The Empathy Engine: Achieving breakthroughs in patient service

This perspective reflects the results of Katzenbach research on the state of customer service in healthcare. It is based on interviews with leaders and practitioners from a range of healthcare contexts. The authors provide guidance for healthcare organizations on how to build thriving Empathy Engines®. When healthcare players transform themselves into Empathy Engines, they not only improve patient satisfaction but create opportunities to improve the quality of care, increase employee engagement, reduce costs and achieve breakthroughs in organizational performance.

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The Empathy Engine® Achieving breakthroughs in patient service


New York Traci Entel Partner +1-212-551-6093 traci.entel

This report was originally published as The Empathy Engine®, Achieving Breakthroughs in Patient Service, by Traci Entel, Nathan Huttner, and Jenny Machida, Katzenbach Partners, 2008.


April 2008

The Empathy Engine Achieving Breakthroughs in Patient Service
William was admitted to Prairie Lakes Healthcare System in Watertown, South Dakota with a serious condition. He required demanding care that included numerous intravenous antibiotics as well as blood transfusions. Given the severity of his diagnosis and the emotional strain he was experiencing, the nurses on his floor recognized the need to think carefully about how best to care for William and his family. Typically, patient care assignments were made by rules—rules that dictated how many patients a nurse could care for and what type of care a nurse could provide based on his or her training. Alissa and Sue, the RN and LPN assigned to William, decided that they could provide him with the best care by having Alissa, the RN, provide only his meds and blood products while Sue, the LPN, focus on providing the care and connection that William and his family needed at this time. This meant that Alissa would be responsible for the meds for nine other patients while Sue dedicated more of her time to William. Without breaking any rules, Sue and Alissa shifted their combined workload to allow for a solution that provided the most empathetic care for William and made them feel good about the work they were able to do. Sue and Alissa’s success in delivering empathetic service in this single patient encounter depended on their willingness and ability to think beyond the typical approach and to respond based on what this individual patient needed. The question facing healthcare leaders is how to replicate this level of empathy and responsiveness throughout their organizations and across thousands of patient encounters, whether those encounters happen over the phone, in a doctor’s office or at the hospital bedside. Enhancing patient service can improve patient health outcomes, employee engagement and an organization’s financial performance. Patients are making clear choices about where they receive care based on service experiences and it is crucial for organizations to create an institutional ability to sense and respond empathetically.

© 2008 Booz & Company Inc.

the Empathy Engine: Achieving breakthroughs in patient service | Executive Summary

Executive Summary
This paper reflects the results of Katzenbach Partners’ research on the state of customer service in healthcare. We conducted interviews with leaders and practitioners from a range of healthcare contexts, including hospitals, integrated health systems, health insurers, specialty facilities, and patients themselves. In this paper, we draw examples and stories from these conversations—and from our work with clients across industries—in order to provide guidance for healthcare organizations on how to build thriving Empathy Engines®. When healthcare players transform themselves into Empathy Engines, they not only improve patient satisfaction but create opportunities to improve the quality of care, increase employee engagement, reduce costs and achieve breakthroughs in organizational performance. Tap into the Informal By harnessing the power of informal organizational networks and existing sources of insight, empathy and energy, organizations can generate substantial patient service improvements without making major changes to formal structures, systems and processes.

ƒƒ Empower employees to innovate within their roles: Today’s patient-focused improvisations can become tomorrow’s SOPs ƒƒ C  apitalize on employee energy: Informal employee networks play a critical role in identifying and driving service enhancements ƒƒ Walk  the halls: Listening to employees on the frontlines demonstrates leadership commitment to empathetic service
Strengthen the Formal By aligning the formal organization around empathetic care, organizations can reinforce empathetic behaviors and begin to achieve impact at scale. The key is to formalize the approach without muting the energy of the informal organization.

ƒƒ Manage empathy as a strategic capability: Empathetic service is a critical skill that can transfer across industries ƒƒ Carve out empathetic roles: Disaggregating service roles can help doctors to be doctors, nurses to be nurses ƒƒ Think big, build small: Large organizations can “feel small” by creating discrete units of innovation
Harmonize the Informal and the Formal Organizations that integrate informal and formal mechanisms achieve the greatest empathetic impact. The informal organization provides the passion, inspiration, and motivation to make changes while the formal provides reinforcement, structure and resources to get things done on a larger scale.

ƒƒ F  ind and cultivate your pride builders: Every organization has master motivators—these frontline leaders should play the starring role in improving empathetic service ƒƒ Tell stories to keep empathy alive: The discipline of storytelling can inspire and reinforce empathetic care ƒƒ L  earn from experiments: Frontline employees are the first to sense changes in the landscape—their adaptation and experimentation should guide organizational evolution


Table of Contents | the empathy Engine: Achieving breakthroughs in patient service

Table of Contents
Introduction The Difference Empathy Makes 4 4 5 6 7 8 8 9 9 10 12 14 14 15 17 19 19 20 21 22 23 24 What Is an Empathy Engine? Where Does Empathy Fit In? Opportunity Knocks Recommendations Becoming an Empathy Engine Tap Into the Informal Empower Employees to Innovate within Their Roles Capitalize on Employee Energy Walk the Halls Manage Empathy as a Strategic Capability Carve Out Empathetic Roles Think Big, Build Small Find and Cultivate Your Pride Builders Tell Stories to Keep Empathy Alive Learn from Experiments

