nmhs: the baldrige journey lee greer, m.d., mba chief quality & safety officer
TRANSCRIPT
NMHS: The Baldrige Journey
Lee Greer, M.D., MBAChief Quality & Safety Officer
“To continuously improve the health of
the people of our region”
• NMMC- Tupelo• 5 Community Hospitals
–Eupora (38 beds) plus LTC–Hamilton, AL (57 beds) plus LTC – Iuka (48 beds)–Pontotoc (25 bed CAH) plus LTC –West Point (60 beds)
• 34 Clinics • Preferred Provider Organization
• 90,000 lives – 114 payer groups• 2,929 physicians & 48 hospital network
VISION
“The provider of the best patient centered care and
health services in America”
NMHS’ Commitment to the Baldrige Framework
LeadershipLeadershipOperations
FocusOperations
Focus
WorkforceFocus
WorkforceFocus
CustomerFocus
CustomerFocus
StrategicPlanningStrategicPlanning
ResultsResults
Organizational ProfileOrganizational Profile
Measurement, Analysis and Knowledge Management
Measurement, Analysis and Knowledge Management
“Every successful quality revolution has included participation of upper
management. We know of no exceptions.”
Joseph Juran
• Servant Leadership Philosophy
• Leadership Development• Employee/Physician
Engagement• Leader Rounding• New Employee Orientation• Extensive Community
Outreach
Leadership
“Ninety-five percent of what leaders like you do is pursue operational efficiency. What about strategic positioning?”
Dr. Michael Porter – HBS
Alignment
Evidence Gathering
SWOT
Approve Plan
Prioritization
Evidence Analysis Workforce
Budget
Entity Plans
Development
EightEPP
Steps
EightEPP
Steps
Deployment
OCTOBER
Evidence Gathering
SWOT
Evidence Analysis
Prioritization
Approve Plan Entity Plans
Budget
Workforce
NMMC Service Line Goals
Workforce Alignment
“Your calling is calling……”
NMMC-Tupelo Employee Entrance
Organizational CultureRECOGNITION & REWARD•Excel – Pay for performance•Team Incentive Plan
– Service/Quality– Financial/Growth
•CSF – Rewards– Stars Online – More than
5,000 awarded in 2012
“The best way to find yourself is to
lose yourself in the service of others.”
Mahatma Gandhi
Relentless Pursuit of Excellent Customer Service
1. Establish a goal of 95th percentile in patient satisfaction.
2. Ensure employees understand the survey questions & the required behaviors.
3. Ensure employees know and understand the top three drivers of satisfaction for their area & the required behaviors.
“In God we trust; all others must bring
data”
W. Edwards Deming
Comparative DataEvidence-based literature and
current practice guidelinesSelected external comparative
databasesBaldrige winners and other
industriesAbove the 90th percentile or top
10%
“We are what we repeatedly do. Excellence, then, is not
an act, but a habit.”
Aristotle
Population-focused Work Systems & Collaborative Work Groups
Work System Implementation• Trial & scale up• Training • Clinical Educators• Policies, Guidelines & Protocols• Hard-wired order sets & prompts
“The achievement of an organization are the results
of the combined effort of each individual.”
Vince Lombardi
Workforce Engagement
• Employee Opinion Survey
• Leader Rounding• Ideas for Excellence• 99th percentile in
Communication
Evidence-Based Care
75
80
85
90
95
100
Com
posi
te C
are
Sco
re
Evidence -Based Care -NMMCQUEST Top Performing Threshold
Overall Sepsis Mortality
0
5
10
15
20
25
30
35
Ove
rall M
ort
ality
Rate
Ideas for Excellence & Clinical Process Improvement
NMHS Heart Failure Care Transition (30-day readmission rates)
Competitor Satisfaction• HCAHPS
• Market Share 40.7%
• Kaiser Health News – Sixth happiest market in United States
It’s All in the Number
“To continuously improve the health of
the people of our region”
HealthWorks!• Interactive children’s
health education center
• School-based curriculum &
community-based programs
• Served >78,000 in first three years
• Improved diet & health knowledge