Following his career, Clarke became a General Manager and changed his first name to just Bob.  He held a variety of executive positions with the Flyers and, for a brief period, other NHL clubs.  Just this past week, Clarke was honored for his management success.  

One team Clarke managed was the (now defunct) Minnesota North Stars – which made a Cinderella run to the Stanley Cup in Clarke’s first year as a GM with the team.

Bob Ganey, North Stars coach, recalled Clarke’s management approach: “He’d pull out a pad of paper and he’d say, ‘What are our needs? Where are we weak?’ And then once that was established, it was, ‘How do we answer those needs? How do we attempt to solve those things?’ That’s a method of work that I still use, not only in my work capacity as a manager, but in other places. What’s the problem? Where are we weak? What do we need and how do we solve that problem?”

A simple approach…but an approach worth featuring as an example of excellence in operations.   To read more about Clarke’s management approach, go to the Flyers web site at:

http://flyers.nhl.com/club/news.htm?id=520693&navid=DL

HFMA has made available the full write-ups of the session in Philadelphia and in Houston.  You can access them by visiting the HFMA web site at either:

http://www.hfma.org/NR/rdonlyres/11530D88-40C8-45BE-9BF7-C383BEEFCCE8/0/400686ValueCareDeliveryRoundtable.pdf

Or

http://www.hfma.org/NR/rdonlyres/CABA400B-1F87-4C5C-B181-CCC497396E53/0/1075_Roundtable200910Aramark_w2.pdf

In the 2005 book, The John Deere Way, David Magee reports on Deere’s commitment to quality and customer service.  Quality extends far beyond the John Deere product lines and dealerships.  The total quality effort is what employees see…that quality in their daily work ultimately results in quality that the customer sees when they “get behind the wheel of a new yellow Deere 710 backhoe loader.”

Hospitals and tractors are certainly different animals, but the importance of quality processes is shared. In a recent blog (2/8/2010), Bob Wachter reviews Atul Gawande’s Checklist Manifesto. The insightful point that Wachter makes is that “the public is so unsettled by our patient safety and quality flaws… (because) they assume that we do know the right thing to do, but simply screwed it up.”  Wachter quotes Gawande: “… under conditions of true complexity – where the knowledge required exceeds that of any individual and unpredictability reigns – efforts to dictate everything from the center will fail.  People need room to act and adapt.” 

Says Gawande: “In a world in which success now requires large enterprises, teams of clinicians, high-risk technologies, and knowledge that outstrips any one person’s abilities, individual autonomy hardly seems the ideal we should aim for. ..what is needed, however is discipline…discipline is hard – harder than trustworthiness and skill and perhaps even than selflessness. We are by nature flawed and inconstant creatures. We can’t even keep from snacking between meals. We are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at.”

Despite demonstrating that checklists produce results, there is resistance to their use because of the (1) Master of Universe mentality (Rock Star; Fighter Pilot; Hero), (2) our jobs are too complex to reduce to a checklist, (3) checklists are too rigid and don’t force us to look up and see and think ahead of what’s in front of us.

Gawande finds two pitfalls in our resistance – the fallibility of human memory when it comes to mundane, routine matters that are easily overlooked under the strain of more pressing events and secondly, people can lull themselves into skipping steps even when they remember them – after all certain steps don’t always matter…until one day they do.

The similarity to a manufacture of a tractor is startling – Gawande is stating that the people need to see the quality that they are producing, and be aware that it is quality based on an established process (like through a check list).  Gawande gave a great example of a cleanliness checklist used in intensive care units in all Michigan hospitals in 2003 to eliminate infections. Said Gawande (in his New Yorker article that inspired the book):  “ In December, 2006, the Keystone Initiative published its findings in a landmark article in The New England Journal of Medicine. Within the first three months of the project, the infection rate in Michigan’s I.C.U.s decreased by sixty-six per cent. The typical I.C.U.—including the ones at Sinai-Grace Hospital—cut its quarterly infection rate to zero. Michigan’s infection rates fell so low that its average I.C.U. outperformed ninety per cent of I.C.U.s nationwide. In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated hundred and seventy-five million dollars in costs and more than fifteen hundred lives. The successes have been sustained for almost four years—all because of a stupid little checklist.”

Within hospital operations, I’ve seen how the successful application of a process called AIDET (Acknowledge, Introduce, Duration, Explanation and Thank You) when applied to support service workers creates a positive reaction within patients and leads to higher patient satisfaction scores. AIDET is a mnemonic device which really does serves as a checklist to support service workers when interfacing with patients. Click here to read Quint Studer’s application of AIDET. 

Like Deere, quality impacts the cost structure at hospitals in every area of the business. Successful hospitals see quality as all pervasive, and instill the camaraderie, discipline and processes in place to create a culture of quality. “The promise of quality always comes first” is from Magee’s work about Deere. Gawande would add that in hospitals, the process that ensures quality (a checklist) is part of that promise.

