• Patient experience is growing in importance as a performance measure for hospitals, especially as patients become more savvy health care consumers.

• Medicare holds back part of its reimbursement, and doesn’t pay it back until the end of a payment period, based partly on HCAHPS scores.

• Hospital leaders are using a variety of tactics to measure and improve patient experience scores.

• Training caregivers on how to improve patient experience is critical.

• The biggest key to improving experience is the physician. Revealing physicians’ scores to colleagues, and maybe even the public, can be a significant incentive for them.

In 2009, University of Utah Health Care had few bragging points when it came to patient satisfaction. Overall, it ranked in the 18th percentile for satisfaction with outpatient care, as compared with its peers nationally. And only 4 percent of its physicians ranked in the top 10th percentile.

Today, just six years later, the system ranks in the 90th percentile. Half of its physicians are in the top 10th percentile — and 26 percent rank in the top 1 percent nationally.

That dramatic improvement came courtesy of a multifaceted Exceptional Patient Experience campaign designed to convince every staff member that patient satisfaction was a top priority. “The culture now is strong, and our business is booming,” says Chief Medical Officer Tom Miller, M.D. “And our patients are so much happier.”

Across the country, hospitals are scrambling to follow University of Utah’s lead as the importance of patient experience becomes ever more clear. The field is quickly shifting its focus to consumers because they are paying an ever-larger share of their health care costs — and are becoming choosier about where they seek care.

“Every day of the week, people walk in here with $5,000, $7,500, $10,000 deductibles,” says Greg Meyers, senior vice president–revenue integrity for Integris Health, the largest health system in Oklahoma. “We don’t even refer to our patients as patients now; we refer to them as customers because when that much money comes out of their pocket, they are becoming much more sophisticated as consumers.”

(Sidebar: How Health Systems Use Alternatives to Surveys to Determine Patient Satisfaction)

Business case for satisfied patients

A direct relationship between patient satisfaction and hospital financial performance was formalized in FY 2013, when the Centers for Medicare & Medicaid Services introduced the Hospital Value-Based Purchasing Program, which rewards — or penalizes — hospitals based on several performance criteria. Along with core measures and hospital-acquired conditions, CMS uses a hospital’s score on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to determine its Medicare pay rate for inpatient care.

CMS holds back part of a hospital’s Medicare pay — 1.5 percent in FY 2015, rising to 2.0 percent in 2017 — each year. The hospital receives all or part of that money back at the end of the performance period, depending on its value-based purchasing score; 30 percent of the amount at risk is based on HCAHPS score.

Meyers, at Integris Health, says the financial risk associated with the HCAHPS score is not the main reason his organization is focusing on patient experience. “The financial impact of that is not nearly as great as the financial impact of losing a large group of patients if we don’t deliver good patient satisfaction,” he says. “Obviously, if it affects our reimbursement, that’s a concern. But we try to take the more global approach.”

That means a patient’s experience with the operational and financial aspects of an encounter with Integris Health are just as important as the clinical aspects. “If someone comes here to have a life-saving heart transplant and we work miracles, but six months later, we are arguing over a hospital bill, it’s almost like all the good clinical work we’ve done goes for naught,” he says.

In 2013, patient experience was the subject of a Lean initiative that sought to identify and implement opportunities for improvement. Among other things, Integris is moving to a single billing statement that includes both hospital and physician charges. “Our patient bill was designed 100 percent using feedback that we got from former patients,” Meyers says. “We are trying to get away from the ‘we know what’s best for everybody’ approach and actually ask people what they like.”

And what they don’t like. He wants all pre-registration and customer service staff to consistently gather qualitative feedback that can be used for continuous improvement. “The last question that we encourage all of our staff to ask the patient is ‘Was I able to resolve your questions to your satisfaction today?’” he says. “And if not, ‘What could I have done differently?’”

Engaging physicians

Of course, physician interaction is an essential element of a patient’s experience in a health care encounter. “If you try it on the employee side only, it lasts a little while but will fizzle away and physicians are like, ‘That’s great. I’m glad you have a patient experience campaign, but don’t bother me,’” Miller says.

At least some physicians will. University of Utah Health Care’s Exceptional Patient Experience initiative, which launched in 2009, was a huge initiative rolled out across the organization. In the school of medicine, every department began receiving patient satisfaction scores for each physician, and department heads got to decide how to use it. Some shared it openly within the department; others blinded the information so no physician knew how another scored. Patient satisfaction scores did improve but physician engagement was mixed.

