A roadmap for improving healthcare service quality

Journal of Healthcare Management

Author Abstract

A data-driven, comprehensive model for improving service and creating longterm value was developed, andimplemented at Mayo Clinic Arizona (MCA). Healthcare organizations can use this model to prepare forvalue-based purchasing, a payment system in which quality and patient experience measures will influencereimbursement. Surviving and thriving in such a system will require a comprehensive approach to sustainingexcellent service performance from physicians and allied health staff (e.g., nurses, technicians, nonclinicalstaff). The seven prongs in MCA's service quality improvement model are (1) multiple data sources to driveimprovement, (2) accountability for service quality, (3) service consultation and improvement tools, (4)service values and behaviors, (5) education and training, (6) ongoing monitoring and control, and (7)recognition and reward. The model was fully implemented and tested in five departments in which patientperception of provider-specific service attributes and/or overall quality of care were below the 90th percentilefor patient satisfaction in the vendor's database. Extent of the implementation was at the discretion ofdepartment leadership. Perception data rating various service attributes were collected from randomlyselected patients and monitored over a 24-month period. The largest increases in patient perception ofexcellence over the pilot period were realized when all seven prongs of the model were implemented as acomprehensive improvement approach. The results of this pilot may help other healthcare organizationsprepare for value-based purchasing.

INTRODUCTION

Patient-centered care has been Mayo Clinic's focus for more than 100 years. The organization's primaryvalue, "the needs of the patient come first," extends beyond clinical needs to include the need for service ofthe highest quality. Healthcare reform legislation has focused greater attention on quality and value and whatthey mean to healthcare consumers. Smoldt and Cortese (2007) contend that value is created for patients andpayers when organizations deliver the best clinical outcomes and service in the safest environment at thelowest cost over time. Paying for value is a pillar of healthcare reform. Under the value-based purchasing(VBP) program, reimbursement for inpatient Medicare services will be determined by a combination ofclinical quality and service quality measures. We anticipate continued future efforts to increase transparencyin healthcare quality data, as well as a VBP program in outpatient Medicare services. To provide the bestpossible service and to ensure that Mayo Clinic Arizona (MCA) is well positioned for VBP, widely acceptedservice quality principles were incorporated in a seven-prong, data- and accountabilitydriven model. Theframework provides a structured, comprehensive approach for healthcare organizations that are beginning orrethinking their service quality journey.

METHODS

Data Collection

A national vendor draws a stratified random sample of approximately 8,000 MCA patients each year as partof an ongoing survey of patient perception of service quality. The 50-item telephone survey asks patients torate on a fivepoint scale (excellent, very good, good, fair, or poor) service quality related to the provider(physicians and mid-level practitioners), the allied health staff (nurses, technicians, and nonclinical staff), thefacility, and global attributes, such as overall quality and likelihood to recommend. The vendor periodicallyreports to MCA the percent of patients rating service quality as excellent, as well as percentile rankings andstatistically determined key drivers of perception of overall quality. The service quality improvement modelwas fully implemented and tested in five departments in which patient perception of excellentprovider-specific service attributes and/ or overall quality of care were below the 90th percentile of clients in

this vendor's national database. Existing patient perception data were used to evaluate the efficacy of thepilot.

Vendor key driver reports (correlation coefficients or r values) were used to determine the strongestassociations with patient perception of overall quality and to prioritize improvement initiatives. Serviceattributes that related specifically to the provider included thoroughness of exam (r = 0.57, p < 0.001),explaining the medical condition (r = 0.57, p < 0.001), involving the patient in healthcare decisions (r = 0.56,p < 0.001), listening (r = 0.56, p < 0.001), demonstrating courtesy and caring (r = 0.53, p < 0.001), spendingenough time (r = 0.52, p < 0.001), and using understandable words and terms (r = 0.49, p < 0.001). Serviceattributes that related to operations and other members of the healthcare team included efficiency (r = 0.62, p< 0.001), teamwork (r = 0.59, p < 0.001), and staff courtesy and friendliness (r = 0.51, p < 0.001).

