goals and objectives for fiscal year 2014 · 2. new care models admission medication reconciliation...

Goals and Objectives for

Fiscal Year 2014

1

Summary of Significant (Top 10) FY14 Goals

2

1. Spread of Care Coordination Model: Expand on pilot experience with refining team membership, improving team

communication and engaging patients and families.

2. Palliative Care: Improve nursing knowledge of and comfort with facilitating End of Life goal setting with patients and

families.

3. HCAHPS: The patient experience of care is publically reported and will become influential in reputational benchmarking.

UPMC is committed to achieving the highest levels of patient satisfaction.

4. Flow: A high level focus on the flow of patients through our organization assures access to the care we provide and

regularly demonstrates operational performance improvement opportunities.

5. Service Line Enhancement: Focus on developing key employed and private physician service lines to assure innovative

growth of necessary patient volumes.

6. Employee Engagement: Improve employee engagement through adoption of My Voice “TLC” paradigm and through the

utilization of the Just Culture survey.

7. Redesign and optimize physician documentation: Leverage our sophisticated eRecord to improve physician

satisfaction, prepare for ICD-10, improve depth of documentation to support quality and coding initiatives.

8. Implementation of Optum CAC and CDI: Leverage new technologies to optimize coding in support of quality and

revenue generation.

9. Implementation of board approved security enhancements: In response to the March 8, 2012, shooting at WPIC and

other events around the country, full deployment of recommended enhancements to hospital security is a priority.

10. Operational Efficiencies: Improve operational and financial efficiencies through georgraphic consolidation allowing

enabling projects for the eventual demolition of the former CHP and through partnering with Supply Chain on leveraging

system buying power on high volume, low cost items.

3

Objective: Primary Care

Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Virtual Group 1. Integrated Payer/

Provider Model

2. New Care Models

1. Pursue VG1 expansion of

physician base and usage

of APPs

2. Expand VG concept to

other practices

3. Review/align incentive

plans

4. Expand concept to other

payers

New model for primary care

for interested physician

groups

2. New Care Models

5. Access

Support enhanced access

through non-traditional office

hours; growth in outpatient

encounters; improved quality.

Create a master plan for

Bethel Park and West Mifflin

to allow for enhanced

primary care presence in

accordance with the South

Hills strategy

5. Access Create 'carepoint' portals for

UPMC in the South Hills that

both feed into surgery/

imaging, but also higher level

care in Oakland and uptown.

4

Objective: Ambulatory Care

Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Front desk standardization

project

5. Access Improve patient experience

in HBCs

Explore opportunities for

enhanced infusion therapy in

the outpatient setting

1. Integrated Payer/ Provider

Model

Incorporate "Orthopedic

Specialists - UPMC" into

South Hills Surgery Center

5. Access

6. Diversified Revenue

Increased Surgical and

Imaging volumes

Grow Surgical Volumes at


5. Access


Greater utilization of existing

capacity, increased revenue,

etc.

5


Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Grow Surgical Volumes at


5. Access


Greater utilization of existing

capacity, increased revenue,

etc.

Grow Imaging Volume at

UPMC West Mifflin

5. Access


Establish greater utilization of

existing capacity, increased

revenue, etc…

Explore Creation of Imaging

Center at South Hills Surgery

Center

5. Access


Prevent patient leakage and

improve patient experience

as services grow at South

Hills Surgery Center.

Open Presbyterian

Prescription Shop

2. New Care Models

5. Access


Demonstrate the ability to

capture employee and

patient prescriptions which

will enhance the patient

experience while developing

new revenue streams.

6

Objective: New Models of Care

Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Spread Care Coordination

Model

2. New Care Models Complete roll out at

Presbyterian Campus.

Complete plan for

deployment at Shadyside

Campus.

Patient Mobility 2. New Care Models Implement patient mobility

project. Expected outcome

is to decrease LOS through

coordinating, refining, and

deploying mobility initiatives

at all PUH SHY units.

