fremont area medical center

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Fremont Area Medical Center

New Management OrientationDeveloped: Sept 2005

Revised: 2/07

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Administrative Overview Agenda

Mission, Vision, Values and PhilosophiesPlanning & Development ProcessChain of Command and Organization Relationships - Direction, Integration, and CommunicationBusiness PlanningContracts & AgreementsOrganizational Goals

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Mission Statement

The mission of Fremont Area Medical Center is to optimize the health status of individuals by providing a wide range of accessible, customer-centered health care services in an efficient, cost-effective manner.

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Vision Statement

Fremont Area Medical Center will be a healthcare provider that passionately pursues excellence in Quality, Service and Safety while embracing our Stewardship responsibilities.

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Values & Philosophies

Direct and Sincere Communication: We encourage direct and sincere communication throughout our organization in the belief that, through dissemination of pertinent information, our opportunities to meet the customer’s needs are enhanced.Behavior - Professional communication skills

should be learned and practiced continually. Focus on the words before you respond and answer with a smile, project a positive, upbeat tone and use the appropriate script.

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Flexibility: We acknowledge that change is the only status quo. We recognize change as a growth process and are open to considering and offering new ideas and approaches to doing things. Behavior - Be responsive to change.

Demonstrate adaptability to allow change to occur and, in some cases, be the catalyst. The last thing you want is to be the keeper of the tradition that creates the roadblock to progress.

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Integrity & Professionalism: We aspire to the highest level of personal and professional ethics as demonstrated by commitment to truth, to deliver what we promise and maintain the dignity of persons with whom we work and serve,Behavior - Regardless of your position, you are

responsible for your actions and reactions as well as your immediate service area. Appearance and body language speak volumes. FAMC employees should take pride in your service and in presenting a professional image.

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Teamwork: We are mutually dependent upon one another for accomplishing personal and organizational goals, recognizing that customer expectations cannot be met without effective working relationships. Behavior - Create a cooperative effort as a

member of the FAMC team to achieve the “above & beyond” customer service goals. Effective teams combine the power of group process, shared responsibility, and mutually supportive teamwork processes to create synergy. The result of such synergy can be extraordinary.

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Efficiency: Our job is to optimize the utilization of the resources available to accomplish the desires results on time. Behavior - Out of respect for the common

good and caring of others, we are called to be good stewards of the resources entrusted to us. We are willing to assume responsibility for using time and materials wisely to provide the best customer service possible.

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Compassion: We display a sincere, caring attitude towards everyone with whom we come in contact, respecting the individual dignity of each person.Behavior - Every interaction with a

customer, whether internal or external, is an opportunity to build a strong relationship and show care and concern.

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Leadership: We take the responsibility for assuring quality and achieving the Hospital’s objectives in an appropriate and efficient manner.Behavior - Be proactive. Reactive behavior

allows circumstances to control your response. Proactive behavior, however, allows you to control your circumstances to a degree. Take initiative and act rather than react.

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Commitment: We have a positive attitude towards our work, the people we serve, FAMC and one another.Behavior - Immediate service recovery:

Customer complaints and problems must be addressed immediately. Understanding the problem before trying to solve it: listen, ask questions, apologize, discuss options, follow through and document according to policy.

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Creativity & Innovation: We encourage creative thinking and problem solving, taking prudent risks and striving to go beyond our limits.Behavior - It takes a lot of courage to

display productive originality. Embrace productive risk-taking strategies that enhance customer service. Recognize and build on the contributions of others.

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Service: We recognize that each interaction with a colleague, patient, resident, physician or member of the general public is an opportunity to provide outstanding service. Throughout the Medical center, we work together as a team achieving this quality of service through continuous improvement efforts.Behavior – Demonstrate inter-collaborative

networks that function to unify FAMC team spirit.

