James I. Merlino, MD

PART 1

• Leading best gynecologic surgical care into the next decade
• Optimal surgical management of stage 3 and 4 pelvic organ prolapse
• Patient experience: It’s not about satisfaction

‌

‌

Andrew P. Cassidenti, MD
Chief, Female Pelvic Medicine and Reconstructive Surgery
Kern Medical,
Bakersfield, California

Amanda White, MD
Assistant Professor, Department of Women’s Health
Female Pelvic Medicine and Reconstructive Surgery
Dell Medical School, University of Texas
Austin, Texas

Vivian Aguilar, MD
Assistant Professor, Obstetrics and Gynecology
Female Pelvic Medicine and Reconstructive Surgery
Dell Medical School, University of Texas
Austin, Texas

Rebecca G. Rogers, MD
Professor, Department of Women’s Health
Female Pelvic Medicine and Reconstructive Surgery
Associate Chair, Clinical Integration and Operations
Dell Medical School, University of Texas
Austin, Texas

Patrick Culligan, MD
Director, Urogynecology and The Center for Female Pelvic Health
Department of Urology
Weill Cornell Medical College, New York Presbyterian/Weill Cornell Medical Center
New York, New York

Sarah Huber, MD
Fellow, Female Pelvic Medicine and Reconstructive Surgery
Department of Urology
Weill Cornell Medical College, New York Presbyterian/Weill Cornell Medical Center
New York, New York

Vincent R. Lucente, MD, MBA
Chief, Gynecology, St. Luke’s University Health Network
Medical Director, The Institute for Female Pelvic Medicine and Reconstructive Surgery
Allentown, Pennsylvania

Jessica B. Ton, MD
AAGL Fellow, Minimally Invasive Gynecologic Surgery
St. Luke’s University Health Network
Bethlehem, Pennsylvania

James I. Merlino, MD
President and Chief Medical Officer of Advisory and Strategic Consulting
Press Ganey Associates
Cleveland, Ohio

Amy A. Merlino, MD
Maternal Fetal Medicine Specialist
Department of Obstetrics and Gynecology
Enterprise Chief Informatics Officer
Cleveland Clinic, Cleveland, Ohio

PART 2

• Deep infiltrating endometriosis: Evaluation and management
• What’s new in simulation training for hysterectomy

‌

‌

‌

‌

Rosanne M. Kho, MD
Head, Section of Benign Gynecology
Women’s Health Institute
Department of Obstetrics and Gynecology
Cleveland Clinic
Cleveland, Ohio

Mauricio S. Abrão, MD
Associate Professor and
Director, Endometriosis Division
Department of Obstetrics and Gynecology
São Paulo University Medical School
São Paulo, Brazil

Alicia Scribner, MD, MPH
Director, Ob/Gyn Simulation Curriculum
Madigan Army Medical Center
Tacoma, Washington
Clinical Instructor
Department of Obstetrics and Gynecology
University of Washington, Seattle

Christine Vaccaro, DO
Medical Director, Andersen Simulation Center
Madigan Army Medical Center
Tacoma, Washington
Clinical Assistant Professor
Department of Obstetrics and Gynecology
University of Washington, Seattle
Uniformed Services University of Health Sciences
Bethesda, Maryland

PART 1

• Leading best gynecologic surgical care into the next decade
• Optimal surgical management of stage 3 and 4 pelvic organ prolapse
• Patient experience: It’s not about satisfaction

‌

‌

Andrew P. Cassidenti, MD
Chief, Female Pelvic Medicine and Reconstructive Surgery
Kern Medical,
Bakersfield, California

Amanda White, MD
Assistant Professor, Department of Women’s Health
Female Pelvic Medicine and Reconstructive Surgery
Dell Medical School, University of Texas
Austin, Texas

Vivian Aguilar, MD
Assistant Professor, Obstetrics and Gynecology
Female Pelvic Medicine and Reconstructive Surgery
Dell Medical School, University of Texas
Austin, Texas

Rebecca G. Rogers, MD
Professor, Department of Women’s Health
Female Pelvic Medicine and Reconstructive Surgery
Associate Chair, Clinical Integration and Operations
Dell Medical School, University of Texas
Austin, Texas

