discuss

Case Study

Impact of a Patient Experience Leadership Structure on Performance and Engagement

Sven Gierlinger, BA1, Agnes Barden, DNP, RN, CPXP2, and Nicole Giammarinaro, MSN, RN, CPXP3

Abstract The patient experience leadership structure at Northwell Health is strategically championed by Culture Leaders, a novel role established to transform the organizational culture from “service excellence” to “patient experience.” This case report describes how the implementation of Culture Leader structure has aided in the improvement of organizational patient experience performance as well as how Culture Leaders remain highly engaged. Responsible for effectuating change by bridging the gap between local and organizational experience strategies, Culture Leader engages key stakeholders within the strategic pillars of culture, care delivery, hospitality, and accountability.

Keywords patient experience, leadership, engagement, accountability, culture leader

Introduction

In every organization, there are individuals who are culture

influencers. Formal or informal leaders, they elicit follower-

ship and have the ability to make definitive impacts on their

colleagues, processes, and organizational culture (1). Lead-

ers effectuate change and their interventions impact out-

comes (2). This case report focuses on how Northwell

Health systematically implemented a patient experience

leadership and accountability structure to drive cultural

transformation. The Agency for Healthcare Research and

Quality describes patient experience as “the range of inter-

actions that patients have within the health-care system (3).”

Patient experience remains a national steadfast priority due

to the intrinsic and positive correlation with patient safety

and clinical effectiveness(4).

Northwell Health is a large, integrated health care orga-

nization comprised of 66 000þ caregivers, 23 hospitals, and 650þ medical practice locations, spanning geographically from Westchester to New York City and across Long Island.

Due to the inherent growth of the organization by means of

mergers and acquisitions, patient experience efforts were

historically siloed, fragmented, and inconsistent, with much

focus on reactive service recovery. There were pockets of

excellence and areas of opportunity to achieve our mission

of providing world-class, patient- and family-centered care.

Description

Northwell is continually growing and evolving. Consistent

challenges include organizational complexity, geographic

span, and diverse communities and workforce. In 2014,

Northwell’s first Chief Experience Officer joined the orga-

nization bringing a unique and refreshed perspective given

his hospitality industry experience at the Ritz Carlton Hotel

Company. The Office of Patient & Customer Experience

(OPCE) was soon thereafter created to standardize strategy,

disseminate best practice, and advocate for customer-

centric standards. The OPCE team is comprised of health-

care professionals from various backgrounds coming

together to create the overarching patient experience strat-

egy. In 2014, the publically reported patient experience

survey, Hospital Consumer Assessment of Healthcare Pro-

viders and Systems (HCAHPS), the Northwell health

1 Northwell Health, New York, NY, USA

2 Patient & Customer Experience, Northwell Health, New York, NY, USA 3 Patient & Customer Experience Education & Research, Northwell Health,

New York, NY, USA

Corresponding Author:

Nicole Giammarinaro, Northwell Health, 2000 Marcus Avenue, New Hyde

Park, New York, NY 11042, USA.

Email: nfilippa@northwell.edu

Journal of Patient Experience 1-5 ª The Author(s) 2019 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/2374373519831079 journals.sagepub.com/home/jpx

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system ranked in the bottom quartile nationally, with

individual hospitals ranging from top to bottom decile per-

formance. During OPCE’s initial discovery phase, incon-

sistencies regarding resources, ownership, scope, and

accountability related to patient experience at the local site

and service line levels were uncovered. To address this

fundamental gap, a novel role, Culture Leader, was created

and integrated into the Northwell patient experience eco-

system and strategy (see Figure 1). At Northwell, our prom-

ise to patients, families, and customers is grounded in the

Culture of C.A.R.E. framework that embodies concepts of

Connectedness, Awareness, Respect and Empathy. Our

patient experience ecosystem operationalizes the Culture

of C.A.R.E. through holistic programming.

Creating Structure and Defining Attributes

Aligned with OPCE and reporting directly to their site or

service line executive director (ie, CEO), we currently have

63 Culture Leaders responsible for executing local patient

and customer experience strategy by engaging key stake-

holders around culture, care delivery, hospitality, and

accountability. Culture Leaders are multifaceted local

experts and change agents who serve on leadership commit-

tees, shared work teams, Six Sigma projects, and patient and

family partnership councils in addition to leading their

respective teams to effectuate local performance improve-

ment and cultural transformation.

Implementing and sustaining the Culture Leader structure

required vision, leadership, strategy, structure, organiza-

tional readiness, and buy-in. Utilizing the tight–loose–tight

leadership approach to effectuate attitude, information shar-

ing, and impact, the cornerstone of the relationship between

the corporate OPCE and site/service line Culture Leaders is

mutual trust (5). The OPCE leadership set clear expectations

and strategy (tight), empower Culture Leaders with the abil-

ity and freedom to translate those expectations to best be

implemented into local culture (loose) but then holds all

accountability for performance (tight). This approach gave

homage and respect that each entity embraces a unique cul-

ture and history while at the same time creating consistency

and responsibility.

