Service Excellence

SITUATION

Upon arrival at WVUH-East it was apparent that the core components of our service Inpatient, ER, and Outpatient were in single digits according to Press Ganey. We were truly at the very bottom of the peer group and, with a 40% market share, the need to improve the service was critical for market gains. Before we could begin any type of promotional program this issue was the first priority that had to be addressed

ACTION

The first part of the plan to improve upon these results was to do a drill down analysis with the senior management team on the Press Ganey reports to determine the root cause of the problem. Once the core issues were identified specific operational goals were determined.  All level of managers were required to read Hardwiring Excellence by Quint Studer as homework. Senior managers including myself rotated the responsibility of meeting all the new admits of the day to determine how the admit process went and if their needs were being met.

The next part was to increase the speed and consistency of the Press Ganey reports to middle managers. At the same time a day long training session was held with the middle managers on how to read the reports, drill down into the details and what their respective operational goals were relative to inpatient, ER or outpatient reports. Quarterly review meetings were held with small groups led by myself for results reviewing and brainstorming of what was working and what needed help.

The third part of this action was to develop a training program for the employees based on the principles of Hardwiring Excellence with a slightly different twist.  A group of employees from each department were selected for a two day training session on how to teach customer service to their fellow employees. The belief is that peers will listen to peers more readably than a manager.  Mandatory sessions were scheduled for all employees to attend customer service training over the next month, and no attendees were required to meet one on one with the CEO for disciplinary action.

As the CEO I made it very apparent that this was a high priority item for me. I posted quarterly results that showed improvement by the cafeteria entrance with handwritten notes of praise for that department. As I rounded on the units I would ask employees about their thoughts on customer service regarding what was working and what was not. I directly corrected any suggestion given to me by an employee on an operational issue that would improve customer service.  I actively fostered a culture, through positive reinforcement, that the employees were empowered to lead service excellence, and I backed the middle managers for any personnel decision that was made relative to customer service issues.

RESULt

• The average ER score of both hospitals went from an aggregate score of 78 in ER to an 87 in 18 months, moving them from percentile rankings of 8 to 75th.
• The physicians of the Jefferson hospital achieved a remarkable 99th percentile ranking.
• Both facilities improved their inpatient score to the 70th percentile ranking.
• The amount of positive letters we received from patients after their stay more than doubled.

Implemented and Developed Cath Lab Program

situation

Prior to arrival at East, the University had secured a certificate of need for an interventional cath lab to be at one of the hospitals known as City Hospital. At the time of arrival the certificate of need had not been implemented for two years. Contracting with the Cardiologist had dragged on for over a year and the entire project which was critical for market and revenue growth was leaderless.

Action

After reviewing the progress and the parties involved in contracting and development, I knew I was going to need to take a strong and direct leadership role. I met with the administrator of City Hospital and outlined an aggressive time line for the opening of a temporary lab while we awaited the construction of a permanent lab. The timeline called for the opening of the temporary lab in six months. This timeline required about $100,000 in construction work, and I authorized him to proceed with a single contractor that we had used before in order to fast track the project. 

The next step was to meet with the University official and the Cardiologist to get the contracting completed. As we met I pointed out the need for the contracting to be completed, and informed them that we would have a lab open an in place within six months. We discussed the timetable not only for the temporary lab, but the date at which I would have the permanent lab opened. As we discussed the need to develop a clinical team that was proficient prior to opening the new permanent lab the Cardiologist began to see the value in proceeding. I closed our meeting with my need to have a definite answer from them within the month, so I could tell their competitors that we had signed them as our group. Within six weeks he had signed as the medical director, and though we did not have his entire group on board I knew that since he was the informal leader that process would be completed by the time the temporary clinic was open.

We opened the temporary lab two days prior to the six month goal with not only equipment in place but personnel recruited as well.  The Bonds had been sold to begin the process for new construction, so the next phase of this project was building the business. We had excellent volume the first month but significantly tapered off the following months. I had my implementation team began to track referrals from the ER to the cardiology group and found that over 50% of those seen in their clinic were treated at the competitors cath lab, the exception being the medical director which treated almost 100% of his cases in our lab. Armed with this data I met with the physician group and presented my findings. I also communicated to them that the primary care physicians were pushing me to bring in another Cardiology group but I was holding them off to allow this group to make the transition of treating our patients in our hospital. We then moved the discussion to what we needed to do to provide greater support for them and how we were willing to assist them with office space adjacent to the hospital. Over the next couple of months our Cath volume began to slowly rise and once the local office was completed increased significantly.

In addition to internal marketing we began to pursue a “toy in the cereal box” marketing approach.  The standard billboard, TV as and direct mail were used, but it has been my experience that the only health care issue men pay attention to is cardiac disease. Using calcium scoring studies on a 64 slice scanner in a manner similar to offering screening mammography, we allowed for patient self referred studies at $350 per study. We filled the scheduling slots to capacity and, through this process, yielded enough false positive and positives to expedite the word of mouth advertising we knew was required to gain market share from the established competition.