Patrick Culligan, MD
Director, Urogynecology and The Center for Female Pelvic Health
Department of Urology
Weill Cornell Medical College, New York Presbyterian/Weill Cornell Medical Center
New York, New York

Sarah Huber, MD
Fellow, Female Pelvic Medicine and Reconstructive Surgery
Department of Urology
Weill Cornell Medical College, New York Presbyterian/Weill Cornell Medical Center
New York, New York

Vincent R. Lucente, MD, MBA
Chief, Gynecology, St. Luke’s University Health Network
Medical Director, The Institute for Female Pelvic Medicine and Reconstructive Surgery
Allentown, Pennsylvania

Jessica B. Ton, MD
AAGL Fellow, Minimally Invasive Gynecologic Surgery
St. Luke’s University Health Network
Bethlehem, Pennsylvania

James I. Merlino, MD
President and Chief Medical Officer of Advisory and Strategic Consulting
Press Ganey Associates
Cleveland, Ohio

Amy A. Merlino, MD
Maternal Fetal Medicine Specialist
Department of Obstetrics and Gynecology
Enterprise Chief Informatics Officer
Cleveland Clinic, Cleveland, Ohio

PART 2

• Deep infiltrating endometriosis: Evaluation and management
• What’s new in simulation training for hysterectomy

‌

‌

‌

‌

Rosanne M. Kho, MD
Head, Section of Benign Gynecology
Women’s Health Institute
Department of Obstetrics and Gynecology
Cleveland Clinic
Cleveland, Ohio

Mauricio S. Abrão, MD
Associate Professor and
Director, Endometriosis Division
Department of Obstetrics and Gynecology
São Paulo University Medical School
São Paulo, Brazil

Alicia Scribner, MD, MPH
Director, Ob/Gyn Simulation Curriculum
Madigan Army Medical Center
Tacoma, Washington
Clinical Instructor
Department of Obstetrics and Gynecology
University of Washington, Seattle

Christine Vaccaro, DO
Medical Director, Andersen Simulation Center
Madigan Army Medical Center
Tacoma, Washington
Clinical Assistant Professor
Department of Obstetrics and Gynecology
University of Washington, Seattle
Uniformed Services University of Health Sciences
Bethesda, Maryland

PART 1

• Leading best gynecologic surgical care into the next decade
• Optimal surgical management of stage 3 and 4 pelvic organ prolapse
• Patient experience: It’s not about satisfaction

‌

‌

Andrew P. Cassidenti, MD
Chief, Female Pelvic Medicine and Reconstructive Surgery
Kern Medical,
Bakersfield, California

Amanda White, MD
Assistant Professor, Department of Women’s Health
Female Pelvic Medicine and Reconstructive Surgery
Dell Medical School, University of Texas
Austin, Texas

Vivian Aguilar, MD
Assistant Professor, Obstetrics and Gynecology
Female Pelvic Medicine and Reconstructive Surgery
Dell Medical School, University of Texas
Austin, Texas

Rebecca G. Rogers, MD
Professor, Department of Women’s Health
Female Pelvic Medicine and Reconstructive Surgery
Associate Chair, Clinical Integration and Operations
Dell Medical School, University of Texas
Austin, Texas

Patrick Culligan, MD
Director, Urogynecology and The Center for Female Pelvic Health
Department of Urology
Weill Cornell Medical College, New York Presbyterian/Weill Cornell Medical Center
New York, New York

Sarah Huber, MD
Fellow, Female Pelvic Medicine and Reconstructive Surgery
Department of Urology
Weill Cornell Medical College, New York Presbyterian/Weill Cornell Medical Center
New York, New York

Vincent R. Lucente, MD, MBA
Chief, Gynecology, St. Luke’s University Health Network
Medical Director, The Institute for Female Pelvic Medicine and Reconstructive Surgery
Allentown, Pennsylvania

Jessica B. Ton, MD
AAGL Fellow, Minimally Invasive Gynecologic Surgery
St. Luke’s University Health Network
Bethlehem, Pennsylvania

