Case Study High-Performing Health Care Organization • March 2009 May 2009 Parkwest Medical Center: Focusing on Patient and Staff Satisfaction J ennifer N. E dwards , D r.P.H. H ealth M anagement A ssociates The mission of The Commonwealth Vital Signs Fund is to promote a high performance Location: Knoxville, Tenn. health care system. The Fund carries out this mandate by supporting Type: Not-for-profit community hospital, nonteaching independent research on health care Beds: 462 issues and making grants to improve health care practice and policy. Support Distinction: Top 5 percent of more than 700 large hospitals (300+ beds) in the portion of patients who for this research was provided by gave a rating of 9 or 10 out of 10 when asked how they rate the hospital overall. The Commonwealth Fund. The views Timeframe: October 2006 through June 2007. To be included, hospitals must have reported at least presented here are those of the authors 300 surveys. See the Appendix for full methodology. and not necessarily those of The This case study describes the strategies and factors that appear to contribute to high patient Commonwealth Fund or its directors, satisfaction at Parkwest Medical Center. It is based on information obtained from interviews with key officers, or staff. hospital personnel and materials provided by the hospital during October and November 2008.      For more information about this study, Summary please contact: Eighty-seven percent of patients recently discharged from Parkwest Medical Jennifer N. Edwards, Dr.P.H. Health Management Associates Center said they would recommend the hospital to a family member or friend— jedwards@healthmanagement.com a patient satisfaction level 19 percentage points higher than the national average. Like other hospitals in this case study series, Parkwest has focused on hiring and supporting staff who subscribe to its vision of providing excellent patient care and sharing responsibility for doing so. The hospital’s goals for quality care To download this publication and and patient satisfaction are spread through the Leadership Evaluation Module, learn about others as they become available, visit us online at through which the performance goals and standards for administrators, managers, www.commonwealthfund.org and and staff are aligned and managers are held responsible for the performance of register to receive Fund e-Alerts. the staff who report to them. Performance-based rewards and recognition help to Commonwealth Fund pub. 1258 Vol. 15 reinforce the standards. 2T he  C ommonwealth F und Parkwest’s leaders believe that staff satisfaction the hospital’s commitment to teamwork and care coor- is a predictor of patient satisfaction. For this reason, dination, contributing to their high scores on the Parkwest uses rounding techniques on patients as well Hospital Consumer Assessment of Healthcare as frontline and support staff. Nurses visit patients at Providers and Systems (HCAHPS). least once an hour to address their needs and help ensure coordination of care among team members. Leadership and Training Supervisors round on their own staff weekly, and Parkwest’s commitment to patient service began at the department heads round on their staff biannually. health system level. Around 2006, Covenant Health Hospital leaders report that employees feel responsible executives and the board of directors began to research both to patients and to each other, creating a strong the business case for quality. They learned of the expe- teamwork culture. Their evidence is a very low staff rience of Baptist Hospital in Pensacola, Florida, where turnover rate. In a state where rates of nursing turnover improving patient satisfaction led to a dramatic growth are in the mid-teens, Parkwest experienced turnover of in admissions and revenue. In 2006, Covenant hired less than 3 percent during 2008. the Studer Group, a consulting firm started by Baptist Finally, Parkwest has begun to solicit feedback Hospital’s former president, Quint Studer, to conduct from patients and families after discharge. They check leadership training in their system and see if they to see if patients need any follow-up information or could achieve similar results. Covenant chose care and solicit ideas for ways to improve. Parkwest Medical Center as the pilot site. Parkwest’s leaders and their advisors began by Organization defining their expectations for achieving high levels of Parkwest Medical Center is a 462-bed acute care facil- patient satisfaction. They created a Leadership ity in Knoxville, Tennessee. It began operations in Development Institute, first enrolling top managers, 1973 as a joint venture between physicians and the executives, and even the board of directors, and even- Hospital Corporation of America. In 1990, it joined the tually training over 200 managers at all levels. They not-for-profit Fort Sanders Health System, which in adopted processes to improve satisfaction based on 1996 became Covenant Health. The Covenant system proven strategies from Baptist Hospital, including the includes seven hospitals and 11 outpatient and spe- Leadership Evaluation Module and rounding on staff cialty facilities. Parkwest is