Culture of an organization: a key success factor in these economic times

In numerous articles published recently, we read that over half of the hospitals and health systems in the U.S. are either in or headed toward a financial crisis. Clearly, if turnaround in these institutions is going to occur, everyone working in them must be coalesced around a common vision and utilizing their best performances to reach common improvement plan goals.

In an article published in the April 2009 HealthLeaders magazine entitled, “The Bumpy Road to Change,” author Carrie Vaughn indicated that cultural change is that “unambiguous phrase seemingly at the heart of every hospital turnaround effort or quality improvement program or employee satisfaction initiative.” Vaughn points out that because cultural transformation is so difficult, some efforts fail while some efforts are successful.

Recognizing that I have stated on numerous occasions in previous posts that the successes for CHRISTUS Health in our first decade have resulted from our ability to establish a “CHRISTUS culture,” I have reflected on our reasons for success and have compared them to those articulated in the article.

As previously stated, our culture has as its foundation our mission (to extend the healing ministry of Jesus Christ), vision (to be a leader and advocate in creating exemplary health care services, processes and structures that improve the health of individuals and of local and global communities so all may experience God’s healing presence and love) and values (dignity, integrity, excellence, compassion and stewardship). This is who we are (mission), where we are going (vision) and how we behave (values). With these three guiding understandings clearly and frequently communicated, they have increasingly become living documents by our Associates, physicians and volunteers expressed in their activities of daily living.

In addition, our culture has, both in the U.S. and Mexico, been built around our Journey to Excellence and our commitment to full and real-time transparency.

The HealthLeaders article listed five tips on how to get cultural transformation efforts off to a good start:
1. Prepare leaders. Find out how senior leaders view their involvement and responsibility in the culture change effort.
2. Acknowledge that the process takes time. For example, it takes about three to five years to become officially designated as a patient-centered hospital by an independent advisory council and recognized on quality checks by the Joint Commission, says an article source.
3. Don’t do too much. You must prioritize, look at the most important items and deal with them first.
4. Be inclusive At Griffin Hospital in Derby, Conn., everyone attends their retreats—business office people, engineering folks, housekeepers, security—not just clinical staff. They view every employee as a caregiver.
5. Recognize every culture is unique. Organizations should be sensitive to geographic culture, the culture of the organization and the personality of the organization.

So, to get there, what did we do at CHRISTUS?

We certainly agree that cultural transformation isn’t easy. As one administrator said, “Cultural change is like stretching out a rubber band. You can stretch it out, but it wants to pull back into its old shape and size.” Recognizing this, we have been patient, but always focused on our cultural brand components. We have often said the successes we have had are no accidents. They have resulted from very intentional plans.

We also knew we had to prepare our leaders, so through annual leadership retreats and quarterly meetings with regional and business unit leaders, the Senior Leadership Team has been able to repeat the message frequently, and with time, these leaders communicated it with the same clarity and energy.

In developing some of the components of the culture, we were also as inclusive as possible. All the Associates and physicians were asked to give input into the values of the organization in 1999 when CHRISTUS formed. Clinical staff are always involved in determining the clinical quality outcomes and metrics that we measure on our Journey to Excellence, and the goals for transparency have been developed from a multidisciplinary group of technology-oriented Associates.

After a decade, the CHRISTUS culture is clearly visible, strongly felt and a rallying point to face the challenges exacerbated by these economic times. It has not always been easy, particularly in the early years of our history. We have, on occasion, let the five causes of failure in cultural transformation listed in the article invade our ministry for periods of time. Those are:
1. Lack of a strong accountability system. Culture change efforts often start unraveling during year two when the initial excitement about the effort wears off, says Quint Studer, founder and CEO of the Gulf Breeze, FL-based consulting firm The Studer Group. Then it becomes apparent there’s no system in place that holds leadership accountable for driving the change and leading by example.
2. Trying to do too much, too fast. It’s great to be excited about the effort, but senior executives should be careful not to overwhelm managers. If you implement one change, like having nurse leaders round on patients, you are likely to be successful, says Studer. But if you implement multiple changes all at once, you risk all of the initiatives failing because your team gets so emotionally exhausted.
3. Narrow approach. Transforming culture is a lot broader and more difficult for people to grasp than a customer service program that focuses on making people smile, says an article source. Organizations can’t just focus on programs; they should take a comprehensive approach, as you are essentially talking about a belief system.
4. Morale. Culture undertakings are impacted by group morale, so you can’t do it in isolation, says an article source Organizations should have the true support and consensus of the entire senior leadership team. Top leaders need to go out and sell the change to staff and be role models for it; otherwise, it sets the tone for the organization not to take it seriously. Everyone in the organization needs to be involved in the effort, as well.
5. Underestimating leadership training and development. “The No. 1 issue leaders face is they don’t have enough time,” says Studer. Many leaders have never been trained to run a good meeting or select or fire staff. If you’re asking people to change behavior, they will need to be more efficient.”

