When Michael Williams, MD, became the CEO of Hill Country Memorial Hospital in Fredericksburg, Texas, in 2008, there was a lot on his plate — perhaps a Thanksgiving-sized plate.
The non-profit hospital's net operating income was negative for the first time since it opened in 1971, staff morale was wavering and money was being dedicated to projects with question return and overused temporary agency staffing. HCM only had two CEOs before Dr. Williams, and he felt stagnancy in the air. "The hospital had found itself in a gradual deterioration that led to severe apathy and a decrease in morale," Dr. Williams says. "What was needed was more of a disruptor, a change-driven kind of leader."
So he took it upon himself to help dig the rural hospital out of its predicament. Now, three years later, HCM finances are back in order, and the Hospital Consumer Assessment of Healthcare Providers and Systems has ranked HCM's consumer perception of quality care in the top 5 percent of all hospitals in the United States. Rural hospitals experience the gamut of challenges, from low volumes to tough quality-of-care measures, but the right mindset can help make any rural system viable.
Holistic approach
When Dr. Williams arrived on the scene, he said there was a combination of factors that led the hospital's state of duress. HCM was spending nearly $1.7 million per year on its temporary workforce, and there were plans to construct a $34 million bed tower. He says the hospital was banking on the inpatient business to grow with the tower plans, which has not been the trend in the surrounding area the past several years. In a way, there was a lack of awareness of how dire the hospital's situation had become. "Without vision and forward thinking about where we were going next, complacency set in," Dr. Williams says. "A lack of leadership allowed that to happen. Complacency and denial almost became malignant."
With that, he says the hospital needed a holistic turnaround and a systematic way of attacking its issues in parallel through lean principles. So far during his three-year tenure, 95 percent of the executive team changed, and his staff rewrote the hospital's mission statement from a one-and-a-half-page-long term paper to a concise, three-word phrase: "Remarkable care always."
Dr. Williams says it was difficult to have the hospital staff fully believe in the initial changes, but the holistic approach eventually caught on as people grew tired of "good." "A 'good' hospital is nothing more than an 'average' hospital," Dr. Williams says. "We treated 'good' as a word we don't like, and we moved the conversation to what makes us remarkable and extraordinary."
Reorganization of patient, financial and clinical aspects
After modifying HCM's management and philosophy, Dr. Williams looked at three areas where the hospital needed immediate improvements: patient satisfaction, finances and clinical programs.
Studies have shown that small rural hospitals in the United States provide a lower quality of care and have worse patient outcomes than larger hospitals. Dr. Williams wanted patients to provide feedback via HCAHPS surveys so the hospital could monitor its progress and aim for higher standards of patient satisfaction. So HCM realigned its goals to focus on the surrounding community and patients. Dr. Williams says patients should expect quality care, regardless of healthcare facility, and they needed to speak up when HCM fell short. Hospitals have to be comfortable with consumer feedback, and patients were able to provide that outlet for HCM to see how patients perceived its quality of care. "You have to focus on the patient," Dr. Williams says. "Healthcare has been too much about providers. That's why waiting rooms exist — people expect to wait."
To boost its clinical side, the hospital wanted to establish service lines that could be profitable in the area, he adds. For example, management realized the hospital is situated in a geriatric community, so HCM aggressively recruited vascular surgeons to meet the demand of a service that had previously gone unnoticed. Rural hospitals must be able to take advantage of service lines their areas need, he says.
Commitment to rural care
Dr. Williams says a lot of the recent healthcare reform seems to be more geared toward urban hospitals. For example, successful accountable care organizations require tens of thousands of people, and rural towns and regions simply can't support that, he says.
While HCM has not had to merge with another health system, he admits that for many rural hospitals, partnerships with other larger hospitals or health systems may be a necessity — or at least a consideration — so patients do not lose that access to care. "There has to be a spectrum of some sort of strategy that leads a rural hospital to look at a loose affiliation all the way over to equity ownership," Dr. Williams says. "That needs to be looked at now sooner than later, and you have to pair with someone who believes what you're doing."
Before a rural provider gets to that point, however, he emphasizes that improvements can be homegrown. It just takes the right culture and commitment to care to ensure that indifference is not infused. "Don't try to chase reimbursement patterns," Dr. Williams says. "Understand your community and start looking at management practices to become more efficient. Position yourself for strength and independence while always being aware of the possible need to consider other options."
