Customers

Health Care’s Service Fanatics

by James I. Merlino and Ananth Raman
From the Magazine (May 2013)

Summary.   Reprint: R1305J The Cleveland Clinic has long had a reputation for
medical excellence. But in 2009 the CEO acknowledged that patients did not think
much of their experience there and decided to act. Since then the Clinic has
leaped to the top tier of patient-satisfaction surveys, and it now draws... more

The Cleveland Clinic has long had a reputation for medical excellence
and for holding down costs. But in 2009 Delos “Toby” Cosgrove, 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) survey 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
learn 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 creating
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 jeopardizing 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
experience a strategic priority, ultimately appointing James Merlino, a
prominent colorectal surgeon (and a coauthor of this piece), to lead
the effort. By spelling out the problems in a systematic, sustained
fashion, Merlino got everyone in the enterprise—including physicians
who thought that only medical outcomes mattered—to recognize that
patient dissatisfaction was a significant issue and that all employees,
even administrators and janitors, were “caregivers” who should play a
role in fixing it. By conducting surveys and studies and soliciting
patients’ input, the Clinic developed a deep understanding of patients’
needs. It gave Merlino a dedicated staff and an ample budget with
which to change mind-sets, develop and implement processes, create
metrics, and monitor performance so that the organization could
continually improve. And it communicated intensively with
prospective patients to set realistic expectations for what their time in
the hospital would be like.
These steps were not rocket science, but they changed the
organization very quickly. What’s more, fears expressed by some
physicians that the initiative might conflict with efforts to maintain
high quality and safety standards and to further reduce costs turned
out to be unfounded. During the transformation the Clinic rose
dramatically in the University HealthSystem Consortium’s rankings
of 97 academic medical centers on quality and safety. Its efficiency in
delivering care improved as well.
Founded in 1921 with a single site, the Cleveland Clinic has long been
one of the most prestigious medical centers in the United States. It
has pioneered many procedures (including cardiac catheterization,
open-heart bypass, face transplant, and deep-brain stimulation for
psychiatric disorders) and made a number of breakthrough
discoveries (identifying genes linked to juvenile macular degeneration
and to coronary artery disease, for example). It expanded aggressively
in the late 1990s and is now one of the largest nonprofit health care
providers in the United States. In addition to its 1,200-bed main
hospital and its community hospitals, it has 18 family health centers
throughout northeastern Ohio; a tertiary-care hospital in Weston,
Florida; a brain treatment center in Las Vegas; and operations in
Canada, Abu Dhabi, and Saudi Arabia. In 2012 its 43,000 employees
treated 1.3 million people, including more than 50,000 inpatients at
the main campus.
For most of the Clinic’s history, providing patients with an excellent
overall experience—in areas such as making appointments, offering a
pleasant physical environment, addressing their fears and concerns
during their stays, and providing clear discharge instructions—was
not a priority. Like most hospitals, especially prestigious ones, the
Clinic focused almost solely on medical outcomes. It took great pride
that U.S. News & World Report repeatedly ranked it among the top
five U.S. hospitals for overall quality of care and listed its heart
program as number one.
In 2007 the Clinic adopted a new care model in an effort to improve
collaboration and thereby increase quality and efficiency and reduce
costs. It abandoned the traditional hospital structure, in which a
department of medicine supervises specialties such as cardiology,
pulmonology, and gastroenterology while a department of surgery
oversees general surgery along with cardiac, transplant, and other
specialty procedures. Instead it created institutes in which
multidisciplinary teams treat all the conditions affecting a particular
organ system. Its heart and vascular institute, for example, includes
everything having to do with the heart and circulatory systems
(cardiac surgery, cardiology, vascular surgery, and vascular medicine),
and cardiologists and surgeons see patients together. The new model
had positive effects not only on quality and costs but also on the
patient experience.
Certain developments, though, soon led the Clinic’s leadership to
realize that these changes and accomplishments would not suffice. In
2008, to help consumers make more-informed choices and to
encourage hospitals to improve care, the CMS began making the
scores in its satisfaction survey and comparative data on the quality of
care publicly available online. It announced that starting in 2013,
roughly $1 billion in Medicare payments to hospitals would be
contingent on performance in these areas, and the amount at risk
would double by 2017.
CMS satisfaction scores are based on randomly selected patients’
postdischarge responses to questions about how well doctors and
nurses communicated with them, whether caregivers treated them
with courtesy and respect, the staff’s responsiveness to 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
give the hospital an overall rating and to say whether they would
recommend it to friends and family (see the exhibit “From Mediocre
to Top Tier”).
From Mediocre to Top Tier

