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Service Delivery Innovation Profile

Program to Engage Employees in Quality Improvements Increases Patient and Employee Satisfaction and Reduces Staff Turnover


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Snapshot

Summary

Sharp HealthCare’s organization-wide strategy, called The Sharp Experience, incorporates a number of mechanisms to encourage employee engagement in improving patient care and service, with a focus on creating an overall culture of engagement and on motivating individual employees to participate in improvement activities. Examples of specific initiatives include an annual all-staff assembly, topic-specific improvement teams, quarterly employee forums, standards for employee behavior incorporated into performance reviews, leadership development courses, employee awards, and performance reports shared across the institution. Since program implementation, Sharp has experienced a significant increase in patient satisfaction, a meaningful improvement in the public's perception of the quality of care and services offered by the system, higher employee satisfaction with a near 50-percent decline in staff turnover, and an increase in market share. Institutional leaders believe that components of The Sharp Experience program focused on engaging employees have played a critical role in driving these improvements.

Evidence Rating (What is this?)

Moderate: The evidence consists of trends in key measures over time, including patient satisfaction, consumer perception of quality, employee satisfaction, staff turnover, and market share.
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Developing Organizations

Sharp HealthCare
San Diego, CAend do

Use By Other Organizations

Approximately 10 other health care organizations have replicated the all-staff assembly event.

Date First Implemented

2001
September

Problem Addressed

Employee satisfaction and engagement remains critical to ongoing organizational performance, yet few health care organizations have formal structures and activities in place to actively engage employees in quality improvement activities and to promote employee satisfaction as a means for enhancing patient safety, quality, and service.
  • Importance of employee experience to organizational performance: Research from service industries demonstrates the positive link between employee satisfaction and organizational performance.1 Other research specific to health care shows that employee engagement has a positive impact on various measures, including employee retention and absenteeism, patient safety, clinical outcomes, patient satisfaction, and organizational reputation.2 In contrast, lack of employee engagement can have very negative consequences. For example, high turnover among clinical staff leads to lower quality, as replacements often lack experience and familiarity with hospital practices; high turnover can also raise costs due to the expenses associated with hiring and training new providers.3
  • Systematic failure to invest in employee engagement: Despite the existence of many programs to support employee engagement and satisfaction, relatively few health care organizations systematically invest in such initiatives.

What They Did

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Description of the Innovative Activity