Transforming the organization from “service excellence”

to “experience” required an elevated, dedicated leader. Cul-

ture Leaders embody a wide variety of skillsets, past experi-

ences, and levels of expertise. Site and service line senior

leadership hand-selected their Culture Leader with guidance

and support by OPCE leadership. Selection criteria outlined

essential attributes of passion for experience, managerial

courage, critical thinking, and deep understanding of local

Figure 1. Northwell health patient experience ecosystem.

2 Journal of Patient Experience

culture. Culture Leaders come from diverse backgrounds

including nursing, allied health, retail, hospitality, theater,

administration, and business. Collectively, such varied back-

grounds coming together with a shared mental model has

resulted in true and honest dialogue. Divergence of comple-

mentary perspectives has fostering of a spirit of innovation

and challenging the status quo.

Investing in Leadership Development

With Culture Leaders identified, OPCE performed a baseline

learning and development needs assessment. Results gave

insight into the creation of a Culture Leader orientation and

individualized development plans. Alongside structured

education and development programming, Culture Leaders

receive individual mentoring and coaching by the Vice Pres-

ident of Patient & Customer Experience and other OPCE

team members. They attend stimulating and engaging

monthly best practice sharing forums and actively partici-

pate on system-wide improvement shared work teams. Cus-

tomized sessions throughout the year are provided for

particular topics, including strategic planning, emotional

intelligence, data and analytics, and performance improve-

ment. To inspire Culture Leaders, OPCE team hosts an

annual patient experience conference as well as Culture

Leader Summit.

Parallel to the implementation of Culture Leader

onboarding, OPCE launched the cultural transformative

large-scale education program, Culture of C.A.R.E. course.

Cascading this 2-hour, experiential curriculum across the

organization was the Culture Leader’s priority, and within

18 months, over 61 000 leaders, physicians, employees, and

volunteers were educated. Culture Leaders and their team

of Facilitators led local-level education after receiving

robust training in a facilitation and presentation skills cer-

tification program. Culture Leaders were held accountable

for deploying at their site/service line, sustainment strate-

gies inclusive of new policy, Culture of C.A.R.E. education

for new employees, behavioral competencies, weekly hud-

dle communications cascade, and patient experience

assessments.

Results

At Northwell, our brand is our promise to consumers, our

employee promise is our promise to one another and Culture

of C.A.R.E. is our promise to patients and families. We have

seen positive results within all 3 of our promises since the

implementation of the Culture Leader structure.

Network of Culture Influencers

We have successfully rebranded from North Shore—LIJ

Health System to Northwell Health due to a comprehensive

internal and external communication and marketing strategy.

Culture Leaders supported and educated regarding the

rebranding during Culture of C.A.R.E. courses. In addition

to the current 63 Culture Leaders, OPCE has educated and

certified over 550 Culture of C.A.R.E course faculty who

facilitate the courses on an ongoing basis. This large body of

patient experience leaders and champions are inspiring and

role modeling customer-centric, empathetic care throughout

our organization.

Patient Experience Performance

Between 2015 and 2016, the Culture Leader role was being

established and is now an integral part of our organization,

partnering with clinical and nonclinical stakeholders. As a

result, within the past 4 years (January 1, 2015, to Novem-

ber 30, 2018, year to date), every HCAHPS domain system-

wide saw improvement. The most significant HCAHPS

domain increases have been within Communication with

Doctors and Communication with Nurses, both with an

increase of 11 percentile points (see Table 1). In 2017, on

the ambulatory and medical practice level, 81 (16%) indi- vidual sites achieved the 90th percentile nationally for

Press Ganey “Recommend the Practice”. According to pub-

lically reported data, Northwell system metrics outperform

the New York State average in the following HCAHPS

domains: Communication with Doctors, Communication

with Nurses, Care Transitions and Rate the Hospital.

Culture Leader Engagement

Realizing the positive correlation between engagement and

experience (6), our organization closely monitors employee

engagement as one of the major contributing factors to

patient experience performance. In 2018, Culture Leaders

participated in the Northwell Health Employee Engagement

Survey. The “engagement score” is a score from 1 to 5

regarding our employees’ commitment, satisfaction, and

willingness to recommend our place to work (1 ¼ strongly disagree to 5 ¼ strongly agree). The Culture Leader overall

Table 1. Northwell Health System Hospital Consumer Assess- ment of Healthcare Providers and Systems (HCAHPS) Perfor- mance Improvements; Source: Press Ganey National Database (discharges 1/15/2015—11/30/2018).

HCAHPS Survey Domain

Change in Percentile Points, (January 1, 2015 to November 30, 2018)

Communication with nurses þ11 Communication with doctors þ11 Communication regarding medications þ7 Care transitions þ7 Responsiveness of hospital staff þ7 Discharge information þ6 Care transitions þ6 Rate the hospital 0-10 þ6 Hospital environment þ1

Gierlinger et al 3

engagement score was 4.60, þ0.32 versus Northwell average and þ0.48 versus national average; see Table 2. This Tier 1 score places the Culture Leader cohort at the 99th percentile

nationally for engagement. Between 2014 and 2018,

employee engagement across Northwell Health has

improved 40 percentile points. Engagement scores for par-

ticular patient experience and service-related questions also

saw improvement. Within the past 4 years, the score for

question, “The person I report to serves as a good role model

for delivering high levels of service,” increased 0.37 points

and question, “This entity provides high-quality care and

service,” has increased 0.15 points.