In a U.S. government survey, the proportion of patients

who gave the Cleveland Clinic’s flagship center the
highest possible score for ...

The Clinic’s overall score was just average that year, and its
performance in some areas was downright dismal: It ranked in the
bottom 4% for staff responsiveness and room cleanliness, 5% for
whether the area near a patient’s room was quiet at night, 14% for
doctors’ communication skills, and 16% for nurses’ communication
skills. “Patients were coming to us for the clinical excellence, but they
did not like us very much,” Cosgrove says. And from stories he’d
heard from patients and their families and consumer research he had
read, he realized that he couldn’t count on medical excellence to
continue attracting patients—for many people choosing a hospital,
the anticipated patient experience trumped medical excellence. He
decided to make improving the patient experience an enterprisewide
priority.

How the Cleveland Clinic Stacks Up

The Clinic’s percentile ranking among hospitals surveyed

for the proportion of patients who gave their institution
the highest possible ...

Leading the Change

Cosgrove understood that to achieve that goal, the Clinic would need
to significantly change how it operated. Getting employees to modify
their mind-sets and behaviors wouldn’t be easy. In recent years cost
pressures had forced hospitals to cut support staff even as medical
complexity and regulatory demands increased. Launching an
initiative that would add to the burden would be challenging.
Obtaining buy-in from physicians would be especially difficult. The
Clinic differs from many hospitals in that its physicians are
employees, but they wield more power than employees often do.
Many are superstars in their specialties; they are a major reason—
maybe the reason—patients choose the Clinic. Cosgrove couldn’t
expect to issue an edict and have them salute and obey.
For all those reasons, he decided to create a new position, chief
experience officer. He initially appointed an outsider who was not a
practicing physician. She left after 24 months. He then decided to call
on a senior physician from inside the organization—someone who
would fully understand the challenges of delivering a great patient
experience while also focusing on medical outcomes and who would
have immediate credibility. He chose Merlino.
Merlino had recently moved his practice from the MetroHealth
Medical Center, a large county hospital in Cleveland, to the Clinic,
where he’d held a fellowship earlier in his career. He was already
working on making the digestive disease institute a “patient-
centered” organization. Before building his surgical practice, he had
worked in government administration and in political public-opinion
research and had served on a community hospital’s board.
During his interview with Cosgrove, Merlino told a story about his
father, who had been a patient at the Clinic several years earlier. That
experience had been terrible: Among other things, his father felt that
the nurses had been unresponsive, and his physician had not always
seen him daily. He had died in the hospital thinking it was the worst
place in the world. “Nobody else should die here believing that,”
Merlino said. Both men admitted they didn’t know what
accomplishing that goal would take. “We will need to figure it out
together,” Merlino told the CEO. Twenty minutes after the interview,
Cosgrove’s chief of staff called Merlino to offer him the job, asking
him to devote 50% of his time to the initiative (he now devotes 80%).
To help carry out the mandate, Cosgrove gave Merlino the Office of
Patient Experience, which currently has a $9.2 million annual budget
and 112 people, including project managers, data experts, and service
excellence trainers. Its responsibilities include conducting and
analyzing patient surveys, interpreting patients’ complaints,
administering “voice of the patient” advisory councils, training
employees, and working with units to identify and fix problems.
Publicly Acknowledging the Problem
Getting employees to take the new mandate seriously was a
considerable challenge. Doctors and nurses typically focus on
performing procedures and treatments and often fail to explain them
fully and in terms patients can understand. The Clinic’s caregivers
were no different.
Ignorance and cost pressures presented two other obstacles.
