Advocate Good Samaritan Hospital has gone from being a good, large community hospital to achieving some of the best health outcomes in the United States and receiving the 2010 Malcolm Baldrige National Quality Award. Executives at the Downers Grove, Ill., hospital (part of Chicago's Advocate Health Care system) attribute much of the progress to the creation of a culture of high performance, continual improvement and workforce engagement. They also point to the top-down transformation in culture that would not have been possible without the support of a strong local governing council, which recognized the competitive advantage that a hospital can achieve by having culture aligned to the organization's strategic plan.
In a hospital, the results of a vibrant culture are easy to spot: physician loyalty as evidenced by growing patient volumes; high levels of satisfaction among physicians, associates and patients; an engaged, friendly staff who go beyond the call of duty; and superior clinical outcomes. Advocate Good Samaritan's experience provides a view into the nature of culture change in health care organizations.
Organizational cultures either can be changed or transformed. Change fixes the past; transformation creates a different future. Successful transformation is rooted in an intentional decision, meaning senior leaders must assume the role of architects and determine the culture needed to fulfill the organization's mission, achieve its strategy and secure a competitive advantage. The goal is not to make it a happy workplace per se, but to succeed as an organization.
Although boards can play different roles in health care organizations, meaningful, sustained cultural transformation happens when the board understands the importance of culture and supports the CEO. This kind of transformation is hard. It requires people to change their behavior, which can create tension, and it requires tough decisions. Some employees may not go along with the transformation and may leave or be asked to leave. The relationship between the hospital and physicians may need to change dramatically. Boards that understand how culture is transformed support the CEO's efforts in creating a compelling vision, establishing mechanisms to align goals, creating behavioral standards and changing leadership practices.
An organization's culture is broadly defined as its collective beliefs, values and observable behaviors. Every organization has a culture that either evolved to its current state or was intentionally created. Evolved cultures, however, often do not support the organization's mission and strategy.
With that in mind, Advocate Good Samaritan President David Fox and senior leaders decided to reshape the culture. "The impetus for our transformation of moving from good to great was the Advocate Good Samaritan executive team," Fox says. Because the hospital is in a highly competitive market, "we concluded that our inability to differentiate ourselves would adversely impact our future. The vision of creating a better future for our patients, physicians and associates was well-received by our local governing council, and our early successes created the desire to do whatever was possible to support the journey."
The quality standards that leaders focused on — which became the metrics for culture transformation — included measures of physician engagement, patient satisfaction, associate satisfaction and a range of clinical outcomes. In culture transformation efforts, the metrics provide the direction and constant reinforcement about what's important and how the organization is progressing.
Advocate Good Samaritan's leaders were particularly interested in how culture impacts patient satisfaction, given the Centers for Medicare & Medicaid Services changes to reimbursement standards. After all, patient satisfaction is due in large part to the behavior of nurses, doctors, administrators and other front-line personnel. Training, work processes and incentives, and a culture that recognizes every staff member's contribution to the patient experience can strengthen behaviors that improve it. All providers will need to make an honest assessment of their current cultures and find a few impactful levers that will lead to sustainable changes in line with higher expectations for patient satisfaction. Advocate Good Samaritan chose levers of systematic relationship building with physicians, associates and patients, in addition to clinical outcomes.
A Different Future
How does a health care organization begin this kind of transformational journey? In 2004, Fox spent his first few months as president meeting one-on-one with doctors to find out what was working and what was not. These interviews, coupled with the overall strategic assessment, highlighted opportunities for improvement. At the time, Advocate Good Samaritan outpatient satisfaction was at the 7th percentile; associate satisfaction at the 46th percentile; and physician satisfaction was unknown because it wasn't measured.
There seemed to be a good relationship between physicians and administrators, but there was some tension around a financially struggling physician-hospital organization that managed contracts. Nursing care was seen as uneven — great on weekdays but not weekends; great on some units but not others.
"We knew we needed to create a different future than the one we were seemingly destined for," says Pattie Skriba, Advocate Good Samaritan's vice president of learning and organizational effectiveness. "We had a mission imperative to be a place of healing, an operational imperative to become the best place to work and practice medicine, and a strategic imperative due to our highly competitive market. Making incremental changes would not get us where we wanted to go; we needed a transformation and that started with the president and senior leaders."
The first step was to create a compelling vision and enroll midlevel leadership in that vision. Senior leaders knew that changing behavior was not about logic, but emotion. Without truly connecting with the workforce, the result would be grudging compliance with the new culture.
The next step was to align the work and focus of the organization from the C-suite to the front line. Senior leaders created six key result areas — health outcomes, associate engagement, patient satisfaction, physician engagement, growth and funding the hospital's future — and identified strategic and quality goals for each. Goals that aligned with the overall organizational goals then were created for every individual leader. That aligned the whole organization from top to bottom. It provided clear and attainable targets that were tied to each individual's performance review. And, as individual leaders met their goals, so did the organization.
Other evidenced-based management practices then were deployed during quarterly off-site leadership development institutes. Leaders became skilled at building relationships; high quality was nurtured through differentiating performance discussions; and recognition practices fueled the cultural momentum. A team of physicians and associates created "behaviors of excellence". The commitment to excellence saturated the organization's culture.
Peer interviewing was a key culture creator. More than 300 high-performing associates were trained to conduct behavior-based interviewing. Today, candidates are screened by the human relations department and interviewed by managers who forward to a peer interview team the names of individuals they feel would be effective in the culture. The peer interview team then makes the final decision. "We found that people let their guard down when being interviewed by peers," Skriba says. This practice now allows Advocate Good Samaritan to screen candidates for competency, but hire for attitude and cultural fit.
Culture transformation takes time. At Advocate Good Samaritan, Skriba noticed small things changing at first. "People started picking up paper on the floor, and greeting you in the hallway," she says. "Pretty soon we started to hear stories - examples of how the culture was shifting. People were getting recognized for acts of compassion and service. Patients were writing more complimentary letters.
"Outcomes began to improve," Skriba adds. "For example, outpatient satisfaction moved from the 7th percentile in 2004 to the 99th percentile in 2006."
To ensure that Advocate Good Samaritan stays on track, its governing council reviews a monthly performance scorecard. Additionally, Fox distributes real-time emails on external recognitions and shares patient/physician comments and letters that reflect the culture to the council and more than 300 other leaders.
Culture transformation was necessary for building relationships with physicians. Proactively working with doctors to improve health outcomes, reduce costs and improve patient satisfaction resulted in the culture Advocate Good Samaritan desired. "Building loyal relationships with physicians is critical to our future," Skriba says. "We made it a key result area and have specific practices that build and maintain relationships with our physicians."
Physicians wanted an efficient, hassle-free place to work, with easy access to information. They wanted excellent, consistent nursing care across all units and on all shifts. And they wanted to be part of an organization that is committed to superior clinical outcomes and that has a vested interest in their financial success. By including physicians in decision-making, adding physicians to the local governing council and its committees, leveraging physician champions on clinical teams and ensuring quality improvements that impact physician practice, physician loyalty grew, as evidenced by a 17 percent market share increase over the past six years.
"Not too long ago, one of our cardiologists, who practiced at both Advocate Good Samaritan and at a competing hospital, met with [Fox]," Skriba says. "The physician told Dave that he had good news, that he and his partners had decided that he could bring all his patients to Advocate Good Samaritan. Though great, that wasn't the most impactful comment he made. He went on to say, 'Now, Dave. What else can we do together?'"
Sidebar - Five Steps to Cultural Transformation
Advocate Health Care's Behaviors of Excellence: