Don't harm me. Heal me. Hear me. For decades, health care organizations have held this high-reliability adage as the aspirational ideal for patient expectation. By reaching near Six-Sigma levels of safety, modern anesthesiologists have delivered on the first two tenets. It's time for anesthesiologists to focus on the third in both practice and leadership (Ann Intern Med 2005;142:756-64).
In 2018, Wazir et al. explored the relevance of patient satisfaction in the perioperative space (Ann Intern Med 2005;142:756-64). With both public and private payers shifting a larger proportion of health care costs to the patient, the authors noted that patients have naturally shifted mindsets toward that of an active consumer. Anesthesiologists have long surmised that our patients' prime desire is safety, and we have subsequently embraced safety as the most sacred value within our medical specialty. An exceptionally high standard of anesthetic safety is now a basic expectation, shifting patients' desires towards that of satisfaction. Analogous advances in flight safety have allowed airline customers to expect their flight to arrive safely at the destination of choice in a timely manner. Customers now rate airlines based on a convenient booking process, pleasurable culinary choices, efficient customer service, and maximal comfort along each touchpoint of their airline travel experience (Adv Anesth 2018;36:23-37).
Hospital systems focus intensely on patient-reported outcomes (PROs) as a quantitative measure of patient satisfaction. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is a component of the Hospital Compare pay-for-performance program whereby the Centers for Medicare & Medicaid Services (CMS) can apply rewards or penalties (often millions of dollars annually) to hospital Medicare payments. Naturally, the HCAHPS survey receives significant attention from health care administrators whose compensation packages are tied to patient satisfaction measures. Unfortunately, the response rates to PRO surveys are generally quite low and granular data reporting is challenging to patients who have multiple physician and non-physician providers in a single hospital encounter. Additionally, administration of the HCAHPS survey is controlled by a single vendor, leading to bureaucratic entrenchment and a lack of innovation in survey methodology (Adv Anesth 2018;36:23-37).
“Anesthesiology is one of the few specialties with a footprint across the entire health care enterprise including the emergency room, labor and delivery, intensive care unit, operating room, procedure units, and outpatient clinics. From the preoperative setting to the dynamics of the operating room, anesthesiologists are “compromisers in the best sense of the word,” striving for novel solutions to the most difficult patient care challenges”
Anesthesiology practices have explored the best means to pursue this patient-focused data. The Anesthesia Patient Satisfaction Questionnaire version 2 (APSQ-2) has achieved enough market penetration to provide a useful baseline for assessing patient satisfaction in the perioperative space. Still, the notion of surveying perioperative patients and extracting meaningful and actionable data is challenging. Data from over 50,000 APSQ-2 survey responses pointed to a few drivers of patient dissatisfaction but concluded that some factors governing patient satisfaction with anesthesia providers are out of their control (Anesth Analg 2019;129:951-9). With further understanding of brand equity, we argue that this may not be entirely true.
A consumer-based service brand equity (CBSBE) model that focuses on the consumer's differential response to the value co-creation activities of a brand based on the experience gained has recently been conceptualized. Validation in the airline industry revealed that for service brands, the consumer's experience is the “nucleus” of value creation. More specifically, brand consistency seems to be an important driver of perceived value. All consumer touchpoints need to be designed in a way that a standard level of service experience is maintained throughout the continuum of the consumption journey. Inconsistent experience across the consumption journey relays a mixed impression and diminishes brand equity. The airline company that seeks to establish high brand equity must ensure pleasant experiences at booking, check-in, luggage handling, boarding, in-flight, and deboarding. Consumers recognize value through interactions with multiple encounters across their consumption journey instead of a dyadic co-creation mechanism (Journal of Retailing and Consumer Services 2021;59:102354).