James I. Merlino, MD
President and Chief Medical Officer of Advisory and Strategic Consulting
Press Ganey Associates
Cleveland, Ohio

Amy A. Merlino, MD
Maternal Fetal Medicine Specialist
Department of Obstetrics and Gynecology
Enterprise Chief Informatics Officer
Cleveland Clinic, Cleveland, Ohio

PART 2

• Deep infiltrating endometriosis: Evaluation and management
• What’s new in simulation training for hysterectomy

‌

‌

‌

‌

Rosanne M. Kho, MD
Head, Section of Benign Gynecology
Women’s Health Institute
Department of Obstetrics and Gynecology
Cleveland Clinic
Cleveland, Ohio

Mauricio S. Abrão, MD
Associate Professor and
Director, Endometriosis Division
Department of Obstetrics and Gynecology
São Paulo University Medical School
São Paulo, Brazil

Alicia Scribner, MD, MPH
Director, Ob/Gyn Simulation Curriculum
Madigan Army Medical Center
Tacoma, Washington
Clinical Instructor
Department of Obstetrics and Gynecology
University of Washington, Seattle

Christine Vaccaro, DO
Medical Director, Andersen Simulation Center
Madigan Army Medical Center
Tacoma, Washington
Clinical Assistant Professor
Department of Obstetrics and Gynecology
University of Washington, Seattle
Uniformed Services University of Health Sciences
Bethesda, Maryland

My pager went off 20 minutes into my case. The circulating nurse announced that it was the chief of staff’s office, and as I migrated over to the phone, everyone was wondering what I had done to warrant a call from the boss. The nurse held the phone to my ear and Dr. Joe Hahn, a neurosurgeon and second-in-command at Cleveland Clinic, congratulated me: “You’re it,” he said. I thanked him and went back to work. My scrub tech wanted to know what happened. I told him I was just appointed chief experience officer at Cleveland Clinic. With a befuddled look, he asked what that meant. I said I wasn’t sure.

Jim gets a fast lesson on how to lead patient experience

Patient experience was a signature issue for Dr. Toby Cosgrove, our then president and chief executive officer. Although the Clinic was revered for its high-quality care, patients did not always like going there. Dr. Cosgrove passionately believed that providing a high-quality experience was as important as the best medical care, and that the experience at the Clinic needed to be improved. Another physician had held the role of chief experience officer before me, but she came from outside the system and was not practicing, which proved to be a challenge in the Clinic’s physician-dominated culture. Dr. Cosgrove wanted a physician who “grew up” in the organization to lead this initiative.

When I left my initial interview with Dr. Cosgrove, I could not define patient experience, did not know what HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) was—at the time were in the 10th percentile—and frankly had no idea how I would move a culture of 45,000 people, including 3,000 employed physicians, to embrace patient-centricity. By the time I left the Clinic in 2015, however, we had pushed our experience scores to the top quartile, realigned our culture, and had become world renown for patient experience.¹

I knew intuitively that improving the patient experience was the right thing to do. In 2004, my father had died at the Clinic from surgical complications; his experience had been terrible. At that time, we did not use the term experience, but based on the items that hospitals are graded on today, my father would have failed us on all of them.

What is patient experience?

Patient experience is not about making people happy. Fundamentally, it is about delivering safe, high-quality, patient-centric care. A 2017 Press Ganey analysis of publicly reported data from the Centers for Medicaid and Medicare demonstrated that when performance on experience measures is high, safety and quality also are high.² Similarly, in 2015, JAMA published an article using data from the National Surgical Quality Improvement Project demonstrating a significant association between patient experience scores and several objective measures of surgical quality, including mortality and complications.³

In my new role, I mercilessly told my father’s story, changed the narrative to include safety and quality, and asked my physician colleagues for their help to improve patient experience. People in health care pay very close attention to what physicians do and say, and I needed the doctors to “own it” if we were going to implement the desired change.

I also had to convince them to see themselves on the “other side.” It was not just a matter of “treating patients the way you would want to be treated.” It was about putting yourself in your patients’ shoes—having empathy for what they are experiencing and recognizing that you or a family member could be sitting in that bed. Before my father was ill, I had never been on the other side so intimately, and it was an eye-opening experience.

