1. Efficiency
Fragmented, high-cost service delivery has been a well-documented failing of U.S. health care. That said, HFHS has always tried to set a high standard in this area because efficiency resides in our DNA. Henry Ford wanted to create products that would advance the country, and he wanted to do it through work processes that were very efficient. For example, when Henry Ford Hospital first opened its doors in 1915, it integrated inpatient and outpatient departments under one management structure. Further, as the hospital grew into a system, it continued to pioneer models to integrate care and delivery. We were early adopters of electronic medical records (EMR), an essential tool for coordinating care. And we integrated financing and delivery by adding a health insurance plan created to deliver low-cost and high-quality care.
Many other examples stand out, but efficiency is an ongoing challenge. For instance, after the turnaround took hold we wanted to bring the expanding health system together in a way that would notably raise the bar for service and performance. In this case, integration meant ensuring that all patients who sought care at any Henry Ford facility would receive the same level of high-quality attention. The Baldrige criteria helped us attack this in a strategic way. The objective was to standardize care protocols across the system and develop a culture of performance excellence among more than thirty thousand employees, physicians, and volunteers.
Delivering on that goal required merging a number of hospital functions. Pathology offers one example: until 2007, each facility had its own laboratory services and private pathology group. According to Dr. Richard Zarbo, senior vice president for pathology and laboratory medicine, “There was no means of standardizing across the system to ensure that all patients saw the same reference ranges, for instance, or even had the same quality on a pathology report.”1
This was extraordinarily frustrating for Dr. Zarbo, who was chair of the College of American Pathologists Quality Committee, and it was disconcerting for doctors and patients alike. Under Dr. Zarbo’s leadership, the disparate lab services were eventually integrated. Practically speaking, that meant around-the-clock results were available throughout the system—previously, some of the suburban hospitals had more limited hours and communication protocols.
Another important target of integration involved strengthening the relationship between the system’s internal medical group and its many independent practice physicians. In 2010, we created the Henry Ford Physician Network as a way to remove barriers to patient care coordination across providers. Run by physicians, the network encouraged collaboration and standardized a higher quality of care while lowering costs. Despite the potential benefits of the network, it was nonetheless a tough sell to independent physicians operating within HFHS who wanted to maintain their autonomy. After much debate, the network was formed to include all Henry Ford Medical Group physicians and also those in independent practice who elect to belong—a total of 1,900 physicians in 2015.
It was around this time that the system’s nurses also created a mechanism for sharing solutions and standardizing best practices. Connie Cronin, former chief nursing officer for the system, said, “It’s important that you have your own identity, but you have to work together. There needs to be similarities across the system, otherwise you are not a system . . . you’re just a group of places.” Connie recognized an opportunity to bring nursing leadership from across HFHS together to accomplish common goals. Topping the agenda were quality and safety standards. The Corporate Nurse Executive Council, now under the leadership of CNO Veronica Hall, meets monthly to standardize clinical protocols, policies, procedures, and even job descriptions.2
Business planning, as well, became much more integrated during the Baldrige process and ever since. William Schramm, senior vice president of business development, says that a lot of the work by his group does not necessarily concern mergers or acquisitions, but is more about creating synergy through collaborative planning and program development. In essence, he said, his group is helping the organization to achieve a desired business model, which is a compilation of the products and services in our portfolio. He summed it up this way: “How do you leverage those products and services to sustain the enterprise over the long term? It really is looking inside and outside the organization to bring together the right pieces and the right approach to sustain the organization.”3
The system’s move to a more integrated model allowed HFHS patients to proceed more seamlessly across sites of care. Interestingly, one of the things that integration accelerated was expansion. We wanted patients to have better geographic access in every part of the market. Our Detroit hospital is centrally located and we had another hospital in the southern part of our primary region, but we did not have any major hospitals to the north at the time. So the launch of two new HFHS hospitals, one that was acquired and another we built, allowed us to improve coverage measurably. In addition, we built ambulatory networks around each in order to enhance our competitive position and strengthen access for patients in need.
Integration has always been a key ingredient to our success, but it was radically accelerated as part of the Baldrige framework we embraced after the turnaround work was completed.
2. Safety
Henry Ford created a cadre of safety procedures that dramatically reduced injury rates for workers at Ford Motor Company—including assigning individuals to a specific location instead of allowing them to roam all about. These were remarkably innovative measures at the time. In his autobiography, Ford mentions the safety benefits of an assembly line, including the fact that workers didn’t engage in heavy lifting, sudden stopping, or repeated bending.4 In a health-care setting, quality is all about safety. That involves patient safety, first and foremost, but also includes safety for the doctors, nurses, and staff members. Safety is what makes and breaks reputations in health care. Without it, liability becomes an issue and fundamentals such as service, trust, ethical conduct, and reliability all vanish.
