Transformation:

A Unique Approach to

Creating A Patient Centered

Care Model

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What: Community Hospital (CH), 450 licensed beds, North St Louis, high Medicare/Medicaidpopulation

Situation: Between 2002 and 2005 CH’s financial and operating performance deterioratedsignificantly:

o Physician attrition due to more attractive business models in local market; patient volume andrevenue in decline

o Patient satisfaction scores and community perception at an all time low - “CH is the place yougo to die”

o Poor employee morale, initiative overload and history of little follow through on changeinitiatives, impeded efforts to turn the hospital around

o Traditional approaches e.g. performance improvement (PI) were tried and failed to work

Solution: Transformation - a fundamentally different approach was needed to disrupt historicalpatterns and produce measurable results - to make CH a great hospital once more

Results: Significant improvements in cost, quality, PSAT and ESAT measures - achieved rapidlyand with low investment

Summary

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CH is located in an economically challenged and culturally

diverse community

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CH!

Demographic St Louis Los Angeles National Year

% below poverty level 25.4% 20.1% NA 2005

$ median household income 27,156 36,687 41,994 2000

Utilization per thousand population: usage of inpatient services is expected to grow from

125.1 cases to 136.7 cases per thousand population

St Louis County: ranked No. 5 among the nation's counties in population decline during the

1990s, with a loss of 48,496 people

Primary Service Area Trends 2005 and 2016:

Population projected to fall 0.2% annually

Percent greater than 65 projected to increase from 12.5% to 15.0%

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“In 25 years of nursing I have never seen anything like this.” RN

“I’ve been here before, and I didn’t want to come back. But this time

everything has been different. I don’t wait for someone to answer my

call light. It’s immediate. My care has been wonderful. And I am 87

years old.” Patient

“I’ve always felt like an outsider. Now I am an insider. They

share information with me.” Patient Spouse

The most enjoyable and rewarding aspect of my job is helping patients

and their families. Now I can spend time with patients and assist with

their needs.” Charge Nurse

“I can be out here with my patients. I can anticipate their needs before they get

to their call lights.” Patient Care Assistant

“It’s nice to know who will be taking care of me and who I can

call when I need help”. Patient

Results: anecdotal feedback from staff and patients

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Results: 160% increase in excellent PSAT scores - “Overall

Quality”

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Results: 70% increase in teamwork scores, 51% increase

in employee satisfaction scores

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Results: 66% decrease in Fall Index, 26% reduction in

stroke ALOS

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! Improving top box “excellent” scores proved substantially harder than expected -

squeezing out poor/fair scores was easier

o Patient experience was negatively impacted by exposure to parts of the

hospital yet to go through Transformation

! Changes in behavior and attitude have a greater impact on PSAT than improvements in

facilities and equipment

o Improvements were made with minimal investments in facility, technology and

new equipment

o PSAT data shows care staff working as a team, patient control of care and

improved communication as most important

! The 60% “tipping point” identified by Griffin Hospital appears to be real

! Such dramatic improvements in fall, LOS and wound measures were unexpected

o Possibly explained by refocusing staff on the core mission of patient care - why

many because nurses in the first place

Transformation produced some surprising results

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John - ED night Supervisor - John was ready to quit prior to joiningthe ED transformation team. John became a strong leader oftransformation as a result of the site visit to John Muir ED. He wasrecently promoted to manage the entire ED.

Transformation led to the emergence of formal and

informal leaders

Jenny - ED Tech - Jenny was a total cynic. After her site visits she

took the lead in bringing members of the ED to the team war room

to explain the new practices and work behaviors. Jenny teamed

with supervisors and managers to lead transformation in the ED.

Jo - Nursing Supervisor - On arrival at Griffin Hospital Jo stated it

was the first time in 25 years she had been asked to think about

what went on in a hospital. She led the transformation effort in the

pilot unit and is now the host for “site visits” to her floor.

Barb - Nursing Unit Manager - Barb was thrown in at the deep end as

manager of the transformation pilot nursing unit. Despite minimal

business education, Barb’s credibility as a nurse and manager

helped make her one of the strongest leaders of transformation.

Barb was recently promoted a Director of Patient Care.

Carla - Housekeeper - Carla came to exemplify great customer

service and a focus on the patient. Early in transformation she led

a workshop for the hospital leadership team on how to create great

customer service.

