Patient Experience: A Critical Indicator of

Healthcare Performance

PAMELA H. GULER, FACHE

S u m m a r y • Patient experience has become a critical differentiator for health-
care organizations, and it will only grow in importance as transparency and consum-
erism dominate the healthcare landscape. Creating and sustaining a consistently
exceptional experience that promotes patient engagement and the best outcomes
is far more than just “satisfying” patients, going well beyond amenities that
may be provided.
Perception of care experience is often shaped by methods we use to address the
biopsychosocial needs of patients. Building relationships and communicating well with
our patients and families are primary approaches. In a complex healthcare situation,
patients may not fully understand or remember the highly clinical nature of treat-
ment. However, they always remember how we made them feel, how we communi-
cated with them as a team, and what interactions they experienced while in our care.
Patients who are fully informed and feel connected to their caregivers are
often less anxious than those who are disengaged. Informed and engaged patients
are enabled to participate in their healthcare. Organizations that focus on develop-
ing an accountable culture—one that inspires caregivers to communicate in a way

F E A T U R E
that connects to patients’ mind, body, and spirit while leveraging standard, evidence-
based patient experience practices—find that patients’ perception of care, or “the
patient experience,” is vastly improved.
Adventist Health System has embarked on a journey to patient experience ex-
cellence with a commitment to whole-person care and standard patient experience
practice across the system. Recognized with several national awards, we continue
to strengthen our approach toward bringing all of our campuses and patient set-
tings to sustained high-level performance. We have found that a combination of
strong, accountable leadership; a focus on employee culture; engagement of phy-
sicians; standardized patient experience practices and education; and meaningful
use of patient feedback are top contributors to excellence in patient experience.

Pamela H. Guler, FACHE, LSSMBB, CPXP, is vice president and chief patient experience officer at
Adventist Health System, headquartered in Altamonte Springs, Florida.
The author declares no conflicts of interest.
© 2017 Foundation of the American College of Healthcare Executives
DOI: 10.1097/HAP.0000000000000003

Pamela H. Guler, FACHE  17

© 2017 Foundation of the American College of Healthcare Executives

 W hat is the patient experience? If you
ask anyone in healthcare this question
today, you will likely hear a variety of an-
swers. Some may say it is patient satisfaction
or qualify it as whether we are nice to pa-
tients and families. Others may refer directly
to how experience is measured via tools
such as the Consumer Assessment of
Healthcare Providers and Systems (CAHPS)
surveys of the Centers for Medicare &
Medicaid Services (CMS). Still others may
offer a comprehensive view of the patient
experience, such as The Beryl Institute’s
(2016) definition: “the
A standard approach to sum of all interactions,
evidence-based practices is shaped by an organiza-
tion’s culture, that influ-
imperative to a successful ence patient perceptions
patient experience. across the continuum of
care.” Regardless of how
we define the patient experience, this topic
has been, and will continue to be, a critical
indicator of future viability for healthcare
organizations. Consumers expect clinical
excellence in their care; how we treat our
patients, communicate with them, engage
them, know them, and partner with them
throughout their lifetime, addressing their
whole health journey, becomes a differenti-
ator as well.
Patient Experience at
Adventist Health System
Adventist Health System is a faith-based
healthcare organization headquartered in
Altamonte Springs, Florida. Our more
than 78,000 employees maintain a tradi-
tion of whole-person health by caring for
the physical, emotional, and spiritual needs
of every patient. With 46 hospital campuses
and more than 8,300 licensed beds in ten
states, we serve more than 4.7 million pa-
tients annually. Our full continuum of
18  frontiers of health services management 33:3
© 2017 Foundation of the American College of Healthcare Executives
integrated care includes medical practice
offices, urgent care centers, home health
and hospice agencies, and skilled nursing
facilities.
As a system, Adventist Health System
has been on a journey of patient experience
improvement for the past six years. Exhibit 1
shows the level of improvement we have
achieved by showing monthly progress from
2009 through July 2016 according to the
Hospital CAHPS (HCAHPS) survey mea-
sure overall rating. The solid line notes
Adventist Health System’s progress in the
“top-box” score (the percentage of patients
responding with a score of 9 or 10 to the
question “Rate the hospital on a scale of
0–10”). The dashed line represents the 50th
percentile for the Press Ganey national
benchmark database (a comparative to
approximately 1,800 other hospitals), and
the dotted line represents the 75th per-
centile. Clearly, our pace of change has
been dramatic. As we reach higher scores,
the challenge to improve becomes even
more daunting, so we have refined our
strategies over time to achieve the desired
performance.
Adventist Health System’s Definition
of Patient Experience
How do Adventist Health System’s caregivers
define the patient experience? That is an
interesting cultural question. A key driver of
our commitment to our patient experience
efforts is our ability to energize and sustain a
culture in which our caregivers continually
connect to the “why”—our mission, vision,
and values—behind everything we do. In 2012,
as we further formalized our efforts around
the patient experience, we asked our em-
ployees how they define this term. More
than 90 definitions were submitted from
across the system, and 600 attendees at
Exhibit 1 Adventist Health System: Overall Hospital Rating Compared with National Benchmarks

