The perfect cure Featured

8:00pm EDT July 26, 2008

Sometimes Larry K. Ainsworth has to deal with the skeptics — it’s just part of the job. They come out of the woodwork every now and then to chide him for his hospital’s pie-in-the-sky goal of providing “perfect care.” The president and CEO of St. Joseph Hospital of Orange hasn’t yet let the detractors stop him from setting his sights high, and he doesn’t plan on letting it happen anytime soon.

“Some people take an issue with that and say, ‘Look, you’re dealing with human beings — that’s unrealistic to demand perfect care,’” he says. “Our view is, how would you feel about getting on an airplane when the motto of the airline is ‘We hope to get you there 90 percent of the time?’”

But perfect care is just one of the goals set forth for the organization. His staff also strives to create healthy communities and provide “sacred encounters,” which Ainsworth defines as a deep, meaningful interaction that reassures the patient that the hospital is completely committed to treating his or her body, mind and spirit.

“The perfect care goal is more about what we do,” Ainsworth says. “Sacred encounters is more how we do it.”

The three goals — perfect care, sacred encounters and providing healthy communities — were set forth by the hospital’s parent organization, St. Joseph Health System, to improve service across the 14-hospital system.

The enormous task that lay in front of Ainsworth was figuring out how to best address those goals in his particular hospital — without deviating too far from the overall vision of the health system. Once he cleared that hurdle, he would have to get his 3,500 employees on board with his plans and find a way to measure progress toward the hospital’s goals.

Here’s how he did it.

Get everyone involved

The first thing Ainsworth did to drive the new goals through his organization was to set up meetings to discuss them with 30 groups of stakeholders, including physicians, nurses, clinical staff, support staff, trustees and management from both the health system and the hospital.

Communicating those goals to his employees was only the top-level reason for the meetings. The deeper reason he met with so many small groups of employees was to get them all involved in the strategic plan.

Ainsworth says there are several approaches an organization can use to improve customer satisfaction. One way is to hire a consultant, who would generally arrive with a pre-planned program of guest relations or set interactions. But Ainsworth didn’t like the top-down, consultant and management-driven approach, so he chose to look inside his organization instead of outside it and used the meetings to jump-start that approach.

During his meetings, he asked for input on how the hospital can achieve those goals. He wanted to not only raise awareness of the big-picture goals but build employee interest on the local level.

His plan worked. At every meeting, his management team was getting inundated with ways to get closer to perfect care and ways to make sure every patient has a sacred encounter.

“We basically put it in their hands,” he says. “And I think when you put a major objective in the hands of the employees, you get a couple things. No. 1, you get a lot of creativity. No. 2, you get a lot of buy-in, because the end result is really theirs. They created it from the beginning. They conceptualized it all the way through implementation.”

The key to getting that input was as simple as the Socratic Method. Ainsworth’s managers sat down with the employees in small groups — no larger than seven or eight people — and asked them to think through and answer several questions.

Many of the questions were focused on their experiences dealing with patients. Ainsworth wanted to know what needed to happen for a patient to have a positive experience at the hospital — he wanted to know the key to making every patient interaction a sacred encounter.

So he asked questions like, “What is the typical patient thinking and feeling when they come in to receive services in our department?” and “What are the behaviors that would actually yield a sacred encounter for that patient?” This method creates true knowledge in the employee, not just rote memorization of what to do in a certain situation.

“Instead of like the Ritz-Carlton where they have scripted answers to requests or questions, the employees are agreeing amongst themselves to standardized behaviors — not set by management but set by themselves based on their own knowledge of what patient need is,” Ainsworth says.

“It’s a wonderful approach because it tells the employee that management trusts them and trusts their knowledge of what the patient really needs and trusts them to design the more consistent responses that are going to yield sacred encounters.”

Ainsworth took all the ideas and tactics gathered from his employees to the board of trustees. The board narrowed the list down to the tactics it supported, and then included those tactics in the hospital’s five-year strategic plan.

But Ainsworth says the process isn’t over when the board votes on an idea. You need to close the circle of communication. After board approval, Ainsworth scheduled follow-up meetings with each group he had asked for input. At these meetings, he detailed which plans were chosen by the board as well as the reasons why they were picked.

Reach for a higher level

Once the organization’s direction is set, it’s important to let your employees know how their day-to-day responsibilities tie into the big picture. At St. Joseph, this is primarily done through manager-to-employee performance reviews.

At the annual evaluation, the employee and manager sit down and set goals for the next year. Then, the manager indicates how the employee’s work can contribute to the hospital’s overarching goals.

