DNV GL - Healthcare CAMC Health System s Baldrige Journey

DNV GL - Healthcare CAMC Health System s Baldrige Journey DRAFT DNV GL 2016 SAFER, SMARTER, GREENER

The Broader View of DNV GL Reducing uncertainty, increasing safety Improving efficiency Enabling sustainability Building trust SAFER, SMARTER, GREENER Det DNV Norske GL Veritas 2016 AS. All rights reserved 31 March 2016 Slide 2

Management System can be used to: Improve systems, processes and efficiency and effectiveness Identify objectives and focus needs and expectations of patients/customers Achieve and maintain the desired quality of services to consistently meet customers stated and implied needs Provide a common framework for coordination and communication between units/departments and healthcare organizations, (tear down silo s) Slide DNV GL 2016 3

Integrated Accreditation Model Integrates ISO 9001 and NIAHO ISO 9001 provides the framework for a sustainable regulatory compliance ISO 9001 allows healthcare organizations to use its combined knowledge, wisdom, and innovation to improve quality and safety ISO 9001 is the framework within which methodologies such as LEAN and Six Sigma are better understood and utilized ISO determines WHAT has to be done but leaves the HOW up to you YOU DECIDE! There are two ways to implement ISO #1 to be compliant during a survey or #2 to drive performance Performance driven systems produce compliance as a natural outcome Introduction of Charleston Area Medical Center 4 DNV GL 2016

CAMC s Baldrige Journey: ENGAGING THE ENTIRE ORGANIZATION IN PERFORMANCE IMPROVEMENT Dr. Glenn Crotty Executive Vice President and COO Brenda Grant Chief Strategy Officer DNV GL Webinar March 31, 2016

MISSION AND VISION Mission: Striving to provide the best health care to every patient, every day. 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.

VALUES Quality Service with compassion Respect Integrity Stewardship Safety

Primary Service Area Secondary Service Area Wayne Cabell Mason Lincoln Putnam Logan Mingo Jackson Boone Wood Wirt Roane Kanawha Wyoming McDowell Pleasants Raleigh Ritchie Gilmer Calhoun Clay Fayette Mercer Tyler Doddridge Harrison Nicholas Hancock Brooke Ohio Marshall Wetzel Braxton Lewis Webster Summers Monroe CAMC SERVICE AREA West Virginia s Population: 1.8 million Primary and Secondary Service Area: 557,328 Upshur Greenbrier Monongalia Marion Taylor Barbour Pocahontas Randolph Preston Tucker Grant Pendleton Mineral 4 Acute Care Hospitals Hardy Hampshire 908 Total Beds Morgan Berkeley Jefferson 48 Ambulatory Sites Provider Based Imaging, Urgent Care, Laboratory 40,000 Inpatient Visits 690,000 Outpatient Visits 115,000 Emergency Department Visits

268 Beds Neuroscience Orthopedics Bariatric Surgery Trauma 3,200 + trauma patients admitted each year Primary Stroke Center Kidney Transplant Medical Rehabilitation CAMC GENERAL HOSPITAL Jackson Roane Putnam Clay Lincoln Boone Kanawha Fayette Nicholas Logan Raleigh Mercer

424 beds Heart and Vascular Center 8,475 procedures performed in Cardiac Cath Labs 1,210 Open Heart Bypass procedures Peripheral Vascular Center of Excellence Oncology CAMC Cancer Center 30,986 CAMC Cancer Center encounters CAMC MEMORIAL HOSPITAL Jackson Roane Putnam Clay Lincoln Boone Kanawha Fayette Nicholas Logan Raleigh Mercer

CAMC WOMEN & CHILDREN S HOSPITAL 146 Beds >2,600 Babies delivered every year 543 Neonatal Intensive Care Unit admissions Pediatric Intensive Care Unit Jackson Roane Putnam Clay Lincoln Boone Kanawha Fayette Nicholas Logan Raleigh Mercer

CAMC TEAYS VALLEY HOSPITAL 70 Beds Community Hospital Jackson Roane Putnam Clay Lincoln Boone Kanawha Fayette Nicholas Logan Raleigh Mercer

CAMC Health System, Inc. CAMC Health Education & Research Institute, Inc. Charleston Area Medical Center, Inc. Charleston Area Medical Center Foundation, Inc. Integrated Health Care Providers, Inc. CAMC General Hospital CAMC Memorial Hospital CAMC Women and Children s Hospital CAMC Teays Valley Hospital

PERFORMANCE IMPROVEMENT JOURNEY 2000 Six Sigma 2005 Baldrige Journey Begins 2007 Lean 2008 Transforming Care Together 2012 Focus On Baldrige Processes & Systems 2015 Malcolm Baldrige National Quality Award