Employees at most hospitals are unaware of CMS scores or don’t
believe they matter all that much, and they don’t understand how to
improve the patient experience. Some executives believe incorrectly
that amenities like better food and bigger TVs are the key, and others
are reluctant to invest scarce funds in a major change program. In
these areas, too, the Clinic was no exception.
One of the OPE’s first projects under Merlino was to broadly publicize
the detailed results of the CMS survey—both for the Clinic as a whole
and for individual units. This was Cosgrove’s idea. Before becoming
CEO, Cosgrove had led the department of cardiothoracic surgery, and
he had been tasked with improving the department’s surgical
outcomes. One method he’d found effective was releasing outcomes
data on every surgeon and program so that all could see how their
performance compared with that of others. He hoped that publicizing
the CMS data would have a similar effect. In one sense, it did:
Employees were shocked by the scores and understood that the
problem was important. But they were confused about what they
could do personally to raise them.
Understanding Patients’ Needs
Merlino recognized that to drive meaningful change, he had to create
a strategy and a plan for executing it. To measure progress, he
decided to rely on the metrics used in the CMS satisfaction surveys—
the Hospital Consumer Assessment of Healthcare Providers and
Systems. This was an easy choice: The CMS data had credibility, they
were available online to consumers, and hospitals’ Medicare
reimbursements would soon be affected by them. But the industry’s
understanding of why patients graded hospitals as they did—of what
patients’ underlying needs were—was limited.
The Clinic had tried to make itself more appealing to patients by
doing things like having greeters at the door, redesigning its gowns,
and improving food services. But these amenities were superficial
efforts—and shots in the dark. It was unclear which, if any, affected
the CMS scores.
Merlino saw that if the patient experience was going to be a strategic
priority, employees had to understand exactly what it meant and
what each person’s responsibility for delivering it entailed. He crafted
a broad, holistic definition: The patient experience was everyone and
everything people encountered from the time they decided to go to
the Clinic until they were discharged. The effort to improve it became
known as “managing the 360.”
Although institutions talk a lot about the importance of empathy in
delivering good care, they actually have little knowledge of what
patients experience as they navigate health care, except for their
interactions with doctors and nurses. So Merlino commissioned two
studies. The first involved a randomly selected group of former
patients who had taken the CMS survey by phone. Researchers
followed up with them, asking why they’d answered each question
the way they had. The second was an anthropological examination of
a nursing unit that had received some of the Clinic’s worst scores in
the CMS survey. Researchers observed interactions between patients
and employees and questioned both parties about things that
happened.
The studies produced a number of findings. Although several problem
areas were not especially surprising, it was clear that employees did
not always keep them in mind. Patients did not want to be in the
hospital. They were afraid, sometimes terrified, often confused, and
always anxious. They wanted reassurance that the people taking care
of them really understood what it was like to be a patient. Their
families felt the same way.
Patients also wanted better communication: They wanted
information about what was going on in their environment and about
the plan of care; they wanted to be kept up-to-date even on minute
activities. And they wanted better coordination of their care. When
nurses and doctors did not communicate with one another, patients
were left feeling that no one was taking responsibility for them.
The studies also revealed that patients often used proxies in their
ratings: If the room was dirty, for example, they might take it as a
sign that the hospital delivered poor care. Another striking finding
was the importance of doctors’ and nurses’ demeanor. Patients
tended to be more satisfied when their caregivers were happy. It
