BY: PHILIP BOYLE, PhD
Trinity Health's experience blending two legacy organizations, Trinity and Catholic Health East (CHE), provided us the opportunity to re-examine a fundamental question: How do you institutionalize Catholic identity?
A mix of providence, discernment and hard work by collaborative design teams helped us find an answer. Our biggest breakthroughs: aligning formation and assessment; shifting the pedagogical method; and becoming aware that some time-tested management processes are essential.
POST-MERGER STEPS
From Day One of the 2013 merger, the mission integration team focused on finding the most effective way to sustain and strengthen Catholic identity. First came assessing the existing mission services across the continuum, followed by gauging institutional needs and capabilities.
The team then created a road map. It developed a document, Essential Elements for Excellence in Mission, that addresses what any ministry, including doctors' offices, surgery centers and partnerships, to name a few, has to be able to do in order to make Catholic identity part of operations. Document in hand, the mission leaders focused on what they thought were key drivers for Catholic identity: formation and mission assessment processes.
They started with an open question: Were the content and aim of executive formation true and useful for the needs of the ministry going forward? For example, if executives are present for formation for a limited number of days — six to 12 days over a period of several years — would the content that is widely agreed upon across Catholic systems meet the fundamental goal of sustaining and strengthening Catholic identity, as well as institutionalizing it for the future?
It is generally agreed that formation should cover certain areas: heritage and tradition; mission and core values; vocation; workplace spirituality; Catholic social teaching; organizational and clinical ethics; servant leadership; holistic health care; diversity; and church relations. However, the team was not convinced that either the typical content or the way it is taught were necessarily relevant or effective for perpetuating Catholic identity.
At the same time the team was working, the Catholic Health Association was exploring Catholic identity. M. Therese Lysaught, PhD, a CHA visiting scholar, was conducting inductive and constructive analyses of the topography and foundations of Catholic identity. Lysaught's study, Caritas in Communion, reminded us that the organizing social principle of Christianity and Catholic health care is caritas, that is, God's superabundant, undeserved gift of love in creation, redemption and sanctification. Our Catholic social principles, if lived out, converge and contribute to caritas and provide the core of Catholic identity.
Trinity Health's team concluded that formation content should address the processes and structures that institutionalize Catholic identity. Caritas and all the Catholic social principles would both organize and link formation and the assessment process. These were critical and game-changing moves.
Another significant change in formation was modifying the pedagogical method, to which CHE's experience in talent management and development contributed an emerging direction. In 2011, CHE had opened a Leadership Academy for both executive talent management and succession planning that explored transformational, operational and mission excellence. The program used a method of "just-in-time" information, namely, addressing emerging significant organizational issues causing chaos, change and necessitating innovative responses. For example, to explore the nature and method of discernment, participants reflected on a local ministry's recent strategic repositioning.
The method required the faculty to develop a nimble and tailored curriculum for each session. Starting with the real-time strategic issues that participants were addressing, faculty layered each session with content on innovation, operational excellence, mission and theology. Because this method of formation doesn't follow a set curriculum for every session, it requires time-intensive preparation to explore fundamentally new issues that are based on emerging local institutional needs. (See story on page 40.)
CATHOLIC SENSIBILITIES
A final element critical to the redesign of the formation process was to align Trinity Health's core values with Catholic social teaching. The team explored potential organizing theologies such as the sacraments or sacred time, but, in the end, followed the "true north" of caritas. They organized the formation program around what they called Catholic sensibilities.
The group had been struck by an analogy to Quaker schools — the schools may employ only a few Quakers, nonetheless all staff and teachers exhibit a way of being and responding to the world that manifests Quaker sensibilities. So, the group reasoned, if a Quaker sensibility is an ability and attitude toward the world that appreciates and responds to a complex cultural situation in a distinctively Quaker way, what, then are Catholic sensibilities?
The group defined them as behaviors that emerge from Catholic social teaching, including caritas, dignity, common good, solidarity, care of those who are poor, stewardship, subsidiarity, participation and association. The group further agreed that these sensibilities offer the only adequate theological explanation of Trinity Health's core values.
