Article

Creating the Exceptional Patient Experience
in One Academic Health System
Vivian S. Lee, MD, PhD, MBA, Thomas Miller, MD, Chrissy Daniels, MS,
Marilynn Paine, MPH, Brian Gresh, MPA, and A. Lorris Betz, MD, PhD

Abstract
Whether patient satisfaction scores can
act as a catalyst for improving health
care is highly debated. Some argue
that pursuing patient satisfaction is
overemphasized and potentially at odds
with providing good care because it
leads providers to overtest and overtreat
patients and to bend to unreasonable
patient demands, all to improve their
ratings. Others cite studies showing
that high patient satisfaction scores
correlate with improved health
outcomes. Ideally, assessing patient
satisfaction metrics will encourage
empathy, communication, trust, and

In health care, two widely held, but

inherently contradictory, beliefs have
emerged. The first is that health care
needs to be more patient centered,1,2 and
the second is that patient satisfaction is
both overemphasized and potentially
opposed to good care. Underpinning this
contradiction is the belief that although
the health care industry should focus
on the patient, it is the provider who
has the ability and right to define what
is a positive outcome. While the patient
experience has been adopted as a measure
of quality by both the Centers for
Medicare and Medicaid Services and the
British National Health Service,3 research
connecting patient satisfaction to health
outcomes is limited and conflicting,3–9 as
Please see the end of this article for information
about the authors.
Correspondence should be addressed to Vivian S.
Lee, University of Utah School of Medicine, 175
North Medical Dr., 5th Floor, Salt Lake City, UT
84132; telephone: (801) 581-7480; e-mail: Vivian.
lee@utah.edu.
This is an open-access article distributed under the
terms of the Creative Commons Attribution-Non
Commercial-No Derivatives License 4.0 (CCBY-NC-ND),
where it is permissible to download and share the
work provided it is properly cited. The work cannot
be changed in any way or used commercially.
Acad Med. 2016;91:338–344.
First published online November 24, 2015
doi: 10.1097/ACM.0000000000001007

338

shared decision making in the health
care delivery process. From the patient’s
perspective, sharing such metrics
motivates physicians to provide patientcentered care and meets their need for
easily accessible information about their
providers.
In this article, the authors describe a
seven-year initiative, which began in
2008, to change the culture of the
University of Utah Health Care system to
deliver a consistently exceptional patient
experience. Five factors affected the
health system’s ability to provide such

are professional opinions on its merits or
harms.10–14 Reconciling these divergent
points of view is critical to advancing
health system redesign.
In February 2008, the University of Utah
Health Care system launched an initiative
called the Exceptional Patient Experience
(EPE) with the mantra “Medical care
can only be truly great if the patient
thinks it is.” What began as a patient
satisfaction initiative has evolved into a
model for cultural transformation and
has since become the cornerstone for
other initiatives focused on quality and
safety, patient-reported outcomes, and
cost reduction.
In this article, we describe the first seven
years of the EPE initiative. Recognizing
that ours is a single institution’s
experience, we emphasize that the lessons
we learned are widely applicable. The
steps we took in implementing this
initiative take their cue from common
management principles, which, as we
illustrate here, apply well to health care.
About the University of Utah
Health Care System

The University of Utah Health Care
system is owned and fully operated by the
University of Utah, a public university.

care: (1) a lack of good decision-making
processes, (2) a lack of accountability,
(3) the wrong attitude, (4) a lack of
patient focus, and (5) mission conflict.
Working groups designed initiatives at
all levels of the health system to address
these issues. What began as a patient
satisfaction initiative evolved into a
model for physician engagement, valuesbased employment practices, enhanced
professionalism and communication,
reduced variability in performance, and
improved alignment of the mission and
vision across hospital and faculty group
practice teams.

