It s all about VISION, EXPECTATIONS, AND ACCOUNTABILITY

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It s all about VISION, EXPECTATIONS, AND ACCOUNTABILITY Anne Lang, Vice President for Human Resources and Legal Services Lauren Reardon, Director of Guest Services and Service Excellence OUR PROFILE 229-bed community hospital, 11 miles north of Boston Services: critical care, medical-surgical, cancer center, maternal/child, pediatrics, emergency Over 30 satellite locations Over 2700 employees-non-unionized Over 750 Medical Staff Over 800 volunteers

ACHIEVEMENTS First and only hospital in Massachusetts to achieve Magnet designation three times Top employer awards: Boston Business Journal, Boston Globe Local and national recognition for quality, patient and physician satisfaction VISION

VISION To ensure that the highest quality care continues to be delivered through the coordination of available resources for the purpose of improving the health of the communities we serve. VISION To care. To heal. To excel. In service to our community.

VISION Selected Preventable Harm Events 108 Baseline 2008 FY2011 October 2010 through September 2011 Updated through August 31, 2011 *Data subject to validation 54 27 0 Goal for FY2009 38 Exceeded our 2009 Goal* Goal for FY2010 4 Exceeded our 2010 Goal* Goal for Q1 FY2012 5 Current Total* Inpatient Falls with Serious Injury 2 Central Line Associated Bloodstream Infections (ICU) 0 Patient Safety Surgical Site Infections 3 Ventilator Associated Pneumonia (ICU) 0 Serious Medication Errors 0

OUR JOURNEY Service Excellence Performance Excellence Leadership Excellence LEADERSHIP EXCELLENCE How many you have heard this comment: Employees do not leave an organization, they leave a supervisor.

VISION Make our leaders the best possible leaders they can be. Make every employee feel valued. EXPECTATIONS Leadership Competencies Organization Orientation, Goal Achievement, and Accountability Commitment to Service Excellence and Continuous Improvement Problem Solver and Decision Maker Relationship and Team Builder People Developer and Communicator

EXPECTATIONS Organizational Orientation Makes decisions that best serve the organization rather then areas of responsibility or self Holds self and others accountable for producing high quality work and work within specified timelines Exemplifies a vision of organizational success that sparks excitement in others. Places a high priority on safety ensuring self and staff role model safety behaviors and tools Establishes and achieves goals EDUCATION Leadership Forums Leadership Courses Leadership Orientation Launching Leaders

ACCOUNTABILTY Accountability: Everyone knows David is a negative force. All he does is complain. Why isn t his supervisor doing anything about it? ACCOUNTABILTY Value: Why doesn t my supervisor ever listen to me? Why can t I have input into decisions?

ACCOUNTABILTY Value: They treat people differently here. REINFORCEMENT Leadership Recognition Likes Card

RESULTS Employee Partnership Survey Results: 99 th percentile overall for AHA Region 1 99 th percentile for Leaders do a good job of communicating major developments. 99 th percentile for I think this organization is highly regarded in the community. SERVICE EXCELLENCE

VISION To demonstrate the PROMISE of Winchester Hospital in every encounter with patients, co-workers and the community. EXPECTATIONS When you are at your very best, what do you: DO SAY ACT To make your patient s experience the every best it can be?

EXPECTATIONS Promoting Teamwork Respect Ownership Maintaining a Positive Attitude Initiative Safety and Quality Empathy Look, I can t promise I ll change, but I can promise I ll pretend to change.

EMPATHY We take care, and we take time to use our best observation skills to anticipate how a patient or coworker would feel in any given circumstance. We put ourselves in their shoes and respond to needs and concerns before they grow into larger issues. We have compassion for others, whether it is a patient or coworker, by taking the time to listen, care and offer encouragement. Empathy: The Human Connection to Patient Care Courtesy of Cleveland Clinic

SERVICE EXCELLENCE Patient Experience Communication Results Comments Weekly Tips Service Excellence Response Team (SERT) Rounds Satisfaction Teams

SERVICE EXCELLENCE It s all about Communication It is about how you make the patient and their family feel Not what you say; it s what people hear How you say what you say INITIATIVES Ear Plugs White Noise Machines and Radios Bereavement Bags and Carts ED Hold Bags Thank you cards New White Boards And more

Our Promise to our Patients

ACCOUNTABILITY Recruitment and Orientation Hire for Attitude and Train for Skill Day is dedicated to Service Excellence Education Evaluations 50% PROMISE PROMISE Dave: Everyone loves Dave, but we are not really sure what he does all day? Needs to be fired The Best Jane: Everybody knows she treats people terribly! Job Results

ACCOUNTABILITY Reward and Recognition Comment Reports PROMISE Cards PROMISE Moments Compassionate Caregiver Award Schwartz Rounds RECOGNITION

RECOVERY RELATE Model Recognize Concern Empathize Listen Apologize Take Responsibility Explain what you are going to do RECOVERY Phone Calls Visit Patients ED letter

PHYSICIAN ENGAGEMENT Medical Executive Committee Department Meetings MD Champions ED Satisfaction Team Recognition Accountability: Goals set in contracts So... How are we doing?

