Overview

RWJ Hamilton adopted the Baldrige criteria, focusing its organizational improvement efforts in the seven categories that have been found to drive performance excellence: 1) leadership; 2) strategic planning; 3) focus on patients, other customers, and markets; 4) measurement, analysis, and knowledge management; 5) staff focus; 6) process management; and 7) organizational performance results. This case study describes how RWJ Hamilton used this approach to achieve improvements in several key clinical performance areas.

Issue: Health care organizations need a proven framework to consistently and reliably improve the quality of care and services they deliver. Many industrial companies, and a growing number of health care organizations, have adopted a systematic approach to performance management encapsulated in the Baldrige Criteria for Performance Excellence (see Issue of the Month). According to the National Institute for Standards and Technology, which manages the award program, the Baldrige criteria "reflect validated, leading-edge management practices against which an organization can measure itself. With their acceptance nationally and internationally as the model for performance excellence, the criteria represent a common language for communication among organizations for sharing best practices. The criteria are also the basis for the Malcolm Baldrige National Quality Award process."[1]

Organization: The Robert Wood Johnson University Hospital Hamilton (RWF Hamilton), located in Hamilton, N. J., is a 200-bed, not-for-profit community hospital affiliated with the eight-hospital Robert Wood Johnson Health System and Network. RWJ Hamilton has annual revenues of more than $170 million. It employs 1,730 staff and has 350,000 residents in its central New Jersey service area.

Objective and Intervention: RWJ Hamilton adopted the Baldrige criteria, focusing its organizational improvement efforts in the seven categories that have been found to drive performance excellence: 1) leadership; 2) strategic planning; 3) focus on patients, other customers, and markets; 4) measurement, analysis, and knowledge management; 5) staff focus; 6) process management; and 7) organizational performance results. This case study describes how RWJ Hamilton used this approach to achieve improvements in several key clinical performance areas.

Milestones: RWJ Hamilton joined Quality New Jersey, one of 44 state-level award programs that use the Baldrige criteria as a framework to promote performance excellence through education, assessment, and sharing of best practices, in the mid-1990s. RWJ Hamilton first applied for a state award in 1999 and was recognized with the Governor's Award for Performance Excellence in the highest category, gold, in both 1999 and 2004. To reap the benefits of assessment, feedback, and learning on an even higher level, RWJ Hamilton started applying for the Baldrige National Quality Award in 2002. Expert examiners conducted a site visit the following year. In 2004, RWJ Hamilton became the fourth U.S. health care organization to receive the Baldrige Award.

Process of Change: The Baldrige organizational improvement process starts with leadership commitment, which requires a partnership between physician and hospital leaders, says Shashi Madhok, assistant vice president of quality outcomes for RWJ Hamilton. To translate this commitment into action, RWJ Hamilton enhanced its strategic planning process by adopting the "Goal Deployment Process" used by 2001 Baldrige Award winner, Clarke American Checks, Inc.. Clarke's process involves identifying long-term "change the business goals"—those requiring dramatic improvements in performance—along with short-term "run the business" goals to improve daily operations and reach long-term goals.[2]

 Benchmarking is an important part of the Baldrige process of organizational learning. Best practices are sought from organizations that have validated the use of Baldrige criteria by undertaking the rigorous self-assessment required of Baldrige applicants or by virtue of having won a Baldrige award. For example, RWJ Hamilton adapted several approaches for promoting a culture of excellence through employee hiring, training, and communication (described below) that had proven effective for service industry leader Ritz-Carlton Hotels, a 1999 Baldrige Award winner.[3] A successful deployment of these strategic improvement initiatives requires an organization to understand the critical success factors that will improve quality in each area, says Madhok. This understanding is gained by seeking feedback from patients and employees and drawing on lessons learned from both successes and failures in previous quality improvement initiatives.

RWJ Hospital seeks a culture in which every employee understands how to use the Plan-Do-Check-Act method to look at variation in processes, how to plan improvements, and how to take action to implement improvements. The Baldrige process emphasizes a results orientation in order to achieve a balanced set of outcomes in terms of cost, quality, and patient and employee satisfaction. Every strategic initiative must identify key performance indicators that staff can use to drive improvement and monitor the effectiveness of their efforts. At the organizational level, a performance measurement system collects key indicator data using a "balanced scorecard" approach.[4] A computerized dashboard displays performance indicators in a red-yellow-green traffic light fashion that highlights areas requiring attention or action. This system permits managers to "keep a finger on the pulse" of the organization's progress in meeting overall objectives, says Madhok. The hospital's board of trustees also receives regular updates on performance results.