Sharp HealthCare’s organization-wide strategy, called The Sharp Experience, incorporates a number of mechanisms to encourage employee engagement in improving patient care and service, with a focus on creating an overall culture of engagement and on motivating individual employees to participate in improvement activities. Examples of specific initiatives include an annual all-staff assembly, topic-specific improvement teams, quarterly employee forums, standards for employee behavior incorporated into performance reviews, leadership development courses, employee awards, and performance reports shared across the institution. Key elements of the program include the following:
  • Organization-wide initiatives to encourage culture of employee engagement: Sharp creates a culture that encourages employee engagement in quality and service improvement through multiple organization-wide initiatives, described below:
    • Six “Pillars of Excellence”: Sharp uses the Pillars of Excellence model developed by The Studer Group (a consulting group) as a framework for all organizational goals and strategies. The model includes five pillars of excellence (service, quality, people, finance, and growth),4 with Sharp having added a sixth pillar (community). The six pillars form the basis for the organization’s strategic plan, organization-wide initiatives, report cards that measure performance, employee evaluations, and meeting agendas.
    • All-staff assembly: Each year, all Sharp HealthCare employees participate in an all-staff assembly held at the San Diego Convention Center. To minimize the impact on patient care, the assembly consists of three identical 3-hour sessions offered over 2 days. Activities include a speech about organizational performance by Sharp’s chief executive officer (CEO), updates on quality improvement initiatives, descriptions of new activities that inspire employees to continue to pursue improvements in service and quality, a speech from an outside speaker who demonstrates the potential of one person to make a difference, and a performance by a 75-person choir composed of physicians and Sharp employees.
    • Action Teams for Change: Action Teams for Change, which exist in all Sharp facilities, focus on specific topics such as service quality, rewards and recognition, and patient, physician, and employee satisfaction. A manager-level staff member leads each team, while frontline staff comprise at least 50 percent of team membership. Teams analyze qualitative and quantitative data relevant to their topic, and then devise tools and initiatives that can be adopted institution-wide to promote improvement. For example, one action team studied other organizations and then developed standards related to employee behavior for Sharp (see below for more details).
    • Employee forums: Each Sharp facility CEO holds a facility-specific quarterly employee forum to provide updates about system- and facility-level initiatives, get feedback from frontline staff, and encourage people to get involved in improvement activities. Forums may be held in a “town-hall” or an “expo” format, with booths depicting various initiatives.
    • Improvement teams using Lean/Six Sigma: The health system implemented Lean/Six Sigma and the Change Acceleration Process across the organization, training 5 full-time black belts, 24 green belts, and a total of 57 leaders as change agents. These employees lead project teams comprised of frontline staff and leaders to drive performance improvement across the health system. Staff participating in these projects learn about Define, Measure, Analyze, Improve, and Control (commonly known as DMAIC) as a problem solving approach and participate in determining the solutions to implement. These teams have led projects such as improving emergency department throughput, accurate specimen labeling, and core measure performance.
  • Activities to encourage engagement of individual employees: Sharp ensures that the overall organizational culture drives down to the individual employee through a separate set of initiatives:
    • Standards of behavior: An Action Team for Change developed 12 specific standards to guide employee conduct, including standards related to customer confidentiality, embracing diversity, education to develop skills and competence, attitude, rewards and recognition, appropriate communication with colleagues and customers, teamwork, service recovery, safety, appearance, appropriate electronic communications, and management of waiting times. Each month, internal communications (e.g., newsletters, e-mails, staff meetings) highlight one standard; in addition, leaders use interactive tools during staff meetings to demonstrate appropriate behaviors. To reinforce such behaviors, one-third of an employee's performance evaluation score depends on adherence to the standards.
    • Ongoing manager-staff communications about performance: Sharp managers set goals for each employee that align with the entity and system organizational metrics. These goals form a significant portion of employee performance appraisals. In addition, Sharp leaders meet with each team member outside the performance review process to further discuss performance. During these meetings, managers praise and thank employees who excel in their work and engage in patient care and service, emphasizing their value to Sharp and asking what the organization can do for them going forward to help in their work. During these sessions, managers may also outline expectations related to improvement for low-performing employees.
    • Leadership development courses: Sharp University offers 2-day, offsite leadership development courses to any staff member with at least one direct report. Initially, courses focused on leading The Sharp Experience endeavor, but they now focus on developing more general leadership skills. Participants receive toolkits and information on a variety of leadership-related topics, including how to hold difficult conversations, map the patient’s experience, and communicate employee opinion survey results to staff. Each session features one Sharp leader who discusses how he or she took a previous leadership education topic and applied it on the job.
    • Employee awards: At the aforementioned all-staff assembly, 18 individuals, departments, and teams receive “Pillars of Excellence” awards recognizing exemplary performance in each of the six pillars.
  • Ongoing accountability and measurement: Sharp ensures ongoing accountability and performance tracking through the following:
    • Accountability team: An accountability team made up of executive steering committee members and management representatives from each Sharp facility sets and monitors performance related to annual system goals. Annual targets focus on two or three areas within each pillar; examples include, but are not limited to, reducing hospital-acquired complications, percent-perfect care, and inpatient satisfaction.
    • Report cards and satisfaction surveys: Sharp monitors performance through a monthly report card that tracks progress towards the goals within each pillar, quarterly patient satisfaction surveys, and annual physician and employee satisfaction surveys. In addition, Sharp administers the Agency for Healthcare Research and Quality Hospital Survey of Patient Safety Culture annually. All data are shared throughout the organization via quality councils, intranet display, clinical and administrative practice councils, staff meetings, communication boards, and e-mail.
    • Monthly dashboards: Each department compiles performance metrics that are shared with quality councils, the medical executive board, and hospital boards. These are also shared throughout the organization using the same methods listed above for report cards.

