When Appalachian Regional Healthcare System's employee engagement scores hit "basement" levels in 2014, the health system implemented a five-step process that boosted employee engagement scores from the 19th to 86th percentile in just 10 months—and improved its Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores and budget surplus along the way, Jennifer Thew reports for HealthLeaders Media.

Just updated: Learn how CMS HCAHPS—and 4 other ratings programs—actually work

The problem

In 2014, Appalachian Regional's staff engagement scores "were in the basement," hovering around the 19th percentile on the Bivarus employee engagement survey, Thew reports. At the same time, Amy Crabbe, SVP of people services at Appalachian Regional, said some of the health system's HCAHPS scores "had hit rock bottom," and a nurse at the health system called the Joint Commission to voice complaints about the health system's EHR negatively affecting nursing workflows.

Get 10 data-driven insights to optimize your employee engagement strategy

Then, Appalachian Regional received a "C" rating from the Leapfrog Group. Kim Bianca, Appalachian Regional's SVP of hospitals and acute services, said the score was a shock to the health system. "We just went, 'Holy cow! How can this be, that we're a C?'"

The 5-step solution

In response, Appalachian Regional developed and implemented a five-step process to increase employee engagement, bolster service, and improve its quality outcomes.

1. Re-envision the leadership team

First, Appalachian Regional took "a hard look at the system's leadership team," Thew writes, shifting some leaders "into new positions, both within the organization and outside of it, that better matched their skills and strengths."  

According to Crabbe, the nurse's complaint to the Joint Commission indicated these leadership changes were necessary, because the complaint showed that nurses didn't feel like their concerns would be acted upon by leaders within the health system.

"Our nurses were feeling like they didn't have a voice," Crabbe said—but "(getting) the right people in the right leadership positions was … the impetus to some significant changes." Ultimately, according to Crabbe, the system prioritized two main qualities when re-shaping its leadership team: The ability to focus on data-driven and strategic outcomes, and an adeptness for change management.

2. Increase leaders' visibility with employees

Appalachian Regional next decided to adopt a practice called employee rounding that increased leadership visibility by putting leaders in direct communication with their front line workers.

As Bianca put it, "The very first thing that I started immediately … was being as visible as I could possibly be." She explained, "I was rounding, rounding, rounding, rounding. I was in every nook and cranny of every unit—in the nighttime, the daytime, on the weekend, on the holidays. I think I pretty much lived here, probably for about a year, honestly. I wanted them to see that I cared about them … that we care, not just myself, but our leadership."

According to Thew, leaders to this day continue employee rounding, and, each month, employees have at least one face-to-face meeting with their supervisors. That meeting includes a standardized set of questions aimed at "get[ing] at the heart of what's getting in the way of the employee doing meaningful, value-based work, and being recognized for it," Crabbe said.

Get the national prescription for nurse engagement

3. Improve communication

To make communication more transparent, Appalachian Regional standardized how each department's communication board articulated the organization's overall vision, and carried that articulation through the employee rounding process as well.

In addition, the health system's CEO started hosting quarterly town hall meetings that have shifted over time from more scripted events to "uncensored back-and-forth dialogue," Thew writes. "When we first had town halls, we would ask people to send their questions in advance, and we would answer them in a scripted way," said Crabbe. "Now we're just to the point where we just open up the floor and ask, 'What's on your mind? What do we need to do?'"

4. Give recognition

Appalachian Regional also demonstrated gratitude toward the system's employees for their efforts to improve the system's care outcomes, Thew reports.

Within the first year of the system's changes, Appalachian Regional ended up with a $2 million budget surplus, stemming from a 2% increase over budget in the operating margin. To thank employees, Crabbe said the CEO immediately decided that the money needed to go back to them. "It was a great day for [the] … whole leadership team. We stood in our auditorium, and by surprise, we handed out $500 checks to every single employee," said Crabbe.

Bianca also said because of her rounding, she's able to know which employees are involved in patient care and sends them handwritten thank-you notes. "People really do appreciate it, and they really feel very special when they get one of those notes at their house," Bianca said.

5. Measure results

With all of those changes in place, the health system made it a priority to track its results, and according to Thew, the changes have spurred measurable improvements. In addition to increasing the budget surplus and boosting employee engagement from the 19th percentile to the 86th percentile, the health system:

• Boosted care quality from below the 50th percentile in four of eight HCAHPS measures up to the 75th percentile in 18 months; and
• Scored HCAHPS rankings in the 75th percentile for six of 10 patient experience domains.

Bianca said of the results are directly linked to improved employee engagement. "Our thought was that when we have engaged employees, everything else doesn't just automatically fall into place," Bianca said, "but it obviously lays an infrastructure for the patient experience and for quality" (Thew, HealthLeaders Media, 4/1).

Just updated: Learn how CMS HCAHPS—and 4 other ratings programs—actually work

Download our one page sheets for summaries on the methodology and metric categories used in five hospital quality rating programs:

• CMS HCAHPS Patient Experience Star Rating
• Healthgrades Patient Safety Ratings and Excellence Awards
• Healthgrades Outstanding Patient Experience Awards
• Leapfrog Group Hospital Safety Grade
• US News and World Report Best Hospital Rankings

Get all the Cheat Sheets