Workforce Engagement Improves Patient Experience at Parkland Health

Added on Apr 18, 2019

At Parkland Health, Workforce Engagement Is the Foundation of Patient Experience Improvement
By Diana Mahoney

The business case for nurturing a robust organizational culture in health care can be seen in some of the recent performance metrics coming out of Dallas-based Parkland Health & Hospital System. Since the launch of an integrated improvement strategy in 2015, the 850- bed safety net hospital has moved the needle on workforce engagement from the 9th percentile to above the 30th percentile, decreased employee turnover by almost 20%, increased the number of units with top-tier engagement by nearly 300%, and consistently improved performance on the global Likelihood to Recommend metric—an indicator of patient loyalty.

In a twist on the “If you build it, they will come” mentality, the gains reflect a deliberate effort by Parkland leadership to improve the patient experience by first removing barriers to optimal employee engagement. Led by Vishal Bhalla, vice president and chief experience officer at Parkland, the multiphase improvement program was initiated during a period when the health system was coming out from under a corporate integrity agreement (CIA) with the Office of the Inspector General and the U.S. Department of Health and Human Services, which had been imposed based on concerns arising from quality and patient safety issues.

“Operating under a CIA creates a different dynamic in terms of work culture,” Bhalla explained. “The environment felt restrictive, the already high levels of stress were exacerbated, and trust among the workforce had been diminished, which was reflected in our employee engagement scores.”

Bhalla, who at the time was director of talent acquisition, understood the importance of employee experience to overall organizational performance and presented his thoughts for embedding employee experience into the broader patient experience strategy to the CEO, Dr. Frederick Cerise. Despite the residual risk aversion associated with the regulatory oversight, Dr. Cerise made the decision to revive the position of chief experience officer, which had previously been cut in a reduction in force, and gave Bhalla the green light to put a plan into action. 

Building Employee Trust

The first order of business, according to Bhalla, was to rebuild employee trust. “My plan was to focus on employee engagement for one year,” he said. “At this point, although we were doing regular engagement surveys, they didn’t really mean anything to employees because there was little follow-up. We wanted to get to the point where the workforce trusted that their feedback mattered.”

To this end, Bhalla set out to get a deeper understanding of employee perceptions of the organizational culture and insight into why previous engagement efforts had failed. “I did more than 150 one-on-one interviews across the spectrum of employees and up and down the hierarchy. I found out that in the previous years, more than 1,300 action items had been established, but when the teams started working on the action items, they often realized that solutions were outside of their circle of influence, so they stalled,” he said. 

In addition to the one-on-one interviews, Bhalla also created a task force comprising a cross section of employees to reflect a “micro-ecosystem of our workforce,” he said. The task force has bylaws and structures in place to ensure alignment with the health system mission, and is organized around action committees to address some of the specific issues that emerged from the interviews and the engagement surveys.

These two actions—the one-on-one interviews and task force development—began to register on the employee trust meter. “Before we even created action steps, our commitment to seeking out employee input raised the engagement survey participation rate from 59% to 79%,” Bhalla said.

Designing and Cascading Action Plans

Action planning was next on the agenda. “I looked at all of the data we had collected from employees, sorted out the independent variables, then did an in-house regression to identify the top three things we could work on as a system, picking one item from the employee domain, the manager domain, and the executive domain that we would work on for a year,” Bhalla explained. The employee objective was to improve performance on the “My unit works well together” measure, while the management and executive objectives were focused, respectively, on “I am involved in decisions that affect my work” and “I have confidence in senior management’s leadership.”

Action plans to support these objectives were developed using a stepwise, inverted pyramid approach. Rather than starting at the senior executive level and cascading plans down to management and then to employees, employee-level planning was prioritized. “For example, the system objective for employees was ‘My team works well together,’ which every individual across the organization can relate to. We brought this to all of the teams and asked, ‘What two things can we do to work well together?’ We all knew why we were doing it and what we had to do, but the how was up to the team,” Bhalla said. “Each team then came up with two simple items to address the objective that were within their circle of influence and, with their supervisors’ blessing, entered them into the simple action planning template.”

The same process was then employed for the system-level manager and senior executive objectives. And while the specific solutions differed for each team based on what made sense for their group, all of them had to be SMART (Specific, Measurable, Achievable, Relevant, and Time-bound) goals to make it into the action plan, Bhalla noted.

