James Merlino, MD: Part 2 of an interview by Bob Morris

MerlinoJames Merlino, MD, has been the Chief Experience Officer of the Cleveland Clinic health system, as well as a practicing staff colorectal surgeon in the Digestive Disease Institute. He is the founder and current president of the Association for Patient Experience. As a member of the Clinic’s executive team, he led initiatives to improve the patient experience across the Cleveland Clinic Health System. In addition he also led efforts to improve physician-patient communication, patient access, and referring physician relations. Partnering with key members of the Clinic leadership team, he helped to improve communication with physicians and employees, and to drive employee engagement strategies. He speaks to boards, c-suite leaders and physicians around the world on the important issues of culture, patient experience, and leading change. Dr. Merlino was named to HealthLeaders magazine’s 2013 list of “20 people who make healthcare better” and is a recognized world leader in the emerging field of patient experience. Dr. Merlino’s wife, Amy, is a maternal-fetal medicine specialist at Cleveland Clinic.

His book, Service Fanatics: How to Build Superior Patient Experience the Cleveland Clinic Way, was published by McGraw-Hill (2014). In January (2015), he transitioned from the Clinic to Press Ganey at which he serves as president and Chief Medical Officer of its strategic consulting operations.

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Morris: When and why did you decide to write Service Fanatics?

Merlino: I want to change the world of health care. We need to be more patient-centric, there needs to be greater compassion, humanism, and empathy in what we do. All of us – the multitude of professionals who deliver care – need to work better together. These are the challenges that need attention and I want to help address them. At Cleveland Clinic under Toby Cosgrove’s leadership, we have started to do all of these things. I wanted to share our story and my experiences in hopes of either igniting this work in others, validating the work others are doing, or just providing words of encouragement to people who are also working on this. The book is also a form of a how-to. For those who have not started and need some guidance, I think the book provides it.

Morris: Were there any head-snapping revelations while writing it? Please explain. Merlino: Yes, we learned a lot. Reflecting over the last 5-10 years of the journey is one thing, but when you sit down and write about it and then read what you wrote, you realize that there was a lot of hard work done by a lot of people and we actually accomplished a lot! People – leaders are so caught up in the day-to-day of operations that sometimes I think we fail to really appreciate the work that gets done.

Morris: To what extent (if any) does the book in final form differ significantly from what you originally envisioned?

Merlino: Originally, I think we designed it to be more of an historical account of our work, but what we decided — over time — was make it more of a “how to book” for both providers, but also for patients. I wanted each chapter to stand alone, meaning that you could read one chapter or a collection of chapters and take away something that is useable in your organization. For patients and the consumer, I think the book provides an in-depth examination of issues that increases understanding of some of the complexities of healthcare delivery. The book also gives them information on what they should expect – or deserve — with their care provision.

Morris: To what extent (if any) was writing this book influenced by Toby Cosgrove’s book, The Cleveland Clinic Way?

Merlino: I helped Toby with writing his book. I was one of a few people who had the honor of reviewing the entire manuscript and offering a critique. Toby’s work, but more importantly his book project, inspired me to work harder to tell the patient experience story. One chapter deals with patient experience – Service Fanatics offered an opportunity to take a chapter of the book and expand it into a completely independent dialogue about a single topic. Morris: To what extent has your MD training proven to be more relevant to your current duties and responsibilities than would training for an MBA?

Merlino: Being a physician who practices medicine gives me real-life experience on the front lines of healthcare – it makes the translation of the strategy of what we are doing easier and more practical because I know how it will affect front-line caregivers and ultimately our patients. Having an MBA certainly provides you with a set of tools to be an effective manager or leader, but in healthcare, working on the front lines is critical to a complete understanding of the business. I equate it to something similar I have heard about military officers: unless you have served on the front lines of battle, you really don’t know what it means to fight or the consequences of your decisions.

Morris: I have frequently heard it said that a hospital is among the unhealthiest environments, especially for those who are already ill. Your own thoughts about that?