Strengthen the Formal

Harmonize the Informal and Formal

Conclusion Summary of Recommendations Endnotes



The Difference Empathy Makes
Service has become critically important in healthcare. Nearly half of patients have switched or considered switching providers based on negative service experiences.1 Frontline workers like Sue and Alissa, featured in our opening story, have committed years of their lives to serving patients because they are passionate about helping people. Yet 40% of Americans believe that banks provide better service than hospitals and clinics and 18% say airlines are better at serving their customers. Based on their experiences, more than one in three Americans (36%) believe hospital and clinic workers are either indifferent (22%) or unhappy (14%) with their jobs.2 The stakes for patient service are extremely high, both economically and emotionally. Now more than ever, patients exercise choice in where they seek care and in how they interact with their providers, insurers, pharmacies, and healthcare support services. The perception and experience of care is critically important for healthcare organizations, and creating compelling service experiences is quickly becoming the battleground in healthcare it is in other industries. Many healthcare leaders have focused on programmatic fixes for service that rely heavily on formal mechanisms and external best practices. However, these top-down approaches do not draw on the valuable insights and energy from within the organization’s ranks and do little to build the emotional engagement that drives change. In our 2007 paper, The Empathy Engine: Turning Customer Service Into a Sustainable Advantage, we argued that companies that foster collaboration across roles and responsibilities to empathize with customers are most successful at consistently delivering great customer service. These companies, called Empathy Engines, have built a sustainable advantage through a holistic organizational commitment to meeting customers’ needs. We believe that consistent empathy is the critical factor in creating a compelling customer experience. Because empathetic customer care is driven by both employee behaviors and leadership decisions, it is an organizational capability that must be cultivated and reinforced. This paper reflects the results of Katzenbach Partners’ research on the state of customer service in healthcare. We conducted interviews with leaders and practitioners from a range of healthcare contexts, including hospitals, integrated health systems, health insurers, specialty facilities and patients themselves. We draw examples and stories from these conversations—and from our work with clients across industries—in order to provide guidance for healthcare organizations on how to build thriving Empathy Engines. We have also included tactical recommendations for leaders who hope to spur an empathetic renaissance within their own organizations. By linking narratives of successful transformations with sensible recommendations, we hope to provide a vision for how to become an Empathy Engine that is specific enough to be useful but general enough to be applicable across the range of situations that confront healthcare organizations.

Americans’ Perception of Customer Service in Healthcare
Industries better than healthcare at providing customer service





Big Retailers




Most important in choosing a hospital/clinic

Understand My Needs




Comfort/ Welcoming Environment


Source: Katzenbach Partners Healthcare Consumer Survey 2007



What is an Empathy Engine®?
In our 2007 paper, The Empathy Engine: Turning Customer Service Into a Sustainable Advantage, we described great customer service organizations as Empathy Engines, a concept that represents a shift away from a siloed, cost-focused customer service approach towards one that is holistic and focused on competitive advantage, involving senior leaders, managers, frontline employees, and customers in an effort to make service a strategic asset. An Empathy Engine is an organization whose processes and behaviors put empathy into action. Companies that act as Empathy Engines sense customers’ problems and consistently act on them by keeping information and values flowing throughout the company. This flow of information includes, most critically, the key insights learned by the frontline during their interactions with customers. The flow of values is the organizational commitment to empathy and customer service that is established by senior leadership and modeled throughout the organization. Senior leaders, managers, the frontline, and customers all play an important role in an Empathy Engine by establishing the potential for strong, empathetic customer relationships. These relationships cannot easily be replicated and are therefore a source of sustainable competitive advantage. The result: financial success and increased stakeholder value.


the Empathy Engine: Achieving breakthroughs in patient service | Where Does Empathy Fit In?

Where Does Empathy Fit In?
Most healthcare executives agree that patient service is a priority, but it is one of many in an ever-demanding operating environment. The U.S. is in an uproar about the rising cost of healthcare, and companies across the industry—providers, payers and other healthcare service organizations—are feeling tremendous pressure to reduce costs while continuing to improve quality of care and patient experience. The challenge of attracting and retaining talent in key clinical roles only complicates matters and makes it more difficult to achieve progress towards each of these operational priorities.3
Patient Service Affects Other Priorities Truly empathetic patient service can address the top priorities of healthcare organizations. Rising costs ƒƒ  Empathetic patient service improves patient satisfaction, which increases quality of relationships, reducing frequency of malpractice suits,4 no-shows,5 provider switching6 and duplicated tests ƒƒ  Taken together, these cost savings can more than offset strategic investments in bolstering empathetic service Nursing shortage ƒƒ  There is a strong correlation between employee satisfaction and patient satisfaction7 ƒƒ Improving patient satisfaction makes for a more positive working environment for nurses and other key clinical roles, reducing turnover and increasing length of tenure Quality of care ƒƒ  Though the relationship between patient satisfaction and clinical outcomes has not been precisely measured, most practitioners and leaders have observed this link in their work ƒƒ  Patient adherence to doctors’ orders depends strongly on whether the patients get their questions answered8 ƒƒ  As patient satisfaction increases and relationships deepen, continuity of care improves, leading to fewer hospitalizations and higher compliance9

For executives in this tight cost-quality squeeze and employees on the demanding frontlines of care, it might seem near impossible to make room for improving patient service. Margaret Moore, the Founder and CEO of Wellcoaches Corporation, a leader in training healthcare providers to master coaching psychology and relational skills, explained, “What we hear all the time is that nurses and physicians want the relational skills and time to connect with patients and energize their forward progress. However, today’s system doesn’t enable the rewarding impact of close connections and relationships in fostering personal responsibility, momentum, and efficacy.” Furthermore, changes in the industry are demanding that healthcare organizations pay careful attention to patient service in order to remain competitive. This is not only true for organizations that are providing direct care such as hospitals or other health facilities, but also for any of the players in the healthcare industry that interact directly with patients. Within the diverse and evolving healthcare landscape, boundaries are blurring. For example, nurses may now engage patients on issues of reimbursement and

Opportunity Knocks | the Empathy Engine: Achieving breakthroughs in patient service

support services, and employees of health insurers may now interact with patients regarding clinical and lifestyle topics. Any organization that has a frontline that interacts with patients can gain from increasing its empathetic service capability. Perception matters and all of the players contribute to that perception. A patient has multiple points of interaction—whether in a facility, at a doctor’s office, in a retail setting or even on the phone. All of these interactions are influential in shaping a patient’s experience of care and, in turn, shaping their future decisions about where and how they receive care.

