Calling Forth the Spirit of Leadership:
Pathway to Organizational Transformation
By Sister Mary Jean Ryan, FSM

NIST
June 6, 2004

Thank you.

Good afternoon. I'm delighted to be with you today, and I applaud the leadership that all of your provide for NIST.

Harry invited me to speak to you today, mostly, I think, because of my ardent belief that the Baldrige process is the best way to improve any organization. So I'm going to talk about some of our experiences with Baldrige, as well as our learnings. As I do that, I will also speak about organizational transformation, because, in my mind, the two are inextricably linked.

Before I get to that, however, I want to tell you a story.

Four Catholic women were having coffee together after a church gathering. Of course, they couldn't help but brag about their sons. "My son is a priest," the first woman said. "When he walks into a room, everyone calls him 'father.'"
Not to be outdone, the second Catholic woman chirped, "My son is a bishop. Whenever he walks into a room, people say, 'Your Grace.'"

"Well," declared the third woman smugly, "my son is a cardinal. Whenever he walks into a room, people say, 'Your Eminence.'"
The fourth Catholic woman quietly sipped her coffee. The first three woman could stand it no longer. "What does your son do?" they finally asked her.

"My son is a gorgeous 6 foot 2 inch stripper," she replied. "When he walks into a room, people say, 'Oh my God.'"

I bet you're wondering what that story has to do with my comments today. Well, it's simple. When I look back on where we were as a health care system 10 years ago, I have to say, "Oh my God." And the truth is that - even after receiving the Baldrige -- when I think about where we need to be 10 years from now, I have to say, "Oh my God."

As I said, I'm here to share some of our Baldrige experiences with you and to explain how our organization has improved as a result of our work with Baldrige. But before I get to that, I want to tell you why I think that Harry invited me to be here.
Since 1998 -- which was one year before health care was eligible to apply for the Baldrige - I've given 66 presentations in which Baldrige was the focus of my remarks. And since that same year, I've given an equivalent number of speeches in which I mention Baldrige in one way or another. So, that's why I'm here. Either that or Harry likes my jokes!

Ok - let me begin …. I believe there are three areas that are essential for what I call. . . "organizational transformation", and by
that I'm talking about an organization that goes from good to exceptional.

The best way I can think of to describe the first area is. . . "the awakening," with apologies to the American novelist Kate Chopin. The awakening is that moment of truth, when you get a slightly sick feeling in your stomach because you realize that things in your organization aren't as good as they could be. I'll talk briefly about my own "awakening" and how it influenced our subsequent efforts to improve our organization.

But it's one thing to know your organization is not as good as it could be. It's another thing to make it better. So the second area I'll address is how we arrived at Baldrige as a way to improve, and how it has influenced our organization and made us better. And third, I will look at the non-scientific piece of organizational transformation. Some people call it leadership; others call it "heart." I believe they are the same.

So let me talk about our awakening at SSM Health Care. To set the stage, I have to go back a few years. . . actually, all the way back to 1872.

SSM Health Care was begun 132 years ago by five Catholic nuns who came to the United States from Germany. Devoted exclusively to health care, our sisters have responded over the years to the needs of various communities. Up until 18 years ago, we were a group of some 20+ hospitals and nursing homes that existed pretty much independently. In 1986, we came together as a formal health care system, and I've been the CEO since that year. I was very young then!

As you can imagine, it has been no small challenge to get everyone in our large, complex, and geographically diverse organization to work together to provide exceptional care for our patients.
From the outset, as the system CEO, I was eager to use some of the current management philosophies to engage our employees and physicians. So each year at our annual leadership conference in Marco Island, Florida, we introduced a promising new philosophy, with great hoopla and enthusiasm. Each one, we were certain, would be the one to transform our organization.

Well, at the end of our very successful 1989 conference - where the focus had been "servant leadership" -- I sat at the pool with another senior executive. Both of us had a vague feeling of unease. It seemed that no matter how much we communicated our system's mission and values, some things were just not happening. Despite our enthusiasm for these management philosophies, there was something missing. Looking back, that was our "awakening."

