5-Star Rating Comes from 5-Star Leadership

In April, the Centers for Medicare and Medicaid Services (CMS) released the 5-star rating system for patient satisfaction. It’s a simplified approach to reporting The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) in a way that will, hopefully, be easier for the public to understand. The mandate is clear: healthcare consumers want an easy-to-understand means of identifying the organizations and clinicians that provide the best care and service, which most healthcare organizations are committed to doing.

Unfortunately, many healthcare organizations and providers are continuing to struggle to boost their scores despite intensive—and often costly—initiatives. What gives?

Culture. Period.

Nothing will drive patient satisfaction scores higher and sustain them with greater consistency than a strong, service-oriented culture—a culture committed to providing exceptional customer service experiences, every customer, every encounter, every day. But culture doesn’t just happen with the flip of a switch; culture is nurtured. And leaders must be the ones to nurture it. They must act as stewards of the culture.

5-Star Leadership Drives 5-Star Ratings

I wrote a blog post about this recently where I outlined the 5 P’s of building a 5-star culture through 5-star leadership. Here, I want to expand on each of those 5 P’s with some specific examples of situations we’ve encountered in our work with hospitals around the country. Here’s what it takes to build a culture that will boost those scores:


Is a positive patient experience woven into the very fabric of your organization? Are goals and strategies to attain them embedded in your strategic plan? Is progress discussed regularly as part of meetings at every level of the organization? Are these initiatives aligned with other organizational initiatives of sitting in a silo?

One organization we worked with had implemented dozens of best practice tactics, but something was missing: consistency. This organization had experienced so many starts and stops along the way to building a service-oriented culture that nobody was taking it seriously anymore. You need to be committed, every day—and you need to be in it for the long haul. Once they started holding everyone accountable with non-negotiable consistency, change began to happen.
The other common problem is with misaligned incentives. We’ve had many realignment conversations in organizations that incentivize productivity but ignore patient satisfaction. When this occurs, the message is that volume trumps service. We use this opportunity to demonstrate that you must align incentives with priorities. Until you do, you perpetuate the myth that productivity and service are mutually exclusive. They’re not.


Healthcare is a service industry. Service industries are driven by people: people who have values and beliefs aligned with your organization’s values and beliefs. You need to identify those people during the hiring process, and then coach and train them on the standards and reinforce their great work throughout their tenure with you. Unfortunately, this doesn’t always occur.

We worked with one organization that had established great standards—exceptional standards in fact. The problem was that these standards didn’t apply to everyone. There were some “sacred cows” who got a free pass. What happens when an organization declares standards and then gives free passes? The standards become meaningless and the leaders lose credibility. The goal should be to hire, train, coach, and reinforce daily. And that means for everyone. When you do, you send the message that everyone is held to the same standard.

Processes (with clear accountability)

Processes that are in place and practiced consistently, including clear accountability for following those processes, can help ensure alignment and consistency. For instance, many hospitals have processes in place for rounding. However, I’ve encountered several situations where senior leaders tell me that rounding is expected but, when I get down to the department level, it’s clear that managers are interpreting this “expectation” as a “suggestion.” It’s not what you expect—but what you inspect—that gets done. Processes alone won’t cut it. You need accountability to ensure that processes are carried out consistently.

Here’s an example that I often refer to as “the Olympic moment.” I had been working with an organization on a culture change journey and, throughout the process, encountered a very resistant, and often, very negative, nurse who kept referring to the journey as “the flavor of the month.” She was clearly jaded from her experiences with past efforts. But, despite her negativity, we persevered, and we made progress. She witnessed her manager making regular rounds and sharing service stories at every meeting (two of their key processes). About two years into the journey, she came to me and said, “This isn’t going away, is it?” I said, “No, it’s not going away. This is what the organization promises.” And the light bulb went on! This was the Olympic moment—the point when even some of your toughest critics climb on board.


Leaders set and communicate the vision. They build processes to ensure the hiring, training, and coaching of employees who share that vision. They develop and hold people accountable to processes designed to ensure exceptional patient encounters every time. But there’s something else they must do to build a sustainable culture of service—they must help every person in the organization clearly see his or her own personal connection to that purpose.

What does that look like? Here’s an example. I was walking down the hall of a hospital one day and came across a painter who was painting the walls and touching up the trim. I stopped and said, “Oh, I didn’t know we were working on this section—so, what are you doing?” He looked at me and said, “I’m making this a place where patients choose to come for care, where employees want to work, and where physicians want to practice.” That was the hospital’s stated vision. He got it! He wasn’t just painting a wall; he was contributing to the vision.


The final P is passion. Nothing happens without it. You may have noticed that none of these leadership behaviors are focused on scores. That’s because exceptional patient experiences aren’t driven by scores—they’re driven by culture. Work on the culture, and the scores will follow.

Demonstrate your passion for excellence every day, even when you don’t think anyone is looking. Someone is always looking. And, when they look, and see your passion, you’ve hooked them. Leaders need to show their passion and let others know that they’re expected to be passionate as well. Healthcare is a people business; it’s hard work, but it’s also special and extremely rewarding work.

What are you doing, every day, to show your passion? Are you able to help others connect to purpose? Do you have service-enhancing processes in place? How are you ensuring that your people know what to do, how to do it, and want to do it? And, finally, are you aligning the stated priorities with the incentives, attention, and right actions?

If you really want 5-star ratings, you need to be a 5-star leader.

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