A Foundation of Values for Patient Experience Excellence
On the Road with Hospital Israelita Albert Einstein, São Paulo, Brazil
This On the Road feature is also available in Portuguese here.
A Perspective on Motivations
Our latest On the Road reinforced the fundamental global nature of patient experience. While various nations have seen systemic shifts in their healthcare organizations towards a focus on the patient and family (the consumer, customer, client, etc.) for which they care, one idea is emerging as fundamental. That patient experience matters in healthcare today. More so, unlike what we have been seeing in the United States and in a few other geographies who have been evolving major incentive programs to reinforce a focus on "value”, there are many systems, organizations and institutions globally that have taken this path forward not due to policy pressure, but grounded in the values to which they approach care. This is not to say that in environments where policy dictates practice these efforts are solely a response to policy as we are seeing a fundamental shift in healthcare focus globally. Yet it is important to acknowledge those places that are acting to address this issue because it is fundamental to whom they are as a healthcare organization. Our latest host, Hospital Israelita Albert Einstein, exemplifies just that.
Framing the Journey
The focus of my travel to Brazil and specifically to Albert Einstein, a leading healthcare institution in Latin America, was two-fold: one to explore and share the story of their commitment and focus on patient experience and two to participate in and support the First Latin American Symposium on Patient Experience. I spent two days getting a sense of not only the Institution’s flagship facility, but also with the visionary support and direction of President Dr. Claudio Lottenberg, I was provided the opportunity to engage in the very values on which it was built in its efforts to impact the community it serves by experiencing their commitment to social responsibility though a partnership with the public health system in São Paulo. This story is less about the practices, of which many are aware and attempting to implement in various ways, and more about the foundation on which those practices are being delivered.
This idea of commitment was no better exemplified than in the welcome and opportunity to learn from the executive team of Albert Einstein as we began my visit. In learning about the rich history from my hosts Dr. Marcelo Alvarenga, Chief Experience Officer and Dr. Sidney Klajner, Vice President and presented by the organization’s President, Dr. Claudio Lottenberg, Henrique Neves, CEO, Dr. Miguel Cendoroglo, Chief Medical Officer, Claudia Barros, Chief Nurse and Quality Officer and Miriam Branco, Director of Human Resources,the foundation on which this patient experience effort was built became quickly apparent.
[On a side note, perhaps my first encounter, as I looked for the appropriate entrance to this vast facility for my first meeting, set the stage. At each entrance were numerous individuals in red coats, the valet team (and an outsourced function of Einstein). What I experienced in the welcome, concern and care from these folks in ensuring first we had was we needed was clear and unwavering. These individuals knew why they were there. It wasn't just about parking cars, it was about making sure people were welcome and had what they needed.]
Hospital Israelita Albert Einstein was built in the years after World War II as a giving back from the Jewish community in São Paulo for the welcome and comfort they were provided. The organization was established and still operates fundamentally based on the four core traditional Jewish principles: Good Deeds (Mitzvá), Health and Healing (Refuá), Education (Chinuch), and Solidarity and Justice (Tsedaká). These values, while perhaps not explicitly present in everyday efforts in the organization, were clearly the foundation on which it seemed every action was taken. Rather than a focus on values for values sake, these concepts are the glue that binds all the organization does in providing care for its community. A critical element of this grounding in values is not just a stated commitment to social responsibility, but also a tangible effort to ensure care for the community they serve. I had the chance to experience this first hand through the incredible efforts they have undertaken to support people across São Paulo.
Albert Einstein’s journey has been intentional commitment over many years guided by the leadership of president Dr. Claudio Lottenberg and Vice President Dr. Sidney Klajner. This commitment at the senior level underlines all our own research has shown with leadership as fundamental to experience success. It takes senior leaders with a commitment to not only focus on experience, but also a willingness to invest effort and resources in achieving excellence. These leaders helped shape a path of success over the last 17 years that defined a visionary journey of commitment to patients and families, the community and the team providing care as well.
