Cleveland Clinic's CXO focuses on the patient experience

Since 2009, Dr. James Merlino has been the chief experience officer at the Cleveland Clinic, which was among the first healthcare organizations to create a CXO role. He will leave that position this year to join performance improvement firm Press Ganey, as president and chief medical officer of its strategic consulting division. Merlino is a colorectal surgeon who founded and serves as president of the Association for Patient Experience, a not-for-profit sponsored by the Cleveland Clinic focused on improving patient satisfaction. He is also the author of a new book called “Service Fanatics: How to Build Superior Patient Experience the Cleveland Clinic Way.” Modern Healthcare reporter Sabriya Rice recently spoke with Merlino about how he became a CXO, what CXOs do, and the challenges he has faced at the Cleveland Clinic in improving safety and quality. This is an edited transcript.

Modern Healthcare: How did you become chief experience officer?

Dr. Jim Merlino: I became the Cleveland Clinic's second CXO in 2009 after I interviewed with our CEO, Dr. Toby Cosgrove. One of the initiatives that Dr. Cosgrove really wanted to drive at Cleveland Clinic when he started was getting the organization back to a more patient-centric environment. He felt we had strayed from the roots of our founding model. Nobody was paying attention to the patient experience. People just didn't think it was important. Cleveland Clinic had become big and famous because of high-volume quality outcomes, and I think it just got lost in the shuffle.

MH: What got you interested in this field?

Merlino: Before Dr. Cosgrove became CEO, my father came into the Cleveland Clinic for an ambulatory procedure and had a complication that was no one's fault. He ended up staying five days in the hospital and, ultimately, succumbed to the complication. I was a fellow in training then. We didn't talk about patient experience back then, but it was the first time I had ever been on the other side of patient care as someone who was about to enter practice. His experience in the hospital and my family's experience was terrible. This was what really got me interested in wanting to be the chief experience officer.

MH: How would you describe your day-to-day role?

Merlino: One of the most important aspects of my job is to keep the fire burning around the idea that we need to make the patient experience better. I actually have a very easy job because Dr. Cosgrove lives that vision and talks about it all the time. He expects people to manage to it and use metrics to improve it. My job is to keep it in front of people. I also have a performance-improvement team that looks for best practices. I'm responsible for making sure that patients have access to get to the right physician in the right department at the right time. I'm also responsible for patient relations and patient complaints.

MH: What is the biggest misperception that people have about the role?

Merlino: Patient experience has been branded as being about making patients happy. It is not. Ultimately, this is about how we deliver care. If you just look at HCAHPS, the CMS-mandated inpatient survey, there are nine questions about communication. When you improve the way nurses communicate at the bedside, falls, pressure ulcers and medication errors all go down. That's safety. When physicians communicate better with nurses, coordination of care is improved. When physicians communicate with patients and families more effectively, compliance with treatments improves.

MH: Why is it important to have a completely separate role for the patient experience officer?

Merlino: In organizations that have adopted this into their culture, the role probably becomes less important. But when you are in an organization that is trying to improve or you're in a bad place, you need to have somebody who's leading it. One reason Dr. Cosgrove implemented it at Cleveland Clinic is because we were in a bad space. If you looked at just our HCAHPS scores, we were among the worst hospitals in the U.S. He did a lot to drive performance improvement before he hired a CXO. But he recognized that, as the CEO, he needed to bring somebody in to execute on his vision.

MH: What challenges were presented at the Cleveland Clinic to improving the patient experience?

Merlino: The biggest challenge was recognizing that this is cultural. You can teach people how to interact with each other and you can execute a variety of different tactics. But at the end of the day, if everybody who comes to work doesn't understand that they're there for the patient and nothing else, you're not going to be able to improve. We've been very successful at developing our culture to the point where people understand that. Even five years ago if you walked around our organization and asked people, “What are you here for?” they would have responded, “I'm a doctor” or “I'm a nurse.” Last December, I asked 10 random employees who are caregivers, “Why are you here?” Eight answered something like, “I'm here to take care of patients.” Because we only got eight out of 10, I look at that as a B, which means we still have a lot of work to do. But I think that's a tremendous improvement.

MH: What unique qualities does an M.D. bring to the position?

Merlino: I think different people with different backgrounds can serve in the role. What makes the role successful is, number one, proximity to the top leaders. At Cleveland Clinic, Dr. Cosgrove made sure this role is really close to him. I sit on the executive team, and I meet with him regularly. The second thing, if you're a physician in this role, you need to have a very strong nurse partner. My partner in crime in patient experience is Kelly Hancock, our executive chief nursing officer. Our success in patient experience belongs as much to her as it does to me. If you're a nurse in the role, you have to have a physician partner.

One of the critical elements we have to understand in healthcare is it's a tribal mentality. Nursing is a very powerful stakeholder group. The physicians are a powerful stakeholder group, etc., etc. You need to have key people representing those stakeholder groups working together to drive an organizational strategy. It's not necessarily that a physician is better than a nurse. It's about how you frame it in the organization and who your partners are.

MH: What advice would you have for C-suite leaders looking to add a patient experience officer?

Merlino: It's important that you look for people who are respected within the organization. I think the role probably needs to be filled by somebody who comes from within because there is a strength to having somebody who understands the cultural nuances and informal leadership processes, as well as the operations. You need to have somebody who understands how improving the patient experience can integrate with what else needs to be done to drive safety, quality and operational performance.