Healing Humankind One Patient at a Time

On the Road with UCLA Health System – February 2011

by Jason A. Wolf

From snow-bound delays in wintery Chicago, our February On the Road takes us to the hills of Los Angeles and UCLA Health System. The warm light of the cloudless California day seemed to set the stage for the shining example of commitment to service, patient care and an environment of healing. While the three-year-old Ronald Reagan UCLA Medical Center itself is an architectural experience, I learned quickly that as Dr. David Feinberg, Chief Executive Officer of UCLA Health System shared, “Our success has not been the result of the building, but rather it has come from our people.”

Prior to moving into the new facility, the leadership team recognized the need to become more focused on the patient and family. While scoring well in service, the prevailing thought was that it was still not good enough. Dr. Feinberg was clear in adding, “80% right isn’t good enough if it leaves 20% with a bad experience.” It required not only a reinforcement of commitment, but also a supporting infrastructure of people and process to ensure its success. My visit with the key leaders and care providers at UCLA told the story of a refocusing of effort, a reframing of vision, the establishment of a framework for success and a process to support and sustain these efforts.

The Perspective from the Top
Countless studies and books suggest the importance of leadership support and alignment in achieving performance outcomes. My own research has shown it to be central to success. Yet often organizations struggle to align leadership commitment to their broader objectives. UCLA seems to have tackled this issue with a broad and far reaching executive leadership commitment to their patient experience efforts. In fact during my visit, we spent time with the top leaders at UCLA from the Chief Executive Officer, Chief Nursing Officer, Chief Medical Officer and Chief Human Resources Officer to key leadership roles committed to patient experience, performance excellence and human resources. I was left with little doubt of the clear focus at the very top of the organization on the importance of driving patient experience outcomes on a daily basis.

In talking about the journey to increased patient experience performance, Dr. Feinberg shared the commitment senior leadership has to engaging with patients and staff every day. He directly tries to walk the halls of the system’s facilities, engaging with patients, family and staff sometimes 2-3 hours per day. When I first asked Dr. Feinberg how they got to this place, he did not hesitate in saying “we did it one patient at a time.”

Dr. Feinberg was very clear in also asserting that this was not an intentional culture change effort, but rather it was about returning people to the passion that brought them to this work in the first place and then providing the systems to support excellent work on a continuous basis. “We worked to ensure that everyone understood they were a healer,” he commented. “It was not simply the care providers on our floors that had this responsibility, but it was our housekeepers, our IT department, Human Resources and all the other people that comprise the system.”

In getting started, the system worked to help its people reclaim their passion and get clarity on their responsibility. There also needed to be the understanding that “the next patient is our most important patient.” This focus on each individual as the most important encounter for staff, was a critical step in supporting the refocused values and the restated vision of the system: Healing humankind one patient at a time, by improving health, alleviating suffering, and delivering acts of kindness.

This vision helped the staff know their most important responsibility was right in front of them. It also helped everyone recognize that is was not just simply about delivery of care, but delivering acts of kindness. This fundamentally shifted how people looked at their roles. It also shifted the very relationships they had with patients and families. Clinical interactions that could at one time seem almost robotic and rote were turned in to individual service encounters and opportunities to touch lives with kindness.

Tony Padilla, Director of Patient Affairs and Volunteer Services, reinforced these beliefs by saying it was not our building, but a recommitment to service. “If we take care of our patients, they will take care of everything else,” he added while laying out the key elements of UCLA’s overall service success. From taking care of patients, to inspired leadership, to great people and a clear supporting infrastructure, this path helped ensure the success of their efforts. With a strong support from executive leadership to sound the charge, improvements were quickly seen.

Dr. Tom Rosenthal, Chief Medical Officer, offered that “rather than working to change the culture, we were relentless is unearthing the passion that people bring to this work and then providing the right structure to support success. We are bringing out what was already in the culture, we didn’t change it.” The change, suggested Dr. Feinberg, came from a shift in how the people at all levels in the UCLA system viewed their work. “People who work here are smart, committed, passionate people, but at times we may have let that get the best of us in how we interacted with our patients,” he added. “We refocused ourselves from it being a privilege for someone to come here, to it being our privilege to serve you.”

“We had to refocus our overall perspectives on patient experience as well”, said Mark Speare, Chief Human Resource Officer. “This is not a linear process, but rather efforts and resulting scores are like steps. You either do it or not.” It was this commitment to act “with a relentless focus and discipline” that Tony Padilla suggested, “led to the law of critical mass where desired behaviors were modeled by senior leadership and everyone at all levels was engaged.” But this was not just the work of inspired masses, it was built on a clear structure of support and a process driven framework that enable the reinforcement of actions and the measurement of outcomes.

