Rating a Facility's 'Soft' Side

September-October 2000


An Indiana-Based System Can Now Measure the Implementation of Its Sponsor's Values

How does a Catholic-sponsored system measure its "value added" in the provision of health care? There are as many answers as there are Catholic systems. Ancilla Systems answers the question through what it calls its Characteristics of Service program, which began in 1990 as a joint effort of the system's Mission Effectiveness and Marketing departments.

Today Characteristics of Service has become more important to Ancilla's board members and executive leaders than they originally expected, because it gives them a way to evaluate the organization's "softer" aspects.

Values Orientation
Characteristics of Service comprises 48 indicators measuring 12 standards of service. These standards are in turn based on Ancilla Systems' five values: Dignity of the Person, Compassionate Care, Quality, Community, and Stewardship. Each of the values is reflected in one, two, or three of the standards. For example, with respect to the value of Compassionate Care, Standard 4 states, "The institution or service meets the personal and individualized needs of the client and employees in a caring manner." Indicators to determine whether the standard is actually being carried out include "Delays and waiting times in all service areas are recorded, reported, and are improving" and "Pastoral care staff network with the community and other units of the organization."

In 1996 an additional indicator was added as Standard 3, Indicator 6: "Timely and appropriate medical care is given to persons near the end of life. This includes provision for patient choice, adequate pain management, appropriate environment and spiritual, psychological and social support." This indicator, although coming under the value of Dignity of the Person, also represents the values of Compassionate Care and Stewardship. Because it places such a strong emphasis on this indicator, Ancilla has gone on to launch two newer system-wide initiatives: a study of the system's end-of-life care (the results to be reported to Ancilla's ethics and board quality committees) and an ancillary study that will periodically review its care for patients who die after long hospital stays. The system has also implemented an American Medical Association program called Education for Physicians on End-of-Life Care.

Reporting Evolution
The reporting mechanism for these characteristics has evolved over the past 10 years. In the beginning, a multidisciplinary team made up of staff members from system hospitals would conduct three-day organizational analyses of each Ancilla facility, to be repeated every three years. The team reported its findings to senior management, sharing them through the system's mission effectiveness vice presidents with the local boards of directors. This process developed a group of people who, having become skilled in Characteristics of Service implementation, could help hospitals comply with both the letter and spirit of the program. That was one of its strengths. A weakness was the fact that the organizational analyses occurred only every three years.

In an effort to make Characteristics of Service a part of patients' and staff's daily lived experience, rather than merely the subject of a periodic assessment, Ancilla's leaders changed the reporting mechanism in the mid-1990s. The new format allowed for a self-evaluation and focused more on the governance responsibilities for monitoring and evaluating the institution. It charged various board committees with assessing compliance with the standards and indicators (the finance committee, for example, was made responsible for the Stewardship standards and indicators). As mentioned, all standards and indicators were reviewed every three years, by board committees (including the one for mission effectiveness) rather than the system-wide multidisciplinary team.

In recent years, in an attempt to develop a more holistic governance process, Ancilla has restructured its hospitals' boards of directors and eliminated many of the committees. At the same time, hospital board members began receiving a monitoring report concerning the finance area. The system's leaders found that some of the Characteristics of Service categories lent themselves very well to this type of reporting format.

The restructuring of the boards led, in part, to a new reporting template. The 48 indicators were divided into five sections:

  • Board orientation. An example is Standard 1, Indicator 3 ("A document which describes the services offered by the facility or service is distributed to all clients").
  • Ad hoc board reports. An example is Standard 1, Indicator 4, which deals with confidentiality ("Protection for the privacy of the client and observance of confidentiality is evident in education of employees, policies, procedures, and practices within the organization").
  • Reports issued through currently existing mechanisms. An example is Ancilla's Social Accountability Report, which is routinely provided to the board and fulfills Standard 10, Indicator 4 ("Social accountability reports or other records demonstrate concern for the poor and a report is made to the appropriate community").
  • Management responsibility. An example is Standard 11, Indicator 3 ("Cross training, re-engineering, developmental and other programs evidence planning for skills of employees"), indicating management's responsibility in the area of stewardship.
  • The Board Monitoring Report, which is described below.

The Board Monitoring Report
The fifth reporting section is the Board's Monitoring Report, which reports indicators concerning finance (Stewardship indicators), patient volumes, satisfaction scores, clinical outcomes, lengths of stay, safety/risk management, managed care, community health status improvement, and others and compares them to a goal established for each hospital. The report codes these areas with the colors red, yellow, and green. Green signifies that the indicator is at or exceeding the benchmark, yellow means that it is within 5 percent of the benchmark, and red means that it is more than 5 percent below the benchmark. The color-coding helps those who use the report to focus on particular areas.

Although all Ancilla hospitals use the same standards and indicators, each is free to prioritize items according to its particular situation. All facilities are expected to monitor waiting times (Standard 4, Indicator 1 as noted above), for example. However, in doing so they may choose to target waiting times in the emergency department, outpatient registration, admissions, or some other department. Indicators concerning clinical outcomes, on the other hand, usually match those employed by the Joint Commission on Accreditation of Healthcare Organizations.

Some Characteristics of Service indicators representing system-wide initiatives or targets are monitored in this process. These include sessions for ethics education, which Ancilla requires local ethics committees to sponsor twice a year (one for hospital personnel and one for the public). Diversity—the ethnic, sexual, and racial composition of the system's management—is another monitored indicator, as is the employee turnover rate.

One advantage the Board Monitoring Report has over other tracking methods is its ability to relate financial indicators to nonfinancial ones. It can, for example, indicate whether increased financial pressures are affecting patient satisfaction and treatment outcomes. By using the scorecard to track the relevant data over a period of time, Ancilla's leaders should be able to anticipate potential problems.

Even better, those leaders can follow trends throughout the entire organization. In 1998, for example, they noted a lack of compliance with Standard 10, Indicator 2 ("Programs to develop persons at the minimum wage level to improve opportunities for promotion are in place") and made improvement in this area a high priority. The system's mission effectiveness leaders got together with those for human resources and designed a threefold action plan. As a result, Ancilla now:

  • Assesses minimum-wage employees' language, reading, and computer skills
  • Insists that supervisors discuss development needs with the employees during annual evaluations
  • Encourages employees to take advantage of the system's new policy of reimbursing them for the costs of workshops and nondegree, work-related courses, as well degree-related ones (for which they could already be reimbursed).

Today all Ancilla hospitals cross train staff so that, if they choose to do so, they will be equipped to take advantage of more highly paid employment opportunities in the system. Supervisors routinely draw up action plans for skill enhancement during employee evaluations. The system has also implemented new tuition reimbursement policies with increased funding.

Values at Work
The Characteristics of Service program was designed, in part, as a marketing tool. But it has since become an important component in the system's assessment process. The program does a number of things, but perhaps the most vital is this: It shows all system board members and employees the extent to which Ancilla's values can be made real in our everyday activities.

Sr. Hahn is senior vice president, Mission Effectiveness, Ancilla Systems, Hobart, IN.

For more information call Sr. Nora Hahn, PHJC, at 219-947-8511.

Ancilla Systems
Ancilla Systems, Hobart, IN, comprises five hospitals and numerous outpatient clinics and other health related centers. The system has 3,825 employees, 1,200 staff physicians, and 1,700 volunteers. Ancilla is sponsored by the Poor Handmaids of Jesus Christ, Donaldson, IN.


Copyright © 2000 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Rating a Facility's 'Soft' Side

Copyright © 2000 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.