Patients First

By Linda H. Heuring July 1, 2003

HR Magazine, July 2003How a financially sagging hospital revived itself with a customer service approach that makes patients and employees its top priorities.

Despite its idyllic setting amid palm trees and sea breezes on Florida’s West Coast, Sarasota Memorial Hospital was not a tranquil place back in 1998. The 828-bed facility was far below par in numbers of patients served and levels of worker retention. In a survey of 800 hospitals by Press Ganey Associates, a health care research firm in South Bend, Ind., Sarasota Memorial’s customer satisfaction ratings were down in the 17th percentile that year. Staff turnover was running at an annual rate of 25.2 percent, and the not-for-profit organization posted a $2.2 million shortfall.

In 2002, three years into a targeted effort to refocus the organization, Sarasota Memorial had $27 million in excess revenues after expenses, turnover for the system’s 3,500 employees had dropped to 16.6 percent, and customer satisfaction had risen to the 90th percentile.

The turnabout, achieved against a backdrop of cost-cutting pressures and industry workforce shortages, was accomplished without layoffs, restructuring or major capital investments. The key to the ongoing effort has been a set of principles that include broad-scale HR involvement to improve customer service.

Although customer service is a major thrust of the multi-departmental program at Sarasota Memorial, not all the problems have been customer-related, says Pam Beitlich, director of service excellence. Her position within HR was created in an effort to find ways to “fix our service” after the 1998 shortfall, and it was obvious even then that the organization had other difficulties that HR could help to address, she says. “We weren’t even treating each other with respect.”

Since then, Beitlich and the hospital’s top managers have been addressing problems related to hiring, retention, morale, working conditions, scheduling and other areas of HR concern.

Such issues are not unique to Sarasota Memorial, of course. For example, about nine of every 10 hospital CEOs have to deal with significant workforce shortages, according to an American Hospital Association report, “A Looming Crisis in Care.”

Nonetheless, Sarasota Memorial has made headway even on such seemingly intractable problems. Last year, according to a Florida Hospital Association survey, the nurse vacancy rate was 12.5 percent statewide and 17 percent in the region from Naples to Tampa Bay, which includes Sarasota. But at Sarasota Memorial the rate is now 11.8 percent.

In fact, nurses at Sarasota Memorial are willing to pass up jobs paying $2 more per hour at hospitals they drive past on their way to work, Beitlich says, because “they know the culture [at Sarasota Memorial] is one that supports them.”

As the culture improved, word began to spread. Registered nurse Melissa LeFebvre heard about the changes at Sarasota from nurses and physicians at another local hospital, and the high standards of care prompted her to switch to Sarasota Memorial. Oncology nurse Lora Rush says it can be worth “more than money if you work with people who are conscientious and caring.” She joined the Sarasota Memorial staff in June 2002 after being impressed with the high level of support that a nurse friend was receiving in her work there.

It wasn’t always that way.

Teams Weigh In

At the start, internal teams were created to tackle matters such as administrative involvement; complaint resolution; management and staff education; performance evaluation/reward and recognition; physical environment; and recruitment, selection and staff orientation. Beitlich says department heads volunteered their “A players,” and she drafted a few people. The teams began to examine ways to improve working conditions as well as service.

“We were really shifting our culture from being focused on ourselves … to what the patient needed,” Beitlich says. It began to work. Customer satisfaction ratings improved, moving from the 17th percentile to the 34th percentile and then to the 68th percentile in three quarters.

Then “we started backsliding,” Beitlich says. There was no structure to sustain the teams’ work, she says, and they didn’t have leadership support.

Finding ways to improve customer satisfaction was one thing; getting buy-in was another. For example, one team recommended that employees walk patients, family members and visitors to their destinations instead of just telling them how to get there or pointing them in the right direction. But when employees escort.ed people, they might return to their workstations to find a supervisor “yelling at them” for being absent, Beitlich says. Employees might initiate such efforts, she says, but “it was evident that if we didn’t pull the leaders in and develop them at the same time, it wasn’t going to stick.”

It was also evident to Dr. Duncan Findlay, CEO of the Sarasota Memorial Health Care System. Findlay, who has been at Sarasota Memorial since joining as a physician in 1972, says, “We had tried our own home-grown efforts, with some success.” But giving classes on behaviors doesn’t work, he says, unless all involved realize they have a stake in the effort—“unless they’ve got some skin in the game.”

