20 People Who Make Healthcare Better - 2009

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Spreading the Message of Selflessness
"It seemed to us that the way to tackle this was to do things that nobody else was doing."—Reg Green

"We were in Italy driving along what appeared to be a perfectly normal road when a car came alongside us and a loud angry sound came through the night of people telling us to pull over," says Reg Green, telling his story as he has countless times before. "We couldn't understand a word, but it was pretty clear what they wanted to us to do. It seemed to me that if we did stop we'd be completely at their mercy, so I accelerated. They accelerated too and the two cars roared alongside each other for a little while. Then the shots rang out."

Green, his wife, son, and daughter were on a family vacation in southern Italy in September 1994 when they were attacked by highway bandits, mistaking the family's rental car for one carrying jewelry from Rome. When the thieves finally gave up their chase, Maggie, Reg's wife, looked into the back seat to ensure their young children were sleeping peacefully. Assured that they were still resting, Green continued to drive until they came across an ambulance and told officials about their ordeal. But after checking on the children once more, the parents realized that 7-year-old Nicholas had been shot in the head.

Nicholas slipped into a coma and never regained consciousness. After two days, doctors declared him brain dead.

"It was then that Maggie said, now that he's gone shouldn't we donate the organs," Green says. "And I said yes. It was as simple as that. It was just so clear to us at that moment that he didn't need that body anymore, but there was some sense that somewhere out there—you couldn't visualize who they were—but that somebody could benefit from this."

The story sparked a media frenzy in Italy, resulting in the Greens meeting with the seven patients who received Nicholas' organs—something that Italian rules normally forbid. Nicholas' organs and tissue went to two young parents who were going blind, a diabetic who suffered from comas, a bed-ridden 15-year-old heart patient, two children who had been on dialysis their whole lives, and a 19-year-old woman dying from liver failure that very night.

Since Nicholas' death, organ donation rates in Italy have quadrupled.

"It captured the whole emotion of the country and it changed the thinking of an entire nation," says Green. "The fact that in Italy the increase [in organ donors] has been so dramatically higher than anywhere else is a pretty clear indication that there has been a special factor involved, and the only special factor that I know about is Nicholas."

Nearly immediately after returning home to California, Reg and Maggie established the Nicholas Green Foundation to continue building awareness and acceptance of organ donation. (Exclusive audio interview with Reg Green.)

"I realized right from the beginning that if we did what everybody else was doing we couldn't add to anything that was already being done by the large organizations," he says. "It seemed to us that the way to tackle this was to do things that nobody else was doing."

So Green set about writing articles, producing educational videos, and going on speaking engagements. "Nicholas' Gift," a 1998 made-for-TV movie starring Jaime Lee Curtis, boosted awareness of Nicholas' story four years after his death and is estimated to have been seen by about 100 million viewers. Green has also penned two books: The Gift that Heals and The Nicholas Effect, the latter of which has sold 40,000 copies and was re-released this year to mark the 15th anniversary of Nicholas' death.

Every penny that any of these products makes goes directly to the foundation to increase organ donation efforts. Though he is now retired from the workforce, Green continues to run the foundation, an admittedly modest enterprise.

"We don't have secretaries and we don't have offices—my office is in my bedroom," he says. "There's nothing very lordly about the thing. It just seemed a way in which we could focus on the things that could be done."

He also doesn't think his and Maggie's decision to donate Nicholas' organs should receive the accolades that it has. For them it wasn't a choice, but merely the right thing to do.

"Our story is very much like everybody else's story, except in a few details," he says. "The fact that it was a murder, the fact that it was a foreign country, the fact that he was a small boy—all of those things heightened the sense of it, but the rest of it is exactly the same as everybody else."

The Green family regularly returns to Italy, where nearly everyone knows their story. This year Green's daughter, Eleanor, who was a toddler when Nicholas was killed, went on her first solo speaking tour there.

Green says he especially enjoys speaking to schoolchildren about Nicholas, even though they can't fully grasp the moral and medical concepts.

"They don't understand about transplantation and what it means," he says. "But they know a little boy did something very good and they want to be very good too, and somehow the message gets across that he was selfless."

