"The Calling:" St. Vincent Hospice

Robert W. Hall

9Third Issue 2004

In BriefSt. Vincent Hospice illustrates lessons relevant to the behavioralside of process excellence. Rather than by rigorous implementationof improvement techniques, quality performance comes from theintense dedication of staff and volunteers to their core mission.They cultivate work culture capabilities that would not ordinarilyoccur to a manufacturing company.

As far removed from manufacturingas anything can be, St. VincentHospice in Indianapolis is a study

of excellence in working culture. A typicalword of mouth recommendation is, "If youneed a hospice, they're the best." Its med-ical procedures are well done, but not tech-nically novel; its improvement techniquesare not benchmarks.

But St. Vincent's has something worthstudying, a working culture based onrespect for all people. "Respect for People"is one of the twin "pillars" of the ToyotaWay, right up there with "ContinuousImprovement," and as everyone discovers,eliminating waste by engineering the tech-niques hits a limit without addressing howwe have to change.1 This "lesson" is howSt. Vincent's working culture makes its per-formance "a cut above."

Much of the public has never heard ofhospice care. If they have, their knowledgeis usually foggy. Because hospice care dif-fers in intent from curative care, it alsobefuddles many medical professionals.Clarifying misconceptions is a part of dailyoperations within St. Vincent, and explain-ing it over and over when people are emo-tional tries the patience. Compared withthe St. Vincent staff, Job had attentiondeficit disorder.

A hospice is not a hospital. Hospitals

are for acute care curative medicine. Ahospice serves the terminally ill and theirfamilies in the last six months of life, afterno further measures to restore health areexpected to succeed. Most patients arepast the prime of life, but not all. St.Vincent has a hospice for children too.They don't convert raw material into prod-uct; they convert raw emotion into some-thing peaceful.

Why Hospice Care is Growing

Retirement plans, including retireehealth care expenses, have become a hand-icap to U.S. global competitiveness. Oldcompanies whose retirees outnumber cur-rent employees are especially hard hit.

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GM's future liability to retirees now exceeds$60 billion, their heaviest financial burden.Comparably high retirement loads helpedsink several old steel companies into bank-ruptcy, and end-of-life care is a big share ofthat expense.2

From 1900-2000, life expectancy inNorth America and other developedeconomies increased by about 30 years.Toward the end of our extended lives, manyof us will acquire ailments that few of ourforebears lived long enough to contract.Infections of various kinds took thembefore the onset of Alzheimer's or othersenile infirmities that may not be the finalcause of death. And during extended dis-ability, our family caregivers are likely to befully employed or geographically remote.Extended care facilities — nursing homes —have become big business. (See Figure 1.)

During the past century, medicinebecame ever more technological.Expensive too. With an ever-bigger arsenalof techniques to try, physicians don't giveup on a patient until they have exhaustedtheir stock of miracles. Consequently,nearly 80 percent of deaths in the UnitedStates occur in hospitals or nursing homes,where dying is seen more as a clinicalevent than a human passage.

However, once the game is up, mostterminal patients prefer to pass away athome, or at least somewhere away frommedical tumult. A hundred years ago, themajority of people died at home. Littlecould be done for them except see to rou-tine needs, usually by family, friends, andchurch. People didn't much like to talkabout it then; still don't, so dying remainsshrouded in mystery. As a total process, it'sa transition for family and friends as well asthe decedent, occurring in stages, oftenaccompanied by all kinds of issues: legal,financial, cultural, and spiritual.

Hospice is a way of shepherding peo-ple through this dying process. It is not aplace of custodial care. Hospice neither has-tens nor prolongs the dying process.Strangely, in so doing it affirms life. Theway a modern hospice works is unlike anyother organization.

A patient is eligible for hospice carewhen their attending physician attests thatcurative treatment is no longer expected tobe effective, and that if the condition takesits normal course, they will live no morethan another six months. Because the sci-ence of such judgments is inexact, somepatients live longer than six months. Inrare cases, one restores to health andleaves hospice to go on about life. In 2003,the average St. Vincent patient enteredhospice care 36 days before death. Sometransfer in only a few days or hours beforedeath, usually because of misconceptionsabout hospice, which the staff regrets.They had too little time to give them thesupport they deserved.

