BEST PRACTICE

InCustomers

by Leonard L Berry

and Neeli Bendapudi

When a company's

offerings are hard

to judge, customers

look for subtle

Indicators of quality.

The Mayo Clinic

knows how to send

the right signals.

N OBODY LIKES going to the hos-pital. The experience is at bestunnerving, often frightening,

and, for most of us, a potent symbol ofmortality. What's more, it's very hard forthe average patient to judge the qualityof the "product" on the basis of directevidence. You can't try it on, you can'treturn it if you don't like it, and youneed an advanced degree to understandit - yet it's vitally important. And so,when we're considering a doctor or amedical facility, most of us unconsciouslyturn detective, looking for evidence ofcompetence, caring, and integrity-processing what we can see and understandto decipher what we cannot.

The Mayo Clinic doesn't leave thenature of that evidence to chance. Bycarefully managing a set of visual andexperiential clues. Mayo tells a consis-tent and compelling story about its ser-vice to customers: At Mayo Clinic, thepatient comes first. From the way it

hires and trains employees, to the wayit designs its facilities, to the way itapproaches care. Mayo offers patientsand their families concrete and con-vincing evidence of its strengths and val-ues. The result? Exceptionally positiveword of mouth and abiding customerloyalty, which have allowed Mayo Clinicto build what is arguably the most pow-erful brand in health care - with verylittle advertising-in an industry wherefew institutions have any brand recog-nition beyond their local markets.

It's called "evidence management":an organized, explicit approach to pre-senting customers with coherent, hon-est evidence of your abilities. Evidencemanagement is a lot like advertising, ex-cept that it turns a company into a liv-ing, breathing advertisement for itself.Other organizations manage evidencewell, too. Ritz Carlton, for example, veryeffectively communicates outstandingpersonal service: Employees at all levels

100 HARVARD BUSINESS REVIEW

take note of customer preferences andare empowered to solve problems onthe spot, continually tailoring the expe-rience to each person. Mayo Clinic doesnot have all the answers; health care isa highly inventive industry, and manyinstitutions could serve as fine exam-ples to business. However, during ourextensive study of the Mayo organiza-tion over a five-month period, we sawevidence-management practices thatrival or surpass anything we've seen in

the corporate sector, practices that areapplicable outside of health care. Aspart of our research design, we inter-viewed approximately 1,000 Mayo em-ployees and patients, observed hun-dreds of doctor-patient visits at two ofMayo's three major campuses (Scotts-dale, Arizona, and Rochester, Minnesota;the third is in Jacksonville, Florida), andstayed in the hospitals overnight as pa-tients. In almost every experience andinteraction, in subtle and not-so-subtle

ways, we got the message that at MayoClinic, the patient comes first.

Many businesses sell products thatare intangible or technically complex-financial and legal services, software,and auto repair are just a few-and theircustomers naturally kxik for clues thatcan help explain what they don't under-stand or see. In fact, in just about any or-ganization, the clues emitted by peopleand things (humanics and mechanics,respectively, as introduced to the man-agement literature by Lewis Carboneand Stephan Haeckel) tell a story to cus-tomers or potential customers. The ques-tion for managers is whether the cluestell the intended story. Mayo Clinic's ef-fectiveness at designing and managingevidence offers a lesson other serviceorganizations would do well to heed:Understand the story you want to tell,and then make sure your people andyour facilities provide evidence of thatstory to customers, day in and day out.

FEBRUARY 2003 101

BEST PRACTICE • Clueing In Customers

Clues in People

When we interviewed Mayo patients,we were struck by how consistently theydescribed their care as being organizedaround their needs rather than the doc-tors' schedules, the hospital's processes,or any other factor related to Mayo's in-ternal operations. The actions of Mayostaff members, according to what wewere told, clearly signal the patient-firstfocus. Here are representative remarks:"My doctor calls me at home to checkon how I am doing. She wants to workwith what is best for my schedule.""When 1 had a colonoscopy, [my doc-tor] waited to tell me personally thatI had a polyp because he rememberedthat my husband died from small bowelcancer, and he knew that I would beworried I may have the same thing.""My oncologist is...the kindest man Ihave ever met. He related some of hispersonal life to me. I was more than myproblem to him. He related to me asa person."

Such glowing praise isn't limited justto the doctors and nurses. One patient,for example, was "amazed" at how wellthe people at the registration desk han-dle requests: "People who come up tothe desk are nervous, or angry, or abu-sive. These ladies at the registration deskjust keep their cool. I wish they couldtrain the customer service reps in de-partment stores."