It is a part of the University of Utah
Health Sciences center, which is led by the
senior vice president for health sciences,
who reports to the president of the
university, and who serves as the CEO of
the health system, the dean of the School
of Medicine, and the chair of the faculty
group practice board of directors. The
health care system operates 4 hospitals
and 10 community clinics in the Salt Lake
City metropolitan area. Pediatric care is
provided through a joint venture with
Intermountain Health Care. In total, the
health system records approximately 1.4
million patient visits annually. As the
state’s only medical school and academic
health sciences center, the health system
covers the full breadth and depth of
services across a continuum of care, as
well as an extensive state and regional
telehealth network.
In 2008, the University of Utah
Health Care system faced increasingly
frequent patient complaints. Criticisms
and complaints ranged from delays
in the scheduling of appointments
to insufficient wayfinding, poor
communication, inadequate care
coordination, and lack of professionalism.
The health system’s overall Hospital
Consumer Assessment of Healthcare
Providers and Systems (HCAHPS) “Rate
this hospital” performance rating ranked

Academic Medicine, Vol. 91, No. 3 / March 2016

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in the 34th percentile nationally, which
corresponded to only 62.4% of HCAHPS
survey respondents rating the health
system as a 9 or 10 on a scale of 0 to 10,
with 10 being the ideal rating.
Quality metrics for the health system were
average compared with those for other
teaching hospitals. In 2008, it was ranked
50th in quality nationally by the University
HealthSystem Consortium, which at the
time included about 88 academic health
systems from across the country.
Launch of the EPE Initiative

At a leadership retreat on February 4,
2008, the then senior vice president
for health sciences (A.L.B.) read a
number of patient complaint letters.
He challenged participants to consider
why the health system was unable to
deliver a level of service and quality that
would be considered excellent beyond
expectations. In short, he asked how the
health system could enable caregivers
to provide an exceptional experience to
every patient, every time, and at every
point within the system.
The leadership retreat participants
agreed on five root causes for the health
system’s inability to deliver consistently
exceptional care: (1) a lack of good
decision-making processes, (2) a  lack of
accountability, (3) the wrong attitude,
(4) a lack of patient focus, and (5) mission
conflict. Working groups, co-led by a
faculty member and an administrator,
each took on one of these root causes.
Additional working groups were
established to address other issues that
arose from the root cause analysis,
including leadership training; valuesbased employment and retention, reward,
and recognition; unit-based action plans;
and communication.
The data that informed the root cause
analysis and the subsequent working
groups and initiatives were derived from
anecdotal patient stories at the system
level and from patient survey results
at the local level. While the patient
complaint letters provided the urgency
for change, short video recordings of
patients describing their exceptional
experiences within the health system
served as inspiration for staff and faculty
and were presented at retreats, staff
and faculty meetings, new employee
orientation, and town halls.

Academic Medicine, Vol. 91, No. 3 / March 2016

Phase 1: Implementing Critical
Initiatives

Establishing leadership in culture
change
Historically, the University Hospitals and
Clinics and the 16 clinical departments
of the School of Medicine effectively had
functioned as distinct entities. These
organizations were united in 2004 to form
the University of Utah Health Care system.
In fact, the two parts of this unified system
could not have been more different. Clear
lines of accountability in the University
Hospitals and Clinics sustained a secure,
stable, and predictable focus on control,
and common, shared measures of success
thrived in this rules-driven environment.
In contrast, led by independent,
entrepreneurial individuals, the clinical
departments’ measure of success was an
individual’s ability to generate her or his
own resources. To improve the patient
experience, the EPE initiative aimed to
align the culture of the unified health
system around patient satisfaction and
engagement while at the same time
preserving the characteristics responsible
for the success of each individual entity.
As part of this process, department chairs
worked with hospital administrators to
appoint physicians to new leadership roles
in clinical operations and ambulatory care
as service line medical directors.
Collecting and reporting data
The University of Utah Health Care system
adopted the Press Ganey Medical Practice
survey (see List 1) and benchmarked its
responses to those from national peers.
Initially, patient satisfaction was assessed
and tracked using mailed Press Ganey
surveys. In January 2011, the health
system became one of the first academic
medical centers to shift to electronic
questionnaires, which increased both
the number of surveys sent as well as
the number of responses received. In
2011, the number of responses received
increased to 41,768 (19.1% response rate).
Using national percentile rankings, Press
Ganey survey results were converted to
color-coded dashboards at the individual
and team levels. Each quarter, clinical
units established their own targets for
improvement.
Fostering values-based employment
The University of Utah Health Care
system revisited its mission, vision,
and values and elected to expand its
core values to include compassion,