West Knoxville’s largest and patients. Training continues quarterly to reinforce medical center. successful strategies and identify new ones. Parkwest’s CEO, Rick Lassiter, joined the hos- pital in March 2008. He is carrying on the quality “Our patients feel they are well cared for, and it’s agenda begun in May 2006 under the leadership of reflected in how they score us.” Covenant Health and former Parkwest President and -Missy Sanford, Director of Clinical Effectiveness Chief Administrative Officer Barbara Blevin. and Quality Improvement Strategies for Success Parkwest Medical Center uses personnel policies, Motivating Staff Performance rewards, and management tools to align staff conduct One of Parkwest’s most effective interventions has with its organizational goals. It also relies on quality been its use of the Leadership Evaluation Module, data and clinical guidelines to improve performance, through which the performance goals and standards but these tools are secondary to the other strategies. of the organization and its administrators, managers, According to Missy Sanford, director of clinical effec- and staff are aligned. Evaluation criteria are estab- tiveness and quality improvement, patients recognize lished from the top down, and everyone’s successes— P arkwest M edical C enter : F ocusing on P atient and S taff S atisfaction 3 and failures—contribute to the performance ratings left the hospital. Parkwest has incorporated their of their superiors. expectations about patient-centered care into the inter- Progress toward meeting the standards is viewing process. Frontline staff interview prospective reviewed quarterly, and action plans are developed and new hires to help determine if they would work well in revised to keep on track. All staff, from frontline care their units. providers to administrators, are scored on their perfor- mance, and their scores are used to determine merit Rounding on Patients and Staff increases. Unlike some hospitals, where there is little Parkwest employs rounding for patients as well as variability in merit pay, Sanford says these are “real frontline and support staff—whom they collectively rewards. Doing one’s job is defined as meeting expec- describe as their “customers”— to monitor their satis- tations. But exceeding expectations by getting a four faction and make improvements as needed. or a five (on a scale of one to five) is rewarded.” Patients are visited every hour by a nurse, who There are five types of performance measures in asks if they need anything and checks on three key the Leadership Evaluation Module: issues, often called the “three Ps”: pain, potty, and positioning. Nurses alert patients to upcoming • Quality—including performance on publicly changes, especially discharge. Care plans are discussed reported quality measures (e.g., Centers for often so that patients’ education and follow-up needs Medicare and Medicaid Services core mea- are addressed during their stay, not in a rush before sures and patient safety indicators) they leave. Nurses also discuss safety concerns, and advise patients to be prepared with questions when • Service—including measures of patient and their physician rounds. staff satisfaction, such as HCAHPS Parkwest managers use a rounding technique • People—including retention and turnover rates with their subordinate staff. In monthly one-on-one of one’s staff meetings, managers talk with their staff about their • Finance—including length of stay on the unit, plans and goals, how work is going, and what changes for unit-based staff, and operating budget might be needed. They ask staff to point out col- leagues who should be recognized and rewarded for • Growth—including the number and type providing superior care. Managers seek to ensure staff of services provided by Covenant Health have the tools and training they need and staff, in turn, institutions make suggestions for system and process improve- This system took time to implement and to train ments. The findings from these monthly rounds are managers and supervisors to use. Staff are given tools reported to the vice president for that business line. to monitor their own progress, as well as to develop Improvements may be made at the unit level or more and track plans for improvement. Further details of the broadly at the executive level. hospital’s philosophy are shared with staff in the In addition, the hospital uses rounds to check in “Standards and Behaviors Guide.” Just two years after with staff in departments that support frontline care, implementation, the system is regarded as a success. such as the quality department, food and nutrition, Patients rate the hospital highly, and staff have a very patient transport, and housekeeping. Nurses and other positive view of their work environment. frontline staff fill out surveys scoring the people who Not all of Parkwest’s employees flourished provide these support services, and biannual meetings under this model of patient-centered care. Staff who are held with each group. This has led to more team- received low evaluations were encouraged and sup- work between the frontline and support staff and a ported in their efforts to improve. Eventually, some