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The four Ps of patient experience: A new strategic framework informed by theory and practice
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The four Ps of patient experience: A new strategic framework informed by theory and practice
Bita A. Kash, Molly McKahan, Lesley Tomaszewski & Darcy McMaughan
To cite this article: Bita A. Kash, Molly McKahan, Lesley Tomaszewski & Darcy McMaughan (2018) The four Ps of patient experience: A new strategic framework informed by theory and practice, Health Marketing Quarterly, 35:4, 313-325, DOI: 10.1080/07359683.2018.1524598 To link to this article: https://doi.org/10.1080/07359683.2018.1524598
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The four Ps of patient experience: A new strategic framework informed by theory and practice
Bita A. Kasha,b, Molly McKahana, Lesley Tomaszewskia, and Darcy McMaughana
aNSF Center for Health Organization Transformation, Texas A&M University, College Station, TX, USA;bCenter for Outcomes Research, Houston Methodist Research Institute, Houston, TX, USA
ABSTRACT
This article proposes a new strategic framework to assist healthcare organizations in achieving great patient experien- ces in the healthcare setting. We synthesize models of practice and literature relevant to the patient experience in order to propose the four Ps of patient experience. Key levers used in this model are: (a) trained autonomous physicians, (b) multi- disciplinary partners, (c) alternative places of care delivery matched to patient conditions and needs, and (d) standar- dized yet flexible processes. Healthcare leaders will be able to use the proposed framework to develop detailed strategies toward improving patient satisfaction and experiences.
KEYWORDS Customer service in healthcare; patient experience; patient as customer; patient satisfaction;
strategic framework
Introduction: The role of the patient experience in healthcare today Healthcare delivery in the United States has made great leaps in areas such as clinical care quality, patient safety, and operational effectiveness, includ- ing the standardization of many evidence-based clinical pathways and pro- tocols. Since the 2000s, the concept of the patient experience has gained importance as health systems move beyond quality and safety targets towards new key performance indicators, including patient satisfaction met- rics (Sofaer & Firminger, 2005). Therefore, creating a positive patient experience measured by patient experience and satisfaction surveys is highly relevant in today’s healthcare environment, as it is often linked to the new payment models (Centers for Medicare and Medicaid Services, 2014). Employer-sponsored health plans show a shift towards higher deductibles, making the patient more inclined to consider value based on price, convenience, and service experience (Claxton et al., 2013). Thus, for the first time in the evolution of innovations in healthcare delivery, health- care providers and health systems are looking for strategies that improve the patients’ experience.
CONTACTBita A. Kash [email protected] School of Public Health, Texas A&M University, MS 1266, College Station, TX 77843-1266, USA.
Color versions of one or more of the figures in the article can be found online atwww.tandfonline.com/whmq.
ß 2018 Taylor & Francis Group, LLC HEALTH MARKETING QUARTERLY 2018, VOL. 35, NO. 4, 313–325
https://doi.org/10.1080/07359683.2018.1524598
Unfortunately, the concepts of patient experience and customer service are not well developed in the healthcare setting compared to other related sectors, such as the service and hospitality sectors. Furthermore, current lit- erature on achieving great patient experience offers mostly anecdotal evi- dence and case reports, with little established theory or rigorous research of experience strategies. However, there seems to be plenty of experimentation by leading hospitals incorporating selected customer service strategies from leading hospitality and hotel brands into their healthcare delivery settings.
The proposed Four Ps framework in this article relies on models of practice and literature related to patience experience and provides a new strategic framework for action.
The Four Ps of patient experience: New strategic framework
Healthcare organizations aim to create a culture of great patient experien- ces similar to and inspired by customer service strategies in leading service and hospitality companies. A positive patient experience measured by widely used patient satisfaction survey tools forms the cornerstone of this new transformation in healthcare. In this article we propose a new strategic framework for patient experience based on both current models of practice and peer reviewed literature. A summary of the key takeaways from models of practice and literature supporting the Four Ps framework are summar- ized in Table 1.
Patient experience is unique when compared to customer experience in other service sectors. Healthcare is a people business characterized by a complex emotional context fueled by fear, pain, and anxiety due to both disease and treatment. The patient experience is also highly linked to and influenced by the overall organizational culture as experienced by interac- tions with physicians, other care team members (partners in care delivery), and the various places and multifaceted processes of care. Concerned with low patient satisfaction scores, organizational leaders often decide to “fix”
the organizational culture, since culture is often the cause and the cure.
