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The Drivers of Quality

The Drivers of Quality. Benedictine Health System Chris Boldt, Vice President Operations Jeri Reinhardt, Director, Quality. Objectives. Describe the primary drivers of Performance Excellence within the Baldrige Criteria

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The Drivers of Quality

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  1. The Drivers of Quality Benedictine Health System Chris Boldt, Vice President Operations Jeri Reinhardt, Director, Quality

  2. Objectives • Describe the primary drivers of Performance Excellence within the Baldrige Criteria • Utilize tools and methods for developing leadership focused on strategy and customers • Identify key customer service standards and a process for service recovery

  3. Purpose In 1985, the Benedictine Sisters of St. Scholastica Monastery established BHS to: • Further the Benedictine health care mission • Efficiently and effectively manage the health care resources of the BSBA • Increase the involvement and participation of the laity in the expanding Benedictine health care ministry.

  4. Mission Statement The Benedictine Health System, a Catholic health care organization entrusted with furthering the health care mission of the Benedictine Sisters of Duluth, Minnesota, provides a spectrum of services with special concern for the poor and the powerless. The System is committed to witness to God’s love for all people by providing high-quality services in a compassionate environment that enhances human worth.

  5. Core Values • Hospitality • Stewardship • Respect • Justice

  6. Vision Creating Benedictine Living Communities where health, independence and choice come to life.

  7. Benedictine Health System - Today • BHS owns and/or manages more than 40 long term care facilities across 7 states • Bed complement • 3500 Long Term Care • 1,120 Assisted Living • 828 Independent Living • Staff • Approximately 5,000 employees

  8. http://www.quality.nist.gov/HealthCare_Criteria.htm

  9. Driver System Results 7 Strategic Planning 2 • Business • Results: • Health Care • Patient • Satisfaction • Financial/Market • Staff & Work • System • Organizational • Effectiveness • Governance/Social • Responsibility People 5 Leadership 6 1 Process 3 Patients, Customers & Markets Measurement, Analysis & Knowledge Management 4

  10. Baldrige 1.1- Senior Leadership: (70pts) • Vision & Values • Leaders set? • Legal & ethical behavior? • Sustainable organization? • Culture of patient safety? • Communication & Organizational Performance • Leaders communicate? • Leaders create focus to accomplish goals? • What measures do leaders regularly review?

  11. Baldrige 1.2 - Governance & Social Responsibility: (50pts) • Organizational Governance • Accountability for management, fiscal accountability, transparency? • Evaluate performance of senior leaders? • Legal & Ethical Behavior • Address any adverse effects of society? • Key compliance process for regulations & law? • Promote ethical behavior? • Support of Key Communities

  12. BHS Leadership Systems • Solid Governance • Annual meeting of local boards with System board • Audit results favorable • Rotating tenure • Annual self -evaluation • National leaders in long term care on staff • Systematic meetings to share, learn and plan among all levels of employees • Ongoing leadership communication • Compliance program

  13. Baldrige 2.1 - Strategy Development: (40 pts) • Strategy Development Process • Key process steps in strategy development? • Addressing SWOT, technology, sustainability, ability to execute? • Strategic Advantages and Objectives • Objectives & timetable? • Ties to strategic challenges?

  14. Baldrige 2.2 – Strategy Deployment: (45 pts) • Action Plan Development & Deployment • Process to develop? • Ensure adequate financial and other resources? • Short and long term goals? • Effect on workforce and needed changes in capability and capacity? • Performance Projection

  15. Common Language • Strategic Challenges • Strategic Objectives • Goals • Focus Areas • Care • Service • People • Finance • Growth

  16. CASCADING OBJECTIVES BHS Strategic Objective BHS Facility Strategic Objective Facility Focus Department Strategic Objective Department Focus Employee Goal Employee Focus

  17. SWOT Analysis

  18. SWOT Analysis – Care Example • Strength • New Nursing Structure • Pain Management • Weaknesses • Falls Management • Opportunities • Risk Management • Baratric Clients • Threats • QIS Survey

  19. People - Example • Strategic Challenge • BHS is challenged to attract, retain and develop highly qualified employees • Strategic Objective • To be the work community of choice • Goal • Employee Commitment at the 4.0 out a possible 5.0 • Employee Retention at 90%

  20. Strategy Deployment • Adoption of “Focus and Execute” a web-based application • Tracking of progress of Action Plans • Team • Open access • Remote management - Webinar • Continuous review of progress on Action Plans

  21. Baldrige 3.1 – Patient, Other Customer & Health Care Market Focus: (40pts) • Patient, Other Customer & Health Care Market Focus • Identify customer segments including potential customers? • Use Voice of the Customer to determine customer requirements? • Keep listen & learning method current?

  22. Baldrige 3.2 – Patient & Other Customer Relationships & Satisfaction: (45 pts) • Patient & Other Customer Relationship Building • Build relationship? • Key access mechanisms for information? • Manage patient complaints? • Patient & Other Customer Satisfaction Determination • Satisfaction & Dissatisfaction level? • Follow-up? • Competitors data?

  23. BHS Voice of the Customer Model Voice of the Customer PLAN BHS Listening and Learning Process Focus of the SDD model Key Stakeholder Relationships and Organizational Performance Results Review of the SDD model Customer Groups Residents Families CHECK/ ACT • Review customer inputs • and analyze processes • to refine VOC methods • Quarterly review of • Action plan progress • and key customer • performance measures • Review to determine customer • requirements and assess • if services, processes and • improvements are meeting • customer needs. • Translate results of analysis • into priorities for improvement Execute Of the SDD model Develop and deploy Action plans • Develop action plans • Assign responsibility • Budget • Determine measurement • improvement DO

  24. BHS Customer Service Standards • Based upon the Core Values of the organization • Behavioral expectations for all staff • Self-evaluation of performance by each employee at annual evaluation

  25. BHS Service Recovery • Service Recovery is bringing a customer back from the brink of defection – and doing so in a timely fashion to the customer’s satisfaction. • The ART of Service Recovery • A = Acknowledge • R= Resolve • T= Trend

  26. Customer Satisfaction Surveys • Nursing Facility • Newly Admitted Resident • Resident • Family – MyInnerview • Assisted Living • Resident - MyInnerview • Family- MyInnerview • Housing • Resident - MyInnerview

  27. Your questions Jeri.Reinhardt@bhshealth.org Chris.Boldt@bhshealth.org 763-689-1162

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