NMHS: The Baldrige Journey

1. NMHS: The Baldrige Journey Lee Greer, M.D., MBA Chief Quality & Safety Officer

2. “To continuously improve the health of the people of our region”

4. NMMC- Tupelo 5 Community Hospitals Eupora (38 beds) plus LTC Hamilton, AL (57 beds) plus LTC Iuka (48 beds) Pontotoc (25 bed CAH) plus LTC West Point (60 beds) 34 Clinics Preferred Provider Organization 90,000 lives – 114 payer groups 2,929 physicians & 48 hospital network

5. VISION “The provider of the best patient centered care and health services in America”

6. NMHS’ Commitment to the Baldrige Framework

7. Organizational Profile Strategic Planning Workforce Focus Leadership Results Customer Focus Operations Focus Measurement, Analysis and Knowledge Management

8. “Every successful quality revolution has included participation of upper management. We know of no exceptions.” Joseph Juran

9. Leadership • Servant Leadership Philosophy • Leadership Development • Employee/Physician Engagement • Leader Rounding • New Employee Orientation • Extensive Community Outreach

10. “Ninety-five percent of what leaders like you do is pursue operational efficiency. What about strategic positioning?” Dr. Michael Porter – HBS

11. Deployment Development Approve Plan Alignment Entity Plans Approve Plan Prioritization Eight EPP Steps Budget Prioritization Entity Plans Evidence Analysis Workforce Evidence Analysis Budget SWOT OCTOBER SWOT Workforce Evidence Gathering Evidence Gathering

12. Workforce Alignment NMMC Service Line Goals

13. “Your calling is calling……” NMMC-Tupelo Employee Entrance

14. Organizational Culture RECOGNITION & REWARD • Excel – Pay for performance • Team Incentive Plan • Service/Quality • Financial/Growth • CSF – Rewards • Stars Online – More than 5,000 awarded in 2012

15. “The best way to find yourself is to lose yourself in the service of others.” Mahatma Gandhi

16. Relentless Pursuit of Excellent Customer Service • Establish a goal of 95thpercentile in patient satisfaction. 2. Ensure employees understand the survey questions & the required behaviors. 3. Ensure employees know and understand the top three drivers of satisfaction for their area &the required behaviors.

17. “In God we trust; all others must bring data” W. Edwards Deming

18. Comparative Data Evidence-based literature and current practice guidelines Selected external comparative databases Baldrige winners and other industries Above the 90th percentile or top 10%

19. “We are what we repeatedly do. Excellence, then, is not an act, but a habit.” Aristotle

20. Population-focused Work Systems & Collaborative Work Groups

22. Work System Implementation • Trial & scale up • Training • Clinical Educators • Policies, Guidelines & Protocols • Hard-wired order sets & prompts

23. “The achievement of an organization are the results of the combined effort of each individual.” Vince Lombardi

24. Workforce Engagement • Employee Opinion Survey • Leader Rounding • Ideas for Excellence • 99th percentile in Communication

25. Evidence-Based Care

27. Overall Sepsis Mortality

29. Ideas for Excellence & Clinical Process Improvement

30. NMHS Heart Failure Care Transition (30-day readmission rates)

31. Competitor Satisfaction • HCAHPS • Market Share 40.7% • Kaiser Health News – Sixth happiest market in United States

32. It’s All in the Number

35. “To continuously improve the health of the people of our region”

37. HealthWorks! • Interactive children’s health education center • School-based curriculum & community-based programs • Served >78,000 in first three years • Improved diet & health knowledge