Qualitative data on staff performance in the pilot areas were collected through focus groups, directobservation, and unsolicited customer feedback. Operational data and physician and staff satisfaction datawere obtained from existing source reports.

The Model and Implementation

The seven prongs in MCA's service quality improvement model, as shown in Exhibit 1, are as follows:

1. Multiple data sources to drive improvement

2. Accountability for service quality

3. Service consultation and improvement tools

4. Service values and behaviors

5. Education and training

6. Ongoing monitoring and control

7. Recognition and reward

[ILLUSTRATION OMITTED]

Prong 1: Multiple Data Sources to Drive Improvement

An ongoing system for listening to internal and external customers is important for improving service quality(Berry and Parasuraman 1997). Such listening guides the allocation of improvement resources, and hard datamotivate process and behavior change. Metrics critical to the service strategy were identified and compiledinto a single, department-level service scorecard. This at-a-glance view of current and past performanceincludes: (1) operational metrics related to telephone service and appointment access (e.g., time to answercalls, call abandonment rates, unfilled appointment rates), (2) patient perception metrics (e.g., patientcomplaints; overall quality, teamwork, access, and value; patient likelihood to recommend), and (3) staffperception metrics (e.g., physician and allied health staff teamwork, staff likelihood to recommend). MayoClinic's goal for patient perception metrics is to rank in the top ten percent nationally. To identifyopportunities for improvement, each department's performance across multiple indicators is color codedgreen (meaning at or above the goal), yellow (indicating an intermediate negative variance from the goal), orred (representing the greatest negative variance from the goal).

Each quarter, executive leaders, department chairs, and their administrators are e-mailed a brief summaryscorecard that provides multiple, corroborating data sources; longitudinal trends; and operational context.This information has led to greater awareness, acceptance, and use of patient perception data by MCAphysicians. For example, volumes data, improvement project outcomes, complaint themes, and survey andfocus group comments are used to explain the patient perception metrics. Service quality is also tracked usinga brand monitor study; referring physician surveys; focus group studies; point-of-care satisfaction surveys;and patient letters, comment cards, and complaints.

Prong 2: Accountability for Service Quality

In Mayo Clinic's multispecialty, integrated healthcare model, accountability for service quality is promotedthrough the ongoing involvement of multiple layers of leadership. The Service Committee, chaired by thephysician lead for service excellence, oversees service quality. It reviews the department-level scorecard andprovides quarterly service updates, which highlight departments performing below goal, to the managingboard, the Clinical Practice Committee (CPC), and other leadership groups. The CPC oversees practicequality and requests action plans and progress reports from department leaders. Subsequent improvements inthe service quality metrics are noted by the Service Committee and reported to the CPC, and the cycle repeatsto ensure continuous service quality improvement (see Exhibit 2).

Accountability for service quality also has been advanced at the provider level. MCA's 2009 patientsatisfaction survey data showed that perception of overall quality is most strongly correlated with perceptionsof the quality of the individual provider (r = 0.66, p < 0.001). The Mayo Clinic Model of Care promises,among other things, a thorough medical exam by an unhurried physician who listens to the patient's concernsand involves her in care-related decisions. Seven provider-specific service attributes (thoroughness, spendingenough time, listening, explaining, using understandable language, involving the patient, and demonstratingcaring and compassion) that align with the promises made in the Mayo Clinic Model of Care, the fiscal year2013 Hospital Consumer Assessment of Healthcare Providers and Systems dimensions, and the idealphysician behaviors identified by Bendapudi and colleagues (2006) are monitored. Provider-specific patientsatisfaction data are combined with other provider-specific metrics, such as productivity, to manageperformance.

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All department chairs have access to provider-specific data, and they determine how the data will be used.Blind bar graphs, which show each provider's score without identifying the person, may be shown indepartment meetings. During performance reviews, providers typically are shown their own five-yearperformance trends and their rankings relative to their peers. Providers with scores below the goal work withtheir department chairs to develop improvement plans that may include individual coaching, other forms ofmentoring, and participation in a physician communication skills-improvement workshop facilitated bytrained MCA peer physicians. Provider-specific data complement other performance indicators that thepersonnel committee uses in reappointment and promotion decisions.

