Focus on Action, Performance Leadership and Setting Expectations Pennsylvania Health Care Association May 22, 2018 Brenda Grant Chief Strategy Officer Charleston Area Medical Center Health System CHANGE AND MORE CHANGE A LEADERSHIP STRATEGY FOR ORGANIZATIONAL SUCCESS 1
PERFORMANCE IMPROVEMENT JOURNEY 2000 Six Sigma 2005 Baldrige Journey Begins 2017-2018 2007 Lean 2008 Transforming Care Together 2012 Focus On Baldrige Processes & Systems Cycles of Learning Communities of Excellence 2026 Cybersecurity 2015 Malcolm Baldrige National Quality Award 3 VISION Charleston Area Medical Center, the best health care provider and teaching hospital in West Virginia, is recognized as the: Best place to receive patient-centered care. Best place to work. Best place to practice medicine. Best place to learn. Best place to refer patients. 2
LEADERSHIP SYSTEM LEADERSHIP SYSTEM Set Direction Change Systems and Structures Align and Cascade Mentor and Develop People Implement Action Plans Achieve the Plan 3
LEADERSHIP COMPETENCY MODEL Leadership Model (Actions) Strategic Operational Frontline (Chiefs, VPS) (AAs, Corporate Directors) (Directors, Managers) Leading through Vision and Values SET DIRECTION Customer Focus Leading through Vision and Values Building Trust (Build Commitment) Business Acumen Customer Focus Customer Focus Setting Healthcare Business Strategy Business Acumen Cultivating Clinical and Business Partnerships Building a Successful Team (Review and Adjust) Making Healthcare Operations Decisions Making Healthcare Operations Decisions Decision Making ACHIEVE THE PLAN System Focus Driving Execution Driving for Results Building Healthcare Talent Coaching and Developing Others Coaching Driving Improvement Driving Improvement Adaptability Courage Compelling Communication ALIGN AND CASCADE (Motivate and Resource) IMPLEMENT ACTION PLANS (Make Change Last) MENTOR AND DEVELOP PEOPLE Building a Successful Team Planning and Organizing (Reward and Recognize) CHANGE SYSTEMS AND STRUCTURES (Raise the Bar) Underlying Leadership Attributes Courage Compelling Communication Emotional Intelligence Courage Compelling Communication PERFORMANCE MANAGEMENT SYSTEM 4
WORKS SYSTEMS AND WORK PROCESSES ENTERPRISE SYSTEM MODEL SYSTEMS THAT GUIDE 5
SYSTEMS THAT DO WORK SYSTEMS THAT SUPPORT 6
Embracing the Baldrige Approach Our organizational performance accelerated as we became process driven and integrated the Baldrige processes and systems throughout our organization. TRANSFORMING CARE TOGETHER TCT is CAMC s approach to redesigning our work processes in support of our mission striving to provide the best health care to every patient, every day. 7
GOALS FOR TCT 1. Increasing direct time with the patient. 2. Decreasing non-value added activity (waste). 3. Increasing employee engagement in improvement activity. 4. Standardizing processes to deliver repeatable and predictable results. FOUNDATION FOR LEAN Highest Quality Healthcare 5S Workplace Organization Standardization Visual Management Problem Solving Human Centered Work Just in Time Continuous Improvement Human Centered Work Problem Solving Built in Quality 5S Workplace Organization Standardization Visual Management 8
FOUNDATION FOR LEAN 5S Principles 1. Sort (Removal) 2. Set In Order (Orderliness) 3. Shine (Cleanliness) 4. Standardize (Adherence) 5. Sustain (Self-Discipline) 5S is the key to Workplace Organization FOUNDATION FOR LEAN Highest Quality Healthcare 5S Workplace Organization Standardization Visual Management Problem Solving Human Centered Work Just in Time Continuous Improvement Human Centered Work Problem Solving Built in Quality 5S Workplace Organization Standardization Visual Management 9
