Five miles from Capitol Hill, Georgetown University Hospital (GUH), the first Magnet® hospital in Washington, D.C., began a transformation that integrated organization development interventions with the Jim Collins' Good to Great approach.1 Collins had discovered that breakthrough results in the best companies weren't the result of one high-risk executive decision, but rather, a series of good decisions, diligently executed and implemented sequentially. Collins' principles have become institutionalized in American business schools and integrated into the strategic plans of academic, insurance, financial service, and healthcare organizations seeking dramatic organizational improvement.2 In 2008, the Institute for Healthcare Improvement issued an urgent national call for better leadership to further develop the quality improvement capabilities of our modern healthcare organizations.3 Recently, organizations in the United States and the United Kingdom have published evidence of improvement in healthcare delivery systems attributed to the good to great principles.4–6
We describe a classic large system intervention that combined new organizing paradigms with good to great principles in our 609-licensed bed, not-for-profit, acute care academic teaching and research facility.7,8 With 3,500 employees and 4 years of hard work, the nursing division helped turn a good hospital into one that's on its way to becoming great. This transformation has resulted in significant improvements in four high-priority target areas: patient care, employee satisfaction, safety management and environmental quality, and overall organizational excellence.
Leadership and values
Collins found that Level 5 leadership is critical to a company's success in moving from good to great. Leaders of great companies are competent, effective contributors who channel “their ego away from themselves and into the larger goals of building a great company.”1 This requires professional will to keep the initiative moving forward, and personal humility to acknowledge that success depends on everyone. Level 5 leaders are “ambitious first and foremost for the cause, the movement, the mission, the work—and not themselves.”1
At GUH, the good to great work was championed, but not owned, by the chief nursing officer. The planning process and expectations for success were framed as the shared, collective responsibility of our hospital departments' leaders and employees who were asked to remember our vision and mission. The starting point began with the anticipatory principle, which states that the image of the future guides the current behavior within an organization.9 Our hospital wanted to be a great hospital and a trusted leader in healthcare; our mission, vision, and values drove us forward.
After reviewing the good to great principles, our clinical departments conducted a SWOT analysis of each department's strengths, weaknesses, opportunities, and threats.10 Clinical departments developed 3-year strategic goals for the four outcome measures (patient satisfaction, managing poor performance, safety management and environmental quality, and excellence), intervention and action plans, success measures, and implementation timelines.
First who, then what
Collins found that great leaders began by building a team with the right people.1 At GUH, this involved empowering departmental managers to engage in a performance management process based on excellence and distinguishing among levels of performance. Poor performers were given a performance improvement plan with clear directives to improve their performance. Data from the biannual employee survey showed that employees wanted better management of poor performers. This process also involved improving our managers' knowledge and skills in performance management and human resources.
The good to great companies weren't great because they were perfect; they began at various levels of dysfunction and infused the transformational process with a healthy dose of reality. Collins notes that good decisions can't be made until the brutal facts are confronted; determining an organization's truth helps leaders uncover the right decisions to be made.1 At GUH, we began with the results of our current patient experience Hospital Consumer Assessment of Healthcare Providers & Systems (HCAHPS) survey.11
The brutal facts at GUH included disappointing scores on the patient experience scales, particularly in the overall rating. These statistics were disconcerting because they were reported to the Centers for Medicare and Medicaid Services and posted for public comparison. Analysis of historic survey data showed the most powerful determinant of patient satisfaction was whether our staff worked together to care for patients. This finding helped us build and sustain momentum for change through “hope, excitement, inspiration, caring, camaraderie, sense of urgent purpose, and sheer joy in creating something meaningful together.”9 The scores didn't rise each quarter. Results predictably bottomed out during the second quarter of 2009 when we implemented electronic nursing documentation, but we believed we could regain momentum and we did reverse the trend.
The hedgehog concept
The hedgehog concept builds on an ancient Greek parable about natural enemies: foxes (sly, scattered, and easily distractible) and hedgehogs (which simplify the world into a single idea that unifies their thinking). When the two matched up, the fox could try multiple strategies, but the hedgehog could always do what he does best—curl into a spiny impenetrable ball. Good to great leaders are hedgehogs who discount ideas unrelated to the central idea that flows from the intersections of three circles: what you do best, what drives your economic engine, and what you're deeply passionate about.1 All three work together synergistically to power an institution's ability to obtain its goals. Collins suggested that for organizations in the social sector, the economic engine is a resource engine with time, money, and brand: time involves attracting and retaining those who are passionate about contribution, money is sustained cash flow, and brand is the well of goodwill from patients and staff.12
Our transformation required embracing the hedgehog concept and engaging in deliberative, iterative, difficult dialogue about our three circles. We believed we could be the best in the world at caring for patients in a holistic way; that our resource engine was fueled by our diverse, dedicated employees; and that we were passionate about teamwork that always puts patients first. We knew our patients wanted us to respond to their concerns and complaints, compassionately address their emotional needs, keep them informed, reduce wait time, and include them in treatment decisions.
