ROHIT VERMA: Good morning. My name is Rohit Verma, and I'm one of the co-chairs of the first Cornell Hospitality, Health, and Design symposium. Welcome to our inaugural event. This is such a great pleasure, to host people from all over the world.
We have delegates all the way from Japan, China, Norway, Sweden, and many, many other countries around the world. So, thanks for making the time to be here. This should be an exciting event for all of us.
We are hoping to create a community of industry and academic scholars, so that we can engage in this discussion on such an important topic at this time for the history for this country and for many countries around the world, where hospitality and health and senior living and design are intersecting. And hopefully we can all together think of ways to create a more healthy and bright future. So that's the objective, here.
So, welcome. We have an exciting panel this morning. Let me introduce the moderator for the first panel, Melissa Ceriale. Melissa is connected with our university in many different ways. In her title, you will see, if you can read on the stage, it says "P '15, '17, '19" or something like that. That means she's parent of the children who we have the honor of teaching here. So, thanks for bringing them here.
She's also an advisory board member of Montefiore Medicine and one of the founding advisory board member of Cornell Institute for Healthy Future. Melissa?
And now my job is done. It's all up to her. [LAUGHS]
MELISSA CERIALE: OK. So I have the pleasure this morning of hosting the panel of Hospitality in Health Care. So we have three panelists with us, this morning, and I will first introduce Dr. Phil Ozuah, my colleague at Montefiore Medicine, of which I'm on the board of trustees.
So, Phil is the COO of Montefiore Medicine. As a brief recap-- all the profiles for our panelists are in your information. So, just a little bit of something that's not printed on them.
Montefiore Medicine has about 100,000 inpatients a year, 7 million ambulatory visits, 36,000 employees, about 18 hospital campuses and over 250 ambulatory locations located throughout the Bronx, Westchester County, and Rockland County. We have about 600,000 visits to our ERs every year, almost 500,000 of them on our main campus, in the Bronx. It's a $7 billion health system. And, with that, I will welcome Dr. Phil Ozuah to the stage.
PHIL OZUAH: Thank you.
MELISSA CERIALE: You're welcome! So here, representing Columbia, New York Presbyterian, the Columbia campuses, Andria Castellanos. Did I say it right? I got it! OK.
Columbia, or NYP, the Columbia campuses, they have about 130,000 inpatients, 800,000 ambulatory patients, 26,000 employees, about 350,000 visitors to their ER every year. They have about a 66% government-payer mix. And I failed to mention that at Montefiore we have an 85% government-payer mix, Medicare and Medicaid.
Andria has got two medical schools that she operates in between. And they're about a $7-billion health system. Andria, please.
MELISSA CERIALE: [LAUGHS]
ANDRIA CASTELLANOS: And I have a son in this school, also.
MELISSA CERIALE: Yes. Andria has a better son than mine, because her son stayed for this, and my son is off on his fall break.
So, our last panelist today is Peter Yesawich. Thank you. Peter is representing the American Cancer-- uh--
MELISSA CERIALE: --Cancer Treatment Centers of America-- thank you-- sorry-- where they have five hospitals, nationally. They handle principally advanced-stage cancer patients. They're the only one with a national footprint. They have about 15,000 patients, and the majority of their patients fall into an older age range.
They are consistently rated among the highest in the HCAHPS scores. They have predominantly commercially insured patients, unlike the other two panelists up here on the stage. So, with that, Peter, please.
PETER YESAWICH: Thank you.
MELISSA CERIALE: You're welcome!
ANDRIA CASTELLANOS: Should we shake hands?
PHIL OZUAH: Yes.
PETER YESAWICH: Good morning.
ANDRIA CASTELLANOS: We're going to shake hands, unlike our presidential candidates.
PETER YESAWICH: Right-- let the debate begin!
MELISSA CERIALE: Thank you, Andria! Thank you! OK. So, a lot of the conversation that we're hoping to have here today is talking about how we bring hospitality into health care and why it's important that we do so. So, let's start right here, next to me, and we'll work our way down. Peter?
PETER YESAWICH: I'm delighted to. Good morning.
AUDIENCE: Good morning.
PETER YESAWICH: Just a little more on CTCA. We have about 6,000 employees. And we have been in business, now, for about 26 years. In fact, Carolyn Lammersfeld-- Carolyn, raise your hand. Where are you? --is our vice president of Integrative Oncology, has a wonderful and fascinating background. So I hope that, during the course of the next few days, you'll have a chance to say hello.
The question is, why are we here? And I will answer that very simply by saying I think in the transformation of the health care world that has occurred, not necessarily since the arrival of the Affordable Care Act, here in the US, but really prior to that, but I think every health care provider has come to the conclusion, whether or not they like it, that we all compete for patients. And, as a result of that, I think naturally the conversation turns to how well you serve patients. And that then takes us directly to this question of, well, what is the difference between patient care and patient service or guest service, and hence the integration of the concept of hospitality with health care.
And I've kind of marvelled at how that has occurred over the course of the past couple of years. Because previously, quite honestly, if you-- we've all had these experiences, in our own health care journey-- where the emphasis, first and foremost, has to be on clinical excellence. We all understand that. But now it goes well beyond that, to understand that the way we serve those patients, to help them do things like manage the stress, facilitate the logistics, enhance their well-being, apart from the clinical procedures that we provide, are essentially very important.
And I'll just conclude by saying that we all know, with the explosive use of the internet-- and we track that very, very carefully, in our company. In fact, we have cancercenter.org, which is our website, is the most frequently visited cancer-care provider site in the world. We have about 2 and a half million unique visitors a month that come into cancercenter.org. And we actually can track the behavior from people who come visit us online, all the way through decisions to treat.
