PREFACE: ORGANIZATIONAL PROFILE P.1. Organizational Description P.1a(1) Main healthcare services. St. Gertrude s Health and Rehabilitation Center

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1 PREFACE: ORGANIZATIONAL PROFILE P.1. Organizational Description P.1a(1) Main healthcare services. St. Gertrude s Health and Rehabilitation Center (SGHRC) is a 75-bed skilled nursing facility (SNF) with an attached 40 apartment assisted living center (The Gardens at St. Gertrude s). SGHRC s main health care services include; a 39-bed rehabilitation center, a 34-bed long-term care facility, two end-of-life care suites and a 40 apartment assisted living center. SGHRC is located on the St. Francis Regional Medical Center Campus (SFRMC) in Shakopee, Minnesota. SFRMC is located in Scott County in the southwest corner of the Minneapolis/St. Paul metropolitan area; one of the fastest growing areas in the country. Being adjacent to SFRMC affords SGHRC the ability to meet increased health care needs of patients and families in the communities served through a full continuum of care. SFRMC provides SGHRC access to a cancer center, dialysis center, cardiology clinic, physician s clinics, Level III Trauma Center/emergency room, pharmacy, medical specialties, dental and eye clinics. SGHRC has a high number of monthly admissions per month compared to other BHS facilities (Fig ). Medicare A and contracted insurance providers comprise 53% of the 2008 payor mix (Fig.7.3-2). Services are delivered primarily to patients and families on an inpatient basis, with onsite outpatient physical and occupational therapy seven days a week and speech therapy services provided five days a week. P.1a(2) Organizational culture. SGHRC and The Gardens at St. Gertrude s are sponsored by the Benedictine Health System (BHS) and the Benedictine Sisters of Duluth, MN. SGHRC s culture is built upon its mission and core values (Fig. P.1-1) and further integrated into its performance management system. St. Gertrude, SGHRC s patron saint, promoted the compassion of the heart of Jesus and a key characteristic of the organizational culture is to provide innovative and compassionate care to a rapidly changing population. SGHRC s Critical Success Factors (CSF s), or Pillars, of Care, Service, People, Finance and Growth represent key areas of performance excellence and provide a structure for the strategic planning process (see P.2a(2)). Figure P.1-1 Purpose, Vision, Values and Mission Purpose: Caring for Others Vision: To become a Benedictine Living Community where health, independence and choice come to life. Core Values: Hospitality, Respect, Stewardship and Justice Mission: The Benedictine Health System, a Catholic health care organization entrusted with furthering the health care mission of the Benedictine Sisters of Duluth, MN, provides a spectrum of services with special concern for the poor and powerless. The System is committed to witness God s love for all people by providing high-quality services in a compassionate environment that enhances human worth. SGHRC s core competencies are short-term rehabilitation, long-term care, end of life care and assisted living (Fig ). These core competencies are strategically vital to the achievement of SGHRC s mission of providing high-quality services in a compassionate environment. P.1a(3) Workforce Profile. SGHRC recognizes its staff as vital to its organizational success. SGHRC employs 183 talented staff members; females represent 88% of the workforce and males 12%. Fifty-six percent are high school graduates, 41% college graduates and 3% possess graduate!

2 degrees. Sixty percent work the day shift, 28% evening shift and 12% work the night shift. Diversity of the employee profile is 75% Caucasian, 19% black, 4% Hispanic and 2% Asian. SGHRC s workforce requirements are identified through the employee Mission and Values surveys, employee performance evaluations and in direct discussions with managers, the Nurse Administrator and CEO. The key requirements and expectations identified as most important to motivate the staff to achieve the SGHRC mission include; working in a facility that provides high levels of quality and customer service, receiving and giving respect, teamwork, enjoying their work, and receiving good training. There are no organized bargaining units at SGHRC. There is a contracted Medical Director and a contracted physiatrist from Sister Kenney Rehabilitation who serve as an extension of the employed SGHRC direct care staff. Maintaining the health and safety of all employees is critical to providing patients, residents and their families high quality service in a compassionate environment. Key health benefits offered to employees include health, dental and life insurance coverage, Paid Time off (PTO), 401k retirement plan with employer match, a scholarship program, employee assistance program, and pretax flex-spending accounts. The Safety Committee monitors health and safety requirements at SGHRC including; safe patient handling and body mechanics, blood borne pathogen and infection control practices, and other safe work practices. Health and safety education and testing are completed upon hire and repeated annually for employees with direct patient contact. P.1a(4) Technologies, equipment and facilities. As SGHRC strives to deliver high-quality services in a compassionate environment, the organization has made significant investments in technology, equipment and facility enhancements to meet the needs of its patients, residents and families. The facilities at SGHRC are comprised of a skilled nursing building (consisting of four separate units, each with their own dining/great room), a forty apartment AL center with a communal dining room, two activity spaces and two additional gathering spaces. Since the facility opened in 1996, three major building projects have been completed to expand the number of skilled nursing beds, add the AL building, and construct two end-of-life suites. Figure P.1-2 demonstrates the investment in equipment and technology at SGHRC to support the delivery of high quality and compassionate patient care. Figure P.1-2 Equipment and Technology Wireless Call System (Arial) Computers: Standard (40), Laptop (6), Point of Care (12) Computer-on-wheels for admissions (1) Electric beds (75) Alternating Pressure Air Mattresses (27) Ceiling Lifts (22) EZ stands/lifts (7) Hover Mat (1) Air transfers immobile patients Pulse Oximeters (6) Electronic Blood Pressure Monitors (4) Bladder Scanners (2) Security System (includes cameras with video recording, monitors, alarms) Silverchair Learning (web-based staff education) It s Never Too Late (web-based activities) Matrix (computerized medical records) Point of Care (computerized nursing assistant documentation) Automated medication ordering to pharmacy Omniview (web-based pharmaceutical information for medication pricing and providing discharge instructions) Wireless Internet Access Electronic entrances with after hour control WII game system for resident activity Defibrillator Bus with lift system P.1a(5) Legal and regulatory environment. SGHRC is licensed in MN as a SNF and the Gardens is licensed as an AL facility as Housing with Services registration. Annual surveys are conducted by the MN Department of Health (MDH) and the State Fire Marshall for compliance with CMS (Medicare/Medicaid regulations), state regulations, CLIA, and the Life Safety Code. SGHRC adheres to OSHA, MPCA, HIPPA, Worker s Compensation, Department of Labor, Scott "

