Insights Series Issue 2: "A culture of diversity, respect, and inclusion"

Siemens Healthineers Insights series Issue 2 Culture of diversity, respect, and inclusion A paper on how to ’Increase workforce productivity‘ at Main Line Health siemens-healthineers.com/transforming-care-delivery SIEMENS Healthineers About Siemens Healthineers Insights series Today, every health system struggles with rising costs and varying quality. Diagnoses and treatments are designed for typical patients. Delivery of care is fragmented and focused on volume. The patient experience journey is in its infancy. And healthcare doesn’t leverage the full potential of data. How can we change that? At Siemens Healthineers, our insights make it possible to turn challenges into opportunities. Our purpose is to enable healthcare providers to increase value by expanding precision medicine, transforming care delivery, improving patient experience, and digitalizing healthcare. 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Please visit siemens-healthineers.com/insights-series Paper Culture of diversity, respect, and inclusion – the key to an engaged and productive workforce Executive summary Diversity, respect, and inclusion are at the core of MLH's decisions in terms of: To deliver outcomes that matter to patients and lower costs for all, executives need • Safety & Quality – Building a culture of speaking committed and productive staff working in up for patient safety • Patient Experience – Care is personal collaboration with organizational leaders. • Employee Engagement – MLH operates in a diverse area; Supporting interdepartmental collabo- investment in comprehensive cultural competence ration and team-based care is vital to training for all employees is the norm achieving higher-value care. Leveraging staff diversity can stimulate creativity “We strive to interact with patients and and innovation and enable value-added their family members as if they were a solutions for patients. Demographic shifts member of our own family.”2 are necessitating changes in operational To develop a culture of diversity, respect, and inclusion models of healthcare systems. that encourages and rewards employees to speak up for safety,1 MLH invests in the dignity of the employee Based in Pennsylvania, Main Line Health (MLH) proactively experience.3 A part of this is reducing the perceived embraces diversity, both for the staff and people they power gradient4 that can often be felt between different serve. This paper details how MLH and their president and health professionals, and the disruptive behavior that Chief Executive Officer (CEO) Jack Lynch are creating a can arise when working in an intense, often emotional culture of diversity, respect, and inclusion across the health environment where people’s care is at stake.5 The initial system. Their purpose was to instill the importance of step to achieving a culture of respect and team-based quality, safety, equity, and affordability for all. care meant resolving disruptive behaviors between the This paper is meant to help other healthcare leaders two main groups concerned: physicians and nurses. First, envision and implement team-based care and positive it needed to be acknowledged that the behavior existed, workplaces in the future. MLH is creating a system where with subsequent education and skill development to every patient receives the same level of safe, high-quality learn new habits and ways of working. care.1 Productive and effective teams are vital to achieving this goal as “mistakes are inevitable when we work alone, MLH’s journey to a culture of diversity, respect, and inclu- so we must work together.”1 MLH’s leadership team sion started with a firm commitment from Lynch and his identified high-impact areas to tackle in order to deliver leadership team to embed it into the DNA of the organi- higher-value care while simultaneously eliminating harm. zation. This included providing positive role modelling, Of equal importance is bringing the elimination of dispari- behavior change, and incentives to create and embed a ties to the forefront of practice. Finally, care services have culture that is alert and forward-thinking. Now everyone to be sustainably affordable. at MLH feels they are directly connected to how success Siemens Healthcare GmbH, 2019 3 Safety and Quality is measured. Fundamentally, the leadership team recog- + Employee Patient nized that creating an environment where an extraordi- engagement Experience nary workforce is grown, sustained, and nourished goes beyond one-off recognition schemes.3 This is reflected in the overall outcome: The cultural shift the leadership team was able to embed at MLH provided both sustain- able impact in their community and in their