Aria Health: Managing Performance from All Angles
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Susan McGann, Chief Performance Officer and Mary C. Magee, MSN, RN; Administrative Director of Quality & Regulatory Affairs
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Aria Health: Managing Performance from All Angles
- 1. Managing Performance from All Angles Susan McGann, Chief Performance Officer and Mary C. Magee, MSN, RN; Administrative Director of Quality & Regulatory Affairs 2 New Targeted/ Measureable Approach • 3 Campus Health System • 485 Beds • 4500+ Employees • 850+ Medical Staff • 127,000+ Annual ED Visits • 146,000+ Outpatient Visits Aria Health
- 2. 3 New Targeted/ Measureable Approach • Decentralized • Department Specific • Connectivity to Strategic Goals • Alignment • Coordination & Oversight • Measures & Formatting Scorecards 4 New Targeted/ Measureable Approach • Strategic Initiatives • Campus Initiatives • Regulatory Initiatives / Tracers • Rounding Activity • Projects: Task Force or Formal Team • Data du jur Initiatives & Projects
- 3. 5 New Targeted/ Measureable Approach “A journey of a thousand miles begins with a single step.” Lau-Tzo Aha Moment •The Board Room Visual 6 New 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. 7 New Targeted/ Measureable Approach 8 New Targeted/ Measureable Approach Scorecards ARIA Scorecard QTOPS BC FC TC Strategic Initiatives Scorecard Built w/ project Quality/Professional Committee Scorecard
- 5. 9 New Targeted/ Measureable Approach Scorecards • QTOPS ARIA Health – BC – FC – TC • Quality & Professional Board • Missed Opportunity • Patient Safety • Strategic Initiatives – Best Place to Work – Medical Staff Development – Environment of Clinical Excellence 10 New Targeted/ Measureable Approach Scorecards
- 6. 11 New Targeted/ Measureable Approach Header LSS Projects Built Mammography Credentialing Pre-Employment O.R. Flow TC ED Flow 12 New Targeted/ Measureable Approach Header
- 7. 13 New Targeted/ Measureable Approach Header Projects Built ARIA Suicide Assessment & Prevention Food for Thought Medical Staff & Hospital Initiative Aligning Unit Measures to Campus Level Crimson Initiative DOH Projects (2) Patient Safety Education 14 New Targeted/ Measureable Approach Frankford Campus Projects Built FC Digital Mammography ICARE Hourly Rounding Visitor Management Community Outreach Plant Operations CAUTI – On the CUSP
- 8. 15 New Targeted/ Measureable Approach 2010 Timeline LSS Kickoff Jan Feb March April May June July Meetings w/ Strategic Initiative Teams Built LSS Projects Admin Training Created new HR QTOPS Planning Meetings Review Verification of QTOPS Metrics ASE Kickoff Senior Leadership Finalize HR Metrics & Built Scorecard Built Quality/ Professional Scorecard Finalized SI Environment of Clinical Excellence Objectives, Measures in progress Attended the Client Conference Aug Sept Tim S - SLT Training Finance Trainin g FC Scorecard Oct Nursing Measures data loading Missed Opportunity Scorecard Training Additional Employees Med Staff SI Projects Presented to Nursing Leadership Tim S-SL Meeting BC Scorecard Planning Discussions FC using ASE in meetings Turnover of Staff Visual Maps Briefing Books - Dan SI Clinical Excellence Pt Safety projects Patient Safety scorecard Infection Prevention Scorecard FC Nursing Scorecards Nov Dec TC Nursing Scorecards BC Nursing Scorecards 16 New Targeted/ Measureable Approach 2011 Timeline Shared drive FC Jan Feb March April May June July Client Conference BC Nurse Managers Training IROUND Training IP Dept ASE presented to BC Managers Meeting Alignment of unit measures to campus level Nurse Managers FC Training Created Templates VR FC Projects Aug Sept Oct DOH Scorecard created Regulatory Projects CORE Measure Campus Level SLT Training Nov Projects FC Dec FC Nurse Managers Feb data reports BC campus level data BC Nurse Managers Training Hosp wide shared drive created IP Nursing measures connected to campus level IRound = Active DC Tracers
- 9. 17 New 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 Compliance Nitty Gritty 18 New Targeted/ Measureable Approach • Turning Rounds and Tracers into real-time usable data • Easy • Efficient • Cost Effective ActiveDC
- 10. 19 New Targeted/ Measureable Approach • Infection Prevention – Hand Hygiene – Ventilator Associated Pneumonia – Infection Prevention Tracer • Safe Haven • Physician Satisfaction “Ask Me Three” Pilot 20 New Targeted/ Measureable Approach • Paper world: 78.2 hrs/quarter - 5 people doing data entry & analysis and 15 people doing the monitoring per hour • Averaged 850 observations per quarter • As of 4.21.11: 220 observations, 6 people, 0 data entry hours • Updated stats to be presented at conference Hand Hygiene
- 11. 21 New Targeted/ Measureable Approach • Standard of care “bundle” for patients on ventilators • Challenges with paper audits • Audits performed • ActiveDC Results= clear picture of opportunities • Campus Administrators / Nursing Directors • “Real Time” feedback & interventions in ICU on existing patients! VAP 22 New 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 / Tracers Major Accomplishments
- 12. 23 New 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 Team Major Lessons 24 New Targeted/ Measureable Approach Contact Information Susan McGann, CPO smcgann@ariahealth.org Mary C. Magee, Admin. Dir. of Quality mmagee@ariahealth.org Q&A THANK YOU!