Source: Press Ganey. Reprinted with permission.

our annual Patient Experience Summit that Critical Factors in Improving

year voted on the “winning” definition:
“treating the patient as you would the person
whom you love the most.”
This simple and meaningful definition,
submitted by a bedside nurse, has resonated
throughout the system for the past four years.
While defining the patient experience may
Patient Experience
At Adventist Health System, four critical
factors serve as a framework for approaching
and sustaining a high level of performance
in patient experience.
Critical Factor 1: Make Culture a

seem like a simple step in a cultural journey,
developing a definition of this important
work from the inside was important to us.
And the fact that it came from a bedside care-
giver rendered the definition all the more
important.
Today, we complement this definition
with the concept of whole-person health and
delivering a consistent patient experience
with uncommon compassion across our
entire system. Consistency is key: We have
found that delivering a standard approach
to evidence-based best practices, built on a
cultural framework of engaged caregivers
committed to our mission, is imperative to
a successful patient experience.
F E A T U R E
Top Priority
An organization might expect to jump im-
mediately into the practices or “tactics” of
patient experience interactions, such as
hourly rounding, when first addressing the
critical factors that produce the best results.
While this approach is tempting (and in-
deed, these practices are covered later in
the article), the most important area of focus
to master first is the employee culture. En-
gaged employees who are committed to the
organization’s mission and dedicated to
the why are the number one leverage point
for driving exceptional experience for pa-
tients and families. Hiring employees with
a service- and teamwork-oriented attitude to

