Studer Group recently sat down with Mark Pelletier, chief operating officer, accreditation and certification operations
for The Joint Commission, to discuss their journey to cultural transformation.
Q: Why did The Joint Commission decide to work with Studer Group?
Inspiring organizations to be highly reliable and commit to zero harm is our mission. However, our customers did not
always see the services we provide in that way. Instead, some organizations felt that we sought out problems and focused on
small issues that were not important to patient safety. This reputation was a barrier to our goal because when surveyors
delivered findings in a way the organization perceived as punitive, they would shut down, become defensive, and refuse to
listen, which did not help mitigate patient safety risks.
We recognized that our approach needed to change so customers would be open to feedback and our efforts to provide
education and to share best practices we have observed. We needed a transformation. We wanted to transition from being just
an accreditor to being a true partner in performance improvement. Achieving a major cultural shift is difficult, and can be
nearly impossible without objective guidance. We knew that we needed help, so The Joint Commission turned to Studer
Group, well-known for their expertise in cultural change.
Q: How is the transformation going?
Studer Group has worked with our organization to create a framework for lasting cultural change. Several key behaviors
have been introduced and implemented to begin and foster our ongoing journey:
Aligned and Objective Goals - Setting objective, measurable goals was the first and most critical
step. Studer Group worked with us to establish the right goals. When creating the goals, we had to focus first on the
results we wanted to see in our organization, not just the tactics to get us there, and this took our team some time to
work through. We experienced some cultural barriers to this heightened level of accountability. Next, we needed to
determine which leaders had the most responsibility and power to make changes in these areas, and who needed to share
goals to create the greatest outcome. Last, we had to prioritize the goals by selecting the actions that would have the
most impact on changing the culture. After finalizing the goals, senior leadership cascaded them to all leaders in a
series of workshops.
90-Day Plans and Monthly Meetings - Studer Group worked with us to create 90-Day Plans with action
steps. The 90-Day Plans helped our team see how long-range goals could be achieved, which made the goals manageable and
provided a roadmap. Also, reviewing 90-Day Plans during monthly meetings was essential to staying on track because it
held leaders accountable and the plans ensured we were on the same page and working on the same target. During the
meetings, we also discussed how each person contributed to the overall goals of the organization and how their leader
could assist them in moving forward.
Leader Rounding on Employees - Communication, especially through rounding, was the key to effecting
lasting change because it promoted a free exchange of ideas between leaders and staff. Employees at all levels, even
those not on the
Evaluation Manager® software, were aware of the organization's goals and understood how they contributed to the
company's success. Through rounding, our leaders gain valuable information and are able to act upon employees' ideas
and concerns, and this resulted in statistically higher employee engagement this past year.
Key Words at Key Times and Tough Conversations - We provided our surveyors coaching to help them
enhance how they interacted with our customer organizations. We wanted them to have the mindset of an advisor, rather
than a critic. To accomplish this, surveyors received training with four primary objectives in mind: 1) provide
meaningful assessments for each organization served; 2) inspire organizations to deliver higher rates of quality care;
3) be transparent throughout the survey, highlighting identified risks the organization is not already aware of; and 4)
educate our customers and help them understand why they are not meeting a standard, linking the standard back to safe
patient care. The Studer Group team helped us develop key words to use at key times when discussing difficult issues
with customers. We also learned how to constructively hold tough conversations that resulted in a win for all
Q: What have been the results so far?
Internally, we have changed how we interact and work together. Our atmosphere which was once closed is now collaborative
and collegial, and thanks to rounding, we enjoy more open communication. Employees more freely share their ideas and have
increased confidence that leadership will listen and act on their concerns. Because of these changes, our employee
engagement results have increased significantly.
Equally as important, relationships with our customers have improved. Many now see us as advisors and partners who help
them achieve patient safety goals. Customers are giving surveyors positive feedback and thanking them for identifying
issues. Our mission is becoming a reality. We are working as a team with our customers to provide safe and
care for patients. As many service-oriented organizations do, we survey our customers. As a result of our journey
with Studer Group, we have appreciated significant improvement in the voice of the customer results we have achieved.
Q: What is your advice for organizations who want to commit to high reliability?
We believe that organizations can use the same framework as us to reach high reliability. For example, creating
objective and measurable goals is a critical first step to getting everyone aligned. Continuous course correction with
90-Day Plans encourages accountability, while ongoing communication provides employees with structured time to discuss
safety matters, contribute to improved quality and safety of care, all which lead to higher rates of reliability.
Here is an example of high reliability in action: Recently, a surveyor was on site at a large organization to audit
infection control standards. Typically, the leader of their infection control initiative would handle the entire
interaction with The Joint Commission surveyor. However, that day, the infection control leader was on vacation, so others
stepped in to review the process. In some organizations, this could have been a problem, but this hospital passed all
standards, and their employee was knowledgeable and confident about the standards that were in place. Why was this
organization different? Because following the correct process was a part of that organization's culture, and not dependent
on a person. That is high reliability - having the proper system in place so that everyone knows how to accomplish a task
the right way, all the time.
Understandably, it can be hard for organizations to know where to begin in their efforts to improve the quality and
safety of patient care, so we have established the Center for Transforming Healthcare which helps organizations solve
common safety problems. Any organization that we accredit can access
Targeted Solutions Tools®(TST®),
an online application that provides guidance for several initiatives, including hand hygiene and falls.
Once organizations make safety a part of their culture, then our shared goal of committing zero harm will be the natural
result. After all, the desire of every person in healthcare is for everyone - including our family and our friends - to
receive the safe, quality, care they deserve. The Evidence-Based Leadership
SM platform that Studer Group helps organizations embed provides a solid foundation for
accountability and ultimately, for cultural transformation.
Studer Group wishes to thank Mark Pelletier and The Joint Commission for conducting this interview and for their
ongoing commitment to patient safety and the delivery of quality healthcare.