safety, qual- ity, and financial performance. People feel valued at MLH and have a sense of belonging. Attaining mutual respect among colleagues is a critical element in creating the high-performance environment for teams to deliver a safe, high-quality experience for patients.1 “If we can establish trust and respect in our organization, we can then be sure every healthcare worker will be that much Main Line Health System – more committed and sensitive to providing Key figures (as of June 2018) compassion, respect, and an equitable 10,965 Employees experience to every individual who gives us 1,355 Licensed beds the privilege to serve and care for them.”1 176,510 Visits to the Emergency Room 62,561 Total discharges 7,529 Births 1,181,619 Outpatient visits 246,755 Home Health visits > 2,000 Medical staff* > 2,000 Volunteers *including dentists and podiatrists Source: Main Line Health System 4 © Siemens Healthcare GmbH, 2019 “We want to improve the health status of our community. That means everybody in our community.” Jack Lynch2 About Main Line Health This disparity can make a real impact on people’s health and lives.8 For example, Lankenau Medical Center is Founded in 1985, MLH is a nonprofit health system that situated between two counties that rank fifth and sixty- provides a comprehensive range of high-quality services in seventh in Pennsylvania’s county health rankings.8 This the greater Philadelphia area, employing more than 10,000 dichotomy points to inequities that exist and which the staff and 2,000 physicians.6 In 2018, MLH had revenue of MLH workforce must understand and recognize. Dealing more than USD $1.7 billion.7 MLH provides both acute and with inequity and its impact on health is not only a pas- rehabilitative care. Acute care is delivered by four hospitals sion, but also business-critical for MLH’s leadership team. (Lankenau Medical Center, Bryn Mawr Hospital, Paoli They understand the impact this can have on the Hospital Hospital and Riddle Hospital). Bryn Mawr Rehabilitation Consumer Assessment of Healthcare Providers and Systems Hospital delivers advanced rehabilitative services, Mirmont (HCAHPS) survey scores and on reimbursement. MLH’s Treatment Center delivers drug and alcohol recovery leadership makes the principles of diversity, respect, and services, and the Lankenau Institute for Medical Research inclusion the center of their strategic plan to better serve studies and seeks remedies for cancer as well as cardiovas- their diverse patient population and achieve their commit- cular, autoimmune, gastrointestinal and other diseases.6 ment to their communities and patients. The commitment of MLH to the highest standards of patient care and professional engagement has been Lynch believes that having a diverse workforce and a recognized by peers and throughout the U.S. In 2018, all diverse leadership team helps in understanding disparities of MLH’s acute-care hospitals were among the Top 20 in in care and achieving equity. MLH is committed to uncom- Pennsylvania, as ranked by U.S. News & World Report.6 promised patient safety, quality, equity, and affordable The System also received the Excellence Award from patient and family-centered care. Their culture considers the Mid-Atlantic Alliance for Performance Excellence, a the system, patient, and innovation and infrastructure in regional Baldrige program. Specifically, in relation to a comprehensive way. To make a purposeful impact on nursing care, all MLH hospitals have been awarded the reducing disparities of care for their community, MLH is ‘Magnet’ credential from the American Nurses Credential- extending beyond their walls and innovating to create a ing Center, the highest distinction for nursing excellence.6 healthier community. Overall, MLH considers both their The collaboration and partnership between physicians and workforce, physicians, and patients as parts of one com- nurses is recognized as an important component within munity, with the following initiatives to make their the Magnet Recognition Program.5 In 2016, only 22 health community healthier: systems in the U.S. had achieved this system-wide distinc- tion. MLH has achieved a ‘World Class’ status in Gallup • Providing a superior experience and Advisory Board satisfaction surveys.3 • Promoting community health • Working with highly-engaged employees, MLH links their strategy to their diverse communities and physicians and partners addresses the health of some of the most vulnerable and • Increasing the value delivered to patients underserved populations. The median household income • Maintaining research and education vastly differs – from under $25,000 to over $100,000. Siemens Healthcare GmbH, 2019 5 “You've got to put in place steps where everybody on the team