Focus on Action, Performance Leadership and Setting ... · dmaic “improve ” strategic

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Focus on Action, Performance Leadership and Setting Expectations

Pennsylvania Health Care Association

May 22, 2018

Brenda GrantChief Strategy OfficerCharleston Area Medical Center Health System

CHANGE AND MORE CHANGE…CHANGE AND MORE CHANGE…

A LEADERSHIP STRATEGY FOR ORGANIZATIONAL SUCCESS

A LEADERSHIP STRATEGY FOR ORGANIZATIONAL SUCCESS

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PERFORMANCE IMPROVEMENT JOURNEY

2000Six Sigma

2005BaldrigeJourneyBegins

2007Lean

2008TransformingCare Together

2012Focus On Baldrige

Processes &Systems

2015MalcolmBaldrigeNational

Quality Award

2017 - 2018Cycles of LearningCommunities of Excellence 2026Cybersecurity

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.

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LEADERSHIP SYSTEM

LEADERSHIP SYSTEMSet Direction

Align and Cascade

Implement Action Plans

Achieve the Plan

Mentor and Develop People

Change Systems and Structures

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LEADERSHIP COMPETENCY MODELLeadership Model

(Actions)Strategic(Chiefs, VPS)

Operational(AAs, Corporate Directors)

Frontline(Directors, Managers)

SET DIRECTION(Build Commitment)

Leading through Vision and Values

Customer Focus

Business Acumen

Setting Healthcare Business Strategy

Leading through Vision and Values

Customer Focus

Business Acumen

Building Trust

Customer Focus

ALIGN AND CASCADE(Motivate and Resource)

Cultivating Clinical and Business Partnerships

Building a Successful TeamBuilding a Successful Team

Planning and Organizing

IMPLEMENT ACTION PLANS(Review and Adjust)

Making Healthcare Operations Decisions

Making Healthcare Operations Decisions

Decision Making

ACHIEVE THE PLAN(Make Change Last)

System Focus Driving Execution Driving for Results

MENTOR AND DEVELOP PEOPLE

(Reward and Recognize)

Building Healthcare Talent Coaching and Developing Others Coaching

CHANGE SYSTEMS AND STRUCTURES(Raise the Bar)

Driving Improvement Driving Improvement Adaptability

Underlying Leadership Attributes

Courage

Compelling Communication

Emotional Intelligence

Courage


Courage


PERFORMANCE MANAGEMENT SYSTEM

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WORKS SYSTEMS AND WORK PROCESSESENTERPRISE SYSTEM MODEL

SYSTEMS THAT GUIDE

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SYSTEMS THAT DO WORK

SYSTEMS THAT SUPPORT

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Embracing the Baldrige Approach

Our organizational performance accelerated as

we became process driven and integrated the

Baldrige processes and systems throughout our

organization.

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.”

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GOALS FOR TCT1. 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 OrganizationStandardizationVisual ManagementProblem SolvingHuman Centered Work

5S Workplace Organization

StandardizationVisual

Management

Problem Solving

Just in Time

Built in Quality

Continuous Improvement

Highest Quality Healthcare

Human Centered Work

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FOUNDATION FOR LEAN

5S Principles1. Sort (Removal)2. Set In Order (Orderliness)3. Shine (Cleanliness)4. Standardize (Adherence)5. Sustain (Self-Discipline)

5S is the key to Workplace Organization

FOUNDATION FOR LEAN

5S Workplace OrganizationStandardizationVisual ManagementProblem SolvingHuman Centered Work

5S Workplace Organization

StandardizationVisual

Management

Problem Solving

Just in Time

Built in Quality

Continuous Improvement

Highest Quality Healthcare

Human Centered Work

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FOUNDATION FOR LEAN

Department Action Plans

How we achieve our values

TOP 5 BOARD

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A3 PROBLEM SOLVING CHART

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.