Merlino: Hospitals are both unhealthy and unsafe, and I think one of the greatest ironies in medical care is that we encourage people to leave hospitals as soon as their circumstances permit. Many patients think we are “kicking them out” to cut costs and that we “don’t care.” The reality is we DO care and that is why we want them to be discharged as soon as it is appropriate. Patients are at risk for hospital acquired infections and other complications in the hospital – the longer they stay, the higher the risk. Because of the nature of the business – complicated patients with multiple diseases and a variety of different combinations of treatment options, there is also inherent extreme variability in what we do. This variability creates an environment where safety is at risk. We need to do more to drive toward greater standards and higher reliability in our culture to make hospitals safer.

Morris: My own opinion is that those who comprise an organization’s workforce must first become “fanatics” before attempting to create “fanatics” among its customers, patients, clients, guests, etc. What do you think?

Merlino: I want the work force to be passionate – I think passion drives the fanaticism, which subsequently leads to better performance and outcomes. I think there is no better field to ignite people’s passion than healthcare. The idea of helping a fellow human being at the time of their greatest need, I think, is a tremendously motivating opportunity for us to become a fanatic about what we do. I want every healthcare worker to come to what they do every day with their passion ignited to serve the patients entrusted to their care. I want them to be able to answer my question “Why are you doing this?” And, I want those answers to be something about taking care of people. If not, they probably should not be in healthcare.

Morris: What specifically can be done to improve the quality of workplace experience for those who cook the food and scrub pots and pans in the kitchens, empty waste baskets and haul trash, clean the rest rooms, and complete all the other unglamorous but essential tasks?

Merlino: As I explain in my book, at Cleveland Clinic, everyone is a caregiver. It does not matter what your role is in the organization – if you work for us, you are part of supporting the mission of Cleveland Clinic. This is an immensely important, critically important point because we want everyone aligned around why they come to work every day, which is to help support the care of patients. The caregivers in our organization who never see a patient are as important as the ones who do. Think about it on its most basic level: you can’t run a hospital without those who provide food or maintenance services. So they are just as important in the ecosystem of healthcare as are surgeons, nurses, anesthesiologists, and others who have direct contact with patients and their loved ones. The first step in starting that journey is to help them realize how essential they are to fulfilling the mission of the organization.

Morris: As I indicate in my review of the book for various Amazon websites, there are dozens of passages throughout your narrative that caught my eye. Here are several. Please respond. First, Cleveland Clinic: Challenges of organizational culture (Pages 1-7, 33-34, 66-67, 98-103, 112-113, and 220-221) Of all the challenges, which proved most difficult? Why? Is it an ongoing challenge?

Merlino: For decades, Cleveland Clinic — like most other large, academic health systems – had become very “legacy based.” The organization was highly successful for a lot of reasons so there were many who wondered why we needed to change anything. We were internationally prominent, patients came to us, and doctors sent patients to us – what’s the issue? The challenge was convincing people that the patient experience is important and something different from what we were doing – that we needed to focus on it; to get better at really treating things beyond just the disease. We need to treat the patient holistically, and provide for the spiritual and emotional dimensions of the journey as well as the medical side. Getting people to recognize that was the hardest challenge of the culture. Now jump ahead 6 years and I will tell you that it has become one of our greatest achievements. Today, everyone knows the patient experience is critical and a priority of the organization and everyone “owns” it.

Morris: Cleveland Clinic: Challenges of patient experience (Pages 1-7, 103-108, 177-178) Which of these challenges proved most difficult? Why?

Merlino: We are in the ultimate service business. There is no relationship in business more personal or vulnerable than the provider-patient relationship. But, we are in the ultimate service business where the customer is not always right! No one wants to be in this relationship – patients don’t want to be patients. Sometimes we do things that they don’t like; many times we cause pain and suffering. We don’t do it on purpose, but it is part of what we do in healthcare. We have to recognize that this makes our job much more difficult. We have had to learn – in fact, we are still learning, how to engage and communicate better with patients. How do we treat patients in an environment of maximal patient-centricity, but set reasonable expectations on what is going to happen. That sometimes they cannot always get their way, or will not always like our decisions, but those decisions are right for their medical conditions. We need to help patients how to understand and hold us accountable for doing the right thing, not necessarily the thing they like. Morris: Patient First approach (13-28) Please explain the process by which this approach was developed.

