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34 Frontiers of Health Services Management Volume 36 Number 3

The author declares no conflicts of interest.

Navigating unprecedented Change Through Agile and Disruptive Leadership Malisha Patel, FACHE

C O M M E N T A R Y

DOI: 10.1097/HAP.0000000000000080

Malisha Patel, FACHE, is senior vice president and CEO of Memorial Hermann Southwest Hospital in Houston, Texas, and Memorial Hermann Sugar Land Hospital in Sugar Land, Texas.

A dept leadership is essential for success in every business, but perhaps nowhere is the need greater than in our swiftly changing healthcare environment. In their feature articles in this issue, Nancy Howell Agee of Carilion Clinic and Gary S. Kaplan, MD, of Virginia Mason Health System under- score the role of leadership now and in the future of healthcare delivery.

Although the authors’ organizations serve different parts of the country, both are experiencing the market dynamics that affect all healthcare organizations today. As they point out, insurers and pharmacies are merging and insurers are acquiring physi- cian practices. New entrants from outside healthcare include consumer tech compa- nies and retailers. Healthcare organizations face leadership recruitment challenges, increased regulation, lower reimbursement levels, and changing workforce dynamics.

At the same time, technology is empow- ering patients to become more active consum- ers. They expect the same level of convenience, transparency, and personalized service from their healthcare providers that they receive from their retailers and financial institutions.

This era of unprecedented change calls for new leadership models that are agile and transformative. As Agee and Kaplan suggest, today’s healthcare leaders must be change sponsors and catalysts for change. Agee rec- ommends that we find ways for our organiza- tions to evolve, stretch, transform, improve, and redefine how we deliver care. Providing safe, high-reliability care is not enough; we must deliver care that is centered on the con- sumer’s needs for affordability and value.

I am fortunate to be a part of a forward- thinking health system that has been on the journey to high reliability for more than a decade, an organization whose leadership continues to strive to advance health and personalize care.

How Memorial Hermann Advances Health and Personalizes Care Based in Houston, Memorial Hermann Health System is one of the largest not- for-profit health systems in Texas. The system has more than 26,000 employees and 6,600 active medical staff members. Our 320 care delivery sites include 17 hospitals, the country’s busiest Level I trauma center, an

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academic medical center affiliated with the University of Texas Health Science Center at Houston, and numerous specialty programs and services.

Particularly at this scale, healthcare leadership must start with a strong foun- dation that includes a clearly articulated vision, mission, and core values. Memorial Hermann’s vision is to create healthier com- munities, now and for generations to come. Our core values—community, compassion, credibility, and courage—underpin our actions, and the patient-consumer is at the center of everything we do.

I serve as the leader of two full-service, acute care hospitals: Memorial Hermann Southwest Hospital, a 547-bed facility in Houston’s Sharpstown community, and Memorial Hermann Sugar Land Hospital, with 179 beds in suburban Sugar Land, Texas. Although the campuses are only 15 miles apart, they serve very different populations, as does each hospital in the system. Nonetheless, the “why” behind the work they do is the same: All of our leaders share a commitment to safe, high-quality, and affordable care for the patients and communities we serve.

Strategic Imperatives: A Solid Foundation In every organization, strategic imperatives, or pillars, guide the work of the leaders and the workforce. At Memorial Hermann, our strategic imperatives drive our work and our commitment to each community. Several of these imperatives align with the American Hospital Association’s Value Initiative that Agee describes in her article.

At the Core: The Workforce As Kaplan notes, employee engagement is essential to an organization’s success. Achiev- ing high reliability is impossible without an

engaged workforce—healthcare’s backbone and future. Leaders must see that all mem- bers of their workforce feel safe and excited to perform at their highest levels. To create this environment, leaders must engage and empower the workforce to speak up, share ideas, be actively involved in decision-making, and help shape the future of the organization.

Quality and Outcomes Eleven years ago, Memorial Hermann embarked on a journey to become a high- reliability health system. Executive leadership identified six factors to drive high reliability: vision; trust, respect, and inclusion; board engagement; leadership development; just culture; and behavior expectations. The lead- ers then adopted a multipronged approach to address each factor:

• Organizational structure. In 2010, a performance improvement, quality, and safety communication and reporting structure was established, including a system quality committee. To ensure board engagement, all system trustees serve on this committee. Between 2010 and 2014, all system board members, C-suite leaders, and medical committee members representing all Memorial Hermann entities completed the Institute for Healthcare Improvement’s “From the Top: The Role of the Board in Quality and Safety” training program. Leadership continues to be tasked with ensuring that each employee and partner throughout the organization understands his or her specific role in the quality process.