3 County and City of Shakopee regulations and requirements. SGHRC has passed all annual surveys and inspections without any significant citations. P.1b Organizational Relationships P.1b(1) Organizational structure and governance. SGHRC is a member organization of BHS, and sponsored by the Benedictine Sisters Benevolence Association (BSBA). Sisters from the BSBA are members of the Governing Board along with local community members. The seven member Governing Board meets quarterly to oversee operations and annually participates in strategic planning and evaluation of the CEO s performance. BHS conducts annual leadership meetings that includes the CEO and SGHRC leaders and holds quarterly regional meetings attended by the CEO and Nurse Administrator. The SGHRC CEO meets regularly with the regional BHS VP of Operations to review performance to plan and key performance metrics. P.1.b(2) Key patient/customer groups and requirements. The key patient/customer groups for SGHRC are patients, residents and families. Patients are defined as short stay customers and services provided by SGHRC to the patient customer group focus on preparing them for their next destination. Residents are defined as long stay customers in the LTC units and AL who call SGHRC their home. The services provided to the resident customer group are activity and program based. Key requirements identified and for all customer groups are skilled, compassionate, and person-centered care. Key requirements were identified and are continually reaffirmed through patient satisfaction surveys, resident council meetings, family meetings and care conferences. Other important customers include the hospital discharge planners and physicians. The Medical Advisory Committee, comprised of key clinical leaders, medical directors and physicians, meets quarterly and the Director of Case Management communicates daily with hospital discharge planners. Through these meetings and discussions the key requirements of timeliness, access, and skill were identified. SGHRC s key stakeholders are BHS, the Foundation, and its employees. Through direct communication with BHS, the key requirements of adherence to the mission of delivering high quality and compassionate care and financial sustainability were identified. Utilization of funds contributed by the community to further the BHS mission has been identified as the key requirement of the Foundation as established through ongoing meetings. SGHRC employees require a respectful workplace that provides high quality services to its customers. The primary market for SGHRC consists of adults 18 and older living in Scott, Carver, Dakota, or Hennepin Counties. The key requirements of this market are the provision of short-term rehabilitation, long-term care, end-of-life care, and AL services. Key requirements of the primary market were identified through market research, feedback from patients, residents and families, and through listening to community members on the governing board. The differences in key requirements among the key customer, stakeholder and market groups are based solely on the patient, resident or families level of need and the ability of SGHRC to delivery compassionate care. P.1b(3) Key suppliers, partners, collaborators, and distributors. SGHRC s key suppliers and partners are physicians, payors, pharmaceutical and general medical suppliers. BHS is also a key partner/supplier of organizational infrastructure and clinical support and SFRMC provides SCHRC with clinical and security services. Figure P.1-3 lists SGHRC key suppliers and partners, their role in delivery of key products/services and their participation in innovation processes. Figure P.1-3 Key suppliers and partners Name/relationship Role/Function Participation in Innovation Processes BHS Information Technology, (Partner) Financial, Human Resource, Innovative information technology. Partnered on Safe Patient Handling Grant. Collaborated on Hazardous Pharmaceutical Waste. Clinical support SFRMC Laboratory, Radiology, Lab & Radiology partnered with us to enhance lab draw/test results #

4 (Partner, Supplier) Emergency Response, Security and the admissions process to outpatient. Minnesota Valley Rehab (MVR) (Partner, Supplier) Physical, Occupational and Speech Therapy Person Centered Care Committee, Strategic Planning, Implementation of SMART software Sodexho (Partner, Supplier) Food Services Person Centered Care Committee, Strategic Planning, Resident Council Omnicare (Supplier) Pharmaceuticals, IV therapy Collaborated on Hazardous Pharmaceutical Waste. Helped to create new policy & approach being used in BHS & MN. Key partner and supplier relationships provide essential functions to our patients, residents and families. SGHRC communicates on an ongoing basis with BHS through , fax, webinars, and telephone and in person meetings. Connectivity to the BHS network provides a link to corporate services as well as a larger network of peers and professionals is an efficient resource for problem solving, innovation and knowledge sharing. Communication with SFRMC occurs daily through the phone and fax with discharge planners. The CEO meets regularly with the CEO of SFRMC and attends the Campus Partners and Campus Facility Committee meetings where campus-planning needs are addressed. MVR has office space at SGHRC and participates in daily Medicare meetings and patient progress reviews. Sodexho provides an onsite director and two dieticians to facilitate direct communication of patient and resident diet changes and catering orders on an ongoing basis. Computerized medication ordering, biweekly drug regimen reviews and quarterly medication room and cart audits are provided by Omnicare and through a consulting pharmacist. Key supply chain requirements of timeliness, billing accuracy and financial stewardship apply to all key suppliers and partners. P.2 Organizational Situation P.2a Competitive Environment P.2a(1) Competitive position. SGHRC operates in a highly competitive market where four nursing homes and four assisted living facilities operate within ten miles of the campus. Two additional nursing homes are considered key competitors given their specialty in short term rehabilitation and physical location on a health care campus, however, neither campus provides acute care services. Collaboration occurs regularly with key competitors on admissions and discharges to serve the mission and meet the health care needs of its community. Other key collaborators include SFRMC and Scott County. Incremental marketplace growth has occurred since 1996 in short term rehabilitation increasing capacity from 20 to 41 beds including 2 End of Life suites. In 2005, AL was added and Elder Waiver expanded the AL reimbursement program in P.2a(2) Principle success factors. Through cycles of refinement in the strategic planning process, SGHRC identified five CSF, or pillars, that have contributed to a positive competitive position and serve as the foundation for the strategic planning process and key strategic objectives; (Fig ). The five pillars are: CARE: To develop and deploy evidence based care and systems to produce superior outcomes and safety SERVICE: To consistently exceed customer expectations PEOPLE: To be the work community of choice and a leader in values-based recruitment, retention, and leadership development and employee satisfaction FINANCE: To optimize financial results by developing and deploying sustainable business models GROWTH: To grow the ministry in both existing and new markets balanced with prudent stewardship Key changes affecting SGHRC s competitive position and opportunities for innovation include; a new faith-based assisted living facility being built in Shakopee, a growing baby-boomer $

5 population requiring higher need for orthopedic rehabilitation after surgery, and changes in the Medicare/Medicaid reimbursement program. The CEO has explored possible collaborative opportunities with the planners of the new Shakopee facility to manage the facility and/or partner on community home care services. Technology innovation, such as providing computerized activities and wireless internet to our patients, residents and families, will help meet the demands of the baby boomer population. P.2a(3) Sources of comparative and competitive data. SGHRC uses several sources of comparative and competitive data from both within and outside the healthcare industry. Data sources within healthcare include; Nursing Home Compare, MyInnerview for family and AL resident satisfaction, Morehead & Associates for employee Mission and Values survey comparators, MDS quality indicators for state and national comparative percentiles, and the BHS Dashboard for comparative data on other BHS facilities relative to financial, care, employee, and resident and family satisfaction measures. Comparative data from outside the health care industry includes demographic (LAWCO, Scott County, Shakopee Chamber of Commerce, and the State of MN), Worker s Compensation and OSHA data. P.2b Strategic Context SGHRC has identified key business, operational and human resource strategic challenges in the pillars of Growth, Finance, and Service. The growth challenge is to expand the short-term rehabilitation capacity to meet the increasing demand for service. Currently, between 60 and 90 patients are turned away each month due to a lack of bed availability. Changes in reimbursement mechanisms challenge financial sustainability and SGHRC must continue to effectively manage its systems and processes and explore innovation as a means to remain sustainable into the future. The financial sustainability model focuses on fundraising through the Foundation as a key approach to meet the finance strategic challenge. The changing senior population requires SGHRC to meet the service strategic challenge to deliver home health care services to the community as the baby boomers demand long term care needs are met in their own homes. Key strategic advantages are focused in the pillar areas of People, Growth and Care. The people and growth advantage of a faith-based culture focused on the mission and core values is critical to organizational sustainability. SGHRC s reputation of providing high quality and compassionate care on an acute care campus that includes a hospital, a medical specialty office building, two clinics, a dialysis center and a cancer care center will ensure long-term organizational sustainability well into the future. P.2c Performance Improvement System. SGHRC maintains an integrated approach to performance improvement. The Quality Council (QC) is chaired by the CEO and coordinated by the Quality Management Coordinator (QMC). The QC is cross-functional team of managers, staff and medical director that meet monthly to review data and performance of various processes and systems. The PDCA (Plan, Do, Check, Act) approach is utilized to systematically evaluate and improve processes. Departments monitor key performance indicators and gather data to be reviewed by an assigned team or QC. Data are analyzed for opportunities, goals are set and action plans are created and implemented. Ongoing performance is monitored for improvement and if needed, the action plans are revised and performance continues to be monitored. Once the goal is met, data continues to be monitored to maintain performance. Managers report performance to department staff and data are posted in employee areas, in the employee newsletter and discussed at resident and family councils to facilitate organizational learning. BHS receives SGHRC data and, along with other facilities, posts results to the BHS Dashboard accessible through the BHS network (E-Source). %

