Independent hospital earns prestigious Malcolm Baldrige quality award

January 15, 2019


An independent Catholic hospital in Jasper, Ind., has won the 2018 Malcolm Baldrige National Quality Award, the federal government's highest recognition for performance excellence. The 137-bed Memorial Hospital and Health Care Center will claim the award at an April 7 conference in National Harbor, Md., hosted by the federal agency overseeing the quality program. That agency is the U.S Department of Commerce's National Institute of Standards and Technology.


Just 115 organizations have received the award in its three-decade history, including five in 2018. The program includes a rigorous framework for improving the operations and performance of organizations of all kinds. The very top performers receive the national Baldrige award having demonstrated significant quality improvements.

Lori Persohn, Memorial Hospital's director of organizational excellence, led the facility's pursuit of the award. "We wanted Memorial Hospital to be the best place for our patients to receive care, the best place for our staff to work and the best place for our providers to practice," she says. "We wanted to remain an independent community hospital."

She says the hospital found an effective way to further all these aims through the Baldrige framework.

Melanie Powell, the hospital's director of business development and marketing, adds that hospital leaders have made it a priority to keep Memorial independent, so the people who live in and care about the community can guide the hospital's course. Powell says the Baldrige process "helped us understand how to be stronger, so we can remain independent."


High performers
According to information from the standards and technology institute, the Baldrige process guides organizations in setting quality-improvement goals and achieving measurable gains in seven areas: leadership; strategy; customer engagement; measurement, analysis and knowledge management; workforce motivation and engagement; operations and results. Organizations are coached by the institute's Baldrige program staff and get feedback and assessments from a team of experts who conduct site visits. The organizational improvement process typically spans several years.

To compete for the national award, organizations must first gain recognition in regional Baldrige-based programs. Applicants for the federal-level award enter in one of six categories: manufacturing, service, small business, health care, education or general nonprofit.

Prior to 2018, SSM Health of St. Louis was the only Catholic health care provider to earn the award. It received the national Baldrige award in 2002 and was the first health system to win it.

Seven years
Memorial's pursuit of Baldrige began in 2011 with a structured approach to improving quality and excellence it called its "Journey to Excellence," J2E for short.

Independent Hospital
w190115_IndependentHospital-1-aMemorial Hospital and Health Care Center, Jasper, Ind., pursued the federal government's highest recognition for performance excellence in order to remain viable as an independent community hospital.

Founded in 1951 by the Sisters of the Little Company of Mary, Memorial includes the hospital campus and 32 outpatient health care centers in eight counties. Persohn says the entire organization participated in J2E.

Persohn says Memorial set a goal to be in the top decile for more than 100 measures of quality, including rankings from the Centers for Medicare and Medicaid Services, The Leapfrog Group and Press Ganey.

The hospital organized teams to develop and execute strategies for improving rankings in all seven performance-improvement areas set out in the Baldrige framework.

New practices
Through J2E, Memorial developed and implemented standardized practices to move the organization toward its quality goals. These include rules for meetings. Agendas now must go out in advance, and conveners must stick to the agenda. Participants follow standardized "ground rules" and minutes go out to participants within two days of the meetings.

Memorial now uses "90-day teams" to carry out its strategic objectives. Objectives are broken down into component parts and then leaders build teams with a subject matter expert, facilitator and representatives from affected departments to implement each part within 90 days. The leaders then convene new 90-day teams — either with the same team members, different members or a blend of veterans and fresh participants — to work on the next goal.

Memorial started daily "safety huddles" in which representatives from all departments meet to talk through and prioritize emerging safety issues, and then determine how to address them. Powell says the huddles have greatly improved communication among departments.

Memorial also created an employee council, tapping about 30 employees from throughout the hospital and outpatient facilities to provide a forum to ensure staff input and perspective is taken into account in decision making.

All in
Persohn says it was a challenge to gain the buy-in from Memorial's 1,700-plus employees necessary to change how they did their work. Transparency helps. Persohn says Memorial keeps all employees informed on the J2E work, involving them as participants on 90-day teams and getting their input through the council. Hospital leaders communicate their support for J2E and the related work.

Every leader and staff member has personal performance goals linked to the broader J2E work. Employees make their own goals and review them with their supervisors. Powell says all employees have their goals imprinted on the back of their work badges.

Persohn and Powell say the standardization and strategic thinking that are now the norm at Memorial have resulted in Memorial improving its ranking in a variety of areas, including staff satisfaction, patient satisfaction and clinical outcomes such as rates of avoidable readmissions.



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