E1314 Benchmarking For Hospitals

FM_Sower_575077.
qxd 11/6/07 11:05 AM Page i
Benchmarking
for Hospitals
Achieving Best-in-Class
Performance without Having
to Reinvent the Wheel
FM_Sower_575077.qxd 11/6/07 11:05 AM Page ii
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FM_Sower_575077.qxd 11/6/07 11:05 AM Page iii
Benchmarking
for Hospitals
Achieving Best-in-Class
Performance without Having
to Reinvent the Wheel
Victor E. Sower
Jo Ann Duffy
Gerald Kohers
ASQ Quality Press

Milwaukee, Wisconsin
FM_Sower_575077.qxd 11/7/07 9:08 AM Page iv
American Society for Quality, Quality Press, Milwaukee 53203

© 2008 American Society for Quality
All rights reserved. Published 2007
Printed in the United States of America
12 11 10 09 08 07 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data
Sower, Victor E.
Benchmarking for hospitals : achieving best-in-class performance without
having to reinvent the wheel / Victor E. Sower, Jo Ann Duffy, Gerald Kohers.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-87389-722-8 (pbk. : alk. paper)
ISBN-10: 0-87389-722-6 (pbk. : alk. paper)
1. Hospitals—Administration. 2. Benchmarking (Management)
I. Duffy, Jo Ann, 1945- II. Kohers, Gerald, 1965- III. Title.
[DNLM: 1. Benchmarking. 2. Hospital Administration—methods.
3. Organizational Case Studies. 4. Outcome and Process Assessment
(Health Care)—standards. 5. Total Quality Management.
WX 153 S731b 2008]
RA971.S695 2008
362.11068—dc22 2007043428
ISBN-13: 978-0-87389-722-8
No part of this book may be reproduced in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without the prior written
permission of the publisher.
Publisher: William A. Tony
Acquisitions Editor: Matt Meinholz
Project Editor: Paul O'Mara
Production Administrator: Randall Benson
ASQ Mission: The American Society for Quality advances individual,
organizational, and community excellence worldwide through learning, quality
improvement, and knowledge exchange.
Attention Bookstores, Wholesalers, Schools, and Corporations: ASQ Quality Press
books, videotapes, audiotapes, and software are available at quantity discounts
with bulk purchases for business, educational, or instructional use. For
information, please contact ASQ Quality Press at 800-248-1946, or write to ASQ
Quality Press, P.O. Box 3005, Milwaukee, WI 53201-3005.
To place orders or to request a free copy of the ASQ Quality Press Publications
Catalog, including ASQ membership information, call 800-248-1946. Visit our
Web site at www.asq.org or http://www.asq.org/quality-press
Printed on acid-free paper
FM_Sower_575077.qxd 11/6/07 11:05 AM Page v
Table of Contents
List of Figures and Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Section I The Basics of Benchmarking . . . . . . . . . . . 1

Chapter 1 Introduction to Benchmarking . . . . . . . . . . . . 3
National Benchmarks, Industry Averages,
or Internal Processes . . . . . . . . . . . . . . . . . . . . 4
Initiation of the Benchmarking Process . . . . . . . . . . . . 7
Strategic and Operations Benchmarking . . . . . . . . . . . . 8
Best in Class . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Inside or Outside Your Industry . . . . . . . . . . . . . . . . 10
Determining How the Benchmark Target Achieves
Its Results . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Ethics, Etiquette, and Benchmarking Protocol . . . . . . . . . 11
Chapter Summary . . . . . . . . . . . . . . . . . . . . . . . 14
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Information Resources . . . . . . . . . . . . . . . . . . . . . 15
Chapter 2 General Process for Benchmarking . . . . . . . . . 17
Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Decide What to Benchmark . . . . . . . . . . . . . . . . 17
Define the Benchmarking Team . . . . . . . . . . . . . 20
Identify Whom to Benchmark . . . . . . . . . . . . . . 21
Establish Baseline for Existing Process . . . . . . . . . 21
Define Objectives and Criteria for Success . . . . . . . 22
v
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vi Contents
Data Acquisition . . . . . . . . . . . . . . . . . . . . . . . . 22
Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Determining the Performance Gap . . . . . . . . . . . . 24
Project Future Performance Levels . . . . . . . . . . . . 25
Integration . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Communicate Benchmarking Findings
and Gain Acceptance . . . . . . . . . . . . . . . . . 28
Establish Performance Goals . . . . . . . . . . . . . . . 29
Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Develop Improvement Strategy . . . . . . . . . . . . . . 29
Develop Action Plans . . . . . . . . . . . . . . . . . . . 29
Implement and Monitor Progress . . . . . . . . . . . . . 29
Recalibrate the Benchmarks . . . . . . . . . . . . . . . 29
Maturity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Determine When Best-in-Class Position Is Attained . . . 30
Develop Objectives for Continuing Improvement . . . . 30
Chapter Summary . . . . . . . . . . . . . . . . . . . . . . . 30
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Chapter 3 Benchmarking Tools . . . . . . . . . . . . . . . . . . 33

Focus Groups . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Flow Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Time-Function Map . . . . . . . . . . . . . . . . . . . . 38
Radar Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Control Charts . . . . . . . . . . . . . . . . . . . . . . . . . 41
Pareto Diagrams . . . . . . . . . . . . . . . . . . . . . . . . 44
Cause and Effect Diagrams . . . . . . . . . . . . . . . . . . 45
Run Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Gantt Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Reliability and Redundancy . . . . . . . . . . . . . . . . . . 48
Failure Mode and Effects Analysis (FMEA) . . . . . . . . . . 49
Cost of Quality . . . . . . . . . . . . . . . . . . . . . . . . . 50
Chapter Summary . . . . . . . . . . . . . . . . . . . . . . . 53
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Chapter 4 Organization Design Issues:

The S32 Framework . . . . . . . . . . . . . . . . . . . . . . . . 55
Smoothing the Way . . . . . . . . . . . . . . . . . . . . . . . 55
Description of the S32 Organization Design Framework . . . 57
Strategy Formulation . . . . . . . . . . . . . . . . . . . 57
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Contents vii
Structure . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Style . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Systems . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Shared Values . . . . . . . . . . . . . . . . . . . . . . . 63
Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Systematic Measurement Practices/Program . . . . . . . 63
Quality Improvement Really Gains Traction When
Strategy Leads the Way . . . . . . . . . . . . . . . . . . . 68
Chapter Summary . . . . . . . . . . . . . . . . . . . . . . . 68
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Chapter 5 Key Characteristics of Best-in-Class Hospitals . . . 71
Clarity of Mission/Vision . . . . . . . . . . . . . . . . . . . 72
Alignment . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Measures of Progress—Clear and Well-Defined Metrics . . . 75
Champions . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Openness to Improvement Regardless of the Source . . . . . 77
Strong Patient-Focused Culture . . . . . . . . . . . . . . . . 77
Strong Leadership . . . . . . . . . . . . . . . . . . . . . . . 80
Systems Thinking . . . . . . . . . . . . . . . . . . . . . . . 81
Motivation to be Recognized as Being Among
the Best Hospitals . . . . . . . . . . . . . . . . . . . . . . 81
Lack of Fear . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Communication Built into the System . . . . . . . . . . . . . 83
Celebration of Results . . . . . . . . . . . . . . . . . . . . . 83
Chapter Summary . . . . . . . . . . . . . . . . . . . . . . . 84
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Section II Case Studies—How Best-in-Class

Status Was Attained . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Chapter 6 Bronson Methodist Hospital: Quality
of Workplace . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
About the Hospital . . . . . . . . . . . . . . . . . . . . . . . 90
Bronson—Before the Change . . . . . . . . . . . . . . . . . 90
The Transformation . . . . . . . . . . . . . . . . . . . . . . 91
Along Came Baldrige . . . . . . . . . . . . . . . . . . . . . 92
The Bronson Way . . . . . . . . . . . . . . . . . . . . . . . 93
The Workforce Development Plan . . . . . . . . . . . . . . . 93
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viii Contents
Current Workforce . . . . . . . . . . . . . . . . . . . . 94
Future Workforce . . . . . . . . . . . . . . . . . . . . . 98
Employee Satisfaction and Well-Being . . . . . . . . . . 99
Staff Learning and Motivation . . . . . . . . . . . . . . 100
Recognizing and Rewarding Excellence . . . . . . . . . 100
Benefits and Services . . . . . . . . . . . . . . . . . . . 102
Diversity . . . . . . . . . . . . . . . . . . . . . . . . . 102
Physician Involvement . . . . . . . . . . . . . . . . . . . . . 104
Impact on Bronson . . . . . . . . . . . . . . . . . . . . . . . 105
The CEO Talks About Lessons Learned, Opportunities,
and Resources . . . . . . . . . . . . . . . . . . . . . . . . 105
Lessons Learned . . . . . . . . . . . . . . . . . . . . . 105
Opportunities . . . . . . . . . . . . . . . . . . . . . . . 106
Key Resources . . . . . . . . . . . . . . . . . . . . . . 106
What’s Next for Bronson? . . . . . . . . . . . . . . . . . . . 106
Measures of Best-In-Class Performance . . . . . . . . . . . . 106
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Chapter 7 Columbus Children’s Hospital: Benchmarking
the Aviation Industry to Prevent Surgical Errors . . . . . . . 109
Initial Development of Pathways . . . . . . . . . . . . . . . . 111
The Motivation for Further Improvement . . . . . . . . . . . 111
About the Ex-Officio Director and Champion
of Operation Takeoff . . . . . . . . . . . . . . . . . . . . 113
The Transforming Experience . . . . . . . . . . . . . . . . . 113
The Importance of Systems . . . . . . . . . . . . . . . . . . 114
The Children’s Quality Initiative in Surgery (CQIS) . . . . . 115
Operation Takeoff . . . . . . . . . . . . . . . . . . . . . . . 117
Launching Operation Takeoff . . . . . . . . . . . . . . . . . 122
The Results . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
What’s Next? . . . . . . . . . . . . . . . . . . . . . . . . . . 122
The Surgeon-in-Chief Talks about Obstacles . . . . . . . . . 123
Measures of Best-In-Class Performance . . . . . . . . . . . . 124
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Chapter 8 Robert Wood Johnson University Hospital Hamilton
Emergency Department: The 15/30 Guarantee . . . . . . . . 127
Setting the Stage . . . . . . . . . . . . . . . . . . . . . . . . 129
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Contents ix
The Action Begins . . . . . . . . . . . . . . . . . . . . . . . 130

Leading the Way . . . . . . . . . . . . . . . . . . . . . . . . 131
Getting Started . . . . . . . . . . . . . . . . . . . . . . . . . 131
A Work In Progress . . . . . . . . . . . . . . . . . . . . . . . 134
The Price of Success . . . . . . . . . . . . . . . . . . . . . . 139
Measures of Best-in-Class Performance . . . . . . . . . . . . 140
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Chapter 9 North Mississippi Health Services: Benchmarking
the Information System Used for Collecting/Analyzing/
Storing Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
About the Hospital System . . . . . . . . . . . . . . . . . . . 145
Leadership Team . . . . . . . . . . . . . . . . . . . . . . . . 147
Development of NMHS’s Management Information
System . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
The Impact of NMHS’s Information System . . . . . . . . . 154
People . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Service—Improve Customer Satisfaction . . . . . . . . 160
Quality—provide high level, evidence-based, quality
care and maintain patient safety . . . . . . . . . . . . 162
Financial—generate the financial resources necessary
to support the mission and vision . . . . . . . . . . . 163
Growth—expand access to health services . . . . . . . . 165
Chapter Summary . . . . . . . . . . . . . . . . . . . . . . . 167
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Chapter 10 Great Ormond Street Hospital for Children
in London: Ferrari’s Formula-One Handovers and
Handovers from Surgery to Intensive Care . . . . . . . . . . 171
Why Focus on the Handover? . . . . . . . . . . . . . . . . . 172
Moving from the Operating Room to
the ICU . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
How Was the Benchmark Selected? . . . . . . . . . . . . . . 173
Initiating the Program . . . . . . . . . . . . . . . . . . . . . 174
What Was Learned from Benchmarking? . . . . . . . . . . . 174
What Wasn’t Transferable? . . . . . . . . . . . . . . . . . . . 179
Researching the Effectiveness of the New Handover
Process . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
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x Contents
Where was the Support? . . . . . . . . . . . . . . . . . . . . 181

Organizational Mission . . . . . . . . . . . . . . . . . . 181
Organizational Structure . . . . . . . . . . . . . . . . . 182
Organizational Staff . . . . . . . . . . . . . . . . . . . . 183
Organizational Culture . . . . . . . . . . . . . . . . . . 183
What Were the Obstacles? . . . . . . . . . . . . . . . . . . . 184
Lack of Financial Resources . . . . . . . . . . . . . . . 184
Professional Health Care Orientation . . . . . . . . . . . 185
Gauging the Gains . . . . . . . . . . . . . . . . . . . . . . . 185
Future Challenges . . . . . . . . . . . . . . . . . . . . . . . 188
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
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Figures and Tables
Figure 1 Outline for the book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii

Figure 1.1 Comparing outcome measures. . . . . . . . . . . . . . . . . . . . . . . . . 5
Figure 1.2 ASQ quality management division benchmarking code
of conduct. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Figure 2.1 Six-phase benchmarking process. . . . . . . . . . . . . . . . . . . . . . . 18
Figure 2.2 Example of relative importance classification. . . . . . . . . . . . . 20
Figure 2.3 Process flowchart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Figure 2.4 Gap analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Figure 2.5 Current state map of ER. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Figure 2.6 Competitive convergence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Figure 3.1 Process flowchart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Figure 3.2 Time-function map. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Figure 3.3 Radar chart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Figure 3.4 Control chart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Figure 3.5 Pareto diagram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Figure 3.6 Cause and effect diagram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Figure 3.7 Run chart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Figure 3.8 Gantt chart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Figure 3.9 FMEA for a process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Table 3.1 Tools for different phases of benchmarking process. . . . . . . . 35
Table 3.2 Types of control charts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Figure 4.1 Robert Wood Johnson University Hospital Hamilton’s
communication system. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
listening and learning methods. . . . . . . . . . . . . . . . . . . . . . . . . 61
Figure 4.3 Balanced scorecard. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Figure 4.4 Narrow measurement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Figure 4.5 Metrics derived from strategic planning process. . . . . . . . . . . 67
Table 4.1 Augmentation of the 7–S to the S32 framework. . . . . . . . . . . . 57
Figure 5.1 Mission and vision statements. . . . . . . . . . . . . . . . . . . . . . . . . 72
Figure 5.2 A form of balanced scorecard. . . . . . . . . . . . . . . . . . . . . . . . . . 78
Figure 6.1 Plan for excellence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Figure 6.2 Plan for excellence accountability. . . . . . . . . . . . . . . . . . . . . . 95
Figure 6.3 Workforce development plan. . . . . . . . . . . . . . . . . . . . . . . . . . 96
Figure 6.4 Bronson leadership system. . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Figure 6.5 Bronson staff performance management system. . . . . . . . . . . 98
Figure 6.6 Recognition and reward system. . . . . . . . . . . . . . . . . . . . . . . . 101
xi
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xii Figures and Tables
Figure 6.7 Green card. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

Figure 6.8 Bronson baby on the way valet service. . . . . . . . . . . . . . . . . . 103
Figure 6.9 Bronson concierge services office. . . . . . . . . . . . . . . . . . . . . . 103
Figure 7.1 Columbus Children’s Hospital mission and vision. . . . . . . . . . 112
Figure 7.2 The results of Dr. Caniano’s study and initial plan. . . . . . . . . . 114
Figure 7.3 Charge to CQIS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Figure 7.4 CQIS plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Figure 7.5 Example of surgical dashboard. . . . . . . . . . . . . . . . . . . . . . . . . 118
Figure 7.6 Operation Takeoff pre-incision checklist. . . . . . . . . . . . . . . . . 121
Figure 7.7 Secret shopper results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Figure 8.1 Robert Wood Johnson University Hospital Hamilton
mission, values, and vision. . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Figure 8.2 ED bed flow analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Figure 8.3 Timeliness of ED initial assessment. . . . . . . . . . . . . . . . . . . . . 132
Figure 8.4 PLAN: Understand problems with the process. . . . . . . . . . . . 133
Figure 8.5 Five Pillars. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Figure 8.6 The 15/30 guarantee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Figure 8.7 Patients who left without treatment. . . . . . . . . . . . . . . . . . . . . 135
Figure 8.8 ED patient satisfaction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Figure 8.9 ED patient satisfaction with physicians. . . . . . . . . . . . . . . . . . 136
Figure 8.10 ED patient satisfaction with nursing. . . . . . . . . . . . . . . . . . . . . 136
Figure 8.11 ED satisfaction with waiting times to see RN. . . . . . . . . . . . . 137
Figure 8.12 ED satisfaction with waiting times to see MD. . . . . . . . . . . . . 137
Figure 8.13 Metrics currently tracked. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Figure 8.14 ED volume 2005–2007. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Table 8.1 Significant five-year growth. . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Figure 9.1 Mission, vision, values. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Figure 9.2 North Mississippi Medical Center’s mission, vision,
values, and critical success factors. . . . . . . . . . . . . . . . . . . . . . 149
Figure 9.3 North Mississippi Health System’s organizational
chart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Figure 9.4 Evidence-based planning process. . . . . . . . . . . . . . . . . . . . . . . 151
Figure 9.5 NMMC’s management information system. . . . . . . . . . . . . . . 155
Figure 9.6 NMMC’s employee retention. . . . . . . . . . . . . . . . . . . . . . . . . . 157
Figure 9.7 Employee satisfaction with training and concern
for employees. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Figure 9.8 Ideas for excellence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Figure 9.9 Employee and patient satisfaction. . . . . . . . . . . . . . . . . . . . . . 159
Figure 9.10 Complaint management process. . . . . . . . . . . . . . . . . . . . . . . . 161
Figure 9.11 Physician satisfaction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Figure 9.12 Care-based cost management. . . . . . . . . . . . . . . . . . . . . . . . . . 163
Figure 9.13 Cardiology worked hours per procedure. . . . . . . . . . . . . . . . . 164
Figure 9.14 Radiology performance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Figure 9.15 Inventory turnover. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Figure 9.16 Not-for-profit healthcare ratings distribution
per Standard & Poor’s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Figure 9.17 Level of active medical staff and market share. . . . . . . . . . . . 166
Figure 10.1 Formula One pit stop. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Figure 10.2 Summary of the new handover protocol. . . . . . . . . . . . . . . . . . 177
Figure 10.3 Technical errors per handover before and after the
new protocol, with 95% confidence intervals. . . . . . . . . . . . . 186
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Preface
F
rom the earliest days of humankind, benchmarking activities
have taken place. Cave dwellers observed that some hunters
were more successful than others. Learning how those best-in-
class hunters were so successful and then adapting their processes,
tools, and techniques to their own situation could be a matter of sur-
vival. While efforts to identify best-in-class processes and products
continued throughout history, Robert Camp’s 1989 book, Bench-
marking: The Search for Industry Best Practices That Lead to Supe-
rior Performance, formalized the process and gave it its name:
benchmarking. Inclusion of benchmarking in the Malcolm Baldrige
National Quality Award criteria has also increased interest in and ap-
plication of benchmarking.
KEY FEATURES OF THE BOOK

• Demystifying the benchmarking process
• Presenting a structured practitioner-friendly approach to the
benchmarking process
• Clarifying how to use tools helpful in benchmarking
• Providing a framework for implementing benchmarking
• Describing and analyzing best-in-class hospitals
xiii
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xiv Preface
ORGANIZATION OF THE BOOK

This book is about benchmarking in hospitals—identifying and
learning how best-in-class hospitals achieved excellence. As shown
in Figure 1, the book is organized to allow readers with no prior
knowledge of the benchmarking process to understand it. In addi-
tion, case studies are provided of best-in-class hospitals to enable the
reader to understand how they attained best-in-class status. The case
studies contain sufficient detail to actually enable hospitals to con-
duct a “first cut” at benchmarking.
The first section of the book discusses the basic benchmarking
process as applied to outcome measures, operational processes, and
strategic processes. There are many misconceptions about bench-
marking. Some think that comparing some outcome measure (for
example, patient satisfaction, infection rate) to national averages
constitutes benchmarking. This is not the case. Benchmarking is
about much more than just how one hospital compares to national
averages. Others think that benchmarking means simply copying
what another hospital is doing. This is not the case. Benchmarking
is about learning from best-in-class hospitals and adapting what is
learned to the specific environment in which your hospital operates.
Others think that there is nothing to be learned from benchmarking
organizations that are not hospitals. This is not the case. Best-in-
class hospitals have often benchmarked against other types of orga-
nizations, including those in the entertainment, transportation,
sports, and hotel industries.
There are many misconceptions about benchmarking. The first
section of the book will address these misconceptions and present
benchmarking as a structured approach to improving one’s own or-
ganization by systematically benchmarking best-in-class organiza-
tions. Also in the first half of the book is a formal, six-phase,
general, structured approach to benchmarking. Even when the
benchmarking process is less formal, this approach can help assure
that the process is effective.
The S32 framework is presented as a way for understanding the
strategic and environmental factors which affect the specific ap-
proach and processes that best-in-class organizations use to achieve
excellence. This understanding is the basis for adapting observed
processes to your hospital’s specific strategic and environmental fac-
tors.
The second section of the book contains case studies docu-
menting best-in-class processes in hospitals that are benchmark
standards. The processes selected for benchmarking are applicable
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The basics of General Understanding Supporting Identifying
benchmarking process for tools useful in benchmarking common
benchmarking benchmarking through characteristics
process organizational of best-in-class
design hospitals
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(b) Section II – Case Studies—How Best-in-Class Status was Attained

Page xv
Chapter 6: Chapter 7: Chapter 8: Chapter 9: Chapter 10:

Strategic Tactical Strategic Strategic Tactical
Benchmarking – Benchmarking – Benchmarking – Benchmarking – Benchmarking –
focus on focus on focus on waiting focus on infor- focus on hand-
employees surgical errors time in ER mation systems over procedures
Bronson Columbus Robert Wood North Great Ormond
Methodist Children’s Johnson University Mississippi Street Hospital
Hospital Hospital Hospital Hamilton Health Services for Children
Figure 1 Outline for the book.

Preface
xv
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xvi Preface
to all hospitals, not just large research and teaching hospitals. The
case studies document the initial state of the process under study,
the motivation for improvement, the process by which improve-
ment was attained, obstacles encountered and overcome, and the
state of the new process. The intent is to provide more than just
outcome measures to hospitals endeavoring to improve their own
processes.
Benchmark hospitals are identified from third-party rankings
such as the Solucient 100 Top Hospitals1 and U.S. News America’s
Best Hospitals,2 as well as secondary sources such as the list of hos-
pitals which have been recognized by winning the Malcolm Baldrige
National Quality Award3 and articles published in the quality and
healthcare literature. Data collection was accomplished through a
combination of site visits, interviews with CEOs and Directors of
Quality, and secondary sources. Each case study profiles one best-
in-class process in a specific hospital.
BRONSON METHODIST HOSPITAL:

QUALITY OF WORKPLACE
Chapter 6 provides an example of strategic benchmarking directed
toward achieving best-in-class status workplace environment. This
project was part of Bronson Methodist Hospital’s application
process for the Malcolm Baldrige National Quality Award which
they won in 2005. Bronson has been recognized many times for its
workplace quality including being named to the 100 Best Com-
panies lists in the magazines Working Mother and Fortune.
COLUMBUS CHILDREN’S
HOSPITAL: BENCHMARKING
THE AVIATION INDUSTRY TO
PREVENT SURGICAL ERRORS
Chapter 7 provides an example of operational benchmarking
directed toward decreasing surgical errors. The project was initi-
ated and championed by the hospital’s surgeon-in-chief and re-
sulted in a system that has resulted in dramatic improvements.
This chapter is also an example of benchmarking outside the
healthcare industry: Columbus Children’s Hospital benchmarked
the aviation industry.
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Preface xvii
ROBERT WOOD JOHNSON UNIVERSITY

HOSPITAL HAMILTON EMERGENCY
DEPARTMENT: THE 15/30 GUARANTEE
Chapter 8 is an example of strategic benchmarking focused on de-
creasing the waiting times in the emergency department. As with
Bronson, this project was part of Robert Wood Johnson University
Hospital Hamilton’s Malcolm Baldrige National Quality Award
journey. They won this award in 2004. The result of this project was
the 15/30 Guarantee, which promises that patients would be seen by
a nurse within the first 15 minutes and a doctor within 30 minutes or
the hospital would waive the ED charges for the patient.
NORTH MISSISSIPPI HEALTH SERVICES:

BENCHMARKING THE INFORMATION
SYSTEM USED FOR COLLECTING/
ANALYZING/STORING DATA
Chapter 9 is an example of strategic benchmarking and provides in-
formation about the long-term and continuing project to provide
best-in-class information systems to a major hospital system. North
Mississippi Health Services received the Davies Award of Excel-
lence in 1997, which recognizes excellence in the implementation
and use of health information technology, and has received the Hos-
pitals and Health Networks Top 100 Most Wired Award and Top 25
Most Wireless Award. They are also the recipient of the Malcolm
Baldrige National Quality Award in 2006.
GREAT ORMOND STREET HOSPITAL

FOR CHILDREN IN LONDON:
FERRARI’S FORMULA ONE
HANDOVERS AND HANDOVERS
FROM SURGERY TO INTENSIVE CARE
Chapter 10 is an example of tactical benchmarking directed toward
improving the handover procedures from surgery to intensive care.
The brainchild of two surgeons, the benchmarking team modeled
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xviii Preface
their new processes on those of the Ferrari Formula One racing

team’s pit-stop processes. The result was a handover protocol that
has substantially improved the process of moving patients from
surgery to the intensive care unit by breaking the link between in-
formational and technological errors.
CONTRIBUTIONS OF THE BOOK

The need for benchmarking in hospitals is apparent from reading the
Press Ganey 2006 Health Care Satisfaction Report. One of the main
conclusions of the report is that the “gap in patient satisfaction is
widening between hospitals that deliver exemplary patient service
and those that provide lower levels of care.”4 Benchmarking provides
an approach to closing this gap. By learning how top-performing
hospitals achieve best-in-class performance, lower performing hos-
pitals can determine ways in which they can improve their processes
and ultimately their performance.
This book provides the who, what, when, where, and why of
benchmarking. Moreover, it provides virtual site visits to best-in-
class hospitals, followed by an analysis of what they did and how
they implemented their improvement processes. The book seeks to
provide readers with practical, usable insights to inform and guide
their decisions for improving their hospitals.
ACKNOWLEDGMENTS
The authors would like to thank the hospitals profiled in this book
for answering our many questions and sharing with us details about
their journeys to best-in-class performance. We would like to thank
the following individuals for providing us with information about
their hospitals and projects:
Tommy Bozeman, Vice President and Chief Information Of-
ficer, North Mississippi Health Services, Tupelo, MS
Donna Caniano, MD, H. William Caltworthy Jr. Professor
of Pediatrics and Surgery, The Ohio State University
College of Medicine, and Surgeon-in-Chief, Columbus
Children’s Hospital, Columbus, OH
Ken Catchpole, MD, Senior Post Doctoral Scientist,
Nuffield Department of Surgery, John Radcliffe Hospi-
tal, Oxford, UK
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Preface xix
Martin Elliott, MD, FRCS, Professor of Cardiothoracic

Surgery, University College London & Chairman of
Cardiothoracic Services, The Great Ormond Street
Hospital for Children, London, UK
Al Rodrigues, Nursing Director of the Emergency Depart-
ment, Robert Wood Johnson University Hospital
Hamilton, Hamilton, NJ
Joyce Schwarz, Vice-President of Quality and Professional
Services, Robert Wood Johnson University Hospital
Hamilton, Hamilton, NJ
Michele Serbenski, Bronson Executive Director, Corporate
Effectiveness and Customer Satisfaction, Bronson
Methodist Hospital, Kalamazoo, MI
In addition we would like to thank Shashi Madhok, Malcolm

Baldrige Examiner and Quality New Jersey State Baldrige Exam-
iner, for her insight into hospital benchmarking. We acknowledge
our employer, Sam Houston State University, which encouraged our
research for this book. Four of our graduate students, Moudgalya
Sivalenka, Matt O’Rourke, Robin Reed, and Abhishek Pulankanti,
also provided assistance with the book. Caroline Balke assisted with
transcribing interview tapes. Judy Sower assisted with proofreading
and made many helpful suggestions that made this a better book. We
would also like to thank the three Quality Press reviewers of the ini-
tial proposal for this book for their insightful and encouraging com-
ments: Dr. Donald Lighter, Luc R. Pelletier, and Amjad Z. Tayeh.
Additionally, we would like to thank Paul O’Mara, Matt Meinholz,
and the ASQ Quality Press for their guidance in taking this project
from concept to finished work.
REFERENCES
1. www.100tophospitals.com/Winners/pil06/benchmarks.asp
2. U.S. News America’s Best Hospitals, July 17, 2006.
3. www.quality.nist.gov/Contacts_Profiles.htm
4. Press Ganey Associates 2006 Health Care Satisfaction Report,
www.pressganey.com/products_services/readings_findings/findings/2
006_health_care_satisfaction.pdf, 11.
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Section I
The Basics of
Benchmarking
1
Introduction to
Benchmarking
A
s organizations strive to improve their performance, some-
one always seems to ask “How are others doing this?” or
“How do we compare to others like us?” or “Has anyone else
figured out a better way to do this?” Questions like these are moti-
vations for benchmarking.
The term benchmarking is often mentioned in the hospital qual-
ity literature, but the process of benchmarking is often misunderstood.
The American Society for Quality (ASQ) defines benchmarking as an
improvement process in which an organization measures its perfor-
mance against that of best-in-class organizations, determines how
those organizations achieved their performance levels, and uses that
information to improve its own performance. The subjects that can be
benchmarked include strategies, operations, processes, and proce-
dures.1 Key aspects of this definition address
• Who? The benchmark target is best-in-class.
• How? Determine how the target achieves its results.
• Why? Use this information to improve our processes.
• What? Strategies, operations, processes, and procedures may
be benchmarked.
Another frequently cited definition of benchmarking is that it
is the process of comparing and measuring an organization’s op-
erations or its internal processes against those of a best-in-class
3
4 Section I: The Basics of Benchmarking
performer from inside or outside its industry.2 This definition in-

troduces another key aspect:
• Where? The target need not be in our own industry.
This is reflected by Joseph M. Juran, the noted quality expert,
who wrote, “As the health industry undertakes . . . change, it is well
advised to take into account the experience of other industries in or-
der to understand what has worked and what has not. . . . The health
industry is different . . . however the decisive factors in what works
and what does not are the managerial processes, which are alike for
all industries.”3
“Steal shamelessly and implement profusely the things that work in

other industries.”
“Quality and Quality Improvement in Health Care Services”
www.asq.org/health/articles
The working definition that we will use throughout this book is

that benchmarking is an improvement process in which an organiza-
tion measures its strategies, operations, or internal process perfor-
mance against that of best-in-class organizations within or outside
its industry, determines how those organizations achieved their per-
formance levels, and uses that information to improve its own perfor-
mance. The balance of this chapter will explore the five key aspects
of this definition:
• Strategies, operations or internal processes may be
benchmarked
• The benchmark target is best-in-class
• The target need not be in our industry
• Determine how the target achieves its results
• Use this information to improve our processes
NATIONAL BENCHMARKS, INDUSTRY

AVERAGES, OR INTERNAL PROCESSES
True benchmarking is not simply comparing a few outcome mea-
sures against industry averages. This is more like a scoreboard an-
swering the question “Who is winning?” or “Am I above or below
Chapter One: Introduction to Benchmarking 5
average?” The answers to these questions are not very instructive

about how to improve operations.
The Agency for Healthcare Research and Quality (AHRQ) has
published a document entitled “Hospital Survey on Patient Safety
Culture: Comparing Your Results: Preliminary Benchmarks.” This
report may be downloaded from www.ahrq.gov/qual/hospculture/
prebenchmk.htm. The methodology involves surveying 20 represen-
tative hospitals in the United States and provides a good estimate of
the national average for patient safety culture. The result on one item
illustrates why national averages are not appropriate for benchmark-
ing. The report shows that only 50 percent of the respondents agree
that patient safety is never sacrificed to get more work done. This re-
sponse is excellent for documenting the current state of hospitals on
this dimension, but does not represent best-in-class: a standard that
hospitals should aspire to attain.
Using national averages as benchmarks for comparison may be
of interest to the general public, government, and accreditation agen-
cies, but it is of limited value as input to a hospital’s process of con-
tinuous quality improvement (CQI). National averages fail to
provide insight into what must be done to improve. Ask yourself,
which is more instructive to your CQI program: a) knowing that
your hospital is slightly better than average nationally in turnover of
registered nursing staff, or b) understanding the processes that the
best-in-class hospital uses to obtain a registered nurse turnover rate
that is about one third of the national average?
Figure 1.1 is typical of information obtained and disseminated by
hospitals. There is value to this information. Residents of the service
Item Hospital X National average

Overall patient satisfaction 84.9 82.5
Check-in 82.0 79.0
Nurses 79.3 84.4
Doctors 84.1 85.4
Tests 85.5 85.8
Family or friends 88.9 85.5
Waiting time 83.6 87.5
Bold – Hospital X lower than national average
Italic – Hospital X higher than national average
Figure 1.1 Comparing outcome measures.

area of the hospital can judge the quality of their hospital compared
to national averages. The hospital’s quality director and quality im-
provement teams can use this information to determine areas that are
most in need of improvement. Progress of the improvement efforts
can be monitored over time to determine whether the actions taken
are effective in closing the gaps.
However, for all its usefulness, the information in Figure 1.1 is
insufficient. First of all, the comparison is to a national average or a
national benchmark. Meeting the national average does not equate to
excellence. It may not equate even to sufficiency.
According to the Press Ganey Associates 2006 Health Care
Satisfaction Report,4 the average wait time in 2005 at a hospital
emergency room was 4.2 hours for a single visit. If the average ER
wait time in your hospital ER is four hours, it is better than the
national average. Is that sufficient? Wouldn’t it be better to know
what the ER wait time is at the best hospitals? Wouldn’t it be even
better to understand how those best-in-class hospitals achieved the
benchmark standard ER wait times?
A Canadian study found that 7.5 percent of patients experienced
at least one adverse event because of medical error in 2000.5 If your
hospital has a medical error rate of 7 percent, it is better than the na-
tional average. Is that sufficient? Wouldn’t it be better to know what
the error rate is at the best hospitals? Wouldn’t it be even better to
understand how those best-in-class hospitals achieved the bench-
mark standard medical error rates?
The Leapfrog Hospital Quality and Safety Survey6 found that
50 percent of hospitals do not have procedures to prevent bed sores.
If your hospital does have such procedures, you are above the
national average. Again, is that sufficient? Wouldn’t it be better to
know what the procedures are at the hospitals with the lowest inci-
dence of bedsores?
Benchmarking should be approached by investigating industry practices

first. The metrics can be obtained or created later. One cannot determine
why a gap exists from the metrics alone. Only practices on which the
metric is based will reveal why.
American Society for Quality7
Without information about the processes used by the best hospi-

tals, we must approach improvement by reinventing the wheel. We
are doomed to make the same mistakes that other hospitals have
made and learned from. A problem with national averages is that we

don’t even know which hospitals are the best performers.
National averages also provide no measure of variation in perfor-
mance and no information about the level for best-in-class performers.
Variation in performance can be a bigger problem than average perfor-
mance. The Nebraska Medical Center’s interventional radiology de-
partment undertook to improve major problems in delays in treatment
that created patient dissatisfaction and loss of patients.8 They found that
it took an average of 1.4 calls to schedule an appointment. Further
analysis revealed that the standard deviation* was 0.989 calls with a
maximum of seven calls. After several improvement projects had been
completed, the average was still 1.4 calls. However, the standard devi-
ation had been reduced to 0.52 calls with a maximum of three calls.
The process was significantly improved, but the average did not reflect
the improvement.
INITIATION OF THE
BENCHMARKING PROCESS
Initiation of the benchmarking process can occur in one of two ways:
top down or bottom up. Top down initiation results from decisions
made at the highest level of the hospital—the Board/CEO/Executive
Team level. Benchmarking directed at activities that will signifi-
cantly affect the mission, vision, goals, and/or strategies of the or-
ganization is generally initiated from the top. Also, benchmarking
directed to organization-wide processes is also often initiated from
the top.
Bottom-up initiation begins with a champion in the ranks of the
organization. The champion could be a department head who wants
her operation to become world-class, or individual employees who
are passionate about finding the best way to do their jobs. Bench-
marking directed at specific processes that reside primarily within a
sub-system of the organization is often initiated bottom-up. For ex-
ample, benchmarking activities associated with improving patient
waiting in the Emergency Department would often be bottom-up.
Regardless of whether initiation is top-down or bottom-up, to
be successful in improving the organization, top management
commitment and involvement are required. Both involvement and
*Standard deviation is a measure of the spread or dispersion of a distribution. The

larger the standard deviation, the larger the spread of the values in the distribution.
commitment are important. One is insufficient without the other. One

necessary form of commitment is providing resources—the scarcest
of which is usually time. While monetary commitment is required to
fund travel, data collection, and other benchmarking efforts, at least
the key members of the benchmarking team should be provided par-
tial release from their routine duties in order to accomplish the project.
But commitment of resources is not enough. Top leadership also
must be committed to making change. Some changes may be able to
be made within the existing organizational culture. Others may re-
quire a culture change. Most people find change to be difficult, so
this commitment requires effort. All of the constituents of the orga-
nization must be convinced of the need for a culture change and must
be provided the opportunity to participate in the change. In some
cases, a culture change may result in an upward spike in turnover as
employees uncomfortable with the change elect to leave the organi-
zation. Skilled and committed leadership is the most essential re-
quirement in order for the organization to successfully realign itself.
The top leaders also must be involved in the benchmarking
process in order to facilitate the change that will be necessary in or-
der to implement what was learned from the best-in-class organi-
zations. Without both commitment and involvement from top
leadership, it is unlikely that the benchmarking project will lead to
meaningful change within the organization.
STRATEGIC AND OPERATIONS

BENCHMARKING
Strategic benchmarking is usually initiated top-down and is focused
primarily on strategic issues related to the organization’s mission,
vision, strategic goals, and strategies. Strategic benchmarking pro-
vides the criteria for decision making at all levels and within all de-
partments of the organization. For that reason, there are always a
number of operational benchmarking sub-projects stemming from
benchmarking which has been initiated from a strategic perspective.
One specific focus of strategic benchmarking is often improving
weaknesses or capitalizing on strengths in the internal environment
or addressing threats or capitalizing on opportunities in the external
environment. An example of strategic benchmarking would be a
benchmarking project initiated by the leadership team at a hospital
to improve processes in outpatient surgery to increase physician and
patient satisfaction and improve clinical outcomes in response to
news that an independently owned outpatient surgery center is being
proposed for location in the hospital’s primary service area.
Operational benchmarking may be initiated either top-down or

bottom-up, but most often it is bottom-up. The usual focus of oper-
ational benchmarking is a single process or related group of pro-
cesses. The objective is to understand ways in which these processes
can be improved, for example, to increase customer satisfaction, in-
crease efficiency, or decrease errors. An example of operational
benchmarking would be a benchmarking project initiated by the
head of the emergency department to improve the admissions and
triage processes to decrease patient waiting time.
Strategic and operational benchmarking are not mutually exclu-
sive. The result of an operational benchmarking project may develop
a distinctive strength in the organization that then becomes part of a
larger strategic benchmarking project to leverage that advantage.
Strategic benchmarking projects often involve a number of opera-
tional benchmarking sub-projects directed at specific processes.
BEST-IN-CLASS
While it is useful to discuss improvement efforts with other hospi-
tals that are convenient, in order to aspire for excellence you must go
beyond convenient and compare yourself to excellent hospitals—
those recognized as being best-in-class. One such best-in-class hos-
pital is Robert Wood Johnson University Hospital Hamilton.9 It won
the 2004 Malcolm Baldrige National Quality Award (MBNQA). It
had a quality program in place in 1999 that was based on its five pil-
lars of excellence—service, finance, quality, people, and growth.
Looking for ways to better serve its customers, the hospital’s man-
agement decided to use the MBNQA criteria as a “framework . . .
for leadership and acceleration of our quality journey.”10 One of its
achievements is best-in-class service in the Emergency Department
(ED). Their 15/30 Program guarantees that every patient will be seen
by a nurse within 15 minutes and by a doctor within 30 minutes of
entering the ED. The hospital backs this program with an extraordi-
nary guarantee—if it fails to meet this guarantee, the ED portion of
the bill will be waived upon patient request. This program has con-
tributed to overall hospital success since 70 percent of the hospital’s
inpatients enter through the ED. Patient satisfaction in the ED was
crucial to the hospital’s success. Payout on the 15/30 guarantee is
less than 1 percent, indicating that they have a process in place to
achieve the desired results. Patient satisfaction with ED increased
from 85 percent in 2001 to 90 percent in 2004.
Another hospital has an average time from entering the ED to
seeing a physician of 47 minutes. The graph on its website shows
that this is better than the national norm of about 55 minutes.

