The Next Innovation in Experience is High Reliability

Podcast Transcript

Steph Bayer: Welcome to another episode of Studies and Empathy, a Cleveland Clinic podcast exploring empathy and patient experience. I'm your host, Steph Baer, senior director of the Office of Patient Experience here at the Cleveland Clinic in Cleveland, Ohio, and I'm very pleased to have joining me today, Chrissy Daniels. Chrissy, welcome to Studies and Empathy. Thank you.

Chrissy Daniels: You, Steph. It is a delight to be here.

Steph Bayer: I'm so excited that you're giving us your time. Chrissy Daniels is the Chief Experience Officer at Press Ganey, the world's leading human experience platform for healthcare. In her role, she works closely with healthcare organizations nationwide to accelerate improvement of patient experience. Chris is well known for pioneering work in healthcare, consumer transparency, and has over 30 years of experience on a national level with her expertise in patient experience, healthcare, consumerism, telemedicine, and medical practice. And personally, I think you've just been a great mentor and friends. I'm so excited to have you here today.

Chrissy Daniels: Well, it is. I'm a huge, I'm an avid listener of the podcast, and so this is for me, this is being on Fresh Air with Terry Groves. I'm so excited to be with you. And I just want to start out by saying thank you to you, Steph. I mean, your willingness to go beyond the headlines of patient experience and really engage in thoughtful dialogue with such diverse voices has meant a lot to me. I spent a lot of time on the loan on planes, and so having your voice in my ear and hearing these engaging questions, it is just a treat for me.

Steph Bayer: Well, I'm honored that you gave us the time both to listen and to join us. I wanted to start; I gave a formal introduction. I read your bio, but can you tell us a little bit about yourself, your background, how you came to be the Chief Experience Officer at Press Ganey?

Chrissy Daniels: Well, I started my career and very proud career at University of Utah. I say I'm an original gangster of patient experience because I was before HCAHPS. I'm actually, I'm an economist by training and I was working in University of Utah as sort of what is now known as an administrative fellow. I was doing special projects for the chief executive officer, and she said, oh, we need help in patient experience. And I had already been handling at that time, this was before complaints and grievances, but patient feedback and I said, great. I never really thought this was going to be my job. I kind of feel like I had an accidental career into patient experience at University of Utah. I was truly blessed to give a lot of professional opportunity. I did construction as an experienced leader. I led lean and cultural transformation with my partner at the time, the Chief Medical Quality Officer, Bob Pendleton.

Chrissy Daniels: But really the turning point for me is one day the CEO came into my office and he said, I'm trying to do the right thing around here. How come the patients are mad and the employees are sad? I need you to figure out what's going wrong. Give me a plan in four weeks. That really is what set my thinking about a patient experience sort of apart. I realize now with hindsight that I was always challenged by my organization to look at patient experience in conjunction with caregiver experience that it wasn't either or. It was yes. And then another senior executive, our senior vice president for health sciences, Dr. Laura Betz, asked a really hard question. He said something very similar; this was three or four years into our experience work. He said, I don't believe medicine is really great unless the patient thinks it is.

Chrissy Daniels: I love that. That's a simple phrase, but it sort of shook us to our core. We are a distinguished academic medical center who took great pride in our quality, and we were delivering great quality outcomes, but the patient's perception of that care was definitely lagging. Our systems were unresponsive. Our processes were more focused on caregiver convenience than patient experience. And with that one simple phrase, we really started to challenge ourselves. So, flash forward, I often say leaders lead by the questions they ask. By asking that one question, we really propel forward my journey to press Ganey happened almost by accident. So many of us as experienced leaders try new things all the time and we never know what is going to catch. I had a physician who told me that she had been maligned on a third-party site where someone had written something very critical of her, and my thought was she said, Chrissy, you have to help me.

Chrissy Daniels: I said, well, I have all these patient comments about you, and they all love you. What if we flood the internet with your patient reviews so that these one-offs will disappear? And that was the foundation of transparency, putting patient reviews on the internet back in 2012, we actually did it to protect our physician's reputations and it turned into industry wide phenomenon. And we've used Press Ganey throughout my journey, and I was the big proponent of the value of Press Ganey. And with that major innovation, it became natural for me to work at Press Ganey, helping clients understand how to leverage the products they were investing in to really bring the patient voice to life.

