Service and Operational Excellence – Why and How

Goal: Make your Hospital/Department/Office/Medical Group Practice a great (better) place for staff to come to work, for physicians to practice medicine, and for patients to come for care.

5 Compelling Reasons why:

  1. Declining reimbursement per patient and worsening payer mix: In order to keep revenues up we need to attract more patients and see them more efficiently:
    1. Quality is an element patients take for granted; Technology patients do not understand; Service wins every time (how people feel when they walk in-first impression-and how they feel when they walk out-lasting impression)

    2. If we have to see more patients, we are going to have to reduce the obstacles to efficient patient care. Efficiency can be accomplished by getting rid of the workarounds and aggravations which get in our way every day (lack of/poor communication, lack of equipment, lack of responsiveness, etc).
  2. Workforce shortage: We are in the midst of a workforce shortage which will triple in the next decade. We do not have to have vacancies and be short staffed if we can create a place where people want to come to work (and I'm not talking about $ as a way of attracting people).

  3. Risk management: There is now evidence in the medical literature that the more patient complaints you receive, the more likely you are to get sued. If people think you care, they will give you some slack; if they feel you do not care, they will sue you even if care given met accepted standards but was not to their liking.

  4. On-line availability of quality and patient satisfaction data: We live in an ever-increasingly transparent environment. Go to for quality data on your hospital and yourself, or for Core Measure data, and soon to be patient satisfaction data (HCAHPS = Hospital Consumer Assessment of Healthcare Providers and Systems - data to be published on line 1st quarter 2008) at that same website. Go to to see individual patient comments on individual physicians. Measurement is public and getting more so, so it is important that we do well for our hospitals.

  5. Clinical Quality and Service Excellence are inseparable: Hospitals with high rates of employee turnover (22-44%) compared to those with low turnover (4-12%) have a 27% increase in mortality index and a 24% longer length of stay - if you consider employee turnover as a measure of service excellence to staff, hospital mortality index a measure of clinical quality, and severity-adjusted length of stay as a measure of operational efficiency, the connection is evident.
5 Simple Truths about our current healthcare environment:
  1. We live in a service economy: Most businesses throughout our culture are now heavily focused on service - hotels, restaurants, car dealers, websites. We live in an experience economy (Starbucks turned coffee and tea into an experience). So, patients/families (consumers of health care services) have developed a service expectation of us. "Good" is not "good enough." If all our patients rate us as 4 out of 5 on patient satisfaction survey, we would be in the bottom quartile of all those measured. "Satisfy" is not enough; we need to "Astonish" our patients and families, and make their ED visits "memorable" in a positive way. It does not mean we have to do a lot. We just have to think about it and incorporate a few specific behaviors (see later). We must also astonish our employees and our medical staff as well.

  2. We all think we give great service: I have yet to meet a physician or nurse who does not believe that he or she gives great care (albeit we sometimes know we don't, but we blame it on obstacles "out of our control" such as delays in triage, holding of patients, etc.).

  3. We think we give great service but that is not always the case: Our perception of the great care we are giving our patients is not always matched by their perception of the care they are receiving. (Look at your patient satisfaction scores - we can always do better). We need to look at patient satisfaction survey information as an educational opportunity to better understand patients' perceptions and get better rather than as criticism and/or judgment.

  4. If the other guy's getting better, you better be getting better faster than that other guy is getting better, or you're getting worse. Everyone is on this Service Excellence train - Hospital leaders are now being evaluated not only on the financial bottom-line but also service results, so there is, and will be, more pressure to excel. You can be getting better and worse at the same time if the other guy is getting better faster than you are. No rest for us any more - Rest areas on the highway of health care are closed forever.

  5. The best definition of madness is to keep doing things the same way and expect different results. Our hospitals/departments/offices/physician groups are not going to change until we commit to do so ourselves, each of us individually. So, what are one or two things that you can commit to doing differently, perhaps one thing to start doing and one thing to stop doing? Can you and your colleagues agree to all do one or two things as a group and then each person choose another to do him- or herself?
5 Key Tactics to create a great place for employees/associates/staff to work and for physicians to practice:
  1. Focus on systems and key metrics: Ensure that you have the tools and equipment you and your staff need to give great patient care. Leader rounding is a critical skill and process to find out what is going well, what needs to be improved upon, and also serves as a process by which to coach staff on new behaviors. Document issues, create an action monitor, and take issues one by one. Determine key metrics, sit down with other teram members/colleagues/staff and brainstorm how to improve. Participate in Collaborative Practice Team meetings - the more we are willing to come in on a day off and contribute, the better.