Quality of Care & Perception of Care
Formal methods of quality improvement and process management, driven by regulatory and competitive pressure, have delivered critical gains in medical care quality. As the industry continues to improve its ability to deliver great medical care to every patient and as patients’ power to choose increases, the quality of the overall experience becomes an even more important differentiator. It is becoming increasingly important for healthcare organizations to compete on perception of care as a complement to clinical dimensions of quality that are harder for patients to assess. One recent study showed that for more than threein-four patients, perception of care rather than objectively measurable clinical factors, like range of services, was the most important factor for their judgment of hospital quality. Good patient service inspires a sense in patients that their provider has their best interests in mind, and poor patient service leaves patients feeling unimportant —a statistic, not a person. A patient who received better patient service will likely report higher satisfaction than a patient who received worse patient service—even if they received the same quality of medical care.10

Opportunity Knocks
Everyone knows that bad customer service does not feel good to anyone —patients, visitors or the healthcare organization employees themselves. And the organizational costs of poor customer service carry additional impacts and risks as well, including employee dissatisfaction11 and more frequent malpractice suits.12 When it comes to delivering service in an empathetic way, employees can truly make a difference, and organizations that help employees do the empathetic work they want to do will win in the marketplace. Empathy is powerful because it allows frontline staff to more quickly understand and respond to patient needs, and better communicate their understanding to patients. Concerted, organization-wide effort is necessary to enable frontline employees to consistently complete the emotionally and cognitively difficult task of engaging with patients’ distress in order to help them. To create this organizational engine, healthcare players should look to other industries, leading patient service institutions, and to the people at their own frontlines. The healthcare industry is especially well positioned to differentiate based on service given the empathetic nature of its work, so the goal should not be to “catch up” to other industries that have made strides in customer service but rather to leapfrog those industries. Healthcare companies need to renew their focus on empathetic patient service. The even better news is that empathetic patient service is driven by employees’ behaviors and leaders’ choices, and organizations can take steps to inform and influence both. This journey does not necessarily require massive organizational overhaul or extensive investment. You can make significant and valuable changes no matter where your organization is on its path to becoming an Empathy Engine.

Organizations that support their employees to empathize will win in the marketplace


the Empathy Engine: Achieving breakthroughs in patient service | Becoming an Empathy Engine

Empathy Engines are continually evolving, responding to customers and employees to improve the patient experience Becoming an Empathy Engine
Companies that achieve customer service greatness are Empathy Engines— institutions organized to consistently empathize with customers across a set of interactions, responding to their problems and forging trust-based relationships. The Empathy Engine is not a static achievement but a continuous evolution. These organizations are in a constant state of change, responding to customers and employees, reinforcing values of service, and evolving to improve the patient experience. In this paper, we examine a variety of approaches healthcare organizations have used successfully across the full spectrum of Empathy Engine transformation. Some will be helpful to organizations at the beginning of their journey while others are geared towards organizations well on their way. Our recommendations are organized around three stages of that evolution. For organizations in the early stages of their evolution, we suggest they Tap into the Informal. This involves harnessing existing sources of empathy and energy that will make a difference in the short term, absent the ability to make formal changes or investments. At this stage, it is critical to reinforce and build positive momentum and ready the organization for broader improvement. Organizations that have already begun to energize employee empathy will want to Strengthen the Formal, creating the structures and processes that build on and multiply the effects of informal efforts. Using the formal organization, leaders can reinforce empathetic behaviors and begin to achieve impact at scale. Organizations that already have empathy pumping in their veins and have built the necessary structures to support that flow will want to Harmonize the Informal and Formal to create sustained advantage. Integrating informal and formal efforts allows organizations to achieve more than they could by working in only one side of the organization. This stage is focused on effecting bottom-to-top transformation and weaving empathy into the fabric of the organization. Regardless of your starting point in this evolution, there are real and concrete steps you can take today to begin transforming your organization into an Empathy Engine.



Tap Into the Informal
When organizations first endeavor to become Empathy Engines, they often face institutionalized formal barriers to building patient relationships, whether complex bureaucracy, an outdated IT infrastructure, or budgetary constraints. Multifaceted problems like these require long-term solutions and often significant changes to structure, processes or systems. In the short term, however, organizations can turn to the informal organization. The informal organization is a powerful lever and often presents the fastest means of change by tapping into what is already present in your organization—employee empathy, energy and ingenuity.

Empower Employees to Innovate within Their Roles
The seeds of long-term change already exist at the frontline of many organizations. Frontline employees often recognize the right thing to do when they see it, but formal barriers and a lack of confidence can keep them from solving problems they can tackle without wider institutional support. This inertia can be overcome by encouraging intuitively empathetic employees to innovate within their roles to improve patient service. In-role innovation can mean deviating from standard service practice when a patient’s unique situation requires it in order to meet emerging needs. As illustrated in the opening story about Alissa and Sue at Prairie Lakes Healthcare System, the exemplar organizations we spoke to empower their frontline service staff to make critical decisions in the moment, when employees know it is the right thing to do for a given patient. It is not the “heroic” stories like changing a patient’s tire in a sweltering parking garage that necessarily make the greatest impact on service across the board; rather, it is the behind-the-scenes strategic choice made by management to trust employees’ empathetic instincts day to day. For example, in a 450-bed hospital we studied, patient service representatives know when and how to navigate the complex hospital system quickly to solve a problem. When a mother needed privacy with her sick child, a patient service representative activated his personal informal network and reached out to a hospital maintenance worker he knew who could fix their door far more quickly than the formal process would have done. These kinds of small decisions—and the fact that employees are empowered to make them day to day—make a difference for broad patient populations on a regular basis. Collaborative, local innovation happened at the Mayo Clinic when a computerized scheduling system did not allow staff to schedule appointments more than six months in advance, though some medical treatments require a follow-up appointment at least that far into the future. The staff began working around the computers, collectively adopting a simple, adaptable system of hand-written sheets to coordinate appointments and reminders scheduled six-plus months into the future. Though basic, the improvised system became a source of pride, demonstrating entrepreneurship in the service of patient needs until the formal system could be remedied. Neither of these innovations was formalized by a policy change or training program—and rightly so. This in-role innovation is not a cure-all, and not the way to make institution-wide change. But it is a way to quickly identify high-impact opportunities for patient service improvement. Encouraging innovation of this kind, whether large or small, fuels the empathetic