List 1
Standard Subjects on the Press
Ganey Medical Practice Survey Used
to Develop the Exceptional Patient
Experience Initiative at the University
of Utah Health Care System
Overall access
•   Ease of getting clinic on phone
•   Convenience of office hours
•   Ease of scheduling appointments
•   Courtesy of registration staff
Moving through your visit
•   Information about delays
•   Wait time at clinic
Nurse/assistant
•   Friendliness/courtesy of nurse/assistant
•   Concern of nurse/assistant for problem
Care provider (CP)
•   Friendliness/courtesy of CP
•   CP explanations of problem/condition
•   CP concern for questions/worries
•   CP efforts to include in decisions
•   CP information about medications
•   CP instructions for follow-up care
•   CP spoke using clear language
•   Time CP spent with patient
•   Patients’ confidence in CP
•   Likelihood of recommending CP
Personal issues
•   How well staff protect safety
•   Sensitivity to patients’ needs
•   Concern for patients’ privacy
•   Cleanliness of practice
Overall assessment
•   Staff worked together
•   Likelihood of recommending practice

collaboration, innovation, responsibility,
diversity, integrity, quality, and trust.
During this process, faculty and staff
reviewed existing cultural language and
revised it to align with the EPE initiative.
The health system then launched a
multistep values-based employment process
focused on the recruitment, retention, and
promotion of employees who delivered an
exceptional patient experience.
Values-based recruitment. The values of
the University of Utah Health Care system
were included in all job descriptions and
applicant screenings and interviews. All
hiring supervisors, managers, and search
committees were trained in values-based
hiring. Targeted interview questions (see
Table 1) were designed to assess applicants
according to the EPE values.

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 Article

Table 1
Guidelines for Conducting a Values-Based Recruitment Interview, as Part of the
Exceptional Patient Experience Initiative at the University of Utah Health Care
System
Value

Leading question

Follow-up question

Key criteria

Compassion

Give me an example of a time when
you were particularly perceptive
regarding a patient’s (or customer’s)
feelings and needs.

Describe what you did. What was
the impact for you? For the patient?

Collaboration

Describe a situation when it was
critical that you establish an effective
working relationship with either an
individual or group, outside of your
own department, to complete an
assignment or deliver a service.

• 
• 
• 
• 
• 
• 

Innovation

Give an example of a problem that
you have personally solved in a
unique or creative way.

How satisfied were you with the
outcome? What did you learn
about problem solving from this
experience?

•  A
  bility to look at issues from different perspectives
•   Thinking outside the box
•   Prepared to take considered risk

Accountability

Tell me about a time when you made What were the consequences
a significant mistake at work.
for you personally? How did you
approach the conversation with
your supervisor/coworker/patient/
customer?

•  O
  wnership for consequences
•   Commitment to putting things right and learning
from the experience
•   Timeliness for communicating with those impacted

Diversity

What has been the most difficult
challenge that you have faced
personally in working cooperatively
with another person who did not
share your values, beliefs, or ideas?

What was the impact on your ability
to get things done? What was the
impact on the other person’s ability
to get things done?

•  L  istening
•   Open to other person’s perspective
•   Being accountable for one’s beliefs, ideas, and
attitudes
•   Self-awareness

Integrity

Can you give an example of a
situation when you saw someone at
work stretch or bend the rules beyond
what you felt was acceptable?

What did you do? What led you to
•   Willingness to hold others accountable
take the action you did? What was
•  W
  illingness to do the right thing, however difficult
the consequence of taking the action
you did?

Quality

Quality is not just one person’s job.
Describe a time when you identified
a potential quality concern and
addressed it personally before it
became an issue.

What was the outcome? Were
you able to resolve the concern by
yourself? If not, who else did you
involve?

•  A
  bility to connect job duties with quality outcomes
•   Willingness to bring quality issues to the attention
of appropriate others or to take personal action
within the scope of job duties

Trust

Tell me what steps you personally
take to build trust with your
supervisor and coworkers.

