Global Care: Enhancing Patient Experience Across Borders

Podcast Transcript

Dr. James K. Stoller:

Hello and welcome to MedEd Thread, a Cleveland Clinic Education Institute podcast that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise.

Dr. Tony Tizzano:

Hello, welcome to today's episode of MedEd Thread, an Education Institute podcast exploring preparing caregivers for global patient services at Cleveland Clinic. I'm your host, Dr. Tony Tizzano, director of Student and Learner Health here at Cleveland Clinic and Cleveland, Ohio. Today I'm very pleased to have Dr. Duaa Hammoda, director of service excellence for Global Patient Services at Cleveland Clinic, here to join US. Duaa, welcome to the podcast.

Dr. Duaa Hammoda:

Thank you, Tony.

Dr. Tony Tizzano:

If you could to get us started, please tell us a little bit about yourself, your educational background and what brought you here to Cleveland and your role here at the Cleveland Clinic.

Dr. Duaa Hammoda:

So I'm a global healthcare leader with over 17 years of experience within healthcare. So spinning around the clinical experience, education, research, and administration. Throughout the 17 years of global experience across different countries where I lived and I, some of them lived for education, others for work. So I consider myself as a person with a global lens for a simple reason that I have spent a decade in Canada, UK, the USA, as well as the Middle East, where I lived in Saudi Arabia as my home country. Throughout this journey, I learned that the differences between the cultures as well as navigating different healthcare systems around the world. In my role as a director of service excellence at the Global Patient Services, I think I found the right platform and I'm aligned with the Cleveland Clinic as a global organization. So working through Cleveland Clinic platform as a director of service excellence was just the right fit with my expertise within the global patient services.

The mission of Cleveland Clinic is really aligned with my expertise as Cleveland Clinic provide the hope for the patients across the world. So Cleveland Clinic is well known before even I came to Cleveland, and when I was a teenager I heard about Cleveland Clinic and I was in Saudi, I was a child, I was 12 years old. I heard about when our king came to Cleveland Clinic to do open heart surgery and that was exciting and that name, that [inaudible 00:02:28] stayed in my mind until later in life, maybe 30 years later or maybe more when I came to here. So we came to Cleveland and it was really, Cleveland Clinic was a brand that I knew as a child that is an important brand and I was working in healthcare at that time. I didn't know when I was a child that I will grow up and go to Cleveland.

But luckily I was so excited to be part of Cleveland Clinic mission and vision to deliver the best healthcare to the world. And through that role, I got hired at Cleveland Clinic and I remember very well that day somebody told me who was in the leadership, navigate yourself throughout the international operation between global patient services and business development. So I started between the business development and global patient services and I landed in the global patient services because I felt that this is where there is a need to improve the patient experience. Not that we don't have good patient experience, but we need probably to be like the benchmark for the word on handling patients travel for care.

Dr. Tony Tizzano:

That is a fabulous perspective and, and I could see where this is a perfect niche for you. So in today's segment, we will focus on preparing caregivers for Cleveland Clinic's global patient services that provide specialized medical expertise, clinical excellence, excellence in superior patient outcomes to patients from around the world. So Duaa, can you please help frame the mission of Cleveland Clinic's global patient services and provide our listeners with an insight into the impetus for this extraordinary service?

Dr. Duaa Hammoda:

So the global patient services established in 1970 and inspired by international readers and the outstanding experience of the leaders who worked at Cleveland Clinic and also donations created global patient services. So back in 1920, the patients used to travel for care to Cleveland Clinic. So this is nothing new to Cleveland Clinic as an organization. So the mission of the global patient services is to provide seamless, culturally attuned care through a holistic approach and ensuring that the diverse values and the needs of the patients are met. So when we say patient journey, it's like we handle the patients from the point pre-arrival to the point that they depart to their home country and they come sometimes back to us again throughout their lifespan. So our relation with the patient doesn't stop at our door and doesn't even start at our doors. So, but we are mindful that those patients are patients for life. So we establish a strong relationship with our patients and we handle them with care.

