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Organizational Analysis Martina Garcia Capella University MHA-FPX5012: Organizational Leadership & Governance Dr. Andrea Lowe September 2023

2 Table of Contents Organizational Analysis ................................................................................................................... 3 Part I: Environmental Analysis ...................................................................................................... 13 Part III: Gap Identification ............................................................................................................. 16 Part IV: Leadership Recommendations ......................................................................................... 19 Part V: Leadership Implications .................................................................................................... 23 Conclusion ..................................................................................................................................... 24 References ...................................................................................................................................... 25

3 Organizational Analysis On July 1, 2023, Dr. Joon Sup Lee took the helm of Emory Healthcare, an academic medical center with eleven hospitals and more than 300 practices throughout the Atlanta metropolitan service area (Hart, 2023). With Dr. Lee’s arrival came a new vision for Emory Healthcare – a realignment of the health care delivery system within a service line model and a laser focus on patient experience within an equity lens. The first signs of the changes to come included weekly announcements of removals of executive-level leaders from across the organization and news of sweeping re-organizations within clinical and non-clinical departments. As one of the smallest hospitals within Emory Healthcare (EHC) and located the furthest away from the headquarters at Emory University, Emory Johns Creek Hospital (EJCH) has enjoyed the benefits of the Emory reputation and resources, while operating with a fair amount of autonomy. Considering the oncoming seismic shift in strategic direction, EJCH has conducted an organizational analysis to evaluate its current position and ability to pivot in response to the vision of its new leadership. The following analysis will include an internal and external environmental analysis of EJCH, an organizational analysis of the current directional strategies and balanced scorecard, a gap analysis, an executive briefing report, and a summary of implications to current hospital leadership. EJCH is a Magnet-designated, acute care, non-profit hospital with 180 (adult and neonatal) licensed beds in the northern suburbs of Atlanta, GA. The hospital offers access to more than 25 adult specialties, with a sizable presence in orthopedics, heart and vascular care, bariatrics, obstetrics, and gynecology, and hosts a growing satellite location of the Winship Cancer Institute. It is the only Imaging Center of Excellence in the Southeast and EJCH plans to build a new outpatient advanced imaging center starting in 2025. These needs are in keeping with the demographics of the community which boasts growing populations of seniors and young families. According to the Governor’s Office of Planning and Budget, the anticipated

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4 growth rate for the service area is 1.2% in the next five years (Population Projections Data, n.d.). This growth is reflected in the increase in deliveries at EJCH, which is currently exceeding budgeted volumes by close to 10% for each of the past twelve months. Among those between the ages of 45-75, cancer and heart and vascular disease are among the top three causes of morbidity and mortality in the community (“Online Analytical Statistical Information System,” 2023). EJCH sits at the intersection of Fulton, Forsyth, Gwinnett, and Dekalb Counties, with Cobb and Hall counties located less than 15 miles away from its campus. Within 20 miles, there are three competing hospitals that are comparable in size: WellStar North Fulton, Northside- Forsyth Hospital, and Northside Duluth. Within 20 miles are Northeast Georgia Healthcare System and Northside Gwinnett (“Hospital Accessibility Index 2020,” 2020). The community is one of the most diverse in Georgia, where more than 36% of residents speak a language other than English at home, and nearly one-third of the community was born overseas. The largest growing segment of the community is the Asian population, which doubled in size from the 2010 census and at 26% is the second largest section of the community after White, non-Hispanic residents (52%). The remainder identify as Black (10%), Hispanic (all races) at six percent, or multi-racial (4.1%). This multinational community is reflected in the concordance of staff, with close to 40% of staff and providers identifying at either East or South Asian (“Quick Facts,” n.d.). In addition to having a large immigrant population, Johns Creek reflects a wealthier and higher educated community, as well. The median household income is $133,948, and a fifth of the population earns $200,000 or more, compared just five percent of Georgians reporting that level of income. More than 69% of households report having a post-secondary degree (or higher) and less than one percent of the community does not have a computer at home (“Quick Facts,” n.d.). While the rest of Georgia has an uninsured rate of nearly 15%, only six percent of Johns Creek households do not have insurance (Harker, 2020).

5 Part I: Environmental Analysis Health care organizations operate within one of the most complex and highly regulated industries in the United States. In addition to the market dynamics and internal shifts identified in the section above, EJCH also must contend with a multi-generational workforce recovering from the collective trauma of the COVID-19 pandemic, as well as legal and regulatory factors. On October 1, 2022, Emory Healthcare converted its electronic health record from Cerner to Epic, which increases its ability to mine data to drive improvements in data collection, reporting and outcomes, but also brought with it changes that resulted in unanticipated consequences. For example, the system allows for staff to use tap-and-go entry to access the system, no longer requiring staff to log in and out of the system in each patient room. Additionally, staff can have more than one patient’s chart open at any given time and can access charts via iPhone. Each of these enhancements to efficiency has corresponded to incidents of protected health information exposures or loss of data integrity and patient safety errors when staff inadvertently chart information in the patient’s account. Such incidents pose legal potential risks in relation to the Health Information Portability and Accountability Act of 1996 (HIPAA), which places protections on patients’ rights to privacy of their health information (Health and Human Services [HHS], 2013). Additional legal risks include the Hospital Price Transparency rule as part of section 2718(e) of the Public Health Service Act. The rule, created under the Trump administration, went into effect January 1, 2021, and guarantees access to consumer-friendly information about gross charges for services and all self-pay and negotiated contract rates for charges (“Hospital Price Transparency Enforcement Updates: Fact Sheet,” 2023). Between 2010 and 2020, Emory Healthcare underwent rapid expansion and acquired seven new hospitals, each with their own chargemasters and individual contracted rates with payors. Coalescing that information into a user-friendly, cohesive format has proved difficult; however, EHC currently meets the minimum requirements by offering an online cost estimator. This may pose a financial challenge for EJCH as competition within the northern market intensifies.