The proposed strategic framework is rooted in the notion that culture is not something that is “fixed,” but evolves as the important organizational levers are moved (Lorsch & McTague, 2016). The proposed Four Ps of Patient Experience is a patient-centered framework that can provide health- care organizations a guide to design and positively influence the patient experience.
The four Ps of patient experience (Figure 1) focuses on the people (physicians and partners), processes, and places experienced by patients as part of their journey in receiving medical care. The Four Ps (levers) are defined as: (a) physicians; (b) partners (other providers, healthcare workers,
and care team staff); (c) places where people interact with the first two Ps;
and (d) processes that define and facilitate the clinical care protocol and patient journey. These levers can be moved to build the appropriate and desired workplace culture that facilitates the achievement of great patient experiences and patient satisfaction goals.
First P/Lever 1: Physicians
The patient’s primary contact and most meaningful relationship with the lead physician (Emanuel & Emanuel, 1992) is the first lever to consider.
Often the lead physician is the primary care provider or the key managing specialist, depending on patient condition. The organization pays special attention to providing the lead physicians with adequate autonomy to prac- tice individualized medicine (to assure patient-centeredness) and relevant
Table 1. Linking the four Ps of patient experience to theory and models of practice.
Patient experience Physicians Partners Places Processes
Time-investment servicea
Provide clear and detailed communication from healthcare professionalsb
Treat patients as whole personb
Identify customer’s hierarchy of needs
accuratelyc
Identify patient perceptionsd
Align patient and provider knowledgee
Encourage effective communication between healthcare professionals and patientsf
Workplace culture
Create a safe, empowering, and satisfying
work environmentg
Build on current cultural elementsh
Address compassion, fatigue, and emotional resiliencei,j
Implement cultural competence trainingc,i,k
Models of practice
Cleveland Clinic: Focus on empathy, engagement, and motivationl
Mayo Clinic: Patient-centered culturel,m
Disney: Focus on standards and tapping
into employee creativityn
Ritz-Carlton: Focus on Gold-standards and
striving to provide the wow experienceo
a(Berry et al.,2002; Lin et al.,2001).
b(Boudreaux et al.,2000).
c(Homburg et al.,2009).
d(Kumar & Reinartz,2016).
e(Dempsey et al.,2014).
f(Elliott et al.,2009).
g(Lowe,2002).
h(Carroll & Quijada,2004).
i(Lonial & Raju,2015; Weech-Maldonado et al.,2012).
j(Sergeant & Laws-Chapman,2012; Waytz,2016).
k(Vogus & McClelland,2016).
l(Merlino & Raman,2013).
m(Berry & Seltman,2008a,b; Viggiano et al.,2007).
n(Beltran et al.,2014; Freeman,2014; Lee,2004; Middaugh et al.,2008; Taylor,1999).
o(Partlow,1993; Saver,2008).
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training and information about management of the multi-disciplinary care team (to assure effective care coordination). Additional training focused on patient satisfaction, performance measurement tools, and payment models linked to performance is also necessary for the lead physician in charge of managing the patient’s condition and needs. Today’s physicians, especially those in charge of care management, need management tools and leader- ship skills to be most effective as the clinical team leaders and role models in creating the optimal patient experience.
Second P/Lever 2: Partners
Partners, such as nurse practitioners, physician assistants, nurses, other care team members, and the front desk and business office staff, come into con- tact with the patient before, during, and after the physician encounter.
Based on studies and models of practice covered in our research, the pri- mary organizational strategies focused on this group should provide part- ners with appropriate customer service training and support, including skill development in emotional resiliency and empathy.
Third P/Lever 3: Places
The third lever of this framework is the variety of places where care can be provided, including alternative access points available with telemedicine
Figure 1. 4 P’s of patient experience.
capabilities. The healthcare organizations need to connect people and patients in the most appropriate places—outpatient centers, emergency departments, and the patient’s home—based on patient conditions and preferences. Since places and access points need to be optimally matched with the patient’s condition and preferences, the traditional triage process needs to be purposefully linked to appropriate places of care. Hence places must be connected to the fourth P, processes.