Leaders of great companies eliminate anything that doesn't fit with their hedgehog concept. Great companies hire self-disciplined people who engaged in disciplined thought, which leads to disciplined action that's integrated into the organization's hedgehog concept.1 Great companies limit scarce resources to arenas directly supportive to their core business. At GUH, we took this seriously. We embraced this culture of discipline on a daily basis, critically examining and re-examining our patient care approaches. This meant that our hospital teams worked relentlessly to identify “noisemakers”—distractions appropriate for our “stop doing list,” such as investing endless time with poor performers and losing time by performing manual versus automatic processes. We focused on patient satisfaction surveys that revealed what was most important to our patients, visibly demonstrating the camaraderie among our team members in their interactions with patients.
Collins used the flywheel concept to demonstrate the central truth of organizational transformation: there's no single defining action, no grand program, no one innovation, no solitary lucky break, no wrenching revolution. Good to great comes about by a cumulative process—step-by-step, action-by-action, decision-by-decision, turn-by-turn of the flywheel—that adds up to sustained results.1
From the outside, organizational transformations often appear as spectacular, radical advances. In reality, transformations that lead to greatness are different from the inside, an incremental, cumulative developmental process. These steps are additive and build momentum; the cumulative effect represents the compound interest of many small steps. The flywheel was represented in our performance dashboard, a multipurpose tool that added rigor to our change endeavors. Initially, this was a vehicle for confronting the brutal facts where we fell short in patient care. Our baseline level of performance and the impact of our interventions became data to be reflected upon in planning by all our nursing staff and not just the leadership team. The dashboard was a transparent tool that became a working instrument for gauging our progress and seeing the collective impact of the many small efforts—the hallmarks of the good to great approach.
Designing our dashboard was challenging. We faced difficult decisions about what factors were most important to our success and how we could best measure change. Collins advised against agonizing about finding the perfect indicators, and for a consistent method for assessing and rigorously monitoring results.13 We created our nursing report card with nursing quality indicators, which were externally benchmarked by agencies such as the National Database of Nursing Quality Indicators® and the National Healthcare Safety Network.14,15 These indicators became our guide for tracking improvement and reinforcing the essence of the good to great flywheel—organizational improvement arises from many small initiatives.
The dashboard displayed the most critical performance indicators targeted for improvement. As a strategic organizing and analytic tool, it evolved as a vehicle for promoting collaboration across the hospital and critical alignment of our strategy with other improvement efforts. The dashboard created visible value for our hospital based on real-time data that depicted longitudinal progress and helped us leverage those data in daily decisions.16
Good to great companies embrace new technologies as accelerators and not creators of momentum. Those that are relevant are directly related to the three circles of the hedgehog concept. Collins concluded that the way an organization reacts to technologic changes is a barometer of its inner drive toward either greatness or mediocrity.1 Healthcare providers have traditionally used technology for billing and scheduling, rather than supporting individual patient care decisions.16 We embraced technology as an adjunct to our patient care improvements. Our nursing documentation system integrates electronic medical records, improvements in the safety and quality of patient care, and our hospital's compliance with regulatory guidelines. New devices now enable our clinicians to fully document care at the bedside. Within 2 years, we'll have an integrated technologic system with standardized work processes, computerized physician order entry, data views, and equipment; an electronic medical record with continuous, standardized data input; and a barcode driven medication system.
Benefits and satisfaction
Our good to great journey didn't include a radical or painful restructuring of our hospital organization and no single breakthrough moment. We celebrated the positive quality improvements in some satisfaction scores, and struggled to understand the wide variations in others. There's a sense throughout our hospital that our 4 years of collective effort and relentless focus on delivering safe, quality patient care have built momentum at GUH. Our mission and values are more alive than ever in our hospital's daily life. The effort of many has been expended through small, cumulative action steps—step-by-step, meeting-by-meeting, day-by-day—as we turned our flywheel in the one direction we saw on the horizon for our hospital's future.
There's no quick fix for the challenges that face the healthcare industry. Our experience has shown the great value of disciplined teamwork, a laser-like focus on our mission, and a long-term perspective. Accountability has taken on new meaning at our hospital. Metrics are reinforced monthly, published in all newsletters, and posted for review on the hospital's intranet for access by all. Achievement in our core measures and HCAHPS patient engagement scores are integrated into a restructured clinical ladder for nurses and include substantial bonuses for nurses who contribute to quality improvement. Our dashboard is now used by the entire hospital and is being considered for use throughout our entire healthcare system.
The kind of approach that takes you from good to great will need to be very different from that which took you from poor to good. Top-down efforts must give way to a bottom-up approach, principally led by empowered patients and engaged staff. It means taking patient choice further. It also means making the radical mindset shift of linking payment to quality and patient satisfaction to get the focus where it needs to be.17
During the good to great work at GUH during the last 4 years, our staff members have become more engaged, accountable, and empowered, and we have evidence of the positive impact of nursing interventions on quality indicators. It has been suggested that healthcare performance improvement is shifting from an “evolution to a revolution” and it simply isn't enough to be good in healthcare.18 At our hospital, we feel that we've started a revolution that's moving in the right direction—toward the greatness that can become a reality.