What do hotels and hospitals have in common? How we can learn from the hotel industry to take better care of patients

Abstract

Despite widely divergent public perceptions and goals, hotels and hospitals share many core characteristics. Both serve demanding and increasingly well-informed clienteles, both employ a large hierarchy of workers with varying levels of responsibility, and both have payments that are increasingly tied to customer/patient evaluations. In the hotel industry, decades of management experience and market research have led to widespread improvements and innovations that improve customer satisfaction. But there has been incredibly little cross-fertilization between the hotel and hospital industries. In this paper, we first consider the changes in the healthcare system that are forcing hospitals to become more concerned with patient satisfaction. We discuss the similarities and differences between the hotel and hospital industries, and then outline several of the unique challenges that neurosurgeons face in taking care of patients and increasing their comfort. We cite specific lessons from the hotel industry that can be applied to patients’ preadmission, check-in, hospital stay, discharge planning, and poststay experiences. We believe that hospitals can and should leverage the successful advances within the hotel industry to improve patient satisfaction, without having to repeat identical research or market experimentation. We hope this will lead to rapid improvements in patient experiences and overall wellbeing.

INTRODUCTION

Hospitals and hotels share many core functions. While hotels have always been ardently concerned with their customer/guest experience, hospitals have only recently become interested in customer (i.e. patient) satisfaction. This has become increasingly important over the past several years, as hospital reimbursements have become linked to patient satisfaction measures, like HCAHPS scores (Hospital Consumer Assessment of Health Care Providers and Systems[2,7]) and Press Ganey surveys. The HCAHPS survey is the first national, standardized, and publicly reported survey of patients’ perspectives of hospital care. It includes questions about a wide range of issues, including communication with nurses and doctors, responsiveness of hospital staff, cleanliness and quietness of the hospital, pain management, communication about medicines, and discharge planning. Under the Patient Protection and Affordable Care Act of 2010, HCAHPS has become one of the measures used to calculate value-based incentive payments in the Hospital Value-Based Purchasing program.

In addition to its effect on reimbursement, however, patient satisfaction may also be a marker of clinical quality. For example, a recent study in the New England Journal of Medicine showed that higher HCAHPS scores are associated with better clinical quality as measured by the Health Quality Alliance scores for treatment of acute myocardial infarction, congestive heart failure, pneumonia, and surgery.[5] While there is some debate on this,[4] it nevertheless underscores the need for hospitals to focus on improving patient satisfaction.

The hotel industry has always been cognizant of this goal—satisfying guests as a minimum, exceeding their expectations as the goal—and has devoted decades of effort and resources toward improving their products and management structures. We believe hospitals can readily leverage these lessons hard-won by the hotel industry. Adopting and adapting hotel practices could lead to significant improvements in patient approval and satisfaction, ultimately benefiting hospital management staff, physicians, employees, and most importantly patients.

HOTELS AND HOSPITALS, SIMILARITIES AND DIFFERENCES

As noted above, there are many similarities between hospitals and hotels, the foremost being the focus on guests/patients who obtain lodging and services. Just as there is a wide variation in hotels (from Motel 6 to the Bardessono hotel in Napa, California), there is a huge range in hospital size, setting, and quality. Both employ a large hierarchy of workers with varying levels of responsibility. Hospitals and hotels also create an experience for their customers/patients, with associated emotions.

Looking beyond these basic similarities, however, we find several important differences. Hotels are paid directly out of pocket by customers, whereas hospitals are usually paid through intermediary insurance companies. In the hospital setting, customers are patients, typically anxious and apprehensive about their impending treatment. While patients often have a choice as to which facility they seek care from, they frequently do not have a choice for seeking care. Most patients have a medical necessity to be at a hospital. At a hotel, on the other hand, customers are guests, typically excited (particularly, if for leisure as opposed to business) about their stay. In most cases, guests choose their hotel and the timing of their stay. Therefore, from the outset, hospitals are at a disadvantage. Hospitals must do more than a hotel to ensure patients’ comfort. The foremost priority of hospitals is, and always should be, to improve patient health, but patient comfort and wellbeing should not be neglected along the way.

HOW TO IMPROVE THE CUSTOMER/PATIENT EXPERIENCE

Neurosurgeons face many challenges in providing their patients with the highest level of satisfaction. Given that they often spend the majority of their day in the operating room, neurosurgeons have much less time than other medical professionals to spend rounding on their hospitalized patients. They often are required to see patients extremely early in the morning, which automatically creates an unpleasant experience when their patients are woken up at 5 a.m. In our experience, these issues represent common complaints when reviewing the University of California, San Francisco (UCSF) neurosurgery Press Ganey scores. Additional challenges arise from the training environment in which many neurosurgeons practice—an environment in which there are residents, physician assistants, nurse practitioners, and others with varying degrees of experience, all working together to take care of the neurosurgical patients. In order to address and overcome these challenges, we consider the following specific ways in which the hotel industry can teach hospitals about each aspect of patient care: (1) preadmissions, (2) the check-in process, (3) the hospital stay, (4) discharge planning, and (5) the poststay experience.

Preadmissions

One major difference between hotels and hospitals, and a potential area for improvement, is the preadmission experience. Prior to admission, patients undergo laboratory tests, receive questionnaires about their current medical state, and often abstain from food and water (if a surgery is scheduled), all contributing to mounting anxiety and discomfort. To minimize this anxiety, it is helpful to provide patients with as much information as possible regarding their upcoming admission, so that they know what to expect. Just as a luxury hotel sends all guests a pre-arrival letter, we at UCSF have launched a pilot project where we send every neurosurgery patient a “preoperative expectations letter” that is specific to their attending neurosurgeon and tailored to the surgery they will have. For example, a patient undergoing a craniotomy for brain tumor resection receives a letter discussing individualized magnetic resonance imaging prior to surgery, who will see them while they are in the hospital (attendings, residents, and nurse practitioners), and what preparations the patient should make for postoperative home care. Although we cannot build the same anticipation as a hotel guest awaiting an upcoming vacation, we should aim to minimize dread and set appropriate expectations for our patient's hospital stay.

Check-in process

Another area for improvement is the check-in process. At the Bardessono, the hotel staff is prepared in advance for a guest's arrival. They are aware that the first 15 minutes’ experience is critical to set the tone of the visit. They know the expected arrival time, have reviewed the guest's profile and photograph; and, when the guest arrives, they greet him or her by name: “We’ve been expecting you.” In stark contrast, hospitals know far more details about their incoming patients, yet have them sign in (often multiple times at multiple desks), wait hours in the admissions area, and typically greet patients with “Name and photo ID, please.” With the amount of information that hospitals have about their patients and their own waiting times, room availability, and physician availability, much could be done to improve this check-in process. Redundant information gathering could be minimized, existing patient photographs could be better utilized to recognize patients, and waiting times could be reduced by both streamlining the admissions process and by ensuring availability of rooms at scheduled patient arrival times. Electronic medical records and technology can and should be used to achieve these goals and improve the check-in process. At the same time, however, we must do a better job of explaining to patients why we often have to ask them for the same information repeatedly (e.g. their name and ID) in order to confirm their identity and ensure their safety.

Hospital stay

Similar principles can be applied to all interactions during a patient's hospital stay. A critical aspect of a patient's hospital experience is their communication with physicians. Even in a technically driven field such as neurosurgery, studies show that one's global physician rating is directly correlated with communication skills, including showing respect, listening carefully, giving easy-to-understand instructions, spending enough time, and explaining things.[8] As neurosurgeons, we should work to improve communication with our patients. A gesture as simple as the physician sitting down instead of standing at the bedside has been shown to make a difference.[13] Interestingly, improved physician–patient communication has also been linked to better patient outcomes,[12] further underscoring its importance.

At USCF, we have adopted the “AIDET SMiLe” training module to guide physicians in their patient interactions.[10] This mnemonic stands for “Acknowledge” (how does the patient want to be addressed), “Introduce” (who you/we are, with appropriate background), “Duration” (of meeting, procedure, stay), “Explanation” (in simplest terms, teach-back), “Thank you” (an honor to serve/help), “Sit down” (patients think you spend 40% more time with them and appreciate the visit more), “Manage up” (talk about the strengths and background of one's team, staff, and institution), and “Listen” (ask and then let the patient talk for 1–2 minutes with nodding to acknowledge). Although every technique might not be applicable, appropriate, or even feasible in each patient interaction, the “AIDET SmiLE” philosophy provides a solid, albeit generalized, guideline for improving patient interactions that emphasizes the basic tenets of good customer service.

