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Philanthropy and Service Excellence What Is the Connection? Camille Haycock, MS, APRN, NEA-BC; Deanna Curry, MS, RN; Xavier Sevilla, MD, MBA, FAAP Providing person-centered care is a fundamental value and guiding philosophy for all health care delivery across Catholic Health Initiatives. Exceptional service excellence with every patient and family encounter is one way in which this value is demonstrated. The consequences of treating every person with dignity, respect, and a positive attitude can have real benefit on clinical outcomes, individual healing, health system reputation, and financial incentives. In our changing health care landscape, there are now financial motivations to improve patient satisfaction. In addition, a connection can be drawn between our relationships with patients, their experience with an organization, and the subsequent philanthropic and charitable donation to that organization. This article describes one health care system’s journey toward improved patient experience through service excellence infrastructure, standard processes, and expected service behaviors. Key words: customer service, patient experience, person-centered care, philanthropy, service excellence
“People will forget what you said, people will forget what you did, but people will never forget how you made them feel” —Maya Angelou
I
N HEALTH CARE SETTINGS, when we speak of philanthropy, we typically conjure up images of foundations raising money from deep-pocket donors for executive-driven projects and innovative ideas that will improve patient care and/or bottom line. These money-raising efforts and foundations are historically far removed from the actual care that is being delivered. At Catholic Health Initiatives (CHI), we believe that every encounter with every patient should develop a
Author Affiliations: Catholic Health Initiatives, Englewood, Colorado. The authors declare no conflict of interest. Correspondence: Camille Haycock, MS, APRN, NEABC, Catholic Health Initiatives, 198 Inverness Dr W, Englewood, CO 80112 (camillehaycock@catholichealth .net). DOI: 10.1097/NAQ.0000000000000061
relationship of healing that is person-centered and focused on customer service and satisfaction. The consequences of treating every person with dignity, respect, and a positive attitude can have real benefits on individual healing, patient outcomes, health care reputation within a given community, and financial incentives. In our changing health care landscape, there are now financial motivations to improve patient satisfaction. In addition, a direct link can be drawn between our relationships with patients, their experience with an organization, and subsequent charitable donations to that organization. In fact, most philanthropic donations come from actual patients or their families and are a result of how they were treated within that organization. Consider the following: Mrs K, an elderly resident from an assisted living facility, arrives at a health care organization via transportation from the care center. She is taken to the front door of the hospital and she walks into a bustling lobby filled with busy people going in many different directions. She is somewhat disheveled looking, clutching her purse, and very
348 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Philanthropy and Service Excellence uncertain of where she needs to go for her imaging tests. Simultaneously, while standing in line at the lobby coffee kiosk, a nurse notices this confused and perplexed elderly woman, gets out of the line, greets Mrs K with kindness and respect, and then escorts her to her intended destination. While walking with her through the hospital, the nurse engages in friendly conversation and learns that Mrs K has just received a life-limiting diagnosis. Mrs K is lonely and scared. Her only child lives overseas and her husband has died. Upon arriving in the imaging department, the nurse personally introduces Mrs K to the receptionist and lets the receptionist know that this “patient” needs some extra attention and is “a very important person.” This “important person” concept travels with Mrs K. throughout her journey through the imaging department, subsequent admission, and eventual discharge to hospice. The nurse, or anyone within the hospital, did not know anything about Mrs K’s personal circumstances, beyond her diagnosis, and yet treated her with dignity and respect and as “important.”
