Malcolm Baldrige National Quality Award
2018 Award Recipient, Health Care
Based in Jasper, Indiana, and sponsored by the Sisters of the Little Company of Mary, Memorial Hospital and Health Care Center (MHHCC) provides inpatient and outpatient care through an acute care community hospital, which includes 32 outpatient primary and specialty care clinics and medical practices, and an ambulance service. Memorial Hospital, which opened its doors in 1951, employs more than 1,700 people and provides medical care for 6,600 inpatients; 254,000 outpatients; and 29,000 emergency department visits annually. Nearly 950 babies are born at Memorial Hospital each year.
- MHHCC has received a Centers for Medicare and Medicaid Services (CMS) 5-star rating for overall quality of inpatient care since the ratings were released, and it achieved national top-10%, net-positive, value-based-payment performance since 2017. MHHCC has also achieved performance excellence outcomes with zero early elective deliveries before 39 weeks (since 2015), zero pressure ulcers in the Skilled Caring Center (since 2016), zero central line-associated bloodstream infections (CLABSI; since 2016), and zero hospital methicillin-resistant staphylococcus aureus (MRSA) infections (since 2015).
- MHHCC’s nationally recognized benchmark performance is demonstrated by an “A” Leapfrog Hospital Safety Grade since 2016. A 2-year reduction in total harm from 6.2 to 1.1 per 1,000 patient days from 2016 to 2018 was achieved. Bedside medication verification results have exceeded the Leapfrog benchmarks from 2013 to 2018, sustaining a level of more than 97%, and MHHCC has sustained CMS top-10% performance in its PSI-90 patient safety composite results since 2017.
- MHHCC has sustained a dominant leadership position in Dubois Country and its primary market area. Since 2015, MHHCC’s inpatient market share in Dubois County has been greater than 70% and its outpatient market share greater than 80%, with no competitor having more than 10%.
- MHHCC’s percentage of RNs with bachelor of science degrees rose from 50% in 2015 to 62% in the first quarter of 2018, and its RN turnover rate has remained below 2% since the first quarter of 2016, well below the top-10% national level of 8%.
Health Care Results
- MHHCC has received a Centers for Medicare and Medicaid Services (CMS) 5-star rating for overall quality of inpatient care since the ratings were released, and it achieved national top-10%, net-positive, value-based-payment performance since 2017. MHHCC has also achieved performance excellence outcomes with zero early elective deliveries before 39 weeks (since 2015), zero pressure ulcers in the Skilled Caring Center (since 2016), zero central line-associated bloodstream infections (CLABSI; since 2016), and zero hospital methicillin-resistant staphylococcus aureus (MRSA) infections (since 2015). Its top-10% performance includes overall risk-adjusted inpatient mortality rates, hospital-acquired conditions, and radial artery access in cardiac procedures.
- MHHCC’s nationally recognized benchmark performance is demonstrated by an “A” Leapfrog Hospital Safety Grade since 2016. A 2-year reduction in total harm from 6.2 to 1.1 per 1,000 patient days from 2016 to 2018 was achieved. Bedside medication verification results have exceeded the Leapfrog benchmarks from 2013 to 2018, sustaining a level of more than 97%, and MHHCC has sustained CMS top-10% performance in its PSI-90 patient safety composite results since 2017. (PSI-90 is a CMS national data set that includes patient safety and adverse events measures.)
- MHHCC’s senior leaders cascade the mission, vision, and core values through the organization in a faith-based culture focused on “Radical Loving Care” and the core competency of “Being for Others.” Enterprise-wide, members of the workforce are enthusiastic about the distinctive culture and are empowered to meet their patients’ medical, emotional, and spiritual needs. “Being for Others” and “Radical Loving Care” are demonstrated in all individual interactions and patient care, and senior leaders reinforce this culture through participating in new employee orientations and workforce Open Forums.
- MHHCC’s senior leaders encourage frank, two-way communication and engagement of MHHCC’s workforce, providers, patients, and other customers. Their extensive efforts include senior leaders regularly visiting departments (i.e., rounding); an open-door policy; hand-written, thank-you cards; the “Really Impressive Moments” recognition program; the Friday Facts email by the CEO, which lists his personal cell phone number; and Patient Family Advisory Councils.
Financial and Market Results
- MHHCC’s days cash on hand improved from 180 days in fiscal year (FY) 2016 to 215 in FY2018. Further, its long-term debt as a percentage of capital improved from approximately 25% in FY2016 to approximately 21% in FY2018, and its days in accounts receivable improved from 48 days in FY2017 to 41 in FY2018.
- MHHCC has sustained a dominant leadership position in Dubois Country and its primary market area. Since 2015, MHHCC’s inpatient market share in Dubois County has been greater than 70% and its outpatient market share greater than 80%, with no competitor having more than 10%. In its larger primary service area (which includes Dubois County), its inpatient market share has been approximately 60% and its outpatient market share has been approximately 70%, with its closest competitor having approximately 10%. This sustained leadership performance is supported by an annual overall increase of 31,151 in total office clinic visits and a 12% growth in total outpatient surgical procedures since 2014.
Customer Process and Results
- MHHCC expands service offerings by acting on market intelligence gathered via techniques such as patient and family advisory councils, analysis of Truven and Crimson data as well as Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and other patient surveys, and MHHCC’s website and diverse social media tools. Leveraging this intelligence, MHHCC introduced a new stroke telemedicine product to prevent market share loss and expand access; gained insight into the opportunity for secondary market entry into Davies County, including the need for the construction of a new clinic to provide services to the Amish community; and targeted the expansion of the oncology service line and use of the tag line “Closer to You” to strengthen its brand and expand into new markets.