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Planning & Development

Under the direction of the Board of Trustees, the Executive Management Team is accountable for short term and long term planningShort term planning occurs at all levels in response to operations and provision of services and is consistent with Mission and Vision of our organization.– Includes determination of qualifications, competency, and volume of

staff needed to provide care, treatment, and services Long term planning is accomplished in the form of a Strategic Plan, which is completed triennially.– Includes financial, space/physical plant, equipment, and other

resource considerations

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Planning Process

Administrative Policies

Pattern of Development Planning System Overview

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Strategic Plan 2007-2010

More Clinically Sophisticated ServicesAligned/Engaged Medical StaffMarket OutreachPost Acute Care ServicesCapital Formation/Cost Efficiency

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Chain of Command and Organization Relationships

Michael Leibert, President/CEO– Began working at FAMC in 1985

Peg Kennedy, Vice President/Chief Operating Officer/Chief Nursing Officer– Began working at FAMC in 1975

Dave Hanen, Vice President/Chief Financial Officer– Began working at FAMC in 1984

Bryan Hehemann, Vice President, Administrative Service– Began working at FAMC in April 2005

Our Administration has more than 75 years of combined experience

See Admin Chain of Command and Organizational Relationships Policies

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FAMC Organizational ChartSeptember 1, 2006

Medical Staff Ops. Strategic Planning Physician Recruitment Safety/Risk Mgmt Corporate Compliance Process Improvement Registration Pt Accts

Dec Support Operations Excellence Staffing Nursing PI Bed control Governance House Supv. Informatics Trauma Services Home Care/Hospice Care Mgmt IC Emergency Services Plt Ops Environ Srvcs Med Social Wkr Nursing Ed. Linen Servcs Food Srvcs

Education/TrngCommunications

Cath Lab

OR GI/Clinic Servcs Perianesthesia Anesthesia Community Health Sterile Processing

Rev: 9/06

FREMONT AREA MEDICAL CENTERBoard of Trustees

Volunteers

Chief Executive Officer

Public Relations/Mktg & Volunteers

FAMC Medical StaffFAMC Foundation

Vice President, Fiscal & Support ServicesCFO

Acute Nursing

Facilities Management

Radiology & Radiation Therapy

Laboratory

Rehabilitation Services

Post Acute Services

Hospital InformationServices

Financial Services

Vice President, Administrative ServicesVice President, Clinical OperationsCOO/CNO

Human Resources

Perioperative Services

Health Care Professionals

Community Outreach

DCHA

Health Information Management

Cardiopulmonary

Material Management

Pharmacy

Emergency Services

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Direction

The Executive Management Team, specifically Dept. Directors are responsible for:– Integration of their services(s) into the organization’s primary functions– Coordinating and integrating inter & intra – departmental services– Developing & implementing P/P that guide & support provision of care & services– Recommending sufficient numbers of qualified competent staff to provide services– Determine qualifications and competence of department staff– Continually assess, improve, and maintain the performance of care and services– Establish internal controls to effectively maintain information & support systems,

recruiting & retaining staff, and conserving physical and financial assets– Orienting and providing department in-service training and continuing education– Recommending department space & resources needed– Participating in selection of sources for needed services not provided by the

department or organization

Found in Leadership Document Policy

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Integration

Organizational & functional relationships of departments are defined in organizational charts.Leaders individually and jointly develop and participate in effective mechanisms to:– Foster communication among individuals & components of the organization– Coordinate internal activities– Communicate with leaders of organization that functionally relate to FAMC

Staff assigned managerial responsibilities participate in cross-functional activities to improve organizational performance. These include:– Performance improvement teams and activities– Ad-hoc committees and task forces– Multi-disciplinary Medical Staff &/or Medical Center Committees

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Communication

Lighter Vein and various other NewslettersAdministrative Staff Meeting – Meets weekly, WedExecutive Management Team Meeting – Meets monthly, 2nd TuesdayManagement Consultation Group Meeting – Meets every other month (odd numbered), 4th Tues Goals Team MeetingsDepartment Staff MeetingsEmployee Meetings

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Business Planning

Policies & Forms

New Program Analysis Policy Program Analysis Form

Program/Equipment Request Policy Business Planning Template FMEA Form

See Administrative & Finance Policies

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Sample Business PlanTable of Contents

1. Executive Summary (1-2 pages) 2. Mission and Vision 3. Market/Competitive Analysis 4. Brand Definition and Primary Strategy 5. Structure 6. Financial Analysis 7. Risk/Contingency 8. Failure Mode Effect Analysis (FMEA) 9. Performance Measures10. Implementation and Prioritization11. Internal Communication

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Sample Business PlanExecutive SummaryEnvironment - market trends, economics, technology, legal.Goals and Objectives - ties to mission, vision and strategic plan.Product or Service description.Market Analysis - customer, competition, risk, partners.Marketing and Sales - pricing, profitability, distribution, advertising, promotion & concepts.Organization and Management.Financial Analysis.Implementation plan with timeline

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Contracts & Agreements

All contracts and agreements must be signed by the CEOAdministration maintains copies of all contracts and agreements– Coordination by Administration assures

technical language which minimizes the risk of exposure.