And the headline there, very simply, is we have far more enlightened patients we ever have before. And that's just not just in terms of diagnostics and treatment, but that's in terms of their understanding of the quality of care. So, the headline, for me, is, we all understand that we have much more engaged, informed, enlightened, patients who are looking beyond the issue of the quality of the clinical care, which is the mandatory, to say, how well will I be treated, and how well will my journey through that treatment be managed? And that's an issue of quality and competition.
MELISSA CERIALE: It's interesting that you're very much at a dichotomy with the other two panelists that we have on the stage. Who your patient--
PETER YESAWICH: That's why I'm here.
MELISSA CERIALE: [LAUGHS]
Who your patient base is, the education level of the patient base.
PETER YESAWICH: Yeah.
MELISSA CERIALE: So let's pass it down the pike, here. Andria.
ANDRIA CASTELLANOS: Sure. Well, Phil and I are very jealous of your payer mix. So what I mean by that is, Phil's payer mix is 85% government, Medicare, Medicaid. Our payer mix at New York Presbyterian is 66% Medicare and Medicaid.
And what that means to us, from a financial perspective, is essentially we lose money on Medicare and Medicaid. And so we make it up-- from a "financial" perspective, we make it up on the commercial payer base. Many of you in the audience are all commercially insured. You're the kinds of patients that help us with our bottom lines.
And so, protecting that payer mix, for us, for all of us, is really important. So, why is that difficult for us, in terms of customer service and hospitality, et cetera? It's expensive to have good customer service. We look at some examples out there in the hotel world, the Ritz-Carltons, as an example, where, when you're a customer at the Ritz, the Ritz can charge you for those services. When you're a customer at NYP or Montefiore or our hospitals, we can't really charge you extra for those kinds of services.
And so, there's a certain level of training that we need to give to our employee base. In hospitals, employees have worked there for many years. Right? The average length of employment in a hospital is probably 20 to 25 years-- something like that. And so we're working with an employee base that's used to things from 25 years ago, from 30 years ago.
And 30 years ago, we never talked about whether a customer or a patient was happy. We never talked about that. We just talked about whether we made them better or not. That was the only measurement we cared about.
And now, all of a sudden, we have to care. And why do we have to care? Because the government pays us to care. So we get reimbursed based on how happy our patients are.
And so, it's a very big challenge for us, from an employee-training perspective, to, who we take care of, and even the surveys, themselves. I'll leave some for Phil to talk about.
PHIL OZUAH: No, no, no, please!
ANDRIA CASTELLANOS: [LAUGHS] But the surveys themselves, we take care of-- for example, at New York Presbyterian, we take care of many Hispanic patients. Now, Hispanic patients, according to the government, are happier patients. I don't understand that, but they're happier
So they answer the surveys that the government gives them. They answer better. And so the government penalizes us for that, because they've done research, and they know that these patients are actually happier. So, in the end, we get penalized-- I'm sure you do, too-- for that. I'm going to turn it over to Phil, to sort of finish it out.
PHIL OZUAH: That's OK. I mean, I agree with everything Andria just said. It's all of those things, and then trying to do this and train people to serve patients in the context of where they have other things on their mind.
So I went to a conference on customer service that Melissa took me to, in Atlanta. This was in a high-end Forbes travel customer-service-- stayed at the Mandarin Oriental, in Atlanta-- a wonderful experience. It was clear to me, from the moment that I walked in, that everybody was focused on my comfort and my experience.
Now, in a hospital setting, such as like the ones up here, Andria's and mine, you have employees that are focused on 100 different things. A nurse can be in with a patient, and, on her mind, she knows that the patient next door is bleeding in their brain. And she's thinking through, have I done all the things-- you know, should I run back and check the vital signs? At the same time as she's supposed to worry about this patient, or he's supposed to worry about this patient, and meet the same standards of attention and care.
So, the challenge that we have is, how do you do all of that, in the context of real life-and-death, top-of-mind focus of staff who sometimes just say, you know, I just need to get the bad heart out and put the good one in. I'll worry about introducing myself later. But right now, let's get you into the room.
So we face all of those challenges. And yet, we have to-- the patients, appropriately, expect a Mandarin Oriental service and a Mandarin Oriental level of attention. And, incidentally, the government expects that, as well. And part of our payer mix is that not only do we not get reimbursed for providing additional hospitalities as services, we actually get our reimbursements cut if the patients are not highly satisfied.
So those are the challenges. But it's ones that we embrace because we have to. And that's part of the reason that I'm here, is to learn as much as I can about how we can do this better.
MELISSA CERIALE: Andria, with my Montefiore hat on for a moment, I never thought I'd be envious of somebody who had 66% government payer mix, where we're at 85%.
ANDRIA CASTELLANOS: [LAUGHS]
PHIL OZUAH: [LAUGHS]
MELISSA CERIALE: So this is an interesting panel, as you can see. We've got two ends of the spectrum, here. Peter I didn't mean to cut you off. You were going to say--
PETER YESAWICH: I would like to respectfully disagree with my colleagues.
MELISSA CERIALE: OK! Here we go!
PETER YESAWICH: I'm going to lighten this up a little bit, here. Good patient service does not cost you anything. In fact, poor patient service costs you a lot. And I think, if you take that perspective, and you say, it's an issue of establishing a priorities-- this is important-- training people appropriately, and then monitoring and recognizing that, that doesn't cost a lot of money.
