Help me understand: Is it possible to be empathic and set boundaries?

Podcast Transcript

Adrienne:  Welcome to another episode of Studies in Empathy, a Cleveland Clinic podcast exploring empathy and patient experience. I'm your host, Adrienne Boissy, chief experience officer here at the Cleveland Clinic in Cleveland, Ohio. I'm very pleased to have Steph Bayer here, who is senior director of patient experience at the Cleveland Clinic. Steph, welcome to Studies in Empathy.

Steph:  Thanks.

Adrienne:  Now I'm super excited about our conversation today because some of the work that you've done over the past couple of years is I think some of our most challenging, and yet you continue to find it exciting. How is it that someone who has spent so much time hearing patient complaints all day, how do you stay resilient? How do you keep going? How do you keep your teams doing that? Not to mention, have fun. It's really a fascinating part of who you are. I can wait to dive in.

You started though as a lawyer. That's your background. Tell me a little bit about that journey and how you leaped from legal to healthcare.

Steph:  Yeah. I am a trained attorney. It was my last year of law school that I realized in the law profession, you pretty much are cleaning up people's problems. I thought, "Gosh. I don't want to make my whole career about cleaning up after other people." I didn't see room in law where it wasn't like that, but I did have an internship one summer in the law department of a hospital. I thought, "Boy, in healthcare, it seems to matter more. Also, you're part of building processes that change lives." That, to me, was way more interesting.

Actually, I never practiced law. When I finished with law school, I went right into the hospital setting.

Adrienne:  Then how did you find your way here?

Steph:   What I did initially, I started at a small hospital, critical access, 25 beds. In those small hospitals, you wear lots of hats.

Adrienne:  Right. You're everything, right?

Steph:  The law part was translatable, compliance, regulatory, accreditation. Then I also did some risk and grievances. From that, I went to the insurance side because I had law school debt to pay off.

Adrienne:  I don't know anything about that in terms of med school debt.

Steph:   With the insurance side, it felt like I started to fall into the traditional legal path. I was cleaning up things. I wasn't building processes. It didn't feel like mattered as much, but I did get to work for some really great insurance companies, Walgreens, CVS, some big places. I did get to spend about seven years in that realm.

Adrienne:  Oh wow.

Steph:   Enough time that I got some good experience and I had some good resume stuff.

Adrienne:  That's great.

Steph:   And then come back.

Adrienne:  And then we got you.

Steph:   Then you got me.

Adrienne:  When you came, you started working in the Ombuds office? Was that your entry point?

Steph:   It was.

Adrienne:  And then you grew to director of the Ombuds office. Now you've expanded into managing several different teams. Talk to me about the Ombuds office here, how it works, what attracted you to that, and what you learned as a result of that.

Steph:   In other hospitals, it would be considered patient relations, maybe patient advocate. Here we call it Ombudsman. It's the liaison with the patients. It's the group that helps to figure out what's going on that isn't meeting expectations and how can we fix it. The nice thing about the way we do it here at the Cleveland Clinic, instead of just addressing patient concerns, we also hear from our caregivers to say, "Where are the barriers for you, and how can we help fix those?"

I came in because of the grievances and my experience in handling and building that. I actually came in as the director of the Ombuds from the insurance side. We were looking at reforming how we were doing things. With that, we built up this amazing team. When you build a new team or when you change things, there's a lot of growing pains. Now we've got a really strong team, and we find ways every day to say how the work matters and how can we still have some fun with the work we're doing and how do we care about other people and not get burnt out.

Adrienne:  I want to call out though something that you said quickly, which I'm not sure everybody heard. Sometimes when I go to other hospitals and they talk to me about their patient relations or patient advocates, the perception, I'm not saying true, but the perception on the part of the clinicians is that, "That just exists for the patients. If I'm getting called by that office, it's because they're going to tell me I did something wrong and blah, blah, blah." The perspective is not necessarily that that office is a resource for them.

Steph:   Mm-hmm (affirmative).

Adrienne:  I want to go back to the comment you made that we've tried to use the Ombuds office as a resource for both. In fact, you've been quite successful in that model because the number of complaints or calls that you get about asking for help, tell me how that's distributed.

