Reflections from a Healthcare Worker: Can we please expunge the term “Service Recovery”? (part 1 of 3)

Craig T. Albanese, MD, MBA

*guest post by Craig T. Albanese, MD, MBA

Imagine this: A new state-of-the-art hospital is built, keeping the same prestigious name and place in the community as its predecessor.  You fill it with the best and the brightest doctors, nurses, and staff members. Five years later the hospital is struggling; volume is down, staff is dissatisfied – patients are migrating to the other hospitals in town.  Sound familiar? Could this happen?  Has this happened? Why would patients leave this “prestigious” institution of healing?

There are many possible explanations.  Based on my many years of experience and expertise in both medicine and business, here is a simple central theory: Healthcare today has become an industry that is dependent on the principles of service recovery – correcting abnormalities that, in many cases, could be avoided.  Rather, its focus should be providing excellent service.  Our doctors, nurses and staff are trained and expert at solving patient medical problems; however, we are woefully inadequate at solving system problems. In fact, we have created most of the problems endemic to our healthcare systems. Thus, there is an ongoing need for service recovery – solving the problems we’ve created instead of avoiding them in the first place.

Why is this? First and foremost, American healthcare built hospitals and their care processes around the wrong customer – the doctor and his/her healthcare team.  The principle customer in healthcare is the patient and the patient’s families (other customers are referring physicians and payers).  Physicians, nurses, and related staff members are stakeholders. So when we allow the wrong customers to dictate process development, the system becomes unbalanced.  We build big waiting rooms.  It becomes acceptable for physicians to be late to clinic, late to the operating room, to order tests that are not needed.  And when the physician and related workers are empowered to run the system, the system in turn blames them – persecutes them –  when care systems go awry.  Finally, the healthcare team, by default, becomes the frontline for fire-fighting process problems, placing band-aids where big fixes are needed, devising short cuts, and “working the system” so that care can be delivered.

In what other industry is this tolerated?  I submit that healthcare should be the ultimate service industry—there is very little about it that is discretionary.  However, we presently have a broken system, broken by well-intentioned smart people, all trying to “do the right thing and help patients.”  Furthermore, this mismatch between intention and output piles despair and frustration on top of inefficient and ineffective processes, compounding the problem.

Let’s look at another service industry—food service.  In contrast to healthcare, this industry is highly discretionary.  How much service recovery can restaurants tolerate before losing business? Think back to the last time you made a reservation for a fine dining experience.  With few exceptions, I’m sure you secured a reservation within a week or so of your desired date.  You arrive at the restaurant.  How big is the waiting room?  Do they even have a waiting room? Probably not, perhaps a few chairs, perhaps the bar. But what is your expectation for your 8pm reservation?  Do you expect that you will be seated on or around 8pm?  What if you were seated at 9pm?  How would you feel?  How many “I’m sorries” and free drinks would it take before you left? What if you were seated and a server doesn’t appear for 20 min?  Would you be angry?  What if the food was cold?  Even if this particular restaurant is known for the best chefs in town, would you ever go back, given this level of service?

Service is defined by high quality, safe, empathetic, and efficient delivery of care in a hospital – or in any healthcare setting or non-healthcare industry.  In healthcare, until we change our processes, eliminate waste, create service standards, and agree that the patient is the primary customer, we will forever be a service recovery industry.  For institutions sensitive to the plight of the patient in this type of environment, service recovery will be characterized by a plethora of coffee cards and free parking to abrogate the long waits and inconveniences bestowed upon our patients; armies of service recovery professionals will gather to dole out sincere apologies, and peer review meetings will continue with the shame and blame culture levied at all professionals involved in any adverse clinical outcome.

About Craig Albanese, MD, MBA

Craig T. Albanese, MD, MBA, is Vice President of Quality and Performance Improvement at Lucile Packard Children’s Hospital at Stanford University Medical Center. In this role, he is responsible for overseeing the children hospital’s Lean transformation. Under his leadership, Craig is approaching Lean transformation by developing a rigorous daily management system to support ongoing improvement efforts and the hospital’s core goals.  In addition, he has recently overseen the implementation of a production control management system in the perioperative services department and is expanding this work to the rest of the hospital. Craig is also a pediatric general surgeon, Professor of surgery, and holds the John A. and Cynthia Fry Gunn Directorship of Surgical Services at Lucile Packard Children’s Hospital.