  2. Focus on staff satisfaction and physician and mid-level practitioner satisfaction: Make those "issues" regular agenda items at your staff meetings.

  3. Treat all others with whom you work as your customer: So, the nurses you work with, the PA's and NP's, the registrars, the techs, the unit secretaries - think about how you might serve them better. Instead of demanding or asking them to do everything for you, ask first what you can do to make their lives easier. Once you address their needs, they are much more likely to satisfy yours.

  4. Say "Thank you" more: Something as simple as committing to say thank you to the staff/physicians you work with at the end of their day (which might be at a time different from the end of your day) goes a very long way toward creating a better workplace. Chocolate also works (Be corny - bring in little Milky Way candy bars and tell staff you love working with them because they are "out of this world" great). What else works? Bagels on a weekend morning or pizza on a very busy night when no one gets to go to dinner.

  5. Get rid of the phrase "It depends": We all have to be on board. If the nurses ever look at the schedule and groan when certain physicians or MLP's are working, it reflects on us all. No double standards - hospital staff are asked to uphold behavior standards - physicians should commit to the same and sign them just as staff are now being asked to do. If any of us come to work with a negative or cynical attitude, we have to call each other on it - looking at the glass half-empty will never get us anywhere. Think half-full always.
5 Basic Strategies to improve patient satisfaction:
  1. Take a fresh look at your department/office/practice and see what you can do to warm up the environment and make it more inviting/caring for your patients. Understand that our patients' perceptions are ultimately the decision-makers with regard to their satisfaction. Perception of care greater than expectation --> you're golden; Perception of care less than expectation --> you're dead. So, "Think bakery" - when you first walk into a bakery, what is the first thing you notice? The smell! But if you work in the bakery you get used to the smell and it no longer affects your senses. So it is true that we get used to a whole host of environmental inputs that our patients are not familiar with - we don't notice but they do - the smells, the noise, the energy level (organized chaos at times), the clutter. Do what you can to get into their minds and hearts and see with their eyes, and try to make the physical space less frightening and cold.

  2. Sit down at the bedside. It's real simple. Patients and families feel you have been present with them much longer when you sit compared to standing at the bedside. To facilitate this, there needs to be a chair and a stool (ot two chairs) by every patient examination space (where physically feasible). Clothing or coat hooks on the walls with big signs that say "For Patient Clothing" prompt the patients not to put clothes on these sitting devices which then makes your life easier.

  3. Use Key Words or Consistent Messages to express your caring: Some folks object to this saying that "Scripts are fake." But we use key words at home with our significant others and with our children all the time - phrases like "I love you" or "You're right" or "Yes dear" or "Whatever you say" or "Say Please" or "Say Thank you". So why not do the same with our patients as we do with our families. Some of my favorites: "We've got more pain medicine than you have pain"; "We're going to do our best to keep you comfortable and informed"; at the end of a patient encounter, "Do you have any questions? Is there anything else I can do for you?" Choose your own words (whatever you feel comfortable with) but use them consistently.

  4. Do not assume that patients and families know who you are and how good you are and how long things are gong to take: Adopt the AIDET approach to communicating with patients and families; "Manage Up" your self and your ED - let patients and families know you are committed to giving them great care.

    A - Acknowledge patient and family, use a greeting, adjust the stretcher/sheet/pillow if needed, smile, make eye contact.
    I - Introduce self with title, manage up, service recovery if needed (apologize if there has been a delay and commit to giving very good care).
    D - Explain how long evaluation and diagnostic work-up will take, use key words for keeping patient informed.
    E - Explain the plan of care, what tests and treatments are to be accomplished, and what you feel is going on.
    T - Say Thank you or Good Bye to the patient.
  5. Make Follow Up Phone Calls to patients who are treated-and-released: Not only is this important in terms of service (Patients love being called the next day), it is a great tool for risk management and quality feedback (Did you make the correct diagnosis?). In one hospital on the east coast, patients who received a follow up phone after an ED visit had a 40 percentile increase in their satisfaction compared to those patients who did not receive such a call.
IN SUMMARY, we live in a service environment and if we want to thrive we need to understand how we can create memorable experiences for our patients, our staff and our physicians. It does not take great exertion of energy and time to do this, just consistent focus and understanding and ongoing learning.

Thank you for all that you give and all that you are.