The Leadership Team Understood that there Could not be Silos or the Team Would Fail
This article discusses the key steps taken to hire and create a team at a new facility and details the education and onboarding that was used, as well as the foundations required to create a culture of excellence. Each new team member hired was considered an investment in the future success of the group. Each leader was committed to finding the right people for the new team even if that meant opening the facility with vacancies.
For the last 13 years my world has been imaging. Eight of those years I was mentored by a great director who taught me about dedication, accountability, and what leadership truly means. In 2011, I was given the opportunity to step out of the imaging world and take a director position at a brand new freestanding healthcare pavilion. I took the position at the new facility because it gave me the opportunity to apply many of the lessons I had learned from my imaging director, work with a true multidisciplinary team, and build a culture of excellence from the ground up. This was a once in a lifetime chance that took me and our team on an amazing journey.
A healthcare pavilion is a relatively new concept in healthcare. CMC-Waxhaw healthcare pavilion was only the second of its kind in the Charlotte, NC area. It houses a freestanding emergency department (ED); outpatient CT, Xray, and ultrasound; outpatient laboratory services; and physician practices. The ED is comprised of 10 beds—seven general ED beds, two observation beds, and one resuscitation room. Part of my new position involved educating the public on what services we had as well as what a freestanding ED was. For the majority of the public, this is a foreign concept. Most people think of the centre as an urgent care or a hospital. In truth, it is neither. The facility is licensed through a main hospital, part of the Carolinas HealthCare System, about 18 miles away and acts as a department of the hospital located off the main campus. Patients can be held up to 24 hours, but patients who need to be admitted are transferred to the appropriate facility depending on their needs or choice.
Breaking Down the Silos
Seven areas make up the team at the pavilion: nursing, respiratory therapy, security, laboratory, imaging, environmental services (EVS), and registration. In a hospital environment, people tend to function in their own silos. In the pavilion setting, the team could not be successful from this same model. Our team was expected to be efficient, self-sufficient, and patient focused. The leadership team understood that there could not be silos or the team would fail. Working with the directors and managers of the primary areas, the goal was to create one team solely focused on creating an exceptional experience for every visitor, every time. A culture centred on the patient was a necessity.
To start the hiring process, the leadership team looked at the job descriptions of each area. It was quickly realised that the traditional model would not work in the new centre. The scope of practice for each area was evaluated and the team worked together to determine how each area could do things that were not “typical” in a hospital environment, but were within the team members’ scope of practice. Registrars were cross trained as unit secretaries and patient representatives. Registrars were also sent to notary classes, as well as additional computer classes to assist with imaging registration. Security officers were trained to do some light maintenance work and learned how to do monthly checks on fire extinguishers and other items.
Respiratory therapists and imaging technologists were likely the most hybrid positions. Therapists and technologists were trained to take vitals, do phlebotomy, and perform EKGs. Imaging technologists were sent to ACLS classes to assist them when performing EKGs and help them feel more comfortable with being involved in a code. All team members, including nonclinical areas, were trained in BCLS. This was important as there are only 10–15 team members on site at a time and if a code blue (CPR) is called, all team members must respond and may have to assist with compressions.
Creating the Foundation
The leadership team wanted to ensure that the right people were in the right positions from the start. Before posting any positions, meetings were held with the service excellence coordinator and human resources (HR) director. The key qualities to look for when hiring team members were discussed and a list of desirable characteristics for team members, as well as leaders, was created. The ideal team member characteristics were: customer focus, self reliance, adaptability, teamwork, collaboration, ownership, and time management. From these characteristics, books on behavioural based interviewing were reviewed. Seven sets of behavioural interview questions were developed—three sets for team level positions and four for leadership positions. A process was then developed that each candidate would follow.
Each new team member hired was considered an investment in the future success of the group. Each leader was committed to finding the right people for the new team even if that meant opening the facility with vacancies.
