Healthcare Quarterly

Healthcare Quarterly 15(Special Issue) December 2012 : 22,23-90.doi:10.12927/hcq.2012.23122
Patient-Centred Care

Organization Culture and Managerial Discipline Key to Quality Improvement: The Mount Sinai Hospital Experience

Esther Green and Joe Mapa

The Excellent Care for All Act requires assessment and improvement of patient experience as a key element of hospitals' commitment to quality. In one of two interviews that speak to improvement efforts focused on the patient experience, Esther Green (EG) talks with Joe Mapa (JM) – the CEO of Mount Sinai Hospital – about the importance of organizational culture and managerial discipline to quality improvement. Culture in this interview includes all members of the team so that everyone is focused on improvement in some way. Discipline speaks to the importance of making expectations for improvement clear in every decision and communication.

Esther Green, in conversation with Joe Mapa

EG: Mount Sinai Hospital has seen improved results in the patient experience. What do you think are the key contributing factors?

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JM: There are two major factors: culture and discipline. Culture of course engenders a shared vision of performance, where the organization is driven to not merely comply with but to exceed standards. The other part is the discipline to ensure that culture is operationalized. You need to embed the direction through clear accountabilities, systems, reporting, communication and, ultimately, evidence, to discern whether or not this culture is translating into benefits for patients.

EG: When you talk about the follow-through on accountability or reporting, how does your organization communicate with your senior team and the broader organization in terms of how the standards are being met?

JM: It goes back to the discipline around the culture: everyone in our organization is accountable for quality or the patient experience in some way. When we define expectations about our performance goals, we want to make sure they are well understood, meaningful, achievable and measurable. We communicate the results, teams analyze and challenge themselves, and we drive toward improvement. In our leadership structure, all of our clinical activities and service lines are organized under Centres of Excellence. The centres structure is the vehicle for dialogue on quality and improvement and brings this conversation back to our senior leadership team. There are checks and balances all the way up to our Board of Directors, who ultimately provide their insight and guidance on our performance.

EG: Excellent. I'm going on to the next question. You talked about clinician engagement, which is obviously very, very important. I'm wondering if you could talk a bit more about how the clinician champions and senior leaders have made the difference.

JM: Clinical champions are indispensible in achieving our goals. While these champions can sometimes be informal leadership roles, we also take steps to embed them formally into our organizational design. In our leadership structure, our Centres of Excellence all come together under one individual, the chief clinical officer. This important leadership position can champion cross-enterprise goals, such as patient safety, quality and clinical outcomes, as a key part of its mandate. The Centres of Excellence nursing and physician co-leaders also act as champions at the program level, as they lead their teams to execute our goals and strategy. The chief clinical officer works with them regularly to coach each centre to ensure continuous improvement.

EG: Can you describe how the rest of the senior leadership team have a quality and patient experience mandate?

JM: Our organizational chart has two complementary components: corporate services and clinical services. No matter what the portfolio, it's essential that patient safety, quality and the patient experience be top of mind. So while individual departments and units may focus on their local experience, we find a lot of strength in our Centres of Excellence structure, which enables us to look at the patient's journey through the organization from a multidisciplinary perspective. We have an Office of the Patient Experience and Outcomes that can partner with care teams as a resource for improving the patient journey within our organization.

EG: There's been a lot recorded in the literature around engagement of patient/family advisors or advisory councils. What is your experience? What is the Mount Sinai experience about patient/family advisors? How might they have influenced change?

JM: Mount Sinai has a significant history in patient-centred care. We engage patients in the improvement of our organization – whether it's long-term planning, experience-based design of our facilities or making changes to the clinical service delivery model. I believe it's essential to set clear corporate expectations and structures to engage patients in all of the key organizational decisions. My leaders and managers have to think about what is the most applicable vehicle for this participation – whether it's patient advisory councils, patient opinion surveys, patient panels and focus groups, or learning about day-to-day interactions from patients. As a health sector, our challenge is holding ourselves accountable to improve and evolve our organization based on that feedback. We take it seriously and learn from it. For Mount Sinai, it's a living agenda and we want to continuously raise the bar. We are a learning organization, and we are always scanning the environment to see how both private and public sector organizations incorporate customer feedback.

EG: When you first established experience-based facility design in your organization, many years ago, were there barriers or challenges?

JM: There are always barriers in every organization, built through decades of culture, traditions and entrenched positions of stakeholders. The best way to break down these barriers is through clinical champions who can change the culture. They can create a dynamic vision about how to include our patients and families, and share success stories about how this patient engagement results in improvements. Some departments and clinics are more attuned to this than others. Psychiatry, for example, has a long history of success with patient engagement and building a patient-centred experience.

EG: Why would psychiatry in particular be ahead of the curve?

JM: I think psychiatry is much more predisposed to group activity, inter-professional behaviour and patient engagement. Other departments may only be in the early stages of this journey. The key to raising the bar on patient and family engagement across the various clinical programs is to understand the culture of the department you're working with, leverage their strengths, and work with them to overcome the barriers between them and your desired future state.

EG: You talked earlier in our conversation about the board. I wonder if you could share a little more about your board's perspective and how that influences success of the patient experience in your organization.

JM: First of all, I believe there's a correlation between great boards and great organizations. Great boards are defined by their vision, insight, oversight and guidance. In their role as stewards of the organization on behalf of the patients and the community, boards need to appreciate the importance of patient experience and feedback. If you can achieve that, then you have captured an essential component of strong governance. Our board has a long track record of careful attention to patient feedback, and this is critical to their role.

EG: Some CEOs have also talked about the fact that the board has invited patients or family members to come to the beginning of board meetings to share a particular story.

JM: That kind of initiative certainly embodies the philosophy we're talking about. For example, we start our board meetings with a discussion of a critical incident, a patient safety situation or a patient story. Concrete examples move beyond the statistics and ground the board in our responsibilities and challenges as an organization. We set the tone at the beginning of the meeting that our board's role is fundamentally about improved patient safety, the patient experience and clinical outcomes.

EG: Is there anything else that you wanted to comment on that I haven't asked about in terms of what you are doing in your organization?

JM: I'd like to comment on the Excellent Care for All Act and the direction that quality is taking within the province. I believe that the government has really used its influence in an appropriate way to shape the quality agenda and raise the bar in all organizations. They have created a framework that will potentially be very powerful in changing the behaviour of the health provider community. The citizens of Ontario – whom we ultimately serve in our role as healthcare leaders – can now see the goals and performance for their own local organization. This is ultimately where many of the components we've talked about today come together: There's no better way to get patients engaged than to start with clear quality improvement goals and an invitation for your patients and families to come on that journey with your organization. 

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