Board Strategic & Facilities Planning Committee
Full Board Meeting
AGENDA
Tuesday, August 20, 2013
6:00 p.m.
Palomar Health
Administration Office
st
1 Floor Conference Room
456 E. Grand Ave.
Escondido, CA 92025
Mins.
Page
Call to Order
2
Public Comments
5
* Approval of Meeting Minutes
3
1
1. Fiscal Year 2013 Strategic Plan Goals Review
55
4
2. Fiscal Year 2014 Strategic / Operational Initiatives Review
55
9
June 18, 2013 Full Board Meeting
Project Update
Adjournment
Distribution:
Steve Yerxa, Chairperson
Linda Greer
Ted Kleiter
Jeff Griffith, Alternate
Michael Shanahan
Michael Covert, CEO
Alan Conrad, M.D.
Johnson Aderohunmu
L_BOD
L_EXEC_MGT_TEAM_MTNG
NOTE: *Asterisks indicate anticipated action; action is not limited to those designated items .
“If you have a disability please notify us at 760-740-6375 48 hours prior to
the event so that we may provide reasonable accommodations."
BOARD STRATEGIC & FACILITIES PLANNING COMMITTEE – MEETING MINUTES – TUESDAY, JUNE 18, 2013
AGENDA ITEM

CONCLUSION/ACTION
DISCUSSION
FOLLOW UP
RESPONSIBLE PARTY
CALL TO ORDER - ESTABLISHMENT OF QUORUM
st
The meeting – held in the Palomar Health Administration Office 1 Floor Conference Room, 456 E. Grand Ave, Escondido, CA 92025 – was called to order at 6:01 p.m. by Board
Chair Ted Kleiter

Quorum comprised of Directors Kleiter, Griffith, Yerxa, Greer

Excused Absences: Directors Kaufman, Krider, Wickes
PUBLIC COMMENTS

There were no public comments.
MEETING MINUTES – Closed Session Full Board APRIL 23, 2013

nd
MOTION: By Director Greer, 2 by Director Yerxa and carried to approve the
April 23, 2013 Strategic & Facilities Planning Committee Closed Session Full
Board meeting minutes as submitted. All in favor, none opposed.
No discussion
1. PALOMAR MEDICAL CENTER


PROJECT HIGHLIGHTS
David Tam, Pomerado Hospital Chief Administrative Officer and Kevin Pokrywa, Senior
Project Manager Facilities Construction provided updates on the chapel and physician
lounge projects, noting that the design process for both is slated for completion within the
next two weeks. The Starbucks project is tracking toward a September opening, as is the
retail Pharmacy
STREET EXPANSION
Ed Domingue, PE, Public Works Director and Julie Procopio, PE, Asst. Public Works
Director presented an update on the status of the Nordahl Road Bridge and Citracado
Parkway extension
o
The Nordahl Road bridge was opened to traffic in November 2012 with a total project
cost of $23.5 million.
o
The total cost projection for the Citracado Parkway extension is $35.5 million; the
current shortfall is $16.4 million; this due in part to unforeseen cultural resources
mitigations costs of approximately $6 million

Biological permitting and design plans will not be finalized until construction is
2013.06.18 Strategic & Facilities Planning Mins
1
1
Mr. Covert to meet with city
representatives a year from now to review
traffic counts on the Nordahl bridge as
relates to flow to and from the hospital
(from a patient as well as first-responder
perspective).
Mr. Covert et al to meet with city of
Escondido leadership in September to
review the outcome of the Tiger grant
application
BOARD STRATEGIC & FACILITIES PLANNING COMMITTEE – MEETING MINUTES – TUESDAY, JUNE 18, 2013
AGENDA ITEM

CONCLUSION/ACTION
DISCUSSION
scheduled; the ability to fund the project is driving project timeline

Next steps include application for TIGER federal grant funding (results to be
announced in September) and reducing the project cost via value engineering and
phasing

