The Patient Experience

Photography by Eric Mull

"You learn humility." — Tom Tallman, DO, patient and doctor

It was March 2010. The week had been exceptionally warm. Tom Tallman set out to do a chore he’d been putting off for too long: taking down the Christmas lights. He was a runner. He was strong and handy. He had no trouble pulling a ladder up to the side of his house and navigating the rooftop to remove the lights. But on the climb down the ladder, he slipped and fell 20 feet to the stone walkway below.

Inside the house, Josh Tallman, 17, heard a crash. It was the ladder hitting a car in the driveway. He rushed outside and found his father unconscious. He called 911. “Don’t die,” he cried.

Tom Tallman came to. He sensed he had a head wound. He tried to reach up and touch it, but his arm wouldn’t move. He was paralyzed from the shoulders down. Paramedics arrived quickly and took him to the Emergency Department at a Cleveland Clinic regional hospital. From there, he was transferred to Cleveland Clinic’s main campus.

So began Tom Tallman’s long medical journey. He isn’t an ordinary patient, not by any measure. He’s Director of EMS, Medical Director for Disaster Medicine, and Chairman of Emergency Response and Resuscitation at Cleveland Clinic. His career has been dedicated to treating unexpected trauma — such as falls from high roofs. Tom Tallman, DO, was about to learn, in the worst possible way, what it feels like to be a patient.

“The first thing you lose is your dignity,” he says, sitting in his office at Cleveland Clinic almost six months to the day after his accident. “Everybody in the hospital sees your butt.”

Dr. Tallman spent days in the Neurological Intensive Care Unit. He had surgery to remove a cervical disc that was impinging on his swollen spinal cord. He suffered the full panoply of physical and emotional hurts available to a formerly strong, competent person reduced to a state of complete helplessness.

“You learn humility,” he says.

Across the country, medical centers are trying to teach physicians, nurses and other care­givers the same lesson — in a less painful way. There is a nationwide movement to make caregiving more compassionate. More patient-centered. More sensitive. More … empathetic.

What is empathy? Deirdre Mylod, PhD, has given the question a lot of thought. She is Vice President of Hospital Services for Press Ganey, a national consulting service that advises healthcare providers on patient satisfaction. For Dr. Mylod, empathy boils down to imagination. “Empathy is the ability to imagine the experience of another consciousness,” she says. But imagination alone is not enough. “You have to use that knowledge to understand another person’s emotional and physical needs.”

Empathy is like emotional cement. It binds the doctor-patient relationship. But it is rarely taught in medical schools. Astonishingly, medical education can even reduce empathy. “Research suggests that empathy actually decreases in medical students and residents during medical training,” Dr. Mylod says.

Empathy Pays

"Caring for people is why we all become nurses."
— Sarah Sinclair, RN, Executive Chief Nursing Officer

The lack of empathy has consequences. Without it there is patient anxiety. Mistrust.

A passionate statement of patient anxiety appeared in the journal Health Affairs in 2009, written by Donald Berwick, MD, then CEO of the Institute for Healthcare Improvement. In 2010, Dr. Berwick was appointed by President Barack Obama to direct the Centers for Medicare and Medicaid Services (CMS).

“I fear becoming a patient,” he wrote. “What chills my bones is indignity. It is the loss of influence on what happens to me. It is the image of myself in a hospital gown, homogenized, anonymous, powerless, no longer myself.”

Many patients share Dr. Berwick’s anxiety. But the experience of healthcare is changing. Healthcare leaders are discovering the benefits of empathy. Studies show that empathy increases patient compliance with their doctor’s advice. From a business standpoint, it helps differentiate healthcare providers in a competitive marketplace. Most decisively, the federal government is bringing the hammer down on hospitals that fail to measure up to certain standards, as measured by patient perceptions. CMS will soon be reimbursing hospitals based on their performance in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.

“CMS is now publishing HCAHPS scores for all hospitals on a public website, hospitalcompare.hhs.gov,” Dr. Mylod says. “Patients can compare one hospital to another. CMS is also aligning hospital reimbursement with HCAHPS scores. Hospitals that score less well will be reimbursed accordingly.”

