Using the Baldrige Framework to Create

Using the Baldrige Framework to
Create Organizational Excellence
August 12
12, 2011
Ken Davis, MD, MSc. HP&M, FACP
CMO, San Antonio Methodist Healthcare System
Speaker Disclosure
Under Accreditation Council for Continuing Medical
Education guidelines disclosure must be made
regarding financial relationships with commercial
interests within the last 12 months.
Kenneth Davis, M.D.
I have no financial relationships or affiliations to disclose.
1
Learning Objectives
Upon completion of this presentation, participants should be
able to improve physician competence, performance and
patient outcomes by being able to:
 Describe the Baldrige framework and why is it important
to creating excellence in healthcare for OU
 Explain
E l i h
how other
th h
health
lth care organizations
i ti
h
have used
d
the Baldrige framework to work towards excellence.
 Integrate and use the Baldrige framework at OU Medicine
to help achieve organizational excellence.
The Truth
Organizational Excellence
Survival
2
Framework for Organizational
Excellence
 “Do the Right Thing
Right,
The First Time,
Every time,
On Time.”
 or, Use the Baldrige Healthcare Criteria as a
Framework for Organizational Excellence
Clinical Excellence:
Sharing Lessons from Baldrige
 North Miss. Medical Center – 2006 Baldrige Winner
– Baldrige
B ld i llessons learned
l
d
 Methodist Healthcare System of San Antonio
– Baldrige lessons shared
 Oklahoma University
– Baldrige lessons enhanced
3
The Baldrige Performance
Excellence Program
 Established by Congress in 1987 as America’s
highest honor for business excellence
 Named for former Secretary of Commerce
Malcolm Baldrige
 Awards in manufacturing, service, small
business, healthcare, education and non-profit
 12 healthcare winners
www.quality.nist.gov
Baldrige Criteria
 7 Categories -> 29 critical business systems
 Not prescriptive - uses the word “How” 200 times
 Internal and external assessment of the criteria
identifies gaps in these business systems
 Method of Business and Clinical Process:
• Identification
• Improvement
• Deployment
4
Baldrige Categories
1. Leadership
p
2. Strategic Planning
3. Customer Focus
4. Measurement, Analysis and Knowledge
Management
5. Workforce Focus
6. Operations Focus
7. Results (450 of 1000 scored points)
Baldrige Categories
1 Leadership
1.
How we:
Lead
2. Strategic Planning
Plan
3. Customer Focus
Meet Customers’ Needs
4. Measurement, Analysis
and Knowledge Mgt.
Convert Information to
Knowledge
5. Workforce Focus
Support our “Peeps”
6. Operations Focus
Do our “Thang”
7. Results
Compare to the Best
5
Baldrige -> Gap Analysis
North Mississippi Health Services

6 hospitals
p

NMMC – 650 beds

37 primary care clinics

23 School-based Clinics

7 Wellness Centers

4 Nursing Homes – 307 beds

6400 Employees

Third largest rural health system in
the country
6
Methodist
Boerne
Medical
Center
Methodist Healthcare, San Antonio Market
STRIC
Methodist
Stone Oak
Hospital
(2008)
Fair Oaks Ranch
Timberwood Park
Scenic Oaks
310
4
Methodist
Ambulatory
Surgery
Hospital
Cross Mountain
MASC - NC
STRIC
281
Grey Forest
16
STRIC
(2 Loc)
STRIC (2 Loc)
1604
Northeast
Methodist
Hospital
Selma
Helotes
Methodist Hospital
Methodist Heart Hospital
Methodist Children’s Hospital
Methodist Specialty &
Transplant Hospital
Cibolo
Live Oak
STRIC (8 Loc)
STRIC
Windcrest
Converse
435
3
Schertz
310
4
151
Kirby
MASC - MC
STRIC
6
5
Lackland AFB
87
90
STRIC
1604
Metropolitan
M
t
lit
Methodist
Hospital
337
4
435
3
181
Elmendorf
Lytle
Somerset
Legend
281
$
16
MHS Hospital
MHS Surgery Center
Baptist
STRIC Imaging
St. Hedwig
China Grove
410
Santa Rosa
TexSan
University
Nix & SWG
437
3
- 8 Hospitals
- 2000 beds
- HCA/Meth Min
- 2700 physicians
Using the Baldrige Framework to
Create Clinical Excellence
1 Leadership
1.
How we:
Lead
2. Strategic Planning
Plan
3. Customer Focus
Meet Customers’ Needs
4. Measurement, Analysis
and Knowledge Mgt.
Convert Information to
Knowledge
5. Workforce Focus
Support our “Peeps”
6. Operations Focus
Do our “Thang”
7. Results
Compare to the Best
7
Cat. 1 – Leadership (120 points)
 1.1 – Senior Leadership
– How do your senior leaders lead?