Medicare and insurance companiesfavor hospice care too. Nationally, medicalexpenses in the last year of life average$40,000, with wide variance of course.End-of-life costs consume about 25 percentof all Medicare spending.3 Medical expens-es are lower if a patient's final landing is inhospice. Hospitals concentrate on acutecare — very expensive. Nursing homes areless expensive. Least expensive: coachinghospice caregivers at home. About 80 per-cent of hospice patients are 65 or older.Like "leaning out" operations, it's a betteroutcome at lower cost.

The Dying Process

The dying process is unique to eachindividual. No date or time of death can beexactly predicted. Toward the end, thebody prepares to shut down physically, ter-minating when all physical systems haveceased to function. Most people die in anorderly progression of steps, which isnature's course, and no reason for medicalintervention. However, this progressionalso exhibits much variance. Some personsprogress through all stages very quickly;others very slowly; and some skip a phaseor two altogether.

An emotional or "spiritual" releaseprocess accompanies the physical shut-down, and these two affect each other. The"spirit" of a person prepares to depart its

11Third Issue 2004

body, its environment, and all attachments.That person may need to resolve unfinishedfinancial business, reconcile close personalrelationships, or receive permission fromfamily or others to "let go." If importantissues are unresolved, he or she will linger— delay shutdown — until they are. Forexample, a person may hang on for daysuntil someone close to them travels from adistance to say a final good bye.

The hospice staff coaches family andfriends to anticipate these stages beforethey occur. For example, during physical

shutdown, changes in metabolism and anoxygen-deprived brain may make peopleconfused. If they speak they may not makesense. However, talk to them, tell themwho's in the room, coming or going. Evenif a comatose person appears totally insen-sate, their sense of hearing is the last to go.Experience at St. Vincent is that both thephysical stages and the mental ones (seebox on next page) are general guidelines,not absolute. Patients and families arecoached as conditions change.

Figure 1.

Graying Populations

In all advanced economies, graying of the population is obvious not only from statistics, but direct observation. End-of-life healthcare is a social problem everywhere. In advanced economies it's an expensive one because the average person has access totechnology for treating extended end-of-life infirmities, thus racking up a high percentage of lifetime health expense. Those thathave exhausted curative options receive better palliative care at lower expense in a hospice. The graph below suggests why mod-ern hospice care is growing rapidly.

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Pain and Palliative Care

Palliative care, which includes painmanagement, is St. Vincent's medical spe-cialty. Terminally ill patients usually expe-rience chronic pain. A drawn countenanceindicates pain, but tolerance for it variesgreatly, with mental and emotional stateplaying a role. For example, unanticipatedpain, as from an accident, is felt moresharply than after a person becomes inuredto it. If a victim is in shock, pain willincrease as it wears off. The state-of-the-art assessing chronic pain has advanced nofurther than "Pain is what the patient says itis." St. Vincent uses the standard one to tenscale asking patients to rate pain.

The objective of palliative care is toallow each patient to live to the fullest aslong as they can. The staff finds painkillerregimens to make them comfortable, andmay use higher doses of morphine. (Nopoint worrying about long-term effects, andcontrary to popular belief, addiction to any-thing properly used to relieve pain is rare.)But patients aren't "zonked;" they preferthem to be as active as possible. Some haveprojects that they are determined to finish.St. Vincent wants to help patients safely doanything that is important to them.

Alleviation of long-term, intense painis not in the standard repertoire of physi-cians practicing curative medicine. Forthem, pain relief is a temporary fix for atemporary condition. Persistent pain iscause for further examination, and perhapsfurther treatment. Curative physicians arereluctant to prescribe palliatives in highdosages or in combinations, fearing that

overdoses or drug dependence mightrequire ancillary treatment — and unwant-ed reviews by third party providers. But atSt. Vincent, pain management, positioningof people, and other details add up to mak-ing the patient as comfortable as anyone intheir plight can be. That's the medical sideof palliative care.

However, palliative care also dependson patient environment. Home is almostalways the best one if care can be managedthere. Patients prefer to see children, pets,and familiar sights, and to have access toactivities they like — anything but the steriledécor and procedural bustle of the averagemedical facility. If they can't stay at home,patients prefer a place that feels like it. StVincent's in-patient unit tries to feel like it.

