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DNV GL © 2016 SAFER, SMARTER, GREENER
DRAFT
DNV GL - Healthcare CAMC Health System’s Baldrige Journey
DNV GL © 2016 © Det Norske Veritas AS. All rights reserved Slide 2 31 March 2016
The Broader View of DNV GL
Reducing uncertainty, increasing safety Improving efficiency Enabling sustainability
Building trust
SAFER, SMARTER, GREENER
DNV GL © 2016
Management System can be used to:
Improve systems, processes and efficiency and effectiveness
Identify objectives and focus needs and expectations of patients/customers
Achieve and maintain the desired quality of services to consistently meet customers’ stated and implied needs
Provide a common framework for coordination and communication between units/departments and healthcare organizations, (tear down silo’s)
Slide 3
DNV GL © 2016
Integrated Accreditation Model
Integrates ISO 9001 and NIAHO®
– ISO 9001 provides the framework for a sustainable regulatory compliance
– ISO 9001 allows healthcare organizations to use its combined knowledge, wisdom, and innovation to improve quality and safety
– ISO 9001 is the framework within which methodologies such as LEAN and Six Sigma are better understood and utilized
ISO determines WHAT has to be done but leaves the HOW up to you – YOU DECIDE!
There are two ways to implement ISO – #1 to be compliant during a survey or #2 to drive performance
Performance driven systems produce compliance as a natural outcome
Introduction of Charleston Area Medical Center
4
CAMC’s Baldrige Journey:
ENGAGING THE ENTIRE ORGANIZATION IN PERFORMANCE IMPROVEMENT
Dr. Glenn Crotty Executive Vice President and COO Brenda Grant Chief Strategy Officer DNV GL Webinar March 31, 2016
MISSION AND VISION
Mission: Striving to provide the best health care to every patient, every day.
Vision: Charleston Area Medical Center, the best health care provider and teaching hospital in West Virginia, is recognized as the:
• Best place to receive patient-centered care. • Best place to work. • Best place to practice medicine. • Best place to learn. • Best place to refer patients.
VALUES Quality
Service with compassion Respect Integrity
Stewardship Safety
CAMC SERVICE AREA West Virginia’s Population: 1.8 million Primary and Secondary Service Area: 557,328
Cabell
Mingo
Lincoln Wayne
Wirt
Jackson
Kanawha
Roane
Ritchie Wood
Boone
Raleigh
Wyoming
McDowell
Logan
Mercer
Clay
Gilmer Upshur
Lewis
Calhoun
Braxton
Webster
Pocahontas Nicholas
Tyler
Doddridge Harrison Taylor
Barbour
Monroe
Greenbrier
Summers
Fayette
Ohio
Monongalia
Wetzel
Marshall
Brooke
Hancock
Marion Preston
Pendleton
Mineral
Grant
Hardy Tucker
Randolph
Jefferson
Berkeley
Morgan
Hampshire
Mason
Pleasants
Putnam
Primary Service Area Secondary Service Area
• 48 Ambulatory Sites • Provider Based • Imaging, Urgent Care, Laboratory
• 40,000 Inpatient Visits • 690,000 Outpatient Visits • 115,000 Emergency
Department Visits
• 4 Acute Care Hospitals • 908 Total Beds
CAMC GENERAL HOSPITAL
Lincoln
Jackson
Kanawha
Roane
Boone
Raleigh Logan
Mercer
Clay
Nicholas
Fayette
Putnam
• 268 Beds • Neuroscience • Orthopedics • Bariatric Surgery • Trauma 3,200 + trauma
patients admitted each year
• Primary Stroke Center • Kidney Transplant • Medical Rehabilitation
CAMC MEMORIAL HOSPITAL
Lincoln
Jackson
Kanawha
Roane
Boone
Raleigh Logan
Mercer
Clay
Nicholas
Fayette
Putnam
• 424 beds • Heart and Vascular Center
– 8,475 procedures performed in Cardiac Cath Labs
– 1,210 Open Heart Bypass procedures
• Peripheral Vascular Center of Excellence
• Oncology • CAMC Cancer Center
– 30,986 CAMC Cancer Center encounters
CAMC WOMEN & CHILDREN’S HOSPITAL
Lincoln
Jackson
Kanawha
Roane
Boone
Raleigh Logan
Mercer
Clay
Nicholas
Fayette
Putnam
• 146 Beds • >2,600 Babies delivered every year • 543 Neonatal Intensive Care Unit
admissions • Pediatric Intensive Care Unit
CAMC TEAYS VALLEY HOSPITAL
Lincoln
Jackson
Kanawha
Roane
Boone
Raleigh Logan
Mercer
Clay
Nicholas
Fayette
Putnam
• 70 Beds • Community Hospital
CAMC Health System, Inc.
CAMC Health Education &
Research Institute, Inc.
Charleston Area Medical
Center Foundation,
Inc.
Integrated Health Care
Providers, Inc.
Charleston Area Medical Center, Inc.
CAMC General Hospital CAMC Memorial Hospital
CAMC Women and Children’s Hospital CAMC Teays Valley Hospital
PERFORMANCE IMPROVEMENT JOURNEY
2000 Six Sigma
2005 Baldrige Journey Begins
2007 Lean
2008 Transforming Care Together
2012 Focus On Baldrige
Processes & Systems
2015 Malcolm Baldrige National
Quality Award
PERFORMANCE IMPROVEMENT JOURNEY
2000 Six Sigma
2005 Baldrige Journey Begins
2007 Lean
2008 Transforming Care Together
2012 Focus On Baldrige
Processes & Systems
2015 Malcolm Baldrige National
Quality Award
TRIPLE AIM
Patient Experience Cost of Care
Quality
TRIPLE AIM
Quality Inpatient Overall Quality - Local Competitors
TRIPLE AIM Cost of Care
Cumulative Savings = $177,019,702 2015 Savings = $21,216,254
Cost Reductions
TRIPLE AIM
Patient Experience
2011 2012 2013 2014 2015 1
2
3
4
5
SCO
RE
CAMCHS Top 10%
G
OO
D
Employee Satisfaction Overall
TRIPLE AIM Patient Experience
HCAHPS Likeliness to Recommend Women and Children’s Hospital
Importance of Organizational Learning and Agility . . .a Baldrige
Core Value
“If the rate of change on the outside exceeds the rate of change on the inside, the end is near.” Jack Welch, Former Chairman and CEO General Electric Corp.