This is an important change for hospitals. Medicare and Medicaid reimbursement accounts for more than half of most hospitals’ revenues.

HCAHPS has some hospitals hopping, but others are ahead of the curve. At Cleveland Clinic, empathy and patient-centered care are summed up by the words “patient experience.” And in the name of patient experience, the medical center has undertaken what CEO and President Delos M. Cosgrove, MD, calls a total transformation of its culture.

“There’s more to healthcare than great outcomes,” Dr. ­Cosgrove says. “There’s the entire experience from the time you call for an appointment, to when you arrive at the hospital — fearful and concerned — to when you get in your car and drive away.”

In 2008, Cleveland Clinic dropped its old hierarchy of doctor-based departments. Clinical services were reorganized into 23 patient-based institutes. Each institute is organized around a specific disease or organ system. Institutes do something that was once unthinkable in terms of medical politics: They combine the “rival” disciplines of medicine and surgery under a single leadership for seamless patient care. Physicians and surgeons, who appreciate the need for better patient experience, have embraced the new system.

Dr. Cosgrove, who holds the Rich Family Chief Executive Chair, gave Cleveland Clinic a new mantra: Patients First. He appointed the first chief experience officer (CXO) in U.S. healthcare, and created an Office of Patient Experience to expedite change. CXO James Merlino, MD, co-leads the Office of Patient Experience with Sarah Sinclair, RN, Cleveland Clinic’s Executive Chief Nursing Officer, and initial holder of the Stanley Shalom Zielony Endowed Chair for Nursing Advancement. The two oversee programs and initiatives designed to enhance patient experience and boost Cleveland Clinic’s HCAHPS scores. Their approach is decidedly data-driven.

“We collect and analyze patient feedback throughout the organization for insights into how patients perceive their experience,” says Dr. Merlino. “Our office maintains a Patient Experience Dashboard. Hospital managers can check in any time to monitor real-time feedback trends specific to their areas.”

Beginning in September 2010, Cleveland Clinic’s entire workforce of 43,000 began participating in a new initiative called the Cleveland Clinic Experience. Launched by the Office of Patient Experience and the Office of Learning and Performance Development, it is the most extreme step ever taken by a major U.S. medical center in the name of empathy, patient satisfaction and employee engagement.

Cleveland Clinic Experience is designed to improve both the patient and employee experience. “Caregivers from all disciplines and locations across the enterprise participate in interactive learning sessions to discuss our mission, values, what it means to be a caregiver and our expectations of how we serve our patients and each other,” Dr. Merlino explains.

Employees at Cleveland Clinic are now called “caregivers” because every job is seen as having a role to play in patient care and experience.

“We all live it,” says Dr. Merlino, who once asked a patient of his to keep a journal of everyone she encountered during her five-day hospital stay. The journal showed that she interacted with eight staff physicians, 16 different departments, residents and fellows, meal deliverers, physical therapists, radiology technicians, front-desk personnel, financial counselors, and phlebotomists. Her journal contained the names of 60 nurses, “and I think I may have missed three people,” she confessed.

“Any one of these caregivers has the power to make or break a patient’s day,” Dr. Merlino adds.

A Kind Word

One of the big lessons of patient experience is that little things mean a lot. A fluffed pillow. A kind word. Timely dispensation of pain medication.

When Dr. Tallman was hospitalized for his fall from the roof, he was forcibly reminded of this fact. “I’ll never forget certain milestones,” he says. “Getting my hair washed for the first time after the accident. My first shower.”

"Any one of these caregivers has the power to make or break a patient's day."
—James Merlino, MD, Chief Experience Officer

Cleveland Clinic has made a clean sweep of typical hospital irritations. There are no limits to visiting hours. Patients can see their medical records. Patient service navigators act as advocates and provide personal guidance throughout the hospital stay. Patients also have access to massage, touch therapies, reflexology, aromatherapy, guided imagery and art and music therapy.

The Quiet at Night program addresses one of the most common hospital complaints: nocturnal noise. The team collected patient survey data on noise from all Cleveland Clinic locations. They produced charts and bar graphs that enabled them to track the problem across time and geography. Recently, they rolled out a set of guidelines so that hospital patients can enjoy a quiet night’s sleep. 

