Patient experience 'never events' from 16 execs at Cleveland Clinic, Providence & more

While patient experience "never events" may not always be entirely preventable, there are certain actions to avoid and strategies that hospitals can implement to foster a great patient experience. 

Here are insights from 16 hospital and health system leaders on how to reduce "never events" and enhance care. 

Editor's note: Responses have been lightly edited for clarity and length. 

Question: What patient experience 'never events' should health systems eliminate?

Jack Vozar. Director at Atlas Healthcare Partners: In my experience as both a [healthcare coach with the Studer Group] and patient advocate, I firmly believe patient concerns, complaints and grievances should never go unaddressed or not be taken seriously. What I have found is that systems do not have a robust enough recovery program. Recovery is really about what not to say to patients. Responses to concerns and complaints often inadvertently blame the patient or cast doubt on the validity of the patient or family concern. Engaging front-line team members is critical to equip them with the tools to provide excellent recovery. I have, in the past, surveyed front-line staff in various departments to understand what complaints and concerns they frequently experience and give them responses that are positive and productive rather than negative and blame assigning. When recovery is delivered through a positive lens rather than the negative, the relationship with the patient has the potential to be stronger than ever, but the team needs the tools. 

Andrienne Boissy, CXO of Cleveland Clinic: We think about the following promises to our patients:

1. We will keep you safe.

2. We will partner with you.

3. We will care for you as a person

4. We will make it easier

Never events are any failures in the above:

1. When we make mistakes that harm (emotionally and physically) and we don’t disclose. When we don’t communicate effectively.

2. When we don’t include the patient as a member of the care team.

3. When we don’t know what matters most to those we care for. When we don’t empathize.

4. When we make or cause avoidable suffering through complex and fragmented access, cumbersome or incoherent billing, getting and making an appointment, prolonged and  unexplained delays and waits, and poor service. 

Interestingly, taking a page from high reliability and safety, we run root cause analyses on experience failures. We grade them in line with SERS events in terms of severity. This has raised visibility and evaluation of experience failures to the credibility and diligence we apply to safety failures.

Julie Danker, CXO of Auscura (La Grange, Ill.): While no patient or employee should experience a "never event," we know that they can and do happen. What is likely a pain point for a patient is probably a pain point for the staff. This then affects overall mood and interaction with patients and visitors. Tracking and trending these through-put opportunities or wait times as an example can be helpful to eliminate poor experiences. "Never events" must be eliminated, and staff engagement and interaction with patients should always be GREAT, an acronym and service standard I helped develop at Warrenville, Ill.-based Edward-Elmhurst Health. The GREAT standard is a reminder that doing a good job interacting with patients is not enough for value-based care. 

Rhonda Medows, executive vice president and chief population health officer of Providence (Renton, Wash.): Health systems should eliminate the following "never events": 

  • Care disruption or delays due to inadequate information sharing and data interoperability.
  • Care and health service delays by leveraging digital health solutions, telehealth and service options that expand the reach of clinicians.
  • Negative impacts on health caused by social determinants by integrating social support and community services. Some examples of this include transportation to care, mail order prescription, care management, post acute care planning and transitional housing.
  • Misunderstandings and unintentional cultural bias by improving patient and community communications and proactive interventions focused on health disparities.

Dwight McBee, CXO of Temple Health (Philadelphia): Never miss the moment. In healthcare, we often witness the greatest joys and profound sufferings in life, so much so that they become part of our regular work routine. Hospitals and health systems should never miss the opportunities to stop and recognize the importance of the moments we share. If COVID-19 taught us one thing, it was to recognize that we are all in this together. Never miss the chance to celebrate life, honor in death and support one another throughout the care journey.

Kevin Conroy, CFO and chief population health officer of CareMount Medical (Mount Kisco, N.Y.): Health systems must eliminate the following patient experience "never events":

  • Questioning and judging the patient or customer's perception.
  • Inconsistencies in patient communication.
  • Delay in capturing and aggregating valuable patient feedback, even with small numbers.
  • Ignoring employee feedback on what is and isn’t working well with your patient experience strategy. 

Dawn Rudolph, president of Ascension Sacred Heart Pensacola (Fla.): Unexplained delays, care team conflict and unclear plans of care are patient experience "never events". You can find the full explanation on these themes here.

There are also certain phrases that we should always avoid. 

"We're short staffed." First of all, this is not the patient's problem and will only increase their anxiety and concerns. Patients will immediately become anxious about whether or not caregivers will be able to meet their needs. It's likely they will then question the decision they made to choose this facility for their care. As volumes change, there is always a potential for staffing challenges. However, there should never be an impact on patient experience or the overall quality of patient care. 