However, today, 10-and-a-half years after CHRISTUS was formed, the CHRISTUS culture is alive and well, essential if we are to grow and be successful in the future.

Celebrating Volunteer Week

Today we celebrate Earth Day and Administrative Professionals Day, both very important reasons to pause and reflect/appreciate our resources and the people who support us on a daily basis.

Today also happens to be the midpoint of National Volunteer Week, which we celebrate in our CHRISTUS hospitals, facilities and programs across the U.S. For the last 10 years, the unselfish efforts of our amazing volunteer family has touched thousands of lives, bringing the energy, guidance, compassion and love that make CHRISTUS the unique health care organization that it is today. (You can see the volunteers at CHRISTUS St. Michael Health System in Texarkana, Texas pictured above.)

As I worked as a young physician and assumed more leadership roles, I was “raised” to believe that volunteers would be the last group to change in a hospital. However, I have learned that is absolutely not the case. Ten years ago when CHRISTUS Health was formed, volunteers led the necessary change in culture from their previous health system affiliations (Sisters of Charity Health System and Incarnate Word Health System) to CHRISTUS Health. They gladly traded the pink coats that identified them as volunteers for new purple ones that identified them as CHRISTUS volunteers. They also embraced a shift from an affiliation with a local hospital foundation (which many of our auxiliaries and volunteer groups donate to on a regular basis) to regional foundations which continued to support the hospital, but had a wider community-focused health care scope as well.

Our volunteers also embraced our transition to a focus on health care retail from our traditional hospital gift shop offerings. In the past, many of our facility gift shops were operated and merchandised by our volunteers, who then donated the profits from those stores to the hospital through the auxiliary. However, in 2007 we decided to revamp and expand our retail offerings in our facilities and online to a setup that we believed would help us better serve our patients and support our plans for sustainability moving forward. Our new CHRISTUS Healthy Living™ Marketplace stores allow our Associates, physicians, patients and community members to purchase items like wellness products, high-quality vitamins and mineral makeup, gourmet food and chocolates, clothing options, CHRISTUS logo merchandise and gifts in our facilities. Some of our Marketplaces even carry specialty products to be used by patients with certain diagnoses (like cancer), and many also offer gourmet coffee options, some of which are prepared by our dedicated volunteers!

This is obviously quite a difference from the way our volunteers oversaw many of these gift shops in the past. However, they have fully embraced our new vision, and we could not continue it without their support.

CHRISTUS has grown from 1,000 to 1,500 volunteers in our 10-year journey, and we are so blessed by each and every one! I am lucky to hear many stores about the volunteers in our CHRISTUS facilities around the country, and I wanted to share a few with you today. May they bless you as much as they have blessed me.

Daisy, who volunteers at CHRISTUS Schumpert St. Mary Place in Shreveport, La., spent 1,234 hours last year working on behalf of the hospital. She prices and stocks items in the gift shop, where she also tends to the flowers and delivers them to patients.

Marti Kaler has been volunteering for the past 55 years at CHRISTUS Spohn Hospital Corpus Christi-Shoreline. She has spent many of those years working at the information desk, helping people find their loved ones who are patients in the facility, delivering flowers and directing phone calls. CHRISTUS Spohn Shoreline is definitely a more welcoming place because of Marti’s presence there.

