Case Study Memorial Hermann Hospital System Healthcare How one hospital system changed its entire culture from the ground up in order to become an award-winning, market-leading example of patient experience and satisfaction excellence. Introduction With over 100 hospitals and medical centers and 19,500 hospital beds, Houston has one of the best and largest medical communities in the world. The Texas Medical Center comprises 49 member institutions, receives 160,000 daily visitors, more than six million annual patient visits, and is home to many of the nation s best hospitals, physicians, researchers, educational institutions and healthcare providers. It is also recognized in all 19 categories of adult care and 10 pediatric care specialties as offering quality patient care and excellence in teaching and research (source: U.S. News and World Report s Annual Survey of America s Best Hospitals). Houston is undoubtedly a highly competitive environment for any healthcare business, which is why hospitals in this region are constantly pushing to advance the experience they offer and keep at the cutting edge of healthcare provision. The Challenge Memorial Hermann Hospital System (MHHS) is the largest not-for-profit healthcare system in Texas and serves the greater Houston community through 11 hospitals, a vast network of affiliated physicians, and numerous specialty programs and services. With nine cancer centers, MHHS offers a full menu of therapies and treatment options for cancer patients. In 2007, MHHS faced the same challenges all hospital systems face today: working in an extremely tough competitive landscape. Particular problems included: Low market share: 17% with no signs of growth At that time M.D. Andersen was the leading hospital in the field of cancer treatment, with more than 70,000 active patients, 25,000 of them new. The facility is, however, not just a hospital; it includes 322 first-class rooms and offers a four-star hotel managed by Marriott. It also has a tram service between its various facilities. In short, M.D Anderson was recognized as THE expert in cancer services. Undifferentiated positioning in the market Although MHHS had equal expertise and equipment as the competition, it was not recognized as an expert in any particular practice area. To make matters slightly more difficult, MHHS had high patient volume and its staff was busy. The problem became the venue of the patient volume. Diagnostic services are not nearly as profitable as treatment services, but diagnostics were where MHHS saw its greatest volume. Patients were going to MHHS for diagnosis and going to another provider for treatment. Surprisingly, research indicated that many MHHS employees were not even aware that the hospital offered cancer treatment. This made the situation more frustrating as the diagnostic staff often had patients in-house that were failing to take the next
logical step: treatment. Educating the public and raising awareness of MHHS s cancer services became an urgent matter. Employee morale and culture The prevailing belief among employees was that MHHS was as good as it could get. Such insurmountable defeat left little enthusiasm and no faith that the situation could be changed. Work had been done around understanding and improving the pillars of excellent service, but efforts fell flat when it came time to translate those values into action. The need for internalization of delivering excellent service was imminent. As a result, MHHS aimed to achieve the following goals: Differentiate its cancer service and treatment of breast, prostate, lung, and colon cancer. Assure MHHS s position as the clear number two for cancer (or even number one for the treatment of routine breast, prostate, lung and colon cancer) in the region. Beyond Philosophy was thrilled to undertake the challenge of improving the patient experience and providing MHHS with a new perspective. The Solution Beyond Philosophy worked closely with MHHS s CRM team to learn about the fit-for-purpose readiness of ongoing initiatives, after which we developed a tailor-made program to address the following specific points: 1. Understand the end-to-end patient experience from the patient s (customer) point of view. 2. Reshape the experience from the patient perspective, with a specific focus on emotional engagement. 3. Achieve employee buy-in through education on what being patient-centered means and how it translates into practice. Over the course of four months Beyond Philosophy helped achieve the stated goals employing various tools: Patient Mirrors, Moment Mapping, patient focus groups, pyramids and Emotional Signature. Many of the tools we applied served all identified purposes with a specific strength in one area or another. The end result was a completely revamped MHHS inpatient and outpatient Cancer, Heart & Lung and Emergency Room experience. Implementation Aim #1: Tools: Understand the end-to-end patient experience from the patient s point of view. Patient Mirror, Emotional Signature, patient focus groups, Moment Mapping Putting our expert goggles on, we walked the experience of patients and scrutinized every emotional and physical step of the patient s journey. We identified, for instance, the very subtle clues that impact perception, sometimes without registering in the patient s mind.
We also engaged the relevant departments in thinking through the patient experience and developing ideas about how to redesign it. Our findings were also validated with patients through in-depth interviews. One of the first and most striking findings came out of a cross-departmental learning and creativity exercise, when MHHS staff discovered that hospital staff and patients have a very different perception of the experience, in general. Hospital staff was driven by internal knowledge of processes, systems and operations. They assumed that for patients there are 14 key steps in the experience, of which being diagnosed is the most stressful, negative point. The in-depth evaluation of the experience revealed otherwise. Patients have a more fluid perception of the experience grouped around four major steps, not 14, of which being diagnosed was key not because it was stressful, but because it was a positive experience. With diagnosis comes relief from uncertainty. Patient Mirrors Insightful Findings While clinical outcomes appeared to be very important for patient satisfaction (as expected), the handling and management of care was what actually determined the lasting memory of the experience and the overall judgement of the quality of the service. We learned that even when the clinical outcome was unfavorable for patients, the families tended to consider the experience as positive, provided that the care management felt genuine, especially in the last days of the treatment. Likewise, a positive clinical outcome would leave patients dissatisfied if overall care management was perceived as poor. Emotional Signature Insightful Findings Care management did not mean going through the basic professional motions. Subject knowledge, level of expertise, etc., were considered a prerequisite, but not what delivered a delight. What made the difference were the subtle clues the staff and the environment gave out to create the sense of exceptional service. Things like: tone of voice, cleanliness of floors, eye contact, etc. Through the Emotional Signature we identified these subtle clues and educated the hospital staff on how to manage them. These outcomes are illustrated in the following Perception Matrix:
By focusing on the patients emotional experiences, we learned that according to patients, emotional well-being is responsible for almost a third of their long term clinical outcome, and that 33.9% of the hospital s service and effort should revolve around managing emotional well-being. This is now clear to any modern healthcare facility, but in 2007 it was a new, ground-breaking concept. The following image illustrates the relative importance of the four key factors that drive patients emotional well-being: The findings not only created various options in which the patient experience can be redesigned, but it revolutionized how hospital staff perceived patients and helped them to better understand their roles in the experience.