Craig obtained his BS in Natural Sciences and Mathematics from Washington and Lee University.  He earned his MD at Downstate Medical Center, subsequently completing his general surgery training at The Mount Sinai Hospital in New York and his pediatric surgery fellowship at the Children’s Hospital of Pittsburgh. He was on the faculty at the University of Pittsburgh followed by the University of California, San Francisco before joining the faculty at Stanford in 2002. In 2008 he earned an MBA from Santa Clara University’s Leavey School of Business. Craig still practices pediatric general surgery.  His 26 years as a surgeon in a broken healthcare system has shaped his passion for increasing value for our patients.

Rounding for Caring

Kimberly Petty,
Managing Director, Experience Design and Business Development

Rounding, the process of visiting patients and families at the bedside, serves many functions within a healthcare organization.  It can be performed by executive leaders, nurse leaders, multi-disciplinary teams, nurses, environmental services and other clinical and support groups.  Objectives for rounding range from improving patient safety, creating more efficient care workflow, enhancing communication and experience, and/or identifying improvement opportunities.

Regardless of the specific approach, for rounding to help drive experience and outcome improvements that lead to lasting growth and loyalty, it must be approached with authenticity and with an eye towards addressing patient needs and goals, not simply following a checklist.

In our recent webinar with members of the National Patient Experience Collaborative, we learned about how nurses at a ministry at Ascension Health added an honorary 5^th P, presence, to 4 P’s rounding. This 5th P was added to remind themselves that how they round is as important as what they do during rounds.  Through their mindful approach to rounding, Ascension has achieved decreased pressure ulcer prevalence, decreased call light volume, noted fewer falls, and experienced higher overall satisfaction.

Having examined several rounding programs, ExperiaHealth has distilled seven principles of rounding for human caring and connection:

1. Ask Open Ended Questions – “What is your personal goal for today?”
2. Address Concerns – “What are your greatest fears or concerns about your hospitalization or visit?”
3. Demonstrate Empathy – “This must be difficult for you.”
4. Confirm Understanding (e.g., Teach back) – Repeat what you heard. Verify Understanding.
5. Level-set Expectations – Explain actions to be taken and next steps; including when you hope to have resolution.
6. Remain Authentic and Present – When engaging stakeholders in dialogue, it’s critical to provide your undivided attention. In the moment, you must remain engaged and refrain from passing judgment.
7. Follow Through – Act on the information you gained from visiting with the patient and set expectations for what will happen next.

When done effectively, the rounding process improves experience for not only patients and families, but for staff as well by reducing interruptions in care delivery and, more importantly, restoring relationships between patients and their care team.

*Members of the National Patient Experience Collaborative may contact us for the full Solution Brief and access to the recorded webinar.

Does Your Medical Staff Suffer from Death by 1,000 Cuts?

Liz Boehm Director, ExperiaHealth Patient Experience Collaborative

In our work with medical professionals we see over and over how good people get ground down by suboptimal processes.  Fatigue and frustration can turn the most dedicated nurse into a growling task master, or cause a doctor to fall from on-time-documentation grace.

Why does this happen?  There are certainly big, systemic challenges – such as lateral violence and poorly designed EMRs – that are tricky to solve.  But there are also the thousands of little inefficiencies that don’t get tackled because they’re easy to overlook, and it’s nobody’s job to fix them.  Believe us, these add up!

Enter the No Excuses Team.  This is a concept created by our partners at Twin Rivers Regional Medical Center in Kennett, MO.  The No Excuses Team is made up of willing volunteers among the nursing staff, facilities, IT, environmental services, and all other departments that contribute to the effective functioning of a medical unit, hospital floor, or clinic.

Twin Rivers NET Team

What can the No Excuses Team address?  The sky’s the limit.

We’ve seen:

• The broken drawer that caused the clutter in the nursing station that meant physicians had no room to do their documentation (and patients often equate “clutter” with lack of cleanliness).
• Support for systemic “thank yous” between team members who need reminding of the contributions others make to their teams.
• The broken printer that results in lab results and orders being delayed, ultimately delaying patient care and discharge, causing poor satisfaction and inefficient use of hospital beds.
• The CPUs that take up too much counter space but that can easily be hung under shelves to make life easier for nurses and doctors.
• The lack of clocks in patient rooms that makes wait times feel even longer than they actually are.