It makes a huge difference, though, in the experience that patients have. So I would challenge the group to maybe think differently about this. You're not adding expense. You're adding, really, a dimension of service that we know, increasingly, not just through our organization, but any that's represented in this room, that clearly can make a difference in the experience patients have.
PHIL OZUAH: This is going to be very exciting panel.
PETER YESAWICH: A quick story
MELISSA CERIALE: It'll be very exciting. [LAUGHS]
PETER YESAWICH: A quick story. And I think, hopefully, you'll appreciate this. I joined the board of this company back in 1998. And the reason that I was asked to join the board was, at the time, they were very interested in understanding how use the principles of marketing to grow the business.
A month after I joined the board, a guy by the name of Horst Schulze joined the board. Some of you may recognize that name as the chairman of the Ritz-Carlton Hotel Company. The reason he was asked to join the board, because he believed what I just said, and that is that good service doesn't cost you. It's an attitude. It's a belief. And it has to be imbued in the organization.
As it turns out, that has to do with a lot of the things you were talking about in the conference today, whether it's the ambient design and all the things that affect the way people react to their environment. But I guess what I would like to really impart to the group is to say, don't be burdened by the idea that this is adding expense and complexity. It's adding a dimension to the patient experience that you want and I want and all the patients that we serve want. It's just a question of calibrating the time and the attention you devote to that.
MELISSA CERIALE: OK, Peter, your two minutes are up. Phil-- Phil?
--I'll pass it to you.
PHIL OZUAH: Right.
ANDRIA CASTELLANOS: We're fighting over who's going to answer. [LAUGHS]
PHIL OZUAH: I mean, I think that the mindset is the right one. But, as the chief operating officer of a $7-billion health system, I can tell you that it costs us a lot of money I have 10,000 nurses registered nurses. To train them to go over-- you know, just to master a script, of coming-- you know, say your name, say what you do, ask for the patient-- you know, do you need anything? I can't train them when they are on duty in the hospital.
And they don't volunteer their time to come in after work to be trained. I have to pay them. And these are highly expensive employees that you take out, and you pay them time and a half to go through hours and hours of training. It undoubtedly hits our bottom line.
And, if you take them off of duty, which we do with the physicians, we don't pay the physicians overtime or anything like that for training. But you take them off of providing care, there's an opportunity cost, because they're not seeing patients and generating revenue, as you do that. Part of-- and it's not the toiletries and things that cost the money, it's actually the time.
And part of what we learned in Atlanta, there's a new software that's being developed-- which I have on my phone, and I'm piloting-- that allows for interactions with our scenarios with real people, and it rates you on your emotional connection and confidence and calmness and all that. And we are piloting this, to see if we can use it for our patients.
Well, Forbes Travel, that produces this, has a business model. When I estimate how much it will cost us, it costs several hundred dollars per employee per year to use this service. When you multiply that by 36,000 employees, et cetera--
So, there's a definite cost that we experience. And we embrace and we try to find ways to do it. But, certainly in Montefiore's experience, it is real, and it is substantial. And it's challenging.
ANDRIA CASTELLANOS: So I agree with both of my colleagues.
MELISSA CERIALE: OK, wait a minute.
ANDRIA CASTELLANOS: I-- [LAUGHS] I think, ultimately--
MELISSA CERIALE: She's a politician.
ANDRIA CASTELLANOS: I am a politician.
I have to be. Two medical schools, one hospital, it's crazy. OK.
But, ultimately, you're right. I think there's a payback, and it doesn't really cost anything. But we are challenged with so many difficulties. And here's where you in the audience can help hospitals like ours, that really struggle with this.
So, the first thing we have to care about when people come to our facility is hopefully getting them better. We also have to keep them safe. So a hospital like mine, that's located in one of the poorest communities in the country, people come from all over the country, all over the world to seek their care with us. We have 400 security officers-- a large police force, for any city. Right? So, just keeping our patients safe is a priority.
When our patients come to us, they speak hundreds of different languages. And here is where the hotel and hospitality industry does this really well and hospitals not so much. In hospitals, we're regulated. Right? So, we must have a translator-- must. We break the law if we don't have a translator, for hundreds of different languages.
And so, not every hospital or hospital system is faced with these kinds of challenges that both Phil and I are faced with. So, we have the whole communication problem. And I think hotels and hospitality industry has probably done a much better job with this.
I think the other thing that the hospitality industry does-- for example, in Disney-- they know where their customers are. We don't know, in our hospital-- and Phil's laughing. We can't find our patients. We don't know-- we don't have tracking devices on them. We don't exactly know where they are and when they're en route and what's going on. And I think that's another very big problem for us, where the hospitality industry can actually be helpful for us.
So there's all these things that make an experience good for a patient, not necessarily the ones we're thinking of. And then there's the whole arrival-and-departure thing. You know, how do you answer the phone? How do you arrive a patient? How do you say goodbye to a patient and a family?
And then, finally, it's the whole family experience. It's not just the one patient. And the hospitality industry does this well.
You're not just nice to the person paying the bill. You're nice the whole family, the whole group. Hospitals don't do that so well, where we have to take into account, and really start to think about the whole experience with, friends and families. And I think those are areas where opportunities for the hospitality industry to really help hospitals.
MELISSA CERIALE: Peter, you have 30 seconds to rebut.
PETER YESAWICH: [LAUGHS] This is not a rebuttal. Let me ask that you think maybe differently about the situation, here. The reason I say this is, I am not a clinician. I've observed the work of clinicians, now, for many years and sat in many discussions and debates and so forth. But here's the analogy I'd love to give you.