greater sense of commitment to improvement. There 4T he  C ommonwealth F und has been a noticeable shift in culture, with staff com- winners. The ideas presented are then considered by monly asking the questions, “What can I do to help the other sites for adoption. One of the recent winners you?” and “What can I do to get better?” from Parkwest was the Rapid Response Team, which sends physicians to the bedside of any patient who Post-Discharge Feedback appears to be deteriorating and requires urgent atten- Parkwest solicits patients’ views on their care through tion. Data from this initiative showed a reduction in post-discharge calls, made within the first 24 to 48 the number of heart attacks occurring on the regular hours after their discharge. A nurse, case manager, or inpatient units, as opposed to in the intensive care unit, unit administrator asks patients or their family mem- where high-risk patients are meant to be; it also led to bers if they have any questions about their hospital greater nurse and physician satisfaction. Parkwest’s stay, and invites them to recognize personnel who Rapid Response Team won the President’s Award for deserve special recognition. Patients and family mem- their efforts. bers are also encouraged to identify opportunities for improvement. This information is then fed back to the Results unit, the quality improvement department, and, if it is Parkwest was selected for inclusion in this case study related to a physician, the credentialing office. series on High-Performing Health Care Organizations This process has identified lapses much more based on its high score on the question: “Would you quickly than a typical patient satisfaction survey. recommend this hospital to a family member or During a recent construction project to expand the sur- friend?” As shown on the table, 87 percent of respon- gical area, calls with patients revealed dissatisfaction dents said they would definitely recommend the hospi- with the flow of information. The unit was able to tal, exceeding the national average by 19 percentage diagnose what had changed in their process as a result points. Parkwest also scored above the national aver- of the construction and create a short-term workaround age on nearly all other HCAHPS measures. Its average to meet patients’ information needs. score on a measure of nurse communication was par- ticularly high, though its performance on a measure Shared Learning of discharge communication was the same as the There is a culture of collaboration and sharing of best national average. practices both within Parkwest and the Covenant Notably, though, exceeding the national average health system. Parkwest managers review patient feed- does not equate to very high scores on many HCAHPS back from rounds and surveys on a monthly basis. measures. On specific measures such as receiving Shared learning is encouraged, and ideas that work in timely help, pain control, and explanations about med- one unit are spread to others. ication, Parkwest’s scores show considerable opportu- Three years ago, Covenant initiated a system of nities for improvement. performance excellence awards. Hospitals submit Nurses report that the hospital leaders listen to applications in as many areas as they wish, focusing them and care about their concerns. They also say that on processes they believe worth replicating. Awards they value the hospital’s patient-centered culture. are given in four categories: bronze, silver, gold, and Parkwest has had very low nursing turnover—below the President’s Award. Forty-two judges from through- 3 percent in 2008—compared with statewide turnover out the health system review proposals and nominate in the mid-teens. Turnover costs money, and these high staff retention rates improve the hospital’s bottom line. P arkwest M edical C enter : F ocusing on P atient and S taff S atisfaction 5 Lessons Learned For More Information With leadership support and improvement efforts, Contact Missy Sanford, director of clinical effective- Parkwest Medical Center has achieved relatively high ness and quality improvement, (865) 373-1951. levels of patient satisfaction. The alignment of staff and organizational goals and the reinforcement of out- standing performance are factors that appear to have shifted the organizational culture. Further, listening to and responding to patients’ concerns reassures patients that the hospital is paying attention to their needs and striving to deliver high-quality, well-coordinated care. Table. Parkwest HCAHPS Scores Compared with National Average Percent of patients who reported that: Parkwest National Average Their nurses “always” communicated well 83% 74% Their doctors “always” communicated well. 85% 80% They “always” received help as soon as they wanted. 70% 62% Their pain was “always” well controlled. 75% 68% Staff “always” explained about medicines before giving it to them. 67% 59% Their room and bathroom were “always” clean. 72% 69% The area around their room was “always” quiet at night. 69% 56% Yes, they were given information about what to do during their recovery at home. 80% 80% Gave their hospital an overall rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest). 