Pamela H. Guler, FACHE  19

© 2017 Foundation of the American College of Healthcare Executives

 accompany their clinical skill is essential to
building a culture of sustained excellence in
patient experience.
Constantly “re-recruiting” high per-
formers, growing solid performers, and
coaching up those who need additional
growth are equally critical aspects. Strategies
for reducing turnover and stabilizing the
workforce are key as well. Establishing and
actualizing these activities takes strong,
engaged leaders at all levels of the organi-
zation. Leadership development that en-
riches leaders with the skills they need to
engage, grow, coach, and lead their teams is
a significant compo-
Communication from the nent of the work we
senior-most levels of the must do. All of these
organization about patient building blocks of a
culture that supports
experience is a priority. patient experience
excellence demonstrate the importance of
alignment between patient experience and
strategic human resources.
Approaches to Growing a Committed Culture
What are some methods for growing a
culture committed to patient experience
excellence? Fundamental to our current and
continued success is an intentional focus on
education and networking throughout the
health system as they relate to patient expe-
rience improvement and excellence. Our
system hosts the annual Patient Experience
Summit in Orlando, which has grown to 700
attendees from all ten states in which Adventist
Health System operates, with national key-
note speakers and sharing of internal best
practices. Networking and celebrating prog-
ress are major components of this summit,
including a spirited awards luncheon hosted
by our CEO.
We springboard from the yearly summit
by conducting monthly online strategy
20  frontiers of health services management 33:3
© 2017 Foundation of the American College of Healthcare Executives
meetings via Skype for each patient setting
(e.g., inpatient, emergency department,
ambulatory), through which hundreds of
participants continue to learn from each other
and from our Office of Clinical Effectiveness
regarding best practices.
Every summit and meeting includes a
patient story that demonstrates the importance
of promoting a strong patient experience.
The sharing of meaningful patient experience
stories is one of the most powerful methods
of connecting to the why with employees
and physicians. Since 2013, we have aimed
to “connect head and heart” through various
innovative methods, such as the following:
• A story portal was developed for our
system’s intranet and marketed
throughout the organization as a place to
submit stories—hundreds of them over
the years—that illustrate meaningful
patient experience interactions.
• Every meeting related to patient
experience opens with a story, usually
shared by the caregiver who was a part of
that story.
• Patient experience stories are shared by
our CEO as “mission moments” through
his regular newsletter, Newsline, to all
employees.
• Story sharing is encouraged in unit-level
department meetings.
• Our system celebrates these stories
through an annual award for “caring
with uncommon compassion.” Criteria
for the award over the years have ranged
from the campus submitting the most
stories to the portal (in 2014) to how story
sharing is leveraged at each campus to
connect to the why (2015) to the campus
with the most powerful story (2016). One
of our 2016 Uncommon Compassion
Award–recognized stories was an
extremely powerful message about the
 care provided to Pulse nightclub shooting
victims in Orlando by our caregivers.
Often, patients are engaged to share
their stories, creating an even deeper oppor-
tunity for our caregivers to connect to the
heart and to recognize the importance of the
patient experience. In fact, a Pulse victim
and patient at one of our campuses opened
the Patient Experience Summit in fall 2016,
sharing thoughts from that difficult time
and relating how our caregivers had become
family until relatives could arrive. We also
recognize the importance of sharing stories
that may not be selected as “best” so that we
may learn from them as well.
Capturing direct comments and accounts
from patients and families is another critical
component to delivering the best patient
experience. Adventist Health System cap-
tures both positive and constructive feedback
through surveys and follow-up phone calls to
patients. Our surveys are designed to allow
for written comments, and our survey part-
ner’s online tools allow us to pull and ana-
lyze these comments. Our chief nursing
officers (CNOs) lead meetings at their cam-
puses where patient comments are reviewed
for trends and discussed for successes and
opportunities. Managers share comments in
their unit meetings, and senior leaders pro-
vide patient feedback to physicians. Sharing
comments provides an opportunity to rec-
ognize employees and physicians for excel-
lent service to our patients and families, as
reward and recognition are critical to sus-
taining excellence in this area.
Above all else, communication from the
senior-most levels of the organization about
the importance of patient experience is a
priority. Senior leadership should also
