Clarke County Hospital (CCH) is a 25-bed critical access hospital located in south central Iowa that serves Clarke County and the surrounding communities. It is a rural affiliate of the Iowa Health System. Its mission is to deliver excellent, compassionate and personalized health care for the people in south central Iowa. These words serve as the foundation for everything we do. Our vision is to be the center of a unified health care delivery system; to be a viable provider of wellness, early detection and treatment; to continue to grow and change to best meet the health care needs of our community; to continue to provide technologically advanced life improving care and to be the employer of choice. The hospital is one of the largest employers in the county with 170 dedicated and caring employees.
CCH is a great place to work and to receive care. It is the kind of place where, when you walk in, people smile and say “hello.” The greeting is genuine and sincere. It is easy when you have engaged leaders and staff who want to provide very good care and are supported with the resources to make it happen. That wasn’t always the case. Early in 2004, the hospital financially was not doing well. The community perception and image of the hospital was one of “a bandaid station.” Unsatisfactory patient experiences, strained physician relationships and a dysfunctional culture were the norm. With new leadership and a clear vision before us, we set out on a course for organizational change.
We realized that although we had a vision for excellence, in order to make profound organizational changes, we needed more employee engagement and lacked some of the basic skills, resources and techniques needed to achieve it. When several of the Leadership Team heard Quint Studer speak at an Iowa Hospital Association conference in October 2007, a fire ignited for Studer’s techniques, principles, strategies and the associated five pillars. It all made practical sense. It matched our vision for the future. The key was connecting back to purpose, meaningful and worthwhile work and making a difference. Thus began our journey of making CCH a great place for employees to work, physicians to practice medicine and patients to receive very good care. With a talented, mature and visionary senior leadership team in place, the climate was right to begin implementing the Studer principles and must haves.
To optimize our journey to excellence, we formalized our partnership with Studer in March 2008 to have access to the coaches and other resources they provide. To anchor organizational excellence, we use Studer’s pillar of excellence approach to develop the organization’s strategic plan, set annual goals and objectives and perform ongoing review. We structure ourselves around the six pillars of….people, service, quality, finance, growth and community with each senior leader responsible for one of the pillars. Annually, senior leadership sets the hospital-wide goals related to the pillars and then cascades them down to the department level to further develop department- specific goals. This creates alignment across the organization with clear expectations and keeps us focused on what needs to occur to be successful. Leadership is held accountable through use of the Leadership Evaluation Manager (LEM) tool. Hospital Pillar goals with monthly progress and results are reinforced by prominently displaying the information on our Pillars of Excellence communication board for employees and the public to view. When goals are met...everyone benefits.
To incentivize staff to reach goals, an employee bonus program is in place for the entire hospital where financial rewards are provided for every employee when specific hospital-wide bonus goals in each of the pillars are met or exceeded. Annually, this bonus equates to approximately $80,000. In addition, a pay-for-performance program was implemented for department leaders whereby merit increases are tied to attainment of hospital-wide and departmental goals and our Standards of Behavior.
Along the way, our challenge has been in keeping staff engaged and helping all staff to recognize that they have the ability to personally affect the overall patient experience, achieve clinical quality outcomes and reach organizational goals. This involves providing our employees with the tools and resources to achieve the results we desire. The key to our success...is our employees.
In January 2008, CCH created and adopted its first initiative….detailed Standards of Behavior. These standards were developed by a group of high-performing employees and are intended to guide us in our daily interactions with our patients and teammates. Our behavioral standards are the foundation of our culture. The expectation was that all employees in every department would adhere to these key behaviors. Since adoption, some employees have struggled with the standards lack of behavioral clarity and inconsistent accountability demonstrated by some. In June 2012, the standards were simplified to one page with bullet points added to each key behavior to more clearly define the expected behaviors and consistent accountability was reinforced. Intense roll out, training and reminders by the Standards of Behavior team continued over the next three months. The behavioral standards are incorporated into new employee orientations, performance reviews, etc. Accountability continues to grow. Leaders have struggled with High/Solid/Low conversations but this too has improved over time. Low performers leave and a sense of relief is palpable in the affected departments.
