Qual­ity quar­ter­back

Hos­pi­tal’s chief ex­pe­ri­ence of­fi­cer faces chal­lenges in open­ing up com­mu­ni­ca­tion

Modern Healthcare - - NEWS - By Sabriya Rice

There were ten­ta­tive glances across the con­fer­ence room ta­ble when chief pa­tient ex­pe­ri­ence of­fi­cer Air­ica Steed asked a mul­ti­dis­ci­plinary team of a dozen staffers to dis­cuss the bar­ri­ers they face in try­ing to im­prove the pa­tient ex­pe­ri­ence at the Univer­sity of Illi­nois Hos­pi­tal & Health Sciences Sys­tem.

“I want to dig deeply into the con­cerns we’re ac­tu­ally see­ing and the road­blocks we’re run­ning up against in solv­ing them,” she said dur­ing the mid-Novem­ber meet­ing.

Steed, the sys­tem’s first CXO, pre­sented the team with a de­tailed list of about 40 open pa­tient com­plaints. It in­cluded one about the clinic not re­turn­ing phone calls to sched­ule an ap­point­ment, a pa­tient walk­ing out of the hos­pi­tal be­cause the doc­tor never came to the exam room, and a pa­tient’s claim that money dis­ap­peared from his wal­let dur­ing a trans­fer. Other com­plaints in­cluded al­leged med­i­cal er­rors, mis­di­ag­noses and in­ap­pro­pri­ate staff con­duct.

At first, no one spoke. There were sounds of shuf­fled pa­pers and ner­vous throat-clear­ing as the team of pa­tient nav­i­ga­tors, pa­tient en­gage­ment of­fi­cers and process im­prove­ment and hos­pi­tal­ity staff thought care­fully about what to say. After an un­com­fort­able minute, they be­gan to open up.

“We don’t get rapid re­sponses from lead­ers about re­solv­ing com­plaints. Pa­tients want im­me­di­ate re­sponses and some­times we wait months,” said one pa­tient en­gage­ment of­fi­cer. Another staffer said some de­part­ments ei­ther don’t take pa­tient com­plaints se­ri­ously or don’t un­der­stand the role of the team in­ves­ti­gat­ing the events.

Since 2012, Steed, a regis­tered nurse with a doc­tor­ate in ed­u­ca­tion and a back­ground in op­er­a­tions and per­for­mance im­prove­ment, has led UI Health’s ef­forts to de­liver pa­tient-cen­tered care. The group’s ini­tial hes­i­ta­tion to share their con­cerns was not sur­pris­ing, she later said. Un­til re­cently, front-line em­ploy­ees were rarely en­gaged by lead­er­ship in such con­ver­sa­tions, and when staff did speak up,

their con­cerns were of­ten seen as com­plaints.

“But if you can tap into what your staff are frus­trated with, you iden­tify 75% of the prob­lem,” she told a Mod­ern Health­care re­porter who shad­owed her that day to see what a CXO at a large aca­demic safety-net hos­pi­tal does.

More hos­pi­tals and health sys­tems are hir­ing chief ex­pe­ri­ence of­fi­cers, or CXOs, as they face grow­ing pres­sures to im­prove con­sumer sat­is­fac­tion, such as through rat­ings on the CMS’ Hos­pi­tal Con­sumer As­sess­ment of Health­care Providers and Sys­tems survey. Low HCAHPS scores, as well as neg­a­tive reviews from con­sumer groups and web­sites such as Yelp, can hurt business and bring fi­nan­cial penal­ties. But ex­perts say the job is a tough one that re­quires strong support from top hos­pi­tal lead­ers, deep un­der­stand­ing of hos­pi­tal per­for­mance im­prove­ment and a deft per­sonal touch. And both the CXO and the or­ga­ni­za­tion have to rec­og­nize that pa­tient ex­pe­ri­ence is closely linked to qual­ity and safety.