As we all recognize, the “in-house experience” is dependent not only on patient's interactions with their physicians, but also on the entire hospital team consisting of nurses, medical assistants, therapists, transport personnel, food service staff, and technicians. Studies have shown that higher nurse-to-patient ratios and good nursing communication have a positive impact on patient satisfaction.[6] Similarly, at a hotel, the concierge, housekeeping staff, restaurant and bar staff are all essential to providing a good overall customer experience. Just as the hotel industry provides customer service training to all team members, all hospital staff must be included in measures to improve satisfaction. Indeed, many patient surveys directly address these facets of their stay, and thereby link reimbursement to the performance of custodians, transport staff, and nurses.

We should also make an effort to better define members of the medical team, as many patients are unfamiliar with all of the people involved in their care. At a hotel, workers have clearly defined roles (e.g. front desk concierge, room cleaning, restaurant waiter); but at a hospital, the various members of the medical team may be foreign to a patient. The medicine service at UCSF has implemented facecards (cards with MD photos, training, and interests that are handed out to every patient), which have been shown to improve patient's knowledge of the names and roles of their hospital physicians.[11]

Finally, we must work to improve communication not only with our patients, but also with their families and caregivers. Particularly in fields like neurosurgery where the disease process often limits patients’ understanding and ability to take care of themselves, we must involve caregivers in our daily rounds and communicate clearly and effectively with them, both during and after the hospitalization.

Discharge planning

An important consideration revolves around patient preparation to leave the hospital. For discharges at UCSF, a nurse reviews discharge instructions and a transport staff member wheels the patient to the lobby. In a frequent worst-case scenario, the patient does not have a follow-up appointment and must call to schedule one.

We must improve our discharge planning to make the patient's transition to home seamless and less stressful. The first step is realizing that patients and caregivers are often extremely anxious when leaving the hospital after brain surgery. We should make sure that patients and their caregivers understand the plan of care, that we address unresolved problems or concerns, and that patients have scheduled follow-up appointments and know whom to contact in the event issues arise at home. Caregivers must be carefully instructed in all of the tasks that they are about to assume, including how to clean and bathe the patient, change dressings, and administer medications. When the patient leaves the hospital, the caregiver sometimes will be assuming the role of nurse, physical therapist, medical aid, pharmacist, and social worker—all in one.

At UCSF, we have a pilot project where nurses perform postdischarge phone calls to all neurosurgery patients, which has shown promise in improving patient satisfaction and outcomes in another study.[1] We are also developing a caregiver program that includes weekly sessions to educate caregivers of brain tumor patients so that they know how to perform their many roles, what to expect, and where to go for help when they need it.

The poststay experience

After discharge, every UCSF patient is mailed a survey regarding their hospital experience. Patients are not given advanced notice about the survey, and currently less than 20% of UCSF patients fill out the Press Ganey evaluations. In contrast, before departure, all Bardessono guests are told that they will receive an electronic or hard copy survey, which is sent within 24 hours. Survey responses are shared with all employees, and the manager/CEO responds personally to all guest surveys, without exception. This response is highly personalized to each guest: it is not a form letter or generic response. The Bardessono also prompts guests to fill out reviews on Yelp or TripAdvisor, so that future guests can learn about their hotel and the experience delivered to former guests.

Like the Bardessono, we need to tell patients about the Press Ganey survey before they leave the hospital in order to engage them and make them feel that they are a part of the improvement process. If patients understand the purpose of these surveys, they are much more likely to fill them out. And although direct response to every patient is not feasible in most hospital and office practice settings, we should at the very least try to contact patients with major complaints so that we can address issues and identify areas for improvement. We should also routinely check online feedback sites. Yelp and TripAdvisor are not the appropriate venues for patient feedback, but we should carefully evaluate the current online rating systems and consider what makes the most sense for us in our practices. As physicians and hospital administrators, we can and must be cognizant of the information that patients are reading about us on the web. As expected, studies show that patient ratings and word-of-mouth narratives can significantly influence a patient's hospital choice.[3]

HOW TO MANAGE SET-BACKS

Despite attempts to improve many areas of the patient experience, things can and will go wrong. Hotels have proactive mechanisms in place to identify patient dissatisfaction, and address or correct problems when possible. For example, if an employee at the Bardessono identifies that a patient is unhappy with a particular meal or a room was not cleaned properly, the manager will reach out to the guest (before he/she complains) to offer a rebate or credit for whatever service was unsatisfactory. Guests are surprised and delighted by this gesture, which converts an unhappy guest into a customer for life.