Context of the Innovation

Sharp HealthCare, a large not-for-profit health care delivery system in San Diego County, CA, operates 4 acute care hospitals, 3 specialty hospitals, 3 medical groups, 19 outpatient clinics, and a health insurance plan. The organization serves approximately 785,000 patients annually, has 2,600 affiliated physicians, and employs more than 14,000 staff. In 2007, Sharp HealthCare received a Malcolm Baldrige National Quality Award.

In 2000, Sharp HealthCare leaders held 100 focus groups with employees, team members, physicians, patients, and community members to learn more about their perceptions of the organization. The focus groups revealed that Sharp was “good, but not great.” Based on these findings, and with the goal of improving organizational excellence at all levels, Sharp in September 2001 launched The Sharp Experience, a comprehensive cultural improvement initiative geared toward improving the experience of patients, staff, and physicians. In implementing this program, Sharp leaders believed that improving the employee experience was critical to improving the customer experience, and that engaging employees in patient care and service would lead to improvements in quality and outcomes. On a more granular level, Sharp leaders wanted to improve employee satisfaction and reduce turnover; while the organization's performance on these measures was not poor, leaders recognized that such improvements would lead to better patient care and service.

Did It Work?

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Results

Since program implementation, Sharp has experienced a significant increase in patient satisfaction, a meaningful improvement in the public's perception of the quality of care and services offered by the system, higher employee satisfaction with a near 50-percent decline in staff turnover, and an increase in market share; institutional leaders believe that components of The Sharp Experience program focused on engaging employees have played a critical role in driving these improvements.
  • Higher patient satisfaction: Between the first quarter of 2002 and the first quarter of 2011, Sharp's scores on Press Ganey satisfaction surveys increased significantly; the percentage of respondents indicating that they were "satisfied" or "very satisfied" with inpatient care rose from 17 percent to 88 percent, while corresponding figures for outpatient (physician) care rose from 50 percent to 80 percent.
  • Higher perception of quality in community: According to a survey of San Diego residents conducted by an independent organization, perception of Sharp’s quality as compared to its closest competitors increased between 2003 and 2008, including the percentage believing that Sharp has the best clinical quality (which rose from 15 percent to 27 percent), customer service (18 to 32), doctors (16 to 24), and nurses (18 to 27), and the percentage believing Sharp is the best place to work (12 to 19) and the best overall health care system (21 to 29).
  • Higher employee satisfaction: According to a survey from Morehead Associates, employee satisfaction scores increased between 2004 and 2009, from 4.08 to 4.48 (on a scale of 1 to 5). Both figures are well above national benchmark scores of 3.99 and 4.14, respectively.
  • Much less staff turnover: Staff turnover (annual turnover for all Sharp employees) decreased by nearly 50 percent, from 14.4 percent in 2001 to just under 8 percent in 2009.
  • Higher market share: Between 2002 and 2008, Sharp HealthCare’s market share increased from 25 percent to 28 percent.

Evidence Rating (What is this?)

Moderate: The evidence consists of trends in key measures over time, including patient satisfaction, consumer perception of quality, employee satisfaction, staff turnover, and market share.

How They Did It

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Planning and Development Process

While the planning and development process for both the overall Sharp Experience program and its individual initiatives was quite complex, high-level elements included the following:
  • Conducting best-practice investigation: Sharp’s marketing and communications division reviewed literature on best practices in organizational change, while leaders on the Model Development team made site visits to successful organizations, such as the Disney Institute in Orlando, FL, the University of Chicago Hospitals, and the Franciscan Health System in Tacoma, WA.
  • Hiring consultant: Sharp hired an outside consulting firm (the Studer Group) to serve as its organizational change coach.
  • Creating organizational change team: Senior leaders created a 20-member interdisciplinary team, with representation from all Sharp facilities and various management levels, to work with the Studer Group coaches. Over 6 months, the team designed a new model of employee and customer engagement called The Sharp Experience.
  • Holding first all-staff assembly: The first all-staff assembly served as the launch of The Sharp Experience. All employees (13,000 at the time) participated in one of the three identical sessions, as described earlier. At this initial assembly, the CEO outlined the new vision and structure for the organization and asked employees to join the “Action Teams for Change” (also described earlier). An outside speaker—a frontline nurse from another organization—spoke inspirationally about health care workers' call to service.
  • Creating Action Teams for Change: After the inaugural all-staff assembly, more than 1,000 employees joined 1 of 10 Action Teams for Change, each focused on a different area (as described earlier).