And we say global patients such a huge umbrella that includes the globe. We're not talking about specific group of people or specific culture or one culture. We're talking about patients from the globe, from China, from India, from the Middle East. And we don't wanna really put the people under one umbrella because each culture is different and each culture has its own, uh, different expectations and healthcare system, different expectations also from the, uh, the care that they're receiving from their doctors and how we handle them. Because if we don't prepare them well enough, then it's hard for them to navigate the healthcare system.

And not only the healthcare system because before they come to here, they need to manage for their visa, they need to go get their visas, they need to find a place to live in, they need to understand the healthcare system, they need to send their even medical records within our system. And like, you know, you're talking about two different healthcare systems, you're talking about different cultures, different languages, different expectations. So this is the job of the global patient services. They are like the gatekeeper for Cleveland Clinic in a way that they handle all the requests for the international patients and they navigate it with care in a seamless way that the patient doesn't feel how many people are involved in the backseat.

Dr. Tony Tizzano:

That's fabulous. So there are many, many moving parts. And I'm astonished to hear that there's this longitudinality where you literally then follow them over the course of their life because they may come back and forth. So it's very clear from just listening to you that you have great passion and enthusiasm for this work. What are the objectives for preparing caregivers to best perform this sort of work?

Dr. Duaa Hammoda:

Uh, the objective to prepare caregivers to deliver the best patient experience basically is there is like, it's way easier when you are prepared to handle international patients. Because I can see the struggle when you're a very busy caregiver on how to handle a patient that doesn't speak the language. So there is the linguistic part, which is I think in my opinion, is the easiest. 'Cause right now on those days we have like, you know, virtual interpretation that take place either through iPads or through the applications on the phones. Or there is like, you know, this is the easiest way, it's just to translate the language. But within this language there is a culture that is hidden in between the words that people don't know what the patient means.

And understanding the culture is one of the hardest pieces that people think, "Oh yeah, I know I have like, you know, I know about the culture." Because every culture there is the culture that is related to the ethnic group, to the language. And within that culture there is beliefs and religion and social economical status, gender differences and educational level like, you know, health education, like, you know, there's a whole bunch of information like, you know, the patient is very complex, so they come from different healthcare systems with different expectations. And our job is to navigate them through this.

Dr. Tony Tizzano:

So once you begin to have some degree of cultural competency, how does this impact safety and quality for individuals coming here?

Dr. Duaa Hammoda:

So I'm glad that you're asking this question because, you know, cultural competency is always seen as kind of the, sometimes people take it easy and they think it's like the icing on the cake, but in reality it's cultural competencies, it's everything in health and in patience, outcome. When we say patient's outcome, this is related to communication. We have patient-centered care and we are focused about the patients and the family. So it is our north star as patient first, but again, this is related to understand where is this patient is coming from. Because the, understanding the culture means we know how to communicate with the patients and how to communicate effectively in a way that the patient is compliant to the care 'cause we need to build a trust. If the patient can, doesn't trust us, then we can't really deliver what we want to deliver.

So I found many incidents happened in the inpatients while I was rounding, that the reason that, you know, somebody will come, the nurse might come and say, "This patient's not compliant," and the reason this patient's not compliant because it is like a gap in the communication, there's a miscommunication, or the message sometimes it's shared strongly because there is a miscommunication. And miscommunication sometimes it's related to the difference in the languages, which is easy, you know, the translation. But many times it's related to misunderstanding the culture or the behavior of the patient because the patient has a different culture beliefs and the, the way that they perceive. Like when the nurse come and give them the medicine, maybe in their home country, the nurse will come and will talk to them and they explain to them and give them the medicine with her hand or something.