Merlino: Dr. Cosgrove coined the term shortly after he became CEO in 2004. He wanted to a simple way for people to think about why they come to work every day, reminding us that we exist for patients. He did not recognize the power of what he had done at the time, but in hindsight, what he did was create an organizational purpose. A way to align our caregivers around our patients – it was very powerful.

Morris: Chief Experience Officer (29-37) Of all that you experience, what do you find most fulfilling? Please explain.

Merlino: My most important role is to remind people why we are here, and that is for patients. It is that simple!

Morris: Transparency: 35-36, 106-108, and 181-186) What are the key points?

Merlino: Transparency is one of the most powerful elements driving real change in healthcare today. We are seeing hospital safety, quality, and experience data on the web for all to see. More hospitals are putting individual doctor communication scores on their websites. This is important information for all healthcare consumers – they have a right to see it to help drive their decision-making. Transparency also helps to drive front-line improvement. If you put a list of 10 doctors personal communication scores up in the doctor’s lounge, I promise you that the physician on the bottom of the list will not be there next month. Physicians are very competitive and no one wants to be on the bottom of the list.

Morris: Cleveland Clinic: Defining patient experience (54-63) What are the criteria?

Merlino: Patient experience is everything from the patient’s perspective. But to execute on improvement, we need to define it so that it relates to the healthcare ecosystem and workflow of the caregivers. A Cleveland Clinic we define our Patients First mantra as first deliver safe care, second high quality care, and third in an environment of patient and family centeredness – where patients and families are satisfied. Prioritizing this is important because you never want someone to challenge you and say “so patient satisfaction is more important than quality?” The answer is absolutely not!

Morris: Delos M. (“Toby) Cosgrove (66-67 and 712-80) For those who aspire to become leaders, what are the most valuable lessons to be learned him?

Merlino: There are many, but what I admire most is that Dr. Cosgrove is an incredibly visionary and innovative leader. He hates status quo and really challenges people to think out-side-the-box. Lesson number one would be to have the courage to challenge conventional wisdom and try new things. Second, he wants speed of execution. Never come to him with an idea but no plan to execute. If he likes the idea, he will want to know immediately about how to execute it. Third, he expects you to learn from failure, but he doesn’t want to hear about it. He wants to hear about the next idea to try, not about what doesn’t work.

Morris: Patient surveys (122-125 and 178-181) Of all that has been learned from them thus far, what has been — in your opinion — most valuable?

Merlino: A lot of healthcare leaders dislike that we do so much surveying but the reality is that they represent the voice of the patient and that is important. Patients fall into a very submissive posture with healthcare providers – they are at an information disadvantage, generally take a passive posture in the healthcare interaction, and are afraid to challenge their doctors. The survey – especially the government mandated ones, give the patient a true, honest voice about what they experience. The surveys are not perfect instruments, but just having them has taken our ability to capture the patient’s voice to a whole new level.

Morris: Service Excellence (157-175) In which area of operations has this been most difficult to achieve? Why?

Merlino: Generally service excellence works in any part of operations, the challenge is not implementation, it is sustainability. And the key to sustainability is empowering people – co-workers, to police themselves. If a caregiver has a difficult interaction with a patient, in the ideal world, the co-worker could seek out advice and support from a co-worker. Another example would be if a caregiver was not afraid to proactively offer support and advice to another caregiver who may have had a difficult interaction. Creating these front-line “coaches” in every area of the hospital is the desired state, but the most challenging and difficult to achieve.

Morris: Doctors and communication skills (181-186) In your own opinion, what is the key take-away from this passage?

Merlino: First, recognizing that we don’t communicate well with patients; second, that most solutions for improvement are pretty easy and often common sense.

Morris: Practical communication skills: Development (186-192) Please explain the process by which these skills are developed.

