Goals and Objectives for Fiscal Year 2012

Transcription

1 Goals and Objectives for Fiscal Year 2012 UPMC St. Margaret Teresa G. Petrick July 8, 2011

2 UPMC St. Margaret: Major Goals and Objectives for FY 2012 Deliver Financial Results and Operational Metrics Established in the FY2012 Budget, Recruitment of additional Primary Care and placement of Specialty Physicians to expand services to the Allegheny Valley Continue to strengthen and build a culture of quality and safety for all patients with a specific focus on the following process measures: Heart Failure discharge instructions, Patient falls and Pressure Ulcers, Patient 30 day readmissions and Hand Hygiene compliance Continue to develop and deliver the Ultimate Patient Experience through Quality Initiatives, a focused Patient Satisfaction plan, Physician and Employee engagement and targeted Operational Efficiencies Continue NDNQI Reporting; Formulate Strategies for Sustaining Nursing Excellence in Collaboration with Professional Practice Council, Expand the use of Physician Electronic Documentation and continue working toward HIMSS EMR Adoption Model (Stage 7), Work collaboratively with Health System leadership to assure appropriate patient access to UPMC facilities and services (i.e. Magee at St. Margaret, Natrona Heights time share) Continue to Improve Recruitment and Retention Metrics over FY 2011 Results or at UPMC Defined Target, Exceed the 50th percentile of the State average of HCAHPS Measures Continue to strengthen and enhance academics at UPMC St. Margaret through community initiatives, FHC enhancement and resident rotations into the rural communities Improve Community Health Initiatives through partnerships with Foundation for targeted initiatives and employee wellness programs. 2

3 UPMC St. Margaret: Major Goals and Objectives for FY 2011 Position for Growth and Development by completing the Master Campus Plan, Completing the A&E for the South Addition, completion of the North Addition and the opening of the Magee at St Margaret Center Proactively mitigating Highmark risk by assessing risk and engaging private practice and employed physicians Continue to develop strength in key Medical Leadership positions 3

4 Objective: Organizational Growth & Development Goal Type Target/Expected Updates Meet or exceed budget growth targets PG & D Achieve Budget Admissions: Med/Surg: 15,291 Rehab: 485 Deliver Outpatient Revenue: $601 Million Increase market share in Alle-Kiski Valley by partnering with UPMC HealthPlan for employer enrollment of Subscribers Seek approval to study/recommend the replacement and construction of new Lawrencville Family Health Center in partnership with St. Margaret Foundation PG&D Mkt Resp PG&D Mkt Resp Increase admissions, outpatient services and ED visits from the following: Alle-Kiski Lower Burrell/New Ken A/E planning for the new Lawrenceville FHC Develop Phase II Plan to enhance and expand cardiology services PG&D Develop and expand cardiology services and St. Margaret Hospital 4

5 Objective: Performance Includes: Includes: Financial and Operating Performance (Perf), Clinical Quality and Safety (Qual/Safety), Integration (Integ) Goal Type Target/Expected Updates Achieve Contribution margin target Perf $84.1M Achieve med/surg length of stay target Perf 4.7 Days (Med/Surg) Achieve cost per case target (based on controllable expense) Perf $4,092 (per adj. case) 5

6 Objective: Performance (Continued) Includes: Includes: Financial and Operating Performance (Perf), Clinical Quality and Safety (Qual/Safety), Integration (Integ) Goal Type Target/Expected Updates Continue Focus of Revenue Cycle Metrics at Entity Level: Perf Days in A/R </= 28 days Charge Capture </= 1.5% (> 3+ Days) Denial Rate </= 1.0% Late Rebill Rate </= 0.75% ED, Radiology and SDS Co-Pay Collections Increase FY10 collections by 10%. Revenue Realization Optimize charges that have an incremental net payment benefit in conjunction with the enhanced capabilities associated with the Cerner upgrade (3 rd Qtr). Complete HBC conversions for B&B and ENT 6

