Journey to a “Great Patient Experience”

On the Road with Memorial Health System – December 2010

by Jason A. Wolf

Memorial Health System and Memorial Medical Center, located in Springfield, IL played host for our December On the Road. The story they shared was one of both vision and a journey of progress, one that is still in motion. It is grounded in the idea of the “Three Greats”, which represent a streamlining of organization strategy designed to make it easily understood and owned by staff, physicians, and the community. It is driven by a purposeful and focused group of individuals across function and role, including clinicians, ancillary services, physicians and administration. It exemplifies a clear commitment to live the values of S.E.R.V.I.C.E. (pictured right) and achieve their vision to be a national leader for excellence in patient care.

The path Memorial is now traveling had its roots ten years ago, first as an overall effort focused on performance excellence with the goal of magnet status and beyond, and one that in 2003 led to the streamlining of the system’s strategy to three clear and powerful “greats”. They include: Great Patient Experience, Great Place to Work, and Great Results. Mitch Johnson, Chief Strategy Officer, and Co-Chair of Memorial’s Great Patient Experience Leadership team, noted this change came as the system wanted to engage employees at all levels in the strategy and direction of the organization. He indicated that in order to be successful, the plan had to be understood and owned by all. “The front line staff is key”, he suggested, ” and our strategic plan needed to resonate there.”

This clear strategy has led to great overall results for Memorial, including strong quality outcomes, healthy financials and a highly engaged workforce. With a focus on workplace and results, the thought was that positive patient experience results would follow. The reality hit in 2007-2008 when reviewing the newly available HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores and analyzing comparisons to new patient satisfaction survey results with national benchmarks, they realized they had some ground to make up. As a core strategy and value of the organization, Johnson said, “there was recognition that we needed a more systematic approach to addressing the patient experience.” More importantly, he offered, “was ensuring we were not simply focusing on the score. The score is a surrogate for the experience. We needed to ensure whatever we did became part of our culture.” This recognition led to the beginning of a clear and measured patient experience effort that not only exemplifies thoughtfulness in planning, but also is continuing to lead to great results.

Framing the Great Patient Experience
The foundation of Memorial’s Great Patient Experience effort came a few years after the strategy was identified. In August of 2008 the Great Patient Experience Leadership (GPE) team was formed with a desire to begin a path to improvement. The team includes representatives of all organizations receiving a patient survey, i.e., physician practices, home health, mental health and each of their three hospitals broken down into segments of inpatient, outpatient, ambulatory surgery and emergency department. It also encompasses resources in education, measurement, communication and rewards and recognition. The GPE Leadership Team is co-chaired by the system’s Chief Operating Officer, Doug Rahn, DBA and the Chief Strategy Officer, Mitch Johnson. This broad cross-section of accountability and direct engagement of senior leadership made it clear from the start that this effort was not just another initiative, but a strategic commitment for the entire health system.

Deidra Glisson, Director of Nursing Operations and Chair of the Memorial Medical Center Inpatient GPE team commented that when the comparative data was first reviewed, it “opened our eyes to what opportunities we had. It led us to an initial effort of benchmarking and understanding what others have done.” This foundation of exploration and planning shaped the first year of the GPE teams existence. “It was a time of purposeful planning.” added Becky Douglas, Director of Planning and Co-Chair of the GPE Measurement team (pictured right with Linda Kelley), “Through the benchmarking process and in the design that followed we challenged ourselves to ensure the ideas developed aligned with our current efforts. We knew we were not in a position to create additional initiatives or have staff feel we were introducing something that could be seen as the next flavor of the month.”

The planning process carried into 2009 when the launch for the GPE effort was planned. A core of recommended practices was identified (we will discuss these further below) and became the central content in a milestone event, the GPE Retreat. This kick-off event was required of all employees across the system. With more than 500 people per session, through 11 sessions, the 6,000 plus members of the staff were introduced to the commitments and expectations of this new patient experience effort. The sessions also included the physicians affiliated with the Health System who, while not required to attend, showed up in great numbers.

The session was kicked-off with comments from the system Chief Executive Officer, Ed Curtis, who according to all of the individuals I met with during my visit, left no doubt as to his or the organization’s commitment to this effort. It was not another initiative, but rather this was without question the primary work of Memorial Health System. Aimee Stash, PhD, and System Administrator of Organization Development provided education regarding the key practices the system was implementing – the use of AIDET and the idea of Greet & Feet (explained below). Toward the end of the session, the system COO and Chair of the GPE Team, Doug Rahn, DBA reinforced that this was not a “nice to do”, but a “must do” and it would be central to the focus of all efforts moving forward. According to Evy Ellis, Organization Development Consultant in the system, when individuals left this retreat there was no doubt as to Memorial’s commitment to this effort or the expectations placed on each individual. “It was like they came to a sacred place,” she added. “You could see a tangible change in their demeanor.” Deidra Glisson offered that after this kick-off retreat there was no doubt that “this was now our journey. It was time to walk the talk.”