Clearly, this is an above-average hospital, but it is not best-in-class.
It should benchmark against Robert Wood Johnson University Hos-
pital Hamilton’s best-in-class performance—not the national norm.
INSIDE OR OUTSIDE YOUR INDUSTRY

While there are a number of hospitals recog-
nized for excellence (e.g. six have won the
MBNQA since 2002), hospitals need not
restrict their search for benchmarking
partners to other hospitals. For example,
there are processes that hospitals share
with hotels. Another MBNQA winner is
the Ritz-Carlton Hotel Co. (1992 and
1999). Its approaches to employee training,
room service, custodial services, customer orientation, and quality
metrics could be instructive to hospitals. Disney is well known for
employee training and customer orientation—both important to hos-
pitals. Both of these organizations were used as benchmark stan-
dards by Bronson Methodist Hospital,11 a best-in-class hospital.
Columbus Children’s Hospital has benefited from operational
benchmarking against the aviation industry. Under the leadership of
Donna Caniano, MD, Surgeon-in-Chief, the hospital has implemented
an innovative approach to ensuring the safety of surgery patients. The
program is called “Operation Takeoff” and was developed by Chil-
dren’s Quality Initiative in Surgery (CQIS) team. Before the beginning
of an operation, the OR team completes a checklist much like a pilot
completes a preflight checklist before taking off. The purpose of the
checklist is to confirm “the name and age of the patient, allergies,
proper incision marking, required antibiotics, and other identifiers that
are unique to each patient.” Terry Davis, MD, Chief Surgical Officer,
says that this “kind of standardization which has made aviation as safe
as it is will be useful in the OR environment.”12, 13
Great Ormond Street Hospital for Children, Britain’s largest chil-
dren’s hospital, benchmarked its patient handoff techniques against
Italy’s Formula One Ferrari racing team. The motivation was a 2005
study that found that nearly 70 percent of preventable hospital errors
occurred because of poor communication and that half of those
problems occurred during handoffs. The hospital improved its pa-
tient handoff techniques by adopting procedures similar to the chore-
ographed pit stops of the racing team.14
Benchmarking is not just copying what other successful organi-

zations are doing. It involves not only understanding what best-
in-class organizations’ goals are and how they have addressed
achieving those goals through improvement of processes and opera-
tions, but also taking that information
back to your own organization to deter-
mine how to achieve comparable results
given the particular internal and exter-
nal conditions that are unique to your
organization. This process will make
your hospital better.
DETERMINING HOW THE BENCHMARK

TARGET ACHIEVES ITS RESULTS
Every organization operates within an external environment mani-
festing unique opportunities and threats. The organization also has
its own internal environment composed of unique strengths and
weaknesses. Environmental and strategic factors affect processes. In
order to understand why certain processes are effective within par-
ticular organizations, it is necessary to understand the strategic and
environmental factors within which the organization operates and
how the organization has responded to them. Differences in these
factors can explain why processes which are effective for one orga-
nization are less effective in another organization. The best way to
understand these factors and their interaction with the processes of
interest is to observe the processes and document the strategic and
environmental factors within which they operate. In Chapter 4 we
will discuss how to do this using the S32 framework to assist in the
collection and analysis of benchmark data.
ETHICS, ETIQUETTE, AND

BENCHMARKING PROTOCOL
The Quality Management Division of the American Society for Qual-
ity has developed the Benchmarking Code of Conduct in Figure 1.2.
Failure to follow these guidelines can result in a variety of negative
outcomes including potential legal liability issues and breach of trust
leading to reluctance to share information in the future. Following the
guidelines will help to assure that all parties in the benchmarking pro-
ject benefit from the experience.
Preamble—To guide benchmarking encounters and enhance the pro-

fessionalism and effectiveness of benchmarking many organizations
have adopted this common Code of Conduct. All organizations are
encouraged to abide by this Code of Conduct. Adherence to these
principles will contribute to efficient, effective, and ethical bench-
marking.
1. Principle of Legality.
• If there is any potential question on the legality of an issue, don’t
do it.
• Avoid discussions or actions that could lead to or imply an inter-
est in restraint of trade, market, and/or customer allocation
schemes, price fixing, dealing arrangements, bid rigging, or
bribery. Don’t disclose costs with competitors if costs are an ele-
ment of pricing.
• Refrain from the acquisition of trade secrets from any means
that could be interpreted as improper, including the breach of
any duty to maintain secrecy. Do not disclose or use any trade
secret that may have been obtained through improper means or
that was disclosed by another in violation of a duty to maintain
secrecy or limit its use. Do not, as a consultant or client, extend
one benchmarking effort’s findings to another company without
first obtaining permission from the parties of the first effort.
2. Principle of Exchange.
• Be willing to provide the same type and level of information that
you request from your benchmarking partner to your benchmark-
ing partner.
• Communicate fully and early in the relationship to clarify expec-
tations, avoid misunderstanding, and establish mutual interest in
the benchmarking exchange. Be honest and complete.
3. Principle of Confidentiality.
• Treat benchmarking interchanges as confidential to the individ-
uals and companies involved. Information must not be com-
municated outside the partnering organizations without the
prior consent of the benchmarking partner who shared the
information.
• A company’s participation in a study is confidential and should
not be communicated externally without permission.
4. Principle of Use.
• Use information obtained through benchmarking only for pur-
poses of formulating improvement of operations or processes,
within the companies participating in the benchmarking effort.
Figure 1.2 ASQ Quality Management Division benchmarking code

of conduct.15
• The use or communication of a benchmarking partner’s name

with the data obtained or practices observed requires prior per-
mission of that partner.
• Do not use benchmarking as a means to market or sell.
5. Principle of First Party Contact.
• Initiate benchmarking contacts, whenever possible, through a
benchmarking contact designated by the partner company.
• Respect the corporate culture of partner companies and work
within mutually agreed upon procedures.
• Obtain mutual agreement with the designated benchmarking
contact on any hand-off or communication or responsibility to
other parties.
6. Principle of Third Party Contact.
• Obtain an individual’s permission before providing his or her
name in response to a contact request.
• Avoid communicating a contact’s name in an open forum without
the contact’s permission.
7. Principle of Preparation.
• Demonstrate commitment to the efficiency and effectiveness of
benchmarking by completing preparatory work prior to making
an initial benchmarking contact and follow a benchmarking
process.
• Make the most of your benchmarking partner’s time by being
fully prepared for each exchange.
• Help your benchmarking partners prepare by providing them
with an interview guide or questionnaire and agenda prior to
making benchmarking visits.
8. Principle of Completion.
• Follow through with each commitment made to your bench-
marking partners in a timely manner.
• Complete each benchmarking effort to the satisfaction of all
benchmarking partners, as mutually agreed.
9. Principle of Understanding and Action.
• Understand how your benchmarking partners would like to be
treated.
• Treat your benchmarking partners in the way you would like to
be treated.
• Understand how each benchmarking partner would like to have
the information he or she provides handled and used, and han-
dle and use it in that manner.
Figure 1.2 ASQ Quality Management Division bench- (Cont’d.)

marking code of conduct.15
CHAPTER SUMMARY
• Benchmarking is an improvement process in which an

organization measures its strategies, operations, or
internal process performance against that of best-in-class
organizations within or outside its industry, determines how
those organizations achieved their performance levels, and
uses that information to improve its own performance.
• Benchmarking goes far beyond simply a comparison to
national averages.
• Benchmarking may be directed toward either strategic or
operational objectives.
• Benchmarking may be initiated top-down or bottom-up. But
either way, top management commitment and involvement
are required.
• It is important to follow the guidelines for ethics, etiquette,
and benchmarking protocol. Failure to do so may isolate you
from best-in-class benchmarking targets or expose you to
legal liabilities.
REFERENCES
1. “The Quality Glossary.” Quality Progress, June 2007, 41.
2. Goetsch, D. and S. Davis. Quality Management: Introduction to Total
Quality Management for Production, Processing, and Services, 4th
ed., Upper Saddle River, NJ: Prentice Hall, 2002.
3. Juran, J. and D. Berwick. Curing Health Care, NJ: John Wiley &
Sons, 1990.
4. Press Ganey Associates 2006 Health Care Satisfaction Report,
www.pressganey.com/products_services/readings_findings/findings/2
006_health_care_satisfaction.pdf, 11.
5. McIlroy, A. “Hospitals Moving Slowly to Cut Down Medical Errors.”
The Toronto Globe and Mail, May 24, 2004. A21
6. Leapfrog Hospital Quality and Safety Survey, 2005,
www.leapfroggroup.org
7. www.asq.org/ learn-about-quality/benchmarking/overview/
overview.html
8. Volland, J. “Quality Intervenes at a Hospital.” Quality Progress,
February 2005, 57–62.
9. Nelsen, D. “Baldrige—Just What the Doctor Ordered. Quality

Progress, October 2005, 69–75.
10. See note 9.
11. Serbenski, M. Executive Director, Corporate Effectiveness &
Customer Satisfaction, Bronson Methodist Hospital, Personal
Communication, October 2006.
12. “ ‘Operation Takeoff’: Changing How Surgery Takes Flight at
Children’s.” Spotlight, December 2005, 3.
13. Caniano, D., MD, Surgeon-in-Chief, Columbus Children’s Hospital,
Personal Communication, October 2005.
14. Naik, G. “A Hospital Races to Learn Lessons of Ferrari Pit Stop.”
Wall Street Journal, November 14, 2006, 1.
15. Okes, D. and R. Westcott (eds.). The Certified Quality Manager
Handbook, Milwaukee, WI: ASQ Quality Press, 2001, 193–194.
INFORMATION RESOURCES
Agency for Healthcare Research and Quality. Hospital Survey on Patient
Safety Culture: Comparing Your Results: Preliminary Benchmarks.
www.ahrq.gov/qual/hospculture/prebenchmk.htm
Camp, R. Business Process Benchmarking: Finding and Implementing
Best Practices, Milwaukee, WI: ASQC Quality Press, 1995.
Camp, R. (ed.). Global Cases in Benchmarking, Milwaukee, WI: ASQ
Quality Press, 1998.
Czarnecki, M. Managing by Measurement: How to Improve Your
Organization’s Performance Through Competitive Benchmarking,
New York: AMACOM, 1999.
Fitz-Enz, J. The 8 Practices of Exceptional Companies: How Great
Organizations Make the Most of Their Human Assets, New York:
AMACOM, 1997.
Sower, V. “Benchmarking in Hospitals: When You Need More Than a
Scorecard.” Quality Progress, August 2007, 58–60.
2
General Process
for Benchmarking
A
systematic approach to bench-
marking is necessary in order for
the organization to adapt, not
just adopt, best-in-class processes to its
particular strategic and environmental
factors. The process we will use in this
book is an adaptation of Robert Camp’s1
five-phase benchmarking process and
QAP’s2 seven-phase general approach to
benchmarking. This six–phase process
is shown in Figure 2.1.
PLANNING
Decide What to Benchmark
Deciding what to benchmark is the first
task in the benchmarking process. A
strategic approach to deciding what to
benchmark is to identify those processes
that must be improved to achieve the vi-
sion of the organization. This often
leads to more questions to clarify the vi-
sion. If our vision is to be the best hos-
pital in our service area, we must clearly
identify the service area and what we
17
Planning
Decide what to benchmark
Define benchmarking team
Identify whom to benchmark
Establish baseline for existing process
Define objectives and criteria for success
Data Acquisition
Questionnaires/surveys
Workshops/conferences
Site visits
Published documentation
Analysis
Determine the performance gap
Project future performance levels
Integration
Communicate benchmarking findings and gain acceptance
Establish performance goals
Action
Develop improvement strategy
Develop action plans
Implement and monitor progress
Recalibrate the benchmarks
Maturity
Determine when best-in-class position is attained
Develop objectives for continuing improvement
Figure 2.1 Six-phase benchmarking process.
mean by best. The definition of “best” is inevitably a multidimen-

sional construct. One hospital’s definition revolves around its five
pillars of excellence: service, finance, quality, people, and growth.
Another hospital’s definition is embodied in its three Cs: clinical
Chapter Two: General Process for Benchmarking 19
excellence, customer and ser- What to benchmark

vice excellence, and corporate Benchmark team
Whom to benchmark
effectiveness. The pillars or Establish baseline
Cs are dimensions of the ex- Define objectives
cellence construct.
Within each dimension,
critical-to-quality measures
are developed and strategic
objectives established. For ex-
ample, market share could be
a measure under corporate ef-
fectiveness. One measure of
how well a hospital is achieving the vision of being the best hospital
in our service area could be market share. The best hospital in the
service area should have the highest market share. Market share
would then become a critical-to-quality measure for this dimension.
A strategic goal could be established to attain the highest market
share in the service area.
The interrelationship among the dimensions and measures must
be recognized. For example, attaining higher market share can be
seen as an outcome of other processes. If our patients are more sat-
isfied, achieve better clinical outcomes, and are exposed to fewer
safety risks while in our hospital, we will attract more patients and
achieve a higher market share.
With multiple interrelated dimensions, measures, and strategic
goals it can be difficult to determine what to focus on first. Some
method of prioritization must be developed. Qualitative estimates of
relative importance can be useful. This involves discussions with
key stakeholders within and outside the organization about what di-
mensions or measures would be most important to improve. One of
the most commonly used approaches is stakeholder analysis, which
consists of listing the major stakeholders and identifying their rela-
tive importance and specific interests for the hospital. Usually the
decision on what to focus on first would be directed by which of
those stakeholder interests are most commonly shared and have the
highest value for the major stakeholders. A classification into cate-
gories of relative importance is often sufficient. An example of the
outcome of such an analysis is depicted in Figure 2.2. It should be
noted that being in the C category does not mean that a particular di-
mension or measure is unimportant. All dimensions and measures
are important. The classification system simply classifies these
items by relative importance at a particular point in time to allow for
prioritization of effort.
A Items—Most important
Hospital acquired infection rate
Registered nurse turnover
B Items—More important
Inpatient satisfaction
Professional employee development
Collection of past due accounts
ER patient satisfaction
Ventilator associated pneumonia rate
C Items—Important
Non-professional staff turnover
Leadership development
Staff succession planning
Employee satisfaction
Community health services
Knowledge management
Occupancy rate
Figure 2.2 Example of relative importance classification.
Input from all constituents, from members of the board to pa-

tients, staff, physicians, and citizens of the community, is important
in developing the benchmarking priority list. With multiple bench-
marking teams, a number of benchmarking projects can be con-
ducted simultaneously. For this reason, it often is unnecessary to
identify the single most important dimension or measure.
Define the Benchmarking Team

Deciding what to benchmark informs the next step: defining the
benchmarking team. All disciplines and departments with a stake in
the process being benchmarked should be represented. This is im-
portant to developing ownership for the new process. Other criteria
such as expertise, time availability, respect within the organization,
interpersonal relations, leadership, and communication skills might
be used.
Identify Whom to Benchmark

Once the decision has been made about what to benchmark and who
comprises the team, the next question is “Who does this better than
anyone else?” Superior performing hospitals can be identified by a
variety of means including third-party ratings such as those by U.S.
News & World Report and Solucient, published articles, and lists of
past winners of state and national quality awards.
After identifying a possible benchmark, it is important to con-
tinue the research to assure that the hospital is a true best-in-class
performer in the particular area in which you wish to benchmark.
Benchmarking against a convenient hospital—one that is not best-in-
class—may provide you with just another way to achieve less than
best practice results.
Best practice is a superior method or innovative practice that

contributes to the improved performance of an organization, usually
recognized as best by other peer organizations.
American Society for Quality3
It is important not to exclude best-in-class organizations outside

the healthcare field. Remember, Bronson Methodist Hospital identi-
fied the Walt Disney Company and Ritz Carlton Hotels, and Great
Ormond Street Hospital identified the Ferrari Racing Team as best-
in-class organizations from whom they could learn best practices to
incorporate into their hospital practices.
Establish Baseline for Existing Process

Before considering examining processes in other organizations, the
benchmarking project team should define the existing process in
their own organization. A good starting point for this is to use flow-
charting. Flowcharting is a step-by-step graphical documentation of
the process from beginning to end. Process and outcome measures
should be established for the existing process.
Establishing a baseline is essential to being able to document the
improvements gained from the benchmarking project. In addition,
the process of flowcharting a process often reveals improvements
that can be made relatively quickly and easily. Establishing the base-
line as a team also serves to put everyone on the same page and gen-
erates questions to be answered when collecting information from a
best-in-class organization.
Define Objectives and Criteria for Success

The team next defines the objectives of the benchmarking project.
Objectives could include specific outcomes expected, time schedule
for the project, work breakdown structure and assignment of tasks to
team members, and specific process requirements. Criteria for suc-
cess could include such things as cost targets, time targets, and
process and outcome targets. An example of a statement of the cri-
teria for success would be to achieve being recognized as having the
lowest ventilator associated pneumonia (VAP) rate for any hospital
in our seven-county service area by the end of the next fiscal year
and the lowest VAP in the state within two years, at a total project
cost not to exceed $250,000.
It is important to realize that improvements to processes gener-
ally provide not only measurable improvements in quality, but have
an economic return on investment as well. A hospital that invests in
process improvements with the intent of reducing RN turnover rate
will derive a quality benefit from retaining experienced professionals
and continuity of service, and economic benefits as well. For a hos-
pital with a staff of 500 nurses, reducing the turnover rate to 5 percent
from 10 percent could save more than $1 million per year at current
average replacement expenses for RNs.
DATA ACQUISITION
A number of options exist for gathering data. These include pub-
lished articles, questionnaires, and attendance at conferences. The
most important means for data acquisition is a site visit. It is impor-
tant to observe the best-in-class processes firsthand. Equally impor-
tant is discussing with those
responsible for the processes Questionnaire/survey
how they achieved best-in- Workshop/conference
Site visits
class performance levels— Published
what worked and what didn’t documentation
work. Tools for acquiring and
analyzing the necessary data
and information are the sub-
ject of Chapter 3.
An important data collec-
tion step is to carefully docu-
ment the process. Flowcharts
can be useful in accomplish-
ing this. See Figure 2.3.
3.2-4 Patient Complaint Management Process
Complaint received through patient contact, telephone, e-mail,

correspondence, survey, Web, physician office; log into patient
complaint management database
Analyze complaint, assessing accountability for resolution
Sufficient no Contact patient for further information

information to or investigate internally
resolve
yes
Resolve complaint, communicate to patient, log resolution in

database, share lessons learned with appropriate department,
team, leadership
Aggregate data, analyze trends, identify system issues, report

to CASE SOT monthly, grievance committee and ET quarterly
CASE SOT prioritizes system issues, charters learn to use

PDCA model for improvement
Customer-focused knowledge sharing at monthly

management update
Figure 2.3 Process flowchart.4

The flowcharts for the best-in-class processes can be compared

with the baseline flowcharts. This comparison often yields many
specific ideas for improvements.
In addition to documenting the best-in-class process, other im-
portant data that should be collected includes:
• What are the key elements of the external environment that
influenced the design and functioning of this process?
Specific examples of information to be collected:
Nature of the competitive environment
Nature of the patient base
Nature of the local economy
External threats or opportunities that this process ad-
dressed
• What are the key elements of the internal environment that
influenced the design and functioning of this process?
Specific examples of information to be collected:
Organization’s mission and vision and their relationship to
the design of the process
Quality and role of leadership
Quality and stability of staff
Internal strengths that were capitalized on when designing
the process
Internal weaknesses that had to be addressed during the
process design
Resources required for the new process
• What worked and what didn’t work during the process
design?
ANALYSIS
Determine the Performance Gap
Gap analysis is comparing the current state of a measure or process
with the desired state or some standard. Figure 2.4 shows a gap
analysis for overall patient satisfaction. When compared to the na-
tional average, My Hospital looks very good. But when compared to
Overall Patient Satisfaction
Gap between
100 My Hospital and
Best-in-class
95
Percent Satisfied
90
My Hospital
85 National average
Best-in-class
80
75
70
1 2 3 4 5
Time Period
Figure 2.4 Gap analysis.
a best-in-class hospital, there is a Determine

gap. This gap is what is to be ad- performance gaps
Project future
dressed by improvement efforts performance levels
associated with the benchmarking
project.
Gap analysis need not be con-
fined to measures of processes.
Comparison of the baseline flow-
chart or current state map (Figure
2.5) for your hospital to the flow-
chart or map for the same process
in the best-in-class hospital can
be quite instructive. Steps in the baseline process that are not also
present in the best-in-class process can be analyzed to determine
whether they add value. Because the environments of hospitals dif-
fer, processes to accomplish the same outcomes may need to differ
substantially, so simply copying another hospital’s process is rarely
appropriate or effective. You must develop improvements that are
appropriate for your environment.
Project Future Performance Levels

Project how the gap will widen or narrow in the future if nothing is
done differently. Is this projection acceptable? What are the ramifi-
cations of the gap on organizational performance? If we find that
Primary care
physician
26
Ambulance
??? Waiting Record Waiting

02CH_Sower_575077.qxd
time time Walk-in
Patient receiving Registration Admitting

Fast track
Processing time = Processing time = Processing time =
11/6/07
Reliability = Reliability = Reliability =

Accurate and Accurate and Accurate and
complete = complete = complete =
Quality = Quality = Quality =
Shifts = Shifts = Shifts =
Number of people = Number of people = Number of people =
11:04 AM
Difficulty = Difficulty = Difficulty =

Shared Shared Shared
Section I: The Basics of Benchmarking
Treatment plan Patient receiving Admit

Page 26
Waiting Waiting Major care Waiting

time time time
Figure 2.5 Current state map of ER.5

Waiting Waiting
time time
Doctor assement Disposition Discharge

11/6/07

11:04 AM

Number of people = Waiting Number of people = Number of people =
time
Shared X-ray Waiting Waiting Shared Shared
time time
Page 27
Imaging Read films Transfer

Chapter Two: General Process for Benchmarking
27
Figure 2.5 Current state map of ER.5 (Cont’d.)

existing plans are not sufficient to close the gap or will result in our
falling further behind the best-in-class performers, we then have
strong motivation for developing new plans.
INTEGRATION
Communicate Benchmarking Findings and Gain Acceptance
Frequently the first reaction to findings about best-in-class bench-
marks is disbelief and denial. It is important to communicate bench-
mark findings in a way that engenders acceptance and commitment
to make improvements based on the findings. Documentation to sup-
port the benchmarking findings and gap analysis are helpful in gain-
ing acceptance and commitment.
“Visiting (best-in-class) companies to watch them in action can be

great, but the exercise is pointless unless your own people are ready
to embrace outside ideas. If they’re not, some adjustment to your
culture is . . . necessary. . . . You’ve got to kill any not-invented-
here syndrome and replace it with a new value of open-mindedness.”
Jack Welch and Suzy Welch6
The best way to overcome resistance is to involve those respon-

sible for the process as participating members of the benchmarking
team. It is more difficult to refute what you have seen with your own
eyes than it is to refute what someone else purports to have seen.
One of the authors, at the time
Communicate a general manager, experi-
Benchmark findings enced this firsthand when
and gain acceptance
Establish performance benchmarking a process. When
goals the author reported what he
had seen, his staff was incred-
ulous. Acceptance didn’t come
until he arranged for key mem-
bers of his staff to visit the
best-in-class company to see
for themselves. The staff mem-
bers came back believing, but
more importantly, they came
back ready for change. And they also came back with ideas for how
they could adapt what they had seen to their processes.
Establish Performance Goals

What should be our goals for closing the gap? In what specific areas
are improvements required in order to achieve these goals? How will
the practices of best-in-class hospitals guide the improvement
process? What will be the magnitude of the gap when these perfor-
mance goals are achieved?
Develop improvement
ACTION strategy
Develop action plans
Implement and monitor
Develop Improvement Recalibrate Benchmark
Strategy
Identify specific actions based
on the best-in-class hospital
that will enable you to appro-
priately change your process
to close the performance gap.
Develop Action Plans

Develop specific plans to implement the actions identified above.
The benchmarking team should assign responsibilities and develop
time tables for completion of the plans as well as measures to mon-
itor progress. It is important to involve key constituents in this step
of the benchmarking process in order to assure acceptance of the fi-
nal result.
Implement and Monitor Progress

After acceptance of the plan by the benchmark team and top man-
agement, the plan must be implemented. Periodic status reports
should be developed and presented to top management and key con-
stituents.
Recalibrate the Benchmarks

Recalibration of benchmarks is a continuous process. Benchmark
standards are dynamic. Standards established today will be obsolete
as the best-in-class organizations continuously improve.
MATURITY
Determine When Best-in-Class Position Is Attained
Periodic measurement and comparison to recalibrated best-in-class
performance provides evidence for progress in closing the gap. If the
objective is to become best-in-
class, you must develop your Determine when best-
in-class position is
processes to exceed the previ- attained
ous best-in-class performance. Develop objectives
for CI
Develop Objectives for

Continuing Improvement
If your strategic objective is
“Become best-in-class,” when
you achieve this goal the ques-
tion becomes “What next?”
Does the new strategic objec-
tive become “Hold the gains”? Staying on top is a difficult job. If the
focus is just on holding the gains, other organizations will eventually
surpass you and you will have to begin the benchmarking process
anew. However, if your goal becomes to “Continuously improve to
maintain best-in-class,” then you are committing to ceaselessly pursu-
ing improvements to your best practices. This includes continuously
monitoring and recalibrating your benchmark standards as necessary.
In a competitive environment, there will be many organizations
seeking to become best-in-class. The result, illustrated in Figure 2.6,
is what Bronson Methodist Hospital refers to as competitive conver-
gence. Once you become just one of several at the top, your strate-
gic objective of being the best-in-class is obsolete. Then the process
must begin again with a new vision, new strategic objectives, new
benchmarking, and, ultimately, improved processes that will take
your organization to a new level of performance. That is shown by
the loop from Maturity back to Planning in Figure 2.1.
Hosp. C
Hosp. B
Hosp. A
time
Source: Bronson Methodist Hospital (adapted)
Figure 2.6 Competitive convergence.
CHAPTER SUMMARY
• The general benchmarking process consists of six phases:

—Planning
—Data Acquisition
—Analysis
—Integration
—Action
—Maturity
after which, you begin the process again with the same
process (continuous improvement) or with a benchmarking
project directed toward another strategic or operational
objective.
REFERENCES
1. Camp, R. Business Process Benchmarking: Finding and
Implementing Best Practices, Milwaukee, WI: ASQC Quality Press,
1995, 21.
2. Keley, E., J. Ashton, and T. Bornstein. “Applying Benchmarking in

Health.” Quality Assurance Project, Bethesda, MD: Center for
Human Services, 4.
3. “The Quality Glossary.” Quality Progress, June 2007, 41.
4. Bronson Methodist Hospital. 2005 Malcolm Baldrige National
Quality Award Application Summary, www.bronsonhealth.com/
PDFs/BaldrigeApp Summary05.p31df, 12.
5. Manos, A., M. Sutter, and G. Alukal. “Make Healthcare Lean.”
Quality Progress, July 2006, 28.
6. Welch, J. and S. Welch. “Dialing for Growth.” Business Week,
October 30, 2006, 134.
Camp, R. Business Process Benchmarking: Finding and Implementing
Best Practices, Milwaukee, WI: ASQC Quality Press, 1995.
AMACOM, 1997.
Sower, V. “Benchmarking in Hospitals: When You Need More Than a
Scorecard.” Quality Progress, August 2007, 58–60.
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Benchmarking Tools
T
here are tools that can be helpful in the different phases of the
benchmarking process. Some of these tools may be familiar;
others might be new to you. You may have used some of these
tools for problem solving, root cause analysis, accreditation compli-
ance, or in some other area. Each of these tools when used effec-
tively can make your benchmarking project easier, more efficient,
and more effective.
In Chapter 1, we defined benchmarking as an improvement
process in which an organization measures its strategies, operations,
or internal process performance against that of best-in-class organi-
zations within or outside its industry, determines how those organi-
zations achieve their performance levels, and uses that information
to improve its own performance. An important aspect of this defini-
tion is, “uses that information to improve its own performance.” The
question comes up, “How do you get the information that you need
in order to improve?” Operating in the dark will often lead to a waste
of time, labor, and ultimately money. Employee morale can also be
greatly affected. No one likes to spin their wheels. The proper tools
can help you identify problems or areas of improvement so that you
have a clearer picture of what’s going on.
In the electronic age there is an abundance of information that is
readily available. The challenge comes in filtering through the avail-
able data and making decisions based on the information at hand.
Without the right kind of data/facts, you’re operating on assump-
tions and educated guesses. While basing decisions on assumptions
may work, it is much more advantageous to base your decisions on
33
documented facts. You’ll be much more likely to persuade active in-

volvement from other groups, once they’ve been convinced that a
problem exists, or that an advantage can be gained by improving a
specific process.
Over the years numerous tools have been developed that will
help you gather the data and filter through it so that you can make
informed decisions. This chapter looks at how some of these tools
can be utilized in the improvement process. This chapter is not
meant to be a comprehensive summary of all of these tools; rather it
will look at specific tools and how they might be useful to hospitals
during the benchmarking process. Table 3.1 shows which tools
might be most useful in each phase. For a more complete listing of
tools, The Quality Toolbox1 is a great source.
FOCUS GROUPS
A focus group can be an extremely useful tool in the planning, data
acquisition, and integration phases of a benchmarking project. A fo-
cus group is a great way to gather qualitative data. How do patients
perceive the registration process of your hospital? What are the
physicians/nurses’ attitudes to-
ward a new electronic medical
records system? What are fac-
tors that affect how satisfied pa-
tients are with your hospital?
With a properly run focus group,
these are the types of questions
that can be answered. The an-
swers to these questions can pro-
vide direction about what to benchmark, initial criteria for success,
and input into the process of establishing a baseline from a customer
perspective.
An additional advantage of focus groups over surveys and
other means of collecting data is the richness of the responses. In
addition to verbal responses to the focus questions, significant in-
formation can also be obtained from non-verbal responses and
ensuing discussions.
Focus groups are usually made up of 6 to 20 people who have a
valued opinion regarding the relevant topic. It is important that the
participants are a representative group. For instance, if you wanted
to gather information on patients’ perceptions of quality of care in
your hospital, you wouldn’t have a focus group of just patients
Table 3.1 Tools for different phases of benchmarking process.
Benchmarking Phase
11/6/07
Benchmarking tool Planning Data acquisition Analysis Integration Action Maturity

Focus group X X X X
Flowcharts X X X X X
12:31 PM
Radar chart X X X X X
Control chart X X X X X
Pareto diagram X X X X
Page 35
Cause and effect diagram X X X X

Run chart X X X X X
Gantt chart X X X X X X
Reliability and redundancy X X
Failure mode and effects
analysis (FMEA) X X
Cost of quality X X X X X X
Chapter Three: Benchmarking Tools
35
entering the hospital through the emergency department (ED). Pa-

tients admitted through the ED have different characteristics from
patients being admitted off the street. Demographic information is
also an important consideration in the makeup of the focus group,
such as age, gender, ethnicity, income level, and education. This of-
ten requires running several separate focus groups. For instance, you
may want to have a focus group made up of hospital administrators
and a separate one for nursing staff.
Typically a focus group will meet with one or two facilitators for
between one to two hours. The facilitators for a focus group are
extremely important. They are the individuals that lead the discus-
sion with well thought out, open-ended questions. They encourage
participants to answer in their own words, without the feeling of
intimidation.
Properly run focus groups can generate a great deal of rich
qualitative data. Being able to draw conclusions from data is the
next step. Focus group sessions are often videotaped to allow mul-
tiple facilitators to participate in the content analysis. Content
analysis basically involves taking large amounts of qualitative data
and breaking it down into categories. There are statistical proce-
dures to follow to assure the validity and reliability of these cate-
gories, and to make sure the categories are measuring what is
assumed. The result of content analysis of focus group data can be
a list of major themes that characterize the participants’ perspective
on the topic. These themes can be analyzed further to lead to bench-
marking topics.
FLOWCHART
Flowcharts are used to define and to understand a process. ASQ de-

fines a flowchart as a graphical representation of the steps in a
process. Flowcharts (such as the one shown in Figure 3.1) are drawn
to better understand processes. They are one of the seven tools of
quality.2 There are conventions for the use of flowchart symbols (for
example see Galloway3); however, the consistent use of a given con-
Chapter Three: Benchmarking Tools 37
3.2-4 Patient Complaint Management Process
Complaint received through patient contact, telephone, e-mail,

correspondence, survey, Web, physician office; log into patient
complaint management database
Analyze complaint, assessing accountability for resolution
Sufficient no Contact patient for further information

information to or investigate internally
resolve
yes
Resolve complaint, communicate to patient, log resolution in

database, share lessons learned with appropriate department,
team, leadership
Aggregate data, analyze trends, identify system issues, report

to CASE SOT monthly, grievance committee and ET quarterly
CASE SOT prioritizes system issues, charters learn to use

PDCA model for improvement
Customer-focused knowledge sharing at monthly

management update
Figure 3.1 Process flowchart.4
vention contributes more to understanding than the selection of a

particular convention.
Flowcharts facilitate the process of continuous improvement.
Questions about which steps are value-adding and which are not are
clarified by a flowchart. “Why is this step here?” and “What can we
do to eliminate the need for this step?” are questions that flowcharts
facilitate. When used in the benchmarking process, they are very

helpful in establishing a baseline for a process to compare with a
best-in-class process.
A flowchart is an excellent tool for outlining the steps involved
in a process. It can be used in the Planning, Analysis, Integration,
Action, and Maturity phases of the benchmarking process. In the
planning phase flowcharts can be used to establish a baseline for a
process. In the analysis phase they can show performance gaps be-
tween an existing process and a best-in-class process. This graphical
comparison of existing to best-in-class can be an effective commu-
nication tool during the integration phase. They can facilitate the de-
velopment of action plans during the action phase. During the
maturity phase, comparison of the improved process with the best-
in-class process can assist in determining whether best-in-class sta-
tus has been attained.
Time-Function Map
Department Place Requisitioned

requisition item received
Place Receive
Purchasing Wait Wait Wait
order order
U.S. Mail
Transport Move Move
Ship UPS/FedEx
Supplier Lead
order
1 Day 3 Days 1 Day 4 Days 6 Days 1 Day 4 Days 1 Day 1 Day 1 Day
23 Days
A special form of the flowchart is the time-function map. It consists

of a flowchart with responsible parties on the vertical axis and a time
line on the horizontal axis. It is especially useful in identifying time-
consuming steps in a process and where most time is lost due to
waiting or movement. A time-function map is very effective in
baselining a process where the objective is to reduce the cycle time
or the waiting time. Figure 3.2 shows a time-function map created
for the process of ordering materials in a hospital. This can be com-
pared with a map of the same process in a best-in-class hospital to
identify an improvement objective. With a time-function map you
can address the same questions as with a flowchart but in addition
ask “Why does each step take so long to complete?”
Place Requisitioned
11/6/07
Department
requisition item received
Place Receive
Purchasing Wait Wait Wait
order order
12:31 PM
U.S. Mail
Transport Move Move
Ship UPS/FedEx
Supplier Lead
order
Page 39
1 Day 3 Days 1 Day 4 Days 6 Days 1 Day 4 Days 1 Day 1 Day 1 Day
23 Days
Figure 3.2 Time-function map.

