Download - Andrew Stephen May, M.D., FAAFP Sullivan County Regional Health Department October 9, 2012
TN Quality ForumHolding the gains
Andrew Stephen May, M.D., FAAFPSullivan County Regional Health DepartmentOctober 9, 2012
Mission, Vision, Values
MISSION: To identify and respond to the public health needs and improve the public health status of Sullivan County citizens through education and service with a highly motivated and well trained workforce. (The two key elements are our customers and our employees.)
VISION: To be a national model and leader in providing public health services.
VALUES: Service: Caring and compassion to all our customers Leadership: Through collaboration and innovation
Fiscal Responsibility: Stewards of public money Integrity: Honesty in all we do
Excellence: Pursuing a higher professional standard
CORE COMPETENCIES: Education Prevention Community Need Workforce
The Sullivan Health Way Journey to Excellence
2002: Changes in Senior Leadership (Regional Director and Medical Director)
2002 – 2004: First Strategic Planning Retreat, MVV Creation
2005: Level l – Interest Award
2007: Level 2 – Commitment Award
2008-2010: WORK WORK WORK towards improving!
2011: Level 3 – Achievement Award
2012 : WORK WORK WORK towards improving!
Figure 1.1-1 Key Result Areas
Public Health and Baldrige Integration
GPI’s DPI’s Customer Satisfaction Survey C3 Stakeholder Satisfaction Survey Workforce Engagement
Survey Healthy Rounding
Assessments
Receiving and Assessing Patients Delivery of Clinical Services Billing and Fiscal Management Education of Patient and Community Community Partnering
Key Work Processes Work System Design
Figure 1.1-1 Figure 6.2-1
Continuous Process Improvement
Plan-Do-Check-Act Performance Improvement Teams (PIT’s)
Continuous Process Improvement
Plan-Do-Check-Act Performance Improvement Teams (PIT’s)
Continuous Process Improvement Model
DefinitionHistory7 componentsRelevance to our missionRelevance to organizational viability
Why EPSDT?(Early Periodic Screening, Diagnosis & Treatment)
A better understanding of the Baldrige Criteria helped SCRHD to streamline strategic objectives from 7 pages down to 1. You cannot do it all at once!
Last Updated 23 January 2009
Performance
Graph &
Strategic
Action
Mgt.
Measures forTrend
Target
DataTarget
Text
Objectives
Plan
Steward
SO
0506
07+/-
0809
0607
Reference
KSO
1.) Train staff on Performance
Management System
UShort May
Percent of staff trained
2008
2.) Support at least three (3) SLs to serve
on the TNCPE Board of Examiners Short Mayes
Number of TCNPE examiners
2009
1.) Deploy the use of DPIs and action
plans to all departments U
Short / LongMcElyea
% APs developed per 1/4
% APs implemented per 1/4
2008-2010
2.) Implement communication & feedback
of strategic planning process with
stakeholder groups (Staff, HC, CC, TDH) Short Mayes
% of stakeholder groups
completed per SPP calendar
(Figure 2.1-1)
2009
(c) Increase the utilization
of continuous process
improvement across all
departments.1.) Reenforce process improvement
system and tools with staff through
various workshops
Short/ LongMay
*Percent of staff trained
*Number of PIs utilized by
individuals & teams
2008-2009
Legend: KRA = Key Result Area; Term: short (1 yr) or long (3 yr); SO = strategic objective; Mgt. Steward = Management Steward; Status (U = underway; C = Completed; % = percent complete)
Blue=Missing or Unavailable; Green=On-Target; Yellow=Alert; Red=At risk/adverse; * = YTD
KRA 1: Management Practice
(b) Increase the utilization
of strategic planning and
action plan deployment
across all stakeholder
groups.
KRA
Term
1
(a) Enhance organizational
effectiveness through the
adoption of Performance
Excellence principles.