How St. Vincent Hospice Works

Structurally, St. Vincent's organizationresembles other health organizations; mul-tidisciplinary teams and a quality improve-ment (QI) process are almost expectedthese days. Technically, it delivers care, justas other organizations deliver products.What sets it apart is that St. VincentHospice also cares for relationships.

Neither company nor agency, St.Vincent Hospice is a community united by acommon mission. Words like cost, sales,marketing, or even efficiency aren't in theworking vocabulary. Instead, within St.Vincent "we" refers to the core of theircommunity, "our network" those they cancall on, and "the calling" to the nature oftheir work.

Figure 2 briefly outlines the operations.In action these are rigorous procedures con-stantly subject to unexpected events, withwhich people cope through the give andtake of multidisciplinary teamwork.

Typical of the way St. Vincent actuallyfunctions is the scheduling of work, doneby a committee of three. Each member isexperienced in several areas and knows thestaff. They meet whenever members' otherwork responsibilities permit — about onceevery three weeks. They schedule to aneight-week horizon, each time adding twoor three tentative weeks. People occasion-

Elizabeth Kubler-Ross' Five Stages of Dying

• Denial and isolation. (Not me.)• Anger (Why me?)• Bargaining (Yes, me… but)• Depression (Yes me.)• Acceptance

Elizabeth Kubler-Ross, probably the best-known student of the dyingprocess, postulated these five emotional stages. Her work in the 1960sstimulated serious study of the dying process, but both her "stage theo-ry" and her studies have been widely criticized since.

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In-Patient: 25-bed capacity; average occupancy varies from 18-23.Keep two beds open at all times for emergency admissions.Two nurses stations; two nurses per shift. Average patient/nurse ratio: 5/1Staffed 24/7/365 with 35 full-time equivalent personnel.

Patients transfer from home when care can no longer be met there — or for short stays when the homecaregiver needs a respite.

Home-Care: Average 100 patients in home care; personnel drive to see the patient. About 80 percent of home care patients are actually at home; the other 20 percent are in extended care facilities, usually nursing homes. Home care is 24/7/365.

Staff: Two teams split coverage of the Indianapolis Metropolitan Area. A team: five RNs; two social workers; one chaplain. Average patient/nurse ratio: 10/1 (A ratio beyond 11/1 exceeds capacity.)Each RN is "on call" one night a week — may not get much sleep. Two backup RNs are on call weekends; fill in for a regular RN as needed.

An RN, social worker, and chaplain do initial assessment of each patient as the team assigned to that case. Visits thereafter: RN weekly; social worker and chaplain monthly. But all go as often as needed. Patient needs vary and may change rapidly.

Most home care personnel attend a weekly interdisciplinary team meeting. All cases are discussed biweekly; actions planned.

Bereavement: Most of this is with families, consisting of two kinds of activity:

1. "Soft touch" interaction.2. Regular procedures which can be documented:

• Bereavement newsletters• Scheduled support group sessions• Regular monthly phone checks with families for 13 months after the death; extends 24 months after a

child's death.• Training classes for bereavement volunteers.

About 1000 families are "somewhere" in this process at all times. Less than 20 percent of them require 80 percent of the attention.

Pediatric: A special unit, but similarly operated. Children require different attention, medically and psychologically. Five to seven children are in hospice at all times. In-patient care is at a nearby children's hospital.

Physician: Dr. Marian McNamara is the medical director, with a back up in her absence. Some patients transfer from their primary care physician to Dr. McNamara; some don't. Dr. McNamara works with attending physicians, for whom hospice is sometimes a learning experience.

Social Work: Social workers handle non-medical personal issues, everything from insurance and Medicare payments to home maintenance. Families on limited incomes, unfamiliar with "the system" and under stress, consume much of their attention. Elderly caregivers for the dying may not be in good health themselves, and thus need assistance.

Overview of Organization and Operations: St. Vincent Hospice

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ally want adjustments, but once a scheduleis firm, everyone is expected to meet it.Anyone that can't negotiates a swap with awilling colleague. The schedulers don'thear about this; teamwork gets it done.

The RF Andon Paging System: St.Vincent is fast answering in-patient calllights. One sampling recorded phenomenalswiftness; response time for five calls aver-aged 40 seconds — none over a minute. Inhospitals, families must frequently go find anurse.