- MHHCC’s patient experience and engagement results demonstrate its core competency of “being for others.” Inpatient overall satisfaction and HCAHPS Rate the Hospital have remained in the top 10% nationally since 2015, and overall satisfaction with outpatient primary care has been in the top 10% since 2016—all with 80% or greater of “top-box” scores. During this same time, MHHCC’s likelihood to recommend scores for obstetrics, post-surgical, and the Inpatient Rehabilitation Center each attained nearly 80% top-box scores and have been at or near top-10% national levels of performance.
People Process and Results
- MHHCC’s Servant Leadership System and associated leadership attributes encourage open communication, high performance, and engagement through strategies designed to empower the workforce. Wide-spread use of interdisciplinary and cross-functional teams, as well as unit and department councils, are used to facilitate engagement for the workforce and physicians. These teams and councils are also used to ensure collaboration and a focus on high performance.
- MHHCC focuses on advancing clinical career progression for nursing staff and on leadership development opportunities for the workforce. Programs include the Nurse Career Ladder, support for registered nurses (RNs) to obtain advanced degrees in nursing and certifications, and the Master’s in Health Administration program in collaboration with the University of Southern Indiana. Leadership development includes opportunities, such as serving as project champions, committee members, 90-day-team facilitators, or instructors.
- MHHCC’s percentage of RNs with bachelor of science degrees rose from 50% in 2015 to 62% in the first quarter of 2018, and its RN turnover rate has remained below 2% since the first quarter of 2016, well below the top-10% national level of 8%. Moreover, volunteer hours have been at or near 20,000 annually since 2015. Tuition reimbursement also rose from $100 thousand in 2013 to approximately $300 thousand in 2017.
- MHHCC’s strategic planning process incorporates feedback from the workforce, customers, and other key stakeholders. All senior leaders, board members, and selected physicians attend a day-long work session that reviews multiple inputs, including data from the quarterly business reviews; information gathered from threats, opportunities, weaknesses, strengths (TOWS) stakeholder sessions; and best-practices research. These inputs, which are incorporated in MHHCC’s Operational Rhythm, are used to stimulate “out-of-the-box” thinking in alignment with MHHCC’s covenants.
- MHHCC’s strategic planning initiatives have contributed to the opening of a nurse practitioner-staffed clinic to enhance access to primary care. They have also led to the formation of an innovative collaboration with local competitors and Indiana University to design, develop, and open a graduate medical education program and family medical practice residency in rural Indiana to address the shortage of physicians and ensure high-quality care for the communities MHHCC serves.
Citizenship Process and Results
- In line with MHHCC’s vision to transform lives through faith-based, compassionate care, the organization supports the volunteer activities of its workforce, community and church-based health programs, and service expansion and collaboration with key partners. MHHCC’s community health needs assessment, for example, led to expansion of services to other counties, additional cancer services, and a partnership with local schools to train future certified nursing assistants.
- MHHCC’s community benefit grew from $1.5 million in 2014 to $2 million in 2017, with a 40% increase in Medicaid application acceptance since 2015. In addition, funds raised through its foundation gala grew from approximately $150,000 in 2013 to approximately $200,000 in 2017; its paper recycling efforts grew from approximately 87,000 pounds in 2015 to 155,000 pounds in 2017; and donated supplies and equipment grew from 500 pounds in 2015 to 2,000 pounds in 2017.
Process Efficiency/Effectiveness and Results
- MHHCC addresses patient expectations and preferences in alignment with its core competency of Being for Others. Individualized care plans are developed with patients/families to help set realistic expectations and enhance communication with members of the care team. Whiteboards and senior leaders routinely visiting patients further engage patients and families in care and decision making.
- MHHCC employs multiple approaches to ensure high performance regarding patient safety. Its efforts include creating a nonpunitive or “Just” culture that encourages the reporting of occurrences, preemptive mitigation, analysis of near-miss events, assignment of a patient safety officer, and institution of safety-focused huddles. Such efforts have resulted in an innovative tamper-evident approach used in the treatment of patients with a history of IV drug use. Collectively, these approaches drive a culture of transparency to prevent errors, and they contribute to the “A” Leapfrog Hospital Group Safety Rating.
- MHHCC uses its 10-step plan, do, check, act, and evaluate (PDCAE) process and Lean to improve its work processes. To build an environment of continuous improvement, a cadre of trained facilitators meet regularly to review project requests and project status, and to support one another in the quest to drive improvement and reduce variation. The Lean Steering Committee and the Local Lean Leaders Against Waste also meet regularly to share best practices.
- MHHCC’s Emergency Department’s “left without being seen” rate has been below 0.5% since 2014, and 100% of lab specimen turn-around times and radiology report addendums have met targets since 2015. In addition, since 2015, greater than 90% of pharmacy order verifications have occurred within 30 minutes, and approximately 90% of Emergency Department radiology exams have been read within 1 hour. Moreover, rates of computer tomographic (CT) exams performed with and without contrast (relative to all exams) have been half of the CMS benchmarks since 2015; chart delinquency rates have fallen from 10% to 1% since 2012; and Medicare cases with physician concurrence have exceeded the benchmark of 80% since 2015.
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