Sullivan County Regional Health Department Strategic Objectives and Action Plan Deployment Matrix
Mission : To identify and respond to the public health needs and improve public health status of Sullivan County citizens through education and service with a highly motivated and well trained workforce.
Vision: To be a national model and leader in providing public health services.
AP S
tatu
s
Past, Present & Target
Benchmark
Last Updated 23 January 2009
Performance
Graph &
Strategic
Action
Mgt.Measures for
Trend
TargetData Target
Text
Objectives
Plan
Steward
SO05 06 07 +/- 08 09 06 07
Reference
KSO
1.) Create Workforce Development Plan
(Michelle to fill in sub elements)
U Short HughesCompleted plan
2008-2009
2.) Establish employee turnover targets
based on revised assessment of T/O.
HOW ARE WE REDUCING??
PROCESS?
U Long HughesTurnover rate (revised)
18% 23% 21% -15% 11% 10% 18%
2008-2009
3.) Improvement plan formulation based
on key theme findings from Workforce
Engagement Survey.
Short Hughes* Completed (documented)
process
2009
4.) Development and Deployment of
"Healthy Rounding" Process.
Short PEC Steering
Group
Number of Rounds performed
every quarter.
2009
Legend: KRA = Key Result Area; Term: short (1 yr) or long (3 yr); SO = strategic objective; Mgt. Steward = Management Steward; Status (U = underway; C = Completed; % = percent complete)
Blue=Missing or Unavailable; Green=On-Target; Yellow=Alert; Red=At risk/adverse; * = YTD
KRA 2: Human Resource Development
Sullivan County Regional Health Department Strategic Objectives and Action Plan Deployment Matrix
Mission: To identify and respond to the public health needs and improve public health status of Sullivan County citizens through education and service with a highly motivated and well trained workforce.
Vision: To be a national model and leader in providing public health services.
AP
Stat
us
Past, Present & TargetBenchmark
KR
A
Term
2
(a) Create a workforce
development plan with a
special focus on employee
communication, retention,
competencies, and
recognition.
Last Updated 23 January 2009
Performance
Graph &
StrategicAction
Mgt. Measures for TrendTarget Data Target Text
ObjectivesPlan
StewardSO
05 06 07 +/- 08 09 06 07 Reference
KSO1.) Government Revenue
Long Mayes Every three year evaluation of program funding
2012
2.) Private Revenue Short/Long
Mayes EPSD&T #'S, FP #'S, WIC #'S, DENTAL #'S
2009
3.) Expense RevenueShort/Long
Mayes Captial, Daily, & Program Expenses; Rehire/Workforce Replacements
2.) Increase capacity for grant writing across the organization Long Mayes Hire grant writer by 2009 2009
Legend: KRA = Key Result Area; Term: short (1 yr) or long (3 yr); SO = strategic objective; Mgt. Steward = Management Steward; Status (U = underway; C = Completed; % = percent complete)
Blue=Missing or Unavailable; Green=On-Target; Yellow=Alert; Red=At risk/adverse; * = YTDKRA 3: Financial Systems
(a) Maintain financial stability through improved financial reporting, capitol improvement & financial management.
KR
A
Term
3
Sullivan County Regional Health Department Strategic Objectives and Action Plan Deployment Matrix
Mission: To identify and respond to the public health needs and improve public health status of Sullivan County citizens through education and service with a highly motivated and well trained workforce.
Vision: To be a national model and leader in providing public health services.
AP
Stat
us
Past, Present & Target Benchmark
Last Updated 23 January 2009
Performance
Graph &
StrategicAction
Mgt.Measures for Trend
Target Data Target Text
ObjectivesPlan
StewardSO
05 06 07 +/- 08 09 06 07 Reference
KSO
(a) Increase system-wide
reliability, availability and
redundancy
1.) Enhance 5 YR IT Plan (Thomas to
provide sub DRAFT elements)
U Short Shaffer Plan approved by LT
2009
1.) Shared Health & eRXLong May
2008-2009
2.) CareSpark IntegrationLong Shaffer
2008-2010
3.) Exploration of EMRLong Shaffer
2011-2012
(c) Maintain mechanisms
that communicate public
health status and health
information for key
stakeholders
1.) Reevaluate community health status
data and follow through with
dissemination
Long May/McElyea Successful reevaluation and
distribution of HSD (both on-
line & hard)
end 2009
1.) Complete deployment for
organizational learning and share drive
utilization.