What would happen at your organization? Would Mrs K be greeted with a smile and escorted to her intended location, or could she be left to find the imaging services on her own, because everyone in the lobby is “too busy” to escort her? Upon returning to her unit, would the nurse be chastised by management or peers for “being gone too long?” Is every patient in your organization treated as if they were “important?” In short, do you have a culture of customer service in your organization? The story of a perplexed patient arriving on the doorstep of a hospital or clinic is lived out every single day, in every organization across the country. After all, health care systems, by nature, are very confusing institutions. All stories, however, may not have the same consequence. As all can conjecture, the rest of this story includes Mrs K’s estate providing a generous philanthropic donation to this hospital. While it should never be the driving motivation behind excellent customer service, it is important to understand that donations are made as a result of how people are made to “feel” within that organization. Front line caregivers are the face of an organization and
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can “make or break” any effort toward organizational fund raising efforts. In fact, there is anecdotal and obvious correlation between philanthropic donation and a patient’s experience within that organization. WHY CUSTOMER SERVICE MATTERS IN HEALTH CARE The “right” thing to do The measurement and reporting of patient satisfaction in health care has become a major industry. Moreover, satisfaction outcomes are now reported on quality scorecards. Physicians are compensated for improved scores, and healthcare systems are rewarded and penalized for patient experience scores. While goals must be set to monitor progress, the improvement of scores should be motivated by organizational core values, while providing respect and dignity for each patient and with every patient encounter. A respectful partnership between care provider and recipient is considered a primary driver in the patient and family experience. In addition, fully engaged staff and providers delivering compassionate communication and care is an organization competency necessary for improved patient experience.1 While it is the “right” thing to do, these care interactions do matter in the course of a patient evaluating his or her own experience with that organization and can influence patient satisfaction scores. Value-based purchasing Within the Centers for Medicare and Medicaid Services Hospital Fiscal Year 2013-2015 Value-Based Purchasing program, the patient satisfaction composite accounts for 30% of the quality score.2 As part of the Affordable Care Act, this initiative rewards hospitals with incentive payments for the quality of care provided to Medicare beneficiaries. Within the Patient Experience of Care domain, the Centers for Medicare and Medicaid Services payment plan awards points for achievement, consistency, and improvement. This plan, launched in Fiscal Year 2013, affects payment for
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inpatient stays in approximately 3000 hospitals across the country. Customer service and patient engagement promotes healing and improved outcomes Research suggests that engaging patients in their care will improve outcomes and lower the costs of that care.3 Patient engagement and patient satisfaction are often used interchangeably and yet are different concepts. To engage patients and their families, customer service tactics must be deployed to achieve the engagement and partnership necessary to improve outcomes and health. Furthermore, customer service tactics must precede any of the engagement efforts needed for optimal health promotion.
Health system reputation Providing an excellent patient experience and superior patient care leads to tangible benefits for the health care system. Recent research4 suggests there is a correlation between patient experience and hospital reputation. In addition, social media and immediate online communication about a patient’s experience with an organization can influence a health system’s standing within that community. In fact, social media and online resources are now a trusted source for information, even from people the consumer does not know.5 THE CHI JOURNEY TOWARD SERVICE EXCELLENCE CHI spans 19 states and includes acute care facilities, physician practices, ambulatory settings, post-acute facilities, and home care. Because of the diversity of organizations across multiple states, the system also experiences a wide degree of patient satisfaction outcomes. This variation in satisfaction scores created urgency at CHI to discover what high performing organizations were
doing to accomplish the top decile scores. CHI’s journey toward improved service excellence was built on the CHI philosophy of person-centered care, and delivered through a collaborative partnership with patients and families. The CHI Service Excellence behaviors support the CHI Core Values of Reverence, Integrity, Compassion, and Excellence. As CHI enters into the “Next Era of Health Care,” it is an imperative that any improvement strategy be aimed at health care continuum services. Therefore, CHI service excellence development efforts are multidisciplinary and require cultural changes spanning all care delivery areas. The outcomes of all efforts are measured using Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) and Clinician & Group Consumer Assessment of Health Care Providers and Systems (CG CAHPS) performance outcomes. The lofty goal was set for all CHI health care settings to perform in the Top Decile (90th percentile) of HCAHPS and CG CAHPS reporting. Service excellence tools were developed in 4 categories: Acute Care, Ambulatory Care, Leadership Competency, and a Service Excellence crosswalk to other initiatives. In addition to building tools and resources for local ministry adoption, behavioral standards were developed to be deployed across the enterprise. A CHI Service Excellence Steering Committee was assembled and composed of high performing market-based organizations from across the CHI enterprise. Tapping the lessons learned and successes of the best within the enterprise supports the development of the CHI national service excellence package.