Technically, St. Vincent's call pagingsystem is the same as at many other healthoperations. Opening a secured door orpressing a call button activates both a lightover the patient's door and an RF transmit-ter. Pagers on nurses' belts either ring orvibrate. Looking down, nurses see theroom number and its urgency code. Thesystem re-broadcasts the RF page at three-minute intervals until someone deactivatesit in the patient's room. Presumably this isa poke-yoke system. Pages can't beignored.

But they are. Nurses can turn a pager

off, and do if it breaks concentration on atask with another patient. Afterward, theymay not remember either the page or thatthe pager is off. And older systems, still inuse, only activate lights. Harried nursesmay not look at lights for half an hour at atime while who-knows-what is happeningto patients. At many hospitals, not answer-ing pages is the most frequent patient andfamily complaint.

What's different about St. Vincent'scall response? The system is simple, unitsare rarely understaffed, and many peoplecarry pagers. Anyone not locked into a taskheads for that room. In addition one of St.Vincent's many volunteers is apt to be onthe floor and can watch for things likeunanswered lights. No one at St. Vincentcan explain how the system technicallyworks. They concentrate on patients andfamilies.4

Most hospitals assign only a nurse andan aide to each room, the page goes only tothem, and they cover more rooms than atSt. Vincent. Overtaxed nurses constantlyinterrupted by patients' minor whines easily

Chaplains: The ethos of St. Vincent chaplains is more "be with" than "do for," but sometimes they see to neglected chores like mowing the lawn. Chaplains don't evangelize. Families may adhere to any kind of religion — or none. About 40 percent have no religious affiliation, so chaplains often perform their funeral service. Chaplains are most needed when a family has severe rifts among them to patch over as the patient is dying.

Volunteers: All 250 are unpaid. The volunteer office "hires," trains, coordinates, and monitors all volunteers — and schedules many of them. All new volunteers must finish eight weeks of training, one day a week, before taking any assignment. No retired professionals, like RNs, can continue in that role as a volunteer, but oftenvolunteer to do something else.

Almost 20 percent of St. Vincent's total work hours are by volunteers. The categories of activity break out almost evenly between home care, in-patient care, bereavement, and other. "Other" includes extra touches such as: musical entertainment, pet therapy, massages, and pro bono legal work by volunteer attorneys — and volunteers organize St. Vincent's only annual fundraiser, the Tree of Life observance each December.

To be accredited as a hospice, volunteers must perform at least five percent of all work hours.

Figure 2.

Overview of Organization and Operations: St. Vincent Hospice (continued)

15Third Issue 2004

acquire a habit of not minding every page. Hospitals using a more complex sys-

tem are generally less effective. If it moni-tors the activity and location of nurses andaides, they resent it, particularly if theythink they are understaffed. There are twolessons here. First trying to maximize theproductivity of people who must respond toemergencies backfires. Second, backup isimportant, just as each team leader in alean system should back up every worker.St. Vincent's working culture beatsTaylorist efficiency engineering withoutbeing efficiency-driven.5

The "Business Model"

"Business model" is not a phrase invogue at St. Vincent, but it works some-thing like this. Patient care operations arepaid for by Medicare or third-partyproviders, and occasionally by patients per-sonally if they have bucks. Charges tothird-party providers don't include muchoverhead because capital and extras come"free" from philanthropy and volunteerism.

Giving is through St. VincentFoundation, which also serves a parenthospital by the same name. Duke Haddad,the executive director, runs a mature phil-anthropic program, capturing three to fivedollars from each one spent in fundraising.

Modest gifts add up, and there are afew large endowments. One, for example,funds landscaping in perpetuity. In 1999the present building was financed by a cap-ital campaign headed by Rhonda Kittle,whose husband passed away at St. Vincent.Determined that the building layout shouldcome out family-friendly, Mrs. Kittle moni-tored the architectural planning and con-struction almost daily.

