By Joe Mandato
“We are in a national emergency.” - President Joe Biden
The COVID-19 pandemic has disrupted the nation’s health and the effective delivery of care. It has cost lives. Nurses and doctors work long and stressful hours tending to the ill and dying. They do so in emotional vacuums where a patient’s family and friends are kept away. Many elderly have decided to age in place -- at home -- rather than risk going to nursing homes. In physical and mental health, telehealth has become commonplace, with care providers offering or even requiring a secure video visit instead of a walk-in appointment. Scientists have developed, and the FDA has approved, vaccines and treatments in warp-speed time, faster than the market was prepared to manage.
The list goes on; these are once-in-a-century developments -- some negative and some positive disruptions to the delivery of care. When we emerge from the unprecedented emergency actions taking place, what should society, and in particular the 20 percent of our economy that is healthcare, look and feel like? What have we learned that we might use to disrupt healthcare for the greater good? Can we shape a new and better normal?
This relates to the challenges of building a “peace” after pain, emergency, and crisis. In WWII, the Allies were so focused on winning that they did too little to prepare for the peace. Here’s an excerpt from an article, “End of WWII was Met with Absolute Chaos” from Stars & Stripes:
“I think there is an illusion that wars end neatly, and they don’t,” said Thomas Childers, an author and University of Pennsylvania historian… Victory in Europe Day left central Europe “in absolute chaos.”
Confusion was the order of the day (or, the years), but soon came the Marshall Plan, a $15 billion plan to rebuild the European continent (in today’s dollars, $162 billion), considered by some to be the most successful economic undertaking in history.
Is it too dramatic to say we face a similar situation today as it relates to healthcare? I believe our healthcare leaders have an unprecedented opportunity and obligation to provide a post-pandemic version of the Marshall Plan. I want to advocate that the plan should rally around one theme, a vastly improved patient experience... i.e., focusing on, even obsessing over, the “care” part of healthcare. This isn’t new advocacy by me -- I’ve long engaged with organizations that have focused on patient experience as the vital component of their success, and I’ve long advocated for the industry to develop strategies that revolve around patient experience. While not new, it remains critically important. I suggest five points for what the post-pandemic, patient-centric healthcare sector strategy might look like.
Healthcare leaders have told me so many times over the years that the industry uniquely faces extraordinary complexity, stemming from, among other things, poor overall population health, a multi-payor system, and pricing opacity. This is a core reason why healthcare leaders cannot focus as much on a culture of delivering a great patient experience as leaders in other industries can focus on delivering a great customer experience. Healthcare is, industry leaders say (directly and indirectly) exceptional, and not to be compared. Yet, as a healthcare industry executive, I have long disagreed with this bias towards healthcare exceptionalism. I see healthcare as an industry like others. The particular healthcare industry traits like multiple payors and poor population health do not constitute, I believe, an excuse for not performing well in the area of patient experience.
The tacit and sometimes explicit healthcare exceptionalism claim I cite is important background as to why industry organizations have too often failed to develop cultures that prioritize patient experience. Money is not the reason, because it costs no more to treat people with respect than without it, including things like physicians and staff members identifying themselves and their roles, addressing patients by name, smiling, managing wait times, and helping patients find their way. Culture is the reason; culture is the way institutions do things, and if it isn’t purposefully defined by leaders, it evolves on its own. Leaders must set the right cultural expectation for the delivery of patient care.
I believe that had our nation’s healthcare organizations previously, before COVID-19 arrived, focused on the simple cultural principle of treating their patients very well, the COVID-19 diagnosis, testing, and vaccine mess, featuring ample finger pointing and blame, would not have transpired. As we know too well, testing lines have been long, as have wait times for results. Vaccine distribution has been a management and leadership miasma. For my part, I couldn’t get an appointment for a vaccine from any one of several large, California hospital systems. Here’s an excerpt from an e-mail from a system:
Please go into your My Health Online account under "appointments" and "vaccination-scheduling" to get an appointment. The website crashes frequently, so it may take some time to get through. Please call our office Tuesday if you need assistance.
Needless to say, neither appointments nor vaccine was available on the site for the remainder of the month. Contrast this with an organization that has had an organizational and cultural principal of treating patients well -- One Medical, an operator of performance-driven, privately financed primary care clinics focused on improving patient experiences. Despite recent allegations of prematurely administering shots to educators, One Medical sourced an adequate volume of the vaccine and had appointments available with easy online sign-up. (Roland Pickens, director of the San Francisco Health network, told the San Francisco Chronicle that “to their credit, One Medical figured it out early ... and ... had infrastructure to get shots in arms quickly.”)
