Creating a Culture of Performance

Creating a Culture of Performance
Excellence at Henry Ford
Health System
SUSAN S. HAWKINS,
ROSE GLENN,
KATHY OSWALD,
ANO WILLIAM A. CONWAY
Henry Ford Health System (HFHS) of Detroit,
Michigan, has earned industry-wide recognition by
engaging its leaders to align the organization’s
strategic objectives with Malcolm Baldrige National
Quality Award criteria and craft a comprehensive
program to integrate performance to drive sustainable growth. One of the largest health care systems
in the United States, HFHS developed a performance
management approach that backed up standards
of excellence with comprehensive training and development, established a performance improvement
framework that emphasized analysis and review, integrated its communications systems with a renewed
focus on innovation, and fine-tuned its performance
strategy to stoke agility throughout the organization. Results included a reduction in in-patient
mortality, innovations in health care best practice,
enhanced employee engagement patient satisfaction,
savings of almost %10 million over four years in relation to harm-reduction efforts, and five national performance awards, including the Malcolm Baldrige
National Quality Award in 2011. © 2013 Wiley
Periodicals, Inc.
Lowered reimbursements and increasing uncompensated care across the 1990s led to decreased investments in infrastrucrure and clinical programs at
many hospitals and health systems in the United
States. The rising crisis in health care and a call
for improved quality and patient safety became a
national discussion. At Henry Ford Health System (HFHS) in Detroit, part of the discussion involved how to integrate performance to drive smart
growth while focusing on what matters most: the
System’s patients., its health plan members, and its
communities.
With more than $4 billion in revenues, HFHS is one
of the largest health care systems in the United States
and a respected leader in clinical care, research, and
education. HFHS has more than 23,000 employees
serving 4.5 million people in southeast Michigan
at more than 140 care delivery sites, with a total
of 102,000 admissions, 418,000 emergency department visits, 3.2 million office visits, and 88,000 surgeries annually. The System’s core components are:
• the Henry Ford Medical Group, with 1,200
physicians and scientists;
• 2,200 private practice physicians;
• four acute care medical-surgical hospitals, including the 802-bed Henry Ford Hospital in Detroit,
which is a tertiary care, level 1 trauma center, as
well as an education and research complex;
• Community Care Services, which includes a diversified portfolio of post-acute and retail services;
• Behavioral Health Services with two behavioral
hospitals; and
• the Health Alliance Plan (HAP), a health insurer.
In 2000, with organization-wide input, HFHS
leadership recrafted the System’s mission, vision,
and values. They recommitted themselves ro their
base in Detroit and their academic mission, and
they determined to relentlessly pursue organizational integration to deliver the best care to HFHS
patients and drive sustainable growth. Leaders and
© 2 0 1 3 W i l e y P e r i o d i c a l s , I n c .
P u b l i s h e d o n l i n e i n W i i e y O n l i n e L i b r a r y ( w i i e y o n i i n e l i b r a r y . c o m )
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subsequently all employees participated in “Renewal,” a cultural training workshop focused on the
values and behaviors of a healthy, high-performing
organization. Four years later, the new chief executive officer (CEO) for HFHS set the path toward
improving performance throughout the System, selecting to embark on the Baldrige Performance
Excellence Program (Baldrige PEP) and adopt its
Criteria for Performance Excellence. The Baldrige
PEP provided a self-assessment roadmap with consultant feedback and challenged HFHS leaders to
compare their results against the top-performing organizations in the United States.
The System’s eight years of experience in using the
Baldrige criteria have included a series of steps in
cultural transformation and continual improvement
in organizational integration and performance, from
the board of trustees and senior leaders to frontline employees. Several key changes, challenges, and
turning points that occurred from 2004 to 2011
highlight the organization’s continuing quest for
performance excellence.
Key Change: Engaging Leadership
The early steps of organizational self-assessment using the Baldrige criteria led to a new focus on engaging senior leadership across the many business
units of HFHS. Realigned in 2004 to drive communication and integration of strategic development,
the System’s board of trustees began to communicate regularly with affiliate and advisory boards at
the business-unit level through quarterly meetings
of all board chairs. The HFHS CFO communicated
regularly with senior leaders via four committees: a
5-member Executive Cabinet; 15-member Cabinet;
a 25-member Strategy and Execution Team (SET)
composed of all Cabinet members and key System
and business-unit leaders, including physicians; and
a 110-member Leadership Execution and Planning
(LEAP) team composed of all SET members and
their direct reports, including physician chairs and
division heads of the Henry Ford Medical Croup
and hospital chief medical officers.
From the 1990s, HFHS’s strategic planning process was a business unit-based model that rolled up
to the System level. In 2005, the planning process
was changed to a top-down model, focusing on the
Baldrige criteria and the System’s mission, vision,
and values. Senior leaders defined the System’s core
competencies (a Baldrige criteria requirement) and
developed a new strategic framework.
The early steps of organizational self-assessment
using the Baldrige criteria led to a new focus on engaging senior leadership across the many business
units of HFHS.
Turning Point: A Seven-Piliar Strategic Framework
The new strategic framework identified seven performance areas (“pillars”): people, service, quality
and safety, growth, research and education, community, and finance (see Exhibit 1 on page 8). Comprising the Henry Ford Experience—which is defined
as a consistent, remarkable experience for all HFHS
customers—these seven pillars are the foundation of
the HFHS strategic planning process. The organization’s strategic objectives, which are aligned across
all business units, fiow from them.
