When you tell people you live in Texas, you tend to get a lot of different reactions. While neither of us was born here, it is our home now. So we get why people seem to either love it or leave it when it comes to the state. One thing you can’t deny about Texans, though, is that they love their football. Texans are obsessed with football, and they show it by wearing team jerseys and caps just about wherever they go. And we’re not just talking about professional teams like the Dallas Cowboys or the Houston Texans—people also proudly wear the insignias of college and even high school teams. If you don’t believe us, check out the book Friday Night Lights by Buzz Bissinger (it was also made into a movie and a TV show if one of those is more your speed).
This whole notion of Texas football mania was brought home to Britt one Saturday when, on a shopping trip to his local Costco, he saw more than forty people standing around watching a Texas versus Oklahoma college game on the store’s big-screen TVs, every one of them wearing jerseys and caps, and every one of them looking as if his entire life depended on the result of the next play.
Paul recalls when he noticed it too: When he first arrived in Texas, all his neighbors seemed to talk about was the result of the latest high school football game—even though none of them had kids in high school at the time! The simple fact is that people (especially Texans, apparently) are inspired by associating with winners. We tend to create a sense of identity that comes from being part of a winning team.
But while it’s easy to know if your football team is winning, how do you know whether or not your organization is successful? “Why, that’s easy,” you’re probably saying. “Winning in business comes down to whether you’re profitable or not.” While we won’t disagree—after all, profits are the fuel that give you and your organization options for a path to future success—this is far from the only measure of a winning organization.
Blasphemy, you say? Not quite. Look, folks, your organization—like both of ours—is on a journey toward the summit of the mountain. The truth is, you might never reach the summit, but you are going to cross peaks and valleys on your journey toward it. And every time you crest one of those extraordinary peaks, you’d better make time to celebrate it as a way to mark the progress you’ve made across those dark valleys. Those peaks, when you take the time to notice them, are all the other metrics aside from financial performance—specifically, employee engagement and patient/customer satisfaction scores—and you need to be paying attention to them in order to beat the drum of progress. In fact, if you’re focused on celebrating the engagement levels of your employees first, and the satisfaction of your patients and customers second, we can almost guarantee that you’re going to see financial success.
Don’t believe us? How about hearing it from Tony Armada, CEO of Advocate Lutheran General Hospital, who shared some advice a mentor once gave him: “If employees and physicians are happy, you’ll get an increase in volume. If you increase volume, you’ll find ways to decrease cost. With that, you’ll increase margin and be able to invest back in employees.” We couldn’t have put it better ourselves.
Unfortunately, we’ve found that most health care organizations these days, unlike Tony’s, have been looking at this equation “bass-ackward,” where everything starts and ends with the financials. It makes for scary situations for today’s leaders, especially in the health care realm, because they were taught to focus on the balance sheet alone—they have never received the kind of management and organizational training a leader really needs to be successful. It’s a monumental problem we’d like to help solve.
It all comes down to this: Health care leaders need to focus more on the people, not the numbers. Allow us to explain.
When you look back at the history of health care, it all began with people wanting to nurture and care for those of us who were sick. But it wasn’t a very scientific process—the first surgeons we had were also our barbers! We didn’t even have what we would call a “hospital” until the 1800s, and even then the element of compassion was more evident than the study of science—there was a religious connection to hospitals, and the nurses were nuns. The focus in those times was on understanding what kinds of things were making people sick and how to make them get well—not on measuring how the caregivers were doing. That meant data was at best inconsistent, if it existed at all.
Compare that to today, where it seems all anybody can say is, “The numbers just don’t add up,” and “The health care system is broken.” This has resulted in a clash of sorts between the veterans, who want to focus more on caring for patients, and the newcomers, who want to get everyone focused on the data—especially the financials.
With all the talk about health care reform (which, honestly, is a misnomer—the health care system is in a perpetual state of reform!), along with the continued changes in the reimbursement system these days, the notion of measuring the financial performance of a health care organization is all anyone seems willing to focus on. Listen, we’re not here to argue against the reality that every organization needs to be financially viable so it has the resources to invest in its people and future vision. But we firmly believe getting to that point—achieving that financial viability—starts with a focus on employee engagement.
