Communication the Cleveland Clinic Way Read online

  Dr. Mikkael Sekeres has been a strong and loyal friend who has continuously encouraged me in my work on communication skills and has graciously edited essays I have written and inspired me with his own writing.

  My parents have encouraged me with love and resources from the day I was born, and there is no way to put into words what I owe them. I’m hoping to pay it forward. My children, Maxine and Joseph, and my wife, Heather, have been extremely patient as I have spent nights and weekends and holidays working on communication skills projects and writing and editing this book. I am hugely grateful for their patience and their love. You three give my life its meaning.

  Chapter

  1

  “I Already Know This” and “Patients Know I Care”

  Designing a Culture That Is Ready for Communication Skills Training

  “Do you teach empathy at Cleveland Clinic?”

  These words would forever change our organization. It was 2006 and our CEO, Dr. Toby Cosgrove, had been invited to speak at Harvard Business School. As he finished his comments, a young student named Kara Medoff Barnett raised her hand. She spoke of her father, a physician, who needed a mitral valve surgery and how their family decided where to have his heart surgery done. They were familiar with the excellent cardiac outcomes we had, yet ultimately they decided against Cleveland Clinic for his care “because we heard you had no empathy.”

  Reflecting on this experience, Cosgrove was “floored.”1 Ten days later, he was in Saudi Arabia attending the dedication of an International Medical City. As he listened to the president of the hospital speak about the type of care they were hoping to provide, he looked over at the king and saw that he was crying. As he looked out into the audience, he realized they were crying, too. In that moment, he recognized, “We are really missing something. We need to treat the soul and spirit of the patient, not just the body.”

  Patients First

  One of the most important changes was Cosgrove’s conception of Patients First as Cleveland Clinic’s motto. Patients First became the True North of the organization. What this meant on the ground level was that any strategic decisions or initiatives that the organization put forward had to involve improving the care and experience of our patients at their core. Although there was marketing associated with the Patients First model and many caregivers were skeptical, repeated messaging reinforced that we all exist for the care of the patient. When there was pushback about the motto, it was usually in the form of “patients first and caregivers last.” That was a noteworthy reflection of our culture at the time. As an organization, we know that both patients and caregivers are important and have intrinsic value. If Patients First was really going to permeate our culture, we would need to be intentional about building programs that had perceived value to the caregivers we wanted to reach. Thinking about how we could evolve programs that not only enhanced the patient experience, but also the experience of our caregivers remains a critical, foundational approach.

  Many changes occurred during these years that helped to evolve our culture toward a more patient-centered environment. Cosgrove wanted to align care physically around the patient. He wanted to streamline service lines so that cardiothoracic surgeons worked alongside cardiologists and radiologists to deliver exceptional cardiac care, to break down the silos of a traditional academic structure, and to create teams of diverse individuals and professionals all working toward Patients First. Although there was initial concern about what that would feel like or look like, he was effective in messaging that alignment was simply the right thing to do for patients. This purpose resonated with most of our caregivers.

  Another change that reinforced the Patients First principle was instituting same-day appointments. Although there are certainly business cases for creating same-day access, it was an organizational initiative that put the needs of the patient front and center. The move required a radical shift in the way scheduling had always been done. Cosgrove was unwavering in the idea that same-day access had to occur; however, he deferred to individual institutes as to how that would be executed. The idea was simple. If people can’t access your services, it doesn’t really matter how wonderful they are. Patients want to be seen.

  We also created Voice of the Patient Advisory Councils (VPACs) throughout the healthcare system. They gave us input on policies regarding conflicts of interest and disruptive physicians, and feedback on facilities. On one occasion, a VPAC asked that members of an architectural firm that was presenting plans on a new building spend a day in a wheelchair and report back to them. The council input was especially relevant because the plans were for a new Neurological Institute. Even parking services were altered to allow patients access to the first few floors of a garage, and physician and employee parking was moved more distally.

  Recognizing the healing power of art in the environment on individual patients, we established an Arts & Medicine Institute. At times, our caregivers play the piano and our patients perform, all with the goal of cultivating an environment of healing. Cosgrove’s commitment to patient experience and to easing the anxiety and fears of patients also bore itself out in the environmental design. When entertaining ideas for a new water display to mark the entrance to Cleveland Clinic, a design firm pitched an idea for an intricate, complex, and light-enhanced feature. Cosgrove challenged the designers: “Do you know what our patients are feeling when they walk through these doors? They are afraid and scared. It’s our job to create a sense of calm, and the most calming thing I can think of is a smooth body of water.” And that’s what we got. A simple, round water feature with infinity edges and subtle lighting.

