CASE STUDY 7

Pursuing Excellence in Healthcare

South Tees Hospitals NHS Trust: Obstetrics Directorate

Fran Toller is the Divisional Manager of Women and Childrens Services at the South Tees Hospitals NHS Trust. Along with the rest of the Trust, the Division has been seriously engaged in the pursuit of excellence since the late 1990s, and they have made substantial progress on their journey. Fran and her colleagues have found a number of tools and approaches helpful as they have reviewed and improved their services, including the PROBE diagnostic tool, The Excellence Model and the Trusts approach to continuous improvement, which they have called Developing Excellence. Frans involvement began as the Developing Excellence programme began to roll out from corporate level to individual divisions. The Trust had done an assessment using The Excellence Model, and wed been involved in that. Now each division was to do an assessment. This Division had a history of being very willing to participate in new ideas, new ways of working, and there was a recognition within the Division that Obstetrics was ahead of the game in relation to willingness to change and to be change agents. We wanted to use Developing Excellence not just as a way of looking at the clinical process and outcomes, but also as a way of looking at the Model as a whole. Nobody had done that yet at corporate level, there was a leadership Trust-wide steering group, and there were Trust-wide steering groups on other things, but within divisions it was actually process review that was going on. So we picked up Developing Excellence and started to look at whether we could do things in different ways, and we made a lot of changes. We looked at leadership development, how we manage people, and so on - all of the way through the Models concepts. In February 1998, led by Fran, a team from Obstetrics became one of the first to use the PROBE tool in a healthcare setting. We didnt do PROBE because we wanted a base line to tell us how bad we were before we made improvements. We did it because we were already doing the work, and we genuinely thought we were a really good service - based on our clinical outcomes and clinical indicators, compared with what we felt was going on nationally in midwifery services. We wanted to benchmark ourselves, and we were looking for a model to help us do that. We thought of using The EFQM Excellence Model, but there would have been a lot of work involved in that. At that stage, we wanted something else that would be a bit easier to do. The PROBE Partnership had begun to collaborate with The Learning Alliance, an NHS-based team established to build capacity and capability for improvement, to test PROBEs applicability in Healthcare and to adapt the tool to this sectors needs. They were looking for people in the health sector to try PROBE, so we joined the pilot project. We picked a broad range of staff, from Health Care Assistants and Ward Clerks to Midwives, Consultants and Managers, and we went through the PROBE process. The results shocked us a bit. Once youve answered all of the questions, the feedback gives you overall scores for Practice and Performance. Our Performance score was quite a lot better than our Practice score, and the facilitator explained that this suggested that our performance might be vulnerable. This was a bit of a shock - we thought we were marvellous! And I actually still think that, at that point in time, compared to other units, we were marvellous. But what we were really good at was - somebody would come with an idea, they would give us the idea

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Pursuing Excellence in Healthcare: a case study

The James Cook University Hospital: Obstetrics Directorate

and we ran with it. But we had no baseline assessment, we had no proof that it had actually made a difference, we never did the full audit cycle. And then, hey presto, another idea came along, and we ran with that one. That was our philosophy - we just wanted to do things better, we were change agent daft! But we didnt have the policies, processes, back up audits, systems and procedures in place. Now I still think that doing all of those changes was right, because we could also be very critical if things came along that didnt make sense. If a change made a difference that gave poorer outcomes, we were very quick in going Cut it, get rid of it. But we werent very good when it didnt actually make any difference at all. We didnt have the proof to support what we were doing, and I think thats what put us in the vulnerable category at the time. And I think that was a lesson for us - we needed proof of what we were doing. We needed to demonstrate that it made a difference, and we needed to get better at completing the cycles and questioning some of the change. Sometimes you have to say Yes, its good, but its resource intensive and its actually not making any difference. After completing the PROBE process, we then picked up the Developing Excellence model on the back of that, better than we had done before. That was the model that we used as the focus for all of our improvement work. We did a massive review of everything we did not only from a process point of view, but also leadership, the way we managed the people, the way we dealt with our customers, and everything that went with that. And the outcomes that we expected to achieve. We linked in with what was going on corporately, but we equally did our own thing. We reviewed everyones job descriptions, we looked at the roles and responsibilities, we defined what the key competencies of roles were. We did lots of leadership development in relation to those roles, and set standards and expectations for those roles. We audited the staff on what they thought they wanted. Compared to the corporate approach, what we did was more focused on the delivery of the service, whereas I think the Trust looked more globally. But that was useful, because somebody like me got picked up in that process in terms of my own development. So, in some ways, our first PROBE in 1998 told us what Developing Excellence was already telling us, but it was a useful tool to actually point some things out to us. It allowed us to say Well the reason why were vulnerable is because were not backing it up with anything. Were just doing it and doing it and doing it, and running round like headless chickens. To sum it up, PROBE pointed us in the right direction of making us a little bit more completer-finishers. As well as overall scores for Practices and Performance, the teams PROBE assessment identified some specific areas as potential opportunities for improvement. Fran recalls that this was helpful, although at first the team experienced some difficulty in relating to some of the questions in quite the way that a private-sector business would relate to them including those questions which focus on the market for the services. One of the big things was financial performance, and particularly managing costs and value. And some of the dilemma that we really struggled with at the time and this was one of the little downsides that we felt with PROBE at that pilot stage, was that it was very business orientated. We found ourselves saying ...but we cant go out and say right we want more pregnant women, or we want less pregnant women, or we want to change the dependency of these women. We really struggled with that, and whilst it identified an area for improvement, we were very much saying Well, we cant do an awful lot about that. This is our business, and pregnancy is one of those things that are out of our control.