Steph:   Initially when I started, mostly we did have complaints and grievances as the perception of what we did. When patients are upset, we're the office that has to kind of find the way to fix it. That is still important to us, and it is what we do, but we also realized that to build credibility and to be able to fix things quickly, we also have to tell the other side that, "Caregivers, we want to help you too. We want to help you." When you call it an advocate, a patient advocate, you're setting expectation even in the title that we're on the patient's side.

Adrienne:  Totally in the title.

Steph:   I think expectation setting is so important to doing this work right, and that's not a fair expectation. What we've seen, and actually in the last year, we saw, for many reasons, we saw a 54% increase in the number of caregivers reaching out to our office compared to the previous year. And now-

Adrienne:  And that's thousands.

Steph:   Thousands.

Adrienne:  We're talking thousands of visitors.

Steph:   We had 20,000 cases in total last year in the Ombudsman office.

Adrienne:  Yeah. It's not like 20 more caregivers called you.

Steph:   No. It's thousands. I think that shows that we're looked at as a resource for caregivers as well as for patients and that we can be a little more neutral in helping to understand expectations on both side.

Adrienne:  It popped into my head as you were talking that this idea, even when we're thinking about language, this idea of patients first is interpreted by some as meaning the patient is right all the time.

Steph:   Mm-hmm (affirmative).

Adrienne:  Can you comment on how that lands on you and how your work addresses that?

Steph:   I now know that it's patients first, caregivers always. We've expanded our motto and how we're looking at everyone's needs. I do though think that patients have a different level of power in healthcare. Patients are vulnerable. They don't have the same understanding, the same education. They're sick. They don't know what's happening. I do think that we do ... If we have to err in one direction, it should be erring on the side of the vulnerable and helping patients, but patients first does not mean that we're not looking out for each other too.

Adrienne:  Mm-hmm (affirmative). A lot of times when I heard patients first then that means the patient is right all the time. In fact, the way you've constructed the Ombuds office is that we're coming in not assuming that anybody is right or wrong, right? But with an idea of, "We'll investigate and be curious and then come to some formulation of an opinion about it." Often, it's not the space that you land. That outrageous request from patients or demands that are inappropriate for care or interfering in care, that isn't want patients first means.

Steph:   No.

Adrienne:  It doesn't mean saying that that's okay.

Steph:   No. If we do look at it from that perspective, if you're seeding to these outrageous demands, and if you're giving a lot of attention to expectations that are not appropriately set, then you're not allowing the patients that need the care to also be heard appropriately because you're burning out caregivers. You're spending too much energy on things that are not appropriate for healthcare. I think it is still patients first when we do set boundaries, when we do, with empathy, establish what's acceptable and what's not.

Adrienne:  In many situations that you and I have both been involved in, and many that you're involved in every day in your prior role as director of the Ombuds office, the role that was often required would be to set boundaries in an empathic way. I have two questions about that. One is, why do you think it's hard for caregivers to do that? Two, how is that actually done? What do you think your team does differently than someone else walking in and trying to be empathic and set boundaries?

Steph:   I think the first part, why is it hard, I think it's not practice. I think anything you don't practice often is harder. You're asking people to have very direct conversations, kind, understanding, but direct. It's not something that they necessarily are practiced in. They're practiced in clinical information. They're practiced in standard of care. This is outside of what's normal. I think that just in and of itself creates discomfort.

How I do that though, I have a question that I start every conversation with. Actually, my old team in the Ombudsman's office makes fun of me for it. I love to say, "Help me understand." One, using that language, I'm asking a favor of you. You're going to help me, so I'm giving you, the patient, some power there because you're going to be the one to help me. Then two, I'm starting from a place of, "I want to understand, so help me understand what a good resolution's going to look like."

Adrienne:  Which is very different than how many conversations start, like, "I understand you're angry."

Steph:   Right.

Adrienne:  "I understand this has been hard for you." Why does your statement work and the other one doesn't?

Steph:   I'm not coming at it with an assumption. It truly is. It's the I'm coming at it from a, "I want you to fill me in", and I'm not coming at it from a place of defensiveness with the patient.

