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Presented by:
E. E. Fibuch, MDAssoc. Dir. Medical Affairs, Medical Dir. for QualitySaint Luke’s Hospital, Kansas City, Missouri
Our Journey to Performance Excellence
Track Session DescriptionDr. Eugene Fibuch will present the experience of St. Luke’s Kansas City as they prepared for and received the coveted Malcolm Baldrige National Quality Award in the health care sector in 2003. He will explain how successful, sustained improvement requires broad organizational change that goes beyond the traditional tools of performance improvement, and how organizations can create this change.
Dr. Fibuch is Professor and Chairman of the Department of Anesthesiology at the University of Missouri at Kansas City, and is the Associate Director of Medical Affairs and Medical Director for Quality at Saint Luke’s Hospital in Kansas City, MO.
Post-Symposium AvailabilityShortly after the conclusion of the Symposium, most General Session and Track Session presentations will be available for viewing and downloading by licensed MIDAS+ clients from our Web site: www.midasplus.com. The presentations are available both in PDF and native Microsoft PowerPoint format.
Our Journey to Performance Excellence
14th Annual MIDAS+ Symposium June 2005 1Tucson, Arizona
Integrating the Baldrige Integrating the Baldrige
Management Model in Healthcare:Management Model in Healthcare:Our Journey to Performance ExcellenceOur Journey to Performance Excellence
This presentation contains information and data that is proprietary and confidential and is the sole property of Saint Luke’s Hospital.
These slides are not to be reproduced for use in any publication or promotion without the written permission of Saint Luke’s Hospital/ Saint Luke’s Health System, Kansas City, Missouri.
This presentation contains information and data that is proprietThis presentation contains information and data that is proprietary and confidential and is the sole property of Saint Luke’s Hoary and confidential and is the sole property of Saint Luke’s Hospitalspital..
These slides are not to be reproduced for use in any publicationThese slides are not to be reproduced for use in any publication or promotion without the written permission of Saint Luke’s Hosor promotion without the written permission of Saint Luke’s Hospital/ pital/ Saint Luke’s Health System, Kansas City, Missouri.Saint Luke’s Health System, Kansas City, Missouri.
E. E. Fibuch, MDProfessor and Chairman,
Department of Anesthesiology
University of Missouri-Kansas City School of Medicine
Associate Director of Medical Affairs,
Medical Director for Quality
Saint Luke’s Hospital, Kansas City, Missouri
E. E. E. E. FibuchFibuch, MD, MDProfessor and ChairmanProfessor and Chairman,,
Department of AnesthesiologyDepartment of Anesthesiology
University of MissouriUniversity of Missouri--Kansas City School of MedicineKansas City School of Medicine
Associate Director of Medical Affairs,Associate Director of Medical Affairs,
Medical Director for QualityMedical Director for Quality
Saint Luke’s Hospital, Kansas City, MissouriSaint Luke’s Hospital, Kansas City, Missouri
ACS MIDAS Symposium
2005
ACS MIDAS SymposiumACS MIDAS Symposium
20052005
ORGANIZATIONAL PROFILEORGANIZATIONAL PROFILE
Saint Luke’s HospitalSaint Luke’s HospitalKansas City, MissouriKansas City, Missouri
Where We Came From…Where We Came From…
•• Founded in 1882Founded in 1882
•• Articles of Agreement Articles of Agreement ––
dated October 3, 1882dated October 3, 1882
•• Charity care was an Charity care was an
important aspect of the important aspect of the
agreementagreement
•• New hospital was New hospital was
designated a teaching designated a teaching
institutioninstitution
Saint Luke’s HospitalSaint Luke’s Hospital
Our Journey to Performance Excellence
2 June 2005 14th Annual MIDAS+ SymposiumTucson, Arizona
Who We Are Today…Who We Are Today…
•• 590 beds590 beds
•• 3200 employees3200 employees
•• 500 physicians500 physicians
•• Not for profitNot for profit
•• Tertiary care referralTertiary care referral
•• Episcopal ChurchEpiscopal Church
•• Primary teaching hospital Primary teaching hospital –– UMKCUMKC
•• InstitutesInstitutes–– Mid America Heart InstituteMid America Heart Institute
–– Mid America Brain InstituteMid America Brain Institute
•• Centers of ExcellenceCenters of Excellence–– Level III Neonatal careLevel III Neonatal care
–– Level I Trauma CenterLevel I Trauma Center
Saint Luke’s HospitalSaint Luke’s Hospital
Part Of A Health SystemPart Of A Health System
•• 10 Hospitals10 Hospitals–– Six metropolitanSix metropolitan
–– Four ruralFour rural
•• 7000 FTE7000 FTE
•• Double ring and Hub Double ring and Hub
DesignDesign
Saint Luke’s HospitalSaint Luke’s Hospital
MissionMissionCommitted to the highest levels of Committed to the highest levels of
excellence in providing health services excellence in providing health services
to all patients in a caring to all patients in a caring
environment…dedicated to medical environment…dedicated to medical
research and education.research and education.
Saint Luke’s HospitalSaint Luke’s Hospital
Our Journey to Performance Excellence
14th Annual MIDAS+ Symposium June 2005 3Tucson, Arizona
VisionVisionThe Best Place to The Best Place to GetGet Care,Care,
The Best Place to The Best Place to GiveGive CareCare
Saint Luke’s HospitalSaint Luke’s Hospital
The Best Place to The Best Place to GetGet CareCareMost Preferred in Kansas CityMost Preferred in Kansas City
*NRC 1997, 1998, 1999, 2000, 2001, 2002, 2003, 2004*NRC 1997, 1998, 1999, 2000, 2001, 2002, 2003, 2004
Saint Luke’s HospitalSaint Luke’s Hospital
The Best Place to The Best Place to GiveGive CareCare
That is why:That is why:
•• High retentionHigh retention
•• High employee High employee
satisfactionsatisfaction
•• HighlyHighly
dedicated and dedicated and
engagedengaged
workforceworkforce
Our People Make the DifferenceOur People Make the Difference
Saint Luke’s HospitalSaint Luke’s Hospital
Our Journey to Performance Excellence
4 June 2005 14th Annual MIDAS+ SymposiumTucson, Arizona
What We Stand For…What We Stand For…
Our Core ValuesOur Core Values
•• Quality/ExcellenceQuality/Excellence
•• Customer FocusCustomer Focus
•• Resource ManagementResource Management
•• Team WorkTeam Work
Be the BestBe the Best
Identify/Analyze ProblemsIdentify/Analyze Problems
High QualityHigh Quality
Corporate ComplianceCorporate Compliance
Courtesy/RespectCourtesy/Respect
Customer SatisfactionCustomer Satisfaction
Ethics/ConfidentialityEthics/Confidentiality
Celebrate DiversityCelebrate Diversity
Cost EffectiveCost Effective
FlexibilityFlexibility
CooperationCooperation
Honest CommunicationHonest Communication
Team CultureTeam Culture
Recognize AchievementRecognize Achievement
OORRGGAANNIIZZAATTIIOONNAALL
EEXXCCEELLLLEENNCCEE
122 YearsServing Kansas City
and the Region
Saint Luke’s HospitalSaint Luke’s Hospital
Why Pursue Baldrige?Why Pursue Baldrige?Why Pursue Baldrige?
“…“…Because it’s Logical”Because it’s Logical”
•• LeadershipLeadership
•• Strategic PlanningStrategic Planning
•• Focus on Patients, Other Customers, and MarketsFocus on Patients, Other Customers, and Markets
•• Measurement, Analysis, and Knowledge Measurement, Analysis, and Knowledge
ManagementManagement
•• Staff FocusStaff Focus
•• Process ManagementProcess Management
Organizational Performance ResultsOrganizational Performance Results
•• Provides a systematic approachProvides a systematic approach
•• Aligns organizational componentsAligns organizational components
•• Requires deployment of best practicesRequires deployment of best practices
•• Requires benchmarking against the bestRequires benchmarking against the best
•• Must achieve high performanceMust achieve high performance
•• Desires sustained improvementsDesires sustained improvements
Why Did Saint Luke’s Hospital Why Did Saint Luke’s Hospital
Embrace the Baldrige Embrace the Baldrige
Management Model?Management Model?
