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Many businesses claim to deliver quality service. But few face the life-and-death stakes that hospitals do.
Emory Healthcare CEO John Fox was dissatisfied with his health system’s “middle-of-the-pack” performance in national quality surveys in 2005 and 2006. He knew the system could do better, and patients would benefit if it did. So Fox, 60, mobilized the troops to do something about it.
The results came in earlier this year. Emory placed its two teaching hospitals — Emory University Hospital and Emory Midtown — in the top 10 among the 101 national systems evaluated by the University HealthSystem Consortium. No system had previously placed two hospitals that high in the same year.
Fox, a former health care consultant, has been CEO of Emory Healthcare — $2.4 billion in net revenue and 16,000 employees — for a decade. He talks about the long road to improving quality and how to react to a fatal mistake.
Q: Would you please describe the quality situation before you decided to improve it?
A: I’ve never been in a place that doesn’t say we have high quality. It’s really pretty amazing in American health care. There are just no low-quality players. It’s a miracle. (I have a dry sense of humor.)
But what’s been happening the last 10 or 15 years is that the measurement for quality has gotten a lot better. A new ranking system for the teaching hospitals was organized in the early 2000s. Emory ranked in the middle of the pack in 2005, the first year of compilation. And Emory again ranked in the middle of the pack in 2006.
We weren’t happy about that. We set a goal of landing our two teaching hospitals in the top 10 in 2012.
Q: What did you do?
A: We really had to develop a culture of quality and safety, which includes avoiding medical errors. We made all the leadership — about 500 to 600 people — go to a quality academy. It was a three-day course that gave all of us the same vocabulary about quality improvement.
But local culture will trump training any day of the week. So we did other things. We established an office of quality with people and data.
We also changed our incentive compensation philosophy. The incentive plan will turn on if we achieve our financial target. But that basically means that you have access to the ATM. But you can’t get an incentive award unless a patient or family is better off. We had broad goals across thousands of people. They had to meet quality, safety or service goals to get incentive awards.
That process took several years to get rolling. But the reality was — we still were not moving up the trajectory the way we needed to be. We had a lot of people — physicians, nurses and others — who were very busy on their own hamster wheel that they’ve been on for years.
In 2009, the results came out again. We had improved, but not at the rate we needed to land the plane in the top 10 in 2012.
Q: Then what did you do?
A: I said we’ve got to make this more intense. More quality improvement training would not have done it. We had to bust through a different way. We put ourselves on a treadmill.
We set up a group called the Quality Acceleration Team, which had 60 or 70 leaders on it. Every two weeks, we would meet for four hours starting at 7 a.m. on Wednesday. The goal was to look at obstacles we had, to bring issues that we were not moving the needle on. In the room, we had physicians, nursing, lab, pharmacy, finance, information services. Health care is a team sport.
The goal was to make decisions right there to move the needle. We might reprioritize staff projects.
The Quality Acceleration Team was probably the last piece of the puzzle. Everything we did was important, but once that bit in the rankings really started to jump. It was the secret sauce. Before that, people were not talking directly enough to one another.
Q: Do you have other tips for any leader who wants to improve quality?
A: Make sure you’re engaging people and not pounding the table. Pounding the table does not work. People are doing what they’re doing because that’s the local culture or that’s what they’ve been trained to do. You’ve got to slow down and listen to them.
The other thing is that when you’re trying to change culture, the currency of leadership is time. If I and the rest of the leaders at Emory are not working on quality, not putting a lot of time into it, it would not be seen as important. I was strapped to the mast at the Quality Acceleration Team meetings like everyone else. There were no exceptions.
A lot of times, leaders say something is important and then they are off on financial issues or something else. Wherever leaders spend their time is what’s perceived as really important.
Q: Where do you go from here?
A: We are not error-free. We have to be vigilant.
Also, transparency is one of our values. Several years ago, a patient donated his own blood for surgery. There was an error in the lab and the patient’s blood got mixed up. He goes to surgery, gets the wrong blood and dies.
Unfortunately, those kind of things happen in American health care. The key for me is how we handle it. The physician did exactly the right thing. He went out and immediately told the family what happened. It was a terrible message to deliver, but the family was told all that we knew.
We believe we have a moral obligation to disclose the truth. We believe the truth is going to come out anyway. Patients understand health care is not risk-free. We create more problems by hiding things than we do by sharing them. I believe that down to my soul.
Each week, Sunday Business Editor Henry Unger has a candid conversation, called “5 Questions for the Boss,” with a top executive in Georgia. Some remarks are edited for length and style.