Creating an Outcomes-Based Culture: How to Engage Front-Line Staff in Process Improvement

Healthcare reform has drawn a great deal of attention toward bending the cost curve in healthcare, and the Affordable Care Act introduces a number of new programs and initiatives that aim to achieve this. Value-based purchasing, accountable care organizations, bundled payment pilots, medical homes — it's enough to make anyone's head spin. But, when you break it down, all of these are just different ways of going about the same goal — better care that costs less.

An outcomes-based culture
At Mercy St. Vincent, a 445-bed hospital with a  Level I trauma center in Toledo, Ohio, we were chasing this idea of better, less expensive care well before conversations around federal healthcare reform really hit. We knew it was coming though — in one form or another — and our goal was to get in front of it. About three years ago, we began to think about how we might redesign our organization to provide better care at a lower cost. To reduce the cost, we knew we needed to improve quality and safety, because doing so takes cost out of the system, and we needed to find a way to make improving these measures a focus for all our employees. Our hospital needed a cultural change.

Given the demands reform places on healthcare organizations, many hospitals and health systems that haven't already gone through this process are embarking on it now. To them, I would advise they give up looking for the silver bullet — something our system had once hoped for — and instead focus on developing a culture that values constant improvement and measurement. Sharing best practices among healthcare organizations is valuable, but it's not the end of the journey. You can't just take a best practice from institution A, move it into institution B and get the results you're looking for. Instead, engage front line workers and utilize them to adapt best practices. Create an environment that gives people permission to try and fail.

Patients first: Journey to zero
Our first challenge at Mercy St. Vincent was figuring out how to define the type of environment we wanted to achieve. Senior leadership sat down and agreed on a system aim, which we often refer to as our north star: "Patients First: Journey to Zero." The first part, Patients First, seems simplistic, but over the last several decades layers and layers of processes have been put into place that take our employees away from direct patient care. "Patients First" is about refocusing every employee on the patient's outcomes and experience. The second part, Journey to Zero, is about pulling all error out of the organization — zero preventable errors, zero work that needs to be redone. We use the word "journey" deliberately; getting to zero doesn't happen with the flip of a switch. It happens over a period of time.

To do this, we of course needed to improve our processes, but more importantly we had to truly engage the entire organization and put in place a new mindset. We began by educating employees about why a culture focused on outcomes and performance measurement was needed. Each employee was educated on how his or her role would change and front line managers received training on working with and understanding data.  

After gaining buy-in for our new culture, we moved on to improving processes. We started with the macro-level goal of reducing our length of stay then moved to examining the micro-level processes impacting the larger issue. For us, that meant essentially examining every process occurring during a patient's hospital stay — from admission to discharge.

A group comprised of senior leadership, front line management, industrial and logistical engineering and Lean Six Sigma consultants began by mapping out the entire timeline for a patient stay from the time the patient shows up at the ER or his or her physician requests an admission until the patient is discharged and the room is cleaned. The group broke down a stay into eight milestones, including 1) initial request for admission 2) bed assignment 3) initial physician order entry for patient, etc. Then, the team broke down every process between each milestone and brainstormed ways to make them more efficient. At this point, front-line employees were engaged and asked to offer additional ideas and critique. Tapping into these employees is critical because they are the ones that understand the processes completely.

Next, we put the new processes to the test, and we saw some major improvements. For example, the time between an initial request for admission and assigning a bed used to take about four hours and require up to eight phone calls. Now, the process takes 10 minutes and zero phone calls. We were able to achieve this by introducing a new technological platform and adjusting human processes around it. We've also had success around speeding up initial physician order entry. We've improved patient transport and nurse processes in a way that now enable us to require physicians to enter their initial orders for a patient within one hour of the patient getting to his or her bed. At other hospitals, this can take several hours or more. Each of these building blocks has helped us reach our macro goal of reducing length of stay; from 5.2 days to 4 days, and if you factor out our NICU, the average LOS is 3.5 days.

Continual improvement
Even though we've achieved our goals, we don't rest on our laurels; our new culture wouldn't have it — we're all about continual improvement now. Each week a small team of hospital leaders rounds on each unit in the hospital to look at performance against process and outcomes benchmarks and address any variation. They ask questions such as, "What are the barriers keeping us from not hitting the target?" and "What can we do as a team to move the needle?"

The initiative has been so successful that Mercy, our parent organization, is deploying our process across its seven hospitals, and Catholic Health Partners, Mercy’s parent organization, is implementing the platform in its other regions

While we didn't develop the initiative in response to healthcare reform, we believe it positions us well to meet reform's demands. Our organization is now keenly focused on high quality care without error, and that very closely mirrors the aim of reform. Additionally, our culture is nimble and the processes we have put in place for continual improvement are robust. The number of core measures we must meet will almost certainly expand, and how our society defines value could change as well. We at Mercy feel confident we'll meet the future demands government and payors place on us because of our culture and the employees within it.

Imran Andrabi, MD, currently serves as president and CEO of Mercy St. Vincent Medical Center in Toledo, Ohio. He is a diplomat of the American Board of Family Medicine and the American Board of Managed Care Medicine.

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Value-Based Purchasing Requires Behavior-Based Hiring

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