BY: SR. MARY JEAN RYAN, FSM
Sr. Mary Jean is president/CEO, SSM Health
Care, which is based in St. Louis. Her article is adapted from a presentation
she gave in San Antonio on March 31, 2005, to CHA's annual Theology and Ethics
In 1990, SSM Health Care, St. Louis, implemented
a management approach called "continuous quality improvement" (CQI) to help tap
the potential of its employees. Five years later, SSM combined the approach with
the "Breakthrough Series," a quality-improvement model developed by the
Institute for Healthcare Improvement (IHI), and rapid results followed.
With quality improvements under way, SSM facilities began to apply for state
quality awards modeled on the Baldrige National Quality Award program. The
feedback from Baldrige helped SSM focus its ongoing quality efforts. Also, it
provided the necessary framework for quality improvements and for establishing a
culture in which leadership is encouraged at all levels. In 2002, SSM became the
first health care system to receive the Malcolm Baldrige National Quality
People frequently ask me how our system,Â SSM Health Care, St. Louis, was
selected to receive the 2002 Malcolm Baldrige NationalÂ Quality Award in the
health care category. To explain that, I'll have to go back a few years.
In 1986, when SSM came together as a formal health care system, those of us
who were the system's executive leaders eagerly sought a way to engage our
employees and physicians. Each year, at our annual leadership conference on
Marco Island, FL, we introduced a promising new management philosophy with great
hoopla and enthusiasm. Each one, we were certain, would be the one to
transform our organization.
At the end of our 1989 conference â€” at which the focus had been "servant
leadership" â€” I sat beside the hotel's swimming pool with William P. Thompson,
SSM's senior vice president for strategic development. Both Bill and I expressed
a vague feeling of unease. It seemed to us that no matter how much we
communicated our system's mission and values, some things we hoped would happen
were just not happening. Despite our enthusiasm for these management
philosophies, something was missing.
What Bill and I realized was this: Despite our serious commitment to these
management strategies, we did not see a constant striving for
improvement. We did not see managers mobilizing employees to work on
projects that were important. And we did not see processes in place that made
the best use of people's talents. In short, we recognized that SSM was not
nearly as good as it could or should be.
Although I hadn't realized it, we were doing two major things wrong. First
â€” and this may already be obvious to readers who have come this far â€” we
were prone to the management "flavor-of-the-month" syndrome. And, second, it was
always we, the system's senior executives, who were sending the truth from the
mountaintop to them, SSM's employees.
As these thoughts surfaced in our conversation, Bill and I searched for an
answer. We knew we had to find some way to tap the potential of all of our
employees, something that would help us improve the complex processes that are
inherent in health care. And we knew that whatever we did had to be for the long
Both of us had heard and read about an innovative new
management approach that, although it had been used in this country primarily by
manufacturing companies, was beginning to be tried in health care. The approach
was known as "continuous quality improvement" (CQI) or "total quality
management" (TQM). Because it sounded promising, we decided to explore it.
To make a long story short, we implemented CQI throughout the system in 1990.
There isn't space here to describe what it was like to make CQI SSM's culture.
Today it can be seen everywhere in the system â€” in our billing processes, in
our surgical suites, on our nursing units, in our emergency departments, in our
dietary departments, and in administration.
Today we at SSM constantly share information, about failures as well as
successes. We share "best practices" and innovative initiatives through
systemwide conferences, "benchmark" visits, our intranet site, phone calls, and
structured face-to-face gatherings. And we constantly compare ourselves to the
very best, both internally and externally.
But that's SSM today. Fortunately for me, I had no idea in 1990 what the
extent of our commitment would be. I guess ignorance is bliss, because back then
I was proud of the fact that I â€” an extremely impatient person â€” was willing
to give the approach five years. By 1995, I assumed, we would have improved
Help from IHI and Baldrige
I was certainly mistaken about
that. In fact, when 1995 came around, we found that we hadn't progressed very
We didn't give up, however. Instead, we looked for tools that would help us
focus our improvement efforts and achieve results more quickly. For the first,
we turned to the Institute for Healthcare Improvement (IHI), a not-for-profit
firm based in Cambridge, MA. The IHI offers a model, called The Breakthrough
Series, with which health care organizations can make rapid improvements in
quality while reducing costs.* And the IHI's model did help SSM achieve rapid
improvement, which, in turn, brought an enormous increase in morale. The
Breakthrough Series turned out to be the missing link between CQI and rapid
For help in focusing our efforts, we turned to the Baldrige National Quality
Since it was established in 1987, the Baldrige program has helped U.S.
organizations, public and private, improve the quality and efficiency of their
Until 1999, health care organizations were not eligible to compete for the
actual Baldrige award. Even so, beginning in 1996, SSM facilities began to apply
for state quality awards modeled on the Baldrige. Although our facilities
applied to these state awards to get feedback, they actually began winning
awards, to our surprise and delight.
