Performance excellence within healthcare organisations is achieved by a combination of quality care, motivated staff, efficient systems, sound economics, good leadership and committed teamwork.
Performance excellence in healthcare is being pursued worldwide; however, there are significant financial challenges to providing safe, high-quality healthcare services to communities. The case studies within this Best Practice Report show that difficult financial challenges can be turned around through continuous quality improvement, good leadership, and multi-disciplinary teams.
In Healthcare Executive magazine, Jessica Squazzo writes that employee engagement in healthcare environments is intrinsically linked to the quality of care patients receive. Research consistently shows that the successful operation of complex healthcare facilities depends, to a great extent, on the people who do the day-to-day tasks that keep the organisation running. These people can be found at every level of the organisation: from those who change the bed linen or sweep hospital floors to the executives in the administrative office.
In forward-thinking organisations, employees are expected to find solutions to problems without specific direction from their managers. Employees will tend to arrive at successful solutions as they identify with an organisation’s goals, purposes and strategic objectives. This is why organisations need an engaged workforce. According to Mark Royal, a senior principal with global management consulting firm Hay Group Insight, for employees to become fully engaged, they must firstly be satisfied that their organisations:
- are led by competent people, capable of positioning the organisation for success
- are imbued with a clear sense of direction
- have a positive business trajectory, and
- have the right people on board to achieve the desired goals.
Employees are taking greater responsibility for plan- ning their careers; they are therefore reluctant to make a long-term commitment to an organisation that appears to provide them with few opportunities to develop their skills. Employees need to be able to visualise a positive future for themselves within organisations. Research shows that the most admired companies invest in employee engagement, both in the good times and the bad. This creates a valuable reservoir of goodwill for when it is needed. In fact, organisations cannot afford to not invest in employee engagement; it is a key resource to drive high levels of productivity, customer satisfaction and performance. 
Writing in Trustee, a magazine for healthcare profes- sionals in the United States, Joe Tye, CEO of Values Coach Inc., and his colleague Anne Toomey argue that while a person may be initially impressed with the physical architecture of a hospital building, the most lasting impressions are created by an organisation’s “invisible architecture.” The following series of questions invited the magazine’s readers to explore the three “invisible pillars” of their organisation: core values, organisational culture and behavioural expectations.
Core Values. Questions to consider include:
- Do these reflect your current organisation and its future aspirations? Core values should mirror who you are today and inspire continuous future improvement.
- Are they operationally relevant? In addition to broad concepts such as compassion and integrity, operational parameters such as productivity and loyalty should also be incorporated.
- Are they socially relevant? Do they reflect social responsibility for the underserved, the environ- ment, public health and behavioural health?
- Are they crafted to inspire employees to take ownership of them because they resonate with their own personal values?
- Would an outsider see these values reflected (or not) in the attitudes and behaviour of the organisation’s employees?
Organisational Culture. Properly implemented strategic plans are underpinned by a sound organisational culture. Questions to be asked include:
- How would you describe your culture to a prospective patient, new employee or physician recruit?
- How is your organisation’s culture represented when recruiting and in new employee orientation processes?
- What strategies and tools are used to reinforce the desired culture, including performance appraisal, education and training, formal and informal celebrations?
Behavioural Expectations. Organisational values and culture need to be translated into everyday attitudes and behaviour. Questions to be asked include:
- What is the organisation’s zero-tolerance point regarding behaviour (e.g. dishonesty, abuse, bullying or gossiping about patients or co-workers)?
- What mechanisms do you use to establish these expectations in the minds of employees, volunteers and physicians, and to instruct people about how to handle transgressions?
The invisible architecture of hospitals affects every aspect of their operations-i.e. clinical quality, patient safety and satisfaction, employee engagement, productivity, and financial performance-as well as their reputation. Leadership teams need to be as inten- sively involved in designing and building these unseen elements of performance as they are with other more visible and more easily measureable aspects. 