It’s es­ti­mated that there are cur­rently about 60 U.S. hos­pi­tal ex­ec­u­tives with the CXO ti­tle, and the num­ber is slowly in­creas­ing. The Cleve­land Clinic was one of the first sys­tems to es­tab­lish the po­si­tion in 2007. Last week, the Univer­sity of Cal­i­for­nia San Diego Health Sys­tem named Dr. Thomas Sa­vides to fill its newly cre­ated CXO role. In Septem­ber, Johns Hop­kins Medicine in Bal­ti­more named Lisa Allen, a pa­tient ser­vice and qual­ity-im­prove­ment ex­pert, as its first CXO. And last month, the Cleve­land Clinic an­nounced that Dr. Adri­enne Boissy would re­place Dr. James Mer­lino, who had held the job since 2009.

Hos­pi­tals gen­er­ally have strug­gled with es­tab­lish­ing and sus­tain­ing safety and qual­ity ini­tia­tives, the Joint Com­mis­sion re­ported in Oc­to­ber. In the past, hos­pi­tals did not as­sign one per­son to over­see per­for­mance on pa­tient sat­is­fac­tion, and that lack of ac­count­abil­ity has been prob­lem­atic, said Donna Padilla, a se­nior part­ner with Witt/Ki­ef­fer, an ex­ec­u­tive search firm that works with aca­demic med­i­cal cen­ters. “Sys­tems are start­ing to re­al­ize if it’s every­body’s job but no one is tapped to lead it, it falls to the bot­tom,” she said.

But Dr. Pa­tri­cia Gabow, who led her­alded per­for­mance im­prove­ment ef­forts at Den­ver Health while serv­ing as its CEO, cau­tioned against ex­pect­ing a chief ex­pe­ri­ence of­fi­cer to be the magic bul­let. She said there must be a broad fo­cus on re­design­ing the care process around the pa­tient rather than con­cen­trat­ing solely on con­sumer ameni­ties. For ex­am­ple, she said, if a hos­pi­tal ad­dresses long waits in the emer­gency depart­ment by sim­ply adding big-screen TVs or gourmet cof­fee ser­vice, they’re miss­ing the point. “If you look at it from a care-re­design process, you say, ‘We don’t want to just make the wait more pleas­ant, we want to end the wait,’ ” she said. “If we don’t do that, this is all for naught and they won’t suc­ceed.”

The Cleve­land Clinic’s Mer­lino agreed that the CXO’s job is to im­prove qual­ity and safety along with cus­tomer sat­is­fac­tion. “Ul­ti­mately, this is about how we de­liver care,” he said. “When you im­prove the way nurses com­mu­ni­cate at the bed­side, falls, pres­sure ul­cers and med­i­ca­tion er­rors all go down. When physi­cians com­mu­ni­cate with pa­tients and fam­i­lies more ef­fec­tively, com­pli­ance with treat­ments im­proves.”

Break­ing down si­los

But CXOs face many or­ga­ni­za­tional chal­lenges. In a Beryl In­sti­tute re­port pub­lished this year, 15 pa­tient ex­pe­ri­ence lead­ers de­scribed dif­fi­cul­ties in work­ing through hi­er­ar­chies, break­ing down de­part­men­tal si­los and cop­ing with limited re­sources. One of their big­gest chal­lenges, they said, is sim­ply es­tab­lish­ing their place and pur­pose within the or­ga­ni­za­tion.

While other C-suite lead­ers have long had clearly de­lin­eated roles, the CXO po­si­tion some­times be­comes a catchall, said Ja­son Wolf, pres­i­dent of the Beryl In­sti­tute, which fo­cuses on im­prov­ing the pa­tient ex­pe­ri­ence. “We don’t ask the CFO to go run labs, but we may ask the chief ex­pe­ri­ence of­fi­cer to also be di­rec­tor of mar­ket­ing,” he said.

Pa­tient-safety lead­ers of­ten talk about cre­at­ing an or­ga­ni­za­tional cul­ture of safety. “The big­gest chal­lenge (in the CXO job) was rec­og­niz­ing that this is cul­tural,” Mer­lino said. “At the end of the day, if every­body who comes to work doesn’t un­der­stand that they’re there for the pa­tient and noth­ing else, you’re not go­ing to be able to im­prove.”