"I've never done this before." There are few things more frightening to a patient than an unskilled caregiver. If the patient is truly frightened, they may immediately ask for a new nurse or assistant. This can permanently damage the patient and caregiver relationship. To avoid this, we encourage collaboration among our care teams to ensure there is always an experienced individual available to assist less experienced staff. From the patient perspective, there is an increased sense of confidence when multiple caregivers are present at the bedside. When done correctly, we can actually utilize these educational opportunities to enhance the patient experience.

Ghazala Sharieff, MD, CMO of clinical excellence and experience at Scripps Health (San Diego): Never hinder the patient from getting what they need. Always accommodate them. Patients should never be confused about what the next steps are. Plan of care should be clear and transitions of care should be seamless. It shouldn’t matter what the phone number is to X-department, because our staff are already aware that the patient has a need. The patient should never feel they need to coordinate their own care. 

When the plan of care involves multiple steps and appointments, someone should be working with the patient closely to ensure the plan of care is being followed. If the patient misunderstood the plan or the sequence of events, it results in delays to care. Why should the patient have to make note of multiple phone numbers to call and get different appointments? They should only have to call one number to speak to someone that can help them navigate through their care. The patient should never feel they need an appointment to be heard and cared for. Patients should feel just as important in between visits as they are made feel during a visit. They should trust that when they send an email or make a phone call, it will be managed and held with the same regard as when a patient is present in office.

Click here to read Dr. Sharieff's full response.

Chris Brainard, senior director of patient experience and engagement at UAB Medicine (Birmingham, Ala.): A patient’s relationship with their healthcare organization is built on trust. Trust is continually gained or lost depending on the patient's experience. In some cases, interactions are so profound they create lifetime brand loyalty. In other cases, one interaction alone can erode or even permanently sever a patient’s trust in their healthcare organization.

Trust in healthcare has never been more important than it is today. The COVID-19 global pandemic has created a new world for the American healthcare industry, a world in which masks and face coverings cover the smiles we once saw, virtual visits supersede in-person care, and visitor precautions leave patients feeling isolated. 

During the visit, never:

  • Get on an elevator or pass someone in the hallway without smiling and speaking.
  • Bad mouth your colleagues, other departments, or the organization to a patient or in front of a patient.
  • Rudely dismiss research a patient has done – graciously offer other trusted materials/resources, and celebrate them for taking an active role and being so engaged in their care.
  • Turn a patient away for lack of records on consults. Focus on what you can do right then and there, and create a plan for the future.

Click here to read Mr. Brainard's full response.

William Isenberg, MD, PhD, chief quality and safety officer of Sutter Health (Sacramento): Patients should always feel welcome and safe. That has never been more true than during the COVID-19 pandemic. 

Integrated networks like Sutter Health have built-in support mechanisms that will help us respond and take care of patients if a surge ever appears. We have begun expanding clinical services for preventive care and individuals with medically necessary, time-sensitive needs, but concerns remain. There have been reports of individuals avoiding emergency care.

California recently announced that childhood vaccination rates have dropped since last year. These are all potential signs of COVID-19’s impact on the public. These are healthcare needs that, if overlooked, can have lasting effects. 

Sutter has adopted digital check-in options, embraced universal masking for staff and patients, set up temperature check stations, increased frequency of cleanings and moved furniture to promote physical distancing in waiting rooms — all in the name of safety. We are here to support our communities so they can confidently reengage and remain connected with their healthcare providers.

Lisa Drumbore, vice president and CXO of St. Peter's Healthcare System (New Brunswick, N.J.): In healthcare, "never events" are primarily viewed in terms of preventable medical errors. Ideally, a strategic, action-oriented focus on "never events" should translate into a reduction in patient harm. From a broad patient experience perspective, applying a systems approach and cultivating a service excellence culture that learns from the ‘voice-of-the-patient’ should allow for the elimination of humanistic ‘never events’ from healthcare. These events may present in small instances, such as extended wait times, or more impactful ones where the patient feels voiceless. Only those entrusted in our care can truly define these events, as each one is personal.

Focusing on re-engineering processes, tasks and flow to eliminate "never events", while critically important, does not account for the greatest opportunity to prevent them — ensuring the fundamental element of workplace empathy. At Saint Peter’s, the leadership team does this in many ways including Personal Advocate Day, held since 2007 to analyze and read every single patient experience survey and comments with respective department managers present. This exemplifies the intersection of high reliability and the patient experience. By truly listening to patients and their families, we can make sure they feel supported, cared for and heard. In this way, we are eliminating patient experience "'never events" by living our mission to minister to the whole person, body and spirit, preserving the dignity and sacredness of each life, providing the highest quality service – always.

