Introduction to Cleveland Clinic

Cleveland Clinic:
Improving the Patient Experience

Tuesday, April 12 2016

Yosanova Savitry
 About Cleveland Clinic
• Founded in 1921, CC was a non-profit academic medical
1 CC at a glance center
• 54,038 patients had been admitted, 27,142 inpatient and
53,757 outpatient surgeries
• The main hospital had just over 1,200 beds

2 • Total assets of $12 billion by the end of 2014

Assets
• Operational expansion in US, Canada, and Abu Dhabi with 147
countries around the world

3 Revenue • $6.6 billion in 2014

4 Mission, Vision. Values • Mission: Better care of the sick

• Mantra: Patients First
• Motto: To Act as a Unit
• Values: Quality, innovation, teamwork, service, compassion,
integrity
• Goal: To give every patient the best outcome and experience

5 Human Resources • 40,000 employees, totaled $2.9 billion in 2009

• Physician-led, multispecialty group practice
• Staff physicians are salaried, with no incentives for extra tests or
procedures
• All physicians are on one-year contracts, renewable after
annual performance reviews
Cleveland Clinic: Performance through Innovation

1 9 5 1
• First successful “stopped heart” surgery

1 9 5 8
• First coronary angiography

1 9 9 8
• First successful larynx transplant

2 0 0 6
• First kidney surgery performed through patient’s navel

2 0 0 8

• Nation’s first near-total face transplant

2 0 0 9
• World’s first heart/liver transplant with total artificial
heart
“Physicians are all on one-year salaried contracts and
received no bonuses or financial incentives for
procedures performed or patients seen...Money should
not factor into the decision whether to operate or not.”
Dr. Delos M. Cosgrove, President of Cleveland
Clinic
Cleveland Clinic delivered the highest quality care at costs
well below the national norm

CC changed from profession-oriented

organization designed around physician
competencies, to a patient needs-
oriented units, such as the Heart and
Vascular Institute.

It is the only hospital to be completely

organized around patient needs.

Each institute is based around a single

organ system or disease (e.g.: heart,
stomach, brain)

Medical and surgical services are

combined under single leadership in a
common location.
 DISCUSSION

WHAT DO YOU EXPECT AS

A PATIENT ?
Patient’s Perspective

Cleveland Clinic had always cared deeply about

technical procedures and clinical outcomes for their
patient.

The hospital always tried to bring ground-breaking

medical innovations to the world

BUT, was it enough?

Was it what patients actually looked for?
Patient’s Perspective

One day in 2007, when the president of CC was giving a lecture at Harvard Business
School a student raised her hand and asked a surprising yet eye-opening questions.

“Dr. Cosgrove, what are you doing to teach your doctors

empathy?”

“As a physician and father of six children, my father cared deeply about
outcomes and technical skill in selecting a hospital and a surgeon, but there were
other factors impacting his decision. My parents, who would be traveling far from
home in pursuit of the best care, expected meaningful communication before
and after open heart surgery. They had heard that this was not always the case at
Cleveland.” Ultimately Barnett’s father had decided to have his surgery at the
Mayo Clinic (Mayo) in Minnesota even though the Mayo heart program was not
as highly ranked as the CC program. Barnett recalled, “My father made his
decision based on reputation and anecdotal evidence.” Barnett’s father’s surgery
was a success and the family was extremely pleased with the care he received
while recovering at the Mayo.
Patient’s Perspective

So, it’s not only about rank, quality, or clinical outcomes.

It’s also about expressing care and concern!

“Here at Cleveland Clinic, we always

positioned quality in terms of outcome. But I have
come to understand that there is more to quality
healthcare than great outcomes. There is the
entire experience that patients have, from the
moment they call for an appointment to the
moment they arrive at the hospital—fearful and
concerned—to the moment they get in their cars
and drive away.” – Dr. Cosgrove, CEO & President of CC
Since 2006, CC has implemented a nontraditional
organizational structure operating as a group practice to
make the hospital more patient-friendly.

How does it work ?

The Cleveland Clinic
Approach
The Cleveland Clinic Approach: Patient Experience
The Cleveland Clinic Approach: Patient Experience

Cleveland Clinic was the first

major academic medical
center to make patient
experience a strategic
objective

CC is also one of the first to

establish an Office of Patient
Experience (OPE) focused on
improving operations, services, or
facilities to meet and exceed
patient expectations.
Patient Experience in the Broader Healthcare Context

In 2007, prioritizing patient experience was a still a

relatively “new” idea. The general assumption was
that because patients came to the hospital out of
necessity rather than choice, healthcare providers
could ignore customer service.