THE CHI INFRASTRUCTURE FOR SERVICE EXCELLENCE The first step in understanding service excellence in health care is to realize that patients are actually “customers” with varying needs and preferences. Much can be borrowed from the service industry, if health care
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Philanthropy and Service Excellence providers first recognize that care must be personalized and tailored to individual need. Each of us can pinpoint an experience we have had with the service industry that created an exceptional experience. When analyzing such an experience, authors agree that it is the way in which the consumer is made to “feel” about the service that creates the superior experience. These behaviors that engender “positive feelings” by the consumer can be borrowed from other service industries and adopted by the health care environment where we build infrastructure and cultural expectations for staff and management. Patient-Centered Care is a foundational philosophy for our company. In fact, we have developed an enterprise definition for “PersonCentered Care” that includes a value-driven statement about how care is delivered. It is not a matter of semantics but an important concept that is entrenched in the philosophy of care provision. This is our cultural foundation for service excellence and customer satisfaction. How to provide this individualized customer service is as varied as each person that seeks care within the health care system and can certainly pose many challenges. While each encounter must be individualized and responsive to the needs of each person, a service-oriented infrastructure can be developed to promote this culture of individualized care. This infrastructure provides a framework and the foundational components for a strategy aimed at an excellent customer experience. The CHI service excellence infrastructure includes a variety of tools and resources designed to promote service behaviors and service recovery while recognizing and rewarding outstanding service. Clear performance expectations are included, and utilization of HCAHPS and CG CAHPS metrics help to measure successes and improvement opportunities. Tools include the utilization of care bundles for hospitalized patients as part of the service excellence infrastructure. These promote the use of well-established practices packaged to-
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gether to help ensure patients experience the best possible outcomes. These care bundle practices include the following: • Care rounding, which allows staff to anticipate the patient’s needs using a proactive versus a reactive approach to care. Purposeful, intentional actions occur at regular intervals with patients and family members and include addressing the patient’s comfort, environmental, and communication needs, while conducting scheduled tasks. • Bedside reporting provides a comprehensive handoff between care providers and ensures continuity of care, reduces patient stress, encourages active participation by the patient and family, and provides educational opportunities. • Team huddles provide a communication vehicle to address patient concerns, potential safety issues, and foster teamwork. • A coordinated hospital discharge ensures a smooth transition from the hospital setting to the patient’s next level of care. • Leadership rounding allows an opportunity to manage the patient’s expectations, practice service recovery, assess staff performance, and provide staff recognition and coaching. Incorporating service excellence behaviors into all CHI programs and work streams is essential for sustained culture change. Service behaviors are included in process improvement and safety activities. Aligning tools across these initiatives helps to promote the use of standardized processes across the enterprise that result in a positive patient experience of care every time. THE SMILE PROGRAM AT CHI Health care organizations have adopted many service industry standards, in our quest to improve satisfaction. Many of our colleagues have incorporated known principles (mentioned earlier) that have been shown to improve scores. Reminding employees to smile as part of providing great customer service has long been a part of many
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improvement efforts. We have added a “twist” to this by developing an acronym to promote service excellence. SMILE is our name for service excellence behaviors and standards. This internally developed designation for expected behaviors is utilized across care settings (Figure 1). All employees are expected to demonstrate these actions with every patient/family/customer in all interactions. The behaviors are also expected to be demonstrated with colleagues, visitors, and volunteers. The CHI’s SMILE behaviors were developed to help decrease patient anxiety, improve the patient’s positive perception of care, and increase compliance with our goal to improve patient outcomes and satisfaction. Positive interactions between patients, families, providers, and employees help improve satisfaction for caregivers as well as those receiving care. Strong interpersonal communication is an expectation of the service excellence behaviors and includes active listening, not multitasking during patient interactions, making eye contact, using appropriate tone of voice, speed of speech, humor, and emotion while talking with patients. The SMILE acronym consists of several components that facilitate communication with our patients. The “S” stands for “smile.” It is an expectation that employees make eye contact and smile when they come within 10 ft of a patient or family member and greet them with open body language and a handshake, if possible. This first step dovetails into “M,” which stands for “maximize confidence.” Here the employee is expected to introduce himself or herself to the patient, highlighting his or her skill set, professional certification, and experience. Employees are expected to speak well of coworkers, providers, other services, and their facility. “Maximizing confidence” helps patients feel more confident in their caregivers and reduces anxiety that the patient may feel about their health care experience. The next letter in the acronym is “I,” which stands for “information.” All employees are expected to explain to the patient in
Figure 1. CHI’s SMILE standards and behaviors.