Take a quick peek at the cover of our book. In case you’d forgotten, the title is Patients Come Second. We applaud all of you who worked past your sense of recoil over that phrase to keep reading to this point. Now we can actually complete the equation by telling you that employees come first, patients come second, and—gasp!—financials come third.
“Wait a minute!” you might be saying. “You just said your company needs to be profitable to operate, so how come profitability is only third on your list?” Well, just as we posit that engaged employees will drive higher patient satisfaction, so too will the combination of high employee and patient measurements push profits higher. You need to add up the first two in order to achieve the third. The more our employees are engaged, the more satisfied our patients will be—which will then lead to more and more business for the organization. It’s really that simple. Your financial performance is actually the lagging indicator, not the leading indicator, of how healthy your organization is.
Unfortunately, most health care organizations seem to have missed the memo on this crucial message. We were talking recently with one frustrated hospital CEO who told us that all her corporate board wants to focus on is making cuts to staff and equipment—controlling costs—as the way to get profits up. We felt for her, because if your job is simply to cut and trim, eventually you’re going to hit bone and muscle. You’re going to start chipping away at the structure that holds the organization together. That’s no way to build toward your future.
Now, we’re all taught that there are two primary ways to boost profit: cut costs and raise revenue. But for health care organizations, here’s the rub: Because they must deal with a high percentage of variable costs, and because the complex reimbursement system restricts how much of that revenue actually stays in the hospital’s hands, it’s harder to get a lot of bang for your buck if you target revenues as the answer. That, of course, leaves cost cutting as the only option most executives consider viable.
Well, we’re here to tell you that there are other avenues for health care organizations to take toward financial sustainability. And if people aren’t open to walking down those paths, they’re basically shooting themselves in the foot. In fact, we’ll go out on a limb and use a four-letter word to describe organizations that focus just on cutting costs as a way to boost their financials: lazy. Yup—we said it.
It’s too easy to pull out a spreadsheet filled with revenues and costs and simply start deleting. That’s not leadership—that’s just math. We think everyone would agree that the better the members of a team or an organization work together, the better the results will be—but how do you measure something like that? Adding up costs is straightforward; it gets a bit murky when you try to think about measuring the experience of working together. Most people might not even know what it’s like to work on a truly great team, so how would they know where to begin measuring that experience? Now you see why it seems so much easier just to cut something.
To borrow a line from the brilliant visionary behind computer giant Apple, the late Steve Jobs, our challenge to you leaders out there is to “think different.” Shift your focus and turn your equation around—focus on your employees first, not your financials. Become accountable not just to your patients and your accountants, but to your employees—which means, as Tom Royer, past CEO of CHRISTUS Health, defines it, “You will do the best you can do, even when no one is looking.” By doing your best to emphasize and support your employees, you’ll drive your organization toward its mission, vision, and values.
“Okay, so if we take a chance and believe you,” you might be asking now, “how are we supposed to go about measuring success with this new equation?” Good question. For any organization, measurement becomes a critical activity to determine whether you are continuing on the right path. It’s a validation of everything you are striving for, and it gives people in the organization confidence that you are, indeed, heading in the right direction. If you can show that your organization has the best patient satisfaction scores, for instance, all your associates can point to that number with pride. Well, as long as you’re being honest about when the numbers aren’t as good, too, cautions John Hill, CEO of Medical Center of Aurora:
Employees always sniff out the “spin” on patient satisfaction results. Always share the good results and bad results without spin. Celebrate improving and great results, and talk frankly about poor or negatively trending results. If the expectation has been set to achieve the ninetieth percentile in patient satisfaction results, talk about the bad results in the context of what is expected, and what is being done to improve the results and achieve the expected results. Never speak publicly in a punitive tone about the results, but nor should you cover up or spin negative results—this moves away from accountability and toward apathy. Employees want to achieve success, and when we’ve shared negative results in a frank and authentic way, the response of our employees has always been positive.
