What Leaders at High Performing Organizations Know

"It's about creating a sense of 'fire in the belly'," says Christy Stephenson, CEO of Robert Wood Johnson University Hospital Hamilton, Hamilton NJ. "My job is to ensure I have the right people on the bus, that they recognize how much I value patient satisfaction and quality outcomes, and they understand this is the fuel for what we do and how we move to a higher standard of care."

At RWJ Hamilton, it's clear that employees are on board in a big way. Last November, Robert Wood Johnson University Hospital Hamilton became the fourth health care organization ever—and only one in 2004—to receive the prestigious Malcolm Baldrige National Quality Award, the nation’s only Presidential award for quality and organizational performance. This award recognizes the great results the organization has achieved across all five Pillars—People, Service, Quality, Finance, and Growth—and the process they used to get them.

In a recent study of seven high performing health care organizations by the Alliance for Health Care Research, respondents said the most influential factors in their success were leadership commitment, accountability, and training.

Collectively, these organizations have made—and sustained—dramatic gains in patient and employee satisfaction for a minimum of three years with most ranking above the 90th percentile for consecutive quarters compared to peer organizations nationwide. They have reduced turnover from an average of 23.6% to 12% annually. In general, they enjoy strong financial returns, increasing market share, and other indicators of growth. So what are they doing differently from other hospitals?

Raising the Bar

"We committed to much more than words on a plaque when we embraced Studer Group's Pillars of Excellence," explains Frank Sacco, CEO of Memorial Healthcare System, a five hospital system in South Florida. "We committed to developing metrics and accountability measures. Together, our Board of Directors, senior leadership and medical staff committed to doing whatever it took to becoming a world-class organization."

"You have to create a 'no excuses' environment," he adds. "If we don’t change health care from within, it will be changed for us." Memorial's success speaks for itself. Sure, the system has been hailed as a model nationally for impressive community partnerships, and received dozens of awards at its hospitals for service, quality, performance, and family friendly employment. But even more importantly, Memorial Healthcare System has created a culture that fosters ownership and innovation, both hallmarks of high performing organizations with people power.

Recently at one of Memorial’s hospitals, a nurse elected to keep a patient despite a physician’s discharge orders because she sensed the child still wasn't well. She saved his life when an underlying condition was subsequently diagnosed. On her own initiative, another nurse woke up a patient after anesthesia, but before surgery, to do a CT scan so she was confident the physician was operating on the correct lung. It's all part of Memorial's culture of patient safety where any employee can "pause for the cause" if something isn't right or "stop the line"” to challenge omission of care, without disciplinary action. And physicians are appreciative. It's risk management at its best.

Walking the Talk

"Every other time we tried to change the culture, we told staff what to do," says Kathy Neuner, vice president of nursing at Clark Memorial Hospital, a 241-bed facility in Jeffersonville, IN. "This time, for 90 days, we didn't ask employees to do anything. Senior leaders first role modeled the Standards of Behavior that we wanted them to eventually adopt. We greeted all patients and staff to model what we meant by a "no passing zone." Within six months, it began to take hold organization wide. In fact, one day I was shocked to see a cardiologist carrying a patient's suitcase to the cath lab! When I went to thank him for taking such great care of our patients, he said, "Well, I notice that you all do it."

After leaders posted a sign in the lobby that "Call Lights Are Everyone's Responsibility," patients and visitors took notice too. "Families were amazed when they saw the leader of the engineering team stop by a patient room to find out what a patient needed," adds Neuner. "It's not really about me going out and doing things with my employees. It's about me doing the right things so they are inspired to follow in my footsteps."

Audrey Meyers, President and CEO at The Valley Hospital in Ridgewood, NJ, is so committed to "communication at all levels" that she conducts "Take a Break with Audrey" Employee Forums 15 times every four months—including some in the middle of the night for night staff—reaching about 1,000 employees, to ensure that employees stay current on progress toward organizational goals.

What has this CEO learned along her organization's journey to excellence? "Building the skills of leaders is essential because they set the climate for success," she explains. "Knowing what I know now, I would have started the Leadership Development Institutes much earlier. I think we expected results to come from providing good service. But it was really after three LDIs that we saw operational results."

