Recently, I had the opportunity to discuss this very topic with a champion of healthcare excellence, Kenneth R. White, PhD, MPH, MSN, RN, FACHE.
For nearly 40 years, Dr. White has served healthcare organizations in clinical, administrative, governance, academic and consulting capacities. He has served as associate director of the graduate programs in Health Administration at Virginia Commonwealth University, as director of VCU’s Master of Health Administration and Dual Degree programs and as their first Charles P. Cardwell, Jr., professor, and he is currently the inaugural Sentara Professor at VCU. He is a fellow and former member of the Board of Governors of the American College of Healthcare Executives, and holds a joint appointment as professor of nursing at VCU. He is also a regular visiting professor to the Luiss Guido Carli University in Rome, Italy, and the Swiss School of Public Health in Lugano, Switzerland.
Dr. White has authored or co-authored many important publications including “The Well-Managed Healthcare Organization,” and his new book written with John R. Griffith, “Reaching Excellence in Healthcare Management,” which received the 2012 American College of Healthcare Executives’ James A. Hamilton Book of the Year Award.
I welcomed this opportunity to interview Dr. White, and talk to him about the new book and his ideas about achieving excellence in today’s healthcare environment. Below are some of the highlights from our discussion.
Question: Why did you write a book on excellence?
Dr. White: My coauthor, John Griffith, and I have long been interested in high-performing healthcare organizations. We have learned much from a few “excellent” organizations in order to continually update our textbook on healthcare management, “The Well-Managed Healthcare Organization.” While this book is primarily aimed at an academic audience, we wanted to reach the practitioner audience with an easy-to-read and slimmer version, which is organized by specific “how-to” questions and answers.
Q: How do you define excellence in healthcare?
KW: We believe that “reaching excellence” is a catchphrase for a revolution. It is a radical change in the management of American healthcare organizations. It is using best practices and evidence to transform patient care at the bedside.
Q: What is the single biggest obstacle most people or organizations run up against when trying to achieve excellence, and how can they overcome that obstacle?
KW: We believe that most organizations have “pretty good” operations and strategic practices. However, the biggest obstacle is the organizational culture. A culture of excellence empowers all associates to identify opportunities for improvement, and management views their role as servant leaders. That is, they find answers to associates’ questions, they empower associates to act, they get the right people together for teamwork and they recognize and reward. In other words, they listen, listen, listen!
Q: What are five ways that a healthcare organization can become excellent?
KW: First , engage in a cultural transformation. Send consistent messages frequently that let everyone know the mission, vision, values, and what gets rewarded.
Second, commit to permanent change — focus on improving systems and relying on protocols. When performance reaches benchmark, set a higher goal — become the benchmark!
Third, use evidence to solve management problems — not only the literature, your organization’s past experience, but also the trials, pilots and suggestions from employees who are close to problems.
Fourth, innovate! You must be willing to try new ways of doing things. Empower, recognize and reward associates for maximizing their intellectual power and problem solving skills to look for new and better ways of providing patient care.
And fifth, align goals, top to bottom, with strategic planning and specific goals for clinical excellence and best practice outcomes. Excellence in this model must be rewards-based.
Q: Many healthcare organizations are feeling pressure to reduce costs these days. How does the pressure to reduce costs affect the pursuit of excellence?
KW: Many organizations appear to be engaging in too many initiatives at once, and it may send mixed messages to employees. We have seen excellent organizations focus on a few major goals and initiatives each year and set goals from the board down to the front-line caregiving team. It may seem counterintuitive, but excellent organizations invest in the right resources and the best associates and physicians in order to get the best outcomes. Success breeds success. In turn, they have leading market shares and improved positive financial performance. They are known as the best places to receive care.
Q: How have your experiences in healthcare contributed to your ideas of excellence?
KW: As a former healthcare administrator, I am grateful to have had some of the best mentors and leadership role models. I have also worked in organizations where great ideas were stymied and performance was thwarted due to a stagnant culture. As an academic, I am passionate about learning best practices and creating an environment in the classroom for our students to learn how to be the best at leading our nation’s healthcare organizations.
