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In 1995, Baptist Hospital in Pensacola, FL, found itself sandwiched between two larger health systems and facing a stagnant market. Like other hospitals, it also was confronting diminishing reimbursement, increasing regulatory requirements, and staffing shortages. Since then, the hospital has made dramatic gains in all its performance criteria and has become recognized as a national leader in quality innovation. Most remarkably, it has steadily improved its market share.
In fact, overall market share has increased more than 3%, while employee turnover has been cut in half. Employee initiatives have resulted in more than $2.5 million in cost savings. And patient satisfaction, as measured by Indianapolis-based Press, Ganey Associates, has been sustained at the 99th percentile for the last 11 quarters.
Lucy Crouch, RN, MSN, director of patient care quality improvement at Baptist, says the dramatic improvements were brought about through an ambitious quality improvement effort centered on five key pillars — service, quality, cost, people, and growth. "Pensacola is a little small for three major hospitals, and we were clearly the underdog," Crouch says. The hospital’s competitors are the large system-based hospitals owned by Columbia/HCA and The Daughters of Charity hospital systems. In addition, Baptist is not easily accessible, she explains.
Against that backdrop, the Health Care Advisory Board had just released a study that concluded little if anything could be done to improve market share. Whenever one hospital added an MRI, a primary care clinic, or other new service, other hospitals in the same market simply mimicked those initiatives. Health care is a copycat business, and Pensacola was used as an example in the report, says Crouch.
In an effort to improve its competitive position, Baptist initially opted for staffing and organizational changes that proved very unpopular with staff internally. Employee morale dropped, and by September 1995, patient satisfaction had fallen from the average range to the 27th percentile.
The hospital’s senior leaders went back to the drawing board. The result was a commitment to the board of directors that the hospital would re-focus its efforts on patient satisfaction and customer service and achieve the 75th percentile for patient satisfaction within a year. Baptist studied emerging techniques from hospitals that were faring well in this area and established seven patient satisfaction teams. "We were very confident that our results would improve in the next quarter," reports Crouch. Instead, Baptist plummeted to the ninth percentile.
The leaders went back to the drawing board once again. "Once we picked ourselves up off the floor, we realized that if we could be good in four key areas that we would thrive operationally," says Crouch. "What we talked about was best service, high quality, best people, and low cost." Eventually, Baptist added growth as a fifth key pillar.
In order to accomplish these objectives, Baptist discovered that it had to undergo a major transformation of its culture, beginning with the way it communicated internally. "We had to change the way we work, and central to that transformation was a philosophy of open communication," she explains.
According to Crouch, bringing that change about required the development of many new mechanisms. Baptist established a communication board in every unit as well as quarterly employee forums in which the hospital administrator holds hour-long sessions to update all employees on where the hospital stands in terms of its five key objectives. In addition, all departmental and meeting agendas are structured around the five pillars.
Another key to open communications was a policy of no secrets. "We literally have a no secrets’ culture," Crouch explains. That means employees have access to the financial information given to the board of directors, and compensation issues are discussed openly.
Another key to facilitating change is a policy of no excuses. "We realized that once you can explain a less-than-optimal result, you quit looking for a solution," Crouch asserts. For example, Baptist had a 30% turnover rate in nursing, which is 5% above the average in the Florida panhandle, 10% above the Florida average, and 15% above the national average. But the hospital attributed that mainly to its location in a military town and the highly qualified but transient spouses it often hires.
Once the new policy was implemented, that explanation was no longer accepted. Instead, Baptist reviewed its selection process, instituted peer interviewing, and improved orientation and training. "We also worked feverishly on employee satisfaction," Crouch says. The new processes paid dividends. Baptist’s turnover rate last year was 16% — 1% above the national average but 9% below the panhandle average and 4% below the Florida average. "The military base has not closed, and we still hire military spouses," she adds.
According to Crouch, another key ingredient to improving the hospital’s culture was the implementation of performance standards developed by a team of frontline staff known as the Standards Team. Its job was to identify "expected behaviors" for all hospital employees. The categories for those standards are attitude, appearance, communication, call lights, commitment to co-workers, customer waiting, elevator etiquette, privacy, safety awareness, and sense of ownership.
For each of those categories, there are very specific behaviors. "Most of the performance standards are very straightforward but also very specific," says Crouch. For example, no call light is allowed to ring more than five times. Likewise, if a visitor approaches a staff member requesting directions, that staff member physically walks that person to the appropriate destination.
As the standards were implemented, every employee was required to read them and sign a commitment to abide by them. The standards also were built into the employee screening process. "We actually have had some people decide not to apply after reading them," notes Crouch. "But that is good, because if they can not make that commitment, they are not going to be successful here."