System-level teams were developed for the areas represented by the pillars, with each pillar team led by
a member of the Cabinet and composed of senior
and other leaders across business units to increase
System integration. Pillar teams became responsible for establishing strategic objectives and initiatives within their respective performance dimension,
aligning action plans to meet performance targets,
and tracking performance against goals. For example, the People Pillar team became responsible for
strategies throughout the System that were aimed at
reducing employee turnover. The Service Pillar team
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Exhibit 1. “The Henry Ford Experience”: 7 Pillars of Performance
People Service Quality &
Safety
Growth Research & Community
Education
Finance
Core Competencies
Organizational Framework Leadership
Care Coordination
was responsible for improving patient satisfaction at
each business unit.
The seven-pillar framework became the basis for
strategic planning, measurement and review, prioritization and resource allocation, and improvement
and innovation across HFHS. Th e pillar framework
served to align System strategic objectives, strategic
initiatives, and related performance measures and
targets for the System and within business units,
from the top of the organization to the individual
employee. This provided a synchronization and consistency of plans and processes against which key
decisions were made. A three-year, rolling strategic plan was developed for the System, guided by
rhe seven pillars as the basis for goal categories and
alignment.
For instance, the Quality and Safety strategic objective aimed for HFHS to become a national leader in
delivering safe, reliable care. The strategic initiative
to achieve this objective became HFHS’s “No Harm
Gampaign,” with an aggressive goal set at a 50 percent reduction in harm events by 2013. Results were
measured at the System level and compared to targets in 27 categories of harm. Each business unit
also had targets in each category of harm where improvement was required. A department would focus
on something that was important to it. For example,
the housekeeping department might focus on implementing proper cleaning protocols to decrease infections. An individual employee in the housekeeping
department might have a goal focused on the response time to clean a room with an identified spill,
or the frequency and method for cleaning isolation
rooms. As a result, by 2011, HFHS was more than
halfway to its 50 percent harm-reduction goal and
earned national recognition for its accomplishment.
The National Quality Forum and The Joint Gommission recognized the No Harm Gampaign with
the 2011 John M. Eisenberg Award for Innovation
in Patient Safety and Quality at the Local Level.
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Exhibit 2. HFHS Model for Improvement (MFI)
Employee
Engagement
Change
Act° Plan
Continuous
Improvement
& Innovation
Check Do
Customer
Needs &
Engagement
d – Debrief and evatuate effectiveness of improvement methods and toots
Key Change: Establishing a Performance
Improvement System
To drive performance across and within pillars,
HFHS leaders developed a model for improvement
(MFI) and emphasized accountability for results
through dashboard reports and organization performance reviews.
Working With a New Model for Improvement
Whether at the System, pillar, business unit, department, or work-unit team level, teams are trained
to use the MFI (see Exhibit 2). The MFI is a flexible plan-do-check-act (PDCA)-based methodology
with a companion toolkit of methods and tools appropriate for a wide range of change initiatives,
from informal work-unit improvement projects to
innovative breakthrough design and redesign. This
model has been systematically improved over many
years to incorporate new methodologies and best
practices. The MFI currently incorporates four key
areas of focus to help ensure successful improvement
results:
• Employee engagement in improvement, redesign,
and innovation through multidisciplinary teams.
• An acute focus on exceeding patients’ and customers’ needs and wants and encouraging their
engagement.
• The use of a variety of improvement tools, chosen according to the aim of each project. These
include Lean (adapted from the Toyota Production Method), Six Sigma, and Kaizen approaches; Failure Modes and Effects Analysis
(FMEA); root cause analysis; International Organization for Standardization (ISO) and other
accreditation processes; pilots and rapid tests of
change; statistical process control; and project
management.
• The use of the Influencer Model for change management that emphasizes understanding personal,
social, and structural motivations to change.
Deployed throughout HFHS, the MFI is also used in
the organization’s leadership system (see Exhibit 3
on page 10) and strategic planning process; in designing and redesigning new work systems, such as
in
building a new hospital, which opened in 2009;
in
dozens of Kaizen and rapid redesign events held
annually; and in daily improvement work. Management encourages and invests in opportunities for
the workforce to develop and test new ideas and
approaches. For example:
• Hospital “innovation units.” Here teams develop
and pilot new approaches, often supported by
specially trained internal experts, or participate
in
care design teams that include patients. In one
instance, nurses developed an evidence-based,
nurse rounding protocol designed to prevent
harm events, such as falls and pressure ulcers.
Nurses used a standardized checklist for each patient during hourly rounds. Based on pilot results,
the protocol was spread to all System hospitals.
Patient falls were reduced by 23 percent throughout the System between 2008 and 2011. Innovation teams include many national and state
partnerships and collaboratives. Employees develop and test new ideas and benchmark with
high performers, such as the Institute for Healthcare Improvement’s 100,000 Lives and 5 Million Lives campaigns and the Michigan Health
and Hospital Association’s (MHA’s) Keystone
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Exhibit 3. HFHS Leadership System
MI
Reward & Recognize
Redesign
Spread
DO
Deploy strategy
&
Develop People
CHECK
Organizational
Performance Review
(OPR)
Center for Patient Safety & Quahty. For example,
HFHS hospitals participate in the MHA Keystone
Center’s Obstetrics Collaborative, which aims to
reduce harm to mothers and infants by tracking
compliance with two evidence-based care bundles known to improve perinatal outcomes. The
care bundles include no elective deliveries (that is,
labor induction or scheduled Caesarean section)
before 39 weeks of gestation and a standardized
order set for the administration of oxytocin (that
is, labor induction or augmentation). Results of
this initiative raised compliance levels with these
two bundles to almost 100 percent at HFHS hospitals.
