Hospitals Must Focus Beyond Clinical Outcomes: Cleveland Clinic's Chief Experience Officer Dr. James Merlino

After Delos "Toby" Cosgrove took over as CEO of Cleveland Clinic in 2005, he led the charge to create a more patient-centered health system and introduced the Clinic's "Patients First" initiative. In 2007, those efforts resulted in the creation of the Office of Patient Experience and naming of the Clinic's first Chief Experience Officer. In July 2009, James Merlino, MD, a colorectal surgeon and vice-chairman of the Clinic's Digestive Disease Institute, took over the Chief Experience Officer role, where his core responsibility is to ensure patient experience at the Clinic meets the highest possible standards. Here, he discusses his role and the growing importance of patient experience and patient-centeredness in healthcare.

Q: What initially drew you your current role as Chief Experience Officer?

Dr. James Merlino: I was a fellow in colorectal surgery [at the Clinic] at the time when Toby became CEO. Prior to his leadership, the Clinic was a very different place. It had very high clinical expectations and outcomes, but there wasn't a lot of attention paid to the holistic patient experience component and I saw that personally. My father was a patient here at that time, and the experience he had in the facility — what he went through — was just terrible. His clinical outcomes were exactly what they needed to be, and his care, from a clinical standpoint was exceptional, but patients weren't treated well. That wasn't the way I wanted to practice medicine and after my fellowship, I left [the Clinic]. I came back for clinical reasons and realized the environment had changed dramatically [under Toby]. I had been involved in and concerned with patient experience as vice-chair of my department and when the [Chief Experience Officer] position became open, I was encouraged to apply for it…    

When Toby rolled out Patients First it was easy for colleagues to joke, "When do you not put patients first?'" but the truth is it's not about the clinical outcomes. My experience in private practice taught me the harsh economic reality of medicine is if you don't treat patients and referring providers well, you can't succeed. It's not about the care; it's about the service around the care.

Q: How would you describe your role as Chief Experience Officer?

My role is to drive strategy and best practices around patient experience and to be the keeper of data used as a tool to drive organizational performance improvement in this area. My role also involves culture building and employee engagement. To ultimately drive patient experience, you need motivated and engaged employees; you need to make sure they're thinking about it all of the time.

Patient experience is really driven by two factors — processes of care linked by seamless transitions and cultural alignment around patient experience. Processes of care are these best practices for experience — things like reducing noise, improving communication among physicians, ensuring patient access and follow-up efforts. However, you can't have good processes that forward face patients unless those caregivers that face patients are engaged. [As a result,] we focus a lot on cultural alignment. We are currently working to align our culture around our values and patient experience. All 42,000 employees will take part in half-day training sessions where small groups of 8-10 employees work with a facilitator to map our mission, vision and values and learn expected service behaviors. We choose an expensive methodology for training, but we choose it because we want to engage our employees and build a culture of service.

Q: Beyond driving a service-oriented culture, what are some other initiatives of the Office of Patient Experience?

The other initiatives fall largely on the process side and align closely with the eight domains included in the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey, such as quietness of the hospital environment, pain management and nurse communication. Each of the eight domains has a project team led by a clinical project manager that drives best practices for that domain. We build process metrics around improvement in the areas, make sure our employees follow the programs and then evaluate outcome metrics to identify improvements.

The Office also oversees the Clinic's Healing Services Program. This is the softer side of patient experience, but it's no less important when you think about driving toward a patient-centric approach. The Clinic offers services such as touch therapy, massage and spiritual interactions and has a Code Lavender team that responds to employees, families and patients after situations such as the loss of a loved one. The team helps comfort family and friends and also works with caregivers (Clinic employees) who may also be affected by the loss.

Q: Although Medicare payments will soon include adjustments for HCAHPS scores, less than 1 percent of a hospital's rate is impacted. While it seems intuitive that improving patient experience is important, it can sometimes be difficult to make a financial case for that. If hospital leaders that wish to improve experience meet resistance because it's difficult to define the return on investment, how should they respond?

Luckily, that hasn't been a battle we've needed to fight here. We've been very fortunate from that side — our CEO drives [experience improvement] strongly. I think the challenge is to get leadership to understand that some things aren't always directly measurable in terms of ROI. On the Medicare side, one percent of reimbursement will be tied to value through the Value Based Purchasing Program, and just 30 percent of that one percent is based on patient satisfaction (HCAHPS) scores. The bigger threat is not from Medicare, but the commercial payor side.

As healthcare continues to become increasingly competitive it is also experiencing greater consumerism. Patients start paying attention to how well they're treated. Generally now if you go to a top medical center, you're going to get good outcomes. Medical care is becoming very good, and people now want more than just outcomes. That's why it's critical to implement programs that drive service. There won't always be clear ROI, but [patient experience] will definitely impact reimbursement.

Q: What is the number one thing hospitals can do to improve the experience of their patients?

The process needs to be set by senior leadership. Staff members need to understand that providing great service is a critical part of what they do every day. Leaders need to provide clarity around why service and experience is so important — why they and their employees need to be engaged around it. You can appeal to emotion — it's the right thing to do and the way you and your family would want to be treated. One of the most important things to start with is to explain the link to reimbursement and the fact that patients not only expect a good clinical outcome, but also a great patient experience and quality service.

Related Articles on Patient Experience:
Study: Hospitals Have Improved Overall Patient Experience
Sophisticated and Powerful Consumers: How Transparency Will Change Hospitals

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