6 Innovation is inherent in the SGHRC culture and is demonstrated through weekly Coffee and Communication meetings and through existing and ad hoc committees whose purpose is to improve processes and systems to better serve the patient care needs of the customer. Leadership 1.1 Senior Leadership 1.1a(1) Set and deploy vision and values. SGHRC is committed to excellence through living the organization s vision and values which are established and reaffirmed annually by BHS. The organizational vision sets the context for the SGHRC strategic planning process and annual action plan development. The BHS ULT (Unified Leadership Team) that includes CEOs from all facilities in the system have input into the development of the strategic planning process including the development of action plans. The SGHRC leadership team (LT), consisting of the CEO, Nurse Administrator, Director of AL and ten department managers, communicates and deploys the vision, mission, values, strategic objectives and performance expectations to staff, suppliers, partners, customers and other stakeholders. The BHS mission, vision and core values are communicated to key stakeholders by framed artwork in main hallway of the facility, printed materials and through discussion at new employee orientation, staff meetings, annual in-service days and via the employee evaluation process. Partners, suppliers and other stakeholders are educated on the mission, vision and core values through ongoing exposure, education and printed materials. The MI (Mission Integration) committee reinforces the mission, vision and values informally and provides ongoing staff education on the core value BHS selects annually by developing examples of living that core value. The LT considers its longevity a key strength and a primary example of how their personal actions reflect a commitment to the organization s values. Annual BHS leadership training, spiritual retreats and education days in and outside SGHRC provide leaders with the opportunity to connect the importance of their work to fulfilling the organization s mission. LT members have personal development plans that are reviewed annually with the CEO and all leaders conduct annual self-evaluations on the core values to meet the customer service requirements. 1.1a(2) Environment for legal and ethical behavior. SGHRC LT creates an environment for legal and ethical behavior by being intolerant of breaches in legal or ethical conduct. Behavior such as falsifying documents, lying and stealing are grounds for immediate termination. Corporate Compliance training is conducted upon hire by the CCO (Corporate Compliance Officer) a member of the leadership team and reviewed at the annual in-service day. Leaders hold each other accountable for creating a legal and ethical work environment through a culture that allows for safe reporting of medical, safety and Human Resource incidents as well as to identify opportunities to improve our environment. 1.1a(3) Create a sustainable organization. SGHRC creates a sustainable organization through the execution of the strategic planning process. The strategic plan is developed using Focus and Execute (F&E), an electronic system that allows for the development of a working document which can be updated, changed, or revised quickly at monthly manager s meetings or as needed. All leaders as well as direct care staff participate in drafting the document. It is through this living document that the organization remains agile, focuses on organizational performance improvement, and meets the demands of a rapidly changing healthcare environment. SGHRC creates an environment for organizational and workforce learning through its culture of promoting growth and development of its leadership and staff. This is reinforced through the employee performance management system and through the scholarship program. The CEO, Nurse Administrator and other managers participate and provide education to new employees &

7 and reinforce the learning through annual in-service days. Personal leadership skills are enhanced through a variety of approaches at SGHRC. Each leader has a personal development plan that is linked to the annual performance review that is created jointly by the leader and CEO and/or Nurse Administrator. These personal development plans are reviewed and revised annually or as needed. SGHRC leaders facilitate all process improvement teams and serve as role models for improvement and innovation by listening and responding to employees, patients, residents and their families. Improvements made a result of listening and responding to key stakeholder needs include; changing shift times to balance workload on units, increasing nursing hours during peak demand times increasing rehabilitation beds to meet demand and the construction of end of life rooms. SGHRC leaders participate in succession planning and the development of new organizational leaders by identifying and growing staff with identified strengths. Through cross training, vacation coverage, and job sharing a leader s knowledge base is expanded and the ability to take on another role is strengthened. Supervisors are supported in developing into new roles that prepare them for movement into leadership positions. Through SGHRC s participation in Prepare, a federally funded national emergency preparedness program, and contingency planning for emergencies the organization has established a three deep approach for leadership roles. 1.1a(4) Culture of patient safety. SGHRC has embraced a culture of patient safety systematically through the review of patient safety results in the QC and in managers meetings. The Incident Review Team analyzes patient incident data gathered through the Matrix system and medication errors are reviewed for root cause to determine appropriate action. Leaders demonstrate and reinforce the culture of patient safety through annual performance reviews and quarterly safety walkthroughs. The CEO and three SGHRC leaders modeled the importance of safe patient handling by installing, educating employees on the ceiling lift system and counseling employees as needed to ensure compliance with safe patient handling requirements. SGHRC has invested a considerable amount of capital in safe patient handing equipment such as the ceiling lift system, toilet lift system and appropriate slings for patients and residents. 1.1b Communication and Organizational Performance 1.1b(1) Senior leaders communicate. Senior leaders communicate with and engage the staff through a variety of approaches. All staff are encouraged to communicate with their direct supervisor, leader, CEO and/or Nursing Administrator on an ongoing basis. A systematic forum established to communicate weekly with staff is the Coffee and Conversation hosted by the CEO and Nurse Administrator each Friday afternoon over the shift change. This forum is open for all staff to bring concerns, ideas, and compliments forward and encourages frank, two-way conversation. The Nurse Administrator captures the concerns, opportunities for improvement or compliments and forwards them to the appropriate leader electronically the same day. Leaders respond to the Nurse Administrator s , if appropriate, after investigating a voiced concern. All concerns are tracked and responses are given to individual employees, if appropriate, and/or communicated in Gert s Gazette (GG), the employee newsletter. An open door policy where employees feel free to stop by manager s offices to discuss issues and management by walking around (MBWA) are commonly used manager approaches to communicating and engaging with staff (Category 5.1c1), F&E information, Mission and Values survey results and State survey results are examples of data shared with staff via in-services, all staff meetings, department meetings, GG, bulletin boards, and on flyers posted in the facility. Managers take an active role in reward and recognition of employees through spoken words of praise, written thank you notes and recognition articles in GG. Recognition received from patients, residents and their families '