Our Journey to Performance Excellence
14th Annual MIDAS+ Symposium June 2005 5Tucson, Arizona
PrePre--Baldrige Management ModelBaldrige Management Model•• Hierarchal governance structureHierarchal governance structure
•• NonNon-- empowered workforceempowered workforce
•• NonNon-- aligned strategic planning processaligned strategic planning process
•• Silo drivenSilo driven
•• Quality Assurance orientedQuality Assurance oriented
•• Focus on “bad apples” (audit mentality)Focus on “bad apples” (audit mentality)
•• TQM would solve everythingTQM would solve everything
•• ReRe-- engineering failureengineering failure
•• Lack of a focused metrics architecture Lack of a focused metrics architecture aligned to strategyaligned to strategy
Saint Luke’s HospitalSaint Luke’s Hospital
QuestionQuestion
Saint Luke’s HospitalSaint Luke’s Hospital
How Did Saint Luke’sHow Did Saint Luke’s
Hospital Implement the Hospital Implement the
Baldrige Management Model?Baldrige Management Model?
Begins With Leadership!Begins With Leadership!
Leadership ApproachLeadership Approach
Medical Staff/Medical Staff/AdministrativeAdministrative
PartnershipPartnership
InformationInformationSharing &Sharing &InnovationInnovation
EmpoweredEmpoweredWorkforceWorkforce
OrganizationalOrganizational
AlignmentAlignment
BaldrigeBaldrigeManagementManagementPhilosophyPhilosophy
FactFact--BasedBased
AgilityAgility
MISSIONMISSION
Saint Luke’s HospitalSaint Luke’s Hospital
Our Journey to Performance Excellence
6 June 2005 14th Annual MIDAS+ SymposiumTucson, Arizona
• Manage People
• Manage Clinical
and Administrative
Quality
• Manage Customers
• Manage Growth
and Development
• Manage Financial
Performance
• Leadership• Strategic Planning• Patient/Customer
Focus• Measurement and
KnowledgeManagement
• Staff Focus• Process Management• Results Focus
Strategic Focus Areas
Level 1 ProcessesCommitment to Excellence
Assessment Model
Balanced Scorecard PerspectivesClinical &
AdministrativeQuality
People Customer FinanceGrowth &Development
SSCC
OO
RREE
CC
AARR
DD
BB
AA
LLAA
NN
CCEE
DD
PP
MM
PP
PROCESSPROCESS SCORECARDSSCORECARDS
Strategic Planning
VISION
MISSION
CORE VALUES
STRATEGY
VERY
IMPORTANT
PRINCIPLES
Level II,
III, IV
Process
Improvement
Plans
90-Day Action PlansIndividual
DevelopmentPlans Performance
Improvement& Innovation
KnowledgeSharing
Saint Luke’s HospitalSaint Luke’s Hospital
SLH Leadership forSLH Leadership forPerformance Excellence ModelPerformance Excellence Model
Examples of Leadership Approach…Examples of Leadership Approach…
Saint Luke’s HospitalSaint Luke’s Hospital
•• CollaborationCollaboration
–– Medical staff and administration coMedical staff and administration co--leaders of leaders of
Balanced Scorecard (BSC)Balanced Scorecard (BSC)
•• EmpowermentEmpowerment
–– Nursing shared governanceNursing shared governance
•• Information SharingInformation Sharing
–– Focused retreatsFocused retreats
•• Organizational AlignmentOrganizational Alignment
–– Strategy, Balanced Scorecard, 90Strategy, Balanced Scorecard, 90--day action plans, day action plans,
Performance Management Process (PMP)Performance Management Process (PMP)
MBNQAMBNQAMalcolm Baldrige National Quality Award RecipientMalcolm Baldrige National Quality Award Recipient
Governor of MissouriGovernor of MissouriMissouri Team Quality Award Missouri Team Quality Award –– Extreme Neuro TeamExtreme Neuro Team
Missouri Quality AwardMissouri Quality AwardBand 6 Band 6 ––Baldrige AssessmentBaldrige Assessment
Kansas City Business JournalKansas City Business JournalBest Place to Work for DiversityBest Place to Work for Diversity
Moody’sMoody’sA+ Bond RatingA+ Bond Rating
Standard and Poor’sStandard and Poor’sAA--1 Bond Rating1 Bond Rating
Ingram’s MagazineIngram’s MagazineBest Hospital in Kansas City Best Hospital in Kansas City –– Gold AwardGold Award
Am Soc of Health System PharmacistsAm Soc of Health System PharmacistsASHP Best Practices Award in Health System PharmacyASHP Best Practices Award in Health System Pharmacy
HRMAHRMAParagon Award for Best HR Practices in KC Metro AreaParagon Award for Best HR Practices in KC Metro Area
Hospitals and Health NetworksHospitals and Health Networks100 Most Wired in Nation100 Most Wired in Nation
NRCNRC2003 Consumer Preference Award2003 Consumer Preference Award
SponsorSponsor2003 Awards/Recognitions2003 Awards/Recognitions
Dept of Health and Human ServicesDept of Health and Human ServicesOrgan Donation Breakthrough Collaborative Organ Donation Breakthrough Collaborative –– 75% conversion75% conversion
Women’s Day MagazineWomen’s Day MagazineRed Dress AwardRed Dress Award
IDG’sIDG’s ComputerworldComputerworldBest Places to Work in Information TechnologyBest Places to Work in Information Technology
American Nurses Credentialing CenterAmerican Nurses Credentialing CenterMagnet Recognition Award for Excellence in Nursing ServiceMagnet Recognition Award for Excellence in Nursing Service
ASHPASHPBest Practices AwardBest Practices Award
NRCNRC2004 Consumer Preference Award2004 Consumer Preference Award
VHAVHAClinical Excellence in Cardiac CareClinical Excellence in Cardiac Care
Hospitals and Health NetworksHospitals and Health Networks100 Most Wired in Nation100 Most Wired in Nation
JCAHOJCAHODiseaseDisease--Specific Gold Seal of Approval, Stroke CareSpecific Gold Seal of Approval, Stroke Care
SponsorSponsor2004 Awards/Recognitions2004 Awards/Recognitions
Our Journey to Performance Excellence
14th Annual MIDAS+ Symposium June 2005 7Tucson, Arizona
SLH Leadership for Performance Excellence ModelSLH Leadership for Performance Excellence Model
Saint Luke’s HospitalSaint Luke’s Hospital
Strategy Development ProcessStrategy Development Process
• Manage People
• Manage Clinical
and Administrative
Quality
• Manage Customers
• Manage Growth
and Development
• Manage Financial
Performance
• Leadership• Strategic Planning• Patient/Customer
Focus• Measurement and
KnowledgeManagement
• Staff Focus• Process Management• Results Focus
Level 1 ProcessesCommitment to Excellence
Assessment Model
Balanced Scorecard PerspectivesClinical &
AdministrativeQuality
People Customer FinanceGrowth &Development
SSCC
OO
RREE
CC
AARR
DD
BB
AA
LLAA
NN
CCEE
DD
PP
MM
PP
PROCESSPROCESS SCORECARDSSCORECARDS
STRATEGIC PLANNING
VISION
MISSION
CORE VALUES
STRATEGY
VERY
IMPORTANT
PRINCIPLES
Level II,
III, IV
Process
Improvement
Plans
90-Day Action PlansIndividual
DevelopmentPlans Performance
Improvement& Innovation
KnowledgeSharing
STRATEGIC FOCUS AREAS
DEVELOP
DEPLOY
MANAGE
Develop the PlanDevelop the Plan
••Clinical & Administrative Clinical & Administrative Quality RetreatQuality Retreat
••Customer Focus GroupsCustomer Focus Groups
••Product Line ConferenceProduct Line Conference
••Growth & Financial RetreatGrowth & Financial Retreat
••Capital Budget ProcessCapital Budget Process
••Operating Budget ProcessOperating Budget Process
••HR Planning ProcessHR Planning Process
••System PlanSystem Plan
••Med Staff Development PlanMed Staff Development Plan
••Risk AssessmentRisk Assessment
••SFA ValidationSFA Validation