Edna Brittain, who celebrated her 89th birthday this month, has been volunteering at CHRISTUS St. Patrick Hospital in Lake Charles, La. for almost 31 years. Today, Mrs. Edna creates beautiful silk arrangements for sale in the CHRISTUS Healthy Living Marketplace. In her earlier years, she was a nursing student at Charity Hospital in Shreveport, La. She married 6 months before graduating as a Registered Nurse, but soon after, her husband was called to active duty in World War II. With the birth of her children and responsibilities to her family, she did not continue pursuit of her nursing degree, but she has put her medical expertise and giving heart to work in many capacities in Lake Charles, and has had a tremendous impact on CHRISTUS St. Patrick.

Our volunteers also show great strength of character and service to others outside their roles in our facilities. One of those is Karen Binford, who volunteers two days a week at the information desk at CHRISTUS Santa Rosa Hospital – Medical Center. Karen regularly takes an acquaintance of hers named Adele to her doctor appointments. On one of these recent trips, Adele began to show signs of a stroke. Karen immediately took her to the Emergency Department at CHRSITUS Santa Rosa Medical Center, where she was given prompt attention. Karen wholeheartedly believes that she acted so quickly because she works in a hospital, but her response and compassion prove the commitment she has (as do all of our volunteers) to our core values and our mission of extending the healing ministry of Jesus Christ.

Learnings from 2008 Hurricanes Affecting CHRISTUS Facilities

In keeping with our continuous improvement initiatives, I asked one of John Zipprich, CHRISTUS senior vice president of legal and governance services, to gather additional learnings from the three hurricanes in 2008 that impacted CHRISTUS facilities. I thought that our learnings and recommendations, which were based on input from some of the affected facilities, as well as from the system level, might be useful to other health care systems that may be affected by hurricanes or other disasters. Perhaps most importantly, there is a broad recognition for more system approaches to contracting and coordination of assets needed during and after a storm event.

PEOPLE
1. Regularly advise Associates of the HR hotline and Websites, require updated information in our online internal phonebook, and explain the use of the Send Word Now tool for enhanced communication with evacuated or displaced Associates. Also, evaluate the latter’s effectiveness as it was reported that the program was not fully utilized.

2. Confirm that Associate and staff commitments are clear and three tiers of responder teams (A, B and C) are in place before storm season in all vulnerable facilities and operating work groups; establish Human Resource policies for bonus and incentive pay during and after a storm, and whether pets are allowed and if so, in what locations.

3. Use armbands for the “ABC” teams who will be working for easy identification.

4. As appropriate, discharge or transfer patients as the storm develops to reduce hospital census, beginning with the most critical, and do this as soon as possible. If feasible, when sending patients to other CHRISTUS facilities, send the nurses, technicians and physicians with the most critical of those to continue care on arrival at the receiving CHRISTUS facility. Develop a system approach to patient transfer to other CHRISTUS facilities before FEMA, state or local Command Center takes control, facilitated by coordination at the system level.

5. Cancel elective procedures when storm impact projection date would not allow patient to be discharged in advance of anticipated evacuation orders.

RESOURCES
1. Back up all information operating systems and begin implementing the information management disaster plan in expected affected facilities.

2. Regularly, such as monthly, test generators with full power load, and confirm that power transfer switch and UPS are in working order.

3. Before storm season arrives, secure additional generators, fuel, food, water and other supplies (recognizing that this has a cost factor) in expected affected facilities sooner rather than later, with generators, fuel, food, water and other supplies deployed by the system command center based on negotiated contracts for prearranged locations ( for example, availability of a fuel tanker on site in advance of a storm), which requires collaboration between the region and/or facility and system Supply Chain Management.

4. Regions in potential storm zones participate in a risk pool for contingency supplies and assets, and when and where deployed, manage these from the system level, even though this may not be an expense covered by insurance in cases where a storm may not impact a CHRISTUS facility or if it only creates nominal damage, which requires collaboration and funding decisions at the regional and system levels, coordinated by System Supply Chain Management and Risk Management.

5. Keep system daily calls for resource coordination and resource deployment, and reconsider the need for satellite phones.