Michael Covert, President and CEO Palomar Health stated that select
administrative and Board leadership will visit with city leadership in September to
chart the outcome of the Tiger grant. He voiced strong concerns re: density and
traffic volume, and how it will impact the hospital. He also noted that, since the
Tiger grant would be federally funded, the due diligence needed in that regard
could push construction out even father, possibly to 2016 or 2017
.
2. PALOMAR HEALTH DOWNTOWN CAMPUS

Utilizing the attached presentation, Sheila Brown, Chief Administrative Officer
Palomar Health Downtown Campus, Daniel Farrow, Director Facilities Operations PMC and
Kevin Pokrywa, Senior Project Manager Facilities & Construction presented an updated
development plan for the downtown campus, with special focus on services for women and
children. The presentation highlighted key elements that work together synergistically to rebirth
the facility to that of a destination campus. Palomar Health planning principles and elements
such as healing environments, quality & safety, operational efficiencies, flexibility, circulation
and sustainability will guide the design efforts.
o
o
Mr. Covert stated that the redesign of Women’s Services will be the highest priority
project
Dr. Tam noted that the infrastructure piece will also be based on highest and best use
Next Steps
•
Approve Funding for Design
•
Engage CDPH and OSHPD
•
Engage Physicians\Staff in the design process
•
Finalize cost estimates based on priority
•
Report back to the Board, end of summer 2013
•
Finalize plans for collaboration with potential strategic partners
•
Execute approved relocations
o Chair Kleiter noted that the beds in the McLeod building have been seismically rated
as viable until 2030.
o Chair Kleiter questioned how the Affordable Healthcare Act will address the mental
health reimbursement system. Ms. Brown noted she is aware of certain programs that
are proposing to support mental illness disease processes i.e. Geropsychology. She
stated she will keep the board apprised of these changes as they occur
o Mr. Yerxa queried Ms. Brown as to whether the organization is currently contracted
with the Tricare insurance program for the proposed chemical dependency unit, to
2013.06.18 Strategic & Facilities Planning Mins
2
2
Information only
FOLLOW UP
RESPONSIBLE PARTY
BOARD STRATEGIC & FACILITIES PLANNING COMMITTEE – MEETING MINUTES – TUESDAY, JUNE 18, 2013
AGENDA ITEM

CONCLUSION/ACTION
DISCUSSION
which she responded in the affirmative
3. POMERADO

PROJECT HIGHLIGHTS
Dr. Tam and Mr. Farrow reported that the operating rooms have been upgraded with new
lights and booms (booms have med-gas upgrades)

BRIDGE PROJECT
Dr. Tam and Mr. Farrow reported that the bridge project is near completion, tracking for a
soft opening in July (landscaping around the bridge should be completed by that time)
Information only
5. Current Facilities / Construction Projects Review

