How do you identify and make quality improvement changes that matter?
Use of Shaw Resource's "customer-inspired^®" quality methodology leads to two statewide quality awards 
for St. Johns Hospitals

ADOBE PDF Version

Like many hospitals in the early '90s, the two St. Johns Hospitals in Ventura County, California-assembled multi-disciplinary improvement teams as a step towards improving quality. And like many similar attempts in well-intentioned organizations, the teams floundered because they lacked a systematic way to identify, analyze, eliminate and prevent problems. Initial enthusiasm waned as team members became discouraged about investing so much time with what seemed to be sporadic, temporary results.

By 1997, the situation had changed dramatically - so much so that St. Johns Hospitals won two statewide quality awards: a "best-in-class" bronze designation from the California Council for Quality & Service and the Governor's Golden State Quality Award for Community from the California Center for Quality, Education, and Development. Both awards are aligned with the criteria of the prestigious U.S. Malcolm Baldrige National Quality Award program. What made the difference? A lot of hard work by St. Johns staff...and Shaw Resources.

Finding customer focus made the difference
"Healthcare must be more customer focused because it is becoming more market driven," says Dan Herlinger, president and CEO of Catholic Healthcare West (CHW) Central Coast, which encompasses four hospitals. "Jim Shaw demonstrated to us that every one of our activities could be adapted to a customer-inspired^® quality improvement approach. Using his methodology made our teams more effective, more focused, and more results oriented." Peter Haggerty, director of laboratory, cardiology, and neurodiagnostics, agrees. "Before we were introduced to the Shaw Resources methodology, we were flying by the seat of our pants -trying to solve problems at the point they showed up rather than identifying root causes and preventing problems from occurring. That limits results."

The Shaw Resources patent-pending model for continuous process improvement, called Customer-Inspired Process Deployment^®, identifies customers and their expectations, defines key processes, sets up effective process improvement teams, and establishes quantifiable measures to evaluate improvement. The methodology focuses on prevention by rethinking process activities to eliminate the real sources of problems and customer dissatisfaction. Shaw Resources helps the teams along the way with consultation, training, coaching, and the use of the firm's proprietary software program, Process Advisor™. Central to Shaw's methodology is the belief that only customers can define quality and that to be successful, an organization must meet and exceed customer expectations. The first step-and often the most difficult-is to identify and define key processes according to customer perceptions, not what management thinks is important to customers. St. Johns started with the three processes customers listed as most in need of improvement: responding to complaints, the emergency department, and diagnostic testing. Additional teams were added slowly and now St. Johns has 22 teams focused on a different key processes. "I'm impressed with how much progress we've made in a short period of time," says Bill Clearwater, vice president and site administrator of St. Johns Pleasant Valley Hospital. "Our activities are much more focused and directed at making actual improvements. It is gratifying to see us making quality changes that are visible and measurable."

Staff become motivated and "jump in with both feet"
"There's been a lot more buy-in from staff since we started using the Shaw methodology," he adds. "They've jumped in with both feet and are active, motivated and excited about new and innovative ideas."

One way the Shaw methodology contributes to staff involvement is the use of permanent cross-level, cross-functional teams to tackle specific areas for improvement.

"Previously we had what we called 'self-directed leadership teams' that were trying to employ standard TQM (total quality management) and process improvement techniques, but we were only able to change operations within our own departments," says Vicki Lemmon, director of nursing. "We were working in isolation."

The Shaw methodology assembles teams around a process defined as the customer perceives it, not how it appears on the organization chart.

We can't directly tie these bottomline results to process improvements but we . . . are instituting changes that make a difference to "You learn so much more when you are sitting with people who represent other aspects of a specific process," Lemmon says. "You begin to understand that a decision in one department may create more steps in the process in another department or it may change things so that another group is no longer in compliance with standards they need to maintain. It may be a quality improvement for us, but it plays havoc in other parts of the organization."

"Our volume went up 12% last year and we are attracting new physicians.

We can't directly tie these bottomline results to process improvements but we . . . are instituting changes that make a difference to customer satisfaction and employee morale."

Unlike many healthcare organizations which often focus their quality improvement programs on patients, St. Johns followed Shaw's advice to consider the needs of all customers inside and outside the organization. This means including some not traditionally thought of as "customers," such as physicians, families of patients, and payors. St. Johns identified physicians as a top priority and the hospital initiated a comprehensive complaint system for M.D.s to register their concerns. "They are our suppliers and partners in giving healthcare," says Dr. Ross DiBernardo, vice president of medical affairs. "The complaint system we started for physicians gives them the opportunity to communicate their concerns in a convenient, user friendly way."

