Major Medical Center Case Study

Synopsis | The Situation

In April, 2014, a community Medical Center comprised of 1,400 employees that was over 2 hours from the nearest airport approached us for implementing our Leadership Accountability System that promised rapid change and results. They were required to be a “full service” medical facility to effectively serve their community, which meant their operating costs were greater than other medical centers of a similar size. In addition, being so remote made it difficult to recruit qualified nursing professionals, which resulted in the added expense of needing to hire “travel nurses” from outside of their community.


The medical center had a very diligent approach to monitoring Press Ganey scores, industry standard metrics and financial data on a weekly and monthly basis. They also had a robust strategic planning process that developed cascading goals for every employee to ensure the improvement and achievement of performance goals.

Unfortunately, while there diligent efforts focused on metrics and accountability, the organization was continuously operating in the red financially and not experiencing significant changes in their metrics, regardless of their efforts. Employee satisfaction was continually declining as greater frustration was setting in on people who worked hard and didn’t see their goals achieved.

The 45 Departmental Directors in middle management also worked hard to achieve their strategic goals and initiatives. They were involved in continuous improvement efforts, but only a few departments achieved significant improvements in operational effectiveness to address the medical center’s ability to survive. In addition, each Director focused on optimizing results for their department resulting in “silo behavior” and an attitude of “blame” and “victimization” when breakdowns between departments would occur. Employee engagement was low and this contributed to low employee satisfaction scores.

If the current multiple year financial trend persisted, the medical center would have not choice but to close its doors or sell to a larger hospital conglomerate that would optimize medical center costs be eliminating local treatment and care options. Selling to a larger hospital system would negatively impact the community given the distance to a larger medical facility located hours away.

IMPAQ’s Solution

In May of 2014, IMPAQ began the change effort by implementing IMPAQ’s Rapid Team Results Leadership Accountability System with the Senior Leadership Team. The purpose of this effort was to establish a “non-negotiable” sense of purpose that would rally the entire organization to achieve breakthrough results.

This effort began by shifting their focus away from only monitoring metrics to identifying the top 8 priority projects that would leverage significant improvement from their existing strategic plan. Then, instead of delegating a single owner for each project, they established “shared ownership” for all 8 identified priorities projects, with specific leadership for each project. Using a new approach to project planning that focused more on cross-functional accountability, they developed new leadership “habits of execution” that enabled them to be more effective at resolving cross-functional breakdowns, more effectively and quickly making decisions that had organizational impact, and developed “recovery plans” to respond to unpredictable breakdowns that occur within a healthcare environment. They developed a clear communication plan to share their “picture of success” with the organization and the non-negotiable improvement projects with the rest of the organization.

The second part of the strategy for change was to create a unified team from the 45 department Directors across the organization. This upper middle management group represented the administrative, clinical and ancillary services of the medical center. The purpose of implementing the Rapid Team Results Leadership Accountability System was to change their role from being Functional Managers to Business Leaders – meaning that they were to take responsibility for cross-functional operational excellence instead of only focusing on their departmental goals and strategic initiatives.

In the first six months, the 45 Middle Managers developed for themselves a clear Vision of Leadership that aligned the group on the impact and reputation they wanted to have as a leadership team for implementing cross-functional change in the organization. They developed several “new habits of execution” that they would hold themselves accountable for improving their performance, teamwork and communication. Instead of blaming the senior leadership team for not providing enough clarity in direction, priorities and resources, they would take initiative for resolving cross-functional breakdowns, improving operational excellence and learning to operate as a highly effective team. They identified 5 task forces from the 45 people to improve their execution and their cross-functional effectiveness.

The Process for Change

Each team spent 2 days establishing their Leadership Execution System, and each team was provided 8 hours of coaching over a six to eight month period to ensure that the mindset and habit changes were guided and reinforced to ensure success.

Then, each team spent 1 day in a follow-up session every six to eight months to measure results, modify goals for improvement and track the impact on business results (the metrics described in the opening situation).


The medical center experienced a 1.5-year culture change in approximately 6 to 8 month increments. Their results included improvements in their “collective execution”, their team relationships, and their business results during each six to eight month period.

Rapid Results in the first 8 months

The Senior Management Team improved 10 of their 11 new Habits of Execution with 7 as significant improvements. Some of the significant improvements included:

  • Setting, communicating and demonstrating clear and unified purpose, direction and priorities
  • Coach and develop Directors to be effective leaders
  • Timely, effective and inclusive decision making
  • Effectively sharing and utilizing resources across functional areas
  • Enhancing trust, respect and accountability at all levels

In addition, they improved team relationships on 15 categories of team effectiveness by an overall average of 53% including the following improvements:

  • Support – 81%
  • Trust – 76%
  • Challenge in a supportive way – 67%
  • Communication – 61%
  • Managing conflict – 56%

The Middle Management Team of 45 people improved 11 of their 17 new Habits of Execution with 6 of those being significant improvements including the following:

  • Align operational improvements with strategic priorities
  • Openly share information, collaborate and proactively surface and solve cross-functional problems
  • Dynamic, open-minded and systems thinking
  • Communicating to others as “1” voice – complete alignment

In addition, they improved team relationships on 15 categories of team effectiveness by an overall average of 41% including the following improvements:

  • Information Sharing – 52%
  • Listening – 45%
  • Communication – 44%
  • Managing Conflict – 45%
  • Trust – 41%

The Medical Center’s Business Results from the first 8 months of using the Leadership Accountability System included:

  • Profit of $3M instead of a forecasted loss of $3.5M
  • RN Travelers went down from 25 to 7 resulting in reduced costs
  • Increased medication scanning from 80% to 91%
  • Met 11 of 11 goals in patient safety and quality
    • Catheter infections reduced from 36 to 6
    • Readmissions decreased by 20%
  • Reduced meeting times and effectiveness of meetings
  • Better communication and alignment between the Middle Management Team and the Senior Management Team
  • More aligned and effective communication with the rest of the organization

Sustained Business Results and Accomplishments after 1.5 Years

  • Eliminated Traveler Nurses and all but one nursing positions filled
  • Aligned effort to reduce costs allowed for a profitable first quarter (a first for the organization in 7 years)
  • 77% response and engagement rate from nursing (an all time high)
  • Accountable Care Organization System is operational and achieving results in first six months for Population Health Management Initiative
  • Continued growth in employee and patient safety
    • 40% reduction in falls with injuries
    • 10% reduction in pressure ulcers (out performing national average)
    • HAI (hospital acquired infection) was less than 1% beating the national average of 4%
  • Passed major audit for Rule 32 reducing lost time
  • 7% reduction in injury falls and asked to present at Healthcare Association
  • Improved medical record efficiency through cross-functional effort
  • Greater interdepartmental support and assistance to accomplish department goals representing a new cultural norm
  • Employees at all levels are using accountability language in meetings with a increase in employee volunteers for participating in task forces
  • Employee Fund Drive achieve 100% of goal with involvement from 80% of all employees raising a record amount of money
  • Hospital and all clinics successfully tested for Meaningful Use generating $1.5M in reimbursement (significant increase over previous year)
  • Recognized by Health Grade as in the top 50 hospitals in the country for safety
  • No turnover in leadership positions and overall increase in employee retention
Notice that the goal of the program is to reduce the incidence of major complications after a stroke among patients who have risk factors for a stroke, not among stroke victims in general. To achieve this goal, the medical center implemented a program requiring doctors to review certain educational materials with all patients who have risk factors for a stroke. Again, the program is only targeting patients who have risk factors for stroke.

Those educational materials, which explain that stroke victims must immediately seek adequate medical attention when they experience stroke symptoms, are based on the finding that people who experience a stroke are frequently not treated quickly enough to prevent major complications, such as brain damage and paralysis. Thus, the medical center hopes that the educational materials will encourage stroke victims to seek adequate medical attention and, thus, avoid major complications.

Which of the following, if true, would most significantly limit the extent to which the program meets its goal of reducing the incidence of major complications after a stroke among patients who have risk factors for a stroke?


(A) Most first-time stroke victims have not been previously diagnosed as having risk factors for a stroke.

The program is not aimed at first-time stroke victims who did not have risk factors prior to their first stroke. Rather, the program is aimed at patients who have risk factors for a stroke. Thus, choice (A) would not limit the extent to which the program meets its goal.


(B) Stroke symptoms, while readily identifiable by those around stroke victims, are rarely perceived by the stroke victims themselves.

The educational materials are designed to encourage stroke victims to seek adequate medical attention when they experience stroke symptoms. But if stroke victims themselves are rarely aware of the fact that they are experiencing stroke symptoms, they will not be able to act on this advice. This would limit the extent to which the program meets its goal, so keep (B).


(C) Some stroke victims who seek immediate medical attention after a stroke can still experience major complications.

The program's goal is not to eliminate the incidence of major complications after a stroke. Rather than goal is to



the incidence of major complications. The program can still achieve this goal even if some stroke victims experience major complications after seeking immediate medical attention. Eliminate (C).


(D) All of the information contained in the educational materials has already been readily available on the internet for several years.

Just because the materials have been readily available on the Internet for several years does not mean that those with risk factors for a stroke have seen or studied those materials. Thus, this statement does not strongly suggest that reviewing those materials with patients who have risk factors for stroke would not be beneficial or that the program will not meet its goal. Eliminate (D).


(E) Because many stroke victims have difficulty moving during and after a stroke, the medical center also provides patients who have risk factors for a stroke with wearable devices that can be used to summon emergency assistance at the push of a button.

The fact that many stroke victims have difficulty moving during and after a stroke suggests that stroke victims might have trouble seeking medical assistance. By itself, this could limit the extent to which the program meets its goal. However, since patients are given wearable devices that can be used to summon emergency assistance, this potential obstacle has been removed. Thus, choice (E) would not limit the extent to which the program meets its goal.

Choice (B) is the best answer.

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