FACILITIES
1. Implement Dubuis, CHRISTUS HomeCare, CHRISTUS Medical Group office and retail operation disaster plans in same timeframes as facility plans or in accord with longer time plans if necessary because of the services provided.

2. Coordinate before storm season and during specific storm alerts with utility providers and local governmental disaster management teams, with particular plans for contingency water supplies both potable and for other purposes, and develop MOUs with the police, fire department, sheriff, utility providers, etc. possibly offering shelter in return for services.

3. Consider investment in plastic window film which was utilized at CHRISTUS Hospital - St. Elizabeth during the last round of storms. The film seems to be effective, as the hospital saw no window breakage. During storm alerts, timely implement plastic-wrapping, including everything (equipment and supplies) you can that might be vulnerable to water and move everything (equipment and supplies) you can to higher levels or areas if first floors or other areas are vulnerable to water intrusion; hire outside labor if necessary for this as well as sandbagging, shuttering windows, etc.

4. Gather all as-built plans, asbestos plans, MEP drawings, and roof plans in one secure facility location, and consider a backup copy at system level with construction management.

BUSINESS
1. Arrange for remediation teams (which could include project management, roofing and structural engineers, MEP engineers, environmental engineers, architects and contractors) and vendors to respond immediately after storm event, with system-negotiated contracts as possible, but in all cases this must be in collaboration with the region/facility and System Risk Management (which must get insurer’s permission for remediators if covered by insurance) and Supply Chain Management.

2. Keep track of all pre- and post-hurricane event-related expenses at the system, region, facility and operating entity according to Accounting and Risk Management requirements for insurance and FEMA claims.

3. The CHRISTUS Emergency Preparedness Website should be updated with the HIPAA waiver provisions, contacts for the Texas and Louisiana health professional licensing contacts information and updated CHRISTUS system contacts and information, coordinated by Risk Management.

4. Re-form the CHRISTUS Emergency Management Council and have quarterly phone conference calls, as well as just prior to the onset of storm season, coordinated by Risk Management.

During our experiences with Hurricanes Gustav, Humberto and Ike, our facilities benefited from being part of a larger system, especially one in which all Associates share the commitment to our mission of extending the healing ministry of Jesus Christ. In many cases, CHRISTUS hospitals in other regions accepted patients transferred from those in the direct path of the hurricanes and stood ready to provide staff or other resources necessary to care for our patients and for each other. CHRISTUS Associates continue to go above and beyond the call of duty in their responses to the hurricanes and their willingness to serve patients as well as fellow Associates. The best-laid plans for dealing with hurricanes and other emergencies can sometimes be rendered ineffective by the swiftly changing nature of these events, but it is our Associates, who, through dedication and the willingness to do whatever needed to be done (regardless of whether or not it was included in their job description), truly demonstrated our mission in action.

Because of the past experiences CHRISTUS regional and system staffs understood how to carefully track the progress of hurricanes Ike and make preparations. Based on the past experience with Gustav, Humberto and Ike, the tools developed in the aftermath of Katrina and Rita need only some updates and “tweaking” as part of continuous improvement processes.

Health Care Coverage Matters

CHRISTUS Health pledged to support and promote Cover the Uninsured Week, a nonpartisan, nationwide effort to urge U.S. leaders to make health coverage for Americans a top priority, held March 22-28. Now in its seventh year, Cover the Uninsured Week is a national effort to highlight the fact that too many Americans are living in a precarious position without the “safety net” of health insurance.

CHRISTUS’ commitment to providing coverage for the uninsured is based on our Catholic heritage, commitment to social justice and our mission of extending the healing ministry of Jesus Christ to everyone.

It is estimated that 18,000 - 22,000 Americans die each year because they don't have health coverage. While extending coverage to all will be a tremendous undertaking, it is imperative that the effort to get all Americans covered begins now.

CHRISTUS Health works daily to serve the uninsured. CHRISTUS is the number one Catholic health care system in providing community benefit, and CHRISTUS facilities and programs also offer discounts to the uninsured and underinsured who qualify.