Stepping Up Performance Analysis and Review
Teams use a variety of analytic techniques, such
as fishbone diagrams, Pareto charts, run charts.
control charts, and trend lines. Graphical displays
with control limits or data trending on run charts
help identify when variation is “common cause”
(requiring no action) or “special cause” (requiring
action be defined and taken). The defined owners
of work processes use customized dashboards with
data on customer, suppHer/partner, and operational
requirements. Managers review System dashboard
measures monthly to assess performance against
strategic objectives and action plans. “Stoplight”
color schemes on these dashboards identify metrics
at or better than the target (green), within 5 percent
of target (yellow), or more than 5 percent behind target (red), allowing focus on strategic initiatives that
are behind target. A sample dashboard is shown in
Exhibit 4. System dashboards are available monthly
to the workforce on the HFHS intranet and through
postings in work areas.
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Exhibit 4. System Dashboard
Pillar Performance Indicator Freq. 2010
Actual
2011
Target
2011
Current
Current
Status
People
I mployee Engagement
Gotlup Q12 ond Pulse Surveys
Monthly
Annual
Semi-Annuai
Customer Engagement
fop Box “Likelihood to Recommend”
Service
Ho’^pital Convimers Assessment of
Heoithcare Providers and Systems
Monthly
Quarterly
Harm-Overall Rate
Per 1000patient days
SofetV fiea(lmission5 to the Hospital
Allpatienti
Monthly
Monthly
Growth
Tri-County Inpatient Market Share< br>Med/Sing only
Admission Volumes
Not incfuding BHS
Total HAP Membership
Quarterly
Monthty
Monthly
Finance
Profitability
Net Operating income
Cost Per Unit
Cost per case mix adjusted admission
Monthly
Morrthty
> 5% Variance to Target | O < 5% Variance to Target | # At or Above Target
Dashboards are widely deployed across business
units and pillar teams, and managers use the data
they contain to make day-ro-day operational decisions related to work processes. For example, all
hospital leaders and managers review dashboards
with quality and safety indicators as well as census,
volumes, revenue, bed availability, and productivity data; ambulatory medical centers’ leaders review
dashboards of patient access/appointment availability, phone access, and timely response and closure of patient telephone messages. Process owners often supplement such data wirh real-time input
from internal customers, patients and families, and
supplier/partner input from performance reviews.
For example, as a result of reviewing appointment
access dashboards at Henry Ford Medical Center
sites across southeast Michigan, a Contact Center was created to improve access. This centralized
the appointment process for primary care and most
specialty services, streamlining appointment-setting
processes and standardizing appointment types. The
Contact Center both improved the service (for example, call response times) and made it easier for
patients to make an appointment.
Organization performance review (OPR) occurs in
all HFHS entities. The OPR process provides a forum for transparency, mutual accountability, and
access to assistance with initiatives as needed. The
OPR process involves:
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• review of current results, including financial
health, relative to target;
• review of action plans and action plan monitors;
• celebration of progress;
• review of root causes of stagnated or declining
results;
• discussion of action plan adjustments and assistance needed from other areas; and
• documentation to spread innovations and opportunities for improvement.
As-needed communication of OPR findings to improvement teams, workforce members, partners,
and collaborators ensures ongoing dialogue about
lessons learned and opportunities to change direction or spread successes. In addition, comparisons
to targets, prior period trends, competitors, other
external benchmarks, and like organizations (inside
and outside HFHS) help ensure that conclusions and
any changes are based on valid assessments. Frequency of reviews at all levels, identification of corrective actions, and communication and follow-up
allow the organization to respond rapidly to changing needs and challenges at all levels and facilities.
The performance management strategy at HFHS
aims to create workforce engagement that fosters
retention, safety, productivity, and profitability.
For example, a few years ago OPRs showed that service scores had not improved at the System level or
business-unit level. This launched a new approach
to service that focuses on customer engagement. A
new System-level team and leader expectations were
created. All employees were required to complete
customer engagement training. In late 2012, executive leaders began rounding at hospitals to talk with
patients and employees about customer engagement
and service improvement. In another example, review of both admission andfinancialdata at various
business units highlighted a potential inconsistency
in
the use of and coding for “observation bed
status.” A new team was launched, led by the
System’s chief financial officer, to understand and
standardize reporting and process around the use of
observation beds, as well as to lead an effort to standardize reporting across all health organizations in
southeast Michigan.
Key Change: Developing a Performance
Management System
The performance management strategy at HFHS
aims to create workforce engagement that fosters retention, safety, productivity, and profitability. The
Performance Management Program (PMP) of annual appraisals and individual goal-setting for the
coming year, midyear reviews, corrective actions,
and career development provides opportunities to
support high-performance work and workforce
engagement. Developing this performance management system meant identifying standards of excellence for employee behaviors, integrating the PMP
process throughout the System, and offering learning opportunities and coursework to provide employees with the tools to excel.
Setting Workforce Standards of Excellence
When HFHS leaders developed the performance pillars in 2006, they also created a Leadership Competency Model (see Exhibit 5) that included standards
of excellence aligned to the Baldrige criteria. These
standards require all leaders to model specific
behaviors:
• Listen and communicate effectively.
• Coach and mentor others.
• Motivate and inspire others.
• Have the courage to innovate.
• Be accessible to others.
• Reward and recognize the accomplishments of
others.
• Be accountable for achieving desired results.