Adrienne:  It's really interesting that actually starting with, "Help me understand." I've heard of this technique before of asking for a favor. Maybe you taught to me. I'm not sure, but it's actually a gesture when you're trying to build a bridge or you're trying to build a relationship of power, of extending power to somebody else, as you said. It also means, on the backend, it implies if you're asking for a favor that the person will ask you for a favor, that they can count on you to maybe return the favor one day.

Steph:   Right.

Adrienne:  It's a very interesting-

Steph:   It helps with some rapport, and it's just a turn of phrase.

Adrienne:  Yeah. It also is humble, right? It's saying, "I don't understand, so please help me." The very opposite of, "I already understand all this. We don't need to talk about your perspective."

Steph:   Right. It doesn't ... People initially also think, "I'm very busy, I don't have time to go into this." It doesn't really take that long when you say to someone rather than, "I understand. This is why I'm here", saying, "Help me understand why I'm here." It doesn't take that much longer for someone to clarify, and it lets them feel they're part of it too.

Adrienne:  Right. We often study that anger curve, that people will emote their anger, and then they take a breath.

Steph:   Yeah.

Adrienne:  Then when they take a breath, you're supposed to come in with a statement of empathy, right?

Steph:   Yeah.

Adrienne:  Not facts.

Steph:   Mm-hmm (affirmative).

Adrienne:  I love that curve. It's really a powerful curve in my own learning. We're oftentimes setting boundaries. I know I would advocate that ... Another reason why it's hard for caregivers is because they feel, because they're so committed to patient care, they want to keep taking great care. Somehow people don't equate taking great care as setting boundaries. I remember a story you told me about where unfortunately, a patient's family was very abusive toward the caregivers, and they were listening to it. There was like this set phone call time. It was just going on and on for 45 minutes that they were getting yelled at and cursed out on the phone. It took I think you swooping in, someone from your team going in and saying, "We agreed this was a 20 minute phone call or a 15 minute phone call and that profanity wasn't going to be a part of it. The phone call's over." Then hung up. Then everybody wanted you there to make sure they hung up if they were getting abused. Do you remember that?

Steph:   Very well, yeah.

Adrienne:  What's your version of that story?

Steph:   That's it. I showed up to babysit the 20 minute timer, and then I would say, "Okay. Time is up." It didn't take long. I do believe you can teach people how to treat you, and I think that you're right that people care so much, they want to make sure that there's understanding, but there are times when that's not reasonable. When perhaps the trust is broken on both sides and you can't recover in that way, it's not reasonable to continue. Then we had to create a new paradigm. That sometimes does mean that you have to set harder, firmer boundaries, but I think as long as you're clear with the expectations, you're clear with what's going to happen, you're still being compassionate. You're still offering understanding, but you don't need to take abuse, and you shouldn't in healthcare ever be subjected to that.

Adrienne:  It's interesting. We just had a conversation with Linda McHugh, the chief human resources here, about how feedback maybe needs to transform from a, "This is what you should keep doing. This is what you should stop doing", to a loving, supportive conversation, which is really interesting based on what you're saying. You can set boundaries in the most difficult of circumstances, even with our patients and family members, and perhaps each other, but doing that in a loving, supportive way. It's just triggering that in my head.

Steph:   I think boundaries are best established and best set with curiosity as part of the conversation.

Adrienne:  Where did you learn to be such an effective communicator?

Steph:   I did take the REDE course when I started here.

Adrienne:  But is it part of negotiation or moderating, training in law school? You really are exceptionally talented at having that loving, supportive conversation and setting boundaries.

Steph:   I think there is an element in the legal training, and particularly I trained ... Once you get past your initial law school classes your first year, you can kind of decide what you're most interested in. I was interested in litigation. In litigation, you're looking for the angle. You're looking to have the ability to communicate in sometimes sharp ways. That didn't sit well with me, which is why I don't practice it, but I did pick up the skills and they're translatable.

Adrienne:  Yeah. That's interesting. Tell me about one of the most powerful moments of connection that you've had.

Steph:   Actually, you kind of referenced it and you were present for it. A couple years ago, we had a family that was abusive. The patient was elderly, and he was not doing well. It was a patient who just needed to go probably to a long term care setting. It wasn't the most appropriate setting in the acute center, anymore. We were doing care, but it just didn't fit what we could do. There was a lot of moral distress for the caregivers present.

Adrienne:  I remember.

