After Delos “Toby” Cosgrove, MD, CEO of Cleveland Clinic in Cleveland, Ohio, made a presentation about the hospital’s record of operational excellence at Harvard Business School in Cambridge, Massachusetts, several years ago, a student asked him what the hospital was doing about teaching its physicians empathy. As it turned out, the student’s father—a physician himself—had elected to have a mitral valve replaced at U.S. News & World Report’s No 2-rated hospital for cardiac surgery survival rates rather the No 1-rated Cleveland Clinic. His rationale: physicians on Cleveland Clinic’s staff had a reputation for poor communication with patients before and after procedures, and the hospital (although known for its caliber of care) was not renowned for patient services. Adding insult to injury, many of the hospital’s scores on the 27-question Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey were extremely low—as low as the 10th percentile. The tide has turned significantly, Mary Linda Rivera, RN, ND, executive director, Office of Patient Experience, Cleveland Clinic, told attendees during “The Shift Toward a Consumer-Focused Healthcare Market,” a talk given at the Eighth Annual Conference of Health Care Providers in Anaheim, California, last December. “Our scores are not quite where we want them yet, but we’re well on our way,” Rivera asserts. “Our patient satisfaction ratings are up and our complaints are down. Patients have told us that they dreaded coming here, but that having seen us, boy, have we changed.”

“As Dr. Cosgrove put it, people came for the care, but they didn’t like us.”

— Mary Linda Rivera, RN, ND, executive director, Cleveland Clinic, Office of Patient Experience, Cleveland, OH

