The Baldrige Award: One Hospital’s Journey

1. The Baldrige Award: One Hospital’s Journey Presented by Jeanette Spradlin, Vice President, Quality Union Hospital, inc. 2013 Governor’s Award (Platinum Level) Recipient

2. CONFLICT OF INTEREST DISCLOSURE NONE

3. OBJECTIVES: Clarify the link between The Partnership for Excellence and the Malcom Baldrige National Quality Award Link the components of the Baldrige criteria to Union Inc.’s Journey to Excellence Define leadership’s role in the Baldrige journey Describe Union’s journey and how it matures an organization

4. WHO WE ARE UNION HOSPITAL, INC. TERRE HAUTE, IN

5. UNION HOSPITAL, INC. Not-for-profit 350 bed Acute Care Hospital in Terre Haute, IN and a 25 bed Critical Access Hospital in Clinton, IN 2400 Employees 345 Affiliated Physicians Multiple outpatient sites/ physician offices including Cancer Center and Ambulatory Surgery Center Teaching hospital with F.P. Residency program

6. MALCOLM BALDRIGE CRITERIA Established by Congress in 1987, the Baldrige Program is managed by the National institute of standards and technology, an agency of the United State Department of commerce. The program helps organizations improve their performance and succeed in the competitive global marketplace. It is the only public-private partnership and Presidential award program dedicated to improving U.s. Organizations.

7. Performance Excellence Framework Organizational Profile 2 Strategic Planning 5 Workforce Focus 1 Leadership 7 Results 3 Customer Focus 6 Operations Focus 4 Measurement, Analysis, and Knowledge Management

8. Performance Excellence Framework Organizational Profile 2 Strategic Planning 5 Workforce Focus 1 Leadership 7 Results 3 Customer Focus 6 Operations Focus 4 Measurement, Analysis, and Knowledge Management

9. Performance Excellence Framework Organizational Profile 2 Strategic Planning 5 Workforce Focus 1 Leadership 7 Results 3 Customer Focus 6 Operations Focus 4 Measurement, Analysis, and Knowledge Management

10. Performance Excellence Framework Organizational Profile 2 Strategic Planning 5 Workforce Focus 1 Leadership 7 Results 3 Customer Focus 6 Operations Focus 4 Measurement, Analysis, and Knowledge Management

11. Performance Excellence Framework Organizational Profile 2 Strategic Planning 5 Workforce Focus 1 Leadership 7 Results 3 Customer Focus 6 Operations Focus 4 Measurement, Analysis, and Knowledge Management

12. PROCESS CATEGORIES Looking for ADLI Approach Deployment Learning Integration

13. RESULTS CATEGORY Looking for LeTCI Levels Trends Comparisons Integration

14. BALDRIGE SECTORS Manufacturing Service Small business (< 500 employees) Education Healthcare (CREATED IN 1999) Nonprofit/Government

15. ELIGIBILITY REQUIREMENTS AT THE NATIONAL LEVEL Organization a distinct organization or business unit headquartered in the U.S. Existed for at least a year Respond to all 7 categories If activities outside of U.s. have sufficiencies for a full site visit If a recipient share practices at quest for excellence conference Been a baldrige recipient

16. ELIGIBILITY REQUIREMENTS AT THE NATIONAL LEVEL 7. Been a top award recipient from state organization that is a member of the alliance for performance excellence 8. Prior national application with a band score of 8 or higher 9. Received a national site visit 10. Greater than 25% of organization’s workforce is outside of the organization’s home state 11. There is no alliance for performance Excellence award program available

17. Resources / Questions / Discussion Al Faber, President/CEO al.faber@partnershipohio.org (614) 425-7157 Baldrige Performance Excellence Program: www.quality.nist.gov The Alliance for Performance Excellence: www.baldrigepe.org The American Society for Quality: http://asq.org/ www.thepartnershipforexcellence.org 15th Annual Quest for Success Conference Celebrating 15 Years of Performance Excellence! September 15-16, 2014 Polaris Hilton, Columbus, Ohio