No discussion
6. Administrative Updates

No discussion
ADJOURNMENT
The meeting was adjourned at 7:12 p.m.
COMMITTEE CHAIR
LINDA C. GREER, R.N.
COMMITTEE SECRETARY
DEBBIE HOLLICK
SIGNATURES:
2013.06.18 Strategic & Facilities Planning Mins
3
3
FOLLOW UP
RESPONSIBLE PARTY
FY13 Initiative: 1. Create a culture of accountability for engagement, quality, safety
and service.
Jul 12
1
Sept 12
Nov 12
2 3
Jan 13
Mar 13
4
May 13
5
Jun 13
6
Initiative Budget: Budgeted
Budget Status:
Report Date: August 20, 2013
Reporting Committees: EMT Safety & Service, BRQC
EMT Sponsors: Opal Reinbold/Lorie Shoemaker
Initiative Status:
• Patient and Family-Centered Care (PFCC) definition approved by Home
team
• “Elevator speech” for PFCC developed, rolled out at Dec Nursing
Summit
• Adaptive Design Champions identified and trained on methodology
• Patient stories integrated into key organizational meetings
• AHRQ Study complete – Results available in October
• Working on new approach to Business Reviews for leader accountability;
launched 5 Practices to Excellence in Nursing; Coaching conversations
taking place as part of the IHI/VHA Collaborative work.
Initiative Managers: Tina Pope, Deborah Barnes, Leslie Solomon
Outcome Measure:
1.
HCAHPS Real Time Top Box Results
for Rate Hospital 0-10 for each hospital.
FY13 Last Quarter (4/13 - 6/13)
2.
Management Support for Patient Safety - Increase the current
baseline (71.9%) per annual survey results
Initiative Risks:
Supervisor/Manager actions promote safety - Increase the current
baseline (73.2%) per annual survey results
Outcome Measure:
Milestones:
1. Participate in the VHA WC IHI Leadership Quality Academy
Collaborative to identify strategies and best practices for
improvement. (18 months)
2. Create a plan of action for inclusion of patients and families into
the process for improving the patient experience.
3. Create a Customer Focused Accountability Dashboard to
hardwire standards.
4. Develop a plan to engage the hearts and minds of staff and
medical staff in developing respectful partnerships with
patients/families and each other.
5. Conduct AHRQ National Patient Safety Survey
6. Reinforce the use of leadership coaching skills to commend and
correct behavioral standards in real time. (throughout the year)
1.
2.
4
HCAHPS Outcomes: Met at Threshold
Threshold - 50% Top Box Percentage for both hospitals
Target - 75% Top Box Percentage for both hospitals
Maximum - 80% Top Box Percentage for both hospitals
FY2013 Q1 Results: PMC = 53%
FY2013 Q2 Results: PMC = 72%
FY2013 Q1 Results: POM = 66%
FY2013 Q2 Results: POM = 63%
FY2013 Q3 Results: PMC = 76%
FY2013 Q4 Results: PMC = 74%
FY2013 Q3 Results: POM = 68%
FY2013 Q4 Results: POM = 61%
Patient Safety Outcomes: current baseline + the percentage
Management support for patient safety – Baseline 71.9%; Results 59%
Threshold - 7%
Target - 10%
Maximum - 12%
Supervisors/Managers actions promote patient safety - Baseline 73.2%; Results
67%
Threshold - 7%
Target - 10%
Maximum - 12%
FY13 Initiative: 2. Stabilize and Optimize Operations PMC & Palomar Health Downtown Campus
Jul 12
2
1 3 4 5Sept 12
9
6
Nov 12
Jan 13
9 7
Report Date: August 20, 2013
Reporting Committees: Board Strategic Planning
Cmte, EMT Transformation Cmte
EMT Sponsor: Sheila Brown, Gerald Bracht
Initiative Manager: TBD
Outcome Measure: Completion of Milestones
Milestones:
1. Establish mechanism to identify, prioritize, resolve and track
issues post move
2. Complete successful patient move to PMC on 8-19
3. Evolve Physician Advisory Council charter to create a joint
physician/hospital leader council to assure safe continuing
operations at PHDC
4. Re-purpose executive rounding to focus on Transition and
Service Excellence
5. Re-purpose Transition Champions for post occupancy issues
and actions identification and communication
6. Complete evaluation and possible transition of Escondido
Surgery Center to Palomar Health Downtown Campus
7. Integrate transformation component into Culture Forums
planning
8. Submit PHDC plan including business cases for program/service
optimization and expansion
9. Conduct drills simulating patient care scenarios between the