– Describe how:
• Senior leaders’ actions guide and sustain your
organization.
i ti
• Senior leaders communicate with your workforce
and encourage high performance
Cat. 1 – Leadership (120 points)
 1.2 – Governance and Societal Responsibilities
– How do you govern and fulfill your societal
responsibilities?
– Describe your organization’s governance system and
approach to leadership improvement.
– Describe how:
• Your organization assures legal and ethical
behavior and fulfills its societal responsibilities.
• Your organization supports its key communities and
contributes to community health.
8
Definition: Leadership Culture
 How leaders influence others to get the work
done
 Organizational culture where:
– leaders use their skills of influencing people
– to enthusiastically work towards goals
identified as being for the common good
– with character that inspires confidence
James C. Hunter
Definition: Leadership Culture
9
MHS Circle of Excellence
Baldrige
Performance
Excellence
Studer
Group
Pillars of Success
Methodist Excellence
Nursing
Magnet Status
Baldrige Performance Excellent: A Culture of Continuous Quality Improvement
Studer Group Pillars of Success: Service, Quality, People, Finance, Growth, Community
Nursing Magnet Status: A Culture of Nursing Excellence
10
NMMC Leadership:
Culture/Alignment/Deployment
Critical Success
Factors
VALUES
PEOPLE SERVICE
ACCOUNTABILITY
COMPASSION
QUALITY
FINANCIAL
MISSION
To continually
improve the health of
the people in our
region
GROWTH
RESPECT
BALDRIGE
CRITERIA
FOR EXCELLENCE
EXCELLENCE
SMILE
Leadership - New Culture
Physicians
Suppliers
Payers
Community
SAFETY
Patient/Family
Board
Management
Staff
11
NMMC: Leadership –
Alignment/Deployment
Mission/Vision/Values
Evidence-based Planning Process
Goals by Critical Success Factors
Scorecards (SL
(SL, Dept,
Dept Personal)
90-day Action Plans
PI Teams: PDCA, 6-Sigma, Lean
MHS Leadership:
Alignment/Deployment
GOALS
System
Hospital
Department
or Svc. Line
Unit
Individual
People
Service
Quality
Finance
Growth
Community
One System goal per Pillar
Goals tied to System Pillar goals
LEM goals
12
Leadership - Skills Training
 Management Leadership Training
 Physician Leadership Training
 Nursing Outcomes College
 Board Education and Planning Retreats
 Clinical Outcome Manager Training
– (Clinical Nurse Leader)
Leadership Model:
Servant Leadership
 Character Development
 Listening
 Accountability
y
 Results
– What you achieve and How you achieve it
13
Leadership Skills:
Crucial Conversations
Dialogue (free flow of information)
Shared pool of information
Group decision
Commitment to act
Patterson, Kerry. Grenny, Joseph. McMillan, Ron. Switzler, Al. Crucial Conversations, Tools for Talking When
Stakes are High. McGraw Hill 2002.
Leadership Culture and
Accountability
Ask yourself everyday:
“Are you trying to do
something or be
somebody?”
y
14
Leadership 360 Feedback
Honest
- Is someone people can trust
- Is a leader people feel confident following
Respectful
- Treats people with respect
- Does not engage in backstabbing, (talking behind backs, “managing down”)
- Does not embarrass or punish staff in front of others
Committed
- Makes clear to staff what is expected
- Holds staff accountable for care standards
- Works with staff in a team approach
- Holds others accountable for care standards
Humble
- Is a good listener
- Is not overly controlling or domineering
Adapted from James C. Hunter “The Worlds
Most Powerful Leadership Principle”
Leadership 360 Feedback
Patient
- Shows patience and self-control with others
- Has a consistent manner and stays calm
Kind
- Shows appreciation to others
- Gives encouragement to others
- Gives credit to those who deserve it
Selfless
- Meets legitimate needs (as opposed to wants) of others
- Is sensitive to implications of their decisions on others
Forgiving
og
g
- Is able to forgive mistakes and not hold grudges
- Spends time on the problem, not assigning blame
What are the greatest leadership strengths/skills this physician possesses?
What leadership skills does this physician need to work on and improve?