Living without health coverage is a growing problem that touches many working families. That is why it is so important for CHRISTUS Health and the communities we serve to come together to demand that our lawmakers continue to work to find solutions and ensure that all Americans are covered.

Following is a recap of some of the events and activities hosted in our regions in support of Cover the Uninsured Week, the nation’s largest mobilization on behalf of America’s 47 million uninsured.

CHRISTUS St. Patrick Hospital

On March 20, CHRISTUS St. Patrick launched its Cover The Uninsured Week activities with A Black Tie Affair benefiting the Calcasieu Community Clinic, which provides free ambulatory medical care and pharmaceuticals to the uninsured and underserved. Other activities hosted throughout the week included:
March 24 – Health Fair at the SWLA Center for Health Services with free health screenings and registration of children in the Louisiana Children’s Health Insurance Program (LaCHIP), which provides free or low-cost health insurance for children. The event was hosted by several community health agencies, including CHRISTUS St. Patrick School-Based Health Centers, and was promoted with a live remote broadcast by local radio station KZWA
March 25 – CHRISTUS St. Patrick hosted a Cover the Uninsured Community Breakfast with a live remote broadcast by KZWA
March 26 – 27 Free health screenings were provided at the Calcasieu Community Clinic and the CHRISTUS St. Patrick School-Based Health Centers sponsored events at five locations to register children in LaCHIP

CHRISTUS St. John Hospital

On March 25-26, the hospital sponsored a manned booth where passer-bys could pick up information on Cover the Uninsured Week and participate in a variety of give-aways. The booth was put into place for a week-long Spring Fling event planned to celebrate National Hospital Week and National Nurses Week.

CHRISTUS St. Vincent Regional Medical Center

Alex Valdez, CEO for CHRISTUS St. Vincent , announced $410,000 in community gifts to increase access to primary care and prevention services. In addition, the facility included prayers specific to Cover the Uninsured Week during daily chapel services and hosted editorial board meetings with the media which included a focus on the uninsured as a primary topic. On March 20, CHRISTUS St. Vincent held an employee health fair and had representatives of the employees’ health insurance plan on hand to answer questions. In addition, CHRISTUS St. Vincent participated in other employee health fairs to encourage insurance enrollment and joined with the Hispanic Chamber of Commerce to host Cover the Uninsured Week activities. On a related note, CHRISTUS St. Vincent will participate in Health and Human Services week in April, with proceeds used to increase access to health care services and information.

CHRISTUS Schumpert Health System

CHRISTUS Schumpert’s local Cover the Uninsured Week activities began with a prayer service on March 23 at the Martin Luther King Health Center in Shreveport, which has been providing free health care services for more than 20 years. The service was led by Bonnie Burnett, vice president for Mission Integration at CHRISTUS Schumpert, and Sister Sharon Rambin. Also as part of national Cover the Uninsured Week, CHRISTUS Schumpert and the Department of Health and Hospitals teamed up with Wal-Mart to enroll families for the Louisiana Children’s Health Insurance Program (LaCHIP). Other programs and outreach targeting the uninsured and underinsured were offered as well.

CHRISTUS Health Central Louisiana

CHRISTUS St. Frances Cabrini Hospital:
On March 23, elected officials, community leaders, and guests gathered at 10 a.m. in the Outpatient Center of CHRISTUS Saint Frances Cabrini Hospital celebrate the beginning of Cover the Uninsured Week. After an introduction by Stephen F. Wright, CEO of CHRISTUS Health of Central and North Louisiana, Alan Levine, Secretary Louisiana State Department of Health and Hospitals, discussed the state’s efforts to meet the needs of the uninsured.

The hospital also conducted or participated in the following events, all of which were designed to increase enrollment of children in LaCHIP, the State Children’s Insurance Program: a health fair at Carter C. Raymond Middle School on March 23; an outreach by the Medicaid Office in the main hallway of the hospital on March 24; a health fair at Buckeye High School in Deville on March 2; and neighborhood outreach initiatives on March 26-27.

A guest commentary publicizing these events and encouraging more families to enroll in LaCHIP appeared in The Town Talk on March 27.