wasn’t that they craved interactions with happy employees; rather,
they believed that if their caregivers were unhappy, it meant either
that the patient was doing something to make them feel that way or
that something was going on that they did not want to reveal.
Making Everyone a Caregiver
At most hospitals the primary relationship is considered to be
between the doctor and the patient; the rest of the staff members see
themselves in supporting roles. But in the eyes of patients, all their
interactions are important.
To understand how many people a patient typically encounters,
Merlino asked one patient—a woman undergoing an uncomplicated
colorectal surgery—to keep a journal of everyone who cared for her
during her five-day stay. It turned out that there were eight doctors,
60 nurses, and so many others (phlebotomists, environmental service
workers, transporters, food workers, and house staff) that the patient
lost track. Few of her 120 hours at the Clinic were spent with
physicians. Moreover, her journal did not even take into account
employees in nonclinical areas, such as billing, marketing, parking,
and food operations—people who did not interact directly with her
but might have had a big impact on her stay. Merlino realized that all
employees are caregivers, and that the doctor-centric relationship
should be replaced by a caregiver-centric one.
To get everyone in the organization to start thinking and acting
accordingly, Merlino proposed having all 43,000 employees
participate in a half-day exercise. Randomly assembled groups of
eight to 10 people would meet around a table with a trained facilitator
—a janitor might be seated between a neurosurgeon and a nurse. All
would participate as caregivers, sharing stories about what they did—
and what they could do better—to put the patient first and to help the
Clinic deliver world-class care. They would also be trained in basic
behaviors practiced by workers at exemplary service organizations:
smiling; telling patients and other staff members their names, roles,
and what to expect during the activity in question; actively listening
to and assisting patients; building rapport by learning something
personal about them; and thanking them. The cost of the half-day
program, including the employees’ salaries, would be $11 million.
Cosgrove embraced the idea, but some members of the executive
team were skeptical. Physicians on the team believed that doctors
would never go along with the plan and should not have to take time
from their busy schedules. The head of nursing at the time worried
about the impact on productivity of taking nurses away from the floor
and questioned whether it could be justified without a quantifiable
ROI. Cosgrove listened to the discussion in silence and then spoke.
Making any exceptions, he said, would undermine one of the
program’s main aims: to eliminate the divide between doctors and the
rest of the staff and create a unified culture in which everyone worked
together to do what was best for the patients. And yes, the ROI was
unclear. “But what will be the cost [for patients and the organization]
of not proceeding?” he asked. The executive team acquiesced.
The program was launched in late 2010. It took a full year for
everyone to go through it. A handful of physicians asked to be
excused but were refused. As hoped, the program had a profound
impact. Nonphysician employees were amazed by the experience of
sitting with doctors and discussing how they, too, were caregivers.
Participants shared frustrations about not always being able to
provide a nurturing environment. Even doctors who had been
skeptical about the exercise felt it was worthwhile.
Embedding Changes
To continue to drive change and to permanently alter how people
performed their jobs, the Clinic instituted a number of other
measures:
Identifying problems.
Merlino put in place systems to track and analyze patients’ attitudes
and complaints and to determine and address the root causes of
problems. Like many hospitals, the Clinic had used a similar approach
to improve safety. Applying the methodology to issues like dirty
rooms, noisy environments, and patient-caregiver communication
was not a big leap. In addition, the Clinic’s business intelligence
department set up electronic dashboards that displayed real-time data
available for all managers to view.