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The non-profit hospital's net operating income was negative for the first time since it opened in 1971, staff morale was wavering and money was being dedicated to projects with question return and overused temporary agency staffing. HCM only had two CEOs before Dr. Williams, and he felt stagnancy in the air. "The hospital had found itself in a gradual deterioration that led to severe apathy and a decrease in morale," Dr. Williams says. "What was needed was more of a disruptor, a change-driven kind of leader."So he took it upon himself to help dig the rural hospital out of its predicament. Now, three years later, HCM finances are back in order, and the Hospital Consumer Assessment of Healthcare Providers and Systems has ranked HCM's consumer perception of quality care in the top 5 percent of all hospitals in the United States. Rural hospitals experience the gamut of challenges, from low volumes to tough quality-of-care measures, but the right mindset can help make any rural system viable.
Holistic approach
When Dr. Williams arrived on the scene, he said there was a combination of factors that led the hospital's state of duress. HCM was spending nearly $1.7 million per year on its temporary workforce, and there were plans to construct a $34 million bed tower. He says the hospital was banking on the inpatient business to grow with the tower plans, which has not been the trend in the surrounding area the past several years. In a way, there was a lack of awareness of how dire the hospital's situation had become. "Without vision and forward thinking about where we were going next, complacency set in," Dr. Williams says. "A lack of leadership allowed that to happen. Complacency and denial almost became malignant."
With that, he says the hospital needed a holistic turnaround and a systematic way of attacking its issues in parallel through lean principles. So far during his three-year tenure, 95 percent of the executive team changed, and his staff rewrote the hospital's mission statement from a one-and-a-half-page-long term paper to a concise, three-word phrase: "Remarkable care always."
Dr. Williams says it was difficult to have the hospital staff fully believe in the initial changes, but the holistic approach eventually caught on as people grew tired of "good." "A 'good' hospital is nothing more than an 'average' hospital," Dr. Williams says. "We treated 'good' as a word we don't like, and we moved the conversation to what makes us remarkable and extraordinary."
Reorganization of patient, financial and clinical aspects
After modifying HCM's management and philosophy, Dr. Williams looked at three areas where the hospital needed immediate improvements: patient satisfaction, finances and clinical programs.
Studies have shown that small rural hospitals in the United States provide a lower quality of care and have worse patient outcomes than larger hospitals. Dr. Williams wanted patients to provide feedback via HCAHPS surveys so the hospital could monitor its progress and aim for higher standards of patient satisfaction. So HCM realigned its goals to focus on the surrounding community and patients. Dr. Williams says patients should expect quality care, regardless of healthcare facility, and they needed to speak up when HCM fell short. Hospitals have to be comfortable with consumer feedback, and patients were able to provide that outlet for HCM to see how patients perceived its quality of care. "You have to focus on the patient," Dr. Williams says. "Healthcare has been too much about providers. That's why waiting rooms exist — people expect to wait."
To boost its clinical side, the hospital wanted to establish service lines that could be profitable in the area, he adds. For example, management realized the hospital is situated in a geriatric community, so HCM aggressively recruited vascular surgeons to meet the demand of a service that had previously gone unnoticed. Rural hospitals must be able to take advantage of service lines their areas need, he says.
Commitment to rural care
Dr. Williams says a lot of the recent healthcare reform seems to be more geared toward urban hospitals. For example, successful accountable care organizations require tens of thousands of people, and rural towns and regions simply can't support that, he says.
While HCM has not had to merge with another health system, he admits that for many rural hospitals, partnerships with other larger hospitals or health systems may be a necessity — or at least a consideration — so patients do not lose that access to care. "There has to be a spectrum of some sort of strategy that leads a rural hospital to look at a loose affiliation all the way over to equity ownership," Dr. Williams says. "That needs to be looked at now sooner than later, and you have to pair with someone who believes what you're doing."
Before a rural provider gets to that point, however, he emphasizes that improvements can be homegrown. It just takes the right culture and commitment to care to ensure that indifference is not infused. "Don't try to chase reimbursement patterns," Dr. Williams says. "Understand your community and start looking at management practices to become more efficient. Position yourself for strength and independence while always being aware of the possible need to consider other options."
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