campuses. Create a plan for ongoing competency maintenance
10. Submit for approval the 5 year PHDC facility capital plan
8
10
11 Mar 13
May 13
9 7
12 13
Jun 13
9 7
Milestones continued:
11. Hold a grand reopening of PHDC for the community
12. Submit plan to celebrate the 1 year anniversary of PMC-West
13. Continue external communication efforts to distinguish campuses
Initiative Budget: Budget
Budget Status: TBD
Initiative Status:
#7 Conscious decision was made not to proceed with Culture Forums
due to focus on stabilizing efforts.
• Patient care drills between the campuses were not conducted due to
the high volume of actual codes, including 192 Rapid Response codes
with 72 OB transfers from PMC ED to PHDC and approximately 52
PHDC to PMC ER high acuity transfers. Each code was reviewed and
action plans were developed.
• The Downtown Facility Plan including service optimization and
expansion, was presented to the Strategic Facility Development Board
on June 18th
• #11 Conscious decision not to hold PHDC grand reopening due to
timing and circumstances although event could have been held.
• PH Foundation to hold Staff & Major Donor recognition and
Anniversary celebration for PMC on August 26 & 27, 2013.
•
Initiative Risks:
•
•
•
Funding
Internal Resource Capacity
Process Re-design
Outcome Measure: Actual: 91.7% (11/12)
Target – 90% Completion of Milestones
5Maximum – 100% Completion of Milestones
FY13 Initiative: 3. Expense Management
Jul 12
Sept 12
1
Nov 12
2 3
4A
Report Date: July 22, 2013
Reporting Committees: Board Finance and Board HR; EMT
Finance and EMT Workforce
EMT Sponsors: Bob Hemker, Brenda Turner
Initiative Managers: LeAnne Cooney, Paul Peabody
Outcome Measure: Expense reduction of $2.5 million from
current FY12 baseline
Milestones:
1.
2.
3.
4.
5.
6.
7.
Design and begin implementing a strategic workforce plan
– Evaluate make/buy decisions (consultants, SMEs, etc.)
– Evaluate skill mix, work status, premium pa
– Evaluate and implement tools to manage labor expense
(i.e., position control, minimum core staffing, labor
standards, leadership development)
– Evaluate benefit plan structure/strategy
Evaluate and begin implementation of consensus driven
Physician Preference Item opportunities
Continue to implement an effective and cost-efficient patient
throughput process
Develop Union contract structure strategy (4A) and
Finalize contract negotiations (4B)
Implement an effective multidisciplinary decision support
system
Evaluate medication management (i.e. formulary, charge
capture, waste)
Align the efforts of Medical Directors, hospital based
physicians, hospitalists, laborists and intensivists with the
financial objectives of the organization
Initiative Budget: Included in FY13 Operating Budget
Jan 13
Mar 13
5
6
May 13
7
Jun 13
4B
Initiative Status:
• Milestone #1: Labor optimization team studied practices for call-in, LOA, flexing, per
diem and part time staffing requirements and PTO usage as drivers for overtime and
contract labor.
• Milestone #2: Initial strategy discussions (1st Qtr) with key members of the medical
staff and supply chain services department. Discussions underway on
EndoMechanical product opportunities. Pending discussions on Spine, Peripheral
Interventional, Diagnostic Cardiology, and Electrophysiology product opportunities.
• Milestone #3: Pilot process began 6/1/13 on 2 pilot units. Progress in all areas and
process measures—team added to address direct admits. Data collected re:
barriers—teams are being initiated to address fixes. Obs status LOS up in 7E, and all
Obs Ortho patients are being cohorted there now for consistency of treatment.
• Milestone #4: Negotiations with both unions are ongoing.
• Milestone #5: Multidisciplinary work-team completed planning meeting July18th
including assessment of current state, needs and interrelationships.
• Milestone #6:
– Formulary evaluated for cost saving opportunities and submitted through P&T
Committee.
– Charge capture optimization underway.
– New regulation (AB377) passed to allow centralization of products and services implementation underway.
• Milestone #7: CEP Hospitalists are in place with aligned incentives; PHDC ED
