Accountability Agreement Tool Kit

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2 Organization-Wide Leadership Accountability Agreement Effective I. HCAHPS Goals (Provider of Choice) # 12 Mos High 12 Mos Low 1 1. Communication with nurses 2. Communication with doctors. Responsiveness of hospital staff 4. Pain Management 5. Communications about Medications 6. Cleanliness of hospital environment 7. Quietness of hospital environment 8. Discharge Information 9. Overall 10. Willingness to Recommend II. Patient Satisfaction Mean Score Goals (Provider of Choice) # Overall Scores 12 Mos 12 Mos Services 4. ER 5. Clinics 6. III. Internal Support Services Scorecard Goals (Provider & Employer of Choice) # Hospital Overall 6 Mos (baseline - if applicable) 1. Timeliness of Service 2. Telephone Etiquette. Quality of Service 4. Professionalism & Attitude 5. Overall IV. Employee Satisfaction (Employer of Choice) # Hospital Overall Current (baseline) 6 Mos (if applicable) 1. Hospital Overall V. Employee Turnover (Employer of Choice) Mos (Date 12 Mos # By Position, Department or Overall Turnover Staff Turnover Current Turnover Goal 1 2 Total # # % # % % % 1. Clinical 2. Non-Clinical VI. Service Excellence Goals (Provider & Employer of Choice) # 6 Mos (baseline - if applicable) 1. Service Huddles 2. DO IT Meetings 12 Mos 1

3 Department-Specific Leadership Accountability Agreement I. HCAHPS Goals (Provider of Choice) # Domain 12 Months High 12 Months Low 1 Goal 1. Communication with nurses 2. Communication with doctors. Responsiveness of hospital staff 4. Pain Management 5. Communications about Medications 6. Cleanliness of hospital environment 7. Quietness of hospital environment 8. Discharge Information 9. Overall 10. Willingness to Recommend II. Patient Satisfaction Mean Score Goals (Provider of Choice) # Specific survey vendor questions as they pertain to your department. 12 Months High 12 Months Low 1 Goal III. Internal Support Services Scorecard Goals (Provider & Employer of Choice) # Criteria 6 Months (baseline - if applicable) 1. Timeliness of Service 2. Telephone Etiquette. Quality of Service 4. Professionalism & Attitude 5. Overall IV. Employee Satisfaction (Employer of Choice) # Domain (if applicable) Current (baseline) V. Employee Turnover (Employer of Choice) 6 Months (if applicable) 12 Months 12 Months # May be by Position Staff Turnover Current Turnover Goal 1 Total # # % # % 1. RNs 2. VI. Service Excellence Goals (Provider / Employer of Choice) # Responsibilities 6 Months (baseline - if applicable) 12 Months 1. Service Huddles 2. DO IT Meetings noted goals, including gaining buy-in and support from my staff. I further acknowledge that % of my performance review will be linked to the outcome of these goals. 2

4 Individual Leadership Accountability Agreement I. Semi-Annual Leadership Empowerment Survey # s 6 Months (baseline) 1. Visionary & Change Agent: This Leader helps me understand change and to see the Big Picture. 2. Builder of Trust & Personal Effectiveness: This Leader practices what he/she preaches, is a good role model, and treats me with courtesy and respect.. Communicator: This Leader keeps me informed so that I truly feel like a knowledgeable insider. 4. Customer Service & Survey Literate: This Leader does a good job of inspiring patient-centered service in my department and is always aware of feedback from our satisfaction surveys. 5. Team Leader: This Leader promotes teamwork within our department and with other departments/units. 6. Meeting Leader: This Leader runs meetings/huddles that inspire me and encourage me to speak up. 7. Project & Time Management: This Leader ensures that I have the tools and training to do my job in a timely and effective way. 8. Creative Problem Involver: This Leader encourages open and creative problem-solving in my department. 9. Empowerer/Delegator: This Leader gives me clear assignments and empowers me to do my best. 10. Employee Developer & Coach: This Leader is effective at coaching me, developing my skills and keeping me on track. 11. Performance & Conflict Manager: This Leader is timely and appropriate with both positive feedback and corrective action. 12. Hardwirer: This Leader is actively engaged in the Service Excellence Initiative Process. ( II and beyond) 1. Overall I rate my working relationship with this Leader as: II. Service Excellence Goals # Responsibilities 6 Months (baseline - if applicable) 12 Months Goal 12 Months 1. Attendance at Training Sessions 2. Participation on OASIS Teams. Patient Rounding (if applicable) 4. Staff Rounding noted goals. I further acknowledge that % of my performance review will be linked to the outcome of these goals.