8 is communicated by management to staff via a bound book with thank you notes placed in the lobby or through passing words of recognition heard in care conference meetings on to line staff in day-to-day conversations. The MI Committee reinforces high performance and a patient focus through a variety of activities, such as; T-shirts, pizza parties, department recognition weeks, employee picnics, holiday party, potlucks, and casual weeks. Leaders also reward staff for key organizational achievements, such as AHCA applications, the BHS Spirit Award and the Benedictine Living Community Award. 1.1b(2) Create a focus on action. SGHRC LT creates a systematic focus on action through the annual strategic planning process and quality roll-up day. These approaches aim at creating an environment that involves all levels of the organization in developing actions to achieve the current strategic objectives, reviewing the previous year s goals and understanding the role each individual plays in attaining the mission, vision and core values. The output from quality roll-up day provides input for the SWOT analysis which identifies organizational opportunities for improvement that feed into the F&E strategic planning process. F&E includes a comprehensive action plan with goals and associated measures. Occupancy (Fig ), calls for beds (Fig.7.5-2), repeat customers (Fig ), and payor mix (Fig.7.3-2), are examples of measures SGHRC provides to BHS for inclusion in the corporate dashboard that is reviewed by senior leadership. The F&E action plans, infection rates (Fig ), patient falls (Fig.7.1-2), concerns from customers, families and staff, and financial measures are examples of metrics reviewed weekly or bimonthly by leaders at management meetings to identify needed action. Senior leaders and board members create and balance value for customers and other stakeholders through the F&E process where measures are identified to measure organizational performance towards its strategic objectives aligned with the five pillars. 1.2.Governance and Societal Responsibilities. 1.2a(1) Organizational governance. The SGHRC Governance Board meets quarterly to oversee the activities of the CEO and the LT. An annual meeting of the BHS board with the local boards facilitates sharing, learning and planning among all levels of leadership. The seven member Governance Board includes two Benedictine Sisters in addition to five community leaders who serve three year volunteer terms. The community members selected to serve on both the BHS and SGHRC governing boards are high level community leaders and include several national leaders in long term care. The CEO and board members sign a conflict of interest statement at the beginning of their term. The Governance Board reviews data to ensure accountability for the ethical and financial areas of the business. Patient and resident satisfaction, employee satisfaction and F&E actions plans are also reviewed, as necessary, by the board. Stewardship and transparency in operations are the shared responsibility of the board and CEO. An annual independent financial audit, a BHS, Clinical Reimbursement Compliance Review (CRCR) and other internal audits are done periodically with results reported to the Governance Board, CEO and LT. Stakeholders are protected by checks and balances of BHS, the vigilance of the Governance Board, corporate compliance policies, and transparency of operations. SGHRC employs a CCO (Corporate Compliance Officer) who trains the board on corporate compliance issues and is the designated SGHRC leader for corporate compliance. 1.2a(2) Performance of Senior Leaders. The performance of all SGHRC leaders is evaluated annually. The CEO s performance is evaluated by the SGHRC Governance Board and BHS VP of Operations with 360 feedback from SGHRC leadership. The CEO evaluates the performance of his direct reports, including the Nurse Administrator and the LT evaluates employed staff performance. All staff set annual goals for personal and professional growth as part of their (

9 annual performance review. Governance Board members attend the BHS Annual Trustee Conference to learn board leadership skills and fiduciary responsibility. The Governance Board and CEO participated in a self-evaluation process to further their development and improve personal leadership effectiveness and that of the Governance Board. The Governance Board sets and reviews goals annually for the SGHRC LT. SGHRC provides board member education as new programs and services are developed or implemented. 1.2b Legal and ethical behavior. 1.2b(1) Adverse impacts on society. SGHRC addresses adverse impacts on society of current and future products and services by partnering with suppliers, partners and identifying proactive solutions. SGHRC was the first long term care facility in MN to be audited for pharmaceutical waste management. The response to the audit involved a collaboration of professional organizations, the MPCA, Omnicare, BHS and the Scott County Pollution Control Agency. Through this process, SGHRC was instrumental in implementing a corporate wide system for management of pharmaceutical waste. Biohazard and infectious waste disposal is managed through the SFRMC hazardous waste management company. SGHRC recycles paper, some plastics and aluminum cans and the Green Committee focuses on reducing current and future negative environmental impacts. All staff has access to MSDS to reference for proper chemical storage, usage and disposal. The facility conducted an evacuation exercise in partnership with the community fire department that is not typically done in a long-term care setting. BHS and Omnicare send out product recalls to individual facilities and the Safety Committee disseminates information to staff regarding product recalls. SGHRC participated in an OSHA survey with no negative findings and a voluntary OSHA audit is scheduled in the near future. Fig shows the key regulatory and legal agencies SGHRC is accountable to and the associated compliance processes, metrics and goals. Figure Key Regulatory and Legal Requirements Regulatory Agency CMS/MDH OSHA MN Dept of Public Safety Compliance Processes Metrics Goal Compliance with CMS regulations and Medicare and Medicaid billing rules & regulations Maintaining a safe work environment through environmental rounds & preventative maintenance program Maintaining safety through Annual Survey; environmental rounds ) CRCR (Fig ) Case Mix Review (Figure 7.6-4) Workers Compensation: Employee Injury (Fig ) MN Dept of Public Safety (Fig ) Zero substandard deficiencies; no occurrences of fraud Reduced rate of employee injury Zero deficiencies SGHRC uses both formal and informal approaches to address risks associated with products and operations. The strategic planning process assesses risks with current products and operations by reviewing data and feedback from the local markets served. In addition, the formal and informal leadership and Governance Board committee structures provide an ongoing mechanism to address risks as they arise with current service offerings. 1.2b(2) Ethical behavior in all interactions. Ethical practices in every customer interaction are a key requirement in fulfilling the mission of the organization. Clinical and business ethical conduct is discussed during new employee orientation and reinforced daily through living the values. SGHRC educates all new hires on Corporate Compliance policies at general orientation where new employees sign a document that they have received this training. During annual inservice days this training is reviewed. Ongoing education is provided on the BHS core values for all staff and during orientation of new hires. All pre-employment screenings include a criminal background check. A compliance hotline number is provided to all employees to encourage and empower staff to report any potential breeches of ethical conduct anonymously. The CCO

10 coordinates investigation of all known breeches. Both the SGHRC and SFRMC Ethics Committees systematically address clinical and financial ethical concerns. Emergency ethics consultations can be requested by employees, patients, residents and/or family members through this committee. 1.2c Societal Responsibilities and Support of Key Communities. 1.2c(1) Societal well-being. SGHRC considers the well-being of society in daily operations and strategic objectives as the organization fulfills its mission of providing high quality and compassionate care to the communities served. The community-based governance board provides guidance to leaders as they deliver a full continuum of care services on the SFRMC campus and strive to overcome the strategic challenge of providing more home-based services to the community. The organization considers the well-being of environmental, social and economic systems it contributes to through the Green Committee that is focused on reducing the negative impact on the environment by using fewer products. Optimal utilization of the land to best serve the needs of the community is influenced by the community-based board members. The Foundation Committee focuses on optimizing the use of in-kind contributions to SGHRC. SGHRC and SFRMC recently determined it would be in the best interest of the community to merge the independent foundations into a single foundation, thereby decreasing confusion and competition for charitable contributions. This process will be completed in c(2) Support of key communities. SGHRC has been an active supporter of the local community since The key communities supported by SGHRC include; Shakopee, Savage, Jordan, Prior Lake, and Chaska. The history, organizational culture and values demonstrate a strong commitment to the communities served. Support of community health by way of financial contributions and scope of services provided has continued to increase. Senior leaders and staff are encouraged and supported in their efforts to provide leadership to community boards or to serve as volunteers to improve the quality of life for area residents. Fig summarizes SGHRC s community support activities, measures and relation to its core competencies. Figure Community Support Activity and Relation to Core Competencies. Community Support Activity Core Competency Community Action Project Blankets donated, toys collected and money donated to the food shelf through MI by all staff. Mission of serving the poor & powerless and senior population. Clinical Site for Health Education for Shakopee HS, Normandale, Hennepin Tech Orientation, supervision, and classroom time provided by Staff Development Mgr, Short Stay Nurse Mgr, LTC Nurse Mgr, Nurse Core Competencies (Short Stay Care, Long Term Care, End-of-Life Care and Assisted Living Care). Community Education: CPR, Age Wave, Skin Care Scott County Medical Reserve Corp & Emergency Preparedness, Shakopee Fire Department Senior Blood Pressure checks Leukemia/lymphoma foundation, Susan B. Komen foundation, India orphanage support Volunteer Opportunities!* Administrator and CEO. Classroom instruction, group presentation and written information provided by CEO, Nurse Administrator, Marketing Dir, and Staff Development Mgr. Training and participation in community emergency response drills by Nurse Administrator, Staff Development Mgr and LTC Nurse Mgr. Donation of staff time & equipment; coordinated by Dir of Case Management. Donation of dollars & materials through MI by all staff. Provide volunteer opportunities for community members in spiritual care, activities, admission packet assembly, & pet therapy. Volunteers have increased by 30% in the past year. Coordinated by Vol. Coordinator. Mission of serving the community and in particular, the senior population. Core Competencies (Short Stay Care, Long Term Care, End-of-Life Care and Assisted Living Care). Mission of serving the poor & powerless and senior population. Mission of serving the poor & powerless. Core Competencies (Short Stay Care, Long Term Care, End-of-Life Care and Assisted Living Care). Community Benefit Dollars Contributed $4,800,000 in 2008 Core Competencies (Short Stay