Harnessing the informal organization allows access to employee energy and ingenuity, without major structural change

Today’s patient-focused improvisations can become tomorrow’s SOPs


the Empathy Engine: Achieving breakthroughs in patient service | Tap Into the Informal

Pick Based on Passion
Issues and opportunities that employees are passionate about can be natural starting places to focus patient service improvement first. These frontline-identified issues are those most likely to get attention, get fixed, and generate momentum towards broader change. The ideal starting point is a project focused on a specific problem that is meaningful to a critical group of employees. Because employees are so close to the patient experience, their feedback can be a critical component in understanding where to start improvements. Employee satisfaction surveys can surface high impact opportunities for change. Examining the tails of the employee satisfaction distribution—exceptionally high and low satisfaction—can suggest some places to look first. For example, perhaps one set of functional teams, or a particular shift, is especially dissatisfied. Understanding their dissatisfaction could reveal a wealth of information about where a good starting point might be. Similarly, understanding the approaches employed by the teams with the highest satisfaction scores may shed light on innovative practices.

problem solving that can become the central pillar of a thriving patient service institution. An organization that detects, supports and celebrates these thoughtful work-arounds—while respecting patient interests, safety and regulations at all times—sends a powerful message to employees about the importance of individual patient needs. It also taps into an invaluable source of on-the-ground intelligence about the types of change that are most needed and most likely to be embraced and adopted by employees. Today’s improvisations and work-arounds often become tomorrow’s SOPs and formal systems. Eastern Long Island Hospital—a 102-year-old community hospital that has achieved best-in-class patient satisfaction and Top 10% distinction in clinical care nationally—has created a working culture where employees rally quickly to address challenges. One example of employee-led innovation occurred in the OR unit. To alleviate patient frustration with delays at the pharmacy after discharge from the hospital, the Perioperative staff installed a fax machine in the unit so that they could fax prescriptions directly to the pharmacy before the patient left the facility. Chief Nursing Officer Pat Pispisa notes, “This idea was a direct result of the Periop staff having discussions with patients and families.” Eastern Long Island Hospital harnesses employee empathy as a key driver of patient care improvement, and employees feel supported in their roles as innovators. In-role innovation, regardless of the scale, can be risky. Some workarounds will need paring back, others building out, but a tolerance and support for informal innovation is critical. Leaders should reduce the risks for staff by providing examples of innovations that have worked, others that have not, and laying out a set of principles to guide employees. Leaders can also bear some of the risk themselves. At Texas Children’s Hospital, where service representatives are encouraged not to rely on scripts but to use their discretion to do “what’s right” for children and their parents, the team has the full support of their leaders, who empower frontline decision-making. Non-clinical patient service team members are empowered to grant $10 vouchers for parking and food when they deem necessary to create a positive experience for patients, and this autonomy makes a difference in employees’ ability to improvise to meet patient needs. These service teams have earned the trust of the leadership—they do not run up costs or abuse the system because they feel a sense of ownership—and leaders keep the faith, reinforcing the empathetic intuition common among their organization’s most effective patient service employees.

Capitalize on Employee Energy

Informal employee networks play a critical role in identifying and driving service enhancements

In the earlier example of the paper-based predecessor to the electronic scheduling system, an informal network of employees emerged, enabling cooperation and making the success of the improvised system possible. Organizational networks, fueled by employee energy, often determine how work gets done. These networks form around the nursing station, in the break room or in the seating clusters of a call center, and when tapped are a powerful source of energy and motivation. For example, a common commitment to patient service catalyzed diverse groups of employees at New York University (NYU) Medical Center to self-organize into powerful networks that drove a major initiative around the institution’s Service Standards, its core values. They worked overtime



because they cared about their patients and the shared patient-employee experience. The effort did not involve a significant financial investment upfront; volunteers discussed the program over pizza at the end of their shifts, and rewarded themselves for their hard work with movie nights. They exerted peer pressure—in a good way—on their colleagues to get involved. By devoting their energy and insights to the program, they transformed it from a volunteer effort into a bonafide program that eventually involved over 500 people and was rolled out to the entire medical center with the blessing of leadership and the resources behind it to ensure its effectiveness. The program has been a success not only because of the end result; it also made the organization feel like a “nicer place to work,” reminded people why they went into healthcare and helped people reconnect with their mission and with their colleagues. Humana employees, motivated by the company’s goal of achieving “Perfect Service,” found ways to use the informal organization to share ideas and connect with one another across departments and functions. Using wikis, employees posted ideas online about how to deliver perfect service that other employees could then view and build on. Bruce Goodman, SVP and Chief Service and Information Officer, described it as a “grassroots effort” that created not only a stronger commitment to service but a shared energy and excitement among employees. This resulted in a tangible increase in employee engagement as well. Following the implementation of the Perfect Service initiative, the employee engagement index rose; it was “the most significant increase in associate engagement” the survey company has seen over a one year period. The informal organization and its networks tend to bolster the existing initiatives that matter most to patient service, because it is those initiatives that generate the most excitement among employees. For example, there are no formal requirements for attending physicians to participate in the Communication Skills Training and Research (“Comskil”) Laboratory at Memorial Sloan-Kettering Cancer Center, a program that involves senior attending physicians and junior faculty alike in improving their ability to communicate empathetically with patients. The program’s leadership made the decision to pursue a ‘word of mouth’ rollout strategy due to the high risks of resistance to a formal, top-down push. Despite the absence of formal incentives or mandates for attending physicians, positive referrals have helped the program flourish and grow. The positive reputation of the program has clearly resulted in enhanced participation among the critical attending physician population. Informal networks at all levels of the organization often present the fastest means of change, circulating empathetic best practices and building momentum for refocusing on patient service. Furthermore, these networks can be leveraged for long-term change by leaders who understand them.

