Southcentral foundation nuka

1. Southcentral Foundation The SCF Nuka Model of Care Th SCF N k M d l f C Customer-Owners Driving Healthcare Charles Clement, Vice President Operations, Chief Operating Offi O ti Officer April Kyle, Human Resources Administrator Steve Tierney, Medical Director Quality Improvement Michelle Tierney, Vice President Organizational Tierney Development and Innovation

2. Today… y Share the SCF Story Transformation of our system – resulting SCF Nuka Model of Care Describe how a customer-owner customer owner system shapes and improves health performance in outcomes, satisfaction, experience of care, and ti f ti i f d overall cost. Describe some of our key improvements to our systems transformation

3. Southcentral Foundation 25+ years of history Innovative, relationship based, customer owned systems d t 1,400 staff 140,000 statewide customers 55,000 ‘local’ customer-owners including 10,000 i 10 000 in over 50 remote villages t ill Expanding local population

4. Southcentral Foundation Medical Services – Primary Care, Women’s Health, Pediatrics, Optometry, Urgent Care Dental Behavioral Health – clinics residential clinics, treatments, after-care, youth, elders Family Wellness Warriors – abuse and neglect treatment and prevention Tribal and Traditional Services Chiropractic, massage, acupuncture Southcentral Foundation

5. Alaska Native Medical Center 150 Bed Hospital Over 400,000 outpatient visits last year Local primary care, regional community hospital, and tertiary care statewide hub Level II Trauma Center, Magnet Status Combined project of SCF and ANTHC Full system – includes medications, etc. Southcentral Foundation

6. Our Choice The Alaska Native people were given this choice and we chose to assume the responsibility for our own health care Change everything Total redesign g With our choices, values and ……

7. Where we were in Jan. 1993 100 % increase in Native population in 10 yrs Long waits for scheduled appointments, 4 to 6 hour waits in ER/Urgent Care common Long waits on phone, pharmacy phone pharmacy, everywhere Poor continuity, little coordination across depts, Increase age, illness burden, space issues Little Littl customer i t input, not used in planning t t di l i System not designed around the customer

8. Everyone was frustrated… y Customers frustrated – waiting waiting, impersonal, paternalistic, crowded, unfriendly y Clinical staff frustrated – too many p p , people, not enough time, no personal g , p relationship, too many demands Management frustrated – lots of unhappy people, hard to motivate staff, poor financial performance, poor facilities f iliti

9. What If If…. What would a healthcare system based on Alaska Native community values look like? What if you actually threw out EVERYTHING in the th medical system and started with Alaska di l t d t t d ith Al k Native community structures and strengths as the base? Asset based philosophy, structures, systems So….. We declared nothing would remain the way it was unless we decided to do it that way.

10. So We wanted Alaska Native people to own d l k i l their own healthcare We wanted to have a system where the values, goals, and strengths of the customer drove the system design We wanted to get to whole person care – physical, mental, emotional, spiritual We wanted family and community to y y matter & to be known personally And – we wanted the best that modern medicine has to offer

11. Why is Customer Owned Important y p Efforts of “experts” who know o ts o e pe ts o o what is best for Alaska Native people (healthcare professionals, missionaries, government officials) Result has been loss of self esteem and confidence leading to d fid l di t dependency Healing and progress on the journey towards health only is possible when the customer/owner takes control and l d the change. d leads h h

12. Scotland Caring and compassionate C i d i staff and services Clear communication and explanation of conditions and l f d d treatment Effective collaboration Continuity of care Good access Clinical excellence Alaska Services and systems built on S i d b il strengths of Alaska Native cultures Not complicated but simple and easy to use Together with the customer as an active partner Relationships between customer owner, family and provider must be fostered and supported Access is optimized and wait A i ti i d d it times are limited Outcome and process measures to continuously evaluate and improve

13. Scotland Alaska Person Centeredness Shared Responsibility Safety of Patients Commitment to Quality l Clinical Effectiveness Family Wellness

14. Why Listen to our story Complete system redesign on Alaska Native values Decrease Decrease Decrease Decrease in ER/Urgent Care over 40% specialty care by over 50% in primary care visits by 20% in admissions and days by over 35% Improved health outcomes Improved satisfaction indicators – customer and employee

15. Question Assumptions Medical Model not questioned in 100 years, but optimally effective for population health ‘Healthcare’ tries to build on one p philosophy – why? Span is so huge p y y p g Knowledge – clinical, system design, change management, operational management – h t have evolved hugely – b t l dh l but not the basic healthcare paradigm – why?

