Health Care System "In Pursuit of Excellence" Case Example

Covenant Health, Tennessee

February 2009

The Organization

Covenant Health is a comprehensive health system established in 1996 by the consolidation of Fort Sanders Health System, Knoxville, Tennessee, and MMC HealthCare System, parent company of Methodist Medical Center of Oak Ridge, Tennessee.

With headquarters located in Knoxville, the system provides comprehensive services throughout East Tennessee. Covenant Health is a community-owned organization committed to improving the health of the people it serves. The organization is governed by a voluntary board of directors composed of community leaders and medical professionals.

Covenant Health includes five acute care hospitals in East Tennessee: Methodist Medical Center of Oak Ridge, Fort Sanders Regional Medical Center and Parkwest Medical Center in Knoxville, Fort Loudoun Medical Center in Loudon, and Fort Sanders Sevier Medical Center in Sevierville. It also includes Peninsula Hospital, a psychiatric hospital in East Tennessee's Blount County.

Approximately 8,500 people are employed by Covenant Health and its member organizations. Working together with approximately 1,000 affiliated physicians, these health care professionals deliver quality care to thousands of patients' throughout East Tennessee.

Covenant Health's mission is "to serve the community by improving the quality of life through better health."

The Initiative

In 2004 the Covenant Health board held a retreat dedicated entirely to hospital quality improvement.  At the retreat the board developed a written "promise of quality" articulating their unwavering commitment to the highest standard of excellence.  In response to the board's renewed commitment to quality, Parkwest Medical Center launched a new initiative focusing on improving emergency department care.  The hospital began by following recommended guidelines from the Institute for Healthcare Improvement related to emergency care.

In 2007 the hospital expanded on the initiative as a part of its work with the StuderGroup focusing on improving patient perceptions throughout the entire hospital experience.  The new initiative is called the Emergency Department Collaborative.

Focusing on Emergency Department Care. Parkwest Medical Center chose to focus on improving emergency department care because for many patients the experience they receive in the emergency department sets the tone for satisfaction with their entire hospital stay.  Patient satisfaction survey results revealed that long wait times and a lack of communication while waiting significantly impacted the perceived quality of care provided. The medical center formed multidisciplinary teams to develop objectives and actionable changes, including emergency department physicians, emergency department managers and staff, and StuderGroup coaches that helped the teams evaluate the data and look for opportunities for improvement.

The Highest Standards for Quality.  The Covenant Health board's commitment to quality set the standard for the highest quality of care.  The board's goal was to achieve patient satisfaction scores of "excellent," viewing scores of "good" or "very good" as insufficient.  Parkwest Medical Center's emergency department satisfaction goals were the same, striving for "excellent" patient satisfaction scores. 

In addition, Parkwest identified specific quality metrics for measurement, with desired outcomes for each.  Key measurements include:

  • Minimizing "door to doctor" time, ensuring that patients are seen as quickly as possible;
  • Providing aspirin on arrival;
  • Providing beta blockers on arrival;
  • Achieving a "door to balloon time" of 90 minutes or less, or what the Centers for Medicare and Medicaid Services defines as "heart attack patients given percutaneous coronary interventions (PCI) within 90 minutes of arrival"; and
  • Minimizing or eliminating the number of patients that leave prior to a medical screening exam.

Redesigning Traditional Processes.  In order to achieve the highest patient satisfaction, Parkwest Medical Center implemented a number of specific changes, including an ED tracking board to help care teams maintain focus on the patients and ensure rapid turn-around targets are met.  The emergency department at Parkwest also significantly redesigned its processes to ensure that family and patients are frequently interacted with before seeing a provider, including patient rounding that requires staff to frequently check on patients and their families waiting in the lobby prior to receiving care.

The Parkwest emergency department also implemented a "pull to full" concept.  Under the new approach, if a patient checks into the ED waiting room and there is an open bed, they are immediately admitted to the bed rather than waiting in the lobby.

Medical Staff Involvement.  Covenant Health physicians are fully engaged in the system's efforts to improve quality of care and patient satisfaction.  Physicians attend system-wide meetings as well as their own department meetings, where they review customer service scores and financial benchmarks, based on the Studer Group's five pillars (service, quality, financial, people, and growth).  Covenant Health believes that providers' involvement in the process and their commitment to be excellent in their care is critical to the organization's success.

Board Direction.  The Covenant Health board is committed to seeking excellence in patient care and providing a safe environment for patients.  The board's "promise of quality," which has been signed by all the Covenant Health board members, is available on the Covenant Health website, and clearly articulates the system's mission, values and vision as well as leadership's commitment to quality. There is a dedicated committee of the board whose purpose is oversight of quality improvement in the system.

In addition, the board reviews a quality dashboard every quarter, evaluating both the performance of the overall system as well as individual facilities.  Facilities with quality metrics that fall below the prescribed goals are required to produce an action plan for improvement.  The board's desire is to ingrain the importance of quality into every aspect of patient care, helping employees to view quality as part of the organization's "DNA" rather than as an initiative or program.

Partnering with the Local Emergency Medical Services.  Parkwest Medical Center worked closely with the local emergency medical services (EMS) to implement on-ambulance EKGs.  The system allows paramedics who encounter patients suffering from a heart attack to transmit their EKG results to the hospital immediately.  When an ambulance carrying a heart attack patient arrives at Parkwest, the emergency department is already aware of the patient's specific needs and an appropriate team of providers is ready to care for the patient.


Covenant Health has experienced an increase in patient admissions in its emergency departments, which correlates with an increase in patient satisfaction. Parkwest Medical Center won the Studer Group "Firestarter" Award in recognition for achieving a 98.9 percentile excellent ranking for Overall Quality of Care.  In addition, while the health system has not yet measured the impact on costs, improved quality metrics such as door to balloon time and door to doctor time may also positively impact length of stay, resulting in reduced costs.

The Emergency Care Center Scorecard.  Parkwest Medical Center's emergency department "door to doctor" time has been reduced to 58 minutes.  In addition, the hospital's Emergency Care Center Scorecard is demonstrating significant improvement in key areas, including aspirin at arrival (96.6% year-to-date); beta blocker at arrival (94.3% year-to-date); left prior to medical screening exam (1.6% year-to-date); and door to balloon time in 90 minutes or less (92% year-to-date).  In August 2008 the hospital achieved a door to balloon time of 90 minutes or less 100 percent of the time.

Limitations Encountered.  Some of the process changes required a significant shift in thinking by physicians and employees.  Improving the door to balloon time called for total commitment by the cardiologists to respond immediately to pages indicating the need for the intervention.  The "pull to full" concept also required a significant process change, and took some time for employees to adjust to.

Advice for Organizations Implementing a Similar Approach.  Support for the effort at all levels of the organization is critical.  A commitment by the organization's governance and CEO has set the tone throughout the organization.  Once the importance of the effort is communicated, collaboration between physicians, managers and staff is essential.  In addition, measurable results that hold teams accountable should be established, encouraging all of the key players to work together, and helping them to clearly articulate their success. 


Because Covenant Health System is comprised of multiple facilities, success at one facility is shared and duplicated at other facilities.  Parkwest Medical Center serves as a "best practice" emergency department for the other organizations in the health system. 

Contact Name:  Sandra Marshall
Title: Sr. Vice President, Quality
Tel:  (865) 531-5449
Fax:  (865) 539-6273



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