39
RADAR CHART
Radar charts are very good at Respect and caring
monitoring your progress on 6.5

several variables and obtain- First impression 6 Effectiveness
ing a concise visual depiction 5.5
on one chart that shows where 5
you are with respect to your

benchmarking goals. They are Meals Appropriateness
excellent for graphically de-

picting multiple dimensions Information
or metrics during the plan- Current
ning, analysis, integration, ac- Goals
tion, and maturity phases of the benchmarking process. During the

planning phase, they are useful for establishing a baseline for exist-
ing processes and metrics. During the analysis phase they provide a
graphical representation for gap analysis and are useful in defining
the relative magnitude of the gaps for multiple metrics and facilitate
acceptance by others during the integration phase. They also provide
a graphical means for showing performance goals for multiple met-
rics. They provide a graphical means for monitoring progress and
assist in recalibrating the benchmarks during the action phase. Dur-
ing the maturity phase, radar charts are useful for determining when
best-in-class position is attained and identifying other gaps to be ad-
dressed in the continuous improvement program. In this phase they
are also useful for monitoring and controlling key processes.
Figure 3.3 is an example of a radar chart that a hospital is using
to monitor patients’ perception of quality of care in the following
categories: respect and caring, effectiveness, appropriateness, infor-
mation, meals, and first impression.5
Each spoke represents a specific factor that the hospital wants to
measure. Survey results from recently discharged patients are shown
by the dashed line. The quality improvement team has determined a
benchmark target for each category that is shown by the solid line.
This benchmark target could be developed by use of national data-
bases or actually benchmarking a best-in-class hospital. For some
metrics, benchmark targets could be obtained from outside the
healthcare industry. For example, an appropriate benchmark for
meals might be a best-in-class hotel’s room service process. The in-
formation in this example indicates that the hospital is close to
achieving their goals in the area of respect and caring, but the area
of satisfaction with meals has the largest gap from their desired level
and might be selected as the next improvement project.
Respect and caring

7
6.5
First impression 6 Effectiveness
5.5
Meals Appropriateness
Information
Goals Current
Figure 3.3 Radar chart.
CONTROL CHARTS
Control charts are used to measure the stability of processes. They

are variations of run charts, which are helpful in visualizing trends
or patterns over time. Unlike run charts, control charts provide
Control chart: not satisfied

Not satisfied = 1, 2, or 3 response on any question.
0.6
0.5
Proportion not satisfied
0.4
CL
p
0.3
UCL
LCL
0.2
CL before ⫽ .303
CL after ⫽ .193
0.1 Sigma level: 3
0
200202
200204
200206
200208
200210
200212
200302
200304
200306
200308
200310
200312
200402
200404
200406
200408
200410
200412
200502
200504
200506
200508
200510
200512
200602
200604
200606
200608
200610
200612
Figure 3.4 Control chart.
statistical evidence for the level of stability of a process. Figure 3.4

is an example of a control chart. The vertical axis represents some
measurable process and the horizontal axis represents time. Along
with the process axis, there are three other lines, the center line, the
upper control limit, and the lower control limit. These control limits
can be thought of as a statistical model of the process showing
boundaries or natural limits of the process’s expected performance
when it is stable. When a process is stable as evidenced by the con-
trol chart, it is said to be “in control.”
Control charts are very useful for establishing a baseline for a
process in the planning phase, documenting performance gaps in the
analysis phase, communicating and gaining acceptance during the
integration phase, assisting in monitoring progress in the action
phase, and in determining objectives for continuous improvement in
the maturity phase of the benchmarking process. One of the first
steps to improving a process is to bring it into a state of control. As
Deming, Juran, and other quality professionals have said, bringing a
process into control does not represent real improvement. It just
makes the process perform as it was intended to perform.
A stable control chart, however, can be an indicator that the im-

provement program is not successful. When you knowingly imple-
ment improvements to a process, the intent is to bring it to a higher
level of performance. This should result in a significant shift in the
control chart. Figure 3.4 shows such a shift. After the shift is recog-
nized, the control chart limits are recalculated to show the state of
the improved process.
There are numerous types of control charts. Some of the more
commonly used control charts are shown in Table 3.2. It is important
to select the appropriate chart for the type of data to be analyzed. A
good reference for the use of control charts is Kelley.6
Table 3.2 Types of control charts.
Control chart type Type of data Examples of use

X-bar and range Measurement data Small samples taken
charts where sample size daily to assess
is 11 waiting time
X-bar and standard Measurement data Monthly mean patient
deviation charts where sample size response to a
is 10 survey item
p-chart Go/no go data Proportion of patients
dissatisfied with
hospital meal
service
u-chart Count data Number of medication
errors per month
Figure 3.4 is an example of a p-chart showing the proportion of

recently discharged patients who were dissatisfied with some aspect
of their hospital stay. The input data for this chart are responses to a
survey where patients are asked to rate their satisfaction using a
multi-point, multi-item scale. This hospital defines “not satisfied” as
a person that responds with a 1, 2, or 3 on any of the patient satis-
faction survey questions. There is a noticeable shift in the chart at
the vertical dashed line. This indicates where, after benchmarking,
the process was significantly improved. The chart shows that the
mean proportion of dissatisfied patients decreased (shifted down-
ward) around December 2004 (200412).
PARETO DIAGRAMS
Airway/Intubation
Frequency (%) – Samples 1 to 1
Category Count
ETT 53.0% 88
Mask 21.1% 35
Natural 20.5% 34
LMA 2.4% 4
Oral 1.8% 3
Nasal 1.2% 2
Trach 0.0% 0
0 20 40 60 80 100
Pareto diagrams are widely used by many in the planning and analy-
sis phases of the benchmarking process. They are also useful in com-
municating and gaining acceptance during the integration phase, and
for monitoring progress during the action phase. This is an excellent
tool for visually displaying areas that might require more attention.
Pareto diagrams are bar charts that are ordered from highest to low-
est. They visually depict in what areas most of the observations oc-
O.P. Surgery Indicator Events CY 2006

Frequency (%) – Samples 1 to 1
Category Count
DIFINTUB 48.0% Difficult intubation 12
UPINTUBA 20.0% Unplanned intubation 5
MFVAPORI 8.0% Malfunction 2
HYPERTHE 8.0% Hyperthermia 2
REINTUBA 8.0% Reintubation 2
RESPARRE 4.0% Respiratory arrest 1
TOXLOCAL 4.0% Toxic reaction to local 1
0 20 40 60 80 100
Figure 3.5 Pareto diagram.

cur. For example, a hospital is gathering data on the anesthesiology

indicator events occurring at outpatient surgery. Figure 3.5 shows a
Pareto diagram. The vertical axis indicates the type of indicator
events observed. This diagram indicates that difficult intubation is
the most frequently occurring indicator event at 48.0 percent. The
cumulative frequency line can be used to show that the two most fre-
quently occurring events (difficult intubation and unplanned intuba-
tion) together account for 68 percent of the total number of events.
CAUSE AND EFFECT DIAGRAMS

Cause and effect diagrams (sometimes called
fishbone diagrams because of their shape)
are useful in determining the particular cause
for an observed effect. They are often used in
conjunction with brainstorming for trou-
bleshooting problems. Using a cause and ef-
fect diagram can also facilitate the logical
assignment of responsibilities in tracking down the root cause of a
problem and beginning the corrective action process. Figure 3.6
shows a cause and effect diagram used to record the output from a
brainstorming session to determine all possible causes for delays in
assessment in the ED.
Cause and effect diagrams can be useful in the planning phase
by assisting in understanding causal relationships in the process be-
ing benchmarked. They can help direct what data should be collected
and analyzed during the data acquisition and analysis phases. They
can also be useful in communicating benchmark findings during the
integration phase.
Equip. Service
Staffing Monitors
RN Stretchers
Comm. in delays
MD
Chairs
Delays in
assessment
X-ray
ED size Bed flow
Triage Lab
Structural Systems
Figure 3.6 Cause and effect diagram.

RUN CHART
A run chart is a graphical representation of the
variation in a measurable characteristic over
time. The measurable characteristic is repre-
sented on the vertical axis, and the time periods
are represented in chronological sequence on
the horizontal axis. Run charts are useful in
providing an indication of a possible shift in the characteristic being
plotted. Figure 3.7 shows a run chart that a hospital uses to track the
number of redos in its imaging department. Included on the chart is
the level of a best-in-class hospital that this hospital is benchmark-
ing against. The run chart provides evidence that the hospital is clos-
ing in on its benchmarking target. It must be noted that the run chart
alone provides no statistical evidence that the apparent trend is due
to anything other than random variation alone.
30 Our hospital
25 Best-in-class
No. of redos per 1000
hospital
20
images
15
10
0
J F M A M J J A S O N D
Month
Figure 3.7 Run chart.
GANTT CHART
A Gantt chart is another variation of a
bar chart. These charts are ideal for pro-
ject planning, scheduling, control, and
reporting. They offer a visual depiction
of the activities involved in completing
a project. Typically included in these
charts is a time line showing the beginning of all of the activities in

the project and the anticipated completion times. These charts also
may include the current status of the activity and which individual
or group is responsible for the particular activity. A Gantt chart can
be used as a primary tool for planning the benchmarking project and
controlling it throughout all phases of the project.
The first step in creating a Gantt chart is to create a work break-
down structure. This consists of identifying each step in the project
from start to end, determining the precedence relationships among
the steps (that is, which step must be completed before another step
can begin), determining who will be responsible for each step, and
estimating the necessary time to complete each step. This up-front
planning is not only necessary for completion of the Gantt chart, but
is invaluable in assuring that everyone understands her role in the
project, and that the project will be completed on time. A small in-
vestment in up-front planning can pay huge dividends over the life
of the project.
Figure 3.8 is an example of a Gantt chart that shows the high-
level activities involved in the benchmarking process outlined in
Chapter 2. This particular chart indicates the first step in bench-
Figure 3.8 Gantt chart.

marking is proper planning. The individual or group that is respon-

sible for each step is also shown as part of the chart, along with the
estimated completion date and the percentage completed. Periodic
updating of the Gantt chart can show whether the project is ahead,
on time, or behind schedule. If behind schedule, the Gantt chart fo-
cuses attention on the activities that are behind so that action can be
taken to get them back on schedule.
RELIABILITY AND REDUNDANCY

Reliability is defined as the probability that a system will perform as
intended on any given trial. Probabilities are expressed as a number
between 0 (no chance of occurrence) and 1 (certainty of occurrence).
Reliability is the flip side of the probability of error. For example, a
reliability of 0.99 equates to 1 error per 100 opportunities.
In order to reduce the error rate of, for example, the delivery of
medications to patients, one should first work to increase the reli-
ability of the basic system. The ability to deliver the right drug to
the right patient in the right dosage at the right time can be in-
creased through training and a variety of technological approaches.
These approaches might increase the reliability from 0.99 (1 error
per 100 opportunities) to 0.999 (1 error per 1000 opportunities)—
a substantial improvement. There is a limit to the reliability that
can be attained with this approach.
A tool that can dramatically increase reliability is redundancy. A
redundant system is one which contains one or more backups. One
example of a redundant system is an electric alarm clock with a bat-
tery backup. This clock is much more reliable (that is, higher proba-
bility of awakening you on time) than one without the battery backup.
Redundancy can be built into all systems. Many hospitals have
built redundancy into the system of administering medication to pa-
tients. One approach used in a major children’s hospital requires that
the attending RN verify the medication first, then a second RN must
reverify the medication before it can be administered to their NICU
and PICU patients. Assume for a moment that through training the
medication error rate at this hospital has been reduced to 1 error per
1000 opportunities (0.999 reliability). By simply adding the redun-
dant step of independent reverification, the reliability is increased to
0.999999 (1 error per million opportunities).*
*The calculation for this is Reliability 1 (1 0.999)2 0.999999 where

0.999 is the reliability of the primary and backup procedures and the exponent 2 is
the number of backups plus the primary.
The risk-adjusted rate of failure to rescue in U.S. hospitals was

found to be 1511 per 10,000 admissions in 2004.7 This equates to a
reliability of about 0.85. Much of the problem is attributed to the
“cacophony of bells, buzzes, chirps, and flashing lights coming from
central stations and patient rooms throughout the unit. . . . Added to
these . . . are interruptions via nurse call, phones, overhead pages,
and medical devices. . . . There can be so many alarms at a given
time that the patient care environment becomes dysfunctional.”8
Decreasing the incidence of false positive alarms can improve the re-
liability of the system. But adding a system that monitors key data
and directs the alarm to a specific care giver along with real-time
data adds a layer of redundancy to the system.
FAILURE MODE AND EFFECTS ANALYSIS

Failure mode and effects analysis (FMEA) is used to examine a prod-
uct at the system and/or subsystem levels for all possible ways in
which a failure may occur. For each potential failure, an estimate is
made of its effect on the total system. The seriousness of the effect is
also analyzed. A review is made of the corrective action being planned
to minimize the probability and effect of any future failure. The failure
mode is the symptom of the failure, which is distinct from the cause of
failure. FMEA can be expanded to include such matters as safety, ef-
fect on downtime, access, repair planning, and design changes.
The steps used for this application of FMEA are:9
1. Define the FMEA project.
2. List all of the tasks required for the project.
3. Identify potential failure modes.
4. Identify the potential effects of each failure mode. Assign a
5- or 10-point severity code for each effect. A typical 10-
point system may use a code of 1 for none to 10 for
catastrophic.
5. Identify potential causes for the failures. Assign a 10-point
occurrence rating for each potential cause. A typical 10-
point system may use a code of 1 for almost never to 10
almost certain.
6. Identify design controls that are in place to control potential
causes. Assign a detection probability rating for each
potential cause. A typical 10-point system may use a code
of 1 for almost certain to 10 for almost impossible.
7. Calculate the Risk Priority Measure (RPM) as: Severity

Code x Occurrence Rating x Detection Probability. The
RPM is used as the basis for determining which potential
cause should be addressed first.
8. Determine actions necessary to address the potential causes.
9. Assign responsibility for the projects and the projected
completion date.
10. List actions taken to address the potential causes.
11. Calculate a new RPM for the improved process.
Figure 3.9 shows an FMEA form used by hospitals to analyze
processes.
COST OF QUALITY
Cost of quality (COQ), sometimes referred to as cost of poor quality
(COPQ), is the cost associated with providing poor quality products
or services.10 Quality costs can be divided into four categories:
• Prevention cost, which is the cost incurred by actions taken
to prevent a nonconformance from occurring.11 Examples
include the cost of the director of quality’s office and salary,
cost of quality training, and cost to implement a program of
continuous quality improvement.
• Appraisal cost, which is the cost of ensuring an organization
is continually striving to conform to customers’ quality
requirements.12 Examples include costs to survey recently
discharged patients to assess their level of satisfaction and
cost of tracking the incidence of medical errors.
• Internal failure cost, which is the cost associated with a
product (or service) failure that occurs before . . . delivery
to external customers.13 Examples include the cost associated
with a near miss event in surgery that is caught before harm
is done, and cost associated with a wrong medication
discovered prior to its delivery to a patient.
• External failure cost, which is the cost associated with a
nonconformance identified by the external customer.14
Examples include the cost associated with an actual medical
or medication error, and the cost of providing a replacement
meal after a patient reports having received the wrong meal.
Failure Mode and Effects Analysis
System: Design responsibility FMEA number

1
Subsystem Key date: Page
Event Prepared by:
Model: FMEA date Action results

Item-part/ Potential Potential Potential cause(s)/ Current design R Recommend Responsibility & Actions taken R
11/6/07
function failure mode effect(s) of mechanisms(s) of controls P action(s) target P

failure failure M completion date M
Sever
Class
Occur
Detect
Sever
Occur
Detect
Enter a Failure mode Consequences From block diagram, Method, test or Design actions System design Actions and actual
system ⫽ loss of on other determine if/how each technique used to to reduce department and completion date
12:31 PM
function function or systems, parts, element can cause detect cause of severity, date
using negative of or people system failure failure occurrence and
verb/noun function detection
format ratings
2 3 4 5 6 9 10 11
7
Page 51

51
Figure 3.9 FMEA for a process.15

On the surface, COQ appears to be an ideal tool for benchmark-

ing. However it does not come without caveats:
• Quality costs are often difficult to determine precisely. Most
accounting systems are not set up to track these costs by
category.
• While guidelines exist for assigning particular costs to
categories (see Campanella),16 ambiguity still exists. For
example, some organizations classify measurement costs
associated with the implementation of a statistical process
control (SPC) system to appraisal; others assign these costs
to prevention. Arguments can be made for either assignment.
So long as the organization is consistent, time series
comparisons for that organization are valid. However,
comparisons with other organizations that may have made a
different assignment are problematic.
• Quality costs may change for no other reason than a change
in the volume of patients. To control for this, some
organizations index COQ to revenues, total costs, or patient
days. There are plusses and minuses to each of these
indexing approaches. Direct comparisons to other hospitals
can be confounded by the particular method selected for
indexing.
Quality, as measured by the cost of quality, often is as much re-
lated to the distribution of costs across the four categories as to the
total cost of quality. Prevention costs can be viewed as more of an
investment than an expense since the purpose of these expenditures
is to ensure that things are done right the first time. External failure
costs are the most critical of the categories since the patient is di-
rectly and sometimes catastrophically affected by these costs. So, a
hospital with a higher proportion of total COQ in prevention and a
very low proportion in the failure categories could be considered
higher quality than one with high failure costs and low prevention
costs (all other things being equal).
COQ can be useful in the planning phase by providing another
approach to establishing a baseline. It can provide a framework for
the data acquisition and analysis phases. It facilitates communica-
tion and goal setting in the integration phase, and development of
improvement strategies in the action phase. Finally, in the maturity
phase, time series analysis of COQ can assist in monitoring the ef-
fectiveness of continuous improvement plans.
CHAPTER SUMMARY
• There are many tools available which can be of benefit in

the benchmarking process. These include:
Focus group
Flowcharts
Time function maps
Radar chart
Control chart
Pareto diagram
Cause and effect diagram
Run chart
Gantt chart
Reliability and redundancy
Failure mode and effects analysis
Cost of quality
• Different tools are most useful at different phases of the
benchmarking process, as summarized in Table 3.1 at the
beginning of the chapter.
REFERENCES
1. Tague, N. The Quality Toolbox, Milwaukee, WI: ASQ Quality Press,
2005.
2. “Quality Glossary.” ASQ Quality Progress 40(6), June 2007, 48.
3. Galloway, D. Mapping Work Processes, Milwaukee, WI: ASQC
4. Bronson Methodist Hospital. 2005 Malcolm Baldrige National
Quality Award Application Summary, www.bronsonhealth.com/
PDFs/BaldrigeApp Summary05.p52df, 12.
5. Sower, V., J. Duffy, W. Kilbourne, G. Kohers, and P. Jones, “The
Dimensions of Service Quality for Hospitals: Development and Use
of the KQCAH Scale,” Health Care Management Review, 26(2),
47–59, 2001.
6. Kelley, D. How to Use Control Charts for Healthcare, Milwaukee,

WI: ASQ Quality Press, 1999.
7. MedPAC. (2004). Report to Congress: Medicare Payment Policy.
Chapter 2: Quality of Care for Medicare Beneficiaries as cited in
Gee, T. “Point-of-Care Alarm Notification,” Patient Safety and
Quality Healthcare, January/February 2007, 30–33.
8. Gee, T. “Point-of-Care Alarm Notification,” Patient Safety and
Quality Healthcare, January/February 2007, 31.
9. Terninko, J. ASQ’s 57th Annual Quality Conference Proceedings,
2003
15. See note 9.
16. See note 9.
Campanella, J. Principles of Quality Costs: Principles, Implementation,
and Use, 3rd ed., Milwaukee, WI: ASQ Quality Press, 1999.
Evans, J. and W. Lindsay. The Management and Control of Quality,
Mason, OH: SouthWestern, 2005.
Galloway, D. Mapping Work Processes, Milwaukee, WI: ASQC Quality
Press, 1994.
Kelley, D. How to Use Control Charts for Healthcare, Milwaukee, WI:
ASQ Quality Press, 1999.
Sower, V., M. Savoie, and S. Renick. An Introduction to Quality
Management and Engineering, Upper Saddle River, NJ: Prentice Hall,
1999.
Tague, N. The Quality Toolbox, 2nd ed. Milwaukee, WI: ASQ Quality
Press, 2005.
4
Organization Design Issues:
The S32 Framework
SMOOTHING THE WAY

Healthcare professionals are probably
more attuned to the complexities of
managing an organization than anyone
else. Why? Because they are accus-
tomed to diagnosing and treating the hu-
man body, which has many interrelated
subsystems. If one subsystem is not functioning, the other parts of
the body can be negatively affected. While people may not die as a
result of an illness affecting one part of the body, they are not
healthy. Analogously, organizations have a number of elements and
subsystems that all need to be operating in alignment. While the in-
terconnectivity of the endocrine, circulatory, skeletal, digestive, ex-
cretory . . . systems is obvious to healthcare professionals, the
interconnectivity of organizational components may not be as obvi-
ous. Yet if we examine high performing hospitals we will find that
resources and staff, structure, and policies are functioning in synch.
While the definition of benchmarking helps us understand how
to identify organizations that can serve as models for improving
quality in hospitals, it doesn’t help us analyze what they did to en-
sure the success of their improvement initiatives. Nor does it provide
us with any insights into how we can design our hospital so that the
benchmarking efforts are successful.
Jack Welch,1 former GE CEO, advised managers to “Pick up
your phone, call companies where you see exciting management
55
breakthroughs—and ask if you can watch them in action.” In the

case studies included in this book, we are essentially doing that:
picking up the phone for you so you can see what high performing
hospitals are doing. Moreover, we are providing a framework for im-
plementing what you learn from studying best-in-class operations.
Benchmarking does not occur in a vacuum. There are organization
design issues that need to be addressed as we move forward in our
improvement efforts. In this chapter we present the S32 framework,
which identifies nine critical organizational design components that
must be considered to keep continuous quality improvement efforts
from stalling or limping along.
How many times have we noted what another hospital is doing
and tried to imitate the process only to find it doesn’t have the same
effects in our hospital as it did in the other one? Did we do some-
thing wrong in our implementation effort? Perhaps . . . but it is also
possible that we didn’t provide the organizational infrastructure to
support the quality initiative. For example, you want to increase staff
retention. You model your retention efforts on what was done in a
hospital such as Bronson Methodist which has been recognized for
its ability to retain excellent staff. However, your retention rates do
not increase to the high levels achieved by Bronson. Perhaps the
problem wasn’t what you initiated, but what you neglected to do.
Jack Welch noted that “visiting companies to watch them in action
can be great, but the exercise is pointless unless your own people are
ready to embrace outside ideas. If they’re not, some adjustment in
the organizational culture is probably necessary.”2 Where Welch
raises one “red flag” cautioning us to evaluate whether the organi-
zational culture needs to be modified, we raise eight additional red
flags and suggest that quality improvement depends on having them
all working in synch.
According to the 7–S framework developed by Waterman3 there
are seven components linked to organizational performance: strat-
egy, structure, systems, style, skills, staff, and shared values. All of
them need to be aligned because they are interconnected, like a set
of interconnecting gears—each different in size,
but all supporting and working as one. In the
S32 we add supplies, a factor similar to re-
sources suggested by Higgins,4 and sys-
tematic measurement. See Table 4.1
Organizations consist of multiple
elements which must be aligned and
working together like multiple inter-
meshing gears. When all elements are
Chapter Four: Organization Design Issues: The S32 Framework 57
Table 4.1 Augmentation of the 7–S to the S32 framework.
S32 Description
⎛ Strategy Who, what, and how
⎜
⎜ Structure Tasks and coordination
⎜
Waterman’s ⎜ Style Procedures and processes
7–S ⎨
⎜ Staff Leadership/management style
⎜ Skills Attributes or capabilities
⎜
⎜ Systems Individual employees
⎜
⎝ Shared values Organization culture
Supplies Adequate resources
Systematic measurement Metrics tracking performance
working together there is a synergy created that propels the organi-

zation to high levels of effectiveness and efficiency. High levels of
effectiveness—the organization is doing the right things—and effi-
ciency—the organization uses the fewest resources to achieve the
most outputs—result in high performing quality organizations.
DESCRIPTION OF THE S32

ORGANIZATION DESIGN FRAMEWORK
Strategy Formulation
Strategy formulation is setting forth the who, what, and how the or-
ganization uses its own strengths and weaknesses to address oppor-
tunities and threats in its environment. Vision is a statement of
aspiration: who we want to become. Vision is a goal that stretches
the organization to move beyond its comfort zone. It pushes the or-
ganization to be more and do more than it is presently. A vision for
a hospital could be to win the state quality award. Once the hospital
wins the state quality award, it must create a new vision, a new goal
At Bronson Methodist Hospital, one motivation for investing in

leadership was a major threat in their external environment—a
vulnerability to unionization. In addition, an emerging strength in
their internal environment was the planned campus redevelopment
project. These sparked some of the first improvement platforms
focused on workforce and service excellence at Bronson.
to aspire to: perhaps winning the Baldrige Award. The mission de-
fines the purpose of the organization. Why does it exist? Who does
it serve? What is special (distinctive competencies) about the orga-
nization? What does it value? These are questions commonly an-
swered in a mission statement. The mission provides a focus for the
organization. This focus is reflected in a set of objectives/goals
which define what the organization plans to do. Strategies, in turn,
define how the organization will meet its objectives. They constitute
the action plan for the organization. Strategies, like objectives, can
be found at all levels of the organization from the overarching top
management level to the departmental level, to the functional and
process levels. Objectives and strategies at higher levels in the orga-
nization guide and constrain objectives and strategies at lower levels
in the same organization. For example, the overarching goal to
achieve patient satisfaction cascades down through the hospital or-
ganization and becomes a specific departmental objective, for ex-
ample, seeing a patient within 15 minutes of arrival at the hospital.
Structure
The basic theory underlying structure is simple. Structure divides
tasks and then provides coordination.5 To a large degree structure is
captured in the organizational chart where the breakdown and group-
ing of jobs, the flow of authority, and the span of control are dia-
grammed. Hospital jobs are grouped by the requirements needed to do
them. Due to the high degree of complexity and learning needed to
perform tasks in the hospital, there is a great deal of specialization. For
example, hospital technicians administering MRIs and those who are
part of a surgical team have different specializations. Coordination is
part of structure even though it is not noted in the organizational chart.
Coordination is like the heating and cooling system of ducts and pipes
connecting rooms and floors in a building. While not as visible as the
walls or floors in a building, the heating and cooling systems are part
of the building’s structure. They direct and facilitate the flow of air
through the building. Likewise, the flow and coordination of informa-
tion about patients to various departments and individuals is critical to
achieving the hospital’s goal of patient satisfaction.
Style
Style refers to the leadership/management styles of top-level man-
agers. It is the way management comes across to the employees, the
vision they project; and it relates more to their actions than their
words. What do they spend their time doing? Their behavior is often
symbolic in nature. What they attend to day to day is a way of mak-
ing their vision of the organization a reality. Administrators who
value quality improvement not only talk about it, they also assign
key influential employees to the quality planning committees which
they themselves often attend. Their attention to quality efforts sym-
bolizes the importance they attach to such efforts. They surround
themselves with individuals who understand quality improvement;
they fund travel for individuals to attend quality training programs
and to visit other organizations recognized for their quality im-
provement programs. They visit and reinforce individuals and de-
partments that are showing improvement.
Bronson Methodist Hospital CEO Frank Sardone and Robert Wood

Johnson University Hospital Hamilton CEO Christy Stephenson clearly
created a vision for their hospitals and had buy-in from their Boards
of Directors and senior leadership team.
Staff
Staff refers to individual employees. They constitute the organiza-
tion’s human capital. In service industries, the relationship between
staff and consumer adds value to the service experience so the re-
tention of competent staff goes a long way in enhancing consumer
satisfaction. While it is critical to have fully qualified staff in the
hospital, it is also important to have adequate numbers of staff so
they have time to use their medical and interpersonal skills. Equally
critical to the staffing function are recruitment, selection, orienta-
tion, deployment, and development of human resources.
At Bronson, unit-based greeters were added to free clinical staff to

focus on the patients. This was a creative and effective solution to the
problem of scarce clinical staff resources.
Skills
Skills refer to the attributes or capabilities of the organization. This
S was alluded to in the previous section on staff. We note that staff
needs to be sufficient not only in number, but also in professional
and personal competencies. However, skills here denotes more than

the individual’s competencies. Skills are those capabilities that are
possessed by an organization as a whole as opposed to the people in
it.6 A patient in a hospital benefits from the competencies of indi-
vidual staff members, but more importantly from the skills of the en-
tire hospital staff working together and complementing each other’s
efforts on behalf of the patient.
Bronson Methodist Hospital introduced structured leadership training

and retraining to bolster the leadership skill within the organization
while Robert Wood Johnson University Hospital Hamilton fosters
empowerment and Great Ormond Street Hospital’s cardiac
department has developed skill in analyzing (without blame to
individuals) what occurs during surgery and handovers to ICU.
Systems
Systems refer to all the day-by-day procedures and processes that en-
able the organizations to get things accomplished. The originators of
the 7–S framework believed that systems were perhaps the most
dominant variable. Information systems, communication systems,
capital budgeting systems, reward and control systems, quality con-
trol systems, performance measurement systems, and strategic plan-
ning systems all exemplify this S.
North Mississippi Medical Center (NMMC), a Malcolm Baldrige

Award recipient, has developed a highly integrated enterprise-wide
information system that plays an integral role in the success of the
hospital. Their information system has evolved from the 1970s into
what it is today, an information system that keeps track of patient
medical services, patient financial services, administrative services,
third-party comparative databases, and other diagnostic/support
systems. They rely on their information system to enable them to
achieve their mission.
Robert Wood Johnson University Hospital Hamilton designed

their communication system, shown in Figures 4.1 and 4.2, to ensure
that employees, physicians, suppliers, and partners understand the
strategic goals and their role in supporting them.
Identify communication objective and target
Develop communication content/message/material
Evaluate and improve communication process Establish measure of communication effectiveness
Determine communication strategy based on

audience requirements (from listening posts)
Two–way communication methods:

One-on-one, orientation, quarterly employee forums,
meetings (BoT/EMT/SLT/MT/MD/Supplier), community
advisory board, VOC, employee satisfaction committee,
shared governance, Internet/intranet, best-practice sites,
communication boards, IoE, “What’s new?”
Deliver communication and evaluate effectiveness
no Utilize alternate strategy

Effective?
based on feedback
yes

communication system.7
Listening and learning Patients Empl. Community

Press, Ganey surveys D Q A
Committees/meetings M M Q
Letters N N N
VOC D D N
Direct contact/rounds D D N
Team talk M
Call center D
Health fairs N N
Open houses Q N
Exit interviews N
Program evaluations N N
Service recovery log W
Website and intranet N D N
D-Daily W-Weekly M-Monthly Q-Quarterly A-Annually N-As needed
C/P-Community/potential customers

listening and learning methods.8
61
Examining procedures and processes reveals how the hospital

operates. Of particular importance is the reward system, since re-
wards guide employees to act in certain ways.
The following is a well-designed reward system at Robert Wood

Johnson University Hospital Hamilton.9 It shows a strong congruence
between strategy and rewards.
Staff Performance Management System
Strategic planning process

5
Set standards and expectations 1

Dashboard/BSV, OPI reports
review of 5 - Pillars results
Education and training figure 5.2-1 2
Requirements met?
Yes No
Recognize and reward 3a 3b Recognize and redirect
Individual performance evaluation 4
It is not surprising that quality improvement efforts often first

focus on changing a particular process or procedure in the hospital.
Systems are where the action is, where concrete alterations can be
effected that will potentially improve the entire organization.
The 15/30 Guarantee at Robert Wood Johnson University Hospital

Hamilton is an example of how a hospital changed patient care in a
particular department, that is ED, as a way of meeting their strategic
goal to improve patient care and satisfaction.
Shared Values
Shared values can be equated to organization culture. Shared values
have also been referred to as the superordinate goals of the organi-
zation. They are the principles and aspirations which guide the
thinking and behavior of members of the organization. They are the
glue that holds the organization together and which provide a focus
for members of the organization. They are vague abstracts, often un-
written and incomprehensible to outsiders. GE’s “Progress is our
most important product” and British Airways’ “We believe excellent
service is anticipating your needs” are slogans that express the
shared values or their companies.
Columbus Children’s Hospital’s mission, vision, and promise are so

ingrained in employees that they don’t even consciously think about
them when making decisions. This doesn’t mean that buy-in for new
initiatives is assured. Physicians and other clinical care employees are
provided opportunities for training and trial runs with new processes
before implementation and are usually won over by results.
Supplies
Supplies of resources refers to having what is needed to achieve the
goals and strategies of the organization. As we noted earlier having ad-
equate staff is as important as having the right staff in terms of their
expertise. This S directs our attention to ensuring that all needed re-
sources are in place. In addition to people, money, facilities, technol-
ogy, and information are among the critical resource supplies needed
to successfully enhance quality.
At Robert Wood Johnson University Hospital Hamilton the expansion

of the hospital increased the hospital’s capacity and allowed ED to
move patients to a hospital bed in a timelier manner.
Systematic Measurement Practices/Program

Systematic measurement (such as Figs. 4.3 and 4.4) refers to metrics
used to track performance over time. These metrics should reflect
the strategic objectives at each level of the organization. At higher
Robert Wood Johnson University Hospital at Hamilton
64
Mission, Vision, Values
Pillars of Excellence
People Service Quality Finance Growth

CSFs
Be recognized as a Distinguish RWJUHH Provide superior Develop partnerships with

Distinguish RWJUHH
11/6/07
center for health – from competitors by operating margins to physicians, communities, and
as an outstanding
the consumer’s emphasizing excellence allow for capital organizations; and maximize
employer
choice for hospital in clinical outcomes reinvestment and the strategic relationship
services, health information and service growth based on with RWJ Health System
and support community needs and Network
11:06 AM
Daily/ Voice of the customer Voice of the customer All payor LOS POS cash Outpatient voulume
weekly/ – E – loyalty – P/C Medicare LOS Patient cash cath lab volume
biweekly Productivity Overall Satisfaction % ALOS > 10 days Total DNFB ED volume per bed
OT expenses $ IP, ED, OP, SDS Admissions
Page 64
PTE utilization Overall room and meals Direct admission

Sick hours Overall satisfaction
by unit
Monthly Vacancy rate (fill rates) Priority indices: Core measures Overall hospital margins New cancer med oncology
Turnover rates –IP, ED, OP, SDS –CHF, AMI, CAP, SIP, Administrative denials cases
90-day turnover rates Loyalty indices: Pneum Operating margins Transfers to RWJUH
Human capital –IP, ED, OP, SDS Medical denials by service Community ed. attendees
value added Outpatient service Medication errors/incident Days in A/R Physician specific volume
OSHA employee commitment reports Net revenue Volunteer hours
injuries/sharps Hours in divert JCAHO safety indicators IP/OP revenue split Market segmentation
Bright Stuff referrals Community ed. CHF readmission rate Days cash on hand Patient origin
satisfaction Debt service coverage
Time per hire Team talk scores Lawsuits per admission Cost per adjusted Key healthcare services
Retention rates patient pay volume
Temporary help $ Cost per adjusted

Exit interviews summary discharge
Charity care % of
total revenue
11/6/07
Quarterly Diversity Patient satisfaction Mortality rates Bond covenant Health risk assessments
Prof./Mgr. positions report Quarterly supplier report compliance Community health
Invest in employee Supplier report cards card Average age of PP&E improvement
development Hospital-based Pneumoccocal infection Community donations Process (CHIP)
Training hours per FTE physician report cards rate Inventory turns
Cost of turnover Community ed. OPI report
11:06 AM
Quarterly satisfaction satisfaction report

survey
Annually Performance appraisal CINJ survival rates Market share

scores PSA/SSA
Page 65
survey
Biannually Community survey

Physician survey
Figure 4.3 Balanced scorecard.10
65
96
94
92
90
88
86
84 Actual
82
Benchmark
80
78
76
74
1st 2nd 3rd 4th
Quarter Quarter Quarter Quarter
Figure 4.4 Narrow measurement.*
levels a robust measure tool such as a balanced scorecard is appro-

priate; at lower levels, such as a department, a more limited mea-
surement tool, such as percentage change, could be appropriate.
Robert Wood Johnson University Hospital Hamilton’s balanced
scorecard approach (Figure 4.3) is an example of a higher-level,
overarching measurement approach. Figure 4.4 is an example of a
lower-level, more limited measurement tool used at the same hospital.
Having a supporting measurement program is essential to
benchmarking, which basically is a performance measurement tool
in which comparative operating performances are measured to iden-
tify best practices. However, once that is accomplished, measure-
ment cannot end; an array of metrics is required to document
improvement and monitor the organization’s performance on an on-
going basis. The array of metrics at Robert Wood Johnson Univer-
sity Hospital Hamilton is derived from the outcomes of the strategic
planning process as shown in Figure 4.5.
Improvements in any of the Ss can bring about some improve-
ment in an organization, but to have a truly high performing organi-
zation all the Ss must be aligned with each other. The need for
alignment lies in the interrelationship of the components. The frame-
work is intended to convey the notion of the interconnectedness of
the variables—the idea is that it’s difficult, perhaps impossible, to
make significant progress in one area without also making progress
in the others.12
*Chart provided by J. Schwarz, Robert Wood Johnson University Hospital Hamilton.

