Big and small, Baldrige winners say it's about the journey
Feedback and site visits provide "addiction" to improvement
It's doubtful that anyone goes into the Baldrige process looking for a site visit the first year. For most organizations, it can take three, four, or more years of applications before you get called and told you are one of a handful of organizations around the country that is lucky enough to be granted that honor. But those who go through that process seem to view it as valuable, not tedious, and 2013's healthcare winners — Baylor Regional Medical Center at Plano (TX) and Sutter Davis Hospital in California — are no different.
Those who orchestrated the efforts uniformly describe a process that they look forward to engaging in and describe staff asking about the arrival of feedback reports like kids wondering how long until Christmas. As winners, they are barred from applying again for five years, and Janet Wagner, RN, Chief Administrative Officer of Sutter Davis, a 48-bed facility that serves the university town a few miles west of Sacramento, wonders what they'll do in the interim to keep them on their quality toes.
"After the last site visit, we sat right down and were already planning our strategy for our 2014 application, what we were going to focus on, what our theme was going to be, where we felt we needed to improve," she says. The call that they won was a huge surprise, but one she thinks they deserve.
In its award notification, the National Institute of Standards and Technology (NIST), the division of the U.S. Department of Commerce that hands out the recognition, outlined more than a dozen reasons why it chose the hospital as a recipient. Among them:
- High performance on key national quality metrics, including ranking in the top 10% of core measure scores for the Centers for Medicare & Medicaid Services (CMS) since 2010.
- Better than benchmark performance for length of stay and readmission rates for pneumonia, heart failure, and heart attack, as well as for general length of stay for Medicare and the overall patient population.
- Low levels of hospital infection rates that beat national benchmarks and the competition. It is in the top 10% for post-operative orthopedic surgical infections — there were none between 2008 and 2012. There have been no CAUTI situations since 2008, and no CLABSI events since 2010.
- The birthing center, which delivers 1,300 babies a year and is an area of focus for the hospital, has a lower than average C-section rate, lower than average elective deliveries at less than 39 weeks, and higher than average use of breast milk only for feeding. It has been the focus of national interest for its collaborative care model, and Wagner says it has even been the subject of a documentary due to its family-centered approach and openness to alternative birthing methods.
- Fiscal health data that includes margins over 25% while maintaining a commitment to affordability.
- Door-to-doctor time in the ED decreased from 45 minutes in 2008 to 22 minutes in 2012, well below the California average, which is nearly an hour.
- Employee and physician satisfaction scores in the top 10%.
Wagner knew that many would think her facility was too small to consider competing for Baldrige, but it has been a progressive organization for some time, with a short average length of stay and strong alignment with physicians. In 2007, it was named to one of the consumer top hospitals lists, and that, she says, got them looking for specific management frameworks with which they could achieve greater success. One was Baldrige, and the team started applying.
They got their first state visit a couple years in, but did not get a site visit from the national organization until 2012. "It was so energizing," she says. "You never know if you'll write an application worthy of a site visit, but we did. Twice! It was a great honor." And they really saw no difference between the two site visits that would lead them to think they could have been a winner in 2013 when they weren't in 2012. That was why they started planning for the next application right away, just as buzzed by the experience as they were the year before.
"We were going to focus on a new category, we had ideas for improvement, we were just set to go, and then we got the call," Wagner says.
When Sutter first started the application process seven years ago, the first question Wagner and her team tried to answer was about core competency. Sutter Davis listed three. "We did not know to narrow it down to that one thing we do best, to refine and refine," she says. "You get smarter with every application and feedback report. You start to see things differently."
By the third or fourth year, they had figured out what they were best at, that what underpinned everything they do was a culture of caring. That was the core competency. "I would say that before, our care was compassionate, good. But not as refined. Now we have developed a very deep understanding of what is important to patients and what drives their loyalty."