Physician complaint system based on M.D. preferences
St. Johns was not the first hospital to launch a physician complaint system, and its team was very much aware that programs in other hospitals had failed. Other facilities were interviewed about why their efforts didn't work, and team members surveyed a sample of St. Johns' own physicians about their preferences. "No physician is going to take the time to sit down and fill out a complaint form," Dr. DiBernardo explains, "but they will make a call to convey their frustration. We use a voice mailbox that's available 24 hours a day, seven days a week to record their complaints, and we acknowledge their comments in writing within one working day." Physicians receive a final report on the disposition of the complaint within three weeks of their original call, and a follow-up card is sent asking if the physician was satisfied with the complaint process. A "no" answer gets a personal follow-up call from Dr. DiBernardo. Our patient volume went up 12% and we are attracting new physicians," Dr. DiBernardo says. "We can't directly tie these bottomline results to process improvements but we can say process improvement is responsible for better communication up and down the organization. Senior management has a much clearer idea about how work is done in the organization and we are instituting changes that make a difference to customer satisfaction and employee morale."

"A complaint is a customer giving us a second chance to make the situation right."

Dealing more effectively with complaints - whether they emanate from physicians, patients, or others-is one of the organization's most significant accomplishments since working with Shaw Resources, according to Herlinger.

"It is a major shift in the culture of the organization to begin to look at complaints as valuable feedback rather than something we are defensive about or want to sweep under the rug," says Herlinger. "But a complaint is a customer giving us a second chance to make the situation right. Shaw calls complaints 'nuggets of gold,' and we have found them to be that valuable."

Analysis of call light response time reveals undetected problem
A common patient complaint in most medical facilities is how long it takes hospital staff to respond to call lights. When a patient is in pain or needs a bed pan, even a few minutes can feel like an eternity. When hospitals launch a quality improvement effort, improving call light response time is frequently at the top of the list.

St. Johns was no different - except in what it discovered.

"When patients complain that it is taking too long to get a response to their call lights, it's easy to assume there is a staff performance problem," Clearwater says. "The Shaw methodology forces you to put aside assumptions and not to jump to conclusions, but to gather and analyze data. In the past we might have addressed this situation by training the staff. Instead, when we followed the methodology and gathered measurable data we discovered a mechanical problem in the call light system was causing a delay between the time a patient pushed the button and when staff received notification.

"Once we knew the glitch was there, it was easy to fix, but we probably would never have found it otherwise," he says. "We would have just gone along assuming that staff needed to do a better job in monitoring and responding to the lights, while staff would be frustrated at the continued complaints because they were doing the best job they could."

Patient transport issue is "gigantic"and affects multiple departments
Another prickly topic that frequently surfaces in healthcare organizations is patient transport - the need to have patients moved from one area of the hospital to another in a way that meets scheduling demands of several departments and is comfortable and reassuring to the patient.

"Patient transport is one of those gigantic issues where the easiest solution may seem to be to add more staff," says Haggerty. "But we wouldn't stay in business long if we did that every time a problem comes up."

The "improve inpatient diagnostic testing" team took on the challenge of examining and rethinking the decentralized transportation system that wasn't working well. The team followed the Shaw methodology including cause-and-effect and root cause analysis focused on eliminating the source of problems, benchmarking, and two-dimensional flowcharting. After looking at all the issues that needed to change and working up a detailed financial analysis, the team recommended that St. Johns switch to a centralized transport system that is automated.

"We were receiving department and physician complaints that patients were not arriving on time," Haggerty says. "Every late transport delays exams and treatments not only for that patient, but for others that follow. With the Shaw methodology we were able to see what was going on in several departments and what needed to happen to make patient transport work smoothly for everyone."

Software helps to calculate scores to compare "apples and oranges"
The Process Improvement Council reviews each team in detail every six months. Each team grades its own progress using qualification standards based on a detailed checklist. During the formal review, the team explains its progress and projects its next activity and qualification rating. Shaw Resources' Process Advisor software helps the team compute its qualification score. The software incorporates a checklist of more than 75 items organized into six levels of accomplishment.

For example, a team might say it is 10% of the way towards completing a task because it has started a flow chart of the process or established a data collection system. Typical scores after two years of work might range from 4.8 to 5.3.

The ratings are useful in comparing "apples to oranges" when it comes to different processes. The organization can compare the process improvement scores of payroll and critical care independent of the work content.

Shaw Resources concepts and techniques shared inside and outside the organization
Employees at St. Johns are also using the Shaw Resources methodology on a smaller scale within their individual departments to streamline paperwork, standardize procedures, and make other process improvements that affect the quality of the customer's experience.

Many team participants have found that they are incorporating the principles into their daily work styles. "It has helped me with my work and given me concepts and techniques I can take with me anywhere," says Clearwater, who added that he finds himself using the Shaw methodology to approach problems in his community activities and at home.

"Continuous process improvement is slow and painstaking work and that can be difficult for healthcare people who are accustomed to instant gratification in taking care of patients," Lemmon says. "It's hard to see the reward while you are building a solid process for identifying issues, gathering and analyzing data.

"But the results are worth waiting for, and when you start to make significant achievements the staff gets excited and wants to be included and involved," she says. "Process improvement is always a work in progress because the standards keep getting higher. It is St. Johns' long term commitment to quality."

For more information on St. Johns Hospitals or other organizations that have benefitted from working with Shaw Resources, please call 888-SHAWRES, or check the website: www.shawresources.com