Steph Bayer: That's a lot in your background there in that answer that I want to pull apart. First, I just want to call you now an OG economist because that's new information for me that you started as an economist.

Chrissy Daniels: Yeah. I actually look at the world a lot through the lens of behavioral economics. I love it. Why do people make the decisions they make? And decision theory is very fascinating to me.

Steph Bayer: Yeah, it really is. And that's a great background for where you've landed now with this patient centricity and how do we make the patient a center part? I also love your advice that yes and say yes and be open, but you talked a little bit just a second ago about how Pres skinny is a leader, and they are in helping get transparency and data to the public in a verified way. I'm actually speaking at a conference coming up over in Asia and they asked if I would judge some different patient experience initiatives. And all over the world, healthcare has looked at differently and a lot of what they're doing is they're talking about Google reviews. And my comment in the judging was, these are great, but how do we know they're verified patients? How do we know that our providers have actually seen this person? And it's not just someone on the internet. And I love the idea that Press Guinea helps provide that verification. They help provide some reliability to the data and it is actually a support for our providers when you can share all of the good stuff too.

Chrissy Daniels: The interesting thing to me is you can see the difference in the quality of the feedback when you look at the feedback. Now, several organizations have done research on this, a Mayo Clinic and a surgeon team at University of Utah. They actually looked at the difference in the quality of feedback you get when you're surveying a patient for performance improvement versus the feedback you get in unsolicited feedback like through Google or Vitals or some other third-party review site. And it's interesting because there's a qualitative difference. It's not just whether they're verified or not. People who give feedback on unsolicited feedback on third party sites are disproportionately negative, but our patients are actually in a relationship with us and when we ask them for feedback or input on how we can make the operation better, we hear from a much more representative group of patients that patients who want to help us, who want to co-design with us, want to make care better, want us to know what we're doing, so we keep doing it.

Chrissy Daniels: That's the power I think, of transparency. Not only that they're verified, but we're hearing from a more representative sample of patients, people who would never think to go put a comment on a third-party site. And when we can share their voices, it really helps that consumer. They want information to understand, number one, what do people like about this operation system provider? We've seen in our research that positive comments are more than twice as influential as negative comments because people want to know what do people like? And transparency helps bring the voice of people who like the care to that environment.

Steph Bayer: I love that point on the positive comments and the power of that because I think so often in patient experience, we can lean towards, we want to fix what's not working perfectly. And one of the things people know, press Ganey for all of the data that you can create from our individual patient surveys and the results of HCAHPS and other survey mechanisms. But one of the things that we've talked a lot about and love to explore more with you is the data matters. It does matter. We're scientists in healthcare, but data absent stories and that qualitative and the power stories, it really isn't as motivating for action. How do we balance it? How do we make sure that we're telling the stories? What are you seeing?

Chrissy Daniels: So we have a little truism at Press Ganey. No stories without data and no data without stories because well, I would say it's not so much true now, but the majority of my career, a lot of the conversation institutionally was about the data in healthcare. We are really good at improving the old saying, you can't improve unless you can measure it. And I fully believe in that, but with patient experience, we are often trying to change hearts and minds, and I always say, no one got into healthcare to move an HCAP score, including me. That's not why anyone gets into healthcare. But we all want to be in healthcare to be real positive difference makers in patients' lives. We tend to bring a defect orientation to improvement in healthcare. We look at what isn't working, and I think that's part of clinical training that we look at what's broken and try to fix it.

Chrissy Daniels: The problem is, is that getting rid of complaints isn't what will let us be successful in-patient experience. The data shows us that the big difference between underperformance and excellence in patient experience is not the absence of complaints. Healthcare will have complaints, but it's the presence of trust building behavior that by more positively doing the right things is what prevents the wrong thing. So, when we only focus on complaints or negative stories, we actually orient our patient experience engine in the wrong direction. So, what if I could reverse my whole patient experience career and start over again? What I would do is I wouldn't have started with the complaints. I would have said, this is what the ideal state to borrow from lien. This is the ideal state. This is what our happiest patient looks like. That is only happening with five out of 10 patients today.