language he can understand about the visit or the procedure that he will be undergoing during his care. This includes an explanation of time expectations or delays in service, including time that may be expended waiting,
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Philanthropy and Service Excellence clinician expected time of arrival, or duration of a procedure. The employees should give accurate time increments when possible. If not possible, the patient should be updated at an agreed-upon time. (For example, “I will be back in 15 minutes to let you know if there are any delays in your scheduled time to begin your procedure.”) “L” stands for ‘lead.’ Employees are expected to take the patient where he needs to go. (As the example illustrates at the beginning of this article, health care facilities are complex and challenging for patients to navigate.) The last acronym letter “E” stands for “express” empathy and appreciation. This is an opportunity for employees to close their patient encounter by remembering to use words that convey empathy such as “care” and “comfort.” This is also a great opportunity for employees to thank the patients for choosing our organization for their health care needs. Figures 2 and 3 provide examples of how a receptionist and nurse can utilize the SMILE acronym for a patient encounter. IMPLEMENTATION OF SERVICE EXCELLENCE AND BEHAVIOR STANDARDS The service excellence tools, SMILE behaviors, and resources are being implemented across CHI in a phased approach (Figure 4). Phase 1 starts with building the case for service excellence at all levels of the organization. We know that leadership within the
Figure 2. Example of SMILE behaviors practiced by a receptionist.
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Figure 3. Example of SMILE behaviors practiced by a nurse.
organization must be the drivers and influencers of the cultural change. Following leadership ownership and accountability, clinicians, staff, and other front-line workers are expected to develop the required skills and behaviors for each patient interaction. It is very important to highlight to clinicians that there is evidence of improved compliance and better clinical outcomes resulting from “hardwiring” service excellence behaviors. Simultaneously, SMILE behaviors are introduced using a multipronged approach, including leadership rounding, new orientation training, and team-based and organizational training programs. The third pillar of phase 1 includes transparency of the data. At this stage, outcomes reporting through CG CAHPS and HCAHPS data are transparent to facilities, clinics, and clinicians. In phase 2, we identify service excellence champions who can be trained to provide coaching, education, and training to their peers. The second part of phase 2 involves assessing the organizationwide competency to ensure employees and providers understand service excellence expectations. In phase 3, we include service excellence and incentive compensation for clinicians and leaders in the organization. At this point, capabilities are in place to support improving the performance of the organization. As has been expressed earlier in this article, this is about changing the culture of an organization and requires rigorous sustainability. Everyone, from senior leadership to
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Figure 4. Service excellence implementation phases.
front-line caregivers, are asked to embrace service excellence. CONCLUSION Published literature and online resources are replete with programs and strategies aimed at improving patient satisfaction in health care.6–8 It really does not matter what tool, tactic, or program an organization chooses to embrace as a service excellence improvement effort. What matters is that patient satisfaction and customer service become a core value of the organization and that each patient is treated with respect and dignity with every encounter. It is important to establish a program, which provides infrastructure and service expectations with accountability, leadership, and owner-
ship. In our organization, we expect that aggregate satisfaction scores will improve over time as a result of our emphasis on this program. We also anticipate an enhanced organizational reputation, brand loyalty, better retention, and employee satisfaction, as well as the financial incentives associated with the Affordable Care Act. While philanthropic fund raising efforts should never eclipse the importance of foundational core values for personcentered care and service excellence as reasons to treat people with love and respect, they are influenced by patient satisfaction initiatives. People who feel cared for are more likely to support organizations so that they can continue to care for others. Philanthropic fundraising efforts should not underestimate the influence and power of the front-line caregivers.
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REFERENCES 1. Balik B, Conway J, Zipperer L, Watson J. Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2011. 2. Centers for Medicare and Medicaid Services. http:// www.cms.gov/medicare/quality-initiatives-patientassessment-instruments/hospital-value-based-purchasing. Published 2013. Accessed May 4, 2014. 3. Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press; 2012. 4. Johnson K. The Link Between Patient Experience and Hospital Reputation. Lincoln, NE: National Research Corporation; 2014.
5. Nielsen Global Advertising. http://www.nielsen.com/ us/en/newswire/2009/global-advertising-consumers -trust-real-friends-and-virtual-strangers-the-most.html. Published 2009. Accessed April 25, 2014. 6. Institute of Medicine. Crossing the Quality Chasm: A New health System for the 21st Century. Washington, DC: National Academies Press; 2012. 7. Ferrari M. Improving Patient Experience in the Inpatient Setting: A Case Study of Three Hospitals. Princeton, NJ: Robert Wood Johnson Foundation; 2012 8. Planetree and the Picker Institute. Patient-centered care improvement guide. www.planetree.org and www.pickerinstitute.org. Accessed May 4, 2014.