The Einstein journey began in the 1999 with focus on Joint Commission International Accreditation and a commitment to the quality standards this designation epitomized. The journey has been grounded in a focus on the concepts leading to a Planetree designation in 2011. This commitment to the Planetree Model had Einstein not only consider all aspects of patient and family centeredness at their facility, it led to Einstein’s establishment as an operating extension of the Planetree effort, working to expand the model to other facilities in Latin America. This focused path forward ultimately led to the leadership decision to launch a formal patient experience effort in 2014 catalyzed by Dr. Sidney Klajner (shortly after Patient Experience Conference 2014). This history of leadership focus and intention helped frame a formidable and aligned executive effort that in engaging all corners of the organization has been on a constant drive towards being the best. As Dr. Miguel reinforced as he provided an overview of this history, "it is no longer important to be the first, we are committed to being the best.”
This commitment to excellence was apparent not only in the statistics that show excellence in outcomes and the extensive global partnerships Albert Einstein has developed, but in the overall attitude exemplified by these senior leaders and the people of Einstein I met along my journey. Two key elements that I have experienced not only in my work, but personal research, that are aligned with high performing healthcare organizations today also came out in our opening conversation. First, a commitment to people, as was shared by Dr. Miguel, "our people make Einstein” and this was reinforced in almost every encounter I had in experiencing the commitment and passion of the Einstein team.
Second and most critical was the idea that "we are never good enough.” This statement is less a self-critique of lack of achievement, but instead a powerful and important realization that in healthcare if we get complacent because we think we have achieved or attained success, we don't hold it long. This idea of constant learning, growing, acting is fundamental to not only sustaining organization success, but central to the idea that in healthcare today, a commitment to patient experience means we can never truly stop striving to be better. This was evident in the voices of this passionate and focused leadership team. It was exemplified in the staying power and passion of leaders that believe this was not just the right thing to do, but efforts that were fundamental to the excellence Einstein looked to achieve. As Dr. Claudio reinforced in our conversations, it takes many voices to make the experience of Einstein sing fully, but what was also evident in his very presence was a servant leader and leadership team that took their work to heart with a clear and confident commitment to excellence overall.
As we review my visit to Einstein, I won’t be able to fully share every conversation on the journey. But it is important to hear how their efforts have come to life and how it was not only good enough for Einstein to do this for themselves, but how their desire to impact patient experience throughout Latin America and truly beyond led to the inaugural symposium as well.
A Journey Through Einstein
As I share a few of the views I was provided of Albert Einstein, I will also highlight a few practices that stood out beyond many of the common themes we now see arising in organizations truly committed to patient experience excellence. While I do not have the room to share the full story of every place I visited, the powerful practices and ideas I experienced will be shared. These nuggets are often simple practices with significant impact for those being cared for and served as well as for those providing care. I start with our visit to the Rehab Unit.
We were welcomed to the Rehab area by Dr. Flavia Camargo and Fatima Gobbi in the waiting area. Before we even entered this integrated center bringing together all aspects of rehab I was welcomed by two powerful experience efforts. The first, a comment tree where people could leave notes about their experience tied to an actual tree in the lobby. This included the good, bad and ugly, but allows people coming to the organization to express themselves, publically and openly in a commitment to shared improvement.
What was innovative, and a powerfully simple idea, was a practice based on the fact that many of the patients in this unit were coming on a regular basis and building relationships with the staff and the organization. What the unit did was installed a monitor in the waiting area that not only provided educational information, but actually showed the comments received by patients and family members and highlighted the actions taken to address these comments. This is perhaps the greatest example of transparency of action I have seen, where people can see their words and the impact they have had. Not only is this an innovative practice, it is a brave practice of owning all feedback that is received and addressing it in ways that are comprehensive and appropriate.
I next had the chance to visit the ICU and speak with Dr. Felipe Piza and also some members of the multiprofessional team on the unit. Some of the central practices they have implemented include the ability for family members or caretakers to be present 24/7 and the application of multidisciplinary rounds (that are more frequently including patient and family members directly). They also provide patients and family members free and full access to their medical charts so they can ask questions and engage in their care. As Dr. Felipe said, "we believe patients and families deal much better with what they know than what they don't know.” This is a profound, but important point central to patient experience.