  Patients First was here to stay.

  Chief Experience Officer

  In 2008 Cosgrove created the executive position of chief experience officer (CXO) after reading an article about the impact a CXO could have on integrating patient experience and organizational priority.2 He hired Dr. Bridget Duffy, a dermatologist by training, who led the Office of Patient Experience. Her passion for patient experience was palpable and highlighted the experiences of both our patients and caregivers to the highest levels of the organization. She was exceptionally effective at sharing the stories of our patients and inspiring many of us to want to be better at what we did.

  In 2009 Dr. Jim Merlino became the CXO. A colorectal surgeon by training, the most powerfully effective quality Merlino had was his ability to speak of his personal experience and leverage it for organizational culture change. He told the story of his father, who had been admitted to Cleveland Clinic for what was supposed to be a routine biopsy. But after several days of complications, his father arrested and died. Merlino described the agony of having to witness his father being reduced to “his most vulnerable state” and the pain of his actual loss. Merlino’s story moved all who heard it, and he performed his role with a very personal passion for the work.3 Under his leadership, the Office of Patient Experience thrived (Figure 1.1), and Cleveland Clinic moved up from the 8th percentile in patient satisfaction to about the 70th.

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  FIGURE 1.1 Organizational Structure of the Office of Patient Experience

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  Merlino partnered with Kelly Hancock, our chief nursing officer, who lives and breathes this work, to drive experience efforts across the system. We defined Patients First as safe care, high-quality care, in the context of patient satisfaction, and value. This was a critical step in our journey. What’s powerful about this definition is that patient experience isn’t merely an average of patient satisfaction scores. Just as caregiver experience isn’t simply an average of their engagement scores. With the Centers for Medicaid and Medicare Services (CMS) reserving the right to change patient satisfaction questions or metrics at any time, designing a patient experience strategy simply to improve your Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores is chasing a number and not evolving a culture. Patient experience cannot exist irrespective of teamwork, excellent clinical care, and superior
outcomes. We wanted a culture of patient experience.

  Without a definition of patient experience, it is very difficult to improve it.

  The Clinic organized a massive effort to set the stage for patient experience in a half-day program that came to be called the Cleveland Clinic Experience (CCE). In these sessions, healthcare providers, environmental services employees, and administrators sat around a table with a single facilitator and a learning map (Figure 1.2).

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  FIGURE 1.2 The Cleveland Clinic Experience Learning Map

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  We spent time talking about the why of Patients First, the values of the organization, our role in patient experience, and learned service recovery skills in a program called Respond with H.E.A.R.T.™ Within these sessions, the term caregiver was introduced and equalized the playing field by breaking down barriers between traditional staff, faculty, and employees. We all became caregivers. All 43,000 Cleveland Clinic caregivers completed the training in a year and a half.

  Service Recovery at Cleveland Clinic: Respond with H.E.A.R.T.

  Hear the story

  Listen attentively.

  Empathize

  “I can see/hear that you are upset.”

  Apologize

  “I’m sorry you were disappointed.”

  Respond to the problem

  “What can I do to help?”

  Thank them

  “Thank you for taking the time to tell me about this.”

  Simply changing the term was not enough. Occasionally during CCE, physicians leaned back in their chairs away from the table. They were there, but they weren’t. Many of these participants received letters from the chief of staff about needing to reattend the course after leaving early or not participating in the process with everyone else. Many clinicians felt these sessions were of variable value to them, yet what they failed to appreciate was the impact of their presence and, in particular, their disengagement. If clinicians at a physician-led organization show up for an educational program or activity, this carries the message to others that the effort has value and is a priority for the organization. If they show up, lean back in their chairs, and leave early, then they give the message that as physician leaders at this organization, we don’t really have to participate like everyone else. There seemed to be a lack of self-awareness that as a physician, you are a leader, and your behavior is watched and interpreted. Modeling that patient experience matters to all of us—or it doesn’t—is a choice we all make and for which we would be held accountable.

  Cleveland Clinic also produced an “empathy video,” which was a window into the lives of patients and caregivers.4 Currently, it has more than 2 million views on YouTube. I became aware of the video’s impact when I went to speak at a national patient experience summit and was prepared to show it as part of my presentation. To my surprise, the speaker right before me from a Texas healthcare system played it. When we’ve asked people what is so powerful about this video, the answers are reminders of why we are here. The video honors that each of us has a story that we carry with us into every interaction. This video embodied the cultural transformation that was taking place at Cleveland Clinic at the time.

  If you knew their story, you probably would treat them differently.

