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Winona Health’s Performance Excellence System Kathleen Lanik Chief Quality & Safety Officer. Our Vision. Winona Health will be a recognized leader in the revolutionary transformation of community healthcare. Our Mission.

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Winona Health’s

Performance Excellence System

Kathleen Lanik

Chief Quality & Safety Officer

Our Vision

  • Winona Health will be a recognized leader in the revolutionary transformation of community healthcare.

Our Mission

  • Devoted to improving the health and well-being of our family, friends, and neighbors.

    • A service environment where people can realize

      their full potential.

    • Excellence & leadership in clinical care & service

    • Customer Focus

    • Stewardship of Resources

Winona health s values
Winona Health’s Values

Integrity– We do no harm.

Service– We serve with compassion, dignity, and respect.

Loyalty– We build relationships that exceed expectations.

Excellence– We improve performance through learning and innovation.

WH’s Performance Excellence System (PES) is designed to:

Create peace of mind by providing compassionate, personalized care

to our family, friends and neighbors.

  • WH’s Performance Excellence System (PES) has Four Quality Standards that Guide all Actions:

  • Safety: Do no harm

  • Courtesy: Be kind, caring and selfless

  • Performance: Deliver an excellent care experience

  • Effectiveness: Obtain results by design

  • WH’s Performance Excellence System (PES) includes:

  • Living Service Excellence (LSE)

    Tools and Initiatives for Staff Performance Management Provides a System-Wide Approach to Staff Excellence

  • Living Performance Excellence (LPE)

    Tools and Initiatives for Process Improvements

    Provides an Organization-Wide Approach to Performance Improvement (PI)

Winona Health’s

Performance Excellence System

  • Living Service Excellence

  • Staff Performance Management

  • Tools

    • LSE Standards/Values

    • Performance Evaluation

    • Role Summaries

    • LSE Award Program

    • Winona Health University

    • Employee Pride Survey

    • Experience Compass

  • Living Performance Excellence

  • Process/Performance Improvement

  • Tools

    • STEP

    • Lean

    • By Design Matrix

    • Experience Compass

    • Root Cause Analysis

    • Fact-based Decision Making

    • Evidence-based Practice

    • Failure Mode Effects & Analysis

Central to WH’s Living Performance Excellence efforts is a Plan Do Check Act (PDCA) method known by the acronym “STEP”

  • The STEP/PDCA process is initiated by:

  • S – See the Opportunity Identifying Opportunities for Improvement (OFIs) and Completing an Opportunity Statement Suggesting an Improvement Initiative

  • T – Team UpTeam is Developed, Goals Set, & Timeline for Development is Established

  • E – Evaluate Evaluating the Plan Through Continued Data Collection and Analysis

  • P – Proceed Proceed to Adopt Change or Determine to Study Further

Lean quality thinking a change in the mental model
LEAN QUALITY THINKING - A Change in the Mental Model -


Whole System Management Strategy

FLOW vs. Silos


Focus On What PATIENTS Expect

Coordinated Care – Not Just Competency of Care

Controlling Cost

Elimination of Waste

Wh quality matrix
WH Quality Matrix

  • Delivery Systems

  • Staff

  • Setting

  • Process

  • Quality Standards

  • Safety

  • Courtesy

  • Performance

  • Effectiveness

Wh experience compass
WH Experience Compass

Needs (North)

Stereotypes (South)

Emotions (East)

Wants (West)

WH’s Performance Excellence process supports continuous pursuit of excellence, and is enhanced by:


Minnesota Council for Quality (MCQ)

American Society for Quality (ASQ)

Institute of Clinical Systems Improvement (ICSI)

Institute for Healthcare Improvement (IHI)


Center for Medicare/Medicaid Services (CMS) Quality Project

5 Million Lives Campaign

Minnesota Hospital Association Call to Action Initiatives

In recognition of its efforts, WH has been recognized by multiple local, state and national organizations.

Performance excellence journey
Performance Excellence Journey

  • Minnesota Council for Quality (2003 – Present)

  • Malcolm Baldrige Criteria (2004 – Present)

  • Accreditation/Licensing Agencies

  • State & National Projects

  • Winona Health-Specific Initiatives

Baldrige Journey

Notable Strengths:

  • Visionary Leadership Focused on the Future

  • Valuing Staff and Partners

  • Patient-Focused Excellence

  • Management By Fact

    “Pretty Good Practices”

  • Systematic 6-Step Process to Manage Staff Performance

  • Mentoring Program

Baldrige journey1
Baldrige Journey

2005 Opportunity for Improvement (OFI)

4.1b(1) – Winona Health does not have a fact-based, systematic process in place to evaluate and improve its systems for the review and analysis of measures and organizational performance. As a result, opportunities to improve the measurement and review systems may be missed and/or effective measurement and review practices may be misunderstood and discontinued.

Question what do we need
Question: What Do We Need?

  • A System That Automates Our Processes

  • A System That Addresses Multiple Needs Within Our Organization:

    • Reporting to wide range of constituents

    • Tracking of data at all levels in the organization

    • Alignment with our strategic plan

    • Supportive of our Performance Excellence System

    • Web-based application for easy access

Solution focus on core competencies
Solution:Focus on Core Competencies

  • Integrated, Automated Technological Systems

  • Strategic & Financial Planning Process

  • Community Commitment

  • Performance Excellence System

Lessons learned
Lessons Learned

  • Commitment of Leadership

  • Focus on Your Strengths

  • Performance Excellence is EVERYONE’S Responsibility

  • There are NO Short Cuts

Questions? act, but a habit.”