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Sparrow Hospital

Sparrow Hospital

Organizational Profile

Sparrow Hospital is located in Lansing, Michigan has been devoted to serving the health care needs of the community for over 119 years.

Sparrow Hospital is a not-for-profit, community-governed, fully accredited major teaching and tertiary hospital.

Products and Services

Sparrow Hospital is part of the Health Care Industry and serves not only the city of Lansing but also the counties of Eaton, Ingham and Clinton.

Sparrow Hospital is comprised of over one million square feet of space and 682 beds. It is located in Lansing Michigan and also includes the Sparrow Professional Building across the street.

The primary way that is used to deliver Sparrow Hospital’s crucial health care services are through direct inpatient and outpatient services. The hospital provides a variety of health care services to communities, as well as fundamental health care service offerings such as oncology, neuroscience, cardiology, women and children’s, orthopedics and primary care.

Mission, Vision, Values and Core Competencies

Mission: The organization exists to improve the health of the people in the communities by providing quality compassionate care to everyone, every time.

Vision: The organization wants to be recognized as a national leader in quality and Patient experience.

Values: The workforce is expected to adhere to the ICARE (innovation, compassion, accountability, respect and excellence) values.

Core Competencies:

Core Competencies include but are not limited to the following: The needs of the Patient always come first, Culture of Caregiver engagement and empowerment, Clinical excellence and Strong stewardship of community resources.

Workforce Profile

Sparrow Hospital is the largest private employer in the region and employs approximately 6,000 Caregivers. The workforce includes non-unionized and unionized Caregivers. The United Auto Workers (UAW) and Michigan Nurses Association (MNA) represent the unionized Caregivers.

1,700 volunteers, 942 Physicians 1,525 Registered Nurses 1,600 providers and advanced practice personnel,

The breakdown of major job functions by percent is as follows:

Ancillary, Clinical, and Business 48% Leadership 9% Professionals 7% Registered Nurses 36% Female Caregivers 77% Male Caregivers 23% Full Time Employment 76% UAW 38% MNA 36% Non-Union 26%

Technology

The hospital has a brand new tower that focuses on key health care services and includes private rooms with the latest technological advances to improve quality and enhance the patient care experience. Clinical technologies available for patient care also include six catheterization labs and a Level 1 Trauma Center. The hospital renovated and expanded surgical suites for a total of 26 licensed operating rooms. EPIC is Sparrow’s electronic medical record (EMR). The implementation provides a comprehensive inpatient and ambulatory patient record, providing Patients direct access to health records. iSparrow serves as a tool to facilitate delivery of high-quality Patient care, and support population health management, research, and disease surveillance.

Target Customers / Markets

Sparrow Hospital considers Inpatient, Outpatient, Emergency and Primary Care patients as the key patient segments. The key market segments are the counties in which surrounds the hospital. The key stakeholders are the communities that are served. Key suppliers are VHA-UMCSC, Cardinal and AmerisourceBergen. Sparrow Hospital’s key partners are Mayo Clinic Care Network, and Michigan State University (MSU). Forging strategic partnerships improves quality, clinical integration and the scope of service in alignment with the Sparrow Way. As a member of the prestigious Mayo Clinic Care Network, SH Physicians can collaborate with Mayo

Clinic experts to bring the best clinical practices and care as close to home as possible. Sparrow and MSU partner to educate the next generation of health care providers in mid-Michigan.

Customer Value Propositions

The following are the customer value propositions: 1. Local access to care with a key collaboration with the Mayo Clinic Care Network.2. Value-based population health model.3. Magnet Designated Hospital, providing quality nursing care.4. Convenient, efficient and service oriented health care model.

In 2012, Sparrow Hospital became the first and only Michigan member of the Mayo Clinic Care Network. This membership allows Sparrow patients and caregivers access to Mayo’s world renowned resources and knowledge with the ability to stay close to home.

The Nurse Magnet Distinction by the American Nurses Credentialing Center is the nation’s most prestigious honor for nursing achievement and considered the “gold standard” for quality nursing care in hospitals. Sparrow Hospital was first designated in 2009, and in 2014 achieved Magnet re-designation, ranking it among the top four percent of hospitals in the nation. Suppliers, Partners, and Collaborators

Sparrow Hospital is one of two hospitals in Ingham County. The Core market area covers Ingham, Eaton and Clinton counties. The other major hospital is McLaren Greater Lansing (MGL), a 389-bed facility. MGL vies for patients within SH’s key markets. There are other SHS affiliates and competitors that compete in the additional 5 counties of Sparrow’s service area. Competitor relationship issues are managed at the Sparrow Hospital System level and are outside of scope.

