Continuous Improvement

Making the Case for Quality

Rural Hospital Thrives With

Continuous Improvement and Innovation

• Not long ago, poor internal communication, low morale, and high staff turnover were the norm at Wright Medical Center.

• A new CEO ushered in a culture change with the hospital focusing on open communication and accountability. Soon publicly sharing all patient comments—both positive and negative—became standard practice.

• After implementing a pillar system with six key areas for performance improvement, Wright Medical Center is now a destination of choice for healthcare in north central Iowa with patient satisfaction scores among the highest in the nation.

• During its decade-long quality journey, the hospital captured several state and national awards, including two Press Ganey Summit Awards and silver and bronze awards in the Iowa Recognition for Performance Excellence program.

At a Glance . . . When Steve Simonin began his duties as CEO of Wright Medical Center (WMC) in late 1996, he took the helm of a small, rural hospital known for poor communication and a negative work environment. Word on the street was that the hospital’s nursing staff “ate their own,” and employees wouldn’t rec- ommend the medical center to family or friends. It wasn’t uncommon to find local residents driving 50 to 75 miles to seek medical care elsewhere. Fast forward to the present and the transformation is astounding: WMC flourishes as a regional healthcare destination and continues to capture state and national quality accolades.

About Wright Medical Center

WMC, built in 1951, is located in the small town of Clarion and serves a rural, agricultural area in north central Iowa. This 25-bed facility is a critical access hospital, a designation that provides the opportunity for Medicare reimbursement, allowing many of the state’s rural hospitals to keep their doors open. Owned by the town of Clarion, the hospital employs more than 300 people and offers a variety of services, including acute and surgical care, emergency services, family practice and obstet- rics, orthopedics, many specialty clinics, and therapy options, as well as hospital and retail pharmacies.

Gaining a Fresh Perspective on Quality in Healthcare

Soon after arriving in Clarion, Simonin gathered a group of trusted leaders and they immediately focused on improving staff communication and creating a more positive work environment. Some success followed, but it wasn’t until a family member in another part of the state became seriously ill

that he began leading WMC’s real quality journey. “When I was on the other side of the hospital bed I began to appreciate healthcare from a different perspective,” explains Simonin.

At the same time, Simonin and his leadership team learned of the Studer Group, a consulting firm that helps healthcare providers focus on compassion and caring with the belief that positive financials will follow. The team appreciated the balanced approach that Studer advocated and soon WMC adopted the pillar system, which provides a foundation for setting goals and evaluating progress toward those goals. As illustrated in Table 1, the pillar system incorporates five focus areas for performance improvement at WMC: quality, service, finance, growth, and people (a sixth category, community, was added later). The hospital began “hard-wiring” the improvement processes into daily activities at WMC to ensure these processes turned into habits.

Simonin explains that the pillar approach helps the hospital to engage employees in forming, execut- ing, and evaluating goals on three levels: personal, departmental, and organizational. The pillar system provides the infrastructure to ensure that the hospital’s overall action plan measurement system covers all key departments and stakeholders.

by Janet Jacobsen

April 2009

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Creating an Environment of Communication and Accountability

To increase market share, leaders at WMC began looking at the reasons why people were leaving the community for their primary healthcare needs rather than utilizing the services of the local hospital. The leadership team carefully studied patient and employee surveys and ultimately decided to introduce a no-

secrets environment where everything from patient satisfac- tion survey comments to strategic planning and financial reports would be posted for all to read. Simonin recalls that some employees were resistant at first to posting customer comments, but for the most part, the major- ity of staff responded positively.

With the motto that “a complaint is a gift,” WMC places great importance on customer feedback. WMC uses a variety of methods to collect voice of the customer data. Patient welcome packets contain a letter from Simonin, which includes his work, home, and cell phone numbers so

that patients may contact him with comments at any time. The hospital encourages its senior leaders to play active roles in community organizations such as the chamber of commerce and churches. “People are very comfortable coming up to us in the grocery store and talking about their ideas for quality and ser- vices,” reports Simonin.

Following the PDCA Model

Utilizing survey data and customer comment information, lead- ers conduct root cause analysis and apply the plan, do, check, act (PDCA) model to guide performance improvement initia- tives. For example, when patients gave low scores and negative feedback about the lack of privacy in the outpatient surgery and emergency room areas, members of the service pillar team took action. They contacted the patients who had expressed concerns, and after gathering and analyzing feedback, the team helped develop new, private waiting rooms.

Another example of responding to patient feedback involves the creation of a “pain team.” Charlie Hammel, quality coordinator and co-leader of the quality pillar, recalls that WMC’s patient satisfaction scores relating to pain management fell sharply from the 90-percent range to between 40 and 50 percent after the hospital expanded its orthopedics services and began performing several joint replacement surgeries each week. “We studied the data and formed a multi-disciplinary team and eventually devel- oped pain protocols, brochures, and recommendations on how to manage a patient’s pain,” Hammel explains. The hospital’s pain management scores improved dramatically and are now typically at 99 percent for orthopedics.

The PDCA model is such an integral tool that WMC uses it prior to launching all new services and work processes. “It’s become so engrained into the culture that most employees don’t even realize they are using it,” Hammel says.