By 2010, however, improving patient

experience had become a part of most
healthcare focus

A 2010 survey of healthcare executives found that

37% ranked “patient experience/patient satisfaction”
a top three priority, the second-most frequent
answer just after cost reduction (40%).
Patient Experience in the Broader Healthcare Context

Customers now have access to comparative data on healthcare

providers, allowing them to make better-informed choices about
their care

US federal Centers for Medicare and Medicaid Services

2006 (CMS) introduced a survey called HCAHPS to measure
patient experience standard in USA

Collecting and submitting HCAHPS data became

mandatory for hospitals receiving Medicare and
2007
Medicaid funding, or else they risked losing up to 2% of
their annual medical payments from CMS.

Each participating hospital’s HCAHPS scores

2008 became publicly available online.

This system pushed hospitals that had put little effort into
managing patient experience to quickly shift resources and
priorities.
Patient Experience in the Broader Healthcare Context

Stronger economic rationale for improving patient experience

CMS announced that beginning in 2012, it would move from a “pay for
reporting” to a “pay for performance” requirement. Healthcare providers
would be financially rewarded or penalized based on their performance
on several quality measures, including HCAHPS scores

HCAHPS for practitioners and management

The office had developed a Patient Experience Dashboard to prioritize
improvement initiatives and continuously monitor new programs.

Some variables in the survey is not beneficial for

hospitals
CC was increasingly concerned that the “perception metrics” collected
through the survey unfairly penalized certain hospitals for variables
outside of their control.
OPE Programs and Services + New Initiatives

• Enlisted famous designer

to redesign its hospital
12 gown
PROGRAMS • Added pull-out beds for
$6.4MILLION family members
• Culture changing
exercise to 42,000
employees

There were still patient complaints, reflected in

HCAHPS scores
 REVISITED

In 2012, CMS announced that healthcare providers would be

financially rewarded or penalized based on their performance on
several quality measures
 > 10% points decline for HCAHPS score
The Case of Bob Jones
The Case of Bob Jones

In September 2011, Cleveland Clinic’s patient named Bob

Facts #1 Jones exploded and complained about his poor treatment at
the CC

Bob Jones had several chronic diseases, including morbid

obesity and some struggles with mental illness and he
needed surgery within the next few weeks to save him from
Facts #2 a potentially life-threatening condition

That particular day, Jones had arrived unexpectedly at CC

and demanded to immediately see his surgeon. But, his
surgeon was not in the hospital that day, and Jones had
Facts #3 failed to show up to his scheduled appointment earlier in
the week

CC had been trying for months to address Jones’s

progressively worsening health. In return, he had been
Facts #4 verbally abusive to the medical staff, missed appointments,
and aggressively made unreasonable demands of nurses
and physicians
The Case of Bob Jones

Should CC “fire” Jones as a patient and leave Jones to

find medical care elsewhere? Or keeping him?

• Lower HCAHPS score due to

Jones’ unreasonable
YES demands
• Jones’ obesity and
noncompliance would
present clinical risks
Keeping
Jones

• Maximize CC’s performance

NO • Jones could possibly die very
quickly
Discussion: The Dilemma

 Dr. James Merlino - a colorectal surgeon and

chief experience officer at Cleveland Clinic – is
in dilemma about what to do with Bob Jones

 Some colleagues believed they had an

obligation to treat Jones with the respect that
all human life deserves,

 At the same time, Merlino knew that even with

surgery, Jones’s prognosis was poor

 Furthermore, Jones would likely never express

gratitude and courtesy for CC’s efforts
 Discussion
Questions

Should they keep Jones? Was it fair for the government to

1
hold CC responsible for HCAHPS outcomes under these
circumstances?
Given that CC had to publicly report their HCAHPS scores,
2 should Dr. Merlino hold departments within CC responsible
for these metrics?
Let’s Discuss!
 Pros and Cons
“Keeping” Jones

Pros Cons

High potential to get higher HCAHPS score if High potential to get lower HCAHPS score
1 managed Bob Jones successfully due to Jones’ unreasonable demands 1

Big opportunity to give Bob Jones a service Bob Jones’s attitudes may be a big
2 recovery 2
challenge

Big opportunity to give Bob Jones and his Jones’ obesity and noncompliance would
3 family a transformational experience of CC present clinical risks 3
 Pros and Cons
“Firing” Jones

Pros Cons

Higher possibility to maximize

1 Potentially result in negative image for the CC 1
CC’s performance

2 Discharge CC of all obligation Neglect customer perspectives 2

Bob Jones could find medical care Give Bob Jones and his family very bad
3 elsewhere 3
experiences