7 Objective: Organizational Growth & Development Do not exceed Mortality Rate within the established benchmark Do not exceed Readmission Rate within the established benchmark Deliver Expected Results associated with Highmark s Pay-for-Performance Initiatives Quality Blue Qual/Safety </= 2.5% overall acute </=1.0 actual to expected (acute) </=1.0 actual to expected (Heart Failure) </=1.0 actual to expected (AMI) </=1.0 actual to expected (Pneumonia) Qual/Safety </=1.0 actual to expected (acute) </=1.0 actual to expected (Heart Failure) </=1.0 actual to expected (AMI) </=1.0 actual to expected (Pneumonia) Qual/Safety Expand scope of quality measures and improve performance for FY2012 quality initiatives and programs (Further delineated within quality measures on subsequent pages) 7

8 Objective: Organizational Growth & Development QualityBlue P4P Qual/Safety VTE Prevention and Care Coordination Rate of 4B VTE Prophylaxis Rate of 6A VTE Prophylaxis Rate of house-wide DVT (index and within 30 days) Rate of house-wide PE (index and within 30 days) Confirmed VTE, no prophylaxis Warfarin discharge instructions 9 month avg. >=90% 9 month avg. >=90% Final 3 months avg. <0.4 Final 3 months avg. <0.3 Final 3 months avg. <5% Final 3 month avg. >=90% 8

9 Objective: Organizational Growth & Development Readmissions Qual/Safety Rate of 7 day readmissions including IP/OBS Rate of 30 day readmissions including IP/Obs 9 month avg.>=2.5% reduction (4.1% to 3.9%) 9 month avg.>=2.5% reduction (13.2% to 12.8%) 7-day readmission pts with defect free care transition 9 month avg. >=90% OR Defect free Care scored individually: Medications: 9 month avg.>=90% Transition Record: 9 month avg. >=90% Transmitted Record: 9 month avg. >=90% 9

10 Objective: Organizational Growth & Development QualityBlue P4P Qual/Safety Surgical Safety Inpatient surgical site infections Outpatient surgical site infections Inpatient urinary catheter removed on POD 2 Temperature management (Normothermia) Outpatient prophylactic antibiotic within 1 hour Outpatient appropriate antibiotic Inpatient Surgical Safety Checklist Outpatient Surgical Safety Checklist Inpatient Beta-Blocker Therapy 9 month avg. <0.6 %or >= 15% reduction (0.7 to 0.6) 9 month avg. <0.4 %or >= 15% reduction (0.07 to 0.06) Final 3 months avg. >=90% Final 3 months avg. >=90% Final 3 months avg. >=90% Final 3 months avg. >=90% Final 3 months avg. >=90% Final 3 months avg. >=90% Final 3 months avg. >=90% 10

11 Objective: Organizational Growth & Development QualityBlue P4P Qual/Safety Emergency Department Throughput ED arrival to departure (inpatient) status ED arrival to departure (observation) status ED arrival to departure (home, etc) status ED arrival to seen by a physician or LIP Admission decision to ED departure Observation decision to ED departure Patients leaving w/o being seen by a MD/LIP CAUTI Rate of HA CAUTI Patients with Urinary Cath order present Patients with completed daily assessment <=230 minutes <=220 minutes <=145 minutes <=25 minutes <=75 minutes <=65 minutes <=1.0% 9 months of < 5 or < 2.0 rate OR >=5% reduction (1.34 to 1.27) Final 3 months avg. >=90% Final 3 months avg. >=90% 11

12 Improve clinical and process measures for the following: Objective: Organizational Growth & Development Heart Failure: Discharge Instructions VBP LVF Assessment ACE or ARB for LVSD Smoking Cessation Appropriate Care HF Qual/Safety Meet or exceed targets set by Center for Quality Improvement and Innovation (CQI2) for measure. Value Based Purchasing (VBP) 12

