The journey of North York General Hospital (NYGH) began with the hospital's place at the epicentre of the severe acute respiratory syndrome (SARS) crisis. SARS brought tragedy and trauma to the NYGH community; it also created the opportunity, and need, for institutional revival and renewal. In response, NYGH invested substantial time and energy in building a culture where staff understand that change initiatives are born at the front lines of the healthcare system, where the collective wisdom of staff drive the changes and where all staff members within the organization feel safe to learn from mistakes and understand their part in inspiring, implementing and maintaining momentum.  

This case study will provide context on the NYGH journey toward strategy-driven change and new organizational capabilities for leadership and learning. Improvements in the emergency department (ED) and general internal medicine (GIM) will serve as a case study to examine how NYGH's cultural transformation efforts led to improvements in these departments, and why we believe this approach will enable the organization to sustain these improvements over time.

SARS: A New Platform for Leadership

NYGH began its transformation journey three years ago, in the wake of the catastrophic events of SARS. SARS, an unknown lethal virus, hit Toronto hospitals, silently attacking patients, family members, staff and physicians. People lost their lives and many staff were impacted for life. In SARS 1, the hospital was one of several hospitals with SARS patients. Unfortunately, in SARS 2 NYGH became the epicentre. After five months of caring for SARS patients, many of them NYGH's own staff, the organization was totally devastated.  

"During SARS, we saw the best that human beings can be and we saw what happens when trust erodes. The echoes of SARS left staff feeling unhappy, disengaged, unsafe and lacking a sense of trust in the organization." (Bonnie Adamson, CEO)

Yet, there was new opportunity as well. During SARS, NYGH's leaders learned that their staff were brilliant; they were the true heroes. They learned that staff already have the ability to self-organize under pressure and that ordinary people can do extraordinary things if given the opportunity or necessity to do so. In addition, they learned that relationships can influence perceptions of quality and safety, and that old ways of thinking and behaving needed to change.

Senior leadership began to see this time as an opportunity for rebirth, growth and fundamental transformation. The organization needed to invest in building internal capacity, become more resilient and improve the level of trust with staff across the organization. NYGH embarked upon a journey to rebuild and transform the organization, co-creating with front-line staff, physicians, all formal leaders and the board, the safest environment possible for patients and the highest quality of care.

Phase 1: Strategy-Driven Change - A Cultural Leadership Transformation

After hundreds of hours and intense listening to NYGH staff, MDs, community members, patients and families, the senior team was able to describe the current reality, their desired future state and the gaps that needed to close. Based on the input and two-way feedback, NYGH designed an organizational strategy. A plan was created with four themes in a strategy-driven balanced scorecard with cause and effect quadrants. The team developed leveraged actions to close the gap, as well as both qualitative and quantitative indicators to track progress.

The team felt that strategy execution depended on a cultural leadership transformation. At the heart of the transformation was a purposeful plan to move "from" the current state "to" the desired future state. In order to do so, the organization focused on moving from a culture of blaming to accountability, from command and control to stewardship, from bosses to coaches, from individuals to teams and from silos to systems. This shift can only occur with consistent leadership aligned with the organizational direction and strategy. We also recognized that our managers and leaders needed new capacities and skills to realize the vision, so leadership development and working sessions for leaders became key. In-house sessions were led by the CEO, and regular meetings for all 120 managers and leaders, both in small groups and together, were rolled out. Meanwhile, senior leaders provided input through regular dialogues and learning sessions for all 120 leaders, including physician leaders.

With a new way of thinking, a commitment to culture change, new skills and cross functional management infrastructure, strategy design and strategy execution became the new way of doing business. The newly empowered and energized organization embarked on a journey to launch several organizational process improvement initiatives.

Regardless of the project or the priority, sustaining change over time is a challenge. Quick fixes to problems are usually accomplished by adding resources or skills, but quick fix results cannot be maintained and sustained until the culture of the organization, including the norms, values, language, thinking and behaviours, truly shifts to a culture of continuous improvement. NYGH's leadership acknowledged that sustainable and meaningful changes could not take place and be sustained in any area of the organization without overarching transformation of the old culture and broad organization support and buy-in from all levels. They made the culture transformation a top priority.

