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1. The CEO Solutions Series: Actionable Solutions for Senior Leaders The 100 Great Nurses Program Value: The Great 100 Nurses Program provides a terrific low cost, high impact, high return opportunity for hospitals to have an enormous impact on our most valuable and mission critical resource – our workforce. • Message: • Why act now….why not wait….why not pass ? • Act Now: Nursing workforce issues are at the top of the priority list for most leaders. We experiencing great nursing shortages putting tremendous stress on our system and are expending more and more for nursing retention and recruitment. It is going to get worse, because certifying, quality, and payer organizations are paying close attention to this issue and are coupling incentives and penalties to nursing services.Leapfrog has made it a major priority, staff to patient ratios are becoming a key patient safety parameter to JCAHO, and certain payers are getting very aggressive. Malpractice cases are being tied to nursing coverage, Since the cost of the program is approximately $1000 per nurse awarded and there is little risk, this appears to deliver unprecedented value compared to any other program TMIT has seen. • Wait: With replacement costs of $40,000 per nurse, those individuals that have participated in such a program have a hard time understanding why a hospital would not want to start such an initiative. The program is entirely scalable to any community, is run by nurses, and requires no technology. • Pass: The argument for passing on this kind of innovative program could include some form of duplicative initiative or effort. With such an upside and no downside risk any other argument would be weak. • We thank THR for sharing this terrific program with us. • Evidence: • Who… benefits from such a program? • Nurses are recognized for their commitment and service by their peers. This provides terrific community based effort that builds goodwill along the entire healthcare value chain. • Non-nursing workforce is energized by recognition of nurses from their departments. This builds esprit de corp across multiple organizations and addresses critical cultural transformation issues addressed in Pay-For-Performance programs. • Hospitals receive enormous benefitsin terms of reduced costs for nursing retention and recruitment, improved employee satisfaction, emphasis on quality, and improved brand perception in services areas. • Doctors are very supportive of the program in that they recognize the vital importance of nursing care to their patient outcomes. Further they enjoy and appreciate the opportunity of rewarding the high performers. • What….are the key elements of the program: • This is an award program that honors nurses who have made a significant impact on the lives of patients, peers, and the community-at-large. • Nurses are confidentially nominated by any individual from the community or healthcare professions. A nomination form must be completed and accompanied by a one page letter of recommendation which contains the nominee’s name and supportive documentation for the nomination. • A selection committee of healthcare providers is randomly chosen each year who use blinded data. The selections are made on the basis of selection guidelines including: • Service as a Role Model • Leadership Qualities • Service to the Community • Being a Compassionate Caregiver • Significant Contributions to Nursing • An award ceremony is held each year at a local concert hall. Scheduled in early May, it occurs in conjunction with National Nurse’s Week. • Where and when has this solution worked at frontline hospitals? • Originally successful in Louisiana, a Dallas nurse launched the program in the Dallas – Fort Worth region 3-4 in 1991 and has recognized 1400 nurses. Support has been led by Texas Health Resources and other area hospitals. • Offering: • How…..can a hospital get started? • Contacts: • Carol Ferguson, RN Director of Patient Safety and Performance Improvement TMIT Ph. (757) 565-411 carol_ferguson@tmit1.org • Cynthia Harris-Perazzo Ph. 800-793-2647 cynthia_perrazo@Premierinc.com • Web Sites: • www.TMIT1.orgPremier CEO Solutions Series

2. The CEO Solutions Series: Actionable Solutions for Senior Leaders Organ Donation Breakthrough Collaborative: A Great Community Solution Value: There are 86,000 Americans on the waiting list for organs – 17 die every day. There are people waiting in every hospital service area. Our hospitals have been very inefficient at converting eligible donors until now. A new collaborative initiated by the Secretary of Health has achieved amazing results that benefit every stakeholder including hospitals, patients, and the community at large. EVERY HOSPITAL SHOULD CONSIDER THIS PROGRAM. • Message: • Why…..Act now….why not wait….why not pass? • Act Now: The prospect of saving an average of 3.4 lives per donor and as many as 8 lives per donor (heart, 2 kidneys, 2 lungs, pancreas, liver, and small bowel) is terrific. The financial impact is margin neutral or margin positive for almost all hospitals, the program builds an organization’s esteem and performance, and it is just plain the right thing to do. Rarely are there instances in any industry where all stakeholders gain. • Wait on Action: The collaborative may end in 2005 and it will be very difficult for hospitals to adopt the best practices without peer support. With so many preventable deaths of patients waiting for organs, the risk is that a delay in taking advantage of the this opportunity may be counted in deaths. JCAHO will soon make conversion a quality measure and quality organizations considering this metric as well. • Pass: It is almost impossible to make a case for not participating in some way. Even