• Training. As part of a system-wide initiative called “Operation Breakthrough: Patient Safety,” everyone in the organiza- tion has completed safety culture training led by local quality and leadership teams.

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36 Frontiers of Health Services Management Volume 36 Number 3

In total, more than 20,000 employees and physicians—including 540 safety coaches to sustain the efforts—have been trained at a cost of more than $18 million (including employee time) to receive the education. The training included three steps: 1. Set behavior expectations. Define

safety behaviors and error prevention tools to help reduce human error.

2. Educate. Teach applications of safety behaviors and error preven- tion tools.

3. Reinforce and build accountability. Put into practice safety behaviors and adopt them as personal work habits. At the hospitals I lead, I hold daily huddles with leaders to emphasize quality and safety.

• Process. Using Six Sigma methodol- ogy, Memorial Hermann system-level leadership categorized serious safety events. Multiple stakeholders across the system—critical care directors, physicians, nurses, and information technology personnel—reached con- sensus in formalizing event bundles to ensure compliance with hospital-ac- quired illness, surgical site infection, ventilator-associated pneumonia, central line–associated bloodstream infection, and Joint Commission hand hygiene practices. The stakeholders identified processes and data types to be collected. Finally, bundle data were extracted and tracked. These efforts have enabled Memorial Hermann to reduce serious safety events, virtually eliminating incidents of central line– associated bloodstream infection and ventilator-associated pneumonia in adult and neonatal intensive care units.

• Recognition. To recognize Memorial Hermann entities achieving zero seri-

ous safety events in a 12-month period, system leadership created the High Reliability Certified Zero Award. The system’s president and CEO, chief med- ical officer, and board chairman present the awards annually. Between 2011 and 2019, they gave out 399 awards.

Delivery System Redesign In 2017, Memorial Hermann senior lead- ership launched Clinical Care Redesign (CCR), a sweeping transformation of the sys- tem’s long-standing business practices. CCR reenvisions the way we care for patients and touches our entire spectrum of care, affect- ing each facility, department, employee, and patient. As a CEO, I am involved in deploy- ment of CCR at my campuses. Each week, the CCR team leads report out to the local exec- utive team and me on progress and barriers.

We initially targeted four areas of oppor- tunity that offered the greatest potential for change: care variation, care progression, case management, and clinical documentation integrity. The goals of CCR are the following:

• Improve the safety and reliability of care • Develop evidence-based standards for

medical necessity • Reduce waste by eliminating unnecessary

variation • Incorporate innovation • Create an exceptional end-to-end

patient experience

The redesign of our operational and clin- ical processes has effected positive change across the organization in a number of ways:

1. Our practices are more standardized. Thanks to the implementation of sev- eral new clinical pathways and the stan- dardization of surgical supply packs, we have reduced unnecessary variation

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across the system. Patients receive a more standardized care experience, and clinicians benefit from reductions in the duplication of work.

2. We are more efficient. Through efforts such as multidisciplinary discharge rounds and streamlined catheter lab processes that improve on-time starts, we are seeing better patient outcomes and cost control.

3. We are more collaborative. Improved clinical and operational efficiencies, jointly enforced by local and system leadership, have brought greater unity to the entire organization. When teams share knowledge and work together, patients receive high-quality, timely, and cost-effective care and are engaged in their care plans.

4. We see accountability as a top prior- ity. Through the use of performance dashboards, the CCR team provides individual hospital leadership access to actionable data and creates a systematic way to compare performance across the Memorial Hermann system and—even better—to share our best practices.

5. We accelerate innovation. As Agee and Kaplan both advise, today’s healthcare leaders must differentiate their organizations as disruptors because healthcare is facing disruption. To that end, Memorial Hermann leadership has been designing, developing, and implementing innova- tions through our CCR to create new value for patients and their families.

The fifth point is worth highlighting with an example of accelerated innovation. Our iGenerate program has inspired employees, physician partners, and volunteers to share more than 8,000 ideas for improvement. By accessing the online iGenerate tool through

Memorial Hermann’s intranet, individu- als can submit ideas for everything from enhancing the patient experience to manag- ing costs. At each business unit, an iCouncil reviews submissions from the unit, and the best are elevated to the system-level iCoun- cil for further consideration. At that point, the ideas deemed to be of greatest value are recognized quarterly and entered into an annual system-wide competition. Each campus pitches its single best idea, Shark Tank style, to a panel of Memorial Hermann senior executives. In 2019, the winner pro- moted a new way to cut waste and costs. Every day in the Memorial Hermann–Texas Medical Center emergency department, about 200 patients are hooked up to car- diac monitors. Past practice was to give each patient a fresh set of disposable cardiac cables and pulse oximetry probes. When the electrocardiogram was finished, everything but the machine was tossed into the trash. Two Memorial Hermann employees saw this practice as throwing away money. They determined that cleaning and sterilization of all electrocardiogram equipment could safely eliminate waste and reduce costs by more than $500,000 each year.