Positive or negative, metrics are important for looking back at your track record. But measuring also acts as an early-warning system so that if you do find yourself going off track—say, if you see a steep decline in employee engagement or patient satisfaction scores—you can correct your course before you really get lost in the desert. As much as we’d like to think that we could live our lives simply by listening to our gut, the truth is that we really do need data and measurements to give us our bearings, the coordinates of where we might be at any given point in time. Any organization can make strategic changes (tied to its mission, vision, and values) in just about any area it wants to if you begin measuring the kind of change you want to bring about.
At our organizations, measuring starts internally with our annual employee engagement surveys, in which we ask employees to answer questions using a scale that runs from 1 to 10. We’ve talked to executives at other organizations who have told us that while they like the idea behind such surveys, they’ve never gotten around to conducting them. Big mistake. You know these same people made time to review their organization’s income statement and balance sheets. Again, think different. If you believe that human capital is your most valuable asset, how can you neglect to gauge how well that asset is performing compared to its potential? The answer is simple: to borrow another corporate tagline, “Just do it.” Make the effort to start conducting regular employee satisfaction and engagement surveys—you won’t regret it.
Now, we’ll go on record here and say that the term satisfaction might be sending the wrong kind of message. For us, it brings up images of Mick Jagger and the Rolling Stones whining about how they can’t get any. That’s why it can seem as though when we conduct a satisfaction survey, we are catering to those individuals who are just never happy. Engagement, on the other hand, is a more powerful—and we think, accurate—term to use in this situation, because it implies that we are measuring who really cares about and likes working for the organization. To put that another way, we want to conduct these surveys not just to see who is happy or satisfied, but more to find out who cares about what we’re doing together as a team.
That’s why conducting engagement surveys becomes a fantastic tool to gauge whether we as an organization have any momentum or a sustainable trajectory to get us where we’re headed. Are we working together to pick up operational speed and grow at a sustainable rate? Without momentum—we crash! Are we pointed in the right strategic direction? Wrong trajectory—let’s pack it in, because we’re done. And to understand our relative speed and course, it can be very helpful to then benchmark these survey results against other like-minded organizations. By comparing yourself to others, you’ll give yourself a good dose of objective reality.
What’s key for each of us and our organizations is this: By having the discipline to conduct the surveys regularly over time, we can analyze the patterns that emerge, patterns that can either give us reasons to celebrate progress or, on the other hand, to hit the pause button and find out where we’re beginning to go wrong. We can then target the areas where we receive the lowest scores and set about trying to improve upon them.
BerylHealth, for instance, tackles the five lowest-scoring categories from the employee engagement survey by creating corresponding ten-person, cross-functional teams made up of leaders from throughout the company (anyone in a supervisory role), who then go about interviewing employees to determine why, say, they are pessimistic about the training and development they are receiving in their jobs. The leadership team tasked with that particular issue has thirty days to research and determine the problem and then another thirty days to come up with an action plan and to make recommendations about how the company can combat the problem.
We’ll share a little tip with you: Make the time to look through each and every one of the survey comments. From experience, we have learned that this information is qualitative gold. It’s a unique bridge into finding out what really makes your employees tick. This is something even the feared military leader General George S. Patton understood all too well. When it came to how his soldiers dressed, how they carried themselves on and off the battlefield, and even how they saluted, Patton was as old school as they came. But when it came to how those same soldiers named and decorated their tanks, well, Old Blood and Guts seemed to have a soft side: He allowed them to do pretty much whatever they pleased. When asked why, Patton simply replied that he got a better understanding of his men based on the graffiti they wrote. In other words, he understood the value of collecting both emotional data and factual data to fuel strategies that could effect change.
Now, the two of us can admit that making the commitment to dive into all that emotional information your employees provide through their mini-essays can be both exhausting and, on occasion, depressing. Reading about all the bad things your employees think and feel not only about the workplace but also about you personally as a leader can really take a toll. Of course, the task at hand is not to identify who among the commenters might be the kinds of whiners, losers, and jerks you need to extricate from your organization. You can’t simply write off every employee who makes a negative comment. What you can do is look for common themes and patterns that tell you it’s not just one person piping up. Common themes and complaints point to common problems. And once you identify the issues, that’s when you can start taking action.