Fully deploy our Pharmacy

MEDS Program on both

campuses

2. New Care Models

Admission Medication

Reconciliation > 90%ile,

HCAHPS scores around

medications > 50th %ile and

discharge prescription

capture rate >20%

Achieve spread of nursing

face to face report and

rounding with physicians

2. New Care Models Enhance collaboration and

communication between care

providers.

7


Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Palliative Care: Expand end

of life training for nursing

2. New Care Models

4. Good Science

1. Achieving spread across

oncology units

2. Increased number of

consults to palliative care

Standardize Palliative Care

Social Work roles at

Campuses

2. New Care Models

4. Good Science

Complete Phase II Advanced

Research Study.

Complete Phase II Advanced

Research Study

2. New Care Models

4. Good Science

Increase patient involvement

in care through pain

medication self-

administration.

8

Objective: Clinical Service Line Management

Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Further enhancements to

Cardiothoracic Service Line

through standardization

2. New Care Models

4. Good Science

1. Decrease ventilator times

2. Decrease CT ICU length

of stay

3. Maintain 3 star SDS

ranking

Develop program initiative for

Neurosurgical Service Line

5. Access


1. Grow neurosurgical

volume at PUH SHY

2. Retain key surgeons

3. Develop young leaders

(Jankowitz, Sekula,

Richardson, Gardner,

Okonkwo, etc.)

Facilitate transitions of care

between Hillman Cancer

Center and UPMC

Shadyside

2. New Care Models

3. Smart Technology

9


Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Optimize Clinical Labs

Building

3. Smart Technology

4. Good Science

7. Corporate Citizenship

Work with Spine VAT

Leaders to standardize on 4

Implant Providers

4. Good Science


Savings of >$600K plus

streamlined OR daily

operations

Develop model for pre-

authorization/patient billing of

specialty molecular/genomic

testing

3. Smart Technology


Develop an electronic pre-op

questionnaire at SHY

3. Smart Technology

4. Good Science

Enhanced patient

satisfaction; decreased nurse

time spend on pre-op phone

calls

Achieve Magnet

Redesignation/submission of

Magnet redesignation

documents

4. Good Science Magnet redesignation

documents to be submitted

April 1, 2014

10

Objective: Physician Alignment

Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Redesign and optimize

physician documentation

3. Smart Technology


Complete design and deploy

Collaborate with Corporate

CVO to refine and deploy

Morrissey administrative

modules for appointment and

reappointment

3. Smart Technology Streamlined appointment and

reappointment processes

11

Objective: Ring Hospitals

Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Transplant 8. Best-in-Class Governance 1. Maintain UNOS

administrative scorecard

results at 94% or > for all

UPMC adult transplant

programs

2. Maintain and/or improve

patient and graft survival

rates for all UPMC adult

transplant programs at

the expected outcomes

for the intervals of 1-

month, 1-year and 3-year

Pursue lab opportunities

specifically within anatomic

pathology

3. Smart Technology


12

Objective: Financial and Operating Performance

Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Achieve LOS Target FY14 budgeted LOS

Achieve Budgeted

Controllable Operating

Margin


Achieve Stage 2 Meaningful

Use objectives

3. Smart Technology Maintains UPMC's eligibility

to receive additional federal

incentive funds

7 South Tower Integration 7. Corporate Citizenship Finalize relocation plans

Complete phases 2 & 3 of

Radiology Renovation

3. Smart Technology

5. Access


1. Improved efficiency,

patient experience,

technology

2. Elimination of 5 short stay

unit, etc.

Complete Surgical Services

Renovation Project

7. Corporate Citizenship Increased room capacity, full

deployment of Responder 5,

Impress, etc.

