Cleveland Clinic's Servant Leadership Journey: Elevating Patient Experience

Case Study Analysis - Implementing Servant Leadership at Cleveland Clinic: A Case Study in Organizational Change by Joseph M. Patrnchak, Former Chief Human Resources Officer, Cleveland Clinic Board Member, Greenleaf Center for Servant Leadership

Introduction

According to Patrnchak (2015) case study, Cleveland Clinic, a globally renowned healthcare institution, embarked on a transformative journey aimed at achieving two closely linked objectives: significantly enhancing employee engagement and elevating the overall patient experience. This endeavor marked a pivotal moment in the Clinic's history, one that required innovative strategies and visionary leadership. At the heart of this transformation was the deliberate integration of the servant leadership concept into the Clinic's cultural framework, igniting a profound shift in the organization's ethos. Complementing this cultural evolution, the Clinic introduced an array of enterprise-wide initiatives, all firmly grounded in the idea that "We are all caregivers" (Patrnchak, 2015, p. 8). These initiatives encompassed caregiver wellness and recognition programs, fostering a sense of unity and shared purpose among the Clinic's diverse staff.

The outcome of this remarkable journey has been nothing short of extraordinary. Cleveland Clinic witnessed substantial improvements in both employee engagement, as per Gallup Q12 survey (Patrnchak, 2015, p. 11), and patient satisfaction, as assessed through the federal Hospital Consumer Assessment of Healthcare Providers Systems (HCAHPS) survey (Patrnchak, 2015, p. 11). This essay delves into the remarkable narrative of Cleveland Clinic's transformation, shedding light on the pivotal role of servant leadership and the interconnected elements that have led to such remarkable progress.

Key Issues identified and their contributing factors

In 2008, Cleveland Clinic embarked on a significant transformation journey with myriad challenges. At the heart of their struggle was a gaping disparity between their exceptional clinical excellence and the quality of the patient experience. In the words of the CEO, Delos Cosgrove, “Patients were coming to us for the clinical excellence, but they did not like us very much” (Patrnchak, 2015, p. 2). Despite being renowned for medical innovations and cutting-edge technology, the organization was concurrently grappling with patient dissatisfaction. What compounded this issue was the knowledge that HCAHPS scores had a direct impact on their Medicare reimbursement levels (Patrnchak, 2015).

The genesis of this patient experience challenge lay in the clinic's longstanding focus on clinical excellence. Over time, the employees’ unwavering commitment to clinical outcomes unintentionally led to a situation where patient satisfaction became secondary. In 2008, HCAHPS survey brought the said predicament to the forefront, which, for the first time, publicly reported the clinic's scores and cast a glaring spotlight on their “Below average” performance (Patrnchak, 2015, p. 2).

Simultaneously, the clinic was grappling with a formidable challenge related to employee engagement which can be defined as: “...a heightened emotional and intellectual connection that an employee has for his/her job, organization, manager, or co-workers that, in turn, influences him/her to apply additional discretionary effort to his/her work” (Gibbons, 2006 as cited in Patrnchak, 2015, p. 3).

In 2008, Gallup Q12 survey revealed the employee engagement levels measured notably lower compared to other hospital systems. “In the 2008 survey, the Clinic’s ratio of engaged to actively disengaged employees was only 2.57:1—far from world class” (Patrnchak, 2015, p. 3). According to Gallup's research findings, there exists a positive correlation between increased engagement levels and a reduction in both malpractice claims and patient safety issues (Harter, Schmidt, Killham, & Agrawal, 2013 as cited in Patrnchak, 2015).

At the core of the said challenge was the clinic's traditional hierarchical leadership model. This age-old approach was characterized by a rigid command-and-control structure, sorely lacking the holistic perspective on leadership necessary for nurturing employee engagement (Patrnchak, 2015). The Gallup Q12 survey utilizes a 5-point rating scale, ranging from 0 (strongly disagree) to 5 (strongly agree), to assess employees' perceptions of their respective firms. The employees of the Clinic provided their lowest grade to the statement "I have a best friend at work" (Patrnchak, 2015, p. 5) in the year 2008. Gallup establishes a direct correlation between this measure and leadership style, as observed (Gallup, 2003)

As the clinic sought to address these challenges, servant leadership principles were introduced, a significant shift from their existing leadership model. However, this change was met with resistance from a workforce deeply entrenched in the hierarchical, command-and-control leadership approach that had defined the organization for years (Patrnchak, 2015).