According to Dean Coddington, senior consultant, and Keith Moore, CEO, of McManis Consulting, a Denver- based management consulting firm in the United States, the following statement about physician-led initiatives is typical of many multi-hospital systems:
“We have a track record as a leading health system. We have a highly developed approach to system leadership, with clear goals and priorities, clear lines of accountability, and aligned incentives for the lead- ership team of the system. However, our physician leadership structure is in its infancy. And we have not started to integrate our system approach to leadership with our physician organization and network leadership. That all lies ahead.”
Coddington and Moore believe that the following key elements are required when building a physician- driven system:
- Mechanisms to capture key data. Future cost accounting systems will need to include all associ- ated care environments, including physician offices within health system networks. In a recent American Hospital Association survey of health system chief financial officers, only 8 per cent indicated that they possessed a “moderate” or “significant” capability to produce accurate cost data for their network of medical practices; however, 75 per cent expected to have these capabilities within the next three years.
- Analysis of patient and practice information. While analytical software supports the collection and analysis of data, it is essential this leads to action- able initiatives. Examples of projects that require physician-led leadership and support include:
- reduction in readmission rates
- chronic care management strategies
- physician network management
- physician and management incentive structures
- gain/risk sharing payments for contactors
- capital decisions, and
- budgeting and forecasting.
- Establishing physicians in leadership roles. Physicians are being asked to take up roles for which they have not been trained, including:
- assisting in using information to design strategies, scorecards, and other initiatives
- translating results in collaboration with nurses and caregivers to meet the needs of patients, and
- designing and interpreting new decision- support data.
- Establishing a culture of physician leadership. Health systems will require significant interactions with physicians if future cost and quality goals are to be achieved. To this end, they will need to employ physician forums to generate ideas, develop best practices, and monitor/adjust approaches. In essence, health systems will need to establish a culture of ongoing initiatives using physician leadership. 
- Balancing clinical and administrative responsibilities. To maintain clinical credibility, 68 per cent of physician leaders continued their clinical practice, and spent-on average-80 per cent of their time on administrative duties.
- Developing business acumen and leadership skills. Postgraduate management degrees are becoming essential for physician leaders. According to a 2011 survey led by the American College of Physician Executives and Cejka Search, some 42 per cent of physician executives hold a postgraduate degree. Among C-level executives (the highest level of executive), 37 per cent specifically hold a Master’s degree in business administration, medical management or health administration.
- Adjusting to different compensation drivers. The transition from specialist to administrator brings with it the need to adapt to new forms of compensation, based upon achieving organisational performance goals. This can constitute up to 60 per cent of bonus compensation.
Susan Freeman, M.D., chief medical officer of Philadelphia’s Temple University Hospital in the United States, believes that a “physician leader never stops being an advocate for the patient, but gains the opportunity to expand his or her framework to become an advocate for all patients served by the organization.” 
Nurse Leaders Possess Unique Skills
In the United States, Susan Hassmiller, senior adviser for nursing at the Robert Wood Johnson Foundation, and John Combes, president and chief operating officer at the Center for Healthcare Governance, write that Institute of Medicine’s 2011 landmark report emphasised the importance of nurse leadership in improving America’s healthcare system. Entitled The Future of Nursing: Leading Change, Advancing Health, the report stated that, “the nursing profession had the potential to effect wide-reaching changes in the healthcare system. Nurses’ regular, close proximity to patients and scientific understanding of care processes across the continuum of care, give them a unique ability to act as partners with other health professionals and to lead in the improvement and redesign of the healthcare system and its many prac- tice environments.” The report continued by stating that, “[p]rivate, public, and governmental healthcare decision makers at every level should include representation from nursing on boards, on executive management teams, and in other key leadership positions.” Nurse leaders posses an intimate knowledge of patient care, and understand the requirements needed to improve healthcare quality and safety. In addition to patient care skills, many nurses are educated in healthcare administration, financial management, quality improvement, and information technology. A number of these nurse leaders are also willing to become engaged in decision-making processes; they also possess the facilitation skills that board leadership requires.  