support the efforts and resources that are
required to improve patient experience. We
Pamela H. Guler, FACHE
© 2017 Foundation of the American College of Healthcare Executives
should all own patient experience, and the
ultimate ownership sits with the CEO. If the
CEO stresses patient experience as a priority,
the entire organization follows. With that
support as a foundation, others in the organi-
zation, such as CNOs and chief patient expe-
rience officers (CXOs), are better enabled
to drive change and sustained improvement.
Critical Factor 2: Engage Physicians
Many physicians are naturally empathetic
with patients, demonstrating strong com-
munication and listening skills. Others may
have challenges in this area and need assis-
tance to improve. A national research study
published in 2009 noted that 75 percent of
patients admitted to the hospital were un-
able to name a single doctor assigned to
their care (Arora et al. 2009). Another
well-reported historical study noted that the
average physician interrupts a patient after
approximately 18 seconds during the opening
description of the patient’s principal con-
cern (Beckman and Frankel 1984). Subse-
quent studies have supported these
findings, including more recent research
that lowered the number to 12 seconds in
F E A T U R E
the case of residents (Rhoades et al. 2001).
To provide the best experience and care, we
must take the time to listen to our patients.
We know that engaging physicians in the
patient experience journey is imperative to
success. We must go beyond that acknowl-
edgment, however, and providing a method
for physicians to enhance skills in relation-
ship building and empathy with patients is a
known best practice.
One key strategy is to develop and internal-
ize a physician–patient relationship–based
communication course taught by physicians
to their colleagues. Other organizations have
internalized education programs of this na-
ture with success, and Adventist Health
 21
 System is now on this path as well, setting
our education program in place, training our
physicians as facilitators of an evidence-
based curriculum, and in turn leveraging
these facilitators to train their colleagues in
these important skills.
In addition to communication skills, an-
other important, yet simple, practice is sit-
ting when talking with a patient. Research
indicates that the patient’s perception of
time spent with the physician increases
if the physician sits, and the patient also
feels the physician is more compassionate
(Ketelsen, Cook, and Kennedy 2014). Yet,
sitting is often a chal-
Engaging physicians in lenge, at least in the in-
understanding patient patient or emergency
experience feedback and department setting:
Physicians are in a
data is important. hurry, they do not think
of sitting, or a chair is not available. Some
of our campuses have hung designated “for
your doctor” folding chairs on the walls of
patient rooms so that the physician always
has a chair to use. Whatever action is needed,
making sure that your physicians can sit,
and encouraging them to do so, is a high-
impact strategy.
Engaging physicians in understanding
patient experience feedback and data is also
important to the improvement journey. We
stratify our patient experience survey feed-
back to the physician level to allow our doc-
tors to gain insights into their patients’
perception of care. Patients hold physicians
in high regard. We find that raw scores from
experience surveys tend to be higher for
questions related to physicians, with a nar-
row or compressed range for movement to
improved percentile performance. In fact, we
often find that movement for a physician in
HCAHPS scores from the 50th to the 75th
percentile requires only a few more patients
22  frontiers of health services management 33:3
© 2017 Foundation of the American College of Healthcare Executives
answering “always” rather than “usually.”
One effective approach with physicians is
to “humanize” the data by sharing how
many more patients would have needed to
answer “always” to move the resulting score
to the 75th percentile.
On the patient side, an excellent strategy
for improving patients’ perception of com-
munication with their doctor is the practice
of physician–nurse dyad rounding. This
practice, when implemented effectively,
vastly improves teamwork and communica-
tion between caregivers, reduces follow-up
phone calls to the doctor from the nurse, and
enables the nurse to better care for the needs
of the patient appropriately and efficiently.
Engaging physicians in this practice, or in
the more advanced practice of multidisci-
plinary rounding at the bedside, provides a
strong framework for exceptional patient
experience and care.
Critical Factor 3: Standardize Patient
Experience Practices
A few years ago, this section might have
been titled “Best Practices for Patient Ex-
perience,” but over time, Adventist Health
System’s overall mind-set has shifted from
a recommended-best-practice approach to
a standard “this is how we care for our pa-
tients” methodology. Recalling that consis-
tency is a key attribute of excelling at patient
experience, as a system of 46 campuses we
have achieved strong improvement in our
patient experience journey over the years,
