[Podcast] Improving the Patient Experience

Jim Merlino, Chief Transformation Officer, Press Ganey Associates

I am always excited to interview one of my favorite people and personal friends, Dr. Jim Merlino. I first met Dr. Merlino at the Cleveland Clinic Patient Experience Summit years ago. He’s an accomplished surgeon and industry leader in improving the patient experience. He draws from more than two decades of experience to address key issues like eliminating harm, enhancing quality, promoting cultural alignment and improving operational efficiencies.

Today Dr. Merlino is Chief Transformation Officer for Press Ganey, a data-driven, patient-focused company that supports health care providers in improving the entire patient experience. It’s his passion—and job—to transform the patient experience through the creation and delivery of individualized plans aimed at transformational and sustainable improvement.

We covered a lot of ground in our podcast, including some intriguing results in Press Ganey’s white paper, 2019 Strategic Insights: Accelerating Transformation.

“Improving the Patient Experience”

Dr. Merlino believes the emphasis on the patient experience is gaining momentum throughout health care. “Over the last ten years, the healthcare industry has evolved,” says Dr. Merlino, “It’s advanced from an idea that the patient experience is about happiness and satisfaction to an understanding that it’s much more transformative than that.”

Safety and the patient experience

Dr. Merlino shared, “In 2019, 4.8 million people in the United States will suffer a preventable safety error in healthcare and hundreds of thousands of them will die from it. This is a crisis and it’s unacceptable.”

Innovative leaders like Dr. Merlino are bringing statistics like these to the forefront and challenging other leaders in healthcare to do better. “We can’t have a great [patient] experience if we're hurting people,” continued Dr. Merlino.

Six core principles healthcare leaders should embrace

Dr. Merlino and his colleagues at Press Ganey have assembled a six-part framework for organizations dedicated to transforming the patient experience. The first three are strategic and the last three are focused on performance and execution:

1. 1. Commit to zero harm
      Merlino believes this is the first, and arguably most important, principle. “Without an emphasis on patient safety, your organization will be incapable of driving high performance. Industry leaders need to actively ensure patient safety is always top-of-mind.”
   2. Patient centricity
      “A focus on patients' interests has to be embedded in the work every day. Leaders have to be thinking about it and using it in their agendas. Everyone has to be executing on it.”
   3. Safety, quality and patient experience are interdependent
      This collaborative approach creates unique synergies because the things you do to improve patient experience improves safety and vice versa.
   4. Data and transparency
      “[Good data] helps clarify areas of improvement so leaders can be intentional with their planning and actions.” Being transparent with data is a well-known best practice and improves confidence with internal people as well as patients.” This holds true in business as well.
   5. Cultural and leadership development
      “Leaders must be the driving force in the patient experience everyday—and that includes frontline managers or assistant managers. Historically, healthcare has been transactional where it needs to be more strategic.”
   6. Execution and accountability
      “It’s not enough to just develop best practices for improving safety, quality and the patient experience; industry leaders and their staff must execute these principles every single day. Everyone needs to be held accountable and everyone needs to be engaged.”

   Prioritizing the patient experience

   As with anything that challenges our current way of thinking, people need to understand why it's important to change, what they need to change and how they need to change it—and it starts with the data. “You can’t argue with data and right now it’s saying we're not performing as well as we should be,” said Dr. Merlino.

   I think we can all agree that safety is important, quality is important and the patient experience is important. When we focus on these together, Dr. Merlino believes we will improve patient outcomes, safety ratings, performance and ranking overall.

   Complete transcript

   Stewart Gandolf:
   Hi again, everybody, Stewart Gandolf. Happy to have you listening today's podcast. Very excited to have a return guest. So, one of my absolute favorites of all time and a personal friend, Dr. Jim Merlino is returning and gracing us with his insights on our podcast. Today, the world of patient experience is really, really gaining momentum in just about every way and fashion throughout health care. I met Dr. Merlino at the Cleveland Clinic Patient Experience Summit years ago and he is now chief transformation officer for Press Ganey. Welcome Jim.