8
Strategic objectives OPI/Pt safety plan

Prior year performance evaluation utilized as an input into stratigic
Determine leading/ 1a Determine departmental 1b

lagging, KPIs/Establish RTB/CTB, KPIs/Establish
targets/Assign SLT owner target/Assign MT owner
planning process and as a measure of effectiveness
Determine who reviews 2a Determine who reviews 2b

and frequency (D/BSC by and frequency (OPI
EMT, SLT, BoT) report by MT, BoT)
Collect data/compare to target 3
Target met? 4
Yes No
Process design and 5a Simplified PDCA 5b

improvement cycle
(figure 6.1-1)
Report via dashboard/BSC 6a Report via CPI report 6b
Daily, weekly, monthly, quarterly, BSC KPIs, OPI report 7

analysis and 5-pillar communication
Figure 4.5 Metrics derived from strategic planning process.11
The S32 framework identifies the array of components that need

to be included in design considerations for quality improvement.
Furthermore, the depiction of the framework indicates that there is
no implied hierarchy among the components nor is there only one
initial force that can drive change and improvement. Each compo-
nent is critical. Our version of the S32 framework differs somewhat
from the original 7Ss and is more congruent with Higgins frame-
work in that we have placed strategy in the center to indicate that the
initial driving force in benchmarked hospitals is strategy.
Strategy
QUALITY IMPROVEMENT
REALLY GAINS TRACTION WHEN
STRATEGY LEADS THE WAY
Figuratively speaking, while quality gains can be made when any of
the interconnected gears starts moving and the others align them-
selves to support that movement, we propose that quality gains are
intensified when the gear that initially starts the others moving is
strategy, as shown in the Bronson Memorial Hospital example in
which the impetus for beginning the change was a strategic need to
respond to a major threat in the external environment. The change
was consistent with attaining the organizational vision to become a
national health care leader and the CEO’s push to raise the bar. In
this case, the hospital used the Baldrige Criteria as their framework,
which reinforced the importance of strategy powering the changes.
This was also the case for North Mississippi Health Services. For
more details on these examples refer to Chapters 6 and 9.
CHAPTER SUMMARY
Benchmarking and quality improvement cannot occur in a vacuum.
Such efforts must be supported by organizational design elements:
strategy, structure, managerial style, staff, skills, systems, shared
values (organizational culture), supplies, and systematic measure-
ment practices. Neglecting to make modifications in these organiza-
tional design elements may not halt quality improvements, but it will
hinder or suboptimize the results of such efforts. Aligning the orga-
nizational design elements is like meshing gears. When they are
working in synch, they will “smooth the way” for quality improve-
ment efforts within the hospital.
REFERENCES
1. Welch, J. and S. Welch. “Dialing for Growth.” Business Week,
October 30, 2006, 134.
2. See note 1.
3. Waterman, R. “The Seven Elements of Strategic Fit.” The Journal of
Business Strategy 2(3), Winter 1982, 287–293.
4. Higgins, J. “The Eight ‘S’s of Successful Strategy Execution.”
Journal of Change Management 5(1), March 2005, 3–13.
5. Waterman, R., T. Peters, and J. Philips. “Structure Is Not
Organization,” Business Horizons, 23(3), 1980, 14–26.
6. Waterman, R. 1982, 289.
7. Robert Wood Johnson University Hospital Hamilton. “2004 Malcolm
Baldrige National Quality Award Application Summary,” 2004, 7
12. Waterman, R., T. Peters, and J. Phillips. 1980, 18.
Higgins, J. “The Eight ‘S’s of Successful Strategy Execution.” Journal of
Change Management 5(1), March 2005, 3–13.
Waterman, R. “The Seven Elements of Strategic Fit.” The Journal of
Waterman, R., T. Peters, and J. Philips. “Structure Is Not Organization,”
Business Horizons, 23(3), 1980, 14–26.
5
Key Characteristics
of Best-in-Class Hospitals
I
t is inevitable when discussing best-in-class organizations that
someone asks “What is it that makes them so good?” While this
is a fair question, the answer is not always so easily determined.
The intent of this chapter is to address that question for the hospitals
profiled in this book. Twelve characteristics were observed that are
common to the best-in-class hospitals included in this book:
• Clarity of mission/vision
• Alignment
• Measures of progress—clear and well-defined metrics
• Champions
• Openness to improvement regardless of the source
• Strong patient-focused culture
• Strong leadership
• Systems thinking
• Motivation to be recognized as being among the best
hospitals
• Lack of fear
• Communication built into the system
• Celebration of results
71
No implications should be made based on the order in which these

characteristics are listed.
CLARITY OF MISSION/VISION
Yoga Berra is credited as saying, “If you don’t know
where you are going, you might just end up some-
place else.” The best hospitals know exactly who they are, what they
are trying to accomplish, and where they are going (see Figure 5.1).
They all have clearly articulated mission and vision statements that
are the results of careful study and that are widely publicized.
Bronson Methodist Hospital–3 Cs

Bronson will be a national leader in healthcare quality:1
Clinical excellence Achieve excellent patient outcomes

Customer and service Enhance service excellence, staff
excellence competency, and leadership
Corporate Achieve efficiency, growth, financial, and
effectiveness community benefit targets
Robert Wood Johnson University Hospital

Hamilton—5 pillars
Robert Wood Johnson Hamilton’s strategic planning process uses
a framework built on five pillars of excellence—service, finance,
quality, people, and growth.2
Mission: Robert Wood Johnson University Hospital Hamilton is

committed to excellence through service. We exist to promote, pre-
serve, and restore the health of our community.
Vision: Our vision is to passionately pursue the health and well-
being of our patients, employees, and the community through our
culture of exceptional service and commitment to quality.
Values: Q – Quality
U – Understanding
E – Excellence
S – Service
T – Teamwork
Figure 5.1 Mission and vision statements.

Chapter Five: Key Characteristics of Best-in-Class Hospitals 73
Columbus Children’s Hospital–CARES
Children’s believes that no child should be refused necessary care

and attention for lack of ability to pay. Upon this fundamental belief,
Children’s is committed to providing the highest quality:3
Patient Care
Advocacy for children and families
Pediatric Research
Education of patients, families, and future providers
Outstanding Service to accommodate the needs of patients and
families
North Mississippi Health Services–CARES
(Our mission is) to continuously improve the health of the people in

our region.
(Our vision is to be) the provider of the best patient centered care
and health services in America.
(Our values are):
Compassion—show compassion for the patient
Accountability—be accountable for actions
Respect—show respect for patients
Excellence—strive for excellence in every activity
Smile—smile for the patients4
Great Ormond Street Hospital
Our mission is excellence, innovation and integration for the health

of children and young people.5
To improve the health of children by being a leading centre of ex-

cellence in Europe for special pediatric services and for research,
evaluation, and education in child health.
Figure 5.1 Mission and vision statements. (Cont’d.)

Establishing and publicizing mission, vision, and values is just

the first step—and perhaps the easiest one. They must actually guide
the organization in everything that it does. This is accomplished
through alignment.
ALIGNMENT
Strategic planning, establishment of mission, vision,
and values are merely exercises unless they actually
guide the organization in every way. In order to do this, the entire or-
ganization must be aligned to the mission, vision, and values. Align-
ment can be viewed in two ways:
• How well all employees are aligned in their thinking and
action with the organization’s mission, vision, goals, and
objectives.
• How well all of the organization’s activities and processes
are aligned to contribute to the attainment of the
organization’s mission, vision, goals, and objectives.
Excellent hospitals exhibit both aspects of alignment.
Ask any employee at Bronson Methodist Hospital what the hos-
pital is trying to achieve and they will tell you about the 3 Cs: clini-
cal excellence, customer and service excellence, and corporate
effectiveness. They may show you their badge card located behind
their identification badge which contains actions they have identi-
fied that they can take to help the hospital achieve excellence in
these three areas. Further, the actions of employees show that they
have internalized the 3 Cs. When one of the authors visited the hos-
pital, he got lost. He asked the nearest employee for directions. The
employee dropped what she was doing and escorted him to his des-
tination. When he asked a custodial employee how they were help-
ing the hospital achieve clinical excellence, the employee quickly
showed him his badge card listing his personal commitment to re-
ducing the incidence of hospital acquired infection by keeping his
area spotless.
Employees at Columbus Children’s Hospital will tell you that
they don’t need to explicitly think about their hospital’s mission and
vision. They are so embedded in their thinking that they are second-
nature—a part of their everyday thinking and acting. When deci-
sions are made about processes, procedures, and activities in these
hospitals one question is always “How does this fit our mission and
vision?”
Alignment is intangible and hard to achieve. Three keys to achiev-

ing alignment are:
• Clarity about what the key goals of the organization are
• Commitment to initiatives that promote key goals
• Accountability for actions that affect key goals6
These keys are explicit parts of the management systems at the fea-
tured hospitals.
Alignment is very much about walking the talk. The talk is what
the organization professes is important. The walk is acting and be-
having in ways that are consistent with the talk at all times. A single
action by administrators that is inconsistent with the professed mis-
sion, vision, and values of the organization is sufficient to counter-
act 1000 vocal affirmations of what is important to the organization.
All of the hospitals featured in the case studies in this book are care-
ful to walk the talk every day. For them, it is not so difficult because
they have truly made the mission, vision, and values of the hospital
their own.
MEASURES OF PROGRESS—CLEAR
AND WELL-DEFINED METRICS
Organizations need some outcome measures to deter-
mine baseline performance, document improvement, and monitor
performance over time. Often, measures cannot be assessed directly.
To actually use the measures, they must be operationalized—that is,
measurable characteristics (metrics) must be defined which enable
an assessment of the measure they represent. For example, you can-
not measure patient satisfaction directly. You have to develop met-
rics for patient satisfaction. One possible metric might be the overall
score on some validated patient satisfaction instrument such as the
KQCAH7 or the CAHPS.8 This can be measured. Another metric
might be the percentage of dissatisfied patients as determined by pa-
tient feedback surveys.
A measure is the criteria, metric or means to which a comparison is

made with output.
A metric is a standard for measurement.
“Quality Glossary.” Quality Progress 40(6), June 2007, 51.
The balanced scorecard is one type of measurement system that

enables organizations to transform mission, vision, and strategy into
action and to monitor the performance of the organization using a
system of metrics called critical success factors (CSF). It provides
feedback around both the internal business processes and external
outcomes in order to continuously improve strategic performance
and results.9 The balanced scorecard is used by some top-performing
hospitals (see Figure 5.2).
CHAMPIONS
It has been said that an organization is perfectly con-
figured to produce the results that are being obtained.
Presumably, an organization interested in benchmarking has deter-
mined that the results being obtained are different than what is de-
sired. Obtaining the desired results requires changing the
organization. This is generally a difficult task. Organizations, like
people, generally resist change.
In order to accomplish the required change, someone within the
organization must champion the process. A champion might or
might not be the initiator of the change process. However, the cham-
pion eventually is the one who provides vision, support, and most
importantly, resources necessary to accomplish the change. There
are strong aspects of change agent embedded in our use of the word
champion; however, the roles of change agent and champion often
are filled by separate individuals.
Champions believe in their projects and are willing to fight for
them against any adversity—and adversity certainly comes with
change. Their level of commitment and enthusiasm for the projects
are the models and inspiration for everyone involved. The word fa-
natical has often been associated with champions. In an organization
that lacks shared vision and buy-in from top management, these
champions might be considered to be troublemakers. But without
these troublemakers, substantial organizational change is unlikely to
happen. The key is for a champion to be the right kind of trouble-
maker and work to involve others, and to achieve acceptance, sup-
port, and resources for the project throughout the organization.
At Columbus Children’s Hospital, Dr. Donna Caniano, Surgeon
in Chief, was initiator of the change, champion of the change, and
change agent. By no means were the results of Operation Takeoff
achieved through her efforts alone; however, it would never have
gotten off the ground without her. At Bronson Methodist Hospital,

CEO Frank Sardone provided the vision to raise the bar and served
as champion, and Senior V.P. Susan Ulshafer was the initiator of the
Malcolm Baldrige National Quality Award project and also served
as the primary change agent.
OPENNESS TO IMPROVEMENT
REGARDLESS OF THE SOURCE
“Not invented here” is nowhere to be found in these hospitals. They
learn from whomever and wherever they can. Robert Wood Johnson
University Hospital Hamilton learned from another hospital in their
group. Bronson Methodist Hospital’s Baby On The Way Valet Ser-
vice was the result of an employee’s idea. Columbus Children’s Hos-
pital learned from the aviation industry. Great Ormond Street
Hospital learned from an automobile racing team. Several of the
hospitals learned from Disney and Ritz Carlton. The source of the
idea is not an issue with these hospitals.
STRONG PATIENT-
FOCUSED CULTURE
All of the best-in-class hospitals have clearly acknowledged that
their first priority is the patient. This is publicized in their mission
and vision statements in various ways:
• Achieve excellent patient outcomes10
• Our vision is to passionately pursue the health and well-
being of our patients . . .11
• Children’s is committed to providing the highest quality
patient care . . .12
• (our vision is to be) the provider of the best patient centered
care . . .13
• (our mission is) to improve the health of (our patients) . . .14
This is hardly astonishing. Every hospital recognizes that its mis-
sion is to see to the health of its patients. What differentiates the
best-in-class hospitals from others is how this is integrated into
everything that everyone in the hospital does. In the best-in-class
Robert Wood Johnson University Hospital at Hamilton
78
Mission, Vision, Values
Pillars of Excellence
People Service Quality Finance Growth

CSFs
Be recognized as a Distinguish RWJUHH Provide superior Develop partnerships with

Distinguish RWJUHH
11/6/07
center for health – from competitors by operating margins to physicians, communities, and
as an outstanding
the consumer’s emphasizing excellence allow for capital organizations; and maximize
employer
choice for hospital in clinical outcomes reinvestment and the strategic relationship
services, health information and service growth based on with RWJ Health System
and support community needs and Network
11:09 AM
Daily/ Voice of the customer Voice of the customer All payor LOS POS cash Outpatient voulume
weekly/ – E – loyalty – P/C Medicare LOS Patient cash cath lab volume
biweekly Productivity Overall Satisfaction % ALOS > 10 days Total DNFB ED volume per bed
OT expenses $ IP, ED, OP, SDS Admissions
Page 78
PTE utilization Overall room and meals Direct admission

Sick hours Overall satisfaction
by unit
Monthly Vacancy rate (fill rates) Priority indices: Core measures Overall hospital margins New cancer med oncology
Turnover rates –IP, ED, OP, SDS –CHF, AMI, CAP, SIP, Administrative denials cases
90-day turnover rates Loyalty indices: Pneum Operating margins Transfers to RWJUH
Human capital –IP, ED, OP, SDS Medical denials by service Community ed. attendees
value added Outpatient service Medication errors/incident Days in A/R Physician specific volume
OSHA employee commitment reports Net revenue Volunteer hours
injuries/sharps Hours in divert JCAHO safety indicators IP/OP revenue split Market segmentation
Bright Stuff referrals Community ed. CHF readmission rate Days cash on hand Patient origin
satisfaction Debt service coverage
Time per hire Team talk scores Lawsuits per admission Cost per adjusted Key healthcare services
Retention rates patient pay volume
Temporary help $ Cost per adjusted

Exit interviews summary discharge
Charity care % of
total revenue
11/6/07
Quarterly Diversity Patient satisfaction Mortality rates Bond covenant Health risk assessments
Prof./Mgr. positions report Quarterly supplier report compliance Community health
Invest in employee Supplier report cards card Average age of PP&E improvement
development Hospital-based Pneumoccocal infection Community donations Process (CHIP)
Training hours per FTE physician report cards rate Inventory turns
Cost of turnover Community ed. OPI report
11:09 AM
Quarterly satisfaction satisfaction report

survey
Annually Performance appraisal CINJ survival rates Market share

scores PSA/SSA
Page 79
survey
Biannually Community survey

Physician survey
Figure 5.2 A form of balanced scorecard.15
79
hospitals, patient-centered care is a part of the culture of the orga-

nization. Everyone buys in and everyone sees the role that they play
in affecting that culture.
STRONG LEADERSHIP
Warren Bennis wrote that management is doing
things right (transactional) while leadership is doing
the right things (transformational).16 Obviously, hospital administra-
tors must be both leaders and managers. However, it is the leadership
component that is essential to becoming best-in-class. Doing things
right by itself won’t get you there. In becoming best-in-class, lead-
ership gets the ball rolling and keeps it rolling while management
controls the process.
Leadership: An essential part of a quality improvement effort.

Organization leaders must establish a vision, communicate that vision
to those in the organization and provide the tools and knowledge
necessary to accomplish the vision.
“Quality Glossary.” Quality Progress 40(6), June 2007, 50.
Leadership is by no means just the CEO. Leadership at the top

is essential, but insufficient to become best in class. One of the
two prongs in Bronson Methodist Hospital’s push to raise the bar
was to determine how to improve leadership throughout the orga-
nization, and leadership comprised one step in their four-step
transformation process. Leadership must permeate the entire or-
ganization. At Bronson, leadership is the biggest area where train-
ing is conducted. LEADERship training is conducted regularly
during the year to expand and improve the quality of leadership
throughout the organization.
Leadership requires vision, openness, communication, consis-
tency, and most of all, it involves leading by example. The entire or-
ganization looks to the leaders to mold the vision for the future. The
best leaders are open to inputs from wherever they might come in de-
veloping that vision. As keepers of the vision, leaders must communi-
cate the vision so that it becomes the shared vision—embraced by
everyone within the organization. The organization is always looking
for evidence that the leader is sincere in promoting the shared vision.
The organization will quickly pick up on any evidence—actions,
words, allocation of resources—that the leader is not serious about the

shared vision.
SYSTEMS THINKING
“The best employee can be defeated by a bad system
every time” has been mentioned as a basic truth about
success and failure for many years. The best-in-class hospitals rec-
ognize that high performance is a combination of well-designed sys-
tems and well-trained employees. Quality pioneers W. Edwards
Deming and Joseph M. Juran consistently taught that the majority of
errors are the result of a faulty system rather than mistakes made by
employees.
Donna Caniano, MD, Surgeon-in-Chief at Columbus Hospital,
echoes the words of these experts. “When you actually look at why the
nurse made the medication error in the first place, it’s a systems prob-
lem.” At all of the excellent hospitals profiled in this book, great at-
tention has been paid to perfecting systems that will lead to excellent
outcomes. Columbus Children’s Hospital devised an improved system
to reduce errors in surgery. Robert Wood Johnson University Hospital
Hamilton redesigned their systems to achieve the extraordinary results
they obtained in emergency room waiting time. Bronson Methodist
Hospital has a system in place that is responsible for its excellent
workplace quality. Systems are important to success—and the best
hospitals realize this, embrace this, and act accordingly.
MOTIVATION TO BE
RECOGNIZED AS BEING
AMONG THE BEST HOSPITALS
The best hospitals, after considerable planning and soul searching,
create a challenging vision for their hospitals. Careful thought pre-
cedes decisions as significant as choosing to alter the vision from re-
gional to national excellence. All major constituents must be on
board with this decision. This is not a decision that can be made
overnight. But all of the excellent hospitals have made the commit-
ment to be recognized as being among the best hospitals. Bronson
Methodist Hospital made the commitment to change its vision from
being a regional leader to being a national leader prior to beginning
its Baldrige journey. Columbus Children’s Hospital is committed to
providing the highest quality in its five CARES categories. North

Mississippi Health Services’ vision is to be “the provider of the best
patient centered care and health services in America.”17
It is very difficult to be among the best in everything. Some hospi-
tals elect to focus on one or a few areas in which to become among the
best-in-class—at least at first. The tendency in having achieved best-in-
class performance in one or a few areas is to question why best-in-class
performance cannot be achieved in all of areas of the hospital.
Considerable courage is required to publicly commit to becoming
one of the best hospitals. However, there is little likelihood of achiev-
ing such a level of performance unless one decides to publicly proclaim
it as the vision for the hospital. But proclaiming is one thing—doing is
another. Considerable planning is required, constituent commitment
must be obtained, resources identified and committed to the effort, and
in many cases, the entire culture of the hospital must be changed. None
of these tasks is easy, as attested by the best-in-class hospitals included
in the case studies following this chapter.
LACK OF FEAR
Doug Hall claims that “managers’ . . . fear to take
action . . . has risen dramatically over the past five
years. . . . Managers have become so accustomed to fearing change
and uncertainty that they don’t realize the impact it has on their cre-
ative abilities. . . . (They) just get used to saying no to new ideas.”18
This is not the case at these hospitals. When the Chief of Surgery
at Columbus Children’s Hospital started Operation Liftoff, she had
no worries that higher administration would fail to support it. And
support it they did—with excellent results. It took courage for the
CEO and Senior VP at Bronson Methodist Hospital to take their vi-
sion of national excellence to their board of directors. That courage
paid off. The board provided their support and the results speak for
themselves.
Best-in-class hospitals create a climate
where ideas and suggestions for improve-
ment are welcomed from all sources. Em-
ployees of these organizations are
empowered to be innovative and are ex-
pected to be so—it is part of everyone’s
job. The organizations are receptive of
these ideas—they are taken seriously and
employees know that.
COMMUNICATION BUILT
INTO THE SYSTEM
All organizations have some sort of formal and infor-
mal communication systems. The best-in-class organizations have
effective two-way communication systems built into their organiza-
tions. Communication is part of everyone’s day to day routine—not
an add-on.
Before its transformation, Bronson Methodist Hospital con-
ducted quarterly employee forums where the CEO would talk about
what was going on and employees could ask questions and provide
input. These were well attended. As Bronson developed its leader-
ship system to include two-way communication at all levels, atten-
dance dropped off to the point where the forums were no longer
held. Why? Because they were no longer needed. Employees ob-
tained the information they needed and had the opportunity to ask
questions and provide input as part of their jobs.
Communication forums with top management, newsletters,
posters, websites, e-mails, and memos are all part of organizational
communication. They have their place in the overall
communication system. But in the best-in-class hospi-
tals, these forms of communication do not comprise the
bulk of the communication system. Two-way commu-
nication is built into the day-to-day systems at these
hospitals. The information that employees need is cur-
rent and systematically made available to them.
CELEBRATION OF RESULTS
Celebrations of success are much more than just par-
ties. They are motivation, recognition, communica-
tion, and acceptance vehicles. Few employees will be motivated to
strive for excellence by the promise of a few hours off and balloons
and food at a party provided by the organization. However, many
employees will be motivated by the prospect of being recognized
and thanked by top management for their efforts and results at a
party held in their honor.
The celebrations also provide feedback to the employees being
honored that their efforts and results are appreciated, are consistent
with what the organization desires, and provide encouragement to do
more in the future. They also communicate to others not involved in the
particular celebration what the organization considers to be important.
Sometimes the event being celebrated has not yet

achieved universal acceptance. The fact that the orga-
nization sees fit to celebrate the event makes it more
difficult to resist accepting the new way of doing
things.
The children of employees at Columbus Children’s
Hospital were invited to the celebration of the success
of Operation Takeoff. Photographs taken of the children at the cele-
bration were posted in the surgical suites to remind everyone to think
of the patient as their own child. The hard work of those involved was
recognized at the celebration, a clear message was sent that there was
a new way of doing things that had achieved improved results, and
powerful images were obtained to continually reinforce the message
about how to think of the patient. This was a very well thought-out cel-
ebration indeed, with a difficult-to-measure but certainly substantial
return on investment.
CHAPTER SUMMARY
In this chapter we discussed twelve characteristics that are common
to the best-in-class hospitals profiled in this book:
• Clarity of mission/vision
• Alignment
• Measures of progress—clear and well-defined metrics
• Champions
• Openness to improvement regardless of the source
• Strong patient-focused culture
• Strong leadership
• Systems thinking
• Motivation to be recognized as being among the best
hospitals
• Lack of fear
• Communication built into the system
• Celebration of results
We believe these characteristics are important to the success of
these hospitals, but this is by no means an exhaustive list.
REFERENCES
1. www.bronsonhealth.com/
2. www.rwjhamilton.org/aboutus/mission.asp
3. www.columbuschildrens.com/
4. www.nmhs.net/
5. www.ich.ucl.ac.uk/about_gosh/trust_vision/
6. Robinson, A., and S. Stern. Corporate Creativity. San Francisco:
Berrett Kohler, 1997.
7. Sower, V., J. Duffy, W. Kilbourne, G. Kohers, and P. Jones. “The
Dimensions of Service Quality for Hospitals: Development of the
KQCAH Scale.” Health Care Management Review, vol. 26, no. 2,
Spring 2001, 47–59.
8. www.cahps.ahrq.gov/default.asp. Agency for Healthcare Research
and Quality.
9. www.balancedscorecard.org/basics/bsc1.html. The Balanced
Scorecard Institute.
10. See note 1.
11. See note 2.
12. See note 3.
13. See note 4.
14. www.ich.ucl.ac.uk/patients_fam/ppweb/didyouknow/. UCC Institute
of Child Health.
15. www.rwjhamilton.org/aboutus/mission.asp. Robert Wood Johnson
University Hospital Hamilton.
16. Bennis, W., and J. Goldsmith. Learning to Lead. Reading, MA:
Addison-Wesley, 1997.
17. www.nmhs.net. North Mississippi Health Services.
18. Hall, D. “A Perfect Brainstorm.” BusinessWeek SmallBiz, Summer
2006, 20–23.
Section II
Case Studies—
How Best-in-Class
Status Was Attained
6
Bronson Methodist Hospital:
Quality of Workplace
E
mployees at Bronson
Methodist Hospital know
they are working at one
of the best places in the country
and they just don’t leave. At a
time when there is a chronic
shortage of registered nurses,
Bronson has an RN turnover of
just 4.7 percent and a RN va-
cancy rate of just 5.3 percent.
Overall employee turnover was
5.6 percent in 2005. For three
years in a row, Bronson was
listed among the “100 Best
Companies to Work For” by
Fortune magazine (2004, 2005,
and 2006), and among the “100
Best Companies for Working
Mothers” by Working Mother
magazine (2003, 2004, 2005,
and 2006). In addition to its
awards for workplace excel-
lence, Bronson has received
many other awards for excel-
lence, including 2001 and 2005 Michigan Quality Leadership
Awards, and most recently, the 2005 Malcolm Baldrige National
89
90 Section II: Case Studies—How Best-in-Class Status Was Attained
Quality Award (MBNQA), the nation’s highest honor for perfor-

mance excellence.
ABOUT THE HOSPITAL

Bronson was founded in 1900 and is located on a 28–acre urban
campus in Kalamazoo, MI. Bronson is the largest downtown em-
ployer in Kalamazoo. It is the 343–bed flagship organization of the
Bronson Healthcare Group, a not-for-profit healthcare organization
serving a nine-county region. The hospital has more than 3,200 em-
ployees and 780 medical staff. The hospital manages almost 80,000
emergency visits and 21,000 admitted patients each year. Bronson
includes the only Level I trauma center in its service area, a high-risk
pregnancy center, a Level III neonatal intensive care unit (NICU), an
accredited Chest Pain Center, and a primary stroke center certified
by the Joint Commission on Accreditation for Healthcare Organiza-
tions (JCAHO).1
BRONSON—BEFORE THE CHANGE

During the mid-1990s, the Bronson vision was to be known as the
system of choice in the region. The Bronson culture was built
around trying to do the right things for their patients and there was
a competitive fire to be better than the competition. While Bronson
was a very good organization, a number of performance indicators
had a declining trend. Bronson had a moderate image in the com-
munity, profitable but declining market share (second to the major
competitor in their market), poor human resource practices with
high union vulnerability, high turnover rate, and employee surveys
told them they also had weak leadership. According to Michele
Serbenski, Bronson Executive Director, Corporate Effectiveness
and Customer Satisfaction, it was a time to invest in leadership.
“We weren’t consistent in the administration of our policies or
leadership processes. Our low scores on the employee opinion sur-
veys supported this.” The vulnerability to unionization was per-
ceived to be a significant threat. Unionization “is going to change
our world and you people won’t even know what you are going to
deal with. You don’t want that.” said Susan Ulshafer, recently
retired Bronson Senior Vice President of Human Resources and
Organizational Development.
Chapter Six: Bronson Methodist Hospital Quality of Workplace 91
THE TRANSFORMATION
Frank Sardone, Bronson CEO, began pushing Bronson to raise the
bar—a phrase that became his mantra. The leadership team focused
on a two-pronged approach:
1. What are we going to do about leadership in the workplace
to make Bronson a great place to work?
2. If people want to work here and they are happy, how can
we get them to provide the best possible service to our
customers?
Frank and Susan, along with the rest of the senior leadership team,
resolved to do something about this and became champions for the
process.
Planning was under way for construction of a $200 million cam-
pus redevelopment project adjacent to the existing downtown hospi-
tal. The new Bronson was designed to create a state-of-the-art, easily
accessible healthcare campus with all private patient rooms. This
was a once-in-a-lifetime opportunity for Bronson. According to Ser-
benski, “We asked ourselves, ‘Do we want to move into this (new)
building which will be beautiful and not have the culture match the
architecture? This has to be more than bricks and mortar. We have to
change how we are as a workforce and the culture to support this.’ ”
So the campus redevelopment project sparked the first of several im-
provement platforms to focus on the workforce and service excel-
lence at Bronson.
After confronting the brutal facts, Bronson decided on a four-
step strategic transformation process:
1. Raising workforce engagement to the strategic level
2. Creating the workforce development plan
3. Focusing on leadership
4. Seeking employee buy-in and using employee feedback
All of this was tied together with measurement. The workforce de-
velopment plan became a key element to support Bronson’s corpo-
rate strategy related to customer and service excellence. The plan to
improve and invest in the workforce was presented to the Board of
Directors as a way to better engage the workforce so that they could
provide better service to customers. The plan was approved by the
Board of Directors without difficulty, and Susan began making
quarterly presentations to the Board. The presentations included

changes that had been made and measurement data to show the ef-
fectiveness of the changes. From the beginning it was a strategic ef-
fort with the Board and senior leadership team fully engaged in the
process and responding with the resources needed to accomplish the
transformation.
Early in the process, representatives from Bronson visited and
networked with other organizations recognized for service and work-
force excellence, such as the Walt Disney Company and Ritz-Carlton
Hotels, to learn firsthand how they did things. Bronson also obtained
and began studying the applications of Baldrige Award–winning or-
ganizations from the healthcare industry as well as outside healthcare.
What can a hospital possibly learn from a company that runs
theme parks or a company that runs hotels? Key learnings related to
culture, leadership, standards, and accountability. Disney and Ritz-
Carlton created a culture focused on service excellence. They had
strong leadership, clear performance standards, and held staff ac-
countable to these standards. Bronson created its own interpretation of
this philosophy, which became part of the Bronson Plan for Excel-
lence: “every day, every interaction, every customer, Bronson em-
ployees are personally accountable to . . . create a great memorable
experience.” With these great ideas gleaned from other high perform-
ing organizations, Bronson had its roadmap to service excellence.
ALONG CAME BALDRIGE

In 1999, Susan Ulshafer, Senior V.P. of Human Resources and Orga-
nizational Development, obtained a copy of the MBNQA Criteria
for Health Care. She showed it to Frank Sardone, CEO, who re-
viewed the Baldrige core values and said, “If this supports our pur-
suit of excellence then let’s do it.” So, Bronson decided to use the
MBNQA as the leadership framework for its quality journey to ex-
cellence. By 2005 the Baldrige framework was fully integrated into
the organizational culture and management processes. According to
Serbenski, the MBNQA Criteria “really helped us connect the dots.
Baldrige helped us to fit the workforce development plan into the
right place in our structure so that it was not a separate thing that HR
did, but part of our strategy. We didn’t realize the connect-the-dots
alignment with leaders’ goals and employees’ goals and all the rest
until we adopted Baldrige.”
The first response from the Board when Sardone shared the new
vision to be a national leader in healthcare quality was somewhat pes-
simistic. Sardone replied, “The people of southwest Michigan deserve

healthcare that is the best in the nation. They should not have to leave
Kalamazoo to receive high quality care and service. It is our vision to
be a national leader in healthcare quality.” The Board bought in.
THE BRONSON WAY

What makes Bronson best in class in workplace excellence? The an-
swer to that question begins with the plan for excellence shown in
Figure 6.1. The mission is the foundation of the plan while the vision
provides direction for the organization. The bottom three components
of the plan comprise the guiding principles for Bronson: philosophy
of nursing excellence, values, and commitment to patient care excel-
lence. The top three components of the pyramid, known as the 3–Cs,
comprise the corporate strategies for Bronson: clinical excellence,
customer and service excellence, and corporate effectiveness.
The plan for excellence is provided to each employee in a con-
venient, one-page format and is reviewed with each employee annu-
ally. The purpose of this review is to insure that each employee takes
personal accountability “every day, with every interaction, with
every customer.” The reverse side of the form (Figure 6.2) outlines
this accountability to deliver high-quality care and excellent service.
The one-page plan for excellence was just the start of the communi-
cation process with employees. The communication process incor-
porated lots of different forms of internal communications and it was
an assignment for leaders to discuss it with their employees. Admin-
istrators would ask employees about the 3–Cs and why they were
important to them. Finally it clicked and the employees understood
and felt part of what we are trying to accomplish at Bronson.
All employees are expected to buy in to the culture and link what
they do in the performance of their duties to the 3–Cs—and they do.
Stop by Bronson and ask any employee for directions. The campus
is a bit confusing to navigate. The most likely response by the em-
ployee is “Let me take you there.”
THE WORKFORCE
DEVELOPMENT PLAN
The Workforce Development Plan (WDP) comprises Bronson’s sys-
tematic approach to attracting and retaining qualified staff and its
commitment to workforce excellence. “The WDP includes innovative
Figure 6.1 Plan for excellence.
strategies related to current workforce needs to ensure that Bronson

maintains its status as one of the nation’s best employers.”2 It also ad-
dresses the strategic challenges associated with future workforce
needs. The WDP is composed of seven interrelated initiatives as
shown in Figure 6.3.
Current Workforce
The key to Bronson’s commitment to current workforce excellence
is its investment in leadership. The Bronson leadership initiative
Figure 6.2 Plan for excellence accountability.
(LEADERship) provides training to the hospital’s approximately

225 leaders through a series of two-day training programs held three
times a year. One resource Bronson uses in its leadership training is
the book Good to Great: Why Some Companies Make the Leap . . .
and Others Don’t by Jim Collins.
The Bronson Leadership System (BLS), shown in Figure 6.4,
was developed as a combination of several best practices. The BLS
is the tool used by the Board of Directors and the executive team to
systematically establish, communicate, and deploy the Bronson mis-
sion, values, and vision.
Developing the current workforce Developing the future workforce

• Leadership development • Partnerships with schools
• Career enhancement and communities
• Succession planning • Youth strategies
• Retention • Recruitment
Diversity and well-being
• Diversity strategic WORKFORCE • Two-way communication
plan DEVELOPMENT • Employee input
• Diversity council PLAN • Listening posts
• Mentor program • Workplace health
and safety
Benefits and services

• Your life; your time Staff learning and motivation
• Your wealth and financial security • Education and training plan
• Your professional development • Career development
• Your health and wellness • Knowledge and skill sharing
Recognizing and rewarding

excellence
• Competitive compensation
• Formal and informal reward
Figure 6.3 Workforce development plan.
The Bronson Leadership System is the top level of the staff per-
formance management system (SPMS), shown in Figure 6.5. The
SPMS supports Bronson’s expectations of high performance work
by all staff and is the primary mechanism for the achievement of ac-
tion plans.3 The SPMS is a comprehensive plan that moves from
strategic planning, to deployment by translating the strategic plans
into performance requirements, development of minimum working
requirements and job standards, through setting and midyear moni-
toring of goals for leaders and employees, and providing education
and training to provide knowledge and skills to achieve the goals.
Corrective action planning is included, as well as planning for re-
wards and recognition that are tied to organizational strategy. The
SPMS concludes with individual performance evaluation that is a
two-way communication process between the employee and the ex-
ecutive team. The overall effectiveness of the SPMS is communi-
cated within the organization using the 3–Cs communication format.
Figure 6.4 Bronson leadership system.
Bronson recognizes that excellence is the result of continuous

improvement and has selected the Deming Cycle, plan-do-check-act
(PDCA), as its continuous improvement model. Continuous im-
provement of the SPMS is accomplished through the use of PDCA.
Plan-do-check-act was actually developed by Walter Shewhart and

endorsed by W. Edwards Deming. PDCA represents a spiral of actions
taken to continuously improve processes. In the planning step, the
process is studied to determine changes that could be made to
improve performance. A team is formed to address information
requirements, tests that might need to be conducted to generate
needed data, and plans for obtaining that data. In the do step,
improvement ideas are tested on a pilot scale. In the check step, data
generated during the do step are analyzed to determine the effects
of the ideas on the process. In the act step the results are thoroughly
analyzed to determine what was learned from the tests. If the results
were favorable and no unexpected side effects are observed, the new
process is implemented. Because there is always room for further
improvement in a process, the PDCA cycle can then be applied to the
new process to create further improvement.
Bronson leadership system ➊

develop HR plans ➋, deploy
Review job performance standard,

MWR ➌
PDCA & 3C’s communication
Aligned leader goals ➍ a Employee goals ➍ b
Education and training ➎
90-day Requirements Midyear

action plans met? ➏ review
Coach & counsel ➐ a Recognize & reward ➐ b
Individual performance evaluation ➑
Scorecard/OPI review of three Cs

performance ➒
Figure 6.5 Bronson staff performance management system.4
Future Workforce
The key to Bronson’s commitment to future workforce development
is necessitated in part by its location. Bronson is located in Kalama-
zoo, MI, a small metropolitan area of about 240,000 residents an
hour away from Grand Rapids. There are three hospitals in Kalama-
zoo County and the workforce is reasonably steady. The pool of
qualified healthcare professionals is relatively small and in demand.
During the mid-1990s, Bronson provided support and funding for
the establishment of the Bronson School of Nursing at Western