Directors, managers, and HR recruiters were educated on the hiring process prior to posting positions. Each of the respective directors came up with hiring requirements for their areas (e.g. imaging would require two years of experience and certification by the ARRT). HR set up screening of applications based on the cri- teria developed by the director. Figure 1 is a flow chart of the hiring process for team members.
The applications were screened by HR based on the manager/director’s criteria and then sent to the hiring manager. The hiring manager conducted a phone interview of candidates who were qualified. If the candidate passed the initial phone interview he or she was scheduled for a peer interview.
Candidates were told to plan to be at the facility for 1-1.5 hours. They would interview with the peer teams and then with me, the service excellence coordinator, and/or the director of HR. If candidates passed both the peer team and the second interview then they were set up for final interviews with the leader of the respective modality (e.g. imaging, nursing, respiratory, etc). For staff level team members, that was the final step and the respective leader decided whether to make an offer. If the candidate was interviewing for a leadership position, there was one more interview. The final leadership interview was conducted by the directors and managers who would have areas at the new facility. This made the hiring of the on-site leaders truly a team decision. It was essential that directors and managers had input into the onsite leads as this was the first step in ensuring this was one team with one focus.
The current hiring process is similar to what was done during the opening with the exception that the team members from the center conduct the peer interviews instead of those that were originally used from the hospital.
The Peer Interview Team
A peer interviewing team was developed across the seven disciplines. This team consisted of high performers that currently worked at the hospital and demonstrated many of the behaviours we were looking to have in the new team. Peer interviewing training was conducted and the team was taught how to look for the desired characteristics. The peer team solely focused on behaviours. The managers/directors scrutinised qualifications and each candidate was interviewed by the peer team. Imaging techs did not interview imaging candidates. The peer team was a multidisciplinary team interviewing all candidates. Each peer team member was taught how to score someone based on the STAR technique developed by Development Dimensions International. STAR stands for: situation, task, action, and result (http://www.ddiworld.com/). For each question the peer team asked they were looking to see if candidates answered the following:
• What was the situation or task?
• What action did the candidate take?
• What were the results of the actions taken?
Once the initial candidates were hired they attended a general hospital orientation. All training was done at the hospital for about 6–7 weeks prior to the opening of the pavilion. In addition, a two-day team orientation specific for the facility was conducted, which took place about two weeks prior to opening. For much of the team, this was the first time they met so orientation was done as one large group. This orientation not only reviewed items such as life safety, facility layout, and parking, but a number of team building exercises were also held. Team members were divided out by shifts, not specialties. This was very purposeful, as it was a key step in ensuring leaders were not enabling the silo effect.
Emphasis was placed on Studer’s AIDET concept, which stands for acknowledge, introduce, duration, explanation and thank.1 Team members were taught how to develop their own AIDET and how to utilise “key words at key times.” The expectation was set that AIDET would be used for “every patient every time.” Additionally, there was a four hour class focused solely on the patient experience and on how to communicate with the patient, actions that could be taken to provide a higher level of care, and how to perform service recovery if the patient’s expectations are not being met.
Team members were taught about the expectations for being a part of the team. The expectations are similar to what Studer calls “standards of behaviour” or Michael Cohen calls “conditions of employment.”2 They include items such as:
• Refrain from negative/disruptive behaviour (e.g., complaining, gossiping, communicating in an inappropriate manner, etc);
• Everyone is required to work as a team with specialty team members as well as the rest of the healthcare team;
• Use respectful tone of voice;
• Be aware of body language and how it affects the message being conveyed;
• Refrain from using/making inappropriate comments; and
• Collaborate with the healthcare team regarding the care of the patient.
All team members signed these expectations during orientation with the understanding they were accountable for them and failure to follow these expectations would result in progressive discipline. A large portion of the orientation focused on patient and team centred culture. Ownership was emphasised and there was a tremendous amount of buy-in as this initial team knew they would set the stage and create the culture through their daily behaviours.