Coverage has been realigned; some success with other physician agreements
Initiative Risks:
•
Competing priorities of Leaders during first and second quarters for move to
and operationalization of Palomar Medical Center
Outcome Measure:
Threshold – $2.0 million
Target –
$2.5 million
Maximum – $3.0 million
Outcome:
•
•
Budget Status:
6
•
Achievements will affect FY14 and have ben
incorporated into the FY14 budget
Significant expense improvement in the FebruaryJune operations, although not able to directly attribute
to the initiative
Milestone #3 - threshold not achieved for pilot units
FY13 Initiative: 4. Strengthen Physician Leadership and Integration
Sept 12
Jul 12
1
2
Jan 13
Nov 12
3
Report Date: July 22, 2013
Reporting Committees: Board Strategic
EMT Sponsor: David Tam, MD, Duane Buringrud, MD
Initiative Manager: Leslie Solomon
Outcome Measure: Physician Leadership Assessment
Score
Milestones:
1. Create and Charter a Physician Leadership Council
2. Prepare and execute a Physician Leadership Skills
Assessment
3. Review results of Assessment and identify targeted
areas for improvement
4. Develop and implement a comprehensive training
module for Physician Leaders
5. Modify / Develop Contract addendum for Medical
Directors
6. Reassess Physician Leadership Skills
4
Mar 13
May 13
5
Jun 13
6
Initiative Budget: Current Physician Development
Funds
Budget Status: TBD
Initiative Status:
• Three Modules of Applied Physician Academy Launched:
Strategic Planning, Role of MD Leader, Change and Culture.
• Post Module review conducted for first three modules
– Strategic Planning Evaluation Data - 95% Favorable
– Role of Leader (Practicing Excellence) – 96% Favorable
– Change (Making a Compelling Case) – 95% Favorable
– Change (Dyads) – 90% Favorable
• Plan developed for Modules 4-6 (FY 14)
Initiative Risks:
• New Nursing Management in Dyad Structure
• Some Medical Directors not fully engaged
Outcome Measure:
• Improvement of Physician Leadership Skills Aggregate Score
• Threshold – 10 % improvement
• Target – 15 % improvement
• Maximum – 20 % improvement
7
FY13 Initiative: 5. Grow Business
Jul 12
Sept 12
Nov 12
1
Mar 13
Jan 13
2
3 1
Jun 13
4 5
Initiative Budget: $775,000
Budget Status:
Report Date: August 20, 2013
Reporting Committees: Board Finance Cmte, EMT
Finance Cmte
EMT Sponsor: Gerald Bracht
Initiative Managers: Lisa Hudson, Robert Trifunovic,
Ann Koeneke, Margie D.
Initiative Status:
•
•
Outcome Measure: Contribution Margin
•
Milestones:
1. Physician Recruitment
Recruit 5 specialty physicians to support targeted service lines:
Neurosurgery, Hand Surgery, Pulmonary/Critical Care,
Neurology, EP.
2. Primary Care Development
Expand referral base via primary care recruitment for Arch
Health Partners and other aligned medical groups to achieve a
minimum net core growth of 3 additional PCPs. Focused PCP
sales efforts.
3. New Program Development
Submit for approval to proceed 3 new programs:
EP, Valve Clinic, outpatient surgery.
4. Fulfill Sub-initiatives in Areas of Focus:
a. Cardiovascular
d. Specialized Surgery: Robotics,
b. Orthopedic/Spine
Bariatric
c. Neuroscience
5. Contracting
Continue with Managed Care contracting expansion.
May 13
•
•
1. Recruitment: Pulmonary/Critical Care, Neurologist, EP physician and
Hand Surgeon recruitment completed. UCSD has placed a
Neurosurgeon in Dr. Stern office to operate locally at PMC.
2. Primary Care Development: At FY13 end the new growth for
primary care is +8. Two MDs have been brought to Graybill and working.
OB group has brought in 2 new (F) physician laborists for model growth
along with a replacement for one gone. 7 primaries with Scripps Coastal
in Escondido have joined Arch and are in active practice now.
3. New Program Development: EP and Valve Clinic business plans
approved. EP program initiated. Outpatient surgery program is
completed.
4. Areas of Focus: FY13 volumes exceeded projected target by 12.5%.
Target areas that increased volume over prior year include EP,
neurosurgery, spine, joint, robotic urology/gyn, neuro/IR/stroke, breast,
general medicine, cath lab, IR, cardiology. The only areas down year