Find the Insiders
In initiating any change or even information gathering effort, consider alternatives and complements to the traditional formal channels. Use your understanding of informal trust networks (physicians trust their favorite nurses, customer service representatives trust their favorite supervisors, therapists stay in touch with old co-workers even when they change units, etc.) to guide who you reach out to and include in research, design and rollout. The informal organization, of which the trust network is one piece, is great at motivating people to go above and beyond their job duties, communicating information quickly, engaging employees in collaborative work, and making changes stick. However, because it comprises relationships, networks and collaborations, it is not as easily seen or understood as the more concrete formal organization.

Organizational network analysis (ONA) can provide a precise, data-driven understanding of the lay of the informal land. ONA identifies the “hubs” throughout an organization – those people who are at the center of trust, communication and energy networks. These “hubs” are key stakeholders of any change effort, and knowing where they are in an organization can be a critical advantage. The “maps” of the informal organization that an ONA reveals can be an invaluable tool in understanding how to put the informal organization to work toward Empathy Engine transformation.


the Empathy Engine: Achieving breakthroughs in patient service | Tap Into the Informal

Listening to employees on the frontlines demonstrates leadership commitment to empathetic service

Walk the Halls
So far, we have focused on how frontline employees can mobilize an organization to be more empathetic through the informal organization. Senior leaders play a critical role in supporting and making room for these efforts. Ultimately, leaders can set the wheels of the formal organization in motion to seek and implement long-term solutions to those institutionalized barriers that inhibit patient service. In the nearer term and more directly, senior leaders can prepare the organization for change by making an empathetic commitment of their own to patients and employees and listening intently to their needs. There is a lot written about how vital it is to listen to patients and use their feedback to improve service. Most organizations have found ways to make this an important part of their operations. But what is often undervalued is the crucial practice of listening to employees. Frontline employees are the organizational link to patients and because they are so close to that patient experience, they can provide unique insight into how an organization is performing in the service dimension. More importantly, they know their organization well and can collect and interpret information on the patient experience in the context of organizational values and goals. When senior leaders do listen to employees, too often they rely exclusively on formal mechanisms like employee surveys to find out what is on employees’ minds. While highly valuable, these mechanisms do not provide the personal and dynamic insight into the day-to-day work and employee experience that informal interactions can provide. The leaders we interviewed talked about the role that “walking the halls” plays in their responsibilities and their commitment not just to patients but to their people. When executives appear on the frontlines, it is not only to provide tours; they devote a significant amount of their time to listening to employees, building their understanding of what happens at the frontlines and demonstrating their shared commitment to serving patients every day. Walking the halls not only increases leadership visibility, it allows leaders to connect with the people who create the patient experience, both on the frontline and behind the scenes. A HealthSouth hospital CEO explained how this practice of hall-walking has made a difference to employees, “Having the senior management team spend time on the floor has been interpreted by our staff as indication of our commitment and our support of their work —there’s more of a feeling of camaraderie and mutual respect.” Proving to employees that leaders have an empathetic understanding of their day-to-day reality can build trust and set a strong foundation for future change. Another HealthSouth hospital CEO explained, “The connectedness between senior management and staff has instilled a real sense of pride and commitment and ownership among everyone who works here.” The halls of a hospital are not the only ones worth walking. Bruce Goodman at Humana talked about the importance of connecting directly with employees in reinforcing Humana’s commitment to Perfect Service. During Humana’s Perfect Service Week, Bruce visited all of the service centers to talk with employees about service and to meet with them face-to-face. He said, “I probably shook 2,000 hands that week.” Baptist Health Care in Florida has taken this informal approach to connecting leaders with the frontline employee experience one step further by creating an organization-wide program. Supervisors, managers, directors and


Tap Into the Informal | the Empathy Engine: Achieving breakthroughs in patient service

executives participate in a “Work in My Shoes” job swapping program, in which they each work one four-hour frontline shift. Participants then share stories in order to build an empathetic understanding of the frontline experience, as well as the patient experience. Connecting the top of an organization with the frontline does not have to be a formalized process— what is important is for executives to develop a vivid understanding of their employees’ working lives. Executives at top-performing patient service organizations have an intuitive understanding of the dynamic feedback loop between patient satisfaction and employee engagement. When frontline employees enjoy the work, they have the emotional energy they need to serve patients well. And when patients have positive experiences, their satisfaction motivates the staff. As one executive we spoke with explained, “If you want people to care for patients, you have to show you care for them.” When senior leaders effectively demonstrate that they practice the values they preach—empathizing with employees just as employees should empathize with patients—they can increase the impact and staying power of patient service changes they make. And understanding employees’ points of view can reveal the day-to-day innovations and organizational networks that employees are already using to improve patient service.

Tap into the Informal: What You Can Do
 ere are some practical steps for how you can start your organization H down the path to becoming an Empathy Engine by leveraging the informal organization: ƒƒ In conversations with fellow leaders and employees, ask what your organization is doing to encourage intuitively empathetic employees to “do the right thing” when they see a barrier to meeting patient needs. Have you provided them with the guidelines and institutional support they need to deviate from standard practice and innovate when the situation requires it? What are you learning from today’s workarounds? ƒƒ In initiating and executing the improvements you want to make, ensure you are tapping into the informal and social networks that exist in your organization—encourage leaders at all levels to seek local networks and “hubs” as sources of insight, energy and on-theground solutions ƒƒ S  pend time walking the halls and take time to listen to employees. Demonstrate the empathy you want to see in your people day to day



Strengthen the Formal
With frontline employees motivated to make changes to patient service and the informal organization engaged around meeting patient needs, it is time to think about using formal elements to reinforce empathetic service and achieve scale. Being intentional about empathy often requires instilling it deeper into an organization through formal elements like role design and hiring practices. The key is to formalize the approach without muting the much-needed energy of the informal organization.