What we realized was this: Despite our serious commitment to various management strategies over the years, we did not see a constant striving for improvement. We did not see managers mobilizing employees to work on projects that were important. And we did not see processes in place that made the best use of people's talents. In short, we recognized that we were not nearly as good as we could or should be.

What I know now that I didn't realize at the time is this: there were two really big things we were doing wrong. First, we were prone to the management "flavor-of-the-month" syndrome. And second, it was always "we" - the senior executives -- who were sending down the truth from the mountaintop to "them" - the employees.

As these thoughts surfaced in our conversation by the pool, we searched for an answer. We knew we had to find some way to tap the potential of all of our employees, something that would help us improve the complex processes that are inherent to health care. And we knew that whatever we did had to be for the long haul.

In that conversation, we learned that each of us had been hearing about the success of continuous quality improvement, mostly in other industries and some in health care. Back in 1989, the concept seemed to show promise as a way to improve everything we did.

To make a long story short, we did some homework and got to know more about CQI. The more we learned, the more we determined that it fit with our values, and we implemented CQI system-wide in 1990. (short pause) I'm not going to bore you with what it was like to make CQI the culture for 23,000 employees and 5,000 physicians in seven regions, at 20+ entities. I'll leave it to you to imagine that scenario. Thankfully, at the time, I had no idea what the extent of our commitment would be. Back then, being an extremely impatient person, I was proud of the fact that I was willing to wait 5 years, which was the time I thought it would take to improve everything and actually be transformed. Fourteen years later, we are still a "work in progress."

So how did we get from CQI to Baldrige? Very briefly, by the mid-'90s, we had reached a plateau with CQI. We just weren't seeing much progress around the system. As we looked for ways to move us forward, we became aware that companies in other industries that were using the Baldrige criteria were significantly outperforming their competitors. Although health care, at that time, was not eligible for the Baldrige Award, we encouraged our facilities to apply for state quality awards, because those criteria were patterned after Baldrige. Since we'd focused on the awards process as a way to improve, we were surprised and delighted when we actually began winning state quality awards. And in 1999, when health care finally became eligible for the Baldrige Award, we submitted our application and became the first health care organization to receive a Baldrige site visit.

I've always maintained that the reason to apply for Baldrige is that it's the best way to get better faster. And having received Baldrige feedback for four years in a row, I can say without a doubt that it's the best thing SSM Health Care has done to improve as an organization.

So let me describe what Baldrige has done for us at SSM Health Care. Baldrige has given us a framework, a focus, and discipline. First of all, in our applications, we had to be able to describe our large and complex organization in 50 pages, including results. This exercise gave new meaning to the word "discipline."

In all honesty, Baldrige has helped us look at our organization in a very different way than we did in the past. Although our CQI culture was firmly established, our approach to improvement was scattered, so it didn't have the overall impact that it could have had. Baldrige has provided a new lens through which we see our organization. It has offered us a way to systematically evaluate our entire organization, and understand the link between the hundreds of processes that make up the health care experience.

So let me take you back, for a moment, to 1997 - two years before health care became eligible to apply for Baldrige. Even though we couldn't officially apply, we were pretty sure that health care would soon become eligible, so we established system wide teams to do a self-assessment around each of the seven Baldrige categories. We did this to familiarize ourselves with the terminology, as well as to identify major gaps between the criteria and our reality.

For instance, early on, we identified two fundamental gaps under the leadership category. They were. . . the lack of a system wide leadership philosophy including expectations, and, even more important, the lack of a common mission statement used throughout the system.

The leadership philosophy and expectations was a critical piece, because if people don't know what's expected of them, we have no way to hold them accountable for their actions -- or lack of action. Fortunately, that was fairly easily addressed. We identified a system best practice in Madison, Wisconsin, where our hospital had recently developed such a document. We asked if we could modify it to fit the whole system; they said "yes", and we did.

