DOCUMENT INFORMATION

David C. Pate, MD, JD, is senior vice president and chief executive officer of St. Luke's Episcopal Hospital. Dr. Pate has served St. Luke's in many capacities, beginning in 1983 as an intern and later chief medical officer. He joined the St. Luke's medical staff in 1986 while in the private practice of medicine, became vice president for primary care development in 1993, senior vice president in 1997 and chief medical officer in 2001. He earned his bachelor's degree at Rice University and his medical degree at Baylor College of Medicine in 1982. In 1996, Dr. Pate received his law degree, with honors, from the University of Houston Law Center, where he continues to serve as an adjunct professor.

In May 2008, he spoke with Jennifer Towne of the Quality Center around health improvement processes.  He commented around the following questions:

Defining health care quality
Employee engagement and how it influences care

• Learn more about how employee engagement influences quality of care from the American Society for Healthcare Human Resources Administration (ASHHRA) of the AHA, the nation’s only membership organization exclusively dedicated to meeting the professional needs of human resources leaders in health care.

Lean methodology
Standardization
Success
Lessons learned

In the last three years there has been a movement in improve quality. Please define quality and why has there been such a movement to focus and improve quality of care?

Defining quality is a challenge; it depends on whose eyes. What's really important to St. Luke's Episcopal Hospital is the consumer's view of quality. [The consumer includes the] patient, the physician, the employer or payer and the government. I think this is one of the challenges for physicians and hospitals because everyone looks at quality different. That's why a single measure of quality doesn't exist.

I look at a broad view such as the safety of care we provide, CMS core measures; and then I look at outcomes and the patient experience. Patients expect they will get safe care, that they will get the best care available and that they'll have a good outcome. They also care about that experience.

For physicians, they look at the quality of the nursing staff. Physicians know that life will be a lot easier and the patient will get better care if there is a high quality nursing staff. They will also consider things like excellent consultant because these days, as sick as the patient's are in the hospital, they know the quality is going to be better if they have access to specialists. Finally, physicians are looking at how efficient a hospital runs since the broken physician reimbursement system makes every physician strive to be more productive to maintain their income.

The employer and payers are looking at things different. There are a variety of measures and physicians haven't always agreed with them. But they are looking at was to provide value to the people that they insure. And then the government has been focusing on the particularly care processes and core measures.

So why focus on quality of care? I think it is a value equation. I think that from a global standpoint, the United States is looking at why we are spend so much on health care and don't have the quality outcomes that other countries have. What we pay and what we receive in return are driving forces.

The Institute of Medicine and Institute for Healthcare Improvement have increased both patient and industry awareness of quality issues. When they tried to quantify the number of patients that die each year in hospitals due to consequences of their care, I think that really hit home. These are all things that caused the industry to face up to the fact that care is not as safe as it could be and our outcomes are not as good as they could be and we need to all be focused on this.

SLEH is in the middle of a 5-year change management campaign. One area of focus is employee engagement. Why was this a concern and why is engaging employees important to the culture, patient care and patient safety?

First for those who may not be familiar with what is meant by employee engagement, I think it is important to make a distinction from employee satisfaction. Satisfaction varies day-to-day. But this fluctuation in satisfaction levels doesn't matter if employees are engaged. And we all really know this, we experience it wherever we go, whether it's a restaurant or store, you run into people and you can tell who's engaged and who's not because they treat you differently.

Engagement is really a physiological investment with the organization. It's a sense of "do I belong, is this organization a fit for me. Do I believe in what it's trying to do and do I want to further its mission and goals." Engaged employee will provide better outcomes. Gallop has a tool to measure engagement and have done studies to look at the difference that occurs between engaged and non-engaged employees. Absenteeism, turnover, safety incidents, those employees not engaged are more likely to have an safety incident than engaged employees. Take customer service for example. Walk through your halls and look lost and see how long it takes before someone helps with direction. That's an engaged employee versus the one that walks past you even though they know you are struggling to figure out which way to go. Customer service, productivity and profitability are all greater with engaged employees.

When I became CEO two years ago, the organization had gone through strategic gymnastics, mergers, sale, new system CEO. It was very discouraging to the employees at the hospital and there was a lot of uncertainty. I tried to get out there and communicate and interact with the employees. I knew that engaged employees were critical to my success in quality and patient safety. 

St. Luke's is using lean methodology as a tool in its change management campaign. Did you look at other methodologies, why did you choose lean? Why did you think it would work in the culture?

