American Association for Physician Leadership

Patient Experience and the CMO

Jason M. Golbin, DO, MBA, MS

Mar 7, 2024

Volume 11, Issue 2, Pages 44-50


Improving the patient’s experience is not easy because it often requires a change in the overall culture of the healthcare organization. Including patient experience as one of the core components of a high-reliability transformational program ensures the organization gives it the attention it requires and unites every employee and every physician around the goal.

“Congratulations — Welcome to your new role! Please analyze our opportunities for improvement from the quality point of view.”

This was the guidance from the system chief clinical officer as I joined his team in 2017 in the newly created position of the system chief quality officer. That is how I found myself immersed in patient experience (PX), which I can honestly say I previously attributed solely to nursing during the many years I had served as a campus chief medical officer, and even prior to that as a practicing pulmonary, critical care, and sleep physician.

I will state up front that patient experience is not just a nursing issue; it is in the hands of every employee and every physician — anyone who touches the patient.

In 2021, I became the system chief medical officer as the aforementioned chief clinical officer became the president and CEO. As the system CMO, I continue to own patient experience in our organization.

Our system began a journey toward high reliability in 2015. A high-reliability organization is an organization that performs in a complex, high-risk environment for long periods of time without a serious failure. We started with a focus on quality, safety, and error prevention.

We partnered with healthcare improvement company Press Ganey and performed a common cause analysis of our serious safety events. We learned that most of these events occurred in the procedural areas, associated with a lack of consistent safety behaviors.

Based on this analysis, we developed the Daily Patient Safety Principles, a guiding document of safety and error-prevention behaviors. We constructed a training curriculum and, using the train-the-trainer model, trained all 16,000-plus staff members and all clinicians. In fact, we mandated this safety training as a condition of credentialing for every physician and advanced practice provider credentialed in our organization.

Over the subsequent years, we saw an initial expected bump in safety events, as we have fostered a culture of increased transparency. During the past four years, however, we have seen an 80% decline in our most serious safety events — those resulting in death and permanent serious harm — on our journey to zero harm. The organization united around this goal.


As part of the journey, we re-assessed what it meant to become a highly reliable organization. While we were making significant improvements in quality and safety, our overall performance still had room for enhancement. We hypothesized that we would hit the “bulls-eye” of high reliability when we were performing strongly not only on quality and safety, but on patient experience and employee engagement as well. We developed a graphic (Figure 1) to support this hypothesis (and because a picture is worth a thousand words).

Figure 1. The “Bulls-Eye” of High Reliability

When we pulled our data, we found that it was not the central line-associated blood stream infections (CLABSIs) nor the readmissions that were holding us back, it was the patient experience. We had wide variation in performance across the organization, with one hospital consistently scoring in the 95th percentile and three other hospitals in the bottom 10th percentile.

All hospitals in the United States administer a patient experience survey called the Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS. This is a multiple-question survey that elicits the patients’ perceptions of the care that they experienced — not necessarily on whether the correct treatment was administered, but instead more focused on how the hospital teams communicated with and treated the patient.

The publicly reported results of the survey, in addition to allowing patients and hospitals to assess how well the hospital compares to other hospitals in the nation, are also used in governmental and payer value-based metrics as well as in scorecards such as the Leapfrog Safety Score.

To best understand and dissect those results, and analogous to what we did for quality and safety, in a continued partnership with Press Ganey, we performed a common cause analysis of our own data. This multiyear review focused on our view of PX data, complaints and grievances, and interviews of leaders systemwide.

The outcome of that root cause analysis demonstrated that we had never established standard expected behaviors for the clinicians and staff as members of our health system. To remedy this, we did exactly that. We linked a set of behaviors to our established I-CARE Values, named the Daily Patient Experience Principles, again linking back to our safety program (Figure 2).

Figure 2. The Daily Patient Experience Principles

Simultaneously, we built a four-hour training curriculum that every employee and most of the clinical staff were mandated to attend. The curriculum was educational yet engaging and focused on a few topics. The training curriculum commenced with background education — why we are looking at patient experience, what is the HCAHPS survey — and then some published data linking patient experience to quality and safety.