Ideas such as this have paid off. While advancing new ways to improve safety and achieve high reliability, Memorial Hermann has received every national award for quality (Anderson 2019). In 2016, during my tenure as vice president of operations, Memorial Hermann Sugar Land received the coveted Malcolm Baldrige National Quality Award (National Institute of Standards and Tech- nology 2016). System leadership continues to apply many aspects of the Baldrige frame- work across the organization.

Transition to Value The term value-based care is becoming mainstream in the healthcare vernacular,

38 Frontiers of Health Services Management Volume 36 Number 3

but what specifically are its implications for leaders?

Patient-Consumer Engagement As Kaplan writes, the days of patients toler- ating long waits, disjointed experiences, and errors are over. We need to build relation- ships with consumers and empower them to exercise more control over their healthcare decisions—engaging them in new, innova- tive ways to make healthcare more approach- able and convenient. At Memorial Hermann, that means a best-in-class experience at each point in the continuum by employing patient journey mapping (an exercise health- care leaders use to understand how patients interact with a hospital or health system) and giving patients the opportunity to provide feedback.

Memorial Hermann also provides two convenient and low-cost alternatives to office visits. With our eVisit service, patients can receive diagnoses and treatment plans for minor illnesses through their private web portals. Patients answer a series of questions about symptoms and medical history, and an affiliated healthcare provider responds within 30 minutes with a diagnosis and care plan. Patients can also schedule a Virtual Clinic video appointment with an affiliated healthcare provider any day of the week. These options cost $25 and $49, respectively.

Improved Care Delivery In addition to fostering a highly collaborative physician enterprise to remove variability and standardize clinical protocols, leaders must also consider social determinants and seek resources to meet local healthcare needs.

Memorial Hermann Southwest, in part- nership with the Memorial Hermann Com- munity Benefit Corp. (a system subsidiary that collaborates with local organizations to improve access to care), recently launched

our first Community Resource Center. The center addresses the holistic needs of Southwest Houston, a community with pervasive health challenges. The center is staffed by Memorial Hermann community health workers who help individuals navi- gate factors that affect their health, such as care access, food security, safe housing, and transportation. In addition, representatives from three federally qualified health clinics connect uninsured and underinsured indi- viduals with primary and preventive care.

Management of the Total Cost of Care To improve patient outcomes while also managing the costs to deliver care, healthcare leaders are looking at taking on more risk via value-based payment models. Of course, in considering new mechanisms, leaders must also focus on measurable outcomes for the patients.

In the recent past, excellence in safety and quality was the definitive hallmark of a high-reliability healthcare organization. Today, excellence is only a part of the equa- tion. At Memorial Hermann, we collaborate with patients as well as insurers and other stakeholders in our communities to provide care that is affordable as well as excellent. Our CCR efforts to standardize opera- tions and improve efficiency are helping to improve patient outcomes and manage the total cost of care.

Conclusion These are challenging times for healthcare leadership, and yet I agree with Agee and Kaplan that great opportunities await. In instituting strategies such as those featured in this issue of Frontiers of Health Services Management, healthcare organizations can go beyond treating illness to preventing it by promoting wellness—that is, by caring for the

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whole patient. Perhaps most important, their leaders can enable patients to become much more engaged partners in their own care.

One of the keys to success for Memorial Hermann has been putting the right leaders in place—talented individuals who move quickly and decisively and are not afraid to question the norm. Healthcare needs more leaders like these who, through both words and actions, consistently reinforce their organization’s mission, core values, vision, and strategic imperatives. Today’s leaders must understand the necessity of an inspired, engaged workforce. As we do at Memorial Hermann day in and day out, they must ask

themselves and their teams, “Will doing this be in the best interest of our patients and the communities we serve?”

References Anderson, M. 2019. “Safety as a Core Value: Former

Memorial Hermann CEO on How to Become a High Reliability Health System.” Becker’s Hospital Review. Published November 12. www.beckershospitalreview. com/hospital-management-administration/safety- as-a-core-value-memorial-hermann-ceo-on-how-to- become-a-high-reliability-health-system.html.

National Institute of Standards and Technology. 2016. “Four U.S. Organizations Receive Nation’s Highest Honor for Performance Excellence: 2016 Baldrige Award to Small Businesses and Health Care Pro- viders.” Published November 17. www.nist.gov/ baldrige.

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