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ABA Health eSource
 June 2005 Volume 1 Number 10

Creating That "Five-Star" Culture
by James W. Saxton, Esq. Foot Noteand Maggie M. Finkelstein, Esq., Stevens & Lee, Lancaster, PA

James W. SaxtonMaggie M. FinkelsteinThe hospitality industry has long known of the benefits of creating and maintaining a five-star service culture. It is only recently that the healthcare industry has realized the importance of developing a five-star service culture. Data substantiates that true service excellence and effective communication can significantly reduce liability exposure and enhance a physician's practice at the same time. Foot NoteMany states are experiencing a medical malpractice crisis and for this reason, during these litigious times, this quest for five-star service has become even more important to the health care industry. Multiple studies have shown that service lapses without recovery and miscommunication drive up verdicts and settlements. Foot NoteOf course, the same conduct is what drives a patient to an attorney in the first place.

Our society has come to demand and expect true service excellence. The end game is to exceed patient expectations by creating not only satisfied patients, but loyal patients as well. Developing a five-star culture can help physicians to increase market share and to become the employer of choice. By doing so, staff retention will increase and overhead concerns will be eased. Foot Note

A five-star service culture is clearly a quest worthy of pursuit for physicians and their staff. Attaining and maintaining this culture, however, is not as easy as it sounds. Rather, it is actually an extraordinarily difficult task to accomplish. Incorporating it into one’s organization requires taking it to a “cultural level.” It requires more than simply talking about it at meetings and creating sound bites for marketing purposes; it is not just a slogan.

The five-star culture deals with behaviors, actions, and reactions. It includes aspects of service as simple as word choice, language, posture, and body language. A five-star service culture is displayed in the conduct of your employees on a day-to-day basis, including the rainy Monday morning when the past weekend was a disaster! It also includes the response of you and your staff to complaints. When that demanding patient approaches your employee, is the employee going to give the necessary 110% at that particular moment? At times like this, the five-star culture truly kicks in and the answer must be a resounding yes!

A recent study published in 2003 revealed what bothers patients about service. Foot NoteAlthough the study was related to hospital patients, the results included service issues related to general physician care and service — Delay in response to patient requests and inadequate communication about procedures. Both of these issues are ones which five-star service can impact positively.

Again, while it is easy to talk about a five-star service practice and to rally around it, it can be difficult to implement and maintain. It has to be pervasive, consistent, and always in the forefront. Following are six steps essential to moving toward a five-star culture which have been used to help healthcare organizations nationwide attain a five-star service culture. While each of the steps could be the basis for an article alone, the descriptions below provide you with a starting point.

1. Extraordinary Leadership and Buy In. Of course an extraordinary leader is essential, but the leader must also truly buy in to the five-star service excellence principles. It must become personal to the leader. Whether it is the CEO of a hospital, its board of directors, or the physicians of a practice, there must be a champion for this cause, and it must start from the top of the organization.

2. Making it Important. Once the leadership has made it personal to it, the five-star service culture must become important to senior staff and to practice managers. This is critical especially when your employees are already busy and perhaps overburdened, or at least feel that way. They need to buy in to the culture. Strategies like tying five-star service culture into compensation rates encourages the buy in.

Commitment to the five-star service culture is not something that can be faked. In other words, for example, if a practice manager truly does not believe that this is important, staff will see that and will themselves not buy in to the concept as well. They see subtle reluctance, body language, and the way statements are made. It must be accepted by senior management. Managers should not hesitate to raise their hand and ask, "I do not understand. Why is it so important?" This question must be answered, because failing to do so means that these managers will not have the tools to spread the five-star service principles throughout the organization.

3. A Kick-Off. There must be a moment in time when the leadership of the organization kicks-off this concept, introducing it organization-wide. The leadership must explain (1) how it is personally important to them and to the organization and (2) that it is going to change the organization and everyone's job on a day-to-day basis in a positive way. This must be done, however, in a way that shows that you are not assigning more work to an often already over-burdened staff. The kick-off needs to convey that the organization as a whole is going to strive for a new level of service, one in which everyone will benefit from the results, both short-term and long-term. Further, that the priority and commitment is not just going to end after the meeting!

4. Being an Example and More. Once the leadership and managers truly believe in the importance of the five-star service culture, they are ready to be an example to others of what true service excellence entails on a daily basis. Remember, employees will not do what you say, they will do what you do! Managers are a mirror for both good and poor conduct. Taking this a step further, truly great organizations have managers that look for opportunities to be examples. For instance, they look for opportunities to pat an employee on the back for doing a great job at service excellence and say something positive to the employee in front of as many people as possible. They look for an opportunity to show true service excellence themselves by, for example, walking a patient to where he or she needs to go when construction in the building makes it difficult to navigate. They become both an example and then look for opportunities to be an example.