Retooling communication competency

For the physicians, we zeroed in on helping them improve how they communicate with patients. Communication is a high-value target for experience improvement, and it directly influences safety and quality. We produced a physician-centric communication guide that provided useful tips (see “Practical tips to help physicians improve communication with patients”). We made communication scores transparent. In addition, working with the American Academy on Communication in Healthcare (AACH), we developed a program specifically designed to help physicians improve their communication skills and practice management.⁴ The outcome was not only better scores but also higher physician engagement and lower burnout.⁵

Keeping it real

Being married to another member of the medical staff—a strong-willed and opinionated one at that—ensured that my strategic approach to improving patient experience was grounded. It gave me a safe place to test ideas and concepts, which in turn allowed me to keep my instincts framed and relevant to the needs of key stakeholders, particularly the physicians.

Read what the ObGyn wife has to say.

The ObGyn wife tells her side

When my husband was appointed chief experience officer, I naturally was happy for his accomplishment but admitted that I was not sure exactly what it meant. What was he going to be doing? Would he give up surgery, which he loved?

The experience “thing” always had been fuzzy to me. I equated experience with satisfaction, and I saw my primary role as taking care of patients, not making them happy. I believed that I had great patient relationships, so what else did I need to know to contribute to this work? The connection to safety and quality did resonate with me, though, and it made talking about patient experience more tangible.

When Jim started teasing apart what steps needed to be taken, improving the culture seemed like an obvious focus. One thing was clear: He would need to get the physicians on board by helping them to see the practical importance of this work. It could not be gimmicky or too touchy-feely. The work had to be relevant and tangible to their everyday practice. One thing he said struck a chord: “Everyone comes to health care to help people, and we all believe we are the best we can be, but clearly there are opportunities to improve, and evolve our skills.” I started to consider specific circumstances in which that made sense.

Practice to be a better communicator

Improving physician communication was a top priority. I believed that I was a very good communicator, so I was not sure I would learn much from participating in a required day-long session designed by the AACH.

For this program we convened in small groups of 8 to 10 physicians, and each person paired with a partner. The course provided an important framework that would help us to better organize the patient encounter, an approach that no one had ever taught me. It showed me how to leverage the patient’s chief complaint to empower her to set the agenda. This would avoid unnecessary and inefficient conversational tangents, such as the doorknob question—when the patient brings up the real reason for the visit as you are leaving the exam room.

The course also taught me that while I was a good communicator, I was not efficient. I learned how to listen more effectively. Notably, how we manage patients and how we communicate are learned skills, just like mastering a new surgical procedure. High performance requires thoughtful review and practice.

Work on relationship skills

I had professional colleagues who were difficult to work with or, as I knew from covering for them, had terrible relationships with patients. These interactions made my job harder and directly influenced patient care. I always found it distasteful to hear, “Dr. X treats people very poorly, but he or she is such a great doctor.” Should not doctors be both excellent at their work and excel at the human relationship side of the business? Maybe we did need to work on certain things.

An early Cleveland Clinic initiative was to immerse every employee, including physicians, in a half-day appreciative-inquiry exercise. This entailed sitting around a table with other randomly selected caregivers—a nurse, valet, environmental service worker, administrator—and discussing various topics, such as our role in the organization, teamwork, and the servant-leader philosophy. Going into this exercise, I was skeptical. But going through it fostered a deeper understanding of how we all need to work better together to drive safe, high-quality patient care. It made me reflect on what patients go through every day and the critical contribution each team member makes. The program made me think about what we do and created greater appreciation and mindfulness of our work.

Think empathy

One of the most impactful efforts was getting people to understand and appreciate being on the other side of health care. The patient experience team crafted an empathy video that showcased people—patients, families, caregivers, physicians—and their thoughts as they experienced the other side of health care. The video frames what they are thinking about in the moment and is a powerful reminder that each person has something happening in their life that affects their daily experiences. The empathy video has been viewed by millions around the world. (See “Empathy: The human connection to patient care,” at https://www.youtube.com/watch?v=cDDWvj_q-o8.)