No wheedling is needed to promptthose that have experienced St. Vincent togive. The attitude of the staff and volun-teers is St. Vincent. Volunteers add theextras and allow paid staff to concentrateon core care. This combination gives greatcare at a price Medicare is willing to pay,and good reason for benefactors to partwith their money. The working culture isSt. Vincent's "business model. "

Getting the Right People on the Bus

Few manufacturing organizationsspend the energy to recruit employees thatfit in and that have an affinity for the mis-sion. A hospice deals with all kinds of peo-ple in the dying process. It isn't for every-body. Both staff and volunteers are asmuch cultivated as selected. Technical skillshould have been demonstrated in a priorjob. For example, RNs are hired only aftera few years experience, never right out ofschool. Young or old, they must be emo-tionally mature; unflappable; devoid of pro-fessional pretension; and ready to give ofthemselves. Highly prized: sensitive anten-nae when interacting with the emotional,the confused, and the distressed. Somecome to this state after personally tendingsomeone close who died.

But passing these hurdles is notenough. Empathizing with patients starts tobecome attachment; then they are gone.And no patient tugs the heart more than adying child. Even some veterans of hospicecannot stomach pediatric care, day after day,year after year, and often at night. That'swhy the St. Vincent community refers totheir work as "the calling" (Figure 3).

The calling sounds religious, but hiringstipulates no religious requirement.Instead it is the ability to do whateverneeds doing. For instance, a home carenurse must take initiative when necessary,improvising with whatever is at hand, butbe patient with caregivers and patients oth-erwise, and sense when to changeapproach. Each day starts at home base;checking overnight logs, mapping five visitsfor the day, gathering supplies. If every-thing goes right, work will finish by five.Seldom happens. A patient enters a newphase; takes more time. One not scheduledhas an emergency. Another's caregiver hasfallen ill; another emergency. Every dayGod tears up the schedule, but it has to befinished anyway.

Training varies by position, but movesquickly from procedure manuals to workingwith a preceptor. A watchful preceptor maydetect within hours that a new hire has the

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right stuff — a commitment to the calling —but for others full commitment comes moregradually. A common path to work up to thisis working as a part-timer or temporary(called "PRNs," the medical acronym mean-ing to take or use when needed).

Volunteer training is thorough. Just asstaff, volunteers need to understand thedying process and hospice regulations inorder to avoid blundering. Volunteers shouldbe emotionally mature also, and most are, orthey would not self-select. Volunteers areevaluated, trained, and assigned a role —then mentored and monitored. Not everyoneis cut out for every role, but a hole can befound for every peg. Rebecca Maher, whodirects the juggling of all volunteer activity,notes that in ten years only one volunteercould not work out in any role.

Some volunteers "come to work" asregularly as full time staff, fully dedicated tothe calling, and stay active for many years.Others, like the attorneys, or the Spanishtranslators, have special roles when calledon, and critical ones too. Some visit homesto fill in for caregivers who need either tohave a break or to run errands.

Pediatrics

Children are not small adults. St.Vincent's objective is to keep children aliveand active as long as possible before thefinal event. Their medical care and emo-tional care are different, which is easily seenif children are under school age. Medically,a child with a terminal condition still has theneeds and interests of one that is growingnormally, while medical status may flip rap-idly. For example, one little girl went toschool on Thursday and died Friday. Bycontrast, they may be terribly ill one day andfeel ready to do anything the next.

Financial issues are common. A fam-ily with young children is apt to live frompaycheck to paycheck before disasterstrikes. Unless their insurance is unusuallygenerous, it wipes them out. The socialworker has to cobble a financial plantogether, drawing on resources like TheTimmie Foundation (named for a little boy)that specializes in helping the very poorwho must choose between keeping thelights on and paying the rent.

Anita Schnaiter, who heads pediatrics,says that cutbacks by third party providers

St. Vincent Hospice Mission ...

Figure 3.

To provide compassionate holistic care for the dying and those who care for them.

"The calling," common to all member institutions of Ascension Health in St. Louis, is prominent in St. Vincent Hospice litera-ture, and printed on every business card:

Service of the Poor: Generosity of spirit for everyone in need

Reverence: Respect and compassion for the dignity and diversity of life

Integrity: Inspiring trust through personal leadership

Wisdom: Integrating excellence and stewardship

Creativity: Courageous innovation

Dedication: Affirming the hope and joy of our ministry.

17Third Issue 2004

exacerbate financial problems with long-term illness in children. Bills are big; cov-erage isn't; and the number of cases toolimited to grab attention. Each year, only13-15 children die of natural causes inIndianapolis. Over half enter St. VincentHospice.

