Book Review: Prescription for Excellence

You may have noticed that health care has been in the news a lot recently. Whether it is the Democratic Party presidential candidates talking about their plans, price transparency, or access to prescription drugs, it is fairly safe to say that the current system is not working for a group of people in our country.

There is so much to fix, including the experience of receiving care. Many patients experience customer service outside of health care and they expect that same level of care, treatment, ease, and convenience.

RxforExcellenceSeveral years ago, the University of California, Los Angeles (UCLA) health system decided to work on fixing the experience of care. Their results were astounding, going from the 30th percentile of U.S. hospitals to the 99th percentile. Dr. David Feinberg, the then CEO of the UCLA hospital system (he has since run the Geisinger Health System and now is the VP of Google Health), was committed to doing better as the UCLA system grew in Southern California.

Using the lessons from other retail leaders who are known for their customer experience, UCLA did some progressive things to enhance and enrich the hospital’s patient experience. The progress is summarized in Joseph Michelli’s book Prescription for Excellence: Leadership Lessons for Creating a World-Class Customer Experience From UCLA Health System.

I appreciate that Dr. Michelli, who has written on companies like Starbucks and the Ritz Carlton, used part of his introduction to the book to acknowledge why it was important for him to write about a health care organization. The demands are high, regulations abound, safety is paramount, and politics are rampant. Delivering excellence in that environment is a unique feat and one that keeps those of us who are part of the business aspect of health care both fired up and very busy.

What I enjoyed about Prescription for Excellence was learning about the leaders from the organization who invested in the patient experience system, called “CICARE” (pronounced See-I-Care). Leaders modeled the behaviors that they asked the staff to model as well, and they were constantly present, speaking to patients to learn more about their care.

What UCLA figured out is that, just like in another industry, the three main elements of hard-wiring a consistently excellent and customized patient experience are: alignment, empowerment, and engagement. CICARE was their system of alignment, they empowered the team to act on it by training them, and engaged them in the work, partly by emphasizing the importance of it.

The following quote in the book sums this idea up nicely, “Relationships-based caste is often about empowerment. Empowerment starts with leaders giving staff members the tools and the trust they need to provide extraordinary service. Those tools include structure service behaviors…When well-selected employees are given resources, trained, and empowered effectively, extraordinary service relationships developing, and customers are empowered to build skills that meet their needs.” (Michelli 64).

Developing systems and allowing people to innovate within those systems are keys to delivering service excellence whether in health care or any other industry.

KEY TAKEAWAY: Excellent service systems are created from aligned, empowered, and engaged team members.


Prescription for Excellence is available for purchase on Amazon for $30 (does not include Prime discount)

Empathy in action

Several months ago, I ran across this emotional video about the power of empathy and leadership in health care:

I often share this video and Jap’s story for several reasons. His positive attitude, coupled with his thoughts of wanting to do more with his life are inspiring. While his injury took away the use of his legs, it gave him a fresh perspective and new motivation in his life.

From a health care delivery standpoint, Jap’s story teaches us that we must do more for our caregivers and that anyone in the hospital can lead to make a patient’s experience better.

As you watched the video, did you notice what happened when Jap woke up from his accident? The first thing he did was scream out. But, nobody came to his aid. He was on the “diving accident floor” in the hospital, and according to the nurses, everyone on that floor screams after they regain consciousness. To the nurses, every scream was, “just another day at the office.” To Jap though, it was one of the scariest and worst moments of his life, and he was alone.

In my current role, one of my main responsibilities is to work on this very issue. Clinicians can become used to or numb to other people’s suffering. It is not because our bedside caregivers are bad people or doing something wrong, it is simply because of the nature of the work. Part of the role of patient experience is to create systems to remind caregivers that, for the patient, this is not just, “another day at the office.” Part of this work is done by creating mechanisms to constantly remind caregivers that our patients do not come to work in a hospital and the days they are here are unique to them. We must help caregivers connect to the fundamental emotions of most patients: That they are scared, stressed and confused.

The other lesson Jap teaches us is that anyone can lead. Carlos, Jap’s nurse in the ICU, not only goes to him when he screams, but instructs the other nurses how to comfort Jap. Carlos was behaving in a way that creates positive, peer-to-peer accountability. Carlos authorized himself to help the entire team care for Jap in his hour of need. Carlos took it upon himself to provide the reminder that this was a unique day in Jap’s life and he will need help to get through it. Carlos embodied how, in hospitals especially, patients expect more than just us treating a disease or an injury; they expect to be treated like people.

This powerful video shares these lessons elegantly and they apply to any work that we do interfacing with other people.

Thank you for sharing your story, Jap.

KEY TAKEAWAY: Patient experience is about reminding people to see care through the eyes of the patient and to treat their emotions, not just their physical condition. Anyone can lead in patient experience, it is up to leaders to create mechanisms for peer-to-peer coaching and accountability. 