Steph:   Actually, you and I went down to the floor and we got all the nurses that were there that day that had been taking some abuse really from the family that had been struggling with the care that we were offering the patient. We had a circle. We went around the circle, and we said, "Dr. Boissy, what I appreciate about you is", and then you would turn to the next person and say, "What I appreciate about you is." It took 10 minutes. I remember by the time it made its way around, everybody was cheerful. I don't like to admit that I have emotions, but it sure got me that day.

Adrienne:  What?! You have emotions?

Steph:   It's something that the nurse director, she and I will often talk about it. They actually have a tough situation in an ICU. She said, "Hey, maybe we can try that again. Just to help reframe it for the caregivers present when we don't really have an easy solution." That moment of gratitude and appreciation can help reset.

Adrienne:  One of my good friends gave me a book. It's called ... It's a children's book. It's called "How Do You Fill Your Bucket?" It's all about just the visuals and the imagery that we all have these buckets that are filled with water, and you're walking around all day. Either these moments with other people can extract from the bucket. There's, I'm sure, a more scholarly article written about it, but there's ... People studying microagressions. Are people filling your bucket, or are they taking withdraws?

I often think about that actually with our caregivers. In order for them to care at the depth and intensity for which is actually required in their work, there's constant draws on that all day long. Then how do we balance that? It isn't just about resilience training or sending them to a class. It's about filling the bucket with a little bit of gratitude or a little bit of appreciation, trying to counteract some of that in the moment. Actually, that was one of the simplest and most beautiful ways that I've ever seen ... Filling someone else's bucket is simply having people articulate, "What I appreciate about you is blank."

Steph:   Mm-hmm (affirmative).

Adrienne:  I do remember some of the comments about the nurse manager in particular. Just so powerful, very young nurses, saying, "I couldn't have done this over these last months," it's months, it's not even just weeks, it was months, "if I hadn't had you." There wasn't a dry eye in that. I think you even cried. I caught it.

Steph:   No witnesses. I don't know. No. It was a really powerful moment. I think with that how do you refill the bucket, I think leaders need to be intentional about that as part of their day to day work.

Adrienne:  Yeah. That's a great point.

Steph:   I know with the Ombudsman department, so I'm going to shift it just a little bit, if you are hearing complaints all day long, and then I ask you to tell me how engaged you are, how safe you feel the hospital is, when you're only hearing the bad stuff, I can't be surprised when you tell me that you're not happy at your job because negativity's contagious. There's science around that. I know you're a neuroscientist there who can help fill me in on why, but there is information out there that says if we're not looking ... As part of leadership, if you're not looking at how to help refill people, then you're missing a big part of what leadership should be.

Adrienne:  Yeah. It's so funny you say that because as I'm sitting here, I'm thinking, "Did I refill anybody's bucket today?" I'm constantly thinking about the draws on time and attention and priorities and projects and strategies and this person and these teams I have to connect. Often, it's not the first thing I'm coming to work thinking about. It is important to think about how much time in a day am I dedicating to actually doing that.

Steph:   Mm-hmm (affirmative).

Adrienne:  As some days we're all probably better than others.

Steph:   And that's going to happen. There are going to be days where we don't have as much time and as much ability, and that's okay because you also have a bucket that needs to be filled, but I do try and build into my day to day work moments where I say to someone, "Thank you for what you did here", or I ... Humor, sarcasm, joking is very important in how our team works. I make sure that we build that in.

Every morning, the team likes to have an update on how many cases came in from the day before so they can have an idea of how busy we are and where the issues are lying. We do this ... This is something they ask for from a communication perspective, which is something leaders need to do. Rather than just communicate and say, "Here are the cases", we say, "Here are the cases. Here are the managers who are onsite or where they are." Then we also include a meme. Today's fat Tuesday and there's a cat who's eating donuts. It's not that interesting, but it had like a little funny caption and we threw that in there. Even throwing in memes, it just helps show that I'm thinking of you in addition to the powerful gratitude and in addition to the other stuff we do.

Adrienne:  I'm still trying to figure out what a meme is.

Steph:   It's a picture on the computer. You can do it.

Adrienne:  I've heard of them. I just want to make sure I'm clear on the definition before I sound like my age. But also in the Ombuds office here, you have this wall. Tell me about the wall.