Adapted from James C. Hunter “The Worlds
Most Powerful Leadership Principle”
15
Physician Leadership Development:
“Training Physicians for Empowered Leadership Positions”
 Elected Physician leaders and those delegated by MECs
 Two year leadership training program
 Topics:
–
–
–
–
–
–
–
–
–
–
–
–
Comparative Clinical Outcome Measures
Servant Leadership
Crucial Conversations
Scripted Patient Communication “AIDET”
High Performing Teams
Integrated Delivery Systems
Creating a Safety Culture
Strategic Planning
Hospital Finance
Health Law
Value Based Purchasing
Others…
New Structure - NMMC
 Clinical Service Lines
– Medicine, Surgery, ED, Oncology, Women’s
• 26 Sections
– Each with Administrative-Physician Leads
– No Nursing Department
– CEO -> Unit Manager
g ((no more than 3 layers)
y )
 Board 1/3rd Physicians
16
MHS Governing Board: MHM/HCA
Community Board
Medical Board
Quality Improvement
Physician Resource
Pt Care Exp and Safety
Medical records
Transfusion
Bioethics
Cancer
MECs
MASH
MSOH
MH
Credentials
Infection Control
Pharmacy & Therapeutics
Peripheral Vasc Intervention
Special Care
Special Care Utilization Review
MSTH MCH MMH MNE
MTH
MHS Governing Board: MHM/HCA
Anesthesia
Cardiac Services
Comm.
Board
Emergency Services
General Surgery
H
Hematology/Oncology
t l
/O
l
Intensive Care
Medical Board
Medicine/Hospitalists
Neurology/Neurosurgery
Orthopedics
Pediatrics
Radiology
gy
Rehabilitation
Transplant
Women’s Services
MASH
MSOH
MH
MSTH MCH MMH MNE
MTH
17
Using the Baldrige Framework to
Create Clinical Excellence
1 Leadership
1.
How we:
Lead
2. Strategic Planning
Plan
3. Customer Focus
Meet Customers’ Needs
4. Measurement, Analysis
and Knowledge Mgt.
Convert Information to
Knowledge
5. Workforce Focus
Support our “Peeps”
6. Operations Focus
Do our “Thang”
7. Results
Compare to the Best
Cat. 2 – Strategic Planning (85 points)
 2.1 – Strategy Development
– How do you develop your strategy?
– Describe:
• How your organization establishes its strategy to
address its strategic challenges and leverage its
strategic
g advantages.
g
• Your organization’s key strategic objectives and
their related goals.
18
Cat. 2 – Strategic Planning (85 points)
 2.2 – Strategy Implementation
– How do you implement your strategy?
?
– Describe how your organization converts its strategic
objectives into action plans.
– Summarize your organization’s action plans, how
p y , and keyy action p
plan p
performance
theyy are deployed,
measures or indicators.
– Project your organization’s future performance
relative to key comparisons on these performance
measures or indicators.
NMMC: Strategic Planning
Annual evidenced – based planning process
 Physicians
 Management
 Employees
 Board Leadership
 Community
 Patients/Families
 Suppliers
 Payers
19
NMMC: Annual Evidence-Based
Planning Process – Physician Role
 Step 1 – January – Gather internal and external evidence
– Satisfaction survey, internal and referring physicians
– Internal and external clinical outcome benchmarking
 Step 2 – February – SWOT analysis
– By physician Specialty Section and Service Line
 Step 3 – March – Leadership analysis
– Medical Executive Committee
 St
Step 4 – April
A il – Board
B d and
dL
Leadership
d hi retreat
t t approvall
 Step 5 – Implementation
– Specific goals, 90 day action plans to individual physician level
 Step 6 – 90 day assessment and revisions at Section,
Service Line, Medical Executive Committee
Methodist Healthcare Strategic and Business Planning Process
Mission
• Serving Humanity to Honor God
• Supporting the health status of the community
• Constantly improving quality
Vision
• A commitment to greatness
• Creating healing experiences
• Never‐ending improvement
• Preference for MHS by all served
Values
• Creating an appropriate work environment
• How we treat each other
H
• How we treat our customers
Market Environment Scan
Review of Organization’s Critical Issues
SWOT Analysis Board, Senior Leaders, Physicians, Community, Vendors
Understanding Customer Demands
1st Q How To:
Evaluate and Improve Strategic and Business Plan Process, and Deployment
90 day Action Plans
Continuous Performance Review
Finalize and Deploy Yearly Business Plan
Development of Facility Yearly Business Plans
Maximize Strengths Minimize Weaknesses Seize Opportunities Eliminate Threats 2nd Q Budgeting Process
Development of System Yearly Business Plan
Breakthrough Strategies
People Service Quality Growth Finance Community
People Service Quality Growth Finance Community
3rd Q 4th Q Validation and Education
Across the Enterprise
2nd Q Validation and Education
Across the Enterprise
Validation and Education
Across the Enterprise
Planning Color Key Blue: Business and Market Analysis (Internal and Retreat)
Purple: Plan Development (Retreat and Internal)
Red: Plan Deployment 20
Using the Baldrige Framework to
Create Clinical Excellence
1 Leadership
1.
