April 12 th, Jean Putnam, RN, MS, CPHQ Network Vice President, Quality Resources/Risk Management Community Health Network Indianapolis, IN

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1 Indiana Association for Healthcare Quality April 12 th, 2012 Jean Putnam, RN, MS, CPHQ Network Vice President, Quality Resources/Risk Management Community Health Network Indianapolis, IN 1

2 1) Demonstrates knowledge in deploying gquality initiatives that drive the strategic plan and establishing accountability at all levels. 2) Distinguishes and defines the use of comparative data to drive performance and link to performance improvement methodologies 3) Engage staff in implementing and improving Value Based Purchasing measures in a quality driven culture 2

3 Failing to prepare is preparing to fail. - John Wooden 3

4 Failure to link quality performance with financial benefits is a major issue Lack of methodology or strategic deployment goal or means to achieve the goal Lack of accountability at all levels of management tto achieve the goal Lack of expertise internally to establish plan 4

5 Strategic Thinking: Reflective dialogue about the future Ability to think systematically Requires you to envision your ideal outcome and HOW you will reach your vision Strategy: What you do and where you invest your resources A long term plan of action designed to achieve a particular goal Adaptable - requiring strategic thinking Reference: Brice Alvord ; Friday, April 13,

6 Strategic Planning: The allocation of responsibility for different outcomes to specific people who are passionate about seeing them through, and the development of appropriate incentives to motivate the right kind of behavior Reference: Brice Alvord ; Friday, April 13,

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8 Promote quality health care focused on the needs of patients, families, and communities Designed to move the system to work better for doctors and other healthcare providers reducing administrative burdens and encouraging collaboration 8

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10 Takes discipline and focus Can t work on everything! Multiple priorities, tasks, and distractions Many will try to pull your focus away from the prize And sometimes, we are our own worst enemy! 10

11 Hoshin or Hoshin Kanri Planning : Hoshin translates as "shining needle", "direction", i " or "compass", and Kanri means "management" Most often translated as "policy deployment or strategy t deployement 11

12 It is an organizational learning method - to deploy the PDCA scientific method - systematically and relentlessly l l designing i and testing nested experiments - deep through h the tissues and layers of your entire organization. If your actions inspire others to dream more, learn more, do more and become more, you are a leader. ~ John Quincy Adams quotes~ 12

13 In preparing for battle I have always found that plans are useless, but planning is indispensable. -Dwight D. Eisenhower 13

14 Level 0 X Matrix (CEO Level) Level 1 X Matrix (COO or VP Level) Level 2 X Matrix (Director Level) 14

15 What MUST be done? Voice of the Customer Voice of the Business Mandated measures, including Value Based purchasing measures: CMS, Anthem, United, etc. (and the list is growing) 15

16 From Systems2win.com 16

17 CEO Level Strategy Deployment Matrix Engage a minimum of 2 directors per vice president (level 1) in Strategy Deployment 6 Drive Total Value Management methodology deeper into the organization 5 Analyze the growth opportunities for out patient registration and determine the execution approach 4 Analyze the growth opportunities for in patient discharges and determine the execution approach 3 Achieve expected $3.4 million VHA annualized savings 3 Improve productivity/efficiency by 2% 2 Engage Physicians, Nursing and other Clinical Staff and establish accountability for improving quality measures 1 Determine Gaps and develop a solution approach to focus on Employee Engagement RESOURCES Primary Secondary en" rating anization's Business System y engaged people (33% actively y above state-wide or national ave erage ard yee engagement implemented monthly Strategy Deployment reviews complete Number of discharges increased > 5% by end of year reased 50% Improvement in composite TVM KPI's at "Green" rating 2.5 million Net Operating Margin greater > 4.25% at or above state/national ave. > 5% by end of ye % of Physician Practices with PQRS Measures in Place Danielle Dyer Kevin Higdon Kurt Meyer Greg Losasso Cindy Hayes ar Improvement Activities (How) eater or equal to 4.25% f TVM KPI indicators at a "Gree tient encounters by >= 5% by >= 5% Deployment as part of the Orga vement from baseline of actively ed Purchasing measures at or a percentile on Anthem Score Ca ue Based Purchasing measures st practice" solutions for employ # of selected outpatient encounters incr TVM Dollar Benefit >$ 1-year Breakthrough Objectives (What to Accomplish in 2011) 3 year Strategic Initiatives (by end of year, 2013) Measures and targets (How much) 1 Operating Margin gre 50% improvement of Grow selected outpa Increase Discharges Implement Strategy 88.5% of Value Base Achieve > or = 95th 100% of "bes 100% of Achieve Top Tier Ranking in all Quality Measures Our Mission It is the mission of Elkhart General Hospital "To create a healthier community" by: *Being a premier provider of health care. Achieve 15% improv engaged) 88.5% of Valu Achieve Best Practice Employee Engagement score Achieve implementation of Strategy Deployment by executives, directors and managers Increase Net Operating Margin to 6% 5 Grow Market Share by 15% *Promoting the health and well being of individuals and families by providing education that may aid in detection and prevention of disease. *Conducting our activities with compassion and respect. *Acting with recognition that health is wholistic and embraces the body, mind, and spirit. *Seeking out and "partnering" with those who share our mission. *Continuously improving the quality and cost-effectiveness of our services *Maintaining the financial viability of the Hospital while continuing our charitable role in the Friday, April 13,