What has been the impact on your
working relationship with your
supervisor? Coworkers? What
actions would you take if you
received feedback to suggest that
your own actions were not seen to
be trustworthy?

•  C
  ommitment to “walking the talk”
•   Awareness of the importance of relationship
building
•   Recognition that trust works both ways in effective
relationships

Values-based retention and promotion.
Starting in 2008, patient satisfaction
metrics were included in annual
performance evaluations. Each clinical
unit or department defined its own
evaluation measurements. In addition,
a focused redesign of human resource
policies led to the development of a welldesigned exit interview process, which
became part of the feedback loop to
improve performance.
Recognizing success
The hospital and faculty group practice
set patient satisfaction targets for
individual clinical units (inpatient and

340

T  aking time to listen
 Observant of nonverbal cues
 Observant of patient needs
 Going the extra mile to make a difference
 Linking job duties with patient experience
What did you learn from this
 Taking ownership for assignment completion and
experience? Was there anything that
service
you would have done differently?
•   Delivery
•   Recognition that one person cannot do everything
•   Working with others

outpatient) with the ultimate goal of
reaching the top 10th percentile of
patient satisfaction nationally. Quarterly,
a group of health system leaders,
typically the CEO or chief operating
officer of the University Hospitals and
Clinics, the senior vice president for
health sciences, and the chair of the
Hospital Community Board, visited the
clinical units that met or exceeded their
targets. As part of these celebrations,
specific patient comments were read
aloud, the individuals cited in these
comments received special recognition,
and the unit received a framed citation.
This practice continues today.

Creating unit-specific action plans
Across clinical units and service
lines, leaders worked with their staff
to determine specific strategies for
improving the patient experience. This
process led to significant innovation
across the health system. Best practices
were recognized, regularly shared, and
implemented in an individualized
manner specific to each department
or service. For example, for the
Cardiovascular Service Line, the scope
of their EPE initiatives ranged broadly
from individual pocket cards that
identified the “gold standards” of
exceptional cardiovascular care to

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scheduling adjustments to reduce the
wait times for patients to schedule
appointments. Provider scheduling
templates were reviewed and revised, and
in some cases, hours of operation were
adjusted and extended. The University
Neuropsychiatric Institute instituted a
“Hi, Goodbye, Manage Up” practice (see
Table 2) for staff working with patients
in the hospital. The Huntsman Cancer
Institute leaders accelerated innovation
by meeting with each physician and her
or his team—nurses, front desk and
medical assistant staff—to emphasize
a team approach to improving patient
satisfaction.
Engaging students and residents
In early 2011, we began to actively engage
residents in the EPE initiative, recognizing
that the principles of the initiative were
concordant with the Accreditation Council
for Graduate Medical Education common
program requirements of professionalism,
personal responsibility, and patient safety.
Since then, expectations, processes, and
sample scenarios have been presented
routinely at all house officer orientation
sessions. In addition, individual
departments and divisions have integrated
EPE initiatives into their training
programs. For example, the orthopedic
surgery service was the first to integrate
residents by engaging them in improving
inpatient rounds in the hospital. As
a result, physician communication,
management of pain, and readiness for
discharge each improved.
Improving communication
In communicating about the EPE
initiative internally, we focused on
developing greater trust between patients
and providers and among staff. Messages
included the clear articulation of
values, staff and patient stories gathered
via an online tool, staff and patient

videos, and best practices developed
and shared across the health system.
Communications channels included
personal meetings between the senior
vice president and department leaders,
intranet and internal print newsletters,
and health system retreats and symposia.
Phase 2: Physician Engagement
and Data Transparency

