HL20: David Fox—Improving Care Through Accountability

In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of David S. Fox, CEO Advocate Good Samaritan Hospital.

This profile was published in the December, 2011 issue of HealthLeaders magazine.

 "We focused on culture, created standards of behavior, decided to hire people who are a cultural fit, and hold ourselves accountable to how we behave."—David S. Fox

In 2004, Advocate Good Samaritan Hospital in Downers Grove, IL, determined it wouldn't thrive in the future if it kept to the status quo, says David S. Fox, president. "Our physician satisfaction was mixed. Our quality was perceived as being good, but not distinguishable. Our nursing care was viewed as uneven by physicians; for example, great on unit X but not so good on unit Y.

And our patient satisfaction was mediocre to poor," he says. Good Samaritan also had technology and facilities that were increasingly being perceived by consumers as slipping behind, staff satisfaction that was OK but not exceptional, and a physician hospital organization that was paying physicians 15% less than Medicare rates, Fox says.

So Good Samaritan, under Fox's leadership, launched an initiative called Moving From Good to Great. "The strategic intention was to become the best place for physicians to practice, associates to work, and patients to receive care," says Fox.

At the time, Fox, who comes from family of physicians and grew up working in hospital settings during his summer vacations in Chicago, had no idea that the initiative would help Good Samaritan earn the 2010 Malcolm Baldrige National Quality Award.

When the good-to-great initiative began in 2004, Good Samaritan did not even know what its physician satisfaction level was, Fox says, because a survey had not been conducted in years. In 2006, physician satisfaction was in the 65th percentile and for the past two years physician satisfaction has been in the 97th percentile.

Good Samaritan has a medical staff of about 950 physicians and —other than specialty areas like the ED and anesthesia, all are on staff at other hospitals. "While some people looked at that as a challenge, we looked at it as an opportunity," he says. The thinking was, by becoming the best place for physicians to work, maybe they would choose to move some of their patients to Good Samaritan, Fox explains.

"It may sound like a cliché but we really embraced the win-win approach where we would become a better hospital and become more successful but do that hand-in-hand with physicians as they became more successful," Fox says.

He does concede that he has an advantage over many hospitals in the nation because his parent company's PHO, Advocate Physician Partners, is an innovator on pay-for-performance clinical integration. "We are in our eighth year of the P4P clinical integration program at Good Samaritan, and our physicians actually receive additional compensation for achieving quality, efficiency, and service outcomes," Fox says.

Becoming accountable

One of the first things that Good Samaritan did to achieve its vision was create much higher levels of alignment and accountability for performance with objective and measurable goals. Good Samaritan took the organization's goals, which it has in six key areas, and cascaded those goals down to directors and frontline managers, says Fox.

It then developed report cards for each of its managers—a typical manager would have eight to 13 goals, which would cover most of the organization's six focus areas. Good Samaritan also made the goal system transparent and put it on the hospital's Intranet. "Everyone in management could actually see performance plans for each of us, and we could also see the monthly report card result for each of us," says Fox, who distributes his performance to about 300 people each month.

This level of accountability launched the hospital in the right direction because for the first time all the members of management knew very clearly what the organization's goals are and what their contribution to the goals are, Fox explains. The goals were weighted to demonstrate priority, he says.

For example, if 20% of the organization's goal was on patient satisfaction— 5% for inpatient, 5% for the ED, 5% for ambulatory, and 5% for outpatient—and a nurse manager for one of the nursing inpatient units didn't have very good patient satisfaction rates, Good Samaritan would establish a weight for inpatient satisfaction of 25% on that unit.

It would score patient satisfaction on a five-point scale with anything over three being pretty good and four being really outstanding. "Everybody knows all the time how we are doing on achieving goals and that allows all of us to know, all year long, where we are doing well and where we are falling short."

Building loyalty

Historically, Good Samaritan hired for skill and prayed for cultural fit. It decided to not only change the focus by screening for skill and hiring for cultural fit, but also include lower-level staff in the hiring decision. Good Samaritan adopted a peer-interviewing system. If the manager determines a candidate could be a good hire, they send the candidate to the unit for shift-based peer interviews.

"We've trained about 450 of our best associates on how to do behavior-based interviewing," says Fox, explaining that two to three staff members will interview the person and give feedback to the manager. "If they say to the manager 'This person is not a good fit for our nursing unit,' then most of the time the nursing manager is obliged to accept their opinion and keep looking," he says.

In addition, the organization established 27 standards of behavior that the staff must adhere to. A group of employees and managers created these standards that are representative of being a high performing and compassionate organization. "We said to the whole organization that we are going to live these behaviors and anyone—myself included—who doesn't live these behaviors will be asked to remediate," Fox says.

The results have been outstanding. Not only has Good Samaritan achieved higher physician, patient, and employee satisfaction rates, which are all in the 90th percentile, but it has improved clinical quality as well. For example, in 2004 Good Samaritan's outpatient satisfaction score was in the seventh percentile, Fox says. "No change happens without leadership saying we can do better, so we said outpatient satisfaction is going to be important."

Then Good Samaritan improved the technology around scheduling and registration, brought in new management where necessary to achieve higher results, adopted best practices for customer relations, and posted patient satisfaction results publically—weekly to the hospital staff and monthly on public boards in every department. By July 2006, outpatient satisfaction was in 99th percentile.

"We focused on culture, created standards of behavior, decided to hire people who are a cultural fit, and hold ourselves accountable to how we behave," Fox says. "As a result of these fundamental management moves, we really dramatically improved our performance over a short period of two to three years."

In 2003 only 40% of heart attack patients at Good Samaritan had door-to-balloon times shorter than 90 minutes. A physician took on the role of improving clinical quality around the cath lab, and the hospital required all ambulance companies it worked with to switch to a 12-lead EKG machine, trained paramedics how to identify a STEMI patient with the 12-lead EKG, and empowered them to call the ED and institute a cardiac alert, so the cardiologists at home could get to the hospital faster. In 2010, 99% of patients had door-to-balloon times under 90 minutes, with the average being 56 minutes, and recently Good Samaritan posted its lowest door-to-balloon time of 11 minutes.

Looking ahead, Good Samaritan, which launched a commercial accountable care organization in January 2011, is not waiting for the next evolution of healthcare reform from Washington, Fox says. "We need to maintain or improve outcomes while we lower the costs of care across the continuum," he says. "So we are moving forward in doing the right thing, which I think is improving the value and really reducing costs of healthcare for our community."

This article appears in the December 2011 issue of HealthLeaders magazine.