6 From a regulatory standpoint, one of the major challenges facing EJCH (and Emory Healthcare as a whole) is the July 23, 2023, Joint Commission decision to make health equity a National Patient Safety Goal, 16.01.01 ( Joint Commission Standards , n.d.). This new accreditation standard requires that hospitals begin to collect race, ethnicity, sexual orientation, language preference, and gender identity data by January 1, 2024, and be able to report on those data by January 1, 2025. Additionally, health systems must be able to report on five social determinants of health, such as lack of housing, transportation, or food security. These rules require reporting on the total patient population, number of patients screened, and number of patients positively identified, with action plans developed and reported by 2025. This increased focus on health equity aligns with the recently updated directional strategies for EHC (see Part II: Organizational Assessment, page 9), Dr. Lee’s vision for the organization, and recent efforts by EJCH to enhance health equity as part of its patient experience strategy and in its diversity, equity, and inclusion employee strategy. TOWS Analysis In addition to the above referenced legal and regulatory threats, Emory Johns Creek Hospital faces other external threats and opportunities, which can be both mitigated or exacerbated by its organizational strengths and weaknesses (see Figure 1). Overall, EJCH is well-positioned to adapt to the changing internal and external forces it faces but needs to be proactive in developing strategies and processes that enable its long-term growth and success. In evaluating the organizational readiness to adapt to shifting internal and external circumstances, a TOWS matrix was used, as it offers a more relational evaluation than the traditional SWOT analysis by reviewing strengths and weaknesses in relation to how they address the threats and opportunities an organization faces (Ginter et al, 2018). Figure 1 TOWS Matrix

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7 Threats Within a 20-mile radius, Emory Johns Creek Hospital has four local competitors: Northside Forsyth, Northside Duluth, WellStar North Fulton, and Northeast Georgia Medical Center. This density of similar-sized community hospitals means increased competition for well- insured consumers and for private practice physicians, as EJCH is the only location which has a blended medical staff of faculty and private practice physicians. On the one hand, the faculty practices are a strength in the sense that they limit the likelihood of entire practices leaving the hospital. However, the mixed model can also be a weakness, as there is a high degree of distrust among the private practice physicians providing call coverage who feel pushed out. This has generated many shifts in the marketplace as practices re-align with different hospitals based on enticements such as new operating rooms, cutting edge technology investments, and joint venture arrangements – and a recent departure of leading Emory oncology physicians to a competitor due to more enticing signing contracts. The intensifying competition in the northern suburbs also impacts the payor mix of the patient population. As EJCH sits at the intersection of six counties (Forsyth, DeKalb, Gwinnett, Fulton, Hall, and Cobb), the hospital (and its competitors) is witnessing significant changes in the counties’ demographics. Both Gwinnett and Forsyth counties recorded two-digit increases in their Hispanic, South Asian, and East Asian communities, with increased demands for resources and services to support limited English proficiency (LEP) patients. Increases in LEP patients are correlated to increased inpatient lengths of stay, higher readmission rates, and increases in patient safety events, which can impact reimbursement (Berdahl & Kirby, 2021) In the EJCH service area, the LEP population often disproportionately reflects either a Medicaid or self-pay population (U.S. Census Bureau, 2020). Additionally, 49% of households covered by private pay insurance are employer-funded plans, which have put increasing pressure on employees to adopt

8 high deductible health plans to save employer costs (eHealth Insurance, 2022). As employees are facing increased out of pocket costs, EJCH saw a nearly 20% increase in billing-related complaints in 2022 compared to 2021 and steady increases in unreimbursed/charity care year over year (Emory Healthcare, n.d.). Inflation has resulted in availability and pricing pressures on the global supply chain. Throughout the last three years, EJCH has struggled to secure reliable and sustainable supply of critical equipment from tubing for IV kits to personal protective equipment to construction supplies, including parts to repair elevators, electronic doors, and surgical robotics. In the most recent report from the EJCH chief financial officer, the hospital reported a nearly six percent increase in supplies and materials costs in 2023 compared to the previous fiscal year. In the shadow of the COVID-19 pandemic, EJCH experienced staffing pressures as nursing and other clinical staff left the workforce or took on travel roles, exacerbating a pre- existing shortage in Georgia – which already ranked sixth in the nation for nursing shortages before the pandemic (Burger, 2022b). As nurses left the hospital in pursuit of the higher wages associated with travel contracts, EJCH also turned to travel nurse contracts to fill open slots, increasing the use of contract labor by 132% (Emory Healthcare, n.d.). Other staffing issues included high rates of burnout and new graduate nurses leaving the profession due to lack of adequate training during the pandemic, exposure to workplace violence, and peer-to-peer incivility (Kim et al, 2021). Opportunities As referenced earlier, EJCH sits at the juncture of six counties. While county demographics pose some challenges to the hospital, they also present a source of opportunity. In the most recent census, Georgia witnessed a massive migration of people from rural counties to metropolitan areas, and the six counties that surround the hospital are among the fastest-growing counties in Georgia, as well. The Atlanta Regional Commission (2022) predicts that by 2050, the region will grow from 5.7 million people to 8.6 million. Additionally, the diversity of the

