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By Karen Kiel Rosser, Mary Greeley Medical Center

In 2008, Mary Greeley Medical Center began looking for a system of evidence-based quality principles. Every accountant knows the Generally Accepted Accounting Principles, or GAAP, as the evidence-based best practices for finance. We knew we needed something like that for Quality and Performance Excellence at Mary Greeley. It was during a presentation on the Baldrige program at an ACHE conference in 2008 that we realized we had found what we were looking for.

From the start, we decided our process to document performance improvement would be a long-term priority and not simply an annual goal. Our decade-long journey began not in a single moment, but as a culmination of several. In the over ten years that ensued, this focus on quality has resulted in Mary Greeley Medical Center becoming the first organization in Iowa to receive the prestigious Malcolm Baldrige National Quality Award. It also helped us earn Magnet Designation, the nation’s top recognition of nursing quality. We are one of only 12 hospitals in the country to have both honors.

Here are some of the lessons we’ve learned along this journey.


Early on, we made the decision not to house our Baldrige efforts in a single department, but rather to expose as many departments as possible to the framework and criteria. We enrolled staff as examiners in the Iowa Recognition for Performance Excellence (IRPE) program. Becoming examiners exposed our staff to the criteria as well as gave them firsthand experience to other organizations striving to radically improve.

Learning from other Baldrige organizations as well as using the IHI’s improvement philosophy, we developed what we call our Big Dot goals. There are four of them: reducing patient harm; improving patient experience; improving workforce engagement; and achieving a positive operating margin. These goals are on wallet-size cards on which employees can describe how they contribute to these goals. Each goal has a measurement that is tracked both organization-wide and in individual departments.

We track our progress on our Big Dot Goals on huddle boards displayed in every department across the hospital. Daily huddles are routinely held near these boards during which we stress operations issues, process improvement, and current performance. Using the vernacular of 4DX, a formula for executing on important strategic goals laid out in the book, “The 4 Disciplines of Execution,” departments create lead measures that align with the Big Dot Goals so each staff member understands how their individual work contributes to the organization’s goals.


Our improvement philosophy is that everyone at Mary Greeley has two roles: Do Our Work and Improve Our Work. To support this, we encourage staff to present improvement ideas through an online system. Additionally, we challenge our leaders to think of innovative ways to reduce costs or generate revenue through the 100-day workout concept.

We created a quality improvement unit which, among other things, oversees rapid improvement projects designed to literally break down our processes, develops ideas to improve them, and then executes these ideas. Each of these projects involves cross-sections of staff, which further hardwires a culture of improvement throughout the organization.


We get feedback from our customers in a variety of ways, including hourly rounding, patient surveys, a patient and family advisory council, social media, letters, unsolicited phone calls, and through informal interactions with patients and families. We collect and track these comments through a customer listening system and complaint management process, which enables us to address problems in an efficient and timely manner. It also enables us to monitor trends that indicate larger opportunities for improvement.


During our IRPE journey, we received Gold-level recognition in 2014 and 2017. We remain the only Iowa organization to reach this top level twice. We have continued to submit our application to the IRPE program even when we are not award-eligible because we receive valuable feedback that helps us remain focused on the process. We also continue to recruit staff to be IRPE examiners. To date we have over 80 years of combined examiner experience!

While we take pride in the honors received for our quality, the real impact of our efforts can be seen in the measurable quality of our care and the opinions of our patients and employees.

Our key measurements are in the Centers for Medicare and Medicaid Services (CMS) top decile, including 30-day readmissions, 30-day mortality, incidence of preventable blood clots, and compliance with sepsis practices, influenza vaccinations, stroke bundle, and outpatient imaging measures.

Inpatient satisfaction, as measured by HCAHPS, has been at or above top-decile performance since 2016. More than 75 percent of inpatients and outpatients would recommend Mary Greeley to others, representing top-decile or near-top-decile levels.

Close to the National Research Corporation top decile, 75 percent of employees “talk up” the organization as a great place to work. Meanwhile, physician engagement ranks in the 82nd percentile.

Our ten-year journey has had a significant impact on our patients and families and staff, and it does not end. The Baldrige framework has become the standard practice for how we do our work – and improve our work. It has allowed us to document, standardize, and improve some of the most complex and seemingly impossible-to-document processes in our healthcare system. Most importantly, it has enabled us to provide continually improving care to our patients.


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