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Nurs Admin Q Vol. 38, No. 4, pp. 348–355 c 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Philanthropy and Service Excellence What Is the Connection? Camille Haycock, MS, APRN, NEA-BC; Deanna Curry, MS, RN; Xavier Sevilla, MD, MBA, FAAP Providing person-centered care is a fundamental value and guiding philosophy for all health care delivery across Catholic Health Initiatives. Exceptional service excellence with every patient and family encounter is one way in which this value is demonstrated. The consequences of treating every person with dignity, respect, and a positive attitude can have real benefit on clinical outcomes, individual healing, health system reputation, and financial incentives. In our changing health care landscape, there are now financial motivations to improve patient satisfaction. In addition, a connection can be drawn between our relationships with patients, their experience with an organization, and the subsequent philanthropic and charitable donation to that organization. This article describes one health care system’s journey toward improved patient experience through service excellence infrastructure, standard processes, and expected service behaviors. Key words: customer service, patient experience, person-centered care, philanthropy, service excellence
“People will forget what you said, people will forget what you did, but people will never forget how you made them feel” —Maya Angelou
I
N HEALTH CARE SETTINGS, when we speak of philanthropy, we typically conjure up images of foundations raising money from deep-pocket donors for executive-driven projects and innovative ideas that will improve patient care and/or bottom line. These money-raising efforts and foundations are historically far removed from the actual care that is being delivered. At Catholic Health Initiatives (CHI), we believe that every encounter with every patient should develop a
Author Affiliations: Catholic Health Initiatives, Englewood, Colorado. The authors declare no conflict of interest. Correspondence: Camille Haycock, MS, APRN, NEABC, Catholic Health Initiatives, 198 Inverness Dr W, Englewood, CO 80112 (camillehaycock@catholichealth .net). DOI: 10.1097/NAQ.0000000000000061
relationship of healing that is person-centered and focused on customer service and satisfaction. The consequences of treating every person with dignity, respect, and a positive attitude can have real benefits on individual healing, patient outcomes, health care reputation within a given community, and financial incentives. In our changing health care landscape, there are now financial motivations to improve patient satisfaction. In addition, a direct link can be drawn between our relationships with patients, their experience with an organization, and subsequent charitable donations to that organization. In fact, most philanthropic donations come from actual patients or their families and are a result of how they were treated within that organization. Consider the following: Mrs K, an elderly resident from an assisted living facility, arrives at a health care organization via transportation from the care center. She is taken to the front door of the hospital and she walks into a bustling lobby filled with busy people going in many different directions. She is somewhat disheveled looking, clutching her purse, and very
348 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Philanthropy and Service Excellence uncertain of where she needs to go for her imaging tests. Simultaneously, while standing in line at the lobby coffee kiosk, a nurse notices this confused and perplexed elderly woman, gets out of the line, greets Mrs K with kindness and respect, and then escorts her to her intended destination. While walking with her through the hospital, the nurse engages in friendly conversation and learns that Mrs K has just received a life-limiting diagnosis. Mrs K is lonely and scared. Her only child lives overseas and her husband has died. Upon arriving in the imaging department, the nurse personally introduces Mrs K to the receptionist and lets the receptionist know that this “patient” needs some extra attention and is “a very important person.” This “important person” concept travels with Mrs K. throughout her journey through the imaging department, subsequent admission, and eventual discharge to hospice. The nurse, or anyone within the hospital, did not know anything about Mrs K’s personal circumstances, beyond her diagnosis, and yet treated her with dignity and respect and as “important.”