One Medical has since inception focused on the patient experience, and its rapid sourcing and delivery of vaccines shows that the culture and leadership of focusing on the patient experience can indeed turn complexity (of COVID-19 or anything else) into relative simplicity. The post-COVID-19 era presents a need and an opportunity for organizations to focus on the patient experience in earnest. They must make patient experience their “hedgehog,” to use a term popularized by Jim Collins in his bestselling 2001 book, Good to Great. Collins explains that in the Greek parable, the wily fox knows many things, but the simple, slower hedgehog knows one big thing, and it turns out that in going up against a wily fox, the hedgehog wins every time. Great companies look and act like hedgehogs, says Collins. For the post-COVID-19 era plan, I suggest healthcare adopt Collins comment. Great healthcare organizations must become patient experience hedgehogs.
My many experiences in healthcare -- these involve my beautiful 99-year-old mother, as well as conversations with other patients, considering that patient experience is my professional passion -- tell me that America is a service economy but not an empathy economy, and that this shows itself nowhere more than in healthcare. Is there a difference between service and empathy? Yes.
Service is defined as “the action of helping or doing work for someone.” In this definition, a person takes an action but does not necessarily have a skill.
Empathy is defined as “the ability to understand and share the feelings of another.” In this definition, a person has an “ability,” or skill.
Empathy is a skill that involves a propensity for nurturing, reaching out, and helping. For instance, a person with empathy is inclined to listen, uses paraphrase and summary statements with customers and patients, and reflects on the feelings shared by a customer or patient. That’s a bare minimum of the skill set that differentiates empathy from service in healthcare and in the American economy overall.
We need providers as a matter of habit, and at all levels beginning with the receptionist upwards, to hire empathetic people, not just service professionals, and make it a priority to instill in these employees the critical importance of treating patients with compassion and sensitivity. Instead of prioritizing expedience and costs in hiring a mere service professional, providers must systematically recruit people who have an inclination for nurturing and empathy, always defining and specifying the traits, background, and capabilities required for the healthcare sector’s empathy-requiring positions. Human resources should work with specialist recruiters who have the expertise and contacts to identify and pre-qualify right people for said roles. Consider how Starbucks recruits for its Barista position. The company says, “Baristas [should] personally connect with, laugh with and uplift the lives of our customers -- even if just for a few moments.” And, take the example of healthcare point solution, Devoted Health, when hiring for its frontline workers. Its co-founder states, “The standing order for the whole company is when doing any action or making any decision ‘close your eyes, imagine the face of someone in your family you love desperately and ask yourself if you were making the decision to impact him or her directly, what would you do?’” Starbucks and Devoted Health can clearly express how frontline workers should treat customers and patients. Large healthcare providers should do the same.
An improved staffing strategy is vital to an improved patient experience. For instance, one way to achieve a better balance of care and reduced wait times is to make greater use of high value, lower-cost (than MDs) providers such as Physician’s Assistants (PAs) and Nurse Practitioners (NPs). These professionals practice and prescribe medicine and are trained in team-based care. They improve productivity and throughput and reduce patient wait times. Although their positive impact on care and efficiency is well known we don’t see PAs (and NPs) often enough. Over 115,500 Certified PAs work in the US today. But, there are more than a million doctors. Post-COVID, healthcare providers need to change that ratio.
It is a fact that when care providers show compassion and empathy for their patients, outcomes improve and errors and malpractice suits decline. Training doctors in compassionate care produces happier doctors who experience less burnout. Just as they did pre-COVID, post-COVID physicians will be overloaded and overwhelmed; they are required by systems and insurers to focus on throughput and EHR system inputs more than on patient care. Sadly, many physicians have by and large lost personal contact with patients, which means that patients in turn become stressed and anxious during visits. To be clear, they have not necessarily lost compassion for patients, but their lower contact levels can be interpreted by patients as less compassion.