My assessment is that the health care industry in this country today looks an awful lot like the hotel business did in the late '60s. And what I mean by that is essentially there were no national brands. One size fit all. We had a very similar approach to delivery of service.
As the industry matured, some remarkable things happened. We began to see brand distinction, differentiation. We began to see customer segmentation, different customers for different events, paying different amounts.
That's precisely where the health care industry is going to go. And, as a result of that-- and it's forced by some of the issues that you've just articulated, which I agree with. But, as a result of that, that's, to me, the wisdom of connecting hospitality with health care. Because you put the two of those together, and you say, well, how do you compete in that environment?
There are going to be customers that want that Ritz-Carlton-style health care experience. There are going to be customers that want the Super 8-quality health care experience. That's a reality. So what we have to do is we think about the maturation of this industry, is to say, well, where does that fit with the whole idea of the integration of hospitality and health care?
MELISSA CERIALE: Well, I might have a little bit of pushback on that, in that I don't know too many people who would say-- only maybe it's just your use of words-- who would want the Ritz-Carlton experience and who would want the Super 8 experience. Everybody wants the Ritz-Carlton, but the ability to pay automatically filters out. And when you're in a highly stressful medical situation, it's even more terrifying.
PETER YESAWICH: Yeah. And I agree with you. And this is the other aberration, I think, in this business, that the consumer is not the purchaser, if you think about that. So the person who purchases the health care services is typically not the consumer. It's the payer, right? --who's the purchaser.
MELISSA CERIALE: Correct.
PETER YESAWICH: OK, and that's obviously going through a whole transformation, too. But anyway, just think about that, quietly, because I think it takes you to some interesting places, in terms of the importance of the principles of hospitality. Right?
MELISSA CERIALE: I see Phil, down here--
PHIL OZUAH: No, no, I think that you've highlighted a very important dimension, here, Peter, which is that every patient that comes through Montefiore into the inpatient setting desires a private room. Almost none of their health plans pays for a private room. And the patients often are not willing to pay out of pocket for a private room.
So, you get dinged on privacy. You get dinged on noise, because somebody else is being cared for. There's a monitor in the room, so I can't always sleep at night, you know, quietly, and so on.
And that's the challenge, I think. If we had a system where patients actually knew what things cost-- you know, like, patients come in and say, I want an MRI. I have a headache. I'd like an MRI. And they maybe pay $20 towards the MRI.
But, as was pointed out, somebody else is paying the cost. And the person who's paying the cost-- employers, mostly, and the government-- are all saying, we can't afford this anymore. And they're dialing down, aggressively, how much they pay.
And so that's the challenge. If it was a completely free market, where-- you know, when I go into in a Radisson residence home, I don't expect five people waiting on me every minute that I go, nor do I pay for that. When I'm at the Ritz, it's a different experience. And you spend-- and that's exactly right, Peter.
ANDRIA CASTELLANOS: Yeah. I think that the other challenge we have in health care that probably the hospitality industry doesn't have so much of is the regulatory environment that we live under. And so, in my hospital, we have regulators in our hospital every single day. Every single day. I know you do, too. Because our hospitals are located less than 20 miles away from each other. So we know each other's service area. We're very similar in that way.
And so, from a regulatory perspective, up until about 15 years ago New York State did not allow hospitals to build private rooms-- did not allow it! So we all, in New York City-- because space is the final frontier, right? --we all have hospitals with double rooms. And then there's some single rooms. There's a few in every unit, just sprinkled around.
And then, the regulators said, oh, wait a second. This is really bad for infections. So now, if you build a new hospital in New York, you have to build single rooms-- have to build single rooms! You can't build double rooms.
So all of us are stuck with double rooms. Yet we get rated by the government on noise and privacy and all of those things, which are virtually impossible for us to compete against. You probably have all private rooms, right? --in your cancer centers? Right.
[LAUGHS] So, we're so different, that it's almost impossible to compare us, in many, many ways. So, the regulatory environment is brutal, particularly in New York state. It's brutal. So, that's all I'll say about that.
MELISSA CERIALE: Yes, sir!
PETER YESAWICH: And I understand, and I agree with that. And I think that really underscores when I was trying to express, and that is that, if you take the view that kind of one size fits all, in terms of delivery, it takes you to that place. But if you pause that say, well, wait a minute. Maybe there are different groups of patients, defined by whether it's disease type, it's insurance type, whatever it may be, where you have different clusters who are seeking different things, it takes you to a different way of thinking.
And that's exactly what the hotel business did. Right? And all I'm suggesting is that, if you think about that, it will take you to a place that I think is really quite imaginative, in terms of understanding how to stay in front of the patients and offer them things that they would find compelling, at the same time integrate this concept of hospitality. So that's all-- I think we're in violent agreement. I think--
PETER YESAWICH: --it's just a question of how you size, really, the market.
ANDRIA CASTELLANOS: Yeah. I think the other challenge-- and we've all done this-- we've set up centers of excellence, where we could manage smaller groups of patients that are similar and apply some concierge medicine to those patients. And we've done that in clusters.
So, for example, we have spine patients who come to us for spine surgery, or cardiac patients who come for percutaneous valves or open-heart procedures or neural patients. But the majority of our patients are general internal medicine. Over 50% of our patients are general internal medicine. They're the patients that are out in the community that come into our ER that are sick. And those are the patients we-- and the experience we struggle with, I think. That's--
PHIL OZUAH: Right. And I agree. I think that, if the market evolves to the scenario that's being talked about, here, it would make it a lot easier to achieve these goals. Now, we still go after it. And I'll tell you something, in a minute, about the importance of research.