• Total number of scheduled maintenance work orders completed in a year as a function of the total number of capital equipment owned by the hospital
• Percentage of CE departments that have administrative support as a function of the number of FTEs
• Total number of FTEs in the CE department as a function of adjusted discharges
• The total number of pieces of capital equipment and unscheduled repairs completed in a year as a function of the hospital’s total patient occupancy percentage
• CE labor expense versus total CE expense
• Parts and supplies expense versus total CE expense
• Service contract expense versus total CE expense
• Total cost of management and maintenance of medical equipment (total CE expense) versus the total capital acquisition costs
• Total CE expense versus the total number of beds that are staffed and operated by each hospital
• Total CE expense versus adjusted patient discharges
• Total CE expense versus the total number of capital equipment it maintains
• Total CE expense versus the hospital’s total operating expense.

From this study, Dr. Wang concluded that using multiple comparisons (both financial and operational) one can gain valuable insights into the current performance of a CE department and find areas that deserve further scrutiny to reveal unique characteristics and/or opportunities for improvement.

For a briefer commentary on clinical technology benchmarking, Dr. Wang authored an article in the October 2009 issue of 24×7 magazine that focuses on technology and service solutions for biomed. Here is a link: http://www.24×7mag.com/issues/articles/2009-10_10.asp.

Initially created as a way for MedLine to raise awareness for its new line of pink gloves, it was done to increase Breast Cancer Awareness. However, it is also obvious that it involved staff at all levels at Providence St. Vincent Medical Center in Portland, Oregon, along with their supplier Medline. I especially enjoyed the environmental service workers dance with their high dusters, and food service people with their plates! What a great way to energize an organization, and have employees be front and center.

I guess it is not surprising that this hospital has been a Thomson Reuters 100 Top Hospital a phenomenal 10 times, last named in April 2009. Their focus on their employees is manifested by this quote on their web site from Janice Burger, chief executive of Providence St. Vincent. “Our highly skilled physicians, nurses and staff are dedicated to delivering outstanding, compassionate care to our patients and their families.”

With an administrative staff that puts their employees first, their patients benefit.

Great job, Providence St. Vincent.

Highlights:

• Press Ganey calls “Response to concerns/complaints” the “Number 1 priority” for our nation’s hospitals.
• Highest correlated item between HCAHPS “Likelihood to recommend” was “staff worked together to care for you.”
• In April 2008, CMS began requiring all hospitals to publicly report HCAHPS data. Only seven months later (October), Press Ganey data showed inpatient satisfaction scores climbed more significantly than at any other point in the 24 year history of Press Ganey (see chart on page 2 of report). The study reports (p. 14), “In October 2008 alone, Press Ganey found a 1.53 percent jump in the overall rating of a hospital and a 1.96 percent increase in the likelihood to recommend a hospital to family and friends, both unprecedented increases in the more than two decades that such data has been collected. Typically, satisfaction follows seasonal ups and downs, with a modest upward trend being found in the past decade.”

What gets measured (and reported)…improves! Thoughts?

According to Barbara Blundi Manaka PhD RN, Associate Director, Programs in Healthcare Management at Temple University, Philadelphia, PA, the concept in structuring the Management Grand Rounds program is to offer students opportunities to visit organizations that are outside the traditional student mindset of a healthcare provider.

In addition to myself, a number of ARAMARK Healthcare senior leaders spent some time talking to and advising the students in the areas of marketing, operations and human resources. There were some good lessons for the students including:

1. Healthcare is a process where care is delivered by more than the doctor and nurse.  Support service workers (food, environmental services and clinical technology management staff) play a significant role in patient satisfaction and clinical quality.
2. For a hospital to truly excel, everyone in the organization must focus on satisfaction, service excellence and operational efficiency.
3. With the difficult job market, five “quick tips” were reinforced for students who are interviewing. Those being:
   1. Be aggressive – finding a job is hard work; network!!!
   2. Stay Positive – don’t panic
   3. Compromise if necessary – pay expectations and further commute
   4. Do not give up – devote part of the day to job hunting and the rest to doing something positive
   5. Train for a new field – outsourcing may require a career field change

Temple graduate student Vicki Freedman frames her point.

ARAMARK Healthcare Vice President of Operations, Sebastian Mitchell, explains to Temple students the importance of staff motivation in meeting a hospital's goals.

From left, Barbara Blundi Manaka PhD RN, Associate Director, Programs in Healthcare Management at Temple University, Philadelphia, PA, discusses the practicum with Cheryl Camuso, Vice President of Marketing, and myself.

The site was appropriate; the healthcare profession best known with playing hardball is the CFO!  I had the good fortune to participate as a member of both discussions and to serve as a host given ARAMARK Healthcare’s sponsorship of the events. When we planned these events months ago, we had no idea that the 2008 world champion Phillies would clinch the 2009 National League East Pennant the night of our event in Philadelphia. The energy of the night was electric … both the discussion and the on-field heroics.

