Structuring Patient Experience: Revealing Opportunities for the Future

Improving the Patient Experience Structuring Patient Experience: Revealing Opportunities for the Future Jason A. Wolf, PhD, CPXP President The Beryl Institute

The Beryl Institute is the global community of practice dedicated to improving the patient experience through collaboration and shared knowledge. We define the patient experience as the sum of all interactions, shaped by an organization s culture, that influence patient perceptions across the continuum of care. 2017 The Beryl Institute

Structuring Patient Experience: Revealing Opportunities for the Future 3 Introduction & Purpose To understand how the work of patient experience is being done, The Beryl Institute renewed its inquiry into how people are structuring, supporting and focusing their patient experience efforts. This exploration looks at the nuts and bolts of experience operations and provides a grounded look into not only what is being done, but also provides the opportunity for organizations to compare their efforts to others and/or explore potential new actions. Our initial inquiry, conducted in 2012, was designed to be a look at the foundational actions being taken to address patient experience. In concluding that paper, the authors offered: While this paper does not suggest just one specific model by which to shape a patient experience function, it reinforces the idea that a dedicated role and centralized structure are key levers to patient experience success. It also reinforces the idea that patient experience is not a passing fad, but a significant strategic consideration for healthcare organizations. Moving patient experience from an initiative to an integrated activity is a critical first step in driving positive patient experience outcomes. undertaking. Most critically, this is data that provides a means not simply to report on what others are doing, but to build cases for investment, focus and intentional action. In this data, you will find many things that reflect the growth of this effort in the last half decade, but more so you will learn from the experiences of others and be provided with information to support action. As we support a continued dialogue on how people are focusing on, investing in and committing to experience efforts, we must remain diligent in ensuring this work is not taken for granted. Rather it is our hope that this information reinforces the centrality of experience itself, represented not only in how many address experience currently, but also in how it can be formalized in those places yet to finalize a path forward. It is our hope that this data and subsequent discussions help support, sustain and/or define a path for all committed to this noble cause. What we have seen and what this inquiry supports is that experience has not just taken root as a focus for organizational efforts, it indeed has evolved into a more integrated and increasingly strategic element of healthcare organizational operations. In fact, in these last five years, structures have evolved, commitments have extended and focus has sharpened. With that, there is much left to learn and many organizations still struggle in both making the case for action and/or determining where to start or how to sustain their efforts. Perhaps this is the greatest lesson not explicit in this data, but supported by so much of what it offers. Experience has become much more integrated into healthcare, yet it is still young enough in principle that it needs care and nurturing, it also requires strong advocates willing to make the case for its value and link its efforts to desired outcomes. This reinforces the very intent of this paper, to provide not just food for thought, but fodder for the building of models to enable bolder actions and reinforce the commitments some are currently

4 Findings Respondent Demographics In collecting the data for this inquiry, 230 organizations representing six countries provided responses to a 54-question online survey. Of all respondents, 90% came from the United States, representing all 50 states and the District of Columbia. While we think the structural issues developed from within the US have some unique components, a deeper view of the integrated aspects of structural considerations as well as the lessons learned are transferable to many other national systems. The inquiry was directed to the breadth of organizations across the healthcare spectrum, but respondents most often came from the hospital space with over 75% of those contributing coming from single or multi-hospital systems (Figure 1). Consistent as well with the noted demographics of our largest respondent group, the significant majority of organizations replying are Not for Profit or Academic settings at almost 90% of the responses (Figure 2). An additional inquiry in this study was the breadth of organization size engaging in this effort. Responding organizations seemed well distributed providing insights into how size impacts investment an opportunity to explore further beyond this paper. It also reinforced that a commitment to, or focus on experience efforts, is not isolated in certain size organizations (Figure 3). So while size may matter in how the work is structured or executed, it does not seem to be a direct determinant of importance. This is critical as it reinforces the notion that we have the potential to impact patient experience across the spectrum of healthcare organizations, regardless of their size or scope and therefore you cannot be two small, or too large for that matter, to ensure a focus on experience. Figure 1. Organization Type Single Hospital 35.0% Multi-hospital System 38.0% Integrated Delivery System 17.9% Physician Practice 2.1% Long-term Care Organization 0.4% Other (please specify) 6.4% Figure 2. Organization Statue For Profit 11.3% Not for Profit 73.1% Academic 15.5% Figure 3. Full Time Employees 1-250 2.9% 251-750 5.0% 751-1,500 10.9% 1,501-3,000 16.4% 3,001-5,000 17.2% 5,001-10,000 19.7% 10,001-25,000 18.1% 25,001-50,000 5.9% Over 50,000 3.8%