Fourth P/Lever 4: Processes
To stay competitive in today’s market, healthcare organizations must develop effective and efficient processes that are patient-centered, informed by the newest models of operations management and research, and designed with the patient/customer perspective in mind. Ever since the publication of the first patient safety-focused Institute of Medicine (IOM) report, “To Err is Human” (2000), engineering the delivery of medicine has been continuously enhanced through the application of operations manage- ment science. Today’s strategies focused on continuous process improve- ment need to include the patient as a key player in and contributor to his/
her individualized care process in order to contribute to enhanced clinical outcomes and patient experience. Standardized processes need to also pro- vide adequate flexibility to allow for physician autonomy and patient-cen- tered care focused on both clinical outcomes and quality of life.
Models of practice informing the four Ps of patient experience
To develop this four Ps of patient experience, we drew on insights and knowledge gained from decades of practice-based organizational research in partnership with hospitals and health systems focused on the patient experience. In this section, we present four leading models of practice often implemented in the healthcare setting: Cleveland Clinic, Mayo Clinic, Disney, and Ritz Carlton. These four were chosen because their customer experience strategies are reported to being used in many hospital systems in the United States today.
Model 1: The Cleveland Clinic
With every patient interaction being equally significant, Cleveland Clinic stressed the importance of hospital staff understanding they are all care- givers. The Cleveland Clinic understands the significance of managing and addressing patient expectations by informing patients of what to expect before arriving at the clinic. To create improvements in patient satisfaction, Cleveland Clinic implemented four changes. First, identify problems
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through understanding root causes by tracking and analyzing patient atti- tudes and complaints. Second, establish processes and norms, in which the most impactful change was the ability for all patients to make same-day appointments to reduce feeling overwhelmed. Third, mandate for hourly rounds since units that perform these rounds had higher patient-experience scores. Fourth, engage and motivate employees by allowing colleagues to recognize and celebrate others (Merlino & Raman, 2013). In addition all managers are required to attend daylong training sessions every three to four months to gain more knowledge and skills on “emotional intelligence, communicating and implementing change, and enhancing engagement”
(Merlino & Raman, 2013, p. 116).
Model 2: Mayo Clinic
Mayo Clinic has strong leadership, a vibrant organizational culture, and a competitive spirit for service excellence, all of which have led to its sus- tained success in high patient satisfaction scores. The clinic is a strongly cultivated patient-centered culture, where the whole organization is designed to better serve the patients (Berry & Seltman, 2008a). The found- ers of Mayo Clinic have instilled the core value of “patients come first”
into the institutional culture, which members of the Mayo Clinic not only embrace, but also regard as their “professionalism covenant” (Viggiano, Pawlina, Lindor, Olsen, & Cortese, 2007, p. 1089). Respect also plays an important role in the patient-physician and patient-nurse relationships because it supports that patient-centered environment. These factors pro- vide a competitive advantage among the physicians and nurses in different departments by improving service to every patient. Communication and teamwork are vital elements of the Mayo Clinic culture (Berry &
Seltman, 2008b).
Model 3: The Disney model applied to healthcare
At Disney, customers always come first. Disney utilizes four service stand- ards to accomplish this goal: safety, courtesy, show, and efficiency. Every employee is told they make a difference, and all work together to provide the best guest experience (Middaugh, Grissom, & Satkowski, 2008). Disney also adopted four habits to provide a great customer experience and improve the workplace culture: listen to your employees; hire for attitude, not aptitude; give people purpose and not rules; and tap into the creativity of the front line (Beltran et al., 2014; Freeman,2014).
Arkansas Children’s Hospital, University of Chicago Hospitals, and Women and Infants Hospital of Rhode Island all had staff turnover issues.
They deployed the Disney model by focusing on the four standards and built a new culture focused on pride and loyalty. Patient satisfaction improved, employee turnover decreased, and productivity increased in all these healthcare systems after adopting Disney standards (Middaugh et al., 2008). East Jefferson General Hospital adopted a variety of Disney strat- egies, including changing the word “employee” to “team member,” creating an easy-to-memorize mission statement, implementing the On Stage/Off Stage approach, and improving the hiring process (Taylor, 1999).
Today, leading healthcare organizations use the Disney created acronym C.A.R.E. (clarify, align, reinforce, empower) to provide patients with a great experience. Clarify to better understand the needs of employees and cus- tomers through interviews, suggestion boxes, and surveys. Align by creating a common purpose based around what the organization stands for, which should become the “emotional pivot” around which the employee and cus- tomer strategies revolve. Reinforce leaders to show a commitment to act as role models and lead by example through training, coaching, and feedback.