18. Our Journey To Excellence INPUTS • Assessment • Training • Tools • Benchmarking • Support MILESTONE World-class Performance 2004 - present • Started attending Days of Sharing at healthcare organizations that were national award recipients • Started attending Quest; became examiners • Attend VHA offerings re. Baldrige criteria 2006 - 2012 • WORLDCLASS HEALTHCARE OUTCOMES • Asked VHA to put together offerings regarding the healthcare criteria and “how to get started:” • Hired Baldrige coaches • Submitted national applications from 2008 – 2012 2014 forward 2013 • OUTSTANDING PATIENT/FAMILY SATISFACTION & ENGAGEMENT • Submit a national application • We continue to prioritize our OFIs in our feedback reports. • We continue to make our approaches systematic with full deployment Late 1990s • Submitted first TPE application • Received Platinum Award • Continuing our efforts • Aware of the Healthcare Criteria • Started learning more about the criteria • OUTSTANDING WORKFORCE OUTCOMES • EFFICIENT AND EFFECTIVE PROCESSES OUTPUTS • Defined processes • Measures • Benchmarks • Improvements • Stakeholder Engagement • OUTSTANDING FINANCIAL PERFORMANCE Why Baldrige? Impacts the entire organization; provides integration with a systematic approach across the organization to reach goals to accomplish mission/vision.

19. At UHI – ANOTHER NAME FOR BALDRIGE As we travel on our Baldrige journey, it is known to staff as our work to become - First, Best … Always.

20. FIRST STEP Creating the organizational profile

21. PROFILE SETS THE STAGE HELPS WITH SELF EVAL. IDENTIFIES GAPS THE APPLICATION FLOWS FROM THE PROFILE Includes: Offerings MVV Workforce Profile Assets Regulatory Requirements Structure Patients, Customers, Stakeholders Suppliers and Partners Competitive Position Competitiveness Changes Comparative Data Strategic Challenges and Advantages Performance Improvement System Core Competencies All in 5 pages

22. Category 1 Leadership 120 points

24. LEADERSHIP MODEL

25. LEADERSHIP1.1 – Senior Leaders Organizational Rhythm Listening and Learning Rounding Engagement with Stakeholders Team Integration Orientation Legal and Ethical Environment Sustainability Performance Improvement Align People and Processes Board Quality Committee Workforce Engagement Robust Learning Leadership Development Innovation and Intelligent Risk Taking

26. OPERATIONAL RHYTHM

27. LEADERSHIP 1.2 – Governance & Societal Responsibility Board Governance Processes How its members represent the community Self Assessments Performance Eval. CEO Charter, Bylaws and Policies Hold SLs responsible – performance goals tied to compensation Community Integration Compliance Address Public Concern Community Support Commitment to Ethical Behavior Caring for the Indigent Environmental Stewards

28. Category 2 STRATEGIC PLANNING 85 points

29. k j • Assess and Set Strategic Direction • All factors from APP plus • Industry Assessment • Community Needs • Competitor Assessment • Detailed StakeholderAnalysis Develop/Refine Objectives and Goals • Critical Success Factors • Objectives and Goals l Align People and Processes • Work Systems • EPM & Key Processes • Action Plans 3 YEAR STRATEGIC PLANNING m Allocate Resources 3-YR Financial Plan • Mission/Vision/Values • Critical Success Factors • Advantages and Challenges • Core Competencies n Evaluate &Improve Operational Rhythm o Assess and Set Annual Direction • Economic Trends • Political and Regulatory Issues • Technology Assessment • Competitor Review • Organizational Capacity & Capability • Workforce Satisfaction / Engagement • Patient Satisfaction / Engagement • Quality Assessment • Mission/Vision/Values • Refined Core Competencies • Advantages/Challenges p Reaffirm /Revise Strategic Objectives ANNUAL PLANNING • Refined CSFs • Refined Objectives and Goals 1 YEAR q Align Processes/People, • EPM and Key Processes • Action Plans and goals r Allocate Resources Annual Budget s Evaluate & Improve Operational Rhythm

30. STRATEGIC PLANNING 2.1 – Strategy Development Focus Groups: Employee Physicians Board Members Employers Vendors Patients/Patients’ Families Community SWOT Analysis Strategic Challenges and Strategic Advantages Develop Objectives, Measures and Goals Allocate Resources Use of Innovation Key Work Systems Align People and Processes Core Competencies

31. STRATEGIC PLANNING 2.2 – Strategy Implementation Action Plans Corporate, Department, Employee Goals Cascade Benchmarks Projections

