Elmhurst Hospital

Before the Framework

Elmhurst Hospital is a patient-centered care facility and a part of the Edward-Elmhurst Health System. Nearly ten years ago, the hospital was facing a state of change – a move to a new facility built from the ground up was planned and a holistic (mind-body-spirit) and transformational patient-centered care philosophy was being adopted. In order to successfully achieve patient-centered care, Sherri Hill, then Quality Director, and the CNO/COO Pamela Dunley knew the organization would require a sophisticated approach for ongoing improvement and implementation. Sherri knew the Baldrige Framework for Performance Excellence could assist in addressing the many challenges. But as is common across healthcare organizations, there can be resistance to adopting yet another “program” and this led to doubt and discouragement from some leadership. However, leadership was determined to move the organization forward, away from fragmented departments and toward alignment of their workforce, strategy, results, and more. It was then that Sherri and Pamela knew the approach had to be about the “evidence-based approach to performance excellence” without the Baldrige label.

Why Baldrige?

It was clear the leadership was interested in a strategic guide to organizational improvement. At the time, there was no other clear alternative for an evidence-based framework being used to improve performance across sectors, and specifically in healthcare. It became something the organization could apply over a period of years without folks knowing they were on the “Baldrige” journey, or with the stigma of “another program”. It was about the journey to performance excellence. Sherri began to ask questions from the framework and integrated the criteria into various department discussions about quality, safety, care coordination and improved work initiatives by focusing on using the data and results to make real progress.

The Journey to Excellence

Without 100% buy-in from senior leadership, Sherri knew Examiner training and the “best” path to understanding the Framework was out of her reach. Instead she needed to pursue other avenues of information about Baldrige to educate herself and share back with the leadership team. By engaging the leadership team with tools and resources focused on organizational excellence, she was quickly gaining the traction she needed to pursue the Framework more formally. When Sherri was named the Associate Vice President of Quality and Safety for Elmhurst Hospital, she knew she had reached a point where she could leverage her leadership alliance with the CNO/COO and begin working on performance improvement at a new level. She had finally reached the point where the organization was more accepting of the opportunity to write and submit an application through the IMEC Recognition Program.

The objective feedback from an external source was a critical, internal selling point. By applying through the IMEC Recognition Program, the Hospital would not only gain more internal clarity and consensus on their systems and results, but facilitate an honest conversation with third party reviewers. The team was on the same page and ready to pursue the organizational blueprint; a document that would serve as a guide for current and future leadership to continue on the journey to excellence. Sherri, Pamela, and members of the senior leadership team completed the application for the 2016 recognition cycle and received a site visit; an in-person perspective that served as a pulse check for where they were and where they needed to go. The organization was on a journey of being the best they could be – it did not matter if they called it “Baldrige” – everyone was aligned around a common goal.

After three years pursuing performance excellence – from the Framework concepts and adopting the true systems perspective, to gaining internal buy-in and application support, all the way to the site visit – Elmhurst Hospital was awarded a Bronze Award for Excellence from the IMEC Recognition Program and were honored at the annual award ceremony in March 2017.

Reflecting on Key Lessons

The Hospital’s journey to excellence was fitting for their organization and the expectations of the internal champions and stakeholders. They had pulled together the right team of individuals and were dedicated to pursuing a long-term path to performance improvement, not simply an award. The team created a structure for themselves to learn, breakdown the silos they had long struggled with, and align with the concepts of the true systems perspective. They were open and responsive to the external feedback and have committed to the continuous process and performance improvements needed to stay on the right track. Opportunities for improvement from the feedback report have generated work plans for teams to review; their inconsistencies became apparent and brought systematic needs to the forefront. As the team continues to do the work they are doing, they now have the Framework and feedback in the background to guide them. Some things are simpler than others, but the commitment to grow and improve will continue to be the true factor for success.

Results

• Dramatically reduced serious safety events by 52% in less than a year.
• Redefined the organization’s strategic plan to incorporate the criteria and ensure more systematic processes
• Contributed to the development of more highly reliable processes and results
• Engaged all levels of the organization in learning and looking for opportunities for improvement and innovation