18 Improvement Activities (How) 1-year Breakthrough Objectives (What to Accomplish in 2011) Measures and targets (How much) 3 year Strategic Initiatives (by end of year, 2013) 1 Achieve Top Tier Ranking in all Quality Measures 2 Achieve Best Practice Employee Engagement score 3 Achieve implementation of Strategy Deployment by executives, directors and managers 4 Increase Net Operating Margin to 6% 5 Grow Market Share by 15% 18 Operating Margin greater or equal t to 4.25% 50% improvement of TVM KPI ind icators at a "Green" rating Grow selected outpatient encounters by >= 5% Increase Discharges by >= 5% Implement Strategy Deployment as part of the Organizat tion's Business System Achieve 15% engaged) % improvement from baseline of actively eng aged people (33% acti vely 88.5% of Value Based Purchasing measures at or above state-wide or national average Achieve > or r = 95th percentile on Anthem Score Card

19 A systematized, teachable, repeatable way to: Confirm the practicality of proposed plans (and their probability of success) Actively solicit (and often act upon) feedback and ideas from the next level down" level people that are responsible for actually implementing the plans Greatly improve wide-spread d understanding di of what needs to be done, why, and how Greatly improve ownership and buy-in from the people responsible for results Demonstrate and encourage non-dictatorial leadership skills for all levels of executives, managers, supervisors, and team leaders 19

20 Catchball is simple. Regardless of who initiates a project (although it's most commonly a manager), that person articulates the purpose, objectives, and other ideas and concerns and then "throws" them to the other stakeholders for feedback, support, and action. Value Stream Management for the Lean Office, by Don Tapping and Tom Shuker. 20

21 Improve productivity/efficiency by 2% Engage Physicians, Nursing and other Clinical Staff and establish accountability for improving quality measures Determine Gaps and develop a solution approach to focus on Employee Engagement Improvement Activities (How) 1-year Breakthrough Objectives (What to Accomplish in 2011) Measures and targets (How much) 3 year Strategic Initiatives (by end of year, 2013) 21

22 88.5% of Value Based Purchasing measures at or above state/national ave. 100% of "best practice" solutions for employee engagement implemented 100% of monthly Strategy Deployment reviews complete Number of discharges increased > 5% by end of year # of selected outpatient encounters increased > 5% by end of year 50% Improvement in composite TVM KPI's at "Green" rating TVM Dollar Benefit >$2.5 million Net Operating Margin greater > 4.25% % of Physician Practices with PQRS Measures in Place 22

