From time to time, headlines highlight people or organizations recognized as outliers because the outcomes of their work garner national notice. More often than not tragic, accidental outcomes rivet our attention. Occasionally, though, it is the opposite: the achievement of an outcome so unusual and inconceivably distinguished that it warrants emulation. The receipt of the 2005 Malcolm Baldrige National Quality Award by Bronson Methodist Hospital, Kalamazoo, Mich., is an example of the latter. It was no accident—this is an organization that pursues validation of its excellence assertively and enthusiastically. It is unusual because it is only the fifth healthcare organization to be counted among the ranks of Baldrige winners, and it is distinguished because the award comes from our nation’s highest elected leader.

The management team at Bronson is quick to point out that it took every employee’s involvement and enthusiasm to win this honor. Among those employees are 15 hospitalists, representing 11 full-time equivalents.

The Baldrige Award

Established in 1987 by an act of Congress, the Baldrige Award is presented annually by the President of the United States to qualifying organizations of any size in five categories: manufacturing, service, small business, education, and healthcare.

The application fee—ranging from $5,000 for large organizations to $500 for non-profit educational institutions—supports a minimum of 300 hours of review by eight or more business and quality experts, with on-site visits generating more than 1,000 hours of in-depth review. An extensive feedback report highlighting strengths and areas to improve is part of the review.

Contenders must be judged outstanding in seven areas to win. (See “Baldrige Award Criteria,” top left.) The criteria focus on two goals: delivering continuously improving value to customers and improving overall organizational performance. This helps organizations enhance their effectiveness and sustainability. Since 1999, when the Baldrige criteria for healthcare were first introduced, 116 healthcare organizations have applied.

Baldrige Award Criteria

Leadership

Strategic planning

Customer and market focus

Measurement, analysis, and knowledge management

Human resource focus

Process management

Results

The Beginning

According to, Katie Harrelson, RN, vice president of Patient Care Services and chief nurse executive, Bronson has always strived to be the best. In the late 1990s, they began looking at various quality models, and discovered the Baldrige Criteria.

“We began using the criteria because they provided a focus, or framework, to help us define who we are,” says Harrelson. “Physicians became partners, and patients are our customers. Bronson’s hospitalists are strong partners, and our relationship with them is great. It had to be in order to standardize care practices and continue our efforts to be a national leader in healthcare quality.”

She describes the organization’s three strategic objectives: clinical excellence, customer and service excellence, and corporate effectiveness. These “3 Cs” provide focus for Bronson and that are on the tip of all employees’ tongues.

As Bronson embarked on the journey to excellence, it already employed hospitalists. “Bronson started using hospitalists at a time when many of the community’s primary care physicians were older and retiring, or looking for an alternative admission method,” says Scott Larson, MD, senior vice president Medical Affairs and chief medical officer, “There were economic pressures, too. It’s less efficient for individual practitioners to conduct hospital rounds for a small number of patients than to use hospitalists, and hospitalists are more familiar with hospital protocol.”

By 2003 Bronson was continuing to integrate hospitalists into their program, and hospitalists were employing the precepts of performance improvement like other Bronson employees.

Excellence requires, among other things, good communication and unprecedented cooperation. Thus, employees from different departments and disciplines needed to identify new ways to improve existing care processes and work together as a multidisciplinary team. Hospitalists had a unique role that led to several changes.

“Hospitalists are involved in pretty much anything that happens at Bronson,” says Hussein Akl, MD, medical director for Bronson’s Hospitalist Service.

It was that involvement that led Bronson to change its approach to hip fracture care. Previously, the surgeon managed the hip fracture patient from admission to discharge. Bronson’s hospitalists proposed a new model, however: The hospitalists would manage the patient medically, leaving the surgeons to focus on what they do best: repairing the hip.

The success of the program is measured in clinical outcomes; length of stay has declined significantly since the specialists began collaborating in this way. In 2005 HealthGrades, an organization located in Golden, Colo., that rates care in 5,000 U.S. hospitals, awarded Bronson its highest rating (five stars) for hip replacement surgery and for treatment of acute myocardial infarction.

Hospitalists also took the lead in preparing for Primary Stroke Center Certification, a status Bronson achieved from the Joint Commission on Accreditation of Healthcare Organizations last year, and are leading physician engagement in Bronson’s computerized physician order entry project.

Dr. Larson emphasizes that achieving a level of excellence that meets Baldrige standards requires alignment, meaning that organizational, department or service, and individual performance goals must be congruent. Dr. Akl concurs: “Hospitalists had to align with our orthopedists to improve hip fracture care, and with neurologists on stroke.”

This level of excellence also requires constant vigilance and measurement, which is why Bronson uses scorecards to follow core indicators that reflect compliance with best practices for conditions like heart failure, and community acquired pneumonia. They also track their risk-adjusted Medicare mortality rate, which at 3.5% in 2005 was better than their 2004 rate (4.8%) and considerably better than the national average. Scorecards are distributed electronically and discussed in all meetings. Targets established at the beginning of the year are reviewed, and the hospitalist service’s performance is examined and compared with aggregate data for other admitting physicians. Management acknowledges that drilling data down to the individual level—except in rare cases—is often difficult and does not necessarily reflect an individual’s true performance.

“Patients are co-managed often, making individual provider data somewhat misleading,” explains Dr. Larson.