feels like they are empowered to speak up for safety and look out for what's in the best interests of the patient.” Jack Lynch2 The challenge safest, highest quality, most equitable, affordable care that we can deliver,”2 said Lynch. In 2009, MLH began their The benefits of a diverse workforce for business and journey to embed a culture of safety and equity. The steps society are recognized by bodies such as the World included building awareness, acceptance, and understand- Economic Forum, particularly with the growing need and ing, and then managing the new ways of working. Lynch difficulty of finding talent for specialist roles.9 Business and Senior Vice President of Human Resources, Paul Yakulis, leaders understand that a diverse workforce can be understood that a new culture needed to support the busi- important to customers and is a focus when recruiting ness strategy of diversity, respect, and inclusion, with the talented people. Inclusion is an elusive challenge – creat- right behaviors identified and reinforced.13 They looked to ing an environment that values people’s unique talents and drive internal crucial conversations, to ask the hard ques- perspectives and makes them want to stay. The leadership tions and to learn where improvements were needed. team at MLH recognized this challenge at its root. As Focusing on diversity, respect, and inclusion in the work- Lynch put it: “If we’re going to develop more diverse team place is the right thing to do, but it doesn’t stop there. MLH’s leaders, we have to grow our own. Top to bottom, employ- incentive was also founded in business strategy, and it is ees must see opportunity. We want all employees to know clear that the focus here is good business.14 MLH’s leader- Main Line Health is interested in their growth.”10 ship team took a key step in 2013 to begin to develop organizational leaders who mirror the patients, and the Health systems are in an era of change, and there are demographics, of the local communities they serve. “It was increasing expectations for safety, equity, and efficiency. the right thing to do because you're going to be making Health professionals can be overwhelmed by this, leading better decisions at a table with people that look a little dif- to disruptive behavior or more passive actions like not ferent from each other and bring different perspectives.”2 answering the phone.5 This can lead to a vicious cycle of a lack of candor, disengagement, and a nonproductive In 2013, MLH replicated a survey by the American College environment. The daily workplace for many nurses is of Physician Executives (ACPE) that measured the impact not conducive to team-based care and can have a very of disruptive behavior between physicians and nurses. negative impact.11 Disruptive behavior between physicians Over 700 providers participated.5 The survey found results and nurses with a culture of silence interferes with patient similar to the 2009 ACPE survey, with ‘yelling’ as the main safety in addition to its damaging effects on teamwork.5 disruptive behavior, followed by ‘degrading comments Teamwork is an important driver of quality in high-acuity and insults.’ Lack of training in how to handle disruptive healthcare settings. Application of established team- behavior was also reported. The results of the 2013 MLH training tools is an effective measure to further quality survey were disappointing to MLH physicians and nurses.5 improvement.12 In response, the leadership team at MLH began several programs to build equity for both their employees and their “My responsibility is to empower people, give them the patients. They believed, and continue to believe, that team resources, tools, processes, standards, and policies that members are more likely to speak up for safety1 when the reduce the likelihood that human beings will make a perceived power gradient between health professionals mistake – and also to do what’s right in delivering the is minimized.4 6 © Siemens Healthcare GmbH, 2019 The STEEEP Principles16 S – Safe Care The patient’s safety comes first T – Timely Care Delivery in the timeliest manner The solution E – Effective Care Care based on the best evidence “Our people own the book [i.e., the ‘manual’]. They and science available created it.”2 The solution to center MLH on the principles E – Efficient Care of diversity, respect, and inclusion started with the Avoiding wastage of time, commitment of the leadership team. Their public metrics money and resources reflect this approach with four of eight executive metrics related to these principles.14 The staff at MLH need to know E – Equitable Care Access to care for all in an and be shown that they are valued and appreciated. The equitable manner Performance Excellence 2020 