Prong 3: Service Consultation and Improvement Tools

The service coordinator provides analysis, education, consultation, and training, either at the request ofdepartment leaders or as a directive from the CPC. Consultation begins with the scorecard, followed byfurther analysis of department-level operational and perception data trends. Fifteen service attributes thatinvolve patient-staff interactions were culled from the patient satisfaction survey. The analysis focuses on keytouch points in the patient experience--telephone, reception desk, exam room--where the quality ofinteractions is controlled by physicians and managers. Data from the four most recent quarters, annual trends,and patient comments and complaints are compiled in a report to help department chairs and administratorsidentify improvement opportunities.

Because patients often use tangible clues in the physical setting to help them evaluate the quality of theirmedical care (Berry and Seltman 2008), evaluation of service quality also includes direct observation ofpatients interacting with the service environment. An audit of service in one outpatient waiting area illustratesthe value of such observation. The service environment appeared to send all the right clues to reinforceMayo's "needs of the patient" primary value--comfortable chairs; natural light; professional, well-groomedstaff; minimal wait times for check-in; and jazz music playing softly in the background. Only by sitting in thewaiting area could one experience the privacy concerns created by calling patients' names over a loudspeaker.Patients were called in groups of three and asked, in the presence of other patients, to provide their dates ofbirth. Patient concerns about identity theft were noted in the satisfaction survey and included in the finalservice audit report to management, with a recommendation to change this process.

A conceptual framework of service quality, the gaps model, was introduced to help managers understand

provider gaps and identify the most likely causes of perceived poor service quality (Parasuraman, Zeithaml,and Berry 1985, 1988). In this model, issues related to understanding the customer, designingcustomer-focused processes and performance standards, hiring the right people, staff education and training,and communicating about services are discussed in the context of department perception data and operations.The goal is to help department managers categorize their gaps in service delivery and develop correctivestrategies. When indicated by the data, new tools are added to the service improvement toolbox. For example,in response to teamwork perception scores, department administrators requested that physicians and alliedhealth staff receive teamwork training together. (Exhibit 3 shows representative service improvement toolsand how each has been used.) The final deliverable of the service consultation is a report to the departmentchair and administrator that includes department-level data trends, conclusions, recommendations, andimprovement resources. The service coordinator meets with department leadership to review this report andprovides an action plan template to be completed during the service quality review.

Prong 4: Service Values and Behaviors

Service quality improvement includes setting and communicating service standards, then evaluatingperformance against those standards. A small, multidisciplinary workgroup was formed to identify servicebehaviors consistent with being patient-centered and employee-driven, concepts that are essential tosupporting the Mayo Clinic Model of Care. Other health systems were benchmarked, and specific,measurable, and attainable service behaviors were identified. Physicians and allied health staff, includingstaff who have won service awards, vetted the draft standards, and further refinements were made. Theresulting five behavior standards are aligned with MCA's core values and create a mnemonic (SERVE) that isrelevant, easy to teach, and easy to remember.

* Solutions-focused (solve problems when and where they occur)

* Empathetic (treat everyone as you wish you or your family to be treated)

* Reliable (own the work; if you don't have the answer, find it)

* Valuing others (protect patient and employee confidentiality)

* Exceeding patient expectations (contribute to an unparalleled patient/ family experience)

SERVE applies to internal and external customer interactions. As internal customers, frontline staff shouldexpect the same service from physicians and administrative leaders as they are expected to deliver to patientsand to each other. SERVE applies to all clinical and administrative departments. Department managers areencouraged to customize SERVE to make it relevant to their staffs roles in the organization and toincorporate specific service behaviors into the appraisal process.

SERVE was incorporated into each phase of an employee's tenure at MCA. Pre-hire screenings andinterviews include a description of the service culture, values, and expectations to identify applicants whoseservice attitudes align with the organization. After hire, SERVE is taught to allied health staff and providersin new employee orientation and department trainings. Service standards are incorporated into the physicianand allied health staff appraisal process. Exiting employees are asked to rate teamwork and service fromcolleagues and are given an opportunity to comment on the service culture. These data are shared with theService Committee for improvement purposes.