Training

All of the organizations in the Alliance study hold quarterly two-day Leadership Development Institutes to train leaders on skills needed to meet organizational goals."

"Measuring is what matters, along with reporting progress and being accountable for results. It's just one of the core competencies we've dramatically improved since beginning LDIs," adds Ed Carthew, chief administrative officer at Sarasota Memorial Health Care System in Sarasota FL. "Today, there are no excuses about incorrect data or wrong sample sizes."

But are LDIs worth the time investment? Chris Budzinsky, vice president of patient care at St. Alexius Medical Center in Hoffman Estates, IL explains, "Health care can change on a dime. We know leadership development works in good times and in bad to create responsive leaders. Using the Linkage Grid, we hold leaders accountable for applying what they learn at the LDI to their daily lives. When we highlight accomplishments of individuals who implemented tools from the previous training, the light bulbs go on for all of us."

Accountability

All of the organizations in the Alliance study revised their leadership evaluation tool to align with achievement of results by objective measures. Seventy-five percent of organizations in the Alliance study—the organizations that experienced the most improvement—now tie compensation directly to leadership evaluations that objectively assess results.

Michael Kittoe, chief financial officer at Delnor-Community Hospital, Geneva, IL, recommends using validated, objective and external benchmarks for establishing goals (e.g. survey data) when possible. But there are other ways too. "If I'm trying to cut down registration wait time, there may not be a good external benchmark," he adds. "So instead I might ask a clinical leader to gather internal data over a month-long period to determine how we are currently performing and the best we've ever done. Then we'd decide together on a realistic goal."

Most leaders actually welcome less mystery in the evaluation process, especially when they feel they have the tools and support to achieve the goals. But those that don't may be low performers who feel increasingly uncomfortable with standardized leadership behaviors. They need to exit for the organization to make the quantum leap that elevates long-term operational performance.

"Some of the employees we asked to leave were very nice, well-intentioned people," explains Christy Stephenson. "But when we moved to a no secrets culture and began reporting more sensitive items—like patient satisfaction by units—those who didn't get results were fish out of water. It was outside their comfort zone. We did use more 'carrot than stick', even pairing low performing leaders with high performing coaches, but in the end, it's an individual choice."

"I had to let four directors go, but I think I'm a stronger leader for it," shares Chris Budzinsky. "If you don't address low performers, your best employees start to question your commitment to role modeling what you say you expect from others. You can't afford for high performers to lose the faith."

Relentless Pursuit of Excellence

Final tips from leaders at high performing organizations? Maintain discipline and relentlessly pursue the consistent use of best practice tools across the organization. "Thank you notes are a huge motivator," notes Budzinsky. "We have to constantly work on the quality to make sure they don't become rote, but I still hear thank you's for notes I sent to an employee's home three years ago."

"Rounding for Outcomes is also probably one of the best things that ever happened here," she says. "I’d been 'rounding' on patients as a nurse for over 30 years, but it was so different from what I do now. Instead of eyeballing a patient's IV, as I did then, now we proactively check for pain, comfort, and so much more."

Interestingly, when Quint Studer polled 4,000 participants at 400 sites on the biggest barriers they experienced in Rounding for Outcomes¹, 67% said it was hard to find the time.

Advice from leaders at high performing organizations? "You have to put it onyour calendar and make it part of what you do every day," suggests Budzinsky. "If a nursing director with 30 patients can do it, anyone can. And the pay-off is huge…there are few quality or risk issues these days at St. Alexius because I don't read about incidents on an occurrence report that's floated around on somebody's desk for two weeks. I hear about what happened on rounds and how it was addressed right away."

"What do I recommend to leaders who say they can't find the time?" adds Frank Sacco. "Find it. If not, you'll be replaced by a CEO or leader who can. Your Board is going to recognize this is being accomplished around the country."

And the rewards are worth it. "When a patient walks out of your hospital and
says 'I don't ever want to go anywhere else. This is my hospital;' I just love that!'" sums up Kathy Neuner. "That's true patient loyalty."