Focusing formation on the core values and explaining them in light of Catholic sensibilities provides a coherent and consistent organizing principle. The lens of these sensibilities grants deeper knowledge and also helps answer questions about the adequacy of the formation — for example, do leaders and colleagues have the preparation they need in order to incorporate Catholic identity throughout the system?
Two practical moves gave significant support to Trinity Health's formation programming. First, both the senior management and board decided to include formation of all employees as a strategic goal, and management likewise required formation of all local senior leadership. Second, instead of bringing executives to one central formation retreat house — a substantial travel and time expense — Trinity Health has moved formation to the local sites.
ASSESSMENT
Working in parallel with the formation team, another team of mission leaders focused on measuring and assessing Catholic identity throughout the new, post-merger Trinity Health. In the past, Trinity and CHE each had used an external vendor to conduct mission assessments. The mission leader team was looking for an assessment method that would apply across the post-merger ministry.
The Malcolm Baldrige Quality Award, a Presidential honor given many industries for quality processes and impact, seemed to offer a possible template. The group studied the extensive open-source material, along with the Baldrige 2013-2014 Health Care Criteria for Performance Excellence,1 and realized the described management practices offered a systematic way to institutionalize Catholic identity.
The group adapted its own version, noting that much of the institutionalization of Catholic identity that occurred during the time stewardship shifted from women religious to the laity depended principally on the guiding force of visionary personalities.
In contrast, the elements of the Baldrige process offer the laity the social conditions for institutionalization of identity that do not depend upon individual personalities. In the pilot phase of development, the team focused on leadership, system design, measurement, operations and impact in order to explore how each of these areas addressed key constituents: those whom we serve, those who serve and the communities in which we serve. The system team developed a document describing the theology and characteristics of each sensibility as it applies to health care settings.
SCORING
Being faithful to the Baldrige scoring method, the group codified its own process. Each new assessment brought further refinement, and as the process matured, we fully adapted all seven Baldrige categories: leadership; strategic planning; customer focus; measurement, analysis, and knowledge management; workforce focus; operations focus; and results.
Devising and refining the scoring process has been no easy task. The assessment scores track the development of institutionalization of each sensibility, in particular:
- Approach: Methods used by an institution to carry out processes such as leadership, system design, measuring and operationalizing. It examines the appropriateness, effectiveness and replicability of the method.
- Deployment: The extent to which the approach or method is applied consistently and used by all work units.
- Learning: Refinement of an approach or method through cycles of evaluation and improvement, breakthrough change, and sharing of refinements and innovations in processes across a ministry.
- Integration: The extent to which the approach or method is complementary and harmonized across processes and work units.
The Baldrige format looks not only at such process issues as leadership and system design, but also the results and impact of institutionalizing Catholic identity. Therefore, the assessment looks at levels of current performance relative to a meaningful measurement scale and in comparison to other organizations and benchmarks. It also examines trends, or the rate of performance improvement or continuation of good performance, and breadth (i.e., the extent of deployment). Finally, an examination of results looks at integration from another perspective, namely, whether approaches are valid indicators of future performance; and whether results are harmonized across processes and work units to support organization-wide goals.
EXAMPLE: SOLIDARITY
When the assessment process examines leadership, which includes both board and the senior team, it examines how leaders communicate solidarity, how they model it, how they hold others accountable for it and how they are held accountable, for example, through incentives. Leadership, like other process areas, is evaluated along a continuum of levels on institutionalization behaviors and practices. For example, do leaders have only an isolated approach related to communications, modeling, and accountability, or do they have a defined and managed method to advance solidarity? Is the approach/method deployed sporadically or uniformly? Does leadership demonstrate that it is learning and improving its management of the sensibility of solidarity? Finally, is solidarity integrated across the institution, both vertically and horizontally?
This institutional development extends beyond leadership to other process areas such as system design, measurement and operations.