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Marianne Aiello is an associate editor for HealthLeaders Media. She may be contacted at maiello@healthleadersmedia.com.

Time to blow up the tried and untrue
"With the way American healthcare has grown up with a lot of workarounds and a lot of misaligned incentives, we have all this waste that we need a thoughtful approach to get rid of."—Patricia A. Gabow, MD

There is no single model for the ideal hospital CEO. Every market, every physician culture and even the mood for community cooperation is different. But if ever those pieces of leadership aligned just right, it may well be in Denver Health Chief Executive Officer Patricia A. Gabow, MD.

True, Denver Health has assembled an outstanding team of senior leadership, which was why HealthLeaders Media has honored Denver Health with the 2009 Top Leadership Team in Healthcare honor for large hospitals and health systems. Every successful team has a team leader, and Gabow provides vision, passion, and just the right push.

Part of her unique fit to Denver Health is that she has spent virtually her entire career there as a nephrologist, rising to the CEO role in 1992. In the next five years, Gabow led the detachment of Denver Health from its ownership by the city to become an independent, not-for-profit authority. The decoupling has been a mechanical key to Denver Health's success as a safety-net health system, but only when added to a culture that Gabow put in place.

First among her tools is a commitment to process improvement built around Lean tools. Without it, she says Denver Health would not be able to support a patient population that is 46% uninsured.

"With the way American healthcare has grown up with a lot of workarounds and a lot of misaligned incentives, we have all this waste that we need a thoughtful approach to get rid of. We are really learning to have a disciplined process to improve the processes of care for quality and efficiency," she says. "And even though we have been at it for five years we feel like we are in kindergarten." The goal of Denver Health's Lean approach is not merely to cut, she says, but to use a disciplined system that gets at parts of the system that add no value.

What gets Denver Health held up as a model for a safety-net health system is its degree of integration, with everything from the 477-bed hospital, a health plan, a network of school and community clinics, a regional trauma center and even the poison control network under the Denver Health umbrella. The board and community set the vision, but communities that would wish to replicate the model would need a change-minded CEO to focus that widespread an enterprise.

Gabow has not been content just to keep her lessons in Denver. A member of several national leadership forums, she has not been shy about sharing her opinions on the direction of the current healthcare reform debate as it relates to safety-net hospitals.

"Getting more people covered is good but what still bothers me is that cost hasn't really been addressed," she recently said during a panel discussion at the HealthLeaders Media '09 conference. "The delivery model hasn't been addressed. We think it is only in integrated models that you have seamless care for the patient with high quality and low cost, and yet that is left out of much of the discussion."

Her opinions are a mirror into what motivates her: a true desire to focus only on changing the pieces of healthcare that are the most impactful.

"I have been in this business for four decades. I was starting to get very frustrated by the fact that what I saw was that we were doing the same things as when I was an intern 40 years ago. We have new drugs, new technology, but the core processes that we were engaged in were just about the same as 40 years ago and you say to yourself, this can't be right. A few years ago I said I want to blow this up and start again."

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Jim Molpus is strategic relationships director for HealthLeaders Media. He may be contacted at jmolpus@healthleadersmedia.com.

Creating a Culture of Healing, One by One
"For people who have a choice, the new stuff won't make a difference. What will make a difference is the patient experience."—Laurie Eberst

Laurie Eberst is not your typical hospital president and CEO. Sure, she has her MBA, and she has to deal with all the headaches of staffing, budgeting, capital decision-making, and morale that all CEOs deal with, but her focus on employee attitude and its effect on patient care is what sets her apart. (Exclusive audio interview with Laurie Eberst.)

So it's not a surprise that Mercy Gilbert (AZ) Medical Center, a three-year-old, 206-staffed-bed Catholic Healthcare West hospital near Phoenix, is a little unusual too.

Before the hospital itself was built, even before the hospital had any employees besides herself, Eberst, a registered nurse by training, wanted to make sure it was a positive place focused on healing.