••Customer RetreatCustomer Retreat
••People RetreatPeople Retreat
••Environmental AssessmentEnvironmental Assessment
••Mission, Vision, ValuesMission, Vision, Values
STEP 4 STEP 4 –– BALANCE BALANCE CUSTOMER NEEDSCUSTOMER NEEDS
STEP 3 STEP 3 –– ALLOCATEALLOCATERESOURCESRESOURCES
STEP 2 STEP 2 –– DEVELOP DEVELOP SAS’sSAS’s && SAP’sSAP’s
STEP 1 STEP 1 –– DEVELOP DEVELOP SIGNIFICANT ISSUESSIGNIFICANT ISSUES
•• 9090--Day Action Planning Process Day Action Planning Process
•• Performance Management ProcessPerformance Management Process
•• Finalize BudgetsFinalize Budgets
•• Board ApprovalBoard Approval
•• Reset BSCReset BSC
•• Deployment RetreatDeployment Retreat
STEP 6 STEP 6 –– CREATE ALIGNMENTCREATE ALIGNMENTSTEP 5 STEP 5 –– FINALIZE AND APPROVEFINALIZE AND APPROVE
•• BSC ReviewsBSC Reviews
•• 9090--Day Process ReviewsDay Process Reviews
•• BSC Department Report FormBSC Department Report Form
STEP 7 STEP 7 –– REVIEW PROCESSREVIEW PROCESS
Saint Luke’s HospitalSaint Luke’s Hospital
Strategy Development ProcessStrategy Development Process
Example of SFA, SAS, SAP and Related MeasuresExample of SFA, SAS, SAP and Related Measures
Saint Luke’s HospitalSaint Luke’s Hospital
Strategy DeploymentStrategy Deployment
• Profitable eligible
IP market share
• Facilitate increased
surgical volume
• Increase profitable
market share
Growth and
Development
• Total Margin• Improve processes related
to payment denials
• Assure financial
stabilityFinancial
•• Infection Control Infection Control
IndexIndex
•• Refine and implement Refine and implement
critical care best practicescritical care best practices
•• Improve patient Improve patient
safetysafety
Clinical and Clinical and
Administrative Administrative
QualityQuality
• Employee
Retention Rate
• Employ systematic
approach to employee
education
• Assure workforce
availabilityPeople
•• Admitting Wait Admitting Wait
TimeTime
•• Deploy targeted IP & OR Deploy targeted IP & OR
capacity enhancement capacity enhancement
strategiesstrategies
•• Improve customer Improve customer
satisfactionsatisfactionCustomerCustomer
SAPSAP MeasuresMeasuresSASSASSFASFA
Our Journey to Performance Excellence
8 June 2005 14th Annual MIDAS+ SymposiumTucson, Arizona
BETTER
Saint Luke’s HospitalSaint Luke’s Hospital
SLH RetentionSLH Retention
75
80
85
90
1998 1999 2000 2001 2002 2003 2004
%
SLH Saratoga Institute
Example of SFA, SAS, SAP and Related MeasuresExample of SFA, SAS, SAP and Related Measures
Saint Luke’s HospitalSaint Luke’s Hospital
Strategy DeploymentStrategy Deployment
• Profitable eligible
IP market share
• Facilitate increased surgical
volume
• Increase
profitable market
share
Growth and
Development
• Total Margin• Improve processes related to
payment denials
• Assure financial
stabilityFinancial
• Infection Control
Index
• Refine and implement
critical care best practices
• Improve patient
safety
Clinical and
Administrative
Quality
•• Employee Employee
Retention RateRetention Rate
•• Employ systematic approach Employ systematic approach
to employee educationto employee education
•• Assure Assure
workforce workforce
availabilityavailability
PeoplePeople
•• Admitting Wait Admitting Wait
TimeTime
•• Deploy targeted IP & OR Deploy targeted IP & OR
capacity enhancement capacity enhancement
strategiesstrategies
•• Improve Improve
customer customer
satisfactionsatisfaction
CustomerCustomer
SAPSAP MeasuresMeasuresSASSASSFASFA
0
1
2
3
4
1998 1999 2000 2001 2002 2003 2004
Perc
en
t
SLH NNISBETTERBETTER
††Index modified for 2 of the 10 measures 01Index modified for 2 of the 10 measures 01--0303
†
Saint Luke’s HospitalSaint Luke’s Hospital
Infection Rate IndexInfection Rate Index
10 Measures of Infection
Our Journey to Performance Excellence
14th Annual MIDAS+ Symposium June 2005 9Tucson, Arizona
Example of SFA, SAS, SAP and Related MeasuresExample of SFA, SAS, SAP and Related Measures
Saint Luke’s HospitalSaint Luke’s Hospital
Strategy DeploymentStrategy Deployment
• Profitable eligible
IP market share
• Facilitate increased surgical
volume
• Increase
profitable market
share
Growth and
Development
• Total Margin• Improve processes related to
payment denials
• Assure financial
stabilityFinancial
•• Infection Control Infection Control
IndexIndex
•• Refine and implement Refine and implement
critical care best practicescritical care best practices
•• Improve patient Improve patient
safetysafety
Clinical and Clinical and
Administrative Administrative
QualityQuality
•• Employee Employee
Retention RateRetention Rate
•• Employ systematic approach Employ systematic approach
to employee educationto employee education
•• Assure Assure
workforce workforce
availabilityavailability
PeoplePeople
• Admitting Wait
Time
• Deploy targeted IP & OR
capacity enhancement
strategies
• Improve
customer
satisfaction
Customer
SAPSAP MeasuresMeasuresSASSASSFASFA
0
1
2
3
4
5
6
IP OP
Patient Type
Min
ute
s
2001 2002
2003 2004BETTERBETTER
Saint Luke’s HospitalSaint Luke’s Hospital
Admitting Wait TimeAdmitting Wait Time
Example of SFA, SAS, SAP and Related MeasuresExample of SFA, SAS, SAP and Related Measures
Saint Luke’s HospitalSaint Luke’s Hospital
Strategy DeploymentStrategy Deployment
• Profitable eligible
IP market share
• Facilitate increased surgical
volume
• Increase
profitable market
share
Growth and
Development
• Total Margin• Improve processes related to
payment denials
• Assure financial
stabilityFinancial
•• Infection Control Infection Control
IndexIndex
•• Refine and implement Refine and implement
critical care best practicescritical care best practices
•• Improve patient Improve patient
safetysafety
Clinical and Clinical and
Administrative Administrative
QualityQuality
•• Employee Employee
Retention RateRetention Rate
•• Employ systematic approach Employ systematic approach
to employee educationto employee education
•• Assure Assure
workforce workforce
availabilityavailability
PeoplePeople
•• Admitting Wait Admitting Wait
TimeTime
•• Deploy targeted IP & OR Deploy targeted IP & OR
capacity enhancement capacity enhancement
strategiesstrategies
•• Improve Improve
customer customer
satisfactionsatisfaction
CustomerCustomer
SAPSAP MeasuresMeasuresSASSASSFASFA
Our Journey to Performance Excellence
10 June 2005 14th Annual MIDAS+ SymposiumTucson, Arizona
BETTER
Saint Luke’s HospitalSaint Luke’s Hospital
Profitable Market ShareProfitable Market Share
6.00%
6.50%
7.00%
7.50%
8.00%
8.50%
9.00%
1Q
02
2Q
02
3Q
02
4Q
02
1Q
03
2Q
03
3Q
03
4Q
03
1Q
04
2Q
04
3Q
04
4Q
04
Example of SFA, SAS, SAP and Related MeasuresExample of SFA, SAS, SAP and Related Measures
Saint Luke’s HospitalSaint Luke’s Hospital
Strategy DeploymentStrategy Deployment
• Profitable eligible
IP market share
• Facilitate increased surgical
volume
• Increase
profitable market
share
Growth and
Development
• Total Margin• Improve processes related to
payment denials
• Assure financial
stabilityFinancial
•• Infection Control Infection Control
IndexIndex
•• Refine and implement Refine and implement
critical care best practicescritical care best practices
•• Improve patient Improve patient
safetysafety