In order to maintain the standards as an active component of the hospital’s daily life, Baptist celebrates a different standard each month using games, prizes, and activities. "Every month, we are thinking about one of our standards and how and why we live it," says Crouch. In addition, employee evaluations now include how well they are complying with the standards. "Employees are not only evaluated on how they performed their job in terms of skill but also how compliant they are with the standards," she says.
To further reinforce the new performance standards, Baptist also implemented a process of reward and recognition. "Most people want to be successful, and they want to do a good job," says Crouch. But rewards and recognition are often overlooked in health care, she adds.
In order to break that trend, anytime an employee demonstrates performance above and beyond a certain standard, he or she becomes eligible for a Wow Award from any employee in the hospital. For example, one Spanish-speaking secretary received the award for assisting a Spanish-speaking patient in both his cognitive therapy as well as his personal care needs.
Once five Wow Awards are accumulated, employees receive a $15 gift certificate. In addition, when employees go well beyond the standards, they are designated as Champions and their stories are presented at a monthly meeting of department leaders where they receive a plaque. Their pictures also are placed in a designated area at the hospital. Each year, several Champions are designated as Legends. Those employees are picked up by a limousine and taken to the hospital board retreat where they have dinner with the board of directors and their stories are repeated.
In addition to the performance standards, Baptist also implemented a range of quality improvement initiatives such as a program to reduce hospital-acquired pressure ulcers, Crouch says. Nursing units that achieve zero in a month receive a banner and a pizza party. A similar program is the hospital’s medication error reduction program. Nursing units that have the highest return rate of discontinued medicated to the pharmacy receive a banner each month. According to Crouch, the key to implementing these measures is consistency. "It can’t be a flavor of the month,’" she asserts. "It was helpful to focus on five key areas because that makes the process very simple but also very specific."
Baptist also placed a new premium on leadership development — another area that Crouch says is often overlooked in health care. "If we are going to be the hospital that patients select, we have to be the hospital that employees select." To bring that about, the Baptist leadership developed its own homegrown leadership development program, called Baptist University. The program offers established and elective courses that include quarterly sessions attended by all hospital leaders and built around the five key pillars. The hospital is now developing several other delivery modules, including computer-based and lecture-based training as well.
The program initially was established through a survey that asked each leader to identify the three individuals he or she considered to be the most highly qualified to help engender the new culture that was being sought. From there, a steering committee selected a final team. To help keep leaders focused, every leader has a 90-day action plan. That plan includes a specific goal related to each of the five key pillars along with specific action steps for achieving that goal. At the end of 90 days, leaders report their results.
"The specific goal under each pillar may not change every 90 days, but what does change is the action plan," says Crouch. For example, the goal under service may be to reach the top 1% of patient satisfaction, but the means to achieve that goal may vary.
Teamwork is also essential, according to Crouch. "You can accomplish a lot more as a team than you can as an individual," she says. To improve its level of teamwork, Baptist established a multitude of teams under each of its five key pillars. For example, under the service pillar, the hospital has eight patient satisfaction teams. Under the quality pillar are a number of teams, such as Target Zero Team for hospital-acquired pressure ulcers, Medication Event Team, and Restraint/Seclusion Team.
To spur innovation, Baptist implemented its "Bright Idea" program, which requires every employee to submit at least one idea for improvement each year. "People doing the work know the best way to accomplish that work as well as the most cost-effective method," says Crouch.
The year the Bright Idea program was implemented, more than $1 million in savings were realized, along with many program improvements. "It is amazing what employees will come up with if you give them the opportunity," says Crouch.
Measurement is also critical, according to Crouch. Under each of the five key pillars, the hospital has established criteria. For example, the primary measure under service is patient satisfaction. Under people, employee satisfaction and turnover rates are gauged. Under quality, hospital-acquired pressure ulcers and use of restraint and seclusion are measured along with other indices. Under cost, operating expense is assessed along with net revenue. Under growth, admission rates are reviewed along with the development of new services.
Positive results from the initiatives continue to pour in. Baptist not only reached the 99th percentile in patient satisfaction, it has sustained that level. In addition, employee morale improved 30% over 18 months, an increase so dramatic that the firm performing the survey initially thought it was the result of a data sampling error. Eighteen months later, the same firm reported the highest level of morale among any of its clients, including its nonhealth care clients.
Finally, as patient satisfaction soared and employee turnover declined, Baptist’s market share showed steady improvement at the expense of its competitors. At that point, the hospital’s leaders seized on criteria provided by the Malcolm Baldrige National Quality Program in Gathers-burg, MD, to realize even further improvements.
"This assessment was a very worthwhile process because it helped us identify our strengths as well as areas for continued improvement," says Crouch. "It is always about getting to the next level." The improvements recognized by the hospital were further validated last year when it became only the second hospital in the country to receive a site visit by the Malcolm Baldrige program.