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Fremont Area Medical Center

New Management OrientationDeveloped: Sept 2005

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Administrative Overview Agenda

Mission, Vision, Values and PhilosophiesPlanning & Development ProcessChain of Command and Organization Relationships - Direction, Integration, and CommunicationBusiness PlanningOrganizational Goals Contracts & Agreements

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Mission Statement

The mission of Fremont Area Medical Center is to optimize the health status of individuals by providing a wide range of accessible, customer-centered health care services in an efficient, cost-effective manner.

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Vision Statement

Fremont Area Medical Center will be a healthcare provider that passionately pursues excellence in Quality, Service and Safety while embracing our Stewardship responsibilities.

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Values & Philosophies

Direct and Sincere Communication: We encourage direct and sincere communication throughout our organization in the belief that, through dissemination of pertinent information, our opportunities to meet the customer’s needs are enhanced.Behavior - Professional communication skills

should be learned and practiced continually. Focus on the words before you respond and answer with a smile, project a positive, upbeat tone and use the appropriate script.

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Values & Philosophies

Flexibility: We acknowledge that change is the only status quo. We recognize change as a growth process and are open to considering and offering new ideas and approaches to doing things. Behavior - Be responsive to change.

Demonstrate adaptability to allow change to occur and, in some cases, be the catalyst. The last thing you want is to be the keeper of the tradition that creates the roadblock to progress.

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Values & Philosophies

Integrity & Professionalism: We aspire to the highest level of personal and professional ethics as demonstrated by commitment to truth, to deliver what we promise and maintain the dignity of persons with whom we work and serve,Behavior - Regardless of your position, you are

responsible for your actions and reactions as well as your immediate service area. Appearance and body language speak volumes. FAMC employees should take pride in your service and in presenting a professional image.

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Values & Philosophies

Teamwork: We are mutually dependent upon one another for accomplishing personal and organizational goals, recognizing that customer expectations cannot be met without effective working relationships. Behavior - Create a cooperative effort as a

member of the FAMC team to achieve the “above & beyond” customer service goals. Effective teams combine the power of group process, shared responsibility, and mutually supportive teamwork processes to create synergy. The result of such synergy can be extraordinary.

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Values & Philosophies

Efficiency: Our job is to optimize the utilization of the resources available to accomplish the desires results on time. Behavior - Out of respect for the common

good and caring of others, we are called to be good stewards of the resources entrusted to us. We are willing to assume responsibility for using time and materials wisely to provide the best customer service possible.

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Values & Philosophies

Compassion: We display a sincere, caring attitude towards everyone with whom we come in contact, respecting the individual dignity of each person.Behavior - Every interaction with a

customer, whether internal or external, is an opportunity to build a strong relationship and show care and concern.

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Values & Philosophies

Leadership: We take the responsibility for assuring quality and achieving the Hospital’s objectives in an appropriate and efficient manner.Behavior - Be proactive. Reactive

behavior allows circumstances to control your response. Proactive behavior, however, allows you to control your circumstances to a degree. Take initiative and act rather than react.

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Values & Philosophies

Commitment: We have a positive attitude towards our work, the people we serve, FAMC and one another.Behavior - Immediate service recovery:

Customer complaints and problems must be addressed immediately. Understanding the problem before trying to solve it: listen, ask questions, apologize, discuss options, follow through and document according to policy.

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Values & Philosophies

Creativity & Innovation: We encourage creative thinking and problem solving, taking prudent risks and striving to go beyond our limits.Behavior - It takes a lot of courage to

display productive originality. Embrace productive risk-taking strategies that enhance customer service. Recognize and build on the contributions of others.

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Values & Philosophies

Service: We recognize that each interaction with a colleague, patient, resident, physician or member of the general public is an opportunity to provide outstanding service. Throughout the Medical center, we work together as a team achieving this quality of service through continuous improvement efforts.Behavior – Demonstrate inter-collaborative

networks that function to unify FAMC team spirit.

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Planning & Development

Under the direction of the Board of Trustees, the Executive Management Team is accountable for short term and long term planningShort term planning occurs at all levels in response to operations and provision of services and is consistent with Mission and Vision of our organization.– Includes determination of qualifications, competency, and volume

of staff needed to provide care, treatment, and services Long term planning is accomplished in the form of a Strategic Plan, which is completed triennially.– Includes financial, space/physical plant, equipment, and other

resource considerations

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Planning Process

Administrative Policies

Pattern of Development Planning System Overview

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Strategic Plan 2004-2007

Ambulatory Surgery CenterCardiovascular & Thoracic ServicesOrthopedic Spine SurgeryBreast Disease Screening, Diagnosis, Treatment, & Women's ImagingAlzheimer’s/Dementia Special Care UnitHospice Special Care Unit

These strategies were selected because they assist FAMC in achieving its desired position, they build on the existing strengths of the medical center by taking advantage of current opportunities, and they address current and potential threats to the medical center.