   Jim Merlino:
   Hi Stewart, great to be here again with you. Thank you for having me.

   Stewart Gandolf:
   I think it was what about eight years ago. The clinic as in its 10th year with the patient experience summit, so, I think I was there for the second one. Lots happened over the last eight or 10 years, right?

   Jim Merlino:
   The industry has really evolved a lot. Yes, it's been 10 years. It's hard to believe, but I do remember, we've been friends for a long time now, and the industry has really moved from where it was 10 years ago or even longer to, from this idea that, the experience is about happiness and satisfaction and smiling, to really recognizing that it's much more important than that. Not that thought's not important, but it really, I think, people understand today that the experience is really more about delivering faith, high-quality patient centered care and that, that's the patient promise, right? If we can't deliver that as healthcare organizations to people, we have no business then being in healthcare. So, I think it's evolved really nicely to be much more important than what it was in the past.

   Stewart Gandolf:
   Some of our listeners who've been with us for all the years and listened to all the podcasts we've done together, there's been points where I feel like we have fans, Jim. I've had somebody from Australia fly all the way through and she felt like she knew us both.

   Stewart Gandolf:
   For those of you that are new to the discussions I've had with Jim over the years, Jim and I talked a lot about exactly that. The thought that patient experience was really, just is the patient smiling at you. And I remember doctors would say very sarcastically, "I don't care if they like me, I just want to get them better." And Jim would, made the point even back then that, that's kind of missing the point. It's much deeper than that. And by the way, it is helpful to the patient, has some satisfaction, but it's much, much deeper. It's more transformative. And one of the things Jim, you just mentioned a moment ago was safety. And I'd like you just to kind of talk about that for a moment in the context of patient experience.

   Jim Merlino:
   It's fascinating that, even today in 2019, that there will be 4.8 million people in the United States that will suffer a preventable safety error in healthcare and for her in 40,000 of them will die from it. And that's striking. And people want to sit and debate about the numbers. But even if you take that four 40 and divide it in half, and say two 20, I mean, it's still too much. I mean, how, what number is acceptable? I hate talking about airline analogies, but we have several former naval aviators are who are consultants in our safety group. And they'll tell you that that is the equivalent of 10, 737 max airplanes crashing every single day in the United States. That's how many people die from safety events.

   Jim Merlino:
   And I think what we recognize today, or at least more and more across the industry are recognizing, that we've got to tackle that problem. And we don't, we haven't traditionally paid so much attention on it because it's not dramatic enough, right? It happens in the drip, drip fashion. But you sit back, you're more mindful about it. You recognize how much of a crisis it really is. And so this idea of, of how, I think innovative leaders are thinking about it today, is that you can't have a great experience if we're hurting people. And by the way, not just patients. Another striking statistic is that it's more dangerous to work in a hospital than it is to build it. And it's our people that are in danger as well and we've got to keep that front and center if we're going to be successful.

   Stewart Gandolf:
   The whole idea of patient experience through leadership of people like you, Jim, and others that are out there, where it's becoming, again from almost a nonissue to a lot of people, to front and center now in the hospital world. It's a big issue on the private practice side, but even pharmaceutical, I was just talking prior to this podcast, to one of the leading pharmaceuticals that has actually been on this program as well. So, even the pharmaceutical industry is really embracing patient experience.

   Stewart Gandolf:
   So, as we get into this today I want to talk about the white paper, in just a few moments, with some of the work you guys are doing at Press Ganey. You guys have about six principles that you think are key to any patient experience effort. And I think before we drill down into what's new, I think it'd be really helpful, because it's such a great place to start, your six transformational principles.

   Jim Merlino:
   Thank you for studying that, Stewart. You know, it's interesting when we work with systems, organizations across the United States. We really have the opportunity to learn from them and as a result of that, and our work and research on the data, what we've done is assembled, what we think is a very good framework for organizations to think about how to frame a strategy to connect these things together. And it consists of six elements as you said. Three of them are strategic, three of them deal with focusing operations.