5. Providing Tools. Many of the strategies for developing the five-star service culture take more than common sense. The employees, staff, and healthcare providers need tools that are designed to attack areas of risk and allow a practice to move towards best clinical practices as well as best risk management practices. Once the areas of true risk are identified, tools can be created and customized to minimize or even to prevent that risk. For example, in the sub-specialty of bariatric surgery, the authors of this Paper undertook to analyze and to evaluate the true liability risks associated with bariatric surgery. The result was the creation of a customized loss control program for an alternative risk financing vehicle, Novus Risk Retention Group, that will be insuring bariatric surgeons. Its loss control program is focused on the risks unique to bariatric surgery both from a clinical aspect as well as a service aspect from which customized tools were created to attack those risks.

The necessary tools include documents, education, strategies and protocols, procedures, and effective communication skills. As stated by Edward C. Rosenow III, M.D., author of The Art of Living…The Art of Medicine (and former president of the medical staff and a 31 year practicing physician at the Mayo Clinic), the single most important aspect of communication is listening and exhibiting body language which shows that the physician or staff is listening to the patient.

Importantly, providing five-star service requires a type of communication that is different than what our day-to-day activities would call for. It requires a heightened level of consciousness to effectively communicate and to change habits. Changing your habits can be a challenge. It requires first noticing desired behavior change, and when noticed, working to alter the behavior to more effective communication, which will eventually become habit. While these are not the type of things that are typically taught in classes for employees, fortunately, these topics lend themselves to education and training, including posture, body language, and tone.

In addition, provide training and strategies for dealing with specific circumstances which arise, such as, for instance, the difficult patient or the angry patient. An angry patient can be diffused. While the common reaction of an employee to angry patient may be to get angry or to shut down and ignore the patient, it is not the most effective means for managing the situation. These patients are ones who can bad mouth a practice and even seek an attorney, as it is often a service lapse which prompts a patient to do so. Instead, employees can learn how to diffuse the angry patient by first allowing the patient to vent, then showing empathy to the patient and the patient’s situation, and finally addressing the patient’s concern and putting forth a plan which will resolve the concern or put the issue on the path to resolution.

6. Keeping It Alive. Importantly, what then has to happen is that you need to kick off again . . . and again . . . and again! In fact, great service organizations, like the Ritz Carlton, kick-off every day at the beginning of every shift. It makes sure that the staff for every shift worldwide has the right frame of mind and focus for what is truly important on that particular day: Service. Subsequent kick-offs should occur at least annually at various staff meetings. Kicking-off again keeps the five-star concept in front of the organization.

Keeping it alive is, perhaps, the hardest part of the strategy. Far too many organizations get to this point (they truly believe the importance of five-star service and have taken the time to get to this point) only to find that after a year, another concern or burden requires certain cost-cutting that puts this program on the sideline. It must be kept alive for several years and requires eternal nurturing. It should get to the point where it is done naturally because an organization sees the benefit and it becomes part of what the organization is. Further, it is kept alive by the employees, because it is become who they are. Getting to this point takes work; it does not happen overnight. Some strategies for keeping it alive include the following:

  • Initially, hiring the right individuals in the first place and making the investment in a rigorous hiring process;
  • Implementing an orientation program that sets forth the real cultural difference and the importance of Communication Plus;
  • Re-orienting employees and determining what tools they need;
  • Kicking-off with employees as set forth above and doing so again and again.
  • Providing the tools that the employees need;
  • Keeping the concept in front of the employees;
  • Yearly in-service training on communication skills;
  • Making true service excellence a part of evaluations and bonuses;
  • Creating a slogan, signs, and cards, and putting it on the website and their t-shirts.

It is seeing it time and time again that will help to keep it alive.

Finally, having an effective event management program, in addition to the “typical” risk management environment is necessary. In other words, treat service lapse and communication errors as an event just as you would a clinical error. The Institute of Medicine's 1999 Report recommended just this – reporting near misses, evaluating near misses, and implementing remedial measures. Foot NotePhysicians and staff can learn from the service lapses or communication errors. By understanding the event and drilling down on why it occurred, done in a non-blaming fashion, one can truly understand what occurred. The information garnered from the event should then be discussed during educational programs for the following year. Use the management of the event to show how the strategies that have been incorporated into the organization can truly work in a positive way. Catch near-misses before they can happen again and talk about how to prevent it from happening again. Through event management one not only keep the issue in front of the organization, but it also shows how positive five-star service excellence can truly be.