Clinical and Clinical and
Administrative Administrative
QualityQuality
•• Employee Employee
Retention RateRetention Rate
•• Employ systematic approach Employ systematic approach
to employee educationto employee education
•• Assure Assure
workforce workforce
availabilityavailability
PeoplePeople
•• Admitting Wait Admitting Wait
TimeTime
•• Deploy targeted IP & OR Deploy targeted IP & OR
capacity enhancement capacity enhancement
strategiesstrategies
•• Improve Improve
customer customer
satisfactionsatisfaction
CustomerCustomer
SAPSAP MeasuresMeasuresSASSASSFASFA
0
2
4
6
8
10
12
14
16
18
1999 2000 2001 2002 2003 2004
%
SLH
COTH Top Quartile
A BondBETTER
*SLH data represents best 5% of comparative group
*
Saint Luke’s HospitalSaint Luke’s Hospital
Total MarginTotal Margin
Our Journey to Performance Excellence
14th Annual MIDAS+ Symposium June 2005 11Tucson, Arizona
SLH Leadership for Performance Excellence ModelSLH Leadership for Performance Excellence Model
• Manage People
• Manage Clinical
and Administrative
Quality
•• Manage CustomersManage Customers
• Manage Growth
and Development
• Manage Financial
Performance
• Leadership• Strategic Planning
•• Patient/CustomerPatient/CustomerFocusFocus
• Measurement andKnowledgeManagement
• Staff Focus• Process Management• Results Focus
Strategic Focus Areas
Level 1 ProcessesCommitment to Excellence
Assessment Model
Balanced Scorecard PerspectivesClinical &
AdministrativeQuality
People CustomerCustomer FinanceGrowth &Development
SSCC
OO
RREE
CC
AARR
DD
BB
AA
LLAA
NN
CCEE
DD
PP
MM
PP
PROCESSPROCESS SCORECARDSSCORECARDS
Strategic Planning
VISION
MISSION
CORE VALUES
STRATEGY
VERY
IMPORTANT
PRINCIPLES
Level II,
III, IV
Process
Improvement
Plans
90-Day Action PlansIndividual
DevelopmentPlans Performance
Improvement& Innovation
KnowledgeSharing
Saint Luke’s HospitalSaint Luke’s Hospital
Focus on Patients and Other MarketsFocus on Patients and Other Markets
•• Patients and familiesPatients and families
•• Residents and studentsResidents and students
•• Physicians viewed as partnersPhysicians viewed as partners
CustomersCustomers
Saint Luke’s HospitalSaint Luke’s Hospital
Key Patient RequirementsKey Patient Requirements
Saint Luke’s HospitalSaint Luke’s Hospital
•• ReliabilityReliability
•• AccessAccess
•• ResponsivenessResponsiveness
•• EmpathyEmpathy
•• CompetencyCompetency
Our Journey to Performance Excellence
12 June 2005 14th Annual MIDAS+ SymposiumTucson, Arizona
Key Patient SatisfiersKey Patient Satisfiers
Saint Luke’s HospitalSaint Luke’s Hospital
•• Wait time Wait time
•• Outcome of careOutcome of care
•• Responsiveness to complaintsResponsiveness to complaints
•• Significant indicatorsSignificant indicators
Relationship BuildingRelationship Building
Saint Luke’s HospitalSaint Luke’s Hospital
•• Employee use of Very Employee use of Very
Important PrinciplesImportant Principles
•• Produce patient loyalty Produce patient loyalty
through personalizing the through personalizing the
delivery of caredelivery of care
•• Centers of excellenceCenters of excellence
Saint Luke’s HospitalSaint Luke’s Hospital
Very Important PrinciplesVery Important Principles
Our Journey to Performance Excellence
14th Annual MIDAS+ Symposium June 2005 13Tucson, Arizona
Market Segmentation ProcessMarket Segmentation Process
Saint Luke’s HospitalSaint Luke’s Hospital
SurveysSurveys
PAPA
AOCAOC
Focus Focus
GroupsGroups
ExternalExternal
DatabaseDatabase
InternalInternal
DatabaseDatabase
NurseLineNurseLine
Complaint Complaint
ManagementManagement
OtherOther
D
A
T
A
S
O
U
R
C
E
RESEARCH
PROCESS
Research and Analysis DepartmentResearch and Analysis Department
External DataExternal Data Internal DataInternal Data
Listening / Learning StrategiesListening / Learning Strategies
FormalFormal InformalInformal
Qualitative & Quantitative Research ToolsQualitative & Quantitative Research Tools
ENVIRONMENTAL ANALYSIS DOCUMENT
Market Segmentation ProcessMarket Segmentation Process
Saint Luke’s HospitalSaint Luke’s Hospital
Different Different
Needs Needs
Emerging?Emerging?
Different Different
Key Satisfiers Key Satisfiers
Emerging?Emerging?
Different Different
Segmentation Segmentation
and Value?and Value?
QUESTIONS
ASKED
PLANNING
PROCESS
Environmental AnalysisEnvironmental Analysis
SLH LeadershipSLH Leadership SLHS LeadershipSLHS Leadership
Leadership RetreatsLeadership Retreats
Segmentation of CustomersSegmentation of Customers
Determination is MadeDetermination is Made
TOOLSTOOLS METHODSMETHODS CORECOREQUESTIONSQUESTIONS RESULTSRESULTSGUIDINGGUIDING
PRINCIPLESPRINCIPLES TOOLSTOOLS METHODSMETHODS CORECOREQUESTIONSQUESTIONS RESULTSRESULTSGUIDINGGUIDING
PRINCIPLESPRINCIPLES
Achieve survey consistency among research Achieve survey consistency among research
toolstools
Identify satisfaction benchmarks for Identify satisfaction benchmarks for
comparisonscomparisons
Report satisfaction trends over timeReport satisfaction trends over time
Recommend viable alternatives to improve Recommend viable alternatives to improve
service personnel or operationsservice personnel or operations
Saint Luke’s HospitalSaint Luke’s Hospital
Customer SatisfactionCustomer SatisfactionResearch ProgramResearch Program
TOOLSTOOLS METHODSMETHODS CORECOREQUESTIONSQUESTIONS RESULTSRESULTSGUIDINGGUIDING
PRINCIPLESPRINCIPLES
Our Journey to Performance Excellence
14 June 2005 14th Annual MIDAS+ SymposiumTucson, Arizona
PressPress GaneyGaney survey tool (weekly, quarterly)survey tool (weekly, quarterly)
Admitting/referring physician survey (annual)Admitting/referring physician survey (annual)
Resident/Student survey (annual)Resident/Student survey (annual)
BaldrigeBaldrige-- based employee survey (annual)based employee survey (annual)
Focus groups (semiFocus groups (semi-- annual)annual)
PostPost-- discharge phone callsdischarge phone calls
TOOLSTOOLS METHODSMETHODS CORECOREQUESTIONSQUESTIONS RESULTSRESULTSGUIDINGGUIDING
PRINCIPLESPRINCIPLES
Saint Luke’s HospitalSaint Luke’s Hospital
Customer SatisfactionCustomer SatisfactionResearch ProgramResearch Program
Measure overall satisfaction, outcome and perceptionMeasure overall satisfaction, outcome and perception
Strict statistical samplingStrict statistical sampling
55--point point LikertLikert scalescale
Segmented by key customer requirementsSegmented by key customer requirements
Statistical trending and regression analysisStatistical trending and regression analysis
Tabulated and distributed weekly (patients)Tabulated and distributed weekly (patients)
Formally trended and reported quarterly (patients)Formally trended and reported quarterly (patients)
TOOLSTOOLS METHODSMETHODS CORECOREQUESTIONSQUESTIONS RESULTSRESULTSGUIDINGGUIDING
PRINCIPLESPRINCIPLES
Saint Luke’s HospitalSaint Luke’s Hospital
Customer SatisfactionCustomer SatisfactionResearch ProgramResearch Program
What is your overall satisfaction?What is your overall satisfaction?
Would you recommend SLH to your friends Would you recommend SLH to your friends
and family?and family?
Do you have any suggestions for Do you have any suggestions for
improvement?improvement?