How we:
Lead
2. Strategic Planning
Plan
3. Customer Focus
Meet Customers’ Needs
4. Measurement, Analysis
and Knowledge Mgt.
Convert Information to
Knowledge
5. Workforce Focus
Support our “Peeps”
6. Operations Focus
Do our “Thang”
7. Results
Compare to the Best
Cat. 3 – Customer Focus (85 points)
 3.1 – Voice of the Customer
– How do you obtain information from your patients and
stakeholders?
– Describe how your organization:
• Listens to current and potential patients and
stakeholders.
• Determines patient and stakeholder satisfaction
and engagement.
21
Cat. 3 – Customer Focus (85 points)
 3.2 – Customer Engagement
– How do engage patients and stakeholders to serve
their needs and build relationships?
– Describe how your organization:
• Determines health care service offerings and
patient and stakeholder support.
p
pp
• Builds patient and stakeholder relationships.
Patients: High Performing
Clinical Teams
 Measures:
–
–
–
–
Staff Engagement
g g
Scores
Staff voluntary turnover
Physician Engagement Scores
Unit Care measures (Process, Outcomes, Efficiency,
Safety, Experience)
– Care: Process, Outcome, Efficiency, Safety, Experience
 Tactics:
–
–
–
–
–
–
–
A
Unit Care Measure feedback
I
D
Hourly rounding
E
Discharge phone calls
T
High/Middle/Low performance measures/action
Designated Physician/Nurse Champions -> accountability
Physician Leadership Feedback Scores
AIDET training
Acknowledge
Introduce
Duration
Explanation
Thank You
22
NMMC: Community Customer
 Health Fairs – annually
involve 25 % of 650,000
person market
 Church Nurse Program
 Good Samaritan Free
Clinic
 School Athletic Trainer
Program
NMMC: Voice of the Customer
 Patients/Families on Strategy/PI
gy
Teams
 Example: Women’s Health Task Force
Breast Care Center
Newborn Follow-up Center
Lactation/Breastfeeding Program
Teen Health Program
Healthy Start Prenatal Clinic
Domestic Violence Program
23
In Support of Key Communities
Define Communities Served
Owners
Bexar County
26‐‐County
26
Service Area
Key Needs Analysis
Market(s) Data (from Strategic Pl
i
Planning Process)
Community Health A
Assessment
Validation of Customer Demands (Strategic Planning Process)
Listening Posts/Ad Hoc Requests
Criteria Used to Gage Support
Decision and Deployment
Support D i i
d
Decisions and Resource Deployment
Notification (Yes/No)
Recheck and Improvement
Response Analysis and Review of Community Support
Appropriate Reports to Constituents
• Community
• Internal Stakeholders
• Regulatory Bodies
• Owners
Ongoing Impact Measurement
Unanticipated Requests
Methodist Healthcare
Ministries of South Texas
 Serve low income and uninsured
families in South Texas
 72 county service area
 Clinics:
–
–
–
–
Primary care medical and dental
School-based
Church-based
Counseling, case management
social services
 1998 – 2010
– $ 340 million
– 3.24 million client encounters
 2010
– $ 52 million
– 516,000 client encounters
24
Created A Shift In View Regarding Physicians
From
To
Physician
Satisfaction
Physician
Partnership
& Loyalty
Trajectory of MHS Physician Relationships
Advocate
Lo al
Loyal
Satisfied
Tried
Heard of
Unaware
25
Using the Baldrige Framework to
Create Clinical Excellence
1 Leadership
1.
How we:
Lead
2. Strategic Planning
Plan
3. Customer Focus
Meet Customers’ Needs
4. Measurement, Analysis
and Knowledge Mgt.
Convert Information to
Knowledge
5. Workforce Focus
Support our “Peeps”
6. Operations Focus
Do our “Thang”
7. Results
Compare to the Best
Cat. 4 – Measurement, Analysis and
Knowledge Management (90 points)
 4.1 – Measurement, Analysis and Improvement
of Organizational Performance
– How do you measure, analyze, and then improve
organizational performance?
– Describe how your organization measures
measures, analyzes
analyzes,
reviews, and improves its performance through the
use of data and information at all levels and in all
parts of your organization.
26
Cat. 4 – Measurement, Analysis and
Knowledge Management (90 points)
 4.2 – Management of Information, Knowledge,
and Information Technology.
Technology
– How do you manage your information, organizational
knowledge, and information technology?