Together we embraced the work

Amy and I shared a unique perspective on this work as the leader of the experience improvement initiative, married to a person experiencing it. We both came to realize that we did not know all there is to know about how to deliver high-quality patient care. Improving experience is both complex and highly nuanced, and it is a vital component of what we do as physicians. The Clinic’s efforts moved the organization to high performance, and everyone played a role. However, we would not have succeeded without the engagement of physician leaders.

Making patients and families happy was never part of the equation. It is about reducing patient suffering and delivering safe, high-quality care in an environment where people feel cared for. That is what the people we serve desire, and it is what we want for ourselves. Although there will always be doubters, especially among physicians, of the importance of patient experience, we must never lose sight that this is the right thing to do for our patients, our families, and ourselves.

Share your thoughts! Send your Letter to the Editor to rbarbieri@mdedge.com. Please include your name and the city and state in which you practice.

My pager went off 20 minutes into my case. The circulating nurse announced that it was the chief of staff’s office, and as I migrated over to the phone, everyone was wondering what I had done to warrant a call from the boss. The nurse held the phone to my ear and Dr. Joe Hahn, a neurosurgeon and second-in-command at Cleveland Clinic, congratulated me: “You’re it,” he said. I thanked him and went back to work. My scrub tech wanted to know what happened. I told him I was just appointed chief experience officer at Cleveland Clinic. With a befuddled look, he asked what that meant. I said I wasn’t sure.

Jim gets a fast lesson on how to lead patient experience

Patient experience was a signature issue for Dr. Toby Cosgrove, our then president and chief executive officer. Although the Clinic was revered for its high-quality care, patients did not always like going there. Dr. Cosgrove passionately believed that providing a high-quality experience was as important as the best medical care, and that the experience at the Clinic needed to be improved. Another physician had held the role of chief experience officer before me, but she came from outside the system and was not practicing, which proved to be a challenge in the Clinic’s physician-dominated culture. Dr. Cosgrove wanted a physician who “grew up” in the organization to lead this initiative.

When I left my initial interview with Dr. Cosgrove, I could not define patient experience, did not know what HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) was—at the time were in the 10th percentile—and frankly had no idea how I would move a culture of 45,000 people, including 3,000 employed physicians, to embrace patient-centricity. By the time I left the Clinic in 2015, however, we had pushed our experience scores to the top quartile, realigned our culture, and had become world renown for patient experience.¹

I knew intuitively that improving the patient experience was the right thing to do. In 2004, my father had died at the Clinic from surgical complications; his experience had been terrible. At that time, we did not use the term experience, but based on the items that hospitals are graded on today, my father would have failed us on all of them.

What is patient experience?

Patient experience is not about making people happy. Fundamentally, it is about delivering safe, high-quality, patient-centric care. A 2017 Press Ganey analysis of publicly reported data from the Centers for Medicaid and Medicare demonstrated that when performance on experience measures is high, safety and quality also are high.² Similarly, in 2015, JAMA published an article using data from the National Surgical Quality Improvement Project demonstrating a significant association between patient experience scores and several objective measures of surgical quality, including mortality and complications.³

In my new role, I mercilessly told my father’s story, changed the narrative to include safety and quality, and asked my physician colleagues for their help to improve patient experience. People in health care pay very close attention to what physicians do and say, and I needed the doctors to “own it” if we were going to implement the desired change.

I also had to convince them to see themselves on the “other side.” It was not just a matter of “treating patients the way you would want to be treated.” It was about putting yourself in your patients’ shoes—having empathy for what they are experiencing and recognizing that you or a family member could be sitting in that bed. Before my father was ill, I had never been on the other side so intimately, and it was an eye-opening experience.