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2007 Organizational Goals

QualityServiceEmployer of ChoiceCommunity HealthFinance

2007 Incentive Plan

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Clinical Quality Goal

GOAL:FAMC will consistently deliver excellent, safe care to improve patients' outcomes and quality of life.

FOCUSED MEASURE:FAMC will attain and maintain a ranking within the top 20% of hospitals for the CMS/HQID measures for Heart Attack, Heart Failure, Community Acquired Pneumonia, as well as Medicare Hip & Knee Replacements.

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Heart Attack Care

Clinical Quality IndicatorMD or Nurse Driven

FY2007 Target Trend

UnofficialGoal: Perform within top 20% of Premier hospitals Jul-Sep 06 Apr-Jun 06 Jan-Mar 06 Oct-Dec 05

CMS/HQID Measures %#

Cases % % % % %

Acute Myocardial InfarctionAspirin at arrival MD 100 4 100.0 100.0 100.0 100.0 100.0Aspirin at discharge MD 100 4 100.0 100.0 100.0 100.0 100.0ACE/ARB inhibitor for LVSD MD 100 1 100.0 100.0 100.0 100.0 N/ASmoking cessation counseling N 100 2 100.0 N/A 100.0 100.0 60.0Beta blocker at discharge MD 100 4 100.0 100.0 100.0 100.0 100.0Beta blocker at arrival MD 100 4 75.0 100.0 100.0 100.0 100.0Thrombolytic in 30 min. MD 60 0 N/A N/A N/A N/A N/APTCA in 90 min. MD 82 1 100.0 100.0 N/A

Composite ~~ 97 95.0 100.0 100.0 96.9 94.1

Historical Performance (status color based on FY2007 Target)

Current Performance

Unofficial

Oct & Nov 2006

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Heart Failure Care


FY2007 Target Trend



Cases % % % % %

Heart FailureDischarge instructions N 90 14 78.6 90.0 81.8 80.0 75.0LVF Assessment MD 98 18 100.0 100.0 100.0 100.0 100.0

ACE/ARB inhibitor for LVSD MD 95 4 100.0 100.0 100.0 83.3 100.0Smoking cessation counseling N 100 0 N/A 100.0 100.0 100.0 66.7

Composite ~~ 93 91.7 96.8 94.1 91.9 87.5


Current Performance

Unofficial

Oct & Nov 2006

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Pneumonia Care


FY2007 Target Trend



Cases % % % % %

PneumoniaOxygen assessment MD/N 100 31 100.0 100.0 100.0 100.0 100.0Pneumococcal vaccination MD/N 90 25 92.0 72.7 62.9 76.2 70.6Blood culture before antibiotic MD 93 23 100.0 100.0 100.0 94.6 90.0Smoking cessation counseling N 100 8 62.5 83.3 100.0 88.9 83.3Antibiotic within 4 hrs. MD/N 90 22 100.0 91.7 91.4 90.7 85.7Antibiotic selection (ICU) MD 70 1 0.0 100.0 100.0 100.0 100.0ABX selection/Immuno (non-ICU) MD 92 13 84.6 87.5 95.7 90.9 77.3Blood culture within 24 hrs. (ICU) MD 93 1 100.0 100.0 100.0 100.0 60.0Influenza vaccination MD/N 90 30 83.3 N/A N/A 84.4 69.6

Composite ~~ 92 91.6 91.1 90.9 90.4 83.7


Current Performance

Unofficial

Oct & Nov 2006

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Surgery Care


FY2007 Target Trend



Cases % % % % %

Surgical Infection Prevention (SIP)Prophylactic antibiotic within 1 hour of incision N 96 23 100.0 94.3 93.1 97.2 90.9Prophylactic antibiotic discontinued within 24 hours MD 93 23 78.3 71.4 96.6 91.7 77.3

Composite ~~ 93 89.1 82.9 94.8 90.3 84.1


Current Performance

Unofficial

Oct & Nov 2006

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Service Goal

GOAL:FAMC will provide exceptional customer service as measured by the Patient/Resident Satisfaction surveys, moving toward the 90th percentile for PRC survey hospitals with patient/resident responses of “Excellent” on the question “Overall, how would you rate the quality of care provided?”

FOCUSED MEASURE:FAMC’s 14 measured service areas will move one third of the way toward the 90th percentile, based on 2005 norms. The 14 service areas include: 5 Inpatient areas, 5 Outpatient areas, Outpatient Surgery, Emergency Department, Long Term Care & Home Health.