5 Department-Specific Leadership Accountability Agreement I. HCAHPS Goals (Provider of Choice) # Domain 12 Months High 12 Months Low 1 Goal 1. Communication with nurses 2. Communication with doctors. Responsiveness of hospital staff 4. Pain Management 5. Communications about Medications 6. Cleanliness of hospital environment 7. Quietness of hospital environment 8. Discharge Information 9. Overall 10. Willingness to Recommend II. Patient Satisfaction Mean Score Goals (Provider of Choice) # Specific survey vendor questions as they pertain to your department. 12 Months High 12 Months Low 1 Goal III. Internal Support Services Scorecard Goals (Provider & Employer of Choice) # Criteria 6 Months (baseline - if applicable) 1. Timeliness of Service 2. Telephone Etiquette. Quality of Service 4. Professionalism & Attitude 5. Overall IV. Employee Satisfaction (Employer of Choice) # Domain (if applicable) Current (baseline) V. Employee Turnover (Employer of Choice) 6 Months (if applicable) 12 Months 12 Months # May be by Position Staff Turnover Current Turnover Goal 1 Total # # % # % 1. RNs 2. VI. Service Excellence Goals (Provider / Employer of Choice) # Responsibilities 6 Months (baseline - if applicable) 12 Months 1. Service Huddles 2. DO IT Meetings noted goals, including gaining buy-in and support from my staff. I further acknowledge that % of my performance review will be linked to the outcome of these goals. 4

6 ANNUAL HCAHPS SCORES NURSING # I Leader Owned Goal % Goal % by Last ¼ Next 12 Y2 Y Months How often did nurses communicate well with patients? 1. During this hospital stay, how often did nurses treat you with courtesy and respect? 2. During this hospital stay, how often did nurses listen carefully to you?. During this hospital stay, how often did nurses explain things in a way you could understand? How often did patients receive help quickly from hospital staff? 4. During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it? 5. How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted? How often was patients pain well controlled? 6. During this hospital stay, how often was your pain well controlled? 7. During this hospital stay, how often did the hospital staff do everything they could to help you with your pain? How often did staff explain medicines before giving them to patients 8. Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?? 9. Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand? How often was the area around patients room kept quiet at night? 10. During this hospital stay, how often was the area around your room quiet at night? Were patients given information about what to do during their recovery at home? During this hospital stay, did doctors, nurses or other hospital staff 11. talk with you about whether you would have the help you needed when you left the hospital? During this hospital stay, did you get information in writing about 12. what symptoms or health problems to look out for after you left the hospital? How do patients rate the hospital overall? Would patients recommend the hospital to friends and family? noted Leader Owned Goals, including gaining buy-in and support from my staff to achieve these. I further acknowledge that % of my performance review will be linked to these goal s 5

7 CASE MANAGEMENT Last Next Discharge 2. Extent felt ready discharge. Speed of discharge process 4. Help arranging homecare services 6

8 DIETARY Last Next Meals 2. Special/restricted diet explained. Temperature of food 4. Quality of the food 7

9 ENVIRONMENTAL SERVICES Last Next Room temperature 2. TV, call button, etc. worked. Helpfulness People Info desk 8

10 ANNUAL HCAHPS SCORES ENVIRONMENTAL SERVICES # I Leader Owned Goal % Goal % by Last ¼ Next 12 Months 2 How often were the patients rooms and bathrooms kept clean? 1. During this hospital stay, how often were your room and bathroom kept clean? How do patients rate the hospital overall? Would patients recommend the hospital to friends and family? noted Leader Owned Goals, including gaining buy-in and support from my staff to achieve these. I further acknowledge that % of my performance review will be linked to these goal s 9

11 HOUSEKEEPING Last Next Room 2. Pleasantness of room décor. Room cleanliness 4. Courtesy of person cleaning room 10

12 PHYSICIANS Last Next Physician 2. Time physician spent with you. Physician concern question/worries 4. Physician kept you informed 5. Friendliness/courtesy of physician 6. Skill of physician 7. Staff include decisions restatement 11

13 LAB Last Next Test & Treatments 2. Wait time for test & treatments. Concern/comfort during T&T 4. Skill of person took blood 5. Courtesy of person started IV 6. Courtesy of X-ray Staff 12

14 OCCUPATIONAL THERAPY Last Next Test & Treatments 2. Wait time for test & treatments. Concern/comfort during T&T 4. Skill of person took blood 5. Courtesy of person started IV 6. Courtesy of X-ray Staff 1

15 PHYSICAL THERAPY Last Next Test & Treatments 2. Wait time for test & treatments. Concern/comfort during T&T 4. Skill of person took blood 5. Courtesy of person started IV 6. Courtesy of X-ray Staff 14

16 RADIOLOGY Last Next Test & Treatments 2. Wait time for test & treatments. Concern/comfort during T&T 4. Skill of person took blood 5. Courtesy of person started IV 6. Courtesy of X-ray Staff 15

17 RESPIRATORY THERAPY Last Next Test & Treatments 2. Wait time for test & treatments. Concern/comfort during T&T 4. Skill of person took blood 5. Courtesy of person started IV 6. Courtesy of X-ray Staff 16

18 OVERALL Last Next Staff sensitivity to inconvenience 2. Extent staff wore ID badges. Info. family re-condition/treatment 17