9 communities served is increasing as well, with predictions of the non-Hispanic white population dropping to 31% by 2050, the Black, non-Hispanic population staying flat at approximately 33%, while the Hispanic (all races) and Asian communities increasing to 21% and 14% respectively (Atlanta Regional Commission, 2022). This population also skews younger, with the highest predicted growth rate by generation among those under the age of 39 (Atlanta Regional Commission, 2022). While Millennials recently overtook their Boomer counterparts as the largest generation, the population of those aged 75 and older in the EJCH service area is expected to grow from four to 12% by 2050. More than 60% of annual births in Georgia are covered by Medicaid, with Georgia women having among the highest in rates of maternal and infant mortality in the country, with 46.2 maternal deaths per 100,000 live births overall and a rate of 66.6 maternal deaths per 100,000 live births for Black women (Armstrong-Mensah et al, 2021). Georgia also ranks 35 th in the nation for infant deaths, at 6.2 deaths per 1,000 live births in 2021, with Black infants dying at a rate more than double of white infants, with 4.5 deaths per 1,000 live births compared to 9.5 deaths per live births (Georgia Department of Public Health, n.d.). For years, Georgia resisted the Medicaid expansion made possible by the Patient Protection and Affordable Care Act of 2010 (ACA), but in 2022, the Georgia was approved to receive a Medicaid waiver to increase health care coverage to adults, including expanded post-partum coverage for new mothers (Harker, 2020). This has a significant impact on our ability to defray unreimbursed costs from self-pay patients who cannot afford private insurance and increases the hospital’s ability to support the health women and families in the community. The ACA also included provisions to put greater emphasis on population health management, health equity, and value-based care (Health and Human Services, 2013). Technological advancements such as telehealth, patient portals, health apps, and integrated electronic health records can enable improved care coordination across the care continuum, with

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10 greater incentives for strategies that address the holistic health of a population, rather than a siloed approach to each encounter. With the conversion to Epic, EJCH has a greater opportunity to leverage this powerful tool to collect, analyze, and report data on the factors that support better outcomes, standardize care, reduce errors, and better serve the inpatient and outpatient needs of the community (Agency for Healthcare Research and Quality, n.d.). Finally, improvements in patient outcomes, minimally invasive surgery, robotics, and medications have resulted in decreased average lengths of stay for many conditions, resulting in shifts from inpatient to outpatient care – with some total joint replacement surgeries being conducted entirely as outpatient procedures. By leveraging Epic and developing a forward- thinking outpatient strategy, EJCH can be well positioned to create a desirable, multispecialty outpatient clinic with advanced imaging and ambulatory surgery offerings to capitalize on these trends ( Kumar, P. & Parthasarathy, R., 2020). Weaknesses In assessing EJCH’s ability to respond to external threats and opportunities, one of the challenges the hospital faces is also one of its greatest strengths – its connection to the larger Emory Healthcare system. Traditionally, the EHC system has been slow moving, dysfunctional, and bureaucratic. Most core operational functions such as scheduling, registration, billing, human resources, and information technology are centralized to support economies of scale yet have typically been disconnected from the rest of the system operations, are duplicative, or so highly matrixed the point of decision-making is obscured. With the emergence of new leadership under Dr. Lee, intense focus has been placed on these functional areas to accelerate and streamline processes, decrease waste and delays, and improve patient and employee satisfaction. Unfortunately, the 2022 conversion to Epic resulted in nearly three months of lost revenue due to billing errors and claims denials. By April, the organization only had approximately six days of cash on hand, which put a freeze on hiring and any strategic

