NMHS: The Baldrige Journey
Lee Greer, M.D., MBA
Chief 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
Organizational Profile
Strategic
Planning
Workforce
Focus
Leadership
Results
Customer
Focus
Operations
Focus
Measurement, Analysis and Knowledge
Management
“Every successful quality
revolution has included
participation of upper
management. We know of no
exceptions.”
Joseph Juran
Leadership
• Servant Leadership
Philosophy
• Leadership Development
• Employee/Physician
Engagement
• Leader Rounding
• New Employee Orientation
• Extensive Community
Outreach
“Ninety-five percent of what
leaders like you do is pursue
operational efficiency. What
about strategic positioning?”
Dr. Michael Porter – HBS
Deployment
Development
Alignment
Entity Plans
Approve Plan
Prioritization
Evidence Analysis
Eight
EPP
Steps
Budget
Workforce
OCTOBER
SWOT
Evidence Gathering
Workforce Alignment
NMHS Goals
Entity/Facility
Goals
Work Unit
Goals
Employee
Goals
NMMC Service Line Goals
“Your calling is calling……”
NMMC-Tupelo Employee
Entrance
Organizational Culture
– Service/Quality
– Financial/Growth
• CSF – Rewards
– Stars Online – More than
5,000 awarded in 2012
Diversity of Thought/Innovation
(IFE)
Good
15,000
# of IFE submitted
RECOGNITION & REWARD
• Excel – Pay for
performance
• Team Incentive Plan
10,000
5,000
0
FY07
FY08
Submitted
Trendline (Submitted)
Data Source: Internal
FY09
FY10
FY11
Accepted/Modified
Trendline (Accepted)
“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 Data
Evidence-based literature and
current practice guidelines
Selected external comparative
databases
Baldrige winners and other
industries
Above 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
Capability: Mean Hours of Training
per FTE
85
Good
Trial & scale up
Training
Clinical Educators
Policies, Guidelines
& Protocols
• Hard-wired order
sets & prompts
Hours
•
•
•
•
Work System Implementation
70
55
*
40
FY08
FY09
FY10
FY11
Mean hours per FTE
ASTD's best
Trendline (avg hrs/FTE)
Data Source: ASTD
* Data not available
“The achievement of an
organization are the results
of the combined effort of each
individual.”
Vince
Lombardi
Workforce Engagement
•
100
95
Good
80
70
90
60
85
2006 2008 2010 2012 2006 2008 2010 2012
Concern for Employee
Communications
Best in Class (Top 10%)
NMHS %tile ranking
Data Source: HRS
%tile ranking
•
90
Good
•
Employee Opinion
Survey
Leader Rounding
Ideas for Excellence
99th percentile in
Communication
% Employee
positive response
•
NMHS Concern and Communication
(EOS)
Composite Care Score
Evidence-Based Care
100
95
90
85
80
75
Evidence -Based Care -NMMC
QUEST Top Performing Threshold
Overall Sepsis Mortality
35
Overall Mortality Rate
30
25
20
15
10
5
0
0.12
Good
0.1
0.4
0.08
0.06
0.2
0.04
Falls cost savings = $273,625
PU cost savings = $617,700
(FY10 vs FY11)
0.02
0.0
0
FY10
Falls
Data Source: QMS
FY11
Pressure ulcers
FY12 YTD
FY10
NDNQI falls mean (0.35)
FY11
FY12 YTD
PU peer reviewed best practice (0.108)
Pressure Ulcers
(# PUs/patient days * 100)
0.6
Good
Falls
(# falls/patient days * 100)
NMHS Falls and Pressure Ulcer Prevention (FY)
14
12
10
8
6
4
2
0
NMMC Respiratory Related Pressure Ulcers
(RR PUs)
Good
# of RR PUs
Ideas for Excellence & Clinical Process
Improvement
IFE Apr 2011: Mole skin
protectant added to kits
FY09
Data Source: Internal
IFE Jun 2010: Skin asessment
added to charting pathway
FY10
FY11
RR PUs
FY12 YTD
NMHS Heart Failure Care Transition (30day readmission rates)
40%
30%
300
250
200
150
100
50
0
20%
10%
0%
Q1
Q2
Q3
Q4
FY09
NMHS HF patient volume
NMHS HF readmissions
Quest 90th (8.9%; '12 8.0%)
Q1
Q2
Q3
FY10
Q4
Q1
Q2
Q3
FY11
Care transition patient volume
Care transition HF readmissions
Q4
Q1
Q2
Patient volume
Care Transition began
Good
Readmission rates
NMHS Heart Failure Care Transition,
30-Day Readmission Rates
Q3
FY12
Self Care College began
Data Source: Premier
Competitor Satisfaction
• HCAHPS
• Kaiser Health
News – Sixth
happiest market
in United States
Good
% Overall rating 9-10 for
hospitals on a 0-10 scale
• Market Share
40.7%
Overall Top Box Hospital Satisfaction
Rating NMMC & Regional Competitors
80%
70%
60%
Data only available for the current year
50%
Competitor A
Competitor B
Tupelo
Rating 9-10
Top Box State mean (68%)
Top Box National mean (68%)
Data Source: HCAHPS
It’s All in the Number
0.12
Good
0.1
0.4
0.08
0.06
0.2
0.04
Falls cost savings = $273,625
PU cost savings = $617,700
(FY10 vs FY11)
0.0
FY10
Falls
Data Source: QMS
FY11
Pressure ulcers
FY12 YTD
FY10
NDNQI falls mean (0.35)
0.02
0
FY11
FY12 YTD
PU peer reviewed best practice (0.108)
Pressure Ulcers
(# PUs/patient days * 100)
0.6
Good
Falls
(# falls/patient days * 100)
NMHS Falls and Pressure Ulcer Prevention (FY)
Good
80%
60%
Good
Good
% of Patients
100%
NMMCI Outpatient Diabetes Management
(FY)
40%
08 09 10 11 12* 08 09 10 11 12* 08 09 10 11 12*
A1c levels procured
Data Source: Centricity
A1c < 7
Lipid
NCQA (Top 10 percentile)
* YTD
“To continuously improve
the health of the people of
our region”
NMMCI (IMA Tupelo) Proactive Community Prevention and
Wellness
The risk of dying from colon cancer is 53% lower
in people screened by colonoscopy
The risk of dying from breast cancer is
30% lower in women screened by
mammography
80%
70%
60%
50%
Good
Good
% of screened patients
90%
40%
30%
20%
Q2
Q3
CY09
Q4
Q1
Q2
Q3
CY10
Q4
Q1
Q2
Q3
CY11
Colorectal cancer
Data Source: IQH
Q1
Q2
Q3
Q4
CY09
Mammography
Q1
Q2
Q3
CY10
All MS clinics
Q4
Q1
Q2
CY11
HealthWorks!
• Interactive children’s
health education center
• School-based curriculum
& community-based
programs
• Served >78,000 in first
three years
• Improved diet & health
knowledge