Patients Come Second

Paul Spiegelman, cofounder and CEO of The Beryl Companies, a patient experience service organization in Dallas, Texas, and Britt Berrett, president of the 900-bed Texas Health Presbyterian Hospital Dallas, argue that the U.S. healthcare system will improve only when leaders prioritize employee engagement above all else. The book's title, which places patients second, is deliberately provocative. The authors reproduce an email exchange with an industry professional named Wendy, who objects that the title gives leaders an excuse to deprioritize patients. Spiegelman responds that the title is meant to spark a necessary conversation: The best way to serve patients is to first invest in the people who care for them.

The book opens with a personal anecdote illustrating how the patient experience often falls short. Spiegelman recounts two contrasting encounters while seeking a vasectomy. The first doctor's office made him wait two hours, denied him a meeting with the physician, and treated him impersonally. The second doctor, recommended by Berrett, provided preparatory videos, a face-to-face consultation, and a handwritten post-surgery follow-up note. The authors define patient experience by citing The Beryl Institute, a patient-experience research organization: It is the sum of all interactions, shaped by organizational culture, that influence patient perception across the continuum of care.

The authors note that healthcare is shifting toward a consumer-focused model with unprecedented patient choice. The federal government ties reimbursement to HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) patient-satisfaction survey scores and low readmission rates, making patient experience a financial imperative. Yet most executives have responded by adding beds or adopting new technology rather than investing in employees. The authors cite the 2007 book Firms of Endearment, which found that companies known for strong employee cultures produced a 1,025 percent return for investors over ten years, compared to 122 percent for S&P 500 companies, as evidence that engagement pays off.

Having established the business case, the authors argue that leadership must shift from command-and-control to transformational, purpose-driven models. They open with the historical case of Ignaz Semmelweis, a 19th-century Hungarian physician who discovered that hand washing reduced maternal mortality from 35 percent to under 1 percent but whose peers rejected his findings. In modern hospitals, the authors observe, departments with the highest hand-washing compliance engage workers in conversations about values and calling rather than simply enforcing rules. They connect this insight to what scholar James MacGregor Burns called transformational leadership, in which leaders inspire followers to internalize organizational goals. Generational shifts reinforce the need for this approach: As baby boomers retire and millennials enter the workforce, employees increasingly seek purpose rather than just financial rewards.

The authors define three building blocks of transformational leadership: mission (why we are here), vision (where we aspire to go), and values (the rules we live by). Berrett describes arriving at Medical City Dallas Hospital, where no mission statement existed. Spiegelman recounts his initial skepticism about mission-driven thinking at BerylHealth, a call center serving healthcare clients. After cross-functional teams developed the mission "Connecting people to health care," the company's focus sharpened and turnover dropped. Employees were renamed "patient experience advocates." The authors introduce BerylHealth's Circle of Growth concept: Investing in employee loyalty drives customer loyalty, which drives profits, which can be reinvested in employees.

The authors contend that fun and humor are essential tools for building engagement and reducing burnout. Berrett describes sitting in a dunk tank for four hours at a company picnic. Spiegelman describes dressing as television host Howie Mandel to emcee a talent show and competing in "Dancing with the Executives." At Texas Health Presbyterian Hospital, the leadership team held 18 employee forums combining mission review with music videos and costumed senior leaders. The hospital's engagement score rose from the 50th percentile to the 81st in one year and reached the 93rd at the time of writing. A survey correlation showed that the 13 percent of employees who reported not having fun matched the 13 percent who were actively disengaged. Engaging physicians proves more challenging, as doctors are socialized to be stoic, but the authors found that approaching reluctant physicians individually rather than as a group yielded enthusiastic participation.

The authors argue that genuinely caring about employees' personal lives fuels engagement. Berrett, a natural hugger, traces his empathetic leadership to weeks recovering in a hospital burn unit at age 15. Spiegelman, more introverted, relies on Beryl Cares, a database tracking birthdays, family events, and accomplishments, from which he writes handwritten notes each morning. They describe employees rallying to support twin 20-year-old BerylHealth employees whose apartment burned down, raising $1,500 that the company matched. Spiegelman also donated a company car to a peer-chosen employee who had given his own car to his mother and had been walking seven miles each way to work.

The authors extend their argument beyond organizational walls, contending that supporting employees' community involvement deepens engagement. BerylHealth's Better Beryl Bureau committee lets employees decide where the company invests community resources. At Medical City, employees chose one major charitable effort each year, contributing over $1 million over a decade. The authors caution that hands-on local service is more effective for engagement than donating to distant causes.

The book addresses the necessity of removing toxic employees, whom the authors categorize as whiners (perpetually negative), losers (competitive in self-pity), and jerks (corrosive influences). Berrett recounts firing a nurse whose pattern of rudeness had been tolerated because she covered a busy shift; the reaction across the hospital was relief. They cite the lifetime value of a single patient as approximately $250,000 and stress rigorous hiring, including personality tests and multi-level interviews. They urge leaders to shift attention from managing problem employees to investing in stars like Thao, a neonatal nurse who remembered a patient couple's anniversary and surprised them with a restaurant dessert.

The authors present their core equation: Employees come first, patients come second, and financials come third. Financial performance, they argue, is a lagging indicator. They advocate for regular engagement surveys, distinguishing between satisfaction and true engagement, and describe BerylHealth's practice of forming cross-functional teams to address the five lowest-scoring categories each year. They emphasize celebrating victories through internal awards and external recognition, such as Medical City earning Magnet designation from the American Nurses Association, a credential recognizing nursing excellence that attracted top talent and raised competitive standards.

On rewards and recognition, the authors insist programs must be personalized and peer-driven. Berrett hands out "Berrett's Carrots," small stuffed toy carrots, at leadership meetings to acknowledge acts of kindness. BerylHealth's PRIDE program (Peers Recognizing Individual Deeds of Excellence) lets employees nominate coworkers for exemplifying core values, with quarterly drawings and $250 prizes. The authors also argue for lifelong learning, noting that dental hygienists face continuing education requirements while hospital executives do not. BerylHealth holds Saturday morning professional development sessions and a 10-week Dashboard of Leadership program for peer-nominated participants. Both organizations maintain book clubs. Spiegelman devotes particular attention to mentorship, describing his relationship with a former client CEO named John, who built a $30 billion enterprise. Spiegelman wrote John a $20,000 check and asked him to serve as a formal accountability partner, and the two have connected monthly ever since.

The book closes by framing employee engagement as a purpose-driven calling rooted in the Golden Rule. The authors present a 10-question self-assessment called the Culture IQ (CIQ) score, with each question mirroring a chapter's theme and rated on a scale of 1 to 10. They encourage leaders to have employees take the same assessment to compare perceptions and benchmark against other organizations, framing the current moment in healthcare as one of historic opportunity.