  The Physician

  The road to becoming a physician isn’t easy. We start with the purpose of wanting to help others, then our empathy erodes throughout residency once we become exposed to the “real” world of medicine and hidden curricula of training.5 The ability to empathize never recovers to what it originally was. If we step back and think about this for a minute with an open mind, is it really a reasonable expectation that we will produce empathic caregivers when we don’t treat caregivers with respect and empathy during their training? There are extremes of disruptive behavior and famous stories of doctors throwing tantrums or surgical instruments, but there are also some significant offensive generalizations about physicians. We sat in a national meeting recently where the presenters proposed that the only way to incentivize physicians was to give them bonuses. Yet the stark reality of the profession is that many physicians no longer find joy in their work. Physicians remain in the highest risk group for professions committing suicide, and over half of them are burned out. Thinking of them as a group that, at times, may be suffering just as much as patients is essential to also seeing them as human.

  The World

  The world of healthcare is changing. In 2001, the Institute of Medicine published Crossing the Quality Chasm, a report that called for patient-centered care.6 It identified key principles to redefine healthcare that included attending to patients’ values and beliefs, recognizing the value of healing relationships and shared decision making, the need to communicate effectively, and customizing care to the patient. The Patient Protection and Affordable Care Act (H.R.3590) and the Health Care Education and Reconciliation Act (H.R.4872) are together known as the Affordable Care Act (ACA). What the ACA outlines is that the old fee-for-service model in healthcare will be replaced by a value-based purchasing model. The Centers for Medicare and Medicaid were driving the point that healthcare institutions were accountable for cost, health outcomes, and experience, the so-called Triple Aim.7 Included in these changes is tying reimbursement to hospital performance in four areas: quality and safety, patient experience, value, and outcomes. Over time, the schedule for the percentage of Medicare reimbursements dependent upon these metrics will increase every year, and the percentage of each category will also change.

  Not only are hospitals accountable, so are individual clinicians according to certain metrics. Patient satisfaction surveys cover multiple domains of care, including communication, discharge, pain management, responsiveness, accessibility, and so on. How did doctors communicate? Did they spend enough time with you? Did you feel as though you were part of the decision making? And on the inpatient side, did you perceive that the healthcare team worked well together? Were your medications explained to you? Did the nurses communicate? There is increasing pressure on individual care providers to evaluate critically the way we practice. This may feel uncomfortable for clinicians, given that formerly we typically had free rein to provide care we felt was appropriate, regardless of cost or evidence. In fact, most of us went into healthcare so that we could function independently, provide great care to patients, enjoy financial security, and exercise control over the way we practice. The very idea that CMS or the hospital is now looking over our shoulders and infiltrating our management is difficult, understandably so. The reality is that “change is inevitable, growth is optional.”

  As daunting as all these changes are to the individual clinician, they provide the burning platform that is critical to creating real change. Simply put, the way we had always done it wasn’t going to work anymore.

  Transparency

  Cosgrove was innovative in thinking about how transparency would drive behavior. He knew that when heart surgical outcomes were published, quality improved. He articulated a desire to have patient experience metrics available to individual physicians. Currently, these scores are available on Physician Compare offered through Medicare. In addition, hospital systems, including Cleveland Clinic, have posted their patient feedback as captured in patient satisfaction surveys to the public on their websites. Multiple websites, including Healthgrades and Vitals, do this as well, but the problem is that there is no confirmation that the reviewer ever saw a given clinician, reviews can exist based on only one or two surveys, and people can say just about anything. Yet, with roughly 60 percent of patients looking for physicians online, transparency is not going away.8

  As highlighted by Merlino, 72 percent of negative HCAHPS comments were about communication (respect, compassion, listening, who is in charge, and the plan). We knew that no single score is enough to build a story of a given provider’s ability to communicate, but several scores pulled from different data sets can.

  In 2010–2011, Cleveland Clinic rolled out individu
al clinician reporting of inpatient and outpatient communication scores. There was fear that this would cause a major uprising. For about six months, we blinded the scores so that physicians knew how their own scores compared with others in their department, but their colleagues’ scores were not identified by name. We didn’t hear a peep. Now, however, all clinicians can see each other’s performance on inpatient and outpatient communication domains from HCAHPS, Clinical Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS), and patient complaints. For a competitive population, transparency can change behavior. No clinician likes to see his or her name on the bottom of any performance list. However, many cannot improve their communication scores simply by trying. They don’t always know what to do or say differently. They may not even be aware of what their current practice is. Showing physicians where they are not meeting a target and then not offering any solutions to help them achieve the target is counterproductive and may result in further disengagement. Transparency can raise awareness of behavior, but to fully support our staff, we needed to offer the appropriate training. The stage was set for communication skills programs.