Structuring Patient Experience: Revealing Opportunities for the Future 5 Patient Experience Leadership In understanding the types of organizations engaged in this inquiry, we first looked to determine how efforts were being led. In our 2012 study, 64% of organizations said they had a dedicated patient experience leader. This was a slightly higher than reported in other research we conducted on the percent of organizations having a senior leader. We believe this to be the case as those tending to reply to this inquiry on structure would have some infrastructure in place. Even with that, we have seen the number increase to 80% of respondents in this inquiry (Figure 4). As the role and organizational approaches have also evolved in the intervening years since our last study, we asked if organizations had a single or multiple leaders committed to this role. In many cases, most often in Academic Medical Centers, partnering roles have been created with Experience Leaders linked to Medical or Clinical Directors of Experience. This support the findings of increasing senior level roles in experience overall. Figure 4. Do you have a dedicated Senior Patient Experience leader for your organization? 20.9% 16.7% 62.3% At the same time, some organization identifying themselves as not having a dedicated senior leader did note their efforts were guided by a patient experience manager or service leader not at a senior level. This tended to occur in smaller organizations. In 21% of organizations saying they did not yet have a dedicated senior leader, they identified Chief Nurse Executives such as CNOs, or VPs of Clinical or Patient Care and VPs of Quality (or similar roles) to be where the leadership accountability for experience rested. This often crossed organization size and was more reflective of the commitment people felt to having an individual solely in an experience role. Experience Leader Title Consistent with the question we asked in our previous investigation, we again wanted to know what the title was of those senior experience leaders. In both the cases of one or multiple leaders, we saw consistency in our findings. In 2012 while we found around one-third of responses having some form of the phrase patient experience in their title, now almost 70% of those responding identified their senior leaders as having patient experience in their title. Director of Patient Experience, in some form appears in around 44% of the replies, while Chief (Patient) Experience Officer appeared in almost 25% of the replies. In showing the elevated nature of experience leadership overall, the other approximately 30% of titles were mainly variations of Vice President, Administrative/System Director and Senior Director. This increase in organizational presence of the role is one clear example of the evolution of patient experience efforts overall. Yes, One Dedicated Leader Yes, Multiple Dedicated Leaders No

6 Experience Leader Background One item we didn t ask in our prior work, but has become of increasing interest in the commitment to this effort is where experience leaders are coming from. As The Beryl Institute has expanded its commitment to developing current and future experience leaders, it was interesting to see the backgrounds individuals bring to the role. What we discovered was both reinforcing but enlightening to where the role is evolving. While still a significant percentage of those responding said leaders were coming from healthcare, 37% were coming from a direct clinical background and 39% were coming up some administrative track. An interesting point is that more people are coming not just from non-traditional roles in healthcare such as marketing or social work, but now 15% of leaders are coming from outside healthcare itself with five percent of leaders identified coming with some background in hospitality. The most frequent backgrounds offered for those considered non-healthcare other were banking and consulting (Figure 5). Figure 5. Patient Experience Leader s background 2% 5% 10% 7% 39% Healthcare - Clinical 37% Healthcare - Administrative Healthcare - Other Non-Healthcare - Hospitality Non-Healthcare - Retail Non-Healthcare - Other Experience Leader Reporting In looking at the roles to which experience leaders are reporting, we discovered an increasing elevation of where the role sits organizationally. Of our respondents, 26% said their senior experience leader reports directly to the Chief Executive or similar role. Another 35% reports to the Senior Leader identified as the Executive Champion for experience. This reflects that 60% of our respondents have senior level access and/or presence in their respective organizations (Figure 6). In the almost 75% of instances where experience leaders reported to a role other than the CEO, we saw the responses most often connected to the Chief Operating Officer (COO) or Chief Nurse Executive (CNO or VP Nursing). The two roles far surpassed others and were almost evenly divided in their frequency. In addition, potential reporting relationships that also emerged were with the Chief Quality Office/VP Quality, the Chief Medical Officer (CMO) and the VP of Human Resources. Figure 6. At what level is this role positioned within your organization? C-Suite (Reporting to CEO) Senior Leader (Reporting to Executive Champion) Director Manager 34% 5% 34% 26%

