Patient Engagement
What If Our Care Were Designed by Patients? (21:20)

With a theme called Physicians Leading | Leading Physicians, you need to talk about patients, says Steve Swensen. “I want to ask ourselves to imagine, what would it be like if our care were designed by patients? And if our leaders were selected by patients? And if our organizations were designed by patients?”

Swensen relates the story of a friend of his, who co-owns a twin-engine Aerostar plane, noting that this story helps keep him grounded on patient centeredness. Every time maintenance work is done on the plane, guess who is the first person to fly it? The mechanic. We can compare the mechanic’s perception of the work at hand and the responsibility to that of being a patient. “If we continually prompt ourselves to think about our care, our systems, our compensation systems, our leader selection process through the eyes of a mechanic who is about to fly in a plane that s/he is repairing, it changes the game.”

Five years ago, Swensen led a group of researchers at the Institute for Healthcare Improvement in looking at learnings from the top leaders in the top organizations across the world. Over a 2-year period, they interviewed over two dozen successful leaders in some of the best organizations in the country, including Brent James and Gary Kaplan, and then spent time with the patients and families they served. From this, they came up with five high-impact behaviors that drove success for these organizations, and the best outcome safety service for their patients. The number one behavior was discovered to be “person-centered” in word and deed. And, they took special care to talk about patients as people, not patients, because the patients told them not to. “We’re people, we’re humans,” they said.

A distillate of this research came down to three wishes of a patient about to undergo care:

Wish 1: Care about me.
Two years ago, Swensen worked with 50 leaders of a large health system, and the leader of that group shared with those 50 leaders a story about her son who had a chronic illness and had to undergo a major elective transplant surgery for a failed kidney. The procedure went fine — there were no medication errors, no readmissions, no infections. But the words she used to describe the experience at her own hospital were: There was no love in the system. So if the first wish of a patient is “care about me”, not only did we miss the wish, says Swensen, but we also put that patient at risk. “Because care without love is at-risk care,” he says, when there are higher rates of safety issues, of patient experience issues, of outcomes, and higher costs.

What’s the best way to heal a wound? Kindness and empathy. The literature is replete with good science showing that wounds heal faster if patients experience kindness and empathy, Swensen adds. Kindness and empathy not only build trust and reduce anxiety, pain, and readmissions among patients, but — the beauty of it is, Swensen says — that it’s a virtuous cycle, because that kindness and empathy come right back to the health care professionals. Not only does they improve outcomes for patients, but they also reduce costs.

A third of prescriptions filled out in America are not filled by patients, the dominant reason being a lack of trust and empathy between patient and provider. But if that trust and empathetic relationship exists, patients are more likely to take their medications and do what is in their own best interest — making population costs go down.

You can’t give what you don’t have, Swensen adds. If we don’t have empathy, if we’re emotionally exhausted or socially isolated, our patients suffer. Even if we can get the mechanic parts right, it doesn’t mean much if we can’t get the relationship part right.

Wish 2: Care for each other.
The second wish Swensen’s research team found was that it was important that care be mutual. Patients understood that if health care professionals care for one another — doctors, nurses, social workers, managers, housekeepers — that they would get better care, have a better experience, and have better outcomes.

Five years ago, Swensen had a debate with Bob Chapman, CEO of Barry Wehmiller Companies, about how in health care, the needs of the patient come first. Chapman’s contention was that the well-being of team members is paramount, and if they’re healthy, the team works well, therefore ensuring the patients receive good care. Neither of them were right, necessarily, Swensen says, but he learned a lot. When Chapman took over as CEO in 1975, they had one company and were financially insecure; today they have 80 manufacturing companies across the planet, with an annual revenue stream of $2.4 billion.

“He looks at his organization as an opportunity to enrich lives,” Swensen says. Chapman says that the machine we build is simply an economic engine to enrich lives. His team of 11,000 employees is predominantly blue collar and unionized, and Chapman instituted rules such as removing time clocks for blue collar employees, since executives didn’t have them. In 2008, during the recession, they should have laid off thousands of team members, but instead, he said, “Our goal is to not lay anyone off. We’ll defer payments on retirement plans, we’ll have furloughs, we’ll take pay cuts.” After the recession, loyalty was sky high. And after being surveyed, 79% of team members said that the leaders of the organization cared for them — which is basically the inverse of most health care organizations in this country. This buys us better patient outcomes, better patient safety, at lower costs.

Swensen offers the example of a member of the Intermountain cleaning staff called Christina. She cleans toilets and changes soiled sheets. But, she sees her job not as a cleaning person, but as a caregiver. Recently, she came into a room and saw a patient who was frustrated in trying to see her father on a different floor. Christina ran up to the floor where the patient’s father was and handed him the phone — and the patient told him that she loved him. A half hour later, the patient’s father died. Christina, having lost her own father recently, embraced the patient who’d just lost hers.

Swensen’s uncle taught him: the best way to succeed is to help someone else succeed.

Wish 3: Put my interests first.
Swensen says he used to look at a glass half full. Now, he sees it as having more opportunity to get the job done. “That’s our health care system,” he says. “Our health care system has 40% waste by the most conservative estimates, and the top three categories of waste we own: overtreatment, failures of care delivery, failures of care coordination.” So, he says, that is our opportunity to put patients’ interests first, adding that we have to be careful of financial incentives when we want to be patient centered.

“Not only is putting patients’ interest first in the patient’s best interest, but it’s in ours,” Swensen says. “If you look at drivers of burnout, one of the drivers is moral distress, and a values dissonance. So not only is it good for patients to put their interests first, it’s good for us.”

From the NEJM Catalyst event Physicians Leading | Leading Physicians at Intermountain Healthcare, July 12, 2017. This talk originally appeared in NEJM Catalyst on August 7, 2017.

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