11 Addition of Community Services Assisted Living, a Chapel and End-of-Life Care added to meet the needs of the community. Total cost: $6,996,774. Care, Long Term Care, End-of-Life Care and Assisted Living Care). Core Competencies of Assisted Living Care and End-of-Life Care 2. Strategic Planning 2.1 Strategy Development Process 2.1a(1) Key process steps and participants. SGHRC utilizes the BHS strategic planning process; a continuous cycle through which the organization s short and long-term strategic directions and performance expectations are set. The BHS strategic planning process was created by gathering all the individual entities strategic planning processes, identifying best practices and developing a final model which was approved by the BHS governing board. Prior to the annual strategic planning meeting held in the first quarter of the year, senior leaders attend Quality Roll-up day (Category 4.1a-1) that lays the context for strategy development. Following Quality Roll-up, a full day, off-site strategy development session is held with managers, direct care staff, board members, corporate senior leaders and key suppliers and partners. The four key process steps are shown in Figure 2.1-1, the BHS Development and Deployment model. Figure BHS Strategy Development and Deployment Model BHS Strategy Development and Deployment Model Focus Align Execute Review External Internal Assessment Vision & Strategy Develop & Deploy Assess Progress Where are we now? Where do we need to go? How will we get there? How are we doing? Strengths & Weaknesses Opportunities & Threats Core Documents Mission Vision Values Organizational Profile Key Stakeholders Relationships Organizational Performance Results Alignment and Deployment of Past Strategies Seven Factor Analysis Affirm Vision What do we aspire to become? Strategic Challenges Vision SWOT Gap Alternative Scenarios to Close the Gap Strategic Objectives People - Care Service - Financial Growth Action Plans Prioritized strategy action Responsibility? Timetable? Resource Requirements? People Budget Capital Performance Projections Key Considerations Alignment Flexibility Impact Sustainability Performance Monitoring How does performance on the identified Measure compare to: Your projected results? Best practice results Past performance? How are gaps closed between expected and actual performance? Who > When > SWOT Governance / Leadership!! S.M.A.R.T. Goals and Targets Governance / Leadership Leadership and Staff Formal Quarterly Review with appropriate actions. Leadership and 4Staff Annually Annually Quarterly Quarterly The Focus step begins with an internal and external assessment that asks, where are we now? Strategy development begins with a comprehensive understanding of the organization s operating environment, relevance of the organization s Mission, the compelling nature of its Vision, and the manner in which it fulfills the BHS Values. Reviews of the extent that the

12 organization meets the defined needs of its key stakeholders, comprehensive trends in organizational performance, and performance to past strategic plans are conducted during the Focus step. These assessments and the resulting SWOT analysis consider all factors critical to the organization s future success draws conclusions from relevant data to gain perspective of external and internal issues and trends affecting or potentially affecting the organization s success. The Align step in the process asks, where do we need to go? SWOT analysis results are compared against the organization s Vision and strategic challenges and advantages and its SWOT results are identified and prioritized. The strategic objectives are established and organized under the pillars of People, Care, Service, Financial, and Growth. S.M.A.R.T. goals are established and targets are set to monitor progress. Core competencies, strategic challenges and advantages are identified during this step of the planning process. The Execute step focuses on deployment and asks the question how will we get there? Action plans, identifying tasks, owners and timeframes, are developed that best advance the identified strategic objectives and goals. Action plans may be short and/or long term in approach, and identify workforce, capital, and other resource requirements for success. Key performance measures are identified to quantify success and contingency plans are considered to enable flexibility within action plans to adapt to changing environmental conditions and priorities. In the Review step of the process SGHRC assesses progress by asking, how are we doing? Key performance measures for each action plan are monitored to assess action plan appropriateness. These measures are aligned with the organizations overall performance results and goals. Quarterly reviews enable adjustments to strategy and/or operating projections. SGHRC identifies blinds spots through Quality Roll-up, SWOT and throughout the year during QC and manager meetings where data and performance to plan are reviewed. The SGHRC short-term planning time horizon is one year and focuses on identifying and addressing areas of improvement and the challenges of reimbursement. The long-term planning time horizon is five years and focuses on the lack of short-term rehabilitation beds and the challenge to serve the community to maintain a competitive advantage. Time horizons are established for each strategic objective based on how urgent the issue is and what financial resources are available to allocate to the project. The strategic planning process addresses these time horizons by collecting, analyzing and reviewing data in monthly QC and Managers Meetings and by ongoing updates to F&E to keep the strategic plan current. 2.1a(2) Addressing key factors. Through cycles of refinement, SGHRC has incorporated key factors identified by the Criteria for Performance Excellence into its strategic planning process. Strengths, weaknesses, opportunities and threats are identified through the SWOT analysis conducted during the Focus step of the strategic planning process. Major shifts in technology, markets, services, customer preferences, regulatory requirements and competition are also identified during the Focus step. An annual external and internal analysis is conducted to address key trends affecting delivery of care to patients, residents and families. Long-term organizational sustainability is continued successfully through a balance of short and long-term objectives as well as through a systematic approach to address all sources of risk with strategic objectives based on core competencies. The ability to execute the strategic plan is accomplished through one on one alignment discussions with leaders and managers conducted during the Execute phase of the strategic planning process and in the Review step where the strategic plan, objectives and key performance metrics are reviewed with managers and their direct reports. 2.1b Strategic Objectives. 2.1b(1) Key strategic objectives. SGHRC s key strategic objectives, goals, and timelines are shown in Fig Major changes or improvements, competitive issues and health care!"