Retooling communication competency

For the physicians, we zeroed in on helping them improve how they communicate with patients. Communication is a high-value target for experience improvement, and it directly influences safety and quality. We produced a physician-centric communication guide that provided useful tips (see “Practical tips to help physicians improve communication with patients”). We made communication scores transparent. In addition, working with the American Academy on Communication in Healthcare (AACH), we developed a program specifically designed to help physicians improve their communication skills and practice management.⁴ The outcome was not only better scores but also higher physician engagement and lower burnout.⁵

Keeping it real

Being married to another member of the medical staff—a strong-willed and opinionated one at that—ensured that my strategic approach to improving patient experience was grounded. It gave me a safe place to test ideas and concepts, which in turn allowed me to keep my instincts framed and relevant to the needs of key stakeholders, particularly the physicians.

Read what the ObGyn wife has to say.

The ObGyn wife tells her side

When my husband was appointed chief experience officer, I naturally was happy for his accomplishment but admitted that I was not sure exactly what it meant. What was he going to be doing? Would he give up surgery, which he loved?

The experience “thing” always had been fuzzy to me. I equated experience with satisfaction, and I saw my primary role as taking care of patients, not making them happy. I believed that I had great patient relationships, so what else did I need to know to contribute to this work? The connection to safety and quality did resonate with me, though, and it made talking about patient experience more tangible.

When Jim started teasing apart what steps needed to be taken, improving the culture seemed like an obvious focus. One thing was clear: He would need to get the physicians on board by helping them to see the practical importance of this work. It could not be gimmicky or too touchy-feely. The work had to be relevant and tangible to their everyday practice. One thing he said struck a chord: “Everyone comes to health care to help people, and we all believe we are the best we can be, but clearly there are opportunities to improve, and evolve our skills.” I started to consider specific circumstances in which that made sense.

Practice to be a better communicator

Improving physician communication was a top priority. I believed that I was a very good communicator, so I was not sure I would learn much from participating in a required day-long session designed by the AACH.

For this program we convened in small groups of 8 to 10 physicians, and each person paired with a partner. The course provided an important framework that would help us to better organize the patient encounter, an approach that no one had ever taught me. It showed me how to leverage the patient’s chief complaint to empower her to set the agenda. This would avoid unnecessary and inefficient conversational tangents, such as the doorknob question—when the patient brings up the real reason for the visit as you are leaving the exam room.

The course also taught me that while I was a good communicator, I was not efficient. I learned how to listen more effectively. Notably, how we manage patients and how we communicate are learned skills, just like mastering a new surgical procedure. High performance requires thoughtful review and practice.

Work on relationship skills

I had professional colleagues who were difficult to work with or, as I knew from covering for them, had terrible relationships with patients. These interactions made my job harder and directly influenced patient care. I always found it distasteful to hear, “Dr. X treats people very poorly, but he or she is such a great doctor.” Should not doctors be both excellent at their work and excel at the human relationship side of the business? Maybe we did need to work on certain things.

An early Cleveland Clinic initiative was to immerse every employee, including physicians, in a half-day appreciative-inquiry exercise. This entailed sitting around a table with other randomly selected caregivers—a nurse, valet, environmental service worker, administrator—and discussing various topics, such as our role in the organization, teamwork, and the servant-leader philosophy. Going into this exercise, I was skeptical. But going through it fostered a deeper understanding of how we all need to work better together to drive safe, high-quality patient care. It made me reflect on what patients go through every day and the critical contribution each team member makes. The program made me think about what we do and created greater appreciation and mindfulness of our work.

Think empathy

One of the most impactful efforts was getting people to understand and appreciate being on the other side of health care. The patient experience team crafted an empathy video that showcased people—patients, families, caregivers, physicians—and their thoughts as they experienced the other side of health care. The video frames what they are thinking about in the moment and is a powerful reminder that each person has something happening in their life that affects their daily experiences. The empathy video has been viewed by millions around the world. (See “Empathy: The human connection to patient care,” at https://www.youtube.com/watch?v=cDDWvj_q-o8.)

Together we embraced the work

Amy and I shared a unique perspective on this work as the leader of the experience improvement initiative, married to a person experiencing it. We both came to realize that we did not know all there is to know about how to deliver high-quality patient care. Improving experience is both complex and highly nuanced, and it is a vital component of what we do as physicians. The Clinic’s efforts moved the organization to high performance, and everyone played a role. However, we would not have succeeded without the engagement of physician leaders.