The author also mentioned in the case study that this resistance to transformation was further compounded by engrained leadership styles and behaviors. The prevailing culture within the organization was one accustomed to a directive, top-down style of leadership. This made it incredibly challenging for both employees and leaders to readily adapt to new, more collaborative approaches. The imperative lay not only in understanding the concept of servant leadership but in the profound transformation of how leaders operated within the organization (Patrnchak, 2015)

Further, adding to the complexity was the dominance of physicians in leadership roles and the deeply ingrained organizational hierarchy. The case study quoted one of the surgeons’ comments: “Hey, in my OR (Operation Room), I’m in charge. Period. That’s the way it has to be, and that’s the way it is. And now you expect me to also be a servant leader? Come on” (Patrnchak, 2015, p. 6). Physicians, in their high-pressure roles, were skeptical of a leadership model that emphasized service to others. This skepticism created a cultural tension within the organization, requiring strategic approaches to bridge the gap and facilitate a shift towards a more service-oriented leadership paradigm. (Chambers et al., 2018).

Amid these challenges, Cleveland Clinic also came to recognize the intricate interconnections between employee engagement and patient satisfaction. They realized that neglecting either element had cascading effects on overall service quality. Therefore, their challenge was not merely the introduction of servant leadership principles but also the alignment of various strategies and initiatives to ensure they had a positive impact on both patients and caregivers (Chambers et al., 2018).

In summary, central issues such as the patient experience gap, employee engagement challenges, leadership model transformation, the need for a cultural shift, and the imperative to enhance both patient satisfaction and employee engagement, which were at the core of Cleveland Clinic's transformational journey. Addressing this multifaceted tapestry of challenges was not only essential for the organization's success but also its unwavering commitment to providing high-quality healthcare.

Options and paths available to the decision-maker, Dr. Cosgrove.

Cosgrove, at a pivotal moment in Cleveland Clinic's journey, was confronted with a profound challenge. The organization faced a substantial discrepancy between its clinical excellence and the quality of the patient experience. HCAHPS scores had laid bare this uncomfortable truth. The status quo was no longer an option, and Cosgrove knew change was imperative. If the CEO could have taken this path to maintain the status quo, this would have meant continuing with the existing leadership model and organizational culture. This approach might have seemed like the path of least resistance, but fraught with risk. The gap between clinical excellence and patient satisfaction would only widen, impacting the organization's reputation and finances. Cosgrove wisely didn't choose this option.

Another option on the table was full-scale implementation of servant leadership principles. This way could had been a tempting proposition but carried significant risks. Despite of initial rejections from Physicians as Cosgrove predicted, such a radical transformation might have triggered resistance and organizational turbulence. This step could have shaken the very foundations of the institution (Patrnchak, 2015).

Similarly, Cosgrove could have focused exclusively on improving the patient experience, potentially at the cost of clinical outcomes. However, as Gallup mentioned that the two were intricately connected (Gallup, 2003). Neglecting clinical excellence in pursuit of patient satisfaction was not a viable strategy. The CEO of Cleveland’s Clinic grasped the importance of addressing both elements in tandem, ensuring that one complemented the other (Patrnchak, 2015)

Instead, while leadership transformation was central to the change, through HCAHPS results Cosgrove understood that the shift could not end there, and wisely did not limit the transformation to the leadership cadre. Rather, recognizing the need for a broader cultural shift was intelligence. The change strategy was not only about how leaders behaved; rather about how the entire organization functioned. Fostering a culture of engagement was fundamental to long-term success (Patrnchak, 2015).