13 advantages are addressed through the accomplishment of key strategic objectives. The strategic objectives guide development of goals that identify the desired outcome as quantified in key measures. The key strategic objectives align with CSF s, or pillars, which are further integrated into the performance management and evaluation processes. Once SGHRC strategic objectives are determined for each pillar, they are cascaded from leaders to managers and to staff. Prior years goals/targets for the key strategic objectives can be found in the category 7 results section. Figure Key Strategic Objectives, Goals and Timelines Key Strategic Objective Goals Timeline!# % Completed CARE: To develop and deploy evidence-based care and systems to produce superior outcomes and ensure patient/resident safety Increase/maintain percent of residents without acquired ulcers (Fig. 99% 12/1/09 100% 7.1-4) Decrease/maintain percent of residents with a fall (Fig ) 8% 12/1/09 100% Decrease number of Short Stay residents with moderate to severe 30% 12/1/09 20% pain (Fig ) Decrease number of LTC residents with moderate to severe pain 5% 12/1/09 60% (Fig ) SERVICE: To consistently exceed customer expectations Increase/maintain LTC resident overall satisfaction (Fig ) 90% 11/1/09 100% Increase/maintain Short Term Rehab Patient overall satisfaction. 90% 11/1/09 80% (Fig ) Increase/maintain AL resident overall satisfaction (Fig ) 90% 11/1/09 80% Increase LTC family overall satisfaction. (Fig ) 90% 7/1/09 100% Increase/maintain physician satisfaction. (Fig ) 90% 4/1/09 100% PEOPLE: To be the work community of choice and a leader in values-based recruitment, retention, and leadership development and employee satisfaction Increase response to I am satisfied with my involvement in decisions that affect my work on employee M&V survey (Fig ) 4.1 score 3/1/ % Increase response to The person I report to is a good 4.1 score 3/1/ % communicator on employee M&V survey (Fig ) Reduce employee injuries. (Fig ) By 25% 9/30/ % FINANCE: To optimize financial result by developing and deploying sustainable business models Achieve & maintain desired cash flow margin (Fig ) 11% 6/30/09 100% Achieve & maintain AL apartment occupancy (Fig ) 97% 6/1/09 70% GROWTH: To grow the ministry in both existing and new markets balanced with prudent stewardship Increase number of TCU beds To 65 beds Complete investigation of potential for developing or partnering for Home Health Care Services. 100% completed % 11/1/ % Raise adjusted net revenues from philanthropy (Fig ) 1.5% 6/1/09 50% 2.1b(2) Address strategic challenges and advantages. SGHRC addresses strategic challenges and advantages, opportunities for innovation and improvements to the business model through a Strategic Issue Assessment conducted as part of the Align step of the strategic planning process. This assessment identifies primary issues and asks the following seven questions in order to determine its validity: 1) Does it impact our ability to achieve our mission? 2) Is it longer term in nature? 3) Is it likely to have a profound impact? 4) Could it impact the health of the community? 5) Does it threaten our ability to provide safe, high-quality care? 6) Will it have great impact on key stakeholders? 7) What is the estimated financial impact? Key stakeholders

14 are involved throughout the entire planning process and in monitoring results to ensure strategic objectives balance their needs. 2.2 Strategy Deployment 2.2a Action Plan Development and Deployment 2.2a(1) Key-short and longer-term action plans. SGHRC s key short and longer-term action plans are documented in F& E see Fig for key strategic objectives and associated timeframes. Action plans contained in F&E are available for review on site. The F&E strategy deployment model is a web-based tool that allows for transparency and availability of performance metrics for all business areas. It further allows the cascading of the BHS Strategic Objectives down to the individual business units and provides tracking and continuous review of progress against action plans. 2.2a(2) Deploy action plans. SGHRC leaders and work teams develop action plans to address the question, How will we get there? during the Execute step of the strategic planning process. Actions are identified, responsibility assigned, a timetable for completion determined, and needed resources are identified. This information is documented in the F&E tracking tool. BHS senior leaders set, prioritize and provide feedback to SGHRC regarding action plan development through an annual planning ULT retreat, in addition to quarterly F&E reviews. Regular performance to plan reviews provide a process to determine when additional resources are necessary or when plans need to be modified based on changing business needs. 2.2a(3) Financial and other resources. SGHRC action plans are determined prior to the yearend budget in order to obtain financial resources necessary to accomplish plans, provide training or acquire capital. The budgeting process takes into account resources needed for the strategic plan as well as for ongoing operations. The CEO prepares a preliminary budget in early spring that is reviewed and approved by the BHS CFO and the Governance Board by June. Each department is accountable to mange operations within their budget and performance is monitored monthly by the CEO. Projects requiring capital are identified through the strategic planning process. Capital projects are brought to the Governance Board for discussion and prioritization. Capital projects endorsed by the Governance Board are advanced to BHS for approval. 2.2a(4) Deploy modified action plans. Progress relative to action plans is reviewed on a quarterly basis in the Review step of the planning process by the management team using the F&E tracking tool. This review provides the opportunity to modify current action plans based on changing trends identified by QC or other sources, lack of progress, project completion, or to create new action plans. 2.2a(5) Key human resource or workforce plans. SGHRC integrates key staffing and HR plans with short and longer term strategic objectives and action plans through the Execute step of the strategic planning process. Key action plans related to human resources and staffing levels include the safe patient handling program, reduction of patient falls and reduction of employee injuries. The leadership development program is expected to positively impact employee retention and satisfaction (People pillar). The performance management process enables the LT to more effectively communicate strategic goals and expectations to direct care staff in order to increase resident satisfaction (Service pillar). 2.2a(6) Effectiveness of action plans. F&E is the primary method used to track action plan progress and each action plan includes a list of subtasks for completion. When utilizing F&E, managers and direct care staff responsible for action plans enter progress on their individual responsibilities every quarter. F&E automatically computes the percentage of tasks completed and provides an overall completion percentage for the action plan. This provides a!$

15 straightforward and prompt method to determine whether actions plans are on target in order determine if action needs to be taken. Quarterly reviews of action plans and associated performance measures by the QC and managers ensure the overall action plan measurement system reinforces organizational alignment. The CEO participates on a team to evaluate the effectiveness of the strategic planning process and is held accountable for the achievement of the action plans through quarterly meetings with the BHS VP of Operations. SGHRC ensures that the measurement system covers all key deployment areas and stakeholders though a balanced representation on the QC and in managers meetings where action plans are reviewed. The QC includes both non-manager representatives as well as contracted services (MVR) staff and the management team is comprised of leaders from all functional areas within SGHRC. Action plans are further reviewed by the Governance Board and the Foundation board to ensure alignment with the mission and the achievement of key strategic objectives. 3. Customer Focus 3.1 Customer Engagement 3.1a Health Care Service Offerings and Patient and Stakeholder Support 3.1a(1) Identify and innovate health care service offerings. SGHRC begins with the mission, vision and values as it identifies and creates service offerings to meet requirements and exceed expectations of patients, residents and families. The core values of hospitality and respect are essential to the delivery of high quality, compassionate care services that meet the needs of patients, residents and families. New employees are oriented to that expectation upon hire. The key requirements of patients, residents and stakeholders are identified in organizational profile (P.1.b2). The CCO plays a key role in identifying and innovating service offerings to attract new patients and provide opportunities for expanding relations with existing patients. Using the PDCA process employees identify a need for a new service or an improvement to an existing service and informs the CCO, LT, or QC. During the planning phase (PLAN) clinical and non-clinical data and research are assembled to formulate a plan for improvement of an existing service or introduction of a new service. The new or improved service is then pilot tested (DO) with new or existing patients and feedback and data are gathered to determine if modifications need to be made (CHECK). Services are then rolled out on a larger scale (ACT). (PDCA Fig ) (Category 6.2c) SGHRC facilitates a quarterly medical advisory meeting with local physicians to identify customer needs and expectations from core competency areas (Fig ). The marketing and admission staff listens to the community and other service providers to learn about what services key patients and stakeholders are happy with and what they anticipate they will need in the future. This information is used in quarterly strategic planning review meetings with the LT to ensure the organization is meeting its key strategic challenges. 3.1a(2) Key mechanisms for patient support. SGHRC determines key mechanisms to support the use of services and enable patients, residents and families to seek information and conduct business by listening to their needs in daily interactions, care conference and through patient and resident satisfaction surveys. A key partner in providing information to new patients are hospital social workers who are in daily contact with admissions staff either by phone or . The Case Management staff continually updates the admissions packet to include updated information on core competency areas. Key mechanisms to support the delivery of services to patients, residents and families include 24/7 contact with our admission staff. The reception desk is staffed Monday Friday from 8:00 am to 8:00 pm and Saturday from 10:00 am to 4:00 pm. Tours of the facility are conducted on an as requested basis. The phones at the nurse s stations are!%