Prong 5: Education and Training

"Frontline employees are not trained to understand customers" (Bitner, Booms, and Tetreault 1990, 71).Patient percent excellent ratings, correlations of provider and staff behaviors with perceptions of overallquality of care, and focus group data related to perception of teamwork and efficiency were used to assess

training needs and design training content for physicians and allied health staff. MCA's department-levelservice education and training were developed to give staff a better understanding of service basics and howbehaviors influence the customer's perception of quality (Parasuraman, Berry, and Zeithaml 1991). Coreconcepts in this department-level education and training include service delivery challenges, such asvariability and simultaneous production and consumption; the service quality gaps model; moments of truthin the service encounter (Normann 2001); perception surveys and benefits of top-box ratings (Otani 2009);common service complaints (Berry 1999); and appropriate service recovery behaviors. Also reviewed areMCA's service values and behaviors and the performance-monitoring and appraisal processes. Finally, therole of frontline staff in identifying and solving service delivery problems and communicating issues upwardis taught.

These service quality fundamentals are supplemented with department-level material to customize thetraining and make the service concepts relevant and meaningful. A high-level review of department data ispresented, and interactive exercises, such as a department-level service quality gap analysis, illustrateconcepts and generate ideas for improvement. For example, when training nurses from the inpatienthematology-oncology unit, typical patient expectations of this service line were listed and compared withactual patient experiences, followed by a brief discussion of ways to close the gaps. In this exercise, aflipchart page is generated to aid future department discussions on performance improvement.

Education and training include examples of employees who go beyond the call of duty. No MCA jobdescription includes duties such as patient haircuts, wedding planning, or car repair, but employees havewillingly provided these services. Survey comments and focus group recordings give meaning to the surveyratings and are incorporated into education and training, as appropriate.

Education and training promote job satisfaction by redefining key frontline roles in terms of their importanceto the total patient experience. The front-door General Services attendants' perception of their role wasreframed from "providing wheelchair assistance and directions" to "being Clinic ambassadors." Theirprimary job functions are to engage the patient and family, create a positive first impression, and set the stagefor clinical services.

MCA's education and training reinforces everyone's role in creating value. Staff are taught the businessbenefits of excellent service performance--market differentiation, positive word of mouth, likelihood thatcustomers will return and recommend, competitive advantage, and future revenue stream. Employees learnthat they can influence patient choice through the service they provide and that they are stakeholders in theorganization.

Nearly 800 trainee evaluations between 2008 and 2010 attest to good understanding of the content andapproach used in education and training. On a five-point scale ranging from least effective (1) to mosteffective (5), trainees rated all items (e.g., customers' basic service expectations, how customers judge servicequality, factors influencing perception) at 4.7 to 4.8.

Prong 6: Ongoing Monitoring and Control

After consultation, department managers are advised to develop tools and implement processes for ongoingmonitoring of service performance. Prong 2 sets the tone at the top for service accountability in theorganization and reinforces Prong 6, which helps ensure frontline staff accountability for performing todepartment standards. With input from the General Services attendants, a checklist of expected serviceperformance standards was created and tested at the hospital and clinic front doors, key touch points wherethe majority of patients interact with staff. The supervisors work alongside the staff so they are able toobserve performance and provide coaching and feedback daily. In addition, performance is compared withthe behaviors checklist and documented on random days by using the security cameras at three mainentrances. The attendants do not know when their performance is being documented. A similar process isused to improve telephone service in the clinic's outpatient departments. At the hospital switchboard and the

clinic central appointment office, telephone service is evaluated with a system that enables call recording,ongoing monitoring, completion of performance checklists, and coaching of staff.