At the heart of this shift were two initial efforts, the establishment of CICARE , a program designed to structure employee interactions in every encounter, and an expanded training effort focused on relationship-based care within the nursing units. Heidi Crooks, Chief Nursing Officer, said, “As we began to increase our focus on service, we need to also reconnect people with their passion for this work.”

One thing that stood out in my visit with UCLA was that their unwavering focus was not simply realized through a list of disconnected initiatives. In my travels I have seen hospitals and healthcare systems try suggested tactics and service tricks that while having the potential for positive impact lead to little improvement. This is most often due to the structure of support around them (or rather the lack there-of), from leadership to process to measurement. This may have been one of the greatest keys I saw supporting success at UCLA. They worked hard to establish and sustain an extensive framework, aligning purpose with people and performance management that provided the structures for success and the measurement to continuously track the path to improvement.

At the Heart of Service Success: The CICARE Program
As we learned during our On the Road at Rush University Medical Center in January, the discussion on scripting raises significant questions in our healthcare settings. How do we create a process to support the most effective interactions with patients and families, while still allowing for the passion and individuality of caregivers to emerge in each encounter? UCLA Health System was able to manage the ability to ensure this balance with their CICARE program.

CICARE represents the six major steps in an encounter that UCLA expects of all staff at every level. Like other scripting acronyms, which seem central to any positive service effort in healthcare today, CICARE creates a standard process for interactions with patients and families. 

While some might call this a scripting program, I would offer CICARE as an awareness tool, that both provides a means by which each department can structure their encounters with patients and families and a process for measuring those interactions through feedback and observation. CICARE has become a central operating principle within the system and is consistently reinforced through both patient feedback and leadership rounding. In addition, it has been expanded to focus not only on direct care providers, but also support staff from IT to HR and now the medical staff as well.

Each department within the system has taken this framework and adapted it to its particular responsibilities and setting. Much again like I observed at Rush, CICARE is much less a script and much more a template for guiding critical dialogues throughout the organization. In addition CICARE has become central to key processes within the organization. Comment cards are available throughout the health system’s facilities where patients and/or family members can provide feedback on individual performance to these core items. Feedback is actively solicited to ensure these behavioral standards are adhered to consistently.

More significantly this process does not simply start at the point of care. CICARE standards are now part of every job description posted with the organization and job candidates must agree to and sign off on these standards as part of the pre-hire process. These steps ensure that any potential employee of UCLA is aware of what will be expected of them and that there is clarity and consistency in the expected behaviors of all staff.

The impact of this effort was clear, but the reality of initiatives versus sustained efforts also challenged UCLA’s efforts. In the year following the implementation of CICARE in the organization, scores on the HCAHPS “Would you recommend?” question more than doubled from the 37th percentile to the 75th in their survey vendor’s ranking. Yet the next few months saw a lag in this performance. While some of this was attributed to the move to a new facility, it also represents a trend I have often seen when organization’s look to address service efforts as simply the initiative du jour.

Too many times service efforts are addressed by disconnected laundry lists of initiatives that leave staff feeling overwhelmed and under-supported. Initial successes slip as the focus shifts to the latest need or newest challenge. They are then often abandoned as unsuccessful or written off as too hard to address. It is this point that breaks the will of many healthcare organizations.

In my observation, UCLA took committed actions that led to a very different outcome. Rather than relying on programs as a means for success they built an operating framework to support and sustain their efforts and results. The outcome was a jump from a slipping score to sustained performance at or above the 90th percentile ranking for over two years. The framework for that success was the UCLA Operating System.

A Framework for Consistent Performance: The UCLA Operating System
What I observed and learned during my visit to UCLA was that a clear leadership commitment to an unparalleled patient and family experience is critical to initiating and supporting success. What was reinforced for me by the leadership team was the need to have the right systems and processes to support sustained outcomes. My personal research has primarily focused on the sustainability of high performance in hospital systems and it was apparent to me that UCLA was executing at some of the very ideas I discovered. I have found that sustainability is based on balancing the creation of common purpose while ensuring agility to respond to organizational needs and demands, balancing the sense of collective action while allowing individual contributions to be made, and balancing clear leadership direction with the opportunity for input at all levels. Sustainability is about having processes that support continuous movement.
What UCLA Health System did was build a supporting infrastructure in four key areas to ensure that their efforts were more than initiatives. If focus and commitment were to be maintained, certain processes and mechanisms had to be established and supported. The process – the UCLA Operating System – provided an integrated set of programs and measures designed to support success.

