Taking Service Excellence From Smile Lessons to Core Strategy

While the best hospitals and other healthcare organizations have always been concerned about quality and the patient experience, the emergence of the Hospital Consumer Assessment of Healthcare Providers and Systems survey, which was endorsed by the National Quality Forum in 2005, and the Consumer Assessment of Healthcare Providers and Systems, have put the focus on service front and center among healthcare leaders around the country. Why? Because these programs move accountability for quality patient care beyond a construct to a measured activity on which a portion of hospitals' reimbursement will be based. That's an entirely different type of accountability, and it has resulted in a renewed interest and emphasis on improving the patient experience.

Accountability matters. This type of accountability — with real sanctions tied to performance — will hopefully result in organizational actions that drive real change. In the past, hospitals have been far too focused on approaches that could be referred to as "smile lessons." There have been a myriad of training activities around service improvement. Organizations have proudly pointed to the fact that their entire organization was trained on XYZ approach to customer service. There are several problems with this approach:

  • The training was often a one-time event that had occurred at some point in the past — sometimes the distant past. There was no consideration of how new employees would be brought into the fold or how existing employees' would be provided with "service booster shots" over time.
  • The training was generic. In healthcare settings, different departments require different types of training to serve their customers — sometimes those customers are patients, sometimes not. But, providing exceptional service internally does impact the patient experience.
  • There were no metrics behind the method. Once training was concluded, it was assumed that employees would simply "go forth and provide good service." That's a dangerous assumption.
  • There were no accountability practices put into place that would provide continuity and sustainability. It's often not what you expect, but what you inspect that gets done. Training the front line is important but to sustain behavior changes, managers and supervisors must also have the tools for coaching, mentoring and modeling for service behaviors.

HCAHPS — and CAHPS — put metrics behind the methods that hospitals use to boost their patient satisfaction scores. Those metrics can be telling; they can also be frustrating. What it takes to move the scores is not always readily, or logically, apparent. Something as seemingly unrelated to perception of the patient experience as whether the bedside tables in the hospital room are promptly cleared of food trays and other "stuff" impact perceptions of not only service — but also quality of care!

Patients do not think like their providers. From your patients' perspective, quality healthcare is demonstrated in countless moments of truth throughout their interactions with your organization. All of those interactions add up to the big quality picture. For instance, consider the following questions.

Pre encounter
  • Is it easy to access your organization?
    • Is your website easy to navigate with a main phone number clearly displayed on the home page?
    • Can customer intuitively find your listing in the Yellow Pages? Are your phone book ads easy to read and free of clutter?
  • When a patient makes an initial phone call…
    • Is the phone answered in three rings or less?
    • Are operators friendly and knowledgeable about your services?
    • Are operators engaged in actively listening to callers or are their hurried or short-tempered?
    • Are callers able to get their needs met with one call or are multiple calls or transfers required?

During the encounter
  • Is parking convenient?
  • Are entrances clearly marked, well lit and inviting?
  • Can patients easily find their way to their first encounter?
    • If the patient stops an employee for directions, does the employee walk the patient to their destination?
    • Is signage written in a language the patient understands without confusing jargon?
  • Are hallways and public areas clean and inviting?
  • Is signage outdated or shabby?
  • Are wastebaskets overflowing?
  • Are the reading selections in waiting areas out-of-date and in bad condition?
  • Are restrooms appropriately stocked and clean?
  • Is the lighting warm and welcoming?
  • Is the patient treated well throughout the encounter?
    • Are staff members trained to make eye contact and be present with the patient?
    • Do staff members respect the patient's privacy and conduct conversations appropriately?
    • Do staff members address patients based on their preference (e.g. "Mr. Smith" vs. "John")?
    • If the patient has to interact with more than one professional, is there a smooth transition so the patient doesn't have to repeat the same information multiple times?
    • Do patients know why they are waiting and how long the wait will be? Are they updated during their wait?
    • Are patients engaged in the care plan and made to feel a part of the team?
    • Is pain managed well?
    • Is the staff responsive to requests?
    • Do staff talk to patients in a language they can understand? Do they check to validate understanding?
    • Do staff members treat all patients with the same level of respect, caring and empathy?

Post encounter
  • Are discharge instructions clear?
    • Does the patient understand when the visit is over and what steps should be taken next?
    • Does a staff member re-cap important information in language the patient understands? 
    • Does follow-up occur?
    • Can the patient expect to receive a follow-up phone call?
    • Are staff members making post-discharge calls trained to elicit questions from patients who might otherwise be reluctant to ask?
    • Should the patient expect a follow-up survey?

While it may seem surprising that none of these questions focuses specifically on clinical care or treatment, the fact of the matter is that patients measure their experience not based on the same types of clinical measures that healthcare providers use, but on more qualitative assessments that tend to be related to their interactions at every point in the care process — that is how they define quality.

HCAHPS and CAHPS are making all of us more appropriately aware of the critical importance of ensuring great care, every time at every point of the encounter. Moving these scores is not easy. Fundamentally, though, moving these scores requires a shift from a focus on "smile lessons" to a methodology of improvement that begins with an assessment of where the service breakdowns are occurring and what perceptions are driving service assessments. Once the assessment has been completed, the next step is to analyze and prescribe changes in both actions and behaviors to drive sustainable results. These changes may require training but, importantly, that training has to move beyond smile lessons to focus on specific and measurable actions that will generate results. And the training must be more than a one-time event, the content must be embedded in performance expectations for both existing and new staff members and must be specific to the service they are providing.

One training session will not shift a culture. Telling staff how you want them to behave doesn't mean it will happen. Effective healthcare leaders will set clear expectations and put in place methods to monitor whether those expectations are being met. It is not about what you expect — it is about what you inspect. Developing an integrated and ongoing process to measure, analyze, adjust and monitor is what will drive patient satisfaction, your HCAHPS/CAHPS scores and — what we are now ardently focused on — your reimbursement.  

With over thirty years of experience in patient care, healthcare marketing, business development and administration, Kristin Baird is a talented speaker and consultant with a passion for service excellence. President of the Baird Group, Ms. Baird earned a bachelor of science in nursing from the University of Wisconsin-Madison and a master's in health services administration from Cardinal Stritch University in Milwaukee.

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