St. John’s updates itself using Baldrige criteria

Depth of change unimagined

What started in 1995 as an internal self-assessment turned into an unimagined retooling management style, and eventually a first-ever state award for St. John’s Regional Medical Center in Oxnard, CA.

"Instead of targeting single areas for improvement, we started applying the Baldrige criteria to our process management so we could involve the greatest number of people at once," explains St. John’s vice president of Medical Affairs and Clinical Operations, Ross DiBernardo, MD. DiBernardo is referring to the Malcolm Baldrige National Quality Award Health Care Criteria for Performance Excellence.

In 1997, St. John’s became the first health care organization to win California’s Golden State Quality award for Quality in the Community. "It was St. John’s real caring about the community that caught the judges’ eyes. They reach outside of their normal patient area to survey the needs of their community at large," says Barbara Blalock, president and executive director of the California Center for Quality, Education, & Development (CalQED) in Danville. The facility is a nonprofit hospital, part of Mercy Healthcare, a division of Catholic Healthcare West.

Managers had to become coaches

Several years ago, St. John’s looked at where health care was headed and realized that they were going to miss the boat unless they changed their approach to business. "We became convinced that a different management style would be required, so we could start to base our decisions more on the requirements of our customers, especially our patients," DiBernardo explains.

But it took little time for the St. John’s management team to realize that superficial alterations would never shape up the organization to Baldrige caliber. "We had to restructure our leadership styles so that managers became more visible to the people we manage. As managers, we had to become coaches," he says.

Employees had to broaden their skill bases to include problem-solving tools and data-based decision making. That began with trainers who educated senior management. In turn, managers continuously teach and coach their staff to incorporate the new ways of working. DiBernardo describes the shift: "In the past, we were guided by opinions. Now we use patient data to guide our decisions." If the profound organizational changes didn’t spin heads, many more surprises were on the way.

Where DiBernardo expected resistance, he found little. "Many of our people are patient-focused in the first place, so changing attitudes was, frankly, easier than I thought. But the systems were not customer-focused and changing them is tough." Nonetheless, a series of process improvement projects has chalked up some noteworthy results:

- Inpatient pain relief ratings rose, thanks to faster call-light response.

- Patient satisfaction in the emergency department improved 5% in six months.

He credits that to waiting room hosts and hostesses who decrease the mystery and unpredictability by telling patients and families how long their waits will be depending on the volume at the time. At each step of the emergency care process, patients also receive explanations of what to expect and why.

As St. John’s worked with the Baldrige criteria, another surprise unfolded, DiBernardo explains. "At first, we thought we would have to modify the Baldrige criteria to fit health care. But when we got into it, we saw that if we use fact rather than opinion to guide our decisions and if we offer good service at affordable cost, we’re not that different than any other service business."

Blalock supports DiBernardo’s observation noting that the health care and business criteria are essentially the same with the language being the primary difference. The health care criteria are simply stated in health care terminology such as patient, nurse, clinician, etc.

Having progressed through the Baldrige self-assessment process, DiBernardo explains, "we decided to submit an application for the state award as a way to inspire and reinforce our managers."

St. John’s takes statewide honors

St. John’s entered the CalQED Golden State Excellence competition primarily for feedback on its overall management systems, but it came back with much more. Blalock notes that one pocket of excellence caught the judges’ attention — the institution’s community service program. So St. John’s became the first health care applicant to win the prestigious CalQED award. The health care category, established in 1996, had no winner the first time out. At this writing, 1998 winners are yet to be announced.

Highlights of the community service program include:

- Baby, Think It Over gives teens a taste of single parenthood responsibilities. Area high school students take 24-hour care of computerized baby dolls programmed to eat, cry, and wet diapers. Now in its second year, the program surpassed by 20 its first annual goal of 100 placements. Though the logistics are difficult, DiBernardo says, the immense potential for change makes small numbers worthwhile.

- Healthy Beginnings increases birth weights of infants born to low-income women. St. John’s matches mothers-to-be with participating physicians. In addition to doctors’ appointments, the women learn how to give their babies a healthy start by curtailing drinking and smoking, as well as taking vitamins and eating a balanced diet.

"The women are delighted with the education, and they appreciate the extra care," he explains. The results represent good news for area neonatal health care resources as the 472 Healthy Beginnings mothers delivered no very low birth weight babies in 1997.

Beyond prevention and health education, St. John’s provides $4 million-worth of "pure charity" care annually — "care that we agree to without expecting compensation," DiBernardo explains. He adds, there’s an additional $12 million of "uncompensated care — where we learn after the fact that the patients would not be able to pay."

Journey without an end

Looking back, DiBernardo reflects that the depth of change at St. John’s is still hard to comprehend. The flow of resources into QI efforts is constant as 22 teams work on process and management improvements. The average team spends six months per project, involving salary expenditures $2,700 to $6,000.

"The quest to improve is never ending," he observes. "We’re still getting used to that. We make one change today, and we’re satisfied. But then we say, OK, what do we do tomorrow?’"