But may I just ask, how many people in the audience now have a company, a school, somebody else, funding your attendance here, today? How many-- can I see hands? And so, most people. And so a few are paying out of pocket.
But imagine, though-- this is the scenario that we face. You know, whoever is paying and funding your stay here has said, I'm not paying for a private room for you at the Statler Hotel.
ANDRIA CASTELLANOS: Have to share. Have to share a room.
PHIL OZUAH: Yes. And so, when you checked when, you were assigned to a double room, and you didn't pick your roommate. So, yeah. So we assign somebody else into that room, who's going to come and go as they please, maybe playing music at 2:00 AM or have an alarm beeping.
Well, that's the experience, when you're coming to a hospital with double rooms. You're walking into a room with a complete stranger, different-- sort of moaning and groaning, and you're supposed to have a good experience.
Now, the research, though, has been extremely helpful to us. Because part of the cost of training that I mentioned earlier is that we are constantly experimenting. So people come in and say, why don't you do it this way? If you do this, this will really be helpful.
Incidentally, as I found out in Atlanta, the Ritz-Carlton, the Mandarin Orientals, they spend a ton of money training their people. What we don't know is, of all the 67 components of the training, which ones work the most? Because they haven't necessarily studied it in that way so that we can just take out the six that work.
I'll give you one example. So, we have a children's hospital that's consistently ranked in the top 1% to 5% in the country, in terms of patient experience. One is, it has a lot of private rooms, because it was built as a newer hospital. But also we were rated very lowly on time that clinicians spent with patients-- in particular, doctors.
Now, our Residency Training director at the time, Dr. [INAUDIBLE], found a study that showed that, if a doctor stood in the doorway for five minutes and spoke with a patient, and another doctor pulled up a chair and sat down for five minutes, at eye level with the patient, that the patients estimated that time spent with them as much longer, with the person who sat down than the one who was standing in the doorway. I went out and bought chairs, little chairs, for doctors to sit down at eye level with little kids, and insisted that everybody do that.
And our scores went through the roof. Now, that's because there was science that drove us, in that way. But, for most of the rest of the things that we do, we don't have that level of empiricism and that kind of rigor.
So, we've brought in Disney to our place. We've brought in the Ritz-Carlton. They all have-- we've brought in, you know, the [INAUDIBLE] restaurant group. They all come in, with a whole package and menu, and a big price tag, [LAUGHS] and to say, well, here's how we do it. We're going to take your team and put them through this yearlong, 18-month-long process [INAUDIBLE].
So, the more that science and empiricism emerges from a group like this, the easier it will be for us to take elements of those and try to translate them-- at lower cost.
ANDRIA CASTELLANOS: Yeah, Phil, I think you're right. I think this is, again, where the hospitality industry, through research, can help health care. So we think we know certain clues about what makes the experience really good for a patient and family. And one of the big buzzwords now is "empathy." Right? Empathy is big.
Can you teach empathy? I don't know. None of us have figured out whether you can actually teach somebody, or 26,000 bodies, to be particularly empathetic. Right?
So, the other thing that plays a crucial role for us-- patients tell us this, but we're not sure whether this links to their experience-- is the clergy. Right? The rabbis, and the priests, and the clergy that are there during the most sensitive moments of patients' lives. And so all of us, all of us have rabbis and priests and clergy. And we have every-- in New York, we have every kind, every type, you name it.
It didn't really seem to make a big impact. And the thing that is challenging for us is, it almost seems like, no matter what we do, no matter how much resources-- the Disney, the Ritz-- we have Disney, we have Ritz, also-- we're not moving the mark in the way we would like to.
MELISSA CERIALE: Or in the way that we need to--
PETER YESAWICH: Or the way we need to.
MELISSA CERIALE: --based on the new government challen-- or-- yeah-- restrictions that they've given us. Yes, Peter.
PETER YESAWICH: Let me offer a thought that might be helpful. I personally have been amazed at the lack of insight that exists generally in health care, in terms of understanding what patients really want. And that's unique to, obviously, their disease type and their age and so forth.
But one of the things that we've done that has proven to be incredibly helpful is, we invest in understanding what patients' expectations are. And that's a different idea than asking them what they want. And let me just explain the difference.
If I said to you, you know, rank these 10 things in terms of their importance to you, when you seek care for orthopedics or something, you'll do that, and I'll get the answer and say, well, that's great. We got an insight. We can move from there.
Here's the different way of doing it. I ask you what expectations you have, along a number of variables. And then I ask you about your experience. So what I do is I calculate the difference between the expectation and the experience, and I look at the gap. And then what I do is I rank the gaps and I say, well, can we affect this one?
And what happens is, it takes you to a really interesting place. I'll give you an example in cancer care. Every year, we poll about 1,000-- not our patients, but 1,000 cancer patients, a very meticulously designed survey. And we look at 29 predictors of satisfaction. We look at expectations and experiences.
The number one thing, the gap, that we've discovered, you might think it's, well, the availability of advanced genomic testing or immunotherapy or spiritual support-- whatever. The number one thing is the lack of the coordination of care. And that is, people don't know where to go, where to show up for an appointment, how am I going to get here, how do I get my medical records-- that kind of thing.
We said, wow! We never knew that! So, all of a sudden, you can focus on that and say, wow, what can we do to coordinate care? And we do that. And then make that a focus.
And what that does is that really allows you to put the spotlight on some things that will hopefully really improve the patient experience. It's a different way of thinking about it, that's all.
ANDRIA CASTELLANOS: Yeah. No, care coordination is certainly, I think, something that we're all trying to do. And, in many respects, again, this is something that the hospitality industry does really well. The concierge, making sure that the customer knows where things are, where they're supposed to be, where their next move is, what's going on.