11 expansions initially planned for the remainder of 2023 and throughout 2024. It is only the last three months where charge capture and receivables are improving to levels comparable to where the hospital was before Epic go live. Changes from external and internal forces have resulted in decreased morale, an increase in organizational departures of seasoned providers and staff, and a high turnover rate in first-year employees. These factors, in turn, have resulted in increased needs for contract labor, which negatively impacts the financials for the hospital (Emory Healthcare Operating Plan, 2023). Strengths Fortunately, before COVID-19 shut down the world in March 2020, EJCH had already been approved for a significant campus expansion, including two new floors to the hospital (with 80 new licensed beds) and three new floors to its adjacent physician office building and new four-floor parking deck. This greatly increased our inpatient capacity, and the new office spaces are airy, highly functional and promote care coordination in the shared spaces. With the increased space for practices and new amenities, this forms a draw for faculty and private practices. The new space is also a draw for staff recruitment, which has benefited from recent expansions in partnerships with schools of nursing, physical therapy, and imaging training outside of Emory University. EJCH benefits from its strength of reputation in the market. It is the only Magnet- designated hospital among its competitors, is ranked third in Georgia by U.S. News & World Report , and routinely scores in the top 25 th percentile for patient satisfaction. These are important differentiators for consumers and for staff recruitment. In 2019, EJCH embarked on two pivotal journeys: One was the embrace of Lean management principles to reduce waste, control costs, and support efficiencies to improve the care experience for staff and patients; the second was the 2020 launch of a diversity, equity, and inclusion (DEI) committee. EJCH made this move prior to Emory Healthcare hiring its first Chief DEI Officer in 2021, resulting in an innovative series of training classes on implicit bias,

12 creating an inclusive work culture, and navigating workplace violence, with customized classes targeting leadership, new employees, and for existing employees. More than 1,100 leaders, providers and staff have taken the class and inspired the rest of the Emory Healthcare hospitals to create similar programs. EJCH also hired its first full-time medical interpreter of Korean, created the most diverse patient family advisory council in the EHC system, and has invested in an expansion of technology solutions and in-person translation partnerships to enhance the delivery of language-appropriate care to LEP patients.

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13 Part II: Organizational Assessment Mission Statement The Emory Healthcare mission is “improving the health of individuals and communities at home and throughout the world.” As an academic medical center, Emory Healthcare’s core mission encompasses clinical delivery, research, and innovation, teaching the health care professionals of the future, and population health through health promotion and injury and illness prevention ( Emory Healthcare information, leadership, partnerships, quality reports, volunteering and more , n.d.). According to Sl åtten et al (2020), the Mission statement forms the guardrails for leaders and staff, serving as the yardstick against which all new initiatives and programs are compared. A well-defined mission statement drives connection, loyalty, and inspiration among its employees, driving improved performance and retention (Sl åtten et al, 2020). Overwhelmingly, staff and providers have articulated their support for DEI initiatives and efforts to better manage the population health of the community, as they too often see the repeat patients who lack a strong medical home with robust care coordination. Emory Healthcare, in partnership with Emory University, has been a growing contender in research and discovery, ranking 18 th nationally in NIH funding with awards reaching $382.7 million in 2021 ( Emory Healthcare Information, Leadership, Partnerships, Quality Reports, Volunteering and More , n.d.). In 2021, EJCH launched a Clinical Innovation and Inquiry Council to foster increased participation in academic research by clinicians at the hospital and hosted its first Clinical Innovation and Inquiry Symposium and first pain management conference in 2022. Vision Statement Emory Healthcare’s vision is to “be the leading academic health science center in transforming health and healing through education, discovery, prevention and care” ( Emory Healthcare information, leadership, partnerships, quality reports, volunteering and more , n.d.).

14 EJCH has embraced this emphasis on prevention and wellness, focusing initially on increasing the physical and emotional wellbeing of its team members. In 2022, the hospital launched CreekWell, to drive the wellness strategy for the hospital, with recent achievements including the creation of a Zen Den for staff to decompress, outdoor gardens, a renovated fitness center, and multiple wellness challenges, such as sleep hygiene and a hydration challenge. The Spiritual Health team routinely rounds among staff with a tea cart to provide mindfulness moments throughout periods of high stress and volumes. The goal for CreekWell is to create a Wellness Center for employees and the community, that would offer fitness and nutrition classes, support groups, and mental health support to meet the needs of the area’s multinational community. Values An organization’s values should be clear and reflect the observed and desired behaviors of its people (Ginter et al, 2018). The Emory Healthcare values are: “We exemplify excellence, innovation, and collaboration;” “We treat everyone with respect, caring and compassion;” “We embrace diversity, equity, and inclusion;” “We steward our resources responsibly to optimize value;” and “We serve with integrity” ( Emory Healthcare Information, Leadership, Partnerships, Quality Reports, Volunteering and More , n.d.). Internally, the values are manifested in what EHC calls the Pledge, an employee promise that outlines expected behaviors, cultural norms and what employees can expect from the organization. The Pledge has served as the foundational document in the creation of the EJCH DEI strategy and training. Organizational Score Card To monitor progress in achievement of its directional strategies, EHC and EJCH use a balanced scorecard (BSC) to articulate the strategies and key performance indicators used to benchmark their progress. The system sets the definitions of the four perspectives and each individual entity develops their annual operating plan based on the BSC. At Emory, we have re-