Effective measuring isn’t just about conducting surveys. To truly get a handle on the satisfaction and engagement levels of your employees, you need to create multiple input channels for them to communicate with you. Sometimes just getting out and walking the hospital hallways is an opportunity for making that connection and learning about what makes your employees tick. “The more I can get out, and the more our leaders can get out and about, I think the better everybody feels about what we’re trying to do to be the best at what we’re doing,” Mike Packnett, CEO of Parkview Health, told us. “And I get such great energy when I do it, too. You get so inspired.”
In many ways, our role as a leader is to play the detective or an investigator you might see on a TV show like CSI. Your survey data serves as the first clue in your investigation of how well your organization is really functioning. It’s not enough, however, just for everyone to say that the organization has a great culture; you’ve got to be willing to dig deeply into other clues and to use other methods to conduct your investigation.
At BerylHealth, for instance, we’ve told you before about the intranet link “Ask Paul,” where employees can submit comments and opinions. Paul also uses another channel (an idea stolen from Britt), holding what he calls Chat-and-Chews, where he meets with employees over lunch to get them to share their ideas and concerns. Steve Moreau, CEO of St. Joseph’s Hospital of Orange, has created his own version of the Chat-and-Chew, which he described for us:
I have a monthly breakfast for frontline staff and each department in the hospital. There are almost one hundred departments. Each department selects one employee to meet with me and have a monthly breakfast with me for a period of six months. Their job, or their free ticket to come to the CEO breakfast each month, is that they solicit questions, issues, rumors, anything they can come up with, and they e-mail them to me in advance. When I come to the meeting, I answer all their questions, regardless of what they are—tough ones, easy ones, whatever—all in front of the whole group. I then answer questions from the group if there are new ones, and provide updates if there’s anything going on that they might want to hear about. Then all of it is published so that the whole organization gets to hear it.
By holding these kinds of sessions, as a leader you show that you’re truly receptive to the needs and issues that are important to your people. You’re on the path to making better decisions because you have gained access to true, actionable data that you won’t find on any financial statement.
That’s not to say that collecting information this way is always easy. Britt recalls a time when he organized a Chat-and-Chew for a group of employees who, in a recent satisfaction survey, were in the bottom 10 percent—those with the biggest complaints. He wanted to find out how to right the ship for them. After an hour of nodding his head at the flood of negative comments, Britt realized his mistake: He needed to embed some positive thinkers along with the negative ones. For the next Chat-and-Chew, he invited an equal number of low and high scorers to set the tone for the conversation. The effect was immediate: The conversation stayed focused on the changes that would really bring about a difference rather than just the comments voiced by a complainer.
This reveals how important it is to recognize the crucial role your star employees play as role models for your less stellar employees. The superstars effectively become ambassadors for the mission, vision, and values of the organization even when you, the leader, aren’t there. That’s something that can be reinforced by building a process or a system around this whole idea. Elliot Joseph, CEO of Hartford Healthcare, told us about just such a program he created, called How Hartford Healthcare Works (or H3W), which has since been implemented across his organization:
H3W requires that every employee is a member of a work group, and every work group has regular meetings at least once a month. Every work group has a leader, and we have created a group of facilitators who are trained in the H3W work, in change management, in the tools of change management—whether it be Lean or Six Sigma, or whatever might be in the toolbox that gets embedded in how you improve. Each work group is data driven, has its own dashboard, and is driven by our trained facilitators, who facilitate multiple work groups. The program is based on teamwork and recognition, so every team meeting has all those aspects of the team meeting.
You can now go across the organization and understand, in every work group, what their priorities are, what they’re measuring, how they’re improving. It’s about idea generation in every work group, so we’ve generated thousands upon thousands of ideas from seven thousand people—now today at Hartford Healthcare, fifteen thousand people—with literally hundreds and hundreds of those ideas having been implemented and executed upon. At the same time, the work group is also a vehicle for communication, so when we have system-wide or organization-wide initiatives to introduce, now there’s an organized framework through H3W to actually execute new initiatives. So you can walk into virtually any department, any work group, and you can ask people who work there, what are their priorities? What are they measuring? What are they implementing? And they have very visible dashboards in place, and it’s almost an entirely different world for people.
