HROs and the Role of Finance South Carolina HFMA Annual Institute Kari Cornicelli, FHFMA,CPA Vice President/CFO Sharp Metropolitan Medical Campus San Diego, CA 1
Reflection Perfection is not attainable. But if we can chase perfection, we can catch excellence. -Vince Lombardi 2
Presentation Outline What is an HRO? Why is an HRO strategy important? What is the role of Finance in becoming an HRO? The Sharp HRO journey What are the quality, safety, and financial benefits? 3
What is an HRO? High Reliability Organization A social system that has developed a culture sensitive to safety that makes it possible for employees to prevent or mitigate accidents or errors. 4
Hospitals Are Different We Have to Work Harder Hospitals Other high-risk organizations Small, frequent accidents Few accidents Victims: patients Victims: operators Double human-based systems Human artifact systems Emotional/negotiated decision-making Rational decision-making Ever-changing Stable Diverse interactions Defined interactions Experience-based practice Procedure-based 5 Source: Bagnara, Parlangeli, and Tartaglia (2010)
HRO Characteristics HROs operate under very trying conditions all the time and yet manage to have fewer than their fair share of accidents. Weick & Sutcliffe 6
HRO Characteristics Resilience Preoccupation with failure and achieving zero defects Proactive analyses Searches for near misses Looks for anomalies Continuously/constantly corrects mishaps Maintains situational awareness 7
HRO Characteristics Challenges become opportunities for safety improvement Refuses to simplify; seeks to ensure understanding Comprehends organizational interdependencies, sensitive to operations Work organized around teams Deference to expertise 8
Patient safety is a national crisis Hospital errors are the third-leading cause of death in the U.S. Why HRO? 1995 to 2010: 956 wrong-site surgeries reported Medication errors: 10M annually, 1.5M harmed Hospital acquired infections (HAIs): 1 out of 20 hospitalized patients Falls: 500K annually, 150K will be injured Preventable adverse events: 10% of all patients 9
Why HRO? Employees are our most valuable asset Employee morale Increasing work comp claims Impact on productivity and teamwork Lost work days Patient, employee, and physician satisfaction Culture trumps strategy 10
How to Begin Analyze serious safety events Understand your safety culture Understand what is driving patient, employee, and physician satisfaction 11
Measurement Lead measurement of cost of adverse events and employee harm Connecting the Dots The Role of Finance Educate stakeholders on financial impact Value-based purchasing: CMS Five-Star Rating, other payor value-based contracts 12
The Role of Finance Continuous Process Improvement Champion of lean processes and standard work Financial Impact on Future Strategies Health care reform Managing risk Population health 13
HRO Metrics Which metrics should we focus on? Quality and safety Serious safety events Patients and employees Are the metrics aligned with strategic and HRO goals? How many metrics should be tracked? How many metrics are duplicated? Do they have the same numerator and denominator? Source? 14
Value Based Purchasing Metrics Fiscal year 2016 to 2018 Domain 2016 2017 2018 HCAHPS + CTM3 Outcomes/ Safety Mortality CLABSI PSI-90 CAUTI SSI Mortality CLABSI PSI- 90 CAUTI SSI MRSA C. Diff CLABSI PSI-90 CAUTI SSI MRSA C. Diff PC-01 15
Value Based Purchasing Metrics Domain 2016 2017 2018 Clinical Care Fiscal year 2016 to 2018 AMI-7a PN-6 SCIP-Inf-2 SCIP-Inf-3 SCIP-Inf-9 SCIP-Card-2 SCIP-VTE-2 IMM-2 AMI-7a IMM-2 PC-01 Mortality Efficiency MSPB 16
CMS Five-Star Rating In place now: Nursing facilities Hospital HCAHPS (added Spring 2015) Dialysis centers Medicare Advantage Plans Home health agencies (started July 2015) Coming soon: Overall hospital rating (2016) 17
18 Star Measurements
Process Improvement is Vital HROs are organizations with systems in place that are exceptionally consistent in: accomplishing their goals avoiding catastrophic errors. -Agency for Health Care Research Quality 19
Continuous Process Improvement Six Sigma Lean DMAIC A3 Problem Solving Change Management 20
Why Have Standard Work? As long as work is done in a chaotic system where random decision-making prevails, system learning and improvement cannot occur. How can you be effective if everyone does things differently? How can you sustain improvements if they depend on who is doing it? 21
The Financial Impact on Future Strategies Improves quality Improves patient satisfaction Improves employee & physician satisfaction Improves safety Improves outcomes Decreases costs 22