To assess the effectiveness of the approach, a survey was sent to all employees, asking whether they’d seen their team’s action plan, they were involved in developing it, and they believed in it. “For teams with a less than 66% positive response, we went to the leader and offered support to help the team build an action plan,” Bhalla said.

Removing Engagement Barriers

To nurture a culture that would be receptive to the improvement activities born from the action plans, Bhalla and his team took a magnifying glass to employee engagement data to better understand the performance in context. “On their own, the engagement scores often do not reflect the whole story, so I built an algorithm to heat-map the organization,” he said. The algorithm comprised multiple metrics, including overall engagement performance and power item scores, which reflect team members’ average response to survey items that most powerfully influence commitment and are used for tier ranking.

The heat maps pointed to units or business areas that needed extra attention. To gain context around the performance challenges for these teams, Bhalla established an information gathering process that included discussions with employee relations, talent management, and the HR business partner; review of pertinent analytics, including turnover, staffing, patient safety, and patient experience; and a meeting with the “leader of the leader”—the person the leader of the unit or business area in question reports to—to get their thoughts.

This information provided the backdrop for meetings with the business unit leader to collaborate on an improvement strategy and make important connections between engagement and other performance areas, including safety and patient experience, Bhalla explained. “We expressed very clearly that we wanted to see them succeed, so the meeting would not be perceived as punitive. Typically, by the end of the meetings, the leaders were feeling energized and positive about their ability to drive change.”

Adding Patient Experience to the Mix

With the engagement process well-established, the second year of the improvement program broadened the scope to include patient experience. “From a planning perspective, we used a similar methodology. We identified units with the biggest return rates for patient experience surveys and the biggest delta from the average organizational performance on the Press Ganey Likelihood to Recommend system measure [reflecting an aggregation of scores from all divisions],” Bhalla said. “Based on that, we selected 12 inpatient units across the system that represented the entire spectrum of our services, with the understanding that if we were able to improve the Likelihood to Recommend score in these units, it would also help the overall system performance.”

Because Likelihood to Recommend is a dependent variable, Bhalla and his colleagues identified the three independent variables that have the greatest impact on that measure in Parkland’s inpatient units: nurse courtesy and respect, provider courtesy and respect, and responsiveness to the call bell, according to Bhalla. “Similar to the engagement action planning process, we got those 12 units together to understand their scores and then to start action-planning around these three things,” he said. “We helped them facilitate the plans, but they came up with solutions.”

With respect to call bell responsiveness, for example, creating more rigor around hourly rounding represented an ideal opportunity to improve patients’ perceptions around this measure. Working with one of the assistant unit managers who volunteered to help with the project, “we measured call button frequency for one shift over a two-week period during which hourly rounding was conducted consistently,” Bhalla said. “The assistant unit manager extrapolated the two-week results for the year and was able to show that consistent hourly rounding on every shift would reduce the number of call bells by about 40%. When she gave that message to her colleagues, there was immediate buy-in.”

In this same vein, each of the 12 units was charged with the task of developing its own interventions and reporting out on its progress monthly. “It took about six months for that project to get to a point where people were comfortable with it and consistently doing it, but once they did and started seeing progress, they understood the value,” Bhalla explained. “Now we’ve reached a point where many of these units are going to start mentoring other units in their business lines.”

To date, the integrated improvement strategy has led to meaningful improvements in both workforce engagement and patient experience. Specifically, over a three-year period, Parkland achieved the following:

  • The mean employee engagement score rose by nearly 6%.

  • The number of Tier 1 engaged units rose from 32 to 122.

  • Turnover rates decreased from 18.5% to 15.1% (with each percentage point reduction resulting in an estimated cost avoidance of $3.6 million).

  • Performance on the Likelihood to Recommend metric for inpatient services rose from 86.6 to 91.3 and for the system overall from 86.4 to 88.7.

The improvement patterns have also helped the entire organization understand the direct, positive relationship between an engaged culture and patient experience excellence, Bhalla stated. “We have been trying to create that link at every level so that front-line employees, managers, and senior executives experience that ‘aha’ moment.”

The next phase in the improvement journey is to bring workforce and patient safety into the mix, Bhalla said. “There is an obvious connection between safety and both culture and experience, and we are very aligned with the vice president of safety and are working together.” As with engagement and patient experience, he stressed, the safety action plans are most powerful when they come from the teams themselves. “They are doing the hard work. My job is to help facilitate.”