15 labeled our four perspectives as the objectives each perspective is set up to achieve (Table 1). Indicators are tracked monthly on the intranet with quarterly reports to the Board of Trustees. Table 1 EJCH Balanced Scorecard Category Objective Performance Indicator & Measurement Target or Internal Benchmark Explanation or References Business operation s Highest quality & safety Reduce CLABSI rate. Reduce Falls a  Target: <0.912 SIR  Target: 13 EHC requires each hospital select two of the 18 Leapfrog metrics. b Financial Purposeful growth & financial strength % EBIDA % Contract labor  Target: 20.9%  Target: 7.9% EBIDA is a commonly used metric to evaluate financial performance based on adjusted net income. Wages are typically the highest expenditure in a budget, but contract labor is at a higher rate. Contract labor also influences employee morale & patient satisfaction. c Customer Best patient access & experience Press Ganey survey: Overall Rating of Care Target: 75.3% top box rating Overall rating of care is a high predictor of patient satisfaction and is the measure used by Blue Cross Blue Shield in their Q-HIP program to incentivize reimbursement. d Learning & Growth Best place to work, learn & grow % of employees reporting sense of belonging (EHC) First year turnover rate  Target: 83.6%  Target: 26.5% Recent studies find that employees who indicate a high sense of belonging more likely to stay in jobs and be more productive. e a “AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017,” (2019) b Hospital Survey Measures (n.d.) c Cleverley & Cleverley (2018) d HCAHPS: Patients’ Perspectives of Care Survey | CMS (n.d.) e Herbert (2022)

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16 Part III: Gap Identification August 31, 2023, marked the end of the Emory Healthcare fiscal year (FY) and EJCH failed to meet its targets in several of the key areas as indicated in Table 2, below. Throughout the course of two day-long director retreats, EJCH leadership conducted a gap analysis and reprioritization process in planning for FY 2024, which began September 1, 2023. Results from that retreat are outlined below, with recommendations to address those gaps in FY 2024 in the subsequent section. Table 2 Gap Analysis Table: EJCH Fiscal Year 2023 Category Objective Performance Indicator & Measurement Target or Internal Benchmark Variance or Gap Business operation s Highest quality & safety Reduce CLABSI rate Reduce falls with injury  Target: <0.912 SIR  Target: 13 Actual: 1.198 Actual: 16 Financial Purposeful growth & financial strength % EBIDA % Contract labor  Target: 20.9%  Target: 7.9% Actual: 18.8% Actual: 11.6% Customer Best patient access & experience Press Ganey survey: Overall rating of care Target: 75.3% top box rating Actual: 71.8% Learning & Growth Best place to work, learn & grow % of employees reporting sense of belonging (EHC) First year turnover rate  Target: 83.6%  Target: 26.5% Actual: 87% Actual: 35% Business Operations In evaluating the reason for EJCH’s inability to achieve target for both central line- associated bloodstream infections (CLABSI) and falls with injury, the infection prevention (IP) team and Falls committee reported the findings from their event investigations. In analyzing the CLABSI data, the IP team indicated that while unit-level audit compliance was at 92%, average documentation of the CLABSI IP bundle in the EHR was 86%, leading to a concern that the

17 method by which CLABSI prevention audits were being performed had opportunity for improvement. The Falls team presented data that indicated two primary contributors to the failure to meet target: 1) no decreases in falls among post-surgical patients between the ages of 20 and 55 and 2) increases of falls with elderly patients correlated with care giver assistance in toileting. Of these, 15% of the adverse events were with patients of limited English proficiency. CLABSIs and falls with injury cause distress in patients and families, but also are associated with increased length of stay and lack of payor reimbursement for interventions in response to the adverse event – both of which contribute to a decreased EBIDA rate (Berdahl & Kirby, 2019). Finance The review of financial data at the retreat confirmed two trends that were recurring themes at the FY 2023 monthly leadership meetings: While inpatient procedures and imaging services remained high, the volumes for outpatient imaging services and ambulatory target did not make any of the services’ monthly targets throughout the year. In analyzing these data, we identified that lack of dedicated outpatient imaging services significantly contributed to last minute cancellations of outpatient visits to ensure the hospital’s ability to complete inpatient and emergency department studies. This resulted in a high degree of patient dissatisfaction and patients seeking services at competitor imaging centers. For ambulatory volumes, inefficiencies in operating room scheduling resulted in many of the practices redirecting their outpatient procedures to either competing ambulatory surgical centers or competing hospitals. Finally, first- year retention continued to hover around 65%, resulting in continued dependence on contract labor to meet safe staffing ratios. Customer In FY 2023, Emory Healthcare leaders switched their primary measure of patient satisfaction from Likelihood to Recommend (which we had used as our benchmark for more than 10 years) to Overall Rating of Care ( HCAHPS: Patients’ Perspectives of Care Survey | CMS , n.d.), as this aligned with increased reimbursement from Anthem/Blue Cross Blue Shield.

18 At Emory Johns Creek Hospital, we had traditionally scored in the top 20 th percentile for Likelihood to Recommend, but rarely scored in the top box for Overall Rating of Care, mostly because the patients tended to measure the hospital against a perception of excellence that a 180-bed community hospital could not compete with, i.e., Johns Hopkins University or Mayo Clinic. One of the main drivers of decreased patient satisfaction was nursing responsiveness, likely a result of the 2023 technology change where call bell notifications were no longer linked to the mobile communication devices nurses carry. Organizational Learning and Growth Throughout the last year, concerted efforts have been put in place to address first-year retention and employee engagement, including the launch of the CreekWell employee wellness initiative; the renovation of our employee health center to include a new Zen Den for staff to use to decompress; the launch of the Culture at the Creek classes to address workplace violence, empathy, and creating an inclusive culture; and the launch of the Justice, Equity, Diversity and Inclusion committee to advance strategies that promote inclusion for staff and equity for our patients and community. Yet, even with these measures in place, increases in workplace violence, including racial discrimination, have resulted in many employees (particularly new graduate nurses) leaving their positions.