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DMAIC “IMPROVE”

STRATEGIC PLANNING AND DEPLOYMENT PROCESS

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PERFORMANCE IMPROVEMENT BREADTH AND DEPTH

ENGAGEMENT IN TOP 5 BOARD TEAMS

198 Departments

990 Performance Improvement Teams

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Action Plan Deployment Example

DEPLOYMENT PROCESS

PillarsStrategic ObjectivesBIG DOTS (3 Years)

System GoalsBIG DOTS (1 Year)

Entity Action PlansEntity Scorecard (1 Year)

Department Action PlansDepartment Scorecard (1 Year)

Individual Performance Planner (All Employees) Individual Scorecard (Managers)

SYSTEM LEVELStrategic

SYSTEM LEVELOperational

ENTITY LEVELOperational

DEPARTMENT LEVELOperational

INDIVIDUAL LEVELOperational

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GOAL CASCADE PROCESS

GOAL CASCADE MEETINGS• Half day meetings with

Entity Leaders, Associate Administrators and all Department Managers

DEPLOYMENT

6. Implement Care Foundations, the Less is Best Campaign, and improve safety systems to reduce harm and improve the safety culture with a focus on CLABSI, CAUTI, CDIFF, DVT/PE, SSI‐Colon, PSI 90.

•Patient Safety Composite

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BIG DOT REPORT

Patient Safety Composite 0.71 0.70 0.69

2017 Individual ScorecardJeff Oskin, VP/AdministratorMemorial Hospital

Goal Measure WeightScore

1 2 3 4

1 Patient Experience Composite Score 20% 69‐69.9% 70% 70.1‐72% > 72%

6 Patient Safety Composite Score 15% 0.78‐0.71 0.70‐0.61 0.60‐0.56 <= 0.55

6 Mortality 15% 0.78‐0.77 0.76 0.75 <= 0.74

6 Complications Index 10% 1.00 0.99‐0.98 0.97‐0.95 <= 0.94

7 HF/CABG 30 day O/E Readmissions 10% 1.02‐1.01 1.00 0.99‐0.95 < 0.95

8 Employee Engagement Composite Score 10% 4.01 4.02 4.03 >= 4.04

18 Operating Expense Reduction 20% $10M $12.5M $13M >= $15M

Action Plan Reporting

42810 Memorial Hospital AdministrationJeff OskinAction Plan

1.6.1 Reduction of Hospital Acquired Infections for CAUTI and CLABSI. Use Memorial QIC meetings to review action plans, results and improvement opportunities.

DEPLOYMENT

6 Patient Safety Composite Score 15% 0.78‐0.71 0.70‐0.61 0.60‐0.56 <= 0.55

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2017 Individual ScorecardHeidi Edwards, Associate AdministratorMemorial Hospital


1 2 3 4

1 Patient Experience Composite Score 20% 69‐69.9% 70% 70.1‐72% > 72%

1 Rounding on Patients 5% 6‐7 8‐9 10‐11 >= 12

6 ICU CAUTI 10% 0.33‐0.31 0.30‐0.26 0.25‐0.21 <= 0.20

6 ICU CLABSI 5% > 0.59 0.59‐0.50 0.49‐0.40 < 0.40

6 Patient Falls – Medical Surgical/Telemetry 5% > 2.5 2.5‐2.1 2 < 2

6 Mortality CHF/COPD/Sepsis 10% > 0.85 0.85 0.84‐0.79 < 0.79

6 Hand Hygiene 5%< 90% Staff < 80% All

90% Staff 80% All

95% Staff 90% All

100% Staff 100% All

7 HF/COPD Readmissions 10% > 0.81 0.81 0.80‐0.75 < 0.75

8 Employee Engagement Composite Culture Index 10% < 3.74 3.74‐3.83 3.84‐3.93 >= 3.94

18 Budget 20% $3.3M $4.1M $4.3M >= $5M


42810B Memorial Hospital AdministrationHeidi EdwardsAction Plan

1.6.1 Work with ICU leadership team to review, build alerts and reports in Cerner to ensure Foley Catheter Bundles are hardwired and working appropriately, ensure participation within CAUTI System Team to ensure shared system learning. A3 process through HAI Team to establish process breakdowns for all CAUTIs. Top 5 Board focus for all ICUs with focus on bundle component critical X.