Management communicated the standards at the
first annual All Leadership Meeting in 2007 and
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Exhibit 5. Leadership Competencies and Standards: Aligned to Baldrige Criteria
Strategic
Planning
Performance
Analysis &
Knowledge
Management
Accountability
for Results/
Execution
Process
Management/
Focus on Safety
systematically rolled them out by providing leaders
with a toolkit and key messages for modeling the
standards of excellence. Senior leaders role model
the standards through open-door policies, leader
rounds, and thank-you notes, among other behaviors. Self-assessments, 360-degree assessments,
Myers-Briggs and Gallup Strengthfinders personality assessments, and supervisor evaluations during the Performance Management Program support
evaluation against the competency model. Leaders
use results in collaboration with their supervisors to
create personal development plans to address gaps
in
leadership competencies and behaviors. Actions
may include course work and development opportunities available through the Henry Ford Health System University’s leadership development curriculum
and/or external opportunities that align with and
support expected leadership competencies.
As a result of this initiative, the number of leaders
who have scores in the top quartile of the Gallup
Q12® survey database has doubled since 2008, and
the number of leaders with scores in the bottom
quartile decreased by almost half. The System’s Service Excellence Steering Gommittee subsequently developed Team Member Standards of Excellence for
all employees and embedded them in performance
management goals. All employees are expected to
meet the following eight standards:
• Display a positive attitude.
• Take ownership and be accountable.
• Respond in a timely manner.
• Gommit to team members.
• Be courteous and practice established etiquette.
• Respect patient privacy.
• Foster and support innovation.
• Honor and respect diversity.
For continuous improvement and clarity, these service standards were updated in 2011 and cascaded to all employees. Although the content of the
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Standards remained the same, the words used to express them were more concise, and the phrasing was
changed to “I am . . . ” state ments in order to make
the service standards more meaningful to employees.
Deploying the Performance Management Program
The PMP process outlines and reviews individual
employee results and behaviors to support both
high-performance work and workforce engagement.
Individual results are categorized around the seven
pillars and account for 60 percent of an employee’s
annual review; adherence to behavior standards accounts for the other 40 percent. The behaviors evaluated for leaders directly correlate to the Leadership
Competency Model; for all other employees, to the
Team Members Standards of Excellence. The PMP
includes three main steps:
• Employees meet with managers before January
1 to identify individual goals and performance
plans, aligned with System, pillar, and businessunit goals.
• By July 31, a midyear review is completed to
review progress to date, refine performance objectives and action plans, and focus on career
development.
• An annual performance review of goal attainment
is completed and documented by year-end. The
annual review is used as input for merit increases
and annual incentive plan awards, with the latter aligned to and dependent on achievement of
HFHS financial and other goals.
It became clear that a systematic approach was
needed to deploy the PMP throughout the organization in a way that assured PMP timelines were
being met for all employees. Management selected
an online, best-practice software tool for identifying and evaluating performance goals and implemented the system in 2008 for nearly 1,400 leaders
throughout the System and then to all employees.
In 2009, the HFHS CEO cascaded a new goal
to all leaders worth 10 percent of leaders’ performance scores: on-time completion of all PMP steps.
including online documentation, for each leader’s
direct reports. This web-based system sends automated reminders of in-process evaluations and approaching PMP deadlines to employees and leaders,
and has led to significant improvement in on-time
performance reviews throughout the system.
Focusing on Workforce Learning and Development
Established in 2004, the Henry Ford Health System University (HFHSU) provides a high-quality and
convenient education and training platform across
HFHS. The HFHSU includes classroom and online coursework, its web-based learning management system provides online course registration, and
each employee has access to a personal learning
site that tracks assigned courses, course completion,
transcripts, and certificates.
The PMP process outlines and reviews individual
employee results and behaviors to support both
high-performance work and workforce engagement.
Individual results are categorized around the seven
pillars and account for 60 percent of an employee’s
annual review; adherence to behavior standards accounts for the other 40 percent.
Leadership training sessions include the New Leader
Academy for newly promoted leaders, the Leadership Academy for selected high-potential managers, the Advanced Leader Academy for potential
successors of senior leaders, and the Physician
Leadership Academy for future physician chairs
and division heads. “Leadership development” is
a specific curriculum within the HFHSU and includes detailed courses in strategic planning; creating specific, measureable, attainable, realistic, and
timely (SMART) goals; strengths, weaknesses, opportunities, and threats (SWOT) analysis; action
plan deployment; and motivating teams toward accomplishing strategic goals. In addition to specific
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training. Leadership Execution and Planning meetings and retreats serve to build skills in planning,
performance review, and other areas of business literacy and leadership development.
Through internal and external courses, conferences, and seminars, HFHS employees access numerous job-specific learning opportunities addressing
process improvement, technology changes, and innovation. In 2007, management launched a stateof-the-art Simulation Center, which allows clinical
team members to practice critical skills and techniques, such as surgical procedures and team
communication approaches, in an interactive and
feedback-rich simulation environment. For those
who need training on the model for improvement,
a fundamental overview of the PDCA improvement
cycle and other elements of the MFI are incorporated into leadership training sessions. Numerous
other employees are provided “just in time” training and coaching on MFI tools and concepts as they
work on projects and daily process improvements.
Training and coaching is provided by System leaders, as well as by process improvement engineers and
clinical quality improvement specialists at the corporate offices and embedded in business units and
product lines.
Shifting From Employee Satisfaction to Workforce
Engagement
In 2008, in partnership with the Gallup Organization, HFHS embarked on shifting from a culture
focused strictly on employee satisfaction to one of
full workforce engagement. The Gallup Q12® survey, deployed every two years since 2008, provides
an assessment of both engagement and satisfaction
by workforce area. HFHS leaders receive results segmented by business unit, work unit/department, and
key workforce segment. HFHS’s overall grand mean
score increased to 4.12 in 2012, an increase of 0.15
from 2010. An increase of 0.1 is statistically significant and often associated with an increase in profitabihty, decreased turnover rates, higher patient engagement, and better/safer patient care. This grand
mean score placed HFHS in the 81st percentile of
Gallup’s health care company-level database, a significant increase from the 53rd percentile in 2010
and from the 25th percentile in 2008.
