For the nurses at Robert Wood Johnson (RWJ) University Hospital in Hamilton, N.J., most days are pretty much the same as the next. There are hordes of patients to be seen, scores of tests to run and endless procedures to perform.
It was even business-as-usual on the day when RWJ Hamilton received the nation's highest award for quality last November. When CEO Christy Stephenson heard the news, she dropped to her knees in her office. The hospital had become only the fourth health care facility to ever receive the Malcolm Baldrige Quality Award.
But for the nurses, the celebration had to wait. They were busy with patients. Sharon Brown, R.N., M.S.N., assistant vice president of nursing, was at an off-site strategic planning meeting.
Brown was devising ways to provide even better care for the 350,000 people who come through their doors each year.
She remembers her cell phone ringing with an urgent message to get back to the hospital as soon as possible. "It didn't dawn on me that we'd won," Brown says. "I just kept telling them to wait. Our meeting was too important to leave."
Brown can be forgiven for skipping one meeting. After all, it's not every day that a health care facility is awarded the nation's only presidential honor to recognize performance excellence across all industries.
With revenues of about $160 million and a staff of more than 1,700 employees, RWJ Hamilton is the smallest facility to receive the award.
But, according to Harry Hertz, the director of the Baldrige National Quality Program, the hospital is "a role model to learn from and emulate."
Quality has always been a top priority at RWJ Hamilton. But over the last six years, the hospital has reworked its policies and procedures to make its name synonymous with superior management as well as top-notch medicine.
It instituted a care model that emphasizes patients' role in their own treatment plans. The staff of each department created their own standards criteria, dubbed "five-star service standards," which guides them through everything from courtesy and etiquette to privacy and safety awareness.
The hospital staff reached out to the community with financial contributions, charity care, education programs, health fairs and screening services.
Most remarkably, the ER adopted what it calls the 15/30 Plan. It guarantees that ER patients will see a nurse within 15 minutes and a physician within 30, or the visit is free.
Since creating these policies, the hospital has seen its quality indicators shoot through the roof. Rankings for customer loyalty and patient and employee satisfaction all top 90 percent. The nurse retention rate is 99 percent and ER wait times have been slashed. And charity care has increased from $5 million in 1999 to $23 million in 2004.
But to the nursing staff, RWJ Hamilton hasn't changed much at all. Their focus, as always, is on quality care. And each department has a role to play in making that job easier. "It's the work of everyone in the hospital to focus on quality systems," says Debbie Baehser, R.N., vice president of patient services. "We really believe that we are all in this together."
Simply the best
The Baldrige Award isn't strictly a health care honor. Since it was established in 1989, it's recognized performance excellence and quality in several categories including manufacturing, service and small business. In fact, health care, along with education, wasn't added to the list until 1999.
"If the same sort of improvements that are being brought to business could be brought to education and health care, it would have major beneficial effects on the country," Hertz explains. "We operate on the philosophy that business has a lot of things that it can teach health care and that health care can teach business."
The U.S. Commerce Department's National Institute of Standards and Technology manages the Baldrige program in cooperation with the private sector.
The award is named for a former Commerce secretary who served from 1981 until his death in a rodeo accident in 1987.
Last year, about 70 organizations applied for a Baldrige award, including 20 health care facilities. More than 300 Baldrige experts review each application. The evaluation process involves 1,000 hours of review and an on-site visit by teams of examiners. Even applicants who don't win are given extensive feedback on strengths and opportunities to improve.
Recipients of the award are evaluated in seven areas: leadership; strategic planning; customer and market focus; measurement, analysis and knowledge management; human resource focus; process management; and results.
In health care facilities, Hertz says, the judges look for customer satisfaction (whether the customers are patients or, perhaps, third-party payers), community service programs, good outcome delivery and employee loyalty and satisfaction. "We look for those organizations that are both steady performers and innovators--leaders of the pack," Hertz says. "In short, we look for the best of the best."
Down to business
RWJ Hamilton never set out to win, Baehser says. Six years ago, the hospital adopted a model to change the organization's culture.