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Pursuing Excellence in Healthcare: a case study

The James Cook University Hospital: Obstetrics Directorate

So there were times when we wanted to say This doesnt apply to us, but the PROBE tool, because we had to put something in the box, made us push ourselves laterally. And maybe we wouldnt have done that without the tool. The experiences of the Obstetrics team, and others involved in the pilot project, have since been use to develop a tailored version called PROBE for Healthcare. The tailoring process has involved some changes in language and emphasis, designed to help healthcare-based teams to readily understand, relate to and learn from the questions that the tool poses. A careful balance is struck to ensure that PROBEs core principles of practice and performance, which are universal and generic, remain intact, thus retaining the opportunity for healthcare-based users of the tool to compare like-for-like with PROBEs 5,000+ worldwide participants in every imaginable type of organisation and sector of activity. The opportunities for healthcare teams to learn from others, and vice versa, are too important to be compromised. A positive side was that it helped us get our heads around the question Are we delivering some things that are actually adding no value? It made us start looking at some services that we provided, that really werent adding any value to the overall patient care process. We looked at things like parent craft, total number of antenatal visits, number of postnatal visits that were done, the way we managed high dependency and low dependency in women. We made lots of lots of clinical changes, looking at value of the service we provided. Customer satisfaction was highlighted as an area we should focus on. At that time we believed we were good in this area - we did these ad hoc little customer satisfaction surveys. But PROBE was asking for regular and ongoing feedback. We didnt have any consistent evidence. In fact at that point, if I remember rightly, we had evidence that would suggest the opposite and we had nothing to counter balance it. The level of complaints was fairly high we knew that nationally the level of complaints in maternity was high, and litigation too, but we had nothing to compare it with. To be fair, the whole NHS has moved on a lot in this area since 1998. We now run annual customer satisfaction surveys. You cant just wait for people to complain. As well as substantially reducing the number of complaints received, and becoming much more proactive in measuring satisfaction, the Division has also involved its customers in many aspects of their service improvements. Customers have contributed directly to the redesign of schemes, in improving patient information and the introduction of patient held records. Customers have taken on a whole meaning of their own, and thats now supported by Department of Healths emphasis on patient and public involvement, and in the governance agenda. But, to be fair, we had started before that process was in place. Some of the challenges that PROBE issued to the team provoked the reaction But that is the Trusts responsibility. Some of the issues were out of our control really, because they were very much dictated by the Trust. But we said to ourselves But they dont have to be. We have to do what the Trust wants, but we can add on to that. And thats what weve done, weve added on rather than blaming corporately. And I would say that if you were using PROBE with other people, where its a section of an organisation, that is quite hard. Its about getting people to realise that they can influence, and asking them So why havent you influenced? And why havent you done it anyway? If you really

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Pursuing Excellence in Healthcare: a case study