16. Analogy - Hitting the target target… If you are in a mechanical, manufacturing mechanical environment then hitting a target is a matter much like the throwing of a rock – figuring out speed, t j t d trajectory, etc. t If you are in a messy, human, complex, adaptive environment – it is like throwing a bird at a target – it is all about the ‘attractor’ Healthcare mostly throws birds at targets and only thi k about th throwing part… l thinks b t the th i t

17. Reality – various ‘platforms’ platforms Healthcare has several ‘platforms’ ICU/ER/OR – high tech, linear, mechanical Procedures – linear, mechanical Consultative – time limited, specific issue limited focused, additive expert support Longitudinal relationship over time – chronic conditions, outpatient, residential, h i diti t ti t id ti l behavioral health, primary care One size does not fit all – first two are product, manufacturing efforts – second two are service and knowledge efforts primarily

18. Control: Who really makes the decisions 100 Patient/Family “Control” The “System” y 0 Low Acuity High 1. Control – who makes the final decision influencing outcome? 2. Influences – family, friends, co-workers, religion, values, money 3. Real opportunity to influence health costs/outcomes – influence on the choices made – behavioral change 4. Current model – t t diagnosis, treatment (meds or procedures) 4 C t d l tests, di i t t t( d d )

19. Reality y Health is a longitudinal journey g j y Across decades In a social, religious, family context Highly i fl Hi hl influenced b values, beliefs, habits, d by l b li f h bit and many ‘outside’ voices. Office visits are brief, reactive stop-gaps Hospitalizations are brief, intense interruptions MUST fix basic, underlying primary care platform first or nothing else will work well

20. Purpose of Primary Care p y Is a Service Industry – NOT a product industry – coaching, teaching, partnering are central – pills and procedures supportive Changes what we think we do, who we hire, how we train, how we structure, how we reward, and how entire system is constructed as a system. We must optimize relationship – personal, trusting, accountable – minimize b i t ti t bl i i i barriers

21. The General Framework Vision, Mission, Key Points Leads to Operational Principles – these are specific enough to be used to evaluate and even score new ideas for whether to implement them into SCF or not

22. Mission, Vision, Key Points Vision: A Native Community that enjoys physical, mental, emotional and spiritual wellness Mission: Working toget e with the ss o o g together t t e Native Community to achieve oug a a d a d wellness through health and related services.

23. Key Points Shared Responsibility We value working together with the individual, the family, and g g , y, the community. We strive to honor the dignity of every individual. We see the journey to wellness being traveled in shared responsibility and partnership with those for whom we p provide services. Commitment to Quality We strive to provide the best services for the Native Community. We employ fully qualified staff in all positions and we commit ourselves to recruiting and training Native staff to meet this need. We structure our organization to optimize the skills and contributions of our staff. Family Wellness We value the f l h family as the heart of the Native Community. l h h f h C We work to promote wellness that goes beyond absence of illness and prevention of disease. We encourage physical, mental, social, spiritual and economic wellness in the individual, h f i di id l the family, the community, and the world in which il h i d h ld i hi h we live.

24. SCF Operating Principles Relationships between the customer-owner, the family, and provider must be fostered and supported Emphasis on wellness of the whole person, family, and community including; physical y, y g; p y mental, emotional, and spiritual wellness Locations that are convenient for the customerp owner and create minimal stops for the customer-owner. Access is optimized and waiting times are limited Together with the customer-owner as an active partner Intentional whole system design to maximize y g coordination and minimize duplication

25. Operating Principles Outcome and process measures to continuously evaluate e al ate and improve imp o e Not complicated, but simple and easy to use Services are financially sustainable and viable y Hub of the system is the family Interests of the customer-owner drive the system to determine what we do and how we do it Population-based systems and services Services and systems build on the strengths of Alaska Native cultures.

26. Customer-owner Changes for Effective Relationships Be active not passive Take responsibility for your health Get information about your health Ask questions about advice Ask for options s o opt o s

27. Healthcare Provider Changes for Effective Relationships No longer a hero but a partner Control does not equal compliance Replace blaming with understanding Give customer options not orders Provide customer with resources Make it simple p

28. Some of our improvements Leadership Mission, vision, key points, principles –making part of f b i of day to day work t f fabric f d t d k Functional structure Training and development – succession planning Standardize Improvement Processes and Tools Facility Design

29. Some of our improvements Strategic Planning Continuous planning cycle p g y Linkage from 20 years to today Automated planning tool and reports p g p Measurement of how we are doing at macro and micro levels

30. Some of our improvements Customer focus Listening p g posts continuously updated y p and evaluated Benchmarked feedback tool for satisfaction Gatherings, listening conferences, customer service reps, and family

31. Some of our Improvements p Measurement and Analysis y Development of Balanced Scorecards and Dashboards for every department coordinated and connected throughout the organization i ti Data Mall for segmentation, understanding performance and registry type information

32. Tab Based Functionality

33. Segmentation of Data

34. Comparison Charts to Identify Best Practices

35. Condition Centered Action List Fictitious Patient Info

36. Some of our Improvements p Workforce improvements Recruitment Processes: group interviewing, behavioral based interviewing, change how we recruit, online tool for applications, same d day offers ff On-boarding including orientation Core Concepts training on building effective p g g relationships Job progressions and career ladders Development Center p • Upfront training for administrative support and Certified Medical Assistants • Learning centers tied to workforce competencies

37. Some of our Improvements Process and clinical improvements Microsystem Optimization -teams • Primary Care: MD, RN, Certified Medical y , , Assistant, Admin Support • Human Resources, HR Generalist and Assistants Redefine work • Move from episodic, reactive care to long-term relationship •M Move from only one-to-one visits t use of f l t i it to f groups, phone, email, fax • Move from doctor-centric to team based approach in l ti i relationship hi

38. Some of our Improvements Process and clinical improvements ocess a d c ca p o e e ts Customer-owner choice of healthcare provider Behavioral Health Consultants Case management and chronic illness management •Depression, asthma, chronic pain, diabetes, HIV etc. di b t HIV, t Advanced Access – appointments when the customer wants

39. Parallel Work Flow Redesign

40. Some of our Improvements Process and clinical improvements Integration of Complementary Medicine Telehealth, telepharmacy and telemedicine t l di i Family Wellness Warriors Initiative Service A S i Agreements t Hospitalists

41. Southcentral Foundation VISION A Native community that enjoys emotional, physical, mental, and spiritual wellness. MISSION Working together with the Native community to achieve wellness through health and related services.

42. Specifics on improvements

43. Relationship-Based System R l ti hi B dS t Tribal Governance Relationships Employee Relationships Community Relationships Provider Relationships

44. Customer/Owner Listening Not just one method of listening Personal P l interaction with staff Group visits Comment cards Customer C t Satisfaction surveys y SCF internet Annual Gathering 24-hour hotline 24 h h tli Listening Conference Governing board Advisory committees Focus groups g p Service agreements

45. Using the Voice of the Customer/Owner 54% of SCF employees are Alaska Native and American Indian people, we bring the voice of the customer interactions throughout the organization Alaska Native and American Indian people recognize our families will utilize these services for generations to come g

46. Core Concepts W ork together in relationship to learn and grow E ncourage understanding L isten with an open mind L augh and enjoy humor throughout the day N otice th di it and value of ourselves and ti the dignity d l f l d others E ngage others with compassion S hare our stories and our hearts S trive to honor and respect ourselves and others

47. Listening Conference Yearly Since 2003 Panel of Board Members, President/CEO and Vice Presidents Open microphone All customer/owners, community invited No agenda

48. Listening Conference continued Starts with a small presentation SCF History Listening Setting Priorities Looking to the future Driving change We re We’re owning the system Your voice matters Thank you /explain the process y p p

49. Listening Conference Microphone is passed around the room to customer/owners Ask questions Opportunities for improvement Compliments C li t Suggestions Notes are taken during the whole conference

50. Listening Conference Transcripts are reviewed Entered into our customer comment database Forwarded to appropriate department/committee/employee Every customer comment is followed up on Tracking and trending

51. The Gathering Yearly since 1997 l i 99 Convention center 161 Booths of all kinds Education Healthy life styles SCF departments Community (Education, Regional Native Corporations, etc.) p ) Activities Entertainment

52. The Gathering g Interactions with employees Feedback from customer/owners Examples • • • • More help for elders Parking More cancer support Better customer service when checking in for an appointment • Helping the homeless/emergency financial situation Information f ll I f ti follow through on survey results by th h lt b committee/managers Tracked through electronic feedback system ensure appropriate action is taken k

53. Website

54. Strategic Planning Cycle W hat are w e trying to accom plish? H ow w ill w e know that a change is an im provem ent? W hat changes can w e m ake that w ill result in im provem ent? AC T - W ha t cha ng e s are to be m a d e? - N e xt C ycle? ST U D Y - C o m p lete th e a na lysis of the d ata - C o m p are d a ta to p re di ti n s dictio - Su m m arize w h a t w a s le a rn ed PL A N - O b je ctive - Q u estio n s a nd P re dictio n s (w hy) - Pla n to carry o ut th e cycle (w h o, w h a t, w h ere , w h en ) DO - C a rry ou t th e p la n - D o cu m en t p rob le m s an d un exp e cte d ob servatio n s b ti - Be g in a na lysis o f the da ta

55. Planning and Improvement Linkages August 2006 Planning and Improvement Linkages Green = Core foundation Pink = Initiatives Orange = Work Plans/Action Items Rose = Employee Evaluation Blue = Improvement Tools Grey = Other Useful Tools Double Line Box = Part of Annual Planning Tool Mission, Vision, Key Points, Operational Principles Established by Vice President Leadership Committee and approved by Board of Directors Annual Planning Process and Cycle, Baldrige Process, Improvement Cycle, and Committee Structure Str ct re are the approaches and systems in which these tools are deployed. Corporate Goals ESTABLISHED AT CORPORATE LEVEL Established by Vice President Leadership Committee and approved by Board of Directors and are derived from the Mission Vision, Key Points and Operational Principles Balanced Scorecard (BSC) Linked to Corporate Objectives and p j measure progress on achieving Corporate Objectives Corporate Objectives ESTABLISHED AT CORPORATE LEVEL Reviewed and updated annually by Vice President Leadership Team as part of Planning Cycle with input from employees/customers Because initiatives tie to Objectives and they are longer term, they should be linked to BSC. 4 Oval Structure Functional Structure Committee Initiative Functional Structure Committee Work Plan/ Action Item Division Work Plan/Action Item Department Work Plan/Action Item OTHER USEFUL TOOLS Project Team Charter Assessment Conference Lessons Learned BSC/DB Definitions Medelearn Intranet Tools including forms Policy & Procedure Templates Committee Reporting Form Employee Performance Action Plan Functional Structure Committee Work Plan/Action Item Division Initiative Department Initiative Department Work Plan/Action Item Department Work Plan/Action Item Work Plan W k Pl or Action Item A ti It Details the short term action items (tests of change or less than quarter in duration) that will be completed and/tested to achieve an initiative. Work plans may be developed at all levels of the organization Department Work Plan/Action Item Link to Improvement Tools Initiatives Strategic activities identified that are longer term (occur in 1-2-3 years) to achieve the corporate objectives. Initiatives may be developed at all levels of the organization. Corporate Initiative Employee Performance Action Plan Employee Employee Performance Action Details for each employee their action Performance Action items for the year linked to initiatives Plan Plan and work plans. ADLI Change Concepts: Survey Monkey: Baldrige Assessment and Developed for most initiatives to outline the details of the initiative. PDSA Developed for work plans that involve improvement activities to outline the details of the work plan. Changes are tested in Rapid Cycle, with one cycle building on another. Employee Performance Action Plan Improvement Tools Operational Principles: Measurement Rules Template: Committee Manager: Project or Project Team Charter Used to test ideas or concepts to ensure consistency with MVKP&Corporate Goals Developed to assist with defining BSC / Dashboards measures. Part of the intranet tool Used to develop Project Team in order to communicate changes, meeting minutes etc corporate wide Approach, Deploy, Learning, Integration: From Baldrige used to evaluate PDSA cycles. Change concepts are used in improvement to assist in generating new ideas when making changes Used to measure success for process changes Feedback: Survey that can be used to assess where the organization/department/committee is based on Baldrige Criteria Dashboards (DB) Operational Measures that monitor the day to day operations. These measures inform where improvement may be targeted. If the annual plan is used as an operational work plan in addition to a strategic plan, DB items may be linked to these operational initiatives/ work plan items. Measurement Rules Template Data and Information drives all aspects of the Improvement Process and is part of all tools. Data are reviewed from the 4 perspectives: Finance/Workload, Organizational Effectiveness, Customer, & Workforce including National Research Corporation-Customer Satisfaction; Morehead Associates-Employee Satisfaction; BSC/DB, Hedis etc.

56. Measurement Linkages

57. Improvement Model: From The Improvement Guide. A Practical Approach to Enhancing Organizational Performance by Langly, Nolan K., Nolan T., Norman, and Provost

58. Continuous Improvement A P A A P P S S D D S D S D Situation as it is From The Improvement Guide. A Practical Approach to Enhancing Organizational Performance by Langly, Nolan K., Nolan T., Norman, and Provost Impr rovement n A P Situation as it Should Be

59. SCF Facilities Supporting Health The key determinant of health (and success in education and finances) is Self Confidence Se Co de ce d a s o p de, Self Confidence draws from pride, honor, dignity, respect Outstandingly beautiful facilities are a key piece of improving Alaska Native pride honor dignity - self pride, honor, confidence

60. Customer-Owner Design Easy to find, welcoming spaces Beauty, light, comfort, colors and textures that are familiar Native feel but not any specific one feel, culture Dignity, pride respect, honor, Dignity pride, respect honor relationship Privacy, ti P i time, li t i listening Family and friends welcome

61. Facility design Smaller, quieter, more personal feeling Not on top of each other spreading infection and being disruptive Accommodates family and privacy both Comfortable exam spaces and on the same level as the clinical people – respect Self management, customer-owner customer owner control Visual, sharing, listening, professional

62. Facility Design Group sociology – Family dynamics - max 15 people, Team dynamics up to 65, over 65 – bureaucracy Back to smaller ‘team’ practices – 6 ‘primary care’. Decentralized Health Information C t D t li d H lth I f ti Centers into every waiting area Shared specialty rooms and equipment central spine Extensive use of glass, natural light, semig , g , privacy

63. Facility Design Emphasis shifted towards more team space and more importance of g p integrated team space More and more team care, ‘virtual’ care (email and phone and home visitors), less visits. l i it No ‘nurses station’ CMS and CMA s with teams – phone CMA’s traffic direct to teams Shared resources – behaviorists, dieticians, pharmacists, coverage staff visible/accessible

64. Facility Design Structural alignment with shift in power to be more balanced – spaces de-medicalized d di li d Family rooms Group rooms G Co-located Mental Health therapists Experiments with merged h d pharmacist, pregnancy and pediatric care

65. Data Slides

66. Diabetes: Annual HbA1C % 100 88.1 88.2 87.3 86.7 88.8 91.0 90.5 91.9 Mar Jun Sep Dec Mar Jun Sep Dec 50 0 2008 SCF 2009 2008 HEDIS 90th Percentile (88.81)

67. Diabetes: HbA1C Poor Control 40 % 23.0 24.2 26.9 26.5 23.7 22.5 22.5 22.8 Mar Jun Sep Dec Mar Jun Sep Dec 20 0 2008 SCF 2009 2008 HEDIS 10th Percentile (32.60)

68. Diabetes: LDL < 100mg/dl % 100 50.3 49.8 48.5 49.1 48.3 52.1 54.0 52.9 Mar Jun Sep Dec Mar Jun Sep Dec 50 0 2008 SCF 2009 2008 HEDIS 90th Percentile (42.31)

69. Diabetes: B/P < 130/80 % 100 34.0 50 39.4 39.8 Jun Sep Dec 0 Mar Jun Sep 2008 SCF Dec Mar 2009 2008 HEDIS 90th Percentile (41.30)

70. Cardiovascular: LDL < 100mg/dl g % 100 50 49.2 49 2 51.0 51 0 50.3 50 3 49.1 49 1 Mar 40.3 Jun Sep Dec 0 Dec 2008 SCF 2009 2008 HEDIS 90th Percentile (52.87)

71. 50 SCF Overall 5 to 9 yrs 10 to 17 yrs Dec Nov Oct Dec Nov Oct Dec Nov Oct Dec Nov 0 Oct % 100 Asthma: Appropriate Meds 97 95 96 95 87 86 87 96 96 84 82 83 18 to 56 yrs 2009 SCF 2008 HEDIS 90th Percentile (Overall 91.94)

72. Cancer Screening: Colorectal (Flex sig and Colonoscopy) % 100 50 48.9 48 9 50.3 50 3 52.2 52 2 55.6 55 6 57.0 57.8 58.2 58.6 Mar Jun Sep Dec Mar Jun Sep Dec 0 2008 SCF 2009 2008 HEDIS 90th Percentile (65.72)

73. Cancer Screening: Cervical % 100 73.4 73.6 73.8 73.6 74.1 75.3 75.5 75.2 Mar Jun Sep Dec Mar Jun Sep Dec 50 0 2008 SCF 2009 2008 HEDIS 90th Percentile (77.46)

74. Cancer Screening: Breast 100 % 59.0 58.2 57.5 56.5 56.5 56.1 56.6 57.4 Mar Jun Sep Dec Mar Jun Sep Dec 50 0 2008 SCF 2009 2008 HEDIS 90th Percentile (61.17)

75. Complex Utilizer: Annual Behavorial Visit 100 % 52.3 53.2 55.6 58.4 58 4 59.0 59 0 Dec Mar Jun Sep Dec 50 0 2008 2009 SCF SCF Target (75%)

76. Controlled Medications: Annual Behavorial Visit % 100 50 30.3 28.8 30.4 32.8 32 8 35.4 35 4 Dec Mar Jun Sep Dec 0 2008 2009 SCF SCF T Target (50%)

77. Access to Recovery: 6 Month Follow-Up of Intakes 94.0 % 100 80.7 50 0 2008 (N=151) SCF 2009 (N=657) Avg A All G Grantees (2008 64 % 2009 63 %) (2008:64.7% 2009: 63.7%)

78. Access to Recovery: Alcohol & Drug Abstinence 100 % 72.7 50 46.1 66.4 76.8 65.5 62.8 70.9 50.0 50 0 0 Intake 6 mo Intake 6 mo Intake 6 mo Intake 6 mo FY09-Q1 FY09 Q1 n=128 FY09-Q2 FY09 Q2 n=122 FY09-Q3 FY09 Q3 n=142 FY09-Q4 FY09 Q4 n=86

79. Access to Recovery: Employment & Education % 100 39.1 39 1 50 18.8 23.8 33.6 28.2 37.3 37 3 29.1 34.9 0 Intake 6 mo Intake 6 mo Intake 6 mo Intake 6 mo FY09-Q1 n=128 FY09-Q2 n=122 FY09-Q3 n=142 FY09-Q4 n=86

80. Su uicides pe 100,00 er 00 Crude Rate: AN Suicides Anchorage & MatSu Residents 100 50 46.70 24.60 0 2004 #Suicides=16 2006 #Suicides=9 2008 #Suicides=3

81. Emergency Dept Visits per 1000 Member Months Visit per 100 ts 00 100 50 42.76 43.97 2008 2009 0 SCF HEDIS 10th Percentile (40.59)

82. Monthly M thl ED Visits Per 1000 Customers Vi it P C t (Historical) 19% Decrease Since 2000 48 40 39 2007 2006 2005 2004 2003 2002 2001 0 2000 Visits per 1000 80

83. Visit per 1000 ts 0 Total Outpatient Visits per 1000 Member Months 400 299.35 322.25 2008 2009 200 0 SCF HEDIS 25th Pctile (274.04) HEDIS 50th Pctile (324.01)

84. 800 693 400 200 07 200 06 200 05 200 04 200 03 200 02 200 01 200 00 0 199 99 Visits per 100 00 1200 Qrtly Outpatient Visits Per 1000 Customers (Historical) 1077 36 % Decrease Since 1999

85. Total Inpt Days per 1000 Member Months Da per 100 ays 00 50 27.00 26.82 2008 2009 25 0 SCF 2008 HEDIS 10th Percentile (16.84)

86. 81.5 71 % D Decrease Si Since 1999 50 23.3 23 3 200 07 200 06 200 05 200 04 200 03 200 02 200 01 200 00 0 199 99 Da per 10 ays 000 100 Qrtly Hospital Days per 1000 Customers (Historical)

87. Discharges per 1000 Total Inpt Discharges per 1000 Member Months 10 5.72 5.98 2008 2009 5 0 SCF 2008 HEDIS 10th Percentile (5.26)

88. 20 19.03 75% Decrease Since 1999 10 4.72 2007 2006 2005 2004 2003 2002 2001 2000 0 1999 missions per 1000 p Adm Qrtly Hosp. Admissions Per 1000 Customers (Historical)

