Our Journey-Excellence For Every Patient D. Montana- Rhodes RN, MSN Leesa L. Bain RN, BSN, MHA

1. Our Journey-Excellence For Every Patient D. Montana- Rhodes RN, MSN Leesa L. Bain RN, BSN, MHA HC3-HealthCare Consultants of the Carolinas

2. Becoming Engaged • 1st formal presentation to the BOT and medical staff in Nov. 2007 • Words (excuses) we have all heard • They are trying to dictate how we practice medicine • Our numbers are too small to be statistically significant • The evidence is not acceptable • They should be focused on outcome measures • We are doing excellent in individual areas why the all or none stance • Nursing indicators are at the goal its the physician driven indicators that are the problem • The nurses are not prompting us • I can’t do it all ( quality personnel)

3. Becoming Engaged • Contacted NCHA Jeff Spade in Feb. 2009 to look for tools to help us improve our quality • Tools available • IHI tools and webinars • Attended Eastern NC Patient Safety and Quality Symposium in August 2009 we were last in line when the graphs were posted in the room full of our peers. • The power of Peer Pressure and the power of embarrassment that we were not representing the care we administered with a positive reflection.

4. Tapping into the moral compass of your leaders and providers. (Don’t hurt me, Heal me, Be nice to me) Tapping the competitive nature of highly skilled Practitioners. ( They want to be the best) Tapping into the expectation of stewardship. $$$$$$ Money talks (especially when it can be taken away). What will be your inspiration ?

5. Quality Strategic Plan Five Critical Success Domains • Establish quality and safety as a strategic priority • Engage physicians, nurses and other clinical leaders • Measuring, managing and monitoring quality data • Build improvement capability (training, culture, etc.) • Clinical Practice

6. Quality Strategic Plan • Comprehensive Assessment • Opportunities for Improvement • Customized Recommendations and Action Plan • Timeline • Deployment and Measurement

7. Quality Improvement Plan Timeline Develop dashboard BOD to establish organizational goals Sample Board Retreat on governing quality Revise job descriptions Conduct AHRQ survey Develop action plan for AHRQ opportunities identified

8. Implementation The Good • Quality Strategic Plan • Willingness of the Board to adopt quality as a priority and learn about their responsibility in maintaining quality • Financial support through grants and the hospital foundation • Willingness of the Board and leadership to be transparent and accept we had a lot of work to accomplish our goals for quality

9. Implementation The Good • Willingness of leadership to accept the need for culture change • Increased transparency throughout organization • Increased communication with physicians, staff and patients • A “no excuses” mindset • Increased teamwork • Building relationships with other area hospitals • Establishing a mentoring relationship focused on quality with our tertiary referral center

10. Implementation The Bad • Culture of safety and quality survey – Management had a wake up call that we did not communicate or maintain the vision of our organization as well as we thought. • Lack of technology • Lack of financial resources • Focused on individual indicators vs. optimal care across the system of delivery

11. Implementation The Ugly • We will do it if all we have to do is sign • Reports of performance per individualized by provider (no one wants to be identified by peers as not being the best) • No formal IT structure ( i.e.. We were not even all working with the same windows platform – huge impact on communication and data presentation)

12. They were successful because… • CEO • Board • Nurse/Quality Leader…”dog on a bone!” • Collaboration • Funding support

13. Trends

14. CHF Graph Comparison

15. And, here we are in 2011

16. And, here we are in 2011 • Fully functional Board Quality Council • Ownership of core measures from unit secretary to MD • Quality on every meeting agenda throughout the facility • Additional key personnel involved in concurrent chart reviews • Provider specific performance reporting

17. And, here we are in 2011 • Board Quality Council will be adding an at large member from the community in May 2011 • Transparency reporting is an expected and accepted part of how we conduct business • Culture Change in progress to ensure leadership and staff fully embrace culture of quality will resurvey staff in 18 months

18. And, here we are in 2011 • All physicians and staff do not want to be the one to break the chain of success. • MDs will now question if components of charts and documenting are not readily available to ensure compliance with optimal care scores.

19. We had nowhere to go but up!