The James Cook University Hospital: Obstetrics Directorate

think its a gap and its doable within your service, why are you waiting for someone to tell you to do it? Another area highlighted for attention was setting explicit service standards. We now know that before you implement a change, you have to ask: What are we expecting as the outcomes? Are we going to measure whether its useful? How are we going to manage that process? We never did that before we did PROBE in 1998. We just did it, and went on gut instinct about whether it was good or not. We have totally changed that around. For example, I have a full filing cabinet of evidence from when we did the Developing Excellence visioning exercise. And that has been very useful when weve been externally as s es s ed. The Trus t has had a CHA I assessment [CHAI is the Commission for Healthcare Audit and Inspection also known as The Healthcare Commission]. Maternity was one of the areas that were picked for that CHAI assessment, and we did very well in it, because we did have the evidence, and we had worked collaboratively, and we did have policies and protocols, and expected outcomes, and so on. So, yes, the key opportunities for improvement identified by that first PROBE have definitely been acted upon. Looking back, we were not a bad organisation, but we were very nave when we did that benchmark. And very nave in understanding what you needed to do to back up and monitor everything that you did. And I think that, if we went back in time, with the knowledge that weve got today, the scores might actually have been lower. Because I think were much more critical of ourselves than we were at that point in time. We were on a learning curve, and PROBE has assisted in that learning curve, it was part of the picture. But it wasnt the only thing, and I think if you use it as the only thing youre just going to be doing it by numbers, and that is not what it is all about. You cant look at the tool and say Right, it tells us that we have to look at business performance now what does that mean? And lets tick that box off, weve done that. It is about how that interplays with everything else that youre doing, and where your priorities are. For example, you might score very low on something, but its also about saying as a service we can live with that being low. Whilst we scored high in another section, but its not high enough because thats really where our standards should be. Customer satisfaction would be one of those things for us, and understanding our customer - understanding what makes them happy, what gives them good outcomes, what they want to get from the service. This wasnt our worst score in the whole benchmarking exercise, but it was the score that should have been the best. I think youve got to ask yourselves: What is our service all about? Where are we going? What are our priorities? Whats absolutely fundamental to be good at? And what do we need to be fairly good at to support that?

We werent yet at that level when we did that first PROBE not at all. I think if anybodys going to use PROBE and think its going to be the answer to their prayers and tell them everywhere that they need to improve well, it isnt! Its a tool, thats all, a tool to assist. But it does allow you to start seeing where your

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Pursuing Excellence in Healthcare: a case study

The James Cook University Hospital: Obstetrics Directorate

weaknesses are, and where you need to put your effort. And it offers an opportunity to listen to other ways of describing your service. As Ive said, we had difficulties getting our heads around some of the questions. But, because the question was there, the debate occurred. And that was helpful in the long run. In common with many other teams who have used tools like PROBE and The Excellence Model, Fran and her colleagues found themselves confronting some fundamental questions that the process brought out into the open. We had to ask ourselves Who are our customers? And we struggled with that for a long, long time. We said they were GPs, they were internal, they were this, they were that, they were the other. And we did that immediately after we completed PROBE saying we have all of these people and we have to engage them all. We now say our customers are the patients. Theyre the patients who receive the service from us. We are working in collaboration with other partners to provide that service, and the other people are our partners, they are not our customers. I think that ultimate decision to say Its only patients is right, because we cant govern who holds the money, who holds the purse strings, whos the purchaser, whos the provider. We are a service provider and our customer in the provision of that service is the patient. But it took us three years to get to that point! The Divisions management team were pleasantly surprised by some aspects of the PROBE process, and saw them as unexpected benefits. One of the real successes out of the process was that we took a multi disciplinary group into a meeting, and asked some really nitty, gritty things about the way staff were managed and the way patients were managed, and I thought the staff would absolutely slate it. I really thought we had a good service, and most people thought we had a good service, but when we were asking such nitty, gritty questions, I thought they might slate it. But they didnt. They were really arguing strongly to be scored high, and it was actually us, the managers, who were saying The tool is not saying were not doing it, but we havent got the evidence of doing it. And it was us having to bring them back down, rather than the other way around. And of course none of thats visible in the result. In our case, the staffs loyalty, and their commitment to the service, was quite surprising. I guess if it was the other way, whilst it would be a bit shocking, it would be important to know that because how do you start off managing change with a group of staff who think youre really naff? Whereas our staff didnt. We were starting off with staff who thought we were absolutely marvellous, and we were saying Right, but we need to make ourselves more marvellous then, and we need to prove that were marvellous. And that was quite a good starting point for us really.