– Describe how your organization:
• Builds and manages its knowledge assets.
assets
• Ensures the quality and availability of needed data,
information, software, and hardware for your
workforce, suppliers, partners, collaborators, and
patients and stakeholders
NMMC: Clinical EHR Infrastructure
 NMHS Network to 140 sites in 33 communities in 2 states
 5000 PCs on Wide Area Network
 Link patient information across 6 hospitals, clinics, schools,
nursing homes, home care
 Eclypsis – 6 hospitals, 73 physician offices
 Logician (Centricity)
–
–
–
–
–
37 o
3
owned
ed cclinics
cs
17 private clinics
4 nursing homes
23 school-based clinics
> 400 home care nurses
 Over 610,000 patients in EMR
27
MHS: Hospital-Clinic Data Exchange Server
Practice – No EMR
Firewall
•
•
•
Lab, Pathology, Microbiology
Radiology, Cardiology, General
Transcription
Filter Preferences
–
–
•
Practice – EMR, No HL7
Firewall
Hospital
Assistant
Browser View
Filt / Sort
Filter
S t
Batch Print
•
•
•
Data Exchange
S
Server
•
•
•
PDF
Office
Assistant
EMR
Practice – EMR / HL7
•
•
Result, Patient Type, Physician Role
No Duplicates
Private, Secure, Audited Exchange
Image Data
Manual Indexing
Filename Based on
Patient Data
EMR
•
Discrete Data
Directly Into Chart
or Worklist
Alerts &
Flowsheet
MHS: Comparative Data Systems
People
S i
Service
Quality
Community
• TNS, PRC, NDNQI, HR Analytics, Business Objects
• Gallup, HCAHPS, PRC and Foresight
• CHOIS, NDNQI, Comet, Premier, Meditech, Safety Surveillor AHRQ, HCA, Ministries Clinics
• Volgistics, National Research Corporation, Target SA Finance
• 3M, PLUS, HOST HCA System, Business Objects, Alliance for Decision Support
Growth
• Meditech, THA PDS, THCIC, Business Objects, Alliance for Decision Support
28
MHS: How We Select and Report Key Measures
External Voice
Comparative Data Systems
Internal Voice
Strategic Planning
People
Strategic Objectives
Service
Quality
Community
Data Selection
Finance
Set Goals
Growth
Develop Action Plan
System
Balanced Balanced
Score Card
Facility
Unit
Users of Users
of
Information
Staff
Report Key Measures + Executive Leadership + MHM + Community Board + Methodist Assembly + MCLE + + PaCES + Medical Leadership + Integration Teams + Quality Councils + MHS QI +
Clinical Quality Measures
 Care
– 1. Process
– 2. Outcomes
– 3. Efficiency
– 4. Safety
– 5. Experience
 Each measure segmented by hospital,
clinical service, nursing unit and physician
29
You can patiently wait it out
30
You can ignore it and do nothing.
You can threaten collective action.
31
You can fight it.
Or, you can embrace it
32
First: We
Fear
the
Change
33
Second: We cautiously Explore the Change
Third: We Embrace the Change
34
Last: We Become the Change
Using the Baldrige Framework to
Create Clinical Excellence
1 Leadership
1.
How we:
Lead
2. Strategic Planning
Plan
3. Customer Focus
Meet Customers’ Needs
4. Measurement, Analysis
and Knowledge Mgt.
Convert Information to
Knowledge
5. Workforce Focus
Support our “Peeps”
6. Operations Focus
Do our “Thang”
7. Results
Compare to the Best
35
Cat. 4 – Measurement, Analysis and
Knowledge Management (90 points)
 4.1 – Measurement, Analysis and Improvement
of Organizational Performance
– How do you measure, analyze, and then improve
organizational performance?
– Describe how your organization measures
measures, analyzes
analyzes,
reviews, and improves its performance through the
use of data and information at all levels and in all
parts of your organization.
Cat. 4 – Measurement, Analysis and
Knowledge Management (90 points)
 4.2 – Management of Information, Knowledge,
and Information Technology.
Technology
– How do you manage your information, organizational
knowledge, and information technology?
– Describe how your organization:
• Builds and manages its knowledge assets.