Most significantly, I was introduced to a simple, but powerful means to engage patients and families in their care experience. Being piloted on the unit was a stop light sign showing three lights – red, yellow and green. The patient and/or family member could change the color of that sign at any time to address any care issues or other things arising for them. Green meaning all was fine at the time, yellow meaning some issues were arising that prompted a quick intervention and interaction with the care team, to red signifying a critical issue that elevated the conversation to the senior nurse and unit leaders to address. The sign represented an unassuming and safe way to begin a feedback conversation and in real time understand how the patient and family were feeling and what they were experiencing during their stay.
As I was being shown this new process, I had the chance to interact with a family of an ICU patient and engage them directly in a conversation of their experience as well. The patients son shared a powerful story of how on his way to see his mother he was treated poorly by the airline employees, but when he arrived at Einstein it was a whole different story. He shared, "When I arrived here all I found were smiles!”. His mother has had to come to the hospital many times in recent years and he shared, "Mom says this place feels like home, she knows the nurses by name and she even likes to bring them gifts.”
Perhaps most significant to the patient experience conversation and what we believe to be central to patient experience excellence came in his last few thoughts. "Over the years this hospital has gotten better, but not only in technology or medicine, we expect that. Where they have excelled is in the human relationship, how they work with and engage us as patients and families, how they may us feel.” In almost no better way have I heard the power of interactions at the heart of the experience effort exemplified.
As part of my tour I was able to spend time with teams from the Geriatrics Unit, Oncology, and the Emergency Department. In each of these clinical environments what emerged as fundamental to their efforts was what I had just heard in the ICU. Outside of their clear and unwavering commitment to clinical excellence, they were working to achieve more. They each strived to create personal and fundamental connections with patients, acknowledging patients and families as unique and understanding everyone’s specific needs. From providing hands on training for the caregivers of those with dementia in Geriatrics, to the individual care and concierge services provided in Oncology where in perhaps some of the most challenging moments of live, people are seen as people with personal stories to tell. In the Emergency Department they faced similar challenges to EDs I have seen around the world in timing, flow and even space, yet their commitment to relationship with their patients was evident here as well. With a process to proactively engage with people in the waiting areas, share information and keep people informed they worked within an understanding and management of expectations. Something we often miss in healthcare and what can be used to ensure we are respective and active in meeting the needs of all in our care.
These subtle practices also were emulated in some of the technological aspects of work at Einstein. As a teaching facility they provide extensive education and training including full simulation not only on the clinical aspects of care, but by bringing in actors that can prepare people for the raw and human elements those providing care can encounter today to strengthen their muscles in communication and compassion. This represents a powerful commitment to the whole experience. And the experience is reaching beyond the walls of Einstein as well with their efforts at innovation through telemedicine, not only to bring their clinical expertise to the far reaches of their community and country, but reinforcing their very commitment to social responsibility – a central focus for Einstein I will delve into further below. As Dr. Milton Steinman guiding the telemedicine effort shared, "Hopefully through our efforts we provide a little drop of Einstein in every hospital that needs us”, referring to an expression from Dr. Claudio Lottenberg, Albert Einstein’s President.
This commitment to clinical and technological excellence was reinforced by an extensive network of services in support of the patients, families and the community engaging with Einstein as well. With a customer service center located immediately inthe main atrium of the facility a commitment to meeting the needs of those in the facility was unquestionable. Led by Rita Grotto, the team here is responsible for addressing all comments and complaints and serves as a rapid response team, providing immediate responses on critical issues and turning around comments submitted via phone mail, email and numerous comment boxes around the facility. All comments are identified with a commitment to address in 72 hours. Leadership in each area receives full updates on the comments regarding their areas and all suggestions and ideas are documented and consistently reviewed. A team of individuals, ambassadors of sorts, can be dispersed to address immediate needs. This commitment to listening and acting creates a buzz of activity, but an evident commitment to care.
