Accomplishments Fiscal Year 2015 UPMC Passavant
UPMC Passavant Summary of Significant FY15 Accomplishments Continue employee engagement initiatives that are aligned with UPMC Passavant s Mission, Vision, Values with the development of the employee survey actions plans to capture the voice of the employee at the departmental level. Ongoing Front line staff team addressing My Voice Survey as well as individual department specific action plans. Collaborate with the UPMC Health Plan to further develop new models of care that drive down costs and improve patient care outcomes. Successfully completed shared saving program with Primary Care Physicians (Genesis, CMI and Private) and initiated education and sharing information with limited specialty practices. Submit application for Magnet and prepare documents for submission. Delayed to 1st Quarter FY2016 Develop the next three year Community Health Needs Assessment in collaboration with the UPMC Passavant Hospital Foundation to improve the health status of residents in the communities served by UPMC Passavant. Ongoing CHNA survey sent out June 2 nd. Achieve continued growth of Ambulatory Care services through the Spine Center, Cranberry campus expansion, and collaborative efforts among the Cranberry campus and Lemieux Sports Complex. Spine Center scheduled to open August 3, 2015. Lemieux Sports Complex scheduled to open August 10, 2015. Cranberry on hold to better understand Highmark impact. Partner with the system and physician leadership to determine the feasibility of clinical service line integration. Foot ankle, exploring ENT for North phase I (St. Margaret/Passavant). Support System efforts in strengthening ring hospital relationships in northern tier, including closer collaboration with Jameson, Grove City and Ellwood City hospitals. Jameson pending AG/FTC approval, Grove City Joint Venture MSO OB completed and Ellwood - on hold Meet or exceed all financial and operating goals related to admissions, outpatient revenue, ED visits, surgeries, ALOS, and contribution margin. Exceeding target YTD Enhance IT capabilities to improve patient outcomes, experience, and continuum of care. Implemented erecord inpatient and observation clinical pathways. Further develop HVI and the Cardiac Product line. Increased outpatient volume Cath Lab and Open Hearts. 2
FY15 s and UPMC Passavant
Objective: Assess Inpatient Capacity Create scarcity via the reduction of bed capacity as appropriate. Framework Focus (If applicable) Sound Finance Reduce and manage LOS. Achieve goals related to ED throughput: Improve ALOS for both IP and OP from prior year indicators. Reduce LWBS from prior year indicators. Achieve goals related to central bed coordination: Improve efficiency from prior year. Continue to monitor appropriate patient placement. In process as census permits. ED s achieved. ALOS YTD 213. DLOS is 141. LWBS 0.14%. In process. 4
Objective: Collaboration with UPMC Health Plan Improve patient and member quality at lower costs. Develop care delivery models that focus on prevention, chronic care, and supportive/palliative care. Continue to enhance the cost sharing program with Primary Care Physicians. Framework Focus (If applicable) Symbiotic Relationships Enhance quality outcomes. Exceed readmission targets required from Highmark Quality Blue Program and UPMC Health Plan HEDIS program. Good Science HEDIS gap closure. Evaluate and reduce where appropriate, the utilization of consultations and overutilization of key hospital product lines. Symbiotic Relationships Solidify shared savings program with PCP s and UPMC Health Plan. Refer to quality dashboard. Educating Medical Staff on utilization of consults and working with system on service line integration. Program up and running. 5
Objective: Primary Care Framework Focus (If applicable) Increase Primary Care Market Share. Sound Finance Symbiotic Relationships Recruit two physicians with existing practices to increase market share. Successfully recruited Dr. Greg Molter. Continue to develop a fully aligned Primary Care network in the Northern Tier. Sound Finance Symbiotic Relationships Recruit Family Practice/Internal Medicine residents to be aligned with Primary Care Provider practices. We recruited 3 Primary Care residents to join existing practices. 6
Objective: Ambulatory Care Framework Focus (If applicable) Establish a Comprehensive Ambulatory Center to provide continued growth and development in the UPMC Passavant Service area. Position Cranberry Campus to be a complete Ambulatory Center to compete against the Medical Mall. Explore feasibility of expanding Wound Care Services for the Northern Region. Sound Finance Initiate construction planning and build out of the Comprehensive Spine and Ambulatory Center. Effectively market and promote programmatic offering in collaboration with PAS medical staff. Sound Finance Initiate construction planning and build out of the Cranberry ambulatory expansion project. Continue to evaluate availability of outpatient services at the Cranberry campus and Northern Region to compete with Highmark Medical Mall. Symbiotic Relationships Good Science Increase inpatient and outpatient volumes for the Northern Tier facilities. Spine Center set to Open August 2015. On Hold at present. Continue to reevaluate. Exceeding targeted volumes. Expanding hours to accommodate. 7