assets
• Ensures the quality and availability of needed data,
information, software, and hardware for your
workforce, suppliers, partners, collaborators, and
patients and stakeholders
36
NMMC: Clinical EHR Infrastructure
 NMHS Network to 140 sites in 33 communities in 2 states
 5000 PCs on Wide Area Network
 Link patient information across 6 hospitals, clinics, schools,
nursing homes, home care
 Eclypsis – 6 hospitals, 73 physician offices
 Logician (Centricity)
–
–
–
–
–
37 o
3
owned
ed cclinics
cs
17 private clinics
4 nursing homes
23 school-based clinics
> 400 home care nurses
 Over 610,000 patients in EMR
MHS: Hospital-Clinic Data Exchange Server
Practice – No EMR
•
•
•
Firewall
Data Exchange
S
Server
•
•
•
Lab, Pathology, Microbiology
Radiology, Cardiology, General
Transcription
Filter Preferences
–
–
•
Practice – EMR, No HL7
Firewall
Hospital
Assistant
•
•
•
PDF
Office
Assistant
EMR
Image Data
Manual Indexing
Filename Based on
Patient Data
Practice – EMR / HL7
•
•
Result, Patient Type, Physician Role
No Duplicates
Private, Secure, Audited Exchange
Browser View
Filt / Sort
Filter
S t
Batch Print
EMR
•
Discrete Data
Directly Into Chart
or Worklist
Alerts &
Flowsheet
37
MHS: Comparative Data Systems
People
Servic
e
• TNS, PRC, NDNQI, HR Analytics, Business Objects
• Gallup,
p, HCAHPS,, PRC and Foresight
g
Quality
• CHOIS, NDNQI, Comet, Premier, Meditech, Safety
Surveillor AHRQ, HCA, Ministries Clinics
Communit
y
• Volgistics, National Research Corporation, Target
SA
Finance
• 3M, PLUS, HOST HCA System, Business Objects,
Alliance for Decision Support
Growth
• Meditech, THA PDS, THCIC, Business Objects,
Alliance for Decision Support
MHS: How We Select and Report Key Measures
External Voice
Comparative
Data Systems
Internal Voice
Strategic Planning
People
Strategic
Objectives
Service
Quality
Community
Data Selection
Finance
Set Goals
Growth
Develop Action
Plan
System
Balanced Balanced
Score Card
Facility
Unit
Users of Users
of
Information
Staff
Report Key Measures
+ Executive Leadership + MHM + Community Board + Methodist Assembly + MCLE
+
+ PaCES + Medical Leadership + Integration Teams + Quality Councils + MHS
QI +
38
Clinical Quality Measures
 Care
– 1. Process
– 2. Outcomes
– 3. Efficiency
– 4. Safety
– 5. Experience
 Each measure segmented by hospital,
clinical service, nursing unit and physician
Using the Baldrige Framework to
Create Clinical Excellence
1 Leadership
1.
How we:
Lead
2. Strategic Planning
Plan
3. Customer Focus
Meet Customers’ Needs
4. Measurement, Analysis
and Knowledge Mgt.
Convert Information to
Knowledge
5. Workforce Focus
Support our “Peeps”
6. Operations Focus
Do our “Thang”
7. Results
Compare to the Best
39
Cat. 5 – Workforce Focus (85 points)
 5.1 – Workforce Environment
– How do you build an effective and supportive
workforce environment?
– Describe how your organization:
• Manages workforce capability and capacity to
p
the work of the organization.
g
accomplish
• Maintains a safe, secure and supportive work
climate.
Cat. 5 – Workforce Focus (85 points)
 5.2 – Workforce Engagement
– How do you engage your workforce to achieve
organizational and personal success?
– Describe how your organization:
• Engages, compensates and rewards your
workforce to achieve high
g p
performance.
• Assesses workforce engagement and uses the
results to achieve higher performance.
• Workforce (including leaders) are developed to
achieve high performance.
.
40
Workforce Focus
 Structured leadership rounding
– Quarterly employee communication meetings
(Town Halls)
 Weekly CEO e-mails to “all”
 Management accountability
– NMMC:
• PRC Employee Satisfaction “Management Index” -
> High, Middle, Low accountability
• Quarterly EXCEL Performance Reviews based on
specific goals by CSF
• Employee bonus - > 6000 employees -Cost/patient
satisfaction
– MHS
• LEM – Leadership Evaluation Manager
• Nurse Practice Councils
NMMC
Dashboard
Report
Turnover Rate FY 05
FT YTD Projection
12%
4%
75%
50%
25%
FY05 Goal
Inpatient
PY Goal
QUALITY
Emergency
FINANCIAL
Composite Quality Score
Outpatient
Ambulatory
M ar
FY 05
Dec
FY 05
S ep
FY 04
June
FY 04
M ar
FY 04
Dec
FY 04
M ar
FY 03
Pr
Pr ior
io Yr
rY Y
r A TD
ct
ua
l
Ju
l
Au
g
Se
p
O
ct
N
ov
D
ec
Ja
n
Fe
b
M
ar
Ap
r
M
ay
Ju
n
% Proj Turnover
S ep
FY 03
0%
0%
Home Health
GROWTH
Productivity by Pay Period
Market Share
7.00
48.19%
91.59
91.42
91.13
92.02
91.6
PdFTEs/AOB
6.50
48%
6.00
48.11%
44%
5.50
40%
5 00
5.00
36%
33.67%
32%
4.50
33.50%
28%
4.00
Q4 04
Q1 05
$11
NMMC
90% tile
50% tile
23
25
19
21
15
17
13
16%
12%
10.46%
10.93%
7.84%
7.29%
8%
4%
Thousands
0%
Q1 03
$10
$9
NMMC
Q2 03
Q3 03
Q4 03
Baptist Health System
Q1 04
Q2 04
NMMC Affiliates
Q3 04
Q4 04
Other MS Hospitals
$8
$7
Actual
Budget
Ju
n
Ju
ly
A
ug
S
ep
Q3 04
FY 05
Ja
n
Fe
b
M
ar
A
pr
M
ay
Q2 04
FY 04
20%
FY 05 Target
Cost Per Adjusted Discharge
N
ov
D
ec
Q1 04
9
7
FY 03
11
3
5
1
24%
O
ct
100
98
96
94
92
90
88
86
84
82
80
95%
100%
June
FY 03
8%
11.21%
10.96%
11%
10.17%
9.07%
8.85% 9.16%8.71%
8.71%
8.44%
SERVICE
Patient Satisfaction
P e r c e n ti l e
PEOPLE
Prior Year
41
Unit Specific Knowledge Boards
42
Using the Baldrige Framework to
Create Clinical Excellence
1 Leadership
1.