with national recognition. That said, we still
encounter some variation in performance
across campuses. The current stage of our
journey is to standardize as a unified system
around specific practices with one consis-
tent method for teaching, validating, and
holding ourselves accountable to those
practices. We know from networking and
benchmarking with other top-performing or-
ganizations, as well as from our own internal
results, that engaged employees who imple-
ment these practices well and with inten-
tionality drive top-decile performance.
What are those standards for patient
experience? They may vary slightly by patient
setting, but some examples are the following:
• Executive leadership rounding on
employees and patients
• Direct leader rounding on employees
• Nurse leader rounding on patients
• Hourly rounding on patients by staff
Once our campuses have entrenched
these standards into their practice, we insti-
tute standards related to bedside handoff,
follow-up phone calls, and nurse–physician
dyad rounding. We deliberately avoided try-
ing to “boil the ocean”—implementing all
the standards at once.
A detailed description of each of these
practices can be found throughout the lite-
rature, including the HCAHPS Handbook
(Ketelsen, Cook, and Kennedy 2014), so they
are not elaborated on here. However, the topic
of hourly rounding merits additional com-
mentary, primarily considering how Adventist
Health System has leveraged paients’ percep-
tion of this rounding to drive improvement.
Hourly Rounding
We have found that hourly rounding, when
conducted purposefully, drives improvement
of patient experience results in the inpatient
setting. What does purposefully mean to us?
We use the acronym COLA, for “care out
loud always,” with our caregivers, encouraging
them to narrate their care with a patient or
family as they address the “five Ps” of hourly
rounds: pain, potty, position, periphery, and
parting. We know that our caregivers are
in the room hourly, so ensuring that they
Pamela H. Guler, FACHE
© 2017 Foundation of the American College of Healthcare Executives
communicate in a consistent manner while
caring for their patients is key.
We connect with our caregivers regu-
larly on the why behind hourly rounding.
First and foremost, hourly rounding is about
safety for our patients. Studies have shown
direct correlations between hourly round-
ing and reduced falls and pressure ulcers.
Hourly rounding also reduces the use of call
lights and allows the nurse to proactively
manage the plan of care. Every caregiver un-
derstands these incredibly powerful reasons
for this very intentional practice.
We also stress the relationship building
between staff and patients that must occur
during conversations, with a focus on em-
pathy and listening skills. One of our edu-
cation methods teaches our busy nurses
how a strong connection can be made in just
90 seconds. Another method teaches
nurses to ask the patient about the most im-
portant thing (MIT) that they can do for him
today. The nurse writes the response on
the communication board in the patient’s
room so that all employees and physicians
who interact with the patient are aware of
it. For the patient, the MIT often is not
F E A T U R E
clinical and may be a personal factor. Any ac-
tivity we can undertake to enhance our rela-
tionship with those in our care is essential to
the patient experience.
Critical Factor 4: Commit to Meaningful
Use of Data
The impact of hourly rounding on patient
experience has been researched and proven
through national studies (Meade, Bursell,
and Ketelsen 2006), but no amount of read-
ing about others’ successes equates to see-
ing hourly rounding—and your employees’
connection to the why—with your own eyes.
Adventist Health System’s survey measure-
ment tools are described later in detail, but
 23
 one feature of these tools is highlighted
here: the additional questions we can ask
the patient.
For our inpatients, we use a format that
includes both HCAHPS and additional
questions. One of those questions simply
asks the patient, “Did a staff member
visit you hourly during the day?” With
this feedback from our patients, we can
easily share with our employees the
vast difference in HCAHPS results be-
tween patients who answered yes to the
hourly rounding question and those who
answered no.
A sample reporting graphic that we use
to share this impact, from board level to
frontline staff, is shown in Exhibit 2. The dots
and triangles on the bull’s-eye reflect national
percentile levels for the top-box scores (the
Exhibit 2 Impact of Hourly Rounding on HCAHPS Perception of Care
24  frontiers of health services management 33:3
© 2017 Foundation of the American College of Healthcare Executives
percentage of patients who answered
“always” or chose the most positive response
to a given HCAHPS question) for each
HCAHPS composite domain. Patients who
answer yes to the hourly rounding question
have a dramatically higher perception of their
care experience as reflected in HCAHPS.
For example, patients who answer yes to the
hourly rounding question score nurse com-
munication “always” 86.9 percent of the
time, while patients who answer no to the