When you bring your employees together to exchange ideas, you open up a channel of communication by speaking to them in the language of change—and they have a voice with which to respond.
You also need to understand the importance of who shouldn’t speak when you gather your employees to collect information. When Britt holds his employee forums, those gatherings where employees assemble to get the latest updates on the organization, the hospital’s chief financial officer doesn’t go through a rundown of the organization’s financials. This report is a given in most other organization forums, whether they operate in the health care field or not. The point in striking the financials from the list of topics is not to disrespect the importance of the numbers; it’s to emphasize that there are other things that we should focus on first.
This gets back to our earlier point about the importance of your mission, vision, and values. If the CFO is the only one talking about the financials, then it seems like that dirty word profit is reserved for only the bean counters. Sometimes those of us who work in the health care field can get on our high horses and spurn discussions of the financials. We act as though we should be more interested in patient care and worrying about the bottom line is such a nuisance. Really? Think about it—we’re still operating a business here. It’s like when you bring up the topic of how everyone needs to watch expenses, and you see a couple of people roll their eyes. You want to reach out and grab them and ask, “How do you like your paycheck?” That would get their attention, right? But what we’re talking about goes beyond this simple point. We have a moral obligation to be wise stewards of the sacred resources we’ve been entrusted with. Patients and families are struggling to pay their health care bills, which means we have the responsibility to be as efficient and effective as we can be. We owe that to our patients and our communities.
So when the time comes to hold employee forums and gatherings, it makes sense to invite everyone on the team—CEO, CFO, CNO, whatever—so that we can talk about all the measures we track throughout the organization. Ron Swinfard, CEO of Lehigh Valley Health System, whose organization has 11,500 total employees, has conducted employee forums for as many as six thousand employees. “We invite literally everyone,” he said. “Housekeepers, service workers, new residents, EMS providers, et cetera. We don’t miss anyone. When people come here for care, they don’t discriminate. They experience and get a feel for the everyday people when they come to the hospital.”
When you start getting everyone involved, interesting things begin to happen. You can have a cool experience like watching a CFO speak with passion about the importance of employee engagement. That means he gets it! He understands that the success of the organization must be measured not just in financial terms but also through patient loyalty, physician satisfaction, performance quality, and yes, employee engagement. Rulon Stacey, a renowned health care executive and former chairman of the American College of Healthcare Executives, and a past winner of the Malcolm Baldrige National Quality Award, put it this way:
The biggest challenge on our road to Baldrige was to infuse a sense of responsibility by leaders, a duty to listen to the team and then embrace what they were being told. It requires courage and commitment to the mission, vision, and values of the organization.
Business schools may churn out executives skilled at identifying an organization’s key performance indicators (KPIs) as a way to measure success. But when the CFO gets up on stage during an employee forum to discuss employee engagement and patient satisfaction scores—well, you get quite a reaction from the crowd. The employees might be expecting a numbers-crunching session, but hearing the organization’s chief financial executive speak instead with passion and personality only helps to emphasize what’s most important to the success of the organization: employees. Sure, you need to collect all the data and KPIs to get a holistic view of how you are operating. But if the data isn’t what’s driving you toward your ultimate goals, don’t emphasize it. If that kind of data is becoming a distraction more than a tool, then stop collecting it.
As a leader, you will periodically ask management to review the progress and measure the health of your organization. But when people spend their time analyzing quantitative data rather than focusing on the human side of things, they seem to forget the changes and achievements the organization has made since the time you last asked them. You might catch yourself saying, “Are you kidding me? Don’t you remember what we did to address that problem?” While you can give in to some frustration, ask yourself why your people have forgotten. Have you done enough to communicate and celebrate the victories that your organization has experienced? That is, have you found ways to effectively take credit for the changes you have put in place as your employees asked?
Remember our football example? People like to associate with winners and organizations that see continued success on their journey toward the mountaintop. You need to find ways to show them that both they and the organization are winning when it comes to things that go beyond the financials. You need to confirm the emotional victories along with the factual ones. That’s why, returning to the BerylHealth example, the leadership teams tasked with recommending changes based on their research are also asked to report back to the rest of the organization at the end of the year about what progress, if any, was made to address each concern. The key idea here is that you as the CEO or leader don’t have to own the sole burden of dealing with that data. Open it up and share with everyone in the organization so that all of you can work together as a team to tackle your weaknesses and celebrate your achievements.