FOUNDATION FOR LEAN TOP 5 BOARD Department Action Plans How we achieve our values 10
A3 PROBLEM SOLVING CHART TOP 5 BOARD SAFETY CROSS Effectiveness: An important tool to know if the safety bundle is being followed on each shift. Only green if all parts of the bundle are completed; serves as an internal audit tool for key processes of care. Addresses accountability as the issue is discussed with the involved individual(s) that day. 11
DMAIC IMPROVE STRATEGIC PLANNING AND DEPLOYMENT PROCESS 3 3 12
PERFORMANCE IMPROVEMENT BREADTH AND DEPTH ENGAGEMENT IN TOP 5 BOARD TEAMS 198 Departments 990 Performance Improvement Teams 13
Action Plan Deployment Example DEPLOYMENT PROCESS Pillars Strategic Objectives BIG DOTS (3 Years) System Goals BIG DOTS (1 Year) SYSTEM LEVEL Strategic SYSTEM LEVEL Operational Entity Action Plans Entity Scorecard (1 Year) ENTITY LEVEL Operational Department Action Plans Department Scorecard (1 Year) INDIVIDUAL LEVEL Operational DEPARTMENT LEVEL Operational Individual Performance Planner (All Employees) Individual Scorecard (Managers) 14
GOAL CASCADE PROCESS GOAL CASCADE MEETINGS Half day meetings with Entity Leaders, Associate Administrators and all Department Managers DEPLOYMENT 6. Implement Care Foundations, the Less is Best Campaign, and improve safety systems to reduce harm and improve the safety culture with a focus on CLABSI, CAUTI, CDIFF, DVT/PE, SSI Colon, PSI 90. Patient Safety Composite 15
BIG DOT REPORT Patient Safety Composite 0.71 0.70 0.69 DEPLOYMENT 2017 Individual Scorecard Jeff Oskin, VP/Administrator Memorial Hospital Goal Measure Score Weight 3 4 1 Patient Experience Composite Score 20% 69 69.9% 70% 70.1 72% > 72% 66 Patient Safety Composite Score Patient Safety Composite 15% 15% 0.78 0.71 0.78 0.71 0.70 0.61 0.70 0.61 0.60 0.56 0.60 0.56 6 Mortality 15% 0.78 0.77 0.76 0.75 <= 0.74 6 Complications Index 10% 1.00 0.99 0.98 0.97 0.95 <= 0.94 7 HF/CABG 30 day O/E Readmissions 10% 1.02 1.01 1.00 0.99 0.95 < 0.95 8 18 Score Action Plan Reporting 1 2 <= 0.55 <= 0.55 42810 Memorial Hospital4.02Administration Employee Engagement Composite Score 10% 4.01 4.03 >= 4.04 Jeff Oskin Operating Expense Reduction 20% $10M $12.5M $13M >= $15M Action Plan 1.6.1 Reduction of Hospital Acquired Infections for CAUTI and CLABSI. Use Memorial QIC meetings to review action plans, results and improvement opportunities. 16
2017 Individual Scorecard Heidi Edwards, Associate Administrator Memorial Hospital Goal Measure Weight Score 1 2 3 4 1 Patient Experience Composite Score 20% 69 69.9% 70% 70.1 72% > 72% 1 6 Rounding on Patients ICU CAUTI 5% 10% 6 7 0.33 0.31 8 9 0.30 0.26 10 11 0.25 0.21 >= 12 <= 0.20 6 ICU CAUTI 10% 0.33 0.31 0.30 0.26 0.25 0.21 <= 0.20 6 ICU CLABSI 5% > 0.59 0.59 0.50 0.49 0.40 < 0.40 6 Patient Falls Medical Action Surgical/Telemetry Plan Reporting 5% > 2.5 2.5 2.1 2 < 2 6 Mortality CHF/COPD/Sepsis 10% > 0.85 0.85 0.84 0.79 < 0.79 6 Hand Hygiene < 90% Staff 90% Staff 95% Staff 100% Staff 42810B Memorial 5% Hospital Administration < 80% All 80% All 90% All 100% All 7 HF/COPD Readmissions 10% > 0.81 0.81 0.80 0.75 < 0.75 Heidi Edwards DEPLOYMENT 8 Employee Engagement Action Composite Plan Culture Index 10% < 3.74 3.74 3.83 3.84 3.93 >= 3.94 18 Budget 1.6.1 20% $3.3M $4.1M $4.3M >= $5M Work with ICU leadership team