Key Change: Integrating Communications Systems
The role of HFHS’s communications experts includes developing and deploying messages throughout the System. The structure of the communications
system at HFHS in the middle of the first decade
of the 2000s was not ideal for integrated messaging. Each hospital had its own public relations and
marketing teams with no formal relationship to the
corporate team, which often resulted in competitive media and marketing efforts. In 2007, HFHS
plans to acquire an existing hospital and build a new
one prompted reorganization of the organization’s
communications structure. The new, integrated organizational structure, a matrix approach, improved
alignment in professional media services and created
a common system approach to communications and
messaging.
Through internal and external courses, conferences,
and seminars, HFHS employees access numerous job-specific learning opportunities addressing process improvement, technology changes, and
innovation.
To communicate with and engage the entire workforce, the HFHS CEO meets monthly with the
System Communications team to evaluate, design,
and improve communication and engagement approaches. To ensure systematic deployment, the
team utilizes a communicators’ roundtable, composed of each business unit’s chief communication
officer, to plan and execute key communications.
Essential messages are integrated into face-to-face,
print, and e-communications, including social media. These mechanisms reinforce the mission, vision, and values; pillar goals, strategies, and metrics;
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team standards of excellence; and achievements and
recognition.
Senior leaders embed communication tactics into the
action plans of every strategic initiative, and performance improvement tools are used to increase
effectiveness of communications. For example, messaging for deployment of the employee HealthEngagement program was developed and tested
through the MFI and then rolled out to employees.
To measure and improve the effectiveness of communications, senior leaders conduct a comprehensive evaluation every three years using surveys,
interviews, and focus groups, with annual pulse surveys repeated in the off years. For example, following a 2008 survey that reflected the need to improve
the effectiveness of sharing Systern messages, senior leaders developed a weekly “Take Five” toolkit
(including System news, quality and safety messages, service messages, business-unit messages, and
a space for local stories or recognitions). Leaders
throughout the System share this and other appropriate information with their teams during weekly,
face-to-face, five-minute meetings called “huddles.”
In addition, because employees identified e-mail as
the preferred way to receive organizational news,
the System Communications team developed a daily
news service called HFHS Morning Post, which is
e-mailed to all employees. A communications pulse
survey repeated in April 2009 showed significant improvement in satisfaction with communication from
senior leaders.
Behavioral standards and the HFHS mission, vision,
and values are deployed to the workforce through
various approaches, including new-hire orientation,
with messages that are amplified by manager tool
kits, training, daily or weekly huddles, and key messages. Other approaches to messaging deployment
include pocket cards, badge attachments, work area
posters, and senior leaders’ open-door policies and
rounding.
The effectiveness of the integrated communications
process passed a major test in 2010 with the development of a new vision statement for HFHS that
involved all HFHS employees. Employee suggestions
were synthesized to make draft vision statements on
which employees were then asked to vote; two-thirds
of voting employees supported the vision statement
adopted. The new vision statement was then deployed, and a subsequent survey of employees found
that 87 percent of respondents were aware of the
new vision.
Senior leaders embed communication tactics into
the action plans of every strategic initiative, and
performance improvement tools are used to increase
effectiveness of communications.
The vision that had been created ten years earher
was “To put patients first by providing each patient the quality of care and comfort we want for
our families and ourselves.” Now it reads “Transforming lives and communities through health and
Wellness—one person at a time.” This change represents the following:
• “transforming lives and communities”: to continually improve the delivery of health care to ensure
it is patient-centered, integrated, equitable, highquality, safe, and efficient.
• “health”: to improve health through innovative
clinical excellence, medical education, and research/discovery.
• “Wellness”: to be a leader in optimizing health
and well-being for all the people served, providing the same quality experience and leveraging
the System’s unique strengths—through culture,
practice, programs, training, environment, and
policy.
• “one person at a time”: to have a renewed focus on creating The Henry Ford Experience for
16 J a n u a r y / F e b r u a r y 2 0 1 3 DOI: 1 0 . 1 0 0 2 / j o e G l o b a l B u s i n e s s an d O r g a n i z a t i o n a l E x c e l l e n c e
every patient, customer, employee, volunteer, and
physician, and to strive for excellence in each encounter.
Turning Point: Renewed Focus on Innovation
Civen the key changes that were made in leadership engagement and the developments in the
performance improvement system and performance
management system, HFHS leaders began to apply to the local and national levels for the Baldrige
award. At first try, in 2007, HFHS was awarded
the Michigan Quality Council Leadership Award.
This important win gave staff members energy, optimism, and possibly too much confidence. Yet,
that confidence spurred them to renew their focus
on innovation and entrepreneurism throughout the
System.
Multiple approaches were used to foster innovation, including culture, workforce strategy, setting
high goals that required breakthrough change, and
creating incubators for innovation, such as the institution’s Simulation Center. The model for improvement was applied to promising new ideas to develop,
refine, deploy, and spread innovations.
Two examples of best-in-class innovations that were
made during this time are the HFHS No Harm Campaign, launched in 2008, and the Henry Ford West
Bloomfield Hospital, opened in 2009.
The No Harm Campaign focuses on reducing both
preventable and unpreventable harm to patients,
with an aggressive goal to reduce harm by 50 percent
throughout the System from 2008 to 2013. In the
first three years of the campaign, the harm rate for
HFHS dropped by 24 percent across seven categories
of harm, compared to a maximum of 2 percent per
year according to benchmarking from the Institute
for Healthcare Improvement and elsewhere.