23 CEO Level Strategy Deployment Matrix Engage a minimum of 2 directors per vice president (level 1) in Strategy Deployment 6 Drive Total Value Management methodology deeper into the organization 5 Analyze the growth opportunities for out patient registration and determine the execution approach 4 Analyze the growth opportunities for in patient discharges and determine the execution approach 3 Achieve expected $3.4 million VHA annualized savings 3 Improve productivity/efficiency by 2% 2 Engage Physicians, Nursing and other Clinical Staff and establish accountability for improving quality measures 1 Determine Gaps and develop a solution approach to focus on Employee Engagement RESOURCES Primary Secondary en" rating anization's Business System y engaged people (33% actively y above state-wide or national ave erage ard yee engagement implemented monthly Strategy Deployment reviews complete Number of discharges increased > 5% by end of year reased 50% Improvement in composite TVM KPI's at "Green" rating 2.5 million Net Operating Margin greater > 4.25% at or above state/national ave. > 5% by end of ye % of Physician Practices with PQRS Measures in Place Danielle Dyer Kevin Higdon Kurt Meyer Greg Losasso Cindy Hayes ar Improvement Activities (How) eater or equal to 4.25% f TVM KPI indicators at a "Gree tient encounters by >= 5% by >= 5% Deployment as part of the Orga vement from baseline of actively ed Purchasing measures at or a percentile on Anthem Score Ca ue Based Purchasing measures st practice" solutions for employ # of selected outpatient encounters incr TVM Dollar Benefit >$ 1-year Breakthrough Objectives (What to Accomplish in 2011) 3 year Strategic Initiatives (by end of year, 2013) Measures and targets (How much) 1 Operating Margin gre 50% improvement of Grow selected outpa Increase Discharges Implement Strategy 88.5% of Value Base Achieve > or = 95th 100% of "bes 100% of Achieve Top Tier Ranking in all Quality Measures Our Mission It is the mission of Elkhart General Hospital "To create a healthier community" by: *Being a premier provider of health care. Achieve 15% improv engaged) 88.5% of Valu Achieve Best Practice Employee Engagement score Achieve implementation of Strategy Deployment by executives, directors and managers Increase Net Operating Margin to 6% 5 Grow Market Share by 15% *Promoting the health and well being of individuals and families by providing education that may aid in detection and prevention of disease. *Conducting our activities with compassion and respect. *Acting with recognition that health is wholistic and embraces the body, mind, and spirit. *Seeking out and "partnering" with those who share our mission. *Continuously improving the quality and cost-effectiveness of our services *Maintaining the financial viability of the Hospital while continuing our charitable role in the Friday, April 13,

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25 Strategy Deployment Tracker - CEO Level CEO Level "0" Tracker 2011 Value Based Purchasing M easures at or above State/National Average Driver Value Based Purchasing measures at or above state/national average Targets or Limits Andon Jan Feb M ar Apr M ay Jun Jul Aug Sep Oct Nov Dec 2011 YTD 2011 Goal 88.5% Plan 68.5% 68.5% 73.5% 73.5% 73.5% 78.5% 78.5% 78.5% 83.5% 83.5% 83.5% 88.5% % From COO's Actual 72.2% 72.2% 76.3% 76.3% 76.3% 85.7% Tracker ytd +/- 4% 4% 3% 3% 3% 7% Employee Engagement Action Plans Complete (%) Goal = 100% of solution sets for employee engagement implemented housewide by M ay % From HR Tracker Plan Actual ytd +/- 20% 40% 60% 80% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 0% 22% 50% 60% 98% 100% 100% 100% 100% 100% 100% 100% 100% -20% -18% -10% -20% -2% 0% 0% 0% 0% 0% 0% 0% 0% Strategy Deployment Review Compliance (%) Inpatient Discharges YTD Selected Outpatient Encounters YTD TVM Key Performance Indicators at "Green" (%) TVM Dollar Benefit Net Operating M argin % of monthly Strategy Deployment reviews complete Goal = Increase the number of Discharges by > 1% or 128 by end of year (2010 Baseline = 12,828) Goal = Increase the number of selected outpatient encounters by > 1% or 2,750 by end of year (2010 Baseline = 274,956) Composite of TVM KPI's at "Green" (2011 baseline 33.3%; 9 of 27 indicators) TVM Dollar Benefit Net Operating M argin M TD 100% M anual input 12,956 by end year M onthly reporting will be 1% Increase From VP SP's Tracker Plan Actual ytd +/- Plan Actual 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% % 0% 0% 0% 0% 0% 0% 1,071 2,142 3,245 4,316 5,387 6,490 7,561 8,632 9,735 10,806 11,877 12,980 22,651 12,980 1,075 2,016 3,147 4,158 5,207 6, ,834 ytd +/- 4 (126) (98) (158) (180) (259) (817) Plan 22,680 45,360 68,719 91, , , , , , , , , , ,876 Actual ytd +/- 21,856 42,042 66,182 86, , , ,969 (824) (3,318) (2,537) (4,464) (4,590) (4,973) (20,706) 50% Plan 33.0% 33.0% 37.0% 37.0% 40.7% 40.7% 44.4% 4% 44.4% 4% 44.4% 4% 48.1% 48.1% 510% 51.0% 39.0% 510% 51.0% Improvem ent Actual 33.0% 37.0% 41.0% 41.0% 41.0% 41.0% % Jen to Input ytd +/- 0% 4% 4% 4% 0% 0% 2% >$2,500,000 actual Plan $102,000 $122,000 $142,000 $162,000 $192,000 $217,000 $232,000 $252,000 $262,000 $225,000 $277,000 $315,000 $720,000 $2,500,000 savings in 2011 Actual $201,530 $52,430 $207,243 $466,476 ($181,014) $1,147,084 (monthly ytd +/- $99,530 ($69,570) $65,243 $304,476 ($373,014) $427,084 values not 4.25% Plan 2.65% 2.87% 3.22% 2.36% 4.53% 6.03% 6.40% 5.27% 2.25% 4.31% 5.07% 5.84% 3.61% 4.25% From CFO's Actual 1.16% 2.11% 3.98% 0.19% -4.43% 0.31% % Tracker ytd +/ % -0.76% 0.76% -2.17% -8.96% -5.72% -2.98% Although the Bowling Chart template was originally introduced for Hoshin deployment, it is also an excellent tool for managing any type of time-phased project. 25

