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Black River Memorial Hospital

• Serve 17,000 residents in Jackson County, WI

• Employ over 300 people• Provide several services

including:o OBo Respiratoryo Surgical Serviceso Rehabo Homecareo Hospiceo ED

Awards & Accolades

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Getting The Most of Your Current Tools

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Audits

• Used Coffee Cup softwareo Provides logic to assist staff in completing the audit correctlyo http://www.coffeecup.com/web-form-builder/

• Data is then sent to a CSV file o We transfer the data to an access data base and write queries to

extract the data in a “user-friendly” format

• Teleformo Paper format that is scanned and the data is placed into the file format

of your choice (access/CSV/Excel)

Coffee Cup SoftwareCreating the Audit Tool

and

Using the Audit Tool

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Teleform

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Know The Power of Excel

• Pivot tables• Formulas• Graphs

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Access

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Access vs ExcelAccess Excel

• Large amounts of datao (1000 plus)

• Continually updating• Basic statistics:

o Mediano Percentage

• 250 or more fields• More in-depth

statistical analysis:o Standard deviations

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Other Suggestions

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Many Hands Make the Load Light

• Modified Duty• Downtime

Resources• Voting options in Outlook (screen shots)• Power of the pivot table

chandlerk@brmh.net

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Staff Engagement in a 

Quality Matrix

2016 Wisconsin Rural Health Conference

Katie Spiegel, MHA, MSN, RN

Aspirus Langlade Hospital

Quality Resource Manager

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Aspirus Langlade Hospital

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25 bed Critical Access HospitalEmergency‐Level IV Trauma Center

Surgical ServicesBirthing Center

Intensive Care UnitRehabilitation ServicesHospice/Palliative Care

1 General  Primary Clinic with OB/GYN2 Rural Health Clinics

Specialty Clinics:  Kidney Care, Cancer Center, Pain Clinic, Orthopedics, Behavioral Health,  Cardiology

Aspirus Langlade Hospital is a Catholic hospital, founded by the Religious Hospitallers of St. Joseph, and is sponsored by Catholic Health Partners, Inc. The Corporate Members of Aspirus Langlade Hospital are Aspirus, Inc. and the Religious Hospitallers of St. Joseph Health Corporation.

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Aspirus System At‐a‐Glance• Non‐profit, community‐directed healthcare system serving 

North Central Wisconsin and the Upper Peninsula of Michigan

• More than 7,000 employees

• Integrated Health System

– 14 Wisconsin counties

– 7 Upper Michigan counties

– 8 hospitals

– 50 clinics

– Home health and hospice care

– Pharmacies

– Critical care and helicopter transport

– High‐quality affiliated physicians

– Member of AboutHealth ACO

– Aspirus Arise Health Plan

• 467,000+ outpatient cases & ER visits; 19,000+ inpatient discharges; 1,400+ deliveries; 420+ open heart cases; 

• Aspirus Network (contracting entity organized as a PHO) integrated network provider that regionally aligns more than 450 Aspirus employed and affiliated independent physicians and 300+ Advanced Practice Providers.

Mission and Vision

Aspirus System:

• To build a patient centered, physician partnered system that provides the highest quality care at the lowest cost to the communities we serve.

Aspirus Langlade Hospital:

• As a ministry of Jesus we heal, promote health and enrich lives

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What is Quality at Aspirus Langlade Hospital?

• Centers for Medicare and Medicaid (CMS)

• The Joint Commission (TJC)

• National Healthcare Safety Network (NHSN)

• Wisconsin Hospital Association’s Partners for Patients 

• CheckPoint, Hospital Compare, & PricePoint

• Scorecards & Dashboards

• Continuous Quality Improvement

• Service Excellence

• Risk Management and Patient Safety

• Case Management & Care Coordination

• Advance Care Planning

• Utilization Review

• Medical Staff Services

• Infection Prevention

• Civil Right Compliance

• Limited English Proficiency Coordinator

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Our System’s Formula For Success

Care: Compassionately 

help people to be as healthy as possible.

Unite: Aspirus entities and people plan and work as one.

Empower: Those closest to the work drive improvement.

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Work To Date• Created our vision for the future of quality resources within 

the Aspirus System:Create a culture of quality and patient safety across the system by building resources 

and capacity to facilitate performance improvement through: collaboration & knowledge sharing; standardized, consistent, accurate, & timely data & 

communication; outcome and regulatory driven best practices with meaningful patient outcomes; timely and prioritized process improvement.

• Inventory of roles and responsibilities

• Knowledge and skills self‐assessment and subsequent professional development plan

• Developing functional peer groups

• Developed model for the future that was approved by Corporate Executive Council.  We are readying for socialization.