Structuring Patient Experience: Revealing Opportunities for the Future 7 Patient Experience Department In looking to understand how patient experience has taken hold structurally in organizations, we also engaged respondents in the specifics on the positioning, size and scope of their experience departments. What we discovered in 2012 was that in almost 40% of organizations there was no formal home for patient experience, meaning no formal department existed. This has dropped to just over one in five organizations today across healthcare that do not have a formal structure to support experience efforts. Our inquiry also discovered a growing systemic commitment to patient experience by determining that organizations have begun to address experience both at system and local facility level. In now almost 30% of our responding organizations, there is an experience infrastructure at both levels (Figure 7). Department Title and Size In 2012, we also asked what the department titles were for organization s addressing patient experience efforts. At that time, we learned that about 36% of all organizations had a department with patient experience in the title, with 21% including service excellence and 13% including customer service as the top three. Currently we found that over 65% of departments across all settings were now using a variation of the title Office of Patient Experience or Patient Experience Department. In much smaller numbers, Service Excellence Departments remained with a few still titled Patient Relations. Figure 7. Where Experience Departments are Positioned 21.1% 23.2% 29.8% 25.9% Facility level patient experience department(s) only System level patient experience department only BOTH System and Facility level patient experience departments No formal patient experience department In looking at how departments were staffed, we looked across four specific segments as depicted in Figure 7. We asked about those with facility and system level departments only and for those with both, we asked about the size of both their system and facility level departments independently (Figure 8). We also looked at the overall number to identify general trends. In both facility level response groups the majority of departments had from one to three people in their department, with approximately 70% in both cases including five or less people. For system level departments, there was also a large number of responses for departments of five or less (around 60% for each), but in these cases, we also saw the other extreme with over 25% of the system level departments in both cases including ten or more people. Across all settings around 20% of all departments include 20 or more people. Figure 8. Patient Experience Department Size By Setting (% of respondents) # OF STAFF FACILITY LEVEL ONLY Department Size SYSTEM LEVEL ONLY Department Size DEPARTMENTS AT BOTH LEVELS Facility Level Department Size System Level Department Size OVERALL % 1-2 40% 21% 44% 21% 32% 3-5 28% 38% 30% 39% 33% 6-9 22% 14% 16% 12% 16% 10-14 4% 5% 4% 13% 7% 15-20 0% 4% 0% 2% 1% > 20 6% 18% 6% 13% 11%

8 Figure 9. Most Frequently Reported Titles Found in Patient Experience Departments Administrative Assistant Patient Experience Specialist Patient Experience Coordinator Volunteer Coordinator Director of Volunteer Services Director of Patient Experience Patient Advocate Chief Experience Officer Manager of Patient Experience Project Manager Staff Titles As we explored how departments are structured we also looked at the various titles now comprising experience departments. In looking across all segments a number of titles show up with great frequency. Not surprisingly the roles tend to include a variation of patient experience in their title. Beyond that cluster, the most frequent titles included variations on Patient Advocate, Direct of Patient Relations, Director of Volunteer Services, Administrative Assistant and Project Managers. The overall list included over 100 different titles. The most frequently reported can be found in Figure 9. Functional Areas Represented As part of this inquiry, we also explored what functional areas now comprise experience departments. We again looked across all four settings and in our analysis found great consistency in the top ten areas included in all departments (Figure 10). Across all settings, seven functional areas were most often cited in the top ten, including: Service Excellence Patient Advocacy/Relations Measurement/Analytics (Survey Management) Staff Training & Development Volunteer Services Interpreter/Language Services Guest Services In addition, two areas organizational development and concierge services also show up in the top ten of three of the four segments. While some of these areas such as service excellence, patient advocacy and measurement seemed to maintain the core of the work and even roots of patient experience today, the expansion to include additional support areas such as volunteer and concierge services show a broader commitment to the level of experience provided. Perhaps of greater interest is the inclusion of staff training and development and organizational development in these top items. This underlines the critical need for experience efforts to focus on not only the needs of patients and families, but also on those providing care as well as the organizational needs to ensure success. This reinforces the central role of culture in experience excellence and its placement at the heart of the definition of patient experience itself.