Prong 7: Recognition and Reward

Teaching desired behaviors and recognizing and rewarding performance elicits more of the desired behaviorand contributes to job satisfaction. Several awards for outstanding service are given at annual recognitionevents emceed by members of the executive leadership team. Departments are recognized on ServiceExcellence Day for achieving the 90th percentile goal for patient perception of overall quality. Individualsare recognized at an annual service awards event with a typical attendance of several hundred employees.Awards include the Distinguished Mayo Clinician, Educator, and Investigator awards; the AdministrativeExcellence Award; and the Excellence in Clinical Nursing Award. Six individuals, nominated by their peers,are recognized for service excellence--performance that consistently goes above and beyond their jobdescriptions. Two of these six individuals receive the prestigious Mae Berry Award for Service Excellence.Only eight of 55,000 Mayo Clinic employees receive this distinction annually. Newer awards--theDistinguished Clinical Team Award, the Karis Award (named for the Greek word for "caring"), and theCommunity Caring Award--were created to recognize physicians and allied health staff for outstandingservice to patients and to one another.

RESULTS

Clinical Departments

The seven provider-specific service attributes that are among the strongest drivers of patient perception ofoverall quality at MCA were monitored during the 24-month pilot period. Trend data from the five pilotdepartments suggest that more frequent distribution of data to providers and a comprehensive approach toperformance management result in greater improvements in patient perception of excellence. Exhibit 4summarizes these results.

Follow-up with these departments confirmed how they used service quality data and improvement resourcesduring the pilot period. Departments with the largest and most sustained increases in service quality scoresimplemented all seven prongs in the model. They increased awareness of and accountability for servicequality by disseminating and monitoring multiple data sources. They requested analysis, consultation, andeducation and training from the service coordinator. They communicated MCA's service values andbehaviors to staff by posting them in their departments, discussing them in department meetings, andincorporating them into performance appraisals. They developed processes to monitor service performance(e.g., posting patient satisfaction data in the telephone staffs work area) and celebrated incrementaldepartment improvements. They recognized high-performing staff (e.g., chairs acknowledging top-ranking orgreatly improved providers and sharing patient comments about specific staff).

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Department 1 used the data in annual performance reviews only, showing providers their scores relative totheir peers' scores on a blind graph. In the first year, perception of excellence improved by 4 to 7 percentacross all provider attributes; in the second year, upward trends leveled off. Less frequent use of the data,combined with Lean initiatives that increased patient throughput in Department 1's diagnostic testing area,may have contributed to the decreases in perception of thoroughness and listening in 2010.

Department 2 used the data in annual performance reviews; in department meetings (blinded); in residenthiring decisions; and to identify providers who could benefit from communication skills training, coaching,and other forms of mentoring. In addition, the department chair requested service quality trainings tailored tophysicians and executive summaries of quarterly performance reports. Recommendations made to thishigh-patient volume department included providers adopting behaviors (sit while talking with patients, make

eye contact) that would communicate "you have my time and attention." Over a two-year period, there was a2 to 6 percent improvement across all provider attributes, with the greatest improvement in perception ofspending enough time with the patient.

Department 3 used the data in ongoing performance reviews and in department meetings (blinded). Inaddition, summary satisfaction data and positive patient comments were e-mailed to providers quarterly andnegative survey comments and patient complaints were discussed privately. Over a two-year period, therewas a 3 to 6 percent improvement in perception of excellence across all provider attributes, with the greatestimprovements in provider listening and explaining.

Department 4 used the data in ongoing performance reviews and resident hiring decisions. This departmentchair requested a comparative graph of all providers and service consultation to understand the data and itsmost appropriate use. The department mean for perception of excellence was established as the performancestandard. Underperformers were referred to individual coaching and other forms of mentoring. Over atwo-year period, there was a 5 to 9 percent improvement in perception of excellence across all providerattributes.

General Services Department

Front-door attendants' behaviors can have an impact on every patient's perception of courtesy and friendlinessand quality of care, which made this department a priority for the pilot. The patient satisfaction survey doesnot include questions specific to front-door service. Qualitative data for this staffs performance were obtainedthrough direct observation, in the responses to open-ended questions in the patient satisfaction survey, and inunsolicited customer feedback. The number of comments praising the staffs kindness and observations oftheir patience, efficiency, and caring for the patients' needs increased after service consultation and educationand training.