Patient safety can be measured in “harm events”—including infections, surgical complications, adverse drug interactions, and misdiagnoses—and by examining mortality rates. In terms of the Baldrige, there was a positive symmetry at play: our work around safety was a leading reason we won the award, and the Baldrige process itself was the main tool we used to focus on improving our safety record.
One area in which we set a new standard in safety was depression care. Most hospitals at the time created metrics around reducing a patient’s symptoms or severity of depression, but we wanted to go further faster. We started by targeting an audacious goal originally proposed by a nurse at HFHS—perfect depression care. To us, truly effective depression care meant that no patients under our care would die from suicide—and we set out to make that happen. In the first four years of the program, the suicide rate among patients fell by 75 percent. Then, in year five, we achieved our goal of eliminating suicides among our patients and have maintained that ideal for more than a decade.5
Our successes in depression care dovetailed nicely with an Institute for Healthcare Improvement initiative called the “100,000 Lives Campaign.” Introduced in 2005, the initiative was geared toward dramatically reducing morbidity and mortality linked to treatment-related infections nationwide over an eighteen-month period. HFHS contributed to that by saving two hundred lives. Out of that came our own evidence-based “No Harm Campaign,” a system-wide sharing of best clinical practices aimed at reducing or eliminating twenty-three sources of harm. Led by Dr. William Conway, then the system’s chief quality officer, the campaign resulted in a 26 percent reduction in harm events between 2008 and 2011, when most hospitals’ rates of reduction were in the single digits.
According to the Institute for Healthcare Improvement, this program is a national best practice. One prime example of this success was Henry Ford Hospital’s reduction in central-line infections from ten per year in 2008 to three in 2011. HFHS has accomplished a 40 percent reduction in mortality since 2004—a result of succ
essful implementation and spread of several improvements. In addition, our definition of harm in the campaign included all harm, whether preventable by standard practices or not. For example, when standard best practices to reduce catheter-related bloodstream infections in hemodialysis patients resulted in only modest improvements, our team developed entirely new best practices. The new system led to a 34 percent decrease in dialysis mortality since its implementation.6 Holding ourselves accountable for patient safety motivated us to find ways to overcome difficult challenges to meet goals.
The work we did during the turnaround, and the focused efforts to dramatically improve quality using the Baldrige framework, enabled us to develop a culture of safety that has, I believe, been crucial to our success.
3. Performance
The Baldrige criteria are about performance excellence—achieved through aligned and integrated processes. While it’s certainly a bigger challenge to deploy these processes across all parts of a large organization such as Henry Ford, the underlying principles, and the commensurate improvements, are intended to be the same for any company. As noted, we started our journey with the intention of using the framework to become better—not simply to win an award. Using that thinking, we integrated the Baldrige criteria into our strategic planning and business operations, and it became part of our routine.
The Baldrige Criteria
Growth in customer satisfaction, engagement, and loyalty
World-class product and service outcomes
Role model process efficiency
Increased workforce satisfaction and engagement
Growth in revenue and market share, and improved financial results
Increased learning outcomes
Improved outcomes (safety and loyalty)
Health care is not a level playing field. For us, pure financial performance is a little different than it is for a public company, or even many other hospitals, because we have so much uncompensated care. If you applied our performance from a cost and revenue standpoint to other markets, even in southeast Michigan, we’d be making a lot more money. Even so, the Baldrige criteria added a strict discipline to the way we plan, execute, and evaluate our performance. Just as Bill Conway and I said when we received the award, our organization took a “zero-defect, no-excuses” approach to health care. The use of dashboards and benchmarking (and comparisons to companies outside the health-care arena) allowed us to measure performance in a manner that pointed us toward top performance. We use the Baldrige criteria to assess key investments, update management systems, and set system priorities. They are also the foundation for our seven-pillar framework, and are reflected in the competencies that drive leadership development and personnel evaluations.
7 Pillars of Performance
I created the “7 Pillars of Performance” at Henry Ford to keep us tethered to the fundamental areas that drive excellence for us. Although they predate our Baldrige journey, during the time we competed for the Baldrige, the pillars became the core construct we use within business units to measure success. As such, they strengthen integration and bring the system closer together.
People
Quality and safety
Service
Growth
Community
Research and education
Finance
The first three pillars—people, quality and safety, and service—are core because they dictate and drive the rest. The people pillar is first, very intentionally, because I believe that if you fail to engage individuals within the organization everything else falters. The quality and safety pillar, as well, is central to all our efforts. As I mentioned, we have been on a quality journey for more than twenty years, and our safety programs have become a benchmark in the industry. The next pillar, service, centers on the patient experience and fans out to include families as well as our own caregivers, such as physicians and nurses. As you might imagine, service is inextricably tied to people and quality and safety.