Building the process entailed creating a record of the method and learnings; therefore, the team developed a theology of the sensibilities and their practical application to health care. As a means to drive consistency, they refined the scoring tool after each assessment and applied it evenly among sensibilities and institutions. To keep the process consistent, scoring draws upon a group of facilitators and note-takers who specialize in two or three sensibilities. This stability has improved the process, and it also has advanced and deepened institutional learning and capacity.
Mission leaders from across the system are being initiated into the note-taking role to increase their understanding of each sensibility, and this prepares them to be facilitators as well as helping them apply their broadened understanding in local formation events.
ASSESSMENT: THE PROGRAM
So what does it take to implement the assessment? Since the Baldrige process is based upon evidence, the system team coaches the local mission leaders for several months in the collection of evidence such as documents, processes and outcome data. A month before the assessment, participants take part in a webinar that gives them an overview, followed by a taped lecture that explores how a sensibility, such as solidarity, is demonstrated in actions of leadership, system design, measurements and operations.
At first blush, a mission leader may find preparation for the assessment overwhelming. Because the assessment relies on hard evidence, the system team works with the local mission leader to collect relevant, but not voluminous, documentation. The system team advises the local leaders to capture enough evidence to facilitate the assessment, but not too much to overwhelm participants. We have learned that 50 pages with an overview summary is about the maximum.
The documents are posted electronically in order to avoid unnecessary printing. Participants can access the material after they have attended the overview webinar and reviewed the taped lecture that addresses the sensibility in which they will participate.
Ideally, seven participants examined each sensibility. Participants came from the board members, senior management, senior directors and managers and an employee on the front lines — and, where advised, a community member. In addition to reviewing the material in advance, each team spends half of the assessment session discussing the evidence and another half scoring.
Participants' most universal comment is that the process seems more a formative experience than an assessment. Many participants say they never before have had an opportunity to consider systematic methods for institutionalizing and advancing Catholic identity.
Immediately after the assessment, an advisory group, including the facilitators and note-takers, debriefs to highlight broad impressions, strengths and opportunities.
The advisory group gathers semi-annually to review the implications of all the assessments and ponder the systemic implications. This theological reflection has many benefits. The experience shapes the facilitators and note-takers, and it allows them to observe best practices and build greater institutional capacity across Trinity Health. The shared community wisdom also opens up a window for discernment about mission's future horizons and directions.
LEARNINGS
From the perspective of mission, finance and workforce development, the marriage of formation and assessment has been worth the effort to strengthen the institutionalization of Catholic identity at Trinity Health.
Starting over in a new system basically wiped the slate clean enough to reimagine both formation and the assessment process. In the end, it has provided unanticipated benefits and real improvements to both formation and assessment processes.
Seriously challenging the prevailing orthodoxy of the content and pedagogical method for formation has created more work for presenters, but it has helped adult learners make the connection between their day-to-day work and Catholic identity. They recognize that the sensibilities can be integrated and applied both to decision-making and work processes. For example, participants come to realize that they have not been using the language nor fully understanding the operational characteristics of a sensibility. This lack of connection makes them curious for more formation to better understand the practical implication of a sensibility so that they can draw a clear line of sight to Catholic identity as they do their daily work. Language shapes reality.
Of course there were pragmatic benefits. As the system built institutional capability, its expenses were reduced. Our legacy systems were spending more than $20,000 per ministry to conduct assessments, but, done in house, our costs, are roughly $6,000 per ministry.
Aligning formation and assessment is developing a culture that knows how to systematically institutionalize Catholic identity. Mission leaders visiting other ministries gain on-the-ground understanding of how to sustain and grow Catholic identity. Executives who have experienced the formation and assessment not only have a common language, but also a common vision of how these programs align with Trinity's strategic vision. Executives begin to realize that their efforts to promote people-centered care, excellence in all areas of care and operations, and stewardship of finances and legacy are not activities separate from, but are, rather, one and the same as living out the Gospel mission.
PHILIP BOYLE is senior vice president, mission and ethics, Trinity Health, Livonia, Michigan. He works from the system office in Newtown Square, Pennsylvania.
NOTE
- 2013–2014 Health Care Criteria for Performance Excellence. www.nist.gov/baldrige/publications/archive/2013_2014_hc_criteria.cfm.