Example #1: Achieving Service Standards and Employee Commitment

"One of the ways we promote a culture of excellence is through our five-star service standards," says Madhok. Every employee agrees in writing to abide by the standards, which define expectations for commitment to patients, coworkers, courtesy, communication, privacy, safety awareness, and ownership for achieving organizational goals. "Our orientation has been redesigned to focus around these standards and to be very interactive with role-playing so that new employees get a feel for our culture," says Deborah Baehser, vice president of patient care services. The patient and coworker commitments are the most essential standards for creating a culture of service excellence, she says.

To obtain commitment to excellence throughout the organization, RWJ Hamilton created a standardized communications program called "Hospital Highlights," which is organized around its "Five Pillars of Excellence": people, service, quality, finance, and growth. The organization's objectives and progress in each of these five areas are highlighted by senior executives during quarterly employee forums and are reinforced by departmental directors during twice-daily staff briefings. Each employee has an "Engage Every Employee" (or "E3") card on which he or she records personal goals that align with departmental and organizational objectives, promoting a sense of ownership for improvement organization-wide.

The hospital encourages a culture of open communication in which any employee can e-mail managers with suggestions for improvement. Hospital leaders make rounds on nursing units to solicit feedback and better understand issues. A shared governance model involves nurses in decisions about practices and procedures and solicits advice on nurse recruitment. Project improvement teams use a "Five-Star Communications Process" to select modes of communication that are most effective for a given audience and purpose. Feedback is regularly solicited on communications effectiveness.

Example #2: Improving Patient Safety

After the Institute of Medicine issued its 1999 report, To Err is Human, "we knew that we needed to make a quantum leap in patient safety," to meet standards such as those subsequently issued by JCAHO, says Madhok. This became one of the hospital's "change the business" goals, propelling a comprehensive strategic plan with six project teams that each took responsibility for initiatives to develop, implement, and measure results for patient safety improvements. The "Hospital Highlights" five-pillar communications model was employed to help promote a culture of safety throughout the organization. Medication safety improvements have centered on the use of technology and careful oversight to enhance the reliability of the medication use process. For example, nurses obtain medication stock directly from an automated dispensing system located on each nursing unit, but only after the medication order has been reviewed by a pharmacist. Variance reports identify problems with high-risk medications. The hospital recently installed computerized physician order entry in the emergency department and will be expanding its use, along with medication bar coding, throughout the hospital.

Example #3: Improving Clinical Outcomes RWJ Hamilton undertakes clinical improvements in partnership with its medical staff, which reviews and adopts evidence-based treatment guidelines through participation on interdisciplinary, disease-specific task forces. The case-management function was redesigned to proactively monitor adherence to these protocols using in-process measures and to bring any deviations in patient care to the attention of the care team during daily interdisciplinary rounds. This provides the opportunity for immediate action to ensure that the care of every patient meets standards. Systemic problem areas are identified through ongoing outcomes monitoring and retrospective trend analysis with feedback to department heads or individual providers as appropriate. A medical quality council—consisting of hospital and physician leaders—approves guidelines, reviews aggregate data, and makes recommendations for corrective actions such as guideline adjustments, process improvements, and performance feedback.

Results: RWJ Hamilton has experienced steady increases in market share and an increase in bed occupancy from 70 percent in 1999 to 85 percent in 2003. In addition:

• Patient satisfaction with inpatient nursing improved from 70 percent in 1999 to more than 90 percent in 2004, placing RWJ Hamilton in the top 10 percent of hospitals ranked by survey firm Press Ganey.
• Employee satisfaction increased in several areas from 1999 to 2003, for example, from 40 percent to 90 percent in satisfaction with participation in decisions, from 90 percent to 100 percent in satisfaction with hospital leadership, and from 70 percent to 97 percent in satisfaction with employee recognition.
• The retention rate for registered nurses increased from 94 percent in 2001 to 98 percent in 2003. Retention among other employees also improved from 80 percent to 96 percent during this time.
• Hospital-acquired infections have steadily declined since 2000. For example, ventilator-associated pneumonias decreased from 10 per 1,000 device days to two per 1,000 device days in 2004. Medication safety procedures were successful in intercepting 93 percent of medication errors before they reached patients.
• A hospital report card recently issued by the New Jersey Department of Health ranked RWJ Hamilton second among New Jersey hospitals for achieving 99 percent compliance to evidence-based heart attack treatment standards in 2003. The hospital ranked fifth statewide for compliance with pneumonia care standards in 2003.