Making patients and families happy was never part of the equation. It is about reducing patient suffering and delivering safe, high-quality care in an environment where people feel cared for. That is what the people we serve desire, and it is what we want for ourselves. Although there will always be doubters, especially among physicians, of the importance of patient experience, we must never lose sight that this is the right thing to do for our patients, our families, and ourselves.

Share your thoughts! Send your Letter to the Editor to rbarbieri@mdedge.com. Please include your name and the city and state in which you practice.

My pager went off 20 minutes into my case. The circulating nurse announced that it was the chief of staff’s office, and as I migrated over to the phone, everyone was wondering what I had done to warrant a call from the boss. The nurse held the phone to my ear and Dr. Joe Hahn, a neurosurgeon and second-in-command at Cleveland Clinic, congratulated me: “You’re it,” he said. I thanked him and went back to work. My scrub tech wanted to know what happened. I told him I was just appointed chief experience officer at Cleveland Clinic. With a befuddled look, he asked what that meant. I said I wasn’t sure.

Jim gets a fast lesson on how to lead patient experience

Patient experience was a signature issue for Dr. Toby Cosgrove, our then president and chief executive officer. Although the Clinic was revered for its high-quality care, patients did not always like going there. Dr. Cosgrove passionately believed that providing a high-quality experience was as important as the best medical care, and that the experience at the Clinic needed to be improved. Another physician had held the role of chief experience officer before me, but she came from outside the system and was not practicing, which proved to be a challenge in the Clinic’s physician-dominated culture. Dr. Cosgrove wanted a physician who “grew up” in the organization to lead this initiative.

When I left my initial interview with Dr. Cosgrove, I could not define patient experience, did not know what HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) was—at the time were in the 10th percentile—and frankly had no idea how I would move a culture of 45,000 people, including 3,000 employed physicians, to embrace patient-centricity. By the time I left the Clinic in 2015, however, we had pushed our experience scores to the top quartile, realigned our culture, and had become world renown for patient experience.¹

I knew intuitively that improving the patient experience was the right thing to do. In 2004, my father had died at the Clinic from surgical complications; his experience had been terrible. At that time, we did not use the term experience, but based on the items that hospitals are graded on today, my father would have failed us on all of them.

What is patient experience?

Patient experience is not about making people happy. Fundamentally, it is about delivering safe, high-quality, patient-centric care. A 2017 Press Ganey analysis of publicly reported data from the Centers for Medicaid and Medicare demonstrated that when performance on experience measures is high, safety and quality also are high.² Similarly, in 2015, JAMA published an article using data from the National Surgical Quality Improvement Project demonstrating a significant association between patient experience scores and several objective measures of surgical quality, including mortality and complications.³

In my new role, I mercilessly told my father’s story, changed the narrative to include safety and quality, and asked my physician colleagues for their help to improve patient experience. People in health care pay very close attention to what physicians do and say, and I needed the doctors to “own it” if we were going to implement the desired change.

I also had to convince them to see themselves on the “other side.” It was not just a matter of “treating patients the way you would want to be treated.” It was about putting yourself in your patients’ shoes—having empathy for what they are experiencing and recognizing that you or a family member could be sitting in that bed. Before my father was ill, I had never been on the other side so intimately, and it was an eye-opening experience.

Retooling communication competency

For the physicians, we zeroed in on helping them improve how they communicate with patients. Communication is a high-value target for experience improvement, and it directly influences safety and quality. We produced a physician-centric communication guide that provided useful tips (see “Practical tips to help physicians improve communication with patients”). We made communication scores transparent. In addition, working with the American Academy on Communication in Healthcare (AACH), we developed a program specifically designed to help physicians improve their communication skills and practice management.⁴ The outcome was not only better scores but also higher physician engagement and lower burnout.⁵

Keeping it real

Being married to another member of the medical staff—a strong-willed and opinionated one at that—ensured that my strategic approach to improving patient experience was grounded. It gave me a safe place to test ideas and concepts, which in turn allowed me to keep my instincts framed and relevant to the needs of key stakeholders, particularly the physicians.

