Journey to Excellence: Proposed Next Steps

1. Journey to Excellence:Proposed Next Steps Presented to TGM byHPRHS Internal Experts April 6, 2009

2. The Steps to Here… • 2007 State and National feedback reports reviewed by IEs. • Each comment given a “current disposition” describing the IE’s analysis as to whether each item remains as described in 2007, or if there has been significant change. • 2009-2010 criteria reviewed and changes considered in defining current OFIs. • Current OFIs prioritized and next steps proposed.

3. A Couple Caveats • We have many strengths, and are definitely improving, but we’ve chosen to focus most of this presentation on the OFIs to inspire continued improvement. • The 2009-2010 criteria do have some significant changes, and we do not yet have the benefit of the Baldrige program’s training related to these changes, so our interpretation may evolve.

4. OFI #1: Strategic Plan Alignment and Deployment • Baldrigese:Strategic objectives, action plans, and timeframes are unclear, which may make organizational alignment difficult. • Translation:We need to have measurable strategic objectives with associated, time-specific actions as part of the strategic plan. • Possible Solution:Adjust strategic plan format to list objectives (which become organizational scorecard indicators and cascade to department scorecard indicators) and time-specific action plans (which cascade to department action plans).

5. The Solution in Action • Goal: Quality • Strategic Objectives:- Achieve publicly reported SCIP composite of 90% or higher.- Achieve nosocomial MRSA infection rate of .39 or lower.- Achieve expected mortality rate index of .73 or lower. • Action Plans:- Implement AHA surgical cite infection prevention protocols… (2010, Taylor, Mengel).- Implement evidence-based practices for prevention of MRSA… (2010, Taylor, Mengel).- Conduct improvement project related to nursing documentation… (2011, Deaton, Mengel)

6. OFI #2: Collection and use of comparative and competitor data • Baldrigese:Unclear how key performance indicators are determined and how comparative and competitor data are collected, aligned and used to drive performance improvement. • Translation:We need a systematic process to determine what to measure and how to get comparative and competitor data related to that measure. • Possible Solution:Implement structured process for determining key performance indicators of the strategic objectives, and implement steps to make every effort to get comparative and competitor data, and that we consistently assign a “target” level of performance for these indicators, i.e., top quartile of peer group.

7. The Solution in Action • Goal: Service • Definition: HPRHS’ mission is to provide exceptional health services … and we will continue to strive to exceed the expectations of our customers. • Comparative & Competitor Data Selection1. What key performance measure should we use?2. How should we define our comparative group?3. Can we get data for top quartile and decile target setting?4. Can we get competitor data for this measure?5. Investigate and make recommendations.6. Senior leadership approves key performance measures and comparative groups, and measures populate appropriate scorecards.

8. OFI #3: Workforce Planning • Baldrigese:Unclear how workforce is prepared for changing capability and capacity needs. • Translation:Availability of qualified employees and providers is a key strategic issue facing HPRHS and the industry. So, we need a workforce plan, aligned with the strategic plan, to ensure workforce issues do not become a disadvantage. • Possible Solution:Create a workforce plan with specific action steps to ensure our workforce is broad enough and deep enough to effectively implement the strategic plan.

9. The Solution in Action • Goal: People • Strategic Objective:- Achieve vacancy rate of 4.5% or lower. • Strategic Plan Action Steps:- Implement targeted recruitment campaigns for difficult to fill positions (2010, Burns). - Develop programs and relationships with regional universities and community colleges to recruit new employees (2012, Burns, Mengel). • Workforce Plan Objective:- Achieve nurse vacancy rate of 4.0% or lower. • Workforce Plan Action Steps:- Implement recruitment campaign targeted to currently employed nurses (2010, Carter).- Investigate partnership possibilities with UNCG, GTCC, RCC, DCC, NC A&T, and WSSU to facilitate new employee recruitment (2012, Burns).