U Short/ Long
May 1.) Completion of written
process that describes
organizational knowledge
2009
2.) Modify Sullivan County Regional
Health Department Intranet to promote
effective and efficient access to
organizational information.
Short Shaffer 2.) Completion of Intranet
modifications
2008-2009
3.) Deploy use of crystal reporting for
performance management measures
(DPI's)
Long May/McElyea/
Shaffer
3.) Completion of electronic
performance management
reporting system.
2009
Legend: KRA = Key Result Area; Term: short (1 yr) or long (3 yr); SO = strategic objective; Mgt. Steward = Management Steward; Status (U = underway; C = Completed; % = percent complete)
Blue=Missing or Unavailable; Green=On-Target; Yellow=Alert; Red=At risk/adverse; * = YTD
KRA 4: IT and Data System
(b) Develop and integrate
plans for an electronic
medical record (WHAT TO
CALL THIS: ELECTRONIC
MEDICINE…)
4
(d) Enhance organizational
knowledge system
Sullivan County Regional Health Department Strategic Objectives and Action Plan Deployment Matrix
Mission: To identify and respond to the public health needs and improve public health status of Sullivan County citizens through education and service with a highly motivated and well trained workforce.
Vision: To be a national model and leader in providing public health services.
AP
Stat
us
Past, Present & TargetBenchmark
KR
A
Term
Last Updated 23 January 2009
Performance
Graph &
Strategic
Action
Mgt.Measures for
Trend
TargetData Target
Text
Objectives
Plan
Steward
SO
05 06 07+/-
0809
0607
Reference
KSO
1.) Continue deployment of patient
satisfaction survey and action planning of
survey themes and findings. Short McElyeaCompleted process
--
-
+
2009
2.) Deployment of patient real-time
feedback process
Short McElyeaDeployment and utlization real-
time process
2009
3.) Train staff on best practices for
customer relationship building. Long Honeycutt1.) Percent of staff trained on
best practices, 2.) customer satisfaction rates
2008-2010
Legend: KRA = Key Result Area; Term: short (1 yr) or long (3 yr); SO = strategic objective; Mgt. Steward = Management Steward; Status (U = underway; C = Completed; % = percent complete)
Blue=Missing or Unavailable; Green=On-Target; Yellow=Alert; Red=At risk/adverse; * = YTD
KRA 5: Customer Focus and Satisfaction
(a) Clarify expectations (survey) and improve customer (patient/ stakeholders) satisfaction
to enhance loyalty
KR
A
Term5
Sullivan County Regional Health Department Strategic Objectives and Action Plan Deployment Matrix
Mission: To identify and respond to the public health needs and improve public health status of Sullivan County citizens through education and service with a highly motivated and well trained workforce.
Vision: To be a national model and leader in providing public health services.
AP
Stat
us
Past, Present & TargetBenchmark
Last Updated 23 January 2009
Performance
Graph &
Strategic
Action
Mgt.
Measures forTrend
TargetData Target
Text
Objectives
Plan
Steward
SO
0506
07+/-
0809
0607
Reference
KSO
6
(a) Strengthen Key
Communities
1.) Continue process to ensure that
SCRHD is represented and engaged on
all defined key community outreach
programs via gap analysis for any missed
opportunities or groups
Long MayTBD
2009-2010
Legend: KRA = Key Result Area; Term: short (1 yr) or long (3 yr); SO = strategic objective; Mgt. Steward = Management Steward; Status (U = underway; C = Completed; % = percent complete)
Blue=Missing or Unavailable; Green=On-Target; Yellow=Alert; Red=At risk/adverse; * = YTD
KRA 6: Public Health Capacity
Sullivan County Regional Health Department Strategic Objectives and Action Plan Deployment Matrix
Mission: To identify and respond to the public health needs and improve public health status of Sullivan County citizens through education and service with a highly motivated and well trained workforce.