Emotional issues take the deftesttouch. Overwhelmed parents need assur-ance that they are doing everything theycan; things will work out. Siblings needattention if a brother or sister is consumingtheir parents. Among St. Vincent's extras isa child life specialist, or "play lady," whocheers (and distracts) dying children and

their siblings. All pediatrics staff come to the calling

with prior pediatric experience. Only adozen or so volunteers are up to workingwith children. No amount of traininginstills the right touch for this, but it isinsightful. Children know more about lifethan we give them credit, but not enough tofully comprehend what they are losing.And what do you tell children about dyingwhen anyone they know is dying? Thebasics when they are ready for them. Beinghush-hush brings up a question later, "Whydidn't you tell me?"

Timeline History of Hospice

Figure 4.

Ancient: All cultures evolved ways to care for the dying; for example in East Africa, wise elders "saw to" the dying; in ancientChina the destitute died in special death houses.

1500-1800: Most people died at home. Religious orders cared for those dying alone.

1800-1900: Hospitals grew as places of curative treatment. People began to regard dying as a clinical event, but most peoplestill died at home.

1935: Hospitals are generally accessible in U.S. towns and cities. Psychosocial studies of dying and bereavement began.

1967: St. Christopher's Hospice, the pioneer of modern hospice, opens in London. Care is multidisciplinary. Palliatives areadministered at timed intervals, not when "it hurts."

1974: Connecticut Hospice becomes the first American hospice to offer home care. Almost all patients who died there hadcancer.

1974-1990: Hospices expand across North America. Most emphasize home care. In 1982 Medicare adds hospice benefits.

1990-2004: The hospice movement expands rapidly. Almost 3000 hospices serve the United States. Patients die of manycauses; only half are now cancer patients. But much of the public remains confused about what a modern hospice actuallydoes.

St. Vincent Hospice evolved from a pilot program directed by Margaret Pike from 1978-1981. The official founding was 1982when the first building opened. The new, larger building opened in 2000.

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Bereavement

Properly conducted, this aspect of hos-pice care requires broad experience. Nosewiping and handholding are insufficient.The objective is to give therapy to thosewho need it. People anchored in friend-ships and activities, experiencing normalgrief, need nothing special. Those withpathological grief may deteriorate in bothmental and physical health. For example,most of us can recall an older, isolated cou-ple that after one died, the other gave up onlife and died soon after. Those are thecases to head off if possible. And children'sdeaths always call for something extra.

At times the emotions of hospice also"get to" staff members, and they needcounseling. All bereavement counselorshave taken a difficult grief journey person-ally; they understand. They cope by havinga life outside the calling. Their advice: Liveit to the full; do what you like, have a rol-licking good time, and leave with noregrets.

Bereavement has become a disciplinedpractice with ethical standards. The skillsneeded: assessment, individual counseling(face to face and by telephone), group work,self-awareness, empathy, and patient listen-ing. Both individuals and cultures vary inhow they express grief, and it depends ongender, age, spiritual beliefs, and relation-ship to the deceased. Some crave a groupthey can open up to; others clam up instony-faced isolation. Bereavement strivesto intervene when needed and how needed.

The crucial skill is listening andobserving to deeply understand (sort of aright-brain, behavioral counterpart to TPSleaders standing in Ohno's circle).6

Because they are constantly observing, St.Vincent's bereavement staff and volunteerssense things gone wrong, or that a patientor family thinks has gone wrong, anywherein hospice operations. Every experiencedmember of the St. Vincent community alsodoes this to some degree. They monitoraspects of quality that data can't describe.Few manufacturing companies would thinkof developing such a capability.

The Quality ImprovementMeeting

On March 10, 2004, the author attend-ed the monthly meeting of the QualityImprovement Committee, which has tenstanding members. All new employeesattend a meeting. Anyone important to anissue is invited.

Topics were normal for a quality outfit:Correct unit log processes to assure thatwhen a patient dies, messages to everyonewho must be notified are prompt and clear,and the record closes clean. A sub-com-mittee continued to check possible incon-sistencies in how Home Health nurseschart. Med lists on the nursing standardsneeded updating, etc.

A new after-death family survey formintroduced the term "confident" asking ex-caregivers to rate the coaching of homehealth nurses. They decided that aftercoaching, nurses should explicitly ask care-givers if they felt "confident" using newprocedures.