The new Henry Ford West Bloomfield Hospital was
built with active involvement of the community, resulting in an innovative building design incorporating a “Main Street” featuring weekly farmers’ markets and a line of retail shops, a Culinary Wellness
Program, and a beautiful atrium with a tea kiosk and
meditation area. Before building the patient rooms
at the hospital, more than 2,000 people (medical
staff, patients, families, and community members)
toured the prototypes of patient rooms to test room
configurations, fixtures, furniture, and equipment;
more than 70 design changes were made based on
their extensive feedback. The new hospital has one
of the highest patient satisfaction rates in the System.
To support innovation across HFHS and in Detroit,
the Henry Ford Innovation Institute was established
in
October 2011. The Innovation Institute pioneered
a unique model of multidisciplinary collaboration
to develop medical products, devices, and therapies
that improve patient outcomes, as well as the costeffectiveness of health care. The founding partners
of the Institute include Detroit’s leaders in medicine
and science, technology, product design, and education: the Henry Ford Medical Group, Wayne State
University’s College of Engineering and the Smart
Sensors and Integrated Microsystems Program, the
College for Creative Studies, and The Henry Ford
Museum.
Multiple approaches were used to foster innovation,
including culture, workforce strategy, setting high
goals that required breakthrough change, and creating incubators for innovation, such as the institution’s Simulation Center.
Key Change: Fine-Tuning Performance Strategy
for Improvement at All Levels
In 2009, multiyear feedback from the Baldrige application process showed that we had incomplete
strategic planning steps, deployment, and alignment. Many performance targets and results remained the responsibility of a few versus everyone.
G l o b a l B u s i n e s s a n d O r g a n i z a t i o n a l E x c e l l e n c e DOI: 10.1002/joe January/February 2013 17
Senior leaders evaluated all current leadership teams
by membership, roles and responsibilities, meeting
frequency, and perceived effectiveness. They determined that the 25-member SET was too large to keep
discussion focused and decision making timely.
The Performance Council sets aggressive strategic
objectives and strategic initiatives for all pillars,
and senior leaders deploy strategy by implementing
action plans and making data-driven decisions.
Turning Point: Performance Council and New Strategy
Process
A Performance Gouncil was created, composed of
business-unit GEOs, pillar team leaders, and leaders
of key corporate areas. The revised structure simultaneously streamlined and better integrated strategic direction. The Perf ormance Gouncil was charged
with overseeing the strategic planning process and
organizational performance reviews, with the aim to
provide a clear direction and rapid decision-making
process to those seeking approval of or input to
projects, policies, and initiatives.
A new Metrics Gommittee also was established,
composed of operational, financial, and pillar leaders, to provide oversight and expertise to pillar teams
and the Performance Gouncil on the best way to define, display, compare, and analyze organizational
performance measures. The Metrics Gommittee’s
structure covers data stewardship, analytics delivery, and—new for HFHS—knowledge management.
The Metrics Gommittee uses nine criteria to guide
selection of measures. All measures must:
• align with internal/external customer requirements;
• be readily collectible (automated collection is
ideal), balancing utility with the ease of data collection;
• be easily understood and consistently defined;
• be reportable at necessary frequency;
• have sound comparative benchmarks or historical trends;
• be aligned with key initiatives or work processes
so progress on the System strategic initiative can
be readily accessed and communicated;
• have defined owners;
• have a defined audience for reports and reviews;
and
• have clear accountability.
Using the model for improvement, the Performance
Gouncil revised the annual cycle for the strategic
planning process to better integrate with the capital
and operational planning processes, include a review
of the HFHS business model, and confirm the key
inputs and outputs of each step. The strategic planning process became a seven-step cycle that spans
an entire year of scheduled, facilitated meetings (see
Exhibit 6). The Performance Gouncil sets aggressive
strategic objectives and strategic initiatives for all
pillars, and senior leaders deploy strategy by implementing action plans and making data-driven decisions.
Results Fuel the Drive to Performance Excellence
Since 2006, Henry Ford Health System has been
recognized by peers in five different national programs that have carefully reviewed its performance.
No other hospital or health system in the nation has
received all five awards:
• Malcolm Baldrige National Quality Award,
2011.
• National Quality Forum/The Joint Gommission
John M. Eisenberg Patient Safety and Quality
Award, Local Level, 2011.
• American Hospital Association McKesson Quest
for Quality Prize, 2010.
• National Business Group on HealthA’^eterans
Health Association Foundation National Health
System Patient Safety Leadership Award, 2008.
• The Joint Gommission Godman Award, 2006.
18 J a n u a r y / F e b r u a r y 2013 DOI: 1 0 . 1 0 0 2 / i o e Global B u s i n e s s and O r g a n i z a t i o n a l Excellence
Exhibit 6. Key Changes to Strategic Planning
Affirm Mission, Vision, Values i
Environmental Assessment
Review Organizational
Performance Conduct Scenario Planning
& Develop Strategic
Objectives
Develop Action Plans & Set
Targets
Develop & Prioritize Strategic
Initiatives
Despite a challenging economic environment and
yearly increases in uncompensated care expenses,
HFHS is the market leader for the tri-county area
of southeast Michigan and continues to demonstrate increasing marketplace performance levels
and trends. Market share growth in 2010-2011 occurred in increases in births (6.5 percent), urgent
care visits (10 percent), emergency department visits (3.8 percent), Community Care Service volumes
(20 percent over two years), and inpatient market
share (3.9 percent). The Pharmacy Advantage unit
has a compound annual growth rate of 25 percent
for the last four years and is contributing the majority of net income in the highly profitable Community
Care Services business unit.