Embracing the Baldrige Approach
Our organizational performance accelerated
as we became process driven and integrated
the Baldrige processes and systems
throughout our organization.
BALDRIGE AND ISO
ISO and Baldrige ISO 9001:2015 Audit Questions
1. What can you tell me about the context of your organization?
2. Who are your interested parties and what are their requirements?
3. What risks and opportunities have been identified, and what are you doing about them?
Baldrige Criteria 1. Organizational Profile:
Organizational Description and Situation
2. P.1b(2) Patients, Other Customers and Stakeholders (Who are they and what are their key requirements?) P.1b(3) Suppliers and Partners (Who are they, what role do they play, what are key supply chain requirements?)
3. Organizational Situation: Competitive Environment and Strategic Context Category 2: Strategy Considerations
ISO and Baldrige ISO 9001:2015 Audit Questions
4. What plans have been put in place to achieve quality objectives?
5. How has the QMS been integrated into the organization’s business processes?
6. How do you manage change?
7. How do you capture and use knowledge?
Baldrige Criteria 4. Category 2: Strategy Key Strategic
Objectives and Action Plans
5. Organizational Profile: P.2c Performance Improvement System – What are the key elements of your PI system, including processes for evaluation and improvement?
6. Category 5: Workforce 5.1a(4) Change Management
7. Category 4.2a(1) Organizational Knowledge Knowledge Management
ENTERPRISE MODEL
ENTERPRISE MODEL
ENTERPRISE MODEL
ENTERPRISE MODEL
TRANSFORMING CARE TOGETHER
TCT is CAMC’s approach to redesigning our work processes in support of our mission “striving to
provide the best health care to every patient, every day.”
GOALS FOR TCT 1. Increasing direct time with the patient. 2. Decreasing non-value added activity
(waste). 3. Increasing employee engagement in
improvement activity. 4. Standardizing processes to deliver
repeatable and predictable results.
FOUNDATION FOR LEAN
• 5S Workplace Organization • Standardization
• Visual Management
• Problem Solving
• Human Centered Work
5S Workplace Organization Standardization Visual
Management
Problem Solving
Just in Time
Built in Quality
Continuous Improvement
Highest Quality Healthcare
Human Centered Work
FOUNDATION FOR LEAN
5S Principles 1. Sort (Removal) 2. Set In Order (Orderliness) 3. Shine (Cleanliness) 4. Standardize (Adherence) 5. Sustain (Self-Discipline) 5S is the key to Workplace Organization
RN DIRECT PATIENT CARE TIME
PERFORMANCE IMPROVEMENT BREADTH AND DEPTH
STRATEGIC PLANNING AND DEPLOYMENT PROCESS
DEPLOYMENT PROCESS
Pillars Strategic Objectives BIG DOTS (4 Year)
System Goals BIG DOTS (1 Year)
Entity Action Plans Entity Scorecard (1 Year)
Department Action Plans Department Scorecard (1 Year)
Individual Performance Planner (All Employees) Individual Scorecard (Managers)
SYSTEM LEVEL Strategic
SYSTEM LEVEL Operational
ENTITY LEVEL Operational
DEPARTMENT LEVEL Operational
INDIVIDUAL LEVEL Operational
GOAL CASCADE PROCESS INDIVIDUAL SCORECARDS
• CEO and COO • Entity Vice-Presidents • Associate Administrators
GOAL CASCADE MEETINGS
Half day meetings with Department Managers
GOAL REPORTING SYSTEM Report quarterly
TOP 5 BOARD
TOP 5 BOARD SAFETY CROSS • Effectiveness: An important
tool to know if the safety bundle is being followed on each shift.
• Only green if all parts of the bundle are completed; serves as an internal audit tool for key processes of care.
• Addresses accountability as the issue is discussed with the involved individual(s) that day.
RESULTS
COMPARION
2011 2012 2013 2014 2015 0.0
0.2
0.4
0.6
0.8
1.0
OB
SERV
ED T
O
EXPE
CTED
RA
TIO
CAMCHS
G
OO
D
1,923 lives saved from
2011 to 2015
Inpatient Mortality
RESULTS Inpatient Overall Quality - Local Competitors
COMPARION
RESULTS
COMPARION
2011 2012 2013 2014 2015 1
2
3
4
5
SCO
RE
CAMCHS Top 10%
G
OO
D
Employee Satisfaction Overall
OUR LEARNING… • Engage leaders as owners. • Identify key organizational issues and
systems that need improvement. • Line of sight from strategic plan to everyday
work. • Focus on the few. • Use culture to drive change. • Communication and transparency. • Innovate for the future.
Dr. Glenn Crotty, FACP, MBNQE Executive Vice President and Chief Operating Officer CAMC Health System, Inc. PO Box 1547 Charleston, WV 25326 glenn.crotty@camc.org | 304-388-7647 Brenda Grant, BSN, MBA Chief Strategy Officer CAMC Health System, Inc. PO Box 1547 Charleston, WV 25326 brenda.grant@camc.org | 304-388-7885
DNV GL © 2016
Questions?
49
DNV GL © 2016
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