13 Improve clinical and process measures for the following: Objective: Organizational Growth & Development Pneumonia: Qual/Safety Meet or exceed targets set by Center for Quality Improvement and Innovation (CQI2) for measure. Antibiotic Selection VBP Blood Cultures VBP Timing of ATB Pneumonia Vaccinations Smoking Cessation Influenza vaccination Appropriate Care Pneumonia Value Based Purchasing (VBP) 13

14 Improve clinical and process measures for the following: AMI: Objective: Organizational Growth & Development BB at Discharge ASA at Arrival ASA at Discharge ACE or ARB for LVSD Smoking Cessation Statin at Discharge Appropriate Care AMI Outpatient Median Time to Transfer Outpatient ASA on Arrival Outpatient MedianTime to ECG Qual/Safety Meet or exceed targets set by Center for Quality Improvement and Innovation (CQI2) for measure. 45 Minutes 10 Minutes 14

15 Improve clinical and process measures for the following: SCIP: Objective: Organizational Growth & Development Antibiotic administration w/in 1 hr VBP Appropriate antibiotic selection VBP Antibiotic discontinuation w/in 24 hrs VBP VTE prophylaxis ordered VBP VTE prophylaxis timely VBP Beta-Blocker Therapy VBP Appropriate hair removal Post-operative urinary catheter removal Post-operative temperature management Appropriate Care SCIP Outpatient timing of prophylactic antibiotic Qual/Safety Outpatient selection of prophylactic antibiotic Value Based Purchasing (VBP) Meet or exceed targets set by Center for Quality Improvement and Innovation (CQI2) for measure. 15

16 Objective: Organizational Growth & Development Improve clinical and process measures for the following: INFECTIONS: Hand Hygiene CLABS-Hospital-wide CLABS rate CDI-Hospital-wide CDI rate CAUTI-Hospital-wide CAUTI rate Surgical Site Infections-Hospital-wide SSI rate Ventilator-associated Pneumonia-ICU VAP rate MRSA-Hospital-wide MRSA rate Qual/Safety Meet or exceed targets set by Center for Quality Improvement and Innovation (CQI2) for measure. 75% 0.5 (per 1,000 device days) / Highmark P4P Sustainability <= (per 10,000 patient days) 1.25 (per 1,000 device days) 6.5 (per 1,000 surgeries) 1.5 (per 1,000 device days) 1.3 (per 1,000 patient days) 16

17 Objective: Organizational Growth & Development Improve clinical and process measures for the following: Pressure Ulcers: Unit Acquired Pressure Ulcers (Stage 1/2) Med Surg ICU IMC Rehab Unit /Hospital Acquired Pressure Ulcers (Stage 3/4) Patient Falls: Med Surg ICU IMC Rehab Injury Index Meet or exceed targets set by Center for Quality Improvement and Innovation (CQI2) for measure. </=3.0% </=8.0% </=6.0% </=2.5% None % 17

18 Objective: Organizational Growth & Development UPMC Health Plan P4P Deliver expected results associated with UPMC Health Plan Pay for Performance Initiative Expand scope of quality measure and improve performance for FY2012 quality initiatives and programs Palliative Care Program Develop and Implement facility specific model of care Geriatric Fracture Program UPMC Health Plan P4P Participate/Collaborate with the Health Plan and Renaissance in the development of a Pilot ACO model Develop and Implement facility specific model of care Develop model to achieve higher reimbursement of MC payments to population sample through enhanced coding and reduce utilization of services 18

