Mary O. Cramer, CPHQ, MBA Master Black Belt Director, Performance Excellence August 2006

1. Developing Performance Excellence at NewYork-Presbyterian Hospital Driving Success and Lessons Learned Mary O. Cramer, CPHQ, MBA Master Black Belt Director, Performance Excellence August 2006

2. NewYork-Presbyterian Hospital Full Asset Merger of The New York Hospital, 2nd Oldest Hospital in the US,Founded in 1771, and the Presbyterian Hospital of New York, Founded in 1868, into One Article 28 Corporation with: • 2,224 Certified Beds • 102,000 Discharges • 11,000 Births • 1,036,000 Ambulatory Visits • 14,500 Employees (plus 1,400 Housestaff) • $2.3 Billion Operating Budget • NYP Health Care System: 58 Facilities, US and Abroad

3. NewYork-Presbyterian Hospital Vision NewYork-Presbyterian To Be Among the Very Top Academic Medical Centers in Clinical and Service Excellence, Patient Safety, Research and Education

4. NYPH Strategic Goals People Development Energized, challenged and committed Performance Excellence Quality, efficiency and service Information Technology Dynamic and data-driven Innovation New ideas Strategic Growth Volume and access

5. A New Organization MOVING TOWARD A NEW ORGANIZATION Initially The Sum Of Two Academic Health Care Systems A + B = “AB” Evolving Toward A Wholly New Entity With A New Culture A + B = “C”

6. Challenges Challenges We Face • Clean and Safe Hospital • Patient, Physician, and Employee Satisfaction • LOS Reduction to Build Capacity • Advancing Standards Based Clinical Practices • Financial Performance

7. What We Heard From Our Employees • Improve Communication • Accountability • Decision Making • Enhance Cross Department Teamwork/Cooperation • Reduce Bureaucracy • Increase Management Skills Nimbleness

8. Importance of Culture Change We Must Be Responsive to Our: • Patients and • Employees Achieving Objectives Requires Changing Skills Without Change We Cannot Reach Our Goals

9. Required investments include more than “bricks and mortar”. We must invest in our people. Required Investment……

10. SIX SIGMA AS A PERFORMANCE EXCELLENCE TOOL

11. Performance Excellence Performance Excellence Quality Efficiency • Embraces All Aspects of Performance • Continuous Improvement • Patient Safety • Innovation Practice • Best Practices • Streamlined Clinical & Operational Workflows • Revenue Enhancement • Resource Management Service • Patient/Family Is Focus • Enhanced Care Experience • Commitment to Patient, • Physician & Employee • Satisfaction

12. Adoption of Six Sigma • Why Is This Different? • Is This the “Flavor of the Day”? • How Do We Know the Change Will Last? • How Much Does it Cost and What is our ROI?

13. The Difference Six Sigma Brings TraditionalQuality Program Six Sigma • Driven By the Customer • Focuses on Processes • Prevents Defects • Improves Entire System • Looks Forward • Concentrates on CTQs • High on Methodology and Data • Driven Internally • Focuses on Outcomes • Fixes Defects • Improves Quality • Looks Backward • Concentrates on Product • High on Theory and People

14. Implementation Objectives: Knowledge Transfer Transformative Cultural Change Accountability Management Discipline No One Left Behind All Levels, All Disciplines Hospital Wide Adoption

15. Training Design TRAINING DESIGN • Curriculum: DMAIC, CAP/WO, LEAN & DFSS • Duration: 17 Days over 6 Months • Training Team Composition: Black Belt with 3 – 4 Green Belts; Extended Team Created Later • Actual Projects Used as Training Projects • Abbreviated Training Delivered to Senior Administration, Medical Staff, Management Staff, and to Line Employees

16. Organizational Commitment Where we are today! Q3 Q1 Q2 Q3 Q3 & Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q4 2003 2006 2004 2005 Class 1 Class 2 MBB Class GE Mentoring Class 3 Class 4 GE Mentoring Class 5 Class 6 GE Mentoring Class 7 Class 8 GE Mentoring Class 9 Class 10 GE Mentoring Self Sustaining Six Sigma Culture

17. Results • Program • 10 Six Sigma Classes • 50 Full Time Black Belts; 26 Active, 20 Returned to Operations • 4 Full Time Master Black Belts • 200+ Green Belts • 140+ Projects • Outcomes • Length of Stay: 3500 Additional Inpatient Admissions (2005); 1000 Additional Admissions (ytd 2006) • Revenue/Cost Avoidance: $68M (2004 – 2006)

18. KEY SUCCESS FACTORS

19. Black Belt Role Role: • Lead Projects Using Six Sigma Methodology • Mentor Others Doing Projects • Introduce Methodology and Tools to Team Members and Broader Audiences • Act as Both Technical and Cultural Change Agent • Reduce Defects and/or Process Variation With Successful Project Management • Help Deploy Six Sigma Thinking Into the Organization • Three Year Commitment

20. Black Belt Selection Criteria Selection Criteria: • Demonstrated Leadership and Project Management Skills • Strong Business and Technical Foundation With Proven Analytical and Statistical Problem Solving Skills • Excellent Communication Skills • Strong Track Record of High Performance With Strong Upward Potential • Performance and Promotibility to Top First or Second Level • Strong Sense Of Organization’s Values • High Degree Of Customer Sensitivity • Long Term Commitment To Organization

21. Black Belt Recruitment 2006

22. Quality Table Of Organization Executive Vice President Chief Operating Officer Vice President, Clinical Practice Evaluation Chief Quality Officer Quality Informatics Quality and Performance Improvement Performance Excellence Innovation Strategies Quality Research