over year include vascular, CABG and bariatric surgery.
5. Contracting: Healthnet, Blue Cross, Aetna under review for effective
date of Jan 1, 2014. Enrollment numbers approx 23,000 cap lives.
Sharp Health Plan Cap effective July 1, 2013, approx 8,000 cap lives.
Outcome Measure: Actual- $10.68 M ahead of FY13 budget *
Threshold – $1.5 M
Target – $ 2.0 M
Maximum - $3.0 M
8
*through end of third fiscal quarter ended 3/31/13
FY14 Strategic Initiative 1: Achieve and maintain Center of Excellence (COE) status in orthopedics/spine,
rehabilitative care, cardiac and cardiovascular care, neuroscience and women's services.
Jul 13
Sept 13
1a
Nov 13
Jan 14
1b
Mar 14
2a
Report Date: August 20, 2013
Reporting Committees: Board Strategic Planning, EMT Business
Development and Physician Integration
EMT Sponsor: Gerald Bracht, Della Shaw, David Tam, Sheila Brown,
Vicky Lister
Initiative Manager: Natalie Bennett, Jill Swartz, TBD
Physician Leader: Malek, MD, McKinley MD/Bried MD, Esmaili, MD,
Sahagian, MD, Revesz, MD
Outcome Measure: COE designation (or equivalent)
Milestones:
1. COE Designations
a. Finalize list COE payor designations and prioritize
b. Create process for acquiring and maintaining formal Request for
Information (RFI) structure submission and tracking
c. Develop internal COE service line standards for non COE areas
d. Develop competitive pricing structure and analyze the impact of
its implementation
e. Address deficiencies from the responses from payors and
implement remedies to close gaps
f. Submit COE applications
2. Market Growth/Position
a. Complete environmental assessment using newly released data
b. Reassess opportunities to advance market position
c. Develop comprehensive business development, operations and
marketing plan
9
1
Jun 14
May 14
2b
1c 1d 2c
1e
1f
Initiative Budget: To be included in FY14 budget
Budget Status:
Initiative Status:
Initiative Risks:
• Inability to manage data requirements
• Lack of departmental alignment to achieve common goals
• Payor approval
• Lack of physician engagement
Outcome Measure:
Threshold:
One COE application submission
Target:
Two COE application submission
Maximum:
Achieve one new COE designation
8/14/2013
FY14 Strategic Initiative 2: Become the dominant provider of primary care in support of the total patient health
experience provided, including the expansion and growth of Arch Health Partners, effective affiliations with local
providers and development of a strong regional primary care network in the secondary markets.
Nov 13
Sept 13
Jul 13
1
2
Jan 14
3
4
Report Date: August 20, 2013
Reporting Committees: Board Finance Committee, Board Strategic
Planning, EMT Business Development and Physician Integration,
EMT Sponsor: Michael Covert, Vicky Lister, Della Shaw
Initiative Manager: Robert Trifunovic, Hollie Garcia
Physician Leader: Scott Flinn, MD, Ken Altschuler, MD, TBD, MD, TBD,
MD
Outcome
Measure: Net newly aligned primary care providers
Milestones:
1. Conduct physician and patient focus groups to understand and
improve primary care physicians’ satisfaction.
2. Develop and implement a consistent and accurate method to identify
and notify primary care physicians of their patient being admitted to
Palomar Health facilities, in order to improve physician satisfaction
and patient safety.
3. Develop a long-term recruitment and retention plan and update
related agreements.
4. Assess geographic need, determine and prioritize development of
new primary care practice locations.
5. Analyze results from focus groups and develop a menu of services
that enhance and attract physician alignments.
6. Research and develop a plan for alignment or affiliation with
physicians and providers in solo practices and groups, health
systems and health plans, which are recognized for high quality.
7. Establish a high-quality, metric-driven hospitalist and skilled nursing
facility program demonstrated by the year 1 performance validation.
10
3
Mar 14
5
May 14
Jun 14
7
6
Initiative Budget: To be included in FY14 budget
Budget Status:
Initiative Status:
Initiative Risks:
• Exclusionary narrow network development
• Financial strength deterioration