In the above view, the Cleveland clinic adopted Serving Leadership with the help of Third Rivers Partners and Ken Jennings with new ideas and language. For example, Jennings suggested speaks not of “servant” leadership, but “serving” leadership (Patrnchak, 2015, p. 6). Key elements included competencies for different leadership levels, training, advisors, resources, metrics, and a community of practice. Implementation began with coaching the executive team and expanded to include various leadership tiers (Jennings & Stahl-Wert, 2003).

Moreover, The Cleveland Clinic has initiated a series of crucial programs since 2009, with the goal of instilling serving leader principles throughout its culture and equipping leaders at all levels with essential skills. One standout program is Executive Rounding, which involves top leaders visiting different units to appreciate caregivers and deeply engage with their concerns, ultimately aimed at enhancing employee engagement and patient satisfaction. In 2008, a significant cultural shift occurred with the introduction of "We Are All Caregivers" (Patrnchak, 2015, p. 8), emphasizing that every Clinic employee, regardless of their role, contributes to patient well-being. This notion faced initial resistance but was gradually embraced, aided by the endorsement of clinical leaders. The term “employee" was replaced with "caregiver" in various materials, from the website to identification badges, reinforcing this idea. These initiatives work in tandem to create a supportive and engaging culture, contributing to a positive patient experience. Cosgrove did not narrowly focus on one aspect; but embraced a holistic vision. The Clinic established a HEART program where all staff and non-clinical staff came together to learn how to respond to each other and the patients by Hearing, Empathising, Apologizing, Respecting and Responding and saying Thank you when a kind gesture was done (Patrnchak, 2015).

In the end, Cosgrove's strategic choice was clear. The CEO of Cleveland’s Clinic did not adhere to the status quo or rush into radical transformation. Additionally, there was no negligence on the critical interplay between clinical excellence and patient experience. Neither the approach was not limited to the change in leadership alone nor focused on isolated initiatives. Instead, Cosgrove embraced the incremental change, allowing the organization to adapt gradually, fostered a culture of engagement and servant leadership that touched every aspect of Cleveland Clinic. Cosgrove's decision was founded on a deep understanding of the profound interconnectedness between leadership, culture, and the patient experience.? This was a journey of purpose and vision, steering the organization toward a future marked by excellence and compassion.

Recommendation for the Leader's Way Forward

To reinforce its commitment to servant leadership and drive continuous improvement, Cleveland Clinic can consider a series of additional recommendations. These suggestions aim to build upon the existing servant leadership foundation and address other specific areas of development within the organization.

First, implementing robust patient and caregiver feedback loops is essential. By actively seeking feedback from both patients and caregivers, the clinic can gain valuable insights into the patient experience and employee engagement. These feedback mechanisms create a culture of openness and responsiveness, a fundamental aspect of servant leadership. Listening to the voices of patients and employees aligns with Northouse's (2021) principle of valuing diverse perspectives. Relying on such feedback can guide the Clinic's continuous improvement efforts and help ensure that their services meet the needs of all stakeholders.

Second, Cleveland Clinic can introduce leadership assessment and internal feedback systems. These systems involve the regular evaluation of leaders by their team members, peers, and supervisors. This 360-degree feedback approach not only provides leaders with valuable insights into their strengths and areas for growth but also encourages a culture of accountability and personal development. This approach exemplifies the servant leadership principle of personal and professional growth, as outlined by Northouse (2021). By actively supporting leaders in their growth and development, the organization reinforces its commitment to servant leadership.

Furthermore, the clinic can establish mentorship programs that pair experienced leaders with emerging talent. These mentorship programs foster an environment of guidance and support, reflecting the servant leadership value of serving and helping others (Greenleaf, 1970). They provide emerging leaders with the opportunity to learn from the wisdom and experiences of their more seasoned counterparts. This helps to not only develop the skills and leadership capabilities of emerging leaders but also ensures that servant leadership values are passed down through the organization.

Alternatively, Cleveland Clinic should also consider integrating servant leadership principles into its values-based recruitment process. Actively seeking candidates who align with the values of servant leadership during the hiring process ensures that new hires are more likely to contribute to a culture of care and empathy from the very beginning. By aligning new employees with the organization's servant leadership values, Cleveland Clinic can strengthen its commitment to these principles and ensure that they are upheld at every level.