It's no accident that employees com-municate a strong, consistent messageto patients. Mayo explicitly and system-atically hires people who genuinely em-brace the organization's values. Theclinic emphasizes the importance ofthose values through training and on-going reinforcement in the workplace,a practice that began in the very earlypart of the twentieth century, whenDrs. William and Charles Mayo startedthe organization. Indeed, William Mayo's

credo-"The best interest of the patientis the only interest to be considered"-guides hiring decisions to this day.

It's difficult to get a job at Mayo Clinicbecause of intellect or technical skillalone. Demonstrated task competenceis essential, of course, but the hiringmanagers are also trained in behavioralinterview techniques, and they are ex-pected to use them to elicit an appli-cant's values. A candidate may be asked,for instance, to discuss a time when he

continuity that, in turn, helps boost thequality of care.

Once hired, all new employees gothrough an orientation process specifi-cally designed to reinforce the patient-first mentality. The program for non-physician empioyees-whether janitors,accountants, or nurses - is designed tohelp all staff people understand howtheir jobs affect patients'care and well-being. If housekeeping fails to main-tain sanitary conditions, for instance, a

Evidence management is a lot like advertising,

except that it turns a company into a living,

breathing advertisement for itself.

set a developmental goal for himselfand how he met that goal, or to describethe proudest moment in his career oreven the moment he found most frus-trating. Interviewers avoid discussinghypothetical situations that allow can-didates to figure out the "right" answerand instead probe for specific detailsthat reflect true experiences and per-spectives. For example, a candidate whoidentifies making a difference in a pa-tient's life as his or her proudest mo-ment may be more attuned to Mayo'svalues than one who mentions achiev-ing a career milestone.

The people who make the cut - in-deed, the people who are drawn toMayo in the first place-are those whotake pride in having the freedom toput patients first. We heard many doc-tors and nurses say that they appreciatebeing allowed to practice medicine asthey feel it should be practiced. Thosefeelings of pride and the alignment ofemployees' attitudes with Mayo's valuescontribute to lower stafPtumover acrossthe board. Annual turnover amonghospital nurses is only 4% at Mayo ver-sus 20% for the industry as a whole -

Leonard L. Berry is Distinguished Professor of Marketing and holds the Zaie Chair ofRetailing and Marketing Leadership at Texas A&M University in College Station. NeeliBendapudi is an associate professor of marketing at Ohio State University in Colum-bus. Berry is author of "The Old Pillars of New Retailing" (HBR, April 2001), and Ben-dapudi is coauthor of "How to Lose Your Star Performer Without Losing Customers, Too"(HBR, November 2001).

patient's health may be compromisedno matter how excellent the medicalcare received. Storytelling figures heav-ily in these programs, with the empha-sis on how employees have used Mayovalues to make difficult decisions on pa-tients'behalf.

Storytelling continues in the work-place because, once people are awayfrom the classroom, the idea of puttingthe patient first can seem distant andsometimes even unrealistic, given thestress and unpredictability of day-to-daywork. Consider, for instance, one storyfeatured at several orientation sessionsand widely disseminated throughoutthe organization. A critically ill patientwas admitted to the Scottsdale hospitalshortly before her daughter was to bemarried, and she was unlikely to live tosee the wedding. The bride told the hos-pital chaplain how much she wantedher mother to participate in the cere-mony, and he conveyed this to the criti-cal care manager. Within hours, the hos-pital atrium was transformed for thewedding service, complete with fiow-ers, balkx>ns, and confetti. Staff mem-bers provided a cake, and nurses ar-ranged the patient's hair and makeup,dressed her, and wheeled her bed to theatrium. A volunteer played the pianoand the chaplain performed the service.On every flotir, hospital staff and visitingfamily and friends ringed the atriumbalconies, "like angels from above," to

102 HARVARD BUSINESS REVIEW

Clueing In Customers • BEST PRACTICE

quote the bride. The wedding scene pro-vided not only evidence of caring to thepatient and her family but also a strongreminder to the staff that the patient'sneeds come first. They got the message:We heard the story again and again inour interviews with employees.