   Jim Merlino:
   So, the first strategy is to really commit to zero harm. If you are not messaging to your workforce, if you're out messaging to the environment that you're, that you're not really thinking about safety and then you're, you're not going to be successful in driving high performance. You have to put that first because again, you can't have a great experience if you're hurting people.

   Jim Merlino:
   The second thing is that, this idea of patient centricity. Commit to a patient centered strategy and make it more than just a lapel pan. So, our focus on patients' interests, it can't be a sign on the wall, a model, a lapel pin. It's got to be embedded in what we do every day. Leaders have to be thinking about it, they have to be using it in their agendas. You have to be executing on it. So people feel it, they see it, they believe it.

   Jim Merlino:
   The third, is to really adopt and message this idea that safety, quality and patients intricity are one. And they're not separate. That you need all three. There are tactics and strategies that you can execute that touch all three. That when you focus that approach, in fact, you get synergies because the things you do for experience can improve safety and vice versa.

   Jim Merlino:
   So, think about them as all three, message them as all three. Create that narrative that you can really latch onto. So, those three strategic elements I think, start the work. And then there's three things to focus on from an execution standpoint. The first one is, data and transparency. We cannot get better, the old adage goes, "Unless we're measuring what we want to improve." And we have good data today. And we should be using that, wrapping that around our strategies. However, data alone is not your strategy. It's a supporting act of good data analytics support all of your strategies and all your tactics and you need to keep it focused. You need to use best practices like being transparent with your data, to both your internal people and also your customers, your consumers.

   Jim Merlino:
   Second, focus on cultural development and leadership development because at the end of the day, if we can't lever our leaders to be driving this force everyday, and that includes, frontline managers or assistant managers. If you have a position where you're leading people or you have a position where you're leading an initiative, you need to be driving this. You need to be consistent and you need to be levering the culture to be helping you to drive this to performance. That's very critical. I think, in healthcare particularly, we've been so focused on a transactional strategy towards HR, we need to be more strategic. Ask the question, who are we hiring, how are we onboarding them, how are we rewarding and recognizing them, how are we thinking about performance managing them, how are we measuring engagement to make sure that we understand the health of our culture?

   Jim Merlino:
   And then lastly, which should be the simplest one but sometimes I think, is the most difficult, is really honing execution and hold people accountable. So, we come up with a bunch of best practices to improve safety, to improve quality, to improve experience, and what we find when we work with organizations, and I think this is true everywhere, is that a lot of times people are talking about best practices, they're really not executing well. We have to think about how do you improve execution? How do you improve the reliability of those processes so that they're really achieving what you need them to do. And ultimately, how are you training your people to use them and holding them accountable for using them. So, it's not rocket science, but what those six principles do, if they give you a framework and how to think about and improve execution.

   Stewart Gandolf:
   The complexity of a hospital environment, or any caregiving, has so many different things. And I can see just coming back to these six principles as a litmus test, right? Whether or not you ever work with Press Ganey or ever worked with my firm, the idea of having, are we really committing to a goal of zero harm? Are we really putting patients at the center of planning delivery in a care? I think we've talked in the past, and maybe I may have talked about this at the first time I did the summit because it was right about that my mother fell and broke her hip and I remember her being lined up in the hallway with other patients to go to radiology and it was convenient for the hospital. Wasn't so great for the little lady shivering in the hallway. But, so that idea of putting the patient first, which is a concept you're familiar with at the Cleveland Clinic.

   Stewart Gandolf:
   But I think all of these things are, and I could see how it'd be easy to drift unintentionally. But I love those six principles. I just think they're great. So, a good word to you and your team for making, defining stuff that, it's not rocket science but it's a really, really important to kind of help guide thinking. And I read your white paper, the special report this year, and I was really excited about it. And obviously we'll have a link to that report on our blog posts readers access directly. The cliff note versions, I'd love you to describe why you thought this was important and timely--what conclusions you drew and maybe what's surprising. Take your time because I think it's really media and I think you've got some good points.