The fact that we did not have a common mission statement was a more complex issue. And I want to spend a bit of time talking about it.

For any organization, the mission is the lifeblood. . . the fundamental reason why we do what we do. Early in our system life, we had directed each entity to have its own mission statement and attendant values. We chose that path because, with health care facilities in seven regions, we have always valued local autonomy. However, our entities did their assignment so well that in 1998, we collected 21 single spaced pages of mission and value statements from all of our facilities. In addition to that, our system mission statement was 85 words long -- I emphasize "long" -- AND it had been written by a committee at the corporate level.

So, in 1998, we began a year-long process to rearticulate our mission and values. The process involved nearly 3,000 employees at every level of the organization from every one of our entities.

Today our mission statement is 13 words, short by design, and the best thing about it is that it was discovered from within our organization. As part of this effort, we also identified five one-word values -- not new values, but ones that had been part of us for more than 125 years.

Now I know it wouldn't have taken long for our communications department to come up with a catchy mission statement and four or five great values that everybody in the system could relate to. But we realized that a mission statement must come from a process that involves as many people in the organization as possible. And a mission statement takes time to develop.

So in other words, if a solid mix of employees has not helped create the mission statement, it will not truly belong to them, and the potential to transform your organization will be hindered. Here's our mission statement:

"Through our exceptional health care services, we reveal the healing presence of God."

It's short, it's simple, and yet profound.

Because the mission and values came from our employees, they embrace them as their own. Let me tell you a story to illustrate this.

Not too long ago, one of our hospital presidents received a letter from the parents of a baby who was stillborn. I'd like to quote from that letter: "When the burdens thrust upon you are so heavy you feel the agony will surely cause you to die. . . That's when you really appreciate the warmth, kindness and empathy given by such wonderful people. If there was anything left undone during our stay in your hospital, God must have kept it a secret, because if it had been revealed, the nurses on the fourth floor would have done it."

You see, even though I am technically the "boss," the mission of SSM Health Care no more belongs to me than it does to the head of dietary or the lab technician, or the nurse, or the housekeeper. Sure I happen to be the CEO. But the agonized parents who wrote the letter I just read to you couldn't care less about me. During their time in our hospital, reality was reduced to one small room and the nurses who cared for them with such compassion. The care that they received was what mattered to those parents, despite the tragic outcome. Through their "exceptional health care services," our nurses were able to extend the SSM Health Care mission to the grieving parents. Through the care and compassion of those nurses, the healing presence of God was revealed.

Many stories, (not unlike that letter) were told during our mission rollout, and employees came away with a deeper understanding that the work they do has great meaning. And, as I've said to many audiences, lest you think that mission is something "soft," let me assure you, if it's done right, it may be the most difficult thing you've ever done. However, if it is done right, your mission statement will touch the very souls of your employees and the people they serve.

This wonderful experience of rearticulating our mission and values might never have happened had we not used the Baldrige framework to improve our organization. And it all happened even before we applied!

Then there was the application process, which I've already described as a remarkable exercise in discipline. We first applied in 1999, and we applied in 3 subsequent years- through 2002 when we received the award. So, the application itself is a great learning experience, and the site visits and the written feedback are invaluable. We now have more than 200 pages of feedback from our applications and site visits, and we've made countless improvements as a result.

The additional value of Baldrige as a business model cannot be overstated, because it offers a structured way to look at an organization. It asks very basic questions, but coming up with the answers is hard. . . And once we'd gone through a Baldrige application and received feedback, we saw our organization in a new light.

Then, from our four applications, among many other things, We learned that our messages were not consistently deployed throughout our vast organization. . . that our human resource goals were not integrated into our strategic plan. We learned that we were better at tracking our finances and operations than we were at tracking the clinical outcomes of our patients. . . and that we did not have a consistent complaint management process. However, the biggest shock, believe it or not, was what Baldrige told us about our wonderful mission statement: "You say you want to deliver exceptional health care services. Yet you haven't defined 'exceptional' services, and you certainly can't measure them until you define them." Besides that, Baldrige told us that we had been comparing ourselves to the average, rather than the very best, when setting our performance goals. In effect, they reminded us that our mission statement doesn't say, "Through our average health care services we reveal the healing presence of God!"

