High Performance Design: How improving leadership structures dramatically improved clinical outcomes at Sentara Healthcare

In 2018, Norfolk, Va.-based Sentara Healthcare was named one of five large health systems in the Top 15 Health Systems in the U.S. by IBM Watson Health. Our recognition as a top-performing health system came after we began to understand the importance of delivering highly reliable quality care and a consistently high rate of improvement across our entire health system. 

Sentara began our quality and safety journey in the 1990's like many other health systems. While we would observe improvement, we would often notice varying rates of improvement by facility or group practice. We would also note that our absolute performance, when measured against top performers, would indicate that year to year performance was not always improving at a rate as high as the best perfomers in our industry. We would work hard to improve over a year or two and then find that we were falling back and not sustaining our desired pace of improvement.

Health systems can no longer only look internally for improvement opportunities. Adaptation also means looking horizontally, for best practices within or outside your system, and externally outside the healthcare industry. If you are not improving at a rate equal to or better than your peers and competitors, then you are not improving, you are really falling behind!

An in-depth self-evaluation helped us realize we were falling behind our high performance peers because of a few root causes. One of them was fragmented implementation. The process of implementing best practices was not standardized and coordinated across our 12 hospitals and four medical groups. An illustrative example is the higher rate of urinary tract infections we used to see in our hospitals. Our protocols around catheter removal were not uniform across the system. It took one of our infectious disease specialists over a year of visiting each hospital and attending nearly 30 meetings to reach consensus on a unified Foley catheter removal protocol for implementation.

Our evaluation found we were making the right decisions most of the time, but we were not executing those decisions as well as we could have. Our siloed leadership structure was partly to blame. Another problem was a lack of organizational discipline to identify and focus on key priorities. We were trying to move the needle on everything, but instead, much to the frustration of our leaders and clinicians, we were not moving the needle significantly on anything. What we needed was new guiding principles and a new clinical leadership structure.

Our four guiding principles and new clinical leadership structure 

In 2013, Sentara created a formal process and leadership structure to tackle clinical quality and access improvement in a consistent manner across our entire system.

First, we established four guiding principles: 

  • Reduce variation in our clinical and operational processes by consistently implementing best practices 
  • Prioritize the patient experience
  • Embed change across the entire continuum of care in all regions
  • Enhance culture and decision-making tools

Next, we transformed our leadership structure from a classic three-legged stool model —where executive leadership, clinical leadership and a network of providers worked in silos — to a high-performance design structure with a direct line of engagement between clinicians and executive leadership.

Procedural decisions in this high-performance structure are made by a centralized clinical leadership council with representation from each hospital and division. The council, which meets on a monthly basis, comprises medical staff representatives, executives, hospital presidents and service line leaders from across the system, including our medical group, hospice, at-home and ambulatory care programs. Each member has an equal vote in major decisions to facilitate engagement and buy-in.

Leadership is now executed in two directions: vertical and horizontal. The vertical leadership executes decisions through the hospital president, nurse executive, vice president of medical affairs and medical staff president. Those decisions are then carried horizontally throughout the system by interdisciplinary, high-performance teams that include administrative, nursing, physician and ancillary leaders. Importantly, each team is supported by the same system data and analytics. The teams create consistency and a true systemness approach to quality that had evaded Sentara in the past.

Eliminating variation and achieving results

One of the key focuses of our high-performance teams was improving quality metrics like readmissions, lengths of stay, sepsis and other measures by reducing unwanted variation. There is a difference between good and bad variation. Some variation is good. You learn through intentional variation. New strategies to improve performance and the patient experience come from trying different approaches. What is not useful is unmanaged, random variation, like catheter removal times, that lead to poor outcomes. Excellence comes from cutting out unnecessary variation.

Our guiding principles, new high-performance leadership structure and focus on removing unintended variation took our hospitals from being all over the map on six key quality indicators to within the same quadrant. It is not an easy task. Even the highest-performing health systems in the U.S. struggle to maintain clinical consistency over 15 or more hospitals. 

A few key successes to share: 

  • Compared to 2015 baseline numbers, our improved clinical leadership structure helped lower readmissions by 13,075. Solutions focused on improving discharge medication adherence, ensuring post-discharge primary care visits within seven days and sending home heart-healthy diet information with patients when they were discharged.
  • Against baseline numbers, we recorded 196 fewer mortalities 30 days post-discharge in 2018.
  • Compared to baseline numbers, mortalities from sepsis decreased by 67. We used artificial intelligence that processed more than 4,000 data points to track patients before they got sepsis and intervened based on algorithms. 
  • We reduced lengths of stay days by 16,000 over our baseline metrics.

In 2020, we set similar goals across our teams, and added a COVID-19 care management procedure across the system so all of our medical teams were sharing best practices around the novel coronavirus in a standardized way. Since we already had a process in place to standardize clinical leadership decisions across each of our hospitals, we could efficiently communicate best practices around COVID-19 quickly. We did not have to start from square one. 

A note about clinician buy-in 

Physicians, nurses and other medical staff have an intrinsic level of buy-in for clinical improvement programs. They want to provide patients the highest quality of care, and they want commitment and the necessary resources from their organization to do so.

It is critical to not attack existing vertical structures in clinical care when creating a new model that aims to eliminate silos. That is counterproductive. Change in leadership structure is not about eliminating specialized medical and executive committees. Instead, it is about building a system that recognizes professional identities and creates new opportunities to connect communications across them.

It is also important to create a recognition system for clinical excellence. We put in place a senior leadership award for individual teams who helped reach our high-performance goals and demonstrated results of systemwide implementation. In addition to recognition in front of senior executives, the individuals are each awarded up to $10,000 for their accomplishments. It is important to reinforce behaviors that cultivate an environment of learning and sharing. 

What is next for Sentara

Sentara is not perfect by any measure. We still have many clinical areas we will work toward improving. 

The area I see the most room for improvement for our high-performance model is the use of technology to accelerate data analysis. Tools that give us real-time analytics, as well as artificial intelligence and machine learning technologies, hold the potential to dramatically improve our clinicians' ability to improve outcomes. We cannot misconstrue data analytics and AI/machine learning tools with the replacement of clinicians. Rather, these tools will allow our teams to accelerate and better absorb vast amounts of data.

Today, each of our hospitals is working toward the same level of consistent high performance and shared learning that can be found at some of the best-performing health systems in the U.S. This kind of teamwork is core to our culture and values. We will continue to scale our high-performance design structure as the organization, and healthcare as a whole, grows and evolves. 

Many health systems like to highlight their high-performing flagship hospital as a representation of its greatest accomplishments. At Sentara, we firmly believe in the axiom that you are only as good as your lowest level performer. We pride ourselves on viewing our performance in the aggregate, targeting consistently high performance and performance improvement across all of our clinical sites as critical to our success.

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