   Jim Merlino:
   First of all, just to comment on what you said, because I remember the story of your mother and you're right, we have traditionally built our processes and systems to be convenient to hospitals and ourselves. And there's a place for that but, but we really need to be thinking about in patient needs better. Because people that unfortunately have themselves, find themselves on the other side are as patients, haven't read the playbook and how we function. And it's shocking. And we need to do better. There's still a lot of work to do. This paper, and thanks for talking about this, this is actually, I'm really proud of it, this paper that the group put together. In Press Ganey we've done a lot to really try and understand deeper insights into what drives performance and this paper actually represents the third of a series of key papers that we've assembled with our research analytics team.

   Jim Merlino:
   The first paper really talked about our finding when we analyze Medicare's publicly reported safety, quality, and experienced data. And we looked at all of that data and it represents every hospital reporting to CMS, just over 4,000. And what we found is that when organizations achieve a top core tile performance and patient experience, which for that study was age caps, they're publicly reported safety and quality metrics are all better. And it was, it validated what we've always believed. What I believed, dating back to my days at the Cleveland clinic, that when you create a culture that delivers on experience, people feel it. They're safer, they're better. But actually, the year outcomes for patients are better too. And that's what the data shows. We took that data and we combined it with our engagement database for physicians, nurses, and other caregivers, which is the largest in the industry, and what we found is that in organizations that are in top core tile performance, this idea of the health of your culture of engagement, all three safety, quality and experience are better.

   Jim Merlino:
   So, those findings were just really exciting to us and we took it one step further and connected it with publicly reported financial data and CMS, all hospitals again, that report that CMS collects information on, and found that when safety quality experience are high-performing, net margins are better and patient spend per beneficiary is lower. Striking. Now, this was exciting for us, and we are data people as well as improvement people. So, it gets us excited. And while its administrative database, well we said, "Okay, let's take it to the next level." So, the second paper was really those transformational principles. How do we create a framework to help people improve? And then the third paper this year we said, "Okay, we know what's true at a global administrative data level.

   Jim Merlino:
   We know we have a framework, let's see if it works at a micro level." And what this paper does, it takes it to that level and it says CEOs and other hospital leaders, ask yourself these questions. Are you improving fast enough? Are you where you need to be? How are you driving your strategy? And when we started to validate how organizations are actually delivering on the work, we found something fascinating, which is that these relationships, while true at the administrative level, are also true with the unit based level. And what we found is actually when organizations take that engagement data, that health of their culture data, and they segment their leaders by performance. So, tier one, tier two, tier three. Tier one are highly engaged leaders, highly with, working with highly engaged teams. Two or three is less so. Tier one hospitals have better safety performance as measured by something most every hospital in the United States cares a lot about, which is leapfrog score.

   Jim Merlino:
   So, if you have more tier one leaders get better leapfrog scores. Likewise, what we found is again, taking it to the business unit level is, that when you have more tier one leaders in more groups, your star ratings are higher. So, better patient experience performance. So and the opposite is true if you're a tier three. So, this is very exciting, right? We said, "Okay, we've taken this into an administrative global perspective. We've created a foundation, a framework. Now we've demonstrated things that are, really meaningful hospitals that directly impact patient care." And, and that's what this paper talks about. And how do you take that information, how do you take that framework, and really think about what the title says, accelerating transformation. And we think that when you consider all of that together and you sit back and think about how your leaders function, when you converge leaders in different areas and you use this framework, you too can deliver better performance on what matters to patients.

   Stewart Gandolf:
   When I first became involved with some of the work you were doing at Cleveland clinic, and I remember asking you about how important it was at getting your CEO, Toby Cosgrove's input and that was absolutely vital, obviously, to transforming an organization as big and complex as Cleveland clinic, and that was, a different day. It's hard to look back on now. It's like, well of course there's patient experience, right? But one of the things that I thought was striking was that the CEO still remains very important at the hospitals you consult with, but the other leaders matter too. Would you like to expand upon that for a moment?