We consider our employees our most valuable asset. Therefore, it is important that employees have avenues available to communicate their concerns. We have implemented the Studer must haves of employee rounding and thank you notes by the Leadership Team. Annually, we survey our employees using the Great Places To Work (GPTW) survey. The data provides insight into employee opinions and concerns. We use this data with departments to create recognition, develop action plans for improvement and facilitate interventions in challenged areas. In 2012, CCH employees ranked the organization in the upper 90th percentile in this national survey to the question, “Taking everything into account, I would say that this is a great place to work.” As the following graph depicts, CCH far exceeded the other hospitals in the Iowa Health network. We also were the only rural hospital participating.
Two-day, off-site LDI’s are held quarterly with the focus being on education and training opportunities for leaders that have been identified by the LDI Team and senior leadership. CCH has made a significant financial investment in leadership and staff development. Most recently, our Leadership Institute has focused on growing leadership skills that need further development, such as crucial conversations. CCH has sent all department leaders to Studer’s Taking You and Your Organization to the Next Level (TYYO), as well as, a number of front line staff. In addition, several leaders and staff have also attended What’s Right in Healthcare.
In order to realize our vision of being the Provider of Choice, we had to start from within. In 2006, the hospital relied heavily on staffing agencies to provide nurses for its Med-Surg unit. Contracted labor costs totaled $600,000 a year. As of 2011, contracted nursing staff has no longer been needed. Senior leadership realizes that in today’s health care market, it is important that employees feel valued and have a sense of ownership within the organization. A peer interview process was implemented where the final applicant interview is conducted – and hiring decisions are finalized– by the peer interview team. This practice lets employees know we trust their judgment while also encouraging employee commitment to our hospital. We acknowledge that CCH can not succeed in serving patients without satisfied employees. To that end, we want to keep talented and valued employees within our organization and therefore use 30 and 90 day interviews with new employees to elicit their feedback and look for opportunities for improvement.
Total Full and PT RN's
Turnover rate (annualized)
We hear from employees that we are patient focused...keeping the patient at the center of everything we do. Our patients tell us they like coming to our hospital for care...patients commonly remark that they can tell the hospital has advanced. Such comments as “wonderful experience”, “everyone was so friendly, helpful, caring and concerned” are common themes. More quantitatively, our patient satisfaction scores reflect a clear satisfaction from our patients.
Our hospital is small, but patient care is no small matter. We focus on improving communication with patients and families through the use of our priority indices provided by Press Ganey. The priority indices help guide our efforts to ensure we are focused on the things most important to our patients. Annual hospital-wide and departmental patient satisfaction goals are established for all survey types. Departmental action plans are developed based on Press Ganey’s top priority indices for each survey type. The Service Measurement team continuously monitors the Priority indices in all survey types and guides improvement efforts to improve the overall patient’s perception of care. We also use the Priority Index questions to help develop scripted language and key words to communicate with patients. Additionally, we continue to place an emphasis on moving our 4s (good care) to 5s (very good care) and look for opportunities to “wow’ our patients experiences. In October 2012, we began focusing on a specific service standard priority each month and post relevant information on computer screen savers hospital-wide.
We implemented Service Pillar dashboards in all departments in 2010. Quarterly at LDI’s, patient satisfaction results are shared with priority focus areas identified for development of next quarter’s action plan by all clinical areas. Support departments who support direct caregivers utilize interdepartmental survey results to develop their action plans. The dashboard and action plans are then shared by the department leaders with their respective staff and prominently displayed in their departments.
Despite our best intentions, sometimes unavoidable delays and miscommunications occur. In 2009, we introduced our Service Recovery with Heart program to convey our sincere apology for inconveniences experienced by our patients or family members. Recovery tool kits are strategically located for all department staff to use in such occurrences.