Key to physician engagement in the
EPE initiative was the sharing of
patient feedback and the progressive
transparency of those data coupled
with coaching and the sharing of best
practices to improve performance.
Initially, department chairs could view
department-level performance data
for their faculty. In 2010, individuallevel data were made available; these
data were benchmarked to the national
database to provide national percentile
rankings. They were presented as simple
dashboards for each provider.
The natural tendency toward competition
began to drive improvements in patient
satisfaction. Over time, within divisions,
providers could compare their own
patient satisfaction data with those
of their peers. High performers were
recognized, and low performers were
offered coaching. Departments then
began to increase transparency without
administrative prompting. For example,
at a faculty meeting in 2009, the chair of
the department of dermatology made
the patient satisfaction data for each
individual provider in his department
available for comparison; other
departments followed suit.
In December 2012, after several
months of internal discussion and
preparation, the University of Utah
Health Care system began to post

each provider’s patient satisfaction
data—scores and comments—on the
university’s public Web site (e.g., http://
healthcare.utah.edu/fad/mddetail.
php?physicianID=u0102229).
Each provider’s “overall willingness to
recommend” score from the Press Ganey
survey was also added to the online
profiles. This score, which averaged
responses to all 10 survey questions,
is represented using the familiar five
yellow stars scheme. In addition, viewers
can review individual survey question
scores and unedited patient comments
for each provider. A link to a description
of the survey and the data source is
provided as well. Less than 1% of patient
comments need to be removed because
of defamatory content. Comments are
updated every 10 days, while scores are
updated biannually.
EPE Resources and Staffing

For Phase 1, the EPE initiative was staffed
by a core support team that included the
chief medical officer, the assistant vice
president for strategic initiatives, and,
over time, up to four staff members (3.5
full-time equivalents). Working groups
and additional EPE committees carried
out the vast majority of the planning
work. Faculty and staff were released
from their other duties to attend these
meetings. In addition, the chief medical
officer identified and engaged medical
directors and clinic managers from each
clinic to foster frontline management
skills to improve operations. Finally,
the core support team provided initial
coaching, while those at the medical
director and clinic manager level
provided additional coaching.

Item

Details

The chief medical officer led the Phase
2 efforts, working with the director
of strategic initiatives, whose teams
focused on teaching the health system the
importance of public online reviews. The
senior director of interactive marketing
and Web and four staff members from
the data warehouse focused on the
development of the Web interface and on
search engine optimization.

Hi

Establish a personal connection at the beginning of shift change or consult.
Introduce self and get to know patient.
Close the shift with a sincere goodbye.

Impact of the EPE Initiative

Table 2
University Neuropsychiatric Institute “Hi, Goodbye, Manage Up” Initiative,
Developed as Part of the Exceptional Patient Experience Initiative at the University
of Utah Health Care System

Goodbye
Manage Up

Transition the trust you have established to the next member of the team.
Identify the caregiver to whom you are handing off the patient. Share a
personal or professional detail with the patient. Make the assurance that she
or he is in good hands.

Academic Medicine, Vol. 91, No. 3 / March 2016

Patient satisfaction metrics
Over the past seven years, patient
satisfaction has significantly increased

341

 Article

Figure 1 Patient satisfaction with the University of Utah Health Care system. Press Ganey Medical
Practice survey results and Hospital Consumer Assessment of Healthcare Providers and Systems
ratings of 9 or 10 (on a scale of 1–10) were compared against quality metrics for the teaching
hospitals in the University HealthSystem Consortium (UHC) over the course of the Exceptional
Patient Experience initiative, 2008 to September 2014.

(see Figure 1). Improvements at the
individual provider level are most
notable. Of the 453 providers who had 30
or more surveys returned in 2014, 50%
ranked in the top 10% (raw score at or
above 95.4) when compared with their
peers nationally. Moreover, 26% ranked
in the top 1% nationally (raw score at or
above 96.7; see Figure 2).
Although the patient satisfaction survey
response rate decreased from that in
2011 (41,768 responses; 19.1%), it has
remained relatively constant recently.
In fiscal year (FY) 2014, we received
65,828 responses from 519,155 surveys
sent, for a response rate of 12.6%. The
response rate was the same in FY 2013

