Company churns out burritos, French toast — and inspiration for health care

This year I am participating in an executive fellowship that is designed to expose leaders in various industries to the Baldrige Framework, a model for organizational excellence. As part of the program, the fellows visit companies that received the coveted Malcolm Baldrige National Quality Award, administered by the U.S. Department of Commerce. Recently, we toured Cargill, a large, Minnesota-based company that has about 75 business units, and spent time with two of them: Cargill Kitchen Solutions, which largely makes egg products for McDonald’s, schools and many other customers; and Cargill Corn Milling, a maker of corn syrup, animal food and ethanol.

We not only talked to leaders and reviewed their strategic plans, but visited the plant. We spoke to employees on the floor, as food was prepared on a massive scale: eggs being cooked by the thousands, breakfast burritos being assembled and placed on conveyor belts, French toast cooked, stacked and placed into boxes.

As we talked to leaders, toured the plant and reviewed their strategic plans, I was struck by three things.

First, everything and everybody was focused on the customer. The customer was at the center of every discussion, every decision and every strategy. From the CEO to the managers to people on the shop floor, they talked about meeting customers’ needs. Usually it was the first thing out of their mouths, and they used the impact on customers as a scale for weighing every decision. Indeed, many staff, from senior leaders to line operators making an hourly wage, said, We know who pays our paycheck; it’s the customer. If we want a paycheck, we better meet their needs.

Reflecting on health care, I recognized how often patients are not included in discussions, not talked about in meetings, and not the focus of the work. I wondered how people in health care would respond if we asked them who pays their check. Most would likely say the hospital executive or an insurance company. Few would say the patient or taxpayers, who fund government health care programs. For those of us who do research, I doubt many would say the U.S. taxpayers cover our salary, so we better deliver value.

Second, the Cargill employees were humble. They openly admitted their shortcomings and relentlessly sought to improve. During a strategic planning presentation several leaders listed processes that “we need to get better at.” Despite winning the Baldrige Award, their leaders commonly said, We are never good enough. Humility is a prerequisite for improvement.

Third, they were accountable for results. Accountability was demonstrated at many levels. Frontline workers, who often handled food such as French toast or omelets, wore gloves and were supposed to sanitize them periodically. Each worker ensured that other workers were compliant. Yet this was not enough. The company also had quality managers who observed performance and routinely swabbed staff members’ gloves to see if they were clean. The quality managers, of which there were many, tasted the food three times a shift to ensure it met the company’s standards. After a breakfast with their senior executives, they served the food they sell.

I wondered what health care would be like if we tasted the food we fed patients, waited in the waiting rooms, slept in the beds. At Cargill, every corporate strategy has measures that cascade down to individual employee goals and behaviors. All employees know and are accountable for how their specific behaviors contribute to the company’s. At the plant, machines reported key statistics for all staff to see: yield (an indication of product wasted), defects, reported observations of unsafe behaviors, and injuries, if any. This data fed into reports that made it to company leaders. 

There was also external accountability. A representative from the USDA was in the plant every day to ensure staff adhered to policies and procedures. Any transgressions are publicly reported. Amazingly, when I asked staff if they resented having an auditor observing them daily, nobody seemed to mind. The staff attitude was, We always need to do what is right for our customers, and the USDA helps ensure we do.

There are some lessons we can apply to health care. First, we can focus more on patients. Our discussions should focus on patients, who should be on hospital committees and improvement teams. Work could be organized around meeting their needs. If we did, hospitals would do away with visiting hours, make food available when patients wanted it, and organize work around what is best patients rather than physicians. For example, patients preparing for surgery would be able to make one visit for all of the needed tests, consultations and procedures. Today, they too often must make multiple visits to fit physicians’ schedules.  

Second, we could be more humble. It is rare for health care organizations to publically admit things they could do better. It is rare for hospital leaders and clinicians to acknowledge the preventable harm patients suffer.  It is rare for a hospital or physician to stop doing procedures they rarely perform. Despite the widespread shortcomings in quality of care and patient satisfactions, whenever I ask clinicians or health care executives to rate the quality of care they provide, they always say excellent. We need to acknowledge that we can continuously improve and always strive to be a little better. Indeed, we have done this for decades. Significant reductions in surgical mortality were achieved over the years because surgeons and anesthesiologists continuously sought to improve. We need to take this same mind set and apply it to the care system and to populations of patients.