The ED has sustained strong patient satisfaction scores in the 94-98th percentile for the last four years. CCH credits much of the success to a change in the contracted ED physician group instituted in 2009. We enjoy and are fortunate to have a positive relationship with an excellent contracted ER physician group who demonstrates their care and compassion with our patients on a daily basis.
Over time, the OP departments have been challenged with inconsistent overall survey results. The Studer resources of AIDET, key words at key times, patient rounding and discharge calls have assisted us in our outpatient improvement efforts. The Press Ganey scores quickly identified a primary problem area….inconsistent use of AIDET in most clinical areas. An AIDET refresher was needed. Therefore, in January 2012, we decided to use Studer Groups AIDET skills lab with all clinical outpatient departments and registration to hardwire AIDET behaviors. In addition, managing up and patient handoffs were emphasized, streamlined and strengthened. Role playing and the feedback provided were instrumental in our improvement efforts. We also increased the number of AIDET validation audits required by these departments. Our overall OP survey scores have improved significantly from the 22nd percentile in 2008 to the 84th percentile in 2012.
The Studer must haves of hourly rounding, nurse leader rounding and bedside shift report have assisted in our inpatient satisfaction scores reaching the 92nd percentile. Improvement in HCAHPS domain scores is a CCH goal this year. In 2012, CCH scored above the 90th percentile in 5 of the 8 HCAHPS domains, however, significant improvement is needed in the other three. The Hospital Environment domain consistently scores in the 98- 99th percentile. Through use of Studer principles and must haves, CCH has seen a consistent increase in patient satisfaction results across all survey types.
To realize our strategic initiative of being a physician-driven organization, CCH hired a Chief Medical Officer (CMO) in 2011, who is a member of the senior leadership team. This individual is responsible for various physician engagement activities that included the development and implementation of a physician satisfaction survey to gauge provider satisfaction with hospital services. Significant physician engagement, as well as, relationship building between physicians and hospital staff has occurred. The CMO also provides a physician perspective to various quality and safety initiatives aimed at improving patient care.
CCH places a high emphasis on providing safe, quality care for our patients. Medication safety is one such priority. In 2006, bedside barcode medication administration was implemented, along with real-time electronic clinical documentation at the bedside. Numerous medication safety alerts aimed at patient safety are continually put in place to improve patient care. Staff is held accountable to heed these alerts. Med rounding is a common practice where nursing, pharmacist and quality representatives review adverse drug events and drill down med errors to ascertain the root cause and make improvements. Total medication errors have decreased 59% over the last three years. System enhancements to our health information system are made annually to assure patient information is timely and accurate.
Significant initiatives were implemented in 2011 in order to meet meaningful use Stage I requirements for a certified EHR. In preparation, meaningful use teams comprised of clinicians, pharmacist, IT staff, medical records and administration were formed. The teams reviewed processes and workflow to assure the focus remained patient-centered. As a result, clinical processes were refined, enhanced and resulting documentation improved. One such initiative was mandatory CPOE for all active Medical Staff members. At the same time, pharmacy coverage was expanded and we began using remote pharmacists for medication order review and verification after hours, as well as, implementation of collaborative practice agreements between pharmacy and Medical Staff. The CMO is truly our physician champion and was instrumental in moving these quality initiatives forward. She was involved in the planning, development, implementation and standardization of evidence-based, diagnosis specific, admission order sets for practitioner use through participation in weekly CPOE meetings. The communication, feedback and problem-solving she provided were advantageous for physician buy-in and support.
The ED implemented the T-System as their EHR with integration to our main HIM system. To aid in accessing medical record documentation anywhere from within or outside the organization, we also initiated a totally paperless medical record system house-wide. This involved numerous process improvements. All practitioners have access to a patient’s medical record remotely.