There were always pretty good patient satisfaction scores, she explains. But with the advent of the Baldrige application and feedback experience, they learned to use those surveys to identify behaviors that each member of the workforce does that drives those scores and the experience that patients and their families have when they are at Sutter Davis.
Based on some Baldrige feedback, they opted to look outside healthcare to improve workforce behavior in key areas. Disney came in to help them learn to "create experiences that touch your heart and soul," she says. Ritz-Carlton, which prides itself on anticipating customer needs, helped staff, including physicians, learn to anticipate when patients might be experiencing something troubling, like anxiety, and what might alleviate it. "That helped us learn to train our physicians differently," she says.
There was no real imperative to do this, Wagner says. "We could have been good enough without it, but we want to be the best. I'm a nurse. Patient care delivery is important to me. When I cared for patients at the bedside, I wanted to give the best care, a standard of care that I could be proud of. Now, I manage a hospital where everyone here is passionate about this and doing their very best to provide the best care there is. My team believed we could do this — we think big and act big, even if we are a small hospital. And look! Now we are a role model."
There is more than just pride in it, though. There are metrics that prove this journey was worth it, and they were pointed out by NIST when it announced the award. The facility is on strong financial footing, infection free, has short lengths of stay, and has growing lines of business, particularly in the emergency and oncology departments. "A lot of that increase is happening by word of mouth, too, which is the best marketing you can get," she says.
The hospital's birthing unit is an object of curiosity — for good reasons — to people who've probably never heard of Davis, California. The ED has wait times that are nearly a third of the California benchmark. All this, Wagner says, comes part and parcel with deciding to take this journey and make Baldrige the modus operandi for the hospital.
And the cost? Nothing. Not a single FTE was added to the payroll to make Baldrige happen, Wagner says. "I don't know who said it, but someone told me when I was thinking about doing this that Baldrige would be the least expensive management consulting I could ever get. And it's the truth. All we did was incorporate this framework into what we do every day."
Her only worry now is how to keep her team excited until they can start work on the next application. According to her math, after all the speaking engagements related to this award are done, that leaves about three and a half years to fill up with other things before they can get excited for the 2018 application. "I think I'd like us to start publishing some of what we have done. We've developed some great leaders through this process. They can share what they've learned with others."
Big state ambitions, small-town hospitality
Baylor Plano, a 160-bed hospital in North Texas, was also recognized for several of its quality metrics by NIST. Among them:
- an increasing share of "all-or-nothing" bundled CMS measurement standards;
- a low rate of ventilator-associated pneumonia that puts it in the top 10% of providers nationally;
- a consistent presence in the top 10% for key measures include pressure ulcers, blood clot prevention, and OR turnaround time. The facility is also extremely efficient at getting patients out of the hospital at discharge.
- exceptional patient satisfaction scores;
- an orientation process for new employees that extends 18 months, which helps keep the retention rate for first-year employees above 90%. For employees regardless of duration, retention now stands at 94%, a point lower than first-year retention, which is currently 95%.
- administrative efficiencies including increased use of preadmission surgical testing and reduced ordering of unneeded services for treating heart failure, sepsis, and pneumonia.
As with Sutter Davis, the journey started several years ago for Baylor Plano, says Pat Cooper, MSQA, RHIA, director of Healthcare Improvement at the hospital. They had been working for the state quality award, the Texas Award for Performance Excellence, and in 2010, when they won, they turned around and submitted that application to Baldrige. With the subsequent feedback report, Cooper and her team made some changes to the way they did things and submitted again twice more before getting a site visit in 2012, and then another in 2013.
Cooper says that there were some consistent themes in the feedback through the years. "It took us a while to understand more about listening to the voice of the customer," she says. "Sometimes in healthcare, we think we know what's best. But there is real value in listening to them, in having them help you to identify the services we need to provide, how we should measure them, and how we should evaluate our processes," she says. "Which is not to say at all that now we have it all figured out, but we have come a long way since 2009."