Vision: To be a national model and leader in providing public health services.
AP
Stat
us
Past, Present & Target
Benchmark
KR
A
Term Last Updated 23 January 2009
Performance Graph &Strategic Action Mgt. Measures for Trend Target Data Target Text
Objectives Plan Steward SO 05 06 07 +/- 08 09 06 07 ReferenceKSO1.) Reevaluation of Community Health Status and Priorities
Short May/McElyea Completed evaluation 2011
2.) develop process for updating statistical graphs and tables
Short McElyea Completed process 2009
1.) Review immunization program processes and implement improvements -- including facilitating improve private sector immunization rates. (DR. MAY TO AP NOTES FROM 1/12 IMMUNIZATION MEETING)
Long Williams/May Immunization rates (for both HD clients and community-wide)
2009
2.) Increase capacity for dental services to uninsured
Short/ Long
Honeycutt dental encounters 957/NA 1043/NA 1200/NA + 1300 1400 1100 2009-2010
3.) Explore feasibility of satellite health department in Bristol, TN.
Long Mayes 2011-2012
Legend: KRA = Key Result Area; Term: short (1 yr) or long (3 yr); SO = strategic objective; Mgt. Steward = Management Steward; Status (U = underway; C = Completed; % = percent complete)Blue=Missing or Unavailable; Green=On-Target; Yellow=Alert; Red=At risk/adverse; * = YTD
KRA 7: Health Status
(a) Continue process for evaluating health status and developing priorities that impact public health
outcomes.
7(b) Enhance services and outputs that impact public health outcomes
Sullivan County Regional Health Department Strategic Objectives and Action Plan Deployment MatrixMission: To identify and respond to the public health needs and improve public health status of Sullivan County citizens through education and service with a highly motivated and well trained workforce.
Vision: To be a national model and leader in providing public health services.
AP
Stat
us Past, Present & Target Benchmark
KR
A
Term
EPSDT Results
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 YTD
Ex-pected Year End
0
200
400
600
800
1000
1200
1400
1600
1800
2000
1056
883
579
690
1222 1264
16751749
1828
846
1692
EPSD&T Count
Sullivan County Washington County (NER) Jackson Madison County
Exa
ms P
erf
orm
ed
How did we do it?
Paper reduction Clinical efficiency flow through Missed opportunity reduction Open Access TENNderCare Outreach Collaboration TennCare Insurance
providers Summer EPSDT Days Telephone update Clinic reorganization
Appointment Show rate (FP)Appointment Show rate (FP)Appointment Show Rates (Family Planning)
66%
84%83%
72%
66%
79%
88%89%
86% 86%87%
81%
68%
82%84%
85% 85%
88%
84%
69%
66%
85% 86% 85% 86% 86% 86%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
Blountville Kingsport SCRHD Best in State
Open access
EPSD&T Count
16751739
579
883
1056
690
12221264
1828
0
200
400
600
800
1000
1200
1400
1600
1800
2000
2003 2004 2005 2006 2007 2008 2009 2010 2011
Exam
s Per
form
ed
Sullivan County
A team was assembled to improve the EPSD&T process including streamlining of required paperwork.
Hold the gains strategies
Sharing of data with staff Celebrating success Performance Improvement Teams (PITS) Positive health results from patients with
stakeholders Revenue benefits for organization Sharing customer feed back via our C3
process and customer surveys
Challenges
Increased outside physician participation Approaching maximal staffing production Declining numbers of children population Measures update, numbers vs percentage EMR strategies, challenges
Questions
Andrew Stephen May, M.D., FAAFPSullivan County Regional Health Department154 Blountville BypassBlountville, TN [email protected]