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Howard R. Epps, MD

AAOS Now

Published 1/1/2014

Enhancing the Patient Experience

Improving the delivery of care goes beyond patient satisfaction

Patient experience has gained importance with the passage of the Affordable Care Act. Defined as “the sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care,” patient experience goes beyond satisfactory outcomes and “making patients happy.”

At the Cleveland Clinic, patient experience is a strategic priority; the organization even has an Office of Patient Experience, under the direction of colorectal surgeon James Merlino, MD. Its mission is to ensure consistent patient-centered care by partnering with caregivers to exceed the expectations of patients and families. It serves as an advisory resource; provides data analytics; identifies, supports, and publishes sustainable best practices; and collaborates with departments to ensure the consistent delivery of patient-centered care.

Recently, Dr. Merlino discussed the activities and successes of the Cleveland Clinic Office of Patient Experience with Howard R. Epps, MD, a member of the AAOS Now editorial board.

Dr. Epps: When and why was the Office of Patient Experience established?

Dr. Merlino: When cardiothoracic surgeon Delos (Toby) Cosgrove, MD, became Chief Executive Officer of the Cleveland Clinic, he wanted to align the organization around patients. He introduced the motto “Patients First” and made patient experience a top strategic priority.

The impetus for this was an experience he had in 2006. He had given a presentation at Harvard and afterward a young woman spoke to him. She told him that when her father needed mitral valve surgery, the family decided to go to the Mayo Clinic, even though the Cleveland Clinic was ranked as the leading heart center and Dr. Cosgrove himself was a renowned mitral valve repair surgeon, “because you don’t teach your doctors empathy.”

It was an epiphany for him because the story summed up the return on investment (ROI) on huge pieces of clinic business. He already believed that “patients first” and patient-centered care were absolutely right, and she had delivered the ROI for it. That’s when he created my position and began to put resources into improving the patient experience.

Dr. Epps: How do you describe the difference between patient experience and patient satisfaction?

Dr. Merlino: Patient experience is not just about making patients happy or satisfied. It is about how we deliver care. Putting patients first means delivering safe, high quality care, in an environment of trust and satisfaction that ultimately drives value.

For example, the HCAHPS (Hospital Consumer Assessment of Healthcare Systems and Providers) inpatient survey has nine questions that relate to communications—three for nurses, three for doctors, and three around medications. When nurses communicate effectively at the bedside, medication errors go down, pressure ulcers go down, and falls go down. Those are safety issues. When physicians communicate better, coordination of care improves and compliance with treatment options increases. Those are quality issues.

When you communicate better, you improve satisfaction and patients are happier. But if you do something that hits all three of those goals, you make care better. You improve efficiency and effectiveness, drive the value equation, and reduce costs.

Patient experience is about delivery of care. We spend millions of dollars and hours of time teaching physicians and nurses how to practice at the top of their licenses, but we don’t spend any time talking to people about how to improve the delivery of what they do every day.

Dr. Epps: That’s important in the outpatient setting as well, isn’t it?

Dr. Merlino: Absolutely. Outpatients have a different set of metrics, but global improvements aren’t targeted to a particular environment. For instance, when you teach physicians how to communicate better, it does not matter whether they are dealing with inpatients or outpatients. How they interact with patients will improve in all settings. I think we have been very successful in making sure that we develop strategies and tactics around issues that will generate improvement across the organization.

Dr. Epps: Did the Cleveland Clinic concept that every employee is a “caregiver” come from the Office of Patient Experience?

Dr. Merlino: Yes. We wanted people to recognize that their role in the organization doesn’t matter. If you work for the Cleveland Clinic, you support its mission, you are part of the team, and you are a caregiver.

Howard R. Epps, MD
James Merlino, MD

It takes 17 people—I actually counted it one day—to get a patient onto the operating room table so I can perform an operation. If one percent of those people don’t do their jobs, it’s a problem. If the transporter doesn’t show up, someone else will transport the patient, but the point is that everybody has a role. Everybody is part of the team and should be aligned around what they are doing for patients.

Dr. Epps: You provide communication training for physicians. Do you have similar training throughout the organization?

Dr. Merlino: We are developing similar courses for nurses. We recently assembled a multidisciplinary team to look at ways to improve how physicians and nurses work together, with the goal of developing high-reliability, high-functioning teams.

Dr. Epps: Right after the Office of Patient Experience started, the Cleveland Clinic had a tremendous turnaround in HCAHPS scores. How long did it take to see those benefits?

Dr. Merlino: We have been concentrating on this strategy for about 4 years. I think the improvement in our hardcore metrics is a result of honing in on a strategy we think works.

Dr. Epps: And what about that ROI you mentioned earlier?

Dr. Merlino: Here’s a simple example. If there is a puddle on the floor, it is a fall risk for the patient and anyone—including the patient’s family—who walks into that room. You don’t need a medical degree to see that, realize the problem, and fix it. Anyone can do that, especially if everyone is always in the moment thinking about the patient.

Physicians don’t spend much time with patients. All the time in the hospital is really managed by the nurses, who have a very difficult job. Increasingly we are asking them to do more at the bedside. Nurses are under more regulation, and we have to create an environment in which people—even the maintenance, environmental services, or food services staff—are able to help the nurses.

We have a program called “No Pass Zones.” If you are an employee walking past a patient’s room and the patient’s call light goes on, you go in. You don’t just keep walking. You make sure everything is okay. It supports the idea that we are all here for the patient, and we are all part of a highly functioning team.

Dr. Epps: You clearly have been improving patient satisfaction scores. Have you looked at employee satisfaction since this started?

Dr. Merlino: Yes, we monitor employee engagement very closely. We do a survey every year and have seen significant improvement. When we started this program, employee satisfaction scores placed us in the 38th percentile among healthcare organizations. Now we are in the 61st percentile, so there is a significant improvement.

Dr. Epps: What has been the impact on employee turnover?

Dr. Merlino: If you look at turnover rates in health care, you have to segment it by groups such as nurses, doctors, and everybody else. Our turnover rate is below industry averages, which also affects our ROI because we’re not training new employees all the time.

Dr. Epps: How did the Office of Patient Experience develop its focus on service and programs?

Dr. Merlino: We looked at hospitals that were doing very well, at the hospitality industry, and other organizations that get high marks for service. We did a lot of benchmarking before we started. In terms of our programs, we developed about a third on our own, took a third from other systems, and the rest from industry.

We often don’t think about developing service excellence strategies in healthcare. What I am talking about is a framework for how we want employees to treat each other and to treat patients so we really wanted to provide some guidance. We want people to be consistent. We want them to use the appropriate language. I think that developing and implementing a service excellence strategy in healthcare organizations is very important to help keep the culture aligned around the patient.

Patient experience has emerged as a dynamic issue for healthcare CEOs, physicians, and industry leaders. No provider can afford to offer anything less than the best clinical, physical, and emotional experience to patients and families. As patients become savvier, they judge healthcare providers not only on clinical outcomes, but also on their ability to be compassionate and deliver excellent, patient-centered care. That’s what our office aims to encourage and enhance.