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DRAFT

DNV GL - Healthcare CAMC Health System’s Baldrige Journey

DNV GL © 2016 © Det Norske Veritas AS. All rights reserved Slide 2 31 March 2016

The Broader View of DNV GL

Reducing uncertainty, increasing safety Improving efficiency Enabling sustainability

Building trust

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Management System can be used to:

Improve systems, processes and efficiency and effectiveness

Identify objectives and focus needs and expectations of patients/customers

Achieve and maintain the desired quality of services to consistently meet customers’ stated and implied needs

Provide a common framework for coordination and communication between units/departments and healthcare organizations, (tear down silo’s)

Slide 3

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Integrated Accreditation Model

Integrates ISO 9001 and NIAHO®

– ISO 9001 provides the framework for a sustainable regulatory compliance

– ISO 9001 allows healthcare organizations to use its combined knowledge, wisdom, and innovation to improve quality and safety

– ISO 9001 is the framework within which methodologies such as LEAN and Six Sigma are better understood and utilized

ISO determines WHAT has to be done but leaves the HOW up to you – YOU DECIDE!

There are two ways to implement ISO – #1 to be compliant during a survey or #2 to drive performance

Performance driven systems produce compliance as a natural outcome

Introduction of Charleston Area Medical Center

4

CAMC’s Baldrige Journey:

ENGAGING THE ENTIRE ORGANIZATION IN PERFORMANCE IMPROVEMENT

Dr. Glenn Crotty Executive Vice President and COO Brenda Grant Chief Strategy Officer DNV GL Webinar March 31, 2016

MISSION AND VISION

Mission: Striving to provide the best health care to every patient, 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.

VALUES Quality

Service with compassion Respect Integrity

Stewardship Safety

CAMC SERVICE AREA West Virginia’s Population: 1.8 million Primary and Secondary Service Area: 557,328

Cabell

Mingo

Lincoln Wayne

Wirt

Jackson

Kanawha

Roane

Ritchie Wood

Boone

Raleigh

Wyoming

McDowell

Logan

Mercer

Clay

Gilmer Upshur

Lewis

Calhoun

Braxton

Webster

Pocahontas Nicholas

Tyler

Doddridge Harrison Taylor

Barbour

Monroe

Greenbrier

Summers

Fayette

Ohio

Monongalia

Wetzel

Marshall

Brooke

Hancock

Marion Preston

Pendleton

Mineral

Grant

Hardy Tucker

Randolph

Jefferson

Berkeley

Morgan

Hampshire

Mason

Pleasants

Putnam

Primary Service Area Secondary Service Area

• 48 Ambulatory Sites • Provider Based • Imaging, Urgent Care, Laboratory

• 40,000 Inpatient Visits • 690,000 Outpatient Visits • 115,000 Emergency

Department Visits

• 4 Acute Care Hospitals • 908 Total Beds

CAMC GENERAL HOSPITAL

Lincoln

Jackson

Kanawha

Roane

Boone

Raleigh Logan

Mercer

Clay

Nicholas

Fayette

Putnam

• 268 Beds • Neuroscience • Orthopedics • Bariatric Surgery • Trauma 3,200 + trauma

patients admitted each year

• Primary Stroke Center • Kidney Transplant • Medical Rehabilitation

CAMC MEMORIAL HOSPITAL

Lincoln

Jackson

Kanawha

Roane

Boone

Raleigh Logan

Mercer

Clay

Nicholas

Fayette

Putnam

• 424 beds • Heart and Vascular Center

– 8,475 procedures performed in Cardiac Cath Labs

– 1,210 Open Heart Bypass procedures

• Peripheral Vascular Center of Excellence

• Oncology • CAMC Cancer Center

– 30,986 CAMC Cancer Center encounters

CAMC WOMEN & CHILDREN’S HOSPITAL

Lincoln

Jackson

Kanawha

Roane

Boone

Raleigh Logan

Mercer

Clay

Nicholas

Fayette

Putnam

• 146 Beds • >2,600 Babies delivered every year • 543 Neonatal Intensive Care Unit

admissions • Pediatric Intensive Care Unit

CAMC TEAYS VALLEY HOSPITAL

Lincoln

Jackson

Kanawha

Roane

Boone

Raleigh Logan

Mercer

Clay

Nicholas

Fayette

Putnam

• 70 Beds • Community Hospital

CAMC Health System, Inc.

CAMC Health Education &

Research Institute, Inc.

Charleston Area Medical

Center Foundation,

Inc.

Integrated Health Care

Providers, Inc.

Charleston Area Medical Center, Inc.

CAMC General Hospital CAMC Memorial Hospital

CAMC Women and Children’s Hospital CAMC Teays Valley Hospital

PERFORMANCE IMPROVEMENT JOURNEY

2000 Six Sigma

2005 Baldrige Journey Begins

2007 Lean

2008 Transforming Care Together

2012 Focus On Baldrige

Processes & Systems

2015 Malcolm Baldrige National

Quality Award

PERFORMANCE IMPROVEMENT JOURNEY

2000 Six Sigma

2005 Baldrige Journey Begins

2007 Lean

2008 Transforming Care Together

2012 Focus On Baldrige

Processes & Systems

2015 Malcolm Baldrige National

Quality Award

TRIPLE AIM

Patient Experience Cost of Care

Quality

TRIPLE AIM

Quality Inpatient Overall Quality - Local Competitors

TRIPLE AIM Cost of Care

Cumulative Savings = $177,019,702 2015 Savings = $21,216,254

Cost Reductions

TRIPLE AIM

Patient Experience

2011 2012 2013 2014 2015 1

2

3

4

5

SCO

RE

CAMCHS Top 10%

G

OO

D

Employee Satisfaction Overall

TRIPLE AIM Patient Experience

HCAHPS Likeliness to Recommend Women and Children’s Hospital

Importance of Organizational Learning and Agility . . .a Baldrige

Core Value

“If the rate of change on the outside exceeds the rate of change on the inside, the end is near.” Jack Welch, Former Chairman and CEO General Electric Corp.