How we:
Lead
2. Strategic Planning
Plan
3. Customer Focus
Meet Customers’ Needs
4. Measurement, Analysis
and Knowledge Mgt.
Convert Information to
Knowledge
5. Workforce Focus
Support our “Peeps”
6. Operations Focus
Do our “Thang”
7. Results
Compare to the Best
Cat. 6 – Operations Focus (85 points)
 6.1 – Work Systems
– How do you design, manage and improve your work
systems?
– Describe how your organization:
• Designs
Designs, manages and improves its work systems
to deliver patient and stakeholder value.
• Prepares for potential emergencies.
• Achieves organizational success and sustainability.
43
Cat. 6 – Operations Focus (85 points)
 6.2 – Work Processes
– How do you design, manage, and improve your key
work processes?
– Describe how your organization designs, manages,
and improves
p
its key
y work p
processes to deliver
patient and stakeholder value and achieve
organizational success and sustainability.
““If the rate of change on the outside f h
f h
h
id
exceeds the rate of change on the inside, the end is near.”
Jack Welch
Former Chairman and CEO
General Electric Corp.
44
Creating a Process Driven Organization
Everything we do is:
Defined - by customer need
Measured - by repeatable data
Improved - in a structured methodology–DMAIC
Aligned - across the organization
Improving customers’ Value (Quality/Cost)
Process Maturity Levels
Stage 4. Integrated Approach
Operations are by defined processes that are repeatable and
regularly evaluated for improvement in collaboration among
organizational units. Efficiencies across units are sought
and achieved.
Stage 3. Aligned Approach
Operations are by defined processes that are repeatable and
regularly evaluated for improvement, with shared learning
and coordination among organizational units.
Stage 2. Early Systematic Approach
Organization
g
is at the beginning
g
g stages
g of conducting
g
operations by defined processes.
Stage 1. Reacting to Problems
Everyone is working hard on urgent problems.
Operations are characterized by activities rather than by
defined processes.
90
45
DMAIC Method for Performance
Improvement
Define
Clinical care
Measure
Billing
Infection control
Analyze
Environmental services
Improve
Marketing
Others…
Control
Category 6: Operations Focus
Quality/Process Improvement
Models
13-Step PDCA
P-D-C-A
D-M-A-I-C
(Six Sigma
Applications)
D-I-S-C
(Lean
Applications)
1. Select Opportunity for
Improvement
I-P-E-C-C
(Project
Management)
Initiate
2. Identify Customer
Requirements
Define
Define
3. Define the Problem
4. Collect Data
Plan
Measure
5. Analyze for Root Causes
Investigate
Planning
6. Find Solutions
Analyze
7. Prepare Implementation
Plan
8. Implement Solutions
9. Monitor Results Against Plan
10. Explain Any Deviations
Do
Check
Streamline
Improve
Execution
Control
11. Take Corrective Action
12. Standardize New Process
92
13. Review
Act
Control
Control
Close
46
Process-Driven Work
Requirements
Work:
- Systems
- Processes
- Measures
Inputs
Outputs
Resources
SA Methodist Healthcare System – SIPOC Management Systems
Leadership
System
Strategic Planning System
Legal, Ethical, Governance System
Organizational Perf. Imp. System
Organizational Belief Systems
Voice Of The Customer
Patient and Stakeholder Relationship Management
Systems:
Inpatient
Outpatient
Emergency
Direct
Care
Suppliers
Processes:
Patient Access
Assessment/Diagnosis
Care Delivery
Discharge/Education
Continuum Of Care
Care Measures:
Process
Efficiency
Safety
Outcomes
Experience
Key Work Systems
Suppliers
Customers
Information Technology
Revenue Cycle and Finance
Facilities and Infrastructure
Clinical Support Services
Enablers
}
Support
System
Suppliers
Human Resources Customer Value (Quality/Cost
Information Technology
Support Services
Learning and Innovation
Public Safety
Supply Chain Management
Inputs
Processes