26 Strategy Deployment Tracker - CEO Level CEO Level "0" Tracker Value Based Purchasing M easures at or above State/National Average Driver Value Based Purchasing measures at or above state/national average Targets or Limits Andon Jan Feb M ar Apr M ay Jun Jul Aug Sep Oct Nov Dec 88.5% From COO's Tracker Plan Actual ytd +/- 68.5% 68.5% 73.5% 73.5% 73.5% 78.5% 78.5% 78.5% 83.5% 83.5% 83.5% 88.5% 72.2% 72.2% 76.3% 76.3% 76.3% 85.7% % 4% 3% 3% 3% 7% 26

27 Improvement Activities (How) 1-year Improvement Activities (What) Measures and targets (How much) 1 year Strategic Initiatives (by end of year, 2011) Achieve > or = 95th percentile on Anthem Score Card 88.5% of Value Based Purchasing measures at or above state-wide or national average Achieve 15% improvement from baseline of actively engaged people (33% actively engaged) Implement Strategy Deployment as part of the Organization's Business System 50% improvement of TVM KPI indicators at a "Green" rating Operating Margin greater or equal to 4.25% 27

28 Assigning accountability Strategy Deployment Tracker Jean Putnam's Tracker 2011 Driver Targets or Limits A ndon Jan Feb M ar Apr M ay Jun Jul A ug Sep O c t N o v D e c Y T D G o a l 88.5% of Value Based Purchasing measures at or above state/national average 88.5% (Data is measured quarterly and reflects one quarter behind) Plan Actual ytd +/- 68.5% 68.5% 73.5% 73.5% 73.5% 78.5% 78.5% 78.5% 83.5% 83.5% 83.5% 88.5% % 72.2% 72.2% 76.3% 76.3% 76.3% 85.7% % 4% 3% 3% 3% 7% 100% Strategy Deployment monthly reviews completed in area of responsibility Plan 100% Actual ytd +/ % 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% % 0% 0% 0% 0% 0% 100% of solution set action plans for employee engagement on target for areas of responsibility Consolidated YTD productivity $ at or below flex budget for all cost centers Anthem Scorecard Score at Top Tier 100% for 2 areas, 4 total solutions Yes (Y) Will be obtained from the productivity reports and should be reported based on most recent data available 95% (Quarterly) (Not available until end of 1st quarter or possibly end of 2nd quarter) Plan Actual ytd +/- Plan Actual ytd +/- Plan Actual ytd +/- 0.0% 25.0% 50.0% 75.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 0.0% 25.0% 50.0% 100.0% 100.0% 100.0% % 0% 0% 25% 0% 0% Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N N N N Y N N N N N % 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% % of HCAHPS measures (dimensions) at or above state/national average 80% Plan 20.0% 20.0% 20.0% 40.0% 40.0% 40.0% 60.0% 60.0% 60.0% 80.0% 80.0% 80.0% 80.0% 80.0% Actual 30.0% 40.0% 30.0% 30.0% 40.0% 63.0% ytd +/- 10 % 2 0 % 10 % -10% 0% 23% % of Clinical Core M easures at or above state/national average 100% Plan Actual ytd +/ % 80.0% 85.0% 85.0% 85.0% 90.0% 90.0% 90.0% 95.0% 95.0% 95.0% 100.0% 100.0% 100.0% 88.5% 88.5% 92.8% 92.8% 92.8% 92.6% % 9% 8% 8% 8% 3% 28