Another story was initially told at aleadership development program for ris-ing Mayo administrators. In one session.Mayo staff members shared experiencesthat showed how the service philosivphy affects care. An emergency roomphysician told of a patient who walkedinto the ER with severe shortness ofbreath. When told she had a bacterial in-fection requiring immediate surgery,the woman expressed concern abouther sick dog, which was in her illegallyparked truck. The attending nurse as-sured her that he would move the truckand take care of the dog, but when hewalked outside, what he saw was not apickup but a semi, which he wasn't li-censed to drive. He was about to have ittowed - for $700 - when he stopped toconsider ways he might save the patientthe expense. In the end, the nurse tookit upon himself to obtain permissionto park the truck at a nearby shoppingcenter for a few days and find a fellownurse - a former trucker - to drive thetruck there. He took the dog to a vet-erinarian and then cared for it in hisown home while the patient recovered.When asked what prompted him to dothis, the nurse replied,"At Mayo Clinic,the patient's needs come first."

Various events celebrating excep-tional service on behalf of patients fur-ther reinforce empk^ees' commitments.The Rochester campus hosts an annualHeritage Week, celebrating the clinic'shistory and values and reinforcing theirrelevance to Mayo's work today throughhistorical presentations and displays,lectures, ecumenical and liturgical ser-vices, concerts, and social events. Em-ployees, retirees, volunteers, patients,visitors, and members of the communityare invited. Mayo Rochester also recog-nizes exceptional service with its quar-terly campuswide Karis Award (Karis isGreek for caring). All staff membersare eligible and can be nominated by a

coworker, patie ily member;the identity oft tor is not dis-closed, which removes political consid-erations from the process. One 1999winner, a world-renowned colorectalsurgeon with numerous scientific recog-nitions, told his tablemates at the awardluncheon that he cherished the Karismore than any other award he'd re-ceived, calling it "the only award 1 havefor just being a really good doctor."

Clues in CollaborationIn 1910, William Mayo said: "In orderthat the sick may have the benefit of ad-vancing knowledge, union of forces isnecessary... .It has become necessary todevelop medicine as a c(x>perative sci-ence." Dr. Mayo's vision protbundly in-fiuences the organization's approachto care. Patients experience the MayoClinic as a team of experts who are fc>cused on patients' needs above all else.

They perceive an integrated, coordi-nated response to their medical condi-tions and, often, to related psychologi-cal, social, spiritual, and financial needs.Elsewhere, doctors may be reluctant toadmit to any gaps in their knowledge.Not so at Mayo. Mayo Clinic assemblesthe expertise and resources needed tostilve the patient's problem. If a Mayodoctor can't answer a question andneeds to bring someone else onto ateam, she freely admits it to the patient.The doctors meet with one another andwith the patient-visible evidence thatthey are collaborating to solve the pa-tient's problem rather than passing itfrom one doctor to another. One patientwe interviewed expressed a commonsentiment when he said,"I have a lot ofproblems, and 1 like that I can go toMayo and be seen by a team of special-ists who work together to see the bigpicture." Collaboration is particularly

The ResearchMayo Clinic has three major campuses (Rochester, Minnesota; Scottsdale,

Arizona; and Jacksonville, Florida); primary care clinics in more than

60 communities; 21 owned or managed hospitals; more than 2,800 staff

physicians; medical technology, medical publishing, laboratory, and

health care benefits-administration businesses; and revenue in excess

of S4 billion. It serves more than 500,000 individual patients annually.

For this article, we conducted the largest service study ever done at

Mayo Clinic. During a five-month period, we interviewed approximately

1,000 Mayo patients, physicians, nurses, allied health staff̂ and managers

at the original Rochester campus and the Scottsdale campus. We also

collected data as participant observers, checking into the hospitals as

patients, observing surgeries in the operating room and more than 250

doctor-patient interactions in the examination room, making hospital

rounds, and flying on the Mayo One emergency rescue helicopter service.

We formally studied service delivery in 14 medical specialties selected to

provide a cross-section of the practice: cardiac surgery, cardiology, derma-

tology, emergency medicine, endocrinology, family medicine, gastroen-

terology, medical and radiation oncology, neurology, orthopedic surgery,

preventive medicine, thoracic surgery, transplant surgery, and urology.

Mayo Clinic gave us complete access to study its service culture and

processes, and our study was approved by the Mayo Clinic Institutional

Review Board.

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important because the institution's rep-utation has become so well known thatpatients often come in looking for a mir-acle. Many have consulted several otherdoctors and consider Mayo the last re-sort, so the physicians there regularlysee patients with complex problems andhigh expectations, a situation that putsthe doctors under extra pressure tomake the right diagnoses and treatmentdecisions and not miss often subtle med-ical distinctions.