16 answered 24 hours a day by a HUC or nursing staff who are also responsible for greeting customers, visitors, and auxiliary health care providers. Social workers are on site Monday - Friday and available by pager on evenings and weekends. Information is also available on a Muzak phone system and on the website for customers to access anytime. A list of providers is given to all patients upon admission along with the providers contact information. An aerial wireless call light system provides direct and immediate contact with the patients nursing assistant 24 hours a day. Approaches for key support mechanisms vary by core competency and are based on data and information obtained from daily interactions with various stakeholders. Case Management staff continually listen to the needs of the various patient groups and provide what is required to meet the mission of delivering high-quality, compassionate care. SGHRC determines key support requirements through listening to the needs of patients, residents and families of the core competency areas as a part of daily operations. SGHRC ensures key patient/resident support requirements are deployed to all staff and processes involved in delivering care by sharing information in QC meetings, managers meetings and through the census board in the workroom. 3.1a(3) Keeping approaches current. SGHRC keeps its approaches for identifying and innovating service offerings and for providing patient and other stakeholder support current with health care needs and directions by continually listening to its patients, residents and families. This continual feedback allows the organization to meet expectations of patients in delivering high-quality, compassionate care. The addition of the end of life suites in 2008 was a direct result of feedback from patients and families. Trade shows, professional affiliations and the expertise of the community based board also provide valuable input to keep service offerings current with changing health care needs of key market segments. 3.1b Building a Patient and Stakeholder Culture 3.1b(1) Culture of customer engagement. Patients, residents and families have increasingly come to SGHRC with more information about service offerings than ever before. An example of this is prior to surgery by an orthopedic surgeon the patient is fully briefed as to medications, rehabilitation expectations and potential discharge needs. Family members typically serve in an advocate role for the well-being of patients and residents of SGHRC and the organization strives to provide as much educational information to patients, residents and families as possible to create a compassionate care environment. Creating an organizational culture that consistently ensures a positive patient experience and contributes to customer engagement begins with the mission, vision and values. The workforce performance management system and workforce and leader development systems reinforce this culture by integrating customer service standards into the annual performance evaluations and new employee orientation. A formal service recovery training program will be rolled out to all staff in March, 2009 and will actively engage employees in seeking out service opportunities as part of the curriculum. In service to the mission of providing compassionate care, how care is delivered to patients and residents is valued over the skill set or credentials an employee possesses. 3.1b(2) Build and manage patient and stakeholder relationships. SGHRC builds and manages patient relationships primarily through marketing to social workers at area hospitals within a 25-mile radius. Giving tours, responding quickly to referrals and making accommodations to meet patient needs are key approaches used to acquire new patients and residents. Our patient relationships develop into new or ongoing relationships when they discuss the quality of care they received in the community and they tell others about their positive experiences and/or they return for further care. This has built trust from area discharge planners,!&

17 patients, residents and families and SGHRC quickly became the provider of choice in the south metro area. Through information from new admission surveys, discharge surveys, by listening and responding to customer requirements SGHRC has added AL beds, end of life suites, bariatric care, a wireless call light system, ceiling lifts, chapel, gift shop and wellness room. SGHRC builds relationships and increases engagement with patients, residents, families and other customers through direct care, housekeeping services, care conferences and in providing therapies. During general orientation staffs are introduced to the FISH philosophy of play, be there, make their day, and choose your attitude. This training is reinforced in annual inservice with FISH essential conversations. Staff listen, become engaged, share stories, tell jokes, and learn about what is important and meaningful to patients and residents. Learning about their individual hobbies, passions, and what brings them joy and providing those things to them through daily interaction, care and service ensures increased engagement. (Figs satisfaction and loyalty, and bed demand) SGHRC builds relationships with our employees and stakeholders through daily interactions, meetings with staff and communications such as newsletters (Category 5). Relationships with the Foundation members are built through regular meetings of the various committees and 1:1 meetings with CEO and Foundation Directors. BHS relationships are built and maintained through meetings, conferences, (Category P.1.b.3) 3.1b(3) Approaches current with health care needs. SGHRC uses customer feedback to keep approaches for creating a patient and stakeholder-focused culture and building customer relationships current with health care needs and directions. Patient and resident feedback has been used to adjust staffing in certain core competency areas, changing meal and therapy schedules to accommodate patient needs, and for adding and eliminating services. Customer feedback has also been used to make changes to the physical environment such as the addition of furnishings, electronics, improved lighting, and installation of ceiling lifts. 3.2 Voice of the Customer 3.2a Patient and Stakeholder Listening 3.2a(1) Feedback on services. SGHRC customers make their needs and requirements known through daily interactions with direct care staff, during care conferences, via Customer Concern Feedback forms and through patient and resident satisfaction surveys. The new BHS Service Recovery Program will allow for more rapid response to customer concerns, more consistent tracking, better follow up mechanisms and identification of process improvements. During the admission process, the social worker provides a Customer Concern Feedback form to the patient, resident or family member and explains how they can be used. This process provides a mechanism by which immediate and actionable feedback is given to SGHRC on the quality of service provided. In 2007 all SGHRC staff members attended the Customer Service Standards training that is now incorporated in general orientation. Staff was trained to be responsive to customer concerns. Strong relationships with discharge planners and physicians make it easy for them to express concerns, suggestions and compliments. Patients, residents and families have ongoing contact with direct care staff, social workers and department managers. Health care practitioners and hospital discharge planners have direct contact with admission staff. SGHRC makes every attempt to address and correct a service recovery concern, support or transaction issue directly within 24 hours of being notified, if not immediately. A nurse supervisor is always on site, the Director of Social Services and Nurse Administrator are available by pager when not in the office as well as the transitional care, LTC nurse managers, and day nurse supervisor.!'