The opening retreat set the standard for both the “what” was going to be done and “how” it would be accomplished. The session presented a clear strategic focus, along with the support and commitment of senior leadership. It was centered on simple, yet critical practices expected of all members of the organization. The intention was to focus on a few key measurable actions and track for progress… and it was progress the organization saw. In the first year alone, Memorial almost doubled the number of its operating areas above their targets, from 6 surveys to 15 above the 60th percentile.

So I am sure you are wondering what were those first simple steps. I preface my discovery by revisiting my recent blog, in which I suggested that the distinction in patient experience excellence is not the practices themselves, but the discipline and commitment of execution to enact and see them through. While the core practices shared by the Memorial team may seem like many you may have tried, it was their focus on execution and the infrastructure to support this that led to their success. Still it is important to point out that based on their benchmarking and research they felt there were some critical first steps to take. Their commitment was to focus on consistent and effective execution.

Key Elements of the Patient Experience Effort
As I mentioned above, central to the Great Patient Experience retreat were two core practices taught to all attendees at every level of the organization – AIDET and Greet & Feet. As many of you know, the introduction of a general communication process such as AIDET or the many other models available often shows up as common practice. What has begun at Memorial Health System is a level of accountability for how this is used. The same for the practice of Greet & Feet, which under any of its names is the purposeful engagement of guests, family members or other visitors to ensure they are properly greeted and escorted to the appropriate place they are looking to go in the facility. This practice is so engrained in the way people behave in the facility, that at one point, even knowing where I was going, Linda Kelley, Manager of Employee Engagement was still compelled to walk me safely to my destination. This is supported by the statement of Deidra Glisson, who added, “we were committed to ensuring this wasn’t another ‘to-do’ or initiative, but rather these actions were part of our day-to-day efforts for every patient, every time!” In addition to these practices, Memorial launched two additional efforts in early 2010, nurse manager rounding and hourly rounding. They also revised the system onboarding process.

Nurse Manager Rounding
From the very first interview of my visit, nurse manager rounding was part of the conversation. Much more than a required action, the nurse manager rounding process at Memorial is structured, supported and constantly being evaluated. The process provides guidance and a structure by which every nurse manager in the house rounds on patients in their unit. This is not to cover basic clinical or care needs, which is the focus of the hourly rounding effort, but rather it is focused on being a presence and providing awareness to the needs of every patient in every unit.

I had the honor of spending time rounding with Cathy Steckel, the Nurse Manager of the 2B Surgical Unit. During my time with this veteran nurse leader, I was able to see the structure and practice put in place. As part of this rounding process, nurse managers all have a binder with key checklists and processes defined. Audra Chestnut, Manager of Employee Development shared one thing that stood out for me in the manager rounding process. She offered that, “the design of the nurse manager rounding program was not to take the person out of the process, but rather it was designed to allow the nurse to truly be themselves in the process.” At the same time, the structure supported more direct follow-up for care needs, awareness of issues before they could become serious, and exemplified support for the front line caregivers themselves by including time for these leaders to ”manage-up” their team.

Observing Cathy was a reinforcing example of what I know so many caregivers do and why so many of us have chosen health care as a profession and calling. Her care and willingness to engage the patients made them feel cared for. Her questions about the service the patient and their families were receiving were clear and heartfelt, so that these individual’s voices were not only heard, but issues were addressed. I observed Cathy, in room after room, support the work of her staff, letting patients and families know they had the best team possible and ensuring they knew she was always available if something was needed. Admittedly, it was hard to pull myself away from this part of my visit. To see the purpose of our work in action is so critical. It is the fundamental reason for these “On the Road” visits. We must never forget what we believe in and why we support efforts towards continually improving the patient experience. It is not just for better scores or “at risk” reimbursements; it is for the health of the people around us. Cathy was gracious enough to let me see that up close and personal. (Thank you Cathy!)

Studies have shown that nurse manager rounding has a measurable impact. The data at Memorial supported this in a significant way. Units that effectively implemented nurse manager rounding made significant positive strides in service outcomes. One unit that was struggling with scores in the 2nd percentile saw not only a tremendous leap, but sustained results now well above the 60th percentile.