Q: Can you give us an example of an organization that you would consider to be excellent?
KW: Yes! I can think of several excellent organizations, and we have several here in Virginia. Sentara Healthcare, headquartered in Norfolk, Virginia, is excellent in many ways. I believe they are leaders in innovation, with services such as the e-ICU. They also were pioneers in many technological innovations in information technology and the electronic health record. They have a few goals, which permeate the system from board to the front lines.
Q: What role do nurses play in delivering excellent healthcare?
KW: Nurses are the reason that patients need hospitals. Nurses are also the infrastructure of our community health partnerships with prevention, long-term care, home health, hospice and palliative care, school nursing and many other roles. The Institute of Medicine’s 2010 report, “The Future of Nursing: Leading Change, Advancing Health,” recommends and advocates for expanded roles for nurses in the primary care delivery system. Nurses were also mentioned in The Patient Protection and Affordable Care Act of 2010, with funds earmarked for nurse practitioner training grants, as well as the establishment of nurse practitioner-led clinics. In this way, nurses will be able to work with their patients and clients to address issues that are broader than the medical diagnosis and treatment of disease. The holistic model of nursing is what is needed to address the mental, emotional, cultural, linguistic, psychosocial and financial needs of patients — in addition to their physical and medical needs. In other words, nurses are the ones who can truly focus on a patient-centered approach to providing healthcare, especially to those with chronic and life-limiting conditions.
Q: How can an organization get physicians, nurses and other personnel to work together to deliver uniformly excellent care?
KC: This is the crux of the meaning of interprofessional care. First, doctors and nurses have different meanings of collaboration. Collaboration occurs when the person with the best idea or most innovative solution is heard out, and when each member of the team has trust enough to question decisions or suggest alternative options. This happens with a cultural shift, and it starts at the top. Healthcare organization leaders are responsible for establishing a team-based culture, getting the right people together, requiring team training, and rewarding team-based outcomes. After a while, “star players” who don’t work well in teams will either change their ways or will find other places in which to command star status. In a team-oriented culture, there are no individual stars, only teams who are high-performing.
Q: How do excellent healthcare organizations deliver the best care — every patient, every time?
KW: This is tough, and what I like to say is that we are looking for improvement and excellence, not perfection. What may be viewed as excellence this month, may be viewed as subpar sometime in the future. The way that excellent organizations do better than most is by having standards, checklists, protocols, more budgeted and required associate training programs, and a robust recognition and rewards program (some “high fives” and some monetary). What gets rewarded, gets done.
Q: How can organizations achieve consistency in patient results?
KC: The easiest answer is to say that to have consistency in patient results, there must be consistency in messages from management. If goals are aligned from top to bottom in the organization, results are measured in real time. Information technology is sophisticated in order for changes to be made quickly to decrease variation in outcomes, and patient outcomes are maximized. Because each patient is different, it is not possible to always have the same consistent results, but it is possible to have the best results that could be expected if the best evidence is used to make decisions about the patient’s care.
Question: Can you comment on the future of healthcare organizations trying to move towards excellence?
KW: It has always perplexed me to see that so many healthcare organizations are pretty good, and many more are mediocre. Mistakes, waste, inefficiency, poor outcomes, poor service, surly nurses and doctors, and poor financial performance are rampant — and we regularly read about, and experience, examples of this first-hand.
I believe that despite the progress that has been made in medicine and technology, what is necessary is a financial incentive for the type of revolution that we believe is necessary to reinvent the American healthcare system. Award programs like the Malcolm Baldrige Quality Award are steps in the right direction but for a meaningful and sustained sea change of culture — there needs to be an environmental jolt in order to wake the sleeping lion that tolerates mediocrity no more.
J. Stephen Lindsey, FACHE, was CEO at HCA Henrico Doctors’ Hospital for 16 years. He has served as an affiliate professor in the MHA program at Virginia Commonwealth University. Mr. Lindsey is a principal of Ivy Ventures, LLC, a consulting firm that helps hospitals grow outpatient service lines. He is a fellow of the American College of Healthcare Executives. He can be reached at: slindsey@ivyventures.com.
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