Another issue that was brought out through the feedback reports and site visits was the need to prioritize work. "There is a lot on everyone's plate, and we are all very busy doing a whole lot of things. So how do you decide to figure out what to do first to get the best result? How do you make sure that what you think is the right thing to do doesn't take people away from the bedside?"
New quality initiatives may seem important — even vital, she says, but if it ends up taking nurses away from patients, it might not be the best thing to do right now. Now, they have a process of looking to see what is already ongoing, where the manpower is already deployed, and whether a particular project can be done without exceeding existing staff capacity. If it is something that aligns with the mission and there is still a capacity problem, then it can be discussed. "We have an online link for all projects now, and a work group will screen them, pitch the ones that seem like a fit, and then they are scored by the group based on an evidence-based criteria set. Then they are sent to the best committee for approval, to be tabled, or to be put on a wait list. That allows us to evaluate new things, as well as keep up with what is already ongoing. Before Baldrige, we did not even have an index of all the teams and projects that were going on in the hospital." Now, they have more than a list. They have even been able to streamline what had been a kind of project free-for-all. Some projects have been sunsetted, while some are monitored less often but still watched in order to look for problematic data changes, Cooper says.
The site visits are particularly ripe for "aha!" moments, she says. During the first one, Cooper couldn't answer the question, "How do you know what you are doing is effective?"
"We knew our outcomes were good, but we had to be better at looking at whether the processes that led to those outcomes were effective, and that we had a way to objectively evaluate that." It's like asking someone who is wearing shoes how she knows she is well shod. You know you are, but you never think of having to prove it to someone, in a way that measure the effectiveness of your daily shoe-tying ritual.
She gives an example of a patient experience team the hospital had. "After a year, we thought we had to step back and look at the team. So we surveyed them and asked them all what might make it better, whether it was a valuable use of time. Through that, we learned we were putting a lot of effort into this team, but we weren't moving the needle at all. The focus group wasn't having any impact. So we restructured it, and now the system we have in place is more effective."
Another example she gives involves her performance improvement processes. Cooper wondered how she could know if they were effective. So she now uses an improvement capability assessment tool that looks at seven specific dimensions of performance improvement. That helps to identify gaps and focus Cooper and her team on finding the important areas to expend their energy, she says. "Learning to assess our processes trained us to be objective, evaluate how we were doing, and to get input from other people involved in the work."
The Baldrige criteria also brought a spotlight onto benchmarking that Baylor Plano hadn't had before. "We hadn't been going outside the organization enough," she says. "We had focused on comparing metrics with others, not processes." So, like Sutter Davis, they went to companies like Ritz-Carlton to benchmark service, to a local company, Park Place Lexus, for hiring practices, and to Virginia Mason Hospital in Seattle for innovation. It's not enough to know about how you do on numbers, but how you compare on the things that lead to the numbers, she says.
It's hard to point to any one change that Baldrige led to and say, because of that, mortality is lower, or financials are better, says Cooper, but like Wagner, she is sure that this years-long journey has been worth it. "This is not something that happens overnight," she says. "It's not like one day you aren't doing this and the next it's all in place. It takes time to weave it into the fabric of your organization. But without a doubt in my mind, it is all connected. I am sure that because of Baldrige, we have shown improvement in key measures — mortality, board engagement, staff retention."
You can't have this be a little side project — it's something that the leadership has to buy into from the start because it involves incorporating the principles of Baldrige into every level of the organization, Cooper says. "This has to become your guiding vision. But when it becomes part of your culture, how you do business, good things happen."
For more information on this topic, contact:
- Janet Wagner, RN, Chief Administrative Officer, Sutter Davis Hospital, Davis, CA. Email: [email protected]
- Pat Cooper, MSQA, RHIA, Director of Healthcare Improvement, Baylor Regional Medical Center at Plano, Plano, TX. [email protected]
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