New Technology for Home-Care Patients
In the United Kingdom, Jane Hendy, from the University of Surrey, and James Barlow, from the Imperial College Business School in London, write that recent develop- ments in communications and information technology- together with an increasing need to care for people with chronic, long-term conditions-have led to larger-scale implementation of telecare and telehealth systems.
Telecare involves monitoring elderly or disabled people to protect their health and safety (e.g. mobility or falls) and home environment (e.g. floods and fires) by helping to manage the risks associated with independent living and provide an emergency response when required. Monitored sensors are used to meet specific needs: these can include movement sensors, fall alarms, bed and chair occupancy sensors, smoke alarms, heat sensors and flood detectors.
Telehealth describes the exchange of data between patients and healthcare professionals in order to assist in the management of an existing long-term condition (e.g. asthma, diabetes or heart failure). Telehealth systems involve patients having frequently used equipment in their own homes. These devices are able to ask a range of relevant health and quality of life questions, which can be answered using a keypad or touch-sensitive screen. Devices monitor vital signs such as blood pressure, blood glucose, blood oxygen, and weight. Data is transferred over a land line-or mobile telephone connection-to the monitoring centre, where it is checked against the patient’s normal pattern. Advice or information can then be given to the patients. This type of technology can help empower patients to better manage their own care.
Telehealth and telecare systems provide independence, security, confidence and quality of life; they also enable patients to stay in their own homes. The United Kingdom’s Department of Health recently undertook the world’s largest randomised, controlled trial of telecare and telehealth services, involving 6,191 patients and 238 general practitioners in Cornwall, Kent and the London Borough of Newham. The trial demonstrated a potential to deliver:
- a reduction of 15 per cent in Accident and Emergency visits
- a reduction of 20 per cent in emergency admissions
- 14 per cent fewer elective admissions
- 14 per cent fewer bed days, and
- a reduction of eight per cent in tariff costs. 
John Bluford, chair of the American Hospital Association, signed off on a 2011 study entitled Call to Action: Creating a Culture of Health, in which it was stated that hospitals are a focal point within their communities, making it important for them to lead the way and serve as role models for healthy living and fitness.  It has been estimated that American businesses could save $1 trillion in health benefits over the next decade by implementing employee health and wellness programmes.  Recent studies have indicated that the costs and savings associated with work-place disease prevention and wellness programmes lead to significant returns on investment (ROI). Reported savings amounted to US $3.27 per dollar invested on wellness programs, and similar savings in absenteeism costs.  A global comparative study of workplace wellness programs in 15 countries showed that employees are eight times more likely to be engaged when wellness is a priority in the workplace, and 1.5 times more likely to stay with their organisation if health and wellness are actively promoted. It was found that wellness is essential for:
- employee engagement
- organisational productivity
- talent retention
- creativity, and
- innovation. 
Green Hospital Buildings
Laura Kinney, practice leader of environmental sustainability at Tacoma-based MultiCare Health System in the United States, writes that Good Samaritan Hospital, one of the organisation’s facilities, was Wash- ington State’s first LEED (Leadership in Energy and Environmental Design) Silver-certified hospital. To make sure the full benefits of the green building were realised, MultiCare used the Green Guide for Healthcare. This voluntary guide provides the tools and structures to help healthcare organisations operate buildings, systems and equipment in a more efficient, effective and sustainable manner. According to Kinney, many organisations make the mistake of operating their new green buildings in the same way they would older buildings. By doing this, they fail to achieve the full financial benefits available with the new design and building standards for LEED. Some of the design features included in the Good Samaritan Hospital are recorded in Figure 1, see below.
A report to California’s Sustainable Building Task Force recorded that an upfront investment of approximately 2 per cent to allow for the inclusion of green design features will, on average, result in life cycle savings of 20 per cent of the total construction costs. Thus, in practice, an initial investment of $100,000 to incorporate green building features into a $5 million dollar project would potentially result in savings of $1 million (non index-linked) over the life of the building. 