To compensate, many organizations provide empathy training for healthcare professionals. Indeed, compassionate care and empathy training have become a must-have for healthcare providers because it can reduce staff burnout and turnover and helps hospitals achieve baseline patient satisfaction scores for improved reimbursement from the Centers for Medicare and Medicaid Services (CMS). These actions are necessary but insufficient. Why? Because although it’s great that hospitals are investing in empathy training, their overarching motive for an investment in empathy often is tactical elements like CMS reimbursements and reduced physician turnover. Instead, leadership’s motive must be the holistic, positive, patient-centric strategy of building an organizational culture of empathy... of disrupting healthcare delivery by becoming front lines of compassion.
I recently co-authored an article about medical schools being key to training would-be physicians in effective, efficient, compassionate care. Many great institutions of higher medical education do this sporadically, but our deep dive into one -- East Carolina’s Brody School of Medicine -- shows that some do it extraordinarily well. Schools like Brody should, in my view, rise in the US News & World Report-type rankings of medical schools, given their commitment to training future physicians in compassionate care. By rising in rankings, there would be tighter alignment between a goal of greater compassion in the healthcare sector and the institutions responsible for early education re: compassion.
I believe physicians should be motivated and incented to practice medicine and should only in rare instances manage or lead complex healthcare organizations involving daunting logistical and human resource challenges. When I engage in any discussion about whether physicians should be c-suite managers and leaders, the response is along the lines of, “Business people only look at the bottom line and don’t know how to focus on great medical care; they caused this problem. Not being practitioners, they don’t have the slightest idea how to develop and deliver great care.”
I disagree. I believe the specialization of skills is the best way to run a large, complex organization. I believe physicians need to practice medicine and that experienced managers need to lead the organizations where physicians practice medicine. If the business people aren’t doing a good job, then the physicians should -- instead of reciting that it’s because healthcare is exceptionally complex and needs physicians to lead the organizations -- replace those business people with better ones. Don’t throw out the baby (specialization of skills) with the bathwater (sub-par business people), i.e., we identified the problem -- poor performing business people but we solved it wrong (just add physicians as business leaders -- they’ll fix it).
Others argue, “Look at Mayo Clinic and Cleveland Clinic, they have physicians as CEOs and they’re the best in the industry.” True, these organizations are the best -- no dispute -- but they’re the best in a poorly managed industry, known for waste and inefficiency. Do we really believe that their model is the only way to manage? I’m not negative on them, I’m negative on the maladaptive evolution of the industry.
In 2018, a Boston newspaper described how the then-CEO of a major medical center took a simple, hardline approach after nurses staged a one-day walkout. What he did was to lock them out of their jobs for four days. His approach was not simple, it was simplistic. The physician-turned-CEO’s tactic damaged the system’s relationship and trust with nurses. Then, costly, traveling nurses were called in on an emergency basis. Dumb, right? Still, the parent company subsequently promoted him to chief physician executive of the larger health network. Do I think he’ll succeed there? Not if we go by any typical business’s definition of success. His largely clinical background doesn’t evidence experience commensurate with the challenges of solving complex organizational issues for the benefit of all stakeholders.
Another example -- Haven, which I have written about previously. This breakthrough entity was created by Amazon, Berkshire Hathaway, and JP Morgan Chase to disrupt healthcare. The CEO was a surgeon-writer-professor, which made little sense to anyone who has led healthcare organizations. While brilliant, he had the wrong background to lead this daring new initiative. They then set a list of complex goals for Haven. Reviewing the long list of priorities -- knowing that many priorities is as good as no priorities -- I knew it could not succeed. And, it did not.
I contend that physicians should practice healthcare -- for which they’ve been trained -- and they should be respected and supported by strong business people. Meanwhile, physicians should recognize that strong business people are skilled in their respective disciplines. Mutual respect would be a more successful way of leading the industry towards a better future. In my career as an investor and business leader, I’ve found profitability and financial success are hardly antithetical to great healthcare. Indeed, knowing that you’re on a financially sustainable, winning team engenders greater compassion by physicians, not less. I don’t see making sustainable financial decisions, so called “hard-nosed, cold, calculating bottom line decisions” as antithetical to empathetic care. I see that strong financials support strong physicians and vice versa.
Lastly, there’s COVID-specific healthcare management. Examples abound of health systems not distributing vaccines efficiently. Why? Although I no longer work at any healthcare organization, the benefit of my career-long industry participation informs me that the reason likely stems from healthcare organizations’ embedded attitudes of exceptionalism whereby -- because healthcare is “different” and above the notion of being compared -- they have staffed their administrative and management ranks with too many physicians and too few people who specialize in complex, but unsexy, operations like human resource management, technology, logistics, supply chain, inventory management, transportation, and customer service.