With culture as the base, NYGH was able to execute strategy-driven change. Each change could be viewed through the strategic alignment model, which aligns skills and structures with strategy and culture. Although the ED/GIM project was only one of 17 process transformations across the organization, the journey represents how critical the culture of an organization is for success to be sustained. The ED/GIM serves as a case study to examine how NYGH's cultural transformation efforts led to improvements in the emergency department and internal general medicine. Because the process also transformed team dynamics and development, we believe the transformation model will enable these changes to persist over time.

Phase 2: Transferring Momentum - Implementation of Multiple Changes

Additional transformation efforts were directed at developing a management infrastructure key to rejuvenating momentum while executing, translating, motivating and engaging the staff using a bottom up approach. As the strategy, culture and leadership became aligned, the newly empowered and energized organization embarked on a journey to launch several organizational process improvement initiatives.  

Prior to engaging in multiple improvement activities, the organization was well on its way toward realizing the successes of the leadership cultural transformation. The third annual NYGH culture survey identified sustained improvements year after year in all areas of the organization's culture, including learning, innovation, management and leadership styles, teamwork, recognition and contribution.  

Strategy execution focused on engaging the entire organization in the adoption of a philosophy of continuous learning, daily improvement and cross-unit alignment. This culture led to the adoption of multiple process transformations, using Lean Toyota and Rapid Improvement Events known as Kaizens. In the area of ED/GIM, eight value stream analyses, 20 kaizen events, three vertical value streams and three cause and effect analysis events have been conducted since October of 2006. To date, ED/GIM successes have included the following:

• A 49% increase in the number of patients that physicians are able to care for
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• A 52% reduction in the time from when a patient leaves a bed to when the bed is available for the next patient
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• A 27% reduction in patient length of stay for sub-acute patients (from 8.3 hours to 6.1 hours)
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• An 86% reduction in the time from when a patient leaves a bed to when that bed is assigned to the next patient
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• A 73% reduction in time from when a bed is assigned to when the patient is in the bed (from 167 minutes to 45 minutes)
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• A 19% reduction in the time from patient arrival to patient discharge in the ED

The impact of this transformation on team dynamics and development cannot be ignored. Staff who participate build on their current knowledge and skills, which are easily translated and adopted for other initiatives, thus increasing the internal capacity throughout the organization.  

"We are so used to having decisions made for us and having to implement them. It was nice to actually make decisions ourselves and actually see them implemented." (Staff RN)

Throughout phase 2, NYGH has used projects like the ED/GIM improvement efforts to promote strategic alignment and organizational learning. One strength of the transformation effort has been the dedication of formal and informal leaders at all levels of the organization. From the boardroom and involvement of the CEO, through the directors and senior leaders to bedside staff, each member of the organization is empowered as a leader and a vehicle for action and change. The formal reporting and accountability structure serve as direct links between the improvement teams and the CEO.  

For example, each kaizen event has a dedicated executive sponsor and a process owner who are engaged in all aspects of the initiative, including setting the scope, defining targets and being responsible via accountability agreements for successful improvement efforts. Additionally, each team member understands that they are accountable to the entire organization. Improvement teams report their accomplishments at open forum "report out" events. These well-attended events are used as vehicles to disseminate results, celebrate successes, share best practices and identify key learning items.

The CEO and other senior leaders attend each of these "report outs" and celebrate each team's efforts and applaud success. The acknowledgement of the team's efforts and the recognition of their hard work and dedication serve to energize and mobilize the teams to maintain gains and continue with additional improvement initiatives. NYGH leaders use these events to reinforce how the culture of the organization has shifted to one of accountability, stewardship and teamwork.  

Through a dedication to a common language and a common framework, participants at all levels are able to see how an organization's vision, mission and values can be translated from boardroom ideas to bedside realities. Improvement events are also opportunities to build capacity in the organization. Team participants are made up of interdisciplinary and cross functional staff members, so they discover opportunities to expand their improvement efforts beyond the barriers that traditional silos and departmental boundaries can create.