Survey and Research
Drug Education Programmes: Price and Availability Have Big Influence
Three Mentor surveys built the following composite picture of drug use—and attitudes towards drug use—among young people in the United Kingdom.
- 67% of 16 to19 year olds said it was never acceptable to take cannabis; 93% said the same about cocaine.
- 8% of 11 to 15 year olds said they thought it was acceptable to try cannabis to see what it is like; only 2% thought that it was acceptable to take cocaine.
- The numbers of 11 to 15 year olds in England reporting that they had experimented with drugs fell from 29% in 2001 to 22% in 2010 (a similar pattern was found in Scotland).
- The surveys found that environmental factors, such as price and availability, significantly influ- enced young people’s use of drugs and alcohol.
Employee Wellness Programmes Offered by Hospitals
In 2010, the American Hospital Association undertook an online survey of all American hospitals on the subject of the wellness programmes offered to healthcare employees. 876 hospital HR leaders, CEOs and wellness leaders responded to the survey. The most common wellness programmes offered by healthcare organisations in the United States were reported as:
- flu shot and other immunisation (95%)
- Employee Assistance Program/mental health services (81%)
- smoking cessation programmes (79%)
- healthy food options (78%)
- tobacco-free campus (76%)
- safety programme (75%)
- health-risk assessments (74%)
- weight loss programmes (73%)
- gym membership discounts (67%).
The main driver for organisations adopting workplace wellness programmes was to reduce health costs. In descending order, the next most important drivers were improving employee health and reducing absenteeism; improving employee morale and productivity; and providing an example to the community.
Lean Six Sigma Contribution in Hospitals
According to respondents to a 2011 survey, Lean Six Sigma methodologies contributed to the following improvements in 12 Mexican healthcare organisations:
Boards of Directors: Few Nurses Represented
- reducing medical errors (90% agreed)
- increasing quality of care (89% agreed)
- promoting wellness and expanding preventative care (86% agreed), and
- improving healthcare efficiency/reducing costs (84% agreed).
Respondents also believed that nurses should have more input and impact in planning, policy development, and management. 
Workplace Wellness: Obesity of Epidemic Proportions
Figure 3, see below, depicts the increasing adult obesity rates in OECD (Organisation for Economic Co-operation and Development) countries. Obesity is defined as having a Body Mass Index of 30 kg/m² or more.
- 44% of diabetes cases
- 23% of ischaemic heart disease cases
- 41% of certain cancers.
Environmental Sustainability in Healthcare
A Practice Greenhealth report on environmental sustainability reported that healthcare organisations in the United States:
- accounted for 16% of the nation’s gross domestic product. (This was expected to grow to 20% percent by 2015.)
- employed more than 4.1 million people in hospitals operating 24/7
- spent US $8.3 billion on energy every year
- operated facilities that were often the largest water users in communities and produced two million tons of waste per year (along with increasing amounts of disposable packaging chemicals, and toxins).
The report noted that substantial savings could be achieved by reducing waste. It was estimated that each dollar a non-profit healthcare organisation saved in energy was equivalent to generating $20 in new revenue. 
Workplace Wellness: Healthy Lifestyles for Young Women
Valuable lessons can be learned from the following organisations:
Heart of England NHS Foundation Trust, United Kingdom
Healthcare scorecard helps improve practices
- your skin matters: tissue viability
- staying safe: preventing falls
- keeping nourished: nutrition
- promoting normal birth: reducing caesarean section rates
- important choices: end-of-life care
- fit and well to care: staff wellbeing
- ready to go, no delays: safe patient discharge. 
The scorecards/dashboards offered a visual reference that helped hospital staff to review data from a range of sources, and enabled sound evidence-based discussions. This enabled Heart of England to increase transparency and improve practices. Figures 4a, see below, and 4b, see top of next page, provide examples.
Further detailed records of the quality indicators used by the Heart of England hospital system may be found at Quality Indicators.