Customer Service or Customer Experience?

One of the recurring topics of this blog relates to, “How we treat each other.” I am passionate about improving the patient experience at hospitals because I believe it has powerful implications for how we treat each other. If clinicians can demonstrate compassion, courtesy, and kindness during a difficult moment in a patients’ life, imagine how that level of care could impact how that patient will treat others in the future. Like other social epidemics, I believe that kindness can catch on as well.

A colleague of mine at Adventist HealthCare shared this 17 minute video with me. In the video, Fred Lee, the author of If Disney Ran Your Hospital, gives a TED talk about the difference between customer service and customer experience.

Lee defines a service as, “Labor done for me that I would otherwise do for myself”. He goes on to share and explain how an experience is far more emotional, difficult to measure, and impossible to fully control through mechanisms like scripting. Defining the journey of a patient as an experience allows us to embrace the fact that it doesn’t mean our patients have to be happy all the time when they are under the care of a hospital.

Lee uses a helpful analogy in the talk to explain this idea. When we go to the theater, sometimes we go to see plays and musicals that make us happy, while other times we see dramas or tragedies that touch our emotions in a different way. Both instances are experiences that speak to the human condition, not necessarily only positive emotions.  Lee describes this as, “We in the hospital business have the job of meeting the emotional needs of a family going through fear, pain and even tragedy together.”

Further, he says that “A hospital without compassion is like a trip to Disney without fun.”

When hospitals and other companies deliver an experience, it resonates with the consumer emotionally. In a hospital setting, emotion is already present. How clinicians understand the emotions of the patient and anticipate the patient’s needs shows how much they care and that they are attentive to the situation.

Lee tells a story of a caregiver who comes to take blood from a patient. In the first scenario, the caregiver follows a script. In the second, the care giver provides an experience. He quotes a Gallup organization study that found that just using the word “gentle” reduced a patient’s pain when receiving an injection. Small touches can radically change a patient’s care experience but it has to be individualized – not every interaction will be the same or have the same effect for every patient.

Lee posts this quote during his talk: “Experiences occur with any individual who has been engaged in a personal and memorable way…on an emotional, physical, intellectual, or even spiritual level. The result? No two people can have the same experience – period.” B. Joseph Pine III, The Experience Economy

Since experience is so individualized, it involves developing active listening skills, focus, compassion and empathy. Conveniently, these are the same skills that we can all demonstrate on a daily basis to each other to make the world a better place, not just in the work setting. While health care is a powerful setting to deliver an incredible experience, we can all be human experience ambassadors with our friends, family, colleagues, neighbors, and even strangers.

The first step is to want to make a difference in this way. Will you join me in being a human experience ambassador?

Can empathy be taught?

On May 29th, I spoke to the leaders at Adventist HealthCare at our semiannual Mission in Motion conference where patient experience was the theme of the day. As part of the plenary session I explained to our leaders why I am so passionate about the work of improving patient experience.

One of the reasons, I explained, was that last year, we touched nearly 80% of our community within 1-degree of separation. By one degree of separation, I am assuming that each employee and each patient has at least, on average, one other member of their household. For example, if we treated a mother, her experience in our care would have influence on her whole family. Imagine if we demonstrated kindness and compassion in a way that exceeded the patient’s expectations. If our team and our patients take those behaviors home, imagine the multiplier effect it could have of people leading by an example of deep kindness.the war for kindness

If you attended the Mission in Motion conference, you would promptly leave the plenary for a mandatory breakout session on selecting the right employees for the job. The session educated attendees on certain behaviors, like empathy, which lead to kindness and compassion that can’t be taught. If leaders do not follow a good process for hiring, it may hurt the whole group. This conventional wisdom is present in the literature around excellent service organizations, like the Ritz-Carlton, that deploy a rigorous hiring process to prevent “bad apples” from entering the bunch.

Enter Stanford University psychologist Jamil Zaki, who presents a compelling challenge to the notion that empathy is not a learned trait. In his recently published book, The War for Kindness: Building Empathy in a Fractured World, Zaki describes how his work and research can help people become more empathetic.

Zaki describes his childhood living in parallel worlds after his parents divorced. He described this experience as an “empathy gym,” noticing how two people could have completely different and yet totally valid views of life. He has created a similar type of course at Stanford, sending students to various exercises and experiential learning environments to build their empathy muscles. While the work is rigorous and difficult, he has shown results.

Further, Zaki shows his work in a way that builds trust in the research. At the end of the book, he takes the reader through each study mentioned, chapter by chapter, and rates the quality of the research on a 5-point scale. While some of the research is yet to be validated, it is certainly interesting, controversial at times, and quite progressive.

The initial set up of the book is quite dense, describing several research studies, as well as a general orientation to historical notions on empathy. It was worth the dense crash course to get to the stories and real world examples of building empathy. Zaki takes us through experiments in using literature to stop recidivism, truly understanding “compassion fatigue” in hospitals, and positive and negative impacts of technology on empathy.