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Service Goal

Fremont Area Medical Center Progress Toward FY 2007 Goals as of 1/31/07

% Excellent Responses to the question: "Overall, would you rate the quality of care received during this stay as: Excellent, Very Good, Good, Fair or

Poor?"

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Actual Target

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Finance Goal

GOAL:FAMC will generate sufficient financial return to fulfill its capital and operational requirements.

FOCUSED MEASURE:FAMC will achieve a total margin of 5.4% for fiscal year 2007.

Current Standing as of 1/31/07: 7.3%

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Employer of Choice Goal

GOAL:FAMC will develop and maintain an employer of choice environment while emphasizing staff respect, communication and teamwork.

FOCUSED MEASURE:FAMC will utilize the Workforce Commitment Index (WCI) derived from ten questions on the Aon employee survey as a measure of staff satisfaction and commitment. The FY2007 goal for FAMC will be based on the September, 2006 employee survey results. The intent is to stay above Aon’s national healthcare average.

(Note: This measure will not be included in the FY2007 incentive plan.)

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Community Health Goal

GOAL:FAMC will work to improve the overall health status of the Population of Dodge County.

FOCUSED MEASURE:In support of the Nebraska Healthy People 2010 initiative, FAMC will make progress towards achieving nine specific objectives in Heart Disease, Cancer, Diabetes, Unintentional Injuries and Wellness. The objectives follow.

(Note: This measure will not be included in the FY2007 incentive plan.)

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Community Health GoalHeart Disease: · Increase the proportion of adults (age 18 and older) in Dodge County who have had their blood pressure checked within the past two years and

know whether it is normal or elevated to at least 97%. (Currently 95%)*· Increase the proportion of adults (age 18 and older) in Dodge County who have had their blood cholesterol level checked within the past five

years to at least 80%. (Currently 67%)*Cancer: · Increase the proportion of women (age 40 years and older) in Dodge County who had mammogram in the past two years to at least 75%.

(Currently 70%)*· Increase the proportion of adults (age 50 years and older) in Dodge County who had a fecal occult blood test in the past two years to at least

50%. (Currently 29%)*· Increase the population of adults (age 50 years and older) in Dodge County who ever had a colonoscopy to at least 50%. (Currently 46%)*Diabetes: · Increase the proportion of diabetic Dodge County residents who receive a hemoglobin A1C test at least once per year to at least 50%. (Currently

27%)*· Increase the proportion of diabetic Dodge County residents who do Self-blood-glucose monitoring at least once per day to 60%. (Currently 51%)*Unintentional Injuries:· Increase the proportion of Dodge County residents who transport children and use appropriate automobile child restraints (for children under 6

years of age) to at least 80%. (Currently 66%)*Achieve “Well City” status in Fremont:· Submit application for Fremont Well City USA by end of year 2007.

* These are the current statewide statistics. FAMC will be working with Three Rivers Health Department to establish local baselines by August 2006 via a phone survey. If needed, interim targets will be established.

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Incentive Plan FY 2007

FAMC Measures Wt. Threshold Target Maximum

Clinical QualityMedicare/Hospital Quality Incentive Demonstration composite measures for AMI, HF, CP, Hip/Knee Replacement (Medicare only)

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Achieve top 20% in 2 of 4 areas at least

2 qtrs, including 4th

Achieve top 20% in 3 of 4 areas at least

2 qtrs, including 4th

Achieve target & top

20% in 4 of 4 areas in 4th qtr

ServiceCustomer Satisfaction Score – Overall quality of care (14 service areas: 5 Inpatient areas, 5 Outpatient areas, Outpatient Surgery, Emergency Department, Long Term Care & Home Health)

.348 of 14 areas achieve their service goal

10 of 14 areas achieve their service

goal

12 of 14 areas achieve their service

goal

FinanceTotal Margin (Percentages include cost of incentive)

.33 4.7% 5.4% 6.2%

Totals 1.00

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Scorecard

FREMONT AREA MEDICAL CENTER2007 ORGANIZATIONAL GOAL SCORECARDAs of January 31, 2007

STATUS

GOAL NOT MET THRESHOLD TARGET MAXIMUM TREND

QUALITY No Change

SERVICE

FINANCE

NOT MET THRESHOLD TARGET MAXIMUM TREND

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End of Presentation

fremont area medical center

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