Some components of HFHS’s integrated system
demonstrate best-in-class customer-focused outcomes. HFHS’s engagement and satisfaction results
for its Health Alliance Plan have met or exceeded
the National Committee for Quality Assurance 90th
percentile level from 2007 to 2010. HAP has been
rated by J.D. Power and Associates as among the
“highest in member satisfaction among commercial health plans in Michigan” for four consecutive
years, and in 2011 it was rated the “highest in the
state.” HFHS ambulatory and community hospitals’
satisfaction levels meet or exceed the 90th percentile
level in Press Ganey patient surveys. For employee
engagement scores, the Callup Q12® survey showed
that Henry Ford Hospital rose from the 18th percentile in 2008 to the 43rd percentile in 2010 to
the 76th percentile in 2012. The Henry Ford Medical Group rose from the 18th percentile in 2008 to
the 35th percentile in 2010 to the 85th percentile
nationally in 2012.
Clinically, HFHS efforts have resulted in national
best practice safety innovations. Insulin protocols
for glycémie control, first piloted in 2003, were
spread throughout the System by 2006 (Horst et al.,
2010), with refinement efforts continuing and new
G l o b a l B u s i n e s s a n d O r g a n i z a t i o n a l E x c e l l e n c e D O I : 1 0 . 1 0 0 2 / j o e J a n u a r y / F e b r u a r y 2 0 1 3 1 9
protocols being developed for special populations
such as obstetrics. The pharmacist-directed anticoagulation service, developed in 2007 to improve anticoagulant medication selection, dosing, and monitoring, and transition from inpatient to outpatient
treatment, resulted in a 35 percent decrease in patients with international normalized ratios (INRs) >
5 (Schillig et al, 2011; To et al., 2011 ). (The blood’s
INR level indicates whether high risk exists for
blood clots—high INR level—or hemorrhage—low
INR level.) HFHS Pharmacy Services received the
2009 American Society of Health-System Pharmacists Safety Award. The Perfect Depression Care
Model (Coffey, 2007) helped save up to 180 lives
from suicide from 2002 to 2011 and was cited by
the Health and Human Services National Suicide
Action Alliance in 2011. The sepsis bundle research
developed at Henry Ford Hospital by Rivers and
Ahrens (2008) and Rivers et al. (2001), officially became the national standard of care in 2001 and is
estimated to have saved 60,000 lives in the United
States in one year alone. An antibiotic lock protocol
for dialysis catheters serves to prevent 80 catheter
infections annually (Moore et al., 2011); these efforts received the National Kidney Foundation of
Michigan Innovations Award in 2011. Deployment
of the National Surgical Quality Improvement Program at HFHS hospitals has resulted in 1,000 fewer
procedural harm events each year (Velanovich et al.,
2009).
All these efforts and others are part of the HFHS No
Harm Campaign, which resulted in a 31 percent reduction in harm events and an 18 percent reduction
in
in-patient mortality throughout the System from
2008 to 2011 (Conway, Hawkins, Jordan, & VoutGoss, 2012). Afinancialmodel created to assess cost
savings of reducing harm events has shown early results totaling nearly $10 million in four years.
This performance demonstrates HFHS’s commitment to excellence and to the communities it serves.
System leaders started the journey toward performance excellence with the intent of using the
Baldrige framework to help HFHS become a better organization—not just to win an award. They
integrated the framework into their strategic planning and business operations to ensure it would become part of everyday work. If they had not adopted
the framework, the organization’s culture would not
have changed. The Baldrige criteria added a strict
discipline to how performance is planned, executed,
and evaluated.
Performance excellence remains an ongoing effort.
The years 2004 to 2011 presented many challenges,
particularly in obtaining and measuring d ata and
finding or creating comparator sets of data for analysis of outcomes and progress. The System’s leaders
needed to understand that the organization and their
innovative efforts were not unique. Dashboard and
organization performance review results have been
critical in helping them identify how they are performing at any given time in any pillar or on any
project. This information, in turn, provides the impetus for timing and rapidity of required change.
Agility has improved—HFHS employees are better
at shifting gears when results show trends moving
in
the wrong direction.
System leaders started the journey toward performance excellence with the intent of using the
Baldrige framework to help HFHS become a better
organization—not just to win an award.
HFHS’s defining characteristic is its people. The culture that has been created among the workforce has
resulted in a unique energy and a can-do spirit that
is the foundation of Henry Ford Health System. Employees at all levels share a passion for engagement
in order to deliver better, safer patient care. System leaders recently established new HR trending
metrics to examine employee retention rates and
improve performance in this area. A new effort
that is under way, to better listen to patients and
20 January/February 2013 DOI: 10.1002/joe Global Business and Organizational Excellence
employees, involves all senior leaders rounding on
patients in HFHS hospitals, asking questions of patients, families, and employees about how they can
better serve them.
As applied at HFHS, the Baldrige criteria were
instrumental in transforming the System’s culture
to focus on performance excellence in every area.
Alignment and engagement of leaders and employees helped to improve integration of processes within
and across business units with an ongoing focus on
measureable results. Disappointing results as well
as imperatives or market influences may alter the
course, but not the direction forward toward improvement. The quest for performance excellence at
HFHS is not to attain perfection, but to continually
improve, to transform lives and communities—one
patient, one person at a time.
References
Coffey, C. E. (2007). Building a system of perfection depression care. Joint Commission Journal of Quality and Patient
Safety, 33, 193-199.
Conway, W. A., Hawkins, S., Jordan, J., & Vout-Goss, M.
(2012). The Henry Ford Health System No Harm Campaign:
A comprehensive model to reduce harm and save lives. Joint
Commission Journal of Quality and Patient Safety, 38, 319-
327.