Instead of merely viewing itself as a place to patch up patients, it combined all aspects of the hospital into a coordinated business plan.
And the Baldrige model of success fit the Hamilton blueprint. "Part of the process is to help us benchmark against the business industry, not just the health care world," Brown says.
The new plan hinged on securing the commitments of every corner of the hospital, from the administrative offices to the nursing floors. "Senior leadership has to drive the changes," Baehser says. But nursing and other staff had to "jump on board with the initiative," Brown says. They needed to feel like their contributions were integral parts of the bigger picture.
Baehser helped develop a management philosophy called E-3--engage every employee. The hospital identified strategic objectives to be achieved through meeting goals from the top, down.
One of the objectives, for example, is increasing patient satisfaction. On a departmental level, a nursing unit's contribution might be raising its own patient satisfaction scores. On an individual level, each employee might be challenged to respond faster to call bells. "It involves the employees on the staff level and aligns them with the success of the organization," Brown says.
Patient satisfaction was one of three areas that the Baldrige judges singled out among RWJ Hamilton achievements, along with the 15/30 program and a vigorous commitment to community health.
In a 2002 Gallup Community Survey of customer loyalty, RWJ Hamilton ranked first among all local competitors in nine categories, including most improved; most personal care to patients; advanced, state-of-the-art technology and equipment; and the best doctors.
Seventy-three percent of customers said they were likely to use RWJ Hamilton again.
Scores for nursing were even higher. In patient satisfaction with nursing and with nursing courtesy improved from 70 percent in 1999 to more than 90 percent in 2004.
The Gallup survey ranked RWJ Hamilton as having the best nurses among local competitors in 2000 and 2002.
The satisfaction rates for the hospital's own employees has risen steadily, particularly among nurses.
Nurse retention rates improved from 94 percent in 2001 to 99 percent in 2003. Baehser attributes the trend to involving nurses in hospital policies and listening to their concerns.
For example, like other departments, the nurses drafted their own service standards, which are the centerpiece of nursing orientation.
Baehser chairs a nurses' advisory committee to attract and retain top-notch staff. Likewise, separate committees on issues like work balance and diversity have helped nurses understand that their well being matters to their employer.
In improving community health, the Baldrige judges noted that the hospital provides free health screenings for more than 900 community residents per month.
Donations to community organizations hit $140,000 in 2003, up from $80,000 in 1999. And RWJ Hamilton staff members have aided the community by serving meals at a local soup kitchen, being members on 88 community boards and raising nearly $100,000 for local programs in 2003.
Still, the hospital's most impressive achievement may be the 15/30 program. Each year, the ER sees 52,000 patients--including about 70 percent of inpatient admissions. The hospital only has to fulfill the guarantee about once a month.
How did they slash wait times? Certainly not by telling nurses to work harder, Baehser maintains. "People ask if our nurses have stop watches," she says. "I tell them absolutely not. Our nurses would rebel if we did that. They don't focus on time. They focus on taking care of patients."
Instead, the hospital changed the way the ER does business--with both subtle and significant shifts. Some changes were relatively minor. A pneumatic tube system was implemented to speed blood results to the lab.
Some triage aspects were redesigned, such as moving X-ray equipment closer to the ER and increasing bedside registration. And new digital X-rays were installed that can be accessed immediately--even by doctors from home.
But the biggest shift might have been the creation of a rapid-admit team, a group of nurses and administrators armed with clipboards. They follow incoming patients to quickly admit them and record insurance information.
That team frees the floor nurses from hours of paperwork. Baehser credits the changes with improving ER satisfaction from 85 percent in 2001 to 90 percent in 2004. And ER visits are up 100 percent from 1999 to 2003.
Throughout the nursing department, each staffer has their own opinion of why the Baldrige program selected their hospital for the award.
"Everyone thought it was because of something they did or something they told the examiners," Brown recalls. "People say, 'I know we won because I told them about our governance committee.' Or, 'I know we won because I told them about this patient I took care of.' Everyone took a piece of this and felt like they owned it. It was a nice feeling."
John DiConsiglio is a freelance writer based in Arlington, Va.
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