The Obstetrics Directorate decided to repeat their use of PROBE three years on from the first time, in March 2001. This time around, the overall scores were substantially improved, particularly the Practice score, to the extent that the suggestion of vulnerability had been completely turned on its head this time, the picture that emerged was of a Practice-led organisation that was in PROBEs contender category, clearly progressing along the journey towards excellence. Wed done an awful lot of work in the meantime, within the Developing Excellence framework. The strengths identified in the second PROBE report reflected that work - around leadership, people management and some other areas. The difference in the scores seemed right. We were able to say Right we have that, we have that, we

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Pursuing Excellence in Healthcare: a case study

The James Cook University Hospital: Obstetrics Directorate

do that, there it is And we had other ways of assessing ourselves that we were doing, that were giving us the same answers. There were still some areas for improvement, or course. We were still talking about customer relationships, still at that time quibbling over who our customer was. And doing PROBE the second time was the catalyst to say Look, this is ridiculous, our customer is the patient. There were other things in the outcome that we still werent so brilliant at such as the Use of Information Technology. At that point in time we were very much driven by The Centre in terms of what we could get from IT, what was available to us, how we could access it. I would say that the NHS has moved on a lot since then, in terms of IT. We now find that, because we have our act together, were very clear about what we expect from service providers in IT terms, and have been able to pursue that and to influence it. Some of the other things that were highlighted the second time, we have been able to achieve. One was well communicated standards. We had standards, but they were sitting on the shelf, not everybody knew about them, not everybody understood them and what they were driving for. I think now this is in place. It has had to be, because we have to achieve CNST status. CNST is the Clinical Negligence Scheme for Trusts. Its an assessment, and Maternity gets assessed separately, and there are loads of standards in there that you have to prove and have the evidence for. Part of CNST is that all the staff know about the standards, we work collaboratively, things are visible, and so on. And the CHAI process has pushed us down that route as well. And that debate, in getting that evidence together, has made us be much more explicit with staff about the service standards and so on. The experience of using PROBE a second time seems to have reinforced Frans perception of its usefulness. It has also provoked some deep thinking about how an organisation progresses and improves, and how this is reflected in an excellence-based assessment like PROBE. And, specifically, about the desirability of reaching the point where both Practice and Performance scores exceed 80% of the maximum possible, in which case the headline PROBE feedback graph would show the organisation in the top right-hand corner, and designate them as World Class. Every time you do it, it moves you on, but for me its not about getting in that top right hand box. If we did another assessment now and probably the timing is right to do that, because its another three to four years on we might actually score ourselves very much the same. That wouldnt be because we havent moved, it would be because our criticism of ourselves is at a higher level. Thats another thing with benchmarking - the more you do, the more you can see that there is to do, and the more critical you get that youre not doing it. I guess thats another use of benchmarking, that it allows you to ground yourself again and say Well we are better, and yes we have done that, and yes we have got that, and no we havent actually picked that up as an issue. You do get much more critical of yourselves. Definitely as a managerial and leadership team we demand much more of everybody. In fact, weve had that debate recently over things like leadership competency and difficulty in filling posts. It is difficult to get people into these posts when our level of expectation is so high. Do we have to actually come down a bit in our expectations, and develop people up to that level? When we first did PROBE in 1998, we would have liked to be in top right hand corner. Now, I would be very worried if we were scoring that highly. Id think Whos going to come and ask us wheres the evidence? Are we absolutely hand-on-heart sure? We would be very critical of every answer now. Id be frightened to death to

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Pursuing Excellence in Healthcare: a case study

The James Cook University Hospital: Obstetrics Directorate

be in the top right hand corner, because it would say were there and I dont think anyones ever there really. Since 2001, the improvement work has continued, of course, and the Division has also exposed itself to external scrutiny in several other ways. We submitted an entry for the North East Excellence Awards (a regional awards process based on assessment against The EFQM Excellence Model). We were short listed, and in the end we were a runner up for that. Our Maternity Day Unit has achieved Developmental Unit status. We did the level one CNST assessment in 2004, and well do level two in February next year. And were looking beyond that, and thinking about Charter Mark, because we feel that thats probably orientated to the service. Weve also got what we call baby friendly initiative, which is a breast feeding accolade. Thats an assessment where the patients are asked what they think, the policies and protocols are looked at, and the leadership, how its developed, how the staff are trained and everything. So its actually the same principles as Developing Excellence and the questions that are asked in PROBE, but on one defined subject matter. We were monitored by the National Baby Friendly initiative, and we were one of the few Trusts in the North East to get that award. And I think thats just indicative of where we are now - for something as fundamental as breast feeding we can go and get an award for it, because weve got the systems processes, procedures, training, leadership etc in place. But we still have a mountain to climb, because the mountains moving all the time, isnt it? Fran has kindly given her permission for these experiences to be written up and made available, so that others who are considering using PROBE in healthcare settings can make better-informed decisions about its suitability for their purposes. So what advice would she offer to someone who is asking Should I use PROBE? Well, the first thing I would do is to ask some questions: What are you using is for? What do you want to get out of it? How would you expect to use the results that you would get? Where are your areas of concern before you start? What do you think you do well, and what do you think you dont do well? And why would you think you do those things well, or not so well, and would you have evidence?