The lesson is that rounding works, if given a structure and process to be successful. As in many other potential initiatives, you cannot simply declare it something leaders must do. Provide them the process and space and great outcomes are possible. In fact, the results were proven to be so effective in driving service improvement that the entire system has declared a committed time when nurse managers can focus on rounding. Starting December 1, these managers will have meeting free time for 90 minutes from 12:30 -2 pm, so they can be on their floors rounding on their patients. This type of dedicated time, which I like to call ‘sacred time’ can be used effectively in many ways and exemplifies Memorial’s commitment that this not be just another initiative, but rather an expected day-to-day behavior.

Hourly Rounding
The idea of hourly rounding also took on a much more significant role in the latter half of 2010. Over 120 one-hour educational sessions were delivered to RNs, LPNs, unit secretaries, nurse techs and others to ensure they understood the principles and purpose of hourly rounding. Key to their success was providing a standard process for people to engage in rounding that was shared by all (a sample of the key words are provided below). Providing a consistent and reinforced process also ensured that items would not be missed and critical actions were taken.

Evy Ellis stressed that, “Fundamental to the successful roll-out of the hourly rounding process was the understanding that this was not simply a service initiative. We wanted all staff to be aware that this was an evidence-based practice that would lead to better outcomes for patients overall.” While research supports this, again as in the case of nurse manager rounding, hourly rounding had real data impact at Memorial. As the training was being rolled out to staff, the impact of its message and resulting action was already felt. Those units receiving the early training and consistently following the process were already experiencing a 50% reduction in falls from earlier measures. These positive outcomes continue to ripple through the system with focused attention on hourly rounding.

System Onboarding
One additional component of reinforcing and sustaining the Great Patient Experience message has been a revised all system onboarding process. The onboarding, which takes place every two weeks, starts with all new employees across the system coming together for their first full day of learning about Memorial Health System. During the onboarding process, they learn about the organization’s mission, vision and values and the meaning of the Three Greats, have a Meet and Greet with the organization’s executive System Leadership Team, and receive content from the GPE retreat from 2009. The recognition was that to reinforce and support the sustained efforts around patient experience, each new employee needed to hear the same messages delivered at the retreat. Aside from learning the core process of AIDET and Greet & Feet, they learn about the Great Patient Experience philosophy and why it is so critical to the vision and mission of Memorial overall.

Linda Kelley (pictured above), who oversees the onboarding process, was proud to share that every employee leaves onboarding aware of the commitment and owning the same level of focus on the importance of the patient experience. She added, “it is critical for staff to understand what is expected of them, but what is equally important is that we have been able to help people better know their role and why it matters to what we do at Memorial.” My observation is that a comprehensive orientation, including a focus on engaging staff early in understanding their role and the organization’s commitment to an unparalleled experience, seems to be a pattern emerging not only during my On the Road visits, but also from other high performing patient experience organizations I have encountered.

SWAT – A Process for Improvement
While I have seen orientation used with some consistency as a process to focus staff on the key elements of a patient experience effort, my visit to Memorial also introduced me to an improvement process directly aligned with ensuring positive patient experience outcomes. The SWAT process (which stands for System Wide Action Team) is a unique and innovative method to identify and act upon improvement opportunities at the unit level. According to the SWAT documentation, it is described as “a systematic process aimed at understanding the current state of important work processes, the level of need for process improvement, and what types of process changes are needed and appropriate to improve the experiences of patients.” According to Amy Lally, Organization Development Consultant, the SWAT evolved when “we discovered we needed a way to assess, diagnose and act on the real issues we were facing.”

An innovation of Memorial Health System’s Organization and Leadership Development (O&LD) Team, the process includes a series of core steps including (1) an initial kick-off meeting with the leader of the unit, department or floor, (2) mystery shopping the unit, department or floor, (3) interviews with leadership, staff, family members, patients and support staff, (4) an analysis meeting conducted by the investigating team, and (5) a feedback report and action plan provided to the leader. While the process is designed to work with those units that need to make significant improvements, it has also been used with higher volume units who have better scores, but who are looking to make incremental improvements. The GPE Measurement team identifies a unit in need of a SWAT intervention, then the O&LD team sanctions a SWAT team and begins the intervention. Once identified the process itself takes just under a month to complete.

One important element of the SWAT process is that it is conducted by a team of employees from across the system. Over 60 individuals were nominated, selected and trained (through SWAT Boot Camp) to be part of SWAT teams that would conduct the process of mystery shopping, interviews and report creation. These cross-functional groups provided the opportunity for broad and practical insights into the challenges a unit was facing. Since the analysis was conducted by a number of eyes from a number of practice areas in the system, it provided a more rigorous and respected report and has led to greater buy-in for the overall process.