10. OFI #4: Key Stakeholder Requirement Determination • Baldrigese:Unclear how voice of customer is used to develop key stakeholder requirements. • Translation:We need a process to take what we hear from key stakeholders and translate their input into measurable, “key requirements.” • Possible Solution:Create a systematic process to define key stakeholder requirements.

11. The Solution in Action • Goal: People • Key Stakeholder: Physicians • Defining Key Requirements:1. List primary sources of listening to the key stakeholder.2. Analyze data from each source and recommend list of key requirements, with associated metrics (integrated with scorecards).3. Share list with key stakeholder and amend if indicated.4. Senior leadership approves requirements and metrics.

12. OFI #5: Segmentation • Baldrigese:Unclear how customer segments and workforce segments are determined and how metrics are used to ensure vision is pursued for all key stakeholders. • Translation:We need to have a way to consider the varying needs of discrete segments within our customer base and workforce, and metrics at the segmented level to pursue being the best for all of our stakeholders. • Possible Solution:Define meaningful segments within stakeholder groups and systematically review performance on key measures for each segment, taking action where indicated.

13. The Solution in Action • Goal: Service • Key Stakeholder: Patients • Defining Segments1. Analyze patient base to determine useful segments.2. Evaluate availability of key performance indicators for each segment.3. Senior leadership approves recommendation for identified segments.4. Patient data reported in aggregate and along segmented dimensions.

14. Other Significant Remaining OFIs from 2007 • Review/refine processes for ensuring organizational ethics. • Determine how to measure the effectiveness of the Leadership System. • Make STOP a systematic process. • Develop processes for succession planning & career progression. • Review/refine complaint processes for all key stakeholders. • Review/refine processes to ensure data availability, accuracy and integrity. • Continue to integrate medical staff into plans and processes. • Design Employee Performance Development Plan to drive accomplishment of strategic & workforce plans. • Formally determine core competencies. • Articulate how we determine when to collaborate vs. compete. • Achieve consistency in finance and patient and workforce satisfaction results. • Present results for innovation, dissatisfaction, perceived value, action plan achievement, work systems, collaborative performance.

15. 2009-2010 Criteria Changes & Impacts to HPRHS • Category 1- Societal responsibilities (also asks for results in 7.6)- SL enhance personal leadership skills • Category 2- Determine core competencies during SPP- Deployment of action plans to key suppliers and partners • Category 3- How do you engage patients and stakeholders to serve their needs and build relationships(also asks for results for customer engagement in 7.2)- Measure patient and stakeholder engagement • Category 4- Additional focus on knowledge management • Category 5- Simplified and focused more tightly on workforce engagement • Category 6- Simplified to: Work System Design > Process Design > Process Management > Process Improvement- Increased emphasis on emergency readiness

16. Lest We Become Discouraged… We have significant strengths including: -Organizational Culture - Leadership System - Involvement in Governance & Strategic Planning- The Concept of STOP for Agility- Collaborative Model- Process Design and Improvement- Results in Quality, Access and maybe even Value (fingers crossed).

17. Potential Next Steps • Consider further prioritizing and approving projects/changes based on remaining OFIs. • Present learnings from Quest for Excellence, 2009 examiner training, and additional information regarding criteria changes to TGM. • Refine and implement internal training program related to Baldrige framework.

18. Proposed Education Plan • Blend in to revamped G.O. presentation (Marsh) • Quarterly SL, Director, Manager offeringsPossibilities include:- August, ’09: Strategic Plan and Scorecards (Deaton, Pickels)- November, ’09: Customer Engagement (TBD)- February, ’10: Organizational Ethics (Lapekas, Forrest)- May, ’10: Site Visit Preparation (Lapekas, Manzo, Fail) • Annual Internal Expert training- June, ’09 & ’10 (Lapekas, Fletcher) • DADLI Education for Process Improvement Teams • Ongoing communication provided via:- Total Care Compass- Regional High Points- Starting Line-Up

19. Questions?