Increasing Satisfaction Scores and Market Share

By focusing on open communication and accountability as well as offering additional services such as orthopedic surgery, the hospital improved patient satisfaction scores substantially while also growing its market share. Figure 1 illustrates noteworthy gains in patient satisfaction scores, which are consistently above 95 percent, and Figure 2 depicts a steady rise in the number of residents from the county who select WMC for outpatient ser- vices. The hospital’s market growth in recent years is 13 percent for inpatient and 8 percent for outpatient visits. With the help of

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Since beginning its quality journey and adopting the pillar strategy for performance improvement, Wright Medical Center (WMC) has garnered a variety of national and state awards:

• WMC received Summit Awards from Press Ganey in 2006 and 2007 for inpatient satisfaction scores that reached the 99th percentile nationally.

• In 2007, WMC earned a bronze award in the Iowa Recognition for Performance Excellence (IRPE) program, which is based on the Malcolm Baldrige Criteria for Performance Excellence. A year later the hospital captured a silver IRPE award.

• Also in 2007, HealthLeaders media named WMC to the Top Leadership Team in Healthcare for small hospitals.

• The Studer Group honored WMC with its Fire Starter Award in February 2005 to recognize the hospital’s performance improvement results and in June 2005 with the “What’s Right in Healthcare” recognition.

• CEO Steve Simonin was named to the Studer Group’s 2008 Fire Starter Hall of Fame for his commitment to clinical, service, and operational excellence.

Capturing National and State Awards

Table 1— Wright Medical Center Pillar Approach for Performance Improvement

Pillar Overall Goal

Quality To monitor and ensure that the best quality of care is delivered by WMC’s work force.

Service To implement services and activities consistent with world-class service. Finance To improve WMC’s cash flow. Growth To identify market opportunities. People To be the employer of choice in WMC’s service area. Community To identify community needs.

Figure 1— Patient Satisfaction Scores at Wright Medical Center

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Jun. ‘05 Dec. ‘05 Jun. ‘06 Dec. ‘06 Date

Inpatient Outpatient Family Practice Emergency Dept. Surgery

Jun. ‘07 Dec. ‘07 Jun. ‘08 Dec. ‘08

quality tools such as the PDCA model, the hospital has improved processes for pain management as reflected by improved patient satisfaction scores shown in Figure 3.

These impressive results have no doubt contributed to WMC receiving several high-profile awards, as detailed in the sidebar Capturing National and State Awards. Aside from this recogni- tion, Simonin says he’s proudest of bringing quality care to this rural setting. See the sidebar Offering Spa-Like Amenities to Increase Market Share for more information about the hospital’s innovative offerings. “A lot of us in rural areas haven’t always had access to the best quality products and services. Through this journey we’ve been able to provide the highest quality healthcare to our citizens and we’re starting to see others from larger communities coming here for their healthcare as well,” remarks Simonin.

Hardwiring Processes for Continued Success

One of the keys to WMC’s remarkable success is the hospi- tal’s decision to connect process improvement goals directly to employees’ performance evaluations and merit raises. Employees can track progress toward goals through dashboards called monthly report cards. Hardwiring patient satisfaction data into the appraisal system helped secure staff buy-in and a con- tinuing commitment to quality.

Simonin believes the biggest challenges in the process improve- ment journey are consistency of leadership and communication. He says that it all comes down to working with people and lis- tening to them, but at the same time holding them accountable for their performance. He says that other executives who are looking to change the culture of their organizations through pro- cess improvement should realize that it’s not something that will happen overnight: “This type of journey is the hardest thing you are ever going to do, but it’s so worth it.”

For More Information:

• To learn more about Wright Medical Center, visit the hospital’s Web site at www.wrightmed.com.

• Wright Medical Center’s CEO, Steve Simonin, recommends the following books, all available at leading bookstores: Leading Change by John Kotter, Good to Great: Why Some Companies Make the Leap and Others Don’t by Jim Collins, and Hardwiring Excellence: Purpose, Worthwhile Work, Making a Difference by Quint Studer.

• Visit the Iowa Quality Center’s Web site at www.iowaqc.org for further information about the Iowa Recognition for Performance Excellence awards.

• For more resources on quality approaches in healthcare, visit www.asq.org/healthcare-use/why-quality/overview.html.

About the Author

Janet Jacobsen is a freelance writer specializing in quality and compliance topics. A graduate of Drake University, she resides in Cedar Rapids, IA.

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Figure 2— Residents of Wright County Choosing Wright Medical Center for Outpatient Care

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Trinity Regional Hospital

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Mary Greeley Medical Center

Mercy Medical Center – North IA

Hamilton Hospital

Other

Figure 3— Patient Satisfaction Scores for Pain Management

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98 98

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91 98

87 88 97

93% Goal

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Patterned after the luxurious Ritz-Carlton hotel chain, Wright Medical Center (WMC) offers spa-like amenities delivered with small-town, friendly care to help increase market share. Orthopedic patients at WMC can relax during their choice of a free massage, hairstyling session, or facial before checking out of the hospital. All patients can enjoy the following amenities designed to offer a more comfortable, resort-style experience:

• Wireless Internet access

• Softer lighting

• Complimentary long-distance phone cards

• In-room video/DVD machines

• Warm, spa-like robes

• Five-star food on demand ordered from an in-room menu

• Free meal passes for family members

• Warm cookies served daily

• Softer sheets and blankets

• Carpeted hallways

Offering Spa-Like Amenities to Increase Market Share