While meeting with the Organization Development (OD) staff, I was impressed by their engagement and focus on the service improvement process. I was equally intrigued by the open willingness of various leaders to engage in the SWAT process and act upon the results. It takes a significant commitment to look beyond simply implementing behavioral practices (such as AIDET, etc.) to develop and implement a process to expose and improve on potential vulnerabilities. At Memorial, the SWAT process is clearly seen as an improvement opportunity versus a punishment for poor performance; more units continue to express interest in this opportunity to strengthen their results.

Lisa Henderson, Nurse Manager of 2E at Memorial Medical Center (pictured right) shared her experience with the SWAT process. She offered, “One of the overall benefits was the feedback received and the opportunity to see things happening through the eyes of others.” She acknowledged that the process could be challenging, the interviewers asked tough questions, they provided raw and valuable insights, but in the end, Henderson said, “the results enabled me to engage my staff in the key areas of our patient experience efforts and weave what could be seen as a list of initiatives into the day-to-day of our work.”

In closing my conversation with the Memorial team, Jared Bartels, Organization Development Consultant, reinforced an important truth I am seeing as central to many successful patient experience efforts. “The reason this is so important is that you can’t just provide training and expect significant results,” he said. I agree fully. As the data of The Beryl Institute’s recent research brief revealed, many organizations looking to impact the patient experience are turning to training as their primary and often only approach. Even as the team at Memorial exemplified, learning is critical to driving positive change, but it is the commitment to sustained execution at all levels that leads to the most significant results.

A True Investment in The Patient Experience
My visit with Memorial Health System and my time on the floors of Memorial Medical Center revealed an organization that saw beyond simple solutions to a committed investment in purposeful actions, the necessary time, and the dedicated people to ensure not only change, but also positive outcomes. The organization has made a number of commitments to the future as well. In January, they will onboard the first System Director of Patient Experience who will carry the mantle of the patient experience effort. The GPE team continues to meet monthly, reviewing policy and process and identifying opportunities for improvement.

An important part of the program I only touched on briefly during my visit (and which I would encourage readers to consider and inquire about further) is the extensive rewards and recognition program the system has implemented to both acknowledge accomplishments and reinforce the importance of key strategies. My eyes were drawn to a sign posted in a location that could not be missed by anyone in the Memorial Medical Center cafeteria. Right as you pass the registers upon paying for your meal was a large sign that read “Congratulations…Thank you for creating a great patient experience.” This sign recognizes the business units, departments and floors that achieve outstanding performance every month. I watched as staff, family members, physicians and patients stopped and if even just briefly, saw this subtle but powerful sign of a commitment to a truly great patient experience.

If this commitment, both public and private was not enough, there was one last thing that stood out to me that added an exclamation to Memorial’s commitment to patient experience. For this last fiscal year ending in September the organization had only one target that impacted the incentive pay of all employees. The target for the Memorial Health System’s Success Sharing Program was performance based on their patient satisfaction and service scores. This was not a unit-by-unit measure, but a system-wide commitment to performance excellence. Everyone celebrated or sank based on the performance of each of 19 individual surveys and their ability to get over half above the increasing performance targets. Just before my arrival, they learned they had accomplished their goal. Collectively the system recognized the challenge and has continued to focus it efforts, its commitment and its dollars on ensuring the best patient experience possible. This truly exemplifies that not only leadership, but also staff across the system were willing to put their money where their mouth (and goals) was. It made me wonder how many other organizations would be willing to take that risk, or show that type of commitment to patient experience outcomes.

My visit to Memorial Health System was an action packed tour, of process and practice, of measures and commitments. It was bookended by nurses on the floor who told me how they lived this purpose every day and by senior leaders who believed their role was to create the framework for patient experience success to occur. As I finished up my conversation with Mitch Johnson, I asked him what he saw as the role of senior leadership in patient experience success. He smiled, sat back and responded with no hesitation. “Our job as leaders is to create an environment that lets people do what got them into this work in the first place,” he said with a smile. It was the same smile I saw as I experienced Greet & Feet as I was walked out of the building at the end of the day; the same smile I saw from the volunteer greeting people at the front door and the same smile I saw on the patient waving goodbye to her nurse and transporter as she was helped into a car to leave with her family member. Memorial exemplified an organization that knows it may not be “there” yet. Rather they remain focused on a continuous and whole-system commitment to positive change and ongoing process improvement, with an unwavering focus on key actions and a purposeful tracking of critical measures. Ultimately they are committed to a journey of providing the greatest patient experience.

My thanks to Dr. Aimee Stash and her team for graciously hosting my visit and to the entire schedule of people that contributed to my continued learning. I do what I do because of what you do every day!