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It's the Little Things That Count

Carolyn Ford, new service excellence administrator, says every employee contributes to the patient experience.

After completing a two-year administrative fellowship with the Health System, Carolyn Ford thought she had found her niche in financial analysis. But the prospect of a role more closely tied to patient care convinced the former occupational therapist to accept a new position: senior project administrator for service excellence. She started last August and brought with her a fresh approach to improving patient satisfaction. Ford recently addressed the challenges involved in building service excellence.

Q. What struck you after analyzing the scores from our patient satisfaction surveys?

A. We’re the No.1 hospital in the country, the No.1 recipient of NIH grants, but at Hopkins Hospital, the percentile ranking for how we serve patients and show compassion is 59th. That falls far short of our goal. We’ve recently improved our scores, but we still have a way to go.

Q. How do you plan to raise those scores?

A. We have some concrete tools for managers, including a Web site ( that’s won national awards. This year, our plan is to consult on service with intact teams—unit by unit, clinic by clinic.

First, we complete a service assessment of the unit. We have a kick-off meeting with every person, regardless of role, who interacts with patients or families. We review the patient satisfaction survey and scores. We’ve found that employees often don’t know the survey questions or how their unit ranks. We have the staff take the patient satisfaction survey, then compare results with scores their patients gave them.

Our goal is to leave the meeting with an action plan. We address things like comfort of waiting rooms, keeping patients informed and handling difficult patients. I check in with the units every month or two to make sure they are posting their scores and to see how they are implementing their plans.

Q. What else is new?

A. We have identified key drivers of patient satisfaction. Patients cited two things as very important: communication and a caring, courteous attitude. Patients score us on a scale of 1 (very poor) to 5 (very good). Our goal is to get more people to check that “top box,” or rate us “very good,” especially in those two areas. Right now, 65 percent of our patients rate us in the top box, meaning we couldn’t have done anything better. If we can use what we’ve learned to give more patients a top-box experience, we can expect all our scores to improve.

Q. What has to happen for patients to rate us in the Top Box?

A. First, communication is key. Introduce yourself and your role in their care. Tell them what to expect and ask them about their expectations. Let patients know you are working with their other caregivers. Communication and patient-centered care reduce fears and anxieties and support the patient safety mission.

Second, use common courtesy and anticipate needs. Satisfied patients comment on the little things—getting help with finding a clinic, having the water pitcher filled, receiving an extra blanket. One patient told us the woman delivering his meals told him a joke every day. Another said, I know that the staff works together; they tell the next shift what I need. In an institution focused on complex solutions, we sometimes overlook the simpler things.

Q. How well do physicians do?

A. Generally, our physicians score well. When physicians commit to being more courteous and keeping patients informed, it’s much easier to get everyone else to buy in to those concepts. Physicians are powerful role models, and we are engaging them in our unit-based service teams.

Q. Any other plans?

A. We’re working closely with Human Resources. We need to be sure we are recruiting not only for aptitude but also for bedside manner, compassion and the drive to serve our patients. A lot of it comes down to frontline managers who are doing the hiring and performance appraisals. Are they hiring to fill a position? Or are they hiring to fill an expectation of this kind of service?

Q. Why is service excellence important?

A. First, it’s the right thing to do—to treat our patients as we would like to be treated. And of course, we’re in a world now where patients have choices. Many treatments, once available only at Hopkins, now are available elsewhere. So for many conditions, patients seek not only a cure but an experience that is convenient, compassionate and built around individual needs. When people feel they were not only treated, but also cared for, that’s really powerful.

Mary Ellen Miller

“Top Box”?

Recently, a new phrase, “top box,” has crept into the health-care lexicon. It can be a noun, as in, “Sixty-five percent of our patients rate us in the top box,” or an adjective: “We want to give more patients a top-box experience.” What does it mean?

“Top box” is actually a performance measurement system used by market researchers who monitor customer satisfaction. The top box is the percentage of customers, or in this case patients, who give the highest rating to any one aspect of their care. Mean scores, by contrast, are not percentages but averages of all the patients’ ratings.

Random patients receive a survey in the mail after they are discharged from the hospital. These recipients are asked to rate all aspects of their hospital experience—everything from, say, the temperature of the food to the temperature of their room—on a five-point scale, from “very poor” to “very good.”

A rating of “very good” is called a “top box” rating. The more top-box ratings, the more likely the mean score will climb. By identifying behaviors that make the difference between “good” and “very good” service, steps can be taken to make the patient experience truly exceptional.

—Anne Bennett Swingle




Johns Hopkins Medicine

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