CCH embraces the latest information technologies available to improve patient care, outcomes and efficiencies. In 2009, CCH was the recipient of a $356,243 federal USDA Rural Development Distance Learning & Telemedicine grant that has enabled us to provide education and medical care via telecommunications technology. In 2010, we were co-recipients of a Broadband Technology Opportunities Program (BTOP) grant along with Iowa Health-Des Moines and three other rural affiliate hospitals, totaling $8,321,815 to further improve health care delivery in rural areas. These grants have enabled us to use telehealth technology to access physician specialists remotely, provide professional/community education, EMS education, video language and deaf interpreter services, as well as, video communication for inpatients family members and for clinical staff prior to transfer between health care facilities. Currently 14 specialties are utilizing telemedicine. In 2012, a total of 179 IP and OP consults were provided and 72 additional inpatient days. This resulted in approximately $165,000 in additional revenue that otherwise would have been diverted to a tertiary facility as patient care services would have been provided there.
May 2012 brought the advent of video conferencing capabilities to the pharmacy department allowing us to implement remote video telepharmacy services. CCH now has 24-7 pharmacy coverage that further enhances patient medication safety through remote pharmacist review and verification of any medications removed from the pharmacy in the absence of an on-site pharmacist. After hours and weekend pharmacy coverage is provided remotely by our partner, the Iowa Health System.
A full time certified echo and vascular ultrasound tech was hired in 2009, enabling CCH to bring echocardiography and vascular service exams in-house five days a week rather than relying on a mobile service once or twice weekly. These digital images are transmitted remotely for cardiologist analysis and interpretation. Occupational therapy services have expanded through employment of our own therapist. We also began performing EEG’s in-house with image transmission and video monitoring done remotely by certified EEG techs with analysis and interpretation by specially trained neurologists.
The economic downturn of the past few years and the advent of health care reform have made financial performance for hospitals difficult. CCH believes that focusing on employee and patient satisfaction and delivering quality care has been the flywheel that drives the hospital’s financial performance. By aligning our goals and initiatives we have been able to achieve a lot. CCH invested over 8 million in infrastructure improvements that included its inpatient unit, specialty clinic and some outpatient areas. All these renovations were paid exclusively with internal cash reserves. Another facility expansion and remodeling project is planned with Phase 1 of a master facility plan approved in January 2013. Much of this is expected to be paid for through a capital campaign and cash reserves.
CCH also invested considerable dollars in information technology (IT) infrastructure and systems that allowed us to implement an electronic health record along with various other IT-related services like telehealth. All Stage 1 meaningful use criteria for Medicare were met and we successfully attested in late September 2011. To date, we have received approximately $1,110,000 in meaningful use incentive compensation payments from Medicare and Medicaid.
The last three years, CCH has collaborated with specialty physicians to provide free vascular screening exams to approximately 50 at risk individuals each year. Three were identified as candidates for further intervention in 2012. This would not have been possible without the support of the physicians and staff at CCH. A variety of health-related educational sessions and health fairs are provided to community groups, schools, etc. As a result of the BTOP grant, 40 AED’s were placed throughout the community with CCH staff training employees at each site. In addition, grant monies were used to install video-conferencing equipment at two local community colleges and four local fire department/city halls that has enabled students and first responders to attend classes and communicate via video conference. As well, video conferencing also occurs between the hospital and local high school where hospital staff teaches health education classes while the student remains in the school classroom. In the last seven months, employees have participated in 15 community presentations or community sponsored events by the hospital. The employees also give back to the community through donations to local food pantries, providing school supplies, clothing to needy families and participation in local fund raisers.
May 2012 – Named one of the nation’s cleanest hospitals by Becker’s Hospital Review: Top 40 Cleanest Hospitals in the U.S.
Aug 2012 – Recognized by Telligen HITREC (the federally designated HIT Regional Extension Center for Iowa) as an early adopter, local leader and advisor in the implementation of Electronic Health Records
September 2012 – Placed Fifth on The Des Moines Register Top 100 Iowa Workplaces for 2012 (mid- sized employer list)
October 2012 – Studer Group 2012 Excellence in Patient Care Award to the ED department
We are proud of our accomplishments and continually work to make CCH an even better place for employees to work, physicians to practice medicine and patients to receive great care. The CCH team is honored to have been named the Health Care Organization of the Month by Studer Group. We look forward to continuing this collaborative relationship and making even more strides on our journey to excellence.