The feedback always causes you to go: "I can't believe we didn't see that." But the reality is that those of us in any organization are too close to it, so, as you know, that's the value of having an external review.

As you may have guessed, we've spent considerable time making improvements based on our Baldrige feedback. We've figured out how to deploy a consistent message throughout our organization. Our HR goals are now part of our strategic plan. We have developed a complaint management process that is used systemwide. And we now benchmark against the highest performing companies, whether or not they're in health care. Best of all, we've figured out how to translate our mission imperative - that is, "exceptional health care services" - into specific and measurable goals. We've set these goals based on 25th percentile data from the Maryland Hospital Association and other best practices.

We are determined to continue to improve every day in every way. But, that commitment to always improve is driven by our belief that we have an obligation -- a sacred trust, if you will -- to deliver health care better than it's ever been done before.

We systematically monitor and continually make improvements in the three core areas that create exceptional health care services: satisfaction (for patients, employees and physicians), clinical outcomes, and financial performance. To do that, we've developed very specific operational metrics at all levels: system, network, hospital, department, and employee. We track our progress daily, weekly and monthly, using our performance measurement system. The centerpiece of that system is our Performance Indicator Report - or P-I-R. At the system level, this is a measurement tool that looks at 16 indicators. At the network and hospital, we monitor 49 indicators.

We believe that it takes this kind of a balanced approach to achieve exceptional results. And I'd like to take a moment to tell you about just a few of those results.

About a month ago, I gave the closing keynote at the annual meeting of the National Patient Safety Foundation. I was proud to talk about what we've accomplished in our Achieving Exceptional Safety Clinical Collaborative. (Our SSM clinical collaboratives involve physicians and other clinicians from around the system in teams that find rapid solutions to compelling health care issues - such as patient safety and secondary prevention of ischemic heart disease.)

The Achieving Exceptional Safety Collaborative is working on 16 recommended practices for better safety, including "Dangerous Abbreviations." What do I mean? Well, physicians learn in medical school to write "QD" , the Latin abbreviation for daily. But when they write it down - perhaps hastily -"QD" can easily be mistaken for "Q- eye -D," which means four times a day. You can see the potential for harm that is present if a patient receives four times the medication that they're supposed to receive.

Intense efforts to raise awareness among physicians - including placing posters in restrooms at our hospital in Madison, Wisconsin - have resulted in a significant change in behavior. Physicians now write the word "daily", rather than use the abbreviation. And that's just one example.

As a result of these efforts, we've reduced our use of dangerous abbreviations across SSM from 22% when we began in January 2002 to 9.8% last year. And, of course, we won't be satisfied until we've completely eliminated their use throughout the system.

Another area. There are few issues more critical in health care today than the nursing shortage. Employees walk when they are dissatisfied with their job. In 2002, the average nursing turnover in the nation was 21%. That same year, the benchmark for nursing turnover was 14%, as reported by Integrated Delivery Systems. At SSM Health Care, turnover among nurses was 11% in 2003.

If employees walk because they are dissatisfied, it makes sense that they stay when they are satisfied. Satisfaction among all employees at SSM Health Care continues to improve. In 2003, system satisfaction was 79%, up from 74% in 2002 and 71% in the year 2000.

As you are well aware, the health care environment today is extremely competitive. Yet despite the environment, our commitment to employee, physician and patient satisfaction has resulted in a significant growth in market share. And our focus on some key things that really matter to our patients - things like rapid response to pain, reduced wait time in the emergency department, and overall timeliness and kindness -- is paying off in increased loyalty scores on our patient satisfaction surveys. For instance, inpatient loyalty increased from 83.9% in the first quarter of 2002 to 86.5% in the fourth quarter of 2003. And our goal is to be in the 99th percentile by 2007.