Mercy Gilbert, which was named No. 1 in the 2008 Baptist Healing Trust Top 10 Healing Hospitals list, is that and more. But it's not just because Eberst has a kind heart. The decision to focus on employee satisfaction and its simultaneous effect on patient satisfaction was made with business principles in mind, she says.

"While we're new, just 12 miles away is another new hospital. For people who have a choice, the new stuff won't make a difference. What will make a difference is the patient experience."

Eberst set out to create a culture of healing within the hospital based at least partially on personal experience because of her mother's experience being hospitalized in California during the construction phase of Mercy Gilbert.

"When she was going through all of that, she couldn't get any rest because it was so noisy," Eberst says. "She got kind of depressed and all she wanted to do was go home. That makes healing incredibly more difficult for patients."

In hiring her leadership team, Eberst was careful to interview candidates not only on their experience and skills, but also to evaluate their approach to quality patient care.

"Culture starts from the top, so leadership needs to be committed to it," she says. "I handpicked everyone who is here who has that philosophy. They hired people on their teams in the same way, so as you cascade that down, everyone is very committed."

By Eberst's reasoning, of equal importance to a caregiver's skill set is determining "whether they're in for a paycheck or whether they just love their jobs. We have turned down highly qualified nurses who have the technical skills that anyone would want."

A positive attitude and optimism are prerequisites, she says, to creating a culture where not only do patients experience an environment more conducive to healing, but also where other employees feed off the positive energy. That cuts turnover and increases employee satisfaction. New hires, regardless of rank, spend a full day on culture indoctrination before they begin work at Mercy Gilbert. Eberst says she's clear that the focus on positivity as a key employee trait is "not a program of emphasis that will change next year. This is truly our foundation," she says.

"We look for what we call eye contact service and discuss cynical behavior vs. skeptical behavior. Being skeptical is healthy, but cynical is unacceptable. You can feel that negative energy and they suck energy from everyone around them. Cynical behavior is not something that changes."

Before caregivers—or anyone else employed by the hospital—has an encounter with a patient or family, they take a moment to reflect on what they're going to do with that person. There's a small pad in front of every patient's room, and every office in the building. "We ask that before entering, employees touch that pad and reflect on their purpose for being there," Eberst says. "Then we go in to do our healing. That has a huge impact on reminding staff and physicians that the patients are why they are here."

Something about the philosophy obviously works. Eberst says Mercy Gilbert is running five years ahead of CHW projections on patient census and revenue targets.

"We're not exceeding those targets because of growth—we've shifted some of the population to come to our hospital vs. competitors. Our quality indicators are very high and we set the threshold very high. I've given lots of tours. Even Cleveland Clinic has come to see what we're doing."

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Philip Betbeze is senior leadership editor for HealthLeaders Media. He may be contacted at pbetbeze@healthleadersmedia.com.

Impassioned Advocate for Nursing Excellence
"We're not just nice, sweet, compassionate girls who hold your hand. We are highly educated, quality improvement experts who use evidence-based practice to produce the best care possible,"—Barbara "BJ" Hannon.

Barbara "BJ" Hannon, MSN, RN, CPHQ, likes to laughingly point out that rural, corn-growing Iowa doesn't have the beach or the mountains or those sorts of high-profile attractions that entice nurses to practice in other states. But one thing the University of Iowa Hospitals and Clinics in Iowa City does have is a rich ANCC Magnet Recognition Program® (MRP) culture. It's this culture of nursing excellence—powered by the force of nature that is Hannon—that draws nurses and keeps them there. And Hannon is on a mission to help every nurse she encounters enjoy this benefit, too.

"One of the reasons that I will go anywhere and talk to anyone about MRP, is that I really want every hospital on the face of this earth to get designated," she says.

The whole ethos behind MRP "is making the environment of nursing better," Hannon continues. "Designation requires that hospitals have participatory scheduling, no mandatory overtime, that they involve nurses in shared governance, that they help nurses use evidence in their practice. All the things that MRP requires make life better for nurses in the hospitals. And because I've been a nurse for 34 years, I know the way it used to be; and it used to be a very authoritarian environment where nurses could not be creative or innovative." (Exclusive audio interview with Barbara "BJ" Hannon.)

