In the recent NEJM Catalyst Insights Council survey report on high-performing organizations, Kaiser Permanente, the Cleveland Clinic, and Intermountain Healthcare receive top mentions as high-performance role models. Insights Council members from each of these organizations say they are flattered to be considered high-performing, but they believe there is still so much room for improvement.
“I think we’re on the right path as a national health care system, trying to become more patient-centered and to streamline efficiencies that for decades have not been there,” says Jacob McKeegan, MD, Medical Office Chief for the Arapahoe Medical Office of Colorado Permanente Medical Group, a division of Kaiser Permanente in Centennial, Colorado. “The more data that comes out, though, the more work there is to be done. Physicians are getting burned out and patients are getting less value from their care. We need to stop carrying that trajectory forward.”
Survey respondents largely believe that there are few high-performing organizations — 74% say less than 20% can be called high-performing.
“To be a [high-performing organization], we need to be able to deliver the same care to every patient every day,” says Robert Estridge, Jr., PA-C, physician assistant and APP Director of the Express Care at the Cleveland Clinic in Ohio.
Estridge says the Cleveland Clinic, which has over 52,000 employees, is constantly working at this goal. For instance, the organization recently mandated a universal safety protocol checklist after several safety events revealed a lack of standardization of protocols around policies and procedures. “Now, every bedside process, every procedure, and every injection requires a safety checklist to be filled out,” Estridge says.
The Cleveland Clinic also has eliminated hierarchies when it comes to patient safety, enabling all caregivers to “stop the line” and speak up about potential dangers, Estridge says. When he recognized inadequate staffing in one department and brought it to the attention of executives, he says, “the Institute Chairman then led the charge to staff the department appropriately.” Implementing these forward-thinking, patient-centric rules, Estridge says, moves the organization deeper into high performance.
Robert Ferguson, Jr., MD, FACS, Chair of the Department of Surgery at Intermountain Medical Center in Murray, Utah, agrees that to be considered high-performing, you have to excel organization-wide. “The seed for high performance can come from an individual department and their success can be inspiring, but you have to have cross-pollination, applying what you learn to other areas and other departments,” he says.
Cynicism is to be expected, Ferguson says, especially by caregivers who have either worked for their entire careers in a single health system, or who have always done things a certain way, but, “how leadership deals with that cynicism is how you get to a culture of excellence,” he says.
A culture of excellence is respondents’ top ranking of key attributes of high-performing organizations, but McKeegan looks at culture of excellence (74%), aligned goals among all stakeholders (61%), and stellar leadership (37%) as more of a bundle than piece parts. In his role as a clinical leader, he is “trying to empower the front line — the people doing the work — to come up with solutions” that align with the organization’s goals and contribute to a culture of excellence.
For instance, going to the front line enables the organization to find out the patient perspective and nurse perspective on why a patient is having difficulty achieving diabetic control. That authenticity and transparency illuminates “the areas we’re doing well and the areas in need of improvement,” he says, which includes looking at data from other health systems. “We need to be critical of ourselves and be aware of our own weaknesses — we can’t rest on our laurels,” he says.
Where Kaiser Permanente and Colorado Permanente Medical Group thrive, he says, is in clearly stating the goal of being high-performing, which puts him among the 55% of respondents who report their organizational goal is stated. “If we didn’t state that part of being high performance is to be patient-centric, we would revert to being more physician- or provider-centric. We need to pay more attention to patients,” he says.
Estridge is torn on whether there should be a standard definition of high performance, as he believes the concept is unique to each organization. “Consolidation in the market might change this, but for right now, what each organization does in the market is so different that we need to live up to internal standards more than industry standards,” he says.