rural or small hospitals with small donor volume likely have people waiting in their community and can generate good will at very low cost or effort by becoming aware of the program. The best practices have low adoption barriers and very little cost. • Evidence: • Who benefits from such a program? • Patients in desperate need of organs receive the gift of life. Virtually every community has patients waiting for organs. • Donor Families have the opportunity of giving the gift of life to as many as 8 people. The average donor saves 3.4 lives! Donor families take great comfort in this gift. They are more satisfied with the care of their loved ones and are less likely to sue than non-donors. • Hospital experience improved employee satisfaction. Nurses, administrators, and physicians take solace from this special and positive aspect of the end of life of their patients. • Communitiesrally around patients on waiting lists. To know that a local hospital is contributing to the donor programs provides a positive public image that benefits all in the community. • What….are the key elements of this solution: • The Organ Donation Breakthrough Collaborative provides the collective input of the best US donor and transplant programs. • New Best Practices that have been developed with world class faculty driven by the Institute for Healthcare Improvement (IHI) model for improvement optimize every step in the process. • A HRSA funded program, it is provided at no cost to hospitals and weaves local Organ Procurement Organizations and hospitals into high performance teams that dramatically increase the conversion of eligible donors to real donors – saving lives and saving money. • Where and when has this solution worked at frontline hospitals? • In less than 1 year as many as 100 hospitals have raised their donation conversion rate from 48% to over 75% saving hundreds of lives. The objective of the program is to drive the conversion rate in the majority of US hospitals over 75%. This is clearly attainable by US hospitals. • Offering: • How…..can a hospital get started? • TMIT has established a one day CEO/Sr. Leader Briefing at the national collaborative meeting in January 2005. The exact date and location is being determined by HRSA. Each hospital senior leader may bring one staff member. They may stay for the whole 2 day meeting. There is no cost. HRSA and Faculty will provide direct one on one briefings. A one day fly in and out program has been designed. • Contacts: • Cynthia Harris-Perazzo Ph.858-945-0539 cynthia_perazzo@premierinc.com • Charles Denham MD 512-479-8508Charles_Denham@TMIT1.org • Jade K. Perdue, M.P.A. National Spread Strategy Leader • 301-443-3124jperdue@hrsa.gov • Resources:www.tmit1.org/PremierCEOSolutions

3. The CEO Solutions Series: Actionable Solutions for Senior Leaders Anti-coagulation Clinics: New Drivers – New Solutions Value: Effective anti-coagulation management will be increasingly important to acute care hospital leaders. It is a key service tied to new Pay-For-Performance (P-4-P)programs, a therapy growing with our aging patient base, and one of the most frequent drugs involved in malpractice cases. There are new drugs on the horizon complicating the issue, however there are solutions that can help hospitals take an organized approach to this area. • Message: • Why act now…why not wait…what if we pass? • Act Now: In addition to preventing adverse events, and law suits a hospital has a robust anticoagulation clinic whereby a majority of the appropriate patients are managed after discharge, they will be prepared to meet future quality and P4P standards. There is still time to establish a program and receive recognition from payers and quality organizations. • Wait: While certain evidence suggests that anticoagulation monitoring will not be necessary with new drugs such ExantaTM, another form of monitoring for liver enzyme levels may be required and will have to be addressed in a similar way. Hospitals that do not coordinate anticoagulation management will be at increased risk of litigation as such systematic management becomes standard of care. • Pass: As time passes the risk will grow and it will be difficult for hospitals to catch up. If a competitor acts first you lose the lead role. • Evidence: • Who benefits from such a program? • The growing number of patients that are inadequately managed due to a lack of a systematic process who face disastrous consequences of preventable GI bleeding, CNS bleeding, and strokes due to clotting. • Hospitals seeking to achieve the top tier performance in P-4-P: Payer programs such as the NQF Safe Practices initiative of the Leapfrog Group have identified this area as a high priority. It requires that hospitals have a systematic anticoagulation management program. • What….are the key new solutions: • Systematic anticoagulation Management (SAM). Originally developed through the Premier Innovation Institute, SAM has four elements: Management by qualified professional, scheduling and tracking, frequent accurate testing, and patient specific support and education. • WebINR is a virtual anti-coagulation clinic, providing a web-based system for patients and physicians. Data is made available to physicians to monitor patient’s INR and provide decision support. WebINR also provides patient tracking, performance reports and patient education material at a low cost. It has demonstrated improvements of “in-range” INR values and reduced morbidity and mortality with patients. • New Drug ExantaTM (Ximelagatran) is a potential replacement which does more required the same monitoring as warfarin. However, recent review by the FDA advisory panel indicates significant delay in its release. Furthermore, it is not indicated for heart valve patients which represent 