Overall Clinic

The clinic's overall service performance, measured with four global perception metrics--value, outcome,quality, and likelihood to recommend--remained strong between 2008 and 2010 (see Exhibit 5). Perception ofoutcome and value of care are at their highest levels since measurement of patient satisfaction began in 2002.Slight decreases in perception of overall quality and likelihood to recommend in 2010 may be the result of anelectronic medical record system conversion that mildly affected (-2.4 percent excellent) patient perceptionof efficiency. Efficiency is strongly correlated with perception of overall clinic quality. Based on prior annualtrends, these attributes are expected to rebound in 2011.

DISCUSSION

This pilot has several implications for healthcare managers. Implementation of the pilot afforded theopportunity to assess the interrelationships of the prongs. For example, because the service scorecard ise-mailed to leadership quarterly (Prong 1) and the accountability loop is in place (Prong 2), departmentleaders are more apt to request consultation and education and training services (Prongs 3, 4, and 5). Duringconsultation with departments, monitoring and control processes (Prong 6) and recognition and rewardprograms (Prong 7) can be put in place. While quick fixes to maximize payment under value-basedpurchasing may be tempting, this pilot showed that the best results come from implementing all prongs in themodel.

Accountability for service quality has been enhanced with a coordinated partnership among key serviceleaders--executive and department leaders, the physician lead for service excellence, and the servicecoordinator. To complement the metrics and consultation activities, leadership must demonstrate a genuinecommitment to service excellence, communicate performance expectations, and create accountability forimprovement. For example, MCA's CEO demonstrates a personal commitment to service and enhancesaccountability for service quality by reviewing metrics and performance goals in monthly meetings with eachdepartment chair and administrator and referring them to the service coordinator as needed.

Because service is a strategic function, the service coordinator should be positioned as an extension of theexecutive leaders who set strategy. Leadership should clarify the service coordinator's role andresponsibilities early. The service coordinator is an analyst, facilitator, educator, and service champion who isresponsible for helping the organization improve service. Department leaders are process owners, and theyare responsible for developing and implementing the action plans that improve service. As an internalmanagement consultant, the service coordinator crosses many boundaries, touches many positions, and hasaccess to sensitive, department-specific information. The service coordinator functions much like an internalauditor, providing objective analysis and recommendations (but not crossing over into performancemanagement) and treating as confidential department-level data and management reports.

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Limitations and Future Research This pilot describes a data-driven model to enhance accountability forservice improvement in an academic medical center with a strong service culture. Even the mostservice-conscious organizations must monitor and adapt to environmental changes that increase transparencyand accountability (Heskett et al. 1994). While this model can be used as a roadmap of what to do to improve

service, its implementation will likely depend on an organization's culture, hierarchy, and attitudes aboutservice. Leadership buy-in is essential; MCA's executive and operational leaders fully support the model.Organizations without a strong service culture might consider pre-implementation activities, such as anall-staff meeting, at which the CEO sets the tone for service. Smaller medical centers lacking a strongcommittee structure should identify potential influential individuals to serve as role models and thoughtleaders to create analogous service accountability loops that promote ownership at the department level.

Perception data has its own limitations. For example, a typical Mayo Clinic patient sees several specialistsduring a relatively brief episode of care. When responding to the provider-specific questions in thesatisfaction survey, patients may be thinking about one provider when another is the object of the survey.This risk is mitigated by repeating the department name and date of service before each survey question.Mso, department chairs are encouraged to interpret provider-specific data in the context of the diseasespectrum and demographics of their specific patient populations (e.g., age, gender, acuity of illness,effectiveness of available treatments).

Results from the initial four clinical and one General Services departments are encouraging. Over the next 24months, the model will be implemented and tested in all remaining departments of MCA. As moredepartments are brought into the service improvement process, the model may need to be refined. Forexample, the action plan reporting process may need to be desensitized and streamlined to hastenimprovement activity. Requests for action plans may need to be prioritized, using criteria such as percentexcellent achieved, percentile rank, patient volumes, and whether a service line is targeted for businessdevelopment.