It’s also critical to seek and call attention to external validation that chronicles what you as an organization have accomplished. Consider how Paul and Britt met: on stage, as recipients of the Best Place to Work awards sponsored by the Dallas Business Journal. Ah, you skeptics are raising your hands again, aren’t you? “Those kinds of awards are just beauty contests,” you might be saying. “They don’t mean anything.” We disagree. In fact, we contend that winning awards like these is a way to both measure and celebrate the success of your organization. And as we noted earlier about football fans, everyone likes to be part of a winning team.
Awards like these function as directional signposts that indicate successes along the path to the mountaintop. By celebrating achievements in employee engagement, we are communicating both our interest in the employee and the value of the employee experience. But don’t just take our word for it. Give it a try. Create an internal award that celebrates the performance of one of your teams. Bang the drum loud and proud! We bet that, all of a sudden, you’ll see other teams scrambling to be recognized as well.
Britt saw this kind of explosion when, at Presby, he helped put together a funny music video celebrating the departments that received the best employee engagement scores. Wouldn’t you know it? After that, other teams came calling, asking why they weren’t being celebrated too. Well, once we told them that recognition was linked to their engagement scores, you should have seen the stampede! Everyone wanted to be a part of a winning team.
But you shouldn’t stop at celebrating employee engagement scores; other metrics are just as powerful. When Britt was at Medical City, for example, he posed a question to his senior leadership team: “How do you celebrate the success of the folks who work in your unit?” At first, he received little more than blank stares in response. Other than noting daily productivity and adherence to budgets, no one had ever thought about how to celebrate the successes their unit achieved. But when Britt asked them to put together a list of the kinds of activities that everyone could measure—in both quantitative and qualitative terms—you could feel the energy being generated inside the room.
The results were electric! Britt’s leadership team found ways to celebrate, for example, the success of the respiratory therapy department in its recent quiz show victory—a regional event known as the Sputum Award. (We know, we know—it sounds kind of gross!) The finance team often struggled to find ways to reduce costs and improve processes, so they created the Bright Idea Awards. Not only did this program inspire numerous initiatives, but the team also put together a hilarious video highlighting the accomplishments of several clever team members. The video was a hit at the next employee forum series, and the award recipients—the stars of the video—beamed with pride.
Collectively, the units at Medical City saw great results when the organization received recognition from an external source, becoming one of the first hospitals in Texas (and one of four hundred out of the nation’s six thousand hospitals) to be designated by the American Nurses Association as a Magnet hospital—a prestigious accomplishment that signifies the hospital is on the cutting edge of delivering high-quality care. Winning this award wasn’t just a chance for the organization and its employees to celebrate what they had accomplished; it also served as an incredible benefit in terms of talent, drawing top-notch nurses around the country who wanted to come work for such an organization. At first, no one thought Medical City could win the award. Now, Dallas is the home to the highest concentration of Magnet hospitals precisely because other organizations in the area had to raise the bar to keep up with Medical City.
Do you see how celebrating your organization’s victories becomes a self-fulfilling cycle? It’s kind of like throwing the life preserver farther and farther out and then challenging your team to swim as hard and as far as they can. Winning an accolade like Magnet recognition becomes a way to measure how far you’ve come—and serves as inspiration for others to follow your lead. The more we celebrate our successes, the more successful we—not just as an organization, but also as a community—become in the future.
That brings us back to the key point of this chapter and of the book in general: Measuring your employee satisfaction and engagement level is the leading indicator of how healthy your organization really is. Higher scores here translate into higher patient satisfaction scores and better financial performance. It’s as simple as connecting the dots. Measuring how engaged your employees are—and finding ways to celebrate the successful changes you implement—is how you can connect back to driving the mission, visions, and values of your organization. Developing recognition that your team can work toward helps you as a leader determine what goals you need to hit in order to stay on track toward fulfilling your ultimate purpose. So what are you waiting for? Get started!
But how? Join us in the next chapter to find out.