What would happen at your organization? Would Mrs K be greeted with a smile and escorted to her intended location, or could she be left to find the imaging services on her own, because everyone in the lobby is “too busy” to escort her? Upon returning to her unit, would the nurse be chastised by management or peers for “being gone too long?” Is every patient in your organization treated as if they were “important?” In short, do you have a culture of customer service in your organization? The story of a perplexed patient arriving on the doorstep of a hospital or clinic is lived out every single day, in every organization across the country. After all, health care systems, by nature, are very confusing institutions. All stories, however, may not have the same consequence. As all can conjecture, the rest of this story includes Mrs K’s estate providing a generous philanthropic donation to this hospital. While it should never be the driving motivation behind excellent customer service, it is important to understand that donations are made as a result of how people are made to “feel” within that organization. Front line caregivers are the face of an organization and
349
can “make or break” any effort toward organizational fund raising efforts. In fact, there is anecdotal and obvious correlation between philanthropic donation and a patient’s experience within that organization. WHY CUSTOMER SERVICE MATTERS IN HEALTH CARE The “right” thing to do The measurement and reporting of patient satisfaction in health care has become a major industry. Moreover, satisfaction outcomes are now reported on quality scorecards. Physicians are compensated for improved scores, and healthcare systems are rewarded and penalized for patient experience scores. While goals must be set to monitor progress, the improvement of scores should be motivated by organizational core values, while providing respect and dignity for each patient and with every patient encounter. A respectful partnership between care provider and recipient is considered a primary driver in the patient and family experience. In addition, fully engaged staff and providers delivering compassionate communication and care is an organization competency necessary for improved patient experience.1 While it is the “right” thing to do, these care interactions do matter in the course of a patient evaluating his or her own experience with that organization and can influence patient satisfaction scores. Value-based purchasing Within the Centers for Medicare and Medicaid Services Hospital Fiscal Year 2013-2015 Value-Based Purchasing program, the patient satisfaction composite accounts for 30% of the quality score.2 As part of the Affordable Care Act, this initiative rewards hospitals with incentive payments for the quality of care provided to Medicare beneficiaries. Within the Patient Experience of Care domain, the Centers for Medicare and Medicaid Services payment plan awards points for achievement, consistency, and improvement. This plan, launched in Fiscal Year 2013, affects payment for
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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inpatient stays in approximately 3000 hospitals across the country. Customer service and patient engagement promotes healing and improved outcomes Research suggests that engaging patients in their care will improve outcomes and lower the costs of that care.3 Patient engagement and patient satisfaction are often used interchangeably and yet are different concepts. To engage patients and their families, customer service tactics must be deployed to achieve the engagement and partnership necessary to improve outcomes and health. Furthermore, customer service tactics must precede any of the engagement efforts needed for optimal health promotion.
Health system reputation Providing an excellent patient experience and superior patient care leads to tangible benefits for the health care system. Recent research4 suggests there is a correlation between patient experience and hospital reputation. In addition, social media and immediate online communication about a patient’s experience with an organization can influence a health system’s standing within that community. In fact, social media and online resources are now a trusted source for information, even from people the consumer does not know.5 THE CHI JOURNEY TOWARD SERVICE EXCELLENCE CHI spans 19 states and includes acute care facilities, physician practices, ambulatory settings, post-acute facilities, and home care. Because of the diversity of organizations across multiple states, the system also experiences a wide degree of patient satisfaction outcomes. This variation in satisfaction scores created urgency at CHI to discover what high performing organizations were
doing to accomplish the top decile scores. CHI’s journey toward improved service excellence was built on the CHI philosophy of person-centered care, and delivered through a collaborative partnership with patients and families. The CHI Service Excellence behaviors support the CHI Core Values of Reverence, Integrity, Compassion, and Excellence. As CHI enters into the “Next Era of Health Care,” it is an imperative that any improvement strategy be aimed at health care continuum services. Therefore, CHI service excellence development efforts are multidisciplinary and require cultural changes spanning all care delivery areas. The outcomes of all efforts are measured using Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) and Clinician & Group Consumer Assessment of Health Care Providers and Systems (CG CAHPS) performance outcomes. The lofty goal was set for all CHI health care settings to perform in the Top Decile (90th percentile) of HCAHPS and CG CAHPS reporting. Service excellence tools were developed in 4 categories: Acute Care, Ambulatory Care, Leadership Competency, and a Service Excellence crosswalk to other initiatives. In addition to building tools and resources for local ministry adoption, behavioral standards were developed to be deployed across the enterprise. A CHI Service Excellence Steering Committee was assembled and composed of high performing market-based organizations from across the CHI enterprise. Tapping the lessons learned and successes of the best within the enterprise supports the development of the CHI national service excellence package.
