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In 2018, Memorial Hospital was a critical access hospital doing its best for the rural communities surrounding Carthage, Illinois. Staff were genuinely committed to patient care. Everyone knew that. But patient feedback told a different story.
Nurse communication sat at the 26th percentile nationally, and physician communication was at the 49th. Leadership could see the gap between staff intention and patient perception. And its team knew one thing clearly: more training alone wasn’t going to close it.
Memorial Hospital needed a culture shift.
A different kind of partnership
That culture shift couldn’t happen in a single department or from a single memo. It had to move through the whole organization — top to bottom, across teams and roles. To do that, Memorial Hospital partnered with Custom Learning Systems (CLS).
CLS began with a comprehensive focus group to understand where the gaps were and why. From there, the work came down to one question: how do you take a staff that already cares and help them show it, consistently, across every department, every shift, and every role?
Hardwiring accountability
Who will do What, by When, and How.
This gave departments a practical tool for turning cultural expectations into specific, measurable commitments. Leaders tracked progress and reinforced behaviors in huddles. They embedded expectations into onboarding and made clear that education was ongoing, not a one-time event.
As staffing changed and external pressures fluctuated, expectations held. Physician engagement emerged as a defining strength. Clinical leaders aligned their communication practices with frontline teams, reinforcing that patient experience wasn’t a nursing initiative. It was everyone’s.
These are not short-term gains that faded after the first quarter. Memorial Hospital experienced durable improvements, maintained over multiple years.
| Measure | Starting percentile | Current percentile |
|---|---|---|
| Communication with nurses | 26th | 97th |
| Communication with doctors | 49th | 91st |
| Communication about medications | 62nd | 98th |
| Willingness to recommend | Baseline | +18 percentile points |
| Cleanliness scores | Baseline | +22 percentile points |
As communication improved, broader trust indicators followed — a reflection of the everyday ownership behaviors that had taken hold across the organization. Areas where Memorial Hospital was already performing well stayed stable.
Memorial Hospital’s transformation didn’t stay inside the building.
The hospital earned and sustained CMS 5 Star patient experience recognition and was published by Becker’s Hospital Review for excellence in nursing and physician communication.
In 2023, Memorial Hospital was named Outstanding Rural Health Organization by the National Rural Health Association.
After earning its first CMS 5 Star patient experience rating, Memorial Hospital’s leadership didn’t celebrate with a banner and move on. It documented the moment and reinforced the lesson. The message it kept coming back to was simple: “It’s the right thing to do.”
That phrase became a cultural anchor: patient experience as a shared standard, not a performance target.
CLS reinforced this through system-wide initiatives, including the Everyone’s a Caregiver® Micro-Webinar Platform and its Vision of Kindness Care Everywhere. Every role influences the patient experience. Clinical or not.
One of the most visible expressions of this was what Memorial Hospital called the License to Clean. Staff across all departments were empowered to address environmental concerns on the spot, regardless of title or assignment.
Compliance became ownership, and that became the linchpin to success.
When leadership messaging, structured accountability, and organization-wide engagement work together, consistency replaces variability and ownership replaces compliance. The results show up in HCAHPS reports, but also in how staff talk about their work, how patients describe their care, and how a community sees its hospital.
For Memorial Hospital, what began as a performance gap became a point of pride.
With Custom Learning Systems to learn how you can transform your culture.
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