After getting those answers, if I felt that the person was using it for the right reasons, I would say that its a tool not to be used in isolation. It gives you some fundamental ideas that should help you reinforce where you think youre coming from, and help you drive the changes that you want, and point you in the right direction. But if you think that using the PROBE tool is going to give you all the answers, it wont. It will actually raise more questions than it will give you answers. And then its about how you will use the opportunity to create a forum for discussion, to have those questions discussed and answered for yourselves. And when youre answering the questions in the tool, be honest. There are no rewards for telling lies. You can tell lies to get a good outcome, but at the end of the day, when someone like CHAI walks in the door, theyll say Youve said youre doing that, that and that but theres no evidence of that. So I guess that would be another question to ask up front Who are you using it for? Are you doing it because youre told to do it? Or using it because you really want to make a change?

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Pursuing Excellence in Healthcare: a case study

The James Cook University Hospital: Obstetrics Directorate

If you use the tool more than once, it really can give you something that says youve put all this effort in and can help you to see that things are better. It also gives you a comparison with where other people are up to, which you dont always get. You can say Well, we think were better, but the whole world might have got better at the same time. If wed never found PROBE and used it, I think wed have found another way to do the job. We needed to look at where we were coming from, and monitor ourselves on what did we need to do to make ourselves better. I think the difference, if you look at The Excellence Model for example, is that its a much more holistic model, and its got a lot of detail in it. PROBE gives you something very pictorial, so you can see where you are and identify aspects that look low and others that look high, and ask Whats going on there? So its very easy visually. And then you get a lot of information afterwards. But if you look at something like our portfolio that we submitted for the North East Excellence Award, it was mammoth, and it included a lot of contextualisation and evidence etc. So you could argue that PROBE is quite user-friendly from that point of view. But different things turn different people on. Some people want detail, detail, detail; but other people would say I couldnt possibly read that 300 page document to understand where we are going wrong - give me a summary. Others want to hear Theres a graph, now you tell me where you think the areas for improvement are... So I think PROBE is just another thing that helps you to reinforce the messages you are trying to give your team, and to hit the buttons for different people who are coming from different points of view. And for some people within your team for example, if you look at consultants who tend to be very audit- and benchmark- orientated if you say to them My gut feel is so and so, theyll ask Wheres your evidence. PROBE can help you to say Well, heres my evidence. If we hadnt had any tool of choice, I personally believe we would have got there anyway, but we might not have been as questioning about things like business performance. One other situation to think about is if youre a manager and youre struggling with turning people on, and yet you can see the problems. Particularly if youve come from outside and into a new posting, and people are entrenched. A tool like PROBE actually gives you something that helps you to sit and talk to your team about the services. Irrespective of the outcome, its a tool to get people in a room and start to open up the debate about your service. Say for example if you look at something like understanding your customers and theyre saying Well, we havent got a problem, and the patients love us, and we hardly get any complaints and we get loads of thank you cards. The tool allows you to sit down and say Ok, lets have a look at what is says in here. Have we got this? Have we got that? Have we got the other? Where would the evidence be? If I asked you tomorrow for the evidence, would it be there? And it helps you to get into hard questions like How reliable is a customer thank you card? Have you ever had a thank you card but then got a complaint from the same patient? It allows you, I think, to have something tangible to discuss and open the level of debate with a team thats maybe reluctant to change.