THE CHI INFRASTRUCTURE FOR SERVICE EXCELLENCE The first step in understanding service excellence in health care is to realize that patients are actually “customers” with varying needs and preferences. Much can be borrowed from the service industry, if health care
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
LWW/NAQ
NAQ-D-14-00046
September 4, 2014
3:34
Philanthropy and Service Excellence providers first recognize that care must be personalized and tailored to individual need. Each of us can pinpoint an experience we have had with the service industry that created an exceptional experience. When analyzing such an experience, authors agree that it is the way in which the consumer is made to “feel” about the service that creates the superior experience. These behaviors that engender “positive feelings” by the consumer can be borrowed from other service industries and adopted by the health care environment where we build infrastructure and cultural expectations for staff and management. Patient-Centered Care is a foundational philosophy for our company. In fact, we have developed an enterprise definition for “PersonCentered Care” that includes a value-driven statement about how care is delivered. It is not a matter of semantics but an important concept that is entrenched in the philosophy of care provision. This is our cultural foundation for service excellence and customer satisfaction. How to provide this individualized customer service is as varied as each person that seeks care within the health care system and can certainly pose many challenges. While each encounter must be individualized and responsive to the needs of each person, a service-oriented infrastructure can be developed to promote this culture of individualized care. This infrastructure provides a framework and the foundational components for a strategy aimed at an excellent customer experience. The CHI service excellence infrastructure includes a variety of tools and resources designed to promote service behaviors and service recovery while recognizing and rewarding outstanding service. Clear performance expectations are included, and utilization of HCAHPS and CG CAHPS metrics help to measure successes and improvement opportunities. Tools include the utilization of care bundles for hospitalized patients as part of the service excellence infrastructure. These promote the use of well-established practices packaged to-
351
gether to help ensure patients experience the best possible outcomes. These care bundle practices include the following: • Care rounding, which allows staff to anticipate the patient’s needs using a proactive versus a reactive approach to care. Purposeful, intentional actions occur at regular intervals with patients and family members and include addressing the patient’s comfort, environmental, and communication needs, while conducting scheduled tasks. • Bedside reporting provides a comprehensive handoff between care providers and ensures continuity of care, reduces patient stress, encourages active participation by the patient and family, and provides educational opportunities. • Team huddles provide a communication vehicle to address patient concerns, potential safety issues, and foster teamwork. • A coordinated hospital discharge ensures a smooth transition from the hospital setting to the patient’s next level of care. • Leadership rounding allows an opportunity to manage the patient’s expectations, practice service recovery, assess staff performance, and provide staff recognition and coaching. Incorporating service excellence behaviors into all CHI programs and work streams is essential for sustained culture change. Service behaviors are included in process improvement and safety activities. Aligning tools across these initiatives helps to promote the use of standardized processes across the enterprise that result in a positive patient experience of care every time. THE SMILE PROGRAM AT CHI Health care organizations have adopted many service industry standards, in our quest to improve satisfaction. Many of our colleagues have incorporated known principles (mentioned earlier) that have been shown to improve scores. Reminding employees to smile as part of providing great customer service has long been a part of many
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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improvement efforts. We have added a “twist” to this by developing an acronym to promote service excellence. SMILE is our name for service excellence behaviors and standards. This internally developed designation for expected behaviors is utilized across care settings (Figure 1). All employees are expected to demonstrate these actions with every patient/family/customer in all interactions. The behaviors are also expected to be demonstrated with colleagues, visitors, and volunteers. The CHI’s SMILE behaviors were developed to help decrease patient anxiety, improve the patient’s positive perception of care, and increase compliance with our goal to improve patient outcomes and satisfaction. Positive interactions between patients, families, providers, and employees help improve satisfaction for caregivers as well as those receiving care. Strong interpersonal communication is an expectation of the service excellence behaviors and includes active listening, not multitasking during patient interactions, making eye contact, using appropriate tone of voice, speed of speech, humor, and emotion while talking with patients. The SMILE acronym consists of several components that facilitate communication with our patients. The “S” stands for “smile.” It is an expectation that employees make eye contact and smile when they come within 10 ft of a patient or family member and greet them with open body language and a handshake, if possible. This first step dovetails into “M,” which stands for “maximize confidence.” Here the employee is expected to introduce himself or herself to the patient, highlighting his or her skill set, professional certification, and experience. Employees are expected to speak well of coworkers, providers, other services, and their facility. “Maximizing confidence” helps patients feel more confident in their caregivers and reduces anxiety that the patient may feel about their health care experience. The next letter in the acronym is “I,” which stands for “information.” All employees are expected to explain to the patient in
Figure 1. CHI’s SMILE standards and behaviors.