Merlino: Care providers – especially physicians, assume that communication skills necessary for effective patient care are just innate – or that they are somehow learned “on the job.” In fact, good and effective communications skill is just like any other thing in medicine, it must be taught, practiced, and occasionally refreshed to be effective. Most physicians learn how to communicate through the teaching of their trainers and mentors in residency. Much of this training is ineffective. We pass along bad habits to generations of medical trainees. Hospitals need to have formal programs in place to help physicians learn better skills and to keep those skills sharp.

Morris: Patient involvement (197-210) Please explain its nature and extent.

Merlino: I want every patient and every family member to be an advocate. We need them to ask more questions of their providers, become educated about their diseases and healthcare delivery. Also learn some of the inherent risks. Imagine if every patient and family member in the hospital was educated about the importance of hand washing and empowered to speak up and challenge caregivers who don’t do it. If a doctor walked into their family members’ room and did not wash their hands, the family member should challenge them to do so or not touch their loved one. This is advocacy at its basic form; it is important for delivering better care, and it’s the right thing to do. We should want people taking more responsibility because it helps us deliver better care.

Morris: “Getting It Done Has Defined Our Success (211-227) How so?

Merlino: We have accomplished so much that make me proud. However, our ability to execute has been a defining part of the journey. A lot of people talk about the importance of patient centricity; some have strategies, but few have buckled down and changed an organization like we have done. We did it! And because of that, you see the improvement in our metrics, and as I said in the book, the change is palpable to our patients and caregivers. That is what really counts.

Morris: Of all the great leaders throughout history, with which one would you most want to share an evening of conversation if it were possible? Why?

Merlino: Barak Obama. Patient experience was a disruptive innovation at Cleveland Clinic driven by our CEO Dr. Toby Cosgrove before it was in vogue around the rest of the country. While people will debate the effectiveness and meaning of the ACA for decades to come, it was that legislation that catapulted patient experience to the top of the healthcare landscape in the United States. It has given it meaning, and more importantly to effect change, it has linked patient experience performance to reimbursement, which will drive improvement. This is good for patients! And frankly, it’s good for us too, because someday we will also be patients. I would love for him – and frankly every member of Congress to read the book, hear what we have done, and understand that a piece of that legislation has real and palpable change, not only for everyone in this country, but for all of them and their families as well!

Morris: Let’s say that a CEO has read and then (hopefully) re-read Service Fanatics and is now determined to establish or strengthen a workplace culture within which personal growth and professional development are most likely to thrive. Where to begin?

Merlino: Make it a strategic priority of the organization and hold your people accountable for improving it. Only you can achieve that kind of effective change.

Morris: For more than 25 years, it has been my great pleasure as well as privilege to work closely with the owner/CEOs of hundreds of small companies, those with $20-million or less in annual sales. In your opinion, of all the material you provide in Service Fanatics, which do you think will be of greatest value to leaders in small companies? Please explain.

Merlino: I think this book is applicable to any company with customers! – And by the way, that seems to be every company. We learned a great deal from other organizations outside of healthcare and I think others can learn from us. My two most important pieces of advice for organizations are, first, to create a strategy where the organization is absolutely focused on keeping the needs of the customer paramount. Make customer centricity a strategic priority and use good data to be your beacon to the center. Second, create an environment where your people are treated as well as your customers. Transform your human resource function from what is likely a very transactional organization to a more strategic one that promotes an appropriate focus on your people.

Morris: Which question had you hoped to be asked during this interview – but weren’t – and what is your response to it?

Merlino: Why is patient experience important to everyone, not just people in healthcare? At the end of the day, we are all part of the healthcare ecosystem. Not only because we work in healthcare but also that, someday, sooner or later, each of us will be a patient. So, understanding and improving the patient experience – how we deliver safe, high quality care, in an environment of patient and family centricity, is important to everyone!

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To read Part 1 of my interview of Jim, please click here.

Jim cordially invites you to check out the resources at these websites:

Press Ganey link

Amazon Service Fanatics link

Institute for Innovation link

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