Avoid further problem of keeping Bob

4 Jones Unable to solving similar problem in the future 4
WHAT TO DO?

#1 KEY TOUCH POINTS

#2 ANTICIPATIVE STRATEGY

#3 VALUES OVER VALUE

How? #1

If CC decide to “Keeping Jones”, CC should pay attention on scale of importance for patient satisfaction

Sources: https://www.healthcatalyst.com/how-cleveland-clinic-improve-patient-satisfaction-scores-data-analytics
Service Recovery Paradox #1

If CC keeps Bob Jones as a patient, it should create recovery plan to make Bob more
satisfied afterwards than before any problems occurred.
Anticipating Consequences: Service Blueprint #2

If CC keeps Bob Jones as a patient, it should plan the best experience possible
by mapping service blueprint, as well as Jones’ actions and desires.

Customer
Behavior

Key Frustration Point

Desired Experience

Interaction with
Cleveland Clinic

Opportunity for
Improvement
Anticipating Consequences: Service Blueprint #2
Anticipating Consequences: Creating Customer Expectations #2

Promise

Expectation

Service
Priority

Prioritize key touchpoints Don’t underpromise Tell them they would

of service or overpromise and wouldn’t get
Anticipating Consequences: Patient Engagement Strategies #2

How to prevent the “Bob Jones tragedy” to ever happen again

1. Open access scheduling.

Patients can now log on through the patient portal, view their provider's entire schedule and make
their own appointments.
2. Patient education.
Make sure that patients understand what's going on with them, as well as what's supposed to happen
next." To that end, CC creates appropriate patient educational materials, which can also be accessed
online
3. Open medical records policy.
Cleveland Clinic has had an open records policy for years, but now everything is getting put online in
personal health records. Patients will be able to review their physicians' notes online after a visit
4. Two way messaging via patient portal.
The telephone has long been the indispensable tool for communications between doctors and patients,
but now communication has been significantly expanded, as well as made considerably more
convenient, with email and other electronic formats made available on the Clinic's patient portal.
5. Patient reported outcomes.
CC has begun a series of pilot projects in which patients can enter data into their own records, enabling
doctors to track their patients' progress, and potentially modify their care, between visits.
Cleveland Clinic Ethics #3

“A patient is the most

important person in the
institution.

It is our job to satisfy

them.”

William Lower, Founder of Cleveland

Clinic
Vission, Mission, and Values #3

Mission: Mantra: Motto:

Better care of the sick Patient First To act as a unit

Goal: Values:
To give every patient the best Quality, innovation, teamwork,
outcome and experience service, compassion, integrity
Our Proposed Solution #3

VALUES

If CC fired Jones as a patient, it

would maximize this part only
without considering the overall
values it would create.
 Our Proposed Solution

CC has all the reasons to discharge its service to Bob Jones. However, it also has
some rationale for keeping Jones. Patient first is CC’s primary and foremost concern.

If CC terminates its service to Bob So, it is advisable that CC sticks to

Jones, CC should consider whether its values and mission, that is
the decision will violate its values or “better care for the sick”
not

Safe Care High Quality Care Patient Satisfaction High-Value Care

“Providing the highest quality patient experience is a primary goal of the

Cleveland Clinic Organization.”-Delos “Toby” Cosgrove, MD
Why is this important?

Humanity: Doing things right, not

doing the right things

Patient centered care: The way

we would want to be treated

Patient’s want it – their “Quality”

Defines CC as an Industry

Government relation
What About HCAHPS?

• HCAHPS does have its usefulness. Generally speaking, HCAHPS helps hospitals
improve shortcomings in these areas.

• But do satisfaction scores really measure quality of care?

• A hospital with high patient satisfaction scores might not be the best when it
comes to quality healthcare, and vice versa.

• There are factors in HCAHPS that unfairly penalizes hospitals that are busy
because of high caseload – CC for example.

• Standardization serves a purpose, and patient experience is absolutely vital. But

still, considering and experimenting the reliability of HCAHPS would seem to be
beneficial for hospitals in the US.

• It is advisable that CC do not focus on HCAHPS oucomes in this particular

decision, because it is indicative, but it is not the objective
Should Dr. Merlino hold departments within CC
responsible for these metrics?

• If Jones was randomly selected to fill out a patient satisfaction survey required by
the government, his responses would likely lower CC’s score

• However, Jones’ contribution to the overall HCAHPS outcomes is partial.

• Since hospital works as a unity and patient experience is seamless, is it best not to
hold specific departments responsible for the overall outcomes.