Many of the healthcare executives that participated identified a number of key strategies and opportunities to help add value. Here are a couple of points from both the Houston session on 9/9 and the Philadelphia session on 9/30/2009:

• The economic environment increased the value of innovation. Processes that normally would not be tried are now opportunities to improve
• A few key goals are identified, reviewed and discussed often.
• CFOs are fundamentally involved in creating metrics, setting benchmarks, encouraging best practices, and working with operations and clinicians to attain best practices.
• There is a direct correlation between the hospital reducing hospital acquired infections and the financial impact. The smaller the infection rate, the more cost effective the care delivered.
• The financial implications of linking HCAHPS scores to reimbursement create an alignment with patient satisfaction and finance goals. It is recognized that staff satisfaction is correlated with patient satisfaction.
• CFOs are part of the process of creating a positive patient experience.  By training employees to deliver personal relevant experiences to patient, patients recommend the hospital in their evaluations and are loyal to the hospital.

Overall these discussions were rich with ideas. One of the take a ways for me, besides the memory of watching my Phillies clinch the NL East Pennant, was the connection that these hospital executives are concerned with value – not just costs. Simply, there is a great deal of synergy that support service functions can bring to the equation.

If you are interested in learning more about these sessions, keep an eye on the HFMA web site as well as the HFM Journal and the magazine Leadership, where they will be covered in detail in the near future.

In the background as the stands begin to fill in Philadelphia, Michael Walsh (center), Senior VP of Finance at Abington Memorial Hospital, shares a thought with Gerald Tofani (left) Chief Financial Officer at Monmouth Medical Center and Christine Winn, VP of Administration at Paoli Hospital.

Todd Nelson (center) of the Healthcare Financial Management Association leads the discussion geared to adding value in challenging economic times. From left are Gerald Tofani, Chief Financial Officer at Monmouth Medical Center, Christine Winn, VP of Administration at Paoli Hospital, Mary Finn AVP Financial Planning Kennedy Health System, Bill Myers, CFO Montgomery County Emergency Services, Anthony Stanowski, VP Industry Relations, ARAMARK Healthcare, Martin McElroy, Principal, Acorn Medical Management and Ray Lefton, VP of Finance, Princeton Healthcare System.

The housing sector has been hit hard for the past four years, and Home Depot has seen an aggressive expansion by Lowe’s, a smaller but formidable competitor.

The article details not just an overall strategy for Home Depot, but also tactics that fit within the strategy.  Home Depot monitors productivity and efficiency, and incents store managers on revenue growth and cost management, as well as on non-financial measures.  Home Depot has a long way to go; and it is by no means guaranteed to be successful.  One thing is certain, though.  Home Depot needs to differentiate itself from its competitors.

Although Home Depot currently owns more stores and thus has greater convenience, Tome concedes that might erode over time if Lowe’s continues on their path of opening stores while Home Depot rationalizes square footage growth. Tome states that Home Depot has a larger assortment of tools than its competitor.  But Tome does not see these items as truly creating a point of differentiation.  Instead, Tome states:

“So then what is the point of difference inside the store?  It is really that belly-to-belly experience between the associates and the customer. The customers who are shopping us today are saying they see a difference.  Our challenge is to invite back those customers who may not love us because we’ve disappointed them.  We need to invite them back so they can experience that point of difference.

We have great prices, and we should always win on product.  But what is the stickiness?  The stickiness has got to be about the human experience.”

Hospitals are the ultimate “personal touch” in the human experience.  How do leading edge hospitals create a point of difference in their market?  One approach is similar to that taken by Tome at Home Depot.

St. Joseph Hospital in Bellingham, Washington, a PeaceHealth facility created a model for their housekeeping department.  Housekeepers have among the most number of patient contacts.  And, like the Home Depot staff constantly wandering the aisles, they are very visible and directly impact the client experience.

Cindy Kline, the VP for Human Resources at St. Joseph Hospital in Bellingham, Washington, a PeaceHealth facility, described how their support staff is involved in the hospital:  “Every housekeeper in this hospital understands how they contribute directly to the hospital’s overall mission and vision.”    Employees are encouraged to “round” with key constituents such as nurses to understand what is working well and what can improve.  Successes are recognized with “thank you “ notes from management, and employees are trained to support patient care by using empathetic language when working with patients.

The results:  POSITIVE!  Here are two examples:
-  Patient satisfaction.  Although statistically we can’t make direct correlation between the housekeeping program and the scores, 80% of St. Joseph’s patients would definitely recommend the hospital (compared to a national average of 68%/state average of 70%).  And 99% say that they definitely or probably would recommend the facility – a very impressive performance.  (Source: Federal FY 2008,  http://www.hospitalcompare.hhs.gov)

-  Low turnover.  St. Joseph’s turnover of housekeepers is at to 4.5%, and 60 housekeepers have established career paths that led them to other positions within the hospital.  Studies have shown that the lower the staff turnover, the higher the clinical and financial outcomes of the hospital.

St. Joseph Hospital in Bellingham, WA is certainly a great example of creating a “belly-to-belly experience” with its clients – using its housekeepers as its front line ambassadors.