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Driving Performance through Accountability to Unit Level Goals
Christine BeechnerMay 19, 2014
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About Us…
• 206 Beds
• 43,000 ED Visits
• 13,000 Discharges• 45% from NY
• Yale – New Haven Health System
A Culture of Excellence
Our Journey
● Began in 1998
● CEO Driven
● A decade of construction● Facility● Culture
● Measurement and Goals by Service
Our Focus
● Vision and Goals● Standards of Behavior● Accountability● Rewards and Recognition● Service Recovery● Continuous Improvement
Sustaini
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A Culture of Excellence
Our Journey
● Began in 1998
● CEO Driven
● A decade of construction● Facility● Culture
● Measurement and goals by service
Our Focus
● Vision and Goals● Standards of Behavior● Accountability● Rewards and Recognition● Service Recovery● Continuous Improvement
Sustaini
Unit Level AccountabilityStarting Point
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● Each unit, service or task that is measured has a unique:
● Contribution to the overall satisfaction● Measure of success● Team of individuals contributing to the results
● Shared responsibility for continued improvement (despite associated percentile ranking)
● Mean score and percentile ranking give clearest picture
Span of Control Design
Chief Nursing Officer
Program Director: Surgery
Surgery Nurse Manager
Ambulatory Surgery Nurse
Manager
Telemetry/MSICU Nurse Manager
Program Director: Oncology
Chemo Infusion Nurse Manager
Inpatient Oncology Nurse
Manager
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Span of Control Design
VP Administration
Program Director: Diagnostic Imaging
MRI/CT Manager
MRI
CT
Imaging Center Manager
Environmental Services Manager
ASU Cleanliness
Inpatient Cleanliness
Inpatient Courtesy
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Implementation Strategy
● Acknowledge past success and present state● Make the case for continued improvement● Discuss formation of goals● Link attainment of goals to performance appraisal for
managers, at manager discretion for staff● Provide support, resources
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Span of Control Report
Executive Owners
• COO• CNO• CMO• CFO• VP Operations
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Dept./Service Achievement ManagerSurgery Stretch LennonLab Stretch Mitas
Ease of Scheduling Stretch FatovicHelpfulness of
Registration (OP)Stretch Campagna
Ambulatory (Helmsley)
Target Kimmons
MRI Target Wishon‐Shah
Mammography Target PerroneCardiology Target McElwain
Sleep Target PolaskiHBO Target Curry
Cleanliness (OP) Target WeeksCourtesy Clean
Room Target Weeks
Spiritual Needs Target Lopez
Dept./Service ManagerHospitalists Rating Archer
SA.P BascianoBLIN Malin
Bone Density VanCampRadiology VanCamp
CT Wishon‐ShahPhysician Rating
(ED)Davison
Dept./Service Threshold –YTD
Manager
Medicine .3 Acevedo
Telemetry 1.9 Peden
HHSC .8 RosenquestPediatrics 1.5 Basciano
HHSC (Cleanliness) 1.7 KosakWPGI (Cleanliness) .8 Kosak
Room Décor .3 CampbellRoom Working .3 CampbellFood Temp .4 PowellFood Quality .2 Powell
Ultrasound (ICE) 1.1 VanCampRadiology (ICE) .1 VanCamp
CT (ICE) 1.5 VanCamp
Nuclear Medicine .6 CifferelliPhysical Medicine 1.2 PonchakSpeech/Language .5 PonchakPhysician (ASU) .2 Lipschutz
2013 YTD Patient Satisfaction Achievement
In 2013, 57 departments and services are assigned threshold, target and stretch goals based upon their previous year performance. To date, 17 areas are below threshold, 27 areas are at or above threshold, 9 areas have met target and 4 areas exceed stretch goals.
Dept./Services Meeting Target and Above Dept./Services within .2 of Threshold Dept./Services below Threshold (with gap)
Patient and Guest Relations Dept. 6/14/2013. patient satisfaction/local targets
Practicalities and Process● Span of control reports
updated first week each month
● Emailed to executive owners
● Present with analysis to Senior Operations Group
● Senior Leader cascades report to each manager and includes review in regular manager meeting
● Structure for survey review/response continues
● Reports built in PG InfoEdge
● Excel files built with conditional formatting
● All managers receive 1:1 training for PG Portal and Quick Reports
● Individual review, analysis and strategy planning around results
Project: 18 Month MarkLessons● Accountability starts at the top
● Ownership by name important
● Accountability must be coupled with ongoing support
● Set fair goals - statistically derived
● Individual launch time with leaders and managers crucial
Results
● Four services and HCAHPS all showed
● Overall improvement● Reduction in variation
● Clarity in reporting
● Focus on goals
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Patient Satisfaction- Overall Mean Score by CY: 2008 – 2014 (Press Ganey, Inc)