The operating system was designed to support sustained excellence by aligning purpose with people and performance management. It is focused on four key areas:

• Purpose
• Strategies
• Objective Management

Performance Improvement
While my brief overview here will help provide context for how you can turn initiatives into lasting results, it only scratches the surface of this impressive and extensive effort.

Purpose
The framing for the effort at UCLA is the alignment of their mission, vision and values. These items shape the work they do every day. At the heart of this is the mission shared above – healing humankind one patient at a time, by improving health, alleviating suffering, and delivering acts of kindness. Central to this mission is UCLA’s relentless focus on one patient at a time, but even more profound is a mission grounded in the very idea of acts of kindness. This is fundamental to UCLA’s commitment to create an environment of courtesy and respect for all patients. It is also grounded in the values that comprise their daily efforts and it is the values of UCLA Health System that underpins their entire performance management process. The values – compassion, respect, excellence, discovery, integrity, and teamwork – are a critical component of the selection process, part of reviews and performance management efforts and observed in all interactions.

Strategies
While purpose frames the direction for UCLA Health System, it is their overall strategy that guides them. Following five areas of strategic focus – service lines, quality, service, coordinated care and value – UCLA ensures they are remaining true to their purpose and values, while delivery effective execution in critical areas to support sustained performance and growth. The commitment to service line efforts not only supports the business viability for the organization, but also allows for innovations and new research. The focus on quality is driven by evidence-based practices and focused on consistent performance. Service is driven by the CICARE process and remains a continually reviewed and refined process based on input from patients, families and staff. Coordinated care allows for commitment to collaborative action from best paths to patient access to clinical services design and beyond. Lastly, value is grounded in a focus on eliminating waste and ensuring that resources are most efficiently used to drive care outcomes.

Objective Management
At the core of execution in the operating system are the regular actions that the system takes to ensure their core commitment – that every patient every time receives the level of care and service they would expect for their own loved ones. This key commitment has lead to a series of practices that support both the CICARE efforts and helps support the business strategies. The practices are aligned to six keys areas including people, quality and safety, service, operations, strategic development and finance. While I will not describe each of these practices in detail, you can see by the comprehensive nature of this effort that there is a focused and sustained commitment to performance in the organization. Some of the key actions include:

Performance Improvement
The final component of the operating system focuses on measurement and continuous improvement efforts – specifically the application of lean methodologies for process improvement, the use of dashboard based metrics to measure with consistency key outcomes and track behaviors, and lastly a process of active daily management. This focus on not simply executing to plan, but ensuring the consistent review and revision of efforts allows UCLA to keep their actions fresh and focused on the key needs of the organization. More importantly, it was the integration of these improvement efforts that is a critical component of the overall operating system and provides a truly systemic perspective on the improvements needed. They support a shared focus on the desired and needed outcomes for the system.

Whiteboard Example – 6 NorthThe idea of active daily management stood out as a proven practice for supporting excellence. The use of this process to get beyond the shared vision of leadership to the execution of process at the department level – where the rubber meets the road – seems central to UCLA’s sustained success. From establishing standard metrics, to performance interventions, to the use of visual controls to ensure focus and compliance (every unit has a white board sharing their key metrics) the process has been designed to support the effective execution of plan.

By including the use of regular team huddles and the use of coaching and feedback the process is not your typical punitive management intervention that criticizes those “in the red.” Rather it is used as an opportunity to help staff develop and grow. It is truly an improvement effort in the broadest sense that allows for individual, team and organizational improvement opportunities.

It was clear to me that while facing many of the same challenges of other systems and medical centers, there was a commitment at UCLA to address their effort in a broad, comprehensive and fully integrated way. By linking people to process, initiatives to measurement and challenges to opportunities for improvement, UCLA Health System has taken their patient experience effort to a truly different level. This is more than simply a hardwiring process. This is redesigning organizational standards and expectations to ensure objectives are met and as the data has shown, not just met, but sustained at high levels.

Ensuring Sustained Focus and Continuous Improvement: CICARE Assessment Rounds
I would be remiss if I didn’t share one additional element of my visit where I had the opportunity to see CICARE and the UCLA Operating System in action. As a healthcare practitioner, while I like the concepts we often share, I am more interested in seeing what they look like in action. The senior leadership team at UCLA was consistent in expressing their belief that their efforts were not perfect and they still had kinks to work out themselves. This comes back to my point earlier that sustainability is about continuous movement. Outcomes come from consistent action, review, interaction and new ideas. This very effort was exemplified during a process called CICARE Assessment Rounds, a leadership observation and shared learning process.