Steed, 36, pre­vi­ously served as a vice pres­i­dent at Ad­vo­cate Health Care, where she helped el­e­vate the sys­tem’s fo­cus on pa­tient ex­pe­ri­ence. She also worked as a clin­i­cal prac­tice con­sul­tant at Price­wa­ter­house­Coop­ers. She is trained in Lean Six Sigma, a to­tal qual­ity im­prove­ment method­ol­ogy. Beyond her cre­den­tials, her per­sonal style helps her win co­op­er­a­tion and trust. She smiles warmly as she greets each per­son by name, with a firm hand­shake. She’s pas­sion­ate about shar­ing in­sights drawn from her broad train­ing and ex­pe­ri­ence. Most im­por­tantly, peo­ple seem to want to talk to her.

“We’re not forc­ing any­thing and we’re re­ally lean­ing on the front­line to tell us what works” she ex­plains.

Steed said when she started the job in 2012, she first went after the “low-hang­ing fruit,” which gen­er­ally in­volved mak­ing the hos­pi­tal a more pleas­ant en­vi­ron­ment for pa­tients and staff. One of the first prob­lems she tack­led was the cus-

tomer ex­pe­ri­ence when peo­ple ar­rived at the hos­pi­tal’s main en­trance. There, staff greeters had to an­swer the phone while simultaneously try­ing to man­age and di­rect the con­stant flow of pa­tients, fam­i­lies and vis­i­tors. This was frus­trat­ing for pa­tients and staff.

So Steed helped launch a part­ner­ship with the Chicago Light­house, a not-for­profit that pro­vides em­ploy­ment and other ser­vices for the vis­ually im­paired. Start­ing last month, all phone calls to the hos­pi­tal’s main phone num­ber now are han­dled by vis­ually im­paired clients of the Light­house, who are paid to help pa­tients with reg­is­tra­tion, ap­point­ment sched­ul­ing, di­rec­tions and other in­for­ma­tion.

The day a Mod­ern Health­care re­porter vis­ited was a long and hec­tic one for Steed, start­ing at 9 a.m. and ex­tend­ing past 10 p.m. She dashed from meet­ing to meet­ing to ad­vise or con­sult with staff, lead an ad­vi­sory panel of pa­tients and their fam­i­lies, and re­view HCAHPS data with other staff. Her day be­gan with an hour of morn­ing rounds, dur­ing which she vis­ited staff work­ing at the cus­tomer ser­vice desk at the hos­pi­tal’s main en­trance. Ac­com­pa­nied by Lor­raine Sain­tus, di­rec­tor of op­er­a­tions ex­cel­lence and cus­tomer op­er­a­tions, she spoke with pa­tients in the wait­ing room. She also met with key mem­bers of the hos­pi­tal’s data an­a­lyt­ics team and with UI Health CEO Avi­jit Ghosh.

In ad­di­tion, she at­tended a quar­terly part­ner­ship meet­ing with staff from Press Ganey, a per­for­mance-im­prove­ment company, which had rec­og­nized her ef­forts as a “suc­cess story” ear­lier in the month. The fo­cus of that meet­ing, at­tended by the hos­pi­tal’s data an­a­lyt­ics pro­gram man­ager and per­for­mance ex­cel­lence lead­ers, was the fu­ture of pub­lic re­port­ing of qual­ity and pa­tient-sat­is­fac­tion data, as well as best prac­tices. “We’re find­ing there is a di­rect pos­i­tive cor­re­la­tion be­tween pa­tient ex­pe­ri­ence and out­comes,” said Dale Chung, re­gional di­rec­tor for Press Ganey who led the meet­ing.

