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Copyright © 2015 Studer Group. Please do not quote or disseminate without Studer Group authorization
Accountability, One First Down at a Time-
Leads to a Winning Team!Michael Hansen, FACHE, President/CEO
Suszanne Deyke, MSN, RN, CEN Emergency Department Director
Sue Hrnicek, MSN, RN, Surgical Services Director
Chad Van Cleave, CFO
Columbus Community Hospital
Columbus, Nebraska
Copyright © 2015 Studer Group. Please do not quote or disseminate without Studer Group authorization
Our Stadium
Introduction
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• Our Mission – is to improve the health of the
communities we serve
• Our Vision – is to deliver the states highest quality
patient care
• Values - ICARE
• Columbus Community Hospital | We are an Acute
Care Facility
3
Mission and Vision
CCH Fight Song
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4
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• Create the Right Environment
• Assume good intentions
• Be supportive
• Communicate openly – explain the WHY
• Be fair and consistent
* Goal – Build Trust
5
Looking Inward
1st and 10
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• Skills Lab – AIDET®
• Engaging in EBP
• Communication Board – UBC
6
Validation
Slide 7
7
Emergency
Department
Communication
Board
Slide 8
Cleanliness /Quietness
Comm w/ NursesComm w/Providers
Discharge Info Overall Rating Pain Mgmt Recommend
Jul - Sep 2014N = 96
85 56 49 63 79 11 68
Oct - Dec 2014N = 101
72 72 62 32 87 50 76
Jan-Mar 2015N = 84
46 8 28 33 20 36 14
Apr-Jun 2015N = 99
80 31 14 60 34 68 40
Jul-Sep 2015N = 76
94 96 70 73 75 93 51
Oct-Dec 2015N = 99
98 78 61 49 72 61 67
Jan-Mar 2016N = 84
95 76 83 90 62 44 50
Apr-Jun 2016N = 26
98 99 89 84 92 84 81
0
10
20
30
40
50
60
70
80
90
100
Yardage obtained
8
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• Experienced leader gaining trust of staff and MD’s
• 25+ years experience and humility are not enough
• Differences between current practice and evidence
based/best practice
• Beginning a culture of accountability
• Mentoring your leadership team-it’s ok to fumble
9
Breaking into Leadership
2nd and 7
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• Video of Dr. Kurt Kapels, Hospitalist
10
Rounding with Providers
3rd and 12
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11
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• Encourage the heart and find their passion
• Successfully deliver the message
12
Punt or Go For it
4th and 1
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13
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14
Leader Evaluation Manager® (LEM)
Like Offensive Coordinators, hospital Senior Leaders must
develop and execute a game plan to be successful.
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• Key factors to achieve high performance
• Alignment
• Readiness for Change
• Fundamentals
• Self Awareness
• Consistency
• Accountability
15
LEM Organizational Goal Development
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• Top Mistakes in Setting Goals
#1: Inappropriately assigning organization-wide goals to middle
managers.
#3: All leaders share the same weights for a goal, even when their
responsibilities don't affect the weights.
#6: Some leaders fail to accept responsibility for far-reaching
organizational goals they directly affect.
#8: Leaders tend to "cherry pick" the easiest goals to meet instead of the
most important.
Source: Top 10 Mistakes in Setting Hospital Goals By Bill Bielenda
16
LEM Organizational Goal Development
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17
LEM Organizational Goal Development
Studer Group provides the coaching and tools necessary to be successful
in goal development, implementation and accountability.
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18
LEM Organizational Goal Development
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• Process begins 60-90 days prior to fiscal year begin
• Involvement from all key stakeholders (e.g. clinical,
finance, compliance, physicians, Board Members)
• CCH focus for FY2017
60% Patient Satisfaction- 30% Inpatient (i.e. HCAHPS)
- 30% Outpatient (e.g. ER, Rehab, Lab, etc.)
20% Employee/Physician Satisfaction (biennial)
20% Finance - 10% Wages, Salaries and Benefits
- 10% Operating Margin
19
CCH Organizational Goal Development
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• Focus on Inpatient and Outpatient Services with
highest volumes
• Goals scored based on percentile rankings using
the National Research Corporation (NRC) database
• Top box scores developed using 12-month rolling
averages
• Top box scores compared to a static percentile
ranking from prior year when entering into LEM
20
CCH Patient Satisfaction Goal Development
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21
CCH Patient Satisfaction Goal Development
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22
CCH Patient Satisfaction Goal Development
• Scoring based upon LEM goal template offered through Studer Group
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23
CCH Patient Satisfaction Goal Alignment
• Top box scores compared to a static percentile ranking from prior year
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24
CCH Physician Satisfaction Goal Development
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25
LEM Accountability Tools
• 90-day Action Plans
• Monthly Report Cards
• Monthly Meeting Model
• Validation Matrix
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26
CCH 90-Day Goal Example
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27
CCH 90-Day Goal Example
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28
CCH Validation Matrix Example
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29
CCH Validation Matrix Example
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30
CCH Validation Matrix Examples
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31
Patient Satisfaction Monitoring & Improvement
• On-demand reports from the NRC
• Breakdown of percentile ranking
• Drill down capabilities for patient comments
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32
Patient Satisfaction Monitoring & Improvement
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33
Patient Satisfaction Monitoring & Improvement
• Real-time access to patient comments
• Recognize and reward staff
• Service recovery
• Development of 90-day action plans
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34
Touchdown!
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35
Touchdown!
CCH Earns ‘Top Performer’ Recognition
for 5th Consecutive Year!
In November 2015, The Joint Commission announced that Columbus
Community Hospital (CCH) was again being recognized as a Top
Performer on Key Quality Measures®.
CCH was recognized for attaining and sustaining excellence in
accountability measure performance for the Surgical Care and
Immunization measure sets.
This is the fifth year we have been recognized as a Top Performer and CCH
is 1 of only 117 hospitals to achieve the Top Performer distinction for
five consecutive years. We know what matters most to patients is the
quality and safety of the care they receive.
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36
Touchdown!
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37
Touchdown!
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38
Touchdown!
Slide 39
Thank You!
Michael Hansen, FACHE, President/CEO
Suszanne Deyke, MSN, RN, CEN Emergency Department Director
Sue Hrnicek, MSN, RN, Surgical Services Director
Chad Van Cleave, CFO
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