Chrissy Daniels: What can we do to be able to do our best work more often? This helps the staff know what they did, it helps them prioritize what they do that matters, and it helps us have the right conversation, which is what gets in your way. We know from the national data that teamwork is the number one thing across all drivers in every episode of care. We know that being able to listen to patients and to explain things goes a long way. And so, the idea that if we could describe the ideal state and then instead of focusing on complaints, focus on consistency. And this is one reason why Leslie Reco is a true innovator in the field of patient experience. For those of you who don't work at Cleveland Clinic, Leslie is the chief safety quality and experience officer at Cleveland Clinic. And she brings this orientation of not how do we do more, but how do we do our best work reliably to the patient experience? And that probably is the most important message that I'm sharing all over the country.

Steph Bayer: It's so true, and Leslie is amazing to work. Besides, I'm so excited that I get this chance, but she's a real innovator. We are currently rolling out to all 70,000 plus caregivers here at the Cleveland Clinic high reliability training. So, what we're gifting our caregivers with the skillset that they're going to be able to carry with them throughout their entire career of how to be a safe organization, to have more standard processes and communicate in ways that we can rely on. And what I love about the design of it, it wasn't just designed with we think high reliability. I think airline industry, we think safety practices and that is the foundation, but we also incorporated some patient experience fundamentals like smile, introduce yourself because those behaviors also help build reliability in each other.

Chrissy Daniels: So at its foundation, when we look at high reliability, it's that we have the skills, relationship skills to create psychological safety. There is a huge emotional component to high reliability, whether it's creating psychological safety on our teams or creating psychological safety with the patient. And truly that's really what patient experience is about. It's not, although so many people say it's about being nice, really it's around creating psychological safety so that that patient feels respected and is willing to speak up, willing to be able to ask or offer important information to understand our positive intent and the reliability skills that we need to offer really complex communication to ensure that as we work caring for more and more of our patients as a team, that we're creating this consistency. And the example I use around why experience is reliability. I compare bedside report to the experience I have with flying on airlines and hearing the flight safety message.

Chrissy Daniels: So many of the concerns I've heard from caregivers are the patients seem sort of disengaged sometimes during bedside report. They don't seem like they're paying attention. And even when we're engaging them, they're not always active and I don't even know if they like it. Well, I would say the same thing about myself as a passenger on a plane. I seem very disengaged during the safety message. I may have heard it several times. I may not be paying attention, but I can tell you one thing that if someone decided not to do the safety message, they would definitely have my attention. I would perhaps start to question all of my safety by skipping that. And I think when we think about how much we're doing to convey consistency and convey that continuous positive intent through things like the daily plan of care visit, that Cleveland Clinic has pioneered the idea that every day we're going to gather.

Chrissy Daniels: And there may be days when patients don't seem all that engaged, but I can tell you that our consistency of showing up is what gives them the luxury to be disengaged. It's what allows them to feel like they're in our safe hands and they don't have to be totally vigilant. So, I couldn't be more of an endorser Dr. Greco's vision to incorporate patient experience in HRO. This is perhaps I think the most important innovation in patient experience in our era is to stop telling our caregivers they need to care more and instead building reliable processes to both build relationships and to communicate complex care so that they can care. Right.

Steph Bayer: Oh, I love that. It's not caring more. We know they care. It's making it easier to care. Right. I love that. And I think it also goes back to what you said you learned earlier in your career where we could be offering the safest, highest quality care there is. But if a patient doesn't feel that back and we're not doing this in a way that allows them to have a peace of mind and some ease and that reliability, then it doesn't matter. It's also what patients are perceiving. And HRO is allowing us to line it all up.

Chrissy Daniels: And set up our caregivers so they can be successful instead of asking them to do more building structures so that the right communication happens in the right cadence. I just think it's very exciting and it kind of builds on something that is making me completely excited. And that is Ganey's partnership with Epic. And I know that Ganey has tons of information and it's in either the PX office or in a report or in the Press Ganey query tool. We know a lot about what every patient is likely to want, but it's not in the right place. It's not convenient to support that caregiver to be able to anticipate a patient's need. And so perhaps the thing I've called it, like I said, there is the history of patient experience prior to and the history of patient experience after the ability to bring predictive patient insights into Epic so that a caregiver doesn't get a percentile rank, which they don't care about or a mean score, but they get human information. This is a me, 57-year-old female who is having her first cardiology visit. We know that patients like Chrissy are very likely to be confused about the next steps in the plan of care. There's one thing you might be able to do for her is have her do a teach back on the plan of care. Those kinds of instructive, destructive insights woven into care delivery is really the holy grail for patient experience.

