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Creating a perfect hospital.

One morning several years ago, I reviewed reports at my desk showing my hospital remained at the absolute top of the universe in patient satisfaction and in the top quintile of publicly reported quality and safety measures.

Then I walked down to a nursing unit with my vice president of medical affairs and began to follow the care of a randomly chosen patient. Before the end of the day, we had seen 27 care processes that had happened in less-than-ideal fashion or gone completely wrong.

Sadly, this was just what I expected to find--and what most CEOs would discover about the processes of care in their institutions if they did similar reviews.

For hospital leaders who bear the heavy responsibility of caring for our neighbors at their most vulnerable, I see two choices. Either we provide every patient with a skilled guardian to stand at the bedside and protect against the daily glitches and risks that we have allowed to develop in our hospitals, or we fix them.

At Wellmont Health System, where I have served as CEO for two years, we are determined to become as error-free as possible by focusing our staff on patients and the processes that make the biggest difference in their eyes.

Although still early in our journey, our improvements in efficiency and safety have been instrumental in turning a $15 million operating deficit into a $20 million operating profit.

Now we are determined to do nothing less than achieve complete safety and the delivery of ideal care throughout our entire health system. We are inviting national leaders in health care safety and quality to join with us in creating the first "beta site" for the Safest Hospital in American Health Care.

Based on what we've learned, here is what we think it's going to take. First we have to define in measurable terms the attributes of "the safest hospital." Health care workers and physicians need tangible goals to reach specific outcomes.

At the present time, there is no consensus on what hospital safe practice really means. Taking myocardial infarction as an example, we must go far beyond the few measures being used by Centers for Medicare and Medicaid Services and American Hospital Association (such as door-to-balloon time and the administration of aspirin and beta blockers) to encompass each of the critical sub-processes that must happen perfectly if the patient is to have an ideal outcome.

At Wellmont, our goal is to look at all critical processes and decision points that have a real effect on outcomes and then focus our efforts to support error-free performance on all of those points--the full continuum of care.

Everyday safety

Next, we must charge everyone in the health system to aspire to error-free performance in every action, every day. We want everyone from our attending physicians to our housekeepers to have a clear notion of, "What does perfect look like?" (starting from the perspective of the patient) and strive to carry out each task accordingly.

One of the reasons no hospital has ever approached perfection is that no hospital leadership team has defined such performance, led as if it was expected and supported people to achieve it in very concrete terms every day.

Our leaders, clinicians and managers are in the process of defining perfect patient care outcomes--and the processes necessary to achieve them--as the starting point in becoming a safe hospital. We will hold each other accountable for moving rapidly toward those standards over a 24-month period.

We're convinced by our own experience and by that of safety and quality leaders in other industries that 40 to 50 percent annual rates of progress toward perfection are possible.

The other half of our recipe to become error-free focuses on helping our staff progress toward these goals by making robust "rapid-cycle" improvements the daily work of the organization--not a series of side projects added to normal workloads.

That means approaching improvement very differently than most health care organizations have come to practice it.

Our first break with common practice is vesting responsibility for progress in the chain of command and in those who control patient care, not in our quality and safety staff.

Most hospitals tacitly hold their small safety and quality staffs responsible for making improvements, while often excusing the physician and nursing managers who actually control care. It's no wonder we haven't made more progress in improving hospital care over the last 20 years.

As an example of changing this approach, one of our largest hospitals has completely solved a chronic lack of availability of nursing equipment at the bedside through an eight-week process led by the hospital president that involved virtually every hospital department and manager, as well as line staff.


The process created a wholly flexible and reliable re-supply system. Our safety team members were our expert facilitators, but we solved the problem through our daily operating structure, and we gained important experience and skills in the process.

Second, we are embracing transparency and learning from all things gone wrong. For the last year, we have piloted the open circulation of daily "problem logs" and "real-time root cause analyses" across the organization to warn others regarding risks that may be present in their own areas and to help leaders gauge the quality and depth of problem-solving ability across the organization.

As a result, a hospitalist who practices in one physician group can review safety and quality problems called out on the previous shift by a peer in another group working in another corner of the hospital. The hospitalist can then take action to avoid the same consequence for a similar patient or contribute knowledge toward a solution.

Third, we are building a structure that allows us to actually get problems solved during daily work, not just patched. Problems occur at high frequencies in organizations like hospitals, but traditionally few are solved to their root cause by our episodic committee-based improvement efforts. Therefore, so-called "workarounds" become embedded into the fabric of the daily routine.

For the past 18 months, we have begun to learn from organizations like Toyota how the creation of team leaders and assistants who are available to help the care team immediately initiate true problem-solving can begin to eliminate safety and quality problems. In addition, we have found the Toyota method of frontline staff calling out obstacles to error-free performance and fixing these in real time to be highly effective.

By intervening at this level, little problems do not become big problems that require multidisciplinary teams at the enterprise level. At Wellmont, while accountability for progress is still anchored in the chain of command, each hospital has available a series of three to five patient safety mentors and one patient safety leader, supported by seven to 10 safety assistants, as problem-solving facilitators and teachers.

Our attending physicians and residents have teamed with safety mentors to resolve hundreds of system glitches ranging from the root causes of why an ordered radiology study was not carried out (a software mismatch between the radiology orders our unit secretaries could enter and the orders that would be received at radiology) to knowing who has a patient chart (a color-coded card placeholder system that physicians helped design).

Leaders lead

The next difference in our approach to quality from convention focuses on the daily role of leaders in the organization. In a traditional hospital, leaders are either engaged in strategy or paperwork far removed from the value-creating core of the enterprise (patient care), or they are "fighting fires"--meeting immediate needs but rarely solving problems to their root.

At great organizations, leaders can be accessed quickly by lower levels of managers and staff in an explicitly designed sequence designed to help get problems solved permanently. We call it the use of a help chain, and we are working hard to improve our roles and impact as leaders by changing our daily work to fit this model.

The final and, perhaps, most important characteristic distinguishing safe, high-performing organizations from their peers is their emphasis on making every member of their staff skilled in applying core principles for designing and improving work. We want our staff members to be "mini PI teams" in how they think about and approach improving their tasks.

Throughout all of our problem-solving and improvement activities, we are focusing not simply on specific improvements or tools but on teaching the underlying principles we would like our teams to apply in the design of every process across the health system. By building this capability, the pace of improvement at Wellmont can become exponential and not limited by the time and attention of a small group of leaders, as is the case at most organizations.

In the end, the rate at which we approach error-free process will depend on how deeply and truly we invest in supporting the thousands of people in our organization to achieve it.

I know we will make many mistakes and need to adjust a great deal along the way. But I believe America needs to see a few models like ours emerge as proofs and learning sites for what is possible. I invite comments on our thinking and partnership from those who seek to set a new standard in health care.

Richard Salluzzo, MD, MBA, is the president and chief executive officer of Wellmont Health System in East Tennessee. He can be reached at


Note: In May, Wellmont announced the creation of The Safest Hospital Alliance, comprised of Wellmont, Adventist Health System and Novant Health.

By Richard Salluzzo, MD
COPYRIGHT 2007 American College of Physician Executives
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2007, Gale Group. All rights reserved.

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Title Annotation:Member Essay
Author:Salluzzo, Richard
Publication:Physician Executive
Article Type:Author abstract
Date:Sep 1, 2007
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