Daniel Durand, MD, chief innovation officer of Lifebridge Health (Baltimore): I believe that health systems should be shooting for a seamless digital customer experience, and that this is more important than ever in the post-COVID-19 reality. That being the case, the following "never events" for healthcare digital consumers are important to keep in mind: 

  • Paper forms should be relegated to the dustbin of history.
  • Patients should only have to give information like insurance and allergies one time per visit.
  • Patients should never get uncoordinated outreach from the same health system.
  • Patients should never have to wonder which type of access point is for which type of care. There should be resources to guide them through the plurality of access points  available to them.
  • Patients should have a single and secure place that both their EHR access and access to care "resides" — integrating their insurance plan is an added plus if possible.
  • Patients should never have to pay exorbitant fees to switch where they choose to keep their data, and with which organizations. 

Some of the "never events" are of course things that still happen, and the idea of achieving a more seamless digital patient experience in which they truly "never" happen is an aspirational goal for most at the present time, but clearly a laudable one. 

Nicole Cable, CXO of InnovaCare Health (Fort Lee, N.J.): According to the National Quality Forum, "never events" are errors that are preventable and serious enough to cause undue harm to patients and ultimately their families. Examples of never events in patient experience are failing to communicate to patients and families in a way in which they can understand, not being culturally responsive with your communication and failing to ensure that shared-decision making is a component of the care we deliver. 

Far too often healthcare providers make decisions about patients without ever really taking time to understand their needs and wants. In fact, providers failing to listen and communicate effectively is one of the leading causes of patient dissatisfaction and lack of care adherence. In order for healthcare organizations to be their best, patients and their families need to be invited to the table. In today’s healthcare world, there is no excuse for poorly laid out facilities, processes that create extra layers of burden, hospital readmissions and patients leaving appointments without knowing their next step. We must focus on the human experience to advance healthcare for the future. 

Sven Gierlinger, CXO of Northwell Health (New Hyde Park, N.Y.): Patients should never die alone. At the height of the COVID-19 crisis, critically ill patients arrived at hospitals across our country in droves – especially in New York. With restrictions on visitation, we found that facilitating remote patient visits with their families has been incredibly meaningful to patients, families and staff members. We learned that having staff at the patient’s bedside often served as physical extensions of the patient’s loved one — connecting through technology such as FaceTime, holding the patient’s hand, brushing hair off their forehead, offering peace and comfort and bearing witness to one’s last breath. When loved ones were unable to be together physically, our front-line staff and patient experience leaders gave the selfless gift of providing those last moments together, to ensure patients were never alone. 

Technology should never outshine the human connection. While technology has been an indispensable tool in connecting families during this time, we must remember that at the core of every experience is always a human interaction. Providing those moments and nuances can’t ever be replaced by stand-alone technology. Advances in technology should always be embraced and used as a tool to help enhance our ability to connect and provide high quality patient-centered care. 

Personal protective equipment should never get in the way of truly connecting with patients and families. With team members covered in PPE, patients are unable to see their caregiver’s face. This can be quite scary and unsettling, especially in an already unknown environment. One innovative solution is creating ID stickers and badges including name, title and an engaging photo. Seeing a person’s face and a simple smile can truly make all the difference in establishing trust. The goal is always to help foster connections and reduce patient anxiety and isolation.

Pam Guler, vice president and CXO of AdventHealth (Altamonte Springs, Fla.): At AdventHealth, we have committed to the service standards of Keep Me Safe, Love Me, Make It Easy and Own It, when we think about delivering an exceptional experience to every person every time. We think about patient experience "never events" within the context of these service standards. Here are some examples of “never events” from this perspective. 

Keep Me Safe: Any clinical experience that is unsafe, for example medication error, or an unclean or unsafe environment. Other examples include a team member not wearing identifying badge or appropriate color-coded by role scrubs as well as breach in patient privacy or confidentiality. 

Love Me: Lack of recognizing and/or addressing the spiritual needs of our patients; ineffective or unclear communication with patients; treating patients with a lack of respect and dignity; and showing a lack of empathy or compassion. 

Make It Easy: Difficulty with timely and easy access to care; leaving a patient or guest feeling lost and not helping them to their destination or next step of care; not working as a team and providing connected care; and suppressing innovation that would improve patient experience. 

Own It: Failing to follow through on commitments to patients; blaming others and speaking poorly of fellow team members to patients; negative attitudes from team members; and lack of service recovery when we fall short of expectations. 

Airica Steed, EdD, RN, executive vice president and COO of Sinai Health System (Chicago): From my point of view, patients should always have an experience without harm, inconvenience or inconsistency. There shouldn't be a situation where they have to wait for communication or care; they shouldn't have to wait for care transition or follow up. It should always be our goal as executives and leaders to deliver care as well as the ideal patient experience to all patients without fail. 

Healthcare should also feel personalized; patients shouldn't feel like a number. They shouldn't feel forgettable or lost in the mix. We should be at the point where we can anticipate what the patients' needs are and wrap their services and experiences around that. We need to make sure patients are heard, recognized and valued. 

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