Objective: Ambulatory Care (cont.) Framework Focus (If applicable) Explore the feasibility of consolidating the HVI into one continuous service area at McCandless campus. (Phase II) Symbiotic Relationships Good Science Improve access and operational efficiency. Consolidated McKnight Road and opened Stonewood to compete with AHN. Collaborate with the Lemieux Sports Complex to provide appropriate services at the Cranberry Campus. Sound Finance Maximize operational efficiency, reduce duplication of services and expenses. In process. Dr. Vonda Wright to begin utilizing Cranberry Fall 2015. Initiate consolidation of physicians offices on Route 8 and McKnight Road. New Models of care Sound finance Reduce operating costs of practices and improve access to services. In process 8
Objective: New Models of Care Framework Focus (If applicable) Implement Care Coordination Model across all inpatient units. Enhance patient and family centered care. Maximize the utilization of the Observation Unit on 3 Main at 70% or greater. Redesign Hospitalist model to a mixed APP/MD model. New models of care Evaluate the following pilot units: 5 South, C2Main and PCU. Develop timeline to deploy model hospital-wide. New models of care Maintain the current nursing handoff process completed at the bedside, involving the patient and family. New models of care Reduce LOS for observation patients. Continue to monitor appropriate placement of patients. Good science Reduce overall Hospitalist program costs. Improve the utilization of resources where appropriate to optimize patient care. Completed pilot. Plan for house wide rollout to be complete by the end of FY. Complete and monitoring Did not achieve. 40% due to high census In process 9
Objective: Clinical Service Line Management Framework Focus (If applicable) Meet or exceed performance standards set by SSOC. Sound Finance Continue increases in room utilization, maintain best in system on-time starts, and maintain below average turnover times. Maintained the best on-time starts at McCandless campus exceeding standards, Cranberry campus ontime starts 2 nd and 3 rd, meeting standards. McCandless campus met the system standard for room utilization 7:30-3p, Cranberry campus continues to improve on room utilization to meet standards. Cranberry campus turnover times exceeded system average, McCandless campus continues to work to improve turnover, meet standards. Align anesthesia and OR staffing grids with utilization data for maximum efficiency. Sound Finance Decrease cost and improved utilization of resources. Aligned anesthesia and OR staffing to improve utilization of resources, monitored and adjusted daily to decrease cost. Continue to meet and exceed performance standards set by Cardiovascular Optimization System Team. Smart Technology Good Science Improve overall performance measures, outcomes data, and patient satisfaction to continually improve care. Refer to CV dashboard. Achieving targets. Partner with system and physician leadership to determine the feasibility of clinical service line integration. New models of care Good science Streamline service line operations. In process. 10
Objective: Physician Alignment Improve patient experience through strengthening relationships with hospital and medical staff. Framework Focus (If applicable) Symbiotic Relationships Provide Studer courses. Develop a formal education program to enhance physician communication skills. Completed. Physicians attended a medical staff course with Advisory Board and partner with system for Physician Leadership training. Support medical staff to modify it s bylaws. New models of care Modernization of Medical Staff Organizational structure. Approved by Medical Executive Committee and be implemented next FY. Continue to develop future medical staff leadership and succession plan. Improve the coordination of care with ED and Hospitalists. Symbiotic Relationships Expand depth and breath of Medical Staff Leadership in a changing complex environment. Ongoing New models of care Facilitate continuity of care. Ongoing 11
Objective: Ring Hospitals Framework Focus (If applicable) Continue to foster relationships with Grove City Hospital, Elwood City, and Jameson. New models of care Sound Finance Increase tertiary referrals to UPMC. Ongoing discussions. 12
Objective: Financial and Operating Performance Framework Focus (If applicable) Admissions Sound Finance Achieve Admissions of 14,295 Med/Surg: 14,009 Rehab: 286 SNF: 0 Admissions 14,844 - Med/Surg 14,533 - Rehab 310 - SNF 1 Emergency Room Visits Sound Finance Achieve ED visits of 51,990 56,591 Total Surgeries Sound Finance Achieve Surgical procedures of 16,065 15,979 FTE s Sound Finance Achieve FTE s of 1,819 1,777 ALOS Med/Surg Sound Finance Achieve targeted med/surg length of stay of 5.2 days OP Gross Charges Sound Finance Achieve OP Gross Charges of $814,847 Controllable Margin Sound Finance Achieve a Controllable Margin of $104,728 4.9 days $848,712 $115,519 13
Objective: Clinical Quality and Safety Framework Focus (If applicable) Outperform the mean of the national benchmark for all NDNQI nurse sensitive quality measures. Strive to eliminate preventable harm and death. Good Science Meet or exceed the quarterly NDNQI targets. Good science Reduce HAI s. Meet or exceed targets for CAUTI, CLABSI, SSI, MRSA and C-diff. Exceeds NDNQI mean past 8 Qtr through March 2015 Falls: 7 of 12 units Pressure Ulcers: 11 of 12 CAUTI: 9 of 12 CALBSI: 11 of 12 CDIFF exceeding system target of 5.40 (6.62) Less than SIR Ratio CLABSI, CAUTI, SSI Achieve maximum reimbursement for participation in P4P Programs: Highmark Quality Blue Program (ends December 31, 2014). New Models of Care Sound Finance Maximize organizational reimbursements by achieving the 90 point Quality Blue Program requirement. Obtained Mid-point Reimbursement 83.0 Score UPMC Health Plan Partners Program. CMS VBP Program. 14 Exceed metrics as required from Partners Program. Meet or exceed metrics required for HCAHPS and Clinical Measures. Consult project on hold Awaiting CMS Calculation final outcomes, should be available in fall 2015.