You get the idea.  One nurse we worked with described the kinds of things a No Excuses Team can tackle as “right next to stupid.”  You’d be surprised how much of that goes on – not because hospitals and clinics don’t care, but because they’re focused on healing patients, they don’t feel empowered to make changes, and tend to let the little things slide.

To make the No Excuses Team work, they need the backing of administration to allow them to escalate the (mostly small) expenses that go into their fixes.  And they need to have their work recognized and celebrated so that the keep striving to make their workplace even better, safer, cleaner, and more efficient.

With no excuses, what can your team get done?

The Healthcare CXO: A Clinical Leader Driving Experience Improvement

M. Bridget Duffy, MD

I recently wrote about why healthcare organizations need a chief experience officer (CXO) just like they need a senior executive focused on quality, safety and performance improvement.  You may argue that the patient experience is everyone’s responsibility.  Shouldn’t quality, safety and efficiency be everyone’s responsibility?  Without a dedicated c-level champion to spearhead improvement in quality and safety our nation’s health system would be in worse shape than we are today.  The same is true of the patient, family and staff experience.  No one seemed to think this mattered much until the government mandated we measure patient’s perception of their care and tied reimbursement to the scores.  To rapidly make strides in this area, build patient and staff loyalty and improve outcomes, organizations need to appoint a credible leader to build an operating infrastructure for continuous improvement in the human experience of care.

So then the question becomes, what makes for a successful CXO? After establishing this role at the Cleveland Clinic and guiding other organizations in their journey to create an experience office, I believe it is critical to appoint a professional with a clinical background.  Why?  Because to truly transform healthcare, we need to focus on improving the human experience in clinical care and not simply create a customer service wrapper around existing broken processes.

To be successful, the CXO needs clinical credibility, strong leadership skills, and the ability to unify doctors, nurses, and staff around a shared mission.  Business cases and service excellence concepts will sway executive, administrative, and support staff, but only a science-based, clinically relevant argument will bring doctors and nurses into leadership positions to drive change throughout the organization.

The CXO cannot succeed alone. The most successful organizations appoint a triad of physician, nursing, and administrative leaders working in partnership focused on innovations that improve communication and experience across the care continuum. These clinical leaders must have respect by their peers as well as a compelling vision to improve clinical outcomes and influence to drive adoption and results. They must also have the authority, accountability and resources to put a credible team in place that will collaborate with quality, safety and performance improvement teams to unify clinical initiatives and outcomes.

Experience transformation takes time and commitment.  In the long-run, a strong culture that strives to constantly innovate around solutions that strengthen human connections, drive towards optimal outcomes, and control cost becomes self-sustaining.  But to make meaningful headway, the experience team needs the support of a Board Committee focused on quality, efficiency and the human experience of care.

Many hospitals and health systems struggle to justify an investment of this magnitude while under intense pressure to rethink reimbursement and restructure their organizations.  But the leading organizations know that driving innovation in the human experience by strengthening a culture of caring, bringing nurses and doctors back to the bedside, and using technology to hardwire the human experience is the only way they will meet their clinical and financial goals in the long run.

ABOUT EXPERIAHEALTH

ExperiaHealth is an advisory and technology firm that fosters partnerships across organizations, revolutionizing healthcare experience and outcomes.  Founded by Dr. Bridget Duffy, the first Chief Experience Officer at the Cleveland Clinic and in the nation, ExperiaHealth accelerates the discovery and adoption of innovations that restore the human connection in healthcare.  The Company’s solutions improve staff and patient satisfaction, drive physician loyalty, and enable healthcare organizations to prosper and create market differentiation in an uncertain healthcare environment. ExperiaHealth’s flagship technology connects patients and providers across the continuum of care, reducing costly readmissions.

For more information, please visit www.experiahealth.com  and follow-us on Twitter at @ExperiaHealth.

Why Your Health System Needs a CXO

M. Bridget Duffy, MD

After more than 20 years working as a physician and then an advisor to healthcare leaders and organizations across the country, it’s rewarding to see an ever-increasing focus on the patient experience. Finally, humanizing healthcare is no longer considered the “soft stuff.”