Michigan University, located close to the hospital, in order to in-
crease the number of registered nurses in the area.
To build the future workforce, Bronson has embarked on three
youth initiatives to encourage Kalamazoo youth to consider careers
in healthcare. There are camps hosted by the hospital to expose 3rd,
4th, and 5th graders to career opportunities in healthcare. Lock-ins
are held in the athletic club for 7th and 8th graders where they learn
about healthcare careers. A health careers job fair is hosted for high
school seniors. In addition, Bronson works closely with high school
counselors to promote careers in healthcare.
In addition, current employees are afforded the opportunity to
advance from staff level to new positions. The respiratory care ca-
reer development program provides a guided pathway for current
employees to become respiratory therapists. During their participa-
tion in the program, employees receive full-time benefits, full pay-
ment for tuition and books, and a 24-hour per day period stipend
while attending classes full time. Upon graduation the employee has
a one-year minimum obligation to remain at Bronson. This program
has resulted in a 0 percent vacancy rate in respiratory therapy at
Bronson.
Employee Satisfaction and Well-Being

Employee satisfaction is regularly assessed through a variety of for-
mal and informal means. The annual employee opinion survey
(EOS) is the primary formal mechanism to assess staff satisfaction
on 16 separate dimensions. The participation rate for the EOS was
93 percent in 2006. EOS results document continuous improvement
since 2001 in most of the 16 dimensions and Bronson achieved best
practice performance on 39 percent of all questions asked on the sur-
vey. Among the highlights from the EOS is the high confidence on
the part of the staff that the administration will use the EOS results
for improvement. In addition to the coded responses to the EOS, the
administration notes carefully all written comments.
It was in the area of two-way communication that Bronson de-
termined the importance of focusing on leadership. The EOS in the
late 1990s said that leadership was poor and pay policy and benefits
weren’t the greatest. During this time Sardone conducted quarterly
employee forums where the CEO would talk about what was going
on. Attendance was good, but people were coming to vent. They
complained about everything: “Parking stinks.” “Pay stinks.” “Blah,
blah, blah.” It was a packed house, and it was at a time when they
had high union vulnerability, so they came to complain. Sardone

held CEO office hours where employees could stop in and talk indi-
vidually to the CEO.
So, Bronson began investing in leaders. As they became stronger
and better armed with information, fewer and fewer employees at-
tended the employee forums. They didn’t need to hear from the CEO
in a big meeting because they already knew the scoop. They knew
that their leaders were listening to them and taking action based on
their input. They knew that they could see Frank in the hallway or
during office hours—but they no longer needed to do that. Bronson
needed to let go of some old things, like the employee forums, that
they no longer needed.
Staff Learning and Motivation

All jobs have a job description designed around core competencies
and that specifies the qualifications and skills required, as well as or-
ganization expectations and values. Leadership is the biggest area
where training is conducted. Bronson LEADERship training is con-
ducted three times each year, and lunch and learn sessions are con-
ducted between the training sessions. Staff are encouraged to take
advantage of targeted population programs to develop skills neces-
sary to qualify for another position in the hospital. Preceptorships,
internships, externships, and scholarships also are used in staff de-
velopment and learning.
Recognizing and Rewarding Excellence

Bronson pays competitive salaries, but not the highest salaries in the
area. Says Serbenski, Bronson “is not at the top of the pay scale. We
tend to sort of be in the happy middle. We have pressure because our
nearest competitor is a union environment and they negotiate a new
contract every couple of years, so we wait to see what the new con-
tract says. We truly believe that people are not going to leave Bron-
son just because of pay. That’s only one piece of the equation for us.
We’d love it if we had the money to be able to always be at the top
of the heap . . . but we don’t. That has not been our rule to live by,
because we have other things like a variety of benefits and services.”
Employee recognition and reward mechanisms are built into the
system. Recognition and rewards take many forms as shown in Fig-
ure 6.6. The celebrations, which are tied to achievement of goals, are
especially important. Sr. VP of HR Ulshafer would always announce
these events with much fanfare and the promise of fabulous prizes.
• Thank you notes

• On-the-spot recognition
• Leader recognition toolbox
• Celebrations (tied to goal achievement) and fabulous prizes
• Hospital Week, Nurses’ Week, Employee Appreciation
• Annual events: picnic, holiday banquet, children’s holiday
party
• Service awards and annual recognition banquet
• Nursing Excellence Awards
• President’s Team Awards
• Bonuses (gainshare, key contributor, productivity, preceptor,
certification/advanced degree completion)
Figure 6.6 Recognition and reward system.5
Everyone knew that the fabulous prizes were inexpensive trinkets

and trash, but they sent a powerful message that achievement of
goals is recognized and appreciated. Leaders have a leader recogni-
tion toolbox that contains Bronson bucks, which can be used on
campus, movie tickets, and logo items which they can award to em-
ployees on the spot.
Gainsharing had been around at Bronson since the early 1990s,
but it wasn’t the gainsharing of today. It started out as a measure to
improve patient satisfaction. It was awarded once a year, so employ-
ees often forgot what they were being rewarded for. The first im-
provement was to move to a quarterly payout. The big improvement
came when gain sharing was expanded beyond just patient satisfac-
tion to include measures for all 3–Cs. Each C is a separate, equally
weighted target. Currently, full-time employees are eligible for a
quarterly gainshare award up to $100 for each target—for a total of
$300 if all three goals are achieved.
Gainsharing is based on department-level goals. At an individ-
ual level, all employees, in conjunction with their boss, are asked to
create their own personal goals—how what they do every day con-
tributes to each strategy. They record these goals on a green card
(see Figure 6.7), called a badge buddy because it fits behind their
identification badge. It took time and additional feedback and com-
munication to help employees learn that these were more than per-
sonal development goals. Some new ways of thinking were required.
Environmental services personnel, for example, had to think about
how they support clinical excellence in what they do every day. One
Bronson will be a national leader in healthcare quality

My personal goals reflect how I commit to My personal goals for the year are:
Bronson’s corporate strategies in my work.
CE:
Bronson’s Corporate Strategies:
CE–Clinical Excellence CASE:

CASE–Customer and Service Excellence
CORE–Corporate Effectiveness CORE:
Figure 6.7 Green card.
answer was that they support clinical excellence by washing their

hands every time they enter or leave a patient’s room because that
helps stop the spread of germs.
Benefits and Services

In addition to the usual insurance, vacation, and holiday benefits,
Bronson has other benefits that set them apart from the ordinary em-
ployer. Some of these benefits are the result of employee sugges-
tions. One of these is free valet parking for employees who are in
their third trimester of pregnancy—the Baby on the Way valet ser-
vice (see Figure 6.8). Valet parking was already available to patients
for a fee. An employee named Rosetta submitted an idea to leverage
that existing resource to relieve pregnant employees from the long
walk from employee parking. One result of this has been that preg-
nant employees can now work longer into their pregnancy.
Another benefit is concierge services available to employees.
The concierge office is located off the atrium in the hospital (see
Figure 6.9). Employees may request a variety of services which the
concierge will perform. These include picking up dry cleaning, tak-
ing vehicles for servicing, ordering flowers, gift wrapping, movie
passes, travel planning, and alterations. All services are provided at
cost—and no tipping is allowed.
Diversity
Diversity has been an opportunity at Bronson. This part of the WDP
considers diversity in its broadest sense. According to Serbenski, “It
is not just about skin color and ethnicity—it’s more than that. Those
are the ways we can easily measure diversity. We have a multi-year
diversity strategic plan that is part of our WDP. We have hired a
Figure 6.8 Bronson Baby on the Way valet service.
Figure 6.9 Bronson concierge services office.

diversity liaison reporting directly to the VP of HR who reports to

the CEO. We have a diversity council, co-chaired by the CEO and
VP of HR, which helps us move forward in diversity awareness, ed-
ucation, planning, and strategy. We are doing everything we can to
recruit minorities to health careers. We currently have a program to
identify minority staff employees for leadership training and partic-
ipation in the leadership mentor program.”
PHYSICIAN INVOLVEMENT
Sometimes physicians can be among the most difficult to involve in
improvement programs. This was not the case at Bronson. At Bron-
son, hospital-driven performance improvements and success created
interest among physicians and resulted in the emergence of physician-
driven performance improvements. According to CEO Sardone,
“They saw us ‘walking the talk’ about our having only one true cus-
tomer: the patients and their families.” Physicians became more in-
volved and provided leadership for programs such as ones to decrease
ventilator-acquired pneumonia, decrease waiting times in the emer-
gency department, and to decrease central line infections. These
physician-driven programs resulted in greater efficiency and im-
proved clinical outcomes. Physician satisfaction increased as turnover
of professional staff decreased. Physicians are included on the strate-
gic oversight teams along with every executive in the hospital.
Bronson has 100 percent adoption of its information technology
systems (IT) by physicians and reports 85.6 percent physician satis-
faction with IT, which puts them in the 99th percentile nationally.
How are they able to achieve this? Currently, Bronson is introducing
a new computerized physician order entry system (CPOE). Before
the go-live date, the IT department set up computers in the lobby that
contained an operational version of the new system. Staffers were
available all day for one-on-one training and to answer any ques-
tions. This setup is called a petting zoo. Physicians and other users
were encouraged to try the new system—”Kick the tires,” as VP/CIO
Mac McClurkan puts it—before the system is introduced. Participa-
tion was encouraged by giving everyone who attended the petting
zoo an opportunity to win a pair of tickets to the Michigan–Michigan
State football game.
Bronson provides a conveniently located physicians service cen-
ter near the physician’s dining room, medical records, and concierge
services. This center handles recruiting of physicians, coordinates
human resource and service functions, provides new-physician ori-
entation and training, and works with physicians’ offices to insure

that they have a seamless IT connection to the hospital. This center
also facilitates the physician satisfaction survey.
IMPACT ON BRONSON
As a result of its journey to excellence, Bronson is flourishing. The
improvements in quality have a measurable payback to the organi-
zation. Since 2000, Bronson’s market share in cardiac services has
consistently increased. In 2005, they had the dominant market share
in their market for the first time with overall inpatient satisfaction
scores in the 90th percentile nationally. Bronson estimates that it
costs $30,000 to $60,000 to replace an RN. RN turnover rate, at
about one third of the national average and about half a national
benchmark, creates a significant cost advantage for Bronson.
THE CEO TALKS ABOUT LESSONS

LEARNED, OPPORTUNITIES,
AND RESOURCES
Lessons Learned
CEO Frank Sardone can cite many lessons Bronson has learned
from its journey to excellence:
• Chief among these is that commitment must start at the top.
Without top management involvement and commitment it
will be a short and ineffective journey. A stable executive
team is also essential to the process.
• You don’t need additional silos of resources in order in order
to accomplish the journey. You must integrate the
improvement activities into the work itself. It cannot be an
add-on activity.
• Culture eats strategy for lunch! Strategic plans cannot be
enacted unless the entire workforce is engaged. Top
management cannot do it alone.
• You must make sure that all employees understand how the
work they do contributes to the attainment of the
organization’s vision. In Sardone’s words, “It (success) really
boils down to the people.”
Opportunities
Sardone also remembers several major opportunities along the way.
According to Serbenski, “We don’t have challenges or stumbling
points at Bronson. We have opportunities.”
• How do you make the MBNQA part of what we do? This
was a difficult issue for Bronson. After several applications,
Bronson decided not to reapply for the Baldrige Award in
2004. Instead, they used this year to address this stumbling
point and prepare for their ultimately successful 2005
application.
• Building the new Bronson was a major opportunity in the
1990s.
Key Resources
Throughout the process of determining key resources needed to ac-
complish the transformation, one constant was to leverage the power
of leaders. Few additional resources were required.
• Greeters were added so that nurses don’t have to do this.
This frees up time for clinical professionals to focus on
patients.
WHAT’S NEXT FOR BRONSON?

“We are pleased to receive the MBNQA and serve as role models,
but that doesn’t mean we are perfect. There are lots of things we
didn’t do well the first time, figured out later, still haven’t figured
out. Our new goal is to win the MBNQA again in 2011—the earli-
est time that we are eligible to apply.”—Michele Serbenski.
MEASURES OF BEST-IN-CLASS
PERFORMANCE
Among the output measures that document Bronson’s best-in-class
performance in quality of workplace are:
Turnover Rate (2005)
5.6 percent overall versus national average 19 percent
4.7 percent for Registered Nurses versus national aver-
age 18 percent
Job Vacancy Rate

5.3 percent overall versus national average 9 percent
5 percent for Registered Nurses versus 10.6 percent
American Nurses Credentialing Center (ANCC)
best practice comparison
Overall Staff Satisfaction
90 percent of employees rated Bronson as a “great place
to work” versus 87 percent for all Fortune Best 100
companies on Great Place to Work Trust Index
Top 10 percent for physician satisfaction in survey by
Professional Research Consultants
100 Best Companies for Working Mothers by Working
Mother magazine in 2003, 2004, 2005, and 2006
100 Best Companies to Work For by Fortune magazine
in 2004, 2005, and 2006
Patient Satisfaction
Considered “excellent” in “top box” patient satisfaction
scores by Gallup
Inpatient satisfaction in 90th percentile by Gallup.
Outpatient surgery patient satisfaction in 95th percentile
by Gallup.
Michigan Quality Leadership Award in 2001 and 2005
Malcolm Baldrige National Quality Award in 2005
100 Top Hospitals by Solucient in 2005
American Hospital Association—McKesson Quest for
Quality Citation of Merit in 2006
Governor’s Award of Excellence for Improving Care in the
Hospital Setting in 2004 and 2005
Consumer Choice Award 2002–2005
Kalamazoo’s Leading Hospital 1998–2005
REFERENCES
1. NIST. “2005 Award Winner,” 2005.
2. Bronson Methodist Hospital. “2005 Malcolm Baldrige National
Quality Award Application Summary,” 2005, 18.

4. See note 3.
Collins, J. Good to Great: Why Some Companies Make the Leap . . . and
Others Don’t, New York: HarperCollins Publishers, 2001.
http://corporate.disney.go.com/index.html The Walt Disney Company
Home Page.
http://patapsco.nist.gov/eBaldrige/HealthCare_Profile.cfm E-Baldrige
Self-Assessment and Action Planning: Using the Baldrige
Organizational Profile for Health Care.
www.Bronsonhealth.com bronson Methodist Hospital Home Page.
www.kalamazoomi.com Kalamazoo, MI, community site.
www.quality.nist.gov NIST Baldrige National Quality Award Home Page.
www.quality.nist.gov/HealthCare_Criteria.htm Baldrige Health Care
Criteria for Performance Excellence.
www.ritzcarlton.com Ritz-Carlton Hotels Home Page.
Lee, F. If Disney Ran Your Hospital: 9 1/2 Things You Would Do
Differently, Bozeman, MT: Second River Healthcare Press, 2004.
7
Columbus Children’s
Hospital: Benchmarking
the Aviation Industry
to Prevent Surgical Errors
T
he process has an accident rate
of 0.000293 percent. That is,
2.93 accidents per 1,000,000
opportunities. The percentage of fatal
accidents is even lower—0.000027
percent or 0.27 fatal accidents per
1,000,000 opportunities.1 Remark-
able? Yes, and even more so when you
consider that this process is among the
most complex of processes—U.S. commercial aviation. How does
commercial aviation achieve such low error rates?
Pilots, like medical professionals, are well trained and certified
before being allowed to take the lives of passengers into their hands.
Like medical professionals, much of what they do, while demanding
a high level of skill, is routine, but, like medical professionals, they
are skilled in dealing with any eventuality. The equipment they use,
as with medical equipment, is well designed and maintained. What
is the rest of the secret to their low incidence of errors?
Part of the secret is the systems of checks that pilots go through
before they are ready for takeoff. These checks anticipate sources of
error and deviations from normal and identify them for correction
before takeoff. The Columbus Children’s Hospital Children’s Qual-
ity Initiative in Surgery (CQIS) Team thought that a similar process
could improve surgical safety and benchmarked their pre-operation
procedures to the preflight check procedures of the commercial avi-
ation industry.
109
Another part of the secret is the redundancy that is built into the
aviation system. Aircraft are designed and built to high quality stan-
dards by certified manufacturers. Highly reliable parts, subsystems,
and components are purchased from certified suppliers. Back-ups
are included in critical systems design. Specially trained and certi-
fied mechanics certify their work on the airplanes. Specific members
of the crew are tasked with inspecting the aircraft as part of the pre-
flight procedure. The pilot has overall responsibility for the safety
and airworthiness of his aircraft. The Columbus Children’s Hospital
thought that similar built-in redundancies could increase surgical
safety.
Columbus Children’s Hospital CQIS Team benchmarked their
pre-operation procedures against the aviation industry. The result
was Operation Takeoff, which is designed to ensure that “patients re-
ceive a safe and accurate surgery.”2
ABOUT THE HOSPITAL

Children’s Hospital opened in Columbus, Ohio, in 1894 with nine
beds, a six-member staff, and seven other employees. During that
first year, 70 patients were treated. “Today, Children’s is the primary
pediatric health care provider for 37 counties, with more than 800
medical staff members and 4,500 employees who provide expert
care to children regardless of ability to pay. . . . Children’s Hospi-
tal and its programs have received accreditation from the following
organizations:
• The Accreditation Council for Graduate Medical Education
(ACGME)
• American College of Surgeons (ACS) Trauma
• Commission on Accreditation of Rehabilitation Facilities
(CARF)
• Foundation for the Accreditation of Cellular Therapy
(FACT)
• Joint Commission on the Accreditation of Healthcare
Organizations (JCAHO)”3
Children’s Hospital has Ohio’s first Level 1 Pediatric Trauma Cen-
ter and the busiest inpatient pediatric surgery center in Ohio.
Columbus Children’s was named to the U.S. News & World Re-
port America’s Best Hospitals List in 2006, it is the only freestand-
Chapter Seven: Columbus Children's Hospital 111
ing pediatric hospital in Ohio to receive Magnet Recognition from

the American Nursing Association, and it is listed in Child maga-
zine’s 2007 10 Best U.S. Children’s Hospitals—number one in Pedi-
atric Emergency Services, with four other subspecialties among the
top 10. In 2005, 96 doctors were recognized as being among the Best
Doctors in America. In 2006, Columbus Children’s was one of 59
U.S. hospitals—including only nine children’s hospitals—named to
the first Leapfrog Top Hospitals list, based on results from the
Leapfrog Hospital Quality and Safety Survey.
The mission, vision, and promise of Columbus Children’s Hos-
pital, shown in Figure 7.1, guide the everyday functioning of the
hospital. According to Donna A. Caniano, MD, Surgeon-in-Chief of
Columbus Children’s Hospital and Chief of the Department of Pedi-
atric Surgery, “The essential mission is really truly grounded in
everybody. That is our brand . . . every child will receive high qual-
ity care regardless of the family’s ability to pay. That is the unique
feature here at Children’s. That’s our brand.”
INITIAL DEVELOPMENT OF PATHWAYS

During the early1990s Columbus Children’s, along with many other
hospitals, was concerned about the possible effects of managed care
on private pay. Even though managed pay was perceived to be more
of a coastal problem and had not had much impact in the state of
Ohio, the hospital’s administration was concerned. One of the ac-
tions they took was to ask Dr. Caniano to investigate the develop-
ment of clinical pathways—clinical guidelines. She decided to start
with appendicitis. “Appendicitis is a well-defined disease. It has a
beginning, we know and understand the course, and we understand
the care of it.” At the time she was given this assignment she was a
relatively junior faculty member. She convened a team of “special-
ists from infectious diseases, radiology, and a cohort of my col-
leagues.” They hammered out a pathway and implemented it.
THE MOTIVATION FOR

FURTHER IMPROVEMENT
In 1999, the Institute of Medicine of the National Academy of Sci-
ences published a study that concluded that almost 100,000 Ameri-
cans die each year as a result of preventable errors in hospitals. This
makes hospital errors the eighth leading cause of death in America
Mission/Vision
Our Mission
Children’s believes that no child should be refused necessary
care and attention for lack of ability to pay. Upon this funda-
mental belief, Children’s is committed to providing the highest
quality:
Patient Care
Advocacy for children and families
Pediatric Research
Education of patients, families, and future
providers
Outstanding Service to accommodate the needs of
patients and families
Our Vision
• In an increasingly dynamic and competitive health care
market, patients, families, physicians, and community will
demand Children’s.
• We will provide the highest quality health care in our re-
gion, centered around the family, delivered with unsur-
passed value and customer service.
• We will become nationally prominent in child health re-
search and primary care and subspecialty education, and
will leverage this position to enhance the health of chil-
dren everywhere.
• The environment we shape will make us proud to be a
part of Children’s.
• For Every Child. For Every Reason . . . The Choice is
Children’s.
Our Promise
Columbus Children’s Hospital. Where your child receives the
best care anywhere in the world. The place where curing and
caring go hand-in-hand.
Figure 7.1 Columbus Children’s Hospital mission and vision.4

ahead of AIDS and breast cancer. Dr. Caniano “really became con-
cerned about quality when I read this report. It really began to pique
my interest.”
ABOUT THE EX-OFFICIO

DIRECTOR AND CHAMPION
OF OPERATION TAKEOFF
As part of her duties as Surgeon-in-
Chief of Columbus Children’s Hospital
and Chief of the Department of Pedi-
atric Surgery, Donna Caniano, MD, is
Ex-Officio Director of the Children’s
Quality Initiative in Surgery Team
(CQIS). Dr. Caniano is the H. William
Clatworthy Jr. Professor of Pediatrics
and Surgery at The Ohio State Univer-
sity College of Medicine and was
named one of the Best Doctors in
America in 2005.5
THE TRANSFORMING EXPERIENCE

By the summer of 2003, Caniano had been promoted to Surgeon-in-
Chief and was supervising a surgical resident who was conducting a
clinical research project on appendicitis. During the course of the
2003–2004 academic year she came to Caniano’s office looking very
nervous. “I have something to tell you and you’re going to be really
upset,” she began. Caniano replied, “Abigail, what do you need to
tell me? It can’t be that bad.” The resident replied that the patients
were not receiving their antibiotics correctly according to the clini-
cal pathway guidelines. This represented a deviation from the path-
way Caniano’s team had developed as well as the Centers for
Disease Control (CDC) guidelines. Caniano did not believe her.
Caniano pulled all of the charts for the past year for children or
adolescents with acute appendicitis and examined in detail a sample
of 105 charts. She found that 64 percent of them received the correct
antibiotic at the right time (Figure 7.2). Among the charts she found
that 14 percent received the right antibiotic but at the wrong time,
which some studies show can actually increase the risk of infection.
In 9.5 percent of the charts she could find no documentation that it
Acute appendicitis and prophylactic antibiotic utilization

1. Number of charts reviewed: 105 (2004)
2. Number—Right ATB/Right Time: 67 (64%)
3. Number—Right ATB/Wrong Time: 13 (12.5%)–greater than
1 hour before incision.
4. Number—Right ATB/Wrong Time: 15 (14%)–during the
appendectomy.
5. Number who did not receive ATB: 10 (9.5%)
Next Steps
1. “Persuasion” Campaign to all nursing, anesthesiology, and
surgical staff regarding delivery of prophylactic antibiotics.
2. Linking the “Time-out” to antibiotic delivery: Right Patient–
Right Antibiotic–Right Time.
3. Measures of success.
Figure 7.2 The results of Dr. Caniano’s study and initial plan.
was given. Fortunately, the patients were children. In adults with

acute appendicitis, not receiving an antibiotic greatly increases the
risk of surgical site infection. This is not the case with children.
Healthy children have a very low risk of wound infection or surgical
site infection. “So, we’re talking about reducing the risk from 2 per-
cent to half a percent. However, if you are the one patient, it is 100
percent.”
Caniano “was devastated! We are a good hospital! When we
train staff we tell them ‘Every time you encounter a patient, it is your
child. That’s what you see.’ So these findings were a transforming
experience for me. Under my watch with people all geared to do the
very best—and we weren’t there. But this was the battle cry. This is
how you get buy in. I took this information everywhere. I took it to
the ER, I took it to nurses, I took it to anesthesiologists. And that is
what we needed.”
THE IMPORTANCE OF SYSTEMS

Dr. Caniano’s scholarly area is ethics. She began to think about qual-
ity from a broader perspective in terms of ethics and care and became
interested in systems. The classic model is when an error occurs it
must be the result of an individual error by a nurse, a physician, or a
technician. The solution is to identify that individual and work with

them to correct it. According to Caniano, “A classic example is when
a nurse makes a medication error. When you actually look at why the
nurse made the medication error in the first place, it’s a systems prob-
lem. She’s the only RN on the floor and she is caring for patients as
well as distributing medications and doing administrative work. So I
came to be quite interested in the systems aspect.”
Dr. Caniano’s thinking echoes that of quality pioneers W. Edwards

Deming and Joseph M. Juran. Both have consistently asserted that
eighty to ninety percent of all errors are the result of systems problems
rather than individual errors. They both advocated the improvement
of systems as being the only way to dramatically reduce errors.
“So we started reading. Here I am reading about Toyota, which

doesn’t seem to have much to do with patients, but it does. I became
convinced of the whole concept of reducing variability. I one hun-
dred percent believe it, for common diseases like this.”
THE CHILDREN’S QUALITY INITIATIVE

IN SURGERY (CQIS)
“Surgeons are a tough group, but we got great buy in because I could
show them the numbers from the appendectomy study. The col-
leagues who bought in at the highest level, in addition to pediatric,
general surgeons, and neurosurgeons, were orthopedic surgeons be-
cause their surgeries often involve insertion of metal devices and
opening of joint spaces. Whenever you put any kind of metal into a
child . . . it is devastating if the child gets an infection.”
The buy in resulted in the creation of the Children’s Quality Ini-
tiative in Surgery (CQIS) with Dr. Caniano as Ex-Officio Director.
Caniano formed the team co-chaired by two surgeons. Comprising
the team were the V.P. for Perioperative Services, who is a nurse
with an MBA; a neurosurgeon; the chief of otolaryngology; an or-
thopedic surgeon; the chief of anesthesiology; the chief administra-
tive surgical officer; and Caniano, as ex-officio director. All of the
team members were volunteers. According to Caniano, “It was im-
portant that younger members and more senior people be repre-
sented on the team. The last thing that you want for something like
Children’s Quality Initiatives in Surgery (CQIS)

Children's Hospital
1. The Charge
a. Develop a comprehensive quality program for surgical services at
Children’s Hospital
b. Program characteristics include direction by surgeons and
anesthesiologists, a program that is systems-based and
evidence-based, and a program that aims to continually
enhance clinical care.
2. Essential components of CQIS

a. Outcomes: morbidity/mortality, functional, patient satisfaction,
quality of life
b. Efficiency: cost, wait times, OR utilization, “right” OR setting,
clinical pathways
c. Safety: adverse surgical/anesthetic events, adherence to national
safety standards
d. Access: Surgical Scene
e. Communication: PAT, discharge instructions, communication with
referring physicians
f. Documentation: OP notes within 24 hours, pre-op antibiotic
administration.
g. Patient-centered care
h. Diversity
3. What we are doing currently
4. Achievable vs. “stretch” goals
5. What resources are needed
Donna A. Caniano, MD
Surgeon-in-Cheif
Children’s Hospital
Modified January 10, 2005
Figure 7.3 Charge to CQIS.
this is a bunch of senior doctors. You need fresh ideas and enthusi-
asm. And for this kind of thing, you can’t have top-down. It has to
be bottom-up. The ordinary staff person has to be just as interested
and see the relevance as the CEO.” The initial charge was given to
the team by Dr. Caniano in September 2004 and was modified in
January 2005, as shown in Figure 7.3.
In the early phase of the initiative the team identified that it
needed more education. The hospital provided funding for four of the
team members to attend a winter meeting of the Institute for Health-
care Initiatives where they took courses on systems issues and starting
initiatives. Then they developed their plan, shown in Figure 7.4, which
Quality Initiatives in Surgery at Children's Hospital
1. The Surgical Dashboard: A single indicator by surgical specialty

that reflects a measure of quality and that has national
benchmarks; reporting on a quarterly basis. Examples include
(1) false positive rates of childhood appendicitis, (2) bleeding
following tonsillectomy, (3) reintubation in PACU, and (4)
mortality rate after Stage I palliation for hypoplastic left
heart syndrome.
2. Development of CQIS: Children's Quality Initiative in Surgery

Co-chairs are Marc Michalsky and Terry Davis
Members are Janet Berry, Scott Elton, Richard Kang,
Jan Klamar, and Alan Tingley; Donna Caniano (ex officio)
3. "Education" phase of project

a. Attendance at the IHI in December 2004 by CQIS members
b. Targeting a "big dot" item as identified as a major source
of morbidity/mortality: surgical site infection
c. Right patient/right antibiotic/right time and linking to
"surgical time-out"
4. "Implementation" phase of project

a. Process measures first
b. Outcome measures second — challenges of SSI data collection
Donna A. Caniano, MD
Surgeon-in-Chief
January 9, 2005
Figure 7.4 CQIS plan.
included the concept of the Surgical Dashboard shown in Figure 7.5.

Each department was charged with developing one item that they
would monitor on an ongoing basis. Most of the items are very mea-
surable things, some of which are benchmarked against best practices
available from the Child Health Corporation of America (CHCA) and
various pediatric specialty organizations.
OPERATION TAKEOFF
Dr. Terry Davis was the Chief Surgical Administrator at Columbus
Children’s Hospital. He co-led Operation Takeoff with Dr. Caniano.
Dr. Davis brought a special quality to the team. He is also a private
pilot. Dr. Caniano had done a lot of reading about the aviation in-
dustry and she was always asking him questions. During the course
of these conversations, they looked at each other and jointly had the
General Pediatric Surgery Dashboard Indicator
% Negative vs. Ruptured Appendicitis Columbus

Children’s Hospital 2004
25
23
20
20
15
15
Negative appy
Ruptured appy
10
5 4
0
CCH Historic control
Percent of Negative Appendectomies and Ruptured Appendicitis

Columbus Children’s Hospital, 2004
The rate of negative appendectomies (i.e. the number of

patients undergoing an appendectomy without pathologic
evidence of acute appendicitis) has historically been reported
as 15%. This national benchmark is typically linked with an
associated rate of ruptured appendicitis on an institutional
basis (23 to 25%). Specifically, authors have cautioned that a
reduction in the rate of negative appendectomies (which may
be the result of longer non-operative observation until the
diagnosis becomes more certain) may result in an increased
rate of appendiceal rupture.
All pathology reports for patients undergoing appendectomy

during 2004 were reviewed. Of the 408 appendices that were
examined in the Department of Anatomic Pathology, 100 were
considered incidental and not included in this analysis. Of the
remaining 308 specimens, 13 (4%) had no pathologic changes
(i.e. Negative Appendectomies), 63 (20%) were ruptured and
232 (80%) were non-ruptured. These data confirm that our pre-
operative diagnostic algorithm, including the appropriate use of
CT scanning, have allowed us to have a very low rate of nega-
tive appendectomies compared to the historical data, without
increasing the overall rate of cases ruptured at the time of
surgery. No comparative regional or national data are available
at this time.
Figure 7.5 Example of surgical dashboard.

idea that the aviation industry might have some ideas they could use
in the OR. According to Caniano, “We were talking about a situation
where I was on a plane and the plane couldn’t take off because a
knob wasn’t working and we all had to get off the plane and that this
was ridiculous. Then we thought about it. Is it ridiculous? It isn’t
ridiculous—we need to do that. The system works in aviation most
of the time.” If the system fails—that is, the person responsible for
taking care of the knob fails to do so—the pilot using his checklist
is a built-in redundancy that will prevent the plane from taking off
until the problem is rectified.
“That’s why we chose the aviation industry,” said Caniano.
“They use a checklist to be sure that everything is right before they
takeoff and they have built-in redundancy. Redundancy is something
doctors generally don’t like. They don’t like being told five times
that they must mark the operative site. The safest industry in my
world is anesthesiology because of that redundancy. Surgeons are
accepting redundancy kicking and screaming, and in my case, will-
ingly. But they are coming in.”
Dr. Caniano is correct in her understanding of the power of

redundancy in preventing errors. For a process such as prophylactic
antibiotic utilization, which for Columbus Children’s Hospital had a
2003–2004 baseline reliability of 0.64 (64 percent receiving right
antibiotic at right time), adding a single redundancy of equal
reliability (that is, 0.64) would increase the overall reliability to 0.87.
Adding a second redundancy would increase the reliability to 0.95. A
third redundancy would increase the reliability to 0.98, which is
approximately equal to the reliability of the improved system under
Operation Takeoff.*
Hospital administration bought into Operation Takeoff and

agreed to fund the project. In the end, it turned out that only about
$10,000 was required for the entire project.
The tools and methods used during the project were not very so-
phisticated. In Dr. Caniano’s words, “We’re not going to teach peo-
ple Chinese.” The team worked with their nurse colleagues to take
*With one redundancy, reliability is 1 (1 0.64)2 0.87. With two redundan-

cies, reliability is 1 (1 0.64)3 .95. With three redundancies, reliability is
1 (1 0.64)4 0.98.
what they ordinarily do prior to an operation and marry that with

what they wanted to accomplish so that it became part of what they
do—augmented. They basically started with the marker board that is
posted in the operating rooms with basic information about the
surgery. What they did was expand that into the Operation Takeoff
pre-incision checklist in Figure 7.6.
The Operation Takeoff pre-incision checklist is based on two
major national healthcare patient safety initiatives:6
• Universal protocol, which includes marking operative site
and verbal verification of several aspects of procedure.
• Reducing surgical site infections by linking timeout and
antibiotic administration, team approach involving surgeon,
anesthesiologist, and nurse.
Operation Takeoff:7
• Standardized the patient verification and timeout process
among services to include surgeon presence before
prep/drape.
• Revised policy requiring site marking on all cases involving
laterality. Also, x can no longer mark the spot.
• Redesigned surgical site verification checklist.
• Use of timeout placards in instrument sets.
• Redesigned OR marker boards, including for away games.
• Large scale marketing and education campaign.
Operation Takeoff is not confined to the OR. In some instances op-
erative procedures are performed in critical care and other patient
units—outside the OR. These procedures are referred to as away
games. Operation Takeoff still applies—they bring the checklist
board with them and have the same timeouts.
When the entire team is ready, the process begins. Do we have
the appropriate equipment? Do we have the appropriate technical
scans? Is the site marked where appropriate? They just keep going
down the checklist. All of these are being monitored. The surgeon is
not given the scalpel until everything is cleared for takeoff. There is
a little metal tent that is put over the scalpel that comes with the kit.
This is part of this initiative. The scrub nurse does not take the tent
off to give the surgeon the scalpel or the laparoscope until every-
thing is go—the anesthesiologist says go; everyone says go and you
are cleared for takeoff.
Figure 7.6 Operation Takeoff pre-incision checklist.
Surgeon buy in is obviously very important to Operation Take-

off, and the results of the initiative help obtain that buy in. Near-miss
events are subjected to root cause analysis in the same way as sen-
tinel events. One near miss—a sentinel event that was prevented by
Operation Takeoff—resulted in the transformation of a surgeon who
initially was reluctant to participate into a champion for the process.
According to Dr. Caniano, “I would like to know right away if
we have an event today. It is hard in medicine to get real-time stop-
ping. But what we would really like is an analysis within 24 hours
because the longer the gap between the event and the analysis, the
more information is lost and distorted.”
The Operation Takeoff board has gone through several modifi-
cations since implementation. Every quarter the nursing managers
for each specialty reanalyze the utility of all the information. The
goal is to remove anything that is extraneous so that the focus can be
maintained on the core issues.
LAUNCHING OPERATION TAKEOFF