TOOLSTOOLS METHODSMETHODS CORECOREQUESTIONSQUESTIONS RESULTSRESULTSGUIDINGGUIDING
PRINCIPLESPRINCIPLES
Saint Luke’s HospitalSaint Luke’s Hospital
Customer SatisfactionCustomer SatisfactionResearch ProgramResearch Program
Our Journey to Performance Excellence
14th Annual MIDAS+ Symposium June 2005 15Tucson, Arizona
NRC Perception Rankings vs. Top CompetitorsNRC Perception Rankings vs. Top Competitors
11
33
22
88
66
1010
1515
20042004
11
33
44
77
22
1010
1717
20042004
11
22
33
55
44
1515
1414
20042004
11
22
33
66
55
88
1616
20022002
11
44
33
55
22
66
1515
20022002
11
22
44
77
55
88
1616
20022002
Best NursesBest NursesBest DoctorsBest DoctorsOverall QualityOverall Quality
11
22
33
55
66
1313
1515
11
33
22
88
66
1010
1515
11
33
55
66
22
1212
1515
11
33
44
77
22
1010
1717
11
22
33
55
44
1313
1212
11
22
33
66
55
1515
1414
SLHSLH
BB
CC
DD
EE
FF
GG
200120012003200320012001200320032001200120032003HospitalHospital
TOOLSTOOLS METHODSMETHODS CORECOREQUESTIONSQUESTIONS RESULTSRESULTS
GUIDINGGUIDINGPRINCIPLESPRINCIPLES
Saint Luke’s HospitalSaint Luke’s Hospital
Customer SatisfactionCustomer SatisfactionResearch ProgramResearch Program
75
80
85
90
95
100
1999 2000 2001 2002 2003 2004
%
IP OP ED
Patient SatisfactionPatient Satisfaction
TOOLSTOOLS METHODSMETHODS CORECOREQUESTIONSQUESTIONS RESULTSRESULTS
GUIDINGGUIDINGPRINCIPLESPRINCIPLES
BETTERBETTER
Saint Luke’s HospitalSaint Luke’s Hospital
Customer SatisfactionCustomer SatisfactionResearch ProgramResearch Program
FiveFive--ByBy--FiveFive
Saint Luke’s HospitalSaint Luke’s Hospital
Customer SatisfactionCustomer SatisfactionResearch ProgramResearch Program
RESULTSRESULTSCORE CORE
QUESTIONSQUESTIONSMETHODSMETHODSTOOLSTOOLS
GUIDING GUIDING
PRINCIPLESPRINCIPLES
30
35
40
45
50
55
60
65
70
75
1Q
02
2Q
02
3Q
02
4Q
02
1Q
03
2Q
03
3Q
03
4Q
03
1Q
04
2Q
04
3Q
04
4Q
04
IP
OP
ED
BETTERBETTER
Our Journey to Performance Excellence
16 June 2005 14th Annual MIDAS+ SymposiumTucson, Arizona
Saint Luke’s HospitalSaint Luke’s Hospital
Educational Benchmark DataEducational Benchmark Data
College of NursingCollege of Nursing
6.1
6.5
6.3
6.6
6.5
6.7
6.0
5.6
6.2
6.1
5.7
2002
5.35.35.45.4Overall SatisfactionOverall Satisfaction
6.26.2Role DevelopmentRole Development
6.05.85.8Core KnowledgeCore Knowledge
6.36.3Technical SkillsTechnical Skills
6.36.2Core CompetenciesCore Competencies
6.36.4Professional ValuesProfessional Values
5.95.75.7ClassmatesClassmates
5.45.05.0Facilities and AdministrationFacilities and Administration
5.85.45.4Course Lecture and InteractionCourse Lecture and Interaction
5.75.45.4Work and Class SizeWork and Class Size
5.25.24.94.9Quality of InstructionQuality of Instruction
2004200420032003Mean SLH ScoreMean SLH Score
Yellow highlighted boxes are for categories in the upper quartile nationally.
SLH Leadership for Performance Excellence ModelSLH Leadership for Performance Excellence Model
• Manage People
• Manage Clinical
and Administrative
Quality
• Manage Customers
• Manage Growth
and Development
• Manage Financial
Performance
• Leadership• Strategic Planning• Patient/Customer
Focus• Measurement and
KnowledgeManagement
• Staff Focus• Process Management• Results Focus
Strategic Focus Areas
Level 1 ProcessesCommitment to Excellence
Assessment Model
Balanced Scorecard PerspectivesClinical &
AdministrativeQuality
PeoplePeople Customer FinanceGrowth &Development
SSCC
OO
RREE
CC
AARR
DD
BB
AA
LLAA
NN
CCEE
DD
PP
MM
PP
PROCESS SCORECARDS
Strategic Planning
VISION
MISSION
CORE VALUES
STRATEGY
VERY
IMPORTANT
PRINCIPLES
Level II,
III, IV
Process
Improvement
Plans
90-Day Action PlansIndividual
DevelopmentPlans Performance
Improvement& Innovation
KnowledgeSharing
Saint Luke’s HospitalSaint Luke’s Hospital
Measurement AnalysisMeasurement Analysis
•• ee-- PortalsPortals
•• Executive Information Systems and Executive Information Systems and
Decision Support SystemsDecision Support Systems
•• Administrative and Financial SystemsAdministrative and Financial Systems
• Clinical Information Systems
Information Technology’s Systems ArchitectureInformation Technology’s Systems Architecture
Data and Information AvailabilityData and Information Availability
Saint Luke’s HospitalSaint Luke’s Hospital
Our Journey to Performance Excellence
14th Annual MIDAS+ Symposium June 2005 17Tucson, Arizona
Information Technology’s Systems Architecture
Data and Information Availability
Saint Luke’s Hospital
• Security policies
• Signed confidentiality agreements
• Strong computer passwords
• State of the art firewalls
• Daily tape backup
• Mission-critical hourly backup
• Off-site underground storage
• Data access maintained 24x7
for employees, physicians, partners, suppliers
Data Security and Access
Data and Information Availability
Saint Luke’s Hospital
Growth
& Development
How do we continue to
improve and create value?
Customer
Satisfaction
Financial
Clinical &Administrative
Quality
People
Plan Design Measure Assess Improve
SLHS Service Design, Management & Improvement Model
How do customers
see us?
How do we look to
financial stakeholders?
In what must
we excel?
How do we ensure a committed
and prepared workforce?
Mission
Vision
Values
Strategy
Saint Luke’s Hospital
Our Journey to Performance Excellence
18 June 2005 14th Annual MIDAS+ SymposiumTucson, Arizona
Comparative/Benchmark Data SourcesComparative/Benchmark Data Sources
Saint Luke’s HospitalSaint Luke’s Hospital
•• Process OutcomesProcess OutcomesCEO Workgroup CEO Workgroup –– VHAVHA
•• Consumer PerceptionConsumer PerceptionNational Research CorporationNational Research Corporation
•• Patient SatisfactionPatient SatisfactionPressPress GaneyGaney
•• HR PerformanceHR PerformanceSaratoga InstituteSaratoga Institute
•• FinancialFinancialMoody, Standard & Poor, FitchMoody, Standard & Poor, Fitch
•• FinancialFinancialCHIPSCHIPS
•• Operations and FinancialOperations and FinancialSolucientSolucient--ACTIONACTION
•• Clinical, Operational, Financial & Clinical, Operational, Financial & MiscMiscNational/State Quality Award RecipientNational/State Quality Award Recipient
•• ClinicalClinicalHEDISHEDIS
•• ClinicalClinicalVHA VHA GreenlightGreenlight ProjectProject
•• ClinicalClinicalMaryland Quality Indicator ProjectMaryland Quality Indicator Project
Data TypeData TypeSourceSource
Performance MeasurementPerformance Measurement
InternalInternal
CustomerCustomer
FinancialFinancial
Learning &Learning &
InnovationInnovationVision & StrategyVision & Strategy
Kaplan & Norton Model
Saint Luke's Health System
Model
Clinical & Clinical &
Administrative QualityAdministrative Quality
Customer Customer
SatisfactionSatisfaction
FinancialFinancial
GrowthGrowth
& Development& Development
PeoplePeopleVision & StrategyVision & Strategy
Saint Luke’s Hospital
Performance MeasurementPerformance Measurement
Saint Luke’s HospitalSaint Luke’s Hospital
•• Primary measurement toolPrimary measurement tool
Balanced ScorecardBalanced Scorecard
•• 5 perspectives5 perspectives
•• Key measures linked to Key measures linked to strategystrategy
•• Scoring criteria set by Scoring criteria set by statistical methods and statistical methods and benchmarksbenchmarks