Conclusion. The five-star service culture is a goal every physician's practice and hospital must strive for, particularly in the current environment. Doing so could be one of the most important, albeit likely one of the most difficult, endeavors. Telling employees to be nice is a good start, but it is only a start. Physicians need to push their organizations to truly achieve five-star culture status on a consistent day-to-day basis. It makes a great deal of difference and some say all "the difference in the world."

A difference can be made which can reduce both the frequency and the severity of professional liability claims. As mentioned above, an abundance of data has revealed that by satisfying patients, physicians can do just that. For example, a lack of communication, which is intimately related to service excellence, is a primary factor which leads patients to sue, as shown by Gerald Hickson, M.D. Foot NoteFurther, Wendy Levinson, M.D. has correlated certain communication behaviors of physicians with fewer malpractice claims. Foot NoteBy truly providing a five-star service in all aspects of the health care industry, physicians can satisfy patients which can not only enhance hospital or physician practice business, but can also reduce the frequency and severity of claims. Doing so is not only a goal to achieve patient satisfaction, but also because it is the right thing to do.


Foot NoteJames W. Saxton, Esq. is Co-Chair of Stevens & Lee’s Health Law Department and Chair of the Health Law Litigation Group, whose practice consists of representing and protecting health care providers in areas of risk management and litigation. He is an active trial attorney in the state and federal courts. He also has served as the Chairman of the American Health Lawyer’s Association’s practice group on Healthcare Liability and Litigation from 2002 until 2005. Mr. Saxton can be reached at jws@stevenslee.com. Maggie M. Finkelstein, Esq. is an Associate in Stevens & Lee’s Health Law and Litigation Departments, concentrating her practice in represents health care organizations and providers in developing and implementing risk management and loss control programs and litigation matters. She is a former law clerk to the Honorable William W. Caldwell, U.S. District Court for the Middle District of Pennsylvania and a member of the American Health Lawyers Association. Ms. Finkelstein received a J.D. from Widener University School of Law (summa cum laude) and a B.S. from Pennsylvania State University
Foot NotePress, I. Patient Satisfaction: Defining, Measuring and Improving the Experience of Care. (2002); Spiegel, A.D., Kavaler, F. "Better Patient Communications Mean Lower Liability Exposure." Managed Care. 1997, Aug.; 119-124; See, e.g., Lester, G.W., Smith, S.G. "Listening and Talking to Patients: A Remedy for Malpractice Suits?" West. J. Med. 1993; 158: 268-272; Shapiro, R.S., Simpson, D.E., Lawrence, S.L., et al. "A Survey of Sued and Nonsued Physicians and Suing Patients." Arch. Intern. Med. 1989; 149: 2190-2196; see also Shaub, M.A. "Customer Service for Building Your Practice." Physician's News Digest. 2002, Nov
Foot NoteBeckman, H.B., Markaskis, K.M., Suchman, A.L., Frankel, R.M. "The Doctor-Plaintiff Relationship: Lessons from Plaintiff Depositions." Arch. Intern. Med. 1994, 154: 1365-1370; see also See Huttington, B., Kuhn, N. "Communication Gaffes: A Root Cause of Malpractice Claims." BUMC Proceedings. 2003; 16: 157-161.
Foot NoteSee Kenagy, J.W., Berwick, D.M., Shore, M.F. "Service Quality in Healthcare." JAMA. 1988; 260: 1743-1748.
Foot NoteGarbutt, Jane; Bose, Diana; McCawley, Beth A.; Burroughs, Tom; Medoff, Gerald, “ Soliciting Patient Complaints to Improve Performance.” Joint Commission J. on Quality and Patient Safety. 2003; 29(3): 103-112.
Foot NoteKohn, L.T., Corrigan, J.M., Donaldson, M.S., eds. "To Err is Human: Building a Safer Health System." Institute of Medicine Center on Quality of Health Care in America. Washington, D.C.: National Academy Press (1999, Nov.).
Foot NoteHickson, G.B., Clayton, E.C., Githens, P.B., Sloan, F.A. "Factors that Prompted Families to File Malpractice Claims Following Perinatal Injury." JAMA. 1992; 287: 1359-1363; see also Hickson, G.B., Federspiel, C.F., Pichert, J.W., Miller, C.S., Gauld-Jaeger, J., Bo, P. "Patient Complaints and Malpractice Risk." JAMA. 2002; 287: 2951-57.
Foot NoteLevinson, W., Roter, D.L., Mulloolly, J.P., Dull, V.T., Frankel, R.M. "Physician-patient Communication: The Relationship with Malpractice Claims Among Primary Care Physicians and Surgeons." JAMA. 1997; 277: 553-559.