To launch the initiative, each specialty—all the doctors, all the
nurses, all the technicians, all the people who clean the floors . . .
everyone—received a letter inviting them to a party in a park across
from the hospital. Everyone was invited to bring their children with
them. Caniano reflected “We brought all of the props—pilot hats,
flight jackets, and the kids got to keep the props. Our photography
department was there. Channel 10, our CBS affiliate was there and
they televised the event. This was the large-scale marketing and ed-
ucation campaign.” And the pictures of the children all decked out
for Operation Takeoff became part of the checklists. “It was obvious
that we should have our children on the checklist, because we think
that when you look at a patient you should see your own child.” The
plan is to periodically change the pictures and have another party so
that when staff graduates they will bring in new children.
The other part of the large-scale marketing and education cam-
paign involved posting the boards throughout the hospital—in the
lounges, in the bathroom stalls—“so that everywhere you went you
would be reminded about it.”
THE RESULTS
The pre-Operation Takeoff baseline for acute appendicitis and pro-
phylactic antibiotic (ATB) in 2004 was 64 percent. In 2006, approx-
imately 98.2 percent received ATB. Dr. Caniano personally reviews
every medical record of every child with appendicitis. The antibiotic
administration error rate for 2006 is 1.8 percent. There were no sen-
tinel events in surgery in 2006 and only two near misses. Dr. Cani-
ano’s response to this: “I am terribly disappointed. Really! I’m not
happy. We are going to get better.”
One of the ways operation takeoff is monitored is through the
use of secret shoppers. Secret shoppers are designated nurses who
are off-shift and who periodically monitor compliance. Janet Berry,
the nurse on the Operation Takeoff team and the V.P. for Periopera-
tive Services, coordinates this process so that even Dr. Caniano is
blind to when the secret shopper is making observations. Figure 7.7
shows the progress that has been made.
WHAT’S NEXT?
Dr. Caniano shares the assessment information quarterly with every
surgeon. “We go through it. It is blinded data right now. After the
Percent of procedures with time out

performed prior to incision
100
90
80
70
60
Percent
50
40
30
20
10
0
Nov ´05 Feb ´06 Sep ´06
Figure 7.7 Secret shopper results.
first year I will tell them that they are going to get an appendicitis re-
port card that is going to be linked to our incentive plan. That will
be the final piece of this.”
The mission, vision, and promise of Columbus Children’s
Hospital is so engrained in each employee of the hospital—so
much a part of the culture—that it will drive the continued im-
provement of Operation Takeoff. According to Dr. Caniano, “It’s
not complete. It never will be until we get it right 100 percent of
the time. But the more you dig down in this, the more work there
is because now we are going after a very small percentage—down
from 30 some percent.”
THE SURGEON-IN-CHIEF
TALKS ABOUT OBSTACLES
There were obstacles that had to be overcome. The hospital was
building its new OR when all this was happening. Some of the nurs-
ing staff said, “We don’t want to do this until we are in the new
building.” “I finally said No!” said Caniano. “We’re not going to do
that. This is not bricks and mortar. This is patient care. If you had a
new drug you wouldn’t hold it up until you had a new nursing unit.
You’d give the drug. We’re going to start it when it is ready to start,
which was at least three months before we moved.”
To help deal with this obstacle, formal meetings were held with
the nurses. There was a pizza lunch for the nurses. Formal training
for nurses and mock runs were conducted prior to launch with prac-
tice boards.
Some surgeons initially resisted the initiative. For the most part
these have been won over by the results of the initiative.
PERFORMANCE
Among the outcome measures that document Columbus Children’s
Hospital’s best-in-class performance are:
Named to U.S. News & World Report America’s Best Hos-
pitals List in 2006
Children’s is the only freestanding pediatric hospital in
Ohio to receive Magnet Recognition from the Ameri-
can Nursing Association
Child magazine’s 2007 10 Best U.S. Children’s Hospi-
tals—Number one in Pediatric Emergency Services;
four other subspecialties among top 10
96 doctors who have been voted to be among the “Best
Doctors in America” (2005)
One of 59 U.S. hospitals—including only nine children’s
hospitals—named to the first Leapfrog Top Hospitals
list, based on results from the Leapfrog Hospital Qual-
ity and Safety Survey
One of the three top “Best Places to Work” in Columbus
Business First’s Best Places to Work Program
No surgical errors in 2006 and only two near misses
REFERENCES
1 National Transportation Safety Board,
www.ntsb.gov/aviation/Table1.htm
2 “Operation Takeoff”: Changing How Surgery Takes Flight at
Children’s,” Spotlight: Children’s Employee Publication, December
2005, 3.
3 www.columbuschildrens.com
4 See note 3.
5 See note 3.
6 “Preoperative Services QIP,” Presentation made on November 17,
2006, by Columbus Children’s Hospital, Slide 3.
7 “Preoperative Services QIP,” Presentation made on November 17,
2006, by Columbus Children’s Hospital, Slide 5.
www.asq.org/healthcare-use/why-quality/overview.html American Society
for Quality’s Quality in Healthcare Page.
www.chca.com/company_profile/pi/index.html Child Health Corporation
of America (CHCA) Home Page.
www.columbuschildrens.com Columbus Children’s Hospital Home Page.
www.ihi.org/IHI Institute for Healthcare Initiatives Home Page.
www.iom.edu Institute of Medicine of the National Academy of Sciences
Home Page.
www.leapfroggroup.org The Leapfrog Group Home Page
Systems Thinking. www2.fhs.usyd.edu.au/arow/o/m12/thinking.htm
Systems Thinking in Healthcare.
www.managementwisdom.com/sythinhe.html
8
Robert Wood
Johnson University
Hospital Hamilton
Emergency Department:
The 15/30 Guarantee
W
aiting, waiting,
waiting . . . in
an emergency
department (ED) only
adds to the pain that
brought the patient to the
hospital. The ED is the
front door to the hospital
for most patients. Sadly
the hospital often strikes
out with its patients before they get through the front door. Strike 1:
Studies show that organizations that make customers wait are likely
to have dissatisfied customers and may lose them to competitors. In
the best of circumstances, modern society typically has little pa-
tience for waiting. People are accustomed to moving in a fast-paced
environment and consider time a valuable, often scarce resource.
Strike 2: Anxiety increases the negative impact of waiting by caus-
ing time seemingly to pass more slowly. The wait time seems longer
than it actually is. This waiting line anxiety only exacerbates the
anxiety from worry about the illness and pain which brought the per-
son to the ED. Strike 3: Unoccupied time causes a person to notice
the passage of time more. Moreover, uncertainty about how long the
wait will be can cause anger, which translates into dissatisfaction. A
hospital where ED patients experience long wait time in addition to
the anxiety of being ill and the uncertainty about when they will be
127
seen in the ED has struck out with their patients and has an uphill
battle to reverse patient dissatisfaction.
Researchers have also found that people tolerate long wait times
the more valuable the service is to them. This explains why patients
endure long waits in the ED. They must . . . but they are not happy.
The first impression of the hospital, like most first impressions sticks
in the patient’s mind for a long time and may cloud all subsequent
experiences in the hospital. A hospital that puts the right foot for-
ward in the ED predisposes the patient for a satisfying experience in
the hospital as a whole. Thus, improvements in the quality of the ED
experience are especially valuable in enhancing overall patient sat-
isfaction.
Robert Wood Johnson University Hospital Hamilton saw the
opportunity to deliver excellence through service at their front door
by reducing the wait time in the ED. At a time when patients com-
monly had an extensive wait in the ED, Robert Wood Johnson Uni-
versity Hospital Hamilton formulated an outlandish goal, the 15/30
Guarantee: To have a patient seen by a nurse within 15 minutes of
arrival in the ED with the ultimate goal to have the patient seen by
a nurse practitioner or physician within 30 minutes of arrival. This
is a standard seldom met in hospitals. Why did Robert Wood John-
son University Hospital Hamilton set such a high goal for the ED?
Joyce Schwarz, Vice-President of quality and professional services,
sees this ambitious goal as consonant with the hospital mantra: To
a Higher Standard. “We benchmark ourselves against best in class,
not national averages.” What might be seen as an outlandish goal to
some people was a perfect fit for Robert Wood Johnson University
Hospital Hamilton.
ABOUT THE HOSPITAL

Presently Robert Wood Johnson University Hospital Hamilton
serves more than 350,000 patients with a staff of over 2500 repre-
senting more than 30 medical specialties. Inpatient (medical, surgi-
cal, cardiology, obstetric, orthopedic, intensive care), outpatient
(ambulatory surgery, emergency, diagnostic, oncology, therapeutic),
health education, health screening, and disease prevention services
are offered on the 67–acre campus to the greater Mercer County
community.
The hospital first opened in 1941 in Trenton, NJ, and later moved
to Hamilton in 1971. The hospital has seen dramatic growth since
the beginning of the twenty-first century (Table 8.1). To accommo-
Chapter Eight: Robert Wood Johnson University Hospital Hamilton 129
Table 8.1 Significant five-year growth.
2000 2005 % Growth

Inpatients 9000 14,000 55.6%
Total births 839 1360 62.1%
Level II nursery N/A 272 100.0%
ED 34,000 54,000 58.8%
Outpatients 122,000 213,000 74.6%
Cardiac cath procedures 585 890 52.1%
Volunteer hours 24,000 55,000 129.2%
Community ed contacts 40,000 139,000 247.5%
Center for health and wellness N/A 11,000 100.0%
date the burgeoning demand, the hospital has built the Lakefront
Tower, which adds an additional 64 private patient rooms.
The hospital uses the mission, values, and vision (Figure 8.1) to
guide decision making.
SETTING THE STAGE

In 1994 Robert Wood Johnson University Hospital Hamilton part-
nered with Robert Wood Johnson University Hospital in New
Brunswick, NJ. As principal hospital for the University of Medicine
and Dentistry of New Jersey (UMDNJ)—Robert Wood Johnson
Medical School, this partnership offered Robert Wood Johnson Uni-
versity Hospital Hamilton a portal to the latest medical innovations
and procedures. The Hamilton hospital also joined the RWJ Health
Network, which includes 13 hospitals, health centers, and satellite
facilities and their thousands of physicians, nurses, and other health-
care professionals. At monthly meetings of this alliance, the doctors,
nurses, and other hospital staff share best in practice processes and
procedures.
Hospital networks are windows to information that is often difficult

for outsiders to secure. Collective brainstorming solutions to problems
and shared expertise can jump start the introduction of best in
practice processes.
Our Mission
Robert Wood Johnson University Hospital Hamilton is committed
to excellence through service. We exist to promote, preserve, and
restore the health of our community.
Our Values—Quest
Q – Quality
U – Understanding
E – Excellence
S – Service
T – Teamwork
Our Vision
Our vision is to passionately pursue the health and well-being of
our patients, employees, and the community through our culture of
exceptional service and commitment to quality.
January 2007
Figure 8.1 Robert Wood Johnson University Hospital Hamilton

mission, values, and vision.2
THE ACTION BEGINS

In the late 1990s, the wait time in hospital emergency departments
was one of the more common complaints and common concerns
nationwide. During the hospital network meetings, innovative and
creative ways to address operations of the ED were frequently
discussed as the issue became a network initiative. One of the net-
work hospitals, RWJUH in New Brunswick, initiated the pilot pro-
ject for the 15/30 guarantee. None of Robert Wood Johnson
University Hospital Hamilton’s three competitors had notable pro-
grams in place to address the ED wait time. Robert Wood Johnson
University Hospital Hamilton recognized that reducing ED wait
time was a way to fulfill their mission of excellence through service

in an area of high importance to potential patients. By addressing
dissatisfaction with ED wait time, the hospital was positioned to take
the lead within the county for ED market share.
Organizations can be reactive to their competitive environment or

proactive. In this situation the hospital wasn’t responding to what
their competitors were doing. All were performing poorly in the eyes
of the marketplace. Robert Wood Johnson University Hospital
Hamilton seized the opportunity to improve and was proactive in
driving up the standard in their market. Being the first to initiate a
program to reduce wait time helped brand them as a leader in
providing quality healthcare service.
LEADING THE WAY

The CEO during the time the 15/30 guarantee was initiated, Christy
Stephenson, and the senior leadership team championed the program
from the outset. An interdisciplinary team was formed to design the
program. ED personnel, including the nursing director and physi-
cians, were joined by personnel from all ancillary departments in-
volved in moving the patient from point A to point B. These
departments included registration, radiology, patient relations, labo-
ratory, environmental services, and inpatient services. Even after the
program was designed and implemented, an interdisciplinary team
monitored its progress and initiated needed changes.
Recognizing that front line staff might be anxious about being
hurried to provide service in the ED, administration sent the message
to the nursing staff that they were to worry only about providing qual-
ity care. They signaled to the front line nursing team that their task was
to care for the patient and provide quality care in an empathetic at-
mosphere. They were not to worry about the financial impact or fear
that someone would be sent to the ED with a stopwatch.
GETTING STARTED
The performance improvement tool used in this improvement was
PDCA (plan, do, check, and act); this guided the team. The process
began with a bed flow analysis (Figure 8.2) and collection of base-
line data on wait times in the ED (Figure 8.3).
300
250
Mean minutes
200
Actual
150 Standard
100 Best
50
0
Jan Feb Mar Apr May June
Figure 8.2 ED bed flow analysis.3
100
95
90
Met 15
Met 30
85
80
75
98 98 98 98 99 99 99 99 99 99 99 99
p– ct– ov– ec– an– eb– ar– pr– ay– un– Jul– ug–
Se O N D J F M A M J A
Figure 8.3 Timeliness of ED initial assessment.4
The hospital analyzed where were the potential bottlenecks from

the patient’s arrival in ED to the patient’s discharge. Potential bot-
tlenecks included not having enough equipment or a stretcher, lab
turnaround time, or lack of staff. Subsequently a fishbone diagram
(Figure 8.4) was used to identify the causes of these bottlenecks.
They looked at the process to see where improvements could be
made, for example, by changing staffing numbers and patterns,
structure, equipment, systems. The fishbone analysis indicated the
need for additional staff as well as the need to streamline the triage
process while still capturing essential information. Another physi-
cian was assigned to the ED to avert the problem that would occur if
Eq Comm. in
RN uip delays
men
St Monitors t Se
MD aff r vi
ing Chairs ce
Stretchers
Delays in
al s assessment
c tur s tem X-ray
ru Triage Sy
St Bed flow
ED size Lab
Figure 8.4 PLAN: Understand problems with the process.5
a critically ill patient arrived in the ED and tied up the one physician
on duty . . . thus making it impossible for the other ED patients to
be seen within the targeted 30 minutes of arrival in the ED. A dedi-
cated radiology staff person was also added as well as a patient rela-
tions representative.
The plan was rolled out as an organizational initiative, not just
an ED initiative. This meant that the radiology, laboratory, inpatient
services, environmental services, maintenance, registration, audio-
pulmonary, and patient relations were just as invested as the ED in
making sure that patients moved through the system efficiently and
accurately. No restructuring of departments was needed. However,
job redesign was required to revamp the triage process.
The 15/30 program was operational in six months, an indication
of how well it fit within the existing organizational culture which is
captured in the five pillars (Figure 8.5) supporting the hospital’s mis-
sion and vision.
FIVE PILLARS
People—focus on internal customer
Service—focus on external customer
Quality—focus on clinical and
operational outcomes
Finance—focus on financial performance
Growth—focus on developing services to
meet customer needs
Figure 8.5 Five Pillars.6

In the service pillar there is the expectation that five-star cus-

tomer service standards are provided to patients. As a result of this
analysis, a bed manager role was created. In 1999 this role was ini-
tiated, it was the first in this area.
Quality improvement initiatives that require change in the orga-

nizational culture take a prolonged period of time as staff values and
priorities are adjusted. It would have been impossible for the ED
improvement program, which impacted other hospital departments, to
have been so quickly implemented if it did not resonate with the
existing organization culture.
With additional resources, a redesigned triage process, and staff

training, the hospital initiated a guarantee which promised that the
patient would be seen by a nurse within the first 15 minutes and a
doctor within 30 minutes or the hospital would waive the ED
charges for the patient (Figure 8.6).
Figure 8.6 The 15/30 guarantee.7
Waiting time was collected and used on SPC control charts to

monitor the program. Random sample audits for compliance with
meeting the 15 and 30 minutes and payout percentage have been
used to measure the success of the program.
A WORK IN PROGRESS
The 15/30 program is an “ever-evolving process . . . every year we
have new challenges in the ED.” Innovative parts of the 15/30 Guar-
antee are slowly being adopted by other hospitals. When Robert
Wood Johnson University Hospital Hamilton began their journey to-
ward the Baldrige Award, the hospital looked at everything in terms
of how the early assessment of a patient, by a physician and a nurse,
would improve clinical outcomes . . . one of the specific areas ex-

amined was the assessment of patients in the ED. The hospital used
a standardized approach, time frame, and standard of care that re-
flected best practice. When results indicated that patients treated by
specialists were treated differently than the patients who were
treated by the family or general practitioners, the process in the ED
was standardized so that ED patients saw a consultant immediately.
Consequently, the appropriate specialist was brought on board more
quickly. As a result complications were reduced, patients were
treated in a timely manner, and clinical outcomes were improved.
Protocols were also improved: for example the hospital developed
clinical guidelines so that if a patient met certain criteria and had a
possibility of pneumonia, that patient was moved up to make sure
that they were given antibiotics within four hours as well as a chest
x-ray and blood culture.
To track progress over time, a quality report card was adopted by
the hospital. The metrics for ED meshed with the hospital’s balanced
scorecard.
The balanced scorecard is a robust measurement tool that allows the

hospital to measure a wide variety of key performance indicators.
Examples of some of the indicators used in the ED are provided

in Figures 8.7 through 8.10. Figure 8.7 tracks the percentage of pa-
tients who came to the ED but left without receiving treatment. Figure
8.8 shows where the hospital stood in relation to other hospitals in the
Press Ganey national database in terms of overall patient satisfaction
6%
Good
4%
Percent
2%
0%
2003 Jan–04 Feb–04 Mar–04 Apr–04
RWJUHH PG Benchmark
Figure 8.7 Patients who left without treatment.8

100%
Percentile rank
90%
80%
Good
70%
1999 2000 2001 2002 2003 1Q04
RWJUHH PG Benchmark
Figure 8.8 ED patient satisfaction.9
100%
Percentile rank
90%
80%
Good
70%
1999 2000 2001 2002 2003 1Q04
RWJUHH PG Benchmark
Figure 8.9 ED patient satisfaction with physicians.10
100%
Percentile rank
90%
80%
Good
70%
1999 2000 2001 2002 2003 1Q04
RWJUHH PG Benchmark
Figure 8.10 ED patient satisfaction with nursing.11

with ED, while Figures 8.9 and 8.10 show the hospital standing in
terms of ED patient satisfaction with nursing and physicians. All the
figures indicate that the hospital’s goal was to be in the 90th percentile.
Finer-grain metrics are shown in Figures 8.11 and 8.12. They are
finer-grain because they track one of the determinants of satisfac-
tion, that is, waiting time in terms specific to the 15/30 guarantee.
Every year the metrics in the report have been refined. Nothing
has remained static. Metrics have moved from measuring 15/30 to
measuring time intervals for the entire patient visit. Figure 8.13 is
not a complete list but it does show the scope and number of metrics
presently used.
96
94
92
90
88
86
84 Actual
82
Benchmark
80
78
76
74
1st 2nd 3rd 4th
Figure 8.11 ED satisfaction with waiting times to see RN.12
90
80
70
60
50
40 Actual
30 Benchmark
20
10
0
1st 2nd 3rd 4th
Figure 8.12 ED satisfaction with waiting times to see MD.13

% LOS admit to unit ^ 75 minutes

% time from arrival to MD w/in 30 min
% ED LOS T&R ^ 155 minutes
% ED Lab tests completed w/in 60 min
% CT Scans w/oral contrast w/in 100 min*
% CT Scans w/o oral contrast w/in 50 min*
% Ultrasounds completed w/in 60 min*
% Patients discharged by 12 noon**
%ED LOS overall ^ 230 minutes
%ED LOS admits ^ 309 minutes
% ED Left w/o Treatment
% clean ready beds assigned ^ 10 mins
% ED Arrival to Triage Nurse ^ 15 min
% Arrival to PromptCare Phys ^ 30 min
Composite Lab TAT
Nosocomial Infection Markers (NIMS)**
Figure 8.13 Metrics currently tracked.14
One of the measures used by the hospital to track clinical out-

comes was health grades that rate the hospital. After programs like
the 15/30 Guarantee to reduce wait time in ED were initiated, the
hospital’s health grade ratings went up and up, an indication of how
patient satisfaction was increasing.
Advances in technology have been behind many of the current
improvements in the ED. For example, PACS is radiology imaging
online which allows the physician to pull up an actual film, thus sav-
ing time. A great effort has been made to work with the squads that
transport the patients to the hospital to insure that the hospital has
advanced notice of the patient’s arrival. With advanced notice, the
hospital can ready appropriate space so the patient can receive treat-
ment quickly and efficiently. An extra triage has been added in the
waiting room. A nurse practitioner has been placed in the triage area
bringing the healthcare provider out to the patient for more timely
care. A medical screening examination can be conducted at this
point to address issues immediately. A hospital-wide electronic med-
ical record and tracking system gives the ED staff real time data in
terms of how many minutes each patient has been waiting and what
the patient is waiting for.
THE PRICE OF SUCCESS

At the inception of the 15/30 Guarantee, the ED had seven beds. In
October of 2001 a new ED was built, which significantly increased
the size to 26 beds. The ED volume has increased dramatically over
the years as shown in Figure 8.14.
Since 2006 Robert Wood Johnson University Hospital Hamilton
has been one of the fastest growing hospitals in the county and in the
state of New Jersey. This has placed great pressure on the ED and
strained the 15/30 Guarantee. Robert Wood Johnson University Hos-
pital Hamilton has responded to the market pressure by building a
new building, which opened in April 2007; this will relieve the pres-
sure on the ED. The hospital is also aggressively working on short-
ening the length of time a patient stays in the hospital. This strategic
core business goal will also help free up beds, enabling the ED
process to flow more efficiently.
The saying “No good deed goes unpunished” applies here. Quality
improvements result in success shown by increased volume and
market share. However, that success brings new challenges which
necessitate new organizational responses. Quality improvement
never allows us to sit down and relax, but only to pause and take a
deep breath as we prepare to wrestle with the new challenge
brought on by the success of the earlier quality improvement
initiative. (This paradox is the reason we use “continuous” in the
term continuous quality improvement programs.)
5500
5000
4500
4000
Better
3500
3000
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
2005 2006 2007 2007 Budget
Figure 8.14 ED volume 2005–2007.15

PERFORMANCE
Robert Wood Johnson University Hospital Hamilton is a Malcolm
Baldrige National Quality Award Winner (2004). Accredited by the
Joint Commission on the Accreditation of Healthcare Organizations
(JCAHO), the hospital has received numerous awards recognizing its
quality of care. In 2007, the Cancer Institute of New Jersey–Hamilton
received the Press Ganey Summit Award, the prestigious symbol of
achievement in healthcare satisfaction. This award is given only to
healthcare organizations in the United States that have maintained pa-
tient satisfaction levels at the top 5 percent for three consecutive years.
Robert Wood Johnson University Hospital Hamilton also received the
Consumer Choice Award in 2004/2005 and 2005/2006, an award de-
termined by consumers’ assessment of healthcare. In a study by the
National Research Corporation, Robert Wood Johnson University
Hospital Hamilton ranked highest in the Trenton region on multiple
quality and image ratings. Moreover, the hospital received five out of
five stars in 11 disease states from the Health Grades organization.
Robert Wood Johnson University Hospital Hamilton has also received
an eHealth Leadership Award for Best Intranet Site in 2003, 2005, and
2006. Additional examples of awards garnered by the hospital during
recent years include the Diversity Excellence Award (2005), Gover-
nor’s Award for Performance Excellence-GOLD (2004), Corporate
Award for Nursing Excellence (2003), and Employer of Choice and
Employer of the Year 2003. Patient and employee satisfaction scores
consistently rank the hospital above the 90th percentile, which is well
above industry benchmarks. Likewise, the employee retention rate is
well above 90 percent. Perhaps one of the highest accolades the hos-
pital has experienced is a higher occupancy rate (95 percent in 2005
and 102 percent in 2006) than their competitors. This is certainly a
vote of confidence and approval from the community served by the
hospital. While the national admissions growth average has been
slowly increasing, Robert Wood Johnson University Hospital Hamil-
ton admissions’ growth rate has been in the double digits and increas-
ing. During 2004–2005 it had 10 percent growth and 12 percent
growth during 2005–2006.
REFERENCES
1. Robert Wood Johnson University Hospital Hamilton 2006 Report to
the Community, 4.
2. Robert Wood Johnson University Hospital Hamilton.

www.rwjhamilton.org/aboutus/mission.asp
3. Chart provided by J. Schwarz, Robert Wood Johnson University
Hospital Hamilton.
4. See note 3.
5. See note 3.
7. Robert Wood Johnson University Hospital Hamilton. Emergency
Services www.rwjhamilton.org/medserv/emerg.asp
Baldrige National Quality Award Application Summary,” 2004, 42.
Baldrige National Quality Award Application Summary,” 2004, 41.
10. See note 9.
11. See note 9.
12. See note 3.
13. See note 3.
14. See note 3.
15. See note 3.
www.quality.nist.gov/HealthCare_Criteria.htm Baldrige Health Care
Criteria for Performance Excellence
http//hcmg.nationalresearch.com/Default.aspx?DN=7,1,Documents
Consumer Choice Award
www.strategichealthcare.com eHealth Leadership Award for Best Intranet
Site
Maister, D. A. The psychology of waiting lines in The Service Encounter,
ed. JA Czepiel,
Solomon, M. R. and C. F. Surprenant, Lexington, MA: Lexington Books,
1985, 113–123.
Nelsen, D. Baldrige—Just What the Doctor Ordered, Quality Press,
October 2005, 69–75.
www.quality.nist.gov
NIST Baldrige National Quality Award Home Page
www.pressganey.com/client_recognition/summit_awards/default.php
Press Ganey Summit Award
www.rwjhn.org/aboutus.htm RWJ Health Network
www.rwjuh.edu RWJUH in New Brunswick
Taylor, S. Waiting for service; the relationship between delays and

evaluations of service, Journal of Marketing 58 1994, 56–69.
Taylor, S. and J. D. Claxton. Delays and the dynamics of service
evaluations, Journal of the Academy of Marketing Science 22 1994
254–264.
www.umdnj.edu/home2web/ University of Medicine and Dentistry of
New Jersey (UMDNJ)-Robert Wood Johnson Medical School
9
North Mississippi Health
Services: Benchmarking
the Information System
Used for Collecting/
Analyzing/Storing Data
J
ohn N. Pane (not a real
person) has had an un-
known ailment for quite
some time. He decides it’s
time to see his local practi-
tioner, who runs some tests
and subsequently refers him
to a specialist, who in turn
runs some of the same tests.
With his problem still un-
diagnosed, the patient ultimately is admitted to the hospital, which
ends up running the same tests that the two physicians ran. This
process of unnecessarily repeating tests is not that uncommon. Some
experts estimate that over 30 percent of tests that are run are re-
dundant.1
Numerous groups are impacted by running these tests. The pa-
tient ends up with additional costs for the tests. He also has to take
the time for the tests to be administered. There is also the added time
to read and interpret the tests. The physician is taking the time to ad-
minister the tests, which takes him away from other duties. The lab-
oratory is using their resources that could have been used on
first-round tests. The insurance company has the added expenses of
having to unnecessarily duplicate the tests. The cost of the redundant
tests is hundreds of billions of dollars every year.2 What’s a solution?
How can we reduce the number of redundant medical tests and save
time and money, while at the same time improving the quality of
143
care of the patient? The answer comes in the way of improved use of
information technology.
From the hospital’s perspective, they would like to know what
the cost of running a particular test is, and how their costs compare
to other healthcare systems. Information technology can be used to
cut down on the redundant tests, and also to see not only how com-
parable healthcare systems are performing but how the best health-
care systems are performing.
Chapter 3 outlines various tools that can be used throughout the
six-phase benchmarking process. In that chapter we discussed the
importance of having access to the right data at the right time, and
some tools that can be utilized in collecting and analyzing that data.
This case study outlines what one hospital system is doing to collect,
analyze, and store the vast amount of data that is available from pa-
tient medical services, patient financial services, third-party com-
parative databases, and other diagnostic/support systems. All of
these sources of information are tied together into an enterprise-wide
information system. Their information system plays an integral part
in making sure they are headed in the right direction consistent with
their mission, vision, and values.
Many hospital systems are looking into how they can make bet-
ter use of information technology as a way of improving quality of
care and patient safety. Some have been successful, many have not.
The healthcare industry has spent billions of dollars on information
technology, and yet still lags behind other industries in its use.
Within the healthcare industry, the country of Denmark is consid-
ered to be leading the pack in the use of digital information in health-
care. The United States is lagging behind them and many other
industrialized countries by as much as 12 years.3 Experts estimate
that information technology will be a major contributor to changes
in the healthcare industry over the next several years.4
The focus on increased use of information technology applied to
the healthcare industry is receiving a great deal of attention. For four
straight years, President Bush has called for better use of informa-
tion technology in order to reduce medical errors and reduce health-
care costs. In 2004, he set an ambitious goal of every American
having a personal electronic medical record (EMR) by 2014. The
benefits of EMRs are numerous. The proper implementation of
EMRs can lead to better access to data, better charting, better care
management, better prescribing, greater efficiency, lower costs, and
higher income.5 Some estimate that U.S. physician offices could re-
alize a savings of $142 billion and U.S. hospitals a savings of $371
billion over the next 15 years.6
Chapter Nine: North Mississippi Health Services 145
Information technology is obviously a good thing for a hospital

to have, as it will significantly reduce costs and save lives. So why
not just spend some money and reap the benefits? It’s not that
straightforward. The successful implementation of information tech-
nology requires first and foremost a great deal of planning in know-
ing what’s out there and knowing what you need. However, in most
cases, the biggest hurdle is not the hardware and software, but the
ability to manage the change in the way the hospital operates.
Another obstacle in adopting new information technologies is the
initial cost associated with implementation. Estimates indicate that es-
tablishing a national information technology network in the United
States would cost $156 billion over five years and an additional $48 bil-
lion in operating costs.7 Justifying the cost is preventing many hospital
systems from beginning the process. However, in the long term, the
benefits of proper implementation can lead to improved patient care
and significant savings. The key here is the proper implementation. It
has been estimated that as many as 33 percent of EMR implementa-
tions fail not because of technological hurdles but because of organiza-
tional obstacles.8 The CIO for North Mississippi Health Services
(NMHS), Tommy Bozeman, points out, “Failures in the marketplace
and the failures to implement have been pretty rife throughout health-
care as long as I’ve been in it. There has been more money probably
wasted and has turned into a cost to the patient, the patient’s family, in-
surance, than there should have been.” He goes on to point out, “The
technology generally is not the issue, I don’t think. Now, you know
some vendors will push some newer technology that might not be
ready for what we call prime time and you have to be careful about that,
but we have a saying around here that technology doesn’t implement it-
self. You can buy the most expensive best technology in the world, but
you have a giant Grand Canyon between that technology and your end
user, and unless you have the wherewithal to connect the end user with
that technology it’s likely not going to provide you the benefits you
thought you were going to get.” Bozeman has been with NMHS since
1975 and has helped to successfully implement not just an EMR sys-
tem, but a highly integrated enterprise wide information system.
ABOUT THE HOSPITAL SYSTEM

The North Mississippi Medical Center (NMMC) started out in 1937 as
The Hospital on the Hill. NMMC, located in Tupelo, MS, is the pri-
mary hospital for North Mississippi Health Services (NMHS). NMHS,
a not-for-profit health system, consists of three hospitals in Tupelo,
(NMMC, a Women’s Hospital, and a Psychiatric Behavioral Hospital),

five rural hospitals located up to 75 miles away from Tupelo, numer-
ous clinics, and several nursing homes. Their primary market includes
more than 24 counties in north Mississippi and northwest Alabama
covering an area of roughly 7500 square miles. With 650 beds, NMMC
is the largest rural hospital in the United States and the largest non-gov-
ernment hospital in Mississippi. NMHS’s on-site location has more
than 40 structures on 111 acres, with an additional 15 structures on 20
acres of off-site locations.
The primary service is acute care, but they also offer services in
many other areas. They have divided their clinical services into five
areas that they refer to as their service lines: cardiovascular, emer-
gency and surgery, medicine, oncology and behavioral health,
women and children. NMMC has approximately 4000 employees,
with more than 300 physicians. They offer a wide range of medical
and surgical specialty services. A few of the inpatient and outpatient
services are:
• Ambulatory Infusion • Imaging Services

Service
• Pain Management Center
• Ambulatory Surgery
• Hyperbaric Therapy
Center
• Rehabilitation Institute
• Behavioral Health Center
• Outpatient Rehabilitation
• Breast Care Center
Center
• Cancer Center
• Home Health Agency and
• Center for Digestive Hospice Services
Health
• Skilled Nursing Facility
• Diabetes Treatment
• Sleep Disorders Center
Center
• Surgical Services
• Emergency Services
• Women’s Hospital
• Family Medicine
Residency Center • Wound Center
• Heart Institute • Wellness Center
NMHS serves a population that is considered one of the least

healthy in the U.S.9 The poverty level of Mississippi is also one of
the worst in the U.S.10 NMHS recognizes that these two factors con-
tribute to higher occurrences of heart disease, obesity, and poor uti-
lization of prenatal care. Another characteristic of the population in

Northeast Mississippi is that there is not a lot of turnover. As a re-
sult, people in the community consider NMMC as their hospital.
A key to the success of NMMC is their culture, which centers on
their mission, vision, and values (MVV). Their MVV, shown in Fig-
ure 9.1, are ingrained in every process carried out at NMMC.
Given their mission and vision statements, NMMC developed
their critical success factors, which are activities that have a mea-
surable outcome (see Figure 9.2).
The order of the critical success factors is intentional. It starts
with creating an environment that draws and nurtures the best peo-
ple to provide the best service. Great service results in happy cus-
tomers and excellent quality. High quality and efficiency produces
good financial results and requests for more services, which results
in growth. All activities are organized and managed according to the
critical success factors, thereby creating organizational alignment
and a comprehensive structure for operational excellence.11
NMMC sets their strategies around these critical success factors.
By focusing on each of these factors, NMMC has developed an or-
ganizational culture that supports their mission and vision.
A contributing factor in the success of NMMC was the process
they followed in the pursuit of the Baldrige Award. NMMC received
the prestigious Malcolm Baldrige National Quality Award in 2006.
Since 1999, there have only been five other healthcare organizations
to have received this award out of 161 applicants.
LEADERSHIP TEAM
Another key factor in the success of NMMC is their leadership team,
which follows a servant-leadership approach. This style of leadership
encourages leaders to serve their constituents while focusing on
NMMC’s values. Starting with the senior leadership team, NMMC has
created a patient-centered care culture throughout the organization.
NMMC uses an untraditional ring structure to show their orga-
nizational chart, as shown in Figure 9.3. In this chart the inner ring
represents the employees, department heads, and teams that directly
deal with the patient or those that provide assistance to those that as-
sist the patient. The second ring is the senior leadership team, who
is in charge of the day-to-day operations at NMMC. The third ring
represents the leaders in charge of operations at NMMC along with
the NMHS. These individuals will spend roughly 70 percent of their
time on NMMC and the remaining 30 percent on aligning operations
Our Mission
Why We Exist
To continuously improve the health of the people of our region.
Our Mission
What We Want To Be
The provider of the best patient centered care and health services in
America.
Vision and innovation are woven into the very fabric of our organiza-
tional culture. The Mission, Vision, and Organizational Values are the
evolutionary result of an organization created by people of vision in this
community in the early 1930s. NMMC and its leadership are dedicated to
continuing that tradition and accomplishment set by community leaders in
Tupelo and surrounding communities. NMMC reaffirms and refreshes the
intentions of our community’s founding leaders to address current needs
and anticipate the future state of health care.
We do this through a carefully crafted and continuously refined process of
strategic planning that correlates current and future health care needs with
the current capability and the future promise of the art and science of med-
icine. The Mission, Vision, and Organizational Values are not just words
but messages that inspire a diverse workforce to achieve our full potential.
The Board of Directors and senior leadership set the set the current Mis-
sion statement in 1994 to reflect the growing refusal to accept the perva-
siveness of disease, which continued to debilitate our region. In 2001, this
process led to the Values statement based on input from employees,
physicians, and the community. Since 1996, as a result of our work with
the Baldrige criteria, we set our sights on organizational performance that
far exceeds merely the acceptable.
Values CARES
Compassion – show compassion for the patient
Accountability – be accountable for actions
Respect – show respect for patients
Excellence – strive for excellence in every activity
Smile – smile for the patients
Compassion, Respect, Smile each works on building
relationships with the patients.
Accountability, Excellence each works on building relation-
ships with the physicians and employees to deliver the type
of care they want for their patients.
Figure 9.1 Mission, vision, values.12