initiative at MLH15 mandated the adoption of the STEEEP Principles as outlined in the P – Patient-Centered Care Institute of Medicine (IOM) report (now the National Patients participate fully in Academy of Medicine) “Crossing the Quality Chasm: care decisions A New Health System for the 21st Century.”16 The vision is to deliver a STEEEP experience every time, everywhere, and to everyone across the System by 2020.1 E E E Siemens Healthcare GmbH, 2019 7 “Job rotations among the facilities are now becoming the norm and the sharing of best practices has become an organizational standard.” Paul Yakulis13 How Main Line Health adopted STEEEP A systematic patient-focused culture Teams have STEEEP Huddles to educate everyone on The leadership team set clear expectations about patient patient safety and equity and, in-turn, to ensure alignment safety and equity, ensured access to education for every- and that the gears of Performance Excellence 2020 run one, and then created accountability measures for smoothly.15 individual, hospital, and System outcomes. Achieving diversity, cultural competence, and eliminating disparities • Safe Care gears to Patient Safety (High Reliability) in care are embedded in every layer of the strategic plan. • Timely Care gears to Service Excellence Executives take responsibility for diversity, all the way (Patient Experience) through to their own incentives. A Diversity, Respect and • Effective Care gears to Quality Inclusion (DR&I) council ensures every employee under- (Top Decile Performance) goes facilitated active learning on diversity, respect, and • Efficient Care gears to Financial Performance inclusion.14 The local community and schools are proac- (Total Cost of Care) tively engaged in the creation of future leaders at MLH • Equitable Care gears to Diversity, Respect, and Inclusion who represent the communities they serve. This keeps (Disparity of Care) the health system rooted within the community and taps • Patient Centered gears to PIVOT21 new, potentially underserved groups. (Organizational Transformation) Lynch has always set the tone from the top. In 2017, There is an emphasis and drive to build a culture of safety he established the directive that all MLH executives and and accountability within teams, encouraging everyone to management participate in a two-day Diversity, Respect, apply tools to prevent errors with peer coaching and and Inclusion workshop, and all 10,000+ employees monitoring to drive superior clinical care.5 participate in a one-day workshop. To help lead this charge and facilitate the education of MLH employees and “It's about holding people accountable for managers, the organization hired Karen Fitzpatrick Smith, performance. It's about understanding the manager of organizational development at MLH and science behind error prevention. We are all certified in Diversity Management in Healthcare from the Institute for Diversity and Health Equity. The leadership striving for zero harm.”2 team never faltered in their commitment to this training, despite other business pressures. This training has fostered open communication across the organization. Lynch is comfortable with saying “we are not perfect, and we can always improve.’’2 Other socially-important programs beyond healthcare provision, such as ‘School at Work’ and ‘Expanding Your Career and Healthcare Opportunities’ with a Career Advisor 8 © Siemens Healthcare GmbH, 2019 scheme, have allowed employees to improve both “When we visit, it's really to go in, thank knowledge and behavioral skills, paving a path for career people, observe, show appreciation, talk advancement. Employees can see and understand their link to and accountability for success through modules about safety, talk about how we can be such as ‘Principles of Patient Satisfaction and Safety.’10 better and to create that two-way channel These programs have helped staff gain confidence and of communication.”2 develop a better understanding of their strengths. This assurance and consistency throughout the System means On the establishment of culturally competent team-based all staff are more willing to speak up about how to improve care, Yakulis commented on how teams now think globally processes and be part of solutions. Those who exhibit the across the health system, and how care is being delivered: values and traits that MLH espouses with respect to innova- “Localized thinking and behavior is receding and is being tion, integrity, and communication are acknowledged with replaced with initiatives to standardize clinical protocols Genuine Excellence Moment (GEM) awards.10 This deep across all facilities with the goal to achieve clinically and cross-cutting approach has allowed MLH to proactively integrated networks. Job rotations