Vital signs Featured

8:00pm EDT March 26, 2009

Perfection is a pretty high ideal to aspire to, but Lee Penrose has a plan to achieve it at St. Jude Medical Center.

“Perfect care” is one of the goals set by St. Jude’s parent organization, St. Joseph Health System. All of the hospitals in the St. Joseph Health System were tasked with that goal, and Penrose is responsible for making what some see as a pipe dream into reality at St. Jude.

It’s a big task, to be sure, but Penrose has methodically improved St. Jude’s performance by focusing on three key areas: finding opportunities for improvement, setting standards for employee performance and motivating St. Jude’s nearly 3,000 employees to reach those standards.

“We’re not perfect yet,” he says of the organization, which posted more than $300 million in net revenue last year. “I don’t know if any hospital in the country can say they provide perfect care 100 percent of the time. But we are heading in that direction.”

Penrose says there probably isn’t a single recipe for a CEO who wants to adopt a metric-based system of measured performance, but he does offer his best starting point.

“I always look at the data,” he says. “Try to start by understanding how well you’re doing. We wouldn’t be an organization run by humans if we didn’t have opportunities for improvement. Virtually every organization out there is going to have opportunities for improvement. The trick is trying to find that right opportunity.”

Define your goal

The first thing Penrose and his team had to do was define what, exactly, was “perfect.” He knew he couldn’t just expect his employees to improve without giving them a more concrete idea of what he was asking them to do. Without context, “perfect care” is just words.

“Sending the message of perfect care is one thing; showing them what we mean by it and defining it for them is another,” Penrose says. “We’ve had a lot of ‘A-ha’ moments amongst the staff when we show them the quality metrics that we are looking at and connect the dots for them. This is what we mean when we say perfect care.”

The basic definition Penrose and his team came up with was simple: error-free care. The more formal definition used is more detailed: safe, timely, effective, evidence-based and sacred. The first four factors are measurable; the fifth ties in with another health system goal — making each patient’s experience at St. Jude a sacred encounter.

Those categories are the benchmarks that Penrose’s employees aim for as they strive for perfection. Everything is measured, monitored and reported.

“We’re looking at the fundamentals of what our caregivers do for patients,” he says. “We have all kinds of quality metrics that we look at simply by measuring how many times we provide care perfectly — meaning we do everything we’re supposed to do and we have the outcome that was intended for the patient.

“That’s how we know when we’ve arrived at perfect. When we are looking at metrics to hold ourselves accountable to or what we should look to target improvement on, they should fit in those categories.”

By tracking patient outcomes, Penrose can see how safe, timely and effective his employees are working. And by measuring evidence-based elements of employee performance, Penrose can read one of the medical journals to see how St. Jude measures up.

“There is evidence that is published all the time,” he says. “A lot of the university hospitals throughout the country have different publications. We use those as basis or starting point for the protocols we put in place for our patients and that we encourage our doctors to go forward with.”

Advocate accountability

One way Penrose measures his employees’ performance is by asking the people whom those employees have serviced.

The organization regularly sends out patient satisfaction surveys and the management team reviews the results of those surveys on a monthly basis.

The number of questions on the survey depends on the type of service the patient received when he or she was at St. Jude. Once tallied, the scores for each particular area of questioning are posted to St. Jude’s Web-based system. Also, written comments from patients are published for all managers every other week.

Making all this information available serves a dual purpose. First, the organization’s department heads can use the survey response scores to analyze trends. From there, they can identify gaps in performance quality and take appropriate action. Penrose has his department heads and managers synthesize the relevant information from the surveys and distill it for their employees, as well, so they know which areas need work.

That leads to the second purpose — motivating employees to improve their performance.

Penrose says you can measure everything from how many patient visits a doctor makes in an hour to the number of medication errors to the percentage of patients who were happy with their stay at St. Jude — those numbers are useless if you don’t hold employees accountable for them. Each department has its own set of metrics for its employees’ daily work.

“We set the expectations and the most important part of setting expectations is following up by holding people accountable,” he says. “We’re doing that at all levels of the organization, from management in their job description, in their merit review, in their bonuses, their incentive plan, etc. For the staff-level employee, it is part of the expectations of how they do their job, and it reflects in their merit evaluation, as well.”

Find opportunities for improvement

Another way to get feedback on how your organization is doing is to simply ask the people who work for you. When Penrose became president and CEO of St. Jude, he rejuvenated a tradition that the organization’s previous leader began: the employee forum. Under Penrose, the forum became a quarterly meeting in which every one of St. Jude’s employees is invited to hear him speak about the hospital’s goals and ask him any questions that may be on their minds. Encouraging two-way communication can help give you a different perspective.