Accountability and Sustaining the Culture
Merely selecting and educating a team was not enough to create a culture of excellence. After all the selection and training came the hardest part for the leaders. Leaders had to ensure that what was taught in orientation was implemented. For many teams, this is where failure occurs. With opening a new centre there was a lot of excitement and energy, but eventually people got comfortable and lost some focus and energy. The leaders had to keep that focus and make sure the mission and vision of the team were at the forefront.
To help ensure team members stay focused, leaders rounded on patients daily. Outpatient imaging patients and ED patients were rounded on by leaders. During patient rounding leaders talked with patients about their services. The following questions are asked during patient rounding:
• Have you been receiving excellent care?
• Have you had any delays?
• Is there anyone you would like to recognise?
After rounding with the patient, the leader provides feedback to the team member caring for the patient. If an issue is identified the leader will perform service recovery immediately. The nurse manager of the ED rounds on outpatient imaging exams, as well as ED patients. The imaginglead does the same. The expectation is that all leaders are responsible for all patients.
Leaders are expected to round with team members every 4–6 weeks. Team members can be rounded on by any leader, not necessarily who they report to directly. Team members are asked what is going well, who they would like to recognise, and what process may not be working (and suggestions to improve that process). Leaders are expected to “manage up” wins as taught by the Studer group. If a team member asks that someone be recognised, the leader sends the team member a thank you note or uses another form of recognition to let that person know another team member appreciates him or her. This has helped to create bonds across the team and reinforces the concept of “one” team.
Team members are encouraged to look for ways to continually improve services. Every quarter, there is a team roundtable that includes the seven areas that work in the ED section of the pavilion. During these meetings, current patient perception scores or other performance improvement initiatives are discussed.
A unit based council (UBC) was developed to help the team address issues and implement improvements. The UBC is made up of team members from all seven areas. During the roundtable meeting, the last 30–45 minutes is led by the UBC and is used to promote communication and process improvement across all areas of the team.
The facility has been open for a little over a year and over 350 interviews have been conducted. There are still some vacancies to fill, but the team is okay with that. The team is phenomenal and willing to fill in the gaps until the right people are found. So far, there have been well over 16,000 ED patients seen and over 13,000 imaging studies have been performed. There is an amazing sense of ownership across the team, as members know how important their roles are to other areas in the team. Because the roles are very different than what is typical to a hospital, there was a period of adjustment for team members to acclimate to the new model and build trust with each other.
Patient perception scores are managed by Professional Research Consultants, Inc. For 2012, the outpatient imaging quality of care was in the 96th percentile and likelihood of recommendation was in the 96th percentile. ED quality of care was in the 100th percentile and likelihood of recommendation was in the 99th percentile. Recently, CMC-Waxhaw was notified it will receive the PRC Top Performer Award for being the top performer in the national PRC ED database.
Employees are surveyed annually on employee satisfaction. The team was ranked as a Tier 1 by Morehead Associates, which is the highest tier attainable. The greatest strengths shown in the survey were teamwork or how the team members relate to each other and customer service. In the era of healthcare reform, all positions must be as cross-functional and efficient as possible. The staffing model is utilised at our facility is being looked at as a model for future centres.
Merriam-Webster defines culture as the set of shared attitudes, values, goals, and practices that characterises an institution or organisation. For many, culture is influenced by upbringing, education, and often past experiences. Leaders are responsible for creating the vision and maintaining the culture that lives in their respective departments.
hiring one team member, managing an existing team, or building an entirely new team
of people, the concepts and models that were used to build the culture at this
centre can be applied. Behavioural and peer interviewing are essential to establishing
the desired culture from the very first interaction with candidates. To be
innovative and truly improve, performance improvement must be owned by the
team, not just the leader. Team members need clear expectations set for them
from the moment they are hired and, more importantly, leaders must hold team
members accountable for these expectations.