Doyle and colleagues showed patient experience is positively associated with clinical effectiveness and patient safety.(1) A 2015 analysis found that hospitals with higher-rated PX provided more efficient care with shorter lengths of stay for surgical patients, as well as higher surgical process metric scores, lower surgical readmission rates, and lower surgical mortality rates.(2) Glickman, et al., showed a linkage between higher patient experience scores and lower inpatient mortality rates after suffering an acute myocardial infarction.(3)

Thomas Lee shared in the Harvard Business Review data gathered by his colleagues at Press Ganey. These data compared the bottom quartile of U.S. hospitals in patient experience scoring to the top quartile of U.S. hospitals in PX scoring in relation to other quality composites. He demonstrated that the clinical quality scoring for readmissions, length of stay, and hospital-acquired conditions were significantly better at the higher-rated PX hospitals than at the lower-rated PX hospitals.(4) By citing these articles and others, we demonstrated to the clinicians that there was peer-reviewed evidence supporting the need to focus on PX.

The training continued by sharing the organizational data current at that time. It was important to lay a foundation with all attendees to help them understand actual performance. Many attendees expressed disbelief — especially the physicians — when the poor performance across the system was delineated. Unfortunately, this information had not been discussed with any consistency previously, nor had it been focused on during prior years.


Once the participants recognized the challenge that we faced to significantly improve our performance, we dove deep into the training. First, we identified that “patients” are not just the “patients.” The term “patients” represents patients, their families, their visitors, as well as our colleagues and our clinicians.

Next, we focused on what the HCAHPS specifically measures: courtesy, respect, careful listening, and clear explanations that can be understood. These all boil down to consistent communication, for which we developed several techniques. The first, the “Power of Words,” moved communication from unacceptable to passable and then to powerful. We gave examples of alternatives to saying “I don’t know” when the staff did not know an answer.

The next focus of the training was the “Power and Importance of Listening.” We developed techniques to enhance listening and the patient’s perception of listening; this we called “Eye to Eye and Heart to Heart.” These are delineated as follows:

Eye to Eye: Make eye contact while positioning yourself within two to five feet of the patient, sitting if possible.

Heart to Heart: Position yourself so you are heart to heart while you actively listen to and observe, without interruption, the patient’s response to your question. We linked this with the training around active listening.

We spent a significant amount of time on the skill of empathy. I always led the education by sharing my own personal story as a pulmonologist.

My role often was to make the diagnosis of lung cancer, inform the patient of the diagnosis, and arrange the therapeutic plan. I had all of that arranged before I saw the patient, then I would share the diagnosis and quickly roll right into the plan: “I’m sorry, but the biopsy revealed lung cancer. I have your surgical appointment all set for you. You are seeing Dr. X tomorrow at 1 p.m.,” etc.

In retrospect, as I explained, I missed the point. I don’t think the patient ever heard anything beyond “lung cancer.” I was utilizing sympathy and immediate action because I thought that was what patients wanted to hear. Rather, or in addition, what I truly needed to use was empathy.

In our curriculum, we suggest that communicating with empathy is the best way to show you care. We describe what empathy is and teach the technique of ESP, the Empathy Formula:

  • Empathy statement: Using a descriptive word to restate a patient’s feelings demonstrates our attempt to connect.

  • Stop: Allowing for silence offers the patient the opportunity to think and speak.

  • Probe: Asking open-ended questions allows us to explore the deeper meaning of what the patient is saying to best identify the correct solution.

We describe how to build an empathy statement by saying “I can see/hear” with a linking statement “why/how” and then name the emotion “frustrated/upset.”

Many participants felt the empathy technique was the most valuable skill that we taught, and they found it not just applicable for patient experience but for life in general.

Lastly, we thought it was critical to link the patient experience training back to the safety curriculum. We wanted to provide a tool for staff and clinicians to offer service recovery and have a de-escalation tool when patients were upset, frustrated, or angry. We used a technique we had previously learned in our safety and error prevention training, CUS.

When clinicians believe there is action (or lack of action) that requires intervention, they can say I am Concerned, I am Uncomfortable, or Stop the Line, thereby empowering everyone to act in the best interest of our patients.

We matched this concept from safety training to our patient experience training in a similar manner. CUS in patient experience training speaks to communicating with a patient (or their family, visitor, etc.) who is upset, frustrated, or angry.

Each letter of the acronym has associated actions. CUS for patient experience means:

Concerned: The patient needs to feel failure is not routine. Be truthful and never blame the patient for the service failure.

Uncomfortable: The patient needs proof of understanding and a plan of action. Demonstrate that you understand the impact of the failure and provide options.

Stop the Line: Immediate action is needed to address the patient’s concerns first, then fix the problem.

Use ESP to demonstrate empathy; allow the patient to share their emotions and plan an immediate follow-up.