There's a price tag to that. There is a price tag to that. And I could probably have 300 care coordinat-- even more-- in my hospital, and it probably wouldn't be enough. And so, again, it's weighing what you can invest, in terms of, it does cost money, and what's the benefit.
I think there's great benefit to care coordination. And I agree with you on that.
PHIL OZUAH: And I think that the method that's being described is absolutely the right one. I mean, in terms of-- by Peter, in terms of combining quantitative and qualitative surveys, if you will, of clients' expectations, as well as what the gap is between expectation and experience. And we have done this in small pockets, not in an entire system.
And we've had remarkable success. One of our smaller hospitals has a very high satisfaction rate for nurse responses. And that's because they spend a lot of time working with patients and understanding what it was that patients needed.
And so now, rather than understanding that when a patient rings a call button, saying, I need to use the bathroom, patient who needs assistance that they expect somebody to appear right away, and not understand that the nurse could very well be with another patient, and it may take him or her 10 minutes to get out and get there.
And so the way that they've overcome that is they round every 40 minutes, with patients, and come in-- before the call button is rung and say, do you need to go to the bathroom? Because sometimes people don't experience the urge to go, if you're on morphine and other medicines, until the bladder is really full. Not to get too physiologic. But, for most of us, that first urge is at about 50% full, which gives you a warning and then at, you know, 75% to 85%.
Now, for some patients, it could be close to 100%, which means there's an accident if you don't go right away. And that then ruins the entire--
ANDRIA CASTELLANOS: Experience.
PHIL OZUAH: --experience for everything. It doesn't matter what else happened during that stay.
Now, for a larger system, though, eliciting those kind of empirical data ourselves-- not to keep harping on it-- is fairly expensive. Just with 7 million patient encounters a year, we spend millions of dollars on our own surveys, not the government's surveys. And you get a 15% response rate, [INAUDIBLE] percentage rate, which means you have to do several, bigger.
And that may not be representative at all of everybody's experience. It could very well be a sliver, which we worry about, of their happiest patients respond and then the most unhappy patients who are motivated to respond, and you don't get a picture. So, to do waves and waves of these things requires some investment of resources, and so on, which we constantly try to do.
MELISSA CERIALE: I'd really like to suggest that all this great survey and empirical data that you've found and are working on is shared with the other end of the panel, at some point.
PETER YESAWICH: I'm happy to do it. Yeah. Happy to do it.
MELISSA CERIALE: It sounds like it would be very valuable information for a segment of the industry that doesn't have the resources or ability to do so. So we have a lot of major challenges. As I'm sitting here, listening to this, sounds to me like the School of Hospitality administration, and this institute, and the work we're doing, needs to be incorporated right into some of the medical schools, like Cornell Weill and Einstein Medical-- wherever, across the country. Because we need to be training these employees with hospitality skills, right at the very beginning. As a suggestion.
So, is this an appropriate time to maybe open this up, to take some questions from the audience? Here we have, in the back row, please?
AUDIENCE: Yeah. I'm not sure if this is a question or a comment. But one thing that I heard all of you struggling a little bit with is the language. So, if the person [INAUDIBLE] or a patient-- and I know from talking [INAUDIBLE] research about the experience that most patients don't want to be called "customers." They don't want to think of themselves in a health care situation as a customer or a consumer. They want to be cared for. Perhaps a "client," or, in the case of the elder living, a "resident."
But it's something that we have to think about the patient experience, the customer experience, but we have to use different language, which can really be tough on the mind, how to deal with all of that at the same time.
ANDRIA CASTELLANOS: Yeah. You know, I think it's a great question. Up until, I'd say, probably 10 years ago, we never thought of patients as customers. But, as the government has asked us to start to think of our patients as customers-- and, quite frankly, as other industries have advised us-- we've started to sort of interchange the word "customer" and "patient." And I think you're right. Patients want to be patients.
But, on the other hand, they have very high expectations that resemble the kind of "customer" experience. So, I think it's a great point. And how we refer to our patients-- I mostly use "patients." But I think it's been a shift, over the last 10 years.
PHIL OZUAH: Oh, yes, it has.
AUDIENCE: Perhaps it's also about shifting the mindset of the patient to think of themselves as being empowered, too. So, you know, it could be a paradigm shift where they feel like, yes, I am a consumer, and I do have a say in my treatment. So it could be a big [INAUDIBLE]
PHIL OZUAH: Right. But I think--
PHIL OZUAH: Right. And I agree. Listen, does anybody here know who the CEO of Montefiore was 30 years ago? Good. Because--
--I'll tell you what he said to me, and what he would say, which was, you know, if a patient sometimes-- at that time, our food was terrible, at Montefiore. It's phenomenal now. We actually get the highest rating. But his attitude was, by the time that you're well enough to taste the food, you should be home.
But we get rated on the food, now. So--
MELISSA CERIALE: We have a question here. Yes.
AUDIENCE: I do have a question, and I just want to follow up with what you've said. Why do we call them "guest"? Well, the doctor, the nurses, the people who come in and take care of them. You know, anybody. Why don't we just call them "guests"? Like the Ritz-Carlton does. OK?
I'd feel much better being a guest than I would a patient, but I definitely don't like the word "customer." it doesn't-- you know, it doesn't appeal to me at all. I feel like I'm in a dime store and you're calling me a "customer." It's-- that's from a hotel.
MELISSA CERIALE: Yes, sir.