32. Category 3 CUSTOMER fOCUS 85 points

33. VOICE OF THE CUSTOMER

34. Category 4 Measurement, Analysis, and Knowledge Management 90 points

35. PERFORMANCE MEASUREMENT, ANALYSIS AND REVIEW SYSTEM

36. ProposedMeasure Measurement Selection Process Actionable? Stakeholder*/ Regulatory Requirement? No Yes Yes Not Selected No No No No SupportsBreakthrough SPP Goal? Critical to Run the Business? No Yes Yes Ye Selected Change the Business Measure Selected Run the Business Measure

37. LEVEL 1 = External and world class LEVEL 2 = External but not world class LEVEL 3 = Internal comparison LEVEL 4 = No comparison Optimal Comparative Database Exists ESTABLISHING BENCHMARKS Is it External? yes no Select most meaningful comparison –Level 3 Determine who to compare to: 1) Inter-entity; 2) Inter-departmental; 3) Historical performance No comparison –Level 4 If World Class – Level 1 Evaluate for: 1) Size, Validity, Reliability; 2)Comparable in structure; 3) Relevance to competitors 4)Ability to segment and statistically analyze; 5) Cost/benefit If not World Class – Level 2 Set Target at Top 10% (or interim goal if gap is large) Set Stretch Goal LEVEL 1 = External and world class LEVEL 2 = External but not world class LEVEL 3 = Internal comparison LEVEL 4 = No comparison

38. KNOWLEDGE MANAGEMENT, INFORMATION and IT Sharing the Message - Workforce Knowledge Data Management Requirements Emails, scorecards, screen savers, State of the Union, Weekly Briefings Leadership meetings, Shared Governance Daily Check In Storytelling Accuracy Integrity/Reliability Timeliness Safety/Confidentiality Data Center Elements; software and hardware requirements Technology Today

39. Category 5 Workforce Focus 85 points

40. WORKFORCE SYSTEM

41. Workforce Environment Effective and Supportive Capability/Capacity; New WF Members Accomplishments; Change; Environment Quarterly C/C reports Grow Our Own Electronic employment forms Preceptor and mentors Onboarding for retention; 60 day touch base Alignment of goals – electronic tracking tied to performance evaluations Transparent and collaborative culture Employee wellness program; incentive on insurance premiums Disease Management Pt. Safety and Satisfaction Ambassadors Concierge, 26 Fund

42. Workforce EngagementOrganization and Personal Success Engagement; Culture; Performance Mgmt. Learning/Development; Career Progression Surveys Action Plans Recognition and Rewards Leadership Team – minutes out to all State of the Union Doc Talks, Weekly Briefings Standards of Excellence Teamwork Performance Manager Succession Planning Leaders on the Horizon LDI Clinical Educators Electronic Education Tuition Reimbursement

43. Category 6 Operations focus 85 points

44. PROCESS BASED MANAGEMENT (PBM)

45. Union Hospital Enterprise Process Model (Revised August 22, 2013) 1.0 Lead the Organization • 1.1 Perform Strategic Planning • 1.1.1 Set strategic direction • 1.1.2 Set objectives and goals • 1.1.3 Align systems to deploy strategy • 1.1.4 Evaluate and Improve 1.2 Deliver Organizational Excellence 1.2.1 Ensure Safety and Deliver Quality 1.2.2 Innovate Purposefully 1.2.3 Ensure Knowledge Management 1.3 Recruit, Engage, and Align Physicians 1.4 Communicate effectively 1.5 Ensure Legal, Ethical Behavior and Regulatory Compliance 1.6 Ensure organizational governance 1.7 Develop and maintain government and industry relationships 2.0 Create Strategic Alignments for Health Services 3.0 Assess, Develop Service Lines & Market 4.0 Build and Sustain Patient / Stakeholder Relationships 5.0 Provide Entry to Health Care 6.0 Deliver Health Care 7.0 Transition of Care 3.1 Understand markets, customers and capabilities 3.2 Develop health care services and service lines 3.2.1 Reinforce service line Infrastructure 3.2.2 Balance Goals 3.2.3 Link Care Continuum 3.2.4 Engage Physicians 3.2.5 IntegrateReferral Sources 3.2.6 Strengthen Customer Service 3.2.7 Build Brand Strategy 3.3 Manage and align the health care services portfolio and service lines 3.4 Develop marketing strategy, forecast, and plans 2.1 Conduct SWOT to identify continuum of services offered 2.2 Determine which services will be delivered within Union 2.3 Determine which services will be provided through strategic alignments 2.4 Identify potential strategic alignments 2.5 Develop and sustain strategic alignments 2.6 Support Key Communities 2.6.1 Improve health of the community 2.6.2 Provide community support and volunteerism 4.1 Develop customer service strategy 4.2 Deploy customer service strategy 4.3 Measure and evaluate customer service 5.1 Provide information on service availability and cost 5.2 Admit / Place 5.2.1 In-patient and OP admissions 5.2.2 In-patient and OP external source admissions 5.2.3 Emergency Department admissions 5.2.4 Mother/Baby admissions 6.1 Clinically assess patient and develop plan of care 6.2 Conduct discharge planning 6.3 Manage and provide treatment and care 6.2.1 In-Patient 6.2.2 Ambulatory Surgical 6.3.3 Out-patient 6.3.4 Emergency 6.3.4 Home/Health Hospice 6.4 Provide Case Management 6.5 Provide in-patient non-direct services (food, chaplain, cleaning etc.) 6.6 Educate patients and families 6.7 Manage patient medical information 7.1 Discharge / Exit 7.2 Transfer 7.2.1 Inpatient 7.2.2 Ambulatory/ Surgical 7.2.3 Outpatient 7.2.4 Emergency 7.2.5 Home Health, Hospice 7.3 Maintain relationships 7.3.1 Inpatient 7.3.2 Ambulatory/ Surgical 7.3.3 Outpatient 7.3.4 Emergency 7.3.5 Home Health/ Hospice