For the execution of the patient experience training, we followed the same plan that we had implemented for safety: the train-the-trainer model. In conjunction with Press Ganey, we trained all leaders, including all physician leaders, and then the trainers trained all 16,000-plus staff members and clinicians.

We required all hospital-based physicians (hospitalists, intensivists, emergency clinicians), all employed physicians in the medical group, and all employed advanced practice providers to take the in-person class. All other physicians were required to take an online version of the class, which I taught. In fact, just like safety training, we made experience training every two years a condition of credentialing at Catholic Health.


We then designed a plan around sustainability using the tools of appreciative inquiry, which we called “appreciative coaching.” Appreciative inquiry is a positive behavior-reinforcement tool that focuses on identifying positive strengths rather than negative issues and weaknesses.(5)

John Gottman incorporated the concept of appreciative inquiry using a five positive to one negative ratio method of communicating.(6) Over nearly a decade, he interviewed 700 newlywed couples, videotaped one 15-minute conversation, and counted the positive/negative interactions in that conversation. He noted that if the positive comments outweighed the negative comments in a 5:1 ratio, this predicted marriage longevity. Ten years later, this was still 94% accurate.

We had introduced the concept of incorporating appreciative inquiry in that same 5:1 ratio to provide positive behavioral feedback during our safety program training, but it had not been implemented to any large extent. This finding has ramifications in the workplace as well; it has been demonstrated that employees are significantly more productive in workplace environments that are focused on positive reinforcement. We incorporated this concept into that of appreciative inquiry to build appreciative coaching.

In safety, we implemented the principle to guide the coaching of each other (peer coaching). The safety program directed leaders and peers to recognize and encourage safe and productive behaviors five times as often as they correct unsafe and unproductive behaviors. For patient experience, we linked the concept but took it to an advanced level.

Appreciative inquiry has been delineated as a tool to enhance the patient experience. Published data suggest that the implementation of appreciative inquiry can drive improvements in HCAHPS.(7) For our program, we developed an electronic tool in which appreciative coaching could be documented. All leaders in the organization, typically defined as managers and higher, are responsible for performing and documenting appreciative coaching episodes. The coaching is based on the Daily Patient Experience Principles. It is organized not as a secret shopper, but as an episode of open coaching.

The leader accompanies the staff member into the patient’s room and explains to the patient that we are working to improve our communication skills in the organization and would the patient mind if the leader observes the interaction. Most patients are not only open to that, but also are pleased that we are focusing on our communication skills.

The leader and the staff member come out of the room and move to the appreciative coaching portion. The leader asks the staff member how they think it went. The leader gives five positive components of the interaction and one area for improvement (following the 5:1 principle). Lastly, the leader asks if the staff member is willing to work to improve in the future.

The goal was to reach all employees at least twice yearly, if not more. We built these goals into our system quality data plan and cascaded those goals into each executive team’s goals. Our concern was to avoid having PX approached as an initiative or as the flavor of the month. By building a large volume of appreciative coaching into our plan, we believe we accomplished three goals: 1) we implemented a positive behavior reinforcement tool for our staff and physicians; 2) we maintained focus on the PX program; and 3) we built accountability into the sustainment plan.


This PX transformational program had great success for its first three to four years. We saw a nearly 100% improvement in the HCAHPS metric of overall rating of patient experience as measured by percentile rank during that time, with one campus demonstrating a nearly 800% improvement (moving from 5th percentile to 45th percentile between the 2018 baseline period and the end of 2020).

What about the physicians? I would suggest that there was mixed engagement and results, with some improving and others remaining stagnant. The outpatient medical group saw a significant improvement in overall ranking; however, our hospital-based physicians did not share that same improvement. In fact, despite the nearly 100% improvement in overall ranking in the hospitals, the physician-specific scores were relatively flat.

Through our root cause analysis process, we found that this was not unique to our organization. In his book Service Fanatics, describing the transformation of patient experience at Cleveland Clinic, James Merlino, MD, describes how he built out a training specifically for physician communication: “…releasing HCAHPS data, educating physicians about measurement, and distributing communication guide were not enough. Physicians are important engines of our organization, critical assets that require continual investment. We had an obligation to help them communicate better. We needed a new program to help improve their skills. And teaching established physicians to communicate better with patients would not be easy.”(8)

We believed that we required a similar level of further investment in our clinical staff. We built out a clinician-specific training program in conjunction with our partners at Press Ganey. We explained it just as Merlino did in Cleveland: “We are continuing to invest in you. Your success and our success are inextricably linked.” Our training was developed to build on what we initially taught and focused on: the Daily Patient Experience Principles.