Aligning the formal organization can reinforce and support empathetic care

Manage Empathy as a Strategic Capability
Empathy is a capability that can be measured, developed, and rewarded; managing empathy as a strategic capability has implications for how organizations design roles, hire people, and fill leadership positions. People learn empathetic service skills from a variety of professional and personal experiences, within and outside of the healthcare industry. Many of these skills are highly transferable to direct patient service, and people who have developed them elsewhere can play important roles in the healthcare system. For example, Eastern Long Island Hospital takes advantage of the local tourism industry by seeking people with experience in hospitality and other service industries. Their CEO attributes the organization’s “unique culture of caring” in great part to the fact that “everyone before they came here was accustomed to providing a service or a trade in the community.” Clinical and non-clinical staff have developed a strong foundation of service skills that are readily applicable to serving patients—especially the emotional stamina required to deliver empathetic service over a long shift. Any organization can enhance its empathetic capability by hiring people who have learned empathetic behavior in the service sector. Another powerful example comes from Texas Children’s Hospital, which drew several of its new patient service representatives from its existing population of valet parkers. The leader of this team recognized not only the service orientation and tenacity of these star employees but also the fact that they were already well networked—these former valet parkers have personal relationships with the maintenance and support staff that help them mobilize the organization to meet patient needs at lightning speed. A hiring strategy like this might require tradeoffs; for example, these employees might require more healthcare-specific training at the outset, or their office skills may be less refined than other candidates’, but service experience and a willingness to learn increase retention and effectiveness in the long run, making up for the added cost of upfront training. At the Mayo Clinic, candidates for frontline roles are asked, “tell a story of when you were truly compassionate.” Delivering empathetic patient service thus becomes one of the core criteria for hiring, along with technical ability, respect for privacy, and professional experience. Including empathy among the core criteria is an explicit acknowledgement that “great care” is more than great medical care; changing the composition of the workforce over time to reflect that reality can significantly increase an organization’s capacity to deliver empathetic patient service and, in turn, great care.

Empathetic service is a critical skill that can transfer across industries


Strengthen the Formal | the Empathy Engine: Achieving breakthroughs in patient service

Formalizing empathy as a capability sends a strong message about the importance of patient service throughout an organization. The Service Standards Initiative at NYU Medical Center—the initiative that was originally driven by volunteer efforts—was ultimately integrated into the organization’s formal HR management practices. For example, the Medical Center began using behavioral interviewing techniques to assess candidates’ experience and capabilities around service behaviors, employees signed a commitment to the Service Standards upon joining NYU Medical Center, and the Standards were built into the new employee onboarding and performance review process. Following implementation of these formal process changes, the organization experienced a 10% increase in the number of employees promoted past their initial 6-month hiring period. Not only is it important to be explicit that empathy is a critical skill for new hires, it is often necessary to reinforce empathy as a central leadership capability. Empathy is one of the six key communication skill dimensions that are taught in Memorial Sloan-Kettering Cancer Center’s Comskil Laboratory. Dr. Carma Bylund, a full-time faculty member of the program, explained, “You don’t have to agree with the patient, you don’t have to have had the same experiences as the patient, it’s that you understand what they are talking about and what they are going through.” Reinforcing these communication skills directly enhances doctors’ effectiveness in their work and gives patients confidence that their needs are being heard and understood. It can also help doctors adapt to changing dynamics with patients. Dr. Bylund talked about how doctors have needed to adjust their approach in order to connect with patients who have looked up health information on the internet and come to their doctor with ideas about treatment possibilities. She noted, “Some doctors can get really frustrated when they feel the patient is undermining their knowledge and experience, but other doctors accept that the internet has become part of it all. These doctors can engage with it rather than put it off; they can validate the patient’s efforts—even when the information they come with might be wrong—for looking up information, and this can really help in connecting with the patient.”

Some doctors have learned to empathize and build connections with the internet-informed patient

Carve Out Empathetic Roles
Building empathy as an organizational capability does not stop at hiring. To better harness capacity for empathetic service, leading providers have begun to rethink traditional roles. Doctors and nurses have a primary and consuming part to play in delivering error-free clinical care. But they often find themselves playing a variety of other roles, whether it is finding an elderly patient another blanket, or rearranging an inpatient room so that a patient can reach the phone, glass of water, and tissues without leaving her bed. These details can be crucial elements to the patient experience. As one HealthSouth hospital CEO explains, “Having the agility to respond to individual needs is very important. There is no one-size-fits-all solution to customer satisfaction because one patient may not have the same priorities as the person down the hall.” Creating teams of people devoted exclusively to patient service disaggregates roles, allowing doctors to be doctors, nurses to be nurses. These patient service teams can be staffed with high-potential employees already in service roles—like the valet parking staff at Texas Children’s Hospital—who may be able to have even greater impact if they work more

Disaggregating service roles can help doctors to be doctors, nurses to be nurses


the Empathy Engine: Achieving breakthroughs in patient service | Strengthen the Formal

Family & Friends Count Too
Patients do not experience healthcare alone. Organizations need to think beyond just the patient to recognize the critical role that families and friends play in choosing, assessing and shaping the experience of care. Family members, especially those of young and elderly patients, often help patients contact insurance customer service, understand their treatment options, determine where to seek care, and influence adherence to doctors’ advice. The results of our Consumer Survey indicate that visitors form strong opinions of the patient experience.