AUDIENCE: Well, coming from a hospitality side, the way the hospitality industry is, [INAUDIBLE] things that we try to do is, through process and technology. Peter almost went there with relative care. The growth industry in hospitality right now is what's called select service. And this is taking a business model that operates with fewer people and more process, more technology. That's spawned from the large hospitals that you're talking about, being to manage people and then the process.
So it's a matter of just-- if you're not hiring nurses to be diplomats, you're hiring them to save lives, but there's a layer of process and a layer of technology that makes a mediocre employee look great. And that's what the hospitality industry people are doing. Also, by the way, [INAUDIBLE] 11 pillars of service [INAUDIBLE] their employees.
MELISSA CERIALE: But a little bit of that shift is happening in the health care landscape, as well, where we're moving away from inpatient service to an ambulatory model.
PHIL OZUAH: If I may just respond, that health care is being pushed in the opposite direction, which is that-- and it's not just my opinion. If you look at Moody's assessment, Standard and Poor, it's virtually impossible for small-, medium-sized hospitals to survive anymore. You don't have the leverage with purchasing. You pay the most for the same thing that other people pay the least for, and the payers pay you the least, because they can afford to pay you the least.
You can't pay Andria's hospital the least, because you couldn't get patients to sign up with a health plan in New York City, if you say Presbyterian Columbia is completely excluded, and all of their network. So the economic pressures, when you have consolidation of health plans-- which there are very few left, believe it or not, they're buying each other and applying tremendous pressures on the health care system-- the systems are being pushed in a direction to have scale and economies of scale and leverage and muscle that's going away from more intimate, in a small setting, a larger and larger system that I think, in the end, suddenly all the experts and economists out there are saying that they're going to end up with very large hospital systems, because of the pressures. And I think there were other things.
ANDRIA CASTELLANOS: You know, just one comment. I really like what you said about using technology to make a mediocre employee a great employee. And the one thing that many hospitals don't do well, we have very clunky technology-- very, very clunky technology. There are reasons for it. There are historical reasons.
If you wanted to replace the IT system in my hospital, overall 100%, it's $1 billion. $1 billion-- with a B. But I do think that there are technologies that can be overlaid, that we could take from the hospitality industry and overlay. We do things like-- I know you do this much better than us, at Cancer Center-- but things like linen, [LAUGHS] things like--
When one of our patients, our guests, requires an extra pillow, it's a monumental task to get-- I still haven't figured it out. But it's a monumental task to get a patient a pillow and a blanket and a sheet, sometimes. Or it feels that way, when that patient doesn't get it.
So I do think there are technologies that are out there that we could apply in the hospital industry that could benefit us.
MELISSA CERIALE: Let me say one thing, here. What's interesting to me, when we talk about bringing hospitality into health care, it's really easy for-- well, I think the fallback is to say, well, we need to have concierge-level service. And there are so many challenges within the medical industry. I look at some hospitals that have a concierge level. And so the patient comes in, and they pay more out of pocket for that, and they think that they're getting great medical care.
But you look at it-- that patient is there for a very specific reason. And now they're shuffled off to a separate floor, where the specialists that they need to be taking care of them are not on that floor. So it's a very complicated and difficult scenario.
ANDRIA CASTELLANOS: I mean, that's a great point. We have a beautiful concierge unit at our hospital-- two of them-- one on our uptown campus, one on our downtown campus. And people always want to be there, and they're willing to pay.
And they'll ask me, well, I want to go to this unit. And I say, go where your doctor tells you to go. Because you might be too sick to get the right care on that unit. You just might be too sick, and we want you where all your specialists are. And it may not be that high-end concierge unit.
PETER YESAWICH: Can I offer a comment?
MELISSA CERIALE: Yeah. We have a lot of questions out there, so, comments, short.
PETER YESAWICH: Yeah, just on the gentleman that made the comment, a moment ago, about the hospitality analogy. I think one of the other things that is occurring, across the stage, here, is the rate at which the delivery of care and the venue of delivery of care has changed. And that is, we've grown up traditionally with big-box hospitals.
And, for example, just in oncology care, roughly 80% of that is outpatient. And traditionally, patients have come to the hospital to get chemotherapy, for example. Half of the agents that are being developed, at this point, targeted drugs, at this point, are oral chemotherapies. So the idea is, you can take a pill at home. You don't necessarily have to travel to a hospital to do that.
That has forced thinking about alternative methods of the physical delivery of care. And that's what I think we need to think about. In your application, and I'm sure you've given some thought-- I've been kind of a student of this and fascinated by it-- there's the whole concept of the delivery of telemedicine. Right? And the idea that someone who would show up in one of your emergency rooms because they got a bad head cold or they have a bruise or a whatever, I mean, you could eliminate that visit, if you had a facility whereby you could immediately engage them through some kind of telemedicine facility. And, as you're probably aware, there's lots of investment capital going behind those services today.
So I would watch that very carefully. Because what I think is going to happen is this rapid transformation of the way we deliver care through the use of technology, which is going to reinvent the places that people have to go to get the care. And I think that's swirling around us, right now. And it's going to become increasingly clear, probably in the next couple of years, and will really alter the inpatient services that you provide. It certainly will for what we do.
MELISSA CERIALE: We have about five minutes left, so who's going to wave most dramatically? Yes, ma'am. There we go. Thank you.
AUDIENCE: A question I wanted to [INAUDIBLE] research that's out there. We did a study, last year, where we polled patients and said, do you think of yourself as a consumer buying services, or a patient needing services? Who [INAUDIBLE] said patients needing services. But, if you asked them the question, what's more important-- the experience, or just service-- they say experience. So that dichotomoy, we do have the principle.