If recruitment and retention are an indication of employee satisfaction, Bronson’s hospitalists are satisfied. Few hospitalists have left; however, one hospitalist who left returned a year later citing Bronson’s well-structured program, the fact that all hospitalists have equal decision-making authority, and physician-based care (Bronson does not use physician extenders) as re-employment incentives.

“Of course, he said the pay was good, too,” quips Dr. Akl. At Bronson, results are rewarded and recognized generously.

The Pebble Project

The Pebble Project links The Center for Health Design, a nonprofit research and advocacy organization, and selected healthcare providers. Its goal is to lead and influence architectural design in the healthcare community using the evidence they gather. They research and document examples of healthcare facilities whose designs improve the institution’s quality of care and financial performance. Pebble Project partners receive access to technical, architectural design, and research information and expertise. This alliance brings recognition and visibility, and the opportunity to co-author research on focus topics. —JW

The Patient’s Perspective

Bronson’s approach to hospital care translates into distinct differences—from the moment patients enter until discharge. Also recognized internationally as a Pebble Project Partner, Bronson’s facility design proves that function follows form. (See “The Pebble Project,” p. 39.) The building has a first-class hotel feel to it, with well-planned spaces and indoor gardens. Staff emphasizes privacy and service—not just care. Acknowledging that patients have needs and responsibilities outside the hospital that don’t pause while they are admitted, Bronson offers amenities such as wireless computers so patients can stay connected to their lives, beepers so family members can leave a surgical waiting area without fear of missing the surgeon’s post-operative visit, 24-hour room service, and a concierge to run errands or quarterback problems.

Increasingly evidence links architectural design to outcomes in many healthcare settings, and Bronson has acted on the evidence. The hospital is easy to navigate, and because a major building campaign finished this facility in 2000 every patient room is private with its own hand-washing station. Patients needn’t worry about a roommate’s noisy guest or snoring, but, more importantly, private rooms are associated with lower nosocomial infection rates and speedier recovery.

Operating and labor costs are also lower because patients are not transferred as often. At Bronson, infection rates fell 11% overall compared with the rate in their former facility that had a combination of private and semi-private rooms.

Bronson continues to monitor infection rates and also tracks employee turnover, outcome measures, length of stay, cost per unit of service, waiting times, patient satisfaction levels, nosocomial infection rates, and organizational behaviors.

Sharing Caring

Bronson’s hospitalists actively engage in information sharing. They share their protocols within the Bronson healthcare system and with other hospitals and providers. One recent project has been the successful effort to improve the discharge process—an area of emphasis for many quality-promoting oversight organizations and other facilities. Their next step is to automate their interventions.

Some also participate in a half-day Physician Leadership Academy, a gathering held quarterly to develop physician leadership skills and collaborate on identifying and implementing best practices.

Because Bronson’s overall atmosphere and organizational culture differ from older facilities or less avant-garde organizations, Harrelson, Dr. Larson, and Dr. Akl have difficulty identifying one unit where care might be considerably different than what the patient would receive elsewhere. Dr. Akl says that the hospitalists as a group discussed this question and determined that all Bronson units are held to the same high standards, but that the Adult Medical Unit (AMU) is an interesting model for serving the geriatric population.

In the AMU hospitalists lead the team to reach desirable outcomes. The unit’s propensity to admit elderly patients created unique needs that staff has met in correspondingly unique ways. Nursing’s commitment and capability is evident because all AMU nurses are NICHE (Nurses Improving Care for Health System Elders) certified. NICHE certification promotes systematic nursing change that ensures sensitive and exemplary patient-centered care for older patients. The hospitalists, too, have participated in this cultural change and created a protocol that anticipates elderly patients’ needs, and all hospitalists rotate through AMU to support this part of the continuum of care.

The Outcomes

Bronson measures everything, and uses established best practices, benchmarks, and data to ensure that they meet and exceed national standards. They monitor clinical excellence using Centers for Medicare and Medicaid Services performance rates, Blue Cross Blue Shield targets, and the CareScience (Philadelphia) database. They also follow the JCAHO standards and Leapfrog Groups’ National Quality Forum’s measures.

They monitor patient satisfaction using Gallup Polls and “listen and learn” methods that build on the idea that the customer’s opinion and experience is often more valuable than that of an outside consultant. And, they monitor corporate effectiveness using tools that measure employee learning, vacancy rates, and commitment to the environment and the community.

Bronson’s persistence and desire to be the best has paid off. Patients receive beta-blockers and pre-surgical antibiotics at rates that exceed best practice. They have significantly reduced the incidence of ventilator-acquired pneumonia in all ICUs—the pediatric ICU has had none since 2004. Patient satisfaction increased from an already high 95% in 2002 to an astounding 97% in 2004.

For the past three years, Bronson has been named by Fortune and Working Mother magazines as one of the nation’s 100 best companies to work for. They have also been named by Solucient as one of the 100 Top Hospitals in the United States for 2005. Another acknowledgment is the Environmental Leadership Award from Hospitals for a Healthy Environment for reducing waste and pollution. The list of their achievements and awards is seemingly endless, but so too is their energy to continue to improve and deliver excellent care.

Bronson’s approach is what it takes to earn that ultimate recognition of quality: the Malcolm Baldrige National Quality Award. TH

Jeannette Yeznach Wick, RPh, MBA, FASCP, is a freelance medical writer based in Arlington, Va.

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