Establishing processes and norms.

Merlino created a “best practices” department within the OPE to
identify, implement, promote, and monitor approaches used by top
performers in the CMS survey. In many cases it tested practices in
pilot projects before rolling them out broadly.
Some efforts were relatively simple. For example, one program
reinforced the basic behaviors taught in the half-day exercise. As part
of the program, managers monitored their employees and coached
those who were falling short.
A related initiative targeted prospective patients—people deciding
where to go for care. A common complaint of potential patients
who’d opted to go elsewhere was that the Clinic was too big and was
difficult to access; people needed a special connection—“to know
someone”—to get an appointment. So Cosgrove mandated that all
patients have the option of getting an appointment the same day they
called, making the Clinic the first major U.S. provider to offer this
service. It created a single phone number for booking appointments,
and centralized scheduling across the enterprise. When patients
called the dedicated number, operators were trained to say, “Thank
you for calling the Cleveland Clinic. Would you like to be seen today?”
A television and radio advertising campaign, “Today,” promoted the
new service and sent a clear message that the Clinic would help
patients with anything they needed, not just complicated conditions.
The campaign was an overnight success: During the first year, visits
by new patients increased by 20%. Same-day appointments now
account for more than one million patient visits a year.
Another common complaint was that despite the creation of the
multidisciplinary institutes, caregivers did not communicate or
coordinate well with one another. Merlino decided to begin
addressing this problem by testing a process to determine the root
causes of communication breakdowns in each unit; remedies would
then be devised on a case-by-case basis. He commissioned a study of
the weekly huddles of critical floor leaders, selecting for the pilot a
floor with one of the hospital’s worst scores in the CMS survey. A
team consisting of the floor’s nurse manager; its assistant nurse
manager; a physician from the specialty that had the most patients on
the floor; the environmental services supervisor (who oversaw
housekeeping); the case manager responsible for discharge,
insurance, and at-home needs; a social worker; and a representative
from the Office of Patient Experience began meeting each week to
discuss patient complaints and concerns.
It quickly identified several problems. First, the social worker and the
case manager—employees critical to ensuring a smooth discharge
process—did not like each other and never talked. The floor, which
conducted a large volume of gastroenterology and radiology
procedures, constantly ran behind schedule. Patients ordered to have
no food or drink before a procedure might go hungry all day if the
procedure was delayed; even worse, procedures were sometimes
postponed until the next day without the patient’s being informed—
leaving him or her not just hungry but confused. Finally, doctors did
not always communicate with nurses after rounds, so nurses were
often unaware of the plans for their patients’ care that day.
These problems were not difficult to fix. Most of them were addressed
by instituting simple processes to surface issues, get people to work
better together, and keep patients informed about what was going on.
For example, the weekly huddles forced caregivers to communicate
regularly with their colleagues, including ones they did not
particularly like. The floor’s scores in the CMS survey went from
among the lowest in the hospital to the highest in less than a month.
Another area that was hurting the Clinic in the CMS survey was
nursing rounds. Rounding on patients hourly is an established best
practice that improves safety, quality, and patient satisfaction. But as
of 2010 the Clinic did not require hourly rounds; some units
conducted them, some didn’t. The units that did had higher patient-
experience scores, and when the Clinic’s leaders learned of the
correlation, they decided to launch a pilot project in the heart and
vascular institute under the direction of K. Kelly Hancock, who was
then its nursing director and is now the Clinic’s executive chief
nursing officer.
For a period of 90 days, the nurses or nursing assistants on
designated floors were required to see patients every hour and to ask
them five questions: Do you need anything? Do you have any pain?
Do you need to be repositioned? Do you need your personal
belongings moved closer to you? Do you need to go to the bathroom?
They had to fill out sheets verifying that they had done this. Nurse
managers held spot audits, and patients being discharged were asked
if the rounds had been performed. Some 4,000 patients in all were
involved, and the results were striking. The units that always
completed the rounds ranked in the top 10% in the nursing-related
parts of the CMS survey; the units that conducted rounds
inconsistently scored much lower. The units that never conducted
hourly rounds ranked in the bottom 1% of all hospitals. So Cosgrove
mandated hourly rounds across the institution.

Engaging and motivating employees.