Pillars Provide Support

What finally cemented the efforts at Sarasota Memorial, Beitlich says, was an approach adapted from the “pillars of excellence” concept in place at another Florida hospital, Pensacola Baptist. During benchmarking that involved hospitals throughout the country, including two others in Florida and one each in Illinois and Connecticut, Pensacola Baptist kept coming up as one of the best, she says. Quint Studer, then president at Pensacola, shared his pillar concept. Later his consulting firm, the Studer Group, contracted with Sarasota to help with the customer service initiative.

Sarasota’s pillars of excellence are service, people, quality, finance and growth. “We do all our meetings, all our strategic planning around these five,” Findlay says. Beitlich adds: “Everybody sets goals based on the pillars. It’s simple. Five things, that’s it. If what you are doing as a leader doesn’t contribute in some way to those five pillars, then you need to [re-examine] what you’re doing.” The evaluation process for leaders was changed to support those pillars, Studer says. Now a leader is responsible for how much his or her customer satisfaction improves.

Ed Carthew, who joined Sarasota Memorial as the pillars concept was being introduced and is vice president for human resources, says much of HR’s role has been in helping to establish goals under the people pillar, including turnover. “Sometimes you tend to spend time on problem situations,” Carthew says, “but it’s so important to spend time with the A-plus players, re-recruiting them to the organization. Make sure they are challenged in their work.”

With priorities on “patients first, employees just a breath behind,” as Chief Operating Officer John Yoder explains it, a new set of teams evolved: leadership development; service recovery; service champions; measurement, reward and recognition; standards/culture; inpatient, outpatient; ER patient satisfaction; and physician satisfaction.

From ER to Cardiac Care

“The emergency department had good people and advanced technology that was all wrapped around very poor systems and processes,” says Dr. Bill Colgate, vice president of medical affairs and medical director of emergency services. With 81,000 patients a year, it’s the second-busiest ER on Florida’s West Coast, he says. Patient care was good, but “chaos was the norm rather than the exception,” he explains. “We weren’t broken necessarily, but we clearly were not a leader.”

To get the patient’s and visitor’s perspectives on ER care, a team consisting of ER workers started in the parking lot. Team members mapped every step of the process, from a patient’s arrival to the time a decision is made about care. First, they “eliminated all the steps that were duplication,” Colgate says. Next to go were steps that didn’t add value. Last, they crossed out steps that some had assumed were required but in fact were only “sacred cows,” Colgate says. The review process had an “amazing” impact on “our turnaround time,” he adds. “It got patients into the rooms more rapidly, and the physician and nurse into the room.”

After tackling major procedures, Colgate says, the team moved on to smaller ones. Lab turnaround time was cut in half by observing routines for six to eight hours, then getting the ER staff and the lab staff together in a room to map the process. That eliminated finger-pointing over the time it was taking to get lab results. “The ER staff now understands the pressure on the lab,” Colgate says. “It led to greater understanding and teamwork.”

ER customer satisfaction ratings rose from the 43rd percentile in 1999 to the 97th percentile in December 2002. Staff turnover in the ER has improved, too, from 24.6 percent in 1999 to 16.1 percent in 2002, and so far this year it’s running at an annualized rate of 9.6 percent.

For Brenda Koval, director of invasive cardiology and chairman of the physician satisfaction team, the customer service problem in the cardiac care lab was a matter of time. Her department performs 100 to 150 heart catheterizations each week, and her team decided to focus on wait times. Many patients are dealing with “fear of the unknown,” she says, and often they had long wait times because a doctor would schedule seven patients for 6 a.m., or patients would get bumped for an emergency. Now her team does scheduling directly with doctors’ offices, reducing both paperwork and hassles for the patients.

Koval posts her customer service scores, and they’re discussed at each staff meeting. Patients are paramount for those on her staff, she says. Her employees “really care about what they do. They have ownership in their jobs.”

Patients First

Signs of Sarasota Memorial’s focus on patients first are evident throughout the hospital. Now, for example, there’s free valet parking. The valet helps the patient into a wheelchair and then takes the car while the driver accompanies the patient the rest of the way. The service is a response to customers’ frustration about scarce parking around the hospital.