Steph:   We have the gratitude gallery. Any time we get a compliment ... Again, in this work, we're hearing a lot of complaints. When you do have a compliment for the team from either a care provider or a patient that says, "You made a difference", we celebrate that. We hang it up on the wall. We have a weekly newsletter for the whole team to fill them in because in a big healthcare system, things shift and change. Every week, we fill them in on what's going on, in addition to sharing the compliments that came in. Last year, we saved all of the gratitude compliments.

At the end of the year, we change every month, we hung it on a wall, it covered my entire office, just as a visual representation for the team of, "Look at everything you do. Look at all the good you do." I would like to say that I planned that all along. It was one of those moments I thought, "I wonder what it looks like." It really was impactful for them to see that here's the compliments in a tangible way. It was good.

Adrienne:  I love that. I do. I love that. In such a space that can be so hard, it's just even more challenging, I think, because of the emotional pull. The scholarly concept there is an emotional bank account that withdraws and deposits. I'm using children's books, but there are more scholarly articulations of it.

I want to spend a little bit of time talking about you made some changes last year to how we manage complaints and grievances that were different than what I've seen anywhere else in terms of the rating system and we distribute monthly reports of our complaints and grievances, categorized by area and topic. Talk to me about changes you made in terms of the severity rating to try to be sensitive to leaders attention spans, as well as how we infuse gratitude into those reports.

Steph:   Compliments and complaints and grievances, those are all managed through the Ombudsman department. We have all this data as well from patients saying, "Dr. Boissy saved my life. I'm so grateful for this hospital." Why are we not using that in our report and sharing that as well as the other side?

What we did with our reports ... Every month, we do send reports. It has a summary of the detail, so you have an idea of what patients are actually saying, as well as more of a cumulative look at the categories we categorize our complaints and grievances. You have an idea of where we maybe have opportunity. Often, communication. We know where we can focus our efforts.

When you see the same report every month, it can get a little stale. It can feel a little heavy and broad, so what we ended up doing was creating a rating and we mirrored it on our serious safety events rating scale. One to five is what we use here. We have a rating scale one to five so that it feels familiar. Ones are those issues that we can't change. Patients still have a right to complain, but we really couldn't have done anything different as an organization. For instance, "I have to have sedation? And I don't like that I have to have a driver afterwards." People complain about that. "I don't agree with the pain management contract." Okay, but that's for safety. You still need it. These are processes that we can't change.

Twos and threes would be communication issues, rudeness, empathy, or delays. "I couldn't get an appointment when I wanted. There was a delay to get my care." Those are things that we need to be a little more intentional about how we can offer programs, especially through patient experience.

Fours and fives are the more serious issues. All fours and fives also get sent to risk management and to their safety so that they also have a chance to put eyes on. Those are things where, "I think I was harmed as a result of care."

Adrienne:  So really serious ones.

Steph:   Yeah.

Adrienne:  You say communication is the most common, right? I think it's over 50% or so of our comments or concerns from patients. What's in that category though? Is it interpersonal communication? Is that-

Steph:   It's really two fold.

Adrienne:  Cross Teams? Phone?

Steph:   It is interpersonal, and it is coordination. The coordination could be things like, "I didn't get the follow up call I expected. I didn't get the information I expected. I submitted paperwork and no one gave it to me so I can have FMLAs. I'm out sick." Those are communication coordination issues that we can do better as an organization in helping patients.

The interpersonal is, "The doctor, the nurse, whoever was rude to me. I don't feel like they expressed empathy." Those are things that we can also train at the individual level.

Adrienne:  Mm-hmm (affirmative). What happens when you have a conversation with someone involved in these? Is the response often, "Oh my gosh. Let me know what I could do. That wasn't what I intended", or do you meet with some feelings or resistance?

Steph:   It's both. I don't think anyone goes into healthcare to be rude, to not communicate, to cause anxiety or suffering for another. I just don't believe it. Certainly, there's a level in everyone that is, "I don't like to see this information because that's not why I'm here." I think that is expressed in different ways.

There are some people who will say, "How can I make this better? Can I call the patient? What can I do?" We can talk them through what they need. There are others who will say, "The patient's mistaken. This isn't what happened", and take it more defensively. I respect that too because it does feel personal. I've had complaints against me which was personal, but we also try and help them level set.