Structuring Patient Experience: Revealing Opportunities for the Future 9 Figure 10. Functional Areas Included in Patient Experience Departments (% of respondents selecting that area) FACILITY LEVEL ONLY SYSTEM LEVEL ONLY DEPARTMENTS AT BOTH LEVELS FUNCTIONAL AREA Functions Included Functions Included Facility Level - Functions Included System Level - Functions Included Arts in Medicine 10% 8% 11% 10% Call Center Services 6% 10% 6% 12% Community Relations 15% 10% 19% 19% Concierge Services 19% 20% 25% 19% Environmental Services 4% 6% 8% 8% Food Services 4% 6% 6% 8% Guest Services 29% 28% 33% 25% Health Education/Literacy 4% 14% 8% 8% Hospitality Housing 8% 6% 0% 6% Interpreter/Language Services 31% 22% 31% 27% Marketing 4% 10% 8% 6% Measurement/Analytics (Survey Management) 58% 64% 50% 62% Organizational Development 23% 24% 17% 33% Parking Services 2% 8% 6% 4% Patient Access 2% 8% 25% 21% Patient Advocacy/Relations 73% 64% 72% 58% Quality 10% 18% 25% 31% Risk Management 8% 14% 17% 10% Safety 8% 10% 22% 21% Service Excellence 75% 84% 86% 92% Spiritual Care 25% 20% 11% 10% Staff Training & Development 42% 50% 47% 46% Survivor Recovery Services 2% 4% 8% 2% Volunteer Services 33% 20% 36% 27% Key: Bold represents the top 10 in each setting

10 Use of Committees Outside the breadth of functional areas now comprising experience departments, we also asked how experience work was being addressed, and specifically the use of committee structures. Almost 90% of all respondents said they were using committees in some capacity. While we did not explore all the ways in which committees were being used, we did want to get a sense of their points of focus. To do this, we asked specifically for the types of committees organizations had established. The most frequent committee names again were not surprising with the most frequently reported including first Patient and Family Advisory Council(s), then many variations on a Patient Experience Steering Committee or Team. After that it was interesting to see communications, quality, rewards and recognition, service excellence and board committees showing up most frequently. For those organizations digging deeper beyond general steering teams, some organizations made mention of measurement specific teams, such as those to addressing specific CAHPS domains or other specific targets or measures. What is evident in this question is that while departments are in place, how patient experience is being addressed continues to expand, and while not always taken on by direct staff, it is engaging many people across organizations in support of and leading experience improvement efforts. No Formal Experience Department While to this point we have focused on the efforts occurring in the almost 80% of organizations that now have some type of patient experience department, the question remained how those that do not have a formal structure are working to address experience efforts. To these organizations we asked from where in the organization were experience efforts being driven and who was supporting patient experience efforts with no formal structure in place. We also asked these organizations to share the titles of the individuals supporting patient experience efforts. Not surprisingly, while there were still several variations of experience leader titles, most often Patient Experience Specialists, the most noted in these organizations mirrored to some extent the functions in which experience accountability rested. With that, the most frequently reported title was Chief Nursing Officer (CNO), but top titles also included CEO, COO and variation of Quality leaders. This reflects that in many cases when organizations do not have formal structures, the accountability tends to sit as a partial responsibility of a leader at the top of the organization. While positive in its placement organizationally, it still represents a diluted focus many say is an impediment to measurable and sustained success. One point of interest as we looked at these organizations with no formal structure was if they were reflective of one specific type or size of organization. To explore this, we examined the profiles of those responding no formal department to find that they encompassed all settings from physician practice to single hospital organizations and included multiple hospital systems and integrated delivery systems. While single hospitals most often reported having no formal structure (44%), multi-hospital systems appeared 27% of the time and integrated systems 13%. In corresponding fashion, the size of these organizations crossed a wide range as well. While 46% of all those with no formal department reported their organization size as between 3000-10000 people, the range of respondents ranged from just over 250 to over 25,000. This provides an interesting observation that a commitment to and investment in experience efforts is not as much about the size of the organization as the will and commitment of the leaders that guide them. In asking the question, If you do not have a formal patient experience department, what functional areas support patient experience efforts?, by far the most frequent response was Nursing/Nursing Administration reinforcing that nurse leaders and nurse leadership often have some accountability for experience. The next groups receiving multiple mentions were Quality or Quality Improvement,