The War for Kindness has many implications. It is a helpful roadmap for how we can be more kind, compassionate, and empathetic as a society. It has challenged my thinking on hiring in health care. While I still strongly believe that systems and processes help protect the team and enhance service, I now believe that a motivated candidate can be taught how to empathize. I also believe that we must coach motivated caregivers to have empathy in a way that does not cause burnout or eventually result in emotional numbness towards patients.

I have already bought copies of this book to give away to friends and colleagues, because it is powerful, hopeful, and challenges assumptions about how we can repair our seemingly broken world. It is surely worth the read not only if you lead people, but if you are interested in making society a better place (this should be everyone!).

KEY TAKEWAY: Can empathy be taught? Jamil Zaki in The War for Kindness argues that it can be. The implications in healthcare mean that our team members would benefit from a culture that has built in systems to train people on demonstrating empathetic concern for patients. This is a must-read book.


The War for Kindness is available for purchase on Amazon for $27.00 (does not include Prime discount).

Health insurance literacy and the unseen costs of health care in the US

This is the third part in a three part series on health literacy. The first was about identifying the competition. The second was about health care literacy. This post is focused on the topic of health insurance literacy. 

Health care in the United States is big, bulky, and complicated. Anyone who has spent time trying to understand their insurance benefits, let alone receiving care, knows just how dysfunctional the health care system can feel to the average person.

As I learn more about health care, I have come to realize how much I didn’t and still don’t know about how it works in the United States. As you may know, my background is in government relations and business, and not as a health care provider. I have no clinical experience other than supporting important clinical functions that help people get well after feeling ill. Despite extensive time, reading, and research of my own, I realized that if areas of our health care system are still a mystery to me, then there is a lot that the average patient who comes to us through the emergency room will not know, ranging from how they receive care, their diagnosis, and the cost of their care.

I remember the first clue I had that the US health care system was broken. When I left my first job to start my next professional opportunity, I opted in to COBRA benefits for my health insurance coverage. I opted in to both a medical and dental plan. I went to the dentist and the claim was denied by my insurance. I went back and forth with the COBRA administrator and the insurance company because one saw that I had coverage, the other did not. When I asked the COBRA administrator to call the insurance company to reconcile the difference, the response I received was “that is not my function”.

My reaction was one of confusion and frustration—how could the administrator for my insurance company not be able to solve an issue relating to their company of employment? Wasn’t that their job? I had thought I was doing everything right, but was still being denied access to the benefits I was paying for.

Feeling hopeless, I asked the COBRA administrator customer service representative what they would do if they were in my situation. “Sir, people in your situation generally have success by calling us, putting us on hold, then calling the insurance company, and merging the calls together”. So that is what I did and it did fix the issue. Reflecting back on this experience, I am still baffled, but thankful that I was able to resolve the issue. I cannot imagine how many other individuals went through the same struggle, but were not able to obtain a successful result.

I did some research at that and found out that 25% of the cost of health care in the United States is administrative, not in treating patients clinically. That means hospital overhead (roles like mine), and paying people to work in the insurance industry account for 25% of spending. As a hospital administrator, that feels high. But when you include the insurance companies in that percentage, it makes more sense.

On that point, in the American College of Healthcare Executives latest issue of the Journal of Healthcare Management, there is an article on health insurance literacy. Not surprisingly, my suspicions were confirmed. As it turns out, my COBRA experience was not unique. It turns out that many people struggle with even the basic terminology that all insurance companies use on a daily basis for pretty much any and every plan they offer. These are terms like co-pay, premium, and deductible.

Many hospital patients will struggle with this gap in health care literacy throughout their care, even though many will not explicitly express it. Patients often can feel like they may not understand their diagnosis or reason for their symptoms. They may not understand the treatment they are being prescribed, they often have trouble identifying caregivers (physicians, nurses, techs), and they can get especially lost in understanding the cost of their care and how to ultimately pay for it.

This is a size-able gap, but one that can be bridged without a major system overhaul. A first step is providing education proactively. Next, insurers need to educate beneficiaries on the basic terminology and benefits of their products. Insurers and providers can and should cooperate in order to change some of our laws to produce fewer bills for the patient, including their explanation of benefits (also known at EOB—aka “this is not a bill”). Finally, insurers need to simplify their processes and stop denying claims for reasons that have nothing to do with fraud, waste, or uncovered services.

Health care literacy is our responsibility. Providers and administrative partners must simplify the healthcare system while also educating consumers/beneficiaries. We should not assume that the consumer will know everything about health care that we know industry on a daily basis. The improvement of health care literacy will help to improve patient care, which should be the ultimate reason why we do what we do.

KEY TAKEAWAY: It is our responsibility to educate consumers on navigating the health care environment, including insurance. We can do so by simplifying our system and working to change laws that no longer make sense. Together, we can make a difference.