The guidelines are called HUSH (Help Us Support Healing). They include closing hospital room doors where appropriate, oiling squeaky hinges, putting pagers on “vibrate,” dimming lights, limiting use of overhead paging and intercoms, limiting the number of times the patient is awakened during the night, and speaking in low voices.

Even the traditional patient gown has been redesigned. Dr. ­Cosgrove made this a priority soon after becoming CEO. He assigned the task to veteran nurse Jeanne Ryan, RN. She went to work with hospital supply vendors and tested several prototypes. “Our goal is to preserve patient dignity and comfort,” she says. “But we also needed to provide access for caregivers. The design has to allow caregivers to perform an exam without exposing the patient entirely. Only what they need to see.”

The glamour quotient of the project rose significantly after Dr. Cosgrove put the challenge to fashion designer Diane Von Furstenberg at a conference in Sun Valley. Ms. Ryan traveled to New York and collaborated with Ms. Von Furstenberg’s team on a new design. They developed a stylish unisex garment that preserves patient modesty, provides caregiver access, and can stand up to repeated washings.

The Cleveland Clinic–Diane Von Furstenberg patient gown was unveiled by male and female nurse models at a very special gathering. It wasn’t fashion week at Bryant Park. It was the Empathy + Innovation Summit held at Cleveland Clinic in May 2010 (see “Where Empathy Meets Innovation”).

In a building across the Cleveland Clinic campus from where the symposium was held, Dr. Tallman has resumed work part time as he continues the arduous recovery from the injuries he suffered in his fall. He will never forget what it felt like to be vulnerable, to need to have his head lifted to take a drink of water, the loss of agency and control. And he will never forget the kindness of his caregivers.

“I was so grateful to the nurses. I asked them, ‘Why do you do this, day after day?’ Each of them, young and old answered, ‘Because we love it when patients get better.’ ”

The healthcare reform act passed by Congress in March 2010 is expected to give many patients wider latitude in choosing doctors and hospitals for their care. Medical centers that offer the highest quality patient experience are bound to benefit. Patients will choose providers who give them not only outstanding outcomes, but the best possible experience.

“This has been a journey for us,” says Dr. Cosgrove, who launched Cleveland Clinic on its adventure in empathy. “We’re on that journey. We’re not perfect and we’re not where we want to be, but we’ve made progress.”

The care cart

"It's the people that keep me going. I know this person is sick, and I do or say whatever I can to put a smile on their face."
— Patrice “Peaches” Houston, patient transporter

One of the most visible caregivers at Cleveland Clinic isn’t a doctor. She doesn’t have an office. Patrice “Peaches” Houston is a patient transporter. She cuts a distinctive figure as she drives the electric cart that ferries patients and family members back and forth across the main campus. She engages her passengers in cheerful conversation as part of her job. Thousands of people see patient transporters like Ms. Houston every day. But too few appreciate their impact.

Scott Simon is one who does. Mr. Simon is a best-selling author and commentator on National Public Radio’s popular “Weekend Edition.” He came to Cleveland Clinic for spinal surgery in early 2010 to correct a condition that had paralyzed his hands.

Mr. Simon blogged about his surgery on NPR’s website and tweeted to more than a million followers.

“I awoke in recovery and began to cry,” he wrote, “because for the first time in two years I could use my hand.”

The journalist was not at a loss for words to describe his experience. He had high praise for the work and character of neurosurgeon Edward Benzel, MD, Chairman of Neurological Surgery, who performed his operation. He named the compassionate nurses who had helped him and his family cope with his condition. But he reserved special gratitude for “Peaches” Houston.

“She filled an anxious time for our family with laughter and warmth,” Mr. Simon wrote. “With her charm and her cheer, she gives great confidence to people.”

Patient transporters at Cleveland Clinic are trained to converse with patients, as well as move them from one place to another. “It’s the people that keep me going,” says Ms. Houston.

“I know this person is sick, and I do or say whatever I can to put a smile on their face.”