2017 BIG DOT Scorecard for CAMCQtr. 1 Qtr. 2 Qtr. 3 Qtr. 4 YTD Target Exceeds Maximum

70% 72% 74%

63% 70% 78%

Achieve DNV Accreditation

Achieve DNV Accreditation with less

than 20 NCs

Achieve DNV Accreditation and ISO Certifiaction

80% Levels1-3 Compliance and

Phase 1 full deployment to 8

inpatient supports

85% Levels1-3 Compliance and

Phase 1 full deployment to 12 inpatient supports

90% Levels1-3 Compliance and

Phase 1 full deployment to 16 inpatient supports

0.80 0.79 0.77

0.71 0.70 0.69

0.0734% 0.0654% 0.0582%

0.895 0.890 0.885

4.02 4.03 4.0446.9% 46.4% 45.9%

85% 87% 89%

All programs accredited

15/15 accredited programs; no

citations

Commendations received in 10/15

programs

$15,752 $15,595 $15,437

$14,875,000 $15,023,750 $15,172,500

$25,000,000 $30,000,000 $35,000,000$19,959,000 $20,158,590 $20,358,180

HCAHPS Patient Experience Composite Score ^

Observed to Expected Mortality

Best Place to Receive Patient-Centered Care

DNV Accreditation and ISO Certification

TCT - Top 5 Board Full Deployment with Assessment Levels 1-3 Compliance and Inpatient Support Services Phase 1 Deployment

CGCAHPS "Timely Appointments, Care and Information" Composite (Q 6,8,10,12,13)

Operating Expense Reduction

Patient Safety Composite

Best Place to Learn

Expense per Adjusted Admission

Excess of Revenue over Expense

Readmissions - 30 Day Observed to Expected

^ HCAHPS quarterly numbers are unadjusted numbers reported by CHERI. (Qtr1 is Oct-Dec 2016; Qtr2 is Jan-Mar 2017; Qtr3 is Apr-Jun 2017; Qtr4 is Jul-Sept 2017)

VBP - Hospital Acquired Infections

Employee Turnover (First year)

Operating Income

Accreditation status of GME programs (15)

Best Place to Work

Best Place to Practice Medicine

Best Place to Refer Patients/Market Growth

Employee Engagement Composite Score

HCAHPS Physician Communication Composite Score ^

CAMC Planning Department - April 1, 2017

Core Values: Quality, Service with compassion, Respect, Integrity, Stewardship, Safety

Best Place to Learn By 2019, CAMC will be recognized as a leading teaching/learning hospital that values and embraces an environment of education, innovation and learning as a strategic advantage to our future success. Learning happens at individual and organizational levels. Strong educational and research partnerships support workforce strategic challenges and performance improvement. Everyone teaches and everyone learns.

Best Place to Work

By 2019, CAMC will be the preferred employer in the region; recognizing the value and professionalism of the people comprising our workforce as the key to delivering quality patient care and excellent service.

Best Place to Receive Patient-Centered Care By 2019, we will achieve QUEST top decile performance in all domains and be recognized as a leader in clinical and service excellence. Our commitment will be evidenced through an engaged workforce who treats everyone to a compassionate, respectful and skillful experience.

Mission: Striving to provide the best health care to every patient, every day. 2017 CAMC Health System Strategic Plan

SO: Improve HCAHPS patient experience results to top decile: 1. Design and implement processes to improve customer convenience and access to services. 2. Improve systems for service recovery at critical patient and family touchpoints through real time customer-driven alerts.

SO: Create transformational change in our processes of care: 3. Achieve DNV accreditation and ISO certification. 4. Strengthen TCT foundation and continued deployment.

SO: Achieve top decile performance on clinical care outcomes: 5. Optimize Cerner and install additional products to reduce variation in care, enhance clinical outcomes, and improve coding and documentation with focus on sepsis, critical care, heart failure, pneumonia, AMI, CABG and COPD. 6. Implement Care Foundations, the Less is Best Campaign, and improve safety systems to reduce harm and improve the safety culture with a focus on CLABSI, CAUTI, CDIFF, DVT/PE, SSI-Colon, PSI 90. 7. Improve the effectiveness of transitions of care to reduce readmissions focusing on Heart Failure, Pneumonia, AMI, CABG, COPD and Hip/Knee through the appropriate use of emergency departments, referring hospitals, skilled nursing facilities, clinics and hospice.

•Patient Experience Composite Score •CGCAHPS “Timely Appointments, Care and Information” Composite •DNV Accreditation and ISO Certification •TCT and Phase 1 to Inpatient Support Departments •Observed to Expected Mortality •Patient Safety Composite •VBP – Hospital Acquired Infections •Readmissions – 30 Day Observed to Expected

Big DOTs

SO: Improve employee satisfaction and engagement to ‘Employer of Choice’: 8. Identify and implement at least one opportunity in each department based on 2016 Employee Survey results to reduce voluntary turnover. 9. Define and implement strategies to create and sustain a culture of professionalism based on core values.

•Employee Engagement Composite Score

•Employee Turnover

SO: Ensure adequate medical resources to meet the needs of current and evolving service delivery and reimbursement models, and create the capability and capacity to respond agilely to healthcare reform: 10. Focus on physician communication as an essential determinant of patient experience. 11. Commit to demonstration of behaviors linked to core values as the foundation of professionalism. 12. Complete revisions to the Medical Staff bylaws in 2017.

SO: Ensure accredited education and research programs and aligned learning forums that address organizational sustainability: 13. Advance integration of research and academic programs into quality and safety priorities and CAMC goals; integrate faculty and residents (QIPS) into structures and process improvement. SO: Create and sustain a clinical learning environment and culture that promotes innovation, patient safety and performance improvement and that fosters individual and organizational learning: 14. Assure accreditation of programs: Improve the clinical learning environment/culture for learners and education affiliates; improve education partnerships to support workforce challenges and address workforce sustainability; improve linkages with CAMC teaching physicians and clinical staff to academic programs. 15. Align leadership development and individual learning to strategic priorities and organizational development and change initiatives. 16. Optimize research potential to address strategic plan, accreditation requirements and to address health disparities and population health initiatives. •HCAHPS Physician

Communication Score

SO: Strengthen competencies for success in the health care reform environment and grow market share in primary and secondary service areas:

SO is Strategic Objective – the 3 year

longer term goal to achieve the

Statement of Direction for the

Pillar.

Annual goals to achieve the Strategic

Objective are numbered under each

Strategic Objective

BIG DOTS are the high level organizational results measures for

each vision pillar.

Goals

Big DOTs Big DOTs

Goals

Goals

Goals

Big DOTs

Big DOTs

•Accreditation status of GME programs

Goals

Best Place to Practice Medicine

By 2019, CAMC will have the capacity and capability to support the practice of medicine in an environment which is based on open communication, mutual respect and patient focused alignment that produces high quality outcomes for the patient experience and engagement/ loyalty of the medical staff.

Vision Pillars

Best Place to Refer Patients/Market

Growth

This is a statement of direction for each

pillar – where do you want to be in 3 years?

MEASURE

ANALYZE

Striving to provide thebest health care to everypatient, every day.

Vision:Charleston Area Medical Center, the best health care provider and teaching hospital in West Virginia, is recognized as the:• Best place to receive patient-centered care• Best place to work• Best place to practice medicine• Best place to learn• Best place to refer patients

Core Values:Service with CompassionRespect QualityIntegrity Stewardship Safety Department Scorecard