hourly rounding question score nurse com-
munication “always” only 59.3 percent of the
time. Now, following the bull’s-eye cross-
walk for these scores by noting where the
top-box dot falls on the graphic, nurse com-
munication ranks at 95th percentile for pa-
tients who answered yes to the hourly
rounding question versus 1st percentile for
those who answered no. Nurse communi-
cation has often been called the “rising tide”
measure—when this metric improves, all
others follow. So leveraging strategies
that greatly impact nurse communication,
such as hourly rounding, is all the more
important.
Through this bull’s-eye graphic, our teams
get the message at a single glance that this
standard process has a strong, positive im-
pact on patient experience when executed
well. In fact, with much time now spent ob-
serving hourly rounds at our campuses and
reviewing their bull’s-eyes, we can even get a
sense of how purposeful the rounds are at
the campuses by noting how close the ligh-
ter dots (or patients who said yes to hourly
rounds) are to the center of the bull’s-eye. In
other words, it shows how impactful and
important rounding and communication are
to the patient experience.
We use data meaningfully to drive change
in other ways. Our goal in all that we do is
to be at or above the top quartile in perfor-
mance for patient experience, with the ulti-
mate goal of being top decile, compared with
the rest of the nation. We also have process
goals in place. For example, for our hourly
rounding question, our goal is for 90 percent
of our patients to respond yes, indicating a
cultural entrenchment of the process. All
of these goals roll into a process called the
clinical close. Much like a financial close,
this process involves an executive review
of performance each month across the sys-
tem, with campuses reporting on a regular
basis to the senior-most executives in the
organization.
As a large system, we also leverage data
in meaningful ways through a spirit of
competition. We all strive to provide the very
best experience for our patients and fami-
lies. As a system-level department, my team
Pamela H. Guler, FACHE
© 2017 Foundation of the American College of Healthcare Executives
provides regular ranking charts that show
how all of our campuses are performing.
This approach serves several purposes,
which include promoting networking to
learn from others and celebrating or rais-
ing awareness of where we stand compared
with others. We encourage individual cam-
puses to report similarly, sharing how their
individual units are performing compared
with others, making this method applica-
ble to both large systems and individual
campuses.
How frequently should survey results be
reviewed? Depending on sample size, pulling
survey results weekly or even daily can lead
us to unnecessarily react, negatively or posi-
tively, to changes. Having a large enough
sample size is critical before assuming re-
sults represent the patient population with
full validity. Our survey partner provides ex-
cellent tools that allow our frontline leaders
to report on their own results in addition to
the standard reports we provide. Teaching
leaders about sample size helps ensure that
they pull results for the right time frame and
validate the data to help them better inter-
pret results and drive sustainable change.
F E A T U R E
Every survey administered, along with the
voice of that patient, matters. At the same
time, we must keep data validity in mind
before making broad statements about
our performance.
Measuring the Patient Experience
So far, the data and reports described re-
flect the survey process we use at Adventist
Health System. We partner with Press
Ganey for all types of acute care surveys—
those for inpatients (HCAHPS), emergency
department patients who are not admitted to
the hospital, and outpatients and ambulatory
surgery patients (OAS CAHPS)—as well as
for surveys for our medical practice setting.
 25
 We partner with other vendors for our home
health and hospice CAHPS surveys. We mail
paper surveys in every instance, and we sup-
plement the emergency department and
medical practice surveys with an e-mail
version. Our survey tools allow us to cap-
ture patient comments, which as men-
tioned earlier is a key to improvement. We
also implement the new CAHPS tools as
they are released from CMS in early-adopter
fashion so that we have the time to assess
our performance with them and strive to
excel in the feedback provided by patients as
part of our mission.
But survey tools are
We must think proactively not our only method
about resource of measuring patient
requirements to handle experience. As noted
earlier, one patient
what is coming
experience standard
in the future. relates to nurse leader
rounding on patients (every patient, every
day). Twenty-five of our campuses have
adopted a tablet computer–based tool called
MyRounding to track these rounds, log
and resolve any issues, capture trends, and
note recognition of employees for sharing.
These bedside rounds, and the ability to
capture and organize feedback from them
easily, are helpful in improving the over-
all experience for our patients and families.
Regular reports are provided to our CNOs
showing round completion, trends, and