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19 Part IV: Leadership Recommendations In planning for FY 2024, Emory Johns Creek Hospital leadership can benefit from continuing to leverage Lean management principles to improve efficiencies and processes, while applying the robust collection of problem-solving techniques Lean offers to tackle more complex issues, such as employee retention strategies and behavior issues, such as resistance to hardwiring best practices. Two of the core principles of Lean management is respect for people and Gemba, or going to where the work is done. These two characteristics are critical for increasing leadership cultural competency, increasing staff feeling of belonging and creating a more welcoming and equitable healing space for EJCH’s patients and community (Aij & Rapsaniotis, 2022). Business Operations Using Lean principles, such as Gemba and second-level problem-solving, can help leadership better understand the barriers and critical success factors to enable improvements in CLABSI bundle adherence. Hugo et al (2022) used Lean to re-imagine maintenance bundle audits to decrease CLABSI rates through more frequent rounding, real-time coaching and utilization of “peer influencers” to support culture change in each department. This resulted in a decrease in their standardized infection ratio (SIR) from 0.9 in 2017 to 0.53 in 2021. Likewise, Epic data combined with a literature review can assist in the development of a stratified risk analysis of fall likelihood among patients. Then, in partnership with the Patient Family Advisory Committee, leaders can use Lean strategies to identify tests of change to decrease falls with injury in the targeted, high-risk patient populations. A retrospective analysis of patient falls data at a tertiary hospital stratified the data by severity level of injury, patient demographics, and underlying conditions or supports, such as care giver presence (Ghosh et al, 2022). This approach provides insight into the contributing factors related to falls and enables more strategic, targeted approaches to interventions. Financial

20 While the highly anticipated outpatient imaging center should break ground in 2024, with an expected opening date 2025, there are opportunities to increase scheduling efficiencies with both imaging and ambulatory scheduling. By conducting a Lean value stream analysis of both areas, EJCH can identify areas of waste to improve processes, reduce cycle time and increase patient flow through both areas ( Kumar & Parthasarathy, 2020). Emory Healthcare could look to the strategy employed by Genesis Healthcare (which also underwent a Lean management transformation in conjunction with a move to a service-line structure) to transform its performance across eight key performance indicators (KPIs), including patient throughput. After two years, Genesis was able to move from underperformance to ranking in the top 10 th percentile nationally across the eight indicators (Harb et al, 2022). As referenced earlier, patient safety and quality indicators play a significant role in the financial performance of the organization, with safety events costing the organization up to $60,000 per event. Disproportionately to their overall presence in the patient population, limited English proficiency patients are two to three times more likely to experience a serious safety event or return to the hospital within 30 days, mostly due to inadequate access to qualified medical interpretation at key junctions of the patient stay, such as admission and discharge planning. By investing in expanded use of visual translation apps and in-person interpretation services at admission and discharge, EJCH could reduce the existing average length of stay (ALOS) of 5.3 days for LEP patients to the 4.1-day ALOS for English speaking patients. By achieving this parity for our LEP versus English-speaking patient population, we could save nearly $4 million per year in unreimbursed care and reduce by the likelihood of readmission within 30 days (Brandl et al, 2020). Customer One September 5, 2023, Dr. Lee announced the decision to return Emory to measuring overall patient satisfaction to Likelihood to Recommend. While this decision will be well-received by frontline leadership and staff, the underlying issues of patient perceptions of nursing

21 responsiveness for requests for assistance still need to be addressed. The Information Technology department indicated plans to re-synch the nurses’ mobile devices with the nurse call system. This technology improvement will remove one of the largest barriers in communication between patient and nurse; however, there are still opportunities to address responsiveness in terms of proactive rounding and better expectation setting on when a patient might realistically anticipate a response to a call for assistance. To address this issue, we recommend the launch of a multi-disciplinary A3 to re-design the concept of proactive rounding, much like the strategy employed by MD Andersen to make more effective rounding practices to remove barriers to care, corral resources and identify where nursing teams were struggling with workflow demands (Salinas et al, 2021). Learning and Growth Recent research into drivers of employee engagement have identified one of the key factors that increase employee retention, especially with Generation Y and Z employees, is the sense of belonging, with employees who say they feel like they belong 34% more likely to stay with their employer (Herbert, 2022). Belonging encompasses concepts beyond traditional notions of engagement which frames the employee experience around productivity and job satisfaction. It also includes the employee’s sense of safety, freedom to be their authentic selves, feeling cared about as a human being, and supported emotionally and through resources in the work they do. This is especially important for multi-racial and ethnic staff members who often encounter racial comments from patients and family members – and even other colleagues. Forging a cohesive, diverse and inclusive workforce where everyone has a sense of belonging is a critical challenge for today’s healthcare leadership (Rahman, 2019). Coming out of the collective trauma of the COVID-19 pandemic, health care workers are experiencing unprecedented levels of burnout, shifting needs on work/life success, and the ongoing societal shifts resulting in increases in reports of workplace violence (Kim et al, 2021). While EJCH has achieved improvements in the sense of belonging in our employee

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22 engagement survey, the hospital is still struggling with keeping new staff. Taking a trauma- informed approach to understanding how to meet the workforce needs more effectively could achieve better results rather than relying on traditional, pre-pandemic human resource strategies (Papa & Robinson, 2023).