The leaders of the Clinic knew that to improve the patient experience
while continuing to drive safety and quality, it would need engaged,
satisfied caregivers who understood and identified with its mission:
providing exemplary care by excelling in specialized care; developing,
applying, evaluating, and sharing new technology; attracting the best
staff; excelling in service; and providing efficient access to affordable
care. A 2008 Gallup survey of employee engagement at health care
organizations highlighted the magnitude of the problem in this
regard: The Clinic placed only in the 38th percentile.
One step taken to address this problem was the launching of a
“caregiver celebration” program. This allowed both managers and
frontline workers to recognize colleagues who had done something
exceptional for patients or for the organization. Recognition made
employees eligible for monetary awards of varying amounts,
culminating in the $25,000 CEO Award of Excellence, presented to
the top caregiver and team members at an annual ceremony.
More broadly, Merlino, Cosgrove, and other members of the executive
team recognized that they needed to make a substantial investment in
developing and managing the workforce. They saw that the
organization’s 2,300 managers needed to be educated in how to
increase the engagement of members of their teams. All managers are
now required to attend a daylong session every three or four months,
during which they are trained in such things as emotional
intelligence, communicating and implementing change, and
enhancing engagement. They must submit annual plans for how they
will improve the engagement and satisfaction of the people they
manage (actions might include discussing job expectations more
frequently, improving communication about activities in the
department or the Clinic, and ensuring that employees have the
resources needed to perform their jobs). Such steps helped the Clinic
move up to the 57th percentile in the Gallup survey. Although this is
progress, Clinic leaders recognize that it is not nearly enough.
Setting Patients’ Expectations
The patient is not always right: Sometimes patients have desires
whose fulfillment would not be in their best interests. Here’s a case in
point: Patients understandably prefer not to be disturbed at night. But
sometimes they must be awakened in order to be given medication, to
have a procedure performed, or to have their vital signs checked.
Because some patients at the Clinic did not understand the reasons
for such disturbances, they were critical when asked in the CMS
survey whether their rooms had been quiet at night.
Similarly, the OPE discovered that patients were upset if they used
the call system to ask for a nurse’s help and did not receive an
immediate response—even if their need wasn’t pressing. When it
probed deeper, it learned that even when patients recognized that
their need wasn’t urgent, the lack of an immediate response often
made them anxious—many feared that if there were an emergency,
nobody would come. They didn’t know that the person answering
calls prioritizes them according to the urgency of the request.
The Clinic found it could alleviate such problems by letting patients
know before they got to the hospital what to expect while they were
there. It created printed materials and an interactive online video for
incoming patients, describing the hospital environment and
procedures and explaining the rationale for them. It also educated
them about pain management and how to communicate with
providers.
In addition, Merlino realized that the Clinic could enlist patients’ help
in improving the hospital experience. For instance, it began asking
patients in semiprivate rooms to limit nighttime noise. It started to
rely more heavily on patients to identify problems and improve
processes. It now asks patients to report rooms that have not been
cleaned properly and to routinely ask caregivers if they have washed
their hands.
Such measures may seem minor, but the effects are important, in
terms of cost as well as patient satisfaction. In 2012 salaries, wages,
and benefits totaled 56% of the Clinic’s operating revenue (supplies
accounted for just 10%, pharmaceuticals for 7%). To hold down costs,
hospitals will clearly have to increase employee productivity. One
approach that has worked well in retailing and service industries is to
encourage customers to perform tasks that employees have
traditionally done—for example, booking airline tickets, checking out
of stores, and answering other customers’ questions. If such a process
is designed empathically, it can enhance patients’ experiences even as
it reduces costs. Hospital leaders may believe that they cannot justify
the kinds of programs described here. CMS’s linking of Medicare
reimbursement to patient satisfaction should help convince them
otherwise. They should also remember this: Changing culture and
processes to improve the patient experience can lead to substantial
improvements in safety and quality. To put it bluntly, a patient-
centered approach to care, which includes giving patients an
outstanding experience, is not an option; it’s a necessity.
Despite the Clinic’s progress, its leaders know full well that they
cannot proclaim victory. Some obvious shortcomings, such as the
still-modest degree of employee engagement, remain. And at a
fundamental level, operating a truly patient-centered organization
isn’t a program; it’s a way of life. Doing the best by patients means
continually analyzing what can be done better and then figuring out
how. There will always be something.
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.