open issues, affording an opportunity for
discussion and accountability with the team.
Another powerful method of capturing
patient feedback is through our follow-up
phone call process. This system has evolved
over the years, and a number of our cam-
puses are moving to a regional call center
approach to make these calls efficient and
consistent, thus meeting the needs of our
patients and families in additional ways.
26  frontiers of health services management 33:3
© 2017 Foundation of the American College of Healthcare Executives
Finally, in our consumer-driven mar-
ketplace, we look outside our typical means
of feedback capture to social media and
other ways to analyze the voice of our cus-
tomers. New software will enable us to
further analyze these inputs.
Our Patient Experience
Organization
We are often asked about the makeup of our
system headquarters–based patient experi-
ence team and how we leverage patient ex-
perience leaders in the field. At the
corporate level, patient experience is a part
of Adventist Health System’s Office of
Clinical Effectiveness, facilitating alignment
with nursing and physicians. Of equal im-
portance are strategic alignments with hu-
man resources and other areas, such as
brand and marketing, communications, and
information technology (IT). The system
patient experience leadership team is com-
posed of a CXO, a system director, and a
system manager overseeing both patient
and consumer experience efforts. The di-
rector oversees a clinical team of project
managers and consultants who focus on
various patient settings and areas (inpatient,
emergency department, ambulatory, post-
acute, and physician strategies). The man-
ager oversees a team of analytics, survey
compliance, and process improvement
strategists. The team leads patient experi-
ence projects and consulting across the
continuum of care while also managing all
CAHPS and other survey efforts, compli-
ance, and reporting for all patient settings,
removing the need for our campuses to
handle these duties. We leverage and in-
fluence a network of patient experience
leaders throughout the system, with most
campuses having at least one leader. Those
roles typically report to the campus CNO
and are critically important to the imple-
mentation of strategies.
Patient Experience and the Changing
Healthcare Landscape
Much of this article so far has featured ex-
amples of patient experience practices
within the four walls of the acute care set-
ting. However, we also have expanded our
focus on the patient experience across the
care continuum. As mentioned earlier, Ad-
ventist Health System places a heavy em-
phasis on whole-person health. Our internal
research has shown that for every inpatient
admission, 20 or more interactions with our
patients take place in other settings. As CXO,
my role and that of my team have expanded
across the continuum over the past few years
to include comprehensive coverage of both
patient and consumer experience.
With a focus on whole-person health, our
faith-based system embodies a set of eight
principles as we care for patients, families,
and communities. These biblically founded
principles are represented as CREATION
health—choice, rest, environment, activity,
trust, interpersonal relationships, outlook,
and nutrition. These principles are entrenched
in our interactions with patients in a way
that enriches the patient experience.
We see our interactions with all con-
sumers as taking place across five themes:
engage me, know me, hold my hand, make
it easy, and give me the best care. With em-
phasis on these themes, the work that we do
becomes much more than a focus on sur-
vey results—we systematically review each
touch point for consumers and patients and
the experience provided. In terms of the IT
environment, our patient portals and cus-
tomer relationship management methods
help us remain viable in the current and
future marketplace.
Pamela H. Guler, FACHE
© 2017 Foundation of the American College of Healthcare Executives
We must also consider whether our
measurement tools can capture experience
perception and reality at each touch point
and allow us to make adjustments as neces-
sary. As our healthcare world transforms
around us, we are finding a strong need to
adapt quickly to broaden our consumerism
focus as well as our emphasis on population
health strategies.
The changing healthcare landscape also
brings expanded attention to other patient
settings for the government-mandated
CAHPS surveys. As each new survey be-
comes available—first voluntary, then
mandatory—our organization must evolve
and ensure that we are complying with all re-
quirements. Often, we are already surveying
a given patient setting with a vendor survey
product, but each new CAHPS survey brings
a tighter focus on compliance and eligibility
that requires increased attention and resources.
The CAHPS surveys are excellent tools that
enable us to best capture patients’ percep-
tions of care, and we must think proactively
about resource requirements to handle what
is coming in the future as each new tool
is added.
F E A T U R E
Transparency of data and pay for perfor-
mance are the final, vitally important consid-
