Other performance percentiles, as measured in the study, were equally disappointing (note that percentile rating is a measure of the percentage of hospitals worse than this one):
Both the CEO and Emergency Department Director were new and the Vice President of Nursing was leaving soon. Nearly half of the ED nurses were temporary contract workers. Nurses working on the hospital floors were slightly less apt to be temporary employees. Two physician groups were contracted to staff ED and Radiology.
Physician/Hospital relationships were extremely poor to non-existent. Not surprisingly, morale was poor. A number of initiatives had been attempted with no viable metrics to determine the impact. However, the overwhelming consensus was that none of them had had any measurable success.
The new CEO was given a long list of goals including the 1,500 action items from the consultant’s study. In an attempt to develop goals and objectives, he held a senior management retreat that resulted in lofty but ill-defined targets. As the result of the management retreat, an Operations Performance Solutions (OPS) department was established with two talented professionals leading ED and In-Patient (IP) teams (their full-time jobs were Director of Radiology and Cardiology, respectively). It was housed in a dedicated suite of offices in one of the two physicians’ office buildings with a full-time secretary, telephone lines, and computer links to the hospital’s central system.
Dalton’s CEO was introduced to Thomas Group via a reference given to the system president. In a series of meetings with the Dalton’s CEO, system president, department heads, and the OPS team leaders, a set of deliverables for a prospective Thomas Group engagement was developed.
*Implementation defined as CFT and BRTs convene on a scheduled drumbeat and identify and resolve barriers that are impeding the hospital’s ability to achieve its goals.
A team of three senior Thomas Group Results Managers met with the CEO and the two heads of the Leadership Teams to map out an architectural structure. It was agreed that the initial activity would focus on the ED and its intersection with IP with the expectation that other issues would come to light during this initial effort. Rather than conduct formal up-front training, specifics of methodology would be introduced as needed or on a pull basis. The goal was to establish the foundation elements of Thomas Group’s proprietary methodology, Process Value Management (PVM), as a template for focusing the resources available on the root causes driving the hospital’s major dilemmas: poor patient, physician, and staff satisfaction, and the resulting poor reputation in the community. This involved defining the key processes, mapping them, identifying driver metrics, obtaining baseline data and estimating improvement goals, and agreeing on the top level barriers. Two workshops were held over a two day period with the objective to stimulate interest in the concepts and generate momentum. The workshop involved the following:
In the ED workshop, a high-level process map was created and a high-level set of barriers agreed upon. While the barriers involved difficult issues, most were process rather than cultural in nature.
The IP workshop developed a high-level process map and also identified a high-level set of barriers. While many of the issues mirrored the ED, the IP was a much more complex environment with deeply rooted cultural issues.
Membership of the IP and ED Leadership Teams was formalized and a drumbeat meeting schedule was set. The OPS secretary became the permanent team scribe and quickly learned some of the tools of PVM - drumbeat scheduling, charters, agendas, minutes, and managing assigned action tasks (AIPs). A management oversight team (BIT) was chartered which included the hospital CEO and the two Leadership Team leaders. A drumbeat meeting was scheduled for once a week.
It was decided to form BRTs on a rolling basis, taking on the highest impact and most straight forward issues first. (The teams are listed in the Executive Summary). Formal meetings were held weekly with individuals conferring more often as needed.
From the beginning, there was strong support from the CEO and his direct superior, the healthcare system CEO. Members of the Leadership Teams and the BRTs quickly engaged and worked around issues of work schedules and hospital routines.
Originally, the medical head of the ED was very reluctant to embrace this initiative. During the implementation, especially the Computer Physician Order Entry project, he became an advocate and was instrumental in aligning the entire ED medical staff. The head of radiology was also hesitant at the beginning. During the early stage of the project, this had no impact. Later, however, the entire issue of physician relationships with hospital administration was addressed.
By the end of the four month engagement, the following metrics improvements had occurred:
In a medical services delivery environment, there are enormous, deeply rooted cultures. The culture can be influenced by creating process-based improvement teams, providing metrics-driven structure, and focusing on areas that have obtainable early wins. This is largely because these cultural norms are the result of people who are highly skilled and extraordinarily intelligent focusing on their primary mission, curing the sick. When this mentality is exposed to the powerful tools represented by process methodology, the results are dynamic. The key is including input from all stakeholders at the onset, beginning with small changes that have significant impact, and then capitalizing on positive response.
Most importantly, a successful service delivery environment is characterized by improved patient care. Improved care not only draws insurers and other health care purchasers concerned with cost and patient outcomes, it helps to restore trust and confidence in the healthcare system as a whole. And that is something all doctors and health care executives are focused upon.