While we obviously cannot extend “comps” to all our patients, hospitals should invest more effort in identifying patient dissatisfaction. Although physicians or hospitals may not be directly responsible for a patient's unhappiness (if, e.g. this is caused by a worsening medical condition), hospitals can and should track patients’ satisfaction pulse on a daily basis and intervene when there is a problem. Good communication is especially important in the case of unexpected complications or errors, when inappropriate management of the situation could lead to a lawsuit or worse. If a patient is dissatisfied, the opportunity to correct their impression of the hospital disappears when the patient leaves. Dissatisfied patients should be identified early by motivated staff, and their concerns addressed as rapidly as possible. It is of utmost importance that physicians in particular spend more face-to-face time with patients when complications arise. Fixing a bad experience can leave a person with an even better experience than never having had a problem in the first place.

Hotels use “shift reports” to track in-house guests’ satisfaction. Documentation is made in a guest's electronic profile every time something positive or negative is said or experienced. Negative experiences get recovered before the guest checks out. The rule at Bardessono is that no guest checks out unhappy, ever. The front desk staff asks every guest about their hotel stay as they are checking out, and they do not accept “fine” for an answer. If the guest is not “raving” positively about his/her stay, the hotel assumes all was not perfect. The manager will come to personally talk to the customer, identify problem areas, and attempt to repair the customer relationship, if possible. This very focused effort ensures negative reviews and scores are not posted on sites like TripAdvisor or Yelp. The cost of investing in a recovery is far less than the potential loss of revenue by having a bad review posted on-line.

One hospital in Wisconsin has implemented a bedside shift report, much like the Bardessono's, that has led to improved patient satisfaction with nursing communication.[9] Furthermore, the personnel doing the hospital check-out process (often a nurse) must ascertain the patient's level of satisfaction at that time; and, if low, steps should be taken immediately to address these issues by the check-out person or a supervisor. Managing these set-backs becomes more challenging once the patient is out of the hospital.

CONNECTION BETWEEN CUSTOMER SATISFACTION, STAFF SPIRIT, AND PRODUCTIVITY

Hospitals and hotels are only as good as their weakest customer-contact employee. A patient's hospital experience is only as good as his/her worst interaction, whether this was with a busy over-worked resident or a medical assistant who did not help them to the bathroom quickly enough.

Employees, not managers, are the most capable of influencing the customer experience. A primary goal should therefore be to serve hospital employees well, so that patients will be well-served in turn. As in the hotel industry, this pressure needs to come from the top down, and hospital managers should work on recruiting and retaining the best people who are proud and happy of the place where they work. People work better and provide better care when they are happy, when they can honestly say: “I work in the best place. I love my job, bosses, and co-workers, and I tell everybody I know.”

There are many ways to improve the performance of staff, but one successful method adopted by the Bardessono hotel is to treat staff as customers themselves. Finding ways to improve their experience at work leads to improved performance and thereby improved guest satisfaction. Some hospitals have adopted similar policies (e.g. employee appreciation days), though the scale of such measures is often anemic. Recognizing the potential payoff should lead to improved attempts to incorporate employee satisfaction into the hospital's overall goals.

CONCLUSIONS

What are the take-home messages for the hospital from the hotel industry? First, we should work hard to improve the first 15 minutes of a patient's experience, which is critical to the overall customer experience. Learning from the hotel industry, we have cited specific ways to improve the preadmissions and check-in processes at hospitals. Second, we stress the importance of enhanced communication with patients and their caregivers throughout their hospital stay. Third, we should track patients’ level of satisfaction on an ongoing basis and intervene as soon as possible when problems arise. Fourth, we should follow-up with our patients after they are discharged from the hospital to obtain feedback that can then be used to improve future performance. We must be aware and beware of our online presence – the hotel industry calls it “reputation management.” In an age of increasing internet literacy, patients will read about us before coming to the hospital and write about us afterwards, so it is absolutely critical for hospitals to know and manage their online reputation. And finally, hospital management should aim to create an environment where all hospital employees are happy and productive so that they can take the best care of their patients. We firmly believe that applying these common-sense principles from the hotel industry, that has been focused on the customer experience for decades, will enhance our patients’ comfort and wellbeing by improving their overall hospital experience.