To enhance the experience our physicians were providing for our patients, we did a deep dive on the physician-patient encounter and looked to improve all aspects of that encounter. We focused our training on three phases of the physician-patient contact: Opening the Encounter, During the Visit and Treatment, and Closing the Encounter. We believed this could then be applied to most hospital and office settings.

We have had an encouraging reaction to the program and our post-event surveys. To augment implementation of this program, we followed it up using the same playbook, appreciative coaching, as our primary tool of sustainment. In addition, we shared current evidence of the importance and impact of patient experience from the physician’s point of view. One article describes a disconnect between a physician’s self-perception and a patient’s perception of empathy.(9) This supports the importance of continued training around empathy using ESP in our world.


One last area of focus for us has been on patient experience data and the display of the data. Often the data exhibited represent different metrics, different time periods, different questions, and different units, predisposing us for failure as we try to improve patient experience. To quote Peter Drucker, “You can’t improve what you don’t measure.” If we present multiple measurements with seemingly no correlation, then physicians will lose faith in those metrics.

Accordingly, we first developed a standard data plan. We built out what we call the Golden Key Data Report (Figure 3). This represents a standard template, with standard metrics and standard time periods, which allows all to view, and more importantly, understand, our data. In addition, this report is transparent, shared with all leaders and posted on each unit and in every office.

Figure 3. Golden Key Data Report

To further augment our physicians’ understanding and connection to their data and the importance of patient experience, we built out physician-specific Golden Key Data Reports for all hospitalists, emergency physicians, and the employed ambulatory medical group. These reports include not just numerical data, but the voice of the patient as well, via patient comments as applicable. Our clinicians have gleaned much about the patient perception from those comments, and it helps our team focus on areas for improvement. Our clinicians eagerly await the latest report.

We then moved to display comparative data in a de-identified manner, reviewing the physician data internally at both the department and campus levels. Physicians are able to see how they are scoring relative to their peers, which helps motivate all to continue to improve their communication skills. We are now moving toward greater transparency in which the PX data will be displayed publicly on the internet for our patients to see. Not only will the data be published, so will the patient comments. We have introduced a process to vet those comments.


Patient experience improvement is not easy. I believe it is analogous to culture change, which is the most challenging operation an organization can undertake. For our organization, including patient experience as one of the core components of our high-reliability transformational program allows it to maintain tremendous importance despite the multiple challenges we all face. In addition, we are building patient experience metrics and goals into our clinicians’ contracts.

Ronald Heifetz famously said, “Attention is the currency of leadership.” We believe that clinicians are the leaders in healthcare, whether informally or by title. For this reason, clinician engagement in improving the experience for our patients is critical for success.

Excerpted from The Chief Medical Officer’s Essential Guidebook by Mark D. Olszyk, MD, MBA, CPE.


  1. 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.

  2. Tsai TC, et al. Patient Satisfaction and Quality of Surgical Care in US Hospital. Ann Surg. 2015 January; 261(1):2–8.

  3. Glickman SW, et al. Patient Satisfaction and Its Relationship with Clinical Quality and Inpatient Mortality in Acute Myocardial Infarction. Circ Cardiovasc Qual Outcomes. 2010; 3(2):188–195.

  4. Lee TH. How U.S. Health Care Got Safer by Focusing on the Patient Experience. Harvard Business Review. 2017.

  5. Appreciative Inquiry. Organizing Engagement. .

  6. Gottman JM, Levenson RW. Marital Processes Predictive of Later Dissolution: Behavior, Physiology, and Health. Journal of Personality and Social Psychology. 1992;63(2):221–233.

  7. Moorer K, et al. Using Appreciative Inquiry as a Framework to Enhance the Patient Experience. Patient Experience Journal. 2017;4,3:128–135.

  8. Merlino, J. Service Fanatics. New York: McGraw-Hill;2015:186.

  9. Abdulkader RS, et al. The Intricate Relationship Between Client Perceptions of Physician Empathy and Physician Self-Assessment: Lessons for Reforming Clinical Practice. Journal of Patient Experience. 2022;9:1–10.

Jason M. Golbin, DO, MBA, MS

Jason M. Golbin, DO, MBA, MS, is executive vice president and chief medical officer of Catholic Health in Rockville Centre, New York.

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