Survey ratings were high; familiesgrateful for attention score high even if theyadd nitpick comments. Staff discussed whohad time to correlate comments with oldcharts to dig out specifics they might dobetter. They bemoaned that surveys onlyput them on the trail of problems after itwas too late to correct them. Then thecommittee voted to give a token of appreci-ation to anyone on the staff praised byname on a survey.

No complex methods; no acronyms.Performance isn't "engineered" here.Instead, it's from attention to the precur-sors of problems in what is happening now,somewhat like Yogi Berra explaining thepurpose of batting practice, "Fix it before ithappens."

The Working Culture

St. Vincent excels in soft skills, an areawhere many manufacturing companieswish they did better. Many people who optfor hospice work have such skills and feelan obligation to practice them, not the casein manufacturing.

Organizational Vigor Ratings by the A-B-C Framework

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21Third Issue 2004

St. Vincent works by sustaining rela-tionships with the numerous stakeholdersthat constitute its community. Manufac-turers frequently don't do that well, or do itwith only a few external organizations.Within St. Vincent, patients and familiescome first, of course; then staff, volunteers,donors, other medical institutions, areaphysicians, other hospices, and on and on.St. Vincent thrives because it "attracts ener-gy" from a broad spectrum of others to thecalling, the improvement of everyone'sexperience with the dying process.

St. Vincent is the opposite of a com-modity business. They could not garner thesame contributions from their stakeholdersif they drifted toward a commodity mental-ity with a profit motive. When the missionis to assuage the final "experience" of eachunique patient, plus family and friends,work efficiency is not a conscious consider-ation. However, waste can be defined; any-thing we do that interferes with carryingout that mission. Almost subconsciously,the St. Vincent staff pays attention to that.

Consequently, applying examples fromSt. Vincent to a manufacturing company'soperations requires translation — andrumination. It relates to "Respect forPeople," that other "pillar" of the ToyotaWay, which Toyota breaks down further: 1)Respect others; make every effort to under-stand each other; take responsibility; anddo our best to build mutual trust. And 2)Teamwork: Stimulate personal and profes-sional growth; share opportunities fordevelopment; and maximize individual andteam performance. That describes St.Vincent Hospice.

Leadership

No one can lead an organization likethis without walking the path of the callingwith everyone else. Ferne Squiers is St.Vincent's new director. Ask others whatshe does, and the likely response is, "rolemodel." Prior directors were role models.

Ask Ferne Squiers what she does, andfirst priority is "quality of all the care weprovide." Yes, she battles budgets andfinancial stability, freeing others to carry

out the mission. She deals with all regula-tory issues and processes. And she repre-sents St. Vincent Hospice to all the rest ofthe world. But what does it take to do thisjob? "I cannot separate my hospice frommy personal life," is her reply. Another les-son to think about.

Robert W. Hall is editor-in-chief of Target anda founding member of AME.

Footnotes:1. The Toyota Way is the company's articulationof its core values as a company, and not thesame as the twin-pillared building Toyota oftenuses when explaining the basis of the ToyotaProduction System.

2. A typical article addressing this issue is "G.M.Says Costs for Retiree Care Top $60 Billion," NewYork Times, March 12, 2004.

3. According to Donald Hoover, a statistician atRutgers University, based on surveys and nation-al health care statistics.

4. Information about paging systems is fromMike Zeiss, Circuit Master, Indianapolis, whoinstalls and maintains these systems for manyhealth care facilities. The pagers are not regulartelephone pagers, but customized for this appli-cation using the POGSAG special protocol. TheRF broadcast has a range of two miles, so nurs-es will receive a page even if they are in theparking lot. These systems began to be installedabout 20 years ago, and have gradually addedfeatures. However, the complex ones are moreexpensive, more troublesome to program andmaintain, and seldom stay in service more thana year.

5. Nurses' resentment of Taylorist managementin hospitals is a long-standing issue, studiedmany times. Nurses are apt to refer to Taylorismas constraining or restrictive of quality care. Atypical survey is Chapter 5 of Nurse Abuse, byLaura Gasparis and Joan Swirsky, PowerPublications, Staten Island, NY, 1993.

6. See "Ohno's Method," Robert W. Hall, Target,Q1, 2002, pp. 6-15.

© 2004 AMETM For information on reprints, contact:Association for Manufacturing Excellencewww.ame.org