Post-COVID, our healthcare sector needs to make better business decisions than this by aligning the organizational structure with the priority and need to deliver a job well done. Remember, we had six months to be better prepared.
Healthcare providers have, through claims of exceptionalism, managed the public expectation (of a poor patient experience) so well that it has let itself off the hook for poor patient experiences. We need this dynamic to change. Healthcare leaders should consider good clinical outcomes and good patient experiences to be coequals and to establish true accountability for this. It’s been shown that a good experience with a care provider can indeed help a patient have a better clinical outcome -- indeed, not mere correlation, but some level of causality.
Hospital systems operate under the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) provision in which patients score their provider through a patient satisfaction survey. CMS withholds reimbursement for institutions scoring poorly. But, let’s get real -- does anyone think there is much correlation between the survey questions and a superior patient experience that compares well to that of an Apple store, Starbucks, or Devoted-type of experience, where efficiency is great and service to customers is extraordinary? I can answer that rhetorical question with my own example, where there wasn’t much correlation at all. Following one unpleasant healthcare experience, I received a survey with questions basically asking whether I was treated like a human being. The survey did not get to the crux of the issue of putting compassionate care into sustained practice. Apple, Starbucks, Devoted, and others admittedly have customer bases with more resources than many patients do, but hospital systems overall have aggregate financial resources that can easily support the delivery of an excellent patient experience.
In addition to sending out HCAHPS surveys, many institutions have a patient experience officer. Problem is, in most cases that person lacks real authority to make proactive, high-impact change. It seems that often these institutions hired patient experience officers to help lessen the financial penalties of HCAHPS rather than to improve the thousands of annual patient experiences in meaningful, consistent, and measurable, ways. When I request industry accountability and authority, I’m asking for a real match between the level of responsibility to improve the patient experience and the authority to do so. This begins with a great leader.
As a young Army officer, I was aide de camp to the Commanding General of Walter Reed Army Hospital, Major General Carl Hughes. What a lesson for me in patient experience! Each morning, first thing, he spent an hour walking the hospital, patient wards, and administrative offices, talking with people, and patients, and listening to them. He understood the patient experience at his hospital. He was visible, present, and aware. He asked questions, and then shared his perspective after each encounter as to his sense of how it could be improved. General Hughes demonstrated with every word and action that he cared about patients. He set the standard and the expectation. Chief patient experience officers should have walk arounds every day with the CEOs of the hospital systems. They should notice -- jointly and together, as a patient experience team -- where opportunities exist, where problems lie, and how to take action to fix them.
Some people believe if healthcare providers had more money they could provide a better experience. We spend more per capita on healthcare than any other nation on Earth yet our outcomes are in the middle. Money isn’t the problem, it’s culture, leadership, poor execution and waste. Most healthcare systems seem not to know whether to pursue financial stability, physician contentment, superior outcomes, more transparent prices, lower costs, or greater patient satisfaction, which means they in effect pursue no priorities. Focusing on the patient experience as the driving mandate, and then organizing to deliver that, is a better route. Unless the healthcare sector’s disparate, many-headed-beast “strategy” changes, the above patient-centered healthcare delivery metrics won’t happen, and this crime of omission will transpire at a time when we have the biggest opportunity in a century to effect post-pandemic change, a time when a new healthcare normal will be written, created, and built. If we don’t demand this change now, the pandemic’s disruptions -- by which I mean both the bad disruptions of lives changed and lost, and the good disruptions, the Clay Christensen-type disruptions, of new ways of doing healthcare -- will increasingly be in the rear-view mirror. Our trillion-dollar sector of questionable performance will remain the same.
About the Author:
Joe Mandato was a 2011-2012 Fellow of Harvard University’s Advanced Leadership Initiative. He is a Managing Director at DeNovo Ventures, a venture firm investing in the life sciences, a Senior Advisor at Sonder Capital and is a Lecturer at Stanford University’s Biodesign program. He has served on a number of public and private sector boards of directors focused on technology and the life sciences. He also serves on the boards of Case Western Reserve University, Headstart and Save the Children. He received his Doctor of Business Administration degree from Case Western Reserve University, where his research focused on the evolving role of boards in ensuring effective corporate governance. He has authored or co-authored articles on healthcare and governance and the book The Entrepreneur’s Journey.
Mr. Mandato is not an investor or management team member at any organization mentioned in this article.