Besides the Nurse Magnet Distinction and the collaboration with the Mayo Clinic, in 2014, SH was designated a Stage 7 Organization by the Healthcare Information and Management Systems Society (HIMSS), signifying SH’s level of achievement and adoption of the Electronic Health Record (EHR)

Strategic Position

Strategic challenges include population health management, Physician alignment and affordability. The strategic advantages include forging strategic partnerships, resource stewardship, practicing Nursing excellence, information technology system integration and market essentiality.

Strategy Map

MissionThe organization exists to improve the health of the people in the communities by providing quality compassionate care to everyone, every time.

Vision The organization wants to be recognized as a national leader in quality and Patient experience.

ValuesThe workforce is expected to adhere to the ICARE Values - Innovation, Compassion, Accountability, Respect, Excellence

Financial Perspective

Customer Perspective

Internal-Business Perspective

Learning & Growth Perspective

Improve operational efficiency through cost reduction and quality improvement.

Metric: Percent Operating Margin

Grow through traditional market share.Metric: Increase surgical volume by 2% in targeted

Strategic Service Lines

Provide excellent customer service

Metric: % of Top Box HCAPS scores

Attract new customers.Metric: % growth of new customers

Improve operational efficiency.Metric: Average time patients spent in the Emergency Department before

being sent home.

Improve customer satisfactionMetric: Percent would recommend

from Loyalty Survey

Utilize best practices to improve care to patients.Metric: Percent of Nurses doing Bedside Shift Report

Increase the Job Enjoyment Score.Metric: Percent from NDNQI survey

for Job Enjoyment

Increase the number of patients that log into My Chart patient information systemMetric: Percentage of patients discharged

that logged into My Chart

Increase number of caregivers that receive training related to hospital

safety initiatives.Metric: Percent of caregivers that have

completed TeamStepps training

Employee Capabilities

Innovation Processes Operation Processes Post-Sale Processes

Information System CapabilitiesMotivation, Empowerment and Alignment

Capabilities

Table of Balanced Scorecard MetricsPerspective Strategic Objective Leading Metric Lagging Metric Why Leading or Lagging?


Improve operational efficiency through cost reduction and quality improvement.

Percent Operating Margin It is a lagging indicator as it is difficult to adjust quickly but can be adjusted over time.

Grow through traditional market share.

Increase surgical volume by 2% in targeted Strategic Service Lines

It is a leading indicator because the data is available daily. Strategy can be adjusted as the numbers present.


Provide excellent customer service.

Achieve 73% top box(nat.avg.) on HCAHPS “Likelihood toRecommend” domain.

This metric is a lagging metric as data lags by two quarters. Information is obtained from patients after they are discharged and called.

Attract new customers.Percent growth of new customers and total # of returning customers

This metric is a lagging metric since the data is not used for future projects or improvements.

Internal-Business Process Perspective

Utilize best practices to improve care to patients.

Increase percent of Nurses doing Bedside Shift Report

This metric is a leading indicator as it is tracked on a daily occurrence allowing immediate feedback on the metric and ability to adjust as needed.

Improve operational efficiency.

Average time patients spent in the Emergency Department before being sent home.

This metric is a leading indicator as it tracked on a daily occurrence allowing immediate feedback on the metric and ability to adjust as needed.

Improve customer satisfaction Percent would recommend

from Loyalty Survey

This metric is a lagging indicator as it provides information after the patient was already seen in the Emergency Department. The data is used to make improvements in the future.

Learning & Growth Perspective

Employee Capabilities Percent from the NDNQI Job Enjoyment Score.

This metric is a lagging indicator as the feedback from the survey is not provided until several months after the survey.

Information System Capabilities

Percentage of patients discharged that logged

into My Chart

This metric is a leading metric as the data can be tracked per discharge and interventions acted upon immediately.

Motivation, Empowerment and Alignment Capabilities

Percent of caregivers that have completed TeamSTEPPS

This metric is a lagging metric as the training for all caregivers takes time.

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Financial Metric #1

Financial Metric Metric Information

Strategic Objective Improve operational efficiency through cost reduction and quality improvement.

Metric Title Percent Operating Margin

What is the source data?

Sparrow Hospital’s financial software program Lawson provides this data as it tracks income in and expenses out. The data is pushed out by the finance department bimonthly.

From how many locations is the source data collected?

Approximately 37 departments throughout the hospital will generate the data that is then collected and tabulated by the finance team.

What is the source data collection frequency?

The data is collected daily and reported out bimonthly.

How is source data inputted into the information system?