among the facilities are prevent a shortage of skilled nurses potentially caused by now becoming the norm and the sharing of best practices chronic exposure to disruptive behaviors. has become an organizational standard.”13 The benefit of improved collaboration between physicians and nurses has MLH’s PARTNERS professional practice model for nursing facilitated new ways of working, and innovative ways to has provided an environment in which nurses are key deliver excellent care. For example, at the Lankenau Heart partners in providing high-quality service through superior Institute, engaged health professionals are working patient care in a culture of safety. The values that underpin effectively in STEEEP teams in the same space around the the PARTNERS model are leadership, collaboration, patient, and a Hybrid Operating Room has been operation- evidence-based practice, engagement, and professional alized that brings imaging to the point of care. development.17 MLH’s residency program for new nurses, and the advancement of clinical quality and safety on selected units through joint nursing and medical teams, The results promotes interprofessional socialization, with collaboration and communication at the forefront of all team interac- The result of any strategy implemented within a health tions. Chief Nursing Officer (CNO) Barbara Wadsworth, system should help people experience higher-value care DNP, RN, said: "They're working collaboratively to create with improved outcomes. Although people access care this environment where we have transparency, communi- differently, their relationship with their physician is the cation, and collaboration, and then we're working much bedrock of medicine. Subsequently, it is vital for health more like a team."18 The leadership team lives their culture, systems to retain and engage their staff. Being subjected to energizing their staff. Lynch participates in nighttime disruptive behavior can lead to staff turnover, and patients rounding at all hospitals, and CNO Wadsworth sends out losing access to much needed care. The issues associated newsletters every two weeks, and is also available via with burnout and staff turnover have been well document- social media when needed.18 ed. The situation in the U.S. may be getting worse. A report Siemens Healthcare GmbH, 2019 9 83% reduction in serious preventable harm from NSI Nursing Solutions19 highlighted that hospital turnover is again on the rise, with 18.2% turnover noted for 2017. The 2017 turnover rate for bedside registered nurses rose over 2.0% to 16.8%. The financial cost of staff turnover is also notable,19 with an estimated salary range for a bedside registered nurse from $38,000 to $61,000, with the average cost of turnover at $49,500. Each 1% change in nursing turnover affects a hospital in the U.S. by an estimated $337,500. Using agency staff brings its own costs; NSI’s survey estimates that cutting the use of 20 agency nurses over a Turnover rate for year can lead to savings of around $1.4 million. The loss of bedside registered nurses care time due to lack of staff is another factor. It has been 16.8% estimated that it takes approximately two and a half U.S. months to recruit an experienced bedside nurse.19 12.4% MLH Compared to the situation in the U.S., MLH is bucking the trend with their highly successful measures to address staff Up to -26% attrition. Nursing turnover for all MLH acute-care hospitals averages around 12.4%, and the average length of employ- reduced turnover rate ment of a nurse at MLH twelve years.18 This can be com- pared with the findings of a survey undertaken by Nurse. com,20 which found that the average length of service of a registered nurse in a U.S. hospital is approximately seven Average length of years. These findings make a real difference on what nurse employment outcomes matter to patients. To understand the impact of engaged nurses and the bottom line for patients in terms 7 years U.S. of receiving team-based care, the 2017 nursing annual 12 years report from MLH17 showed that the PARTNERS professional MLH practice model was a key component to decreasing hospital-acquired pressure injuries by 83%. This shows Up to +71% how these very real problems in health systems can be tackled by people working together. nurse retention 10 © Siemens Healthcare GmbH, 2019 “Three years after we launched our initial Culture of Safety initiative we saw an 83% reduction in serious preventable harm. There are people alive today because of that work, which makes me proud.” Jack Lynch2 Conclusion To achieve higher-value care is a process for both leaders and staff in health systems. MLH strives to enhance the “We realized that you can't have a culture experience of their patients and local