CASE STUDY 8 Process improvements boost patient satisfaction and quality at Stanford University Hospital Sharon Flynn Hollander, Laurel Gunderson & Jody Mechanic
Over the past several years, Stanford University Hospital has implemented a multi-faceted response to the healthcare economic crisis. In the January 1993 issue, this publication described wide-ranging restructuring initiatives that resulted in substantial reductions in costs, and these efforts are ongoing. As a parallel to those efforts, and their logical outgrowth, we are using process-management strategies to get at the specifics of quality and cost-effectiveness in our patient-care activities. Like many institutions, we have initiated many quality improvement efforts in the past decadesome more effective and long-lasting than others. Those that were good sparked dramatic service improvements in some parts of the hospital. Others were little more than big talk campaigns that roused a lot of emotion among employees, but really did very little to produce the changes we needed. What our older quality efforts have had in common was a lack of breadth and continuity. One program might develop an idea that would take care of a problem in one specific area, but it didnt fit in anywhere else. We didnt know how to integrate or coordinate these efforts. To solve this problem we decided to use a processmanagement approach to coordinate all our quality initiatives around the goal of moving the organization toward patient-centered care. Significantly, although Stanford University Hospital has cut $50 million from the budget over the past four years, our patient satisfaction ratings have never been higher. We attribute this accomplishment directly to the TQM and process-management efforts, and specifically to four aspects that changed the way we previously thought of quality management. This process: Challenged us to think through the identity of the hospitals customers, both internal and external. Increased the amount of feedback to caregivers on concerns expressed by our patients. Forced us to use quantitative measures to control and evaluate the effectiveness of routine sub-processes. Kept us accountable and focused on our mission with regularly scheduled review sessions.

A walk through
With support from top management, a PatientCentered Care Team (PCCT) brought together managers from all areas of the hospital. Under the direction of our consultants, Shaw Resources, the team decided to limit its work initially to those processes that directly involve patient care, eliminating such behind-the-scenes functions as data processing. We also narrowed our focus to inpatient hospital care; outpatient processes will be tackled at a later date. The Patient-Centered Care Team then did something that we had never considered beforewe walked through a typical hospital experience, from admission to discharge, from the patients point of view. We supplemented our biweekly meetings with outside reading assignments and information gathered in videotaped focus groups with former patients.

What our quality efforts had in common was a lack of breadth and continuity.
It was a startling experience. The Customer-Supplier Process Model (see chart, page 3) used by Shaw Resources as a template for our work forced us to look at our organization from a totally new perspective. We began analyzing processes through the eyes of the patient, rather than from our own experience or knowledge of what was efficient or cost-effective.

The next step was to identify specific areas to address through separate process management teams of the Patient-Centered Care Team. We chose to concentrate in this first phase on the following processes and we launched one team per month until all seven were up and running: Admit Patient Provide Laboratory Support Provide Hotel Services Provide Patient/Family Support Manage Patient Care Provide Diagnostic & Treatment Support Management Complaints A process owner was identified for each team (based on who had the most resources and was most accountable for that process) and that individual selected appropriate people to serve. Team members set the agenda and frequency of meetings. After a team has been in operation for a while, members report back on their work and results to the Patient-Centered Care Team at six-month intervals. The accountability of these report-back sessions is integral to the forward movement of each team. In addition, these report sessions have offered an opportunity for collaborative problem solving by top administrators. Any early fears we had about team members becoming too focused on boxes and circles of a process flow-chart were dismantled when the report-back sessions started. The Patient-Centered Care Team keeps its focus on the big picture and the individual teams concentrate on the details of measurement, change, and improvement. All of the teams have experienced breakthrough insights in identifying customers and customer expectations, and using measurements that quantify change. Described here are examples from the Manage Patient Care Team and the Provide Diagnostic & Treatment Support Team.

we quickly learned that patients have different expectations and definitions of quality than we do as healthcare providers. The Manage Patient Care Team is different from all others because its members are homogenousall are RNs with similar education, professional experience, job responsibilities, problems, and the same manager, Zimmerman, who is also the process owner of this team. In many ways, this homogeneity allowed the group to coalesce and move into action quickly. The Manage Patient Care Team asked nurse managers to proactively collect patient complaints based on defined quality measurements. This was a difficult transition for many of us, Zimmerman says. No one wants to hear a complaint and it took a great deal of effort to convince units that there would be no shame attached to having a high number of complaints. In a two-month period, managers of ten general medicalsurgical units gathered 178 documented complaints.