So there is a difference in the practices and their expectations from the healthcare system. So back home, the nurse does probably different way on addressing, you know, the importance of taking medication, explaining it in their own language and in their own culture because she understands where this patient's coming from. And now like, you know, what we see is like many times there is like, you know, there's a miscommunication, there is a gap. And what I do basically, when I round on the patients, I listen to them and I listen of course to the caregivers, and you can identify the gap the moment you speak to both. And it's a very simple thing. It's nothing, it's not like the patient's not compliant, not that the patient doesn't wanna take the medication, simply the patient didn't understand because, you know, sometimes-

Dr. Tony Tizzano:

Right.

Dr. Duaa Hammoda:

Yeah.

Dr. Tony Tizzano:

But you have the advantage of understanding both sides of the equation. But I think the word that you really brought up is trust and how that trust segues into empathy. So if we look at how we try to build empathy, I think that's probably one of the key things you mentioned to me in an earlier conversation.

Dr. Duaa Hammoda:

Yes.

Dr. Tony Tizzano:

How do we accomplish that gaining empathy within a, within a visit?

Dr. Duaa Hammoda:

Well, empathy is the driving engine. If we all have empathy... Empathy is a unique language. You don't need to speak the language to have empathy, but people reads it and they can see it in your, you know, nonverbal communication. As you get into the room, as you talk to them, as you keep an eye contact, as you listen to them with kindness, you listen to understand the patients and not to cut them off because, you know, this patient is really trying their best to explain why they're here and what they want. And they've been really dreaming on coming to Cleveland Clinic. Maybe it took them like one year to get, you know, their paperwork done and the logistics to get into here. It's not easy for them to, you know, get through not only our healthcare system, also there are visas, there are, you know, other logistics involved before they get into the clinic.

So by the time they're here, we really, you know, they are waiting to meet that famous doctor that they were like, you know, they search a doctor and they really wanna see the doctor. So by the time they come to here, they expect more. And that puts Cleveland Clinic under pressure because we are perceived as best in the world, which means we have to be the best and we are the best. And I always say if we have like, you know, patient experience scores of 85%, that's not enough. We are Cleveland Clinic, we have to be 100%.

Dr. Tony Tizzano:

In trying to build this skill of building empathy. What can we do to help prepare caregivers to understand different ways to express emotion and approach to suffering? Wait, no. What are some things that we can do in, in that regard?

Dr. Duaa Hammoda:

So what we can do to, uh, prepare the caregivers to, um, uh, to basically amplify the empathy is to learn more about the cultures. Cultures may differ. And like, you know, how do we learn about cultures? There's no way that we learn about all the cultures, but we have to know that there are things that are common between cultures. Like empathy, I would say is like, it's not just being kind, but also try to understand why the patients are behaving this way and the way to understand why they're behaving this way or why they're acting. Or they're, sometimes the patient might be quiet, but even when they're quiet, that tells you maybe the patient is not understanding what you're saying. And many times, and have seen this many times, that the patient will, you know, nod their heads that they understand English and they don't. So we have to be mindful.

So we have to think about whether this patient is coming from individualistic or collective cultures. And there is a difference. Now, individualistic cultures, the empathy is defined differently because their empathy defined by, expressed by validating their personal feelings and emphasizing individual wellbeing. But in the collective cultures, uh, the empathy often involves prioritizing the group harmony. So the group, the family, like, you know, everybody has to be in agreement when the doctor comes and explain the care plan. And, you know, sometimes we think, "Okay, why the entire family is here? Why the entire family is involved with the care?" Because that's how they understand. They need the validation-

Dr. Tony Tizzano:

Mm-hmm. Great point.

Dr. Duaa Hammoda:

... they need the validation of the family. And we have to think also who's the decision maker in the family with the decisions, like decisions in terms of the healthcare of doing the operation, not doing, of doing this procedure or not. Is it the mother? Is it the, the husband? Is it the brother, is it the son? Is it... So, and, and we really need to stay mindful because whatever... Like my standards, I don't have to, uh, to push my standards on the other. And that's how we have to stay mindful is our standards are good enough to us, but not to everybody else and to every single culture. Because every single culture, they have a history behind that behavior and beliefs.