13


Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

CSI - Operational Efficiencies

1. Decrease regulated

medical red bag waste

2. Implement reusable

sleeve project for SCDs

3. Expand equipment depot

to include critical care and

bariatric beds/supply

4. Reduction of linen misuse

8. Best-in-Class Governance 1. Decrease waste and

dollars spent and

efficiency of operations

2. Achieve related system

savings of $750,000

3. Achieve related system

savings of $1 million

4. Achieve linen expense

benchmarks

Increase use of recycling and

reprocessing of single use

items in SHY surgical

services

4. Good Science


Expense reduction

Complete TUG

implementation

3. Smart Technology 1. Completion of

Implementation for TUG

Linen - FY14 Q1

2. Completion of

implementation for TUG

trash collection - FY14

14


Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Implement badge readers at

PUH & SHY parking facilities

1. Standardization

2. Equipment upgrade

Implement trial of K9 security

service at PUH

Security enhancement

Implementation of board

approved security

enhancements

Security enhancement

Implementation of Optum

CAC and CDI

3. Smart Technology


Complete the pharmacy

optimization project

7. Corporate Citizenship Close MUH pharmacy to

streamline operations with

calculated FTE savings

Create CV IT platform for

UPMC HVI

3. Smart Technology Continue partnership with

ISD to implement the CVIS

platform across all UPMC

facilities and CV modalities

15


Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Transition from use of white

board to electronic smart

board for patient flow in

PACU

3. Smart Technology 1. Improve communication

2. Improve workflow

Grow and expand

Neurodiagnostic Services at

Shadyside

3. Smart Technology

5. Access

Create a program

comparable to the

Presbyterian Campus, 24

hour EEG capability,

Outpatient services/revenue

Collection Manager 3. Smart Technology 1. Improve patient safety by

introducing positive

patient identification at

the point of care

2. Expand Collection

Manager to MUH ED,

PACU & Dialysis

3. Expand Collection

Manager to include SHY

ED and DAS and GI lab

16


Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Implement Rauland Borg

Nurse Call Spectralink

integration on applicable

units at SHY

3. Smart Technology

Increase ability to trend to

address and mitigate call bell

responses times

Assume responsibility for and

improve engagement with

local community groups

7. Corporate Citizenship Succession planning for

former VP of Community

Relations position

Observation Patients 2. New Care Models


1. Decrease LOS

2. Decrease Utilization

3. Optimize Observation

Units

17

Objective: Clinical Quality and Safety

Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

HCAHPS

1. Improve at least 75% of

HCAHPS domain scores

2. Improve environment of

Care scores

3. Expand Patient and

Family Advisory Council

(PFAC) to allow real-time

process for feedback to

associates and

physicians

1. Improvement in at least 6

of 8 domain scores

2. De-cluttering of rooms

with standardization of

receptacles.

Improvement of HCAHPS

related to noise and

environment

3. Monthly meetings with at

least 2 patient or family

attendees. Attendees

would be nominated by

the Unit Directors and

clinical leaders. Video

PFAC for staff educators

and vignettes for Infonet

1. Decrease serious events

and HACs, fall rates with

injuries, and hospital

acquired pressure ulcers

4. Good Science 1. Decrease serious events

and HACs

2. Achieve benchmarked fall

rate of < 4%

18


Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Optimize STEMI Programs at

HVI Locations

2. New Care Models

4. Good Science

Partnership between

Interventional Cardiology,

Emergency Medicine and

EMS providers to enhance

"first medical contact to

intervention" throughout

UPMC Cardiology programs.