•• Tracks overall organization Tracks overall organization performanceperformance
•• Provides organizational Provides organizational alignmentalignment
Our Journey to Performance Excellence
14th Annual MIDAS+ Symposium June 2005 19Tucson, Arizona
Building Trend ChartsScoring Zones, Benchmarks, Stretch Targets, Trend Analysis
Net Days in Accounts Receivables
(IP; OP)
30405060708090
100110120
199
8
99Q
1
99Q
2
99Q
3
99Q
4
00Q
1
00Q
2
00Q
3
00Q
4
Ave
rag
e D
ays Annual Goal
Risk
Immediate
Action
Required
Moderate Risk
Needs
Improvement
Stretch
Target
Current
Performance
Current
Performance
Saint Luke’s Hospital
Balanced Scorecard Trend ChartsBalanced Scorecard Trend ChartsPerformance MeasurementPerformance Measurement
Saint Luke’s HospitalSaint Luke’s Hospital
Days Cash on Hand
125
175
225
275
325
375
425
19
98
99
Q2
99
Q4
00
Q2
00
Q4
01
Q2
01
Q4
02
Q2
02
Q4
03
Q2
03
Q4
04
Q2
04
Q4
Avera
ge D
ays
Longer than Expected
Wait Time (IP; OP; ED)0%
5%
10%
15%
20%
25%
19
98
99Q
2
99Q
4
00Q
2
00Q
4
01Q
2
01Q
4
02Q
2
02Q
4
03Q
2
03Q
4
04Q
2
04Q
4
% N
ot
Me
eti
ng
Exp
ecta
tio
n
Eligible IP Market Share
7%
8%
9%
10%
02
Q1
02
Q2
02
Q3
02
Q4
03
Q1
03
Q2
03
Q3
03
Q4
04
Q1
04
Q2
04
Q3
04
Q4P
erc
en
t E
lig
ible
Mark
et
Sh
are
Maryland Quality Indicator
Index
0
2
4
6
8
10
19
98
99Q
2
99Q
4
00Q
2
00Q
4
01Q
2
01Q
4
02Q
2
02Q
4
03Q
2
03Q
4
04Q
2
04Q
4
Av
era
ge S
co
re
Human Capital Value
Added
$40,000
$50,000
$60,000
$70,000
$80,000
$90,000
$100,000
19
98
99
Q2
99
Q4
00
Q2
00
Q4
01
Q2
01
Q4
02
Q2
02
Q4
03
Q2
03
Q4
04
Q2
04
Q4
Ne
t R
even
ue A
dd
ed
/
FT
E
Clinical & Administrative Clinical & Administrative Quality PerspectiveQuality Perspective
•• Inpatient Clinical Care IndexInpatient Clinical Care Index
•• Outpatient Clinical Care IndexOutpatient Clinical Care Index
•• Patient Safety IndexPatient Safety Index
•• Operational IndexOperational Index
•• Maryland Quality Indicator IndexMaryland Quality Indicator Index
•• Infection Control IndexInfection Control Index
•• Medical Staff Clinical Indicator IndexMedical Staff Clinical Indicator Index
•• Net Days in Accounts ReceivableNet Days in Accounts Receivable
Saint Luke’s HospitalSaint Luke’s Hospital
Our Journey to Performance Excellence
20 June 2005 14th Annual MIDAS+ SymposiumTucson, Arizona
Medical Staff Clinical Indicator IndexMedical Staff Clinical Indicator Index
Saint Luke’s HospitalSaint Luke’s Hospital
Knowledge SharingKnowledge Sharing
•• ReportsReports
•• RetreatsRetreats
•• Story BoardsStory Boards
•• CMECME
•• PublicationsPublications
•• EE--mailmail
•• CommitteesCommittees
•• Best PracticesBest Practices
Sharing DaySharing Day
SLH Leadership for Performance Excellence ModelSLH Leadership for Performance Excellence Model
Organizational KnowledgeOrganizational Knowledge
Saint Luke’s HospitalSaint Luke’s Hospital
• Manage People
• Manage Clinical
and Administrative
Quality
• Manage Customers
• Manage Growth
and Development
• Manage Financial
Performance
• Leadership• Strategic Planning• Patient/Customer
Focus• Measurement and
KnowledgeManagement
• Staff Focus• Process Management• Results Focus
Strategic Focus Areas
Level 1 ProcessesCommitment to Excellence
Assessment Model
Balanced Scorecard PerspectivesClinical &
AdministrativeQuality
People Customer FinanceGrowth &Development
SSCCOO
RR
EECC
AARR
DD
BB
AALL
AA
NNCCEE
DD
PP
MM
PP
PROCESSPROCESS SCORECARDSSCORECARDS
Strategic Planning
VISION
MISSION
CORE VALUES
STRATEGY
VERY
IMPORTANT
PRINCIPLES
Level II,
III, IV
Process
Improvement
Plans
90-Day Action PlansIndividual
DevelopmentPlans Performance
Improvement& Innovation
KnowledgeSharing
• Manage People
• Manage Clinical
and Administrative
Quality
• Manage Customers
• Manage Growth
and Development
• Manage Financial
Performance
• Leadership• Strategic Planning• Patient/Customer
Focus• Measurement and
KnowledgeManagement
• Staff Focus• Process Management• Results Focus
Strategic Focus Areas
Level 1 ProcessesCommitment to Excellence
Assessment Model
Balanced Scorecard PerspectivesClinical &
AdministrativeQuality
People Customer FinanceGrowth &Development
SSCCOO
RR
EECC
AARR
DD
BB
AALL
AA
NNCCEE
DD
PP
MM
PP
PROCESSPROCESS SCORECARDSSCORECARDS
Strategic Planning
VISION
MISSION
CORE VALUES
STRATEGY
VERY
IMPORTANT
PRINCIPLES
Level II,
III, IV
Process
Improvement
Plans
90-Day Action PlansIndividual
DevelopmentPlans Performance
Improvement& Innovation
KnowledgeSharing
SLH Leadership for Performance Excellence ModelSLH Leadership for Performance Excellence Model
•• Manage PeopleManage People• Manage Clinical
and Administrative
Quality
• Manage Customers
• Manage Growth
and Development
• Manage Financial
Performance
• Leadership• Strategic Planning• Patient/Customer
Focus• Measurement and
KnowledgeManagement
•• Staff FocusStaff Focus• Process Management• Results Focus
Strategic Focus Areas
Level 1 ProcessesCommitment to Excellence
Assessment Model
Balanced Scorecard PerspectivesClinical &
AdministrativeQuality
People Customer FinanceGrowth &Development
SSCC
OO
RREE
CC
AARR
DD
BB
AA
LLAA
NN
CCEE
DD
PP
MM
PP
PROCESSPROCESS SCORECARDSSCORECARDS
Strategic Planning
VISION
MISSION
CORE VALUES
STRATEGY
VERY
IMPORTANT
PRINCIPLES
Level II,
III, IV
Process
Improvement
Plans
90-Day Action PlansIndividual
DevelopmentPlans Performance
Improvement& Innovation
KnowledgeSharing
Saint Luke’s HospitalSaint Luke’s Hospital
Staff FocusStaff Focus
Our Journey to Performance Excellence
14th Annual MIDAS+ Symposium June 2005 21Tucson, Arizona
•• Quality/Excellence:Quality/Excellence:“Tell me about a creative idea or change you’ve “Tell me about a creative idea or change you’ve
successfully put to work in a recent assignment.”successfully put to work in a recent assignment.”
•• Resource Management:Resource Management:“Tell me about a time you were assigned several “Tell me about a time you were assigned several
important projects at the same time. How did you important projects at the same time. How did you
go about setting priorities?”go about setting priorities?”
BehaviorBehavior--Based InterviewsBased Interviews
by Core Valueby Core Value
Saint Luke’s HospitalSaint Luke’s Hospital
•• Customer Focus:Customer Focus:“Tell me about a time you had to deal with an “Tell me about a time you had to deal with an
upset patient.”upset patient.”
•• Teamwork:Teamwork:“Tell me about a time when you had to get “Tell me about a time when you had to get
cooperation from other departments to cooperation from other departments to
accomplish a certain task.”accomplish a certain task.”
BehaviorBehavior--Based InterviewsBased Interviews
by Core Valueby Core Value
Saint Luke’s HospitalSaint Luke’s Hospital
•• Shared BehaviorsShared Behaviors::“What is expected of me as an “What is expected of me as an
employee of Saint Luke’s Health employee of Saint Luke’s Health
System?”System?”
•• Job Specific AccountabilitiesJob Specific Accountabilities::“What am I accountable for because “What am I accountable for because
of the job I hold?”of the job I hold?”
•• Personal CommitmentsPersonal Commitments::”What goals will I commit to for the ”What goals will I commit to for the
coming year based on my own coming year based on my own
individual talents?”individual talents?”