Structuring Patient Experience: Revealing Opportunities for the Future 11 Engaging Patient and Family Advisors Figure 11. Do You Engage PFAs? In deepening our understanding on how experience efforts operate and building on one of the fastest growing points of focus in experience efforts reported in the 2015 State of Patient Experience Study, that of engaging patient and family voice, we took time in this exploration to look at organizational commitment to engaging patient and family advisors (PFAs), not just on formal councils, but in any capacity. 22.4% 34.6% 9.8% 34.1% We first asked respondents to provide a foundational perspective on the use of PFAs in their organizations. The responses, reflected in Figures 11-13, show a significant commitment to having PFAs involved with a wide range of numbers of individuals participating in each organization. An item of note, one reinforcing the findings in 2015, is that while the engagement of PFAs has been a point of conversation in healthcare for decades, two-thirds of all organizations now engaging PFAs have only been doing so for five years or less. Our respondents also underlined that this role remains a primarily volunteer role in healthcare with almost 90% of organizations responding that PFAs were unpaid in their capacity. For those responding their PFAs were paid, it most often seemed it was made available for a single individual, such as a Patient and Family Advisory Council Chairperson, who received a minimal stipend or honorarium for service. In addition, we looked to understand the capacity in which PFAs were engaged in supporting organizational efforts. Most often reported was in support of patient experience department activities (87% of respondents), followed closely by their involvement as members of organizational committees (72% of respondents). We less frequently saw their role identified as chairs or co-chairs of committees or actual members of an organization s board (24% and 23% of respondents respectively). These findings show that PFAs still play a more direct advisory role to experience efforts than the broader strategic efforts in healthcare organizations. This offers an opportunity as organizations look to expand the capacity or impact of PFAs in their midst. Yes - at the System level only Yes - at the Facility level only Yes - at both the System and Facility levels No Figure 12. Number of PFAs engaged across an organization 1-5 6-10 11-15 8.7% 22.8% 8.1% 8.7% 16-20 21-30 31-50 20.1% 13.4% 18.1% More than 50 Figure 13. Length the organization has been engaging PFAs 20.1% 14.9% 33.8% 31.2% 0-2 Years 3-5 Years 6-10 Year More than 10 Years

12 Patient and Family Advisory Councils (PFACs) In this effort, we also looked more specifically beyond the engagement of PFAs to the commitment to and investment in PFACs. There is a significant commitment to PFACs in this respondent group, but it should be noted as patient experience-focused organizations they may tend to this focus as part of their efforts. In asking the organizational levels of PFACs, the numbers that are in place, who leads them, their size and the investment commitment, we find a picture of a growing and sustained commitment to engaging PFACs, but one still with a sense of inconsistency in application and even in best ways to move forward. Organizations reports PFACs across organizational levels (Figure 14) with the largest concentration reported at the facility level. Of interest in this exploration is that just 7% of respondents offered they had no PFAC in any capacity. We were also curious about the number of PFACs in action. While on singular occasions, larger systems reported hundreds of councils in place, the responses revealed that almost twothirds of the organizations responding have four or less councils in place and of that 36% have only one council in operation. In exploring who has leadership accountability for PFACs (Figure 15), just over half of all organizations reported their PFAC was led by a staff member. This was followed closely by a shared leadership role between staff member and PFA, reported in 43% of organizations. It is evident organizations still tend to directly control the nature and efforts of PFACs overall, with just 13% being led by patients or family members directly. We also looked to gauge the size of PFACs and determine some general numbers about both total individuals involved as well as the balance between patient/family and staff members on the council (Figure 16). While staff involvement was most often no more than five people and almost all council structures reported staff involvement of no more than 10 individuals, as expected patient/family involvement reached slightly higher. Over two-thirds of all organizations reported councils including from six to fifteen patient/family members. Based on these numbers it seems typical councils run 15-20 people in size overall. Figure 14. At which level(s) does your organization have a formal Patient and Family Advisory Council (PFAC)? (Reported as % of respondents selecting that area) 26.1% System Level Facility Level Figure 15. Who leads/chairs your PFAC(s)? 42.9% 7.0% 73.2% 12.9% Staff Member Patient or Family Member 40.1% Department/Unit Level None 12.9% 52.1% Both (Co-Leads/Chairs) Other (please specify) Figure 16. On average, how many PATIENT/ FAMILY and STAFF members comprise each of your PFACs? Count Patient/Family Staff 1-5 21% 72% 6-10 45% 25% 11-15 22% 2% 16-20 8% 1% More than 20 5% 0%

Structuring Patient Experience: Revealing Opportunities for the Future 13 Lastly we looked to get a sense of the financial commitment organizations were making towards PFAC efforts. While many respondents offered that budget dollars for PFAC activity were part of a larger experience budget overall and therefore hard to directly quantify, 44% of all organizations said they have a committed budget for PFAC activities while 56% do not (Figure 17). In looking at the actual budget amounts provided, excluding for some outliers at the top end of the budget due to size of system, most budgets were under $10,000 with an average of $7,000 per year. Figure 17. Do you have a committed budget for PFAC Activities? 44% 56% What we learned about PFAs and PFACs is that while there is a growing understanding of the value of these resources in organizations and therefore an increase in implementation of these efforts, organizations are still looking to determine how to best use PFAs and PFACs overall. Opportunities to understand processes for effective leadership, thoughtful staffing and appropriate investment all remain. This reinforces the need for continued learning and sharing in this area. It also reveals an opportunity for extended research into investment, structure, value and outcomes. Yes No