Next, developing specific servant leadership metrics is another critical step. To reinforce the organization's dedication to servant leadership, key performance indicators (KPIs) should be established that directly measure and report on servant leadership behaviors and principles. By tracking these metrics regularly, the clinic can transparently demonstrate its commitment to servant leadership, aligning actions with stated values.

Another way is fostering cross-departmental learning exchanges should be encouraged. These exchanges enable employees to spend time in different departments, gaining a broader perspective on the organization's functions. Such a practice promotes empathy, understanding, and collaboration among staff, which aligns with the recommendation for cross-functional collaboration (Reeves et al., 2015). By facilitating learning and collaboration across departments, the organization strengthens its servant leadership approach by encouraging employees to understand and support one another.

Undoubtedly, leadership rotation programs are yet another way to promote servant leadership within the organization. These programs provide leaders with the opportunity to experience different roles and responsibilities within the clinic. Such firsthand experiences can deepen their understanding of various functions and the challenges faced by their colleagues. They can develop a more profound sense of empathy and a willingness to serve, both fundamental aspects of servant leadership (Northouse, 2021).

Last, Cleveland Clinic should consider expanding its community engagement initiatives. These initiatives involve employees in outreach programs and partnerships with local organizations, extending the culture of care beyond the clinic's walls. By fostering such initiatives, the organization can have a positive impact on the broader community, aligning with its commitment to patient-centered care (Koh et al., 2020). In doing so, the organization not only serves its immediate community but also reinforces its servant leadership values by acting in the best interests of the community's well-being.

By incorporating these additional recommendations, Cleveland Clinic can create a comprehensive framework for advancing its servant leadership culture. Each recommendation aims to cultivate a culture of continuous learning, empathy, and service, thereby fostering employee engagement and patient satisfaction. Furthermore, these recommendations underscore the organization's unwavering commitment to exceptional healthcare through the principles of servant leadership.

Conclusion

In conclusion, the Cleveland Clinic case study serves as a powerful illustration of the transformative potential of servant leadership within a complex healthcare environment. It highlights the importance of balancing clinical excellence with the patient experience and the critical role of leadership in achieving this equilibrium. Cosgrove's approach characterized by gradual but deliberate change, cultural shift, and alignment with the organization's values, offers valuable lessons for leaders in any industry. As the Clinic continues its journey, it is poised to further enhance employee engagement and patient satisfaction, reaffirming its commitment to exceptional healthcare and continuous improvement. This case study is a testament to the enduring relevance of servant leadership and its potential to drive excellence and compassion within organizations. These recommendations collectively serve as a roadmap for Cleveland Clinic's ongoing pursuit of servant leadership, cultivating a culture of continuous learning, empathy, and engagement that elevates both employee satisfaction and the patient experience, further solidifying the Clinic's position as a beacon of excellence in healthcare.

References

Chambers, R., Jennings, K., & Stahl-Wert, J. (2018). Reframing servant leadership: Enhancing leadership through trust. Berrett-Koehler Publishers.

Gallup. Gallup (2003). Strengthening care through engagement. https://www.gallup.com/workplace/285674/improve-employee-engagement-workplace.aspx

Greenleaf, R. K. (1970). The Servant as leader. The Greenleaf Center for servant leadership. https://www.greenleaf.org/products-page/the-servant-as-leader/

Koh, H. K., Brach, C., Harris, L. M., & Parchman, M. L. (2020). A proposed 'health literate healthcare organization' framework. Health affairs, 29(2), 160-167. https://pubmed.ncbi.nlm.nih.gov/23381529/

Northouse, P. G. (2021). Leadership: Theory and practice - International Student Edition (9th ed.). SAGE Publications, Inc. (US). https://bookshelf.vitalsource.com/books/9781071856567

Patrnchak, J. (2015). Implementing servant leadership at Cleveland Clinic: A case study in organizational change https://csuepress.columbusstate.edu/cgi/viewcontent.cgi?article=1003&context=sltp

Reeves, M., Davis, M. A., & Oles, T. (2015). Cross-functional collaboration: In leading sustainable change (pp. 97-120). Routledge.