Anyone who appears to need help gets it. Jolene Brown of Sarasota, who goes to Sarasota Memorial for tests and cancer treatments, recalls her first visit after learning her illness is incurable. Arriving at the hospital alone—her family was back in New York—she sat down and cried. An employee emptying trash cans walked up to her and said, “Lady, you look like you need a hug,” and he gave her one. He then took her to a hospital chaplain, who stayed with her through the admission process and accompanied her to her room. Without the chaplain’s caring attention, she says, “I would have run scared.”

In another customer-centered change, patients on gurneys now have the elevator to themselves and their medical attendants, their privacy no longer subject to the prying glances of strangers.

Patients’ meals are served by food service waiters wearing tuxedo shirts, cummerbunds and black trousers. Waiters open food containers, provide condiments and utensils, resolve problems with the meals, read the next meal’s menu to the patient and adjust orders to accommodate individual preferences. The increased emphasis “not just on the image and appearance of the service staff but also their communication skills and their interaction with the patient” improves customer service, says Gerard Violette, director for food and nutrition services and chairman of the measurement team.

The effort is not just window-dressing. These steps relieve nurses to do their jobs, he says. “If we’re not doing our job in food service, it really leads to the nursing staff getting involved way more than they should” with patients’ meals.

Teamwork and Tools

The team concept—underscored by food service’s awareness of nurses’ jobs—has taken hold at Sarasota Memorial, although a few employees balked, Beitlich says. “It wasn’t the right person in the right job. It starts to become a lot more apparent when you see behavior that doesn’t fit in anymore.” Says Findlay: “Not being nice is not tolerated. Just being good at your job is not good enough at this hospital. You have to be part of the team.”

Employees’ behaviors are hard to change, though, if they lack the tools for their jobs, Beitlich says. If ER nurses have to run around looking for blood-pressure cuffs or intravenous-drip poles, she says, patients will see nurses who are hurried, agitated and angry. “We thought we’d start with [the nurses] telling us what they needed to do to make the patient happy,” Beitlich says. The leaders quickly found they had to focus on tools and employees, too.

To keep tabs on what employees need and how things can be improved, leaders conduct “rounds” every day. While making rounds in the ER, Beitlich noticed that the only fax machine was at the far side of the room. The nurse who had to make a long trek for every fax was not complaining, Beitlich notes. “People won’t tell you,” she says. “They think, ‘Well, this is just the way it is.’ ” But when she told the nurse she could buy a fax machine for the near side of the ER, Beitlich says, the nurse was astonished. “A $120 fax machine. You can’t even believe the win,” Beitlich says. “Is it always about money and buying things? No. It’s all about listening. Developing your people.”

Making rounds, Findlay says, is also “very much about who would you like me to reward.” He says rewards are personal and specific, such as: “Thanks for what you’re doing. Joe Smith told me about it.”

Sarasota Memorial created an employee recognition program that enables leaders, co-workers and customers to have employees rewarded for going above and beyond their normal work duties. Patients, their family members or employees fill out forms called “StarGrams,” naming the hospital staffer and describing his or her commendable behavior. Guidelines for the incentive program outline types of eligible behaviors. For example, “Thanks for coming in on your day off to help us when we were understaffed” is acceptable. But “Thanks for being you” is not.

Employees receive points redeemable for merchandise, ranging from stethoscopes to portfolios. “We wanted to focus our employees on specific behaviors … exceeding patients’ expectations,” Beitlich says. “We wanted to stay away from money. Although money can be a motivator, it isn’t a long-term kind of incentive.”

A New Culture

Findlay and his leaders have worked to create a culture that supports employees. “It has been tough,” he says. “We’ve invented a lot of these things as we’ve gone along. We’ve become an attractive place to work.” But there’s still work to be done to achieve the goal of becoming “the best community hospital in the United States,” he says.

To sustain their efforts, the senior staff and supervisors participate in two-day off-site retreats every quarter to review the scores, make sure they’re on track and hear from one another and outside experts about ways to be more effective as leaders. Findlay holds employee meetings on all shifts to share what was learned at the retreats.

“I think the genius is in the simplicity and the ability to keep on track and reward people,” Findlay says. “It’s all just a combination of very simple stuff.”

Linda H. Heuring, a freelance writer in Evans, Ga., is a former newspaper reporter and editor and has worked as a corporate communications professional.



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