DEPLOYMENT

6 ICU CAUTI 10% 0.33‐0.31 0.30‐0.26 0.25‐0.21 <= 0.20

2017 Individual ScorecardLisa Songer, Critical Care DirectorMemorial Hospital


1 2 3 4

1 Patient Experience Composite 20% 69‐69.9% 70% 70.1‐72% > 72%

1 Rounding on Patients and/or Employees 10% 12‐15 16‐19 20‐41 >= 42

6 ICU CAUTI 10% 0.33‐0.31 0.30‐0.26 0.25‐0.21 <= 0.20

6 ICU CLABSI 10% >= 0.59 0.59‐0.50 0.49‐0.40 < 0.40

6 Pressure Ulcers 10% >= 4.46 4.45‐3.01 3.00‐2.01 <= 2.00

6 Hand Hygiene – Unit Staff 5% 89% 90‐94% 95‐99% 100%

6 Hand Hygiene – Other 5% 79% 80‐89% 90‐99% 100%

7 Mortality – Sepsis 10% >= 0.96 0.95‐0.91 0.90‐0.82 <= 0.81

8 Employee Engagement Composite Culture Index 20% <= 3.98 3.99‐4.01 4.02‐4.05 > 4.05


42810D Memorial Hospital AdministrationLisa SongerAction Plan

1.6.1 Continued focus on Catheter Removal through Daily MDTR. Working with CAUTI Team. SICU manager assigned to lead initiative with Professional Nursing to re‐train staff on insertion technique. Working with Products Team to evaluate and implement condom catheter use for male patients. A3 completed by staff and shared in monthly manager meeting related to CAUTIs. CPICU manager working with multi‐disciplinary team on Top 5 Board with Critical Care Intensivists to decrease Foley Catheter Device utilization.

DEPLOYMENT

6 ICU CAUTI 10% 0.33‐0.31 0.30‐0.26 0.25‐0.21 <= 0.20

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2017 Individual ScorecardMegan Hatfield, Nurse Manager Cardiopulmonary ICU (CPICU)Memorial Hospital


1 2 3 4

1 Patient Experience Composite 20% 69‐69.9% 70% 70.1‐72% > 72%

6 CAUTI 15% 0.48‐0.46 0.45‐0.36 0.35‐0.25 < 0.25

6 CLABSI 15% >= 0.61 0.60‐0.51 0.50‐0.41 <= 0.40

6 Mortality – Sepsis 15% >= 0.96 0.95‐0.91 0.90‐0.82 <= 0.81

6 Hand Hygiene – Unit Staff 5% <= 89% 90‐94% 95‐99% 100%

6 Hand Hygiene ‐ Other 5% <= 79% 80‐89% 90‐99% 100%

8 Employee Engagement Culture Index 10% 4.00 4.01 4.02 >= 4.03

18 Budget – Blocked Beds 15% 97.0‐97.4% 97.5‐98.2% 98.3‐98.9% >= 99%


42167 Cardiopulmonary ICU (CPICU)Megan HatfieldAction Plan

1.6.1 Charge nurse assessment every shift to ensure device need (MDTR/shift huddles). Missy (Top 5 subject matter expert) leading team to focus on critical X’s: Use of Condom Catheter for all male patients prior to Foley Catheter placement, ensure Foley collection bag emptied, peri‐care documented 2 times a day, physician order and nurse driven protocol for all Foley Catheters.

