James Merlino, in his book “Service Fanatics: How to Build Superior Patient Experience the Cleveland Clinic Way” offers a transformative vision on how to improve the patient experience. The book, which recounts the author’s experience as Customer Experience Executive (CXE) at the prestigious American healthcare institution, offers the reader interesting insights into how hospitals can improve the way they treat their patients.

Of all the topics covered in the book, I would like to highlight three that I felt were essential when dealing with a process such as the one carried out by James Merlino in his hospital: the importance of culture and leadership, the need to involve doctors in change, and the convenience of turning patients into partners.

The importance of starting with Culture and Leadership

The culture of an organisation goes far beyond “the way we do things around here”. According to James Merlino: “Organisational culture is a system of shared values and behaviours that focus caregiver activity on improving the patient experience”.

The first step to achieving a shared culture of patient-centricity is to get everyone in the organisation, regardless of their position, to feel committed to this vision. To this end, Merlino created the mantra “Patients First”, which was presented through a variety of communication elements, including badges worn by healthcare staff.

In addition to achieving a shared vision, creating a common culture requires generating a high level of employee engagement. In the author’s words, do our employees “come just to work, do a job and get paid, or do they feel they are part of something special, working for an organisation that has a consistent vision and giving their best to make it better and better?

One of the most important steps in aligning the clinic’s culture with the Patients First philosophy was to make no distinction between doctors, nurses, technicians, administrators and other staff. For the Cleveland Clinic, they all fall into the same category of “caregivers”.  

In fact, patients and their families interact relatively little with doctors, but a lot with nurses, cleaning staff, auxiliary technicians, students, kitchen staff, etc.). Everyone who works in the organisation is important, has a role to play and must be part of a team aligned around the patient. That is what the programme is all about, i.e. you don’t need to be a doctor or a nurse to be able to help.

To align the values and behaviour of all hospital staff, all staff, regardless of their role, went through a training programme using the Learning Map methodology, which is a visual representation of the organisation’s opportunities, challenges and complexities. In groups of 10 people from different departments and ranks, guided reflections were facilitated on the topics expressed in the map, such as how to realise corporate values, how to deal with difficult patient situations, or the relationship between different roles within the hospital and their impact on the patient experience.

This whole process of cultural change was led by Cleveland Clinic’s own CEO, Toby Cosgrove, who played a leading role in the design and delivery of the training programme.

The role of doctors in the patient experience

In very few professions is as much attention paid to staff training and preparation as in medicine. However, empathy, communication and the need to treat patients humanely have not featured prominently in the demanding curricula of medical schools.

Contrary to what some hospital managers think, who write off the doctors and pivot the entire patient experience on nurses and assistants, for James Merlino the participation of doctors in the programme was non-negotiable.

Firstly, because doctors have great leadership and authority over other healthcare professionals. Leaving them out of the programme would be tantamount to telling other caregivers that patient experience is a minor issue.

Secondly, but not least, because doctor-patient communication is one of the factors that has the greatest impact on the overall patient experience.

The problem is that doctors, although they do not always communicate adequately with their patients, have little awareness of their need for improvement. The doctor is usually surrounded by other professionals who respect him or her and are not able to give negative feedback, and most patients are polite and highly respectful of doctors. This means that they do not dare to say what they think to their faces, although they do say so in satisfaction surveys or, even worse, by venting their frustration on social media.

To make physicians aware of this improvement, James Merlino organised meetings with small groups of physicians in which he shared how the US Department of Health measured their patients’ experience, with a special focus on communication issues. Surprisingly, most of the physicians did not know how they were being measured and were unaware of the impact that a poor assessment had on the clinic’s revenue from Medicaid and Medicare, the US public health programmes for low-income people and those over 65.

Once the doctors were aware of the need to improve their communication skills, the patient experience management began to share with them on a regular basis the scores obtained in the surveys and provided them with a training programme in communication skills based on best practices identified among doctors.

Another interesting aspect is that the communication training workshops were given by doctors, not by external consultants or communication experts, because it was felt that only a doctor had the authority to train other doctors in such a critical aspect of their professional practice.

Turning patients into partners

One of the characteristics of the doctor-patient relationship is asymmetry. The doctor is a scholar, a person who has been trained for years (or decades) and who knows much more about the subject than the patient. A patient who is also in a particularly vulnerable situation, full of fears, uncertainties and anguish, often becomes a mere passive recipient of the information provided by the doctor. Often, the patient does not even dare to ask questions or question certain instructions given to him by his doctor.

For James Merlino, a great experience requires doctors to engage patients much more and for patients to be much more knowledgeable about their disease and the treatment they are prescribed. In fact, it is more than proven that more empowered patients demonstrate better adherence rates to treatment, significantly improve recovery times and greatly reduce the chances of relapse.

Making patients active subjects in their treatment requires doctors to be more active listeners and to encourage patients’ questions and participation, as well as to better manage their expectations. One of the findings of the patient experience programme is that doctors who raised more reasonable expectations of patients on critical issues such as pain management consistently achieved better outcomes than those who minimised postoperative discomfort and inconvenience.

Conclusion

The importance of cultural change, the role of physicians in the patient experience and the need to turn patients into partners are three of the learnings from this extraordinary and highly recommended read. It discusses many other interesting topics such as the need for continuous improvement processes and how to gain a deeper understanding of how patients expect to be treated.

But, without a doubt, the most interesting thing that counts has to do with the need to develop empathy and a sense of responsibility (what the Americans call ownership) among all the employees of the institution.

Something that, without a doubt, they express in a masterful way in the fantastic video Empathy-Human Connection with the patient, which I leave you here and which perfectly summarises the principles that govern the Cleveland Clinic Way of Patient Experience.

Don’t miss it!