   Jim Merlino:
   Every leader counts. Every person counts. It's funny, when I first was given the role playing into the role by Toby, we get a follow up conversation after my interview and he goes, " You know you're going to be in charge of patient experience. You're going to fix this." And I chuckled and I thought, "Oh my God, why did I sign up for?" But I thought, being a colorectal surgeon, you, I don't mix comments right? You tend to, I tend to say, what's on my mind. It's how we function.

   Stewart Gandolf:
   You're not too shy.

   Jim Merlino:
   And there's nothing shy about colorectal surgery, Stewart.

   Jim Merlino:
   But I looked at Toby and literally I said to him, I said, "If we're going to fix this, we're going to do it together and it's going to require a lot more people than just the two of us." And Toby taught me a lot of things. One of the things that he really impressed upon a lot with, with me and as well as his team, was this idea of teams working together and you need everybody engaged in it. Because it's not something, you're talking about changing culture here. It's not something that one person can just execute on a process. But when you think about that team and you think about cultural transformation, and he talked about this a lot, it's the CEO or the president, it's the top person leaving the organization that drives that culture.

   Jim Merlino:
   And if they're not doing it, it's not to say that you can't improve, but you can't improve as fast as you need to or you won't get the highest performance that you want to get to or you need to get to. Because if the top guy is not talking about it, or the top woman is not talking about it, then people will say, "Oh, it's not their initiative." It's important but it's not important. And I had this litmus test, actually, I said it today in the talk I gave, I said, "Listen, you can walk around the hospital, you can ask anybody in front line, person, frontline manager, leader, true or false is patient experience strategic priority at X organization?" Everybody's going to say, of course, right? Nobody's against it.

   Jim Merlino:
   Nobody stands up and is against safety. But if you asked them the question differently and say, "You know what, can you name the top three priorities for the organization?" What have they taught you? Is patient experience one of them? In organizations where the CEO is leading it, people will say it's absolutely a priority. And that's the difference between having the top person leader versus not.

   Stewart Gandolf:
   One of my mentors of my career, from one of his mentors told me, it's as the CEO. It's like find one message, tell it to them, tell them that again, tell them again and again and again and again until you're so sick of it, you can't stand it and then tell them some more. And then eventually, one or two things people will remember. And that's really what it takes. It's the, it's like the, there's that skepticism in health care of, oh this is another flavor of the month, right? And this too shall pass. We just have to be patient.

   Jim Merlino:
   That's totally true.

   Stewart Gandolf:
   So-

   Jim Merlino:
   Well, we used to have the saying that people would hide under their desks waiting for it to pass over, right? Because it was just the flavor of the month. But if you really want to drive true change to true evolution, you've got to keep it front and center. My, our executive chairman, Pat Ryan, who was our CEO and now Joe Greskoviak is our present CEO, Pat moved up to executive chairman. He's been in healthcare his entire career. And one of the things he says, "You've got to focus", he says, "Where people fail in execution", excuse me, "Is when you have too many things going on and people can't stay focused on what's important." And he always challenges you. What are the three things? What are the three things you're working on? And if you get away from the three things, he pulls you right back. What are the three things and we can learn a lot from private industries and I think one of the things we can learn from them is focus and execution.

   Stewart Gandolf:
   So, that leads me actually to some of the things we talked about as some key things in the next steps. One of the things you mentioned, the importance of asking the right questions, key questions. Can you expand upon that a little bit for us?

   Jim Merlino:
   I think there's this movement in the industry. So, we improved in my previous organization because we had a suite of questions that provided deep insights into what was important for patients. And it really allowed us to determine what are the key drivers of meeting patient's needs. And they're different, in different environments, you need to know. And one of the trends today is that, people want to get away from asking too many questions, because I think like, survey fatigue. And it's ridiculous for two reasons. Number one, because people like to talk about their healthcare experience. They're more likely to answer a survey about healthcare than they are about, they're the new shoes they bought.