During the third quarter of 2011, more than 80% of HCAHPS respondents said they would “definitely” recommend the hospital (about 20% higher than the national average), and about 80% (~2% more than the national average) said physicians “always” treated them with courtesy and respect, listened carefully to them, and explained things in a way they could understand. Improving HCAHPS scores is critical given that under the new Centers for Medicare and Medicaid Services (CMS) Value Based Purchasing Rule, a patient’s experience of care, as measured by HCAHPS, will account for 30% of each Medicare inpatient prospective payment system (IPPS) hospital’s value based purchasing (VBP) score. Overall VBP scores for individual hospitals, when compared with all Medicare IPPS hospitals, will determine whether they will be able to recover some, or all, of Medicare fee-for-service payments withheld for federal fiscal year 2013 (beginning October 1, 2012). Changing the Culture To turn the tide, Cleveland Clinic established the Office of Patient Experience (becoming the first academic medical center to do so), overseen by a chief patient experience officer. James Merlino, MD, vice chairman of Cleveland Clinic’s Digestive Disease Institute, currently holds the CPEO title. The office’s first step was getting constituents to recognize that change was needed. “Telling highly skilled physicians they needed to do things differently was not easy, and there was pushback,” Rivera concedes. Counter-arguments presented to less-than-enthusiastic players explicitly conveyed that providing better patient service was the right thing to do and what they would want for themselves and their families; that it would improve the hospital’s public image; and, most importantly, that Cleveland Clinic stood to lose $11 million in annual fee-for-service payments if it did not bring its HCAHPS scores to the 90th percentile or higher. Before progress could be made, however, Cleveland Clinic had to alter its culture to align with a patient services-centric model in which every staff member, from clinical to maintenance, acknowledged his or her role in ensuring a consistently positive hospital experience for patients. This began with a three-hour workshop called the “Cleveland Clinic Experience,” mandatory for all 43,000 employees and led by trained facilitators. Seated at tables of eight, attendees learned about the institution’s mission, patient service vision, and values, as well as how to support each other in attaining objectives set in tandem with these. Covered in detail was “Respond With Heart,” a communications model intended to support the sustainability of the new culture by increasing staff accountability for providing top-caliber service to patients whatever their position within the organization. “We realized that while we had taught people how to respond to complaints, we weren’t teaching them how to prevent them,” Rivera says. Preventive measures discussed included, but were not limited to, greeting patients with a smile and concluding all interactions by posing the question, “What else can I do for you?” A variety of constituents were purposely seated together at each table, from physicians and nurses to individuals working in the IT and environmental services. “Our purpose in mixing up the composition of the tables was to emphasize to everyone that no matter who they are, they have the same responsibility for the patient experience,” Rivera explains. Because management believed a didactic format might spur resistance to the messages being conveyed, the workshop also was structured to be interactive, with free exchange of ideas and feedback. During the workshop, Rivera conveyed many other examples of how employees would be expected to operate in a patient-focused environment. For example, staff were told they can no longer bypass the room of any patient whose call light is on; rather, they must investigate the problem and either rectify it or immediately find someone who can. Similarly, instead of leaving a spill on a hallway floor for the janitor to remove, the first individual to notice it is required to wipe it up. Positive Results A Joint Commission survey conducted following the completion of the Cleveland Clinic Experience demonstrated the program’s effectiveness. The provider’s clinical outcome scores were high, but employees were shown to be its greatest strength—“something that would not have happened before,” Rivera reports. Moreover, 92% of staff members polled said the program had been delivered with sufficient efficacy to support the hospital’s mission to provide world-class patient care, and 87% said its content would prove valuable in performing their jobs with enhanced attention to service. The Office of Patient Experience designs specific initiatives to introduce processes that support the eight domains included in the HCAHPS survey, including quietness of the hospital environment, pain management, and nurse communication. Each of the eight domains has a project team led by a clinical project manager that drives best practices for that domain. Process metrics are constructed around improvement in the eight areas, with management ensuring that employees follow the programs and subsequently evaluating outcome metrics to identify improvements. One initiative, launched by Cleveland Clinic’s Nursing Institute, is known as “Purposeful Hourly Rounding,” and calls for nurses to exhibit four key behaviors during hourly rounds. They must introduce themselves (tell patients their name and role) and explain the purpose of rounding (for first visit). They also must assess the four Ps—pain, position, potty (toileting needs), and possessions/personal items—and close each patient interaction with an inquiry about individual needs and reassure them that a nursing staff member will return within the hour. Similarly, a “Code Lavender” team responds to employees as well as patients and their families after patient losses or in the wake of personal experiences that may adversely affect them. Such services as massages, Reiki therapy, and the delivery of refreshments are provided to staff for a period of 78 hours following the loss or other incident, based on the belief that “taking care of them will have a positive impact on the way they take care of patients,” Rivera explains. Pursuing Employee, Patient Partnerships Beyond cultural changes and instituting new patient-centered processes, Cleveland Clinic has made (and continues to make) concerted efforts to support patient-centricity by eliminating departmental silos and fostering partnerships between constituents. Whether or not their performance is reflected in HCAHPS scores, the Office of Patient Experience now meets regularly with representatives of individual departments and works with them from the inception of projects, rather than after the fact. “One huge transformation we’ve seen has been with the facilities, construction, and environmental services department,” Rivera notes. “We started sending them patient input—complaints and comments—and began regular communication meetings. They now include us in their code committee meetings and call us when they will be making changes.” For example, the facilities department solicited input about a planned patient emergency department re-design and what alterations patients might want to see based on feedback conveyed to the Office of Patient Experience. Toward the same end, the provider has formed patient advisory councils for each of its institutes and community hospitals. “We try to connect with them before we finish something or even when we start an initiative to see if we hit the targets properly,” Rivera states. Recently, recommendations from council members who had previously visited a patient at Cleveland Clinic’s main campus were incorporated into a new visitors’ guide to that facility. Participants suggested that a “welcome message” from Cosgrove, which had traditionally appeared on the cover of previous guides, be replaced by messages from former visitors. “The gist of these messages was along the lines of ‘We know you’re concerned, we understand that this is a big campus, but here’s what you need to know and everything will be OK,’” Rivera explains. “It turned out well. Patients can be very objective and innovative; you have to trust that if you’re going to improve the experience.” Recently, Rivera notes, some of Cleveland Clinic’s most “critical, hardcore” patients, among others, were asked to contribute ideas for a pamphlet and complementary video intended for distribution to patients scheduled to undergo procedures there. Entitled “What to Expect During Your Hospital Stay,” the pamphlet included information on measures that would be taken to keep the hospital quiet, why it might not always be so, how patients might contribute to lower noise levels, the roles of various caregivers, how to manage pain, and much more. A correlation between higher patient satisfaction scores and whether patients had been exposed to the material was later found; Rivera says its effect might not have been as strong had patients not been asked to put their mark on it.Julie Ritzer Ross is a contributing writer for Health CXO.