When I first became CEO, letters from the patients had a profound effect on me. Most of them were uplifting, praising the care they received in the organization. But I noticed that I also had a stack of letters saying it was a terrible experience. I thought, how can this happen, it's the same organization. The answer that occurred to me was that there was too much variation. If my wife was coming to the ER and it was late at night, would I care who was on duty, would I trust my wife's care to the system to know that whatever day or time of day I brought her in, she would receive the best care? If I was honest with myself, I would say no. I would want to know which doctor it was so I could determine if that was the doctor I wanted to take care of her. I wanted a system that no matter what time people came in they could be assured they would receive the best possible care. The root of the problem was too much variability. We need to do more to standardize care. There is too much inefficiency.

I wasn't familiar with any of these process improvement methodologies, but I started reading about lean and thought this was exactly what we need. I wanted to make process improvement ingrained throughout the organization, make it the responsibility of every manager, we trained everyone on this methodology, we use it was a standard operating process and we aren't going to be using it just this year. I wanted to focus on eliminating waste in our system and a lot of it is waiting time. And I wanted to focus on bringing value to these customers and make our care more efficient.

We did a lot of communication back to the organization. People don't understand what lean is. They think, with the name, that it means downsizing. The key was when we started realizing a lot of success. We brought those people back and had them talk to the rest of the organization about what they did and what they accomplished. We then chronicled everything and put it on our intranet.

One of the 6s in lean is standardization. Ten years ago, there was a movement in the health care industry for more standardized processes. The movement didn't go far. There was a lot of backlash with employees saying this won't work with every patient, with doctors saying that medicine is a mix of art and science, you can't have standardization. Why is it becoming more acceptable now?

Standardization backlash is certainly a barrier that I've had to deal with. Every patient is an individual. There is a lot of focus, as it should be, on patient centered care and it should be. However, that said, there is evidence of best practices. There are some things that we just need to all agree on. Yes, the patient is an individual, but every patient ought to receive this level of care. If the process gets standardized, then every patient gets the same care every time on a timely basis. This is the benefit to standardizing care.

Physicians are opposed to cookbook medicine. And one of the concerns is that they are afraid that it'll take away from their individuality and if they all did things the same way, they wonder how they'll compete with other doctors.

It gets to a couple things. One thing is we work at the hospital where we and our families get our own care. Do you like this variability where it matters who's on call or who's working and what time of the day the patient comes in? Why shouldn't every patient get the best possible care? We need to look at what is right for the patient because it could be you or a family member. We need to stop thinking individually. We need to come together to do what is right and do it consistently right then our outcomes will improve.

In a culture with public reporting and pay for performance, we'll all do better. If doctors are doing things differently for patients with the same condition, then, by definition, someone is getting better care than someone else. That's not what we want. It takes a lot of work and persistence. You have to show the doctors the data and show them how it is making a difference, how it's improving patient care and how it's making things better for them.

How are you going to know that SLEH's 5-year change management campaign is successful?

One, I would hope at the end of the 5 years when I ask everyone in the room, "if the person you most loved was admitted, would you trust the system." Hopefully everyone will say yes, they don't today.

Second, after having been a physician and then becoming a CEO, I was surprised on how little data I had making management decisions. When I cared for patients, I had a lot of data and objective measure on what to do for my patients. I had a lot of things to help me assess the status of my patient's condition. I didn't have this information when I first became CEO.

We manage by metrics now. Everything that is important for us to be spending time on has to be measurable, otherwise how do we know it is improving? One of the ways I'm going to know that we are obtaining our goals is by measuring all these things-room turnaround, ER wait, etc., We are benchmarking against ourselves and externally. Internally you can tell if a process is broken by looking at your performance. If your measurements tell you that you are only making goals 70 or 80 percent, then the process is broken. Those are ways that we'll be able to tell if our processes are fixed and we are truly delivering high quality care more efficiently and with better outcomes.

Here a few things that I've learned.
First, this can't be successful unless the CEO owns it. The CEO needs to invest a lot of time. I have a meeting every week with my executive staff. I have a biweekly lean report and on the opposite week, we walk through the department. You learn a tremendous amount on what people are doing and you see who are the rising stars. It's also important because employees see the CEO walking the talk. I can say it's a priority, but if they don't think I make it a priority, then they won't buy into it.
Don't use lean as a tool. Many CEOs are looking at lean as a tool rather than organizational transformation. You'll get quick improvement by implementing it on projects, but it won't be sustainable. It needs to be ingrained in the culture.