So we have to say... I think, you know, the simplest thing is just stay respectful, respect the patient, respect their beliefs, listen with open heart, without judgment because this is how we learn. And the moment, you know, we listen to the patients, they open up. Like I do my rounds and I just walk into the round and god knows what's happening in the, inside the patient's room. So I see patients from all over the world, and I don't speak all the languages, but I have one thing that is unified is I have the global lens that I'm wearing and I do have that empathy. The moment I get into the room, whether the patient from China or from Latin America, or from India or from... Yes, I speak Arabic, but I don't speak all the languages. But they know and they understand that I care and why I care because I listen to them and they can see it and read the empathy in your face. You don't have to talk sometimes. And I-

Dr. Tony Tizzano:

Yeah. And that last word where you say you listen.

Dr. Duaa Hammoda:

I listen and I listen and I listen forever (laughs).

Dr. Tony Tizzano:

That, that is... I think that is the key.

Dr. Duaa Hammoda:

Yeah.

Dr. Tony Tizzano:

So as you manage this global patient experience, and it may seem nuanced and multifaceted, how do you develop this deep appreciation and understanding of these cross-cultural dynamics? I mean, this isn't something that you can just open a book and get.

Dr. Duaa Hammoda:

No.

Dr. Tony Tizzano:

I mean, how can you load the, the physician's mind or the caregiver's mind, the nurse's mind to, how to be receptive to this? What, how do you begin to approach that?

Dr. Duaa Hammoda:

Well, understanding, you know, all the cultures is not something that you learn it on the spot. It's something I would say it's a life learning thing. I learned it over time working with the global patients in one side and living in different cultures. I think we have to be, of course you need to expose yourself to different cultures. Some of us are lucky enough and they can travel, some of us cannot travel. But I think the word is globalized the way it is now. And opening up means, you know, sometimes you open Netflix and you watch a movie in a different language. This is another culture. I know sometimes I watch like, you know, movies that are translated in English in different languages and like, you know, this is one thing. And, you know, trying, even if your colleague from different culture go reach out to that colleague and learn about their culture, we have to be open.

You know, we can't learn about the culture if we are closed. If we believe we are the best, it's not possible to learn about what's happening in the world. The only way is to be better version of yourself is to open up to other cultures and understand the world. And the world is so big and so huge and there are unlimited opportunities. And the only way to be better is to learn from these cultures. There are toolkits for the caregivers. There are trainings we put online. Actually I developed training under my learning. It's called Cross-Cultural Empathetic Communication. And I created that training a couple of years ago. The reason we created that training is to help our caregivers, you know, to enable them to understand, you know, how to handle international patients. Because there is anxiety when you deal with different cultures.

And I understand, I really feel bad sometimes. It's just like, you know, not bad. I feel kind of, you know, some people feel anxious of dealing with different things 'cause that's not familiar, that's not what they're learned or what they learned and what they did before. But I think, you know, since we are a global organization, every caregiver of us could have the opportunity to work somewhere else in Cleveland Clinic. And we're still under the umbrella of Cleveland Clinic, but in a different part of the world. And that's where we need to really expand our knowledge and experience. Exposure is one thing. Educating yourself is another thing. I always educate our caregivers as I round like, you know, about the miscommunication. Sometimes small things and it's in a friendly way, you know, we can communicate. I think, you know, the more we open up to learn about different cultures and listen to them and like, you know, understand why they're behaving this way.

I always try to understand where is this behavior is coming from without judgments because there is a lot, like, you know. I give you an example about how the patients react differently also. And that's taught me something. Like, you know, there are patients who are more emotionally expressive and there are patients who are more reserved. And I handle this every time I round the patients. And, and I don't wanna generalize now, but like, you know, I'm talking in general because I don't wanna give examples, but like, you know, this is of course doesn't apply to all patients, but there are cultures that are more expressive and the moment they have a problem, they will reach out to you and they'll explain everything, okay? And they want service recovery on the spot.