We didnt expect that patients would be dissatisfied with nursing care. We were Wrong!
There were more complaints than we anticipated, and we didnt expect that patients would be dissatisfied with nursing care, Zimmerman says. We were wrong. The number one complaint was related to nursing care, followed by an uncaring attitude from caregivers, call light response time, and response time to requests for pain medication.

Responding to complaints
In addition to collecting patient complaints, the members selected as a starting point two processes that are very important to the patientspain medication delivery time and call button response time. The team discovered that, typically, patients were being supplied with pain medication within 4.5 minutes of their request, but that this respectable number was averaged from a wide range of response times. More study showed that the delay almost universally was caused when no pain medication appeared on orders after surgery. The nurse had to locate the physician and obtain a pain medication protocol before any drug could be obtained or administered. This could be a timeconsuming process.

Understanding patient expectations

Patients have high expectations when they come to Stanford University Hospital, comments Joann Zimmerman, assistant director of nursing for medical/surgical. They expect expert care and take for granted the technology or experimental drugs that might save their lives. But if their meal is left on a table just outside their reach from the bed, or if it takes ten minutes before someone responds to their call bell, they are highly critical. From our point of view, we were providing quality care. But

As a result of these findings, doctors orders on all patients admitted to general medical-surgical units are now scanned when the patient arrives to see if a pain medication protocol is indicated. If none is noted, the physician is contacted at this pointbefore the patient is in pain and requesting medication. Reducing call button response time is a lengthier, more involved challenge. According to our previous research, we knew we answered 95 percent of all call lights within one minute. What we didnt realize was that answer had a different definition to us than it did to the patient. We were pleased to be able to say that within 60 seconds, a patient pushing a call light could expect to hear a clerk respond with a reassuring The nurse will be right with you. But from the patients point of view, the call light was not answered until someone appeared in the room, which could be as much as ten to 15 minutes later. The team decided that the best way to adapt this process to fit the patients expectations is to train clerks to categorize call lights (elimination, pain med, comfort, etc.) and then give patients a more realistic time estimate of when their need or request will be met. For example, a patient with a low-priority request in the comfort category will be told The nurse will be there in five minutes so that he or she wont be expecting someone to pop in the door within seconds. Soon, the nurses beepers will be coded so that they

know immediately what patients needs are by category and, therefore, how quickly they need to respond. Weve always measured our quality by the standards of the healthcare professionals, not by the measures of patients, adds Zimmerman. It was the caregivers agenda, not the patients agenda. Through process management, we got a different viewpoint on what we have taken for granted. Nurse managers now make rounds three to five times per week to interview patients about the quality of care. Constant and consistent communication is nipping off minor annoyances before they have time to bud into major problems, and the patient inputs become valued information for the Manage Patient Care Team to study.

Unexpected results
Meanwhile, members of the Provide Diagnostic & Treatment Support Team were getting acquainted. This group brings together managers of several nursing units and departments that provide diagnostic and treatment servicesthe cath-angio lab, the cardiology lab, dialysis, endoscopy, nuclear medicine, the pharmacy, the pulmonary/blood gas lab, the neuro lab, radiation oncology, radiology, rehabilitation services, and respiratory therapy.

Many of these people didnt know each other and we had to spend a great deal of time identifying the common threads in our respective areas, says Judy Lanigan, process owner of the Provide Diagnostic & Treatment Support Team and assistant director of nursing for ambulatory/psychiatry. Once we used the template (see chart, below) to create flow-charts of the processes in each department, we could see the similarities. We were all surprised at the parallels and at how interdependent we are. I think one reason that our previous quality efforts have not been the solutions we hoped for is that they tried to solve problems within the confines of one department, she adds. Once we saw the flow-charts it was clear to us that this would not work. Patients move from one area to another and they dont care that they may have crossed an organizational boundary. They judge their total experience in the hospital. This was even more dramatic when we took the additional step of completing a flow-chart from the patients perspective. The team has identified numerous areas for further improvement and measurement. Some of these are: (1) patient transport; (2) clarification of physicians orders; and (3) turnaround time of reports to physicians.

Simultaneous with the patient-centered care efforts at Stanford was a move to decentralize support services to the point of care. This major organizational change, which was initiated earlier as part of our cost-reduction programs, enhanced the work of the process management teams and helped boost our patient satisfaction ratings. For example, studies showed that patient treatments were often delayed while supplies were delivered to the unit. Now the hospital has a mini-supply room on each floor, controlled by a state-of-the-art computerized inventory and tracking system. We can now guarantee that supplies will be available within five minutes.