   Jim Merlino:
   The second thing is, you can't understand what's important for patients and their families if you don't ask the right questions. And so, net promoter is a great example. Net promoter is a great metric and it's important for certain indications. But you can't improve the experience. You can't improve safety. You can't drive quality. You can't drive the experiences patients have with net promoter score. Because it's like you walk into your hospital and you get a survey, it says, rate your hospital zero to 10, and you rate it and you get back to the NPS of eight or whatever we work it out to be. Well, that's great. They liked us, maybe, if we got a B. But what if they came back and your net promoter was four, why was it four? Could they not get the appointment they wanted? Did the physician not communicate clearly with them? Did they get bad medication instructions?

   Jim Merlino:
   You just don't know. So, you need to have deeper insights to be able to really understand what's important for patients. And by the way, those things like appointment when needed, if you need it right away, did your physician or your nurse or, communicate effectively with you, did you understand your medications? Those are important for the experience, but they're also important for safety. So, you need to know like what's happening in your environment.

   Jim Merlino:
   A funny story. So one of the big trends in the industry today, service industries today is the red green button. And you're starting to see them in bathrooms at airports, right?

   Stewart Gandolf:
   Yep, all the time.

   Jim Merlino:
   And I think its ridiculous because what can you tell from pushing a red or green button? So, when I go in, I don't feel so well, I got to go to the bathroom, so I push red. When I walk out, I'm happy, I push green. There's no user guide for that and it doesn't help you understand if there's a problem. It's kind of a fun example but it doesn't tell you anything.

   Stewart Gandolf:
   For those of you that don't know the net promoter score, the NPS, the simple question was, and there's some data behind this. It asks us one question, it's would you, how likely are you to tell your friends or family about or refer your friends and family to us? And that is, there is some, a place for that. But you're right, it's too simplistic. Healthcare is very, very complex and these measures are important, right?

   Stewart Gandolf:
   This is people's lives we're talking about. And I think that the idea of doing an NPS is okay for, getting stars, which is great, but there's certainly, when we're talking about data and measuring ourselves and understanding, again the patient's point of view, one of the things I marvel at, how the philosophy of patients first just pervades some organizations and doesn't in others. I always think about Cleveland clinic with the same day appointments or when one thing that always amazes me, if somebody has the worst day of their life for cancer diagnosis and then they're going to go do some tests, and how long does that take? Weeks sometimes and just imagine the patient's point of view. So the, all of these things matter and they're all key variables and you can't improve what you can't measure, totally agree on that. But you've got a bunch of data, right? We've asked some good questions, does it stop there? Is data enough, Jim?

   Jim Merlino:
   I don't think data's enough. I think it starts with good data to, help you understand the needs of your patients and frankly your caregivers as well because the same applies there. You can't just pull button at the time clock and have them push it if they're happy, and one button, and another button if they're sad, because that doesn't tell you why. It's not actionable. You have to decide how do you take that information, how you use good analytics to interpret it, and make it actionable. And the actual part is what we've spent the most time talking about, which is the exciting work, which is the building the strategy and then executing. I think that is ultimately, where the focus needs to be.

   Stewart Gandolf:
   That's like we've got data, great. We've got to get over it and get to the action of coming up with a strategy to execute based upon that. And finally, we talked before about reliability and is this predictable? Is it duplicatable, what kind of processes? Let's talk a little bit more about how to make things more reliable.

   Jim Merlino:
   I think we can learn a lot from industries that are highly reliable. So, there's three that are generally considered in that category, the airlines, nuclear power, and the military. And while the military is not an industry per se, it kind of functions like one. And the reason it's considered highly reliable is because for instance, you don't read stories in the front page of newspapers every single day of 19 year old kids dropping bombs by accidents on ships and having them blow up. And so the question is, how did the military take highly complicated processes, where when errors are made, when people die, and make them very repeatable and consistent and safe so that kids, essentially, can operate them. And, and that's through the principles of higher liability.