erations in the changing healthcare land-
scape. With consumerism as an ever-present
factor surrounding healthcare outcomes—
including patients’ perception of care—we
must sustain improved performance.
Sharing Best Practices with Other
Organizations
One of the most exciting aspects of our work
in the patient experience realm is the growth
of expertise and networking available across
the United States. Many organizations now
have a CXO or similar role dedicated to the
patient experience. Benchmarking and
 27
 networking with each other occur through a
number of vendor and nonvendor partner–
sponsored forums. We constantly network
with other large organizations via our Press
Ganey partnership as well as through orga-
nizations such as The Beryl Institute. We
recently adopted a practice for executive
leadership rounding that started at UCLA
Health, at the University of California Los
Angeles, and was replicated at the Cleveland
Clinic. This practice is just one example
of the many lessons learned from others
and implemented in our own organization.
In turn, we have shared our practices re-
lated to storytelling and other culture-
building efforts, as well as methods for
developing patient experience standards
and reporting.
Change Initiatives Undertaken in
Patient Experience
As described, our patient experience work
over the past six years has included the es-
tablishment of standards, education, and
culture-building efforts. Standards are in
place for core service skills that apply to all
employees, including service recovery.
Additional standards for how we interact
with patients are in place for different pa-
tient settings (e.g., inpatient, emergency
department, ambulatory) that go beyond core
service skills. We have developed tools that
are employed with patients every day with the
primary goal of engaging them in their care,
communicating with them completely, and
preparing them to care for themselves with an
eye toward whole-person health. An example
of such a tool is our inpatient My Care Folder,
which is provided at admission and follows
the patient through his stay and departure
from the hospital. We have similar stan-
dardized tools across our system to establish
a unified and consistent experience.
28  frontiers of health services management 33:3
© 2017 Foundation of the American College of Healthcare Executives
We have also adopted a common language
across the system for interpreting and re-
porting patient survey results. A robust, con-
sistent reporting approach is key to fully
understanding how we are performing. With
Lean Six Sigma experts on staff in our pa-
tient experience department, a level of data
rigor has been introduced that brings added
structure to our understanding of perfor-
mance. Our clinical close process is also
entrenched in our culture as a top priority
for senior-level executives. The process keeps
patient experience at the top of mind for all.
Finally, we are creating patient and fam-
ily advisory councils (PFACs) throughout our
system—a high priority for 2017. A number
of campuses already have their own coun-
cils, and a system-level council is now being
formed. The patients’ voice is crucial to all
of our experience efforts, and PFACs help
ensure that those voices are heard and en-
gaged in our journey.
Conclusion and Lessons
Learned
Delivering an exceptional patient experience
is both a clinical and a business imperative in
today’s healthcare environment. Consistently
doing so is not easy work; it requires lead-
ership diligence, engaged employees and
physicians, standard practices, and a strong
culture committed to always placing the pa-
tient and family at the center of the conver-
sation. Adventist Health System has learned
many lessons along our journey, and I offer
the following as our top ten:
1. Always keep the patient at the center
of the discussion. Think of what is best
for the patient.
2. We all own the patient experience, and
the ultimate owner is the top of the
organization. If the CEO conveys the
 importance of patient experience,
others will consider it important.
3. Culture, standard practices, or data alone
will not solve the patient experience
issue. All must be leveraged and aligned
to drive and sustain change.
4. Employee engagement should be the
first priority. Use the power of storytelling
to connect to the why. Reward and
recognize, and build a positive culture
related to patient experience.
5. Consistency and high reliability are key.
Establish evidence-based standard
practices and a consistent method
for teaching and validating them.
6. Don’t try to boil the ocean with patient
experience strategies. Focus on
entrenching the standards carrying
the largest impact first.
7. Maintain focus. It is not easy to sustain
top performance.
8. Collect, analyze, and apply meaningful
data to drive change.
9. Patient experience is extremely
important across the continuum of
care. Look outside of your four walls
with strong focus as well.
10. Understand consumerism, transparency,
and the healthcare climate of the
Pamela H. Guler, FACHE
© 2017 Foundation of the American College of Healthcare Executives
future, and map strategies that will
ensure success.
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