Winona Health’sPerformance Excellence System

Kathleen Lanik

Chief Quality & Safety Officer

Our VisionWinona Health will be a recognized leader in the

revolutionary transformation of community healthcare.

Our MissionDevoted to improving the health and well-being of our family, friends, and neighbors.

A service environment where people can realize their full potential. Excellence & leadership in clinical care & service Customer Focus Stewardship of Resources

Winona Health’s Values

Integrity – We do no harm.

Service – We serve with compassion, dignity, and respect.

Loyalty – We build relationships that exceed expectations.

Excellence – We improve performance through learning and innovation.

WH’s Performance Excellence System (PES) is designed to:

Create peace of mind by providing compassionate, personalized care

to our family, friends and neighbors.

WH’s Performance Excellence System (PES) has Four Quality Standards that

Guide all Actions:

Safety: Do no harm

Courtesy: Be kind, caring and selfless

Performance: Deliver an excellent care experience

Effectiveness: Obtain results by design

WH’s Performance Excellence System (PES) includes:

Living Service Excellence (LSE) Tools and Initiatives for Staff Performance Management Provides a System-Wide Approach to Staff Excellence

Living Performance Excellence (LPE) Tools and Initiatives for Process Improvements

Provides an Organization-Wide Approach to Performance Improvement (PI)

Winona Health’s Performance Excellence System

Living Service Excellence

Staff Performance Management Tools

LSE Standards/ValuesPerformance EvaluationRole SummariesLSE Award ProgramWinona Health UniversityEmployee Pride SurveyExperience Compass

Living Performance Excellence

Process/Performance ImprovementTools

STEPLeanBy Design MatrixExperience CompassRoot Cause AnalysisFact-based Decision MakingEvidence-based PracticeFailure Mode Effects & Analysis

Central to WH’s Living Performance Excellence efforts is a Plan Do Check Act (PDCA) method

known by the acronym “STEP”

The STEP/PDCA process is initiated by:

1. S – See the Opportunity Identifying Opportunities for Improvement (OFIs) and Completing an Opportunity Statement Suggesting an Improvement Initiative

2. T – Team Up Team is Developed, Goals Set, & Timeline for Development is Established

3. E – Evaluate Evaluating the Plan Through Continued Data Collection and Analysis

4. P – Proceed Proceed to Adopt Change or Determine to Study Further

LEAN QUALITY THINKING - A Change in the Mental Model -

1. Process Whole System Management Strategy

FLOW vs. Silos

2. Quality Focus On What PATIENTS Expect

Coordinated Care – Not Just Competency of Care

3. Controlling Cost Elimination of Waste

WH Quality Matrix

Delivery Systems Staff Setting Process

Quality Standards Safety Courtesy Performance Effectiveness

WH Experience Compass

Needs (North)

Stereotypes (South)

Emotions (East)

Wants (West)

WH’s Performance Excellence process supports continuous pursuit of excellence, and is enhanced by:

Memberships

Minnesota Council for Quality (MCQ)

American Society for Quality (ASQ)

Institute of Clinical Systems Improvement (ICSI)

Institute for Healthcare Improvement (IHI)

Participation

Center for Medicare/Medicaid Services (CMS) Quality Project

5 Million Lives Campaign

Minnesota Hospital Association Call to Action Initiatives

In recognition of its efforts, WH has been recognized by multiple local, state and national organizations.

Performance Excellence Journey

Minnesota Council for Quality (2003 – Present) Malcolm Baldrige Criteria (2004 – Present) Accreditation/Licensing Agencies State & National Projects Winona Health-Specific Initiatives

Baldrige Journey

Notable Strengths: Visionary Leadership Focused on the Future Valuing Staff and Partners Patient-Focused Excellence Management By Fact

“Pretty Good Practices” Systematic 6-Step Process to Manage Staff

Performance Mentoring Program

Baldrige Journey

Baldrige Journey

2005 Opportunity for Improvement (OFI)

4.1b(1) – Winona Health does not have a fact-based, systematic process in place to evaluate and improve its systems for the review and analysis of measures and

organizational performance. As a result, opportunities to improve the measurement and review systems may be

missed and/or effective measurement and review practices may be misunderstood and discontinued.

Past Data Reporting Schedule

Past Data Reports

Question: What Do We Need? A System That Automates Our Processes A System That Addresses Multiple Needs Within

Our Organization:Reporting to wide range of constituentsTracking of data at all levels in the organizationAlignment with our strategic planSupportive of our Performance Excellence SystemWeb-based application for easy access

Solution: Focus on Core Competencies

Integrated, Automated Technological Systems Strategic & Financial Planning Process Community Commitment Performance Excellence System

Performancesoft Data Management

Performancesoft Data Reports

Performancesoft Books

Lessons Learned

Commitment of Leadership Focus on Your Strengths Performance Excellence is EVERYONE’S

Responsibility There are NO Short Cuts

“We are what we repeatedly do. Excellence, then, is not an

act, but a habit.”

-- Aristotle

Questions?