Though cynics may argue that this renewed sense of responsibility is due to top-line financial penalties tied to patient satisfaction, I disagree. The enlightened hospitals and health systems with whom we collaborate are not just chasing scores. They are driven by passion and purpose to deliver high-quality care in a way that makes a difference in the lives of the patients, families and communities they serve.

At the forefront of this healthcare revolution are dedicated Chief Experience Officers (CXOs), leaders responsible for shepherding the experience transformation movement in their oganizations. Some say everyone should “own” patient experience.  Everyone should “own” quality as well, but without a dedicated Chief Quality Officer or a Chief Performance Improvement Officer, and Board Committees focused on quality and efficiency, it is difficult to garner resources and deliver results.

The same is true with experience improvement.  While every physician, nurse and staff member who cares for patients should feel responsible for ensuring a superb experience, it is vital to appoint or anoint a leader who actually owns that work for the entire organization. Without a strong, respected CXO leading the charge, patient experience will take a back seat to other initiatives, it will become disjointed, and it will result in fatigue for staff and organizations.

The role of a CXO as a critical c-suite position in healthcare is now gaining traction. Years ago when quality and safety were questioned at hospitals across the country, chief quality and safety officers were appointed, national consortiums and annual meetings were set, and committees and board of directors were created. High-level quality and safety positions were established because there was an absolute need, and these roles are still essential today. Now, fast forward. The same is true for patient experience. I think 15 years from now we will look back and say, “Can you believe we didn’t have the role of a Chief Experience Officers until 2008?”

*Interested in reading more? Follow up post: What makes a Healthcare CXO successful

ABOUT EXPERIAHEALTH

ExperiaHealth is an advisory and technology firm that fosters partnerships across organizations, revolutionizing healthcare experience and outcomes.  Founded by Dr. Bridget Duffy, the first Chief Experience Officer at the Cleveland Clinic and in the nation, ExperiaHealth accelerates the discovery and adoption of innovations that restore the human connection in healthcare.  The Company’s solutions improve staff and patient satisfaction, drive physician loyalty, and enable healthcare organizations to prosper and create market differentiation in an uncertain healthcare environment. ExperiaHealth’s flagship technology connects patients and providers across the continuum of care, reducing costly readmissions.

For more information, please visit www.experiahealth.com  and follow-us on Twitter at @ExperiaHealth.

With Gratitude for Nurses

To our valued Nurse Partners,

We would like to send our sincerest gratitude to all of the nurses with whom we have had the privilege of working with through our partnerships. We are grateful for your tireless commitment to optimizing the healing experience for the patients you serve, and for making your hospitals and clinics better places to work.

ExperiaHealth knows that nurses work continually to enhance patient care, whether by improving conditions for one patient or joining together to help solve problems for numerous individuals. Patients can sense the hard work, dedication, and compassion that nurses put into their care—that daily effort goes so far in enhancing their healing. When we talk to patients about their experience, the feedback is near universal – “The nurses were amazing.” The ability of nurses to act selflessly on behalf of their patients—whether through constant physical care or attending to the emotional aspects of illness—truly makes the profession of nursing a noble one.

While we recognize your enduring commitment, National Nurses Week provides us the opportunity to formally celebrate! ExperiaHealth would like to send all of our nursing partners a special Code Lavender. With this Code Lavender we send out our personal admiration for all of the strength and energy nurses provide to their patients and we honor you for the human connections you bring to healing.

Our Sincerest Appreciation and Gratitude,

The ExperiaHealth Team

*in honor of National Nurses Week: May 6th-12th

Key Insights from the April 2013 CXO Roundtable –Day 2

Liz Boehm Director, ExperiaHealth Patient Experience Collaborative

Last week physicians, nurses, and executives representing more than 21 health systems, hospitals, and clinics joined ExperiaHealth in San Francisco to network, share best practices, and push the envelope on what makes a great healthcare experience.  The insights were incredibly thought-provoking and utterly practical.  Yesterday I posted the key learnings from Day 1 of the event.  Here’s a sampling of the insights gleaned on Day 2:

• Carmen Natale, System Director and Troy Bishop, MD Summa Health System:  Summa Health System has designed a series of programs aimed at helping high-risk patients transition seamlessly from the inpatient services to their homes or rehab facilities.  The Bridge to Home program pairs a high-risk patient with a nurse who visits in the hospital to set patient goals, visits at home within 5 days of discharge to support follow-up care, and calls at the 15 and 30 day marks to ensure the patient is on track.  The programs collectively reduce costly 30-day readmissions (9.9% among BTH participants v. 35.5% among BTH-eligible patients who did not participate) and ED use, and have helped strengthen the relationships between Summa doctors and their patients – proving that a little human touch can go a long way.
• Paul Berggreen, MD, Arizona Digestive Health:  Dr. Paul Berggreen and his colleagues at Arizona Digestive Health saw the rise of smartphones, the poor design of paper-based patient instructions for GI procedures and thought, “there has to be a better way.”  Not finding one on the market, they invented an app that allows patients to enter the date and time of a specific procedure (and the specific prep prescribed by their doctor), and that then automatically alerts patients on key dates and milestones for their prep.  5 days before, it tells them to arrange a ride.  3 days before, to stop eating seeds and nuts.  1 day before to manage their prep by the hour.  And the day of, to get in their car and drive to their appointment.  The app is useful for making sure that patients show up at the appointed time, but even more so for improving bowel prep.  Dr. Berggreen and a colleague conducted a study showing statistically significant improvement on Boston Bowel Prep Scores for colonoscopy patients.  And that’s a real win for patients – because no one wants to do a colonoscopy twice!
• Cheryl Bailey, RN, CNO, Cullman Regional Medical Center:  To help improve the transfer of knowledge to patients and caregivers at the time of discharge, Cullman Regional Medical Center implemented ExperiaHealth’s Good to Go discharge solution.  The iOS-based platform lets nurses record their verbal discharge instructions right on an iTouch as they deliver them – without disrupting their normal process.  They do teach-backs and answer patient questions while recording, link relevant internal documents and resources, then send the patient a link via text or email that can be accessed using a secure PIN generated at discharge.  Discharge HCAHPS scores are up 63% and readmissions are down 15% since implementing the system.  Patients love it, and nurses and managers are using it for training and improvement – leaving everybody Good to Go!
• Manali Patel, MD, Stanford’s Clinical Excellence Research Center:  The Stanford Clinical Excellence Research Center, an ExperiaHealth partner, has a mission to bend the cost curve while improving clinical outcomes and experience.  Dr. Patel and colleagues developed a new late-stage cancer care model based on the best clinical science available, designed to help patients make the best decisions based on the most complete information about their clinical prospects.  The model, dubbed “RIO,” is built on three key elements:  Respect of and family goals with low-cost care coaches who assure patients and families understand the “big picture”; Immediate relief of symptoms with protocol-driven 24/7 symptom control call center that prevents unnecessary hospitalizations and emergency room visits; and, Optimization of care at and near home with economical alternative infusion sites.  The RIO model is currently being tested at more than 10 sites to see if reality lives up to the concept.  Based on Dr. Patel’s detailed grasp of cancer care, her passion and compassion, we believe the results will surpass expectations.
• Kathleen Myers, MD, ScribesSTAT: For every yin there is a yang.  Although this CXO Roundtable focused on delivering great patient experiences that drive loyalty and growth, we know that enabling that means also attending to solutions that on the surface appear to meet the needs of physicians and other healthcare workers.  The doctor-patient relationship is central to the patient experience.  And while EMRs are intended to create an infrastructure that enables better data-based insights and health management, more systematic and portable documentation of patient encounters, and a meaningful audit trail of patient record access, they also make it more difficult for doctors to connect in a human way with their patients.  Dr. Kathy Myers showed us how scribes can free doctors up to spend more time with patients, improving patient satisfaction (one clinic saw an average score increase of 2.43 points, or 45% in percentile ranking) and education while also boosting practice and doctor revenue (an average of $185.91 daily revenue increase at the same clinic).  The model even serves as a proving ground for promising pre-med students.  Who says you can’t have a win-win in healthcare?

The collective brain power, clinical and administrative experience, passion, and compassion assembled at the CXO Roundtable were truly astounding.  In the week since participants returned to their home institutions, we have seen a phenomenal bias to action as participants continue to network, begin plans to implement new solutions, and brainstorm opportunities to advance the work of humanizing healthcare and putting the science behind the human experience.

Through this unique and powerful group, we intend to make sure that mavericks and change agents continue to get the networking, information, and moral support they need to transform healthcare.