How a hospital's chief experience officer tackles barriers to better quality

There were tentative glances across the conference room table when chief patient experience officer Airica Steed asked a multidisciplinary team of a dozen staffers to discuss the barriers they face in trying to improve the patient experience at the University of Illinois Hospital & Health Sciences System.

“I want to dig deeply into the concerns we're actually seeing and the roadblocks we're running up against in solving them,” she said during the mid-November meeting.

Steed, the system's first CXO, presented the team with a detailed list of about 40 open patient complaints. It included one about the clinic not returning phone calls to schedule an appointment, a patient walking out of the hospital because the doctor never came to the exam room, and a patient's claim that money disappeared from his wallet during a transfer. Other complaints included alleged medical errors, misdiagnoses and inappropriate staff conduct.

At first, no one spoke. There were sounds of shuffled papers and nervous throat-clearing as the team of patient navigators, patient engagement officers and process improvement and hospitality staff thought carefully about what to say. After an uncomfortable minute, they began to open up.

“We don't get rapid responses from leaders about resolving complaints. Patients want immediate responses and sometimes we wait months,” said one patient engagement officer. Another staffer said some departments either don't take patient complaints seriously or don't understand the role of the team investigating the events.

Since 2012, Steed, a registered nurse with a doctorate in education and a background in operations and performance improvement, has led UI Health's efforts to deliver patient-centered care. The group's initial hesitation to share their concerns was not surprising, she later said. Until recently, front-line employees were rarely engaged by leadership in such conversations, and when staff did speak up, their concerns were often seen as complaints.

“But if you can tap into what your staff are frustrated with, you identify 75% of the problem,” she told a Modern Healthcare reporter who shadowed her that day to see what a CXO at a large academic safety-net hospital does.

More hospitals and health systems are hiring chief experience officers, or CXOs, as they face growing pressures to improve consumer satisfaction, such as through ratings on the CMS' Hospital Consumer Assessment of Healthcare Providers and Systems survey. Low HCAHPS scores, as well as negative reviews from consumer groups and websites such as Yelp, can hurt business and bring financial penalties. But experts say the job is a tough one that requires strong support from top hospital leaders, deep understanding of hospital performance improvement and a deft personal touch. And both the CXO and the organization have to recognize that patient experience is closely linked to quality and safety.

It's estimated that there are currently about 60 U.S. hospital executives with the CXO title, and the number is slowly increasing. The Cleveland Clinic was one of the first systems to establish the position in 2007. Last week, the UC San Diego Health System named Dr. Thomas Savides to fill its newly created CXO role. In September, Johns Hopkins Medicine in Baltimore named Lisa Allen, a patient service and quality-improvement expert, as its first CXO. And last month, the Cleveland Clinic announced that Dr. Adrienne Boissy would replace Dr. James Merlino, who had held the job since 2009.

Hospitals generally have struggled with establishing and sustaining safety and quality initiatives, the Joint Commission reported in October. In the past, hospitals did not assign one person to oversee performance on patient satisfaction, and that lack of accountability has been problematic, said Donna Padilla, a senior partner with Witt/Kieffer, an executive search firm that works with academic medical centers. “Systems are starting to realize if it's everybody's job but no one is tapped to lead it, it falls to the bottom,” she said.

But Dr. Patricia Gabow, who led heralded performance improvement efforts at Denver Health while serving as its CEO, cautioned against expecting a chief experience officer to be the magic bullet. She said there must be a broad focus on redesigning the care process around the patient rather than concentrating solely on consumer amenities. For example, she said, if a hospital addresses long waits in the emergency department by simply adding big-screen TVs or gourmet coffee service, they're missing the point. “If you look at it from a care-redesign process, you say, 'We don't want to just make the wait more pleasant, we want to end the wait,' ” she said. “If we don't do that, this is all for naught and they won't succeed.”

The Cleveland Clinic's Merlino agreed that the CXO's job is to improve quality and safety along with customer satisfaction. “Ultimately, this is about how we deliver care,” he said. “When you improve the way nurses communicate at the bedside, falls, pressure ulcers and medication errors all go down. When physicians communicate with patients and families more effectively, compliance with treatments improves.”

But CXOs face many organizational challenges. In a Beryl Institute report published this year, 15 patient experience leaders described difficulties in working through hierarchies, breaking down departmental silos and coping with limited resources. One of their biggest challenges, they said, is simply establishing their place and purpose within the organization.

While other C-suite leaders have long had clearly delineated roles, the CXO position sometimes becomes a catchall, said Jason Wolf, president of the Beryl Institute, which focuses on improving the patient experience. “We don't ask the CFO to go run labs, but we may ask the chief experience officer to also be director of marketing,” he said.