Performance ManagementPerformance Management
Process by Core ValueProcess by Core Value
Saint Luke’s HospitalSaint Luke’s Hospital
Our Journey to Performance Excellence
22 June 2005 14th Annual MIDAS+ SymposiumTucson, Arizona
•• Assure financial stability by SLH departments and Assure financial stability by SLH departments and
services collectively achieving operating margin goal.services collectively achieving operating margin goal.
Department Director Personal Commitment:Department Director Personal Commitment:
Assure financial stability of East 3 by meeting budgeted Assure financial stability of East 3 by meeting budgeted
gross revenue and maintaining supplies, salaries and other gross revenue and maintaining supplies, salaries and other
expenses within 2003 budget. Measured with the monthly expenses within 2003 budget. Measured with the monthly
flex budget report.flex budget report.
Registered Nurse I Personal CommitmentRegistered Nurse I Personal Commitment::
Achieve 100% accuracy on charge entry and documentation Achieve 100% accuracy on charge entry and documentation
measured by quarterly unit auditsmeasured by quarterly unit audits
Alignment of Strategy with the Alignment of Strategy with the Performance Management Process (PMP)Performance Management Process (PMP)
Saint Luke’s HospitalSaint Luke’s Hospital
Employee SatisfactionEmployee Satisfaction
Segmented according to the life cycleSegmented according to the life cycle
of an SLH employeeof an SLH employee
Saint Luke’s HospitalSaint Luke’s Hospital
SLHAlumni
AlumniSurveyDesign
in Process
Recruitment
Process
Survey
Hire
Intro
Period
Celebration
9090--DayDayIntro PeriodIntro PeriodCompleteComplete
Employee
Opinion
Survey
RandomRandomSelectionSelection
Renew
Interviews
1 to 41 to 4Years ofYears ofServiceService
Stay
Interviews
5 to 155 to 15Years ofYears ofServiceService
Separation
Exit
Interview
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
20000
Apps HR Interviews Filled
2002
2003
2004
Selection Process ResultsSelection Process Results
Saint Luke’s HospitalSaint Luke’s Hospital
Our Journey to Performance Excellence
14th Annual MIDAS+ Symposium June 2005 23Tucson, Arizona
Human Capital Value AddedHuman Capital Value Added
40
50
60
70
80
90
1998 1999 2000 2001 2002 2003 2004
$K
SLH
Saratoga Institute
BETTERBETTER
†2004 comparative data not available
†
Saint Luke’s HospitalSaint Luke’s Hospital
DiversityDiversity
5
6
7
8
9
10
1998 1999 2000 2001 2002 2003 2004
%
SLH KC BETTERBETTER
Saint Luke’s HospitalSaint Luke’s Hospital
SLH Leadership for Performance Excellence ModelSLH Leadership for Performance Excellence Model
• Manage People
• Manage Clinical
and Administrative
Quality
• Manage Customers
• Manage Growth
and Development
• Manage Financial
Performance
• Leadership• Strategic Planning• Patient/Customer
Focus• Measurement and
KnowledgeManagement
• Staff Focus
•• Process ManagementProcess Management• Results Focus
Strategic Focus Areas
Level 1 ProcessesCommitment to Excellence
Assessment Model
Balanced Scorecard PerspectivesClinical &
AdministrativeQuality
People Customer FinanceGrowth &Development
SSCC
OO
RREE
CC
AARR
DD
BB
AA
LLAA
NN
CCEE
DD
PP
MM
PP
PROCESS SCORECARDS
Strategic Planning
VISION
MISSION
CORE VALUES
STRATEGY
VERY
IMPORTANT
PRINCIPLES
Level II,
III, IV
Process
Improvement
Plans
90-Day Action PlansIndividual
DevelopmentPlans Performance
Improvement& Innovation
KnowledgeSharing
Saint Luke’s HospitalSaint Luke’s Hospital
Process ManagementProcess Management
Our Journey to Performance Excellence
24 June 2005 14th Annual MIDAS+ SymposiumTucson, Arizona
ProcessProcess ScorecardsScorecards
Achieving Strategic Alignment Achieving Strategic Alignment
Throughout the SLHSThroughout the SLHS
Saint Luke’s HospitalSaint Luke’s Hospital
Saint Luke’s HospitalSaint Luke’s Hospital
Saint Luke’s Health SystemSaint Luke’s Health System
Department UnitsDepartment Units
Individual EmployeesIndividual Employees
•• Avoid departmental or unit silosAvoid departmental or unit silos
•• Recognition that all work is a process Recognition that all work is a process
designed to meet customers’ needsdesigned to meet customers’ needs
•• Do we really understand how well our Do we really understand how well our
processes are working?processes are working?
•• Serves to link daily operations, inServes to link daily operations, in-- process process
measures and BSC outcomes measuresmeasures and BSC outcomes measures
•• Used by process owners to monitor overall Used by process owners to monitor overall
process performanceprocess performance
Why Process Level Scorecards?Why Process Level Scorecards?
Saint Luke’s HospitalSaint Luke’s Hospital
Level 1 ProcessesLevel 1 Processes
•• Perform Financial ManagementPerform Financial Management
•• Satisfy CustomersSatisfy Customers
•• Enhance Growth and DevelopmentEnhance Growth and Development
•• Provide Clinical and Administrative Provide Clinical and Administrative
ServicesServices
•• Manage Human ResourcesManage Human Resources
Saint Luke’s HospitalSaint Luke’s Hospital
Our Journey to Performance Excellence
14th Annual MIDAS+ Symposium June 2005 25Tucson, Arizona
Level 2 Processes :Level 2 Processes :
Manage Human ResourcesManage Human Resources
•• Hire staffHire staff
•• Orient new employeesOrient new employees
•• Train staffTrain staff
•• Develop staffDevelop staff
•• Motivate staffMotivate staff
Saint Luke’s HospitalSaint Luke’s Hospital
Level 3 Processes:Level 3 Processes:
Motivate StaffMotivate Staff
•• Segment employeesSegment employees
•• Determine employee satisfactionDetermine employee satisfaction
•• Recognize employeesRecognize employees
•• Provide and administer benefits and Provide and administer benefits and
compensationcompensation
•• Provide a safe work environmentProvide a safe work environment
Saint Luke’s HospitalSaint Luke’s Hospital
•• InIn-- process measuresprocess measures::–– RetentionRetention
–– Stay Interview ResultsStay Interview Results
–– Employee Recognition Program SurveysEmployee Recognition Program Surveys
•• Angel for an AngelAngel for an Angel
•• Quality TeamworkQuality Teamwork
•• Employee of the MonthEmployee of the Month
•• Clinical Excellence in NursingClinical Excellence in Nursing
•• Manager’s Tool KitManager’s Tool Kit
–– Participation:Participation:
•• Wall of FameWall of Fame
•• Outcome MeasureOutcome Measure:: “I am recognized for my work.”“I am recognized for my work.”
Recognition Process ScorecardRecognition Process Scorecard
Saint Luke’s HospitalSaint Luke’s Hospital
Our Journey to Performance Excellence
26 June 2005 14th Annual MIDAS+ SymposiumTucson, Arizona
Recognition Process ScorecardRecognition Process Scorecard
Saint Luke’s HospitalSaint Luke’s Hospital
DEEP BLUE Stretch Target
10 Outstanding
LIGHT BLUE Stretch
9,8 Exceeds
Expectation
GREEN Goal
7Meets
Expectation
YELLOW Moderate
6,5,4 Needs
Improvement
RED Risk 3,2,1
Immediate Action
Performance Level
August, 2004
Measure Monthly Performance
Scoring Criteria (2003)
BSC Retention 90.0 > or = 86.9% 85.1 - 86.8% 83.3 - 85.0% 79.7 - 83.2% 76.0 - 79.6%
Job: 70.2 > or = 67.3 61.7 - 67.2 56.5 - 61.6 51.7 - 56.6 < or = 51.6
Supervisor: 65.1 > or = 70.6 59.9 - 70.5 49.2 - 59.8 38.4 - 49.1 < or = 38.3
Commun: 64.0 > or = 55.3 54.6 - 55.2 53.3 - 53.9 58.5 - 53.2 < or = 53.1
Stay Interview Results
Benefits: 56.3 > or = 72.5 60.8 - 66.6 54.9 - 60.7 49.0 - 54.8 < or = 48.9
Angel: 4.6Teamwork: 4.0EOM: 4.5Nursing: 4.7
Employee Recognition Programs survey results
Tool Kit: 3.6
4.6- 5.0 4.1 - 4.5 3.6 - 4.0 3.1 - 3.5 < or = 3.0
Employee participation in Recognition programs
377> or = 310 302 - 309 296 - 301 275 -295 < or = 274
Employee sat :”I am recognized for my work.”