Nursing excellence champion
Hannon has a background in emergency department nursing and was working as a nurse researcher when her hospital—a large academic medical center with around 2,500 nurses, which includes some 2,000 registered nurses—decided to apply for MRP designation. Hannon was appointed project coordinator, and seven years later, has successfully steered the organization through initial designation in 2004 and re-designation in 2008.

To describe the difference between the hospital pre-MRP designation and post, Hannon shares a story about when the orthopedic surgeons at her hospital were designated third best in the nation and the organization celebrated by blanketing the place in posters saying, 'congratulations orthopedic surgeons.' But nowhere was there any mention of the nurses.

"And I remember thinking, one of the reasons these orthopedic surgeons are so great is because of the nursing staff," says Hannon. "Nurses do the joint program, the teaching, get the outcomes, ensure no surgical site infections, no DVTs, and there was not one mention of the nurses. And that was huge for me."

Following the hospital's first designation as an MRP recipient, the situation was quite different: Nursing is now represented on every single task force; physicians, nurses, and other interdisciplinary team members focus on collaboration; and the hospital built a display cabinet in a prime location that Hannon ensures stays up to date with recognizing the accomplishments of the organization's many nurses.

Hannon has not only transformed her own hospital's nursing environment; she's working on everyone else's too. She dedicates large portions of her own time to traveling around Iowa and beyond to talk about ways to improve the nursing environment through such means as engaging nurses in evidence-based practice or improving multigenerational communication. She also acts as an unofficial MRP consultant, which is the only part of her speaking engagements she charges for. All her speaking fees for MRP talks go directly to her MRP budget, which she spends solely on her staff nurses. Her speaking engagements have allowed her to do fun things such as little celebrations to recognize specific nurses, or big things such as taking 18 staff nurses to last year's annual MRP conference in Salt Lake City.

Hannon's evangelism for MRP designation lies in the fact she sees it as a useful tool for bringing attention to nursing, promoting nursing excellence, and improving quality of care.

"What MRP means to me is getting rid of the invisibility of nurses and putting nurses where they belong, which is out there at the forefront," says Hannon. "I believe the MRP has the power to elevate the image of nursing and respect for it. We're not just nice, sweet, compassionate girls who hold your hand. We are highly educated, quality improvement experts who use evidence-based practice to produce the best care possible."

Promoting staff nurse power
Within her own organization, Hannon sees her role as MRP coordinator as focusing on excellence in nursing in every aspect, whether it's working on performance improvement initiatives, tracking nurse-sensitive quality indicators, or improving nurse satisfaction.

She recently found a way to help more bedside caregivers be part of the Professional Practice Council by turning the meeting into an interactive Web site. Hannon notes that bedside nurses find it hard to get away from their patients to attend council meetings, so now she holds the discussions electronically. She will blog about a particular topic and nurses are able to add their responses electronically, with 24/7 access, allowing far greater participation than at a conventional meeting.

The tool has proven so successful that Hannon was asked to share her methods at the recent ANCC MRP national conference so that other organizations could learn from her best practices.

Hannon is focusing her attention now on additional ways technology can increase staff nurse participation in shared governance in the future, such as plans to use webcams and stream meetings live online.

No matter where she turns her attention in the future, Hannon considers it her mission to inspire improvement in the profession she loves so deeply. She will continue sharing her relentless energy to encourage others around the country to make the commitment to creating the best nursing environment they can, whether or not it leads to MRP designation.

"I just love nurses," says Hannon. "I would rather spend my time with nurses than anyone else. And I really want to talk to those nurses who are going to give it up because they are burned out. Find me and I'll talk to you."

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*MAGNET™, MAGNET RECOGNITION PROGRAM®, and ANCC MAGNET RECOGNITION® are trademarks of the American Nurses Credentialing Center (ANCC). The products and services of HCPro, Inc. and The Greeley Company are neither sponsored nor endorsed by the ANCC. The acronym "MRP" is not a trademark of HCPro or its parent company.

Rebecca Hendren is editor of the HealthLeaders Media e-newsletter, Nurse Leaders Weekly. She may be contacted at rhendren@hcpro.com.

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