Resources Used and Skills Needed

  • Staffing: The program required one new full-time staff member to serve as the director of The Sharp Experience; otherwise, existing staff integrate the initiatives and activities into everyday responsibilities.
  • Costs: Exact data on program costs are not available. However, such costs can be considerable due to the size of the Sharp employee base. Program-related costs include the salary/benefits of the director, labor expenses associated with replacement staff while clinicians (particularly nurses) attend various events, facility rental costs for outside events, fees for outside speakers, and other costs associated with individual initiatives.
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Funding Sources

Sharp HealthCare
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Tools and Other Resources

Sharp HealthCare hosts quarterly site visits for individuals interested in replicating the lessons from The Sharp Experience in their own organizations.

Adoption Considerations

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Getting Started with This Innovation

  • Ensure top leadership buy-in: Leaders at the top level of the organization must be committed to this type of culture change, provide financial support, serve as role models for a new culture, and actively lead this activity.
  • Assign accountability: Although all employees work to improve quality and service, the senior vice president of marketing and communications and the vice president of customer strategy at Sharp take day-to-day responsibility for implementing several elements of The Sharp Experience program and for monitoring progress. These responsibilities are included in the job descriptions for these positions; assigning this type of accountability helps to ensure that leaders remain focused on the strategy. Every leader in the organization has to lead this activity in their words and actions for an initiative of this size and scope to get traction, stay the course, and succeed.
  • Let employees drive change: Since employees touch the lives of patients, they should design and participate actively in driving quality improvement initiatives. Sharp's Action Teams for Change provided a formal structure that allowed employees to play a role in developing the core components of The Sharp Experience.
  • If necessary, start small: Start on a small scale if the organization cannot implement culture change broadly. Employee excitement from participating in quality and service improvement activities will be noted in other areas of the organization, which then may become more interested in adopting change.
  • Use external feedback: Sharp used the Baldrige criteria to guide their efforts and for course correction. This structure helped maintain the focus on all six pillars of excellence, gave very effective feedback, pointed the organization to some areas that had been overlooked, and helped to build engagement and accelerate the change.

Sustaining This Innovation

  • Embrace long-term commitment to change: Culture change takes a long time, especially in large organizations. At Sharp, it took a few years for the momentum to fully build; however, once efforts took hold, the organization was able to achieve significant improvements.
  • Institutionalize mechanisms to ensure ongoing focus on employee engagement: For example, the all-staff assembly and the leadership development courses at Sharp serve as ongoing mechanisms for focusing on employee and leader engagement.
  • Solicit and act on employee suggestions: When employees see their suggestions being implemented and resulting in organizational success, they become even more engaged and willing to stay or become involved in improvement activities.

Use By Other Organizations

Approximately 10 other health care organizations have replicated the all-staff assembly event.

More Information

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Contact the Innovator

Sonia R. Rhodes
CEO/CXO
Sonia Rhodes Experience Design
E-mail: Rhodes.Experience@gmail.com

Innovator Disclosures

Ms. Rhodes has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

U.S. Department of Commerce National Institute of Standards and Technology. Baldrige National Quality Program. 2007 Award Recipients. Sharp HealthCare. Available at: http://www.baldrige.nist.gov/Contacts_Profiles.htm

Footnotes

1 Schneider B, Hanges PJ, Smith DB, et al. Which comes first: employee attitudes or organizational financial and market performance? J Appl Psychol.2003;88(5):836-51. [PubMed]
2 Lofgren DG, Rhodes S, Miller T, et al. Marketing the health care experience: eight steps to infuse brand essence into your organization. Health Mark Q. 2006 May;23(3):101-23. [PubMed]
3 Institute for Healthcare Improvement. No Nursing Shortage Here. Available at: http://www.ihi.org/knowledge/Pages/ImprovementStories/NoNursingShortageHere.aspx
4 The Studer Group. The Five Pillars. Available at: http://www.studergroup.com/dotCMS/knowledgeAssetDetail?inode=109970
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: December 07, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: November 06, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: October 25, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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