Outputs
47
Project Level – Authority Rules
Complexity
Simple
Minimal
Moderate
Maximum
Project Size
Just Do It
Small Team
Large Team
Strategic Project
Participation
Anyone can do it
Unit based or two
departments
Crosses departments or
disciplines
Enterprise wide
Minimal Expense
Signature level authority
Signature level authority
Signature level authority
Organizational
Requirements
Aligns with mission
Aligns with mission
Aligns with mission
Aligns with mission
Policy and
Procedure
Fits w/in existing
policies
Fits w/in existing
policies
May require
policy/procedure
change
May require
policy/procedure
change
Improvement
Approach
Empowered to act
Rapid cycle
improvement
DMAIC Green Belt level
DMAIC Black Belt level
Tool Box
Minimal
Meeting Templates
-Team/project charter
-Agenda
-Minutes
-Team structure
“Just in time” training
material
Data collection template
Flow charts
Run charts
Control charts
Scatter diagrams
Cause and effect diagrams
-Fishbone
-Process type
FMEA/RCA process
Meeting Templates
-Team/project charter
-Agenda
-Minutes
-Team structure
“Just in time” training
material
Data collection template
Flow charts
Run charts
Control charts
Scatter diagrams
Cause and effect diagrams
-Fishbone
-Process type
FMEA/RCA process
Control charts
SIPOC diagram
COPQ worksheet
Relationship table
Meeting Templates
-Team/project charter
-Agenda
-Minutes
-Team structure
“Just in time” training
material
Data collection template
Flow charts
Run charts
Control charts
Scatter diagrams
Cause and effect diagrams
-Fishbone
-Process type
FMEA/RCA process
Control charts
SIPOC diagram
COPQ worksheet
Relationship table
Financial
Parameters
Opportunities for Cost Reduction &
Quality/Safety Enhancement
OLD Cost
Drivers
15%
CARE
85%
48
MHS 2010 Risk-Adjusted ALOS
5.00
4.50
4.00
3.50
Days
3.00
2.50
2.00
1.50
1.00
0 0
0.50
0.00
MH
MCH
Expected ALOS ‐ CS Sel
MSTH
MMH
NEMH
Expected ALOS ‐ CS Std
MSOH
Observed ALOS
Premier Select
Premier Standard
97
Practitioner
Profiles
49
MHS Order Sets and Protocols
Evidence Based Care Team
Multidisciplinary System‐wide Create
Revise
Pilot
Medical Record Committee Medical Board
Additional
Review
by EBCT and
Specialty Group
no
yes
Approval
Implement
Measure*
*evaluate adoption, periodic review, revision based on clinician feedback
Individual Patient Care
Direct Physician Intervention
Standard Care by Protocol
50
Using the Baldrige Framework to
Create Clinical Excellence
1 Leadership
1.
How we:
Lead
2. Strategic Planning
Plan
3. Customer Focus
Meet Customers’ Needs
4. Measurement, Analysis
and Knowledge Mgt.
Convert Information to
Knowledge
5. Workforce Focus
Support our “Peeps”
6. Operations Focus
Do our “Thang”
7. Results
Compare to the Best
Cat. 7 – Results (450 points)
 Trend
e do
of top
op dec
decile
e scores
sco es nationally
a o a y ((from
o
health care and/or other industries) on:
– 7.1 Health Care and Process Outcomes (120 pts.)
– 7.2 Customer-Focused Outcomes (90 pts.)
– 7.3
73 W
Workforce-Focused
kf
F
d Outcomes
O t
(80 pts.)
t )
– 7.4 Leadership and Governance Outcomes (80 pts.)
– 7.5 Financial and Market Outcomes (80 pts.)
51
Summary
 Success (a.k.a. Survival) in healthcare requires
empowering physicians as partners.
partners
 Cost reduction and quality/safety opportunities
require aligned, informed, and empowered
clinical leaders.
 The Baldrige process offers a framework for
achieving physician partnerships and clinical
excellence for our patients
Linkage Items
 What are the 7 Baldrige categories and how can
they be used as a framework to achieve
organizational excellence.
 What is my role in achieving organizational
excellence.
 Every
y leader has two conversations in their
department:
– Cascade the Baldrige framework to their staff
– Discuss Baldrige and individual accountability to
one’s “one up” leader
52