1/3 of anti-coagulated patients. • Where and when has this solution worked at frontline hospitals? • Loma Linda VAMC have obtain great results using SAM with both reference lab and point of care testing devices – Preceptorship has been established and is open to all. • El Camino Hospital – a 300 bed community hospital - has successfully implemented WebINR to monitor their patients with minimal investment • Offering: • How…..can a hospital get started? • Contacts: • Dr. Alan Jacobson (For Systematic Anti-coag Manag’t course) Ph 909-422-3097akjacobson@linkline.comJerry L. Pettis V.A. Medical Center • Franck Guilloteau, CTO TMIT Ph.512-482-8888 • Franck_Guilloteau@tmit1.org • Resources: • SAM Preceptorship – two day course at $300/person – contact Dr. Jacobson at akjacobson@linkline.com • The Anticoagulation Forum (ACF) is a network of anticoagulation experts who work together to ensure safe and effective antithrombotic therapy for patients all over the country. • The Anticoagulation Therapy Management Certificate Program is a six-week, 40-hour course taught five to six times per year at the University of Southern Indiana School of Nursing and Health Professions • Web Sites: • www.tmit1.org/PremierCEOSolutions • www.acforum.org - Anticoagulation Forum • www.webinr.com – WebINR service • http://health.usi.edu/anticoag/ - Online Anticoagulation Therapy Management Certificate Program

4. The CEO Solutions Series: Actionable Solutions for Senior Leaders Specialty Hospital Dilemma: Solution Options Value: The jury is out regarding the impact of specialty hospitals and the future of the current moratorium, however the best plan of action is clear – general hospitals should aggressively focus on quality solutions in cardiac and orthopedic services. Market forces will dictate the future for general hospitals. They should not delay adoption of performance solutions that drive optimal clinical or process outcomes. • Message: • Why….. Act now….why wait…..why not pass? • This particular report is a work in progress – the picture should clear in the next 180 days regarding the moratorium on specialty hospitals, however it appears that it will be important for all organizations should aggressively concentrate on quality in cardiac and orthopedics services. • Act Now: A MEDPAC report that will be given to the key commissioners who will address the moratorium in March of 2005 will likely express that the impact of specialty hospitals on general hospitals is less impact than lobbyists have said. Further that case volumes will come back. Some feel that the moratorium will be extended past June, however that it may not continue for an extended period. The Pay-For-Performance programs are increasingly focused on cardiac and orthopedic outcome and process measures. They will likely become a major feature to many reimbursement programs in the future. • Delayed Action: It appears risky to delay aggressive focus on these service lines. The technologies are maturing and general hospitals have the opportunity of developing out their service lines during the moratorium so that they can compete regardless of whether the moratorium is lifted or not. • Pass: There appears to be little rationale for inaction at this point regarding performance improvement. Technology selection is most often driven by existing IT architecture, however integrated systems appear to be succeeding over a “best of breed” tack. • Evidence: • Who benefits from seizing performance solutions in cardiac and orthopedic areas? • Hospitals at risk for physician departures should weigh the risk of loss of major referral streams and the impact of the major market shift that can occur. • Hospitals at risk for payer contract market shift should consider the impact of market shifts resulting from public release of quality metrics. • Hospitals in highly competitive markets are rapidly recognizing the serious impact that outcomes can have on their share in highly competitive markets. • What….are the key new solutions: • New Care Models and Best Practices: There are great lessons to be learned from the cardiac and orthopedic specialty hospital experiences. Since they can focus on specific care paths, processes, and quality metrics, they have identified many innovations in care delivery that are transplantable to general hospital service lines. Processes and workflow have been streamlined and hand offs that are a great source of risk for adverse events and rework costs have been minimized. • Digital Hospital Solutions: Specialty hospitals are “fresh build” opportunities that allow them to take advantage of the latest technologies. Filmless organizations can leverage these technologies to remove process steps, re-design processes, and generate unheard of integrated outcomes impact. • Where and when have these solutions had impact at frontline hospitals? • Hospitals like Nebraska Heart Hospital that are “fresh build” examples of simplifying care processes going entirely digital from the start. Although expenditures for IT and modality solutions were 35% of the full cost of the facility, the workflow optimization and improvement in care process resulted in outcomes that rival our leading hospitals in the nation. Customer satisfaction remains in the mid 90% range and staff satisfaction is extraordinary. • Those hospitals that simply install technologies without redesigning care process have not experienced the same gains. • Offering: • We will continue to develop case study examples and decision support information and plan to provide between now and the Premier Governance Conference. • Contacts: • Cynthia Harris-Perazzo Ph.858-945-0539 cynthia_perazzo@premierinc.com • Charles Denham MD Ph 512-479-8508charles_denham@tmit1.org • Resources: • www.tmit1.org/PremierCEOSolutions