What Business Are We Really In?

Each Scripps Health management meeting starts out by answering the question: What business are we really in? The meeting begins with a physician and a patient reliving a specific experience at Scripps to remind us all why we do the work we do. At Scripps, we believe the business we are in is to provide the highest quality of care for our patients.

Background

Scripps Health is a not-for-profit, community-based healthcare delivery network that includes four acute-care hospitals on five campuses, 13 clinic locations, an extensive ambulatory care network, home healthcare, and associated support services. Scripps Health now has approximately 11,000 employees, more than 2,600 affiliated physicians, and $1.9 billion in annual revenue.

Structure for Quality

At Scripps, quality denotes patient satisfaction, patient safety, and clinical outcomes. While it may sound unrealistic, Scripps considers every employee and physician to be on our Quality Committee. During a series of interviews conducted a couple years ago, we asked numerous staff, managers, and executives, who is accountable for quality, and each one of them said “I am.”

On a functional level, here are three key committees focused on quality throughout the organization. At the highest level, we have a Board Quality Committee. The Board Quality Committee is chaired by a board member and includes six of the 14 board members (43 percent), two former board members and the chairman of the board. The Board Quality Committee meets on a monthly basis to discuss performance metrics and share best practices.

In addition, Chris Van Gorder, the CEO of Scripps Health, chairs an Executive Cabinet meeting with the chief executives at each of our business units as well as other corporate executives. There is a standing quality agenda item at each weekly meeting.

As the chief medical officer, I have the executive accountability for quality. I chair the Joint Quality Leaders meeting, which includes an administrative quality leader and a physician quality leader from each of our hospitals, Home Health, and Scripps Clinic.

One of the most important things we have done recently is hire an administrative counterpart to my position at the corporate office. I work with Mikele Bunce, PhD, who has a strong background in quality, performance improvement, and pay-for-performance.

Mikele and I have no formal relationship with the quality leaders and the physician quality leaders throughout the system, but our Joint Quality Leaders meeting has created the crucible for the exchange of ideas across campuses. We understand that quality patient care occurs at our hospitals and clinics, and we see our role at the corporate office as support for the work done at the sites. This monthly meeting focuses on key quality metrics where our current performance is below our target (which we title The Red Zone), work done at system-wide quality subcommittees (e.g., Stroke Taskforce, Risk Managers Meeting), information systems for quality, culture change, and industry news/planning for the future.

Accomplishments

Over the past year, Scripps has made a number of changes, which we believe have been very successful. Of primary importance was the creation of a three-year corporate quality plan. Our plan is organized into sections: Strategic Planning; Competencies; Education/Communication; Measurement and Reporting; Quality Initiatives (Clinical Care, Patient Safety, Patient Satisfaction); Monitoring and Accountability; Reward, Recognition and Reinforcement; and Industry Leadership and Innovation — all focused around quality. We looked at activities in each category along a spectrum from “meeting regulatory requirements” to “performance excellence,” rated our current performance, and then analyzed the gap between current performance and performance excellence. Our plan was developed to close that identified gap and move our organization along the continuum towards performance excellence where needed.

This was the first year that Scripps had a Success Shares plan. Scripps bases 25 percent of management incentive compensation on quality metrics, but for the first time ever, all staff had an opportunity to receive a significant monetary incentive payment based upon financial performance and patient satisfaction scores. By meeting our goals, we just paid out approximately $8 million to employees, exemplifying our belief that everyone in the organization is responsible for quality.

We have developed a number of educational events for our employees and physicians. On November 30, 2007, we had our Inaugural Quality Summit, which focused on surgical patient safety. We also have a performance improvement training scheduled for our whole management team on January 30, 2008, as well as a five-day “master’s level” program for those interested in more detailed knowledge and skills beginning spring/summer 2008.

Scripps created a new quality award, which is a recognition program for multidisciplinary teamwork on projects developed from evidence-based medicine. Awards were presented at the Quality Summit. Each facility had a team winner and the perpetual award is hanging in a place of prominence at each facility.

Scripps continues to work on its information systems for quality. We have completed phase one, stage one of an enterprise data warehouse, which we call our Quality Data Management System (QDMS). QDMS will support our efforts in quality as well as clinical research, and then expand to other areas such as finance. In addition, we have continued to work towards deployment of an electronic medical record. Our chief nurse executives have taken this project to another level by standardizing workflow across campuses to decrease variation, which, in turn, improves patient safety and clinical outcomes.

Scripps Health’s promise to our board of trustees are the performance metrics tied to our strategic plan. We create one-year objectives to meet our three-year goals as we believe that culture change is a multi-year process. In 2007, Scripps Health met our Quality Strategic Objective targets for patient satisfaction, patient safety, and clinical process measures. In addition to clinical process measures, we monitor outcome measures of interest to our patients. Our Medicare mortality rates continue to be some of the best in the nation.

Most recently, Scripps was named as one of FORTUNE 100’s Best Companies to Work For 2008 (#56). We believe it is a truism that the more satisfied your employees are, the more satisfied your customers will be.

What Have We Learned?

Quality is a responsibility of everyone. Quality has to be supported at the highest level of the organization as being a priority in the overall strategic plan.

Learn from the best. Internally, we learn from each other through the sharing of best practices. Externally, we learned from a pilgrimage we took to Intermountain Health, where we heard that two of the keys to their success were developing a quality education program and creating an enterprise data warehouse, both of which have been incorporated into our quality plan.

Quality/performance excellence requires a culture change. We do not consider our job one of quality management (i.e., maintaining the status quo), but quality improvement. Improvements require change and change can be met with hesitation and anxiety. To change our culture, we set long-term goals and short-term objectives, and communicate both to staff to motivate as well as to set attainable outcomes.

Multidisciplinary team efforts are essential to success. One cannot improve patient care without engagement and support of physicians and without the input of all affected parties.