Critical
success factors Values
mpassion
Co
People • •
Service
ce • Smile
Ac
Mission
countability
To continuously
improve the
Growth health of the
Quality people of
len
our region
Financial
el
•
Re c
spect • Ex
Baldrige
criteria
for
excellence
Figure 9.2 North Mississippi Medical Center’s mission, vision, values,

and critical success factors.13
with NMHS. The second and third rings make up the system leader-
ship team. The outer ring consists of physicians, elected or ap-
pointed, who play an active role in the strategic and operational
decisions of NMHS.
“We (senior leadership) believe that leadership is an honor and an
obligation: a responsibility to ‘enable’ the ability of every employee,
physician, and volunteer who chooses to spend their careers with us.
NMMC’s leadership system is designed to leverage the potential of
every leader, front-line employee, and key partner. Inherent to this is
the relentless focus on the mission, vision, and values and the critical
success factors of people, service, quality, financial, and growth.”14
The senior leadership team relies heavily on the evidence-based
planning process (EPP), which is used to make sure that NMMC is
on the right track with regard to following their mission, vision, and
values. Figure 9.4 describes the eight-step process they follow in or-
der to ensure that everyone knows what needs to be done. These
steps essentially amount to collecting the right data from internal
and external sources, analyzing the evidence, and acting upon the in-
formation to see where they stand.
A major factor in the success of NMMC is their ability to man-
age the vast amount of data that is available and process this data to
determine where improvements can be made. Their management in-
formation system is a key to this capability.
Physician Lead
cted ers
Ele
VP Finance
el
ns C
u
Co
President
IO
SV
al
NMMC
ner
CS A
S
Pro VP
V
V P Ge
Li
DM
fS
ne
CMO
Employees
ADM e
S L in
Teams
SVS M
DHs
AD
C EO
SV
Lin
e
SV
NM
e
n
R
S Li
H
AD Line SVS M
HS
VP
M AD
VP Facilities
Se rs
rv ice L ade
in e Physician Le
Figure 9.3 North Mississippi Health System’s organizational chart.15
DEVELOPMENT OF NMHS’S
MANAGEMENT INFORMATION SYSTEM
The combination of NMHS’s strategic goals and a strong leadership
team has enabled the development of a unique enterprise system that
has received national recognition. NMHS’s information system was
not created in a day; instead, it has taken many years and is still
growing. From the outset, the plan was to create a progressive sys-
tem, one which would be nurtured and grown to meet NMHS’s
strategic goals and operational needs. Tommy Bozeman, CIO, has
been with NMHS since 1975 and has been instrumental in the de-
velopment of the information system. He made the observation that
since 1975, NMHS has not had any implementation failures. “We
must be doing something right.”
Approach
Step 1 (S1) Step 2 (S2) Step 3 (S3) Step 4 (S4)

Gather internal and external SWOTs and Analyze evidence, review Review MVV/EPP,
evidence: EA, Baldrige feedback departmental/ CSFs, identify challenges, prioritze SSF-Based
and Supplier/Physician/ SL LRP surveys determine priorities, reconcile goals and review Learn and
Employee/Health Link/Work LRPs, develop NMMC goals SRPs Integrate
Link/Community feedback and produce HR/IS/Facilites/
11/6/07
Capital SRPs
–BOD, SysLT, SLT, DHs, DOS –DHs and SLAs –SysLT/SLT workshop week –LPR (BOD, SysLT, SLT,
Medical staff)
11:10 AM
Step 5 (S5) Step 6 (S6) Step 7 (S7)

Communicate and align Reconcile, finalize, Roll-out NMMC and department goals,
Deploy CSF-based goals, review approve 90 day APs translate to EXCEL personal performance
LRPs/SRPs and create and budgets plan, develop work processes
Page 151
budgets, 90 day APs and PSCs and measures and implement plans
–Operational Goals Retreat –BOD, SysLT, SLT –All employees

(SysLT, SLT, DHs)
Step 8 (S8) Learn and

Annual fact-based cycle (Fig. 2.1-3) Integrate
Chapter Nine: North Mississippi Health Services
–BOD, SysLT, SLT, DH

151
Figure 9.4 Evidence-based planning process.16

The information system’s beginnings date back to 1975, when it

started out as a general and new patient accounting system. Why
start with an accounting system? The system leadership team felt it
a priority to have a good financial system in place and that NMHS
needed to be financially stable in order to provide good patient care.
An obstacle that NMHS, a large rural hospital system, had to
overcome was the geographical distance between the various hospi-
tals in the system. They wanted to make sure that each hospital had
the same information system functionality as any other one. They
didn’t want to have a new patient record based on where the patient
entered one of their hospitals. They wanted a single system to be
able to track the patient, regardless of where they entered NMHS.
NMHS made use of project teams in the development of expan-
sions to their system. These teams consisted of end users, depart-
mental information system (IS) representatives, IS department
representatives, and physicians. A key point here is the makeup of
the IS Department. With the increased emphasis on information
technology, NMHS saw the need to support the effort in the budget.
The IS department began including individuals with clinical exper-
tise, not just individuals with a technical background. In order to en-
sure the information system would meet the needs of the various
users, registered nurses, a pharmacist, medical technicians, and a
respiratory therapist became members of the IS department. Also,
each department had a separate IS representative to work with the
development of the system, again to make sure it would meet the
needs of their specific department. The purpose of the project teams
was to come up with a detailed request for proposal (RFP) that con-
sidered costs, benefits, and risks.
Overseeing the project teams and ensuring the proper integra-
tion of the overall information system was the clinical IS steering
committee, made up of the CEO, COO, CFO, IS department direc-
tor (now the CIO), medical staff director, VP of nursing, physician
user representative, community hospital representative, off-campus
service representative, and project team leaders from each of the four
project teams. This committee developed the five-year strategic plan
in accordance with NMHS’s strategies, allocated the resources to the
project teams, and resolved any issues.
A requirement of the project teams is to consider what features
are needed with the information system. This process often involves
the IS department speaking with many different users, from all ser-
vice lines of the hospital, to determine the requirements of the infor-
mation system. The result is a very detailed RFP that can be hundreds
of pages in length, and outlines precisely what users want.
CIO Tommy Bozeman reflects on the importance of proper

planning: “One of the reasons for our success is that we do a very
thorough, agonizingly thorough, job on the front end of evaluating
what it is we are trying to accomplish with a system. That agoniz-
ingly thorough process includes interviewing all the constituencies,
making them come to the table, making them take part in identify-
ing their needs and their wants. And that turns into a very compre-
hensive request for proposal.”
Bozeman continues: “One of the major differences that sepa-
rates us as a buyer, I think, from a lot of other healthcare buyers is
that because we do such a thorough job of identifying what we need,
what we want, what we want to do within the request for proposal,
that becomes part of the contract. And believe you me, once the ven-
dor knows that’s part of the contract which they’re told on the front
end, their answers get real honest.”
An important factor in the development of their information sys-
tem was the extensive user involvement in specifying what they
needed in terms of system requirements, training, and system sup-
port. Bozeman points out, “If I had to pick one of the keys to our
success, it’s involving the users on the front end to elicit and pull out
from them what it is they think they must have to do their jobs. And
also to make them what we call ‘green grass and blue sky’ in the fu-
ture and think of all the things they might want to have.”
Routine departmental and committee meetings were held to
manage the implementation of the various systems, again with the
involvement of the entire hospital system, including nursing staff,
physicians, IT staffers, department heads, service line administra-
tors, and senior leadership members. Bozeman comes from a back-
ground in teaching and coaching. This foundation gave him the
realization of the importance of a team, “You understand that you
need the people underneath you to work together as a team because
you’re not going to be successful if they don’t work together as a
team and strive for the common goal.” The heavy involvement of the
various users helped in the implementation of the various systems.
The end users from the project teams were responsible for the poli-
cies and procedures of the system. The type of training was depen-
dent on the particular module. In some cases, the users would meet
every day for a week and in others users would get a memo showing
snapshots of the screen. A popular way of getting users to migrate to
the new system was to train a few users, who would then train the
others. This is referred to as train the trainer.
The NMHS’s information system today has evolved by continu-
ing to add more systems that can seamlessly interact with one
another. The fact that any new system ties into the existing system
does not happen by chance. According to Bozeman, “It didn’t make
sense to me 15 years ago, that you would have these silos or islands
of information existing within our delivery system, because we were
beginning to develop what we wanted to call an integrated delivery
environment and clearly to do that you needed an integrated infor-
mation system environment. That’s been our vision all along.”
The current enterprise-wide system provides access to electronic
medical records, patient care systems, diagnostic systems, adminis-
trative and financial systems, support system, and the cost informa-
tion decision support system. In 1997 NMHS received the
prestigious Davies Award of Excellence, which recognizes health
systems that stand out as excellent examples of successfully imple-
menting the use of information technology in the area of EMRs.
NMHS’s Davies Award Manuscript provides a more comprehensive
history of the development of their information system.17
THE IMPACT OF NMHS’S

INFORMATION SYSTEM
NMHS’s information system plays an integral part in their success.
Information technology has a significant impact on NMHS’s critical
success factors. Figure 9.5 shows the role of NMMC’s information
system and how it is aligned with the business processes of the hos-
pital. Figure 9.5 also indicates how information technology is in
alignment with NMMC’s evidence-based planning process. The in-
formation system component is heavily utilized in providing infor-
mation to leadership for the purpose of setting targets, benchmarks,
and goals. The information system also provides information to as-
sist with NMMC’s performance scorecards. Their system continues
to grow and support the strategic goals of NMMC by capturing and
providing timely information in all five of their critical success fac-
tors of people, service, quality, financial, and growth.
People
One of the ways NMHS measures if they are maintaining experi-
enced employees is by looking at their employee retention rate.
These rates are captured in their information system, which provides
summary reports similar to Figure 9.6, which presents two column
charts the first of which indicates the percent employee retention
over the years by healthcare segment and the second chart based on
Deploy and learn
EPP
11/6/07
Comparative databases
People – Human Resources Inc., PGA
Service – PGA
Quality – AHRQ, Apollo, CareScience, CMS, DST Health Solutions,
Epinet, FOTO, HAVEN, IQH, JCAHO, MDS, National Tumor Registry,
NISS, Pyxis Reporter, QMS, Trauma One, UDS, Vermont Oxford Network
11:10 AM
Data Financial – Solucient, 3M

selection Growth – Solucient
Page 155
Critical Targets, Performance Senior leader Improvement

success factors benchmarks, and scorecards review teams
goals
Approach
Integrate
Solucient and
CareScience
Chapter Nine: North Mississippi Health Services
Figure 9.5 NMMC’s management information system.18

155
156
Patient care
systems E7000 Administrative and

financial systems CIDS
Example: laboratory EMR
information system FONS
Data
collection
11/6/07
Diagnostic Support
systems system
Example: Lab Example: Time and
instrumentation attendance system
11:10 AM
Users of information
Employees • Clinicians • Physicians • Nurses • Suppliers • Payors • Board • SLT
Page 156
5 year rolling information systems plan
External
Section II: Case Studies—How Best-in-Class Status Was Attained
External competitors • Vendor user groups • HIMSS • Consultants • Davies Award
Figure 9.5 NMMC’s management information system.18 (Cont’d.)

one of the five service lines at NMMC. Indicated on the charts are
also target rates for the retention rates. These charts provide a wealth
of information in terms of where they are and where they want to be,
and how they have performed over time. Bozeman points out, “One
of the reasons people have stayed here is our management style. Our
leadership style has been, I want to say hands off, but when we hire
people we tell them, ‘Look, we hired you because you absolutely
have the skill set we’re looking for.’ You are essentially empowered
Employee retention
100%
90%
Good
80%
70%
60%
50%
40%
02 03 04 05 06 YTD
Primary hospital employee retention
Behavioral health
Home care
Benchmark (Baldrige winner)
NAHCR
SL employee retention
1
0.9
Good
0.8
0.7
0.6
0.5
0.4
/ n/
io D/
d gy
rd Me olo me en
Ca ES gery c o r
r On BH W hild
Su C
Q4 05 Q1 06 Q2 06 Q3 06
Target
Figure 9.6 NMMC’s employee retention.19

to do your job and nobody is looking over your shoulder. And I think
people feel that they are an integral part of any successes that we
have in healthcare.”
NMMC’s employees live and breathe the mission, vision, and
values. NMMC has implemented a performance management sys-
tem, called EXCEL, which allows for individuals to set personal
goals based on supporting the organizational values. EXCEL de-
scribes what and how specific jobs are done. For the employee, this
system helps reinforce what role they have in the process and what
are the performance expectations. The employee’s progress toward
their goals is monitored over time. In addition to EXCEL, employ-
ees also have departmental meetings, ongoing customer service
training, and routine newsletters, that all focus on the values of the
organization.
Another report that is generated to ensure that the people factor
is being met is the employee’s level of satisfaction with their train-
ing and the perceived concern for employees (see Figure 9.7). This
chart indicates that the satisfaction with training has increased, as
well as the concern for employees.
Yet another indication that employees are more actively in-
volved in NMMC is that the number of suggestions for improving
quality has significantly increased over time as well as the number
of suggestions that were accepted (see Figure 9.8).
NMMC’s information system allows them to analyze data that
they might not otherwise have access to. For example, Figure 9.9
100%
80% Good
60%
40%
20%
0%
2000 2002 2004 2006
Satisfaction with adequacy of training

Concern for employees
National satisfaction with feeling valued
Figure 9.7 Employee satisfaction with training and concern for

employees.20
1,200%
Good
1,000%
800%
600%
400%
200%
0%
2002 2003 2004 2005 2006 Proj
Ideas submitted for excellence

Ideas accepted
Figure 9.8 Ideas for excellence.21
med variance/pt days

100% 7
6
80%
Satisfaction
LOS and
60% 4
Good 3
40% 2
20% 1
Good Good Good 0
0% 1
00 02 04 05 06 00 02 04 05 06 00 02 04 05 06 00 02 04 05 06
Inpatient satisfaction Employee satisfaction

Benchmark (90th percentile) Medication variances (E-1)
Medicare Overall LOS
Figure 9.9 Employee and patient satisfaction correlates with im-

proved patient outcomes.22
graphically indicates that over time, employee satisfaction has in-

creased along with patient satisfaction, and as these two satisfaction
levels have increased, the length of stay and medication variances
have decreased.
NMMC makes use of more than just internal data to see where
improvements can be made. They also utilize numerous external
sources to compare how they are performing in their critical success
factors. In the area of people they have Human Resources, an out-
side company, administer employee satisfaction surveys. As a result
of this survey, NMMC also receives data on how other hospital sys-
tems are doing.
NMMC’s information system also contains comparative infor-

mation from outside the healthcare industry. For instance they look
at other industries to see how much is going toward charity, educa-
tion, and safety.
Service—Improve Customer Satisfaction

NMMC has various groups of customers. The patients and their
families make up one group of customers, while the active medical
staff makes up another group. NMMC also considers local em-
ployers and third-party payors as another group of customers. In
addition to being customers, the physicians and payors are also
considered to be partners of the hospital system. The information
system serves an integral part in collecting and reporting the satis-
faction levels and areas of interest of these various groups. NMMC
collects this information from different sources. Numerous teams
and departments are set up to listen and learn from the various cus-
tomer groups.
One source of information used to measure patient satisfaction
is patient satisfaction surveys. NMMC contracts out the patient sat-
isfaction survey to Press Ganey and Associates, the nation’s largest
comparative database of patient satisfaction. The reports generated
from the results of the survey data are an integral part of the decision
making of the senior leadership team. The survey data are just one
source of information in determining patient satisfaction. NMMC
also uses focus groups, phone surveys, a customer service hotline,
physician support visits, and nurse manager input to gather informa-
tion. Once this data becomes part of the information system, then the
data can be further analyzed to see where improvements can be
made. Figure 9.10 summarizes the complaint management process.
Physician’s satisfaction levels are gathered through surveys,
manpower studies, medical staff committees, and physician support
services. In order for NMMC to better accomplish their goals, the or-
ganization needed an increased involvement in the decision making
from the physicians. By including the physicians in the organiza-
tional decision-making process, the satisfaction level of the physi-
cians has increased dramatically over the years. Figure 9.11 compares
the physician’s level of satisfaction in 2006 with their target level, as
well as the 90th percentile in the areas of overall satisfaction, ease of
practice, and leadership.
The third group of customers is the employers and insurance
companies, the ones typically paying for the healthcare. NMMC
Customer Input
CareLine • Website • Community advocate line
Written patient feedback • NM rounds
Spontaneous contact • Physician support visits
Notification (E-mail and/or phone)

Front line staff • NM/DH/SLA
Response
Immediate: phone call • Patient/Family visit • letter
Resolution
Feedback ASAP • Service recovery
Output
Trending/analysis to CST, SLA, DH, and NM
Action
Problem identification
Performance improvement per PDCA (6.1a[3])
Figure 9.10 Complaint management process.23
100%
90%
80% Good
70%
Percentile
60%
50%
40%
30%
20%
10%
0%
Overall Ease of practice Leadership
2006–Benchmark(90th percentile) “Top Box” –Target
Figure 9.11 Physician satisfaction.24

wants to ensure that their money is well spent. Again, through

surveys and customer visits, data are collected and analyzed in the
information system, to see how well the healthcare dollars are being
spent and the satisfaction level of the payors.
Quality—Provide High Level, Evidence-Based,

Quality Care and Maintain Patient Safety
NMMC’s information system plays a key role in accomplishing this
factor. Their enterprise information system is able to capture patient
information from when they first check in until they check out. Med-
ical information as well as financial information is stored in their
system. One of the innovative modules of their information system
is their care-based cost management (CBCM). This approach looks
at costs that go beyond the cost of equipment, supplies, and person-
nel. CBCM looks at lowering costs by improving the processes fol-
lowed in providing patient’s care and preventing complications.
NMMC began implementing CBCM in 1992. They started with
physicians performing a clinical practice analysis whereby the
physicians compared their individual practice procedures with that
of their peers, both locally and nationally. These comparisons are
done electronically and in some cases in real time to provide imme-
diate feedback to the care givers. Related to the CBCM approach is
the identification of the top 10 diagnosis-related groups (DRGs) not
fully funded by Medicare. DRG is a way of classifying specific hos-
pital care processes, such as heart failure and shock, simple pneu-
monia, and chronic obstructive pulmonary disease. From this list,
one or two processes are identified based on which ones may lead to
improved performance. The CBCM approach has expanded its in-
volvement from physicians to include everyone in the care team.
With the successful implementation of CBCM, NMMC has man-
aged to save millions of dollars. Figure 9.12 shows the financial
gains that NMMC has realized from the CBCM approach.
NMMC has electronically tied into databases from Solucient and
CareScience. This allows for real-time data comparisons with other
healthcare systems throughout the country. Solucient is the market
leader in providing information products to the healthcare industry.
Their healthcare database is made up of more than 26 million dis-
charges per year from 2,900 hospitals, which is 77.5 percent of all
discharges.25 CareScience provides a centralized database of patient
data from healthcare systems around the country. Their data is ana-
lyzed to identify areas for improvement with respect to patient safety,
quality, and financial savings.26
12
10 Cumulative financial gains from outcomes
management of focused DRG losers
8
$ millions
6
4
2
0
1999 2000 2001 2002 2003 2004 2005 2006
Figure 9.12 Care-based cost management making the business case

for quality.27
Financial—Generate the Financial Resources Necessary

to Support the Mission and Vision
From the beginning of the development of NMMC’s information
system, the leadership team recognized the need to be financially
stable. A major component of their information system is the finan-
cial online network system, which is a general accounting system, a
patient billing system, and an accounts receivable system. This fi-
nancial system ties in directly to their EMR in order to handle pa-
tient billing. This system also handles the employee payroll. This
allows NMMC the ability to easily generate financial reports and to
share their data with companies like Solucient and CareScience. Fi-
nancial reports as well as productivity and comparison reports are
given to department heads and service line administrators. These bi-
weekly reports are used to identify how well a specific group is per-
forming nationally, as well as an indicator of needed improvement.
Figure 9.13 is one example of the kind of information generated in
the biweekly report. This figure indicates the quarterly productivity
levels of the cardiology department versus Solucient’s national pro-
ductivity numbers for other healthcare systems.
Figure 9.14 is an example of another report that is generated for
the radiology department. These two graphs indicate the number of
hours for radiology to complete their process and enter the informa-
tion into the system. The significant drop in time in 2005 is attrib-
uted to the use of picture archiving and communication system
(PACS). This system creates an electronic copy of the medical im-
age that then becomes part of the patient’s EMR.
Another component of the information system is the advanced
medical system, which is used in their supply chain. Their suppliers
Worked hrs per 100 procedures

130%
120%
110%
100%
90%
Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 YTD
2003 2003 2003 2004 2004 2004 2004 2005 2005 2005 2005 2006
Hours worked per procedure Solucient benchmark
Figure 9.13 Cardiology worked hours per procedure.28
are electronically connected with this system to process more than

78 percent of NMMC’s routine orders. The ability to electronically
automate the majority of the supply orders has helped NMMC in
terms of reduced costs, improved scheduling of deliveries, and en-
suring they have the correct amount of supplies at any particular
time. One of the ways that NMMC measures their inventory effi-
ciency is by monitoring their inventory turnover. A higher inventory
turnover translates to more efficiency. Figure 9.15 indicates that
NMMC is well above the industry standard.
NMMC’s goal of financial stability is reflected in their AA bond
rating. Standard & Poor’s has grouped the not-for-profit healthcare
Radiology report Radiology report

procedure to dictation turnaround
3.0 24 Good
Good 21
2.5 18
2.0 15
Hours
Hours
1.5 12
9
1.0
6
0.5 3
0.0 0
01
02
03
04
05
06
01
02
03
04
05
06
20
20
20
20
20
20
20
20
20
20
20
20
YTD YTD
Procedure completion to dictation Turnaround Goal
National comparison
Figure 9.14 Radiology performance.29

60
Good
50
40
30
20
10
0
2001 2002 2003 2004 2005 2006
Inventory turns Target (26 turns)
Industry standard (23 turns)
Figure 9.15 Inventory turnover.30
systems based on financial stability (see Figure 9.16). The NMMC’s

AA rating places them in the top 10 percent of not-for-profit health-
care systems.
NMMC considers their financial online system as one of their
mission critical modules. They continually back up their critical sys-
tems. In the case of a catastrophe, they have a hot site data center
setup that is located several hundreds of miles away.
16%
14% Good
12%
10%
NMMC
8%
6%
4%
2%
0%
AA+ AA AA− A+ A A− BBB+ BBB BBB− Spec.
grade
Figure 9.16 Not-for-profit healthcare ratings distribution per

Standard & Poor’s.31
Growth—Expand Access to Health Services

NMMC’s fifth critical success factor is in large part enabled by suc-
cessfully accomplishing the previous four. Having good people
provides a good service that improves quality of care, which improves

financial stability, which will then enable growth. One way of measur-
ing growth is to look at market share. Using Solucient data, NMMC is
able to track their percent of market share among Mississippi hospitals.
NMMC considers one of the keys to growth is to increase their physi-
cian base. Their information system can use this data to monitor their
level of growth. Figure 9.17 indicates the number of active physicians
and the level of market share over time.
Challenge: Expand access to services and market share

300 50%
Good
Active medical staff
250 48%
Market share
200 46%
150 44%
100 42%
50 40%
0 38%
2000 2001 2002 2003 2004 2005 2006
YTD
Active medical staff Market share
Figure 9.17 Level of active medical staff and market share.32
NMMC uses their information system to continually monitor the

number of patients they have in different areas, such as outpatient,
nursing home patients, newborn patients, and surgical patients.
When an increasing or decreasing trend is recognized, adjustments
are made to staffing or physical structures. For instance, in 1998
they noticed that there was an increasing trend in the number of out-
patients, more than 12 percent in a five-year period. In response to
the projected growth, an outpatient tower was constructed.
PERFORMANCE
Among the outcome measures that document North Mississippi
Medical Center’s best-in-class performance are:
Malcolm Baldrige National Quality Award (2006)
Solucient 100 Top Hospitals: National Benchmark for
Success
American Hospital Association’s McKesson Quest for

Quality Prize
Recipient of the Davies Award of Excellence, which recog-
nizes excellence in the implementation and use of
health information technology, 1997.
Hospitals and Health Networks Top 100 Most Wired
Award (2001–2007)
Hospitals and Health Networks Top 25 Most Wireless
Award (2004–2006)
P.C. Week’s Fast Track 500
Nightingale Award Hospital of the Year—Mississippi (2006)
CHAPTER SUMMARY
An integral part in the success of North Mississippi Health Services
is their information system. Their nationally recognized system has
evolved over many years. Starting out as an accounting system,
many more modules were implemented. Some of the keys to their
successful implementation have been the involvement of everyone
impacted by the system and the eye for detail in the request for pro-
posals. Management’s requirement that any module included as part
of the overall information system must seamlessly tie in with all the
other systems has led to accurate, reliable, timely, and secure use of
the vast amount of information collected at NMHS.
REFERENCES
1. Governor Chris Gregoire. Policy Brief, Office of the Governor.
Washington, November 23, 2005, retrieved May 2, 2007, from
www.ofm .wa.gov/ budget06/highlights/assets/pdf/
briefs/healthbrief.pdf
2. Glavin, T. “CSPP Applauds Introduction of Frist-Clinton Health Care
IT Legislation,” Computer Systems Policy Project, June 16, 2005,
from www.cspp.org/documents/HCIT_Frist-Clinton_PR.PDF
3. Anderson, G. F., B. K. Frogner, R. A. Johns, and U. E. Reinhardt.
Health Care Spending and Use of Information Technology in OECD
Countries, Health Affairs, May/June 2006 25(3), 819–831.
4. The Institute for the Future, The Robert Wood Johnson Foundation,
Jossey-Bass, January 2003.
5. Allen, M. “Bush Touts Plan for Electronic Medicine,” Washington

Post, May 28, 2004.
6. See note 3.
7. See note 3.
8. Kelley, K. “Electronic Medical Records: Hospitals Harnessing the
Power of Service-Oriented Architecture,” DMReview, May 22, 2007,
from www.dmreview.com
9. United Health Foundation, “America’s Health Rankings: A Call to
Action for People & Their Communities,” 2006, from
www.unitedhealthfoundation.org/ahr2006/Findings.html#Findings
10. U.S. Census Bureau, 2005, from
www.census.gov/hhes/www/poverty/poverty.html
11. North Mississippi Medical Center. “2006 Malcolm Baldrige National
Quality Award Application Summary,” 2006, ii.
12. www.nmhs.net
Quality Award Application Summary,” 2006, i
Quality Award Application Summary,” 2006, iii.
17. Health Information and Management Systems Society, Davies
Awards of Excellence, 2007, from
www.himss.org/content/files/davies_1997_northmississippi.pdf
22. See note 21.
25. www.solucient.com/aboutus/aboutus.shtml
26. www.carescience.com

29. See note 28.
www.nmhs.net North Mississippi Health System Home Page.
www.quality.nist.gov Home page for NIST Baldrige National Quality
Award.
www.himss.org/ASP/index.asp Home page for Healthcare Information
and Management Systems Society.
www.ahima.org Home page for American Health Information
Management Association.
www.eclipsys.com Home page for Eclipsys, NMHS’s EMR provider.
http://aspe.hhs.gov/_/topic/topic.cfm?topic=Health%20Information%20
Infrastructure U.S. Department of Health & Human Services, Health
Information Infrastructure.
10
Great Ormond Street
Hospital for Children:
Ferrari’s Formula
One Handovers and
Handovers from
Surgery to Intensive Care
S
eldom does a hospital re-
ceive front page cover-
age in the Wall Street
Journal, especially in an arti-
cle about Ferrari racing crews,
and seldom are a hospital’s
physicians invited to speak to
boards of directors of multimillion dollar corporations. Great Or-
mond Street Hospital for Children (GOSH), London, England, did
both. Why? Because they had successfully benchmarked their hand-
off from cardiac surgery to the intensive care unit (ICU) against pit-
stop techniques of the famous Ferrari Formula One race car team.
ABOUT THE HOSPITAL

GOSH has long been recognized for its care of children from
throughout the world. Founded in 1852 during a time of high infant
mortality and malnutrition, GOSH was the first children’s hospital in
the English-speaking world. According to Sir Cyril Chantler, Chair-
man of GOSH Board of Directors, “GOSH cannot be average.”1 This
echoes the mission of the hospital:
To improve the health of children by being a leading centre of
excellence in Europe for special pediatric services and for re-
search, evaluation, and education in the field of child health.2
171
The 335-bed hospital has 315 doctors, 900 registered nurses and
healthcare assistants, and 135 allied healthcare professionals, rep-
resenting the widest range of children specialists under one roof in
the United Kingdom. GOSH is the largest pediatric epilepsy
surgery center in the United Kingdom, the second largest in
Europe, the largest unit treating children’s brain tumors (over 100
per year), and the largest pediatric intensive care unit in the United
Kingdom (48 beds, plus eight high dependency beds and five tran-
sitional beds).
The high standards of GOSH were originally set by Dr. Charles West
more than 150 years ago when he first articulated the objectives: “the
medical and treatment of poor children, and medical advice for those
not admitted, the attainment and diffusion of knowledge regarding
the diseases of children and the improvement of teaching with regard
to childhood diseases, the training of nurses for children, and the
education of all classes in the management of sick children.”3
The rating of excellent is the highest possible rating given by the

independent Healthcare Commission. Only six trusts out of 157 in
the United Kingdom received this rating with GOSH being one. The
rating is based on the level of care delivered to hospitalized children
in five areas: access to child-specific service, access to care near
their homes, appropriate levels of trained staff, staff having child-
specific training, and opportunities for staff to maintain their skills.
WHY FOCUS ON THE HANDOVER?

External and internal drivers made GOSH aware of dangers in
handover procedures. In the mid-1990s in Bristol, England, there
was very high mortality for surgery in congenital heart disease fol-
lowed by contentious public inquiry. One of the important findings
of a subsequent study was that the journey from the operating room
to the intensive care unit (ICU) was high risk. This external
environment impetus to change was followed by an internal driver
for change. Interest in human factors led staff physician, Professor
Marc de Leval to question whether staff-related factors, such as
exhaustion, were more important than patient-related factors, such
as the position of the coronary arteries. De Leval reviewed all the
arterial switch procedures done in the United Kingdom over a two-
Chapter Ten: Great Ormond Street Hospital 173
year period with a psychologist watching the operation. Once

again, the journey from the operating room to the ICU was demon-
strated to be a high risk factor. This knowledge created a height-
ened awareness of the danger. Staff came to accept that there was
an element of danger associated with what they were doing so they
were receptive to change.
MOVING FROM THE

OPERATING ROOM TO THE ICU
So many things can go wrong, and sometimes do, as the tiny vul-
nerable person is transferred from the surgery to intensive care.
Moving the little body from one bed to another is only one part of
the complex set of movements that must take place. Wires, equip-
ment, people, and information move about in an intricate dance
where a misstep can place the child in mortal danger. Within 15 min-
utes all the technology and support systems, including ventilation,
two to four monitoring lines, multiple vasodilators, and inotropes,
are transferred two times: going from operating theatre system to
portable equipment to intensive care systems. Intimate knowledge of
the patient gained during a procedure lasting up to eight hours must
be transmitted from the surgical team to the intensive care unit team.
HOW WAS THE

BENCHMARK SELECTED?
In the GOSH case, there was no survey or directed search for a
benchmark to guide changes in the changeover procedure. The
proverbial light bulb went on as two tired doctors, Alan Goldman
and Martin Elliott, sat down to relax after lengthy surgeries. Martin
Elliott, MD, FRCS, Professor of Cardiothoracic Surgery, University
College London and Chairman of Cardiothoracic Services, recalls:
“I’d done a transplant, then an arterial switch in the morning and we
were both pretty knackered [exhausted]. The Formula One came on
TV just as we were sitting down . . . at the end of surgery, and we
just realized that the pit stop where they changed tyres and topped
up the fuel was pretty well identical in concept to what we do in
handover—so we phoned them up.” The two doctors recognized the
importance of teamwork in transforming the highly risky pit stop
operation into one that was both safe and quick. They wondered: “If
they can do it, why can’t we?”
Serendipity is a characteristic of creativity. A serendipitous discovery

is one made by fortunate accident in the presence of sagacity
(keenness of insight).4 In the GOSH case it was serendipitous that
they chose to watch the Formula One and recognized the nature of
the relationship between their work and pit teams.
In Formula One motor racing, the pit stop team completes the
complex task of changing tires and fueling the car in about seven
seconds (see Figure 10.1). The doctors saw this as analogous to the
team effort of surgeons, anesthetist, and ICU staff to transfer the pa-
tient, equipment, and information safely and quickly from the oper-
ating room to ICU.
INITIATING THE PROGRAM

The GOSH benchmarking effort was not driven from the top down
nor can it be tied to an individual person or team. A number of indi-
viduals contributed to birthing this change initiative.
Awareness of the need to look at human factors in cardiac
surgery was initiated by de Leval. The idea that a pit stop was a good
parallel to what happened in a handover can be attributed to Gold-
man and Elliott, while the development of a more formal protocol
was led by human factors expert Ken Catchpole, MD, Senior Post
Doctoral Scientist, Nuffield Department of Surgery, John Radcliffe
Hospital, Oxford, UK. What served to unite them was a common
interest in reducing error and improving quality. Benchmarking to
improve handoffs also fit well with the mission of the hospital.
Moreover, it was supported by both the culture of the department
and organizational structure of the hospital.
WHAT WAS LEARNED

FROM BENCHMARKING?
GOSH doctors visited and observed the pit crew handoff in Italy.
While visiting the Formula One pit crew the GOSH doctors became
interested in the way they addressed possible failure. The crew sat
around a big table analyzing and reanalyzing, asking, “What could
go wrong?” and “What are we going to if it does go wrong?” and
“How important is it if it goes wrong?” Everyone’s ideas were given
equal weight until the group ranked them using the failure modes
and effect analysis (FMEA).
2 Car up on jack 1 Car stopped

8 Car down off jack 7 Driver readied
9 Driver cleared to go
5 New wheel on
STOP
3 Wheel nut off

6 Wheel nut on
4 Old wheel off
3-6 Driver’s visor cleaned
3-6 Fuel in
Figure 10.1 Formula One pit stop.5

FMEA includes describing all parts of a process and listing the

consequences if each part fails. The FMEA scheme has indices from
1 (lowest risk) to 10 (highest risk) for each of three criteria [Severity
(S), Likelihood of occurrence (O), and Inability of controls to detect
(D)]. The overall risk of each potential failure is the risk priority
number (RPN): the product of (S), (O), and (D) rankings. The RPN can
be used to prioritize which potential failures will be the focus of risk
reduction actions.
This anticipatory planning made the pit crew more prepared than
the medical team whose strategy tended to be waiting until some-
thing went wrong to work out what they should have done. Observ-
ing the pit crew, the GOSH doctors noted the value of process
mapping, process description, and trying to work out what people’s
tasks should be. They learned the keys to a successful pit stop:
• The routine in the pit stop is taken seriously
• What happens in the pit stop is predictable so problems can
be anticipated and procedures can be standardized
• Crews practice those procedures until they can perform them
perfectly
• Everyone knows their job, but one person is always in
charge
Following the trip to Italy, the GOSH team videotaped the handover
in the surgery unit and sent it to be reviewed by the Formula One
team. The GOSH research team and observers from the Formula
One team analyzed the film and noted a great difference in the
process map (flowchart). The handover process of the pit crew was
a very short process map compared to the hospital’s process map.
The process in the hospital was much, much longer because the level
of complexity of the medical process was much greater.
From the analysis came a new 12-page handover protocol (a
short version is shown in Figure 10.2). A copy of the protocol was
laminated and put by the bedside. If a staff member had not received
training in the new process or if someone needed a quick refresher,
the posted protocol could be read through in five minutes, leading to
understanding of what needed to be done.
The new protocol was divided into four stages. The first stage
occurs before the patient arrives at the ICU. This is the preparatory
stage. Sufficient information is provided to the ICU to allow them to
Phase 0:
Pre-Handover The Patient Transfer Form is completed by the anes-
thetist and collected from theatres at least 30 minutes
before the patient is transferred to the ICU.
The receiving nurse ensures the bed space is set up
according to the monitoring, ventilation, and other re-
quirements specified on the Patient Transfer Form.
The receiving doctor ensures that all appropriate
paperwork is ready.
Phase 1:
Equipment and On arrival the team transfers the patient ventilation,
Technology monitoring and support from portable systems used
Handover during the transfer to the ICU systems.
Monitor
Ventilator
ODA Power
Consultant
anaesthetist
Anaesthetic
registrar
Pump
Drain Pump
Receiving
nurse/registrar
Nurse
Nurse Urine
Surgeon
SAFETY CHECK: The anesthetist checks the equip-

ment and that the patient is appropriately ventilated
and monitored and is stable. The receiving nurse and
doctor are identified and confirm their readiness.
Phase 2:
Information The anesthetist, then the surgeon, speak alone and
Handover uninterrupted, providing the relevant information about
the case, using the Information Transfer Aid Memoir.
SAFETY CHECK: The receiving nurse and doctor
should use the Information Transfer Aid Memoir to
check that all necessary information has been ob-
tained, and ask appropriate questions.
Phase 3:
Discussion The surgeon, anesthetist, and receiving team discuss
and Plan the case as a group. The receiving doctor manages
the discussions, identifies anticipated problems, and
anticipated recovery is discussed.
The ICU Team now has responsibility for patient care
and confirms the plans for the patient.
Figure 10.2 Summary of the new handover protocol.6

set up all of their equipment so that everything can be ready when

the patient arrives. Before the initiation of the new protocol it was
not uncommon for the patient to arrive in ICU before things had
been set up to receive that patient. That meant the patient stayed on
temporary support for a longer period of time.
In the second stage the patient arrives in the ICU. There is an
equipment checkoff, and different team members are given specific
tasks. This is important so that everyone knows what they should be
doing and what should have been done. Even though every person
has defined tasks they also understand what everyone else’s tasks
are. This means that if someone is called away or held up, somebody
can cover for them. Assigning each task to a particular person means
that not even the little things will be forgotten. At this point there is
a safety check where the physician in charge stands back and says,
“Right, we’ve got all the equipment plugged in.”
The next stage is the briefing during which the operation is dis-
cussed. After the anesthetist and surgeons give their perspective,
everyone is able to have a discussion. Then the patient’s recovery is
mapped out, especially what is expected in the next 24 hours. Di-
viding the handover into stages eliminated people crowding around
and giving briefings as all the equipment was being set up.
Dr. Catchpole, a human factors expert, pointed out that “it’s a
mistake to believe that if you do it [the briefing and equipment set
up] at the same time it would be quicker. That’s not the case. We ac-
tually showed that our whole process was quicker [by separating the
briefing and equipment setup]. The new process eliminated another
problem: somebody missing some information or not setting up the
equipment correctly because someone was talking to them while
they were in the midst of working with the equipment.”
Other aspects of the Formula One training process noted by the
GOSH researchers were the repetition of filming from different an-
gles and the multiple rehearsals of the handover. These rehearsals
ensured that each person knew their responsibilities down to the
smallest details. The GOSH observers were struck by not only how
fast, but also how quiet and disciplined the pit crew was. Every crew
member knew the role and responsibilities and kept out of the way
of others as they fulfilled their roles. To help the medical team man-
age the same feat, a dance choreographer was involved to help the
team position themselves to stay out of the way of others. They also
learned to recognize the need for space around where they are stand-
ing. This meant that the movement around some of these events in
handovers was modified. Working with the choreographer also in-
troduced the discipline of quietness and calm. Professor Elliott noted
that the handover team tended to talk a lot. After the new process
was introduced the handover became one of the quietest activities in
the hospital, especially during hand-off briefings. While the main
theme changes were more sophisticated procedures and better chore-
ographed teamwork, another aspect of the Formula One handover
process easily transferred to the hospital setting. The lollipop man is
the one who waves the car in and coordinates the pit stop. He main-
tains overall situation awareness during the pit stop. In the old hos-
pital handover there was no one like the lollipop man so it was
unclear who was in charge. Under the new handover process, the
anesthetist was given overall responsibility for coordinating the team
until it was transferred to the intensivist at the termination of the
handover. These same two individuals were charged with the re-
sponsibility of periodically stepping back to look at the big picture
and to make safety checks of the handover.
Ferrari caused the hospital to view its own practice from a com-
pletely different perspective. Ferrari didn’t tell them exactly what
needed to be changed or how to make the change. The hospital, how-
ever, was able to take what Ferrari did well and adapt it to fit their
situation.
In the aviation field this ability to stand back, take in everything that
is happening as a gestalt, and then anticipate what might happen
next is referred to as situation awareness. This is what the lollipop
man does for the pit crew.
WHAT WASN’T TRANSFERABLE?