Third, we need much greater accountability. People working in health care need cascading goals in which all employees are accountable for their behavior. In many health care organizations, clinicians wash their hands 50 percent of the time or less, despite having soap or alcohol gel readily available. And there are no consequences.  Moreover, poor scores on performance measures and patient satisfaction are reported quarter after quarter, generally without a clear plan for who is accountable, how they will be accountable, and how they will improve.  Many hospital boards and leaders care deeply about patients, yet they seemed resigned to accept poor performance, recognizing that health care is complicated and improvement is difficult. It is, yet improvement is possible. Central line-associated bloodstream infections, which kill nearly as many people as breast cancer, were once deemed inevitable. Now they are seen as almost entirely preventable—in large part because clinicians and leaders held themselves personally accountable for infections.

Mostly what I learned on my visit to Cargill is that excellence is a choice. It is not easy, and it requires a system like the Baldrige Framework, yet it absolutely is possible.

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What health care can learn from corn milling — Points from Pronovost
July 24, 2012 at 12:49 pm

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Peter Neupert July 20, 2012 at 10:51 am

Great post. The health delivery system can learn a lot from other industries on how to deliver value (vs. volume) regarding health outcomes and patient care. More importantly -- it needs to reengineer its systems and workflows around the patient (and family/caregivers). Improvement is absolutely possible -- but it could be accelerated if the incentive and policy framework was more aligned towards value and the role of the consumer in driving/determining value.

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Harry Hertz July 20, 2012 at 4:19 pm

Peter,
Thanks for this great post about your experience at Cargill and with the Baldrige Fellows Program. I would add an additional chracteristic to the humility we see in Baldrige Award reecipients' leaders; they are visionary leaders. They not only know what their customers/patients want today, but they learn and anticipate what will delight them in the future and then implement the changes through improvement and innovation. Thanks for being one of those innovators!

Harry

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Barry Rogstad July 20, 2012 at 6:59 pm

outstanding Dr. Pronovost

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Mark Inge July 24, 2012 at 4:01 pm

I'm reminded of the contrast of my recent experiences at CarMax (good) and the MVA (bad). When the processes work together *for the customer*, the experience is better.

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Joseph Pauley July 26, 2012 at 11:51 am

The American Society for Quality published our book, "Establishing a Culture of Patient Safety", in 2011. We turned the Army hospital at Redstone Arsenal in Alabama from #31 to #1 in MEDCOM in terms of patient safety, patient satisfaction, staff productivity, and staff satisfaction. Patient satisfaction is now more than 95%. We live in Potomac, Maryland and would welcome an opportunity to meet with you to tell you about the concepts of Process Communication and how they deal with the people and communication aspects of quality. We are here from 30 July - 1 August and from 13-24 August. (We will be in Hawaii training the staff at Tripler Army Medical Center the first week in August and in Vienna, Austria.soing training during the end of August and early September. Do you have time to meet with us during the weeks we will be here? Joe Pauley
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Stephanie August 2, 2012 at 1:11 pm

Thank you for such a wonderfully written article. Who would I contact about obtaining reprint permissions?

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Richard Corder August 16, 2012 at 11:34 am

Terrific post Peter!

Thanks for sharing your insights and opinions - the reality is that we have much to learn from others. My experience prior to healthcare and hospitals was in the hotel business - when I took an environmental services role at a hospital and inspected the bathrooms by sitting on the toilets and the bedrooms by lying in the beds, my team looked at me like I was from another planet.

The more we can remember who it is that we work to serve, the better.

I also appreciate your comments on accountability and have found that organizations that have made the choice to be excellent have moved to a culture and a mind-set that fosters a personal willingness to answer for outcomes - not a default to blame. I remind myself of the he old adage of, "if it is to be, it is up to me"

Thanks Peter

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