Patient-safety leaders often talk about creating an organizational culture of safety. “The biggest challenge (in the CXO job) was recognizing that this is cultural,” Merlino said. “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.”

Steed, 36, previously served as a vice president at Advocate Health Care, where she helped elevate the system's focus on patient experience. She also worked as a clinical practice consultant at PricewaterhouseCoopers. She is trained in Lean Six Sigma, a total quality improvement methodology. Beyond her credentials, her personal style helps her win cooperation and trust. She smiles warmly as she greets each person by name, with a firm handshake. She's passionate about sharing insights drawn from her broad training and experience. Most importantly, people seem to want to talk to her.

“We're not forcing anything and we're really leaning on the front-line to tell us what works” she explains.

Steed said when she started the job in 2012, she first went after the “low-hanging fruit,” which generally involved making the hospital a more pleasant environment for patients and staff. One of the first problems she tackled was the customer experience when people arrived at the hospital's main entrance. There, staff greeters had to answer the phone while simultaneously trying to manage and direct the constant flow of patients, families and visitors. This was frustrating for patients and staff.

So Steed helped launch a partnership with the Chicago Lighthouse, a not-for-profit that provides employment and other services for the visually impaired. Starting last month, all phone calls to the hospital's main phone number now are handled by visually impaired clients of the Lighthouse, who are paid to help patients with registration, appointment scheduling, directions and other information.

The day a Modern Healthcare reporter visited was a long and hectic one for Steed, starting at 9 a.m. and extending past 10 p.m. She dashed from meeting to meeting to advise or consult with staff, lead an advisory panel of patients and their families, and review HCAHPS data with other staff. Her day began with an hour of morning rounds, during which she visited staff working at the customer service desk at the hospital's main entrance. Accompanied by Lorraine Saintus, director of operations excellence and customer operations, she spoke with patients in the waiting room. She also met with key members of the hospital's data analytics team and with UI Health CEO Avijit Ghosh.

In addition, she attended a quarterly partnership meeting with staff from Press Ganey, a performance-improvement company, which had recognized her efforts as a “success story” earlier in the month. The focus of that meeting, attended by the hospital's data analytics program manager and performance excellence leaders, was the future of public reporting of quality and patient-satisfaction data, as well as best practices. “We're finding there is a direct positive correlation between patient experience and outcomes,” said Dale Chung, regional director for Press Ganey who led the meeting.

By making herself visible and available across the organization, Steed seeks to build relationships and encourage open communication. Indeed, as she walked the halls, she often was taken aside by staffers who shared updates from their departments. One employee in a rush to the ladies' room stopped to give Steed a nursing department update.

Steed said these efforts at UI Health are new since she started the job in 2012, but she is seeing positive results. For instance, staff are less intimidated about speaking up about problems now.

One key result is UI Health's improvement on its HCAHPS scores. The HCAHPS survey measures patients' perceptions of their hospital experience and is based on a 0% to 100% scale. The survey covers nurses' and doctors' communications with patients, staff responsiveness to patients' needs, how well information about new medication is communicated and whether key information is provided at discharge. In 2014, the hospital scored 62% overall, compared with 57% in 2010.

In Steed's view, poor patient-satisfaction scores are symptoms of other problems, such as poor care coordination. “You can't just narrowly focus on patient experience without properly finding the root cause,” she said.

The Beryl Institute's Wolf said it's important to place the chief experience officer in the C-suite with close access to senior executives because that sends a signal to all staffers that the organization is prioritizing customer satisfaction and quality. “If the CXO is buried too deep down, you've already made a statement before you've even started,” Wolf said.

Steed's office is a few feet from the offices of the hospital CEO and other senior executives. She said she meets with them regularly, shares feedback gathered through her daily conversations and has input into the system's strategic direction.

“This is an important function,” said Ghosh, who has been CEO since August. He said he meets individually with Steed once every two weeks to talk about goals and projects. “With this position in place, there's a focus on trying to solve these problems in a more systematic kind of way,” he said.

Before her workday ended, Steed attended a meeting to hear the concerns of patients and families, as well as to recruit them to serve as volunteer “secret shoppers” and greeters. The meeting attendees suggested that the hospital provide transportation between various buildings on the campus to ease patient access, and that it should work to reduce wait times and better communicate when there are going to be delays. “These are things we already know we're grappling with, but it doesn't hurt to hear them again,” Steed said.

After two years of making her presence known throughout the hospital, Steed acknowledged that it hasn't been easy fostering open communication with staff and customers. “Patient experience is not an easy job,” she said. “It's ever-changing and really based on the needs and individual nuances of the organization.”

As in every organization, there are staff who are resistant to change. Her approach to dealing with them is to focus the conversation on what's best for patients. “They're not likely going to argue with that,” she said.

Follow Sabriya Rice on Twitter: @sabriyarice