Support service assistants

Another structural shift was the merger of housekeeping and transportation personnel and the decentralization of these services. Stanford Hospital now has support service assistants (SSAs) assigned to each unit to provide housekeeping and transport services. The same employee cleans a patients room, takes him or her to X-ray, and delivers meals. The contributions to patient-centered care have been enormous: It has reduced the number of faces a patient sees in the course of a day. (Too many interactions from too many different peoplea high probability at a teaching hospitalare a major source of patient complaints.) It personalizes the service patients do receive. It is not housekeeping that is making their rooms spotlessits Rose, or Jose, or Mike. It has given the SSAs more feelings of connection and ownership for doing a good job. They see immediately how their jobs affect patient care. Hours of training, coaching, and preaching about the importance of prompt service cannot equal the impact of seeing for themselves how a patient feels to sit and wait for a wheelchair. It has saved money by eliminating a second layer of supervision. SSAs report to the nurse manager in the unit. The introduction of SSAs and decentralization has not been without challenges. Nurse managers were unaccustomed to hiring and supervising this level of personnel and needed additional training. Previously, these support employees were distanced from the patients and had little direct contact with them. Now they

Before I never thought about why a room was empty. My job was to clean. Now I know that Room 304 is empty because Mrs. Smith has died.
Already, minor process improvements are showing results. Reminder calls to outpatients about their appointments in the cardiology lab have limited late arrivals to one since March of 1993. Routine surveys of patients before and after respiratory therapy treatments sparked a new policy of re-orientation for professional staff that has been gone on leave. Patients can spot when a caregiver is not at ease working with new equipment, Lanigan explains. This discomfort is jarring to the patients expectations of what the treatment experience should be like. By interviewing respiratory therapy patients we discovered this had occurred when someone had been on leave for a while and new equipment had arrived during that period. The respiratory therapy department subsequently changed its process to check off returning staff on familiarity with new equipment or procedures.

deliver their services bedside and get to know patients by name and faceand they care about the outcomes. Before I never thought about why a room was empty. My job was to clean. Now I know that Room 304 is empty because Mrs. Smith has died. SSAs now receive training and counseling on death and dying.

and everyone connected with the hospital-physicians, staff, and most of all, patientsis benefiting.

Next steps
As the process management teams continue their work, the Patient-Centered Care Team is wrestling with how to attack our next set of challenges. We have identified three next steps: Educate staff on the process management methodology, especially the value of complaints in improving patient-centered care. Currently, process management teams involve fewer than 100 of the approximately 4,700 employees of the hospital. Training needs to take a variety of forms and levels of depth to accommodate the diverse range of educational levels, cultural backgrounds, and licensed and non-licensed positions. Continue to effectively manage the overwhelming amount of data available to the process management teams. Unlike some organizations, a hospital already has a wealth of information recorded. The challenge is to analyze it productively and feed it back to employees in a way that is meaningful and produces change and improvement. Devise reward systems that are valued by our people. In the 90s a reward for a job well done no longer necessarily needs to be money. Many employees prefer a flexible schedule or an extra day off to a bonus in the next paycheck. Dovetail patient-centered care activities with process management. There are no quick fixes in a healthcare organization our problems are too complex, our issues too critical to the well being of our patients. But process management has pointed us all in the same direction with the same goal in mind. We are seeing real change and real results that will be long-lasting because they are altering the core infrastructure of our organization. Outstanding performance and patient-centered care are not based on how many resources you have but on the quality of your leadership, says Zimmerman. Process management has taken our leadership skills up a notch

TQM Case Studies

The Case of TQM and Innovation.. .......................... ................................................................1

Bharti Broadband saves with Six Sigma........................................................................................6

Case studies by Niraj Goyal

Newspaper Focuses on Customer Service..........................................................................8 Reducing IT User Downtime Using TQM............................................................15 Fixing Payroll Problems: A TQM Case Study in Human Resources........................................21 Improving Financial Services Through TQM: A Case Study...................27 South Tees Hospitals NHS Trust: Obstetrics Directorate ..................................33 Process improvements boost patient satisfaction and quality at Stanford University Hospital.41 References..46

REFERENCES http://archives.digitaltoday.in/businesstoday/22031999/case.html http://www.expresscomputeronline.com/20041011/casestudies16.shtml www.isixsigma.com www.comparisonintl.com/ www.ShawResources.com