TRIPLE AIM Quality Patient Experience Cost of Care

TRIPLE AIM Quality Inpatient Overall Quality - Local Competitors

TRIPLE AIM Cost of Care Cost Reductions Cumulative Savings = $177,019,702 2015 Savings = $21,216,254

TRIPLE AIM Patient Experience Employee Satisfaction Overall 5 4 SCORE 3 2 1 2011 2012 2013 2014 2015 GOOD CAMCHS Top 10%

TRIPLE AIM Patient Experience HCAHPS Likeliness to Recommend Women and Children s Hospital

Importance of Organizational Learning and Agility...a Baldrige Core Value If the rate of change on the outside exceeds the rate of change on the inside, the end is near. Jack Welch, Former Chairman and CEO General Electric Corp.

Embracing the Baldrige Approach Our organizational performance accelerated as we became process driven and integrated the Baldrige processes and systems throughout our organization.

BALDRIGE AND ISO

ISO 9001:2015 Audit Questions 1. What can you tell me about the context of your organization? 2. Who are your interested parties and what are their requirements? 3. What risks and opportunities have been identified, and what are you doing about them? ISO and Baldrige Baldrige Criteria 1. Organizational Profile: Organizational Description and Situation 2. P.1b(2) Patients, Other Customers and Stakeholders (Who are they and what are their key requirements?) P.1b(3) Suppliers and Partners (Who are they, what role do they play, what are key supply chain requirements?) 3. Organizational Situation: Competitive Environment and Strategic Context Category 2: Strategy Considerations

ISO 9001:2015 Audit Questions 4. What plans have been put in place to achieve quality objectives? 5. How has the QMS been integrated into the organization s business processes? 6. How do you manage change? 7. How do you capture and use knowledge? ISO and Baldrige Baldrige Criteria 4. Category 2: Strategy Key Strategic Objectives and Action Plans 5. Organizational Profile: P.2c Performance Improvement System What are the key elements of your PI system, including processes for evaluation and improvement? 6. Category 5: Workforce 5.1a(4) Change Management 7. Category 4.2a(1) Organizational Knowledge Knowledge Management

ENTERPRISE MODEL

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.

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 5S Workplace Organization Standardization Visual Management Problem Solving Just in Time Highest Quality Healthcare Continuous Improvement Human Centered Work Problem Solving Built in Quality Human Centered Work 5S Workplace Organization Standardization Visual Management

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

RN DIRECT PATIENT CARE TIME

PERFORMANCE IMPROVEMENT BREADTH AND DEPTH

STRATEGIC PLANNING AND DEPLOYMENT PROCESS

DEPLOYMENT PROCESS Pillars Strategic Objectives BIG DOTS (4 Year) SYSTEM LEVEL Strategic System Goals BIG DOTS (1 Year) SYSTEM LEVEL Operational Entity Action Plans Entity Scorecard (1 Year) ENTITY LEVEL Operational Department Action Plans Department Scorecard (1 Year) DEPARTMENT LEVEL Operational INDIVIDUAL LEVEL Operational Individual Performance Planner (All Employees) Individual Scorecard (Managers)

GOAL CASCADE PROCESS INDIVIDUAL SCORECARDS CEO and COO Entity Vice-Presidents Associate Administrators GOAL CASCADE MEETINGS Half day meetings with Department Managers GOAL REPORTING SYSTEM Report quarterly

TOP 5 BOARD

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.

RESULTS Inpatient Mortality 1.0 OBSERVED TO EXPECTED RATIO 0.8 0.6 0.4 0.2 0.0 2011 2012 2013 2014 2015 CAMCHS 1,923 lives saved from 2011 to 2015 COMPARION GOOD

RESULTS Inpatient Overall Quality - Local Competitors COMPARION

RESULTS Employee Satisfaction Overall 5 SCORE 4 3 2 1 2011 2012 2013 2014 2015 GOOD CAMCHS Top 10% COMPARION

OUR LEARNING Engage leaders as owners. 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. Communication and transparency. Innovate for the future.

Dr. Glenn Crotty, FACP, MBNQE Executive Vice President and Chief Operating Officer CAMC Health System, Inc. PO Box 1547 Charleston, WV 25326 glenn.crotty@camc.org 304-388-7647 Brenda Grant, BSN, MBA Chief Strategy Officer CAMC Health System, Inc. PO Box 1547 Charleston, WV 25326 brenda.grant@camc.org 304-388-7885

Questions? 49 DNV GL 2016

Thank you! www.dnvgl.com Click here to join us for our upcoming webinars and Healthcare Symposium SAFER, SMARTER, GREENER DNV GL 2016