79% 64% Yes, they would definitely recommend the hospital. 87% 68% Source: Hospital Compare (www.hospitalcompare.hhs.gov), based on surveys from patients with overnight stays from July 2007 to June 2008 (most recently available data). 6T he  C ommonwealth F und Appendix. Selection Methodology Selection of hospitals for inclusion in this case study series is based on data voluntarily submitted by hospitals to the Centers for Medicare and Medicaid Services (CMS). Between October 2006 and June 2007, hospitals or their sur- vey vendors sent a survey to a random sample of recently discharged patients, asking about aspects of their hospital experience. The survey instrument, called the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), was developed with funding from the Agency for Healthcare Research and Quality (AHRQ). CMS posts the data on the Hospital Compare Web site (www.hospitalcompare.hhs.gov). The survey contains several questions about nurse and physician communication, the physical environment, pain management, and whether the patient would recommend the hospital to family or friends. One question inquires about the patient’s overall experience: “Using any number from 0 to 10, where 0 is the worst hospital possi- ble and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?” HCAHPS is a relatively new survey, and hospitals across the country are not yet achieving very high scores across all of the questions. Nevertheless, some hospitals are scoring significantly better than others. By profiling hospitals that score within the top 5 percent (among those that submitted at least 300 surveys) on the question con- cerning overall experience, this case study series attempts to present factors and strategies that might contribute to and/or improve patient satisfaction. An initial list of top scorers among all hospitals submitting HCAHPS data contained a disproportionate num- ber of very small, southern hospitals.1 Concerned about the ability to generalize experiences and lessons and repli- cate strategies, we profiled one hospital from this list but chose to then examine high scorers among larger hospitals that were more diverse in: region of the country, urban/suburban/rural setting, and teaching/non-teaching status. We thought that such diversity would provide lessons that would be useful to a broader range of U.S. hospitals. Therefore, for this case study series, most hospitals were selected from among 736 large hospitals (300 or more beds), primarily based on their ranking in the percentage of survey respondents giving a 9 or 10 rating on the “overall” HCAHPS question. In the future, we will present case studies of hospitals of different size, ownership sta- tus (e.g., public, private), and other peer groupings. While high HCAHPS ranking was the primary criteria for selection in this series, the hospitals also had to meet the following criteria: ranked within the top half of hospitals in the U.S. on a composite of Health Quality Alliance process-of-care measures as reported to CMS; full accreditation by the Joint Commission; not an outlier in heart attack and/or heart failure mortality; no major recent violations or sanctions; and geographic diversity. 1 Further examination and analysis may reveal reasons for this. A bout the A uthor Jennifer N. Edwards, Dr.P.H., M.H.S., is a principal with Health Management Associates’ New York City office. Jennifer has worked for 20 years as a researcher and policy analyst at the state and national levels to design, evaluate, and improve health care coverage programs for vulnerable populations. She worked for four years as senior program officer at The Commonwealth Fund, directing the State Innovations program and the Health Care in New York City program. She has also worked in quality and patient safety at Memorial Sloan- Kettering Cancer Center, where she was instrumental in launching the hospital’s Patient Safety program. Jennifer earned a Doctor of Public Health degree at the University of Michigan and a Master of Health Science degree at Johns Hopkins University. A cknowledgments We wish to thank Missy Sanford for generously sharing her time and experiences with us. Editorial support was provided by Martha Hostetter. This study was based on publicly available information and self-reported data provided by the case study institution(s). The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund’s case studies series is not an endorsement by the Fund for receipt of health care from the institution. The aim of Commonwealth Fund–sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area of interest, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied institutions’ experience that will be helpful in their own efforts to become high performers. It is important to note, however, that even the best-performing organizations may fall short in some areas; doing well in one dimension of quality does not necessarily mean that the same level of quality will be achieved in other dimensions. Similarly, performance may vary from one year to the next. Thus, it is critical to adopt systematic approaches for improving quality and preventing harm to patients and staff.