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8 mc gann-magee_aria_health


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  • 1. Managing Performance fromAll AnglesSusan McGann, Chief Performance Officer andMary C. Magee, MSN, RN; Administrative Director ofQuality & Regulatory Affairs2New Targeted/Measureable Approach• 3 Campus Health System• 485 Beds• 4500+ Employees• 850+ Medical Staff• 127,000+ Annual ED Visits• 146,000+ Outpatient VisitsAria Health
  • 2. 3New Targeted/Measureable Approach• Decentralized• Department Specific• Connectivity to Strategic Goals• Alignment• Coordination & Oversight• Measures & FormattingScorecards4New Targeted/Measureable Approach• Strategic Initiatives• Campus Initiatives• Regulatory Initiatives / Tracers• Rounding Activity• Projects: Task Force or Formal Team• Data du jurInitiatives & Projects
  • 3. 5New Targeted/Measureable Approach“A journey of a thousand milesbegins with a single step.”Lau-TzoAha Moment•The Board Room Visual6New Targeted/Measureable Approach• Campus Administrator• Information– Campus Initiatives– Projects: Task Force or Formal– Regulatory• Sources of information• Mechanics of gathering information• Pulling it all together• A NEW Day in the Life……..A Day in the Life…
  • 4. 7New Targeted/Measureable Approach8New Targeted/Measureable ApproachScorecardsARIAScorecardQTOPSBC FC TCStrategicInitiativesScorecardBuilt w/projectQuality/ProfessionalCommitteeScorecard
  • 5. 9New Targeted/Measureable ApproachScorecards• QTOPS ARIA Health– BC– FC– TC• Quality & ProfessionalBoard• Missed Opportunity• Patient Safety• Strategic Initiatives– Best Place to Work– Medical StaffDevelopment– Environment of ClinicalExcellence10New Targeted/Measureable ApproachScorecards
  • 6. 11New Targeted/Measureable ApproachHeaderLSS ProjectsBuiltMammographyCredentialingPre-EmploymentO.R. Flow TCED Flow12New Targeted/Measureable ApproachHeader
  • 7. 13New Targeted/Measureable ApproachHeaderProjectsBuiltARIASuicideAssessment& PreventionFoodforThought Medical Staff&Hospital InitiativeAligning UnitMeasuresto Campus LevelCrimson InitiativeDOHProjects (2)Patient SafetyEducation14New Targeted/Measureable ApproachFrankford CampusProjectsBuiltFCDigitalMammographyICAREHourly RoundingVisitorManagementCommunityOutreachPlantOperationsCAUTI –On the CUSP
  • 8. 15New Targeted/Measureable Approach2010 TimelineLSSKickoffJan Feb March April May June JulyMeetingsw/StrategicInitiativeTeamsBuiltLSSProjectsAdminTrainingCreatednewHRQTOPSPlanningMeetingsReviewVerificationof QTOPSMetricsASEKickoffSeniorLeadershipFinalize HRMetrics &BuiltScorecardBuilt Quality/ProfessionalScorecardFinalized SIEnvironmentof ClinicalExcellenceObjectives,Measures inprogressAttendedthe ClientConferenceAug SeptTim S -SLTTrainingFinanceTrainingFC ScorecardOctNursing Measuresdata loadingMissedOpportunityScorecardTraining AdditionalEmployeesMed StaffSIProjectsPresentedtoNursingLeadershipTim S-SLMeetingBC ScorecardPlanningDiscussionsFC usingASE in meetingsTurnover of StaffVisualMapsBriefingBooks - DanSI ClinicalExcellencePt SafetyprojectsPatient SafetyscorecardInfectionPreventionScorecardFC NursingScorecardsNov DecTC NursingScorecardsBC NursingScorecards16New Targeted/Measureable Approach2011 TimelineShareddriveFCJan Feb March April May June JulyClientConferenceBC NurseManagersTrainingIROUNDTrainingIP DeptASEpresentedto BCManagersMeetingAlignmentof unitmeasuresto campuslevelNurseManagersFC TrainingCreatedTemplates VRFCProjectsAug Sept OctDOHScorecardcreatedRegulatoryProjectsCORE MeasureCampusLevelSLTTrainingNovProjects FCDecFC NurseManagersFeb datareportsBC campuslevel dataBC NurseManagersTrainingHosp wideshared drivecreatedIP Nursingmeasuresconnectedto campuslevelIRound = Active DCTracers
  • 9. 17New Targeted/Measureable Approach• How is it used?– Board Mtgs: phasing out the paper– Senior Leadership: key metrics, variance & status reports• Campus Administrator: key metrics, projects, initiatives, variance& status reports– Committee Mtgs: dashboards, results, progress– Campus “Coffee & Scores”: results, discussion– LSS Report Outs– NEW – under construction: Regulatory ComplianceNitty Gritty18New Targeted/Measureable Approach• Turning Rounds and Tracersinto real-time usable data• Easy• Efficient• Cost EffectiveActiveDC
  • 10. 19New Targeted/Measureable Approach• Infection Prevention– Hand Hygiene– Ventilator Associated Pneumonia– Infection Prevention Tracer• Safe Haven• Physician Satisfaction “Ask Me Three”Pilot20New Targeted/Measureable Approach• Paper world: 78.2 hrs/quarter - 5 people doingdata entry & analysis and 15 people doing themonitoring per hour• Averaged 850 observations per quarter• As of 4.21.11: 220 observations, 6 people, 0data entry hours• Updated stats to be presented at conferenceHand Hygiene
  • 11. 21New Targeted/Measureable Approach• Standard of care “bundle” for patients onventilators• Challenges with paper audits• Audits performed• ActiveDC Results= clear picture of opportunities• Campus Administrators / Nursing Directors• “Real Time” feedback & interventions in ICU onexisting patients!VAP22New Targeted/Measureable Approach• ASE– Total number of scorecards– Total number of measures– Total number of projects / initiatives– Nursing Measures Created, Data Loaded & Unit Scorecards Created– Briefing Books, Falls Dashboard – Used with Task Force– Projects loaded into Medical Staff Dev-SI– Project loaded into Clinical Excellence-SI– Two of three campuses with scorecards, projects, & initiatives– FC – Expanded metrics, using in meetings– Additional training of staff & leadership– Patient Safety, Infection Prevention Scorecards, Missed Opportunity, DoH– Visual Maps, Templates for VR and Status reports– Rapid Deployment• iROUND/ActiveDC– Adoption of concept / idea– Rapid deployment– Training– Pilot Testing– Real Audits / TracersMajor Accomplishments
  • 12. 23New Targeted/Measureable Approach• Directional Building – it does matter!• Measure Inventory• Data Definitions• Nomenclature & Labeling• Buy-in• Ownership & Accountability• It’ll take off!• Usage brings out new ideas Support TeamMajor Lessons24New Targeted/Measureable ApproachContact InformationSusan McGann, CPOsmcgann@ariahealth.orgMary C. Magee, Admin. Dir. of Qualitymmagee@ariahealth.orgQ&A THANK YOU!