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23 Part V: Leadership Implications While health care systems continue to recover from the response to a global pandemic, health care leaders are challenged with new expectations in competencies and skills to guide their teams into the uncharted future. The introduction of Lean management principles into health care have driven many improvements in operational processes and eliminated work duplication; however, the one principle that has not always received the same centrality of focus is the concept of “respect for people.” To be successful, leaders must embrace Lean concepts of humility and Gemba to understand the shifting dynamics in their teams (Aij & Rapsaniotis, 2022). Additionally, Lean represents a rich treasure trove of problem-solving tools that leaders can use to build their teams’ ability to lead change and become drivers and sustainers of improvements through root cause analyses, rather than tacit recipients of change ( Bijl et al, 2019) . Finally, as health care diversifies and equity becomes a priority in driving improvements in outcomes, health systems must be intentional in building inclusive teams while also being willing to dig deep into patient data and practice patterns to understand root causes of disparities and identify solutions to address them ( Lamba et al, 2022). With these increased capacities, leaders will be better able to engage their teams in meaningful ways to improve performance and productivity. They will also contribute to fostering an environment where people feel supported in their work, empowered to raise concerns, and equipped to lead changes to improve the experiences of their colleagues and their patients. With increased engagement and belonging, it will foster better organizational outcomes.

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24 Conclusion As EJCH positions itself for the future, fully integrating Lean management into our culture will foster shared values of continual process improvement, transparency, and alignment with our organizational goals. EJCH serves a multinational community and equally diverse workforce, uniquely positioning it to develop strategies and research to contribute to the body of knowledge to support health equity and inclusion among the providers and staff. Use of Lean needs to extend beyond being run by only organizational engineers on high-level projects and become the main problem-solving mechanism that helps teams solve complex societal challenges. Finally, the hospital (and health care in general) must learn to adapt to the changing expectations of the younger workforce that values inclusion, greater autonomy, flexibility, and input into decisions that influence their jobs. The generational shift challenges health care leaders to question the status quo, traditional structures and processes, and adapt their leadership styles and management strategies to recruit and retain Generation Y and Z employees and providers.

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25 References Agency for Healthcare Research and Quality. (n.d.). Chapter 4, emerging trends in care coordination measurement . https://www.ahrq.gov/ncepcr/care/coordination/atlas/chapter4.html AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017. (2019). In Agency for Healthcare Research and Quality . https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/ pfp/hacreport-2019.pdf Aij, K. H., & Rapsaniotis, S. (2022). Leadership requirements for lean versus servant leadership in health care: A systematic review of the literature. Journal of Healthcare Leadership , 9 , 1–14. https://doi.org/10.2147/JHL.S120166 Armstrong-Mensah, E., Dada, D., Bowers, A., Muhammad, A., & Nnoli, C. (2021). Geographic, health care access, racial discrimination, and socioeconomic determinants of maternal mortality in Georgia, United States. International journal of MCH and AIDS , 10 (2), 278– 286. https://doi.org/10.21106/ijma.524 Berdahl, T. A., & Kirby, J. B. (2019). Patient-provider communication disparities by limited English proficiency (LEP): Trends from the US medical expenditure panel survey, 2006– 2015. Journal of General Internal Medicine: 34 (8), 1434-1440. https://doi.org/10.1007/s11606-018-4757-3 Bijl, A., Ahaus, K., Ruël, G., Gemmel, P., & Meijboom, B. (2019). Role of lean leadership in the lean maturity-second-order problem-solving relationship: a mixed methods study. BMJ open , 9 (6), e026737. https://doi.org/10.1136/bmjopen-2018-026737 Brandl, E. J., Schreiter, S., & Schouler-Ocak, M. (2020). Are trained medical interpreters worth the cost? A review of the current literature on cost and cost-effectiveness. Journal of Immigrant and Minority Health, 22 (1), 175-181. https://doi.org/10.1007/s10903-019-00915-4