89. Customer Satisfaction (Top Box % ) 100 % 68.2 71.2 2008 2009 50 0 SCF **Mayo 69% y **Clev. 66% **JH 75%

90. Customer Satisfaction (Top Box % ) % 100 70 74 08 09 73 73 83 91 53 56 66 66 08 09 08 09 50 0 Clinics 08 09 Dental 08 09 Home Hlth SCF Emerg. g Serv. Outpt BH p

91. % BSC Customer Satisfaction (Positive Response) 91.7 88.5 100 50 0 2008 SCF 2009 BSC 2009 Target (85%)

92. Ability to Give "Input" (Top Box % ) 100 % 65.3 65.0 08 09 50 0 SCF CAHPS (Top Box) 2009 (53.5%)

93. FY Operating Margin 15.0 12.5 11.0 11.1 8.6 8.8 8.4 2.4 2.3 2009 5.0 2008 % 10.0 10 0 0.0 2007 2006 SATO 2005 2004 SCF 2003 2002 -5.0 MGMA 90th %tile 2009 (1.3)

94. FY Total Revenue ($Millions) 200 150.3 149.0 128.5 143.2 146.3 102.5 120.2 174.6 100 0 2009 9 2008 8 2007 7 2006 6 SATO 2005 5 2004 4 2003 3 2002 2 SCF MGMA 90th %tile 2009 (77.4)

95. SCF Customer Growth (# Empanelled) 80,000 59,992 # 60,000 40,000 40 000 20,000 18,216 0 FY 1999 FY 2009

96. Relat tive % chan from baseline nge b Cumulative Per Capita Expenditures Relative % Change with 2004 as Baseline 30 27 26 26 25 20 15 15 10 5 5 0 -5 2004 2005 2006 2007 2008 -10 SCF Cumulative Primary Care SCF Cumulative Hospital Services National Health Spending National Hospital Care Expenditures National Physician and Clinic Services Expenditures

97. Workforce Commitment Indicator 5 S Score 4 3.83 3 83 3.91 3 91 3.92 3 92 4.07 4 07 2003 2005 2007 2009 3 2 1 0 SCF Morehead Nat HC Ave 2009 (4.10)

98. Courses per 100 FTE s F Development Center Courses per 100 FTE 10 8.59 8 59 3.94 5 0 SCF Local Hospital 2010

99. % of Workforce Promoted 20 % 13.50 10 11.80 12.60 2007 2008 8.70 8 70 0 2005 2006 SCF 2008 Saratoga 90%tile (11.50)

100. % of AN/AI Workforce Promoted 20 % 14.1 10 9.5 9.2 9.5 2006 2007 2008 0 SCF 2009 2008 Saratoga 90%tile (11.50)

101. "I understand mission & core values" 5 4.31 4.32 2003 2005 Sco ore 4 4.43 4 43 3.87 3 2 1 0 SCF 2007 2009 Morehead Nat HC Ave 2009 (4.34)

102. 90 Day Turnover Rate % 20 10 7.1 5.9 59 3.4 0 2007 SCF 2008 2009 2008 Saratoga 90%tile (7.30)

103. "This org. cares about employee safety" 5 S Score 4 3.88 3 88 4.05 4.17 4.30 2003 2005 2007 2009 3 2 1 0 SCF Morehead Nat HC Ave 2009 (4.16)

104. Score Benefit Satisfaction & Organizational Support 5 4 3 2 1 0 3.69 3.66 3 69 3 66 3.89 3 67 3 73 3.87 3 68 3.93 4.02 3.67 3.73 3.68 05 07 09 I am Satisfied w/ Benefits SCF 05 07 09 Org Support Work vs Pers. 05 07 09 Org Interested in HealthWellness 2009 Morehead Natl HC Ave (Sat 3.66 Sup 3.82) 3 66 3 82)

105. 62 55 59 41 42 43 35 VAL 58 PEDS 50 47 48 Overall Overall Overall Overall Overall Overall 0 Overall % 100 FMC % Appointments Available at 0800 for Whole Day (FMC/PEDS/VAL) 03 04 05 06 07 08 09 SCF 09 SCF Innovative Target (50%)

106. 4000 Behavioral Health Urgent Response Capacity g p p y 3984 3867 2915 3000 # 2005 2000 1000 1176 1114 2004 2005 333 0 2003 2006 SCF 2007 2008 2009

107. Continuity of Care with Primary Provider 100 83 73 % 71 76 6764 50 35 0 99 00 01 02 03 04 05 06 07 08 PEDS FMC VAL * 09 MHS (44.85%)

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