Numerous transformational journeys have failed because although the institutions put all the right mechanics in place they disregarded one pivotal element - putting the right people in the right roles in addition to the right tools into place. In the world of healthcare, many would argue that physician engagement can be the biggest challenge to implementing change. At NYGH physicians have been key in the development and execution of the organizational transformation and change. Due to their involvement and engagement in all elements of the organization's strategy, physician participation in kaizens has been invaluable and has served to foster a greater atmosphere of collaboration.  

Securing the commitment and engagement of clinician staff, which is critical for success, has been accomplished by focusing each event on the need to enhance the overall quality of the patient care experience. For example, ED/GIM improvement efforts and successes have focused not only on the merits of increasing flow and improving utilization, but also on the benefits of improved patient safety, satisfaction and access to care. The rallying cry for improvements around patient safety brings everyone together around a common cause and further feeds the sense of teamwork and cohesion across the organization.

"I never saw the big picture, it wasn't important. I've learned that everyone's role is important - for the patient's satisfaction, we have to work together." (Member, kaizen event)

Phase 3: Sustaining Changes over Time

As NYGH enters the final two years of its five-year transformational journey, it will deploy several approaches to sustaining improvements, both in ED/GIM and throughout the organization. These include various elements of a sustainable management infrastructure, including the use of a strategic balanced scorecard and management system, widening the use of kaizen and value stream methodologies across the institution and building new skills in leadership, intuition and decision-making.

From the outset of this journey, NYGH has believed that a balanced scorecard is a critical tool to ensure strategy execution and sustained improvement. Not only is it critical to track the right set of metrics, but the scorecard also needs to be used as the centrepiece of a cascading dialogue up and down the organization. NYGH's scorecard reports metrics across four themes: operational and clinical excellence; patient and family driven care; responsiveness across the continuum; and leading and partnering in system transformation. This scorecard forms the basis of accountability agreements that exist for all of the leaders within the organization and each transformation effort. These agreements break up the scorecard into specific metrics and accountabilities as well as an associated set of activities intended to improve or maintain those metrics.

For example, to ensure the sustainability of the results from kaizen and value stream events, not only are the performance results reported at the end of the improvement week, but they are also reviewed on a weekly basis. The successes and areas for targeted further action become part of the performance metrics for the process owners of each event and part of the accountability agreements that each VP has with the CEO. This formal accountability structure ensures that efforts are continuously monitored, refined and evaluated along the continuum of the initiative and beyond. The CEO, through the steering committee and the board of directors, keeps a pulse on the efforts and outcomes.

In phase 3, the organization will add the use of qualitative information, including anecdotal evidence, to the data set to be used as part of the scorecard. NYGH is seeing emerging evidence that the organization has become more coherent, has internalized the new culture in many ways and is beginning to incorporate the use of skillful intuition into decision-making, evaluation of results and recalibration.

For instance, in a recent series of Rose Garden dialogues with staff, Bonnie Adamson discovered the following examples of staff using their stories and intuitions to improve decision-making:

• A nurse was under pressure to discharge a patient from the ICU in order to maintain patient flow. Observing him, she had a feeling something wasn't right; she said, "Don't discharge him." Two hours later, the patient arrested; the team was able to save his life.
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• During a management and leadership dialogue on ED/GIM, it became evident that when there are bottlenecks in patient flow, sometimes simple things can help the most. Two weeks later, housekeeping recognized there was a bottleneck and pitched in, working overtime, until it was resolved. No one asked them to do this; they noticed and responded to the situation, based on their new situational awareness.

These are exceptions to normal rules and protocols. They may be rare, but they indicate a growing ability of staff to both reduce variation in practice and, at the same time, use judgment and healthy team interactions to make good, balanced decisions on behalf of patients. Including these kinds of data in performance evaluation will allow for the evolution of the strategic balanced scorecard into a nimble "just-in-time" tool and for NYGH to move from simply measuring results to strategy-driven performance management. NYGH believes this coupling of quantitative and qualitative measures will enable an ongoing "Bedside to Boardroom, Boardroom to Bedside" alignment of metrics, for instance, between NYGH strategy and ED/GIM performance evaluation.

NYGH looks forward to the next two years as a time of excitement and new challenge. This will be a time of sustaining the changes made since SARS and also of retaining and extending the organizational resilience that enabled the whole community, working together, to make them.

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