Objective: Clinical Quality and Safety Enhance the UPMC Passavant Culture of Safety. Develop IT systems to gather patient outcomes, produce meaningful alerts to improve care, and personalize the experience. Framework Focus (If applicable) Good Science Identify and improve upon areas of opportunity presented by the COS survey. Develop Department based work plans to address areas of opportunity. Continue the Leadership Visibility Rounding program. Continue to educate staff and leadership on the Just Culture algorithm. Smart Technology Maintain the Joint Commission requirement for the OPPE/FPPE review process and identify areas of opportunity. COS Complete My Voice meetings started Jan 2015. Leadership rounds continue Patient Safety Week the Patient Safety Team rounded to every Department/Unit and educated the frontline staff on the UPMC Just Culture Model with Staff. Additionally the Just Culture Model is reviewed prior to each Hospital RCA and available for review at each PPEC meeting On-going/Crimson OPPE/FPPE 15
Objective: Workforce Framework Focus (If applicable) Enhance employee experience; Putting People First Improve Employee Engagement. Improve Employee Physical and Financial Wellness. Improve Employee Safety. On target. My Voice Action plans implemented. Hospital My Voice Council meeting monthly and making recommendations and follow through for improvements. Safety Steering Committee guiding safety management plan and has decreased overall employee incidents. Following action plan from 2014 Gap Assessment. Improve leadership competence and drive results. Define the Talent Management infrastructure required to support it. Align leadership development curriculum and programs to the new leadership competencies. On target. TMR 9 Box review completed on Director level staff. Succession planning. Simplify Communications. Reduce the number and simplify HR policies. ally respond to changes in the industry and regulatory environment. Best in Class Governance Streamline and identify key metrics to better drive business decisions. On Target. Creating a system Exclusion from Patient Care policy which will eliminate all Business Unit specific policies. Reviewed by HR policy committee in April and being recommended to become an Administrative policy and will go to the next level for approval. Review and share HR Human Capital Scorecard quarterly to help drive business decisions. On going development of staff and hospital leadership. 16 Symbiotic Relationships Conduct a needs assessment and education plan to determine FY15 class offerings. Completed. FY15 educational opportunities being offered based on needs assessment.
Objective: Other Hospital or Community Services Specific Objectives Framework Focus (If applicable) Magnet Designation. Meet the goals of the Community Health Needs Assessment and begin three year planning process. Continue to partner with Passavant Hospital Foundation and Ladies Auxiliary to support community outreach. New models of care Good science Submit application and prepare documents for submission FY15. New models of care In collaboration with our nursing and operations leadership, begin to organize, plan, and prioritize the needs of our community for the next three year CHNA. Sound Finance Partner with the Passavant Hospital Foundation to provide funding opportunities and grants to establish community based programs for education and treatment. Support and provide resources for community outreach efforts. Plan to submit application by end of this FY. On track. Received $234,323.00 of funding this year in collaboration with the Foundation and Auxiliary. - $214,323 Department Grants - $20,000 HCIP 17
Objective: Other Hospital or Community Services Specific Objectives (cont) Upgrade the Teletracking Bed, Pre Admit, &Transport Tracking applications to the XT platform. Framework Focus (If applicable) Smart Technology Upgrade the application software and hardware as it is no longer supported by the vendor. Complete Implement Instrument Tracking in Sterile Processing. Smart Technology Improve instrument location, OR turnover time, and infection control tracking. Project underway 4 th quarter completion. Aeroscout Temperature Tracking. Smart Technology Improve operational efficiencies and reduce potential for loss of medications. Project on hold FY16 18