to review, build alerts and reports in Cerner to ensure Foley Catheter Bundles are hardwired and working appropriately, ensure participation within CAUTI System Team to ensure shared system learning. A3 process through HAI Team to establish process breakdowns for all CAUTIs. Top 5 Board focus for all ICUs with focus on bundle component critical X. 2017 Individual Scorecard Lisa Songer, Critical Care Director Memorial Hospital DEPLOYMENT Goal Measure Weight Score 1 2 3 4 1 Patient Experience Composite 20% 69 69.9% 70% 70.1 72% > 72% 1 Rounding on Patients and/or Employees 10% 12 15 16 19 20 41 >= 42 6 ICU CAUTI 10% 0.33 0.31 0.30 0.26 0.25 0.21 <= 0.20 6 ICU CLABSI 10% >= 0.59 0.59 0.50 0.49 0.40 < 0.40 6 Pressure Ulcers 10% Action Plan Reporting >= 4.46 4.45 3.01 3.00 2.01 <= 2.00 6 Hand Hygiene Unit Staff 5% 89% 90 94% 95 99% 100% 6 Hand Hygiene Other 42810D Memorial 5% Hospital 79% Administration 80 89% 90 99% 100% 7 Mortality Sepsis Lisa Songer 10% >= 0.96 0.95 0.91 0.90 0.82 <= 0.81 8 Employee Engagement Composite Culture Index Action Plan 20% <= 3.98 3.99 4.01 4.02 4.05 > 4.05 1.6.1 Continued focus on Catheter Removal through Daily MDTR. Working with CAUTI Team. SICU manager assigned to lead initiative with Professional Nursing to re train staff on insertion technique. Working with Products Team to evaluate and implement condom catheter use for male patients. A3 completed by staff and shared in monthly manager meeting related to CAUTIs. CPICU manager working with multi disciplinary team on Top 5 Board with Critical Care Intensivists to decrease Foley Catheter Device utilization. 17
DEPLOYMENT 2017 Individual Scorecard Megan Hatfield, Nurse Manager Cardiopulmonary ICU (CPICU) Memorial Hospital Goal Measure Weight Score 1 2 3 4 1 Patient Experience Composite 20% 69 69.9% 70% 70.1 72% > 72% 6 CAUTI 15% 0.48 0.46 0.45 0.36 0.35 0.25 < 0.25 6 CLABSI 15% >= 0.61 0.60 0.51 0.50 0.41 <= 0.40 6 Mortality Sepsis 15% >= 0.96 0.95 0.91 0.90 0.82 <= 0.81 6 Hand Hygiene Unit Staff Action Plan Reporting 5% <= 89% 90 94% 95 99% 100% 6 Hand Hygiene Other 5% <= 79% 80 89% 90 99% 42167 Cardiopulmonary ICU (CPICU) 100% 8 Employee Engagement Culture Index 10% 4.00 4.01 4.02 >= 4.03 Megan Hatfield 18 Budget Blocked Beds 15% 97.0 97.4% 97.5 98.2% 98.3 98.9% >= 99% Action Plan 1.6.1 Charge nurse assessment every shift to ensure device need (MDTR/shift huddles). Missy (Top 5 subject matter expert) leading team to focus on critical X s: Use of Condom Catheter for all male patients prior to Foley Catheter placement, ensure Foley collection bag emptied, peri care documented 2 times a day, physician order and nurse driven protocol for all Foley Catheters. Clinical Management Coordinator DEPLOYMENT Top 5 Board Team Score Solid Distinguished 70% 70.1 72% > 72% Patient Experience Composite 0.45 0.36 0.35 0.25 < 0.25 CAUTI 0.60 0.51 0.50 0.41 <= 0.40 CLABSI 0.95 0.91 0.90 0.82 <= 0.81 Mortality Sepsis 90 94% 95 99% 100% Hand Hygiene Unit Staff 80 89% 90 99% 100% Hand Hygiene Other 4.01 4.02 >= 4.03 Employee Engagement Culture Index 97.5 98.2% 98.3 98.9% >= 99% Budget Blocked Beds 18