The rounds are a powerful exercise that the team adapted after a visit to New York Presbyterian. Every Friday, leaders from across the system are grouped, many meeting for the first time, and assigned a certain location, floor or unit to visit. During the rounds they observe staff, engage with patients and look for how CICARE practices are being put into action.

The process begins with the leaders collectively gathering in an auditorium where service wins are shared and opportunities are discussed. New leaders are also introduced and welcomed to the process. Letters describing exemplary service are read and those mentioned or receiving positive feedback are recognized. This introductory process reengages the group and allows for a sense of shared accomplishment. The group then breaks up into groups of two to four people for a designated period of time to round their assigned area. As part of the process to also create greater interaction among departments, many individuals may be meeting for the first time and spend a few minutes in the foyer with introductions. This in itself was a powerful exercise in bringing together leaders from all corners of the organization around one purpose – excellence in service and patient care. The energy from doing this was palpable.

For the CICARE rounding I had the honor of accompanying Patty Brownstein, Malou Blanco-Yarosh and Doug Gunderson on a visit to 8 West. The unit was bustling with activity and the value of this rounding process was immediately seen. In visiting one room and talking with the patient’s family, we learned that the patient had requested and was waiting for a walker, but the response was delayed. With the intervention of the team on rounds, a walker appeared just moments after we moved on from this patient’s room. The interactions during rounds are not just to engage with patients and families, but also to observe the CICARE process at work. How staff members are executing on these ideas and what things can be done to improve are all part of the observation process. Most importantly it carves out time for these leaders to engage further with patients, families and staff.

I have to admit that my rounding with nurse managers is emerging as a favorite part of any On the Road visit. In this process you see the essence of an organization’s commitment to experience and service. More importantly you are exposed to the real passion that drives us to this work every day and the expertise and care that these incredible nurse leaders bring to what they do. We learned a great deal in a short period of time on our walk through the halls and rooms of 8 West and it was soon time to return to the auditorium.

It was the post rounding review that could potentially be the most productive part of the process. People didn’t just return to check in on process, but rather real issues were raised and shared in the room where the right people could deal with them. If a dietary or environmental services issue was raised, it was addressed right there in real time or referred to where it could be dealt with quickly. If specific feedback or support was needed from one unit or another, it was acknowledged and the appropriate people assigned accountability to manage next steps. This debrief was not information sharing for the sake of listing headlines, it was reporting out with the intention of driving outcomes. Issues that could fester or get lost in the chaos of our typical days in hospitals were brought to the surface and the opportunity for quick responses and immediate service recovery were acted upon in the moment.

Often rounds are seen as a necessary evil, be they hourly rounding, staff rounding or others. This process of leadership rounding went well beyond simply being present on the floors to being active and engaged. It was about connecting leaders at all levels and responding without hesitation. It ultimately exemplified the very essence of UCLA’s commitment to every patient every time.

Healing Humankind One Patient at a Time
When I first walked into the Ronald Reagan UCLA Medical Center, I was aware of the improvements they made and was already impressed by the commitment to patient and family experience expressed by the leadership of the organization. What I did not anticipate was the depth and breadth of the efforts UCLA Health System has taken on to ensure a lasting and consistent service experience for everyone that enters their doors. This On the Road feature is not long enough to cover every detail of what UCLA has done through its CICARE effort, a focus on relationship based caring and the intricacies of the powerful UCLA operating framework. What I hope it has done is provided you with a sense of what a true commitment is to service success. This overview of an effort driven by senior leadership vision, enacted by leaders and staff at all levels and across all functions and grounded in a process that ensures consistency in rigor, action, measurement and improvement, exemplifies the true scope of what it takes to drive and sustain successful service efforts.

When I asked Dr. Feinberg how he ensured sustainability of this work he acknowledged that the people, processes and infrastructure were central to their success. But for him it seemed to also come back to passion. “As soon as you can show me the patient who deserves less care then the person that came before, that is when we can relax,” he said with a smile. It looks like UCLA Health System won’t be “relaxing” any time soon.

My greatest of appreciation to the leadership and staff of UCLA Health System for sharing their story with us, to the nurses who revealed the inner workings of the operating system and shared the passion they bring to their work and to the patients who openly talked about the service they received during their time at UCLA. Also a special thanks to Tony Padilla and his team for an incredible overview of the patient experience at UCLA.