HFMA VIEWS

Scott MacStravic, Ph.D.

I recently read another of the countless, invariably laudatory articles about Herb Kelleher, founder of Southwest Airlines. [K. Sutherland “Plane Smart!” Cincom Expert Access Apr 11, 2006] It described the corporate culture he created and the ways it has played out in customer service and company success.

Lots of elements of his strategy and culture are perhaps not wholly applicable to health care and hospitals. His principle and practice of “hiring for attitude, everything else can be trained” is only partially adoptable in health care, where professional training and credentials are the sine qua non in most hiring decisions. But this principle is not wholly applicable to airlines, either, since pilots, at least, must be highly trained as well as licensed. And attitude is clearly a major element in serving “customers,” along with training in treating patients.

Other elements are directly adoptable:

• “dedication to the highest quality customer service delivered with a sense of warmth, friendliness, individual pride and company spirit” (Southwest’s mission)
• “focus on the intangibles (meaning the joie de vivre, spirit of employees), because anyone can buy the tangibles”
• Proving dedication to customers – such as when Southwest started in the 1970s, serving only cities in Texas, and realized that passengers in Houston were driving 45 minutes each way to Houston International Airport to take a 40-minute ride – so it moved to downtown Hobby Airport to save them that time

Southwest’s dedication to its employees is equally strong – it clearly and consistently recognizes its employees as individual human beings, not just workers. Every employee who becomes a parent gets a letter from the corporate office. So does every one who has a death in the family. Anyone out sick for a length of time gets regular contacts asking how they’re coming along.

And Southwest’s customer service notoriously extends to both non-customers and well past when passengers get on or off the plane. Southwest flew into New York City, for example, where it has no routes, just to remind people there that there is another option besides JetBlue. It celebrates examples such as the employee who helped a non-passenger fix a flat tire in the parking garage, and another who drove employees from an airport hotel in his own car when the hotel van broke down to be sure they made their morning flight, then came back and drove the employees of a rival airline as well.

But perhaps the principle and motto most clearly transferable to health care is Southwest’s “Herbocratic Oath,” which reads the reverse of the Hippocratic Oath that has so long served the medical profession. Herb calls for all to “First, do Good!” rather then primum non nocere – first, do no harm.

Hospitals and physicians have always been, and are particularly now focused on reducing medical errors, ensuring patient safety, i.e. doing less harm than the estimated 100,000 or so patients being killed each year, and countless others with nosocomial infections, medication errors and other harm short of death. All such efforts are essential, to reduce malpractice insurance costs, bad PR, and patient dissatisfaction, as well as fulfill the do no harm oath.

But the essential mission of hospitals and physicians is to first do good. And they do so much good, not just in annual “community benefit” expenditures that have failed to persuade communities that there is any significant difference between for-profit and not-for-profit institutions. They have enormous positive impacts on the lives of individual patients and their families.

I recently had an article I wrote edited for publication, with the editor sending it to me for review, with repeated questions about what I meant when I cited the “health and life quality impacts” that health care providers deliver. If an editor of a health care publication isn’t sure what I meant, can the American public be more familiar with the concept?

In general, providers, especially physicians, have been loath to accept accountability for the good that they do. One justified this reluctance as follows: “…you can hold a physician accountable for doing the right thing, but you can’t really hold him (sic) accountable for whether it works or not. That’s really in God’s purview.” [A. Robeznieks “Tennesee Doctors to Get Paid for ‘Doing the Right Thing'” American Medical News Feb 2, 2004]

Hospitals and physicians tend to be measured by outsiders based on how little harm they do – how low their mortality, complication and infection rates are, for example. They rarely even know what the total positive impact, the total “good” they have done for patients, simply because they don’t follow up to find out how they’ve done months or more after discharge. Instead, they get their patient satisfaction surveys done as soon as possible, before patients get the bill.

Why don’t hospitals and physician practices identify and celebrate their successes, along with minimizing their failures? Why don’t they report on the employees who have gone out of their way to serve patients, even after discharge, for example? Why don’t they remind employees of the patients whose lives have been dramatically improved or restored by services each had a role in delivering? Why don’t they remind patients, themselves, by asking about them, and offering them opportunities to contribute case examples, testimonials, or serve as “references” to other patient prospects?

If providers spend too much time on doing no harm, they will have something to be proud of as they reduce the harm they do and remind patients, employees and the public of that fact. But how much more impact can they have if they spend roughly equal effort focusing on the good that they do, and reminding everyone in sight of that fact? Otherwise, their reports of doing less harm merely reminds people that they are still doing some harm, and omit mentioning how much good they are doing all the while.