Growth, although arguably a result of good performance, is the pillar that keeps us facing forward. In health care, I have found, people sometimes consider growth to be a benefit rather than a strategic focus. Patients show up in the ER and we serve them—end of story. But a hospital, like any other business, needs to create marketing strategies and brand objectives, and to understand the needs of customers.
The next two pillars—community and research and education—are likewise a less common focus for most health systems. As an anchor institution of Detroit, however, we were founded to serve the community and, in essence, we are a neighborhood asset. As such, we connect to the community through a variety of outreach initiatives and strive to create collaborative partnerships, stepping up when the community needs our support. Academics has also been a part of our core since our creation, when Henry Ford made it his mission to bring the best doctors over from Johns Hopkins University, and ten years later, when Clara Ford decided to found a nursing school.
We built a pillar around education and research to keep us focused on the requisite opportunities and threats that come with being an academic institution. For instance, an academic program attracts remarkable talent because the brightest people in the field often want to teach, innovate, and advance the science and art of medicine, nursing, and allied health professions. In terms of looming threats, we rely heavily on graduate medical education payments from the federal and state government, so we must constantly be ready for changes in payment policies and legislation.
The final pillar is finance. We put it last, intentionally, because if the other six pillars are strong, we believe we will have a stable financial organization. Yet, the finance pillar is where a lot of our performance monitoring and management support are provided; through a project management office, our leaders can access the analytics, support, and technology that help them make good business decisions.
While the seven-pillar structure aids the integration of the business units, emphasizing that they are part of a larger system, it also leaves directors free to manage their units with an appropriate amount of autonomy. The pillars provide the desired “ends”—but creative, innovative leaders and caregivers have the freedom to determine the “means” by which they will achieve the results.
The Baldrige criteria propelled us to “think big,” even beyond the seven pillars, and to compare our organization with top companies across the country. That mode of thinking and operating was rather new for HFHS. When I came to Henry Ford, there was a deeply embedded belief that suburban patients would never come downtown for care. Employees believed there was a limit to how well we could perform and grow, financially and otherwise. The thinking was, “Well, this is the inner city. If we have a dreary hospital that’s not clean and we have low patient satisfaction and employee morale, what do you expect? This is as good as it gets in Detroit.” That was unacceptable to me.
As part of our culture work, we tried to eliminate the victim mentality. We also tried to expunge the belief that we couldn’t attract patients from a broader geography. The turning point came down to one major win—the Vattikuti Urology Institute’s robotic surgery program. The minute Dr. Menon started bringing patients in from outside the U.S. (and domestically from all fifty states), the context changed for us. We learned that we could attract patients from anywhere if we had world-class programs and superb service.
The other idea I reshaped to point performance upward was the context around our market size. I had worked in much smaller markets, and we had always been able to attract new patients. We had a 4.5 million-person population base in Detroit. We didn’t have to attract all of them, but we certainly could attract many more than we were. It was all about maintaining a positive mind-set. I was a relentless cheerleader for Detroit and for Henry Ford, and I never accepted negativity.
Our Baldrige work gave us the structure to push past our self-limiting mind-set. In fact, a number of the major strategic moves that we made between 2007 and 2011 were influenced by our Baldr
ige journey. The two new hospitals and our ambulatory centers, for example, signaled significant expansion and required careful planning and teamwork. I believed at the time, as I do now, that Baldrige enhanced our ability to accomplish those projects because we were thinking differently about process, organization, leadership, timelines, and budgets.
Not only did the Baldrige structure help drive growth, it also helped us to fund it. It was the consistency of our improved performance over a period of several years that enabled us to issue debt to pay for some of those capital projects. Furthermore, it gave confidence to philanthropic donors, contributing to our growth and helping us to raise $270 million in our capital campaign over a period of about seven years.
Finally, I would posit that our Baldrige journey opened the door for direct net gains, thanks to reduced costs. That would seem self-evident in most industries—improving the quality of a system can reduce costs—but it was not always the case in health care. Why? Insurers and Medicare at the time were paying hospitals for the higher utilization generated by mistakes, errors, or bad outcomes.7 In essence, the medical system had built-in financial incentives for bad care.8 Then, when Medicare changed its rules in 2007, hospitals were held accountable for certain common errors. By improving care and eliminating patient harm events, Henry Ford Hospital reduced expenses by $1.9 million, or $40 per patient, in 2010. We extrapolated the cost savings over our five hospitals to the tune of $10 million. As Bill Conway has said, “You can save lives and save dollars at the same time.”
Unconventional Leadership Page 7