Steph Bayer: It's very exciting because it's going to make it easier for folks to have a structured process, to know their patient, to not have to add more time to be able to access that relationship foundation. And the other thing that I love about high reliability and patient experience together is that we're going to go back to the airline example. Crews change all the time, but it's okay that the people are changing because the processes are standard and reliable. So, we know that in healthcare today, there's a lot of churning, there's a lot of changing the healthcare staffing. We should maybe gear towards that next. Sure. People want to know what you think. It's so hard to keep your same level of longevity as we used to see with the teams. High reliability allows us to have some buffer against some of those risk.

Chrissy Daniels: Oh, I do say that in the old days of patient experience, I knew that I could get to excellence, but I need two and a half years with a manager. And then if they would say, as soon as a nurse is on my unit for three or four years, they're good. So, we would literally wait it out.

Steph Bayer: You invest, and you wait.

Chrissy Daniels: I remember once a brilliant surgical nurse, Colleen Prasad said to me, I used to keep people for a long time, but it seems like I can only keep 'em for two and a half years. How do I get them to competent and know that they're only going to stay two years? And so, we started to think about reliability in that lens, and then we've been trying to bring our turnover down, and I think we all have made great progress there. But what if the turnover never gets down to where it was? That's where reliability thinking like plan of care visits or bedside report and actually teaching. And this is why I'm so excited that you said you're bringing that leadership competency of reliability leadership to all of your leaders. Most of us of a certain age got promoted in healthcare for firefighting. I was like the best firefighter.

Chrissy Daniels: If you had a fire and you gave it to me, I would get that fire out. We could respond and react, get something under control. But we were never taught how to keep something going forever and ever. You went from fire to fire to fire. It feels to me like what I think of that as like a sprint, like a 50-yard dash. Now we're being asked to lead marathons, making sure that we have no harm, zero harm, no collapses, no falls, and we're doing it, but we're doing it with different leadership skills than we used to. It's not firefighting that's getting us there. And so needed to learn new leadership skills myself. And when I recognized my own bias that I recognized that I wasn't consistent and that's why my teams weren't consistent, that I didn't really have a way of saying what was important to me every day, connecting with my staff about the same things, keeping work alive and vibrant when I built my own skills, when I changed, my team changed. And so, the fact that the organization's investing, and I think of it as giving marathon skills to all of us, 50 yard, nothing that will hold back excellence in any way. Once we all get the right tools to solve the problems of today, that's when things are going to change. So, I love this idea that it's not a PX toolkit or a safety toolkit, it's a leadership toolkit to lead the kind of consistent reliable care that our communities need.

Steph Bayer: I mean, it speaks to why high reliability and patient experience need to go hand in hand in that connection. When we think about the turnover rate and the burnout in healthcare, are you seeing, because you do a lot of work also in Press Ganey around engagement and how caregivers feel supported. Are you seeing any practical strategies in addition to high reliability that organizations are leaned into advance PE to protect their workforce in this new world?

Chrissy Daniels: Well, it's interesting. Our workforce is foundationally changing. And the majority of American caregivers right now I think are millennials. And we learned a lot in the pandemic. We learned about what we liked, and we learned what we didn't like. What we learned that we liked is you actually see in the engagement data and the patient experience data that in the early period of the pandemic, our performance went up. We were purpose-driven, connecting to and with the patients. We saw unprecedented involvement and transparency within organizations where the frontline felt connected to their senior team, that they understood how decisions were being made, and it was all about the patient.

Chrissy Daniels: People love that. But now that we want to get back to our day-to-day business, our teams are still demanding it. The workforce of today is craving belonging. They are craving purpose. They are craving a voice, and they want to be part of very strong teams. So, when we look at what's going to advance and stabilize the workforce of tomorrow, interestingly, we go back to a space where there's psychological safety, where there's equity, where there's excellence, and where there's human-centered design. At Presca, we talk about the human experience because it is a human experience. People want to be respected, they want to be valued, they want to feel safe, and they want to make a difference, whether it's our patient, our consumer, our clinical caregiver team, or the operators who support them. I think it's an exciting time for activating empathy, being able to demonstrate empathy in the way we design care to be delivered care that patients want, that the data supports and that the teams can actually deliver. So, for me, it's not either or. It is a big yes.

