Have Staff Really Lost Sight of the Patient Experience?


Dr. Delos (“Toby”) Cosgrove, President and CEO of the famed Cleveland Clinic, wrote an article on LinkedIn recently: “Patient Experience: Time for Hospitals to Look Under the Bed.”

Cosgrove described his process of going to visit patients after heart surgery (good, which sounds like the Lean practice of “going to the gemba” to see what's really happening and it shows customer / patient focus).

During one visit (“many years ago”), Cosgrove had a patient's family tell him that he needed to look under the bed… what was there?

Cosgrove writes:

I looked, and to my everlasting humiliation, saw litter and dustballs. The patient and family felt neglected and disrespected – and they were right to be offended.

It's good that Cosgrove would be willing to tell this story in a fairly public forum. As I wrote about yesterday, it's important to first expose problems so we can solve problems.

When a Lean leader goes to the gemba, he or she then “asks why” and “shows respect” to the customers and those doing the work.

I'm not sure if Cosgrove's assessment of the situation seems plausible…

Ultimately, patient experience is determined by your caregivers – all of your caregivers, not just doctors and nurses. Receptionists, housekeeping, greeters, administrative staffers – they all impact the patient experience. They need to be motivated and engaged. Patient experience should be top-of-mind in everything they do. Employees will follow the agenda set by senior leadership. Administrators need to be clear about what service and experience is and why it's important; you can't let employees guess. Ask employees to imagine what it's like to be a patient or the family member of a patient. Ask them how they would like to be treated. Remind them that this is consistent with the ethical practice of medicine. Finally, explain the link to reimbursement. Medicare has begun indexing payments to patient satisfaction scores and commercial payers are following suit.

I'm not sure if staff members have lost sight of the patient being the priority. Nurses, doctors, housekeeping staff – they see patients every day.

It could be interpreted as Cosgrove falling back on a somewhat traditional management approach of blaming the workers (they aren't aware or motivated?) I wish he had asked “why?” or at least said something about this being a system issue and not being the workers' fault.

A Lean problem solving approach would ask WHY there is dust under the bed, with questions such as:

  • Do we have the proper housekeeping staffing levels (in general and on each particular day)?
  • Is there clear standardized work for how to clean a room (including under the bed)?
  • Are there good management practices in place to ensure work can be done properly?
  • Do staff have all of the tools and supplies they need?
  • Do staff have enough time to do the work properly?
  • Are staff pressured into cutting corners on quality in order to get the work done more quickly?

These are all systemic issues, owned by management and senior leadership.

I could think of a lot of potential countermeasures to ensure the rooms are always cleaned properly… I don't think a bunch of training about “remember the patients” would really solve that problem. There's got to be something in the nuts and bolts of the operation to be improved.

Cosgrove did make one closing point I agreed with:

The move by Medicare and other payers to reward patient satisfaction is important. But it will not make or break our institutions. The real motivation for change needs to come from the heart. Not everything can be measure by ROI. We can't forget why we became doctors and nurses and administrators. In the final analysis, we work for a better patient experience because it's the right thing to do.

Yes, sometimes it's just the right thing to do.

Coincidentally, Bill Waddell wrote a post today about how manufacturing leaders can't expect to get cycle time reduction by merely pressuring people to work faster. I think the same lesson applies in healthcare and other settings.

…these guys think you reduce the time line by measuring it and lighting a fire under people to get stuff done faster. Getting them to work faster, according to these guys requires getting people to “feel the jungle” (an absurd phrase if ever I heard one) and make an “emotional investment.”

“Threatening people is a good means of getting them to make that emotional investment in feeling the jungle. When people are working as hard as humanly possible, reduce cycle times by outsourcing or getting people to fail fast to enter a white space with a higher probability of success” – another academic soufflé of a phrase.

As Bill called it — “nonsense.”

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. Thought provoking.

    I’m ambivalent about the Cosgrove quote you cite – do we KNOW he was blaming workers, or, if he has good relationships w them, was he perhaps sounding a call? Is he among them, in every sense, or standing outside and talking at them?

    This was written to the public (“determined by your caregivers”) so it’s probably even a marketing piece. Hm: I wonder why Toby (his nickname) didn’t say “Receptionists, housekeeping, greeters, administrative staffers – *WE* all impact the patient experience. *We* need to be motivated and engaged. …”

    But then he shifts to speaking to supervisors: “Administrators need to be clear … you can’t let employees guess. Ask employees to imagine what it’s like…”

    What does Lean say about this? Does a Lean leader speak in second and third person, or is the correct mind set “we”?

    This all connects to something I discovered the other day and I mean to blog about – when I do, I’ll come back here.

  2. Your 6 questions/suggestions are excellent, Mark. Especially the one about whether standard work exists or not. It’s hard to know the other answers (staff level requirements, tools needed, etc.) until we’ve defined the process with some level of standardization. Establishing consistency in basic processes has got to be one of the greatest opportunities for improvement in healthcare, and clearly falls into the “it’s not low-hanging fruit, it’s tripping on water melons” category.

  3. Through my MD lens, I don’t think he is blaming so much as invoking the typical MD attitude: “we’ve all got to work harder and do better for the patient.” (implied is the individual effort involved, not the team) This is as opposed to: “what is wrong with our system to allow dirt under the bed and what do we as a team need to put into place to fix the problem?” that Mark articulates.

    Ditto for his exhortations about being ‘motivated and engaged’. This is classic doctor speak. Not that it’s bad, but it usually doesn’t solve the underlying system problem.

    So my take is, he is not blaming, just not analyzing the problem correctly. Our MD culture is just entirely different.

  4. Mark,
    Thanks for sharing both the article and your thoughtful insights! It does appear to have a tone of shame and blame but the intent is spot on, every staff member owns the customer experience.

  5. Mark, as an employee at the Cleveland Clinic, I do not view Dr. Cosgrove’s comments as blame and shame. He has gone out of his way to make us all feel like “caregivers”, regardless of our role in the organization.

    Our first concern is with the patient and their overall experience, not just clinical outcomes.

    I’ve heard Dr. Cosgrove speak many times on this issue and his tone is not to blame, but to invite caregivers to become more involved with patient care. He is letting everyone know that we all have a role to play in the overall patient experience and we should all feel a little disappointed when our systems allow us to miss opportunities to make the patient experience better.

    I can appreciate your questioning leadership’s motives, however, in this case, I believe Dr. Cosgrove is showing some humility as a leader and admitting that we still have opportunities to improve.


    • Tim – Thanks for your perspective. Like I said, it’s great that Dr. Cosgrove is admitting there are problems and opportunities. I guess the danger of writing anything (especially something short) is that the nuance and tone and complete message doesn’t come across in an isolated piece.



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