Because we also give compliments, we can show trends. If you're someone who gets one or two complaints, but you get six compliments a year, that's a nice balance and I'm not as concerned about how you're communicating. If you're someone who has the lead for the number of complaints in your institute or in your hospital, then we might want to give you some interventions and talk to leadership about how we can help.

Adrienne:  Right. I like that point that you're making, that we often look at communication across data sets before we dive in with assumptions that somebody's a horrible communicator to better understand. Always starting with, "What was your intention? What's going on with you as you've read this?",  as opposed to leading with what we think I think have been effective for us.

What can caregivers do to prevent or head off or address a complaint when it comes? How can we do better?

Steph:   The one thing I would love to see every caregiver do ... I think often caregivers enter encounters with an agenda for clinical needs. "This is a physical. This is an appointment for a specialist. This is what I'm doing, and here's my agenda clinically." I don't know if our caregivers are always asking patients, "What do you want to accomplish today? What does a good outcome for this visit look like for you?" I don't know that we're setting an agenda with curiosity and including the patient upfront. I think if we did that, I think if we asked a patient, "What's going to make this a good visit for you?", before we have the visit, then we can check that box and we can avoid some grievances and complaints. It's one question, but "What's going to make this a good visit for you today?" will help us understand what we need to address.

Adrienne:  That's interesting. One of the questions we train around is expectations. I lead my clinic visits with that. "Tell me what you're hoping we can accomplish today." Just to understand. Sometimes people are very clear. "I just want that clinical piece. I just want to know what drug to go on." Other times, it's more, "Nobody's been able to diagnose me. I'm totally frustrated." Then making them feel actually that it's more important that they trust someone, that I need to spend more time on the trust side. It's interesting to hear you say that as a most important question because you're right, I'm not sure that we ask it.

Steph:   That's why you're a great physician. You're asking it. I think that-

Adrienne:  I get many complaints too. I think that's a really important point. I appreciate you saying that. And I've had many complaints against me. The complaints are often some mismatch. I thought I was doing a great job at x, and the patient actually needed y. Sometimes it's about mismatched expectations. They want a prescription for something or they want a diagnosis that I'm actually not able to give or won't give, and that creates dissatisfaction.

I recently had a patient file a grievance against me because they didn't want information shared with their local referring physician. Unfortunately, in our electronic health record, information automatically sometimes gets shared or is visible to the referring physician. I thought how interesting that technology has advanced transparency and making connections in terms of data, but I'm not sure we made room for the patient to say, "No, I don't want my data shared." Then that reflected on their trust in me. We all have something to learn, right? Even figuring out whose data is it.

Steph:   Right.

Adrienne:  What's my responsibility back to the person that sent them here to be honest? I think those questions are fascinating, and I'm not sure we have answers to them. But I, don't worry, I have, as best as I am trying, like everybody else out there, it happens that we're going to disconnect-

Steph:   It does.

Adrienne:  ... in the way that we want to. It's an awful feeling, I have to say. It feels like you failed. I feel like I have failed when I read comments like that from my patients. When we send out communication reports to our physicians, I often get emails back saying, "What is going on with this patient?", or, "I'm so upset." It hurts people in a way that you said feels very personal.

Steph:   It does, but, and I don't want to sound callous, but I'd much rather hear someone's hurt than not affected because I worry about apathy more than I worry about that. That means they care. I like working with colleagues that care.

Adrienne:  Yeah. I don't have anything to say after that. Some other things now just before we wrap, you've taken on a whole new expanded role, right? Now you're managing End of Life as well as Bioethics as well as Spiritual Care as well as-

Steph:   Shared Medical Appointments.

Adrienne:  ... the Ombuds office and Shared Medical Appointments.

Steph:   That's it, yes.

Adrienne:  How do you think about building that team? The teams are quite seemingly very heterogeneous. They're not all aligned and oriented and doing the same work. Can you take some of the lessons from Ombudsman and bring it over there? How are you thinking about that as you've gotten your hands kind of dirty in this new role?

