To do a better job of consistently fulfilling its mission to provide superior quality healthcare services across an integrated delivery network that includes 27 acute care hospitals and more than 320 behavioral health facilities in the U.S., Puerto Rico and the U.K., Universal Health Services (UHS) decided to focus on its people.

“Our approach, from a corporate level was, how do we build a high-performance team?” said Paul Stefanacci, MD FACS MBA, vice president of quality and chief medical officer of the acute care division. “We understood that leadership and a skilled workforce were critical.”

The role of system leadership

UHS system leadership sets and communicates the vision, purpose and priorities for all facilities and team members. It also holds the facilities and providers accountable for meeting those objectives.

“But right there in the middle is the most critical part and that is supporting the development and growth of a competent workforce,” Stefanacci noted. “We need to translate the purpose, goals and objectives into results. And that happens with a competency-based workforce.”

Clarity of purpose

The system leadership starts by providing an organizational focus through purpose, in this case achieving high reliability in care delivery. The underlying guidelines animating this purpose are delivering patient-centered care and achieving superior patient outcomes. “Purpose acts as the unifying principle that drives everything the organization does. It goes beyond mission,” Stefanacci said.

Meaningful data for actionable insights

With diverse care settings, medical and related services, geographies, patient populations and other variations, UHS’ facilities had developed myriad performance measures over the years, making it almost impossible to have a standard measure set to evaluate performance across facilities, providers, service lines and quality teams. To remedy this, UHS took a major leap forward in its quest to improve quality by standardizing performance measurements across the system.

UHS developed a single measure called the Q Score. The Q Score provides one source of information composed of the same domains and indicators as those used by CMS’ Hospital Compare and from Leapfrog’s safety survey. Ted Donnelly, MHA BSN, corporate director of quality, explained that “the quality team at each location can now monitor their progress on initiatives to address care and processes on a real-time basis. That information is organized for presenting to executive leadership and the medical staff, so the team can demonstrate what they’ve done, what they need to do and what it means for the system. They are able to engage their stakeholders,” he said.

Effective performance improvement by local quality teams

UHS is shooting high. Its actionable goals include zero patient harm and service excellence with performance targets of top decile results.

Each location’s quality teams are expected to lead and support change initiatives, including using a common performance improvement methodology and standardized tools and techniques. As a consequence, “we’re pushing the needle using NAHQ resources to help develop a competency-based quality workforce and elevate quality program expertise,” Donnelly said. “Work is ongoing to raise the bar for the quality teams and provide the resources to expand their capabilities.”

Local leadership accountability

“Receiving an F as its Leapfrog Hospital Safety Grade in 2016 jumpstarted a new era of quality at UHS’ Southwest Healthcare System,” said CEO Brad Neet, FACHE MBA BSN RN. Southwest consists of two Southern California hospitals about five miles apart, sharing one license for a total of 260 beds, one medical staff and one executive leadership team. “We didn’t necessarily believe the grade was indicative of the care being provided in our organization,” he said. That said, Neet was committed to providing the best quality care and for the external metrics to recognize that.

To transform performance, Neet began by promoting the quality director to the executive team. “If quality is going to be important in the organization, quality needs to report to the CEO,”  he said.

Then focus shifted to the workforce. “It’s the 1,500 team members that we have at Southwest who are really going to get it done,” Neet said. “They’re the ones on the front line. They’re the ones who work the hardest. They’re the ones who you’ve got to have engaged in order to make the purpose, the mission and everything else have an impact ultimately with excellent outcomes and quality.”

Creating leading quality indicators

Led by newly promoted Nikole DeVries, MSN RN CHQP, director of performance improvement and patient engagement, Southwest’s quality team set two related goals: improving team member engagement and improving patient experience. Because much of the quality data they saw was lagging, such as readmissions and CAUTIs that had occurred months before, the team also developed concrete leading key performance indicators so they could gauge real-time progress on their two goals.

One leading measure for team member engagement is that unit leadership will review staff suggestions monthly, execute 75% or more of the accepted suggestions and post the outcomes of 100% of the enacted suggestions for team review. For patient experience, it’s measuring how often purposeful hourly rounding and bedside reports are done and how often correctly, including following a script for communicating with patients and standing at specific spots in the room when conversing with patients.

“If you don’t currently have a way that you’re looking at measures or outcomes daily or on a shift-by-shift basis and having those leading indicators, that’s not how you’re going to drive quality,”  said DeVries.

Making results highly visible

As a motivator, Southwest posts prominent scoreboards of the Q Score, bedside reports and other leading and lagging indicators in public hallways so team members as well as patients and other visitors see them. “People play differently when they are keeping score,” said DeVries.

Leveraging corporate support

The Southwest quality team collaborated with the facilities’ chief nursing officer and the corporate quality team to identify and then develop the best leading indicators for nurses, which were the rounding and bedside reports. The corporate data analytics team and the development of the Q Score also has “saved me a lot of time and now I don’t have to run all this date,” DeVries noted.

About a year ago, corporate also determined that all acute care hospitals should have daily safety huddles. Despite some initial wariness about how practical they would be, they are working, says Neet. “People show up. They participate, including executive leadership.”

“We have a great relationship with our corporate partners [UHS headquarters],” said Neet. “They do offer great support, but it takes a two-way street. Because you have to be able to work with them and have an open and honest dialogue.”

From F to A

By putting all of these strategies in place, Southwest dramatically turned around its performance in two short years. It steadily improved its rating with Leapfrog, earning an A grade by the fall of 2018. They attribute their success to building a high-performance team inclusive of leadership and with a skilled workforce. Leadership provided the vision, but the most critical part and that which is supporting the development and growth of Southwest is a competent workforce.

To learn more about competency-based training and workforce development, please contact NAHQ at

– Paul Stefanacci, MD FACS MBA

Vice President, Quality and Chief Medical Officer, Acute Care Division
Universal Health Services

– Ted Donnelly, MHA BSN

Corporate Director, Quality
Universal Health Services

– Brad Neet, MBA RN BSN

Chief Executive Officer
Southwest Healthcare System

-Nikole DeVries, MSN RN CPHQ

Director, Performance Improvement and Patient Engagement
Southwest Healthcare System


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