• With patient satisfaction assuming such a prominent role in health care, patients
also need to look beyond “room service” and look at other factors that more
strongly affect clinical outcomes.
Cleveland Clinic HCAHPS Score Todays

Overall Hospital Rating

• This is a summary question at the end of the HCAHPS survey asking patients to
rate the hospital on a scale of 0-10, 0 being worst and 10 being best.
• On this chart we display the percentage of patients providing a 9 or 10 rating.

Sources: http://my.clevelandclinic.org/patients-visitors/patient-experience/measurement/main-campus
Cleveland Clinic HCAHPS Score Todays

Would Recommended Hospital

• A second summary question asks patients if they would recommend the hospital
to friends and family using this scale: Definitely Yes | Probably Yes | Probably
No | Definitely No.
• Results are displayed as the percent of patients responding ‘Definitely Yes.’

Sources: http://my.clevelandclinic.org/patients-visitors/patient-experience/measurement/main-campus
Cleveland Clinic HCAHPS Score Todays

Nurse Communication

• These results represent feedback from three separate survey questions asking patients how often
nurses:
• Treated them with Courtesy and Respect
• Listened Carefully to them
• Explained things in a way they could understand
• Results are grouped into one composite score based on the percent of patients responding
‘Always.’
Sources: http://my.clevelandclinic.org/patients-visitors/patient-experience/measurement/main-campus
Cleveland Clinic HCAHPS Score Todays

Doctor Communication

• These results represent feedback from three separate survey questions asking patients how often
doctors
• Treated them with Courtesy and Respect
• Listened Carefully to them
• Explained things in a way they could understand
• Results are grouped into one composite score based on the percent of patients responding
‘Always.’
Sources: http://my.clevelandclinic.org/patients-visitors/patient-experience/measurement/main-campus
Cleveland Clinic HCAHPS Score Todays

Medication Communication

• These results represent feedback from two separate survey questions asking patients
about new medications given to them during their hospital stay:
• Purpose for new medications explained
• Side effects described
• Results are grouped into one composite score based on the percent of patients
responding ‘Always.’
Sources: http://my.clevelandclinic.org/patients-visitors/patient-experience/measurement/main-campus
Cleveland Clinic HCAHPS Score Todays

Pain Management

• These results represent feedback from two separate survey questions asking patients about pain
management while in the hospital:
• How often was your pain well controlled?
• How often did the hospital staff do everything they could to help you with your pain?
• Results are grouped into one composite score based on the percent of patients responding
‘Always.’

Sources: http://my.clevelandclinic.org/patients-visitors/patient-experience/measurement/main-campus
Cleveland Clinic HCAHPS Score Todays

Staff Responsiveness

• These results represent feedback from two separate survey questions asking patients about help
they needed during their stay:
• Getting help as soon as wanted after pressing the call button
• Getting help as soon as wanted to use the restroom
• Results are grouped into one composite score based on the percent of patients responding
‘Always.’
Sources: http://my.clevelandclinic.org/patients-visitors/patient-experience/measurement/main-campus
Cleveland Clinic HCAHPS Score Todays

Discharge Process

• These results represent feedback from two separate survey questions asking patients about the
discharge process:
• Staff verified patient will have help needed after leaving the hospital
• Patient received written instructions regarding symptoms or health problems to monitor
after leaving the hospital
• Results are grouped into one composite score based on the percent of patients responding
‘Yes.’
Sources: http://my.clevelandclinic.org/patients-visitors/patient-experience/measurement/main-campus
Cleveland Clinic HCAHPS Score Todays

Cleanliness

• These results represent patient feedback about the cleanliness of their room and
bathroom throughout their stay.
• Results are displayed as the percent of patients responding ‘Always.’

Sources: http://my.clevelandclinic.org/patients-visitors/patient-experience/measurement/main-campus
Cleveland Clinic HCAHPS Score Todays

Quiet at Night

• These results represent patient feedback about noise levels at night throughout their
stay.
• Results are displayed as the percent of patients responding ‘Always.’

Sources: http://my.clevelandclinic.org/patients-visitors/patient-experience/measurement/main-campus
Cleveland Clinic HCAHPS Score Todays

Care Transition

• These results represent feedback from three separate survey questions asking patients if they strongly agree
that:
• Staff took patient and family or caregiver preferences into account in deciding what patient health
care needs would be when they left
• They had good understanding of the things they were responsible for in managing their health
• They clearly understood the purpose for taking each of their medications
Results are grouped into one composite score based on the percent of patients responding ‘Strongly Agree.’

Sources: http://my.clevelandclinic.org/patients-visitors/patient-experience/measurement/main-campus
Awarding
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