14 Operationalizing Patient Experience - Measurement and Investment In looking beyond how organizations structured their efforts, we wanted to get a sense of how they then operationalized their efforts. Key to this was how they measure performance and the commitments they are making in budget and longer-term investment. These ideas reinforce that experience is not just about having the structures, but the intention to do something with it once in place. Measuring Patient Experience Performance In asking about the methods by which organizations measure performance it was not surprising to see government mandated and non-mandated experience and satisfaction surveys at the top of the list. Of greater interest was the evolving cluster of data collection methods catching up to those typical top choices. Led by the use of PFACs, this second group of measures included more immediate and real-time feedback methods such as beside surveys and the monitoring of social media. It also included follow-up/discharge phone calls (Figure 18). Of interest in the other category was the use of complaint information as a source of data and the inclusion of some new and innovative feedback mechanisms such as e-panels and text message driven surveys. It remains clear that experience efforts must be committed to understanding their performance and aware of the growing, rich and broad means through which this information can now be collected. Investment in Patient Experience Efforts We also looked to gauge what types of investments organizations were making financially to support their commitment to experience efforts. In asking the question of budget associated with experience departments we received an extensive range, clearly driven by both size and commitment, from zero to $3-million dollars. It was difficult to analyze the overall dollar amounts people considered as investment as some identified staff/people investment as separate from their operating budgets while some included this information in their numbers. What we found in analyzing responses is that about 25% of all respondents reported having a budget of $1-million or more, while over 67% had budgets of $300,000 or less. Of those in the lower numbers, 10% reported having no budgets with almost 20% reporting they were unsure. Figure 18. What methods do you use to measure patient experience performance? (Reported as % of respondents selecting that choice) Government Mandated Surveys 86.5% Patient Satisfaction Surveys (beyond govt. required) Patient/Family Advisory Councils or Committees Bedside Surveys/Feedback during Rounding 86.5% 80.1% 75.9% Monitoring Social Media 73.8% Calls to Patients Post-Discharge 72.3% Patient/Family Focus Groups or Interviews Outside Ratings/Rankings (US News & World Report, Healthgrades, etc.) 58.2% 57.4% Others (please specify) 19.1% An opportunity here is to further explore the structure of investment in patient experience. It seems the two greatest costs alluded to in comments were first survey vendor expenses and then direct team expense. This seemed to leave little room in budgets for new or innovative resources or tools to support experience efforts. This provides a line of sight to new opportunities in a focus on experience excellence, reflected in the next question we explored with respondents.

Structuring Patient Experience: Revealing Opportunities for the Future 15 Figure 19. What outsourced tools/resources do you invest in to support your patient experience efforts? (Reported as % of respondents selecting that choice) Survey/Feedback Tools 85.9% Interpreter Services 56.2% Parking/Valet 40.5% Training 35.7% Patient Education 33.5% Consulting 29.2% Data Analytics 29.2% Food Service 25.9% Interactive Technology 25.4% Environmental Service 25.4% Outsourced Resources Used in Patient Experience Efforts To take the inquiry from abstract budget dollars to specific direction of investment we asked organizations what outsourced tools and resources they invest in to support patient experience efforts. Not surprisingly, survey and feedback tools topped the list. The next level of investment included direct personal services for patients and family members to support their experience including interpreter services and parking. The next set of investments found in at least one-third of respondents were focused on education and development with training and patient education (Figure 19). These grouping are interesting as they reflect both the reality of many in our sample group needing to address specifics of measurement and tracking data, it also showed an awareness of the general services desired and the learning needed to ensure the best in experience outcomes. In looking at this data and where people see their focus and direction headed, we then turned our focus to the final reflections we asked of our respondents, the strengths, challenges, and potential changes they would consider in looking at how they currently structure their efforts. Laundry/Bedding/Linen 22.7% Telemedicine 18.4% Call Center 13.0% Mystery Shopping 12.4% Talent Assessment 11.9%

