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There is nobody who walks the path to the NIST Malcolm Baldrige Quality Excellence award and calls it a sprint. It is something deliberately undertaken with some knowledge that it will be a matter of years before you have any real chance of being one of the organizations named a winner. And St. David’s HealthCare in Austin, TX, is no different. For them, it was a journey of more than a decade before they got the call in November that they were among the 2014 winners.
The joint venture with St. David’s HealthCare Foundation, HCA, and Georgetown Community Health includes six hospitals, six ambulatory surgery centers, and several physician practices. Initially, the Baldrige method was viewed by a new CEO as a great method to assess the organization when he joined in 2003, says David Thomsen, vice president of quality for the organization. "He didn’t talk about the award at all," Thomsen says. "It was just questions we used to assess our approaches and deployment across the breadth of the organization."
Indeed, even as word about Baldrige spread, it wasn’t the award that was the idea in mind, but merely the benefit of the framework the Baldrige method provides. "Our mission is to provide exceptional care every day," Thomsen says. "This allows us to ask questions about how we lead, how do we use data, how do we mine data."
It took four years of simply asking questions and putting new structures in place before the organization even put together a state application, and another year before they received any recognition from Texas for their efforts. "We kept applying and getting feedback," he says. In 2013, there was a national site visit, and another this past year. "We simply had a methodical approach," Thomsen explains. "We took things slowly and let them sink in deeply until they were hardwired. We weren’t concerned about the end point of an award, but about the process."
During the years they put the structure in place, Thomsen says the organization struggled with many of the same issues other healthcare organizations do. One of the items that was a big problem — and solving was a big success — involved tackling emergency department wait times.
"Understanding customer requirements is category three for Baldrige," Thomsen says. "How can we listen to our customer requirements about emergency department wait times?" Years ago, people didn’t care as much about speediness. But now, there are freestanding EDs, urgent care centers, drug stores with clinics inside, and a population that can’t wait three minutes for a meal, let alone an hour for a doctor with a crying sick child. "You don’t want to rush something if there is a severe problem, but if it’s not, you want to get in and out in less than an hour," he says. "You want to see a doctor in 10 minutes."
The organization looked at several issues including where, geographically, it had services. Texas is a non-certificate of need state, so there is a lot of competition. They did some research and located four freestanding emergency departments in specific areas based on demographic needs that would suit patients who didn’t want to come to a busy hospital. They also changed the way they see patients, with immediate bedding. There is no triage, and every patient sees a physician within 10 minutes — down from about 30 minutes. Average length of stay is 45-60 minutes. Everybody associated with the ED knows with a few clicks on their phone or tablet or computer how long the wait time is in the ED.
The feedback report for the winning application came the week before Thomsen spoke to Hospital Peer Review and already he was getting ready to pull the team together for digestion, discussion, and consideration of how to improve. As a winner, the organization can’t apply again for five years. "But there is an annual rhythm to this," he says. "We will still sit down and write the application every year even if we can’t submit it."
They are also doing internal examiner training so that they will be better able to do internal critiquing during those off years, he says. "I see it as an investment in the future of healthcare."
Another element of investment is participation in the annual Quest for Excellence conference put on by NIST (scheduled for April; see http://www.nist.gov/baldrige/qe/index.cfm) — something Thomsen recommends for anyone interested in the Baldrige experience. "It helped us to really understand how the whole thing hangs together, and exposed us to a wide range of people in organizations in and outside of healthcare for whom this has worked," he says. "Service expectations of patients and consumers in general have changed dramatically over the years. The information you can get from FedEx or Ritz Carlton? That matters to us in healthcare. We find ourselves wondering how we can leverage the idea of the Apple Genius Bar for physician scheduling."
It pays off. The organization is not just successful in terms of quality, but financially successful, Thomsen says, having been able to provide some $50 million in community grants to non-profit organizations in the last year, and more than $200 million since 2007.
Thomsen acknowledges that the entire Baldrige journey from stem to stern may not be for every hospital. But it’s right for St. David’s. And understanding it is beneficial "whether you commit to the journey or not," he says "whether you are a barbecue joint or a school district or a small hospital" with a couple dozen beds. Reading the criteria, asking yourself the questions, even filling out the application every year, whether you send it in or not, can be a good exercise.
That said, just about every Baldrige organization will also tell you the best part of the exercise (if sometimes most harrowing) is going through the feedback report. Indeed, if there is one thing that winners say they will miss it’s the five years of feedback.