And finally, a financial result. In 1999, the first year we applied for the Baldrige, our St. Louis network lost $20 million. Well, since then, with many process improvements, SSM St. Louis has made a $50 million financial turnaround.

And for SSM Health Care as a system, we reported a positive operating margin of 3½% in 2003, compared to a negative operating margin of minus 2.2% in 1999.

So what I can say without hesitation is that our commitment to CQI and Baldrige has made us very different organization than we were in 1990 -- even in 1995. Our improvement efforts are more consistent throughout the system. In addition, learnings from CQI teams at one hospital are shared with teams at other hospitals, because we have established a system-wide culture of sharing and replicating.

So, let me summarize my first two points: Our "awakening" - the recognition that we were not as good as we could be -- occurred in 1989. What we did about it was CQI, which eventually led us to Baldrige. And as an organization, we are at a new place - a far better place - today than we were then.

Now I'd like to move to my third area of focus, that intangible piece that I call "heart." I want to give you an example of what I mean. It's from the book My Grandfather's Blessings by Rachel Naomi Remen, a physician.

Dr. Remen says this: "The ways and means by which people serve may vary from time to time and from culture to culture, but the nature of service has not changed since our beginnings. No matter what means we use, service is always a work of the heart. There are times when the power of science is so seductive that we may come to feel that all that is required to serve others is to get our science right, our diagnosis, our treatment. But science can never serve unless it is first translated by people into a work of the heart."

Dr. Remen tells the story of Molly, one of her former patients, who was hospitalized with fractures of both elbows. Molly had been in an automobile accident as she was driving to the airport in a city 2,000 miles away from her home. When she awoke in the hospital, her arms were encased in rigid casts that went from her shoulders to her wrists.

Molly has multiple food allergies and other very special dietary needs and can become dangerously ill if she inadvertently eats the wrong things. So it was critical that her food needs were addressed while she was in the hospital. Soon after she was settled into her bed, a dietitian took more than an hour to carefully document her unusual food needs. "The questions she asked were so thoughtful," Molly told Dr. Remen. "She really knew her stuff. In all these years no one has ever asked me some of those questions or understood so quickly and completely how things were with me. I was really impressed."

Within a few hours, special food was ordered for Molly. Three times a day, this food was served to her by professionals who brought it to her bedside on a tray and put it before her on her bed table. Then they left.

"'The first time this happened," she told Dr. Remen, "I just sat there, looking at the food, unable to feed myself. I was certain that someone would come to help me, but no one did. After a while, the woman in the next bed noticed that I could not eat. Trailing her own IV lines, she had gotten out of bed and fed me my dinner.'

"The same thing had happened at every meal. In the four days that Molly was in the hospital without the use of her arms, no one on the staff ever helped her to eat. Day after day, the right food would be brought in, and the patient in the next bed would feed it to her."

I hate to think that something like that could happen at SSM Health Care . . . or at any hospital, for that matter. We want the hospital experience to be a positive one, in which the patient is safe, receives the highest quality care, and experiences caring and compassion from everyone with whom they come in contact. See, part of our goal is to help our employees receive the scientific knowledge they need to provide the best care. . . but an equally essential part of the equation is about heart. And that brings us to leadership . . . in the broadest sense of the word.

When I ask audiences who are the leaders in their organization, I sometimes worry that they think immediately of the CEO and others in executive administration. I worry, because I happen to believe that the leadership that builds an excellent organization is not the CEO making one pivotal decision. Rather, it's the minute-by-minute, day-by-day actions of every employee wanting to learn more, wanting to teach more, wanting to improve everything they do.

Real leadership is not about authority, control, or giving orders. It's not about titles and executive benefits. The leadership I'm talking about does not necessarily concern corporate strategic planning or executive decision making. Clearly both are vital to organizations, and I don't deny that there are individuals who must be accountable for the overall success of the enterprise.

