A Public “Safety Net” Hospital Aims for Excellence: Mission-Driven Transformation to Improve Health in East Hawaii

Abstract

The East Hawaii Region of the state-owned Hawaii Health Systems Corporation (HHSC) aims to achieve what few “safety net” health systems even dream of—performance excellence on par with the best hospitals in the U.S. Anchored by its mission, Hilo Medical Center and the other facilities that are part of the HHSC region that serves the east side of the Big Island of Hawaii, have achieved significant milestones toward this ambitious aim. This case outlines the significant challenges associated with operating a public, unionized healthcare system where there are severe physician shortages, describes the key leadership actions taken to improve performance, and invites students to analyze potential future actions that would further advance this organization toward achieving its vision.

This case was prepared for inclusion in Sage Business Cases primarily as a basis for classroom discussion or self-study, and is not meant to illustrate either effective or ineffective management styles. Nothing herein shall be deemed to be an endorsement of any kind. This case is for scholarly, educational, or personal use only within your university, and cannot be forwarded outside the university or used for other commercial purposes.

2024 Sage Publications, Inc. All Rights Reserved

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Resources

Appendix: Operating Charter and Rules of Conduct

“Inspired by Aloha”

Patient Centered

Employee Focused

Fiscally Sound

Outstanding Quality

Executive Management Team, East Hawaii Region: Operating Charter and Rules of Conduct

Preamble

The relationship of the CEO with his or her executive management team (EMT) and the unity of that team is of crucial importance to the success of the organization. The creation of a mutually agreed upon structure, with fair and clear expectations, is essential to create and maintain a great leadership team. An Operating Charter and Rules of Conduct that will guide our behaviors and interactions was developed at our first annual management retreat held on December 1, 2016. The charter will be reviewed regularly and updated annually each December.

Definition

Operating Charter: The development of codes and rules by which team members agree to abide, norms that enhance the decision-making process, group cohesion, and the sharing of common goals; encourages helping behavior, cooperation , integration, and organizational citizenship behaviors

Behavioral and Communication Expectations

Each executive, including the CEO, will treat requests for information, meetings, and consultations by their fellow members as a high priority.

All communication will be open, honest, respectful, professional, and courteous. We grant each other permission to address unacceptable behavior.

Discussion, debate, and constructive disagreement are encouraged and will be welcomed by fellow executives and the CEO.

The CEO and individual executive(s) are expected to actively facilitate other executives in the achievement of their goals. This expectation will be part of the performance evaluation criteria.

Conscious effort will be made by the CEO and all EMT members to encourage direct communication between each other and between our direct reports.

The CEO and executive(s) agree the following behaviors are unacceptable:

  • “Triangulation”—when one person will not communicate directly with another person, but will communicate with a third person, which can lead to the third person becoming part of the triangle.
  • “Splitting” (aka “divide and conquer”)—in which one person plays the third person member against the one that .he or she is upset about. This is called playing the two people against each other, but usually the person doing the splitting will also engage in character assassination, only with both parties.
  • Passive aggressive behavior—The indirect expression of hostility, through procrastination, stubbornness, sullenness, or deliberate and/or repeated failure to accomplish requested tasks for which one is (often explicitly) responsible.
  • Blind cc of business email communication.
Board Protocols

Requests from board members for information and or opinion will be treated as a priority and answered openly and honestly.

  • The CEO will be kept fully informed of board requests and associated responses.
  • Full cooperation is expected in all confidential requests from the Board Chair to members of the executive team.

Members of the executive team who have a significant disagreement with a CEO decision or any work related problem should follow the following protocol:

  • Have a direct conversation with the CEO and attempt to resolve the issue together. The CEO will actively participate openly and in good faith. Retaliatory behavior is prohibited. If not resolved, the executive(s) will inform the CEO that a meeting is requested to discuss the issue in question with the board chair. This meeting may be held either with or without the CEO present.
  • The board chair will attempt to facilitate a resolution of the issue and if appropriate require a review of the decision and possible change.

The CEO will follow the same protocol regarding issues and complaints brought to his attention by executives’ direct reports, and/or staff.

  • The executive(s) will require their direct reports and staff to follow the same protocol when “taking it up a level.”
  • This protocol does not override any employee’s right to utilize the compliance hotline as appropriate.
Decision-Making Process and Executive Team Unity

The CEO and executive(s) agree that consensus is the desired mechanism for reaching decisions amongst the EMT.

  • If consensus cannot be achieved after constructive debate, the CEO will make the decision.

When decisions are reached following this process, the executive(s) are expected to fully and actively endorse the EMT position, lending their credibility to the team decision.

  • Communication that verbally or non-verbally shifts responsibility away … for example “the CEO said” or “EMT decided so I have no choice” is not acceptable. The executive(s) will communicate EMT decisions and explain and justify them to their direct reports and staff.

When an executive cannot support the decision in good conscience, he or she will communicate that to the group during decision-making and to the CEO.