This level of caring for the whole family was also apparent in two services provided for patients and families as well. A family waiting area and lounge is offered to provide a comfortable place to wait as loved ones are in surgery or a place of respite for those receiving care. Offering rest areas, snacks and even services such as massage, the commitment of the team is to personally care for the over ten-thousand individuals that use their services monthly. This level of care is not only for those currently at the facility, but also for those planning to arrive. A full team of navigation and patient support services individuals work with patients planning to come to the facility to ensure they have what they need from personal to the tactical needs of insurance, etc. This team’s commitment is to take the stress out of what can be the stressful nature of a healthcare encounter, by going above and beyond for those who will be in their care.
In all that I experienced, what I saw was a coordinated and committed effort to care in the broadest sense for all who were engaging with Einstein for their healthcare. From the subtleties offered in clinical practice to the comforts provided in compassion and supportive services, the Einstein experience seemed to be designed to provide a full web of comfort and support for all in their care. But the reality of Einstein’s efforts doesn’t stop at those receiving care, there is a clear commitment to those providing it as well.
Aside from the accolades as being a "best place to work”, Einstein works to provide the infrastructure to support that. From transportation to and from work for staff that come sometimes for hours from all corners of the São Paulo region, to inexpensive meal options, to training support, I can say in all my travels this is the first organization that has a designated area for staff only. I am not talking about break rooms or back hallways, but a fully designated space, including a large outdoor rooftop green space, a full gym with scheduled exercise classes and quiet spaces to rest or regroup. This commitment in space and resources was an underlying factor in building a team focused on the best in care. As Miriam Branco shared in our opening meeting, "If we take care of our people, they will provide the best for our patients.” This last stop on my visit to the Einstein facility reinforced the very message that started my day shared by Dr. Miguel, "Our people make Einstein.” Perhaps that was the most evident takeaway from this visit, that at every turn, in every conversation and in every moment I saw a smile, I received a "bom dia”, I saw a commitment beyond just the practice of medicine, to a focus on true care. This for me reinforced the values of Einstein and more so the sense of social responsibility that was fundamental to its identity. To further explore this commitment I had the privilege to spending time with individuals associated with Einstein in the public healthcare sector of São Paulo. A powerfully compelling message that the healthcare conversation was not about Einstein at all, but about the people it served.
A Commitment to Community and Social Responsibility
The second day of my visit took me to the locations of community efforts and public partnerships Einstein has established. This was an important addition to my visit urged by Dr. Claudio who reinforced the importance that I look beyond the walls of Einstein’s central facility to the true impact he has worked so hard with his team to ensure they were having for the entire community. I am truly grateful for his intervention here in providing me the broadest view on all that Einstein represents in living its values for every individual, in every encounter.
The experience I had was not about simple moments of community outreach done for the sake of public relations, but truly exemplified a commitment to the values on which the organization was built. While these efforts probably deserve a second article all to themselves, it is important they be part of the broader Einstein story. I had the chance to visit a public hospital, a public health and psychosocial health center, and perhaps the most profound On the Road experience I have even had in visiting Unidade Paraisópolis, a community health facility that defined the ultimate in experience.
In my visits to the public health offerings a few common themes emerged. Einstein was looking to take the level of care that some may have thought only reserved for those with means or access, to the entire São Paulo community. One of the newest efforts was Hospital Municipal Vila Santa Catarina. A formerly abandoned medical facility, Einstein has worked through a community, government and private partnership to bring this facility back to life. Just months from it reopening, its commitment is to bring the Einstein experience to people throughout São Paulo. Now a major center for labor and delivery and a surgical center focused on critical transplants, it is bringing critical clinical needs to the community. More so it is bringing an experience of care, compassion and service to the public health sector that is changing the way in which people think about how healthcare is delivered.
