plans for theirpatients' care that day.

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These problems were not difficult to fix. Most ofthem were addressed by instituting simple processesto surface issues, get people to work better together,and keep patients informed about what was going on.For example, the weekly huddles forced caregiversto communicate regularly with their colleagues, in-cluding ones they did not particularly like. The fioor'sscores in the CMS survey went from among the low-est in the hospital to the highest in less than a month.

Another area that was hurting the Clinic in theCMS survey was nursing rounds. Rounding on pa-tients hourly is an established best practice that im-proves safety, quality, and patient satisfaction. Butas of 2010 the Clinic did not require hourly rounds;some units conducted them, some didn't. The unitsthat did had higher patient-experience scores, andwhen the Clinic's leaders learned of the correlation,they decided to launch a pilot project in the heart andvascular institute under the direction of K. Kelly Han-cock, who was then its nursing director and is nowthe Clinic's executive chief nursing officer.

For a period of 90 days, the nurses or nursing as-sistants on designated floors were required to seepatients every hour and to ask them five questions:Do you need anything? Do you have any pain? Do youneed to be repositioned? Do you need your personalbelongings moved closer to you? Do you need to go

to the bathroom? They had to fill out sheets verifyingthat they had done this. Nurse managers held spotaudits, and patients being discharged were askedif the rounds had been performed. Some 4,000 pa-tients in all were involved, and the results were strik-ing. The units that always completed the roundsranked in the top 10% in the nursing-related parts ofthe CMS survey; the units that conducted rounds in-consistently scored much lower. The units that neverconducted hourly rounds ranked in the bottom 1% ofall hospitals. So Cosgrove mandated hourly roundsacross the institution.

Engaging and motivating employees. Theleaders of the Clinic knew that to improve the patientexperience while continuing to drive safety and qual-ity, it would need engaged, satisfied caregivers whounderstood and identified with its mission: provid-ing exemplary care by excelling in specialized care;developing, applying, evaluating, and sharing newtechnology; attracting the best staff; excelling in ser-vice; and providing efficient access to affordable care.A 2008 Gallup survey of employee engagement athealth care organizations highlighted the magnitudeof the problem in this regard: The Clinic placed onlyin the 38th percenule.

One step taken to address this problem was thelaunching of a "caregiver celebration" program. This

HOW THE CLEVELANDCLINIC STACKS UPTHE CLINIC'S PERCENTILERANKING AMONG HOSPITALSSURVEYED FOR THE PROPORTIONOF PATIENTS WHO GAVE THEIRINSTITUTION THE HIGHESTPOSSIBLE SCORE

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HOW THE CLEVELANDCLINIC STACKS UPTHE CLINIC'S PERCENTILERANKING AMONG HOSPITALSSURVEYED FOR THE PROPORTIONOF PATIENTS WHO GAVE THEIRINSTITUTION THE HIGHESTPOSSIBLE SCORE

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allowed both managers and frontline workers to rec-ognize colleagues who had done something excep-tional for patients or for the organization. Recogni-tion made employees eligible for monetary awardsof varying amounts, culminating in the $25,000 CEOAward of Excellence, presented to the top caregiverand team members at an annual ceremony.

More broadly. Merlino, Cosgrove, and othermembers ofthe executive team recognized that theyneeded to make a substantial investment in develop-ing and managing the workforce. They saw that theorganization's 2,300 managers needed to be edu-cated in how to increase the engagement of mem-bers of their teams. All managers are now required toattend a daylong session every three or four months,during which they are trained in such things as emo-tional intelligence, communicating and implement-ing change, and enhancing engagement. They mustsubmit annual plans for how they will improve theengagement and satisfaction ofthe people they man-age (actions might include discussing job expecta-tions more frequently, improving communicationabout activities in the department or the Clinic, andensuring that employees have the resources neededto perform their jobs). Such steps helped the Clinicmove up to the 57th percentile in the Gallup survey.Although this is progress. Clinic leaders recognizethat it is not nearly enough.

Setting Patients' ExpectationsThe patient is not always right: Sometimes patientshave desires whose fulfillment would not be in theirbest interests. Here's a case in point: Patients under-standably prefer not to be disturbed at night. Butsometimes they must be awakened in order to begiven medication, to have a procedure performed,or to have their vital signs checked. Because somepatients at the CHnic did not understand the reasonsfor such disturbances, they were critical when askedin the CMS survey whether their rooms had beenquiet at night.

Similarly, the OPE discovered that patients wereupset if they used the call system to ask for a nurse'shelp and did not receive an immediate response-even if their need wasn't pressing. When it probeddeeper, it learned that even when patients recognizedthat their need wasn't urgent, the lack of an immedi-ate response often made them anxious—many fearedthat if there viere an emergency, nobody would come.They didn't know that the person answering calls pri-oritizes them according to the urgency ofthe request.

The Clinic found it could alleviate such problemsby letting patients know before they got to the hospi-tal what to expect while they were there. It createdprinted materials and an interactive online video forincoming patients, describing the hospital environ-ment and procedures and explaining the rationale forthem. It also educated them about pain managementand how to communicate with providers.

In addition. Merlino realized that the Cliniccould enlist patients' help in improving the hospitalexperience. For instance, it began asking patientsin semiprivate rooms to limit nighttime noise. Itstarted to rely more heavily on patients to identifyproblems and improve processes. It now asks pa-tients to report rooms that have not been cleanedproperly and to routinely ask caregivers if they havewashed their hands.

Such measures may seem minor, but the effectsare important, in terms of cost as well as patientsatisfaction. In 2012 salaries, wages, and benefits to-taled 56% ofthe Clinic's operating revenue (suppliesaccounted for just 10%, Pharmaceuticals for 7%). Tohold down costs, hospitals will clearly have to in-crease employee productivity. One approach that hasworked well in retailing and service industries is toencourage customers to perform tasks that employ-ees have traditionally done—for example, bookingairline tickets, checking out of stores, and answeringother customers' questions. If such a process is de-signed empathically, it can enhance patients' experi-ences even as it reduces costs.

HOSPITAL LEADERS may believe that they cannot jus-tify the kinds of programs described here. CMS'slinking of Medicare reimbursement to patient satis-faction should help convince them otherwise. Theyshould also remember this: Changing culture andprocesses to improve the patient experience canlead to substantial improvements in safety and qual-ity. To put it bluntly, a patient-centered approach tocare, which includes giving patients an outstandingexperience, is not an option; it's a necessity.

Despite the Clinic's progress, its leaders know fullwell that they cannot proclaim victory. Some obviousshortcomings, such as the still-modest degree of em-ployee engagement, remain. And at a fundamentallevel, operating a truly patient-centered organizationisn't a program; it's a way of life. Doing the best by pa-tients means continually analyzing what can be donebetter and then figuring out how. There will alwaysbe something. C HBR Reprint RBOSJ

116 Harvard Business Review May 2013