community by of safety, you can't be committed to connecting and engaging their workforce, who should eliminating harm, if you're not committed identify with those they serve. to equitable care.”2 MLH’s journey to create a diverse and inclusive environ- ment has taken years. As Lynch says: “We have not yet MLH’s strategy to differentiate itself by providing culturally perfected this and understand that this is a marathon, competent patient-focused care needed authentic drive not a sprint to the finish line.”2 The real impact is only now from the leadership team to be successful in eliminating becoming evident through their robust nursing staff base, disparities, both for patients and staff. To cultivate a the quality of care delivered, and their rankings in the culture of respect and safety centered on the principles competitive U.S. healthcare landscape. The leadership of diversity, respect, and inclusion, MLH implemented team set the tone for promoting cultural competence and multiple programs, including the initiative to reduce staff wrole-modeled respectful behavior with the business sense attrition due to disruptive behavior between professionals. of developing talent. This is an important learning for Ultimately, an engaged and productive workforce can help everyone involved in healthcare: a strategic focus on health systems improve access to care. To some, diversity, diversity, respect, and inclusion is vital to engage and respect, and inclusion may feel like abstract, soft areas retain staff in order for them to give their utmost to within the tough world of delivering higher-value care. the community. However, as shown by the leadership team, when man- aged effectively, they can have a positive impact on patient outcomes and employee satisfaction and retention. • Diversity represents a core value of a health system: The healthcare team that treats patients every day represents the people they serve and communities where they live, as well as the health system. • An engaged team-based care approach is a win-win for all: Diverse, productive, and interdisciplinary teams are more likely to think differently while identifying disparities in a patient’s treatment, and come up with innovative methods of working. The systematic reduc- tion of the risk of disruptive behavior arising between staff builds trust, and engagement in the system’s strat- egy enables the success of a team-based care approach. Siemens Healthcare GmbH, 2019 11 Insights series, issue 2 About the authors Watch the full video! Interview with Jack Lynch, President and CEO at Main Line Health siemens-healthineers.com/video-jack-lynch 12 © Siemens Healthcare GmbH, 2019 Sandeep Nijjer Senior Marketing Manager for Transforming Care Delivery at Siemens Healthineers Jack Lynch Sandeep Nijjer is a member of the Marketing team at President and CEO at Main Line Health Siemens Healthineers, and is is responsible for the Executive Develop- ment Academy program. He qualified as a pharmacist in England with experience in all sectors of care. He also has experience in academia John J. (Jack) Lynch III has been president and CEO of Main and was responsible for ensuring newly qualified graduates were fit to Line Health (MLH), suburban Philadelphia’s most compre- practice. Sandeep Nijjer has also worked within life science consultancy hensive healthcare system, since 2005. During his tenure, for both pharmaceutical and medical device firms. He has a Master of Jack Lynch and his team have strengthened the organiza- Pharmacy degree from University College, London, and an MBA from Cass Business School, University of London. tion’s commitment to quality and safety and enhancing the technology to support significant advances in those areas. He has also fostered a period of expansion, including the addition of an acute care hospital and four health centers. He has cultivated a work environment that has garnered recognition from several independent rating organizations. Prior to joining MLH, Jack Lynch served as an executive Herbert Staehr, PhD with the St. Luke's Episcopal Health System in Houston, Vice President, Global Head of Transforming Care Texas, for nearly 20 years. There, he advanced to the posi- Delivery at Siemens Healthineers tion of executive vice president and CEO, and was also CEO of the system’s flagship facility, St. Luke's Episcopal Herbert Staehr is passionate about healthcare and, as global head of Hospital. He served on the boards of a variety of profes- Transforming Care Delivery, drives activities to equip healthcare pro- viders to deliver higher-value care. Prior to this position, he led Portfolio sional associations, including the Texas Hospital Association, Development and Marketing within the Enterprise Services and the Greater