And there are cultures that is like, you know, if they have issue, "Oh no, no, no, we don't wanna share it" because they are more reserved. But like as the caregivers, we have to know, like there are differences between the cultures. Our job is to help the patients and not to push our expectations and our standards on them. It's just our job is to help those patients to get the best experience in Cleveland Clinic where we have the best care in the world. Okay? And to help to deliver that care and make their life easier without, you know, trying to judge, "Why is this patient telling me this or that," you know? And I have seen that. I think it just like, you know, there are more expressive cultures and all, again, this is coming from the culture.

Dr. Tony Tizzano:

So it's understanding these various differences. Are the toolkits you talk about, are they culture specific? You have one for one culture, another for another culture?

Dr. Duaa Hammoda:

Actually we created a toolkit for certain cultures. It depends on the population that we see the most, uh, and I mean, patients population. So we created actually toolkits and, uh, which is not yet published, but we will include it under the training, under my learning. And that is a plan. So to help the caregivers to look into this toolkit and to understand the differences between cultures more like a responsiveness reserve culture or collective culture, individualistic culture. There's so many cultures within each culture. And mind you, when we say culture within culture, we have the patient's culture, we have the culture of the organization, we have the culture of the caregivers as well. So we have to be mindful that we're not dealing with one culture. And even when we say the patient culture, if the patient is 18 years old, okay, and his parents are like in their fifties or sixties, okay, then we are dealing with two different cultures here.

Dr. Tony Tizzano:

Of course.

Dr. Duaa Hammoda:

Okay? Because that patient is tech-savvy. Okay. That child or whatever, the 18 years old, I don't... Yeah. And then you have the, the parents culture plus the other, all the other cultures on [inaudible 00:21:48].

Dr. Tony Tizzano:

A tremendous mix.

Dr. Duaa Hammoda:

Yeah.

Dr. Tony Tizzano:

We're in many different locations that we've alluded to and we try to build systemness as an important initiative for us as an organization. How are these efforts standardized across all our locations?

Dr. Duaa Hammoda:

So to deliver consistent, high quality, safe care, we standardize our processes across the sites, global patient services sites. So our global patient services team across Ohio, Florida, Canada, and London. We meet frequently and we share knowledge in a way that, you know, we exchange best practices and lessons learned. We also like, you know, I can speak about the patient experience, how we standardize our practices here in GPS Ohio, GPS Florida as well. And, and we're doing this also with London, other sites, is whatever we do here, like, you know, monitoring the patient experience surveys, monitoring the data, looking into the trends, putting improvement plans, we work it across. So, and we share the best practices.

So we do have actually, we try to streamline all the processes and we have the same platforms where we share the data, and we have like, you know, kind of, we wanna deliver consistent quality and foster ongoing improvement and throughout the, all the global patient services. We also integrate advanced technology to streamline and enhance the patient journey, balancing the innovation with personalized, uh, with the personalized human interaction as well. So we have right now online appointments. The patients can do it online through MyChart. Uh, MyChart also is translated in different languages. Each site, you know, it depends what population they see more. We translated MyChart, we worked with the team on doing transition. So the patients can go on MyChart and it's available in Spanish and is available in Arabic. And these are like, you know, the most common languages spoken from our international patients. We have patient portals that helps the patients navigating theirselves. And this is across like all sites, whether you're in London or you're in Florida or you're in Cleveland. So you can use the, uh, MyChart. And we have the same like, you know, MyChart system.

Each regional team is customized also to meet specific needs based on their p- patient's population. So here in Ohio, each region has its own team. So like, you know, we have a, a team for Latin America, we have a team for Canada, we have a team for the patients coming from the GCC region from the Middle East. We have a team also coming patients from Europe, from Africa and so on. So we have teams for each. Each team is like, it speaks like, you know, kind of culturally and l- linguistically aligned with the patient's population in a way that they can help, work as a liaison between them and the payers. Sometimes, because we can add... I forgot to mention something about what complexity of our practice is, we have the payers. So those patients are not like, you know, all of them insured. Some of them are self-pay, some of them are sponsored by their governments and some of them are insured by international insurance. So this adds to the complexity of managing them. But like, you know, this is how we work and how our teams are all geared on helping those patients.