Achieve accreditation as

STEMI receiving center

Collaborate with Corporate

Quality and Analytics to

develop and Deploy

physician OPPE/FPPE tab in

Crimson

3. Smart Technology


Physician access for their

own data on regular

schedule

Implement reliable and

variable rounder model in

PUH ICUs

2. New Care Models Improved workflow and

increase patient satisfaction

related to responsiveness of

staff

Decrease Readmissions 1. Integrated Payer/

Provider Model

2. New Care Models

4. Good Science

Increase access to private

PCPs and specialists at

discharge

19


Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Implement wireless

temperature tracking for

refrigerators and freezers in

the CLB and PUH building

3. Smart Technology Meet regulatory requirements

for monitoring temperature

tracking for medication and

specimen refrigerators

Pilot Rothman Index 3. Smart Technology Decrease LOS and ECG

utilization

Improve efficiency and

accuracy of surgical

specimen labeling process at

SHY

3. Smart Technology

4. Good Science

Increased accuracy and

efficiency

Spread biometric login for

McKesson at PUH

3. Smart Technology Safe and efficient log in to

McKesson

Fully deploy scan on re-stock

at all McKesson Accudose

Cabinets

3. Smart Technology

4. Good Science

Decrease medication errors

related to wrong stocked

medication drawers

Create a compounding

pharmacy at PUH that will

serve the health system

2. New Care Models

4. Good Science


Annual drug outsource cost

savings of >$1M

20


Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Reduce Radiation exposures

in nuclear cardiology

2. New Care Models

4. Good Science

Reduce radiation dose and

overall scan time for nuclear

patients by shifting to stress

only imaging on low CAD

probability patients

Implement SHY house-wide

sepsis response program

4. Good Science Reduce sepsis mortality rate

Risk/Patient Safety

standardization


Achieve Highmark Objectives 6. Diversified Revenue Achieve benchmarks

21

Objective: Workforce

Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Utilization of Just Culture

process for human resource

situations

Integrate MyVoice

recommendations focused

on the TLC paradigm


8. Best-in-Class Governance

Enhance staff engagement

Integration of Environment

service staff & other support

staff in UB PPC

4. Good Science


Increase HCAHPS scores

related to environment

Address absence

management thorough

management education, time

reporting pilot at SHY, and

targeted staff education



Create integrated approach

to employee safety and

wellness resulting in reduced

days away from work and

reduced costs

Integrate inclusion practices

into HR processes through

programming which focuses

on developing and retaining a

diverse workforce



Develop pathways for service

workers to move to

supervisory roles. Increase

overall diverse

representation in workforce

and within supervisory and

management roles

22


Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Decrease RN turnover to

below 10%

Current RN turnover = 9.58%

Further develop volunteer

services program across BU

Implement oncology

education modules for

Kazakhstan nurses

Educate 10 Kazakhstan

nurses in preparation for

Oncology Hospital

development

Create a standard for

Nursing Assistant (NA)

training

Decrease NA/PCT turnover

by 10%. Current turnover =

24.78%

23

Objective: Other Hospital or Community Services Specific

Objectives

Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Flow

1. Maintain or Improve ED

Flow metrics

2. Address opportunities in

transport Process

3. Implement Teletracking

Upgrade

4. Implement same day PCI

discharge Program at

SHY campuses

5. Align physician teaching

services by unit at SHY

campuses

6. Improve OR efficiency

and turnover time

processes at SHY

1. Integrated Payer/Provider

Model

2. New Models of Care

3. Smart Technology

5. Access


1. Achieve Benchmarks

2. Decrease Wait Times

3. -

4. Reduce overnight

observation admissions

by discharging

appropriate patients same

day. Start at PUH and

SHY; spread to system

Cath programs through

HVI Leadership Council

initiatives

5. Enhance collaboration

between care providers

6. Operational efficiencies;

physician and patient

satisfaction

24


Objectives

Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Implement Dragon (Voice

Recognition) functionality in

SHY and PUH

3. Smart Technology Decrease reliance on

transcription services

Integration of UPMC Bedford

HIM functions

3. Smart Technology


Explore efficiencies in certain

surgical specialties across

various UPMC hospitals

• Improve the utilization of

GI space

Consolidation of services and

cooperation to improve

operational efficiency

Support system Engineering

& Maintenance Directors

through the monthly Facility

& Engineering Council

meetings

7. Corporate Citizenship 1. Improved facility

operations and reliability

2. Creation of Hospital

Division building system

standard specifications

which will reduce 1st time

construction cost

Long Term Goals and Objectives

FY2014 – FY2016

25

Summary of Significant (Top 10) Long-Term Goals for FY14 – FY16

26

1. Patient Mobility: Expand on pilot experience of increasing and maintaining mobility of hospitalized patients in all

settings, including ICUs to decrease complications of immobility.

2. Palliative Care: Improve nursing knowledge of and comfort with facilitating End of Life goal setting with patients and

families.