Houston Hospital Counsel, and the United Way. Solutions business of Siemens Healthineers. He received his undergraduate degree from the University Before joining Siemens Healthineers, Herbert Staehr worked with of Scranton in Pennsylvania, and his Master of Health a major private hospital group in Germany in senior leadership roles Administration degree from the Washington University including serving as managing director of an acute care and a post- School of Medicine in St. Louis, Missouri. acute care hospital. Earlier, he led the group’s Corporate Development department. He was employed for several years in the Healthcare As former Governor of the American College of Healthcare Consulting practice of McKinsey & Company on various European and Executives, Jack Lynch serves on the boards of the Delaware international assignments. Herbert Staehr holds a PhD in Healthcare Valley Healthcare Council, the United Way of Southeastern Economics from the University of Hohenheim, Germany. He obtained a Pennsylvania, The Haverford School, and the Malcolm dual degree (Bachelor of Arts and Diplom-Betriebswirt) in International Business and Finance from the European School of Business, Germany, Baldrige National Quality Award Board of Overseers. and Dublin City University, Republic of Ireland. Siemens Healthcare GmbH, 2019 13 Literature 1 Lynch, J. 2017. The Three-Legged Stool: Why Safety, 11 Small, CR, Porterfield, S et al. 2015. Disruptive Quality and Equity Depend on Each Other. Journal of behavior within the workplace. Applied Nursing Healthcare Management (JHM), 62 (5), p298-301. Research, 28 (2), p67-71. 2 Lynch, J. 2018. Personal interview, Dec. 6th, 2018, 12 Tawfik, DS, Sexton, JB et. al. 2017. Context in Quality Bryn Mawr. of Care. Improving Teamwork and Resilience. Clinics in Perinatology (Clin Perinatol), 44 (3), p541-52. 3 Kanel, KT and Schmeltz, R. 2016. Levers of Excellence in Hospital Leadership: Lessons from the 13 Schaeffer, P. 2017. Driving Culture Change at Main Chief Executives of Pennsylvania’s Best Hospitals. Line Health. HR Pulse Magazine from ASHHRA, Pittsburgh Regional Health Initiative. Summer 2017 issue. 4 Brooks, A-M, Phillips, E et al. 2013. Building a Culture 14 Advisory Board Company. (2015). Health of Safety: Aligning Innovative Leadership Rounding system CEO: The business case for investing in and Staff Driven Hourly Rounding Strategies. Internal diversity. [Online] URL [Accessed: 23. Work Environment, Safety and Clinical Outcomes. November 2018]. Nurse Leader, 12 (1), p39-44. 6 Main Line Health System. 2017a. Overview of Main 15 Lynch, J, Buongiorno, M et al. 2017. Performance Line Health System. [Online] URL [Accessed: 23. November 2018]. 16 Institute of Medicine (IOM) 2001. Crossing the Quality Chasm: A New Health System for the 21st 7 Main Line Health System and Affiliates. 2017. Century. Washington (DC): National Academies Press. Consolidated Financial Statements for the Years Ended June 30, 2017 and 2016. 17 Main Line Health System. 2017b. Nursing. Annual Report. 8 Lynch, J and Onyekere, C. 2014. Serving the Most Vulnerable: Population Health and the Reduction of 18 Gooch, K. 2016. How 5 health systems are Health Care Disparities. Webinar series: Institute for recruiting, retaining nurses during an RN shortage. Diversity in Health Management. Becker Hospital Review. [Online] URL Fourth Industrial Revolution. [Accessed: 23. November 2018]. 10 Catalyst Learning Blog. 2017. Main Line Health Improves Diversity among Leadership Team Starting 19 NSI Nursing Solutions. 2018. 2018 National with Frontline Employees. [Online] URL 21 PIVOT stands for Promoting Innovation by Valuing [Accessed: 23.November 2018]. Organizational Transformation 14 © Siemens Healthcare GmbH, 2019 At Siemens Healthineers, our purpose is to enable health- care providers to increase value by empowering them on their journey toward expanding precision medicine, trans- forming care delivery, and improving patient experience, all made possible by digitalizing healthcare. An estimated 5 million patients globally benefit every day from our innovative technologies and services in the areas of diagnostic and therapeutic imaging, laboratory diagnos- tics, and molecular medicine, as well as digital health and enterprise services. We are a leading medical technology company with over 120 years of experience and 18,000 patents globally. Through the dedication of more than 50,000 colleagues in 75 countries, we will continue to innovate and shape the future of healthcare. Siemens Healthineers Headquarters Siemens Healthcare GmbH Henkestr. 127 91052 Erlangen, Germany Phone: +49 913184-0 siemens-healthineers.com Published by Siemens Healthcare GmbH · Printed in Country · 7165 03190.5 · ©Siemens Healthcare GmbH, 2019