CHRISTUS Coushatta Health Care Center:
Throughout Cover the Uninsured Week, information on Medicaid, LaCHIP, and a medication assistance program was available in the hospital. In addition, a representative from the Department of Health and Hospitals was available on March 27 to enroll participants in the Kid Med program.

How Hospitals and Physicians might Avoid Reimbursement Cut Jitters

The Wall Street Journal Health Blog recently reported that many physicians are asking Congress to change a system that forces them to block reimbursement cuts every year.

By many measures, whether clinical effectiveness, accessibility or affordability, health care in the U.S. is not performing well, and is broken in many of its processes and outcomes. The typical approach to something that is broken is often to apply more resources, thinking that more will solve any and all problems.

However, the Obama administration has stated repeatedly that the expenditures in health care are excessive, and in fact believe that the U.S. economy can only be fully healed if health care costs--which are a significant part of our gross national product--are significantly reduced.

This is based on data--that has been reaffirmed on numerous occasions and through numerous processes--which indicate that although millions of Americans do not have access to good care, there is an even larger portion of Americans who are receiving excessive care. Because excessive funding for this care has been available in some communities, many of these locations now have an oversupply of hospitals and the technologies that are inherent in each.

This is best demonstrated by the number of CAT scans and MRIs that are available for use by the population who live near the health care facility. It is well-known that if MRIs, CAT scans and basic cardiology, radiology and laboratory services are duplicative, they will be over-used, resulting in much-higher utilizations when compared to the acceptable norms.

Because of this knowledge, Obama and his team believe, appropriately so, that the “fat” in health care causes excessive expenses which could be reduced significantly if protocols based on evidence-based medicine were utilized consistently throughout the country.

Likewise, these phenomena require excessive expenditures to pay for them through governmental payment systems including Medicare or Medicaid, or through private payers, which would include private insurance companies and self-pay (for those who have no insurance).

Because it can be proven that these payment costs are excessively high based on overutilization or misutilization, both physicians and hospitals face the possibility that the government and insurance companies will arbitrarily reduce their reimbursements for what they believe to be unnecessary services on an annual basis. In addition, because a larger portion of self-pay individuals are unable to pay for these highly expensive services, the portion that they pay is continually declining, and results in the rising bad debt that plagues almost every health care provider in the country. We expect this trend to continue to worsen, especially as the global economic crisis reaches its peak, resulting in higher numbers of unemployed individuals who have lost employer-provided health care coverage.

Because of this unknown each year (How much will my reimbursement decrease?), both hospitals and physicians are looking for a plan that will provide more stability and prevent the government from having to swoop in and block scheduled payment decreases on an annual basis. How can this be done? What method would make this possible? There is only one answer to these important questions.

The government, private payers and people responsible for paying their own health care bills should be willing to pay the appropriate fee based on the lowest possible cost for a service that is properly utilized only when it is indicated due to clinically evidence-based medical principles. Obviously, the cost must have a small margin built into it so that new and innovative technologies can be explored and acquired when they have proven themselves to provide an even more cost-effective, high quality improvement to the protocol. Recognizing that this margin is reasonable if it is applied to the true costs of a properly constructed utilization protocol for any procedure or service, then it should be consistently reimbursed, and could be built into health care reform successfully. Such a priced procedure would only be impacted by the inflationary cost of supplies and labor, which could be analytically determined and justified into incremental reimbursement rates each year. These could be considered in the budget preparations of both the government and private payers, and would need to be budgeted for by the self-insured individual in his/her personal expense accounts.

If overutilization could be removed from the equation described above, the tension created every year by the government/other payers wanting to reduce their reimbursement to physicians and hospitals could be reduced. These payment rates would eventually be driven by appropriate utilization and pricing structure, and would form a system that could tolerate supply and labor cost adjustments, both positive and negative, depending on the economic situation at the time. For today, this would mean in fact that the prices could possibly be reduced since during this global economic crisis we are seeing a reduction in both supply and labor costs.

It would seem that the stability resulting from the structure outlined above could be a significant answer to the questions that were raised and provide a roadmap for the cost reductions that are being demanded by both the Obama administration and the insurance sector without significantly reducing the quality of care and the reimbursement for those who are providing it.