As a result of these and other improvements, patient mortality has steadily declined hospital-wide. For example, mortality for patients with congestive heart failure decreased from 8 percent in 1999 to 2.5 percent in 2003.

Lessons Learned: Visionary leadership is the foundation for RWJ Hamilton's success, according to Gail Currie, the senior examiner on the Quality New Jersey review team. "They have completely embedded a culture of what they call excellence through service," she says. "It exists at every single level of their organization. And that comes from vision at the top. They've stayed the course to do this even as the reimbursement environment worsened. They know that doing the right thing, in the right way, at the right time, will in fact make them a stronger organization."

The Baldrige model emphasizes the importance of customers—i.e., the people an organization serves—which RWJ Hospital interprets broadly to include patients, employees, and the community. "You want customer input from the very beginning when you're doing strategic planning," Madhok says. "If you cannot satisfy your customers, you cannot achieve success. And you cannot predict what your customers will need, you must hear from them." Currie's examination team found that RWJ Hospital is "intensely patient-focused in the way the [Institute of Medicine] spoke of. This doesn't mean just having high patient satisfaction. It means the way they design their work systems, processes, services, and facilities." As an example, Currie praises RWJ Hamilton's healing garden, where patients can receive chemotherapy in "beautiful, quiet surroundings rather than in a stiff chair in a hospital room." RWJ Hamilton learned the importance of involving employees in adapting best practices. Baehser says that the hospital did not initially involve employees enough in developing its five-star service standards, a concept borrowed from Ritz-Carlton Hotels.

Getting a team of frontline staff involved helped ensure their successful translation to the local environment. "Employees are our assets. We are always listening to our employees and their needs and working to improve their well-being, and that's what improves productivity for us," says Madhok. Likewise, the hospital's management recognizes that improvements in patient care can be achieved only through effective teamwork and a partnership with the physicians on its medical staff. RWJ Hamilton exemplifies the Baldrige ideals of fact-based management and the alignment and integration of management systems, according to Currie. "A lot of organizations have good processes in different areas, but they all operate in their own little silos." In contrast, RWJ Hamilton has achieved "a highly integrated interdependency of finely honed management systems," she says. "They work hard to peel through the blizzards of data that health care organizations are required to collect, to focus on what's really critical."

Implications: The Baldrige criteria offer a balanced approach to achieving overall performance excellence for any organization, says Madhok. Applying for a Baldrige award promotes rigorous organizational self-assessment. External evaluation and feedback from reviewers can be used to establish an internal baseline for improvement and provides a valuable opportunity for organizational learning. The essence of the Baldrige program—and its state-level counterparts—is not an award but a process of voluntary accountability for organizations that wish to achieve performance excellence. "When I talk about Baldrige organizations, I'm not talking about a handful of winners, but [about] the thousands of organizations that use the Baldrige framework as a model for doing business. They assess and learn and improve, and do it over and over again," says Currie.

For More Information: RWJ Hamilton's experiences with the Baldrige Award are described in more detail on its Web site. Contact Connie Resnick, RWJ Hamilton's manager of special projects, at cresnick@rwjuhh.edu. Contact Gail Currie, senior examiner for Quality New Jersey and director of external consulting for New York–Presbyterian Hospital, at gac9005@nyp.org.

References
1. Baldrige National Quality Program, Health Care Criteria for Performance Excellence, Gaithersburg, Md.: National Institute of Standards and Technology.
2. Clarke American Checks, Inc., Baldrige Award Recipient Profile, Gaithersburg, Md.: National Institute of Standards and Technology.
3. The Ritz-Carlton Hotel Company, LLC, Baldrige Award Recipient Profile, Gaithersburg, Md.: National Institute of Standards and Technology.
4. R. S. Kaplan and D. P. Norton (2000) The Strategy-Focused Organization: How Balanced Scorecard Companies Thrive in the New Business Environment. Boston, Mass.: Harvard Business School Press.

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This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Fund-sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied organizations' experiences in ways that may aid their own efforts to become high performers. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case studies series is not an endorsement by the Fund for receipt of health care from the institution.