Dr. Tony Tizzano:

That's fabulous. You paint a picture with many, many layers. So despite all that you're doing, when you look at the future, what are some things you see on the horizon, "Like, I hope we can do this, or I hope we can do that"?

Dr. Duaa Hammoda:

There are ample opportunities to raise the bar in managing international patients who traveled with the US for care. As this field continues to evolve, this is a new field. So we are, I wouldn't say lacking of this, lacking of standards, let's say. Uh, we are in the process of evolving these standards. Now we try to adopt the best practices on the domestic side and customize it accordingly for the international patients. So this area is quite new because this is a new business. It's not like it's been there for ages. And now we are putting, you know, the blocks together. And one of the things we did, and that's really, you know, I give the credit to Cleveland Clinic on that part, is we created an entity and, uh, that oversees the international program within US, to establish like, you know, standardized patient experience survey. And we have the benchmarking data for that. That's where we, you know, help on standardize the, the international patient experience across the US.

So there is more to do, like, you know, quality indicators for international patients. We're not talking about the medical or the quality indicators related to the treatment. We're talking about the quality indicators related to how we coordinate the care, like access, language, you know, the linguistic side, how we handle those patients. Time, you know, time, waiting time and, um, how long it takes us to help the patients to be discharged and how do we handle them when they go home. Things like this, it's just how we handle the patient journey from the beginning until they leave to their home safely.

And this is like, you know, an opportunity I would say to expand and we are working on it like, you know, with the other international programs. And actually, in fact, I'm presenting in one of the meetings, um, on these quality indicators. We wanna really convince the community that we really need this, like not related-

Dr. Tony Tizzano:

Of course.

Dr. Duaa Hammoda:

... to medical treatment, but it's related to the, how we handle the service quality of the service, and coordinating the care in general, giving the fact that those patients have complex needs.

Dr. Tony Tizzano:

Sure. Well, there's little doubt with you at the helm that you're going to get there.

Dr. Duaa Hammoda:

And the AI world. This is something I'm sure a lot of people like that. The AI world will help us on navigating a seamless patient experience, a seamless patient journey for specified for the international patients through different platforms. So I'm pretty sure like we'll have, we should be, uh, this is how I visualize the future is in the future we'll have each patient coming out with a personalized care plan in their own language, in their own culture with the cultural specification that they need.

Dr. Tony Tizzano:

And artificial intelligence can help us get there.

Dr. Duaa Hammoda:

Yes. Artificial intelligence. Yes.

Dr. Tony Tizzano:

So Duaa, in a previous conversation you talked about takeaways and you talked about a quote from Gandhi. Can, can you recount that for us? Because that was really interesting.

Dr. Duaa Hammoda:

A patient is the most important visitor on our premises. They are not dependent on us, we are dependent on them. They are not an interruption in our work, they are purpose of it. They are not an outsider in our business, they are part of it. We are not doing him a favor by serving him. They are doing us a favor by giving us an opportunity to do so.

Dr. Tony Tizzano:

There are no more profound words. Thank you so much. Well, thank you so much, Duaa. This has been a wonderful and enlightening episode of MedEd Thread. To our listeners, thank you very much for joining and we look forward to seeing you on our next podcast. Have a wonderful day.

Dr. James K. Stoller:

This concludes this episode of MedEd Thread, a Cleveland Clinic Education Institute podcast. Be sure to subscribe to hear new episodes via iTunes, Google Play, SoundCloud, Stitcher, Spotify, or wherever you get your podcasts. Until next time, thanks for listening to MedEd Thread and please join us again soon.