DEPLOYMENT

6 CAUTI 15% 0.48‐0.46 0.45‐0.36 0.35‐0.25 < 0.25

DEPLOYMENT

Top 5 Board Team Score

Clinical Management Coordinator

ContributorSolid

ContributorDistinguishedContributor

70% 70.1‐72% > 72% Patient Experience Composite

0.45‐0.36 0.35‐0.25 < 0.25 CAUTI

0.60‐0.51 0.50‐0.41 <= 0.40 CLABSI

0.95‐0.91 0.90‐0.82 <= 0.81 Mortality – Sepsis

90‐94% 95‐99% 100% Hand Hygiene – Unit Staff

80‐89% 90‐99% 100% Hand Hygiene ‐ Other

4.01 4.02 >= 4.03 Employee Engagement Culture Index

97.5‐98.2% 98.3‐98.9% >= 99% Budget – Blocked Beds

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DEPLOYMENT


Clinical Management CoordinatorCharge Nurse

ContributorSolid



0.45‐0.36 0.35‐0.25 < 0.25 CAUTI

0.60‐0.51 0.50‐0.41 <= 0.40 CLABSI






ContributorSolid



0.45‐0.36 0.35‐0.25 < 0.25 CAUTI

0.60‐0.51 0.50‐0.41 <= 0.40 CLABSI




DEPLOYMENT


Clinical Management CoordinatorCharge NurseClinical Nurse

ContributorSolid



0.45‐0.36 0.35‐0.25 < 0.25 CAUTI

0.60‐0.51 0.50‐0.41 <= 0.40 CLABSI






ContributorSolid



0.45‐0.36 0.35‐0.25 < 0.25 CAUTI

0.60‐0.51 0.50‐0.41 <= 0.40 CLABSI




ContributorSolid



0.45‐0.36 0.35‐0.25 < 0.25 CAUTI

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DEPLOYMENT


Clinical Management CoordinatorCharge NurseClinical Nurse

ContributorSolid



0.45‐0.36 0.35‐0.25 < 0.25 CAUTI

0.60‐0.51 0.50‐0.41 <= 0.40 CLABSI






ContributorSolid



0.45‐0.36 0.35‐0.25 < 0.25 CAUTI

0.60‐0.51 0.50‐0.41 <= 0.40 CLABSI




ContributorSolid



0.45‐0.36 0.35‐0.25 < 0.25 CAUTI

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PERFORMANCE IMPROVEMENT SYSTEM

• DMAIC has helped CAMC create a process and a culture for high performance.

$0

$50,000,000

$100,000,000

$150,000,000

$200,000,000

$250,000,000

$300,000,000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

CUMULATIVE TOTAL ANNUAL IMPROVEMENTS

SUSTAINABILITYCost Reductions

Cumulative Savings = $249,118,7932017 Savings = $41,321,810

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RESULTSInpatient Mortality

2013 2014 2015 20160.0

0.2

0.4

0.6

0.8

1.0

OBSE

RVED

TO

EXPE

CTED

RAT

IO

CAMCHS PREMIER TOP QUARTILE

GOOD

1,997 lives saved from 2011 to 2016

WORKFORCE ENGAGEMENT / SATISFACTION RESULTS

Employee Satisfaction Overall

2011 2012 2013 2014 2015 20161

2

3

4

5

SCOR

E

CAMCHS Top 10%

GOOD

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“Grow Our Own” RESULTS

Development: Direct Education Expenditures (as a % of Payroll)

2010 2011 2012 2013 2014 2015-2%

0%

2%

4%

6%

8%

$0

$50,000

$100,000

$150,000

$200,000

$250,000

$300,000

$350,000

Pe

rce

nt

of

Pa

yro

ll

Do

llars

(in

$0

00

s)

CAMC CAMC % ATD Best %

GOOD

RESULTSInpatient Overall Quality - Local Competitors

0%

25%

50%

75%

100%

2011 2012 2013 2014 2015

PERC

ENTI

LE

CAMCHS TMH RAL LOG TOP 10% COMPARION

GOOD

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RESULTSInpatient Overall Quality - Regional Competitors

0%

25%

50%

75%

100%

2011 2012 2013 2014 2015

PERC

ENTI

LE

CAMC Cleveland Clinic Duke

GOOD

OUR LEARNING…• 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. • Innovate for the future.

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Focus on Action, Performance Leadership and Setting ... · dmaic “improve ” strategic