Result

• Within the first year we did 250 diagnostic cases from not having any market share
• Established a Cardiology program and clinic that continue to grows
• Improved the clinical capacity of our Emergency room service on a 24 hour a day basis
• Exceeded the criteria required to perform interventional studies in year 2
• Completed the permanent cath lab with equipment superior to that of the competition using their physicians

ER turnaround time

situation

The poor reputation of the hospital was originating in the quality, service and turnaround time of the hospital’s emergency room. After having had a complete turnover of ER physicians, the medical staff was punctuated with temp physicians and nurses. The nursing leadership had also been non-confrontational so there were significant employee issues. Consequently, time for patients being admitted was running between 4 to 6 hours, and non admit patients times were running 2 to 3 hours.

action

It was apparent that, before any operational issue could be addressed, management changes and a sense of vision had to be instituted along with definable goals.  Consequences for not meeting those goals had to be enforced whether it was employee, manager or physician.

The first and most obvious issue that was addressed was the changing of departmental leadership to an individual that was willing to tackle the employee issue. Within a matter of 30 days so called “sacred Union cows” of the ER nurses were either terminated or reassigned. The Physician contract company was given a list of positions that had to be filled by permanent placement and physicians that had to be removed over the next six months.

While employee changes were under way we set about the task of studying the problem of ER bottle necking and realized several changes we could make while we were developing a new ER team.

1. The triage process was very bureaucratic and had been excessively tampered with by outside departments
2. The discharge times from the hospital were so late in the day that they created a capacity constraint for moving patients out of the ER to a room.
3.  Inconsistent transfer requirements from receiving nursing units with obvious attempts at stalling admits
4. Significant delays in lab result collection and reporting
5. Labor resources in the Fast Track unit designed for quick turnaround of non-emergent patient were constantly pulled to the main ER exacerbating the wait time and actually adding to the main ER backlog of patients.
6. Start time for the Fast track unit was based in nursing shifts and not when demand for service began consequently they always started behind.
7. Basic supplies such as linen were not adequately stocked by support departments causing nursing to leave the unit to have to locate supplies.

We began to aggressivly use an industrial engineer to help us identify work flow problems and I took on the role of fixing issues that required multi-department involvement. As the quality of the personnel improved we were able to separate real issues from personality problems. At the same time we had come to realize how the experience in ER would impact the Press Ganey score of inpatient unit, so we used this information to sell everyone the ER was a hospital problem not a department problem. 

Within a year we implemented a full electronic information system for the ER, and since we had already become so data driven we were able to isolate smaller issues that were nearly impossible to detect using a manual charting system.

result

• Turnover time for non admit patients improved to 45 minutes to an hour
• Turnover for admitted patients averages 2.5 hours
• Patients with outlier stays greater than 4 hours became seasonally driven and averaged 4 per month
• During this same time volume grew by 10,000 patients a year
• Satisfaction scores moved into the top 25 percentile of peer groups

Market Strategies

Construction of a Medical Fitness center and MOB

situation

Fairmont General had to deal with tough competition from larger hospitals north and south. When the hospital south of their location announced it was going to build on the interstate and within 10 miles of the most lucrative market for FGH the hospital needed a counter measure.

action

The population of the contested market tended to be two income families under the age of 55. Given the hospital was constrained by geography and resources to build a new hospital in that area we had to develop a unique strategy.

The decision was made to build a medical mall called a HealthPlex. Within this structure would be physician offices that would fit that market area, a full fledged medical fitness center. Pharmacy services, diagnostic services up to CT scanning, physical medicine services, and a walk-in clinic. The strategy was based on the belief that when it came to inpatient of surgical service distant or time was not an issue for customers, but when it came to routine medical services that time and convenience were significant in the minds of the consumer.

The largest component of the $13 million dollar HealthPlex was the medical fitness center. We knew that we lacked the knowledge base to get the project off the ground quickly, so we brought in an outside company for a 5 year management contract. Our proforma was for a $300,000 profit on 1,500 members. In order to maintain that volume we targeted customers that were not necessarily to beautiful people. Our target market was anybody over the age of 35 that had not led a life of fitness. All programs and scheduled were built around the demands and needs of this target group. Through aggressive advertising toward our market we were able to open the unit with 800 members prior to the first day.

The medical offices we set up were two female family practioners, two OB/GYNs, and orthopedics. These were practices that would readily support the diagnostic services set up in the HealthPlex and the physical medicine services as well

From the Pharmacy with a drive-thru to the coffee shop by the front door everything we did was to cater to a highly mobile very busy customer base. We even built the HealthPlex as close to an interstate exit as we could.

By directly managing the construction process I was able to bring the project in not only on time but on budget as well, so that we did not have to adjust our pro formas. My only regret of the project is that I should have built it bigger.

result

• Membership surpassed 2,000 making it significantly more profitable than the Performa and two years earlier than expected.
• Physical therapy volume grew by 45%.
• All Physicians located in the HealthPlex are at capacity on the amount of patient they can see.
• The afterhours clinic is always at or above capacity the exception being the summer months.
• The pharmacy tripled the amount of prescriptions from those of their previous location.