CONCLUSION

Much has been written about measuring and monitoring patient satisfaction to improve service, butmeasurement alone will not improve the patient experience or create value. Analysis of service quality data atthe department and individual provider levels, supplemented with a comprehensive, research-based,seven-prong improvement model, has steadily improved the Mayo Clinic patient experience. Bysimultaneously employing top-down and bottom-up tactics, widely accepted service quality principles havebeen more deeply incorporated into the Clinic's culture. Continuous service quality improvement is a journey.A long-term approach that focuses on creating value by delivering an excellent service experience is the rightthing to do for the patient. With value-based purchasing on the horizon, improving service quality will helpsustain the organization into the future.

PRACTITIONER APPLICATION

Pooja Mishra, FACHE, director, Oncology Operations, WellStar Kennestone Hospital, Marietta, Georgia

The need for personalized service in healthcare has never been clearer. A patient recognizes the differencebetween being cared for and merely being processed. Patients are more likely to talk about experiences thatwere outside of their expectations--whether they exceeded them or fell short. The need to measure patientexperience in concert with outcomes and quality data has increased over the years, and healthcareorganizations have responded with measures such as voluntarily reporting inpatient patient perspective datato CMS and implementing value-based purchasing. Kennedy, Caselli, and Berry present a seven-prong modelfor improving service quality. Their valuable work highlights the importance of consistency in aresults-oriented environment.

As I observed during my years as director of service excellence at WellStar Kennestone Hospital, the bulk ofthe work in driving patient experience is having an engaged team. Employee engagement is key to drivingpatient experience and is a strong foundation for the other building blocks of a patient-centered culture inwhich feedback (solicited and unsolicited) leads to adjustments that help staff exceed patient expectations.

Our organization focuses on a patient-centered care bundle that includes components such as hourly roundingon patients, initiating caring moments with patients and their family members, elevating trust andunderstanding by performing shift reports at the patient's bedside, multidisciplinary rounding with effectiveteamwork to develop and act on the patient's plan of care, being respectful and responding to patient needsimmediately, and providing a respectful environment with a designated quiet time. Data collection (through

patient satisfaction surveys, post-discharge phone calls, and unsolicited feedback trends) to drive outcomes,an accountability structure, consultation and routine monitoring, ongoing education and support, culturebuilding, and recognition also help yield consistent--and exceptional--service delivery at the bedside.

Regardless of their many efforts to improve patient experience, organizations commonly report how difficultit is to sustain results. Kennedy and colleagues provide one example: despite their strong, systematicapproach to patient experience, changes within the organization, such as the EMR implementation they cite,can have significant impact on patient experience. Many units and centers can boast exceptional patientsatisfaction results, but few can deliver those results again and again. To work toward sustainable exceptionalpatient experience, organizations can focus on the following aspects that, in my observation, yield lastingresults:

1. Employee and provider engagement. Engagement is the foundation upon which we can build patientexperience.

2. Shared accountability. Organizations should set up systems for shared rewards based on achievement ofgoals.

3. Consistent practices. Basic practice models that allow for delivery of consistent service while maintainingcompassionate interactions need to be hardwired into staff to eliminate inconsistencies.

4. Training and retraining. New employees quickly pick up on culture. If new employees are trained to usecertain behaviors but those behaviors are not reflected in existing culture, the training will probably fall bythe wayside. To keep the objectives fresh and the team synchronized and invigorated, retraining must be partof the culture.

These four aspects complement the seven prongs that Kennedy and colleagues delineate. An engaged,accountable, and educated workforce and a focus on consistency can set organizations on the path to thepersonalized service patients deserve.

REFERENCES

Bendapudi, N. M., L. L. Berry, K. A. Frey, J. Turner Parish, and W. L. Rayburn. 2006. "Patient Perspectiveson Ideal Physician Behaviors." Mayo Clinic Proceedings 81 (3): 338-44.

Berry, L. L. 1999. Discovering the Soul of Service: The Nine Drivers of Sustainable Business Success. NewYork: Free Press.

Berry, L. L. and A. Parasuraman. 1997. "Listening to the Customer: The Concept of a Service-QualityInformation System." Sloan Management Review 38 (3): 65-76.