If we were to apply this to the perioperative continuum, we would see that value creation is not dyadic between a patient and one provider or one specialty, but instead involves all perioperative players and the consistency of the patient's perceived experience across the entire perioperative journey. While some touchpoints along the patient's journey may be beyond their sphere of influence, anesthesiologists as health care leaders can positively influence perioperative colleagues to focus on the patient experience throughout the collective work continuum, thereby creating enormous collective value during the medical encounter.
Anesthesiologists as health care leaders
Conroy et al. eloquently stated that anesthesiologists are especially well suited to health care leadership roles. The authors argue that anesthesiologists are unique among our physician cohort and particularly suited to be outstanding health care leaders because of our training and broad perspective across the health care system. Anesthesiologists are natural collaborators, positive influencers, exceptional communicators, and consensus builders. Anesthesiology is one of the few specialties with a footprint across the entire health care enterprise including the emergency room, labor and delivery, intensive care unit, operating room, procedure units, and outpatient clinics. From the preoperative setting to the dynamics of the operating room, anesthesiologists are “compromisers in the best sense of the word,” striving for novel solutions to the most difficult patient care challenges (Anesth Analg 2022;134:235-40).
While the role of chief executive officer is certainly attainable, we suggest that the role of chief experience officer (CXO) is one that is also well suited to anesthesiologists. Anesthesiologists interact with nearly every medical specialty and have the unique opportunity to craft positive synergy across multiple service lines and multiple cross sections of health care providers. Through efforts in perioperative medicine, anesthesiologists even collaborate with primary care networks for surgical optimization and long-term follow-up. Anesthesiologists are the very physicians who COULD influence all aspects of the perioperative patient experience just as they have done with patient safety.
The CXO Role
While the role of CXO is expanding, there is still no established blueprint for the position within hospital systems. High-performing health care organizations recognize that patient experience is as vital as classic executive roles such as finance, operations, and marketing. Many CXO candidates come from outside the health care industry, frequently from customer service or technology positions. Some candidates come from within health care organizations, usually from operational or clinical backgrounds. Characteristics cited as vital to the CXO role include the ability to connect with multiple stakeholders, both on the front lines and in the C-suite, along with the ability to implement and navigate change by exerting influence across institutional silos (asamonitor.pub/3W0D3gc).
Data show that organizations who have formalized a CXO role are more likely to have higher HCAHPS scores relative to overall hospital rating. These organizations also have patients who are more likely to recommend the hospital to others. While limitations to this study certainly exist, the signal to noise ratio is increasing for those aiming to “improve patient experience and the resulting reimbursement associated with value-based contracting.” Further, the recommendation is made that hospitals should, at a minimum, “assign specific accountability for the patient experience with a key leader” who can successfully develop and lead improvement efforts (Patient Experience Journal 2021;8:69-76). The value-based contracting reimbursement opportunity from improved HCAHPS scores alone is a solid foundation upon which to build the value proposition for the role and to improve the hospital's bottom line. Quantifiable quality and safety improvement efforts could further bolster the return on investment.
The path forward
Building brand equity by crafting positive patient experiences throughout the continuum of perioperative care presents enormous financial opportunities for health care organizations and the intrinsic qualities of a high-performing CXO mirror those of a high-functioning anesthesiologist. Health care providers and hospital administrators alike stand to benefit from anesthesiology leadership in the role of CXO by creating brand equity at their institutions. We should move away from the dyadic model of viewing perioperative issues as unique to anesthesia, surgery, nursing, scheduling, etc. to one that is more focused on providing a harmonious and congruent experience across all touchpoints in the patient's perioperative journey. When discussing value creation in the perioperative continuum and anesthesiologists as health system leaders, the patient's perspective and the patient's experience should always be at the forefront of the conversation.
Disclosures: Dr. Kamdar is a preferred shareholder of Perceptive Medical and scientific advisory board member of HAI Solutions LLC, PIPCare, and HeartCloud Inc. Dr. Dutton performs data and safety monitoring for Cerus Corporation, is a consultant for Edwards Lifesciences and Medtronic, and holds stock in US Anesthesia Partners.