Novant Health, United States
Project team reduces infection rates
- leadership conferences
- computer-based training modules
- infection prevention personnel/nursing unit staff, and
- a $325,000 promotional effort employing cutouts of cartoon characters stationed around the hospitals to help remind people about hand hygiene. 
All hospitals were able to observe the performance of the others in the system. The penalty for failing to reach the 90 per cent target was the forfeiting of end-of-year bonuses (from the director level up). Novant reduced MRSA infection rates by 60 to 70 per cent-down to 0.15 infections per 1,000 patient days. The hand hygiene target was subsequently increased to 95 per cent. Novant Health data similar to the bar graph below, see Figure 5, may be found on the Novant Health website.
Cedars-Sinai Medical Center (CSMC), United States
Lean Six Sigma aims at zero errors
- Hand washing compliance rates rose from 66% to 95% in 18 months, and remained steady at 98%.
- Surgical site infection rates per 100 procedures fell from 15.5 to less than 5.
- Readmissions: 30 day all-cause readmission rates among heart failure patients was reduced by more than 50% within eight months.
- Ventilator-Associated Pneumonia (VAP) rates fell over a 10-month period to five incidences out of 9,580 ventilator days. No VAP cases occurred anywhere at CSMC for six of those 10 months. This rate was more than 70% below the average for similar hospitals in the National Healthcare Safety Network.
CSMC believed its aggressive goal-setting successes were largely due to leadership at all levels of the organisation. It believed that leadership involved driving change; when people were first committed to change, then established far-reaching goals, success was assured. 
Catholic Health Partners (CHP), United States
Organisation structure change improves value
CHP set itself the goal of delivering high quality services at 40 per cent less cost. A new business model focused on improving patient flow. At a chosen location, the average time from patient admission to discharge for all patients was 5.3 days (above the national average of 4.9 days). By eliminating non-value added activities and encouraging collaboration, CHP was able to improve the value in care provided, and significantly shorten the length of stay for patients to 3.9 days. New job roles were created-and standard procedures established-to provide a more predictable patient flow. Since patients spent 30 per cent less time in the hospital, all aspects of patient care became more efficient. Nurses and physicians spent more time with patients, which improved levels of care, experience, and the flow through the hospital. Building a culture of learning and innovation was a key part of the restruc- turing processes. Open discussions enabled staff to learn about problems in the care process; creativity was encouraged to enable staff to tackle issues. New operating models were introduced that provided patient flow visibility from one department to the next; this helped to improve throughput for physicians, patients and employees. A more predictable operation framework enabled physicians to plan their work more effectively. Eliminating waste in the patient flow process led to reduced costs, and the improvement of many other services provided by CHP. 
Heartland Health, United States
Continuous Quality Improvement brings excellent financial performance
- delivering the best and safest care
- improving individual health, and
- improving community health. 
AtlantiCare, United States
Cross functional teams reduce costs significantly
- Health Coaches: each patient was assigned a health coach whose responsibilities included educating patients about their conditions, and helping them make appointments and navigate the system.
- Physicians: high-performing specialist physicians were assigned a manageable panel of patients. New patients were scheduled hour-long visits.
- Social Workers and Behavioural Health Providers: the team-based care model recognised that life problems exacerbate health problems.
- Pharmacists: medication compliance rates were almost 98 per cent.
Teams were accountable for the Institute of Medicine’s Triple Aim of:
- improving the health of the population
- improving patient experience, and
- reducing the per capita cost of care. 
MultiCare Health System, United States
Environmental sustainability in healthcare
- eliminating mercury where possible
- reducing the quantity and toxicity of healthcare waste
- minimising the use and exposure to hazardous chemicals
- reducing healthcare’s environmental footprint through resource conservation
- integrating sustainable design and building tech- niques, with environmentally sound operational practices to create a true healing environment.
Among the initiatives carried out by MultiCare Health System were the following:
- Cafeteria: the Nutritional Services department, in conjunction with its suppliers, implemented a number of beneficial environmental sustainability projects.