The Sharp HealthCare HRO Journey 23
Sharp HealthCare Not-for profit Largest health care system in San Diego 4 acute care hospitals 3 specialty hospitals 2 affiliated medical groups Health plan Full range of programs and services 24
Largest private employer in San Diego 17,000 employees, 2,600 affiliated physicians, 2,000 volunteers Largest market share in San Diego County $3.4 billion in net revenue Sharp HealthCare 25
Sharp HealthCare s Vision To be the BEST place to work, BEST place to practice medicine, and BEST place to receive care 26
Sharp HealthCare s HRO Journey The HRO is a comprehensive initiative that will help us advance The Sharp Experience and ensure we meet our health care mission. 27
Sharp Organizational Motivators Alignment with The Sharp Experience, Baldrige, Planetree, and Magnet Strengthen performance under the Pillars of Excellence Opportunity for improvement in current safety and process-defect performance 28
Sharp Organizational Motivators Safety an ever-increasing priority for consumers, regulators Safety science is an area of knowledge expansion Zero harm and zero defects 29
Sharp HealthCare s HRO Journey Created five overarching organizational objectives Engaged national HRO consultant Dialogued with respected health care systems Conducted a system safety assessment of serious safety patient events and employee harm Implemented listening and learning tours Initiated training for leaders related to effective assessment feedback 30
Serious Safety Event Rate (SSER) # of Serious Safety Events Analysis of Serious Safety Events 2.50 Rolling 12-month average of serious safety events per 10,000 adjusted patient days 26 2.00 21 1.50 16 1.00 11 0.50 6 0.00 1 Serious Safety Events (SSE) Serious Safety Event Rate (SSER) 31
Patient Safety Average number of days between SSEs at Sharp HealthCare in 2014 3.1 Every three days a patient in our system experienced a preventable event that resulted in serious harm or death. 32
Personal Safety Average number of days a Sharp employee was seriously injured on the job in 2014 1.3 Every day in our system, one of us experiences a serious preventable injury. 33
Work Comp Case Incident Rate Number of OSHA recordable injuries x 200,000 total hours worked Hospitals Ambulatory 7.6 FY2016 Hospital Goal 4.7 FY2016 Ambulatory Goal 34
35 The Cost of Personal Harm
Speaking Up Challenges Result of communication openness dimension demonstrate that 38% of staff said that they might not be comfortable speaking up about something even if a patient might be harmed. Staff feel free to question the decisions or actions of those with more authority Staff are not afraid to ask questions when something doesn t seem right Staff will freely speak up about things that may negatively affect patient care 48% 40% 25% 36
Most Valued Assets Our Employees Direct Costs 37
Most Valued Assets Our Employees Indirect Costs 1. Impact to coworkers productivity and work schedule. 2. Loss of efficiency due to break-up of clinical team. 3. Impact to supervisor s productivity and schedule. 4. Recruitment costs for replacement of workers. 5. Training costs for new/replacement workers. 6. Loss of production for remainder of the day. 7. Failure to fill orders/meet deadlines. 8. Overhead costs while work was disrupted. 38
HRO Organizational Objectives Establish system-wide leadership accountability Promote safety through teamwork and collaboration Develop a mutual respect environment Ensure availability and deployment of continuous process improvement tools Ensure a comprehensive approach to high reliability by identifying and spreading best practices and working with experts 39
Action Team Mutual Respect Teamwork Reliability Huddles Continuous Performance Improvement Measurement HRO Action Teams Main Efforts Create an environment of mutual respect promoted by self-regulation and group ownership Utilize tools to reduce authority gradient Refresh and reinforce Sharp Behavior Standards Utilize tools to reduce authority gradient Provide team training and skills for all Create structure for daily reliability huddles across Sharp entities Conduct team huddles for each shift Promote more performance improvement projects across the system Share and adopt best practices Create local learning systems for teams Adopt Serious Safety Event Rate for safety measurement Utilize systems thinking in cause analysis 40
Huddles Deployment of Action Teams Recommendations Mutual Respect Employee Safety Measurement Continuous Process Improvement Teamwork 41