Read what the ObGyn wife has to say.

The ObGyn wife tells her side

When my husband was appointed chief experience officer, I naturally was happy for his accomplishment but admitted that I was not sure exactly what it meant. What was he going to be doing? Would he give up surgery, which he loved?

The experience “thing” always had been fuzzy to me. I equated experience with satisfaction, and I saw my primary role as taking care of patients, not making them happy. I believed that I had great patient relationships, so what else did I need to know to contribute to this work? The connection to safety and quality did resonate with me, though, and it made talking about patient experience more tangible.

When Jim started teasing apart what steps needed to be taken, improving the culture seemed like an obvious focus. One thing was clear: He would need to get the physicians on board by helping them to see the practical importance of this work. It could not be gimmicky or too touchy-feely. The work had to be relevant and tangible to their everyday practice. One thing he said struck a chord: “Everyone comes to health care to help people, and we all believe we are the best we can be, but clearly there are opportunities to improve, and evolve our skills.” I started to consider specific circumstances in which that made sense.

Practice to be a better communicator

Improving physician communication was a top priority. I believed that I was a very good communicator, so I was not sure I would learn much from participating in a required day-long session designed by the AACH.

For this program we convened in small groups of 8 to 10 physicians, and each person paired with a partner. The course provided an important framework that would help us to better organize the patient encounter, an approach that no one had ever taught me. It showed me how to leverage the patient’s chief complaint to empower her to set the agenda. This would avoid unnecessary and inefficient conversational tangents, such as the doorknob question—when the patient brings up the real reason for the visit as you are leaving the exam room.

The course also taught me that while I was a good communicator, I was not efficient. I learned how to listen more effectively. Notably, how we manage patients and how we communicate are learned skills, just like mastering a new surgical procedure. High performance requires thoughtful review and practice.

Work on relationship skills

I had professional colleagues who were difficult to work with or, as I knew from covering for them, had terrible relationships with patients. These interactions made my job harder and directly influenced patient care. I always found it distasteful to hear, “Dr. X treats people very poorly, but he or she is such a great doctor.” Should not doctors be both excellent at their work and excel at the human relationship side of the business? Maybe we did need to work on certain things.

An early Cleveland Clinic initiative was to immerse every employee, including physicians, in a half-day appreciative-inquiry exercise. This entailed sitting around a table with other randomly selected caregivers—a nurse, valet, environmental service worker, administrator—and discussing various topics, such as our role in the organization, teamwork, and the servant-leader philosophy. Going into this exercise, I was skeptical. But going through it fostered a deeper understanding of how we all need to work better together to drive safe, high-quality patient care. It made me reflect on what patients go through every day and the critical contribution each team member makes. The program made me think about what we do and created greater appreciation and mindfulness of our work.

Think empathy

One of the most impactful efforts was getting people to understand and appreciate being on the other side of health care. The patient experience team crafted an empathy video that showcased people—patients, families, caregivers, physicians—and their thoughts as they experienced the other side of health care. The video frames what they are thinking about in the moment and is a powerful reminder that each person has something happening in their life that affects their daily experiences. The empathy video has been viewed by millions around the world. (See “Empathy: The human connection to patient care,” at https://www.youtube.com/watch?v=cDDWvj_q-o8.)

Together we embraced the work

Amy and I shared a unique perspective on this work as the leader of the experience improvement initiative, married to a person experiencing it. We both came to realize that we did not know all there is to know about how to deliver high-quality patient care. Improving experience is both complex and highly nuanced, and it is a vital component of what we do as physicians. The Clinic’s efforts moved the organization to high performance, and everyone played a role. However, we would not have succeeded without the engagement of physician leaders.

Making patients and families happy was never part of the equation. It is about reducing patient suffering and delivering safe, high-quality care in an environment where people feel cared for. That is what the people we serve desire, and it is what we want for ourselves. Although there will always be doubters, especially among physicians, of the importance of patient experience, we must never lose sight that this is the right thing to do for our patients, our families, and ourselves.

Share your thoughts! Send your Letter to the Editor to rbarbieri@mdedge.com. Please include your name and the city and state in which you practice.