Steph:   My approach, and we are like five months into a bit of a redesign in better aligning our patient-facing service and patient experience, my initial approach is curiosity. It's the same way I approach the Ombudsman and how I approach patients. I want to understand how they feel and what's working and what they feel is working and why. I want to understand the important work they do. That's what we've been spending a lot of time in doing recently.

We're now at a point where we're finding opportunities to better collaborate. When you have all these resources touching patients, there's going to be overlap, so how can we shore up the distance where our services are so that we seem seamless? We've learned to do a daily huddle call, in which we share information.

We've learned ... Right now, we're working on a empathy project. I can't wait to show it to you. It's not time yet, but each team is giving me ideas of how they display empathy. I've asked the question of each team, how do you impact patient experience, you? The answers I'm getting back are moving and powerful, and we're sharing this. It's that rising tide, lifting all ships. It's making people feel more committed. When the pain points are coming, when changes do have to occur as we adjust, they have a generous intention. They know that we're all in it for the best.

Adrienne:  It makes me think of a couple things. One was the idea that there's a lot of overlap in our patient-facing services, which is why we pull them together. With you leading that effort to figure out in situations where we've got Spiritual Care and Bioethics and the Ombuds, what's the right engagement strategy? Do all of those people need to be there as we're trying to navigate an optimal outcome for both caregivers and patients? We've learned a lot by doing that. You, this last year, in different roles ... We implemented some policy change as outcomes of some of that recognition around messages in MyChart and recording of our caregivers, hot topics in healthcare, which I'm sure many other organizations are facing. Share what you did there and how we're thinking about better coordinating when we have really complex cases.

Steph:   We're taking some lessons learned. We're doing some debriefs and some really tough moments. These moments are cases where we may have missed expectations or we just didn't have the trust throughout with our patients or their families. In the debriefs, we'll have spiritual care, bioethics, Ombudsman all involved saying, "I was part of that. I was part of that too", to say, "Are there lessons learned?" Sometimes we find the lessons were that we didn't clarify what's appropriate and what's not soon enough.

For instance, it's not appropriate for a patient to pull out a phone and start recording an encounter in a confrontational way. How do we address that? Not everyone has the tools they need and the language they need to address that, let alone the policy to support them.

Adrienne:  Mm-hmm (affirmative).

Steph:   So we developed those policies. With that policy, and what I love about this work, is that we didn't just say to the enterprise, "Here's the policy that says you don't need to be recorded." We said to the enterprise, "Here's a policy, and let's start with empathy." Patients may be recording because they have family members in a distance that they need to share the information. They may not understand and they need to refer back to it. Start with asking the patient, "Why are you recording?" Do you consent? You have a choice. If you consent, the patient can continue. If you don't consent, how else can you get the patient that information they need? We're not starting from a position of confrontation.

But then we also are helping people understand how to say to someone, and the language is actually quoted in the policy, "Here's how you tell someone I'm not comfortable with that."

Adrienne:  That's right.

Steph:   I think that's important that we're taking these opportunities where we may not have always seen the space as often when we had different groups involved. We're saying, "Oh this is happening more often than we realize and we need to have a solution."

Adrienne:  Yep. And you've done that with challenges in MyChart communications or the electronic health record communications, setting policies about that. You've done that with caregiver recording policies. You've done that with ... Most recently, we saw funerals and morgue policies, right?

Steph:   Yeah.

Adrienne:  And they're all based in real cases that we've had that have enterprise implications.

Steph:   Yes.

Adrienne:  We're so lucky. I think that's a huge way to demonstrate value to both our patients and our caregivers. You really led that charge. We've very grateful. Part of the message, people who are listening who are part of the Cleveland Clinic, is certainly to know those resources are available. For those of you who are listening and have classically thought about a patient advocate, certainly encourage you to think about expanded roles in terms of how patient-facing services and patient experience can really impact policy change at the enterprise level.

I want to apologize to all law schools and litigation firms that we have Steph Bayer. It's really a blessing for all of us in the enterprise. I want to thank you for spending your time with us today.

Steph:   Thank you.

Adrienne:  This concludes Studies in Empathy podcast. You can find additional podcast episodes on our website, my.clevelandclinic.org/podcasts. Subscribe to Studies in Empathy podcast on iTunes, Google Play, SoundCloud, Sitcher, or wherever you get your podcasts. Thank you for listening. Please join us again soon.