In a similar fashion Einstein has committed to the public health system overall. I was able to experience this in a visit to AMA Paraisópolis and CAPS Adulto Paraisópolis. This public health facility provides low acuity medical assistance from primary care issues and vaccinations, to pediatric care and dentistry. The commitment here is to ensure a level of care for all in the community, grounded in clinical excellence, but also acknowledging the humanity at the heart of healthcare. A high volume health center in a low-income area, all I saw was smiles, attentiveness and compassion, even in the midst of a power outage in which people had to revert to paper recordkeeping. This similar experience took place in CAPs where there was a level of honor and care for those struggling with behavioral and mental health issues. This was not just an overnight facility, but also a day facility that worked with caring for and developing those with a range of mental health issues. In all of these settings a team approach to care was central and a acknowledgement of dignity and respect for all regardless of their means or social status was present. These brief, but important stops on my visit reinforced the very values on which Einstein was founded and how it has committed to expanding its efforts in supporting healthcare throughout the region.
The most compelling experience of my entire visit came during my visit to Unidade Paraisópolis. I am hoping we can do more to expose The Beryl Institute community to this exemplar of an integrated effort of public health as these paragraphs cannot do it justice. I must share that as a community health center providing care for the mothers and children in one of the poorest areas of São Paulo, they are truly taking on the real work of healthcare in a systemic way. This may be no more evident than in the pride not only for the work they do, but more so for the broader impact they. You could see this pride in the very smile of my host Dr. Adriana Pasmanik, as we traveled the vast health center.
The program at Unidade Paraisópolis unfolded before my very eyes as we walked this facility that seemed to stretch the hillside. The power of this place was its commitment to total health of those it served. From outside the entrance that provided access to a primary care facility for pediatrics and mother-baby care, I could hear the joyful laughs of children as if they were floating in the sky, their faces yet to be revealed. As we first explored this full service pediatrics center that not only provided clinical care, but the medications needed to heal (at no charge) I was impressed by the commitment to community and the evidence of the same level of attentiveness, respect and personal care as I saw at the main facility. The way in which people were greeted and treated underlined the central construct that in healthcare we are human beings caring for human beings regardless of the means from which we come.
But as Dr. Adriana began her tour of this facility, I realized we had entered a world of care I had never myself seen. What is happening at Unidade Paraisópolis is not just a clinical healthcare offering, but a true commitment to the health of the community, primarily with a focus on children and specifically at-risk children, and supporting mothers both expectant and new on not only how to care for their children and themselves, but on how to provide for their family by learning new skills. The center was a combination of recreational facility for the children in its care, and educational center creating valuable knowledge and life skills, including providing library services for the children of the community. It was a health center that provided broader specialty health services as well from various therapies, to counseling and support.
Education ranged from preschool through preteen programs that extended not just to traditional learning, but music and the arts. It included programs for mothers in preparing for birth and for mother and babies in that critical first year of care. There were classes on cooking and other crafts that would support mothers in generating income to support their families. There was a gathering place for people in the community that just wanted to convene around a conversation or as I saw even a simple knitting circle. Dr. Adriana provided a perfect description of the intent of these programs saying, "We don't teach the children (what they learn at school), we are committed to completing them by providing the things they do not get.”
The buzz throughout the facility from the sound of laughter and the pattering of children’s feet on an exploration to interview people about their lives, to the beats of drums in a music class, the chatter in lessons on doing hair or the sweet scents coming from the kitchen in which lessons on baking cookies were being offered, the learning offerings were a constant. I noted that even when the power was out (a semi-frequent occurrence in Paraisópolis) the hum of the generator seemed to complement the symphony of sounds representing perhaps the most fundamental concept in patient experience itself. People were treating all those in their care with dignity and respect and they were doing so with compassion and care, true commitment and with a level of seriousness that I can only describe as the purest form of true healthcare and in the broadest terms I have experienced in all of my On the Roads.
And while these few paragraphs can never do justice to the extent of this community program or provide the tangible feeling of wonder and amazement the emanated from this place, it is important we acknowledge in patient experience this fundamental point. It is not just about the clinical efforts we undertake or the business results we achieve, but about the responsibility we have – the social responsibility we bare – for the communities we serve. And yet for its distinction what may have been the most powerful and fundamental idea shared (and one consistent in all we have seen in patient experience excellence globally) came from the words of Dr. Adriana. She said as we were wrapping up our visit, "The most important thing here is the people who work here. They come every day and work not only with their heads, but their hearts.” That perhaps may be the best summary of what I experienced here. The experience at Unidade Paraisópolis was truly work of the heart AND represented all that is good at the heart of healthcare itself.