By mak­ing her­self vis­i­ble and avail­able across the or­ga­ni­za­tion, Steed seeks to build re­la­tion­ships and en­cour­age open com­mu­ni­ca­tion. In­deed, as she walked the halls, she of­ten was taken aside by staffers who shared up­dates from their de­part­ments. One em­ployee in a rush to the ladies’ room stopped to give Steed a nurs­ing depart­ment up­date.

Steed said th­ese ef­forts at UI Health are new since she started the job in 2012, but she is see­ing pos­i­tive re­sults. For in­stance, staff are less in­tim­i­dated about speak­ing up about prob­lems now.

One key re­sult is UI Health’s im­prove­ment on its HCAHPS scores. The HCAHPS survey mea­sures pa­tients’ per­cep­tions of their hos­pi­tal ex­pe­ri­ence and is based on a 0% to 100% scale. The survey cov­ers nurses’ and doc­tors’ com­mu­ni­ca­tions with pa­tients, staff re­spon­sive­ness to pa­tients’ needs, how well in­for­ma­tion about new med­i­ca­tion is com­mu­ni­cated and whether key in­for­ma­tion is pro­vided at dis­charge. In 2014, the hos­pi­tal scored 62% over­all, com­pared with 57% in 2010.

Find­ing the root cause

In Steed’s view, poor pa­tient-sat­is­fac­tion scores are symp­toms of other prob­lems, such as poor care co­or­di­na­tion. “You can’t just nar­rowly fo­cus on pa­tient ex­pe­ri­ence with­out prop­erly find­ing the root cause,” she said.

The Beryl In­sti­tute’s Wolf said it’s im­por­tant to place the chief ex­pe­ri­ence of­fi­cer in the C-suite with close ac­cess to se­nior ex­ec­u­tives be­cause that sends a sig­nal to all staffers that the or­ga­ni­za­tion is pri­or­i­tiz­ing cus­tomer sat­is­fac­tion and qual­ity. “If the CXO is buried too deep down, you’ve al­ready made a state­ment be­fore you’ve even started,” Wolf said.

Steed’s of­fice is a few feet from the of­fices of the hos­pi­tal CEO and other se­nior ex­ec­u­tives. She said she meets with them reg­u­larly, shares feed­back gath­ered through her daily con­versa- tions and has in­put into the sys­tem’s strate­gic di­rec­tion.

“This is an im­por­tant func­tion,” said Ghosh, who has been CEO since Au­gust. He said he meets in­di­vid­u­ally with Steed once ev­ery two weeks to talk about goals and projects. “With this po­si­tion in place, there’s a fo­cus on try­ing to solve th­ese prob­lems in a more sys­tem­atic kind of way,” he said.

Be­fore her work­day ended, Steed at­tended a meet­ing to hear the con­cerns of pa­tients and fam­i­lies, as well as to re­cruit them to serve as vol­un­teer “se­cret shop­pers” and greeters. The meet­ing at­ten­dees sug­gested that the hos­pi­tal pro­vide trans­porta­tion be­tween var­i­ous build­ings on the cam­pus to ease pa­tient ac­cess, and that it should work to re­duce wait times and bet­ter com­mu­ni­cate when there are go­ing to be de­lays. “Th­ese are things we al­ready know we’re grap­pling with, but it doesn’t hurt to hear them again,” Steed said.

After two years of mak­ing her pres­ence known through­out the hos­pi­tal, Steed ac­knowl­edged that it hasn’t been easy fos­ter­ing open com­mu­ni­ca­tion with staff and cus­tomers. “Pa­tient ex­pe­ri­ence is not an easy job,” she said. “It’s ever-chang­ing and re­ally based on the needs and in­di­vid­ual nu­ances of the or­ga­ni­za­tion.”

As in ev­ery or­ga­ni­za­tion, there are staff who are resistant to change. Her ap­proach to deal­ing with them is to fo­cus the con­ver­sa­tion on what’s best for pa­tients. “They’re not likely go­ing to ar­gue with that,” she said.

Air­ica Steed, cen­ter, holds a “deep dive” meet­ing with pa­tient en­gage­ment and hos­pi­tal­ity staff to ad­dress pa­tient com­plaints.

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