Excellence in American hospital care is rare. It is common knowledge that many hospitals fall alarmingly short on safety, quality, effectiveness, patient satisfaction, and cost. As Mark Chassin wrote in Health Affairs, “quality and safety problems in health care continue to routinely result in harm to patients. Desired progress will not be achieved unless substantial changes are made to the way in which quality improvement is conducted.”
What exactly should those “substantial changes” look like? Hospitals seeking excellence are pursuing various paths, but the best documented and most comprehensive is the “Baldrige journey.” The journey requires submission of a 50 page “Application” to rigorously developed, structured “Criteria,” followed by thorough review and scoring by a team of trained judges. Almost half of the score is on results for patient care quality, patient satisfaction, worker satisfaction, and finances.
The very top scorers have usually been on the journey for several years. They are visited by a seven member audit team which spends a full five days on site, validating the response. The winners are obligated to publish their Applications, with some redacting of competitive information. Absolutely no information is ever released about other applicants.
Baldrige winners and others pursuing excellence share the following characteristics in which they:
- Use a multi-dimension scorecard, tracking and benchmarking their patient care quality, patient satisfaction, caregiver and worker satisfaction, and financial stability, with multiple measures for each dimension.
- Work carefully and steadily on improvement, and move closer to benchmark each year, performing substantially better than national averages.
- Build a responsive culture of “servant leadership” that requires all managers to spend an hour a day on the front lines, listening and responding effectively to all work-related concerns.
- Focus on worker satisfaction as the key to both quality and patient satisfaction, implementing a concept of “service excellence.”
National public data is now available on two scorecard dimensions, patient care quality and patient satisfaction. Summary quality measures of mortality, patient safety, and readmissions measure real setbacks, and there is substantial variation between hospitals. I suggest that the hospitals with the lowest ranks for mortality, safety, and readmissions are “lousy.” Patients should avoid them.
In two separate sets of data for hospitals in New Jersey and the five counties of New York City, the range of relative performance in each was more than 2 to 1 on mortality and 3 to 2 on safety, but only about 1.5 to 1 on readmissions. Mortality and safety are alarming; a patient is twice as likely to die and half again as likely to get hurt if they choose a “lousy” hospital. Many hospitals with low quality scores had low patient satisfaction scores as well, but many did not, suggesting that patients do not always know what’s best for them.
Repeated failure is the proper indicator: A hospital is “lousy” because it has failed to improve, not because it has encountered some bad luck. The proper action for the governing boards of these institutions is to choose from one of only three options initially described by GE CEO Jack Welch: “fix it, sell it, or close it.”
When queried, poor performing hospitals often make one of the following excuses:
“Our patients are sicker.” This is a recurring theme, something like Lake Woebegone’s children all above average. In fact, the measures have been carefully and thoroughly built to adjust for most variation in patients. Some of the nation’s top referral centers score very well. The right answer to “Our patients are sicker” is, “Really? Have you documented how that is so? We should report that to the measurement authorities for further study.”
“We’re short of staff.” These people have the cart before the horse. They’re short of staff because they’re a lousy hospital, not the other way around. When they make an honest effort to get better, they’ll attract and retain committed staff. Baldrige recipients and Magnet hospitals claim that they are “great places to get care” because they are “great places to give care.” Both document low workforce turnover and vacancy rates.
“We aren’t paid enough.” Hospitals such as Atlanticare in Atlantic City, Henry Ford in Detroit, Sharp in San Diego, and North Mississippi in Tupelo all work in challenging economic environments. They are all Baldrige winners. Maybe the “lousy” hospitals should study the public responses and start the Baldrige journey? It takes as little as three years to move from lousy to respectable or better.
As Welch suggests, the governing boards of these institutions should give management a year to “fix it,” that is, to make tangible improvement. Those hospitals that don’t improve should be merged with more effective managements or closed. And the other hospitals that fell short of benchmark on the public measures have fair warning. As other hospitals move forward, the bottom will only become more obvious.