What has the Baldrige process done for SSM? It has given us a framework, a
focus, and discipline. This framework, focus, and discipline were essential
because our CQI approach to improvement was scattered and thus didn't have the
overall impact that it could have had. Basically, the Baldrige program provided
a new lens through which we could see our organization. It offered us a way to
systematically evaluate our entire organization and understand the linkages
among the hundreds of processes that make up the health care experience.
For instance, we realized, after just reading through the criteria for the
Baldrige Award, that we had 21 pages of mission statements for
our individual facilities, rather than a single mission statement for the
system. Now, if it's focus you need, 21 pages of mission statements is probably
not the way to achieve it. That's human nature, I suppose: We often overlook the
things that are excruciatingly obvious to others. The Baldrige program helped us
at SSM see things we couldn't see for ourselves.
However, we did at least have the good sense to involve our nearly 3,000
employees, at all levels of our organization, in a yearlong process to
articulate a single mission statement for SSM Health Care. They did an amazing
job. The statement they came up with has only 13 words: "Through our exceptional
health care services, we reveal the healing presence of God." It's a great
mission statement. When, in 1999, health care organizations became eligible for
the Baldrige Award and SSM entered the competition for it, we made the statement
the focus of our first Baldrige site visit. We were so proud of it that we
bragged to the examiners. "Isn't it great?" we asked them. And when we got our
feedback report, we learned that the examiners did indeed think that those 13
words constituted a great mission statement.
And then the excruciatingly obvious reared its ugly head again. The feedback
also told us: "You say you want to deliver exceptional health care
services. Yet you haven't defined 'exceptional' services, and you
certainly can't measure them until you define them." Besides that, the feedback
pointed out that we had been comparing ourselves to averages, rather
than to the best when setting our performance goals. So, for example,
we were pleased to demonstrate that our infection rates were better than
average, employee satisfaction was better than average, and patient loyalty was
better than average. But when the examiners saw all those "averages," they
reminded us that our mission statement doesn't say, "Through our better than
average health care services, we reveal the healing presence of God!"
Talk about the excruciatingly obvious!
As a result of this feedback, we figured out how to translate our mission
imperative â€” that is, "exceptional health care services" â€” into specific and
measurable goals. We set those goals based on nationally recognized
best practices for clinical outcomes, satisfaction, and financial
What else did we learn from Baldrige? Among many other things, over
four years and some 200 pages of feedback, we learned that our messages were not
consistently deployed throughout our vast organization. We learned that although
we had human resource goals, they were not integrated into a strategic and
financial plan. We learned that we were better at tracking our finances and
operations than we were at tracking the clinical results of our patients. And we
learned that we did not have a consistent complaint management process.
As readers may have guessed, we've spent considerable time making
improvements based on our Baldrige feedback over the years. We've figured out
how to deploy a consistent message throughout our organization. We now have a
strategic, financial, and human resources planning process. We've learned how to
track the clinical results of our patients. And we've developed a complaint
management process that is used systemwide.
At SSM, our commitment to improve is driven by our belief that what we do is
more than a job, more than a career; it is a sacred trust. Baldrige has
helped us move in the right direction, and that's the good news. The bad news is
that while we are far better than we ever were before, we are still not where I
want us to be.
People sometimes ask me if I'll ever be satisfied. The answer is: "Yes, I
would be satisfied if, as a system, our patient loyalty was 100 percent, if
every single one of our patients was completely safe 100 percent of the time, if
there were no needless deaths, if our clinical outcomes were the best
in the world, if physician and employee satisfaction were 100 percent, if we
were the employer of choice in every one of our communities, and if we were the
hospital of choice in each of our communities. Then I would be satisfied.
Maybe." But until that day comes, there's work to be done.
The third element that helped us improve
quality was seeing leaders at every level of the organization.
As the system's CEO, I realize full well that our success as an organization
rests not in my hands. Rather, success rests upon the people who day in and day
out â€” no matter how tired they are â€” form teams to keep our patients safe,
develop processes to prevent infections, and work together in all sorts of ways
to provide exceptional care. Our success rests upon the people who offer a
gentle touch, a kind word, an open ear, a good idea. Let me tell you about one
of the people in SSM who offered a good idea.
Armando arrived in Madison, WI, from Mexico a couple of years ago and got a
job in housekeeping at our St. Marys Hospital Medical Center. In Mexico, he had
owned his own catering business. Not only was he adept at cooking; he also had a
keen mind for business. However, he did not speak any English. But Armando's
potential quickly became obvious at St. Marys and his supervisor suggested that
he enroll in the English as a Second Language course offered, free of charge to
employees, at the hospital during work time.