Empower team members by providing expectation clarity, freedom to per- form daily tasks, and opportunities to coach, recognize, and reward cow- orkers (Beltran et al., 2014; Lee,2004).
Model 4: Ritz-Carlton applied to healthcare
Ritz-Carlton’s Quality Management Program, including Gold Standards, Detailed Planning, Quality Data, and Quality Results, has an end goal of creating a memorable experience for guests. The Gold Standards include a two-day, culture immersed orientation with senior leaders, extensive on the job training and job certification, frequent recognition, empowerment for employees to address guests’ needs, and annual staff surveys. Detailed Planning addresses factors like teamwork, ensuring all elements are right before opening hotel doors, and housing a unique quality leader in each hotel. Quality Data includes training employees to note each guest’s likes and dislikes and developing daily reports to aid in the identification of problems, such as time spent to service rooms. Quality Results, received through guest satisfaction surveys, are used to exceed expectations and cre- ate a memorable experience (Partlow,1993).
Valley View Hospital implemented several Ritz-Carlton strategies to improve quality and patient experience. First, strive to provide patients with a memorable experience by overcoming the busy factor and focusing on serving, anticipating the needs of patients and their families, and deliv- ering what is needed to get well. Second, screen for talent management using Talent Plus to identify the strengths and talents of all employees, where the strengths become the focal point for proper employee placement.
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Third, empower employees with guidelines, such as the ability to create a comforting environment for the patients. Fourth, understand that all levels are involved in providing customer service (Saver, 2008).
Literature supporting the four Ps of patient experience
Patient expectations and perceptions influence patient experience and satisfaction
Prior literature corroborates and supplements these practice models. One of the key lessons learned from a comprehensive review of literature is that patients view healthcare visits as a “time-investment” service (Berry, Seiders, & Grewal, 2002), so the more time spent with the provider, the higher perceived service and patient satisfaction (Lin et al., 2001). Also, patient satisfaction increases when providers treat the patient as a whole person, convey themselves in a professional and confident manner, and communicate instructions clearly and in detail (Boudreaux, Ary, Mandry,
& McCabe, 2000). The strongest overall satisfaction indicator is patient communication with nurses (Boudreaux et al., 2000; Elliott, Kanouse, Edwards, & Hillborne, 2009; Vogus & McClelland, 2016). This is also attested in the Mayo Clinic’s “patients come first” mentality, as well as fac- tors including respect, communication, and teamwork, to ensure the care environment is patient-centered.
In healthcare, patient perception is what drives patient satisfaction (Kumar & Reinartz, 2016). Considering the patient itself as a member of the care team and as a partner, the healthcare organization can implement strategies focusing on both patients (managing expectations) and employees (employee training and workplace culture). In practice, consumer percep- tions are obtained by Ritz-Carlton employees when guests’ likes and dis- likes are noted, which is very similar to healthcare providers considering the patient as a partner. Customer-need knowledge, or understanding patient needs and their level of importance, can help create a more positive patient experience, leading to improved satisfaction (Homburg, Wieseke, &
Bornemann, 2009). Employees that portray a higher degree of empathy toward patients seem to better understand their needs. In scenarios where factors can be more easily controlled, potential failures can be predicted and prevented (Homburg et al., 2009; Sivakumar, Li, & Dong, 2014). These strategies and evidence from research on managing the patient experience relate to the first two Ps of the patient experience framework: physicians and partners, as well as Cleveland Clinic’s and Ritz-Carlton’s gaining infor- mation on attitudes and needs.
One of the most important factors to consider while managing the patient experience is the emotional aspect. It is ideal to align knowledge
between provider and patient to ensure confidence in patients and to help eliminate fear, confusion, and anxiety. When knowledge is not well aligned, the gap between provider and patient can widen from patient emotions and vulnerability, creating a more negative experience (Dempsey, Wojciechowski, McConville, & Drain, 2014). This is a strategy that requires both training of physicians and partners and the development of processes that keep the patient informed, while allowing access to information by all partners involved. Such strategies can be observed in practice at the Mayo Clinic in building the patient-provider relationships to support the patient- centered environment.