(58,693 responses from 467,394 surveys
sent). The absolute number of responses
we received, however, exceeded most
benchmarks. For example, HCAHPS
requires only 300 responses per year per
hospital.
Parallel improvements in quality, risk
management, and employee satisfaction
Despite concerns to the contrary,
neither the quality nor the cost of care
has suffered over the course of the EPE
initiative. In fact, improvements in
these areas have occurred alongside the
improvements in patient satisfaction.
In 2010, the University of Utah Health
Care system was ranked number 1 in
quality in the nation by the University

HealthSystem Consortium, out of more
than 118 academic medical centers,
and recorded continuously increasing
absolute scores for quality and safety
over the study period. (The University
HealthSystem Consortium performance
metrics continue to evolve—in 2014, they
included mortality, effectiveness, safety,
equity, HCAHPS, and efficiency.) For
the last six years, our health system has
consistently ranked in the top 10 in this
cohort. At the same time, our average
total facility expenses per case-mixindex-adjusted discharge decreased by
0.5% between 2007 and 2013, compared
with an average increase of 2.9% across
all University HealthSystem Consortium
members over the same period.
With improved patient satisfaction
has come a lower rate of malpractice
litigation.15 Malpractice premiums
declined from $10.7 million in 2007 to
$7.3 million in 2012, despite a significant
increase in the number of physicians
practicing and a more than 40% increase
in professional revenue. This rate of
decline in our malpractice premiums
exceeded national trends.16
Finally, we saw increases in employee
satisfaction as well as in patient
satisfaction. Responses to recent internal
surveys rank quality of care, teamwork,
and likelihood to recommend facility
among the highest-scoring factors. Most
notably, both the School of Medicine
and the University Hospitals and Clinics
received an average score of 84 out of
100 with regard to “staff ’s concern for
and interest in their patients,” a score of
85 with regard to “likelihood you would
recommend this facility to friends and
family for care,” and a score of 85 with
regard to “overall quality of care at this
facility.”
Unanticipated benefits

Figure 2 Percentage of providers at the University of Utah Health Care system with patient
satisfaction scores in the top one percentile, benchmarked against the Press Ganey Medical
Practice survey database. Only the 453 providers who had at least 30 surveys returned that year
were included in the comparison.

342

Unexpected benefits of posting patient
reviews on our Web site have included
sharp increases in our Web traffic and
improved search engine optimization. In
February 2013, Google began indexing
the provider profiles, including the five
star ratings. In March 2014, the profile
pages received 122,072 views, a large
increase from the 75,970 views they
received in March 2013. Additionally, in
a separate patient survey, respondents
ranked “patient satisfaction ratings and
comments” as the second most important
feature of the provider profiles, second

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only to “specialty focus.” The provider
profiles and patient rankings and
comments appear at or near the top of
most major search engine results when
users search for a specific provider, which
providers have come to value.
Improving Patient Satisfaction
and the Value of Care

Despite accounting for almost onefifth of the U.S. economy, health care
has generally received poor patient
satisfaction ratings. Some studies have
suggested that an overemphasis on
patient satisfaction can be detrimental
to providing good health care and
to fostering good health.2–5 These
studies cite correlations between high
patient satisfaction ratings and higher
overall health and prescription drug
expenditures, higher inpatient care
utilization rates, and increased mortality.
They also posit that patient satisfaction
is just a poor measure of quality of care.
Similarly, others have expressed concerns
that patient experience initiatives place
physicians at the mercy of unreasonable
patient demands, including narcoticseeking behavior.17,18
In contrast, recent meta-analyses and
reviews have shown that high patient
satisfaction correlates with improved
outcomes.3,4,7 Thus, how the “exceptional
patient experience” is defined and how
the data assessing it are collected are
critical. Manary et al10 have suggested
that more positive correlations between
patient satisfaction and quality or
outcomes are found when the survey is
(1) related to a specific event or episode
of care (rather than related to general
impressions of a plan or provider); (2)
timely (within days, not months); and
(3) focused on the patient–provider
relationship. All of these characteristics
were part of our EPE initiative. Response
rate also can impact the validity of the
survey. Although our response rate
declined from 19.1% the first year to
12.6% the next two years, we did receive
over 65,000 responses in 2014.
Patient engagement initiatives should
focus on empathy, communication,
trust, and accessibility (see List 1). These
factors affect the types of care that
Otani et al9 identified as contributing to
patient satisfaction: staff care, nursing
care, and physician care. While the
relationship between patient satisfaction