18 3.2a(2) Former customers and competitors. SGHRC listens to former customers to obtain actionable information and to obtain feedback on services, support, and transactions during the patient discharge conference. Each former customer is asked the question, how can we improve upon your stay? The responses are logged on Customer Concern Feedback forms and aggregated for analysis. The community based board, BHS leaders, community forums, tours of other facilities and interactions with others in the long-term care community provide SGHRC with listening mechanisms to obtain feedback on services, support and transactions provided by the competitors. This information is incorporated into the strategic development process and analyzed for potential new service offerings against the needs of customers. 3.2a(3) Customer complaints. SGHRC customer complaints are currently logged manually and reviewed by a social worker to determine if there are any vulnerable adult issues that need to be investigated and/or reported to The Common Entry Point (adult protection agency) or police department. If there are no vulnerable adult issues, the complaint is brought to the attention of the appropriate department manager to address. The complaint management process ensures that complaints are resolved promptly and effectively to maintain high-quality service and high levels of customer satisfaction. Each complaint is looked at individually, priority is assessed and a plan of action/correction is developed and executed. If a pattern is found or the complaint is significant or deals with patient safety, the CEO or Nurse Administrator will be directly involved to resolve the issue and recover customer confidence. The management team, resident council and Partnering with Families (family council) are approaches used to gather complaint data and information, discuss ideas, educate staff and make process improvements based on aggregation and analysis of the data. Customer complaints are reviewed during QC and manager meetings and brought to strategic planning. Opportunities for improvement are identified and action plans are created and deployed to the staff member(s) responsible for addressing a concern. 3.2b Determination of Patient and Stakeholder Satisfaction and Engagement 3.2b(1) Patient and stakeholder satisfaction and engagement determination. SGHRC uses several survey tools to determine patient and stakeholder satisfaction and engagement. Annual satisfaction tools include LTC resident satisfaction survey, entered into a corporate wide data base. MyInnerview AL resident, LTC and AL family satisfaction survey, data entered into website. SGHRC uses these measurements to capture actionable feedback to increase satisfaction, secure patient engagement by reviewing and discussing data at QC, managers meetings and strategic planning. Patterns in the data are identified and action plans are developed by the appropriate department to improve performance throughout the organization and with key partners and suppliers, as appropriate. An example of this would be increasing requests for wireless internet access by patients and residents lead to adding that service in SGHRC and AL. 3.2b(2) Customer satisfaction relative to competitors. Comparative information on patient satisfaction relative to their satisfaction with competitors on the quality of care delivered by other facilities in the state is obtained from MDH Nursing Home Report Cards (available on the MDS website, compares facilities in MN with a 5 star rating system). Satisfaction survey data from the BHS dashboard are used to compare SGHRC to 37 SNF and 27 AL within BHS and MyInnerview compares facilities from their nationwide data base of b(3) Patient and other stakeholder dissatisfaction. CCO gathers all pt/resident and family concerns and complaints that are followed up on immediately. Information is aggregated to identify trends that need to be addressed, discussed at monthly QC and annual Quality Roll-up. 3.2c Analysis and Use of Patient and Stakeholder Data.!(

19 3.2c(1) Identify current and future patient groups and market segments. SGHRC captures feedback from employees, patients, residents, and families through satisfaction surveys and third party research to identify current and future patient groups and market segments. Industry trends are also analyzed and participation in professional organizations such as SWIM (Social Workers In Marketing), South of the River, and Elder Resource Association provides data and information to identify future patient groups and markets. 3.2c(2) Identify and anticipate key patient requirements. SGHRC actively solicits feedback from patients, residents, families, physicians, SFRMC and BHS. SGHC reviews information from competitors, market studies and our professional association to determine emerging trends and services that would help SGHRC anticipate the needs of current and future patients and residents. Examples include; installation of the patient lift system, end of life suites, wireless internet service, It s New Too Late (web based program), inclusion of bariatric care and plans to expand TCU beds. 3.2c(3) Improve marketing, build a customer-focused culture and identify opportunities for innovation. SGHRC uses customer data and information to improve marketing to determine where potential customers are and to deliver appropriate messages to them. Recent improvements to marketing approaches include; brochures, signage, newspaper ads, website, online advertising, participation in trade shows and press releases. The Foundation serves as an advocate in marketing SGHRC services in the community. SGHRC is focused on training employees to serve their customers over the next few months through the Service Recovery Program developed by BHS. Through this program, policies and processes that are not customer focused will be identified and changed or eliminated. Customer and employee satisfaction results and industry best practices are used to drive innovation at SGHRC. Analyses of current policies, procedures, and types of care are conducted to identify opportunities for innovation and improvement. These opportunities are compared to patient, resident and employee feedback prior to implementation. 3.2c(4) Approaches for listening, patient satisfaction current with health care service needs. SGHRC keeps its approaches for patient listening, customer satisfaction and use of patient data current by listening to their customer needs and expectations and making changes accordingly. This approach is deployed to staff by communicating the changes to those who are requesting them. The ongoing evaluation of the quality of services provided by SGHRC and the changing needs of our customers provide a mechanism to keep these approaches current with health care trends and directions. 4. Measurement, Analysis and Knowledge Management 4.1 Measurement, Analysis, and Improvement of Organizational Performance 4.1a Performance Measurement 4.1a(1) Select, collect, align and integrate data. SGHRC selects data and information based on identified customers, regulators and BHS priorities, identified key processes, workforce results, and identified financial markets and objectives. Each department or function collects and monitors data for daily operational and overall organizational performance. These data are reported to the QC monthly for review, analysis, alignment and integration into organizational strategic objectives and action plans. The analysis process identifies missing or supplemental data to ensure the organization is focused on the appropriate set of performance indicators. Department leaders select or recommend measures to drive performance and these measures are approved through the strategic planning process. SGHRC has identified key organizational performance measures in three areas; CMS, BHS dashboard and financial. Key performance!)

20 indicators for CMS include pressure ulcer rates (Fig ), infection control rates (Fig ), catheters (Fig.7.1-8), patient falls (Fig.7.1-2), and restraints (Fig ). Examples of SGHRC data used on the BHS dashboard include; absenteeism, turnover, workers compensation (Fig , and ) employee suggestions (Fig ), Mission & Values employee survey results (Fig ,2,3), and MyInnerview patient and resident satisfaction survey results (Fig ,2,3). Key short and longer-term financial measures identified by SGHRC include performance to budget, occupancy (Fig ) and payor mix (Fig ). SGHRC uses key data and information to support organizational decision-making and innovation during the annual performance review as part of Quality Rollup. Results are analyzed to determine performance priorities for the annual strategic planning session. The output of the strategic planning session is placed into F&E and updated periodically, based on performance throughout the year. In turn, key organizational data and information are reviewed monthly at the QC to determine if action plan changes were effective. 4.1.a(2) Key comparative data and information. One aspect of the SGHRC data selection process is the selection of comparative data and information. Measures are selected to ensure comparable sources of data are available from a variety of local, regional and national sources both within and outside the healthcare industry. (Category 3.2.b.2) SGHRC ensures the systematic use of comparative data through the inclusion of key comparisons on financial, workforce and customer satisfaction measures. Comparative data are also used on the BHS dashboard that is reviewed monthly in the managers meeting and on quality roll-up day. Comparative data are obtained from a variety of local, regional and national sources both within and outside the healthcare industry. 4.1a(3) Performance measurement system current. SGHRC utilizes a variety of approaches to keep its performance measurement system current with business needs and directions. Professional journals, trade association conferences and presentations, regional meetings, the BHS Dashboard, and informational bulletins from a variety of sources are used to update the performance measurement system on an ongoing basis. The BHS dashboard is updated monthly. QC meets on a monthly basis to review quality performance indicators and determine if any changes need to be made to the SGHRC measurement system. SGHRC ensures that performance measurement systems are sensitive to rapid or unexpected organizational or external changes through the strategic planning process which provides the opportunity to re-evaluate the measurement system systematically. Through the PDCA process, measures are identified for performance improvement, data are collected and reviewed, action plans are created, and effectiveness of the action plans are evaluated through ongoing monitoring. For example, a recent change was made to the medication error rate from the old mechanism of errors per dispensed doses to error rate per 1000 resident days. This change was made to standardize data collection and allow for benchmarking. Figure Leading/Lagging Indicators, Correlations and Action Plans. Leading Indicator Lagging Indicator Correlation Action Plans # of referral calls (Fig 7.5-2) # of pressure ulcers present on admission "* # admissions (Fig ) Bed Availability/ # admissions unable to take (Fig ) # of pressure ulcers acquired in facility Residents without acquired pressure ulcers (Fig ) GROWTH: short and long term increase in beds to meet increased demand. CARE: education, documentation changes and weekly rounds. Customer Satisfaction (Fig to 7.2-5) Repeat Customers (Fig ) Patient loyalty (Fig ) SERVICE: Personcentered Care Committee, Resident Council Financial budget Actual financial Variance to budget (Fig FINANCE: projections,