closely with patients and visitors. Ideally these roles are designed to allow these empathetic high performers to focus their efforts more explicitly on service, taking non-clinical tasks off the plates of physicians, nurses and technicians. By separating select responsibilities into clinical and patient service components, an organization can allow all involved to concentrate more closely on the tasks best suited for them, giving them more time and mental space to empathize. Role redesigns like these allow organizations to reduce the tradeoffs faced by staff trying to juggle a complex set of responsibilities to patients, administrators and regulators. Non-clinical employees, like the “Patient Service Representative” at the Mayo Clinic and the “Patient Care Technician” at Baptist Health Care, provide a critical service complement to the clinical work of nurses and doctors. While it might seem that costs constrain role redesign and the new hiring that goes with it, consider how the redesign could reduce costs. First, by taking work off the plates of highly trained (and highly compensated) clinicians, they are freed to better perform their core responsibilities, increasing their satisfaction and reducing turnover. And second, patients feel their individual needs are being understood by dedicated, caring staff who may be even more effective at meeting non-clinical needs than their clinically trained counterparts. These can also be attractive roles for nonclinical employees as they can be a gateway to clinical roles; at Baptist, for example, the Patient Care Technician job has been a stepping stone into the Phlebotomist position. Sometimes simply shifting the focus of a role can have an impact on patient service. At Humana, the Customer Service Specialist title was changed to Customer Care Specialist to reinforce the organization’s commitment to creating an empathetic patient experience. At one hospital, nurses rechristened the Desk Attendant as “Patient Greeter.” The nurses, thanks to their experience at the frontline, understood that this simple change in name would not only shift the greeter’s focus from the desk to the patients, it would also serve as a reminder of the importance of the role from the patient’s point of view. The name change also demonstrates the nurses’ understanding of a critical feedback loop at work—give someone responsibility for the patient experience and they will work to improve it and gain energy from the improvement.

ƒƒ More than a quarter of both visitors and
patients believe patient service needs to improve, but visitors are especially dissatisfied

ƒƒ Higher proportions of visitors said
employees did not do a good job of providing them with helpful information, making them feel like their needs were understood, or creating a caring environment

ƒƒ Visitors are more likely than patients to say
that healthcare lags behind other industries in terms of service Visitors to facilities are only one segment of the larger family and friends network that influences the perception of care. Demonstrating patient empathy needs to include a conscientious effort to provide good service to family and friends as well.


Strengthen the Formal | the Empathy Engine: Achieving breakthroughs in patient service

Think Big, Build Small
Vibrant organizational networks support internal flows of information and can bridge silos to increase responsiveness. Small hospitals consistently outperform larger ones in terms of patient satisfaction, with hospitals of 50 beds or fewer holding a four-point advantage over hospitals of 600 beds or more.13 Part of this difference can be attributed to the power of a vibrant informal organization. Many employees of an 80-bed Community Hospital grew up together and have strong social bonds beyond the bounds of the hospital. This close community of employees, from mechanics to dietary aids and doctors, means that well-being “is felt and understood; when people work here, they understand the importance of delivering care and service holistically.” Larger hospitals, too, can grow big while retaining this positive feeling of smallness, though it requires being more explicit about when and how to formalize processes that are more natural to smaller organizations. Best practice sharing is something that happens effortlessly in a small organization where employees see each other regularly and have the opportunity to exchange ideas and experiences. In a larger organization, it is more difficult to share and spread employee innovations broadly. When a nurse or a call center representative develops a new way to deliver superior patient service, for example, the informal organization can only help her spread her idea so far, usually within her own work unit or shift. But there are most likely others in the organization in similar roles that can benefit from her innovation. To address this challenge of bigness, at Texas Children’s Hospital—a 450-bed facility—the hospital floor has been designated as a unit of innovation. If there is a new idea about how to deliver patient service on the floor, the unit tries it out in a localized mini-pilot. The unit heads then meet regularly and share which ideas are working. In this way, innovations work their way up the formal organization, fueled by the units’ energy for making things better. It is possible to capture the advantages of smallness on an even larger scale. For example, HealthSouth has created a new focused network that connects five of its hospital CEOs on a quarterly conference call. The calls allow the CEOs to share patient service successes and challenges across facilities. Perhaps most importantly, they spur problem solving on pressing issues like how to create an organization-wide capability to respond to patients’ individual needs more quickly, or how to translate customer service ratings into actionable service improvements. One inherent benefit of smallness is the close proximity of employees to the patient experience, regardless of their function. In a small hospital, where employees know each other and their patients, even a lab technician hears stories from the frontline. Institution-wide understanding of the patient experience is useful because, while it is frontline staff, like nurses, nurses’ aides and doctors who interact most with patients, patient service is affected by people throughout an organization, including back office billing staff and medical equipment technicians. In a larger organization, where these employees are further removed from the patient experience, clarifying the ways that their work affects patients can have important benefits, especially as a way to motivate their work. Close attention to the areas of their work that impact the patient experience the most, like the time it takes them to resolve a billing dispute, enables rapid and effective frontline problem solving. Vice President of Support, Bill Powanda, noted that at Connecticut-based Griffin Heath, “everyone is a caregiver,” regardless of

Large organizations can ‘feel small’ by creating discrete units of innovation


the Empathy Engine: Achieving breakthroughs in patient service | Strengthen the Formal

their role at the hospital. “We believe that providing an exceptional patient experience must start in the parking lot and end in the parking lot,” he says. Helping people understand how their work makes a difference to patients and holding everyone responsible for patient service helps to establish patient service as an organization-wide priority. An innovative new program called “Ticket to Ride,” designed and tested at University of Pittsburgh Medical Center (UPMC) Presbyterian, does just that. Instead of looking at the transport of patients as a process of impersonal handoffs, UPMC Presbyterian made a critical shift towards the concept of personal “handovers,” which position non-clinical Transporter employees as important participants in patient care. In this new program, patients carry a piece of paper that contains information about where they are going and special instructions about their care. Upon arrival at their destination, the Transporters make a point of engaging with the technician or clinician who is receiving the patient to personally ensure all instructions are handed over. Not only has this innovation supported patient safety and increased patients’ confidence about their care, it has also empowered and energized the Transporters, who previously had not recognized or taken pride in their role as caregivers. Having started small, the Ticket to Ride approach at UPMC Presbyterian will now roll out rapidly across the University of Pittsburgh Medical Center’s 13 acute care hospitals.