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26 Cleverley, W. O., & Cleverley, J. O. (2018). Essentials of health care finance (8th ed.). Jones & Bartlett Learning. Emory Healthcare (2022). Emory Healthcare FY2023 Annual Operating Plan . https://workspace.emory.org/vpn/index.html Emory Healthcare (2020). Emory Healthcare FY2020-2025 Strategic Plan . https://workspace.emory.org/vpn/index.html Emory Healthcare Information, Leadership, Partnerships, Quality Reports, Volunteering and more . (n.d.). https://www.emoryhealthcare.org/about Ghosh, M., O’Connell, B., Afrifa-Yamoah, E., Kitchen, S., & Coventry, L. L. (2022). A retrospective cohort study of factors associated with severity of falls in hospital patients. Scientific Reports , 12 (1). https://doi.org/10.1038/s41598-022-16403-z Ginter, P.M., Duncan, W.J., & Swayne, L.E. (2018). Strategic Management of Health Care Organizations, 8 th Edition . Hoboken, NJ: Wiley. Harb, N. H., Said, P. A., Gusta, S. L., Wesson, A. M., Brautigam, J. D., Lemke, J. H., DeLessio, S. T., Cropper, D. P., & Shammas, N. W. (2022). A regional health system journey from volume to value: roadmap to the recognition as a 15 top health system in the USA for quality excellence. Journal of Healthcare Leadership , 14 , 203–213. https://doi.org/10.2147/JHL.S378664 Harker, L. (2020). Fast facts on Medicaid expansion. Georgia Budget and Policy Institute. https://gbpi.org/fast-facts-on-medicaid-expansion/ Hart, A. (2023, May 1). Emory Healthcare names new CEO. www.ajc.com . https://www.ajc.com/news/health-news/emory-healthcare-names-new-ceo/ ESEDEKJIIVBWPGV2FUF3YGFUQ4/ Health and Human Services. (2013, June 9). About the Affordable Care Act . HHS.gov. https://www.hhs.gov/healthcare/about-the-aca/index.html#:~:text=The%20Patient

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27 %20Protection%20and%20Affordable,insurance%20available%20to%20more %20people Herbert, C. (2022, September 16). Belonging at work: The top driver of employee engagement. Qualtrics.com . https://www.qualtrics.com/blog/belonging-at-work/ Hospital Accessibility Index 2020. (2020). [Dataset]. In ArcGIS Online . Atlanta Regional Commission. https://www.arcgis.com/home/item.html? id=2ef4fa41b2ca4688b1974c8868567f3f Hugo, M., Rzucidlo, R. R., Weisert, L. M., Parakati, I., & Schroeder, S. (2022). A quality improvement initiative to increase central line maintenance bundle compliance through nursing-led rounds. Pediatric Quality & Safety , 7 (1), e515. https://doi.org/10.1097/pq9.0000000000000515 HCAHPS: Patients’ Perspectives of Care Survey | CMS . (n.d.). https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/ hospitalqualityinits/hospitalhcahps Hospital Price Transparency Enforcement Updates: Fact Sheet. (2023). In cms.gov . Centers for Medicare and Medicaid Services. https://www.cms.gov/newsroom/fact-sheets/hospital-price- transparency-enforcement-updates Hospital survey measures . (n.d.). Hospital and Surgery Center Ratings | Leapfrog Group. https://ratings.leapfroggroup.org/measure/hospital/hospital-survey-measures Hugo, M. C., Rzucidlo, R. R., Weisert, L. M., Parakati, I., & Schroeder, S. K. (2022). A quality improvement initiative to increase central line maintenance bundle compliance through nursing-led rounds. Pediatric Quality & Safety , 7 (1), e515. https://doi.org/10.1097/pq9.0000000000000515

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28 Kim, J., Chae, D., & Yoo, J. C. (2021). Reasons behind Generation Z nursing students’ intentions to leave their profession: a cross-sectional study. Inquiry , 58 , 004695802199992. https://doi.org/10.1177/0046958021999928 Kumar, P. & Parthasarathy, R. (2020). Walking out of the hospital: The continued rise of ambulatory care and how to take advantage of it [White Paper]. McKinsey & Co. Lamba, S., Omary, M. B., & Strom, B. L. (2022). Diversity, equity, and inclusion: organizational strategies during and beyond the COVID-19 pandemic. Journal of Health Organization and Management, 36 (2), 256-264. https://doi.org/10.1108/JHOM-05-2021-0197 Online Analytical Statistical Information System. (2023). [Dataset]. In Office of Health Indicators for Planning (3.18). Georgia Department of Public Health. https://oasis.state.ga.us/ Papa, A., & Robinson, K. (2023). Leadership and trauma-informed care: working to support staff and teams. Journal of Emergency Nursing , 49 (2), 172–174. https://doi.org/10.1016/j.jen.2022.11.001 Population Projections Data (n.d.) [Dataset]. Governor’s Office of Planning and Budget. https://opb.georgia.gov/census-data/population-projections Quick Facts. (n.d.). [Dataset]. In U.S. Census Bureau . https://www.census.gov/quickfacts/fact/table/johnscreekcitygeorgia/INC110221 . Rahman, U. (2019). Diversity management and the role of leader. Open Economics , 2 (1), 30– 39. https://doi.org/10.1515/openec-2019-0003 Salinas, B., Villamin, C., & Gallardo, L. D. (2021). Integration of lean visual management tools into quality improvement practices in the hospital setting. Journal of Nursing Care Quality , 37 (1), 61–67. https://doi.org/10.1097/ncq.0000000000000563

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29 Slåtten, T., Mutonyi, B. R., & Lien, G. (2021). Does organizational vision really matter? An empirical examination of factors related to organizational vision integration among hospital employees. BMC health services research , 21 (1), 483. https://doi.org/10.1186/s12913-021-06503-3

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MHA-FPX5012_GarciaMartina_Assessment1-1

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