“In some instances, an individual employee can’t affect our ‘healthiest communities’ goals,” Ainsworth says. “But most of the time, they can do something, at least tangentially, to contribute to perfect care or sacred encounters.”

Once that discussion occurs and the goals are set, metrics are set at the same time. Managers will check in periodically throughout the year to determine how their employees are doing, then at the end of the year, they’re evaluated on their performance. Ainsworth rewards the employees who hit their targets — their incentive compensation is determined based on progress toward their individual goals.

Performance evaluation isn’t difficult when you track as many different variables as St. Joseph does. The hospital meticulously collects data on everything that goes on within its doors. If Ainsworth wants to know how many bloodstream infections were acquired at the hospital last year, that information is readily available.

The depth of information at his fingertips helps the leaders of each department set benchmarks for progress toward the goal of perfect care. Each department has several areas on which it focuses, and each employee’s performance is measured against these benchmarks.

There are three levels of achievement for each area: threshold, target and exceptional. Ainsworth says the levels are determined by the likelihood that an employee will be able to meet them. For example, employees have an 80 percent likelihood of achieving the threshold level, 50 percent likelihood of achieving the target level and only a 20 percent chance of reaching the exceptional performance level.

“As you’re progressing up the chain of difficulty, there is a decreasing likelihood that we’ll actually be able to achieve that goal,” he says. “Obviously, exceptional is going to be much tougher to achieve than threshold. That’s the way the metrics are set.”

Ainsworth also ties financial incentives in each employee’s compensation plan to his or her overall performance level. This system gives employees a compelling reason to strive for the higher levels of performance, while making sure the hospital is held accountable for meeting national standards.

For instance, Ainsworth’s executive management team has several performance goals devoted to improving five Medicare-chosen focus areas. The hospital is held accountable for improvements in those areas, which include the hospital’s emergency department response to heart attacks and the staff’s treatment of patients with congestive heart failure, among other things.

Because of the data, Ainsworth knows where his hospital stands. His management team sets its performance-level goals based on how St. Joseph ranks in national databases.

It’s easy to collect easily quantified and measured facts, like the number of patients with a particular disease or the average number of days of their hospital stay. However, it’s a bit more difficult to develop metrics that measure how close an interaction was to being a sacred encounter.

Ainsworth measures the hospital’s particular brand of service by making sure his staff asks each patient several questions about their experience. The staff has a list of seven or eight questions like “Were you looked after in a compassionate fashion?” and “Did people seek to understand your needs before they cared for you?”

By asking questions like those, Ainsworth is able to determine if employees have been exhibiting the types of behavior that will keep the patients comfortable.

Put it all together

While getting existing employees involved in the process and holding them accountable helped drive the changes necessary to make St. Joseph a better organization, you also need to focus efforts on making sure any new employees fit into your new system.

“Hospitals can be very cold,” he says. “When patients are feeling very vulnerable and at risk emotionally, physically, mentally — some hospitals do a real good job of bringing warmth and compassion to that circumstance, others don’t.”

To find employees who can deliver the type of compassion and caring necessary to achieve the organization’s goals, Ainsworth takes extra care in the hiring process. When recruiting, his team tries to find the motivation a person had for entering the health care field in the first place by asking a series of questions that attempt to determine if the candidate is simply looking for employment or something more.

By showing his staff the power of asking questions from the very beginning, Ainsworth is working to ensure that a patient will never feel cold and alone at St. Joseph.

“We clearly understand that just being nice at the bedside isn’t good enough,” he says. “People are here to be healed, and they’re only healed through a combination of people who are treating them with compassion but also people who bring great clinical competency to the bedside, as well.”

Ainsworth knows perfect care is a goal that will transcend many five-year plans. Providing sacred encounters is another goal that will never go away. As part of its goal of creating healthy communities, St. Joseph spent $48 million in fiscal 2007 on wellness outreach initiatives in the surrounding area — but with obesity and other problems still running rampant, that goal won’t be crossed off Ainsworth’s checklist anytime soon, either. Even after achieving significant improvement in patient satisfaction surveys and being showered with awards and accolades, Ainsworth’s work isn’t finished.

“It’s going to be a long time coming,” he says. “But what it does do is it provides motivation for a quest. On a daily basis we’re saying, ‘We’ve got a lot of room to go to be perfect, but we’ve got to keep trying.’”

HOW TO REACH: St. Joseph Hospital of Orange, (714) 633-9111 or www.sjo.org