Mayo Clinic encourages this type ofcollaboration through various organi-zational incentives. All physicians aresalaried, so they don't lose income byreferring patients to colleagues, and theorganization explicitly shuns the starsystem, downplaying individual accom-plishments in favor of organizationalachievements. In the words of one car-diovascular surgeon,"By not having oureconomics tied to our cases, we are freeto do what comes naturally...to helpone another." Doctors who are focusedon maximizing their incomes or whowant to be the star of the show don'twork for Mayo Clinic. A surgeon spe-cializing in the liver explained, "The

virtual interaction is just as commonas in-person teamwork at hallway orbedside consults. One physician toldus, "I never feel I am in a room by my-self, even when 1 am." Recently, for ex-ample, a Mayo ENT specialist in Scotts-dale called together 20 doctors from allthree campuses to discuss a difficultcase-a patient with skin cancer at riskfor metastasis and, owing to the neces-sary surgery, nerve injury and disfig-urement. The team, assembled in a day,met by videoconference for an hourand a half and reached a consensus fora course of treatment, including spe-cific recommendations on how aggres-sively to sample the patient's lymphnodes and how best to reconstruct thesurgical wound.

Mayo's electronic medical record(EMR) improves the clinic's ability topresent a seamless, collaborative orga-nization and manage the evidence thatpatients see. The EMR provides an up-to-date narrative ofthe patient's symp-toms, diagnoses, test results, treatmentplans, procedures, and other relateddata, connecting in- and outpatient in-formation and communicating across

In just about any organization, the clues emitted

by people and things tell a story to customers

or potential customers. The question for managers

is whether the clues tell the intended story.

kind of people who are attracted towork for Mayo Clinic have a value sys-tem that places the care of those in needover personal issues such as salary, pres-tige, and power. There is little room forturf battles. It is never a problem to add[a new case] on to the workload of tbeday. It's simply the best thing to do forthe patient."

Mayo also supports teamwork withits use of technology. Staff memberspartner via a combination of face-to-face and remote collaboration usinga sophisticated internal paging, tele-phone, and videoconferencing systemthat connects people quickly and easily.Remote teamwork through voice or

disciplines in outpatient practices. Thisconnection is critical to patient-first de-cisions in ways that patients don't nec-essarily see. One emergency room physi-cian said it had prevented ber fromintubating a patient who had asked notto be resuscitated, for instance, and oth-ers told ofthe importance of tbe EMR inmanaging patient medications to avoidallergic reactions or dangerous drug in-teractions. But patients notice and ap-preciate the single source of informa-tion as well, as we beard time and againin our researcb. One patient told us: "Onmy last visit, the doctor pulled up al! mytest scores from the past five years on acomputer and showed me the trends,

HARVARD BUSINESS REVIEW

and we discussed what to do. I thoughtthat was excellent." In short, patientstold us in numerous interviews thatMayo's team service gave them a sensethat the organization was coordinatingits resources to provide the best possiblecare, with the patients' needs foremostin employees'minds.

Clues in Tangibles

In health care,the visual clues about aninstitution's core values and the qualityof care are particularly difficult to sepa-rate from the actual service becausepeople spend significant time in the fa-cility-some stay for days or even weeks.The physical environment is also con-nected to medical outcomes: The po-tential of design to promote healingthrough stress reduction has been doc-umented in dozens of studies. For thesereasons, more medical institutions aremaking an effort to create open, wel-coming spaces with soft, natural light.Mayo Clinic goes further with its designphilosophy, which is perhaps as wellhoned and articulated as that of anymajor service provider in America, andpays strict attention to how every detailaffects the patient's experience.

From public spaces to exam rooms tolaboratories. Mayo facilities have beendesigned explicitly to relieve stress, offera place of refuge, create positive dis-tractions, convey caring and respect,symbolize competence, minimize theimpression of crowding, facilitate way-finding, and accommodate families. Inthe words ofthe architect who designedMayo Rochester's new 20-story GondaBuilding: "I would like the patients tofeel a little better before they see theirdoctors." A well-designed physical envi-ronment has a positive impact on em-ployees as well, reducing physical andemotional stress-which is of value notonly to employees but also to patientsbecause visible employee stress sendsnegative signals. In our interviews, pa-tients commented on the lack of appar-ent stress; one said,"It did not seem likea doctor's office when we went to Mayo.There was no tension."