Sharing the Wealth
My visit to Albert Einstein also provided me the chance to engage in and provide a keynote at the First Latin American Symposium on Patient Experience. While this event in itself could garner an article of its own for its historic first step in bringing the dialogue on patient experience to Latin America, I share here what this means for our larger movement. The commitment of Dr. Marcelo and the entire leadership and patient experience team at Einstein did something profound in this event; they opened the conversation to all corners of the continent. In bringing together over 700 people to learn from Einstein and from one another they set the foundation for what the future of patient experience can be in this region of our world.
The topics covered reinforced the integrated nature of patient experience from quality and safety, to people, processes and ultimately practices that healthcare organizations could engage in to address the experience of all they served. Most importantly Dr. Marcelo challenged the crowd that this was their conversation and the opportunity to share their stories would continue to expand, inviting all organizations to consider sharing their stories for the 2nd symposium in 2017. From the conversations I had, the connections I made and the commitment I saw, I am certain we will see many new voices joining the conversation and sharing their stories in the year ahead. I also know this is a global patient experience event that will hold a place on my calendar for many years to come.
Why We Must Listen and Learn
As I conclude what is without question the longest On the Road I have been honored to author, I do so with profound gratitude and great humility. To have the honor to visit such places as Einstein, or to learn from and engage with the many numbers of you who are reading this now has been a fundamental part of my own experience journey. This generosity that undergirds our community of practice, the willingness to connect and share, remains a core value of the Institute, and one I believe is fundamental to our movement overall.
What I learned in my time with the Einstein family is that there are thousands of opportunities to learn and thousands of voices with stories to tell, but with that it takes a focus and commitment to not just acknowledge the importance of this work, but a resolve to purposefully ensure that experience matters. That is what I saw, experienced, and felt in my time at Einstein. I saw a generosity of spirit, a commitment to community and an intention in action that must be central to any patient experience effort today. It also reinforced that we all must maintain our focus on a critical point at the heart of all we do in healthcare. That in our willingness to learn, in our own acknowledgement that we may not know everything, is where we exemplify our greatest strength. It is in our willingness to listen in which we come to understand, it is in our thirst for understanding that we continue to improve, and in our effort to improve that we know we are ultimately focusing on doing all that is good and right in healthcare.
In the end, Dr. Claudio Lottenberg may have best summed up my entire visit with Einstein in the ideas he shared with the attendees at the symposium. He declared with passion, "If it is important for patients, it must be important for us. And not just because they are patients, but because they are human beings!”. This is the vision that has led Einstein forward on their rich 17-year journey to change healthcare in Brazil and beyond. This idea is one central I believe to the experience movement overall…we are after all simply human beings caring for human beings.
In finding this fundamental alignment in philosophy it reinforced something else I have come to see, that at its core experience is a global conversation grounded in core principles and actions. While systemic structures and constraints vary, these ideas do not. My experience at Einstein was an unquestionable reinforcement of the global nature of experience and the opportunity that we all have in coming together to lead this movement forward. That is the opportunity we have been given and been challenged to take on – to share wildly, steal willingly and know that together we can accomplish great things for all striving for the best in healthcare.
I offer my deepest gratitude to Dr. Claudio Lottenberg, Dr. Sidney Klajner, Henrique Neves, Dr. Miguel Cendoroglo, Claudia Barros, Dr. Marcelo Alvarenga and many other leaders for their hospitality, time and heartfelt conversations and send my greatest appreciation to the entire Einstein team for making my visit one that provided new insights and reinforced my deepest beliefs. And thanks to all for their willingness to share of themselves in the sprit of Good Deeds (Mitzvá), Health and Healing (Refuá), Education (Chinuch), and Solidarity and Justice (Tsedaká) that are not only the unwavering values of Einstein, but truly central tenets of all that is good in our efforts to positively impact patient experience around the world. Muito Obrigado!
To learn more about the patient experience efforts at Hospital Israelita Albert Einstein, please contact:
Dr. Marcelo Alvarenga
Chief Experience Officer