Clinical Management Coordinator Charge Nurse DEPLOYMENT Top 5 Board Team Score Solid Distinguished 70% 70.1 72% > 72% Patient Experience Composite 0.45 0.36 0.35 0.25 < 0.25 CAUTI 0.60 0.51 0.50 0.41 <= 0.40 CLABSI Solid Distinguished 0.95 0.91 0.90 0.82 <= 0.81 Mortality Sepsis 90 94% 95 99% 70% 100% 70.1 72% Hand Hygiene > 72% Unit Staff Patient Experience Composite 80 89% 90 99% 0.45 0.36 100% 0.35 0.25 Hand Hygiene < 0.25 Other CAUTI 4.01 4.02 0.60 0.51 >= 4.03 0.50 0.41 Employee Engagement <= 0.40 Culture CLABSIIndex 97.5 98.2% 98.3 98.9% >= 99% 0.95 0.91 Budget Blocked Beds 0.90 0.82 <= 0.81 Mortality Sepsis 80 89% 90 99% 100% Hand Hygiene Other 97.5 98.2% 98.3 98.9% >= 99% Budget Blocked Beds Clinical Management Coordinator Charge Nurse Clinical Nurse DEPLOYMENT Top 5 Board Team Score Solid Distinguished 70% 70.1 72% > 72% Patient Experience Composite 0.45 0.36 0.35 0.25 < 0.25 CAUTI 0.60 0.51 0.50 0.41 <= 0.40 CLABSI Solid Distinguished 0.95 0.91 0.90 0.82 <= 0.81 Mortality Sepsis 90 94% 95 99% 70% 100% 70.1 72% Hand Hygiene > 72% Unit Staff Patient Experience Composite 80 89% 90 99% 0.45 0.36 100% 0.35 0.25 Hand Hygiene < 0.25 Other CAUTI 4.01 4.02 0.60 0.51 >= 4.03 0.50 0.41 Employee Engagement <= 0.40 Culture CLABSIIndex 97.5 98.2% 98.3 98.9% 0.95 0.91 >= 99% 0.90 0.82 Budget Blocked <= 0.81 Beds Solid Distinguished Mortality Sepsis 80 89% 90 99% 100% Hand Hygiene Other 97.5 98.2% 98.3 98.9% 70% >= 99% 70.1 72% > 72% Budget Blocked Beds Patient Experience Composite 0.45 0.36 0.35 0.25 < 0.25 CAUTI 19
DEPLOYMENT Clinical Management Coordinator Charge Nurse Clinical Nurse Top 5 Board Team Score Solid Distinguished 70% 70.1 72% > 72% Patient Experience Composite 0.45 0.36 0.35 0.25 < 0.25 CAUTI 0.60 0.51 0.50 0.41 <= 0.40 CLABSI 0.95 0.91 Solid Distinguished 0.90 0.82 <= 0.81 Mortality Sepsis 90 94% 95 99% 80 89% 90 99% 4.01 4.02 97.5 98.2% 98.3 98.9% 100% 70.1 72% Hand Hygiene Unit Staff 70% > 72% Patient Experience Composite 100% 0.35 0.25 Hand Hygiene Other CAUTI 0.45 0.36 < 0.25 >= 4.03 0.50 0.41 Employee Engagement Culture 0.60 0.51 <= 0.40 CLABSI Index Solid Distinguished >= 99% Budget Blocked Beds 0.95 0.91 0.90 0.82 <= 0.81 Mortality Sepsis 80 89% 90 99% 97.5 98.2% 98.3 98.9% 100% 70% >= 99% Hand Hygiene Other 70.1 72% > 72% Budget Blocked Beds Patient Experience Composite 0.45 0.36 0.35 0.25 CAUTI < 0.25 20
PERFORMANCE IMPROVEMENT SYSTEM DMAIC has helped CAMC create a process and a culture for high performance. SUSTAINABILITY Cost Reductions $300,000,000 $250,000,000 Cumulative Savings = $249,118,793 2017 Savings = $41,321,810 $200,000,000 $150,000,000 $100,000,000 $50,000,000 $0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 CUMULATIVE TOTAL ANNUAL IMPROVEMENTS 21
RESULTS 1,997 lives saved from 2011 to 2016 Inpatient Mortality 0.8 GOOD OBSERVED TO EXPECTED RATIO 1.0 0.6 0.4 0.2 2013 2014 2015 2016 0.0 CAMCHS PREMIER TOP QUARTILE WORKFORCE ENGAGEMENT / SATISFACTION RESULTS Employee Satisfaction Overall 5 3 2 1 2011 2012 2013 CAMCHS 2014 2015 2016 GOOD SCORE 4 Top 10% 22
Grow Our Own RESULTS Development: Direct Education Expenditures (as a % of Payroll) Dollars (in $000s) 6% $250,000 $200,000 4% $150,000 2% $100,000 $50,000 $0 2010 2011 2012 CAMC 2013 2014 CAMC % 2015 0% GOOD 8% $300,000 Percent of Payroll $350,000-2% ATD Best % RESULTS Inpatient Overall Quality - Local Competitors 100% GOOD PERCENTILE 75% 50% 25% 0% 2011 CAMCHS 2012 TMH 2013 RAL LOG 2014 2015 TOP 10% COMPARION 23
RESULTS Inpatient Overall Quality - Regional Competitors 75% GOOD PERCENTILE 100% 50% 25% 0% 2011 2012 CAMC 2013 2014 Cleveland Clinic 2015 Duke OUR LEARNING Identify key organizational issues and systems that need improvement. Line of sight from strategic plan to everyday work. Focus on the few. Use culture to drive change. Innovate for the future. 24
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