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System Rollup Pillar Scorecard‐Optimal Care

BU Pillar Scorecard Composite ‐ Optimal Care

Business Unit Metrics Scorecard ‐ Optimal Care

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Collaborative Work

Preparing Leaders and Frontline Staff

• New Employee Orientation (NEO)

• New Nurse NEO

• Leadership Training

• Physician Engagement

• Visual Management Boards

• Tracers

• Rounding

• Katie’s Open Door Policy38

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Urinary Tract Infection

Infection after Cesarean Section

Blood clot while hospitalized

Adverse drug event due to too much insulin

Readmission after falling at home

Our Golden Rule: It is always about the patient…

How do we know we are engaging frontline staff?

• Employee Generated Data

• Scored on Indexes:  

– New Employee Index (NEI), Organizational Health Index (OHI), Work Environment Index (WEI), Engagement Index (EI), Leadership Index (LI), Safety Culture Index (SCI) 

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Very Acceptable to Exceptional 76.0 and aboveHIGH SCORES

Not a Strong Position 61.0‐75.9GENERALLY ACCEPTED SCORES

Requires Attention 46.0‐60.9NEGATIVE SCORES

Generally Dire Situation 45.9 and LessIN NEED OF IMMEDIATE ATTENTION

*Following Data from preliminary 2016 Work Climate Survey by The Jackson Group

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Results DB Mean Variance

NEI 

Index

The orientation process I received was helpful to me 84.4 86.4 ‐2.3%OHI

Index

I can initiate action to change things that need to change 70.5 67.9 3.8%*Overall, teamwork seems to be a value that is widely practiced at my organization 80.4 77.8 3.3%*

My organization is a quality organization 85.7 83 3.3%WEI 

Index

In my work area, we have a smooth, efficient way of getting the job done 80.3 78.6 2.2%In my work area, we have the supplies and equipment we need to do excellent work 84.4 81.4 3.7%*I am involved in decision‐making in my department/unit 74.4 70.4 5.7%*New ideas are welcome in my department 80 78.6 1.8%

EI

IndexCo‐workers I see around me are committed to doing quality work 85.2 83.3 2.3

This last year, I have had opportunities at work to learn and grow 83.7 81.5 2.7%My job is important to helping this organization accomplish its mission 90.7 90.4 0.3%

LI

Index

My department director successful involves employees in decision‐making 79 74.1 6.6%*My department director appreciates the employees for the work they do 84.5 80.6 4.8%*

I see my department director as providing quality service 85.1 80.8 5.3%*SCI

Index

Employees feel free to openly discuss things seen, positive or negative, in the work area 76.9 73.2 5.1%*The person to whom I directly report seriously considers staff suggestions for improving safety and 

preventing errors84.1 82.7 1.7%

In my work area, we discuss ways to prevent errors from happening again 86 85.9 0.1%Safety or prevention of errors is not sacrificed to get more work done 85 81.7 4%*

What It Feels Like & How do We Sustain?

• Enhance Change Management Skills:

– Change will wait for no one.  Change is fast and will only get faster.

• It is not all about “ME”, it is about “US”

– Focus on SYSTEM, not silos.

• Learning about life in a highly matrixed environment.

• Continue to drive improvement to frontline staff.

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Questions?

Katie Spiegel MHA, MSN, RN

Aspirus Langlade Hospital

Quality Resource Manager

katie.spiegel@aspirus.org

715‐623‐9317

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Engaging Physicians in

Quality Improvement:Best Practices

Shelly EgstadQuality Director

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• 25 bed independent CAH• 2016 Top 20 Hospital-NRHA • Top 100 CAH-4th consecutive year

from iVantage • Net Revenue- $45 million• Primary service area population-

22,000• Key services: ED, OB, Rehab Services,

Hospice, OP services

• Culture: A way of thinking, behaving, or working that exists in a place or organization.

• If you do not develop your corporate culture it will develop itself. Monique Winston

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Relationships• Respect• Accountability and follow

through • Trust• Communication• Listening-Intentional rounding

• What’s going well?• What do we need to improve?• Do you have the tools and

equipment to do your job?

Peer Review • Learning vs. Judging • Evidenced based • Just Culture• Recognize the good

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Value Their Time• Well run meetings

• Standardized format for agenda/minutes

• Agendas sent out ahead of meeting• Minutes available shortly after meeting

or follow up to-do list sent• Specific time allotted for each agenda

item• Action or Information

• “Easy to do business with”

Recognition• Thank you notes• Awards for Improvement • Physician Champions• Doctor’s Day• Recognize their challenges

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Hire Right Medical Staff Robust credentialing process Committee appointments by interest Employees Coach staff how to approach physicians Hold staff accountable

Invest in Their Success• Educational Opportunities

• Journal articles, info from conferences• WHA, RWHC

• Leadership Training• Include physicians in hospital leadership training• WHA Physician Leadership Conference

• Succession Planning

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“It’s all about the culture.” It takes time Persistent, consistent

work

Questions?