Applying the Art of Excellence to Patient Care – Aboard a Cruise Ship!

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A recent cruise upon the Norwegian owned Viking Orion ship demonstrated how much hospitals could learn from the cruise industry regarding process, customer satisfaction, cultural diversity, infection prevention, just in time alignment and integration of communication via technology, customer centricity, human factors, and an amazing amount of more. As one quick example, embarkation and disembarkation (insert the words admission and discharge here) has ample opportunity of application to hospitals and is something Viking accomplishes very, very well.

Upon further reflection, there are many other similarities. As with a well-managed cruise ship, a hospital operates within limited parameters of space, resources, and time frames. Their efficient use of supplies, personnel, synergies, and equipment via methodology, innovation, and best practice promote optimal outcomes that support the mission.

Comparisons Between a Cruise Ship and a Hospital:

  • Cruising guests have a typical “length of stay” of 72 hours to two weeks – which compares well against many typical hospitalizations. There are fewer outlier guests with cruise trip durations of months. This is analogous to patient experience of long-term care or rehab, for example.
  • Cruise ships and hospitals are each complex adaptive systems of interconnected parts, multiple specialties, distributed control, and in perpetual motion.
  • Similar to hospitals, reputable cruise ships abide by accreditation and regulatory standards – including similar health and safety requirements.
  • Satisfaction, outcomes and loyalty metrics are just as important to cruise ships as they are to hospitals. Within these two industries, each with ample competition and customer/patient satisfaction incentive, approximately 70% of the guests during an on-ship presentation raised their hands when asked who were returning Viking customers. Conversely, patient hospital choice in the United States is often limited by insurance. But despite significant effort to improve patient satisfaction and outcomes, hospitals continue to struggle. Only 22% of Florida’s 168 eligible reporting hospitals managed the overall highest rating of 4 or 5 stars (Medicare.gov Hospital Compare, Oct 2018).
  • Finally, keeping a self-contained small city fully operational 24 hours a day are accurate descriptions of both a hospital and a cruise ship.

In all fairness, there are significant differences also. One example is a staffing comparison. During this cruise, there were approximately 930 guests on board and slightly more than half that many staff. Cruises have far fewer staff per guest than hospitals have staff per patient. And yes – unlike hospitalized patients, cruising guests are generally healthy and choose to cruise. While a hospital may care for patients of all ages, Viking caters to Baby Boomers with most of the guests on the ship approaching or of retirement age.

Examples of Cruise Ship Operations (and possible applications for hospitals in italics):

  • A quick scan of the ship-provided-guest-identification-card brings up a photograph and information of the guest to verify identity. (Application in hospitals may be for patients who are unconscious, confused, otherwise unable to speak their name and date of birth, or perhaps for police if the patient elopes.)
  • The use hand sanitizer stations and sinks with running water are encouraged by an attending staff member of each guest before stepping onto the ship or into dining areas. (Hospitalized patients seldom properly wash their hands before meals and they are often provided “finger foods”. Hand sanitizers (let alone sinks) are not often found near hospital vending or coffee machine areas, or at multiple hospital entry points. Also, unlike cruise ships, hospitals are frequently visited daily by many others for deliveries, inspections, visiting, sales people, general public, students, interviews, etc. – which can serve as vectors for infection.)
  • Use of Human Factors includes cabin design consideration of a bedside light switch to the bathroom area to safely light the way at night when needed. (Unlike a typical hospital bed with no such bedside light switch to aid the patient and/or Nurse in a high “fall” situation.)
  • Each cruise staff routinely greet guests with “good morning” (or afternoon or evening as appropriate) which helps orient international travelers to local time zones. Recorded crickets are heard chirping within public restrooms and outside deck areas in the evening. (Twelve-hour clocks are common in hospital patient rooms with no indication as to whether it is day or night.)
  • An LCD screen in each cabin provides a guest-specific daily agenda with current date, time, location, weather, and special instructions every morning. For example – “John D. Please join us on Deck One by 10 am with your ID card for the tour on shore. You may wish to bring the umbrella in your cabin closet with you.” Also, a live video outside the ship provides a quick look at the local weather. (Perhaps for an Inpatient, the screen could display HIPAA compliant Patient first name and last name initial, room number, hospital name, city, date, Nurse name and contact, approximate times of meals, lab draw, therapies, and medications. Remember – call your Nurse before getting into or out of bed!)
  • Cabin cleaning is efficiently conducted when the guest is out of the room to allow for best cleaning and the least disruption for the guest. (Could Environmental Services be notified to clean the room while the patient is in CT? Also, for the safety of patient belongings or valuables, an in-room safe can only be opened by patient ID band or personal code.)
  • Do not disturb door signs are provided should the guest choose to rest during the day. (Can a hospitalized patient request 20 minutes of quiet uninterrupted time during an afternoon – perhaps with the door slightly open for nurse visual checks?)
  • The Viking mission is integrated throughout operations, services and process – and revolves around the guest. For example, many Viking ships are nearly identical in design to provide returning guests a comforting orientation. Way finding signs, printed material, video, maps, overhead announcements, website, and more focus first on consideration of guest needs. (How can mission be reflected in policy & procedure, evaluations, patient grievance process, agendas, bylaws, patient education, construction, technology, incident reports, continuity of care, etc.?)
  • Staff hiring places a priority on the Affective Domain (attitude, values, and motivation). Cruise ships hire “happy” people who are eager to please customers with personalized service before investing in training the specific knowledge and skills needed. Staff are provided recognition when a guest mentions them by name favorably on evaluations. (Applications to healthcare are obvious.)