46. Union Hospital Enterprise Process Model (Revised August 22, 2013) 8.0 Deliver Human Resource Services 9.0 Deliver Financial Services 10.0 Deliver IT 11.0 Provide & Manage Facilities & Equipment 12.0 Deliver Supplier Chain Management 13.0 Manage Organizational Risk 8.1 Develop and manage HR planning, policies, and strategies 8.2 Recruit, select and onboard workforce 8.3 Develop, coach and counsel workforce 8.4 Reward, Recognize and retain workforce 8.4.1 Provide benefits 8.4.2 Manage workforce satisfaction/ engagement processes 8.5 Manage promotion/ reassignment and separation process 8.6 Manage employee information 8.6.1 Manage employee licensure and certifications 8.6.2 Manage employee competency 8.7 Ensure workforce safety, security and wellness 8.8 Provide administrative duties 9.1 Perform planning & management accounting (Controller) 9.2 Perform revenue cycle management 9.3 Perform general accounting & reporting 9.4 Manage fixed assets and capital project accounting 9.5 Manage payroll 9.6 Process accounts payable and expense reimbursements 9.7 Manage treasury operations 9.8 Manage internal control 9.9 Manage taxes 9.10 Medicare/Medicaid cost reporting 10.1 Manage IT strategy and governance (Dir. Of IT) 10.2 Develop & manage IT service relations 10.3 Develop & manage IT vendor relations 10.4 Manage business resiliency and risk 10.5 Manage organization information 10.6 Develop & deploy Business solutions (Controller) 10.7 Maintain business solutions 10.8 Deliver & support IT service 10.9 Manage IT knowledge 11.1 Design, construct, and/or acquire facilities (Dir. Of Plant) 11.2 Maintain facilities and equipment 11.3 Perform biomedical testing / preventive maintenance 11.4 Monitor and manage environmental health and safety 11.5 Dispose of facilities 12.1 Develop sourcing strategies 12.2 Select suppliers/partners 12.3 Negotiate and manage contracts 12.4 Procure materials and services 12.5 Evaluate material / service and provide feedback to suppliers/partners 12.6 Receive, and distribute materials / services 12.7 Manage logistics and warehousing 13.1 Establish organizational risk framework 13.2 Manage operational risk 13.5 Manage liability coverage 13.6 Ensure emergency / disaster preparedness 13.7 Credentialing and privileging 13.8 Conduct Peer Review

47. SWIMLANE CORRIDOR 150 feet of process maps 31 key processes

48. SWIMLANES

49. Category 7 Results 450 points

50. 7.1 Healthcare & Patient Focus Results; Work Process Effectiveness Results; Supply-Chain Mgmt. Results 40 Graphs CMS Indicators Risk Adjusted Complication Index Patient Safety Results Risk Adjusted Mortality Index LOSVAT Savings Door to Doc Times Ortho Implant Spend Pharmacy Supply Fill Rate Clinical Pharmacy Interventions Lab TATs Uptime for Critical IT Systems Emergency Preparations Go back to the profile and think about your main services, CSFs, core competencies, key stakeholders Data must be segmented and appropriate comparisons given Data must include trends over time