Mutual Respect Action Team Recommendations Update Sharp s Behavior Standards to reflect a requirement for mutually respectful interactions Establish a clear, consistent, fair, and timely accountability process Establish a safe environment where person-to-person feedback is invited and well-received 42
Teamwork Action Team Recommendations Train leaders in HRO leader skills Train all staff, leaders, and physicians in reliability and teamwork Train select staff on advanced teamwork Implement reinforcement tactics 43
Reliability Huddles Action Team Recommendations Develop standardized templates for huddle use Educate leaders on how to run an effective huddle Roll out huddles for all departments at Sharp clinical and nonclinical 44
Daily huddles in every unit followed by: Reliability Huddles Daily hospital leadership huddle Every unit sends a leader Review SSEs Service and throughput issues Quick hits and problem solving Recognize wins 45
Continuous Process Improvement Action Team Recommendations Increase the number of certified Yellow Belts Deploy A3 as a problem-solving tool Deploy learning boards Implement processes and tools to replicate best practices 46
A3 Problem-Solving Tool Process Owner/Manager: Location: Date: A3 By: Current Situation: Counter Measure: (Recommendation) Plan: Root Cause (5 Whys): Results/Validation: 47
48 Learning Boards
Learning Board Content Problems Working On Completed 49
Measurement Action Team Recommendations Use Serious Safety Event Rate (SSER) calculation as a standard metric Train Quality and Patient Safety Staff in Safety Event Classification (SEC)/Common Cause Analysis (CCA) Redesign the Root Cause Analysis (RCA) process Train RCA teams system-wide (~100 people) Revamp hospital MD peer review process 51
Employee Safety Action Team Recommendations Conduct system-wide job hazard analyses Enhance the current behavior-based safety program Train safety staff on cause analysis Establish Top 5 committees system and local level Safety training for executives 52
Employee Safety Goals 1. Create accountability with front-line management and employees 2. Reduce lost duty days 3. Reduce patient movement injuries 4. Reduce repetitive motion injuries 5. Reduce slip/trip fall injuries 6. Reduce push/pull/lift objects, boxes, carts, etc. injuries 53
Employee Safety Programs Ergonomic injury prevention plan (RMI) Safe patient movement/minimal lift program Slip/TRIP fall prevention program Transitional, modified or light duty Behavior based stay safe 54
HRO: What Lies Ahead A never-ending journey Cultural and organizational transformation Education and learning Great change and reward Time, resources, commitment Be part of an organization seeking excellence and making a difference in the lives of others 55
Unified HRO Behaviors and Skills Teach Create Support Structure Set Expectations Hold Each Other Reinforce Monitor Accountable 56
Unified HRO Mindset Employee Safety Huddles Teamwork HRO Skills: Everyone Mutual Respect Continuous Process Improvement Measurement HRO Skills: Leaders 57
High-Level Proposed Timeline HRO Model Design HPI Assessment Continue White, Yellow, and Green Belt Training Continue and Expand Huddles HRO Leader Training Employee Safety Strategies HRO Training for All 2015 2016 2017 58
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San Diego s Health Care Leader SM Malcolm Baldrige National Quality Award, 2007 Elite Status, SRSMG and SCMG, 2010-2014 MAGNET Designation for Nursing Excellence: Sharp Grossmont Hospital and Sharp Memorial Hospital Press Ganey Beacon of Excellence Award and Guardian of Excellence Award; Multiple entities, 2013-2015 Sharp HealthCare named in 2016 as Ethisphere Institute s World's Most Ethical Company Forbes 2016 America s Best Employers, #16 U-T San Diego readers poll, 2015 Best Hospital Group Sharp HealthCare Best Hospital #1 Sharp Mary Birch, #2 Sharp Grossmont, #3 Sharp Memorial Best Medical Group #1 SCMG, #2 SRSMG HealthCare 2014 Energy Champion Hospitals & Health Networks Most Wired, 2012-2015 Sharp HealthCare is on a journey A journey to become the best health system in the universe 60
Quality, Safety, & Financial Benefits Reduce patient harm Improves quality Improves patient satisfaction Improves financials Reduce employee harm Improves employee satisfaction Decreases employee turnover Improves financials 61
Quality, Safety, & Financial Benefits Improve reimbursement Value-based purchasing CMS Five-Star ratings Continue The Sharp Experience journey Best, Best, Best 62
63 Questions