19 Objective: Performance (Continued) Includes: Includes: Financial and Operating Performance (Perf), Clinical Quality and Safety (Qual/Safety), Integration (Integ) Improve clinical/ process measures for the following (cont): Develop and Implement Patient experience improvement plan HCAHPS Qual/Safety Exceed National Achievement Threshold set by CMS at the 50 th Percentile. (* Current 50 th Percentile) Increase HCAHPS outcomes to exceed 50 th Percentile. Communication with nurses Exceed 50 th Percentile (76%)* Communication with doctors Exceed 50 th Percentile (80%)* Responsiveness of hospital staff Exceed 50 th Percentile (62%)* Pain management Exceed 50 th Percentile (70%)* Communication about medications Exceed 50 th Percentile (60%)* Cleanliness of hospital Exceed 50 th Percentile (71%)* Quietness of hospital Exceed 50 th Percentile (54%)* Discharge information Exceed 50 th Percentile (82%)* Overall rating of hospital Exceed 50 th Percentile (67%)* Willingness to recommend Exceed 50 th Percentile (70%)* 19

20 Objective: Performance (Continued) Includes: Includes: Financial and Operating Performance (Perf), Clinical Quality and Safety (Qual/Safety), Integration (Integ) Collaborate with UPMC Magee to decompress the St. Margaret Campus Integ Identify and shift Admissions from specific physicians or discreet services. 20

21 Objective: Reputation Includes: Academic Excellence (Academic), Outstanding Community Citizenship (Community), Recognition for Excellence (Recognition) Increase the number of Unit Directors and Directors within the Nursing Division who have obtained National Certification Academic Unit Directors and Directors will increase National Certification in FY12 by 3%. Facilitate evidence-based research activities at the unit level Improve community health through targeted initiatives and employee wellness programs Academic Community All Unit Directors in collaboration and nursing education will implement an evidenced-based project in FY12. Continue to provide Disease Awareness related to Cardiovascular Risk, Diabetes Symptoms and Management; expand education programs to employees through the UPMC Health Plan activities. Provide free flu shots/vaccinations to Senior Citizens 21

22 Objective: Reputation (Continued) Includes: Academic Excellence (Academic), Outstanding Community Citizenship (Community), Recognition for Excellence (Recognition) Monitor community and financial assistance services Community Continue Participation in Health Fairs, Library Lectures, etc. to provide Wellness and Clinical Programs UPMC St. Margaret will continue to work with the Foundation to support wellness programs in our local schools and communities Community Maintain Financial Assistance and Community Initiatives at FY 2011 level 22

23 Objective: System Evolution Includes: Workforce, Information Technology (IT), and Organizational Evolution (Evolution) Reroute the Fiber and Copper Cabling Infrastructure that provides data and voice service to the buildings on the main campus to support the construction of the Resource Center IT Provide connectivity and redundancy using a new route for the Fiber plan and deploy a network based solution for phone services to replace the copper voice backbone Implement the Cerner Capacity Management Solution as the pilot site for UPMC IT Assist with the development of the solution to Insure that productivity and hospital throughput are not negatively affected Implement Voice Recognition for Directory Assistance for internal O dialed calls to the Call Center IT Reduce the number of calls to the Call Center which require operator assistance and decrease end user wait times for service Convert the PC s in the Patient Rooms of a Med/Surg Unit into a Electronic Media Portal for Patient and Family use. IT Provide a technological solution to help improve patient satisfaction 23

24 Objective: System Evolution (Continued) Includes: Workforce, Information Technology (IT), and Organizational Evolution (Evolution) Maintain average Merit Increase Workforce Ensure Average Increase does not exceed system target of 3%. Timely Performance Evaluations Workforce on-time 0% warning status 0% late status Business Unit Turnover Overall One Year Turnover Nursing Turnover Redesign of Retention Council to match Magnet re-designation model. Workforce < / = 12% and below UPMC Avg < / = 28% and below UPMC Avg < / = 8% and below UPMC Avg Use of survey feedback (Best Places to Work/NDNQI etc.) to identify action plans for improvement to be completed through Retention Council Vacancy Rates Workforce Overall Nursing < / = 3.5% and below UPMC Avg < / = 3.5% and below UPMC Avg 24