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Baldrige Hospital Champions Focus, Agility and Process Improvement

By Topic: Change Management Performance Excellence Process Improvement TransformativeAdaptive Change By Collection: Blog


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The COVID-19 pandemic caught our hospital, our nation and the entire world by surprise.

Even though Adventist Health White Memorial faced many of the same pandemic-related obstacles as other hospitals and health systems—including staffing and resource shortages, capacity overflow and falling revenue—the culture AHWM has built as part of its pursuit for performance excellence allowed the organization to navigate these challenges with success.

Beginnings of a Baldrige Journey

AHWM is a private, faith-based, nonprofit, teaching hospital, dedicated to serving more than 2 million individuals near downtown Los Angeles. For more than 100 years, we have been deeply dedicated to the health and well-being of our community, and it is our mission to continue to do so for many more years to come.

As part of that mission, AHWM leadership decided in 1997 to commit to the Malcolm Baldrige Performance Excellence Program. With long-range foresight, planning and determination, we began our journey. AHWM leaders began systematically hardwiring new quality and service processes into the organizations’ approaches to care delivery and business operations. We also intentionally committed time and resources to fully develop our approach to process management, knowing that the discipline learned by improving our process management approach could easily be applied to other scenarios.

All the while, we maintained focus on serving our community. Our underserved neighborhood and payor mix required us to approach excellence differently, driving us to find innovative ways to address the challenges faced by our inner-city hospital. Many may have doubted that an inner-city hospital could attain such a high recognition but—after years of hard work and dedication from the clinicians, staff, leaders and associates—AHWM earned the Malcolm Baldrige National Quality Award in November 2019.

Pivoting During a Pandemic

Amid our Baldrige Award celebrations, COVID-19 cases began appearing in the U.S. By February 2020, our AHWM team jumped into action in a committed, organized and disciplined manner. We stood up daily command centers involving representatives from all areas of our organization, connected with other hospitals around the world, implemented evidence-based practices and formed task forces to address the various challenges of the pandemic.

After spending many years developing the Baldrige model of solid working relationships between cross-functional areas, our staff was prepared to respond quickly and make life-saving changes during the pandemic.

While there are countless examples of our Baldrige culture playing out in action during the pandemic, one particular scenario comes to mind. During a surge of severe COVID-19 cases this past winter, our inpatient census soared. To expand capacity, we converted all possible areas, such as our Ambulatory Surgery Center, to accommodate these patients.

One day, a physician placed an urgent call to our respiratory care department from a patient’s room: “The high flow respirators aren’t working!” Within minutes, a team of clinicians, technicians and facilities leaders arrived to address the issue. Together, clinicians in full COVID PPE in the patient room and our facilities people on the other side of the thick protective plastic covering the entrance, engaged in a critical troubleshooting discussion. The ensuing discussion revealed the issue wasn’t the respirators at all; we pulled building plans for this converted unit and discovered that the oxygen lines in this older building were only capable of sustaining five high-usage respiratory machines. At the time, due to the surge, our hospital was using six times the usual daily amount of oxygen. With this new information and some quick decision-making, the patients in the annexed unit were safely moved to a new hospital tower that was fully capable of sustaining the necessary oxygen consumption.

This highly efficient collaboration and quick action would not have been possible without the years we spent on our Baldrige journey to develop trust throughout all levels and departments within AHWM.

When the COVID-19 vaccine was released earlier this year, it brought with it a ray of hope for overcoming this virus and ample opportunities to, once again, leverage our culture of continuous improvement and performance excellence to efficiently serve our patients. The vaccination roll-out created a whole new set of process challenges, but we continued to use our Baldrige teachings to guide our leadership and decision-making. We quickly pulled teams together and focused on serving the health needs of our community, setting up vaccination clinics on campus and taking mobile units out into our neighborhoods.

Using the Baldrige Framework for the Future

Throughout the pandemic, our goal was to continue to provide the exceptional clinical care and service to which our community was accustomed. Being a Baldrige organization allowed us to communicate more clearly and be more agile, creating trust, all of which are invaluable when faced with a prolonged crisis. We have become an organization that is aligned and deliberate about the actions we undertake. Process improvement is now our culture. The work that was established through Baldrige made us more resilient and set us up for success in weathering the pandemic. Looking forward, that same work will now guide us through the recovery process and position us for future success.


John G. Raffoul, DPA, FACHE, is president of Adventist Health White Memorial in Los Angeles (raffoujg@ah.org). Learn more about the work AHWM did to earn the Malcolm Baldrige National Quality Award here.