Some aspects of the Formula One handover were not transferable to
the medical handover process. When the consultant from Formula
One went to GOSH and looked at the whole handover process, he
said it would be best to engineer out parts and get new equipment.
He noted the complex technical problems with the handover. In the
operating room, the child is connected to a lot of equipment and
statically powered through an AC cord with wires. There is a venti-
lator, which is a special anesthetic ventilator, on the operating table,
which is very stable. Moreover, there is equipment to control the
baby’s temperature. So when the infant needs to moved from the op-
erating table, all this equipment must be disconnected and converted
from AC to DC power. At that point there is no ventilator so the anes-
thetist must use a bag to blow the lungs up and down. The child is
moved to a cold trolley, covered with a blanket, and wheeled down

a corridor. Upon reaching the intensive care unit, everything has to
be once again dismantled and remantled and reconnected to other
monitors and a ventilator. The Formula One consultant asked, “Why
don’t you just have one thing that does both and has its own power
supply and its own ventilator?” This was obviously what needed to
be done, but it turned out not to be feasible since manufacturers were
not interested in producing the needed equipment. They were not in-
terested because the market is very small (only children) and hospi-
tals would never be able to replace all its beds at the same time due
to the exorbitant cost of the proposed new equipment. While the For-
mula One crew can count on using technology to improve their han-
dover process, the hospital team could not; they had to rely more on
human beings and less on state-of-the-art technology.
What happened at GOSH characterizes the challenges faced by

healthcare professionals in other contexts. What is technologically
possible is often not within the reach of hospitals. Even though the
value of the Formula One consultant’s idea (to use technology to build
better equipment) was obvious to everyone, it was not implemented.
The human factor side was seen as a mode of compensating for
technological limitations.
The lack of resources as well as inherent differences in the na-

ture of the handover meant that the transferability of multiple re-
hearsals and exhaustive contingency planning was not possible.
Adequate time and money allowed motor car racing to have re-
hearsal after rehearsal after rehearsal. In healthcare those resources
are scarce, so one of the things GOSH had to do was design a new
process that was simple, easy to learn, and didn’t need a lot of
practice. The reason the motor car racing team can do everything
in such a short period of time is that everything is very carefully
choreographed and each person is very well rehearsed in perform-
ing the small number of tasks assigned. They complete their work
very accurately in precisely 6.9 seconds The GOSH handover takes
somewhere between 8 and 15 minutes because they are dealing
with a living person, not a piece of machinery. While the Formula
One team could identify all of the contingencies and practice how
to deal with them, this was not possible for the GOSH team. There
are too many permutations of what could go wrong for the health-
care team to practice every contingency. Although it was true the
GOSH team could emulate Formula One’s handover process in

some aspects, they could not address all possible contingencies in
their training program. The healthcare handover team had to be far
more flexible than the motor car racing team because of the com-
plexity of the surgical handoff. Benchmarking against the Formula
One team pushed the hospital to anticipate problems rather than
wait until something goes wrong to deal with it. The GOSH re-
searchers tried to build into the process the importance of antici-
pating and being prepared to respond . . . even if they didn’t know
quite what would happen, even if they couldn’t rehearse every lit-
tle detail.
RESEARCHING THE EFFECTIVENESS

OF THE NEW HANDOVER PROCESS
Studying the effectiveness of the new process was not suited to an
experimental design using a control group. It would have very diffi-
cult to use a randomized trial design in which half the intensive care
used the new process and half stayed with the conventional handover
process. What made an experimental study difficult were the train-
ing and scheduling patterns of the teams and the impossibility of hid-
ing the new process from some staff members once it was initiated.
So everyone involved in handover in cardiac surgery and ICU was
properly introduced to the new process in a sequential training se-
ries. The new teamwork process was observed and assessed by psy-
chologists. Team performance was also measured by using various
Likert-type scales for dimensions of teamwork. The results of the
new process were also evaluated using an error-capturing checklist.
Another checklist captured information about the quality in han-
dover. Duration of the handover was recorded. Thus, controls be-
came part of the protocol of the new handover process.
WHERE WAS THE SUPPORT?

The organizational mission, structure, staff, and culture provided
support for the GOSH change initiative.
Organizational Mission
Using what was learned from benchmarking against other indus-
tries to make changes in the department’s handover moved it to
best-in-class status and fit perfectly with the hospital’s mission to

be one of the great children’s hospitals in the world. The hospital
has two mottos. The main one is “the child first and always.” The
second one is “excellence through safety.” In recent years the hos-
pital has come to view safety and reducing errors as a way, ulti-
mately, of saving money. Since the benchmarking effort was aimed
at reducing errors and the dangers of handovers, it fit well with the
mottos and strategies of the entire hospital. This fit between the
mission and the goal of the change initiative precluded any institu-
tion holdups.
The more tightly the change effort can be tied to the organizational
mission and goals, the easier it will be to get buy-in from other
departments and top administration in terms of tacit support. This is
particularly important when the improvement effort is not overtly
driven from the top of the organization.
Organizational Structure
In the United Kingdom, unlike in North America, most of the car-
diac units are managed as integral units. Cardiology, surgery, and
nursing are not separate divisions; they are not under the division of
medicine, the division of surgery, the division of nursing. Nursing,
intensive care, cardiology, and surgery are all under one department
head. When decisions are made, there is no need to negotiate with
different department heads that may feel threatened and think their
turf is being invaded. The organizational structure at GOSH is
streamlined so there are not discrete departments, rather there are
clinical units. These clinical units have a natural focus on people
rather than on specialty areas. Wherever there is need for a particu-
lar focus, the hospital tries to strengthen the management structure
so neural surgery, neurology, urology, nephrology, etc. are together.
Medical, nursing, and academic components are included in the
group to support the natural focus on particular needs of people.
There are exceptions to this structural arrangement and sometimes
they are not initially inclusive enough. In the case of the cardiac unit
undertaking change in the handover process, anesthesia was not in
the unit. This posed a problem since anesthesiologists are key play-
ers in the handover process. Once an anesthetist was appointed to the
research group, planning was enriched by input from this specialty

and coordination of the change was much easier.
In any change process, one of the most challenging issues to resolve

is how to get all the important players involved. This is especially
difficult when various players report to different administrators.
Careful analysis and plans will lie fallow if the organizational
structure cannot handle the coordination that is needed to
implement the improvement. It is critical that the administrator
responsible for the change have some authority over everyone
involved in the change, even if that person is not in a direct report
position in the formal organizational chart. Here again we see a
potential for conflict because one administrator may be seen as
encroaching on the authority of some other administrator. In cases
such as this, there is a need for higher level administrators to
intervene and diffuse this potential conflict by clearly (1) indicating
the importance of the change to the success of the organization in
meeting its overarching goals and mission, and (2) clarifying the time
and extent of the one administrator’s control of the other
administrator’s staff or resources. This is the time for the “let’s all pull
together for the common good” speech from top administration.
Organizational Staff
Staffing the handover change initiative was relatively easy. No new
staff was required. GOSH already had trainers, although one addi-
tional one was added to help introduce the new handoff procedures.
For the old staff it was more of a change in practice rather than re-
training. According to Professor Elliott, “It was fairly obvious when
you look at the diagrams and talked about it with the people who are
doing it that what we set up was better than what was there before.
So it wasn’t ever really a huge problem [to get staff buy-in].”
Organizational Culture
The culture in the department, developed under Professor de Leval,
fostered a sense of self-criticism making staff receptive to change.
Staff was accustomed to analyzing their actions as a first step to im-
proving what they were doing. The department spent nearly four
years creating a no-blame culture around the analysis of incident and
error. The transition to a no-blame culture was helped by using soc-

cer rules during hospital meetings, and to have these meetings
chaired by individuals committed to that philosophy. According to
Professor Elliott, “If someone was approaching a blame state, we
would raise the yellow card (a warning in soccer). And if they
achieved a blame state, then they got a red card (expulsion from the
game) and had to leave the meeting. That worked really, really well.
It was kind of a joke and people laughed so the atmosphere was very
much elevated and people stopped [attributing] too much blame.
You’re never going to get rid of it completely, but it’s much less so
than it ever was.” With a culture receptive to an internal audit of what
they were doing and an awareness of the element of danger in their
work, the department was primed for change.
GOSH overcame what is often the most difficult part of setting up

programs that demand an organization to be self-critical. They had
embedded in the organization an acceptance of critical analysis
devoid of blame.
WHAT WERE THE OBSTACLES?

Lack of Financial Resources
The stumbling block was acquiring financial resources. “It [hand-
over] was such an obviously good idea to study but getting any kind
of grant-giving body to take an interest in this was quite difficult,”
according to Professor Elliott. Actually quite a bit of the required
funding came from the hospital’s own internal resources. However,
at the time external grantors placed a high priority on projects
directly related to molecular biology and genetics rather than on
projects for improving processes to reduce errors. Eventually
GOSH was awarded a grant that helped pay the salary for a human
factors expert. Travel funds for the trip to Italy were paid for by
Formula One, while travel overtime was funded by Ferrari. The fact
that it took almost four years to implement the new handover
process was mainly due to the need to overcome this funding ob-
stacle. Much of the time in the beginning was spent trying to get
grants. And since that wasn’t the funding priority of many grantors,
it was an uphill battle.
Obviously, within medical circles, something (like improvement of a

process) that does not directly relate to medicine is not mainstream so
it may be difficult to find buy in from medical professionals in the
funding or publishing fields. The challenge to be accepted and
recognized for what you are doing when you are working outside the
mainstream of any discipline is always an issue. What is interesting is
that disciplines define value in terms relating specifically to the discipline
rather than in terms relating to the impact on society. One way of
breaking through this barrier is to “let the world know what you are
doing.” In the case of the GOSH example, corporate boardrooms and
the Wall Street Journal were faster to recognize the impact of the
benchmarking efforts than some members of the medical community.
One lesson that might be learned from the GOSH example is that
getting the word out to the real stakeholders in quality healthcare is
critical in breaking through professional constraints on what constitutes
a valuable contribution.
Professional Healthcare Orientation

A major difference existed between the Formula One team and the
GOSH staff in the way they were oriented. Hospital staff see them-
selves as there to help each other so that whenever there is a crisis,
everyone rushes to the crisis. Their natural instinct to help leads staff
to get in each other’s way. In Formula One handover there is a very
clear role distinction. People don’t speak too much and they just do
their jobs, get out of the way, and trust everybody else to do theirs.
The racing team had more specific and accurate role assignments
than in the hospital.
GAUGING THE GAINS

A number of broad categories were measured. Technical errors were
monitored and scored (see Figure 10.3). Information omissions were
monitored and scored, as was the duration of the handover.
Team performance, leadership and teamwork, task management
work space and equipment, and situational awareness were all ob-
served and analyzed by psychologists. It is clear that gains have been
achieved; for example, error rates have continued to go down. In or-
der to see whether improvements are being sustained there are plans
to repeat the study.
Ventilator on test lung
Monitor and alarms

already set
Pre-handover
Pump stand already available
Time off ventilation

is minimized
Minimum time off
safe monitoring
Pumps located appropriately
Equipment plugged in
and checked
Drains located safely and
put on suction Equipment and
technology handover
Urine bag located
appropriately
Lines messy/confusing
All equipment ready

before briefing
Personnel attentive
during briefing
Briefing overseen
by anaesthetist
Check for readiness
Briefing well ordered Information handover
Discussion ordered
and inclusive
Mean by type
0.0 0.20 0.40 0.60 0.80 1.00

Technical errors per handover
Handovers before new protocol

Handovers after new protocol
Figure 10.3 Technical errors per handover before and after the new
protocol, with 95% confidence intervals.7
It is easy to rest on one’s laurels once positive results have been

achieved. What characterizes continuous improvement is the built-in
ongoing monitoring of results. There are many reasons that could slow
or reverse the improvement trend, such as changes in staff or
administrators, the tendency to let up once the excitement and glow
of a change initiative wears off, and unforeseen alterations in the
situation.
The real gain for patients was safety. Results showed that the
new handover procedure had broken the link between technical and
informational errors. Before the new protocol was introduced, pa-
tients who had experienced less than perfect equipment had a higher
rate of information omissions in the briefing. With the new protocol,
just because someone made a mistake with the equipment didn’t
make it any more likely that somebody was going to forget to relay
an important piece of information to the ICU team.
We know from safety studies that it is the patients that have multiple
things go wrong with them that eventually have adverse outcomes.
According to Professor Catchpole, “If you can stop mistakes building
up, if you can break this link between one thing and another, then
you can make the process safer.”
Before the new handover protocol, approximately 30 percent of

the patient errors occurred in both equipment and information; af-
terward, only 10 percent of the patient errors occurred in both areas.
Even though it was not perfect, the hospital did improve. Separating
the time when the equipment was changed and the information was
exchanged into different stages in the protocol severed the link be-
tween errors in equipment handling and briefings.
Dr. Catchpole found the hospital’s reaction to the success of
the benchmarking effort interesting. People did not react to the
improvement in handover by saying, “This is great, we don’t need
to do anything more.” What they did say was, “This is great, but we
can do even better.”
The Ferrari racing team doesn’t say, “We won that race, so we can sit
back.” Rather they say, “We won that race and we want to win the
next one and the next one and the next one.” In this healthcare case,
the staff seems to have bought into the idea that “Yes, this process
is working great now . . . but it could be made even better.”
Without this attitude of “we can do better,” continuous im-
provement cannot occur.
FUTURE CHALLENGES
The real problem facing the GOSH cardiac unit in the future is
keeping the new handover process in place. The European Working
Time Directive and normal staff turnover means new members are
added to the team over time. Some of them are inexperienced and
need training. Even the more experienced ones who come to GOSH
from other hospitals need retraining because handoffs are done dif-
ferently in the cardiac unit at GOSH. Training is always time con-
suming and therein lies the challenge. Another type of challenge is
replicating the handover in other areas of the hospital. There are
more hand-offs now because of changing working hours, changing
staff rotation systems, and less-experienced junior staff due to
shorter working hours.
According to Professor Elliott, there is an ongoing challenge to
“review our practice and see if we can do it any better and institute
new handoff procedures whenever we need them. . . . We will
continue to monitor error. Our aim is to have error at zero, or as
close to zero as possible in every area we are capable of measuring
it.” He continued, “You know how close we are already? Miles away.
You never get to zero, but just having it as an aspiration keeps it im-
mersed in the culture.”
PERFORMANCE
Great Ormond Street Hospital, the first institution in the United
Kingdom to offer inpatient care to children only, is a major trainer
of Britain’s pediatric nurses. GOSH has the most specialties for chil-
dren under one roof in the United Kingdom and the widest range of
children’s specialists under one roof in the United Kingdom. When
Princess Diana pared down her charity commitments from around
100 to six, the Great Ormond Street Hospital for Children was one
of the six. This certainly was indicative that the Princess of Wales
viewed GOSH as best-in-class. Other commendations include:
The Healthcare Commission placed GOSH in the best top
20 percent acute care hospitals to work for.
In 2006, The Healthcare Commission rated GOSH excel-
lent in clinical care, the highest mark available.
GOSH has a 5 A rating for the quality of research at the
Institute of Child Health.
The hospital has 23/24+ for the quality of teaching, which
places them at the top of the rating scale.
GOSH has a highly successful research program resulting
in the improvement in the success rates of bone marrow
transplant operations, the development of new drugs for
epilepsy, arthritis, and HIV, new ways of making key-
hole surgery in children more effective, and better un-
derstanding of pain, cancer, and genetic disorders.
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Index_Sower_575077.qxd 11/6/07 11:11 AM Page 195
Index
15/30 guarantee, 9, 62 baseline, 21

3 Cs, 72, 96–97, 101 benchmarking processes,
5 pillars, 72 five phase, 17
7–S framework, 56 initiating, 7–8
six phase, 18
benchmarking team,
A defining, 20
benchmarking,
acceptance, gaining, 28–29 criteria for success, 22
action, 29 definition, 3–4
actions plans, developing, 29 establishing baseline, 21
Agency for Healthcare Research and ethics, 11–13
Quality (AHRQ), 5 etiquette, 11–13
AHRQ, see Agency for Healthcare objectives, 22
Research and Quality operations, 8–9
alignment, 74–75 planning, 17–22
Allen, M., 144 protocol, 11–13
Alukal, G., 26–27 results, 11
American Nursing Association, 111 rules, 11–13
analysis, 24–28 strategic, 8–9
Anderson, G. F., 144–145 target, 21
Ashton, J., 17 target selection, 17–21
ASQ Code of Conduct, 12–13 benchmarks,
ASQ Quality Progress, 36 national, 4–7
attainment of best-in-class, 30 not transferable, 179–181
recalibrating, 29
transferable, 174–179
B benefits, 102, 185–188
Bennis, W., 85
Baby on the Way Valet Service, Berwick, D., 4
102–103 best-in-class hospitals, 71–85
balanced scorecard, 66 best-in-class,
195
196 Index
Bronson Methodist Hospital, C

89–108
Columbus Children’s Hospital, CAHPS, 75
109–125 Camp, Robert, 17, 32
definition, 5, 9–10 Canaino, Donna, 10, 76, 111, 113
determining attainment, 30 care-based cost management (CBCM),
Great Ormond Street Hospital 162
(GOSH), 188–189 CARES, 73
North Mississippi Medical Center Catchpole, Ken, 174, 178, 187
(NMMC), 143–169 Cause and effect diagrams, 45
performance measures, 106–107, CBCM, see care-based cost manage-
124, 140 ment
BLS, see Bronson Leadership System CDC, see Centers for Disease
Bornstein, T., 17 Control
Bozeman, Tommy, 145, 150, 153–154, celebration of results, 83–84
157 Centers for Disease Control (CDC),
Bronson Leadership System, (BLS), 113–114
95, 97 challenges, 188
Bronson Methodist Hospital, 10, 23, champions, 76–77
37, 58–60, 72, 80 Chantler, Sir Cyril, 171
3 Cs, 96–97 CHCA, see Child Health Corporation
about, 90 of America, 117
before, 90 Child Health Corporation of America
current workforce, 94–97 (CHCA), 117
excellence impact, 106 Child magazine, 111
future workforce, 98–99 Children’s Quality Initiative in
lessons learned, 105–106 Surgery (CQIS), 10
mission, 72 clarity of mission/vision, 72–74
opportunities, 105–106 Claxton, J. D., 142
performance measures, 106–107 clinical pathways,
physician involvement, initial development, 111
104–105 Code of Conduct, 11–13
plan for excellence, 92, 95 Collins, J., 108
registered nurses, 89 Collins, Jim, 95
resources, 105–106 Columbus Children’s Hospital Chil-
target selection, 92–93 dren’s Quality Initiative in
transformation, 91–92 Surgery (CQIS)Team, 109–110,
workforce development plan, Columbus Children’s Hospital Chil-
93–104 dren’s Quality Initiative in
workplace excellence, 93 Surgery (CQIS), 115–117
Bronson Plan for Excellence, 92 Columbus Children’s Hospital, 10, 63,
Bronson School of Nursing at Western 73, 76, 109–125
Michigan University, 99 about, 110–111
Bronson staff performance measure- CARES, 73
ment system, 98 clinical pathways, 111
Brown, T., 189 Children’s Quality Initiative in
Business Horizons, 58 Surgery (CQIS), 115–117
Business Process Benchmarking: mission, 73, 112
Finding and Implementing Best motivation to change, 111–113
Practices, 32 Operation Takeoff, 10, 117–124
BusinessWeek SmallBiz, 85 performance measures, 124
Index 197
systems, 114–115 de Leval, Marc, 172

transformation, 113–114 Deming Cycle, 97
commitment of resources, 8–9 Deming, W. Edwards, 97, 115
communicating benchmarking find- diagnosis-related groups (DRGs), 162
ings, 28–29 diversity, 102–104
communication, 83 DRGs, see diagnosis-related groups
competitive convergence, 30 Duffy, J., 40, 75
complaint management process, 161
computerized physician order entry
system (CPOE), 105 E
concierge services, 102–103
continuing improvement, ED wait times, 127–142
Bronson Methodist Hospital, 106 effect of changes, 106, 122–123,
Columbus Children’s Hospital, 123 134–138, 160–165, 185–188
developing objectives for, 30–31 effectiveness, 181
Robert Wood Johnson University electronic medical record (EMR), 144
Hospital Hamilton, 134–138 Elliott, M. J., 175, 177, 186
continuous quality improvement Elliott, Martin, 173, 179, 184, 188
(CQI), 5 employee well-being, 99–100
Bronson Methodist Hospital, 106 employee retention, 157
Columbus Children’s Hospital, employee satisfaction, 99–100,
123 1158–59
Great Ormond Street Hospital EMR, see electronic medical record
(GOSH), 188 EPP, see evidence-based planning
Robert Wood Johnson University process
Hospital Hamilton, 134–138 ethics, 11–13
control charts, 41–43 etiquette, 11–13
types, 43 European Working Time Directive,
COPQ, see cost of poor quality 188
COQ, see cost of quality and continu- Eveleigh, C., 189
ous quality improvement evidence-based planning process
Corporate Creativity, 73, 174, 190 (EPP), 149, 151
Cost of quality (COQ), 50–52 EXCEL, see performance manage-
cost of success, 139 ment system
CPOE, see computerized physician or- excellence impact, 106, 122–123, 139,
der entry 160–165, 185–188
CQIS, see Columbus Children’s Hos- excellence, 159
pital Children’s Quality Initia-
tive in Surgery (CQIS)
Curing Health Care, 4 F
current state map, 26–27
Czarnecki, M., 32 failure mode and effect analysis
(FMEA), 49–50, 174, 176
Failure Mode and Effects Analysis in
D Health Care: Proactive Risk
Reduction, 190
data acquisition, 22–24 financial impact, 163–165
Davies Award of Excellence, 154 financial resources,
Davis, S., 3–4 lack of, 184–185
Davis, Terry, 10 findings,
de Leval, M., 175, 177, 186 communicating, 28, 29
198 Index
Fishbone diagrams, 45, 133 support, 181–184

Fitz-Enz, J., 32 target selection, 173–174
five pillars of excellence, 9, 133 technical errors, 186
five-phase benchmarking process, 17 growth, 165–166
flowcharts, 36–39
time-function map, 38–39
FMEA, see Failure mode and effect H
analysis
focus groups, 34–36 H. William Clatworthy Jr. Professor of
Formula One Ferrari, 10 Pediatrics and Surgery, 113
Formula One pit stop, 175 Hall, D., Chapter 5 refs.
Fortune, 89 Hall, Doug, 82
Frogner, B. K., 144, 145 handover protocol, 171–190
Health Affairs, 144–145
Health Care Management Review, 75
G Health Information and Management
Systems Society, 154
gainsharing, 101–102 healthcare orientation, 185
Galloway, D., 36 Higgins, J., 56, 69
Gantt chart, 46–48 How to Use Control Charts for
gap analysis, 24–25 Healthcare, 43
Glavin, T., 143
Global Cases in Benchmarking, 32
goals, I
establishing, 29
Goetsch, S., 3–4 If Disney Ran Your Hospital: 9 1/2
Goldman, A. J., 175, 177, 186 Things You Would Do Differ-
Goldman, Alan, 173 ently, 108
Goldsmith, J., Chapter 5 refs. implement plans, 29
Good to Great: Why Some Companies improvement strategy,
Make the Leap...and Others developing, 29
Don’t, 95, 108 improvement,
Great Ormond Street Hospital Bronson Methodist Hospital, 106
(GOSH), 10, 73 Columbus Children’s Hospital, 123
about, 171–172 continuing, 30–31
beginning, Great Ormond Street Hospital
benchmarks not transferred, (GOSH), 185–188
179–181 North Mississippi Medical Center
effectiveness, 181 (NMMC), 160–166
effects, 185–188 Robert Wood Johnson University
mission, 73 Hospital Hamilton, 134–138
motivation to change, 172–173 industry averages, 4–7
observation, 174–179 industry comparison,
obstacles, 184–185 different industry, 10–11
opportunities, 188 same industry, 10–11
organizational culture, 183–184 information system,
organizational mission, 181–182 impact on people, 154–160
organizational staff, 182–183 impact, 154–166
organizational structure, 182–183 information technology systems, 105
performance measures, 188–189 initiation of benchmarking, 7–8
Index 199
integration, 28–29 Leapfrog Top Hospitals, 111

internal processes, 4–7 Learning to Lead, 85
Lee, F., 108
lessons learned, 105–106
J
John Radcliffe Hospital, 174 M
Johns, R. A., 144–145
Jones, P., 40, 75 MacDonald, C., 175, 177, 186
Journal of Change Management, 56, 69 Maister, D. A., 141
Journal of Marketing, 142 Malcolm Baldrige National Quality
Journal of the Academy of Marketing Award (MBNQA), 89–90
Science, 142 management information system,
Juran, Joseph M., 4, 115 150–156
management role, 7–8
Managing by Measurement: How to
Improve Your Organization’s
K Performance Through Com-
petitive Benchmarking, 32
Keley, E., 17 Manos, A., 26–27
Kelley, D., 43 maturity, 30–31
Kelley, K., 145 MBNQA Criteria for Healthcare,
key characteristics, 92
alignment, 74–75 MBNQA, see Malcolm Baldrige
celebration of results, 83–84 National Quality Award
champions, 76–77 McClurkan, Mac, 105
clarity of mission, 72–74 McEwan, A., 175, 177, 186
clarity of vision, 72–74 McQuillan, A., 175, 177, 186
communication, 83 measure, 75
lack of fear, 82 measures of progress, 75–76
measures of progress, 75–76 medical tests, redundant, 143–145
metrics, 75–76 medical tests, repeated, 143–145
motivation, 81–82 metrics, 75–76
openness to improvement, 77 Michigan Quality Leadership Awards,
patient-centered culture, 78–80 89
strong leadership, 80–81 mission alignment, 74–75
systems thinking, 81 motivation to change, 113–114,
Kilbourne, W., 40, 75 130–131, 172–173
Kohers, G., 40, 75 motivation, 81–82, 100, 111–113
KQCAH, 75
N
L
Naik, G., 10, 190
lack of fear, 82 national averages, problems with, 5–7
launching, 122–123 Nelson, D., 9, 141
leadership team, 147–150 NMHS, see North Mississippi Health
leadership, 80 Services
Leapfrog Hospital Quality and Safety NMMC, see North Mississippi Med-
Survey, 6, 111 ical Center
200 Index
North Mississippi Health Services opportunities, 105–106

(NMHS), 143–169 organizational culture, 183–184
about, 145–147 organizational mission, 181
North Mississippi Medical Center organizational staff, 182–183
(NMMC), 60, 73, 145 organizational structure, 182–183
financial impact, 163–165 outside industry comparisons, 10–11
growth impact, 165–166
impact on people, 154–160
impact on quality, 162–163 P
impact on service, 160–162
information system, 154–166 PACS, see picture archiving and com-
cardiology, 164 munication system
CARES, 73 Pareto diagrams, 44–45
complaint management process, patient safety culture, 5
161 patient satisfaction, 159
employee retention, 157 patient-centered culture, 78–80
employee satisfaction, 158–159 PDCA, 97, 132–134
evidence-based planning process, Pediatric Anesthesia, 175, 177, 186
149–150 performance gap,
ideas for excellence, 159 determining, 24–25
information system impact, performance goals,
154–166 establishing, 29
inventory, 165 performance levels,
leadership team, 147–150 projecting, 25–28
management information services, performance management system
150–156 (EXCEL), 158
mission, 73, 148– 149 performance measures,
patient satisfaction, 159–162 Bronson Methodist Hospital,
performance management system, 106–107
158 Columbus Children’s Hospital,
performance measures, 124
166–167 Great Ormond Street Hospital
physician satisfaction, 161 (GOSH), 188–189
quality, 162–163 North Mississippi Medical Center
radiology, 164 (NMMC), 166–167
Robert Wood Johnson University
Hospital Hamilton, 140
O Peters, T., 58, 67, 69
Philips, J., 58, 67, 69
objectives, physician involvement, 104–105
defining, 22 physician satisfaction, 161
obstacles, 123–124, 184–185 picture archiving and communication
Okes, D., 12–13 system (PACS), 163
openness to improvement, 77 Pigott, N. J., 175, 177, 186
Operation Takeoff, 10, plan for excellence, 94, 95
117–121 plan-do-check-act, 97
launching, 122 planning, 17–22
obstacles, 123–124 plans,
results, 122–123 developing, 29
operations benchmarking, 8–9 implementing, 29
Index 201
Press Ganey Associates 2006 Health balanced scorecard, 66

Care Satisfaction Report, 5, 6 communication system, 61
Princess Diana, 188–189 cost of success, 139
process flowchart, 37 mission, 72, 78–79, 130
professional orientation, 185 motivation to change, 130–131
progress, monitoring, 29 performance measures, 140
protocol, 11–13 Robinson, A., 190
Psychiatric Behavioral Hospital, 146 role distinction, 185
rules, 11–13
run chart, 46
Q
QAP, 17 S
quality care, 162–163
quality impact, 106 S32 Framework Organization,
information system, 154–166 56–57
Quality improvement strategy, 68 S32, 55–69
Quality Management, Introduction to shared values, 63
Total Quality Management for skills, 59–60
Production, Processing, and staff, 59
Services, 3–4 strategy formulation, 57–58
Quality Progress, 3, 7, 9, 21, 32, 75, structure, 58
80 style, 58–59
supplies, 63
systematic measurement practices,
R 63–68
systems, 60–62
radar chart, 40–41 Sardone, Frank, 59, 91–92
Readers Digest, 189 Schwarz, J., 66
recalibrating, 29 Schwarz, Joyce, 128
recognizing excellence, 100–102 Serbenski, M., 10
redundancy, 48, 49 Serbenski, Michele, 90–92
redundant systems, 48 serendipity, 174
reduntant medical tests, 143–145 services, 102, 160–162
Reinhards, U. E., 144–145 seven-phase benchmarking approach,
Reliability, 48, 49 17
reliability calculation, 48 shared values, 63
repeated medical tests, 143–145 Shewhart, Walter, 97
resetting, 29 situation awareness, 179
resources, 105–106 six-phase benchmarking process,
results, 18
target achievement, 11 skills, 59–60
rewarding excellence, 100–102 Solomon, M. R., 141
Ritz-Carlton Hotel Co.10 Sower, V., 32, 40, 75
Robert Wood Johnson University Hos- SPMS, see staff performace manage-
pital Hamilton, 9, 59–66, 72, ment system,
127–142 Spotlight, 10
15/30 Guarantee, 62 Spotlight: Children’s Employee
5 pillars, 72 Publication, 110
about, 128–130 staff learning, 100
202 Index
staff performance management system The Ohio State University, 113

(SPMS), 96 The Quality Toolbox, 34
staff, 59 The Service Encounter, 141
Standard & Poor, 164–165 The Toronto Globe and Mail, 6
Stephenson, Christy, 59, 131 time-function map, 38–39
Stern, S., 73, 174, 190 tools, 34–35
strategic benchmarking, 8, 9 cause and effect diagrams, 45
strategy formulation, 57–58 control charts, 41–43
strategy, cost of quality, 50–52
affect on quality improvement, 68 failure mode and effect analysis,
strong leadership, 80–81 49–50
structure, 58 fishbone diagrams, 45
style, 58–59 flowcharts, 36–39
success criteria, 22 focus groups, 34–36
success, 139 Gantt chart, 46–48
success, pareto diagrams, 44–45
defining22 radar chart, 40–41
supplies, 63 redundancy, 48–49
support, 181–184 reliability, 48–49
surgery handovers, 171–190 run chart, 46
surgical dashboard, 117–118 transformation, 91–92, 113–114
surgical safety, 109–125
Surprenant, C. F., 141
Sutter, M., 26–27
systematic measurement practices,
U
63–68 U. S. Census Bureau, 146
systems thinking, 81 U.S. News & World Report, 110
systems, 60–62, 114–115 Ulshafer, Susan, 90–92
United Health Foundation, 146
University College London, 173
T
Tague, N., 34
target results, 11 V
target selection, 21
Bronson Methodist Hospital, valet service, 102–103
92–93 values alignment, 74–75
Great Ormond Street Hospital, vision alignment, 74–75
173–174 Volland, J., 7
Taylor, S., 142
team,
defining, 20 W
The 8 Practices of Exceptional Com-
panies: How Great Organiza- Wall Street Journal, 10, 185, 190
tions Make the Most of Their Washington Post, 144
Human Assets, 32 Waterman, R., 56, 58, 60, 67, 69
The Certified Quality Manager Hand- Welch, Jack, 28, 55–56
book, 12–13 Welch, Suzy, 28, 55–56
The Hospital on the Hill, 145 West, Charles, 172
The Journal of Busines Strategy, 56 Westcott, R., 12–13
Index 203
Western Michigan University, 99 employee satisfaction, 99–100

what to benchmark, 17–20 employee well-being, 99–100
within industry comparisons, 10–11 future workforce, 98–99
Women’s Hospital, 146 motivation, 100
workforce development plan, 96 recognizing excellence, 100–102
benefits, 102 rewarding excellence, 100–102
Bronson Methodist Hospital, services, 102
93–104 staff learning, 100
current workforce, 94–97 Working Mother, 89
diversity, 102–104 workplace excellence, 93

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List of Figures and Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Section I The Basics of Benchmarking . . . . . . . . . . . 1

Chapter 3 Benchmarking Tools . . . . . . . . . . . . . . . . . . 33

Chapter 4 Organization Design Issues:

Section II Case Studies—How Best-in-Class

The Action Begins . . . . . . . . . . . . . . . . . . . . . . . 130

Where was the Support? . . . . . . . . . . . . . . . . . . . . 181

Figures and Tables

Figure 1 Outline for the book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii

xii Figures and Tables

Figure 6.7 Green card. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

KEY FEATURES OF THE BOOK

ORGANIZATION OF THE BOOK

(a) Section I – The Basics of Benchmarking

Chapter 1: Chapter 2: Chapter 3: Chapter 4: Chapter 5:

(b) Section II – Case Studies—How Best-in-Class Status was Attained

Chapter 6: Chapter 7: Chapter 8: Chapter 9: Chapter 10:

Figure 1 Outline for the book.

BRONSON METHODIST HOSPITAL:

ROBERT WOOD JOHNSON UNIVERSITY

NORTH MISSISSIPPI HEALTH SERVICES:

GREAT ORMOND STREET HOSPITAL

their new processes on those of the Ferrari Formula One racing

CONTRIBUTIONS OF THE BOOK

Martin Elliott, MD, FRCS, Professor of Cardiothoracic

In addition we would like to thank Shashi Madhok, Malcolm

4 Section I: The Basics of Benchmarking

performer from inside or outside its industry.2 This definition in-

“Steal shamelessly and implement profusely the things that work in

The working definition that we will use throughout this book is

NATIONAL BENCHMARKS, INDUSTRY

Chapter One: Introduction to Benchmarking 5

average?” The answers to these questions are not very instructive

Item Hospital X National average

Figure 1.1 Comparing outcome measures.

6 Section I: The Basics of Benchmarking

Benchmarking should be approached by investigating industry practices

Without information about the processes used by the best hospi-

Chapter One: Introduction to Benchmarking 7

made and learned from. A problem with national averages is that we

*Standard deviation is a measure of the spread or dispersion of a distribution. The

8 Section I: The Basics of Benchmarking

commitment are important. One is insufficient without the other. One

STRATEGIC AND OPERATIONS

Chapter One: Introduction to Benchmarking 9

Operational benchmarking may be initiated either top-down or