ANDRIA CASTELLANOS: Yes. I mean, in our patient-satisfaction surveys, patients will tell us, the food isn't so good, and you didn't really-- my pain was pretty high, and-- you know, all these things-- and they had an extraordinary experience. And they would recommend us to all their friends. And so, it's validated for us, time and time and time again. But that's not--
You know, you have to balance it. You could save somebody's life, you could do a heart-and-lung transplant, and, if they had a bad parking experience, they're answering that survey--
--I'm serious, they're saying they had a bad experience. [LAUGHS]
PHIL OZUAH: That's true.
AUDIENCE: [INAUDIBLE] Because the point that was based on expectations and experience, I think, is very key. [INAUDIBLE] patients.
The other piece that I feel that we may lose an opportunity to talk about is mainly what has to happen in those [INAUDIBLE] care. And [INAUDIBLE] that conversation, because somehow, we've put ourselves in a position where we are taking from another industry. But the complexity of health care is not something that [INAUDIBLE] very quickly. [INAUDIBLE] that are happening here [INAUDIBLE] are posing a huge problem for us.
So we do need the [INAUDIBLE]. But I also think that maybe the conversation is not hospitality [INAUDIBLE], but both of them moving together to a different place. Because it's not working [INAUDIBLE] patient satisfaction [INAUDIBLE]. And the patient doesn't know necessarily what they want, because we're not asking the right questions, in the surveys.
PHIL OZUAH: Julia, I couldn't agree more. And somebody was asking me, last night, about how they might get into transferring hospitality into health care. And I said, well, why didn't you come down and we'll set up an experience for you. But when you're standing in one of these critically ill floors and see how this staff, what they're dealing with, and how they're moving, and that, when they run past you without saying hello or making eye contact, and you're with them, and you understand their justification for that, and why they do what they do, and the level of tension that's there, and their own anxiety and tension about making sure that nobody gets hurt and that the patient is safe, trying to figure out, though, how do you, in that context--
Which is not a vacation. It's not simply a guest at a resort. How do you, in that context, still bring the other elements in? And then-- and maybe hospitality can learn from health care-- but how do you deal with crisis, you know, when there's something--
AUDIENCE: [INAUDIBLE]. I think one of the patients, one of the survey respondents, or an interview respondent said, that here is the thing. The ability to make choices when I'm sick is very low. And my incentive to make choices when I'm healthy is very low. So health care has a very different--
MELISSA CERIALE: It's a big challenge.
AUDIENCE: It's a big challenge [INAUDIBLE].
MELISSA CERIALE: I know Rohit is about to cut me off, but I've got one gentleman back here who's been waving desperately. Yes, sir.
AUDIENCE: As we seem to be moving toward a national-wide health care insurance, and it may not be that far off at all, what's going to happen to the service of hospitality?
ANDRIA CASTELLANOS: Well, you're talking about a single payer. A single payer will absolutely diminish service in hospitals like mine, in major academic medical centers, like Phil and mine. Because our reimbursement will be cut dramatically, from a single-payer system. I think it will devastate academic medicine.
PHIL OZUAH: Right. And, by the way, I think that we may move to a single payer, but not in the way that you think. And there may be two single payers. There's the government single payer, but there's also the privately insured single payer, that the companies are buying up each other and becoming bigger and bigger and bigger, and therefore having extreme power and monopoly to produce returns and dividends. And there are only so many ways that one can do that.
So, yes, we already, in many ways, deal with that, at Montefiore. Essentially we're 85% Medicare-Medicaid. Well, we already have a single payer, on the one hand, and the policies are not always aligned-- Medicare's expectations, and Medicaid's expectations. And, in many ways, we're dealing with one or two big payers now, on the commercial end. They may have different names-- Anthem, Cigna, some-- you know-- and corporately, they're one.
But all of this is being driven by the fact that we are 17% GDP, and it's unaffordable. And so something is going to have to give.
MELISSA CERIALE: Which shifts the landscape to why it's so important that we are changing the delivery of health care from having patients sick and in our hospitals and turning that to population health and keeping our population healthy and out of hospital situations. All right. You've got to wrap this up, Peter.
PETER YESAWICH: A final note of optimism for the gentlemen. I want to disabuse you of the notion that we will ever get to a single-payer system. And the reason for that is, I would ask every one of you in this audience-- because you are not reflective of the demography of this country. I realize we have a number of international guests. Would you accept that?
And I would tell you the answer is a resounding "No." So what happens, I think, is we focus far too much on the supply side, and we ignore the demand side. And when you look over the fence, and you realize that there are different patients, different customers who want different levels of care, and they're prepared to find ways to pay for it-- and employers, by the way-- I think it gives you a little bit of a sense of relief. I'm sure people disagree with me, but a little note of optimism for you, sir. So.
PHIL OZUAH: Can I just say that, walking in here, I had no idea that anybody would be interested in this panel. [LAUGHS]
So, I'm really surprised and quite gratified at this level of interest. Thank you all.
MELISSA CERIALE: Thank you to our panelists. Thank you for coming.
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Panelists discuss the incorporation of hospitality thinking in health care companies, Oct. 10, 2016 at the Cornell Symposium for Hospitality, Health, & Design.
Featuring: Melissa Ceriale P’15, ’16, ’18, Board of Trustees, Montefiore Medicine; Andria Castellanos, Group Senior Vice President and Chief Operating Officer, NYP/Columbia New York Presbyterian; Robert Ritz MHA ’87, President, Mercy Medical Center; and Peter Yesawich SHA ’72, MS ’74, PhD ’76, Chief Growth Officer, Cancer Treatment Centers of America.