Jim Anderson became CEO of Cincinnati Children’s Hospital Medical Center (CCHMC) in 1996, after serving on the Board of Cincinnati Children’s for 20 years, including four years as Chairman. A lawyer and manufacturing executive by background, Jim has shepherded Cincinnati Children’s to unprecedented levels of excellence in patient care, teaching and research. Cincinnati Children’s ranks third among all paediatric hospitals in NIH-funded research, and is among the top 3 or 4 children’s academic centres nationwide in scale and quality of teaching and care. A participant in the Robert Wood Johnson/IHI Pursuing Perfection initiative, CCHMC has earned an international reputation for quality, and in 2006 was awarded the McKesson Quest for Quality Prize in recognition of its extraordinary accomplishments. In particular, the AHA recognised Cincinnati Children’s exceptional commitment to patient-centredness, and its achievement of stunning results (see table 1). Mr Anderson was interviewed in August 2006 about leadership for quality at Cincinnati Children’s.

INTERVIEW

JR: Jim, it’s often said that the measure of leadership is results. What results are you most proud of?

JA: I get consistent feedback from throughout the organisation that everyone knows the transformational vision for Cincinnati Children’s and the strategy for achieving that vision, and is engaged and enthusiastic about doing their part in getting there. What I’m most proud of is the depth and penetration of that engagement throughout the organisation, in every discipline and unit. That sort of engagement is essential for execution (the most challenging and most important aspect of any strategic plan).

JR: How do you know that engagement is present? Do you measure it somehow?

JA: The feedback loop I rely on comes in two forms: anecdotes and measured performance. I walk around the organisation keeping my senses tuned to the question “Is the transformation of the organisation happening?” and I’ve learned to place a high value on the soft signals—the intuition, the body language and stories that emerge as I observe what’s happening with that question in mind. And then if I have questions or concerns about the soft signals, I dive into the hard data—the results of hundreds and hundreds of projects in every aspect of the organization—to learn more about whether we’re moving toward our vision of perfection in everything we do.

JR: And Cincinnati Children’s results are spectacular. I know this has been a team effort, but what is your role as CEO in achieving those results?

JA: My contribution has been to send an unambiguous signal that the quality transformation of Cincinnati Children’s is a very high priority for me personally, and for the institution. At every possible opportunity—formal and informal meetings with staff, Board, faculty—I channel attention to this transformation and why it’s important for our mission.

A key part of this message is that we’re not talking about excellence just in clinical care, or customer service. An organisation can’t be tops in one or two things and mediocre in others. We pursue perfection in everything—human resources, housekeeping, facilities, research, supply chain management, safety, efficiency.

The other important thing about this signal is that it’s not just “Gee, I think this is important, what do you think?” I have made it clear to managers and leaders throughout the organisation that effective engagement in pursuing this transformation—getting the needed results—is not up for debate.

JR: Can you give an example of that sort of communication?

JA: Each of our major projects has a “Cabinet Champion”, a member of the executive team who works with the project team. I’ve been the Cabinet Champion for some of our key projects, and at times, as projects seem to bog down amid tensions across strong cultural elements in the organisation, I’ve had to tell the team that “It’s fine to study this some more, to get some more data or to talk about these issues a third or fourth time, but it’s not fine not to get results. If you can’t get the results, we’ll find people who can. The goal won’t change. The people working to achieve the goal will change.”

JR: Hmmm. So your signal about results is clear, or as Tom Cruise would say in A Few Good Men, “Crystal”. What results are you intending to achieve?

JA: We have six priorities: Patient Safety, Reduce Hassles, Access, Flow, Clinical Excellence and Team Wellbeing. Within each of those priorities, we have established a comprehensive set of metrics that give us some indication of progress. The total number of measures—99—is probably too many, and not all of the measures are fully developed and resourced, but each measure has a baseline and a goal, and we track progress toward our transformation on that basis [see table 2].

JR: So who’s responsible for achieving these goals?

JA: It sounds messy, but the answer is “we all are”. It was interesting to observe the interview process for the AHA Quest for Quality Prize. We had 50 or so people in the room, and when we were asked questions, virtually anyone in the room could (and did!) give the answer. We don’t see quality and safety as being the responsibility of “the quality staff” or some other designated group. Transformation is everyone’s job.

That said, the line managers in each business unit are responsible for achieving specific aims within these six priorities. It’s an important part of each manager’s performance feedback: “How are you doing at leading this transformation? What results are you achieving?”

JR: Do you review all this annually?

JA: No, we don’t like setting goals out into the misty future. We set 90 day goals for all improvement projects, and review them on that schedule. This helps us maintain a sense of urgency and action. This approach is similar to the process by which we review the progress of each of our 18 business units toward achieving our overall strategic objectives, so our managers are accustomed to being accountable for their results on a 3–4 month cycle.

JR: It seems that quality is integral to your business strategy. Is there really a business case for quality? Does Cincinnati Children’s “do well by doing good?”

JA: Absolutely. Quality—becoming excellent in everything we do, particularly in the three major categories of medical outcomes, patient and family experience, and value—is a powerful business strategy for Cincinnati Children’s.

Here’s a good example of a quality improvement that at first glance would appear to hurt us economically, but which has in fact been a strong positive for our operating margins. We implemented an evidence-based protocol to reduce unnecessary admissions for bronchiolitis. Bronchiolitis had been one of our highest volume sources of admissions from our community, and the protocol effectively reduced those admissions and their associated revenues by 53%. But we could then use the beds that opened up to admit more complex patients from our global referral base, and the revenues and margins on those patients more than made up for the loss in revenues for unnecessary bronchiolitis admissions. And we didn’t have to spend capital building more beds to accommodate those global referrals! It was a win for everyone—our patients and families, our local payers, and for Cincinnati Children’s.

Over the years of our quality journey, we see the primary effect of the ongoing transformation in terms of operating productivity. We are experiencing better throughput, reduced hassles for staff, and smoother functioning of our support infrastructure. The net result is that we are seeing many more patients, without adding many more staff, but with substantial improvement in staff satisfaction and engagement. We’ve made a strategic bet on quality. And it appears to be working.

JR: What’s been the role of the Board in CCHMC’s ongoing quality transformation?

JA: It is the Board that enables an organisation to define and execute a strategy of transformation. Done with impact such strategy carries with it higher than normal risk of adverse publicity (the result of broader transparency), cost (funding unproven projects of various sizes; possibility of additional malpractice claims), medical staff unrest (changing prior practices) and employee morale (too many changes too fast with insufficient resources). The CEO needs the Board to accept these risks and continuously to insist on the changes that are necessary to execute the strategy. We actively work our strategy of change through our Board and all of its committees.

JR: If you had one piece of advice to a hospital CEO who wanted to embark on this quality transformation, what would you say?

JA: Don’t let anyone tell you it can’t be done and done successfully. Then, just do it; do it carefully and thoughtfully but with the sense of urgency and persistence that it deserves.