Strengthen the Formal: What You Can Do
Formal efforts are critical to reinforcing empathy and achieving impact at scale. Here are a few things you can do on the formal side of your organization: ƒƒ M  anage empathy as a strategic capability in the ways you design roles, hire into the organization and promote from within. Be explicit about the importance of empathy—and what empathetic service looks like in your operating environment—as a criterion for hiring, rewards and advancement ƒƒ Identify groups of current employees in your organization who have particularly strong customer service experience or inclination, and ensure their capabilities are being applied optimally in the service of patients. They are your best candidates for roles explicitly focused on patient service ƒƒ E  nable best practice sharing by identifying and creating opportunities for smaller, more personal communities—such as hospital units, co-workers on a shift, or leadership peer groups—to connect, learn from one another and share ideas with the broader organization



Harmonize the Informal and Formal
With the informal organization empowered and the formal organization aligned to support patient-focused care, it is time to harmonize the two. The informal organization provides the passion, inspiration and motivation to make changes while the formal provides much-needed reinforcement, structure and resources to get things done on a larger scale. This final phase is focused on sustaining the changes—and the resulting empathetic care— by relying on both the informal and formal sides of the organization and weaving empathy into the fabric of the organization so it is not something you “do” but part of who you “are” as an organization.

Find and Cultivate Your Pride Builders
Middle managers and supervisors play an integral and oft-needed role in supporting the delivery of empathetic care at the frontline—if they are not supporting their people, their people cannot support patients. There are certain managers who are uniquely able to make people feel good about the work they do every day. This is a latent asset that all organizations have and can capitalize on. Good managers support their employees, but “pride-building” managers inspire their employees to take pride in the work itself and achieve extraordinary results, regardless of how routine or challenging the work may seem. Pride in a job well done is infectious and these pride builders can often serve as more credible and effective agents for change than “HR” or “Management.” When trying to increase the number of employees delivering empathetic care, look to pride builders to make it happen. Finding those managers who are considered pride builders is relatively easy. The pride builders are the names that come to mind when you and your fellow leaders think about the frontline managers who have fiercely loyal, high-performing teams that take genuine pride in their day-to-day work and seem to have an extra reserve of energy. Once you have identified these managers, it is important to figure out what it is they do that separates them from other good managers. Years of research have demonstrated that the behaviors that set them apart can be codified and shared with others to build a broader pride-building capability within the organization.14 Healthcare organizations can learn from companies in other industries that have used pride-building efforts to motivate large groups of employees to improve service. Bell Canada, a large telecommunications provider based in Toronto, needed to make radical changes to many of its programs and processes to keep up with changes in the industry. As part of their turnaround plan, they looked to distinguish themselves on customer service but they did not have time for formal programs that would take years to implement. They started by seeking out their pride builders—those managers who were already demonstrating the desired behaviors and encouraging them in their people—and brought them together to share best practices and build on the already existing energy to transform the organization. A series of local performance improvement pilots, driven by the best practices and energy of pride builders, yielded impressive customer service results: employee commitment, customer satisfaction and sales all increased. Under strong CEO leadership, pride building became a “movement” within Bell Canada. In the first three years of the effort, the informal community of pride builders grew from an initial group of 12

Integrating informal and formal mechanisms achieves the greatest empathetic impact

Every organization has master motivators—these frontline leaders should play the starring role in improving empathetic service


the Empathy Engine: Achieving breakthroughs in patient service | Harmonize the Informal and Formal

to a thriving network of over 1,000 managers who connected locally and virtually to innovate, learn from one another, and pilot new ways of meeting customer needs. Performance pilots driven by pride builders resulted in a 29% increase in customer satisfaction, a 10% increase in productivity, and a 13% increase in employee pride and motivation. In healthcare organizations, like at Bell, tapping existing sources of pride and providing the formal resources to support and cultivate pride-building efforts can build momentum and energy and dramatically improve how an organization delivers patient service.

The discipline of storytelling can inspire and reinforce empathetic care

Tell Stories to Keep Empathy Alive
Stories can energize and inform, and when even the most empathetic employees need to hear how important their work is to patients, stories can remind them of how their everyday work is creating a shared narrative of patient service values in action. As the CEO of a HealthSouth hospital put it, “Stories are an incredibly powerful way to change culture—they take abstract ideas and make them real to the people doing the work day-today.” In addition to informal storytelling, The Mayo Clinic has developed a process to train leaders to gather stories from the frontline and share them throughout the organization, from administration to nursing station. One leader explains, “Storytelling is a huge part of our culture and one of the ways we try to keep employees connected. You hear stories and you are proud to work at a place that empathizes with patients.” Not only do the stories energize the veterans, they introduce the culture to new employees. “We start with stories on the first day of work for new employees.” These stories help to ground people’s work in the shared patient-centric values of the organization. Stories can also play a role in inspiring better service, energizing and informing staff. When a large regional health network was struggling financially, the leadership shared the troubles with the staff and encouraged them to spot opportunities for savings. As employees successfully spotted opportunities to save, like making a change in the food packaging at the cafeteria ($40,000 a year), the leadership made sure to “keep sharing the success” through stories distributed across the organization. This same approach applied to patient service can prove profoundly motivating, since service is intuitive and the impact on patients can be emotionally powerful. As one executive explains, “business language has zero emotional currency.” A well-told story, not branding language, triggers an emotional response and can motivate employees to deliver empathetic patient service.

Not All Stories Are Created Equal
Stories that energize and inform share a few central characteristics that make them meaningful.

ƒƒ They tell the story of exemplary care
from the point of view of the patient, highlighting his or her individual context, and clearly explaining how the emp