Steph Bayer: I think we take for granted how much we do crave purpose and empathy and connection to our teams. Actually, right now, my dad is hospitalized at the same time. My best friend, her dad, is also here at the Cleveland Clinic. So, we caught up the other day in the lobby just by chance, and she's actually in more of a business role in her world. And she said, I'm so jealous that you get to work here. And I said, really? And she said, you're working in a place with purpose, a place where the work matters, and I can see it in your teams, how committed are to making a difference and well as know as patient experience. I was thrilled that that was her perception as a family member. But I also thought she's right. That is what separates healthcare from making just a dollar. It's that life connection that you get to do here and what a gift.

Chrissy Daniels: And as we wrap up, just being able to think about the stories we're telling. When I think about why you get into healthcare, yes, we wanted to save a life, but in the saving of that life, we wanted to help people and for people to feel connected to us, connected to the way we transform their life, we want that real virtuous cycle of hard work and making differences. So, it's one thing to save someone's life, it's another to feel the affection and respect between each other. A funny story, once we're looking at creating efficiencies in practice, trying to create access, and one suggestion was that the post-surgical visit be handled by an advanced practice provider and a surgeon says something to me, I'll never forget Blake Hamilton, he's a urologist. He said, no, that's my victory visit. You're not taking that from me. That's the visit that lets me keep practicing medicine. When I get to see the difference I made, he knows clinically that he had the outcome, but what he wants is that moment of seeing someone return to functionality, to have the life that they wanted to see. Not only did he capture the tumor, but he gave someone back purpose in their lives, and that's what fills him up. And so patient experience, we're full of those purpose making stories, and our obligation is to ensure that caregivers understand how grateful patients really are.

Steph Bayer: This is such great advice. And I think maybe just the last question while I have your time, your so valuable time as I think it through, and we've talked about purpose and empathy and connection, these can sometimes feel like softer concepts, and we know that there's a lot of hard work around that. What advice do you have though to an organization, especially in these tight financial times, budgets constricting to continue to value and improve lives? What advice would you leave us with?

Chrissy Daniels: I think it's perilous for patient experience leaders to take a narrow focus of their work. I think when all as experienced leaders that we talk about are percentile ranks or cap scores, we're creating irrelevance for us. When we focus and expand our perspective, I'd like to think of what's the next connection you could make? Brian Carlson makes great connection. He's at Vanderbilt, he's ACXO. He sees the connection between teams and patient experience. So, he leapt over the fence to think about employee engagement and how he could strengthen teams. You see that connection between the psychological impact of the increased incivility on our caregivers, how that's impacting turnover and burnout, and you leapt over your fence to not only resolve this kind of most difficult patient complaints through both systems and processes, but also creating those connections to support those caregivers who've experienced disrespect. A third leader, Jennifer Baron at uc Davis, she recognizes that she can't advance experience unless she's creating a culture of belonging and kindness. And so, her foundational work is on how they're treating one another, which will then manifest in how we treat our patients. So, I would say in times of financial difficulty, we need to stretch our wings. We need to make those connections, and we need to lean into leadership. And as long as we're being protective in our thinking, we kind of doom ourselves. But if we're expansive in our thinking, if we're more holistic, that's where that next generation of experienced leaders will come from.

Steph Bayer: That is great advice. Thank you for your time today. I'm so grateful.

Chrissy Daniels: Well, we sound like we're having such a great conversation because we we're always having such a great conversation. I love being here with you. I love to hear from any of your listeners, but excited about the path and the industry leading role you're taking in imagining what experience is going to become.

Steph Bayer: This concludes the Studies and Empathy podcast. You can find additional podcast episodes on our website, my dot cleveland clinic.org/podcast. Subscribe to the Studies and Empathy podcast and iTunes, Google Play, SoundCloud, Stitcher, or wherever you get your podcast. Thank you for listening. Join us again soon.