• Inability to affiliate with payers and care delivery groups
• Outside health system alignments driving patient flow
• Lack of physician engagement
Outcome Measure:
Threshold:
15 net newly aligned primary care providers
Target:
18 net newly aligned primary care providers
Maximum:
23 net newly aligned primary care providers
8/14/2013
FY14 Strategic Initiative 3: Develop a delivery model that supports care coordination and transitions across the
continuum, with emphasis on chronic disease management, illness prevention, and patient involvement.
Jul 13
Nov 13
Sept 13
1
2
3
Jan 14
Mar 14
May 14
5
6
4
Report Date: August 20, 2013
Reporting Committees: Board Finance, EMT Business
Development and Physician Integration
EMT Sponsors: Della Shaw and Steve Gold
Initiative Manager: TBD
Physician Leader: Conrad, MD, Singh, MD
Outcome Measure: A plan for phased implementation of a
system of coordinated transitions of care
Milestones:
1. Establish an interdisciplinary team to identify the care
components and touch points across all transitions of care
2. Develop the vision of Palomar Health’s transitions of care
across the continuum
3. Obtain input and approval for the vision from appropriate
leadership and stakeholders
4. Develop value-based metrics to be used with the future
implementation of the care continuum
5. Perform gap analysis of services needed to meet the vision
and metrics
6. Develop framework which supports coordination of system
care components, addresses deficiencies as identified in the
gap analysis, and supports the agreed upon vision and value
metrics
7. Develop plan for phased implementation of transitions of care
model for agreed upon disease conditions for FY15 and
beyond.
Jun 14
7
Initiative Budget: To be included in FY14 budget
Budget Status:
Initiative Status:
Initiative Risks:
• Lack of focus and discipline around planning process needed
to develop the plan
• Lack of participation by broad group of stakeholders across
the continuum
Outcome Measure:
Threshold:
Achieve first five (5) milestones
Target:
Achieve first six (6) milestones
Maximum:
Achieve all milestones
11
5
8/14/2013
FY14 Operational Initiative 1: Build and operate a decision analytics structure that supports the real time
availability and standardized use of information and expertise for knowledge management and measurement of
value based metrics of care.
July 13
B2
B1 A1 B3 B4 B5
Sept 13
A2
Nov 13
A3 B6
Jan 14
B7
Mar 14
May 14
June 14
B8 A4
Report Date: August 20, 2013
Initiative Budget: To be included in FY14 Budget
Reporting Committees: Board Finance, EMT Systems and Resources
Budget Status:
EMT Sponsors: Bob Hemker, Paul Peabody, and Opal Reinbold
Initiative Status:
Initiative Manager: Chris Bryan
Physician Leader: Kolins, MD, Lee, MD, Kanter, MD
Outcome Measure: Develop and implement an Enterprise Data
Warehouse and Analysis Tool kit
Milestones:
A. Initiate development of an Enterprise Data Warehouse (EDW)
1. Select EDW solution partner
2. Create a decision support advisory group, reporting to IT Governance to
Initiative Risks:
validate RFI with key decision support stakeholders and send to potential
• Scope control- organization must be clear on scope and
vendors
adhere to change control processes
3. Develop work plan to achieve Phase 1 scope
• Delay in developing organizational model- Many
4. Implement Phase 1 Scope
organizations wait to perform this task which creates
B. Partner with VHA/Truven and implement analytic toolset
unnecessary ambiguity and poor design
1. Hold stakeholder presentations and determine required resources
Outcome Measure:
2. Develop implementation project plan and allocate resources
• Threshold: Implement Phase 1 scope of EDW or achieve
Phase 1 parallel go-live for Truven Analytics
3. Begin build of Care Discovery Quality Measures (CDQM) and Action OI
• Target: Implement Phase 1 scope of EDW and achieve
4. Begin submitting CY13Q3 data into CDQM parallel with Premier and
Phase 1 parallel go-live for Truven Analytics
validate accuracy
• Maximum: Implement Phase 1 scope of EDW and
5. Begin build of CareDiscovery Advance
achieve Phase 1 final go-live for Truven Analytics