Embracing the Baldrige Approach

Our organizational performance accelerated

as we became process driven and integrated

the Baldrige processes and systems

throughout our organization.

BALDRIGE AND ISO

ISO and Baldrige ISO 9001:2015 Audit Questions

1. What can you tell me about the context of your organization?

2. Who are your interested parties and what are their requirements?

3. What risks and opportunities have been identified, and what are you doing about them?

Baldrige Criteria 1. Organizational Profile:

Organizational Description and Situation

2. P.1b(2) Patients, Other Customers and Stakeholders (Who are they and what are their key requirements?) P.1b(3) Suppliers and Partners (Who are they, what role do they play, what are key supply chain requirements?)

3. Organizational Situation: Competitive Environment and Strategic Context Category 2: Strategy Considerations

ISO and Baldrige ISO 9001:2015 Audit Questions

4. What plans have been put in place to achieve quality objectives?

5. How has the QMS been integrated into the organization’s business processes?

6. How do you manage change?

7. How do you capture and use knowledge?

Baldrige Criteria 4. Category 2: Strategy Key Strategic

Objectives and Action Plans

5. Organizational Profile: P.2c Performance Improvement System – What are the key elements of your PI system, including processes for evaluation and improvement?

6. Category 5: Workforce 5.1a(4) Change Management

7. Category 4.2a(1) Organizational Knowledge Knowledge Management

ENTERPRISE MODEL

ENTERPRISE MODEL

ENTERPRISE MODEL

ENTERPRISE MODEL

TRANSFORMING CARE TOGETHER

TCT is CAMC’s approach to redesigning our work processes in support of our mission “striving to

provide the best health care to every patient, every day.”

GOALS FOR TCT 1. Increasing direct time with the patient. 2. Decreasing non-value added activity

(waste). 3. Increasing employee engagement in

improvement activity. 4. Standardizing processes to deliver

repeatable and predictable results.

FOUNDATION FOR LEAN

• 5S Workplace Organization • Standardization

• Visual Management

• Problem Solving

• Human Centered Work

5S Workplace Organization Standardization Visual

Management

Problem Solving

Just in Time

Built in Quality

Continuous Improvement

Highest Quality Healthcare

Human Centered Work

FOUNDATION FOR LEAN

5S Principles 1. Sort (Removal) 2. Set In Order (Orderliness) 3. Shine (Cleanliness) 4. Standardize (Adherence) 5. Sustain (Self-Discipline) 5S is the key to Workplace Organization

RN DIRECT PATIENT CARE TIME

PERFORMANCE IMPROVEMENT BREADTH AND DEPTH

STRATEGIC PLANNING AND DEPLOYMENT PROCESS

DEPLOYMENT PROCESS

Pillars Strategic Objectives BIG DOTS (4 Year)

System Goals BIG DOTS (1 Year)

Entity Action Plans Entity Scorecard (1 Year)

Department Action Plans Department Scorecard (1 Year)

Individual Performance Planner (All Employees) Individual Scorecard (Managers)

SYSTEM LEVEL Strategic

SYSTEM LEVEL Operational

ENTITY LEVEL Operational

DEPARTMENT LEVEL Operational

INDIVIDUAL LEVEL Operational

GOAL CASCADE PROCESS INDIVIDUAL SCORECARDS

• CEO and COO • Entity Vice-Presidents • Associate Administrators

GOAL CASCADE MEETINGS

Half day meetings with Department Managers

GOAL REPORTING SYSTEM Report quarterly

TOP 5 BOARD

TOP 5 BOARD SAFETY CROSS • Effectiveness: An important

tool to know if the safety bundle is being followed on each shift.

• Only green if all parts of the bundle are completed; serves as an internal audit tool for key processes of care.

• Addresses accountability as the issue is discussed with the involved individual(s) that day.

RESULTS

COMPARION

2011 2012 2013 2014 2015 0.0

0.2

0.4

0.6

0.8

1.0

OB

SERV

ED T

O

EXPE

CTED

RA

TIO

CAMCHS

G

OO

D

1,923 lives saved from

2011 to 2015

Inpatient Mortality

RESULTS Inpatient Overall Quality - Local Competitors

COMPARION

RESULTS

COMPARION

2011 2012 2013 2014 2015 1

2

3

4

5

SCO

RE

CAMCHS Top 10%

G

OO

D

Employee Satisfaction Overall

OUR LEARNING… • Engage leaders as owners. • Identify key organizational issues and

systems that need improvement. • Line of sight from strategic plan to everyday

work. • Focus on the few. • Use culture to drive change. • Communication and transparency. • Innovate for the future.

Dr. Glenn Crotty, FACP, MBNQE Executive Vice President and Chief Operating Officer CAMC Health System, Inc. PO Box 1547 Charleston, WV 25326 glenn.crotty@camc.org | 304-388-7647 Brenda Grant, BSN, MBA Chief Strategy Officer CAMC Health System, Inc. PO Box 1547 Charleston, WV 25326 brenda.grant@camc.org | 304-388-7885

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Questions?

49

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