Horst, H. M., Rubinfeld, I., Mlynarek, M., Brandt, M. M.,
Boleski, G., Jordan, J., Gnam, G., & Conway, W. (2010).
A tight glycémie control initiative in a surgical intensive care
unit and hospitaiwide. Joint Commission Journal of Quality
and Patient Safety, 36, 291-300.
Moore, C. L., Ajluni, M., Soi, V., Johnson, L., Adams, B.,
Amburn, L., Sykes, J., Besarab, A., Zervos, M., & Yee, J.
(2011). Reduction of catheter-related bacteremia (CRB) and
healthcare utilization by use of a prophylactic gentamicincitrate lock solution. American Journal of Kidney Diseases,
57(4), B69.
Rivers, E., Nguyen, B., Haystad, S., Ressler, J., Muzzin, A.,
Knoblich, B., Peterson, E., & Tomlanovich, M. (2001). Early
goal-directed therapy in the treatment of severe sepsis and
septic shock. New England Journal of Medicine, 345, 1368-
1377.
Rivers, E. P., & Ahrens, T. (2008). Improving outcomes for
severe sepsis and septic shock: Tools for early identification
of at-risk patients and treatment protocol implementation.
Critical Care Clinics. 24(3 Suppl), S1-A7.
Schillig, J., Kaatz, S., Hudson, M., Krol, G. D., Szandzik, E.
G., & Kalus, J. S. (2011 ). Clinical and safety impact of an inpatient pharmacist-directed anticoagulation service. Journal
of Hospital Medicine, 6, 322-328.
To, L., Schillig, J. M., Desmet, B. D., Kuriakose, P., Szandzik,
E. G., & Kalus, J. S. (2011 ). Impact of a pharmacist-directed
anticoagulation service on the quality and safety of heparininduced thrombocytopenia management. Annual Pharmacotherapeutics, 45, 195-200.
Velanovich, V., Rubinfeld, I., Patton, J. H., Jr., Ritz, J., Jordan, J., & Dulchavsky, S. (2009). Implementation of the National Surgical Quality Improvement Program: Critical steps
to success for surgeons and hospitals. American Journal of
Medical Quality, 24, 474^79.
Additional Resources
Baldrige Performance Excellence Program, www.baldrigepe
•org
Institute for Healthcare Improvement, www.ihi.org
Michigan Health and Hospital Association’s Keystone Center
for Patient Safety & Quality, www.mhakeystonecenter.org
HFHS No Harm Campaign, www.hfhs.com/noharm
Susan S. Hawkins, senior vice president of performance excellence for Henry Ford Health System in Detroit, Michigan,
leads strategic planning, process engineering, operational analytics, and clinical quality and safety initiatives across the
System. Hawkins has applied engineering, business, and quality improvement methods to projects throughout HFHS since
1986. She has served as faculty for corporate quality management courses, is a trained facilitator for rapid-cycle improvement workshops, and has an ongoing role in teaching
HFHS leadership development courses on project management, mentoring, and quality and safety. She holds a bachelor’s degree in industrial engineering from the University
of Michigan and a master’s in business administration from
Wayne State University. Hawkins is a member of the Baldrige
Performance Excellence Program’s Board of Examiners. She
can be reached at shawkini@hfhs.org.
Rose Glenn is the senior vice president of communications
and chief marketing officer for Henry Ford Health System.
G l o b a l B u s i n e s s a n d O r g a n i z a t i o n a l E x c e l l e n c e DOI: 1 0 . 1 0 0 2 / j o e l a n u a r y / F e b r u a r y 2 0 1 3 21
Sfce leads a team responsible for marketing and public relations strategies to further the growth, preference, and customer engagement ofthe $4 billion health system and its subsidiaries. A summa cum laude graduate of Indiana University
of Pennsylvania, Glenn received her master’s degree in strategic public relations from George Washington University. She
is accredited by the Public Relations Society of America and
certified by the Society for Healthcare Strategy and Market
Development. She can be reached at rglennl@hfhs.org.
Kathy Oswald is senior vice president and chief human resources officer for Henry Ford Health System. She started her
career as a secretary at the Chrysler Corporation’s Jefferson
Assembly Plant in Detroit in 1972 and became Chrysler’s top
female executive as chief administrative officer before retiring
in 2000. Oswald then joined Right Management as president.
Great Lakes Region, and joined Henry Ford Health System
in her current role in 2008. Throughout her career, Oswald
has received numerous awards for her professional achievements and tuas recognized among Human Resource World’s
“Top 50 HR Executives in the World” in 2000 and Crain’s
“200 Most Influential Women” in 2007. She can be reached
at koswaldl@hfhs.org.
William A. Conway, MD, is senior vice president and chief
quality officer of Henry Ford Health System, chief medical
officer of Henry Ford Hospital, and Breech Chair for Health
Care Quality Improvement. Dr. Conway is a pulmonarycritical care physician and has championed many quality innovations at HFHS, including the No Harm Campaign. He
has developed processes at Henry Ford Hospital that have
markedly improved outcomes in the critical care and postoperative settings and reduced hospital-acquired infections.
Dr. Conway was recognized in 2004 as a Health Care Hero
by Crain’s Detroit Business for his leadership in surgical infection prevention, and received the Keystone Center Patient
Safety and Quality Leader ship Award by the Michigan Health
and Hospital Association in 2006. A graduate of Creighton
University Medical School in Omaha, Nebraska, Dr. Conway
joined Henry Ford Hospital as a resident in 1973. He can be
reached at wconway@hfhs.org.
22 January/February 2013 DOI: 1 0 . 1 0 0 2 / j oe G l o b a l B u s i n e s s a n d O r g a n i z a t i o n a l E x c e l l e n c e
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