Aria Health: Managing Performance from All Angles

Managing Performance from All Angles

Susan McGann, Chief Performance Officer andMary C. Magee, MSN, RN; Administrative Director of

Quality & Regulatory Affairs

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New Targeted/Measureable Approach

• 3 Campus Health System

• 485 Beds

• 4500+ Employees

• 850+ Medical Staff

• 127,000+ Annual ED Visits

• 146,000+ Outpatient Visits

Aria Health

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• Decentralized

• Department Specific

• Connectivity to Strategic Goals

• Alignment

• Coordination & Oversight

• Measures & Formatting

Scorecards

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• Strategic Initiatives

• Campus Initiatives

• Regulatory Initiatives / Tracers

• Rounding Activity

• Projects: Task Force or Formal Team

• Data du jur

Initiatives & Projects

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“A journey of a thousand miles

begins with a single step.”

Lau-Tzo

Aha Moment

•The Board Room Visual

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• Campus Administrator

• Information– Campus Initiatives

– Projects: Task Force or Formal

– Regulatory

• Sources of information

• Mechanics of gathering information

• Pulling it all together

• A NEW Day in the Life……..

A Day in the Life…

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New Targeted/Measureable ApproachScorecards

ARIA Scorecard

QTOPS

BC FC TC

Strategic InitiativesScorecard Built w/ project

Quality/Professional Committee Scorecard

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• QTOPS ARIA Health

– BC

– FC

– TC

• Quality & Professional

Board

• Missed Opportunity

• Patient Safety

• Strategic Initiatives

– Best Place to Work

– Medical Staff

Development

– Environment of Clinical

Excellence

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New Targeted/Measureable ApproachHeader

LSS ProjectsBuilt

Mammography

Credentialing

Pre-Employment

O.R. Flow TC

ED Flow

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ProjectsBuiltARIA

Suicide Assessment & Prevention

Food for

Thought Medical Staff&

Hospital Initiative

Aligning Unit Measures

to Campus Level

Crimson Initiative

DOH Projects (2)

Patient SafetyEducation

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Frankford Campus

ProjectsBuiltFC

Digital Mammography

ICARE

Hourly Rounding

VisitorManagement

Community Outreach

Plant Operations

CAUTI –On the CUSP

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New Targeted/Measureable Approach2010 Timeline

LSSKickoff

Jan Feb March April May June July

Meetingsw/

StrategicInitiative Teams

Built LSS

ProjectsAdmin

Training

Created new HR

QTOPS

PlanningMeetings

ReviewVerificationof QTOPS

Metrics

ASEKickoff Senior

Leadership

Finalize HRMetrics &

Built Scorecard

Built Quality/ProfessionalScorecard

Finalized SIEnvironment of Clinical ExcellenceObjectives, Measures inprogress

Attendedthe Client

Conference

Aug Sept

Tim S -SLT Training

Finance Training

FC Scorecard

Oct

Nursing Measuresdata loading

Missed Opportunity Scorecard

Training Additional Employees

Med Staff SI

Projects

Presented to

Nursing Leadership

Tim S-SLMeeting

BC Scorecard Planning

Discussions

FC usingASE in meetings

Turnover of Staff

Visual Maps

Briefing Books - Dan

SI ClinicalExcellence Pt Safetyprojects

Patient Safety scorecard

InfectionPreventionScorecard

FC NursingScorecards

Nov Dec

TC NursingScorecards

BC NursingScorecards

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New Targeted/Measureable Approach2011 Timeline

Shared drive

FC

Jan Feb March April May June July

ClientConference

BC Nurse ManagersTraining

IROUND TrainingIP Dept

ASE presented

to BC Managers Meeting

Alignment of unit

measuresto campus

level

Nurse Managers

FC Training

Created Templates VR

FC Projects

Aug Sept Oct

DOH Scorecard

created

RegulatoryProjects

CORE MeasureCampus

Level

SLTTraining

Nov

Projects FC

Dec

FC Nurse Managers Feb data reports

BC campus level data

BC Nurse Managers Training

Hosp wide shared drive created

IP Nursing measures connected to campus level

IRound = Active DC Tracers

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• How is it used?

– Board Mtgs: phasing out the paper

– Senior Leadership: key metrics, variance & status reports

• Campus Administrator: key metrics, projects, initiatives, variance

& status reports

– Committee Mtgs: dashboards, results, progress

– Campus “Coffee & Scores”: results, discussion

– LSS Report Outs

– NEW – under construction: Regulatory Compliance

Nitty Gritty

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• Turning Rounds and Tracers

into real-time usable data

• Easy

• Efficient

• Cost Effective

ActiveDC

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• Infection Prevention

– Hand Hygiene

– Ventilator Associated Pneumonia

– Infection Prevention Tracer

• Safe Haven

• Physician Satisfaction “Ask Me Three”

Pilot

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• Paper world: 78.2 hrs/quarter - 5 people doing

data entry & analysis and 15 people doing the

monitoring per hour

• Averaged 850 observations per quarter

• As of 4.21.11: 220 observations, 6 people, 0

data entry hours

• Updated stats to be presented at conference

Hand Hygiene

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• Standard of care “bundle” for patients on ventilators

• Challenges with paper audits

• Audits performed

• ActiveDC Results= clear picture of opportunities

• Campus Administrators / Nursing Directors

• “Real Time” feedback & interventions in ICU on existing patients!

VAP

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• ASE– Total number of scorecards

– Total number of measures

– Total number of projects / initiatives

– Nursing Measures Created, Data Loaded & Unit Scorecards Created

– Briefing Books, Falls Dashboard – Used with Task Force

– Projects loaded into Medical Staff Dev-SI

– Project loaded into Clinical Excellence-SI

– Two of three campuses with scorecards, projects, & initiatives

– FC – Expanded metrics, using in meetings

– Additional training of staff & leadership

– Patient Safety, Infection Prevention Scorecards, Missed Opportunity, DoH

– Visual Maps, Templates for VR and Status reports

– Rapid Deployment

• iROUND/ActiveDC– Adoption of concept / idea

– Rapid deployment

– Training

– Pilot Testing

– Real Audits / Tracers

Major Accomplishments

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• Directional Building – it does matter!

• Measure Inventory

• Data Definitions

• Nomenclature & Labeling

• Buy-in

• Ownership & Accountability

• It’ll take off!

• Usage brings out new ideas Support Team

Major Lessons

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Contact Information

Susan McGann, CPO

[email protected]

Mary C. Magee, Admin. Dir. of Quality

[email protected]

Q&A THANK YOU!

Aria Health: Managing Performance from All Angles

Health & Medicine

Transcript of Aria Health: Managing Performance from All Angles