Academic Medicine, Vol. 91, No. 3 / March 2016

and quality of care remains unclear,
measures of patient satisfaction
increasingly are factored into physician
reimbursement models. For example,
the Centers for Medicare and Medicaid
Services began using HCAHPS ratings
to calculate physician payments in
2015. The HCAHPS questions tend to
assess the process of delivering care,
communication, and engagement in
health care decisions, similar to the
survey questions we used.19
Making patient satisfaction data
available also has helped to address the
growing desire among patients for more
information about their providers. A
2012 Local Consumer Review Survey
showed that 85% of consumers used
the Internet for information on local
businesses and that 72% trusted
Web reviews as much as personal
recommendations, provided there
were multiple reviews and the reviews
appeared to be authentic.20 A separate
Price Waterhouse Cooper study showed
that 42% of consumers used social
media to access reviews of physicians or
treatments.21 These numbers are only
going to grow. Moreover, the data that
health care systems collect from their
patients are seen as more valid than those
collected through public physician rating
systems.3,22
The challenges that the University of
Utah Health Care system faces with
regard to patient satisfaction are common
in health care, and the approaches to
improving the patient experience that we
have described here are likely adaptable
to other institutions. Several other health
systems in the United States also have
posted patient satisfaction scores online.
Among the first worldwide to take this
approach was the National Health Service
in 2008. Our results are consistent with
theirs—over a two-year period from
2009 to 2010, based on 10,274 Web-based
ratings, patient satisfaction correlated
positively with outcomes measurements
(lower mortality and lower readmission
rates).3
The Virtuous Cycle of Patient and
Physician Engagement

Driven primarily by data transparency,
peer-to-peer competition, and the sharing
of best practices at the system and provider
levels, our EPE initiative has created a
virtuous cycle. Stronger relationships

between patients and providers have
enhanced the engagement and satisfaction
of both groups. In addition, by training
future providers in this environment, we
can ensure that this culture of outstanding
service, as well as of quality and safety, will
continue in the future.
In conclusion, what began as a patient
satisfaction initiative evolved into a
model for physician engagement, valuesbased employment practices, enhanced
professionalism and communication,
reduced variability in performance,
and improved alignment of the mission
and vision across hospital and faculty
group practice teams. This system-wide
shift to patient-centered care sets the
stage for broader health system delivery
transformation.
Acknowledgments: The authors would like to
acknowledge the assistance of Danielle Sample,
Joe Borgenicht, and Kirsten Stewart in preparing
this manuscript.
Funding/Support: None reported.
Other disclosures: None reported.
Ethical approval: Reported as not applicable.
Previous presentations: Betz AL. Courage. Address
of the chair of the Board of Directors of the
Association of American Medical Colleges.
Presented at: Learn Serve Lead 2014: The AAMC
Annual Meeting; Chicago, IL; November 8, 2014.
V.S. Lee is A. Lorris Betz Senior Vice President for
Health Sciences, dean, School of Medicine, and CEO,
University Health Care, University of Utah, Salt Lake
City, Utah.
T. Miller is chief medical officer, University Hospitals
and Clinics, University of Utah, Salt Lake City, Utah.
C. Daniels is director of strategic initiatives,
University Hospitals and Clinics, University of Utah,
Salt Lake City, Utah.
M. Paine is assistant vice president for strategic
initiatives, University of Utah Health Care, University
of Utah, Salt Lake City, Utah.
B. Gresh was senior director of interactive
marketing and Web, University Health Care,
University of Utah, Salt Lake City, Utah, at the time
this work was completed. He is executive director of
multichannel content marketing, Cleveland Clinic,
Cleveland, Ohio, now.
A.L. Betz is senior vice president for health
sciences emeritus, University of Utah, Salt Lake
City, Utah, and immediate past chair, Board of
Directors, Association of American Medical Colleges,
Washington, DC.

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Academic Medicine, Vol. 91, No. 3 / March 2016