16 Reflections on Practice - Lessons Learned In reflecting on organizational efforts overall, it is important to understand what organizations believe works, impedes and what they would change about their efforts. What was interesting in this analysis and perhaps not surprising is that those items perceived as strengths to some were also identified as similar challenges for others. Most consistent responses to the question What do you see as the strengths of your current patient experience structure? were: Senior level/executive/c-suite buy-in and visible support Staff commitment and accountability across the organization Alignment to other functions, namely quality and safety Having and maintaining a patient experience department and/or team Focus on measuring, achieving and reporting on results Most consistent responses to the question What do you see as the challenges of your current patient experience structure? were: Uncertain or non-existent senior leadership support Minimal resources to support effort No formalized structure or commitment to functional leadership Limited buy in from various groups within the organization such as physicians, leadership, staff, etc. Competing priorities that dilute or minimize focus Strengthening connections to communication efforts for both external messaging and internal engagement These findings are interesting not only due to the overlap of ideas discovered that seem to have the greatest influence on the success of patient experience department efforts, but also due to the simplicity of what these reported actions represent. These are not difficult suggestions to consider but rather it seems these constraints come from the very essence of the findings themselves; they are fed by diluted strategic focus, lack of leadership will or commitment to formally address, scarcity of resources and a wavering organizational buyin across levels. These are constraints reflective organizational strategy and commitment above all else. They are reflective of what these healthcare organizations deem priority and how clear they are on the outcomes they might achieve through this focus. These findings help us to identify the opportunity that still exists, and in an optimistic sense shows the gap to greater outcomes and commitment is not too wide if the case can be made and sustained as to why a focus on experience is critical. Elevating the conversation on criticality, value and impact of a focus on patient experience may be the biggest opportunity for all regardless of the stage in which they find themselves. In asking organizations what they would do if they could change something about their patient experience structure, the most consistent responses included: Having additional staff and/or resources for the patient experience department Realigning reporting structure/positioning to more senior levels in the organization Creating greater alignment to other efforts in the organization Integrating all the functions that can and do impact patient experience

Structuring Patient Experience: Revealing Opportunities for the Future 17 Recommendations for Action Consistent with what we asked of our respondents in identifying their reflections on practice, we also were curious about the top strategies and/ or tactics they would recommend to organizations structuring patient experience efforts. From the range and breadth of responses, consistent themes clearly emerged. What was also apparent in the recommendations was that while offered in the context of structuring patient experience efforts, the responses reflected the strategic perspective patient experience must take on overall in not only gaining traction, but leading to positive outcomes. organizational outcomes Implement appropriate technology solutions that both meet your organizational needs and are realistic understanding your organizations capacity to embrace and use effectively These recommendations are clear, simple and understandable, but will still require commitment, focus and intention in ensuring they ultimately become priorities that can drive results. At The Beryl Institute, we have long said and still maintain that the essence of patient experience is not held in some hard to find secret that organizations must aggressively search for and/or pay excessively to access. Rather there are fundamental principles and practices that when applied with rigor and persistence can ensure great outcomes overall. This idea is represented in the summary of recommendations for action provided by our respondents and reflected in the following eleven points that summarize their ideas on how best to structure patient experience efforts: Have a Senior Patient Experience Leader (CXO, VP, etc.) Have a clear and shared definition of patient experience/shared purpose for experience Ensure C-Suite Leadership engagement/ executive buy-in Develop, share and engage others in the patient experience strategic plan Strive for alignment across functions and through the organizational hierarchy Establish consistent and broad communication efforts Engage all stakeholders from patients and families to physicians Create means to inform and engage front line as critical to patient experience efforts Connect efforts to and reinforce importance of employee engagement Implement a means to collect and disseminate proven practice Identify and implement practical and measurable tactics such as rounding, bedside shift report, etc. and tie to experience and broader clinical/

