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Accountability and Alignment: Assessment, Goals and Standards. Presented by Brad Weeks. Free T-Shirt Giveaway!. Two Kinds of Accountability. what's. how’s. Under Achievers. What do they think?. IHI Model for Improvement. What are we trying to accomplish?.

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Presentation Transcript
ihi model for improvement
IHI Model for Improvement

What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in improvement?

*Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009.

slide10
Is it possible for a leader to meet the goals, but not meet behavioral standards, and still receive a good evaluation?
slide12

Case Study on Leadership Performance

100%

75%

50%

15%

6%

3%

1%

0%

Substantially Exceeds Expectations

Substantially Below Expectations

Below

Expectations

Meets Expectations

Exceeds Expectations

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In order to achieve long-lasting results in your organization, you must hold leaders accountable for measurable results.

Al Stubblefield

President Emeritus, Baptist Health Care

best practice goal setting
Best Practice Goal Setting
  • Annual organizational goals completed
  • Goal cascading to direct reports
  • Annual leader goals completed
  • Alignment and equity review
sample patient experience goal
Sample Patient Experience Goal

Increase perception of HCAHPS Overall Rating to 74 percent 9s and 10s with a stretch goal of 82 percent 9s and 10s as measured by vendor by the 4th Quarter FY2012.

≥ 82.0 = 5

79.0 – 81.9 = 4

74.0 – 78.9 = 3

71.0 – 73.9 = 2

≤ 70.9 = 1

goal setting guidelines
Goal Setting Guidelines
  • 6-8 total
  • Each goal is weighted to reflect importance and time spent
  • Weights between 10% and 50% each
  • Total weights add up to 100%
  • Alignment is crucial
  • Quality = efficiency and effectiveness
goal or tactic
Goal or Tactic?

Round on employees to improve morale.

Achieve 90th percentile in employee morale.

Develop new protocol to reduce infections.

Reduce Hospital Acquired Infections by 5%.

Tactic

Goal

Tactic

Goal

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People

Service

Quality

Finance

Growth

Increase Employee Retention to 88%

Improve Employee Satisfaction to the 90th Percentile

Improve Physician Satisfaction to 85th Percentile

Inpatient: Increase HCAHPS Overall to the 90th Percentile

ED: Increase Patient Satisfaction to the 80th Percentile

Decrease HAI by 30%

96% Compliance in Core Measures

Achieving Operating Income margin of 4% or Greater

Increase Inpatient Volume by 5% as compared to last year

Increase Outpatient visits by 10% as compared to last year

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Weight

25%

Weight

30%

Weight

20%

Weight

25%

People

Service

Quality

Finance

Goal:

Reduce annualized turnover to 25% with a stretch goal of 15% for fiscal year.

Metric:

≤15.0 = 5 19.9 – 15.1 = 4 25.0 –20.0 = 3 27.5 – 25.1= 2 ≥ 27.6 = 1

Goal:

Achieve HCAHPS percentile rank of 85 with stretch goal of 95 as measured by vendor for the fiscal year.

Metric:

≥ 95 = 590 – 94 = 485 – 89 = 385 – 84 = 2 ≤ 74 = 1

Goal:

Decrease pressure ulcers to less than 2 occurrences for last 6 months of fiscal year.

Metric:

≤ 0 = 51 – 1 = 42 – 2 = 33 – 3 = 2 ≥ 4 = 1

Goal:

Manage unit productivity to budget.

Metric:

≥ 105.0 = 5103.0 – 104.9 = 4100.0 – 102.9 = 390 – 94 = 2 ≤ 89 = 1

Example: Patient Care Manager

service goal metric examples
Service Goal Metric Examples

≥ 70th = 556th – 69th = 450th – 55th = 3 26th – 49th = 2 ≤ 25th = 1

≥ 80th = 571st – 79th = 465th – 70th = 3 45th – 64th = 2≤ 44th = 1

Baseline Below

25th Percentile

Baseline Between

26th and 50th

≥ 98th = 594th – 97th = 490th – 93rd = 3 75th – 89th = 2 ≤ 74th = 1

≥ 90th = 581st – 89th = 475th – 80th = 3 55th – 74th = 2 ≤ 54th = 1

Baseline Above

70th Percentile

Baseline Between

51st and 70th