The Sharp HealthCare Journey to Excellence

Institutional culture change has certainly been tougher than originally anticipated. Perhaps our greatest challenge was the reality that we were good, some would even say we were very good. Status quo would have been sufficient and certainly a lot easier. The fuel that drives change can easily run dry in the face of resistance without the burning platform of poor performance. We had none of that. No one would have raised an eyebrow if we had collectively said, “If it’s not broken, don’t fix it.”

To our good fortune, our leadership at Sharp had the foresight and clarity to realize that sitting idle in today’s healthcare marketplace was not only shortsighted, but could threaten the long-term viability of our organization. The reality of pay-for-performance was coming, and we had to position ourselves with growing regulatory pressures and rising patient expectations to improve the product we delivered for our patients, staff, and physicians.

In 2001, a grassroots commitment was made to create the best place to work, practice medicine, and receive care — one component not less nor more important than the next. We called our commitment the “Sharp Experience,” based on the premise that it is the customer experience that drives consumer decisions more than anything else. We partnered with the Studer Group, a healthcare consulting organization who had created dramatic results in healthcare systems throughout the country and had a tested and proven roadmap to improve operations and service to achieve tangible outcomes.

My position as physician leader for the Sharp Experience began well after joining the Sharp Rees-Stealy Medical Group in 1994. In October 2001, I received a call from our medical director, Donald Balfour, MD, asking if I would be interested in assuming the appointment of physician “Fire Starter.” My role was defined as “bringing the Sharp Experience to the physicians of the Sharp Rees-Stealy Medical Group.”

My first several months were spent in training and learning about physician coaching and performance improvement. Fundamentally, I had to learn how to teach and train physicians and to create receptiveness and enthusiasm for cultural and behavioral change. The vision for what we were to become began to crystallize, but the pathway to change and engage physicians across a large multi-specialty group spread over 12 sites and 50 miles was more challenging.

We began our efforts with a system-wide training event for all physicians to describe and define the physician’s role in the Sharp Experience. We refined our training efforts by bringing one-hour training sessions to the site level to assist physicians in improving the patient experience and perception of care. We took a prescriptive “how-to” approach: How to create a first impression? How to foster trust? How to improve compliance, drive loyalty, and improve outcomes? Training efforts were repeated in electronic versions, prompting and reminding physicians of important behaviors that matter.

We found that as performance improved and patient satisfaction began to rise, physicians who struggled became illuminated in our evolving performance culture. Individual physician coaching was deployed for those physicians that struggled. Not all physicians responded to intensive outreach to improve, and a number of physician contracts were not renewed based on performance measures. A commitment without accountability carries little weight.

We transitioned from opinion-based performance assessment to measurement-based performance assessment. The change was an uncomfortable, pivotal, cultural shift, foundational to identifying opportunities to improve clinical and service measures. We created dashboards of performance, reported results to physicians, and coached and trained to improve outcomes. We measured hemoglobin A1C control, mammography, cervical cancer screening, controller use in asthmatics, vaccination rates, patient satisfaction, patient complaints, productivity, peer review, formulary compliance, and generic utilization. The director of quality, Jerry Penso, MD, provided lists of patients to our physicians needing mammography, cervical screening, or improved diabetes control. Performance measurement was provided to physicians, and training and support was deployed to assure every physician had the resources and support to improve.

Leaders were developed and trained to lead, and accountability for performance was embedded at the highest levels of the organization. The effort to achieve outcomes intensified, painfully at first, but as results in patient satisfaction and quality began to materialize, even skeptics confessed that our roadmap, in order to work, had to be driven by expectations and payment for performance. Physician reimbursement in our employed physician model began to align a portion of salary to clinical measure performance and patient satisfaction. Recognition for high-performing physicians was profiled to thank the best for all they had done. We found recognition replicated behavior and took little time and money. Physician recognition was more important to the physician work experience than we realized and placed the Sharp Experience as a physician-friendly cultural shift.

We began to tap engaged physician influence to drive the clinical work unit. We realized the greatest impact on front-line staff behavior was not necessarily the training they had received but what they saw their physicians say and do. A key organizational shift was to coach and train physicians to lead their clinical work unit. Physician visibility and support for the Sharp Experience was a realized necessity to sustain change. Example is not the main thing in influencing others — it is the only thing.

Our quality and service continued to gravitate to the top of databases. The better we became, the more we validated our efforts and believed in our mission. Constitutional alignment of large numbers of physicians is a challenge, but nothing made it easier than a proven roadmap to measurable performance excellence.

By the end of 2007, the Sharp Rees-Stealy Medical Group had become the number-one-ranked medical group in the state of California in quality and service out of over 170 medical groups by the Blue Cross Quality Report Card. We were the recipients of the 2007 AMGA Acclaim Award for Performance Excellence. Over the preceding five years, we had improved patient satisfaction with our physicians from the 17th percentile to over the 80th percentile. Physician satisfaction improved in each of the five measured years, and Sharp HealthCare was the recipient of the most coveted and prestigious award for organizational performance: the 2007 Malcolm Baldridge Award.

At its core, the Sharp Experience is not about our objective measures of improvement, nor the awards on a national scale, or revenue from pay-for-performance. The core of the Sharp Experience is about deploying proven tactics to change the culture of our organization. It is about succeeding by doing things better and providing every patient the care we would expect for our family. The Sharp Experience is about purpose, worthwhile work, and making a difference for those who have entrusted us with their care, and creating the sort of physician experience we hoped we would have when we joined this profession in the first place.

It has become clear again, we best serve ourselves by our dedication to others. Every patient, every time.