Application of Just-in-time, Task-directed, Guest-centrist Technology:

At a restaurant dining area on the ship, the guest ID cards of two guests are swiped by a staff member (or cabin numbers are provided) at the entrance area. The guests are invited to clean their hands. Immediately thereafter, a waiter greets and addresses the guests by name and takes them to an assigned numbered table.

Within a few minutes, the waiter enters the breakfast orders of these two guests into a hand-held smart phone. Soon thereafter, another waiter arrives with the orange juice requested of one guest. Within moments, yet another waiter brings the cinnamon roll, decaf coffee, and a large spoon for the oatmeal requested of the other guest. After finishing the meal, the chef comes to that table to ask how the eggs benedict ordered by the first guest was. Often this occurs with no verbal communication among the restaurant staff. Customized service is provided by portable technology while providing the potential of real time food inventory, nutritional preferences, dishes to wash, visit volumes by day, time, duration for staffing purposes, etc. The use of technology quickly connects tasks and items with specific needs and location – and the name of the beneficiary. (Possible application may be processing outpatients throughout the surgical experience or the admission, transfer, and discharge bed management and staffing throughout a hospital?) 

Elsewhere, headphones aid a self-guided tour of art work throughout the ship for guests, the cultural diversity of staff and guests is embraced, shared and welcomed, a colorful indoor garden and live violin music invites a respite, and scenic window views are accessible by those in wheelchairs.

Granted, a hospital admission stands no chance of being confused with a pleasure cruise. Patients usually have little alternative other than to be in the hospital – whereas passengers are on the ship by choice. But regardless of situation, superior operations result in a sense of connectedness among the recipients and the environment with purpose, gratitude, and meaning. It is a type of contentment that goes beyond the needs listed by Abraham Maslow – and it gains further importance during a hospital admission. In short, life continues during illness and deserves not only notice, but the respect and attention of integrated, appropriate, and timely support. This is where the art of excellence compliments the science of healthcare.

I encourage others to relax where staff anticipate your needs before you do aboard a Viking cruise ship. Experience the remarkable soul-rejuvenating comfort of simply being human. While you are there, go to the World Café on Deck 7 for breakfast. Watch the coordinated operation of teamwork combining quality, accuracy, efficiency and speed as Cooks and Chefs prepare eggs in dozens of different ways on demand by hundreds of guests. This provides a glimpse of the attention to detail and finely choreographed process so evident throughout the ship.

Having cruised with other cruise lines and worked for decades throughout healthcare, I have seen hundreds of attempts at quality improvement. Healthcare has learned of process and tools from aviation, power plants, hotels and more. Nonetheless, it is rare to encounter application of mission as holistic as I experienced aboard this cruise. I invite Viking to share your operations behind the scenes with those of us striving to improve healthcare. As with life, improvement is a journey and quality is the appreciation of the extraordinary you encounter along the way. Thank you for your pervasive and comprehensive commitment to excellence.

Finally, I encourage healthcare improvement and safety organizations participation as together we explore and learn from those who excel in operations to provide exceptional service and quality within any industry.

Special thanks to Thomas Leitner, General Manager, Viking Orion, for his time and insight and to Viking Corporate Communications for the review and approval of this article. There was no sponsorship by any entity in any manner and healthcare related opinions, applications, and content are strictly those of Hii.

Reference:

Medicare.gov Hospital Compare, (Oct 2018).   https://www.medicare.gov/hospitalcompare/results.html#dist=25&state=FL&lat=0&lng=0

Viking links of interest:

https://www.vikingcruises.com/oceans/why-viking/viking-difference/main.html

https://www.vikingcruises.com/oceans/ships/viking-orion.html

Viking recognition and awards – https://www.vikingcruises.com/oceans/why-viking/awards/index.html

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