23. Performance Excellence Table Of Organization Chief Quality Officer Performance Excellence Master Black Belt Nursing Quality Master Black Belt Financial Improvement Master Black Belt Operational Excellence Master Black Belt Quality & Patient Safety Black Belts (2) Black Belts (12) Black Belts (12) COO MS/CHONY COO NYP/CU COO NYP/WC

24. Project Selection Criteria Criteria Example Clinical Excellence Improved patient outcomes, reduced infection rates & appropriate utilization of ancillary services Regulatory and Safety NYS Department of Health; JCAHO; CMS Physician Satisfaction Competence of nursing staff, availability of facility-based specialist, access to the OR, ease of scheduling, state of the art equipment Staff Satisfaction Home/work life balance, collegial respect, rewarding career Patient Satisfaction Outstanding clinical care, caring environment & facility aesthetics Financial Performance Increased revenue, decreased cost, cost avoidance, implementation support Ease of Implementation Technological change needed, organizational acceptance, project span/scope (across multiple campuses) Time to Complete Time the project will take to complete Sustainability Systems and structures to support the change; control measures in place

25. Successful Project Characteristics • Directly Aligned With Strategic Initiatives • Active Senior Leadership Sponsors • Significant, Tangible Benefit – Financial or Otherwise • Cross-Campus Design • Engagement Of CEO And Senior Leadership • Ongoing Management Metrics

26. Completed Projects • Cath/EP Room Turnaround Time • Accuracy & Timeliness of Pharmacy Charge Posting • Patient Wait Times in Radiology • Medication Delivery Turnaround Time • CT OR Room Turnaround Time • Radiology Turnaround Time in ED • Hip Fracture LOS • Timeliness of Cancer Registry TNM Staging • Housekeeping Turnaround Time • Ambulatory Surgery Turnaround Time • Non-Invasive Cancellation Reduction • Antibiotic Delivery in Cardiothoracic ORs • PACU Criteria Met to PACU Exit • Scheduled Induction Wait Time in L&D • Blood Delivery Turnaround Time • Billing Compliance for Screening Mammograms • Pyxis Overrides • ED Throughput • Smoking Cessation Counseling • Craniotomy LOS • Nursing Communication Patient Satisfaction • Radiology Report Turnaround Time • Ambulatory Surgery Wait Time • Transport Response Time for Patient Care Units • ICU Throughput • Outpatient Lab Charge Capture • Intradisciplinary Plan of Communication • Hem/Onc Infusion Center Cycle Time • Isolation Room Throughput • Outpatient Transplant Room Utilization • Use of Abbreviations in Medical Records • Medical Records to Ambulatory Care • Information Transfer for Antenatal to L & D • Attending of Record Accuracy • Improve AOB Process in Radiology • Antibiotic Utilization • Inpatient Tray Accuracy • Discharge Instruction Process • Call Bell Response Time • Psych ED LOS • Pediatrics LOS Reduction • C –Section LOS Reduction

27. Care Coordination Model PT/OT Turn-Around Time SNF Placement Improvement Patient Geographic Localization PICC Line Delays Ventilator Patient Throughput MRI Delays ICU Transfer Cycle Time Attending of Record Documentation Patient Acuity Documentation Chemotherapy Admission Cycle Time OR First Case Starts Inpatient Insurance Accuracy Charge Posting Accuracy Laboratory Outreach Specimen Handling Biomedical Equipment Repair Cycle Time Reduction Restraint Documentation Patient Vaccination Rate Improvement Medication Reconciliation Blood Stream Infection Reduction Improvement - Staff Back-Fill Process Emergency Department Revenue Enhancement Cardiac Cath Lab Revenue Enhancement Ambulatory Surgery Revenue Enhancement Clinical Denial Avoidance ED Door to Treatment Time Reduction Laundry Process Improvement OR Add-On Delay Reduction Pressure Ulcer Reduction Ventilator Associated Pneumonia Reduction Outpatient Oncology Billing Accuracy Active Projects

28. Sustainability • Projects Must Continue to Advance Strategic Initiatives and Exhibit Visible Senior Management Sponsorship • Outcomes • Must Continue to Be Systematically Measured • Must Leverage Best Practice • Must Continue to Be Systematically Communicated

29. Communication Plan • Media • Official Hospital Memoranda • NYPress Articles • Intranet • Executive Portal • Performance Improvement Team Web • Meetings • Monthly Clinical Dept. Heads & Physician Groups • Annual Management Kick-Offs & New Employee Orientation • Monthly Department Head and Key Personnel Meetings

30. PROJECT DASHBOARD

31. Patient Satisfaction Dashboard Scale: 0=Very Poor, 25=Poor, 50=Fair, 75=Good, 100= Very Good

32. Length of Stay Dashboard

33. Length of Stay Detail – Actual and Variance

34. LESSONS LEARNED

35. Course Corrections • Fully Integrate PE Tools; e.g. CAP/WO, LEAN, DFSS • Ensure Ongoing Green Belt Involvement • Leverage Best Practices Across Campuses • Assure All Black Belts are Fully Qualified • Enhance Awareness of Performance Excellence • Programs

36. So, in Order to Succeed…… • Senior Leadership Support and Involvement • Project Selection Aligned With Strategic Initiatives • Ongoing Measurement • Resource Commitment; During and Post Projects • Communication, Communication, Communication!

37. Mary O. Cramer moc9005@nyp.org 212-746-5939