   Jim Merlino:
   And the same thing for the airlines. We as a surgeon, I used to never liked the airline analogies, right? People would say, "Oh, if you could just be more like the airlines surgery would be better." It's like, patients are not all like flying planes. And they are, they're different. But we can learn things from those industries and through the process of higher reliability and no one industry is more in need of this than others because when we make mistakes, obviously people die and the statistics are staggering. But, how do we take good process? Make sure that it's based on evidence. Make sure that it's intuitive and simplified and efficient and wrap good culture around those processes making sure that the people understand how to function with those processes, how to hold people accountable for it, so they can see how they're operating, and to deliver results. That is where we can learn a lot from other industries or highly reliable industries and take it to healthcare. Because that's what we need to do, is make healthcare more reliable, consistently perform at high performance so that we deliver better for the people we serve.

   Stewart Gandolf:
   And hospitals and in health care, pretty broadly, the doctors, the surgeons are at this core of everything. Some probably are still to this day, adapting patient experience, sort of a mindset more than others. And can you share any tricks or tips for the surgeons or, that want to be leaders or people that, how do we convince our colleagues to be kind of get with the program based upon your experience?

   Jim Merlino:
   I think it starts with education. I think people need to understand why it's important and that's the burning platform that we should all be concerned about. I mean, at the end of the day it's the right thing to do, but we have to help them understand why. And it starts with really showing them the data and that we're not performing as well as we should be. We're not performing to the level that we'd expect for our families. The second thing I think it entails is bringing a framework for improvement. Helping people understand the how to do it. The "what" that they need to be doing. And the third is that we need to be leading it. We need to be holding people accountable for it. I think the good news is that most people in healthcare are here because they want to do what's right for patients. That's why they, they go into healthcare.

   Jim Merlino:
   It's the passion that they grow up with wanting to do this work and that represents most people. But there's a small fraction where that gets away from them and they lose perspective or they're not at it for the right reasons to begin with. And as leaders, we have to put a stake in the ground in saying, "That's intolerable." This is important. Safety's important, quality's important, experience's important. You can't trade off. They're all important. We need to deliver on performance on all three. And everyone has a role and we need you to know what your role is and we're going to hold you accountable for it. It's not okay to not be involved. So that's how I think about it as someone who has led this.

   Stewart Gandolf:
   In healthcare, and in particularly in a hospital where the doctors are at the top of the pyramid and it's really crucial for all whole bunch of reasons for them to be on board. And the work that you guys have been doing, Jim, at Cleveland clinic and at Press Ganey and some of the other people you've introduced me to, it's really an exciting time to be around patient experience. We talked a little bit as well about some of the people we've met on the pharma side or various hospitals, some of the work that you're doing on the practice side. Everybody cares about patient experience. And I think it's a lot more than lip service these days and it's just kind of a tidal wave. So, very exciting times. Any other sort of parting thoughts, Jim? Because I love having you on this, our little program here. Any other words of advice or comments at this stage?

   Jim Merlino:
   Just to agree with you I think, you and I obviously talked about this a lot and you know, we're good friends because we share perspective and very similar things and, and agree on most. And that is that it is exciting and I don't think that there has been more of an exciting time to be in healthcare. And I think a lot of people look at what's going on and they get depressed or they get down and I said, don't get down. This is exciting. This is our opportunity to really evolve, to do what's right for people.

   Jim Merlino:
   And I look at the things you're doing and how you've evolved, that's exciting. I couldn't be more exciting, I couldn't be more excited about the work we do at Press Ganey. I'm obviously biased, but it's important stuff and it is an honor, absolute honor to be able to spend time and work with so many different organizations and so many leaders in this field. I can't imagine anything else that I'd want to be doing at this point.

   Stewart Gandolf:
   A lot of people in marketing want to be, are like frustrated, wanting to be clinicians, and that's just not my calling. It's not what I want to do. I love what I do. I love running our agency. I love helping patients, connect them to better care. And that's what's exciting to me. But this patient experience is really a passion project for me. It's not a big revenue center for us. It's just something that we do as well. It's like, how can I help good people that are trying to transform health care in a meaningful way and having friends like you, Jim really helped me reach that. So, I'm honored that you've attended our program again. Thank you for participating in for all the great work you and your team and your peers do.

   -30-