As Armando's English improved, his confidence on the job increased. When an
opening occurred in the hospital's cafeteria, Armando applied for it and got the
job. He continued with his English classes. It wasn't long before Armando saw
ways to make improvements in the cafeteria. And he took a huge risk. With the
help of his English teacher, Armando presented a written proposal to his
supervisor. He had noticed that when tomatoes were sliced for sandwiches, the
end slice containing the stem was thrown away â€” thereby wasting part of the
tomato. He suggested that the end slice be diced, and that the diced tomatoes be
put in the salad bar. He calculated that his proposal would save St. Marys
nearly $4,000 annually.
Now this story is about several things. It's about an exceptional manager who
recognized the potential of an employee, and about a hospital that created the
environment that called forth the leadership potential of an employee. But,
above all, it's about the employee's willingness to step out of his comfort zone
and demonstrate leadership.
Of course, the reader may be thinking: "We're talking about $4,000 out of an
annual hospital budget of $500 million. That's nothing." However, I would argue
that Armando's suggestion is indicative of the kind of contribution that is
possible when you cultivate a culture in which every employee is a leader.
Such a culture is essential for SSM's success. We believe that we must make
it not just possible but imperative for people to contribute, at all
levels of the organization. If we fail to create that kind of culture, we
jeopardize our ability to achieve our mission.
Let me mention some other leaders, leaders whose story has inspired us for
more than a century.
In 1872, Mother Mary Odilia Berger, a German nun, wrote a letter to the only
person she knew in the United States, a man she had nursed during the
Franco-Prussian War two years earlier. This is what she wrote: "Dear Mr. Wegman,
the present state of affairs [in Germany] is so discouraging that we feel
inclined to cross the ocean."
With those words, she took a risk that is almost unimaginable in our time.
Her lifework, she believed, was to start a religious congregation and be of
service to people in need. She knew that couldn't happen in Germany; she had
tried and failed to do so there three times. So, although she did not speak
English, she was willing to risk everything by making the hazardous ocean
journey to reach a country where there was a chance â€” just a chance â€” that
she might realize her lifework.
In October 1872, five sisters sailed from Europe, reaching New York City in
November. There they boarded a train and arrived in East St. Louis, IL, on
November 16th, which happened to be a bitterly cold day. They crossed the
Mississippi River by ferry. They arrived in St. Louis with only $5 among them.
The sisters subsisted by begging. They begged for money, for supplies, for
food, and for medicine, such as it was. They begged so they could be of service
to people in need. As it happened, the needs in St. Louis were great in November
1872, because that was the year of a smallpox epidemic. These sisters, these
selfless women, willingly â€” and even lovingly â€” went into the homes of
people with smallpox to provide nursing care. Often there was little they could
do other than ease a person's final hours, but they did that with love.
This is SSM's legacy. Those early sisters were willing to do whatever needed
to be done to care for the sick. In fact, they were willing to sacrifice their
own lives, if need be, to care for people with a deadly and contagious disease.
They did this because there was something deep inside them that wanted to make a
difference in people's lives â€” and that thing was leadership. I would venture
to guess that most of the readers of this article are in health care because
they also want to make a difference in people's lives.
If so, they are not alone. The vast majority of people in our organizations
are there for the very same reason. However, the question is: Are we tapping
their potential for leadership? Are we ensuring that they can make a difference
for our patients?
Let me elaborate. Every day when our employees go home from their jobs, they
become, in effect, CEOs, chief operating officers (COOs), and chief financial
officers of small corporations called "families." In these families, our
employees perform a whole host of functions, including dietary, transportation,
finance, medical emergencies, public relations, community relations â€” you name
it, they're in charge of it. They provide in-service education on topics ranging
from new math to appropriate behavior in school, from how to get into college to
how to change a tire, and including how to make Grandma's chocolate cake.
Not only do our employees manage the family's day-to-day operations; they
also establish a vision for the future, they set appropriate goals, and they put
in place strategies to achieve that future.
But then they return to work, where, in many instances, they are told what to
do and exactly how to do it. The leadership abilities that are so evident in the
home environment are never utilized in the work environment. I believe that is
an unforgivable waste of talent and potential.
What does all of this have to do with exceptional clinical outcomes? With
patient loyalty? With patient safety? Let's go back to Armando's story. Taken
literally, Armando and tomatoes have absolutely nothing to do with clinical
outcomes. But if you look at what that story represents, it has
everything to do with them. Armando's story is about the kind of
culture that facilitates exceptional outcomes; the kind of culture that nurtures
that inner something within each of us that strives to be the very best.