  • Good faith effort will be made to reach a consensus that can be supported. On occasions that consensus cannot be reached and the CEO has to make a “hard call,” the executives will develop an agreed upon communication plan as to how that decision should be communicated by EMT to their managers and staff.
Focus on Results and Continuous Improvement
  • The CEO and executive(s) endorse a culture of continuous improvement, excellence, and achievement.
  • Each executive will ensure that his or her departments also endorse a culture of continuous improvement. The departments ' focus will be on improving work processes and integrating systems to achieve meaningful results.
  • The CEO and executive(s) will research and define best practices and bench marked standards.
  • Every department of the hospital and Critical Access Hospitals will have at least one measurable and time-limited improvement project that aligns with the East Hawaii Region’s strategic goals.
  • These projects will be developed at the department level with guidance by the executive, and approved by the executive and CEO.
    • They will be reviewed at least monthly with progress recorded on the EMT tracking sheet.

Customer Service Culture

The CEO and each executive acknowledge that:

  • We are in the patient care AND customer service business.
  • We are responsible to both internal and external customers and we have a responsibility to facilitate other executives in the achievement of their goals.
  • The CEO and executive(s) will follow a customer service standard, measure performance against that standard, and ensure that it is followed.
  • The CEO and executive(s) will utilize AIDET principles in everyday communication and will require the same of their direct reports and staff.

Fiscally Sound

The CEO and each executive acknowledge that he or she are responsible for the financial performance of his or her respective areas and that he or she has a duty to utilize the region’s and the taxpayers resources in the most efficient and effective way possible.

Operational decisions will be made with strong focus and review of the impact on the region’s budget and finances.

Significant expenditures for equipment and services and hiring of new positions will all require validated supporting data.

Employee utilization of leave, overtime, and vacation will be monitored to minimize abuse of entitlements.

Team Focused

  • Our standard of communication, behavior, and decision-making, as agreed upon in this charter, will also be the expectation for our interaction with physicians, managers, and staff.
  • The CEO and executive(s) will exemplify the behavior we expect, placing special emphasis on clear and frequent communication and requiring the same of our direct reports.

Excellent Quality

The CEO and EMT shall promote a collective mindfulness of quality and patient safety as demonstrated by:

  • awareness of all the “on the ground” issues that affect patient care;
  • mapping processes to understand the components of operations to identify potential risks or identify opportunities for improvement;
  • setting high standards for quality care and continuously monitoring performance against those standards.

Planning and Executing

The CEO and executives agree:

  • To involve stake holders early in the process of major changes so that they understand the rational and the method.
  • To have a clear end result in mind and accompany the desired change with an implementation plan.
  • To have a written plan, with time limited flags on path, measurable results, benchmark goals and a means to sustain the action and gains.

General Expectations

Round regularly with your direct reports and staff.

Seek opportunities to acknowledge, reinforce, and reward excellence. Celebrate the achievements of our staff, managers, and colleagues.

The CEO and executive(s) should “manage up” the CEO and other executive members.

Availability

The CEO and executive(s) agree to be available at all times to the CEO and other EMT members.

  • This accessibility should not be abused for minor issues and common sense should be exercised when contacting each other. Interruptions during vacations should only be for significant matters unless the executive specifies otherwise.

Emails and texts from among the EMT will be given priority.

Vacations

Executive and CEO agree that “presence” is very important.

  • Two weeks (including weekends) or less is ideal.
  • Longer vacations require special approval.
  • If executive(s) are near the maximum limit for retained vacation hours and need to use vacation hours to avoid the loss of vacation hours, they will spread those hours out over the course of the year.

Leave Notification

Executive will inform CEO administrative assistant of any scheduled or unscheduled absence and applicable coverage plan. He/she will distribute information to other executives.

Travel

One professional trip to the U.S. Mainland will be approved each year, finances permitting. Whenever possible, this professional trip should be associated with a major meeting of a relevant professional association. All additional professional trips to the U.S. Mainland will receive special scrutiny on a case-by-case basis.

In-state travel and training will have a clear and direct association with improving the ability to fulfill executive duties.

Task specific training travel will be directed to line staff and managers.

Work Hours

In general work hours will be whatever it takes to do an excellent job. The exact when and where will be up to the individual executive.

  • The CEO will not need to be informed for routine absences related to appointments.

Dress Code

Professional business dress and a well-groomed appearance are expected of the CEO and executives when on campus. Casual wear including jeans, work boots, slippers, and t-shirts are discouraged except in special circumstances when they may be appropriate.

The same standard will be required of the executive(s)’ direct reports and staff within the limits of the BUs and EHR dress code.

Meetings

Weekly EMT meeting is a high priority. Any executive who cannot attend a regularly scheduled meeting must inform the CEO in advance. Punctuality is expected.

Phones will be muted during the meeting and answered only for emergencies. Laptops will be used only in exceptional circumstances.

Department Heads and Executives are expected to have a minimum of monthly meetings with their direct reports and more as necessary.

Hiring and promotion

The selection of the right internal or external candidates for management positions is crucial to the success of our organization. For positions at the department head level or higher, mutual interviewing of the top candidates and final selection agreement between the EMT member and CEO will be required.

Positions at the coordinator or working supervisor level require a verbal discussion with the CEO.

The executive(s) will require a similar process for their direct reports and will actively supervise the selection and hiring process.

Figure

This case was prepared for inclusion in Sage Business Cases primarily as a basis for classroom discussion or self-study, and is not meant to illustrate either effective or ineffective management styles. Nothing herein shall be deemed to be an endorsement of any kind. This case is for scholarly, educational, or personal use only within your university, and cannot be forwarded outside the university or used for other commercial purposes.

2024 Sage Publications, Inc. All Rights Reserved

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