What I see as real leadership is being responsible for what happens in our area of work--whatever that area happens to be. It's about being accountable and holding others to account. It's about owning our work and performing our jobs with integrity, as an expression of ourselves, our creativity, and our commitment.

Whether leadership is inherited...or a developed trait, people who are real leaders demonstrate the ability to step out, show their colors, and spread the word.

If I've learned anything from our quality journey, it is to give up the illusion that because I am the CEO I am the leader and everyone else is a follower. . . Or that a chosen few people with executive titles are the leaders, ready and able to imbue the entire organization with their infinite wisdom. While some of us provide executive leadership for the system or for facilities within the system, we say that there is no one at SSM Health Care who is not a leader.

I'd like to tell you another story about some of the leaders in my organization, and I hope you'll agree that it illustrates what I mean by heart. Cardinal Glennon Children's Hospital is one of our St. Louis hospitals, and it's a very special place. Part of what we do involves community education, and we recently produced a video about Footprints, a Glennon program that helps families whose children are likely to die before they reach the age of 18.

Footprints helps these children live their lives to the fullest, during whatever brief time they have. During the taping of the video, several caregivers recounted the same story. . . a story that had touched them deeply more than 20 years before - in 1981. It's a story that we have promised to keep alive.

A baby was born that year with multiple severe birth defects, and it was obvious he would never go home from Glennon. But his mother had one wish before he died. Even though he was hooked up to IVs and other equipment, she wanted him to be taken outside to feel the breeze on his face.

It was a challenging task, given the baby's condition, but the Glennon staff felt it was important to honor the mother's request. So on a cool, fall day, the mother held her baby in her arms, and, accompanied by our caregivers, went outside to a courtyard. As they stood together, the baby's doctor -- who was an intern at the time -- picked a flower, and placed it in the baby's hand.

Well, the baby died shortly after that, but our doctors and nurses were grateful that the mother had felt some semblance of peace because they'd been able to grant her simple wish.

One of our nurses who was present that day decided to let the mother know that her son's story was being told to the video crew by many of our employees. Even though she knew the mother had moved several times, the nurse wrote to her, hoping against hope that the letter would reach its intended destination.

Several weeks after she sent the letter, our nurse received a phone call from the mother. She'd received the letter and had read it tearfully, because so few of the people in her life now even knew about her baby. The two women talked -- somewhat emotionally -- for 20 minutes, and then the mother had one more request. "Please use my son's name whenever you tell his story," she said, "as a remembrance of his life."

So I will tell you his name: Andrew Kilmer. . . As a remembrance of his life.

How different it would have been had our staff convinced the mother not to go outside because of Andrew's condition; how different if our nurse had not written the letter that led to the phone call, which provoked such deep emotions for both women. To me, that is a story about leadership. . . about extending oneself to others with compassion. . . and that really is "heart."

Earlier in my remarks I suggested that creating an organization of leaders will take energy. And that the commitment must be for the long haul. However, it is the calling forth of leaders that will ultimately transform an organization. Baldrige has helped us to recognize this essential truth, and we will be forever grateful for our Baldrige experiences.

I'd like to close with a further thought from Rachel Naomi Remen, the physician who told the story about the woman with the two fractured elbows. Dr. Remen says:

"There is a parable about the difference between heaven and hell. In hell, people are seated at a table overflowing with delicious food. But they have splints on their elbows and so they cannot reach their mouths with their spoons. They sit through eternity experiencing a terrible hunger in the midst of abundance. In heaven, people are also seated at a table overflowing with delicious food. They, too, have splints on their elbows and cannot reach their mouths. But in heaven, people use their spoons to feed one another. Perhaps hell is always of our own making. In the end, the difference between heaven and hell may only be that in hell, people have forgotten how to bless one another."

So, before I leave you, I want to offer you my personal blessing: May you be blessed with enough challenges to keep life interesting, but not daunting, may you know the infinite goodness that resides within you, may you enjoy peace and happiness, and may you never forget how to bless one another. Thank you and God bless you.

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