RESULTS Would patients recommend the hospital to friends and family? Bars below tell the percent of patients who reported YES, they would definitely recommend. Sharp Memorial Hospital, CA Winchester Hospital, MA Poudre Valley Hospital, CO 84% 83% 82% Advocate Good Samaritan, IL Baptist Hospital, FL Massachusetts Hospitals National Atlanticare Regional Med Ctr, NJ Heartland Regional Med Ctr, MO Robert Wood Johnson University Hospital, NJ 74% 74% 74% 71% 70% 65% 60% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Winchester Hospital Massachusetts Hospitals National Results taken from hospitalcompare.hhs.gov website (release date April 2013) Data from July 1, 2011 through June 30, 2012 Patient Discharges RESULTS Would patients recommend the hospital to friends and family? Bars below tell the percent of patients who reported YES, they would definitely recommend. New England Baptist Mass General Brigham and Women Hospital Winchester Hospital Faulkner Hospital Beth Israel Deaconess Medical Ctr Newton Wellesley Hospital Lahey Clinic Tufts Medical Center Beverly Hospital State Holy Family Boston Medical Center National Hallmark Health 91% 89% 86% 83% 81% 80% 79% 78% 74% 74% 74% 72% 72% 71% 70% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Winchester Hospital State National Results taken from hospitalcompare.hhs.gov website (release date April 2013) Data from July 1, 2011 through June 30, 2012 Patient Discharges

RESULTS How often did nurses communicate well with patients? Bars below tell the percent of patients that their nurses "ALWAYS" communicated well. Winchester Hospital, MA 81% Sharp Memorial Hospital, CA 81% Heartland Regional Med Ctr, MO Advocate Good Samaritan, IL 80% 80% Poudre Valley Hospital, CO 79% Massachusetts Hospitals 79% Baptist Hospital, FL 79% National 78% Atlanticare Regional Med Ctr, NJ Robert Wood Johnson University Hospital, NJ 72% 76% 66% 68% 70% 72% 74% 76% 78% 80% 82% Winchester Hospital Massachusetts Hospitals National Results taken from hospitalcompare.hhs.gov website (release date April 2013) Data from July 1, 2011 through June 30, 2012 Patient Discharges RESULTS How often did nurses communicate well with patients? Bars below tell the percent of patients that their nurses "ALWAYS" communicated well. New England Baptist Faulkner Hospital 84% 85% Winchester Hospital 82% Newton Wellesley Hospital Mass General Holy Family Hallmark Health Brigham and Women Hospital State Beverly Hospital Beth Israel Deaconess Medical Ctr Tufts Medical Center National Lahey Clinic 80% 80% 80% 80% 80% 79% 79% 79% 78% 78% 78% Boston Medical Center 71% 60% 65% 70% 75% 80% 85% 90% Winchester Hospital State National Results taken from hospitalcompare.hhs.gov website (release date April 2013) Data from July 1, 2011 through June 30, 2012 Patient Discharges

Percent of Winchester Hospital patients who reported that their Nurses communicated well Usually Sometimes - Always 81% of Patients 16% of Patients Always Usually 3% of Patients Sometimes Always is the Key Word

PERFORMANCE EXCELLENCE The latest step in our journey. Let us tell you our Emergency Department story. INTRODUCTION OF LEAN Knew we had to begin piloting Lean principles and tools.

EMERGENCY DEPARTMENT Lean Initiatives: Value Stream 5S Green belt projects RESULTS Wait time from Door to ED room Shift Mar4-10, 2012 1 19 minutes 2 29 minutes 3 13 minutes Mar 4-10 2011 59 minutes 73 minutes 36 minutes % Reduction 67% 60% 63%

EMERGENCY DEPARTMENT Service Excellence Initiatives: Hospitality Associates, 1-9:pm, 7 days/week Call Backs Bedside report with nurses and physicians: PPD (Pain, Plan, Delay) Team nursing ED RESULTS: LIKELIHOOD TO RECOMMEND

KEY TAKEAWAYS It is all about consistency It s the little things It is always about striving to be the best