Journey to Excellence

Memorial Hospital_1.jpg​Memorial Hospital and Health Center in Jasper joins an elite group of hea​​lth c​​are organizations to receive the Malcolm Baldridge National Quality Award, the nation’s top quality honor.

On Nov. 13, 2018, the phone rang in Kyle Bennett’s office. Bennett, president and CEO of Memorial Hospital and Health Care Center in Jasper, was expecting a call – but he was not entirely sure who would be calling. He knew that if the call was from the 202 area code, it would likely be Wilbur Ross, the Secretary of Commerce, giving him the exciting news, that Memorial had joined an elite group of health care organizations in receiving the Malcolm Baldrige National Quality Award. If the call came from the 301 area code, it would likely be an official with the National Institute of Standards and Technology, the arm of the Department of Commerce that oversees Baldrige, calling to say that while outstanding, Memorial would not be a Baldrige recipient.
​As Bennett recalls, a group of people had gathered outside of his office to hear who was on the other end of the line. The director of ​corporate compliance, Marsha Shepherd, stood in the doorway, peering in, looking for a sign. John Dillon, vice president of ambulatory services, recalls Bennett was stoic, giving nothing away. “At the end of the conversation, Bennett turned to look at Marsha while concluding the call with the words, “Thank you, Mr. Secretary,” causing the group to erupt in cheers.​

​​Named for the late Malcolm Baldrige, the Secretary of Commerce under President Reagan who was a huge advocate of quality improvement, the award was established by Congress in 1987. The Malcolm Baldrige National Quality Award is the nation’s highest quality award recognizing performance excellence and U.S. companies that have implemented successful systems. (see box 1) Health care organizations did not become eligible to receive the award until 1999. Since that time, just 25 health care organizations have received it. Memorial is only the second in Indiana, with Schneck Medical Center in Seymour receiving the award in 2011. The process is rigorous. Most organizations who apply never receive the award. Just 115 organizations have received it since its creation. So, why did Memorial undertake the challenge? 

 “It’s not about the award. It’s about improving. The most import​​ant part of the process is the feedback report. External, independent experts look at our organization and provide external feedback about how we can get better.”  -Kyle Bennett, President and CEO​​

Memorial began its quality journey by applying for The Partnership for Excellence (TPE) award in 2012. The TPE is the Baldrige based state performance excellence program for Indiana, Ohio, and West Virginia. Organizations frequently begin by applying for their state award before attempting the national award. The TPE has four levels of recognition — bronze, silver, gold, and platinum. Memorial received silver recognition in 2013, with reviewers highlighting its strategic planning process. Through the TPE application process, it became clear that the hospital needed a resource dedicated to organizational excellence. That’s when Lori Persohn stepped in as director of organizational excellence to focus full time on the process. Memorial again received silver recognition in 2015 and attained platinum in 2016, a major accomplishment.​ 

After receiving the TPE’s highest level of recognition, Persohn recognized that Memorial needed to take time off before applying for the national award. “Some of our results weren’t what we wanted them to be,” she explains. Even though they did not apply, they “kept the cycle going and kept pushing.” Adds Melanie Powell, director of business development and marketing, “We weren’t going to allow ourselves to go backwards.” One of the processes that showed great promise was the establishment of multidisciplinary 90-day action teams to tackle an issue. Powell explains, “Instead of having a strategic plan and that you say at the end of the year, ‘what did we accomplish?’, we start at the beginning of the year and break down the work and assign initiatives to 90-day action teams.” The process is designed to be focused and efficient. Some projects conclude in 90 days while others go for additional 90-day cycles. Memorial’s leadership team carefully tracks the teams’ progress, ensuring that work remains on track.

One of the teams set its sights on improving outcomes by implementing daily safety huddles. “Safety huddles are nothing new,” explains Tonya Heim, chief nursing officer. But the multidisciplinary process led to a breakthrough. Two team members, a security manager and the director of nursing for the skilled unit, provided crucial input. “They suggested that every issue raised in the huddle be assigned a “scope and severity” rate,” said Heim. The concepts came from their backgrounds in long term care and disaster planning, respectively. “Every item that is brought up is rated on a scope and severity scale. How it’s rated determines how quickly it is addressed.” The patient safety officer posts minutes on the hospital’s “HUB,” or intranet, giving the entire organization visibility into the focus of safety efforts. Approximately 25 people attend the daily huddle, which lasts less than 10 minutes, with people off-site dialing in. Heim adds that the huddles occur daily at the same time and in the same location. “We made it absolutely reliable,” she says.

By 2018, Lori Persohn says she knew they were ready to apply for the national award. The application resulted in a site visit from a team of independent examiners who spent several days on site, verifying the processes in the application. The examiners were thorough – they asked to review more than 250 documents during the visit. “Our culture, our mission, values, our vision, our communications and our workforce – those were things that I had no doubt in my mind would come through – and they did,” Persohn said.

Organizations that receive the Baldrige award generally receive a lot of public attention, and Memorial is no exception. The organization takes 47 people Washington, D.C., where the Secretary of Commerce will present them, along with the other recipients, with the award in an April 7 ceremony. With 1700 employees, Memorial could not take everyone. Bennett says they decided they could take 20 staff and five from the leadership group, in addition to the presenters, administrative team, and Board members. To guide the selection process, they had an essay contest asking people to write why they wanted to attend. Sixty-eight people submitted entries, which were de-identified and reviewed by a team of three. The Quest for Excellence Conference will immediately follow the ceremony. Quest, as it is known, showcases the Baldrige recipients to a large, public audience. Memorial will also host “sharing days” for other organizations with an interest in learning from them and they will share their journey with their local business community.

Memorial’s story does not end with the award. Even as good as the organization is, Bennett points out that the feedback report contains 37 opportunities for improvement – or OFIs. “We’re committed to continuing,” he says even if the rules don’t allow a recipient to reapply for five years. Lori Persohn expresses the sentiment of the entire team when she says, “We want Memorial Hospital to be the best place for our patients to receive care, the best place for our staff to work, the best place for our providers to practice and we want to remain an independent, community hospital.”​
Baldridge-Crystal.jpg​​​The MBNQA is given yearly in six different categories, including education, service, manufacturing, small business, health care, and nonprofit. Organizations that apply for the Malcolm Baldrige National Quality Award are judged by an independent board of examiners. Recipients are selected based on achievement and improvement in seven areas, kno​​wn as the Baldrige Criteria for Performance Excellence. 
The seven categories​ include: 

  • Leadership: How upper management leads the organization, and how the organization leads within the community. 
  • Strategy: How the organization establishes and plans to implement strategic directions. 
  • Customers: How the organization builds and maintains strong, lasting relationships with customers. 
  • Measurement, analysis, and knowledge management: How the organization uses data to support key processes and manage performance. 
  • Workforce: How the organization empowers and involves its workforce. 
  • Operations: How the organization designs, manages, and improves key processes. 
  • Results: How the organization performs in terms of customer satisfaction, finances, human resources, supplier and partner performance, operations, governance and social responsibility, and how the organization compares to its competitors. ​
    *Source ASQ (American Society for Quality)​​​ ​ ​