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BEST PRACTICE > Clueing In Customers

and floor, glasswork sculpture sus-pended above, and a multistory wallof windows looking onto a garden. Thebuilding's soaring lobby houses a can-cer education center because, as one ad-ministrator put it, "the more visible thecenter, the more you remove the stigmaof having cancer." The lobby of MayoClinic Hospital in Scottsdale is also vi-sually stunning, with its atrium,indoor waterfall, stonework,and wall of windows over-looking a mountain range.

Mayo doesn't limit its fa-cilities' clue managementto public spaces. After all,the scary stuff in a medicalfacility happens elsewhere-inthe catheterization lab, in diagnos-tic imaging, in the hospital room. AtMayo hospitals, staff members write thenames of attending doctors and nurseson a white board in every patient'sroom, which helps stressed-out patientsand families keep track of multiple care-givers and serves as a visible clue thatthere's a real person they can talk withabout any concerns. In-hospital show-ers, microwave ovens, and chairs thatconvert to beds are available for familymembers because, as one staff memberexplained, "People don't come to thehospital alone." The pediatric section ofthe emergency department of Mayo'sSt. Mary's Hospital in Rochester trans-formed artwork by local schoolchildreninto a colorful array of wall and ceilingtiles. The resuscitation equipment inpediatric examination rooms is hiddenbehind a large picture (which slidesout of the way when the equipment isneeded). While the hospital was underconstruction at the Scottsdale campus,officials arranged to have an automo-bile lifted into the building so physicalrehabilitation patients would be able topractice getting in and out of a car in theprivacy of the hospital.

Environmental clues in the outpa-tient setting are orchestrated just ascarefully. Mayo Clinic buildings includequiet, darkened private areas where pa-tients can rest between appointments.Public spaces are purposely made softerwith natural light, color, artwork, piano

music, and the sights and sounds offountains. In examination rooms, thephysician's desk is adjacent to a sofalarge enough for the patient and familymembers, a design that removes thedesk as a barrier between doctors andtheir patients.

Mayo also understands that the wayemployees present themselves sends

a signal to patients. Patientsdon't encounter doctors in

casual attire or white coats.Instead, the more than2,800 staff physicianswear business attire, un-less they are in surgical

scrubs, to convey profes-sionalism and expertise. It's

a dress code that some outsideMayo have called"pretentious,"yet we'dargue that it's no more pretentious than,say, the dress code for airline pilots. Air-line passengers don't want to see theirpilot in a polo shirt, and patients feel the

them. Offended, Morris said that sheworked in a laboratory, not with pa-tients, so why should it matter? Her bossreplied that Morris had contact withpatients in ways she didn't recognize -going out on the street wearing herMayo name tag, for instance, or passingpatients and their families as she walkedthrough the halls-and that she couldn'trepresent Mayo Clinic with dirty shoe-laces. "Though I was initially offended,I realized over time [thatl everything Ido, down to my shoelaces, representsmy commitment to our patients andvisitors," Morris told us. "T\venty-eightyears later I still use the dirty shoelacestory to set the standard for the servicelevel I aspire to for myself and my co-workers."

A dirty shoelace might seem prettyminor, given the important work of car-ing for the ill. But a shoelace is some-thing a customer can see, whereas med-ical expertise and technical ability are

Clearly identify a simple, consistent message, and

then manage the evidence-the buildings, the

approach to care, even the shoelaces-to support

that message, day in and day out

same way about doctors. In effect. MayoClinic doctors-just like service work-ers in many other industries - work ina uniform; it's a visible clue that com-municates respect to patients and theirfamilies.

Such attention to visual clues ex-tends to the most minute detail. MayoRochester employee Mary Ann Morris,the administrator of General Serviceand the Office of Patient Affairs, oftentells a story about her early days withthe organization. She was working in alaboratory-a job that required her towear a white uniform and white shoes-and after a hectic morning getting hertwo small children to school, she arrivedat work to find her supervisor staring ather shoes. The supervisor had noticedthat the laces were dirty where theythreaded through the eyelets of Mor-ris's shoes and asked Morris to clean

not. It's a piece of evidence, a small butintegral part of the story Mayo tells toits customers. We aren't arguing that"patients first" is the only story a med-ical institution might choose to tell pa-tients. A hospital might instead chooseto signal,"We hire the smartest doctors,"and manage the evidence with promi-nent displays of academic credentialsand awards, a lecture series, and heavypublicity about new research. WhatMayo Clinic has done better than justabout any organization we can think of,however, is clearly identify a simple,consistent message and then managethe evidence-the buildings, the ap-proach to care, and, yes, even the shoe-laces-to support that message, day inand day out. ^

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106 HARVARD BUSINESS REVIEW

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