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Chain of Command and Organization Relationships

Michael Leibert, President/CEO– Began working at FAMC in 1985

Peg Kennedy, Vice President/Chief Operating Officer/Chief Nursing Officer– Began working at FAMC in 1975

Dave Hanen, Vice President/Chief Financial Officer– Began working at FAMC in 1984

Bryan Hehemann, Vice President, Administrative Service– Began working at FAMC in April 2005

Our Administration has more than 71 years of combined experience

See Admin Chain of Command and Organizational Relationships Policies

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See FAMC Organizational Chart

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Direction

The Executive Management Team, specifically Dept. Directors are responsible for:– Integration of their services(s) into the organization’s primary functions– Coordinating and integrating inter & intra – departmental services– Developing & implementing P/P that guide & support provision of care & services– Recommending sufficient numbers of qualified competent staff to provide services– Determine qualifications and competence of department staff– Continually assess, improve, and maintain the performance of care and services– Establish internal controls to effectively maintain information & support systems,

recruiting & retaining staff, and conserving physical and financial assets– Orienting and providing department in-service training and continuing education– Recommending department space & resources needed– Participating in selection of sources for needed services not provided by the depart or

organization

Found in Leadership Document Policy

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Integration

Organizational & functional relationships of departments are defined in organizational charts.Leaders individually and jointly develop and participate in effective mechanisms to:– Foster communication among individuals & components of the organization– Coordinate internal activities– Communicate with leaders of organization that functionally relate to FAMC

Staff assigned managerial responsibilities participate in cross-functional activities to improve organizational performance. These include:– Performance improvement teams and activities– Ad-hoc committees and task forces– Multi-disciplinary Medical Staff &/or Medical Center Committees

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Communication

Lighter Vein and various other Newsletters

Administrative Staff Meeting – Meets weekly, WedExecutive Management Team Meeting – Meets as Needed, whenever calledManagement Consultation Group Meeting – Meets Monthly, 3rd Tues Goals Team MeetingsDepartment Staff MeetingsEmployee Meetings

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Business Planning

Policies & Forms

New Program Analysis Policy Program Analysis Form

Program/Equipment Request Policy Business Planning Template FMEA Form

See Administrative & Finance Policies

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Sample Business Plan

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2007 Organizational Goals

QualityServiceEmployer of ChoiceCommunity HealthFinance

2007 Incentive Plan

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Quality Goal

GOAL: FAMC will maintain an environment that enhances excellence in providing exceptional quality and safe care.

FOCUSED MEASURE: Improve overall outcomes and quality of life for patients and residents of FAMC.– Acute: Achieve second decile or above in the four clinical areas of

AMI, HF, CAP, Hip/Knee Replacement (Medicare Only) Composite Quality Score (CQS) on the Hospital Quality Incentive Demonstration Project

– Post Acute: Improvement in the management of oral medications, based on CMS data collected through the OASIS, currently measured at 38.6%

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CMS Goals Report

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Service Goal

GOAL: FAMC will provide exceptional customer service as measured by the Patient/Resident Satisfaction surveys.

FOCUSED MEASURE: – FAMC will achieve 75% (comprised of “Excellent and Very Good”

patient/resident response) on the question “What’s the likelihood of you recommending FAMC” in seven service areas which are Inpatient, Outpatient Ambulatory Services, Emergency Department, Long Term Care, Home Health, and Hospice.

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Employer of Choice Goal

GOAL: FAMC will develop an employer of choice environment around proven pillars of staff satisfaction, development, and empowerment.

FOCUSED MEASURE: – Note: a Steering Committee is presently defining this Focused

Measure for the Board’s review and approval at a later date, which will not be included in the 2006 incentive plan

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Community Health Goal

GOAL: FAMC will work to improve the overall health status of the population of Dodge County.

FOCUSED MEASURES: – FAMC will make progress towards achieving the objectives based upon

the healthy People 2010 initiative.• Reduce the proportion of adults who are obese to 15 percent (20.2% based on 2004)• Reduce the mean total blood cholesterol levels among adults to 199 mg/dl. (205.24

mg/dl., 2003)• Reduce the proportion of adults who engage in no leisure-time physical activity to 20

percent (30% , 2004)• Increase influenza immunization rates among adults 65 years and older to 90

percent. (65%, 2003)

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Finance Goal

GOAL: FAMC will achieve the projected net gain through meeting operational budgets and optimal utilization of available resources. To systematically identify leveraged saving opportunities across all areas of supplies, purchased services, and labor.

FOCUSED MEASURE: – FAMC will achieve a Net Gain of 4.7% for Fiscal Year 2006. Identify

strategic areas in which to focus efforts where supply and labor costs can be reduced through development of a disciplined, unified approach.

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Incentive Plan

FAMC Results Wt. Threshold Target Maximum

QualityAcute: Hospital Quality Incentive Demonstration Project for AMI, HF, CP, Hip/Knee Replacement (Medicare Only)(Composite Quality Score)  

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 Achieve 2nd decile or above in 2 of 4 areas

 Achieve 2nd decile or above in 3 of 4 areas

 Achieve 2nd decile or above in 4 of 4 areas

ServiceCustomer Satisfaction Score   

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 4 of 7 surveys 

 5 of 7 surveys

 6 of 7 surveys 

FinanceTotal Margin 

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 4.1%

 4.7%

 5.4%

Totals  1.00 

     

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Contracts & Agreements

All contracts and agreements must be signed by the CEOAdministration maintains copies of all contracts and agreements– Coordination by Administration assures

technical language which minimizes the risk of exposure.

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End of Presentation