- Waste management: MultiCare planned to recycle more than 50 per cent of its solid waste and thereby make substantial savings. Opportunities for improvement were identified and significant potential cost savings gained from improved processes for handling regulated and hazardous waste.
- Green buildings: MultiCare is building Wash- ington State’s first LEED Silver-certified hospital.
Measure and Evaluate
The following scorecard is an example of performance data published for each of the hospitals operated by Mission Health, based in Asheville, North Carolina.
Complete details are available on the Mission Health website.
This self-assessment will assist organisations-in particular healthcare organisations-to develop and improve employee wellness programmes. Assess your organisation by considering the questions below, and circling the most appropriate rating using the scheme provided:
1 = Not at all; 2 = Planned; 3 = Partially; 4 = Reasonably well; 5 = Best Practice.
- Any score of less than 21 indicates that an organisation’s wellness programmes may need attention.
- Any question resulting in a score of 3 or less points is an opportunity to make improvements.
- Scores of 30 and above indicate that mature wellness programmes have been put in place.
NB: The full employee wellness (healthcare) self-assessment may be found on the bpir.com website.
Summary of Best Practices
The following is a summary of the best practices and/or insights associated with healthcare excellence covered in this Best Practice Report:
- Develop and communicate your organisation’s goals, purposes and strategic objectives with the support of your staff; this will engage your workforce.
- Encourage engagement by ensuring employees:
- are led by competent people
- have a clear sense of direction
- are selected to achieve desired organisational goals
- are continuously invested in, which creates a valuable reservoir of goodwill for both good and bad times.
- Develop core values that reflect organisational aspirations, and inspire employees because they resonate with their own personal values.
- Reinforce the desired organisational culture in performance appraisals, education and training, and within formal/informal celebrations.
- Translate organisational values and culture into everyday attitudes and behaviour, and eradicate unwanted behaviour (e.g. dishonesty, abuse, bullying, and gossip).
- Establish a culture of ongoing initiatives using physician leadership to ensure future cost and quality goals are achieved.
- Include nurse representatives on boards and executive management teams to improve healthcare quality and safety.
- Employ new technologies—such as telehealth and telecare systems—to provide patient independence, security, confidence and quality of life, and to save on substantial treatment costs.
- As a healthcare organisation, serve as a role modelfor healthy living and fitness.
- Use “green principles” to operate healthcare organisation buildings, systems and equipment in a more efficient, effective and sustainable way.
- Use Lean Six Sigma to improve processes and eliminate waste.
- Use business excellence models such as the Baldrige Criteria for Performance Excellence and the EFQM Excellence Model to provide an overall assessment of your healthcare organisation’s operations, services and performance results.
- Use benchmarking (and the BPIR) as a means to learn from the best practices of other healthcare providers.
Words of Wisdom
David C. Pate, MD, JD, FACHE St. Luke’s Health System
“The greatest wealth is health.”
“I learned a long time ago that minor surgery is when they do the operation on someone else, not you.”
“A hypochondriac is one who has a pill for everything except what ails him.”
“According to the surgeon general, obesity today is officially an epidemic; it is arguably the most pressing public health problem we face, costing the healthcare system an estimated $90 billion a year. Three of every five Americans are overweight; one of every five is obese. The disease formerly known as adult-onset diabetes has had to be renamed Type II diabetes since it now occurs so frequently in children.”
“Lean is about the total elimination of waste and showing respect for people.”
“I got the bill for my surgery. Now I know what those doctors were wearing masks for.”
James H. Boren
“Don’t think of organ donations as giving up part of yourself to keep a total stranger alive. It’s really a total stranger giving up almost all of themselves to keep part of you alive.”
“There’s a need for accepting responsibility for a person’s life and making choices that are not just ones for immediate short-term comfort. You need to make an investment, and the investment is in health and education.”
“When does life start? When does it end? Who makes these decisions? […] Every day, in hospitals and homes and hospices […] people are struggling with those profound issues.”
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