Lessons Learned

Patient experience is an art and science, and thus, our newly

defined and empowered Culture Leader group needed to be

prepared and supported to execute complex strategies.

Investing time, education, and development in Culture

Leaders was essential. As a result, Culture Leaders are

revered throughout the organization because they represent

the “voice” of our patients and families. Having Culture

Leaders in non-patient facing/clinical subsets was also

another key driver. There are Culture Leaders from areas

of the organization including Finance, Foundation, Infor-

mation Technology, Procurement, Human Resources, and

our innovative Research Institute. Engaging these noncli-

nical, operational teams around experience helped drive our

promises and further engage our people to professional and

moral purpose.

Conclusions

Our organization took a pragmatic approach to defining and

establishing a patient experience structure. Culture Leaders

are part of the C-Suite, enabling patient experience to have a

powerful and persuasive presence during strategic planning,

decision-making, and innovative programming. Their com-

mitment, dedication, and passion has had a powerful ripple

effect and in turn, they role model, inspire, and lead their

teams to excellence. As a result, we have seen significant

improvement in patient experience scores and are proud they

remain highly engaged in this important work and the orga-

nization. Since the Culture Leader role is constantly evol-

ving, we look forward to seeing the future great impacts they

will have on our community.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect

to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, author-

ship, and/or publication of this article.

References

1. Uhl-Bien M, Riggio RE, Lowe KB, Casten MK. Followership

theory: a review and research agenda. The Leadership Quarterly.

2014;25:83-104.

2. Avolio BJ, Reichard R, Hannah S, Walumbwad F, Chan A. A

meta-analytic review of leadership impact research: experimen-

tal and quasi-experimental studies. The Leadership Quarterly.

2009;20:764-84.

3. The Agency for Healthcare Research and Quality. What is

patient experience?; 2016. https://www.ahrq.gov/cahps/

about-cahps/patient-experience/index.html. Accessed June 7,

2018.

Table 2. 2018 Employee Engagement Scores for Culture Leaders only; Source: Press Ganey Employee Engagement Survey Database; n ¼ 48).

Survey Item Score Versus Northwell

Results Versus National

Health-Care Average

I like the work I do. 4.83 þ0.32 þ0.36 Patient safety is a priority in this entity. 4.79 þ0.34 þ0.41 I feel comfortable raising concerns when I see something that may

negatively affect patient care. 4.72 þ0.44 þ0.49

I would recommend this entity to family and friends who need care. 4.68 þ0.32 þ0.42 My job makes good use of my skills and abilities. 4.65 þ0.42 þ0.52 I would recommend this entity as a good place to work. 4.63 þ0.38 þ0.61 Northwell Health conducts business in an ethical manner. 4.63 þ0.42 þ0.51 This entity provides high-quality care and service. 4.60 þ0.29 þ0.34 I would like to be working at this entity three years from now. 4.58 þ0.25 þ0.42 This entity treats employees with respect. 4.58 þ0.48 þ0.64 I get the training I need to do a good job. 4.57 þ0.40 þ0.58 My job responsibilities are clear. 4.54 þ0.19 þ0.33 Overall, I am a satisfied employee. 4.54 þ0.35 þ0.52 I get the tools and resources to provide the best care/service. 4.44 þ0.42 þ0.50 Overall Engagement Score 4.60 þ0.32 þ0.48

4 Journal of Patient Experience

4. Doyle C, Lennox L, Bell D. A systematic review of evidence on

the links between patient experience and clinical safety and

effectiveness. BMJ Open. 2013;3:e001570.

5. Sagie A, Zaidman N, Amichai-Hamburger Y, Te-eni D,

Schwartz D. An empirical assessment of the loose–tight leader-

ship model: quantitative and qualitative analyses. J Organ

Behav. 2002;23:303-20.

6. Lowe G. How employee engagement matters for hospital per-

formance. Healthcare Quarterly. 2012;15:29-39.

Author Biographies

Sven Gierlinger was a previous luxury Hotel Executive, brings a

unique perspective to the patient experience dialogue. However, it

was his personal patient experience spending three months in

hospitals that motivates him to challenge the status quo in health-

care. As Chief Experience Officer for Northwell Health, Mr. Gier-

linger is driving culture transformation grounded in quality,

engagement and experience.

Agnes Barden is the vice president of Patient & Customer Expe-

rience at Northwell Health. With over 30 years of clinical and

administrative experience, Dr. Barden is a Certified Patient Expe-

rience Professional who advocates for compassionate care and

patient-centeredness.

Nicole Giammarinaro is the director of Education and Research

for the Northwell Health Office of Patient and Customer Experi-

ence. Ms. Giammarinaro is a Certified Patient Experience Profes-

sional who is passionate about creating humanistic educational

offerings and research studies.

Gierlinger et al 5