language he can understand about the visit or the procedure that he will be undergoing during his care. This includes an explanation of time expectations or delays in service, including time that may be expended waiting,
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Philanthropy and Service Excellence clinician expected time of arrival, or duration of a procedure. The employees should give accurate time increments when possible. If not possible, the patient should be updated at an agreed-upon time. (For example, “I will be back in 15 minutes to let you know if there are any delays in your scheduled time to begin your procedure.”) “L” stands for ‘lead.’ Employees are expected to take the patient where he needs to go. (As the example illustrates at the beginning of this article, health care facilities are complex and challenging for patients to navigate.) The last acronym letter “E” stands for “express” empathy and appreciation. This is an opportunity for employees to close their patient encounter by remembering to use words that convey empathy such as “care” and “comfort.” This is also a great opportunity for employees to thank the patients for choosing our organization for their health care needs. Figures 2 and 3 provide examples of how a receptionist and nurse can utilize the SMILE acronym for a patient encounter. IMPLEMENTATION OF SERVICE EXCELLENCE AND BEHAVIOR STANDARDS The service excellence tools, SMILE behaviors, and resources are being implemented across CHI in a phased approach (Figure 4). Phase 1 starts with building the case for service excellence at all levels of the organization. We know that leadership within the
Figure 2. Example of SMILE behaviors practiced by a receptionist.
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Figure 3. Example of SMILE behaviors practiced by a nurse.
organization must be the drivers and influencers of the cultural change. Following leadership ownership and accountability, clinicians, staff, and other front-line workers are expected to develop the required skills and behaviors for each patient interaction. It is very important to highlight to clinicians that there is evidence of improved compliance and better clinical outcomes resulting from “hardwiring” service excellence behaviors. Simultaneously, SMILE behaviors are introduced using a multipronged approach, including leadership rounding, new orientation training, and team-based and organizational training programs. The third pillar of phase 1 includes transparency of the data. At this stage, outcomes reporting through CG CAHPS and HCAHPS data are transparent to facilities, clinics, and clinicians. In phase 2, we identify service excellence champions who can be trained to provide coaching, education, and training to their peers. The second part of phase 2 involves assessing the organizationwide competency to ensure employees and providers understand service excellence expectations. In phase 3, we include service excellence and incentive compensation for clinicians and leaders in the organization. At this point, capabilities are in place to support improving the performance of the organization. As has been expressed earlier in this article, this is about changing the culture of an organization and requires rigorous sustainability. Everyone, from senior leadership to
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Figure 4. Service excellence implementation phases.
front-line caregivers, are asked to embrace service excellence. CONCLUSION Published literature and online resources are replete with programs and strategies aimed at improving patient satisfaction in health care.6–8 It really does not matter what tool, tactic, or program an organization chooses to embrace as a service excellence improvement effort. What matters is that patient satisfaction and customer service become a core value of the organization and that each patient is treated with respect and dignity with every encounter. It is important to establish a program, which provides infrastructure and service expectations with accountability, leadership, and owner-
ship. In our organization, we expect that aggregate satisfaction scores will improve over time as a result of our emphasis on this program. We also anticipate an enhanced organizational reputation, brand loyalty, better retention, and employee satisfaction, as well as the financial incentives associated with the Affordable Care Act. While philanthropic fund raising efforts should never eclipse the importance of foundational core values for personcentered care and service excellence as reasons to treat people with love and respect, they are influenced by patient satisfaction initiatives. People who feel cared for are more likely to support organizations so that they can continue to care for others. Philanthropic fundraising efforts should not underestimate the influence and power of the front-line caregivers.
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5. Nielsen Global Advertising. http://www.nielsen.com/ us/en/newswire/2009/global-advertising-consumers -trust-real-friends-and-virtual-strangers-the-most.html. Published 2009. Accessed April 25, 2014. 6. Institute of Medicine. Crossing the Quality Chasm: A New health System for the 21st Century. Washington, DC: National Academies Press; 2012. 7. Ferrari M. Improving Patient Experience in the Inpatient Setting: A Case Study of Three Hospitals. Princeton, NJ: Robert Wood Johnson Foundation; 2012 8. Planetree and the Picker Institute. Patient-centered care improvement guide. www.planetree.org and www.pickerinstitute.org. Accessed May 4, 2014.
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