It is, for example, the kind of a culture that facilitated a significant
safety improvement at our SSM DePaul Health Center in St. Louis. Every year,
DePaul has about 96,000 patient transports. Approximately 95 percent of patients
(excluding those in the ICU) are transported to ancillary areas by unlicensed
personnel. Patients can be away from their unit anywhere from 45 minutes to four
During that time, how are transporters to know the severity of the patient's
condition â€” whether, for instance, the patient has a high probability of
falling or becoming confused? To ensure good communication among the various
people involved in transporting, as well as with those performing the medical
procedures involved, a CQI team developed what we call the "hall pass."
The hall pass is a form that monitors the patient's condition during visits
to ancillary areas. It is filled in by the patient's nurse, as well as by all
the various ancillary departments in which the patient undergoes testing. The
hall pass includes contact information for the patient's nurse, information
about the patient's medical condition, and updates concerning changes in the
patient's condition that might occur as a result of the procedures performed. It
also very clearly notes when the patient will require a nurse during transport.
This ensures that no patient goes to a testing area without proper clinical
Why did we develop the hall pass? The long answer would be: To foster
communication among the various "silos," if you will, because communication
helps us keep our patients safe. And that's the truth. But you may find more
significance in the short answer: The hall pass was the direct result of a
Who came up with the hall pass idea? The hospital's president? The COO? The
chief nurse executive? Me?
No. The hall pass was developed by Linda Thompson, DePaul's administrative
director of risk management, and Lisa Boyle, RN, director of patient safety.
Linda and Lisa are people in our organization who saw an opportunity for
improvement, put together a team, and developed a solution. That is real
You see, real leadership is not about authority, control, or giving orders.
It's not about titles and executive benefits. The leadership I'm talking about
does not necessarily concern corporate strategic planning or executive decision
making. Clearly, strategic planning and executive decision making are vital to
organizations, and I don't deny that there are people who must be accountable
for the overall success of the enterprise.
But if I've learned anything from our effort to improve quality, it is to
give up the illusion that because I am the CEO, I am the leader and everyone
else is a follower. Or that a chosen few people with executive titles are the
leaders, ready and able to imbue the entire organization with their infinite
wisdom. Although some of us provide executive leadership for the
system, and for facilities in the system, we have learned to say that there is
no one in SSM who is not a leader.
Ultimately, it is an executive's ability to call forth leaders that will
transform the organization.
Integrity Is the Key
After 15 years of effort â€” and
with the help of CQI, the Baldrige program, and our decision to encourage
leadership at all levels â€” our system has developed a culture of performance
improvement. But some readers may be asking, "Just why is it so imperative to
constantly push ourselves; to improve every day in every way? Don't we have
enough to do already?"
I would suggest that the reason for the pursuit of excellence is because it's
a matter of integrity. We don't make improvements solely because of
regulations or to win awards, or even because of To Err Is Human, the
Institute of Medicine's now notorious 2002 report on errors in U.S. medicine.1
We make improvements because we are people of integrity.
Let me explore that thought. The word "integrity" comes from the same root as
"integral," which means "essential to completeness." I see integrity as the
quest that human beings instinctively embark on to make themselves whole.
Innately, we know that we are not whole persons, and so we constantly strive to
be better, to be whole. And this quest continues throughout our lives. Integrity
pushes us to constantly improve.
Integrity is also something more. It has to do with how we live our values.
If, for instance, I value kindness but have been unkind to someone, I'll feel
like something isn't quite right in the pit of my stomach. If I value honesty
but find myself telling a white lie, I feel uncomfortable. But when I live
completely in sync with my values, I feel good about myself.
But there must also be integrity at the organizational level. If we
are people of integrity, how can we rest if the organization for which we work
is anything less than the very best? If the safety of our patients is ever at
risk, how can we rest? If our patient outcomes are not as good as they should
be, how can we rest?
When the first Baldrige examiners pointed out that SSM had been satisfied
with no more than better-than-average results, they, in effect, called into
question our integrity as an organization. The way I interpreted their comments
was: "If you say you're about exceptional health care services, but you're
content with better-than-average results, how can you call yourselves people of
That is a question that keeps me up at night and causes me to push so hard
during the day. I push because it is through our exceptional health care
services that the healing presence of God will be revealed.
Not long ago, a surgeon at one of our facilities, Cardinal Glennon Children's
Hospital in St. Louis, operated on a little boy with a cleft lip. Following the
surgery, the mother went into the recovery room, and when she saw her son, she
wept. When the surgeon asked her what was wrong, she said, "He's beautiful!" The
surgeon smiled and said, "He was beautiful before." The mother replied, "I know,
but now everyone can see it."
It is stories like this that make me push so hard. When exceptional clinical
expertise is combined with that other element â€” some people call it mystery;
some call it the healing presence of God â€” the health care experience is truly
- Â Institute of Medicine, To Err Is Human: Building a Safer Health
System, National Academies Press, Washington, DC, 1999.
Copyright Â© 2006 by the Catholic Health
Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.