Managing the healthcare workplace culture
The workplace culture sets the tone for how employees perform, interact with and provide care for patients. An ideal healthcare work environment is often described as one that is safe, empowering, and satisfying (Lowe, 2002).
However, today’s healthcare workers, especially physicians and nurses, are faced with increased levels of administrative burden, stress, and burnout, especially in an unmanaged emotional culture that creates callous and indif- ferent employees (Barsade & O’Neill, 2016; Bovier & Perneger, 2003). With the cultivation of an appropriate workplace culture that encourages commu- nication, empowers physicians and staff, and fosters teamwork as proposed in the 4 Ps of Patient Experience, these risks can be reduced for healthcare workers. For example, Disney’s C.A.R.E. culture inspires communication, empowerment, and teamwork through aligning and reinforcing values.
Historically, one of the most comprehensive, relevant, and recognized reports that touches on both patient experience and the workplace culture in healthcare is “Crossing the Quality Chasm” by the IOM, defining six aims for healthcare: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity (2001). Rapid progress towards these six aims requires organizational transformations in terms of clinical care, adminis- trative capabilities, as well as social technologies (Gamm, Kash, & Bolin, 2007). Cultural elements in pursuit of the IOM aims include patient and workplace safety training, the ability for any staff member to speak up or report safety issues, assurance that all employees feel they work in a just environment, understanding that learning is a continuum, designing care teams with complementary healthcare professionals, and measuring care quality for performance improvement (Carroll & Quijada, 2004). Most of these innovations and strategies also fall under the 4 Ps of Patient Experience framework, which also recommends strategies related to train- ing of physicians and partners. These cultural elements can also be detected in all four models of practice discussed above, as each model encourages
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empowerment, creates a patient- or consumer-centered environment, and depends on effective employee training.
Uniquely, healthcare organizations are also faced with having to provide guidance and resources on compassion fatigue and emotional resilience as healthcare jobs require constant empathy. Compassion fatigue, the incap- acity to empathize, and emotional resilience, the ability to maintain a sense of purpose and positive wellbeing while adapting to a variety of conditions, are both key issues in the healthcare environment today (Sergeant & Laws- Chapman, 2012; Waytz, 2016). Empathy drains energy and cognitive resources, while also depleting itself (Waytz, 2016). Several strategies can be utilized to help improve empathy and morale, including proper training, job satisfaction measurement, an environment of servant leadership, and cultural competence awareness (Homburg et al., 2009; Lonial & Raju, 2015;
Vogus & McClelland, 2016; Weech-Maldonado et al., 2012). As mentioned in the first two Ps of patient experience, training physicians and partners to acquire capabilities in the areas of empathy, resilience, and teamwork will be effective levers to influence patient experiences.
Conclusion
Healthcare, as a service industry, has a history of translating strategies from other service sectors, primarily hospitality, and experimenting with implemen- tation of these borrowed strategies and concepts. We share learnings from these strategies in applied models of practice and literature, but believe that the con- cept of patient experience needs further development before more industry-spe- cific strategies can be formulated towards achieving the common goals of great patient experience and satisfaction. The four Ps of patient experience, informed by both models of practice and relevant literature, presents healthcare leaders and researchers with key levers that can be used to influence the patient’s experience: (a) capable, trained, and autonomous physicians in leadership roles;
(b) partners (care team members) fully engaged in the delivery of care process with patient experience as the central focus; (c) places of care delivery that are most appropriate for the patient condition and are easily accessed; and (d) patient care and flow processes that can be standardized to achieve optimal operational targets. This new strategic framework can facilitate the development of more detailed strategies toward building a culture of great customer service supported by evidence-based practices.
Acknowledgments
This article is a result of many years of research co-funded by the NSF I/UCRC Programs and participating industry members. The authors would also like to thank Mr. Jacob Kolman for reviewing and editing this manuscript.
Funding
This research was funded by an NSF Industry-University Cooperative Research Centers Program (IUCRC) grant support for CHOT at Texas A&M University and industry mem- bership funds.
Notes on contributors
All authors were affiliated with the National Science Foundation (NSF) Center for Health Organization Transformation (CHOT) at Texas A&M University School of Public Health.
Changes of affiliation: Molly McKahan is now at BSA Health System in Amarillo, TX. Bita A. Kash is now at both CHOT, Texas A&M University (as previous) and the Center for Outcomes Research, Houston Methodist Research Institute.
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