Creating a Culture of Excellence Mercy Regional Health Center. Kansas Healthcare Collaborative Summit on Quality October 22, 2010

Transcription

1 Creating a Culture of Excellence Mercy Regional Health Center Kansas Healthcare Collaborative Summit on Quality October 22, 2010

2 Objectives Identify two best practices to develop leadership team and improve engagement of employees Identify two best practices to medical staff quality initiatives Explain the benefit of a balanced scorecard and feedback reports in aligning behaviors to achieve improved performance. 2

3 Understanding Change

4 ANNUAL EMPLOYEE SURVEY 2010 Ministry Goals 2009 Threshold Target Stretch 2010 Actual Engagement 71st 77th 80th 83rd Participation 89.6% 90% 93% 96% %

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6 25 20 Comparison of Distribution of First Line Leadership Scores < >95 6

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8 Variance Impact of Financial Performance Beat the Budget Better than last year Operating Margin $2.00 M $3.7 M Compensation Ratio $ 50 K $2.2 M Supply Expense /Net Patient Revenue $ 50 K $1.1 M 8

9 Physician Satisfaction Overall Goal 3.8 Stretch Feb Aug-08 Feb Aug Feb-10 Aug-10 3 Nursing Staff Hospital Mgmt. Operating Room Overall 9

10 Roadmap CEO Senior Leadership Lead Leadership Development Accountability Communication Employee Engagement 10

11 What is Important to Your Employees Good working conditions Feeling in on things Tactful disciplining Full appreciation of work done Management s loyalty to employees Good Wages Promotion and growth with org. Supervisor s understanding of personal problems Job security Interesting work KHA Leadership Institute 2010 Wichita State University 11

12 Leadership Development Commitment to Quarterly Leadership Commit to Quarterly Leadership Training Elect your committee members Pre-reading assignments Agenda driven by Senior Leadership Team Linkage assignments Signed off on each month Have Fun!

13 Leadership Development Book Club Hardwiring Excellence QBQ! Crucial Conversations Zapp! Crucial Confrontations What Got You Here What You Accept Is What You Teach Five Dysfunctions of a Team Encourage participation builds the team Monthly 60 to 90 pages If unable to attend, submit a summary of the assignment

14 CEO Communication Communication focus on why Orientation Standardized agendas by framework Structured results focused monthly meetings Quarterly employee meetings (75%) Senior Leader Rounds Night Shift Rounds

15 MONTHLY MEETING AGENDA I. Transform I. Physician alignment/engagement activities II. Committee Updates II. Perform I. Excel I. Quality I. Insert quality focus or initiative ENTER to add more items II. Review departmental scorecard III. Patient Safety Initiatives II. Service I. Patient Satisfaction Results II. AIDET Implementation III. Stewardship I. Monthly financials (Please most recent DORs and Action OI) II. Review Workload/Expense III. Productivity and cost per unit of service IV. Action to reduce supplies expense 15% V. Opportunities for improvement II. Relate I. EOS plan of action update II. Employee retention III. New employees in department IV. Update on employee performance III. Grow I. Growth opportunities - Personal or Professional IV. Perform Advocate I. State and National Advocacy II. Community volunteering update

16 Leader Rounding Build Relationship Capturing wins - What is working well today? Do you have the tools and equipment to do your job? Staff or Physician Recognition? Is there anything we can do better to improve safety?

17 Thank you notes Specific recognition reinforces desired behaviors Send to employee s home Medical Staff recognition Manage up to administration

18 Call to Action When we do what we have to do we are compliant. When we do what we choose to do we are committed.

19 Building a Culture of Excellence A Medical Staff Performance Improvement Model

20 Commitment to Physician Leadership Development Consulting and education to help physicians and hospitals succeed Leadership training Proven models Impetus for change

21 Hospital Physician Alignment CEO and medical staff must be on the same page Create and communicate an organizational vision or goal Transparency Focus on quality improvement Building a culture of trust

22 Quality Assurance Quality Committee Medical Executive Committee Physician Risk manager CEO Hospital Quality Director Hospital Risk Manager Hospital Board

23 Peer Review Old definition: Dept review of charts New Definition: The evaluation of an individual physician s professional performance for all relevant competency categories using multiple sources of data, and the identification of opportunities to improve care.

24 The Physician Performance Pyramid Take corrective action Provide Periodic feedback Measure performance against expectations Set, communicate and achieve buy in to expectations Manage poor performance Appoint excellent physicians

25 The bad apple theory vs. performance improvement

26 Physician Excellence Committee (PEC) Process began January man hours over five months First meeting on June 24, 2009 Single multidisciplinary committee 10 physician members

27 Performance Dimensions Technical Quality Medical Knowledge Service Quality Relationships Citizenship Patient Safety/ Patient Rights Resource Use

28 PEC Process Three categories to classify the indicators used to measure physician performance Review Rule Rate

29 Rule Indicators Identifies individual instances of noncompliance with administrative or clinical processes complied with by most physicians Examples: Illegible orders (Excellent 2/yr, Acceptable 5/yr) Documentation not completed in time (Excellent 2/yr, Acceptable 6/yr) Patient complaints (Excellent 1/yr, Acceptable 4/yr) Inappropriate physician behavior (Excellent 0/yr, Acceptable 2/yr)

30 Rate Indicators Identifies potential performance differences among physicians using aggregated outcomes or processes of care Examples: % excellent rating on physician feedback form (Excellent 95%, Acceptable Med Staff Avg) Surgical site infection (Excellent 2%, Acceptable 2-5%) CMS Best Practices AMI pt receiving aspirin Antibiotic before surgery

31 Review Indicators Identifies cases potentially requiring physician review due to case complexity or significance Examples: Unanticipated death of patient Significant complications Missed Diagnosis

32 PEC Process QM case screening Physician reviewer assigned See Review form Decision on Overall Provider Care and Documentation issues Committee review Follow-up to provider (if Additional info is requested) Class Assignment Send feedback to all physicians

33 Physician Review Form

34 Physician Feedback Report

35 Physician Comments Challenges to data 9/10 cases reviewed reveal accurate data Part of the improvement process Why didn t someone tell me this was a problem?

36 Personal Example Antibiotic not given within 6 hours of diagnosis of pneumonia That s not my fault Antibiotic not given in ED; was given on floor later Led to discussion with ED dept director to reinforce policy of antibiotic timeliness in ED

37 Performance Improvement History and physicals Deficiencies in H&P criteria brought into compliance Operative reports timeframe Brought to light discrepancy between medical staff policy and HFAP rules/regs Type and cross match policy Eliminated many unnecessary T&C

38 Performance Improvement Physicians in the red for a rate or rule in consecutive quarters are sent a letter from PEC Calling the issue to attention; asking for change in behavior Repeat offenders meet with Dept chairs to problem solve Recognition program

39 Outcome What is the single greatest motivator for physician performance improvement? FEEDBACK Measure, report, compare to peers and standards/goals, use measures that are meaningful to physicians

40 Questions Ryan Knopp, MD Past President, Medical Executive Committee John Broberg, FACHE President and CEO