“This is a big organization,” he says. “We have almost 3,000 employees working for this hospital. Trying to communicate a single vision to that many people is not easy.”

Penrose usually speaks for the first 20 minutes of the one-hour session; the remaining 40 minutes is a town-hall format.

When you find opportunities for improvement, you need to have a plan in place to deal with them. At St. Jude, Penrose pulled a team of people together to identify any potential barriers to perfect performance.

The outcomes department is composed of members of St. Jude’s quality department, and it is responsible for finding and closing any gaps between St. Jude’s actual performance level and its goal of perfect care.

Whenever the organization notices a particular area that could use improvement, this team is called in to investigate. Penrose staffed it with employees who are skilled at determining the cause of a problem and developing solutions.

“If they see a failure on our part, they will do a root-cause analysis to identify the cause,” he says. “Then, they’ll try to understand if it was a one-time event or do we have exposure for this failure to occur again.”

“If it is an isolated type of cause, they may be able to put a simple fix in place. If it is more systemic, then they’ll probably pull a process improvement team together to address the cause and find a remedy and implement that remedy.”

That process improvement team needs to include several employees who are familiar with the work that needs improvement. If the system itself needs to be fixed, the first thing that needs to be done is determining what Penrose calls “standard work.”

“On the road to perfect, we have a much higher probability of reaching perfect if we are doing standard work — if we are approaching our work the same, every time, with every patient,” he says.

“We understand that every patient is unique and has unique needs, but a lot of what we do is process-oriented. The more we can standardize around those processes, the more likely we are to get it right every time.”

To determine which processes should be standardized, the team assigned to the problem researches that system’s metrics and patient outcomes. The root-cause analysis begins where the gaps in performance occur and trends are identified. The volume and frequency of failures as recorded in the metrics and as shown in the trends leads to the trouble spots upon which the organization must focus.

Get focused

Penrose emphasizes focus over and over again with his management team. He says that without focus, a management team won’t pick the most important targets for improvement. You only have a finite amount of resources, and your metrics may tell you that several projects deserve attention.

“You have to prioritize,” he says. “If you try to tackle everything at once, you’ll fall down.”

To combat this problem, Penrose established a top-down, bottom-up approach to focused management.

From a top-down standpoint, the executive team needs to refer to the organization’s vision, mission and long-term goals to determine which problems should be tackled first.

The top executives are the most familiar with the organization’s strategic plan, and so they must always have the big picture in mind when deciding what problems are the most critical.

To get the bottom-up perspective, Penrose goes to the department level to understand what issues are the most important to each department.

“There are things that are happening to your organization, inside your organization all the time,” he says. “Some of them are things we’re reacting to; some are things that we, proactively, we want to build and create. Understanding what internal and external forces are working in the organization — that are driving where people are spending their time — is something that we need to be considering.”

To try to understand those factors, ask for input from the people who know best.

“We encourage each department to focus, identify their top area of focus,” he says. “Then, we also make sure we are communicating from a top-down standpoint what our organizational focus is. Hopefully, if we are doing our job right, there is a connection between the two.”

However, the two groups aren’t always on the same page. Penrose says that about half the time the two sides don’t agree on what should be the organization’s top priority, but that doesn’t mean he’s changing St. Jude’s core mission every time one of the departments has a problem.

“It sparks a conversation,” he says. “The other 50 percent of the time, the focus area for a particular department is somewhat reactionary. That isn’t a bad thing. There is some force at work that is causing the focus for that department to be other than what the organizational focus is.”

So if that happens, the first step is making sure everyone in management is aware of the issue. Once they know about it, they can begin working to resolve it so that department can bring its main focus back into lockstep with the organization as a whole.

“It’s like trying to get everyone rowing in the same direction, so to speak,” Penrose says.

No matter what industry you’re in, you can use the same techniques Penrose used at St. Jude to improve employee performance and strive for perfection.

“As you start breaking it down, we all have processes, we all have humans involved in those processes,” he says. “We all have opportunities for process improvement. It’s the same type of thing. Understand what the outcomes are that are key to your industry or to your business. Start to measure those outcomes, measure your performance. Benchmark yourself if you can against others, and identify your opportunities for improvement.”

How to reach: St. Jude Medical Center, (714) 871-3280 or