18 Structuring Patient Experience - An Opportunity Revealed As we look at what was learned in this inquiry, it reinforces the conclusion shared at the end of our report in 2012, namely that the exploration does not suggest just one specific model by which to shape a patient experience function. While we can say that the very structure that frames a patient experience function may not be as consistent as the operational structures of other organizational functions such as human resources or finance for example, what we are seeing emerge as consistent are the strategic components and considerations of what comprise an effective and successful patient experience effort. industry uncertainty. For we cannot and must not waiver from our commitment to those we serve and one another. Therein lies the opportunity to structure patient experience for the future. The seeds of which I believe we have found here. Warmest thanks to our respondents for your generosity, honesty, contributions and commitment. You are the face of patient experience and your lessons will serve as a catalyst for us all. The consistency revealed here as well as in complementary explorations serves to reinforce there are clear and distinct strategic decisions and actions organizations who are committed to patient experience can and should consider. These guiding ideas and proven efforts comprise what is continuing to establish patient experience as a functional commitment for organizations around the world. At the same time, it is underlining the breadth of what experience can and should ultimately encompass. I offer that if we believe experience is the integration of quality safety and service, and it is delivered across the continuum of care through the interactions of people supported by the culture of our organizations, then experience itself sits at an intersection of opportunity. If the success of experience depends on people and engagement, culture and communication, process and protocol and the ability for individuals to make the best choices in addressing quality, safety and service then we will and should see the broadening of experience efforts to not just collaborate with, but encompass the functions that drive engagement and communication, outcomes and ultimately experience. With that, as respondents here showed and as reflected in efforts around the world that there is a commitment to hold firm on ensuring the best in experience, we will see a broadening of experience structures to ensure they can support all the levers and mechanisms it takes to drive the best outcomes overall. This is perhaps in looking forward an invitation to consider, a challenge to take on and an opportunity to embrace. The findings reflected in this study show us that experience efforts remain critical to healthcare today, even in the face of market and

Structuring Patient Experience: Revealing Opportunities for the Future 19 About the Author Jason A. Wolf, PhD, CPXP President Founding Editor, Patient Experience Journal Jason is a passionate champion and recognized expert on patient experience improvement, organization culture and change, and sustaining high performance in healthcare. As President of The Beryl Institute, Jason has led the growth of the organization into the leading global community of practice and thought leader on improving the patient experience, engaging over 50,000 members and guests in more than 55 countries and establishing the framework for the emerging profession of patient experience. Jason is the Founding Editor of the Patient Experience Journal, the first open-access, peerreviewed journal committed to He also established and currently serves as President of Patient Experience Institute, an independent, nonprofit, committed to the improvement of patient experience through evidence-based research, continuing education and professional certification. research and practice in patient experience improvement. Jason is a sought after speaker, provocative commentator, and respected author of numerous publications and academic articles on culture, organization change and performance in healthcare, including two books on Organization Development in Healthcare and over 25 white papers on patient experience improvement.

20 Also from The Beryl Institute 2016 Guiding Principles for Patient Experience Excellence The Role of Family Caregivers throughout the Patient Experience Reflections from PX Professionals Impacted by Personal Healthcare Experiences The Role of the Volunteer in Improving Patient Experience The Role of Technology in Patient Experience: Insights and Trends 2015 The Critical Role of Spirituality in Patient Experience Leadership and Sustaining Patient Experience Performance State of Patient Experience 2015: A Global Perspective on the Patient Experience Movement A Dialogue on Improving Patient Experience throughout the Continuum of Care Patient Advocate: A Critical Role in Patient Experience The Power of Person- Centeredness in Long-Term Care: A View Across the Continuum 2014 Defining Patient Experience: A Critical Decision for Healthcare Organizations An Invisible Barrier to Compassionate Care: The Implications of Physician Burnout The Power of Selection and the Use of Talent in Driving Exceptional PX The Association between Patient Experience and Hospital Financial Performance The Chief Experience Officer An Emerging & Critical Role 2013 Voices of Measurement in Improving Patient Experience Voices of Physician Practices and Medical Groups: Exploring the State of Patient Experience Enhancing the Patient Experience through Live Entertainment Voices of Patients and Families: Partners in Improving Patient Experience Voices of Practice: Exploring the Patient Experience in Action - Highlights from On the Road with The Beryl Institute Voices of the Future: Student Perspectives on the Patient Experience Voices from the C-Suite: Perspectives on Patient Experience 2012 The Role of Organization Culture in a Positive Patient Experience: A Leadership Imperative Patient Perspectives on Outstanding Experiences: The Impact of Emotionally Intelligent Staff The Role and Perception of Privacy and its Influence on the Patient Experience Structuring the Patient Experience Effort: An Inquiry of Effective Practice Charting a Course to Quiet: Addressing the Challenge of Noise in Hospitals Physician Perspectives on Patient Experience Benchmarking the Patient Experience: Five Priorities for Improvement 2011 Return on Service: The Financial Impact of Patient Experience Creating PEAK Patient Experiences The Role of Cultural Competence in Delivering Positive Patient Experiences The State of the Patient Experience in American Hospitals The Revenue Cycle: An Essential Component in Improving Patient Experience Enhancing the Patient Experience Through the Use of Interactive Technology 2010 Four Cornerstones of an Exceptional Patient Experience Insights into the Patient Experience Research Brief Zeroing in on the Patient Experience: Views and Voices from the Frontlines Perspectives on a Patient- Centered Environment

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