Debra Dooley, MBA, executive director of business intelligence for Hill Country Memorial Hospital, another of the 2014 Baldrige winners, is hoping there will be an informal group of winners that sends applications around during the five years. If there is, she’ll find it.
Hill Country started the journey to an award just about eight years ago, when the leadership noted the facility was performing in the 45th percentile of hospitals in a national healthcare benchmarking program. "We are a small community hospital," she explains. When the 86-bed facility was built in 1971, 93% of the community gave to the building fund. The new leadership considered it unacceptable to be at that level of performance.
Dooley had gone to a quality conference and heard Sister Mary Jean Ryan — the first Baldrige recipient in healthcare — speak. It got her thinking about frameworks.
Initially, she and a group of other members from leadership and management just researched the Baldrige criteria and started asking and answering the questions. Where they couldn’t answer, there was a gap, and where the gaps were largest every year, they worked to fill them. "Over time, we improved our rankings," she says.
The organization submitted an application first in 2010, then again in 2011. It skipped 2012 to dig in a little and work on some of the issues identified in the cherished feedback report. In 2013, Hill Country achieved a site visit, and was recognized for best practices in leadership.
It was a remarkable shift, she says, for a small organization. "We had so many informal processes in place," she notes. "A systems discipline was difficult for us, and we had to transfer knowledge, so that it wasn’t just a single person with the necessary information of a particular process."
Think of something like patient satisfaction, says Emily Padula, RN, MHI, executive director of integration and outreach. Customer experience scores were good, "but we had relied on our wonderful people for too long, that they would do great work all the time, rather than showing them what great pre-op teaching looks like, for instance."
They created front-line team councils to determine the best processes of care and appropriate measures of success. "We weren’t just telling them to fix something, but giving them the ownership of it, asking them to tell us what it looks like for pre-op teaching to be successful," Padula explains. "The front-line team is the knowledge expert. We just facilitate them."
Among the other initiatives the organization created because of Baldrige was the "Strategic Breakthrough Initiatives" (SBI) program. Dooley explained that the hospital often had a plan for a quality project and an end goal in mind, but the teams weren’t consistent in achieving the goals they set. When they looked at what better performing organizations were doing, they were better at action planning. For instance, a hospital working a particular core measure would have a team that reported weekly to executives for a quarter to make sure that something was hard-wired into the system. "We asked ourselves, what are the short-term action plans that would move us toward our goals?"
The first issue they used the SBI program on was to improve elective induction births under 37 weeks gestation. "We were at about 7% and had a goal of 3%," Dooley says. "We involved the physicians and researched best practices. We put scheduling tools in place. If someone wanted to screen outside the parameters, the obstetrics medical director had to approve the schedule."
Last year, there wasn’t a single such early elective induction.
There are other metrics that the hospital has achieved in the last few years that are also remarkable. It is the top hospital for patient satisfaction for joint replacements among 5,000 nationally, and it leads every hospital in the state of Texas for value-based purchasing. These aren’t stats of a facility in the 45th percentile of anything.
"If we want to get to a certain place, we have to figure out how to get there," explains Padula. "We assign the team lead, they get a coach and a team. The team meets weekly and also meets with executives weekly to update them, to brainstorm, and to talk about barriers." The executives help them overcome those hurdles and coach them through difficulties. At the end of a quarter, the project is handed off to a long-term owner; a check-up is scheduled a year later to make sure the changes have been effective.
This emphasis on creating solid action plans with a focus on moving forward quickly has been a great success. While Dooley says participation isn’t required, it is very much encouraged, and so far everyone in middle management has been on a team and about half the staff members have been involved. Among the staff, quarterly personal goals — linked to organization and department goals — often include suggestions of engaging in activity with one of the strategic breakthrough initiative teams.
Participants gain, too: They learn project management skills and to use Lean tools they might not otherwise have access to. And while there is never any penalty for not participating, there may be rewards for those who do, Dooley notes.
It takes a special person to work at Hill Country. Just one in 10 people who apply is accepted, says Padula. Each person who applies is put through a standardized value screening, including physicians. The CEO teaches every orientation section on the facility’s culture, and also evaluates staff quarterly on how they live the values and vision of the hospital.
It’s not something they write on a piece of paper and forget, but something they all live and believe in, she says. "Each value has a definition and a set of behaviors that are associated with it. We all have to commit to them and sign them."
These are all things that have become more important through the lens of Baldrige. The feedback meeting from the last application for the next few years was due to occur around press time. "Then we will look for gaps, look at our strategic plan, our action plan, our SBIs and keep working," Dooley says. "We just have to keep climbing."
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