Berry, L. L., A. Parasuraman, and V. A. Zeithaml. 1988. "The Service-Quality Puzzle." Business Horizons31 (5): 35-43.

Berry, L. L., V. A. Zeithaml, and A. Parasuraman. 1985. "Quality Counts in Services, Too." BusinessHorizons 28 (3): 44-52.

Berry, L. L., and K. Seltman. 2008. Management Lessons from Mayo Clinic. New York: McGraw-Hill.

Bitner, M. J., B. H. Booms, and M. S. Tetreault. 1990. "The Service Encounter: Diagnosing Favorable andUnfavorable Incidents." Journal of Marketing 54: 71-84.

Heskett, J. L., T. O. Jones, G. W. Loveman, W. E. Sasser, Jr., and L. Schlesinger. 1994. "Putting the Service

Profit Chain to Work." Harvard Business Review 72 (2): 164-74.

Normann, R. A. 2001. Service Management: Strategy and Leadership in Service Businesses. New Jersey:John Wiley and Sons.

Otani, K. 2009. "Patient Satisfaction: Focusing on Excellent." Journal of Healthcare Management 54 (2):93-103.

Parasuraman, A., L. L. Berry, and V. A. Zeithaml. 1991. "Understanding Customer Expectations of Service."Sloan Management Review 33 (3): 39-48.

Parasuraman, A., V. A. Zeithaml, and L. L. Berry. 1988. "SERVQUAL: A Multiple Item Scale forMeasuring Consumer Perceptions of Service Quality." Journal of Retailing 64 (1): 12-40.

Parasuraman, A., V. A. Zeithaml, and L. L. Berry. 1985. "A Conceptual Model of Service Quality and ItsImplications for Future Research." Journal of Marketing 49: 41-50.

Smoldt, R. K., and D. A. Cortese. 2007. "Pay for Performance or Pay for Value?" Mayo Clinic Proceedings82 (2): 210-13.

Denise M. Kennedy, MBA, service coordinator, Mayo Clinic Arizona; Richard J. Caselli, MD, medicaldirector for service, Mayo Clinic; and Leonard L. Berry, PhD, distinguished professor of marketing, MaysBusiness School, Texas A&M University

EXHIBIT 3

Service Improvement Resources and Tools

Service Improvement ApplicationResource

Service consultation Service Coordinator is aninternal consultant tomanagement, providingobjective analysis andexpertise and positionedsolely as an improvementresource. Accountability andoversight are achieved throughother means.

Telephone system and A training coordinatorworkflow analysis observes call handling-volumes, time to answer, holdtimes, transfers, use of frontand back office lines andprovides a report of issuesand opportunities forimprovement.

Provider Resources include a day-longcommunication skills interactive group workshop,building mentoring, or more intensiveone-on-one coaching services.Providers may self-refer or bereferred by their departmentchairs.

Service basics education Staff develops a betterand training understanding of servicebasics and how behaviors

influence the customer'sperception of quality. Basiccore content is customizedwith department-level data andrelevant interactive exercisesare included.

Service auditing A department's serviceenvironment, patient flow, andstaff performance areobjectively analyzed. A finalreport of observations andrecommendations is provided.

Service best practice Practices and work samplesdatabase from areas performing at orabove benchmark are compiledin a spreadsheet designed tofilter by service attribute,department, process owner, orprocess.

Multidisciplinary A facility that is ideal forsimulation center small, intact team educationand training is used toimprove communication andteamwork skills.

Performance monitoring Expectations and performancechecklists are standardized and processcontrol is encouraged tosustain improvements.

Action plan template Issues, potential solutions,accountable people, andcompletion dates areidentified.

Kennedy, Denise M.^Caselli, Richard J.^Berry, Leonard L.

Full Text: COPYRIGHT 2011 American College of Healthcare Executives.

Source Citation:

Berry, Leonard L., Richard J. Caselli, and Denise M. Kennedy. "A roadmap for improving healthcare servicequality." Nov.-Dec. 2011: 385+. . Web. 1Journal of Healthcare Management Business Insights: EssentialsNov. 2012.

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