6. Begin submitting CY13Q4 data using CDQM and exit Premier contract
7. Submit FY14Q1 data into Action OI (data available for use within 7 days)
8. Submit data into CareDiscovery Advance (available for use within 30 days)
12
8/14/2013
FY14 Operational Initiative 2: Create a positive experience for all key stakeholders by improving clinical and
business throughput and efficiency through all transitions of care.
Jul 13
Sept 13
Nov 13
Jan 14
1
Report Date: August 20, 2013
Reporting Committees: Board Quality Review Committee, EMT
Safety and Service
EMT Sponsor: Sheila Brown , Opal Reinbold, Lorie Shoemaker
Initiative Manager: Shannon Brown, Tina Pope, Leslie Solomon,
Maria Sudak
Physician Leader: Pasha, MD, Kolins, MD, Buringrud, MD,
Martin, MD
Outcome Measure:
1.
HCAHPS real time top box results for Rate Hospital 0-10
for each hospital
2.
Press Ganey survey results for physicians and
employees
Milestones:
1. Create a standardized patient flow process to enhance
efficiency and satisfaction for all key stakeholders
2. Engage the medical staff to maximize efficiency and to
enhance patient care, safety and service
3. Implement and spread best practices across the health
system from activities learned by participation in the IHI/VHA
Collaborative
4. Further the plan to engage the hearts and minds of the staff
and medical staff in developing respectful partnerships with
patients/families and each other
* Employee Engagement Target score might be changed after
FY2013 survey results are released
Mar 14
May 14
2
3
Jun 14
4
Initiative Budget: To be included in FY14 Budget
Budget Status:
Initiative Status:
Initiative Risks:
• Competing priorities
• Financial constraints
Outcome Measures:
• HCAHPS Target: 80% top box percentage for both hospitals
• Press Ganey Physician Engagement Target: 35% Overall Score
• Press Ganey Employee Engagement Target: 75% Overall Score*
Overall Outcome Measure:
Threshold: 1 of 3 met at target level
Target:
2 of 3 met at target level
Maximum: 3 of 3 met at target level
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FY14 Operational Initiative 3: Develop and implement a strong physician integration and alignment model that
allows for effective communication, partnership and accountability in the management and care of patient.
Jul 13
Sept 13
Nov 13
Jan 14
1
Mar 14
May 14
2
Jun 14
3
Report Date: August 20, 2013
Initiative Budget: To be included in FY14 budget
Reporting Committees: Board Human Resources, EMT Safety and
Budget Status:
Service
Initiative Status:
EMT Sponsors: Duane Buringrud, David Tam, Brenda Turner
Initiative Managers: Leslie Solomon, Brad Krietzberg, Maria Sudak
Physician Leader: Conrad, MD, Kolins, MD, Fadul, MD, Martin, MD,
Cloyd, MD, Buringrud, MD, Flinn, MD, Lee, MD
Initiative Risks:
Outcome Measures: Press Ganey, HCAHPS, Physician Engagement
• Medical staff participation
Milestones:
• Competing priorities
1. Implement Phase I
• Financial constraints
• Physician Leadership Module 3
Outcome Measure:
• Physician Orientation (Stage 1)
• Complete for policies and procedures assessments for perioperative • Press Ganey Physician Engagement Target: 35%
• Press Ganey Physician Engagement Response Rate Target: 50%
and cardiology services
• PG Patient Satisfaction Physician Questions Target: 50%
• Form Physician Advisory Council for external relationships
• HCAHPS Care from Doctors Listening carefully: 60%
2. Implement Phase II
• Establish one relationship with one external organization for
• Physician Leadership Modules 4 and 5
physician engagement
• Physician Orientation Evaluation (Stage 1)
Overall Outcome Measure:
• Develop web-based summary leadership Modules 1 & 2
Threshold:
3 of 5 met at target level
• Procedure revisions complete for Greeley pilot
Target:
4 of 5 met at target level
3. Implement Phase III
Maximum:
5 of 5 met at target level
• Physician Leadership Module 6
•
•
•
•
Launch Action Team Pilot
Develop web-based summary physician Modules 3 and 4
Establish plan for next phase of policies and procedures assessment
Establish relationship with one external organization for physician
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