3. Further enhancements to cardiothoracic service line through standardization: Capitalize on quality and clinical

leadership in this key clinical service line.

4. Service Line Enhancement: Focus on developing key employed and private physician service lines to assure innovative

growth of necessary patient volumes.

5. Develop succession plan for high volume physicians at SHY: Maintain key service lines, in particular those anchored

by private practice physician leaders.

6. Explore efficiencies in certain surgical specialties across various UPMC hospitals: As health care changes

progress, we are challenged to aggressively steward system resources to preserve assess to all care for our patients.

7. Employee Engagement: Improve employee engagement through adoption of My Voice “TLC” paradigm and through the

utilization of the Just Culture survey.

8. Integrate MyVoice recommendations focused on the TLC paradigm: We recognize that an engaged workforce

treated with dignity and respect delivers the highest quality care to our patients.

9. Meet organ donation consent rates of 75: As a leader in the national and international transplant communities, UPMC

is committed to supporting local donation rates known to improve transplant access for patients.

10. Develop operational plan for use of new Luna Parking garage at SHY: Opening of new parking facility will ease

congestion on SHY campuses, decrease shuttle expenses, improve associate satisfaction and improve onsite parking

access for patients and families.

11. Begin construction of UPMC Lemieux Sports Complex: Create an Orthopedic Sports Medicine program franchise in

the North Hills to match our Southside complex.

27

Objective: Primary Care

Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Virtual Group 1. Integrated Payer/

Provider Model

2. New Care Models

1. Pursue VG1 expansion of

physician base and usage

of APPs

2. Expand VG concept to

other practices

3. Review/ align incentive

plans

4. Expand concept to other

payers

28


Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Begin construction of UPMC

Lemieux Sports Complex

5. Access


Create an Orthopedic Sports

Medicine program franchise

in the North Hills to match

our Southside complex

Explore Creation of Imaging

Center at South Hills Surgery

Center

5. Access


Prevent patient leakage and

improve patient experience

as services Grow at South

Hills Surgery Center

29


Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Patient Mobility 2. New Care Models Coordinate, refine and

deploy mobility initiatives at

all PUH SHY units

Palliative Care: Expand end

of life training for nursing

2. New Care Models

4. Good Science

1. Achieving spread across

oncology units

2. Increased number of

consults to palliative care

30


Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Further enhancements to

cardiothoracic service line

through standardization

2. New Care Models

4. Good Science

Maintain 3 star SDS ranking

Develop program initiative for

Neurosurgical Service Line

5. Access


1. Grow neurosurgical

volume at PUH SHY

2. Retain key surgeons

3. Develop young leaders

(Jankowitz, Sekula,

Richardson, Gardner,

Okonkwo, etc.)

Continue development of

Magnet goals; implement

shared governance structural

model among councils

4. Good Science Further develop shared

governance structure to

prepare for Magnet

application

31

Objective: Physician Alignment

Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Develop succession plan for

high volume physicians at

Shadyside

5. Access


Work with physicians and

their groups to assure

continuity and volume

32

Objective: Ring Hospitals

Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

33


Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Develop operational plan for

use of new Luna Parking

garage at SHY

Smooth transition into use of

new garage

34


Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Meet organ donation consent

rates of 75%

8. Best-in-Class Governance Meet organ donation consent

benchmarks

35


Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Utilization of Just Culture

process for Human Resource

situations

Integrate MyVoice

recommendations focused

on the TLC



Enhance staff engagement

36


Objectives

Goal

Strategic

Framework Focus

(If applicable)

Target/Expected

Outcomes Results

Explore efficiencies in certain

surgical specialties across

various UPMC hospitals

• Improve the utilization of

GI space

Consolidation of services and

cooperation to improve

operational efficiency

Support system Engineering

& Maintenance Directors

through the monthly Facility

& Engineering Council

meetings

7. Corporate Citizenship 1. Improved facility

operations and reliability

2. Creation of Hospital

Division building system

standard specifications

which will reduce 1st time

construction cost

goals and objectives for fiscal year 2014 · 2. new care models admission medication reconciliation...

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