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Multiple, disparate initiatives sponsored bydifferent departments and stakeholders - a“try it and evaluate” approach

Single roadmap, created together byadministration, physicians and nursing staff- integrates multiple initiatives andeliminates those that do not “fit”

Focus on task and how to improveaccomplishment of tasks

Physicians, nursing and ancillary staff focuson the entire patient experience - doctorcommunication, control over care,environment, human touch…

Mixture of top down, consultant driven andbottom up initiatives - use of humantechnology is incidental

Intense, rapid, experiential process buildsfront line ownership from the beginning -staff define and take responsibility for newwork practices and behaviors

Sustainability relies on existing performancemanagement systems and managementskills

Sustainability built in from the start - trainedproject managers, emerging leaders,director/ manager leadership development,staff retreats, unit scorecards…

Steady and incremental improvement ofexisting ways of working - often driven byanalysis of defects

Teams required to be future oriented anddeliver breakthrough thinking and do whatis in the best interests of the patient -always

Transformation ApproachTraditional Approach

A radically different approach was used to disrupt historical

patterns and create front-line ownership for the change

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Transformation: A Four Phase Approach

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Phase II - creating an intense experience leading to innovation

and mindset change

Rapid delivery in 60 and 90 days to disrupt historical patterns:

Immersion to promote creativity and capture hearts and minds :

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1. A draft framework of the “generic” patient journey(s).

2. An initial set of “key themes,” “opportunity areas,” or “pain points” in the patients’ or care givers’

experience.

3. A list of learnings about the observation research process and recommendations for improving

effectiveness and impact.

Phase III - breaking the mold: observational research, water

cooler, pilot & test, A Day In The Life, Patient Journeys…

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Phase IV: ensuring benefits are realized and implementation

costs are managed

ICU CMR 3rd Floor 4th Floor 5th Floor 6th Floor 7th Floor 8th Floor 9T AMCU 10th Floor ED

Kickoff 01/17/07 02/15/07 02/15/07 03/02/07 12/02/06 12/02/06 01/03/07 01/04/07 03/02/07 01/17/07 05/02/07 08/02/07

Retreat I 2/19-2/22 3/5-3/8 3/5-3/8 1/8-1/11 1/8-1/11 1/29-2/1 1/29-2/1 2/19-2/22

Retreat 2 4/30-5/3 5/14-5/18 5/14-5/18 2/26-3/2 2/27-3/2 4/9-4/12 4/9-4/12 4/30-5/-3

Dress Rehearsal 2/12-3/19 2/12-3/19 2/19-3/20 2/19-3/20

Phones n/a 5 ordered 12 ordered 8 ordered 10; due 2/14 10; due 2/14 13 ordered 11 ordered 4 ordered 8 ordered

COWS

Intro Rounds

Hourly Rounds

Communication Boards

Care Partner

Admission Packets

Call Light Mgmt n/a

Everyone's Concierge

Chart Sign Off

Facilities Adjustments

New Ideas

Flow Coordinator n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a

Self Managed Team/Code X n/a

Mentor/Agency & Float Prog X n/a

Improved Discharge/Admit X n/a

Care Planning with Patients X n/a

Ancilary Departments

Radiology

Surgery

Dietary

Housekeeping

Transformation Dashboard

House Wide Rollout Schedule

!Management structure in place

!60 day design + 60 day

implementation cycle

!Care units paired for max. speed

and efficiency

!60% “tipping point”

Transformation Dashboard

!Transformation at a glance

tracks new care model rollout

!Approach integrates PI,

Relationship Based Care,

Transformation and

Phased Approach

!Four phase structured

methodology and tools

!Sustainable - builds

ownership and capability from

the start

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90-day value proposition and costs

Value Proposition

! Integrated with Existing Initiatives - approach can be used to address failing Lean, Six Sigmaand operations improvement projects

! Speed to Result - demonstrated results by the end of the first 90-day design cycle

! Reduction in Cost - reduced length of stay for Medicare and Medicaid patients, fewer falls andhospital acquired wounds to treat

! Proactively Respond to Demands for Transparency - influence consumer choice by improvingpatient centeredness and quality metrics per http://www.healthgrades.com andhttp://www.chart.gov

! Boost Nursing Staff Retention and Recruiting - retain great staff by increasing employeemorale

! No Investments in IT, Major Equipment and Facilities - benefits accrue from changes in workpractices and behaviors

Program Investments and Cost - Approx $2 million

! Backfilling for front line team members

! Internal program support, project managers and performance measurement experts

! Facilitation and consulting support

! Minimal tool acquisition costs (cell phones, whiteboards etc.)

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