68.2% Historical Data Not Available
Employee Opinion Survey ResultsEmployee Opinion Survey Results
0
10
20
30
40
50
60
70
80
90
100
Diversity Mission Pride Accomplishment Overall
Satisfaction
%
2000 2001 2002 2003 2004BETTERBETTER
Saint Luke’s HospitalSaint Luke’s Hospital
RESULTSRESULTS
Saint Luke’s HospitalSaint Luke’s HospitalKansas City, MissouriKansas City, Missouri
Our Journey to Performance Excellence
14th Annual MIDAS+ Symposium June 2005 27Tucson, Arizona
•• Improved Financial PerformanceImproved Financial Performance
Organizational RewardsOrganizational Rewards
Baldrige Management ModelBaldrige Management Model
100
150
200
250
300
350
400
450
1999 2000 2001 2002 2003 2004
Days
SLH A Bond BETTERBETTER
Days Cash on HandDays Cash on Hand
•• Improved Clinical OutcomesImproved Clinical Outcomes
Organizational RewardsOrganizational Rewards
Baldrige Management ModelBaldrige Management Model
0
5
10
15
20
25
30
35
2000 2001 2002 2003 2004
% o
f P
ati
en
ts
SLH
National Average
Next Best
BETTERBETTER
Patients Receiving Patients Receiving tPAtPA Following Ischemic StrokeFollowing Ischemic Stroke
20
25
30
35
40
45
1998 1999 2000 2001 2002 2003 2004
Tests
/Dis
charg
e
SLH
COTH Top QuartileBETTERBETTER
Inpatient Tests/Discharge Inpatient Tests/Discharge –– High CMI HospitalsHigh CMI Hospitals
Organizational RewardsOrganizational Rewards
Baldrige Management ModelBaldrige Management Model
Our Journey to Performance Excellence
28 June 2005 14th Annual MIDAS+ SymposiumTucson, Arizona
Saint Luke’s HospitalSaint Luke’s Hospital
Obstetrical/Obstetrical/PerinatalPerinatalIndicator RatesIndicator Rates
3.23.2
0.050.05
0.060.06
0.490.49
0.030.03
15.715.7
21.821.8
30.230.2
0404
0.00
0.02
0.03
0.23
0.00
20.1
16.8
24.5
0404
3.63.63.13.13.73.74.24.25.35.36.36.34.24.20.0MeconiumMeconium Aspiration Aspiration –– Other Other
(Good(Good ↓↓))
0.50.50.600.600.50.50.60.60.300.40.20.4MeconiumMeconium Aspiration InbornAspiration Inborn
(Good(Good ↓↓))
0.60.60.700.700.80.80.80.80.600.600.70.70.80.80.3Birth Trauma Inborn (Good Birth Trauma Inborn (Good ↓↓))
0.530.530.540.540.500.500.440.440.310.400.390.420.42Wound Disruption or Wound Disruption or
Infection (Good Infection (Good ↓↓))
17.317.321.021.025.925.929.229.221.125.332.435.6VBAC (Good VBAC (Good ↑↑))
21.321.319.719.718.518.517.817.819.219.919.916.914.8Primary CPrimary C--Section (Good Section (Good ↓↓))
0.030.03
29.629.6
0303
0.030.03
27.227.2
0202
0.040.04
25.425.4
0101
0.040.04
24.324.3
0000
0.00
26.8
0303
0.00
26.126.1
0202
0.080.08
23.3
0101
0.00
20.8
0000IndicatorIndicator
Anesthesia Complications Anesthesia Complications
(Good(Good ↓↓))
CC--Section (Good Section (Good ↓↓))
NTHNTHSLHSLH
Saint Luke’s HospitalSaint Luke’s Hospital
Mid America Heart InstituteMid America Heart Institute
Physician Recredentialing Report: Dr No.Physician Recredentialing Report: Dr No.
2003 2003 –– 1Q041Q04
89.5%89.5%38383434100.0%100.0%3333Quarter 1 2004Quarter 1 2004
85.4%85.4%41413535100.0%100.0%4444Quarter 4 2003Quarter 4 2003
94.6%94.6%56565353100.0%100.0%1111Quarter 3 2003Quarter 3 200378%78%93%93%
95.1%95.1%41413939100.0%100.0%7777Quarter 2 2003Quarter 2 2003
Top 50% Top 50%
ScoredScored
higherhigher
thanthan
Top 10%Top 10%
ScoredScored
higherhigher
thanthan
%%DenDenNumNum%%DenDenNumNumAMIAMI--3:3:
ACEI at discharge for ACEI at discharge for
LVSDLVSD
98.8%98.8%168168166166100.0%100.0%7777Quarter 1 2004Quarter 1 2004
99.4%99.4%176176175175100.0%100.0%6666Quarter 4 2003Quarter 4 2003
98.4%98.4%187187184184100.0%100.0%5555Quarter 3 2003Quarter 3 200394%94%99 %99 %
99.4%99.4%162162161161100.0%100.0%15151515Quarter 2 2003Quarter 2 2003
Top 50%Top 50%
ScoredScored
higherhigher
thanthan
Top 10% Top 10%
ScoredScored
higherhigher
thanthan
%%DenDenNumNum%%DenDenNumNumAMIAMI--22
Aspirin at dischargeAspirin at discharge
CMS CMS -- MissouriMissouriMAHIMAHIPhysicianPhysician
How We Achieved ItHow We Achieved It
COMMITMENT OF
SENIOR LEADERS
ASSIGNEDASSIGNED
SENIORSENIOR
LEADERSLEADERS
AS CAT LEADERSAS CAT LEADERS
EMBRACEDTHE CRITERIA
WROTEWROTE
APPLICATIONSAPPLICATIONS
TO GAINTO GAIN
KNOWLEDGEKNOWLEDGE
USEDUSED
FEEDBACKFEEDBACK
TO IMPROVETO IMPROVE
BENCHMARKED
AGGRESSIVELY
PERSEVEREDPERSEVERED
THROUGHTHROUGH
MULTIPLEMULTIPLE
REFINEMENTSREFINEMENTS
RESTRUCTUREDRESTRUCTURED
METRICSMETRICS
ARCHITECTUREARCHITECTURE
ALIGNED
THE
ORGANIZATION
MAINTAINEDMAINTAINED
OUROUR
FOCUSFOCUS
PROUDLYTOLD
OUR STORY
PREPARED FORPREPARED FOR
SITE VISITSITE VISIT
Baldrige Business ModelBaldrige Business Model
Assessment ProcessAssessment Process
Our Journey to Performance Excellence
14th Annual MIDAS+ Symposium June 2005 29Tucson, Arizona
Saint Luke’s Hospital
Sustaining Performance Excellence
Saint Luke’s HospitalSaint Luke’s Hospital
Sustaining Performance ExcellenceSustaining Performance Excellence
•• Leadership drives and sustains the Leadership drives and sustains the
processprocess
•• Leadership at all levels is importantLeadership at all levels is important
•• More difficult to change the culture than More difficult to change the culture than
to learn the toolsto learn the tools
•• Valuable team building experienceValuable team building experience
•• Trust is extremely important Trust is extremely important
Lessons LearnedLessons Learned
•• There are no “quick fixes”There are no “quick fixes”
•• Must always focus on the customerMust always focus on the customer
•• Should never be satisfied with the Should never be satisfied with the
present level of qualitypresent level of quality
•• Decisions must be driven by data and Decisions must be driven by data and
compared to “best”compared to “best”
•• Employees make it happen!Employees make it happen!
Lessons LearnedLessons Learned
Saint Luke’s Hospital
Sustaining Performance Excellence
Saint Luke’s HospitalSaint Luke’s Hospital
Sustaining Performance ExcellenceSustaining Performance Excellence
Our People Make the DifferenceOur People Make the Difference
They Are Our Competitive Advantage!They Are Our Competitive Advantage!
Saint Luke’s HospitalSaint Luke’s Hospital
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