29 Driver Targets or Limits Andon Jan Feb M ar Apr M ay Jun 88.5% of Value Based Purchasing measures at or above state/national average 88.5% (Data is measured quarterly and reflects one quarter behind) Plan Actual ytd +/- 68.5% 68.5% 73.5% 73.5% 73.5% 78.5% 72.2% 72.2% 76.3% 76.3% 76.3% 85.7% 4% 4% 3% 3% 3% 7% Quality measures are on the top of everyone s tracker then employee engagement, g then finance. Increase quality and the $ will follow! Friday, April 13,

30 (Year) STRATEGY DEPLOYMENT IMPROVEMENT TARGET COUNTERMEASURE ANALYSIS Area: Percent (%) of HCAHPS Measures (dimensions) at or above state/national average is below target Date: 5/31/11 Name: Jean Putnam Why are only 3 of 10 HCAHPS Dimensions at or above State/National Average? Negative impact of ED wait time on patients being admitted Why? Patients are waiting longer in ED due to physicians acclimating to new software and negative attitudes Why? New software found to decrease productivity, which frustrates physicians and staff Staff not aware of impact of HCAHPS on VBP Why? Consistent t message does not always filter down to departments t Why? Some managers aren't comfortable articulating the message Root Cause Staff not really accountable to HCAHPS scores Why? No solid process for holding them accountable Why? No clear, strong behavioral standards for accountability Processes not consistently in place to increase scores (ie hourly rounding, bedside reporting, scripting) Why? Not implemented housewide Why? No accountability for timely implementation prior to 2011 Why? Difficult to implement Why? Many other priorities, scores had been increasing, no solid process 30

31 (Year) (Year) Target DEC JAN FEB MAR APR MAY JUN JUL Actual Min. (Year) Actual 0% 30% 40% 30% 30% 40% YTD result Target 0% 20% 20% 20% 40% 40% 40% 60% 31

32 Tem mporary Temporary ISSUES OR GAPS COUNTERMEASURES WHO WHEN Patients are waiting longer in ED due to physicians acclimating to new software and due to negative attitudes To be determined by ED Process Team? ED Process Team? Jean to talk to Bev Myers No official accountability for timely implementation of hourly rounding or bedside reporting Hold each nursing manager accountable for implementation of hourly prior to 2011 rounding and bedside reporting through PMF's in 2011 Nursing Directors 31-Dec-11 Permanent Permanent No clear, strong behavioral Conduct Customer Experience Training for all employees (4 hrs) in May - standards for accountability August and have each EE sign agreement Customer Experience Team 31-Aug-11 Consistent message does not always filter down to departments Hourly rounding, bedside reporting not implemented housewide Create summary of Board Scorecard; Post summary and Scorecard to Intranet and DivePort; Present at DD/Mgr meetings monthly; Send scorecard to all DD/Mgrs via ; Offer to come to any department to speak on core measures Jean Quarterly, starting in May, 2011 Implement housewide hourly rounding and bedside reporting for all nursing units. Nursing Directors 32

33 About 80% of all quality efforts have no measurable results Most failures in quality are due to a poor choice of strategy (Dr. Juran) In order to choose a quality strategy wisely, organizations need to know how to manage for quality. 33

34 Change..What Change? 34

35 Jenn Burkett Director of Performance Improvement and TVM Elkhart General Hospital 35

36 % of HCAHPS dimensions at or greater than the National Benchmark % of respondents answering "9" or "10" on HCAHPS survey for overall rating of hospital % of Clinical Value Based Purchasing Measures at Goal Patient Falls (unplanned descent to floor) per 1000 IP and OBS days 36

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39 Timely data Assignment of primary responsibility with expectation of secondary support Data Abstracters as facilitators Core Team structure Improvement activities at the process level 39

40 Jean Putnam, RN, MS, CPHQ Network Vice President, Quality Resources/Risk Management Community Health Network 40

41 Reinertsen JL, Gosfield AG, Rupp W, Whittington JW. Engaging Physicians in a Shared Quality Agenda. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; (Available on Nolan TW. Execution of Strategic Improvement Initiatives to Produce System-Level Results. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; (Available on Physician Engagemenet g System Engagement g 41