In 2011, a surgeon came to Miller, alarmed by a few negative comments that yielded a low star rating on Vitals.com, one of several online physician review sites, that contrasted with her excellent Press Ganey ratings and reviews. “And then it hit me: The best defense is an offense, so why not post all of our information online for the public to see?” Miller says, referring to the thousands of ratings — the vast majority of which are positive — collected each year. “I immediately said, ‘This is what we’ve got to do.’”

In 2012, University of Utah became the first health system to post Press Ganey satisfaction ratings and comments to its Find-a-Doctor webpage, allowing patients to check out a physician before requesting an appointment.

That got physicians’ attention. The number of physicians seeking help to improve their communication skills and bedside manner jumped immediately.

“When the information is out there for the whole world to see, you pay attention to it because it’s your reputation,” Miller says. “Instead of needing to constantly say, ‘Your scores are low, and you should be nicer, blah, blah, blah,’ and getting a lot of pushback, we heard, ‘Wow, these are patients talking about me online. I’m going to do better.’”

And they did, as evidenced by the high scores that University of Utah Health Care can brag about today.

Getting Started

When the University of California-San Diego Health System developed a new strategic plan, experience was broadly defined and emerged as its centerpiece. “We call it the big ‘E,’ meaning the experience of the clinical team members, the physicians, administrative staff and patients,” says Thomas Savides, M.D., who was appointed chief experience officer last year. “If the people who work in the organization aren’t themselves having a good experience, they won’t be able to translate one to the patients, and the patients can tell.”

Savides, who maintains his practice as an interventional gastrologist, works in a management dyad with Julie Kennedy Oehlert, the health system’s chief administrative officer for ambulatory services. Oehlert, whose job title includes associate chief experience officer, is in second management dyad with the dean of clinical affairs. That structure ensures that physicians, administrative staff and clinical staff are all led by a senior executive responsible for the experience strategy.

Because this is new for the system, the work started with a multi-day “experience immersion” retreat for the executive team, followed by visits to San Diego-area businesses outside the health care field — Apple Computer, Whole Foods, local retailers and others. “That gave us a deep dive into how they look at experience from the customer’s perspective, as well as from a team member’s perspective,” Savides says.

The emphasis on experience is being embedded into policies and procedures throughout the organization, with representatives from all departments linked to the Office of Experience Transformation in some way. Meanwhile, the “experience immersion” is now cascading through the organization, with top executives facilitating the sessions.

Staff are being introduced to tools to support a good patient experience, but the more important task is inspiring all staff to see their work in a new way. “This is more of a cultural transformation than a training methodology,” Savides says. “We’re showing how to provide hospitality under any circumstance, doing the right thing at the right time for the right patient without it being a taught thing.”

A View From the Front

At Cleveland Clinic, which pioneered the concept of “chief experience officer” nearly a decade ago, CXO Adrienne Boissy, M.D., says patient satisfaction is just a small part of patient experience. “Patients will never have an exceptional experience with us if we don’t deliver safe, high-quality care,” says Boissy, a neurologist and the third executive to serve in the CXO role.

To that end, the CXO position resides in Cleveland Clinic’s Office of Clinical Transformation along with the top executives in charge of quality, safety, population management and value. “The way we think about things moving forward is that all of these are connected,” Boissy says.

The CXO job title is gaining traction in the industry, but the focus on patient experience is so new that best practices, job descriptions and even definitions are not yet settled ground. Boissy’s advice: “Make sure you have a definition because everybody thinks patient experience is something different. And without agreeing on what it is, we will never achieve it.”

Patient experience directly reflects an organization’s culture, so no improvements can be made without taking that into consideration. Boissy encourages health care executives that are planning to appoint a CXO — as well as CXOs stepping into the role — to take time to understand the culture before initiating changes.

“There’s no better way to do that than spending some quality time on the front line,” she says. “Before we sweep in with any programs, there has to be time invested in getting to understand what it’s really like to provide care at your organization.”

Because the chief experience officer is a new position in many organizations, top leaders must be clear on exactly how the CXO can succeed. “If there are multiple layers of management above you, that’s going to be very limiting,” Boissy says. “And if you’re not set up with enough support to actually make things happen, you’ll be held accountable for change that you weren’t empowered to make.”

Her last tip is to know what good patient experience looks like and how the entire health system can deliver on it. “My dream state, in 10 years, is that every single caregiver is a chief experience officer,” she says. “And that there’s enough ownership and empowerment in every single caregiver that you don’t need somebody to occupy this role.”