Aim #2: Tools: Reshape the experience from a patient perspective, with a specific focus on emotional engagement Moment Mapping, Pyramids It was crucial to demonstrate to staff how they could actually deliver the experience and achieve a positive, lasting memory. Concrete initiatives were aligned to the brand in order to deliver a consistent experience across the board. In order to improve communication and convey a sense of care, the Patient Journal was introduced. Keeping a treatment journal is a therapeutic process for many cancer patients. Patients were given a journal within which they documented their cancer journeys. The journal could be used to track medical and treatment details, appointments, resources and all other personal health information. Studies have shown the healing benefits of writing, which promotes understanding and acceptance of the event while lessening negative emotions associated with it. A MHHS Patient Journal In addition, to counter the sense of loneliness and powerlessness, patients were given inspirational survivor stories to comfort them through diagnosis and treatment. Indeed, each patient and survivor was given the opportunity to share their stories with patients going through similar challenges. Finally, to honor the strength and courage of patients, a celebration ritual was introduced at the end of each treatment. Patients would be presented with a certificate that they could choose either to shred to pieces on the spot, symbolically putting the experience behind them; or keep it as a reminder of the life-changing stage they had just gone through. Aim #3: Tools: Achieve employee buy-in through education on what being patient-centered means and how it translates into practice. Moment Mapping, Pyramids The program was designed such that it involved staff from beginning to end. More than 1,000 staff members participated.
During the Moment Mapping part of the program, employees were asked to give their input on a brown paper wall posted in a highly-trafficked and visible area: this exposed as many staff members as possible to the patient-centeredness concept. Staff members were asked to use their breaks to gather around, add their comments and ideas, and discuss the items posted on the wall. A trained patient experience staff member and a Beyond Philosophy consultant would join many of these informal discussions using the opportunity to educate staff on the patient experience. The relaxed, informal nature of the knowledge and idea exchange allowed staff to be more receptive and openly curious about the concept. The MHHS Brown Paper Workshop In addition to raising awareness and initiating the discussion about patient-centered care, staff members were empowered to personally determine the way patient-centered care would be implemented. Every stakeholder had the opportunity to provide suggestions, comment on other people s suggestions and ultimately determine what the ideal patient experience would look like in practice. Being part of the solution allowed for a successful follow-up once implementation was in place. The Pyramid in action
Buy-in from doctors and nurses became easy because results very quickly were reflected in patient behavior. Many patients that would return with a relapse of their disease were labeled non-compliant. Staff quickly realized that treating the disease ensured the patients would leave the hospital, but satisfaction and emotional engagement would make sure they were compliant after they left the hospital. The Results After implementing the first phase of steps in the MHHS patient experience program, the following outcomes were achieved: Market share jumped from 17% to 23% within two years. Projected losses through 2010, when the hospital was expected to break even, turned into profits in 2009. MHHS fully redesigned its inpatient and outpatient Cancer, Heart & Lung and Emergency Room experiences. Patient satisfaction scores within the MHHS initially varied from 18% to 81%. By the end of the program, patient satisfaction scores increased by 20% on average, allowing for high-performing hospitals to rank it in the 92nd percentile. Through the dedication of MHHS patient experience champions, MHHS achieved a landmark cultural shift. Hospital staff could now see what they were doing through a patient s point of view. Regardless of their position and role, from cleaning staff to nurses, doctors and security, being patient focused meant becoming the carers and healers patients relied on when going through the most vulnerable periods of their lives. Operations were revised and managed to reduce a particular procedure from 40 to five days, becoming more effective AND efficient a change that incurred zero costs, just an alteration in the way scheduling was made. In the beginning, the proposed initiatives that came out of the program served as a training mechanism and reminder for staff of what being patient-centered meant. Equipped with knowledge and tools, MHHS today does not rely on formal projects to deliver an exceptional patient experience. On the contrary, patient-centeredness is expressed in various shapes and forms and runs in the pulse of MHHS staff. This change did not stop in 2007 and within MHHS s cancer services. Rhonda Dishongh, director of customer experience design for Memorial Hermann, played a key role in executing the program and continues to drive the culture of patient-centricity. In fact, it has spread throughout the entire hospital system and continued to evolve, enabling MHHS to be a renowned, successful and award-winning healthcare provider. Among those awards: National Quality Forum National Quality Healthcare Award, 2009 Healthgrades Distinguished Hospital Award for Clinical Excellence, 2009 Gold Circle Award for Quality, 2010 Press Ganey Top Improver Award, 2010 Press Ganey Success Story Award, 2011 Gold Circle Award for Operations, 2011 President s Cup for Best Performance Overall, 2011 NAATP Quality Improvement Award, 2011