The data is electronically uploaded into the finance system on an ongoing basis. A report is completed at the end of a pay period including the metrics.

Which mathematical function is used to hierarchically aggregate the source data? Explain in detail how the calculation takes place.

Operating Margin = Operating Income/Operating Revenue

It typically excludes interest expense, nonrecurring items (such as accounting adjustments, legal judgments or one-time transactions) and other income statement items not directly related to a company's core business operations.

What is the numeric TARGET for this metric?

Stay within the previous year budget by 2%.

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Financial Chart #1

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Financial Metric #2

Financial Metric Metric Information

Strategic Objective Grow through traditional market share.

Metric Title Increase surgical volume by 2% in targeted Strategic Service Lines

What is the source data? Lawson Database that tracks number of surgeries.


The data is collected from five service lines.


The data is tracked on a daily basis.


The data is automatically entered by the Lawson Database and a monthly report is generated and shared.

Which mathematical function is used to hierarchically aggregate the source data? Explain in detail how the calculation takes place

Current Total Number of Surgeries = Previous Year to date / Current Year to dateA completion number of surgeries performed from the previous year will be compared to the current year and the difference will be evaluated as a positive or negative metric. The goal is to have more surgeries each year.


Increase each service line by 2%

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Financial Chart #2

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Customer Metric #1

Metric Metric Information

Strategic Objective Provide excellent customer service

Metric Title Percent of Top Box HCAPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Overall Rating of Care scores

What is the source data? Sparrow Hospital patients discharged from an inpatient unit. PRC – Professional Research Consultants


The data is collected from one location.


The collection frequency is monthly.


The data is inputted per the Patient Experience Department.


A 32-item survey instrument and data collection methodology for measuring patients’ perceptions of their hospital experience. Inpatient 2 Prospective Payment System (IPPS) hospitals must achieve at least 300 completed surveys over four calendar quarters. To ensure that HCAHPS scores allow fair and accurate comparisons among hospitals, it is necessary to adjust for factors that are not directly related to hospital performance but which affect how patients answer survey items. CMS and the HCAHPS Project Team (HPT) apply adjustments that are intended to eliminate any advantage or disadvantage attributable to the mode of survey administration or characteristics of patients that are beyond a hospital’s control. In addition, the HPT undertakes a series of quality oversight activities, which include site visits of HCAHPS survey vendors to inspect survey administration procedures and trace records, and statistical analyses of submitted data, to assure that the HCAHPS Survey is being administered properly and consistent


Minimum Target = 71% (National Average for Top Box Results for Overall Rating of Care)Target Goal = 72% Top Box

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Customer Chart #1

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Customer Metric #2


Strategic Objective Attract new customers.

Metric Title Percent growth of new customers.

What is the source data? The source data is Emergency Room Visits.


The data is collected from one data source.


The data is collected every month.


When patients are admitted they are put into the system. Through this process the new patients are flagged into the database that also tracks Emergency Department visits.


The market share is represented by the total sales of all brands or products competing in the same market that is captured by one particular brand or product, usually expressed as a percentage.Each month the total number of patients seen in the Emergency Department is broken down into new patients and existing. The new patients percentage is then divided by the total number of patients.


Increase each year of new patients seen in the Emergency Department by 2%.

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Customer Chart #2

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Internal Process Perspective

Internal Process Metric #1


Strategic Objective Utilize best practices to improve care to patients.

Metric Title Increase percent of Nurses doing Bedside Shift Report

What is the source data? Direct Observations from Nursing Directors


The data is collected from 10 inpatient units.


The data is collected three times per week.


The data is inputted per the administrative assistant to the Director.


Baseline data is collected and later used a comparison.The data is collected how many nurses are performing bedside shift report. Total number of nurses on the unit doing bedside shift report divided by total number of nurses multiplied by 100 gives the percentage of bedside shift report compliance. If there are 10 nurses on the unit and 8 are doing bedside shift report they would have a 80% compliance rate.


The target metric is 100% compliance.

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Internal Process Chart #1

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Strategic Objective Improve operational efficiency.

Metric Title Average time patients spent in the Emergency Department before being sent home.

What is the source data? The computer program that is used to admit patients to the Emergency Department.


The data is collected from one data source.


The data is collected daily.


The data is inputted from the triage nurse in the Emergency Department.


The average sum of time spent from check into the Emergency to Department to discharge from the Emergency Department.When the patient checks into the Emergency Department the triage nurse logs them into the system which starts the clock running. When the patient is first put into a room it also logs the time. Lastly when a patient is discharged the final time is recorded. Therefore the admit time is subtracted from the discharge time.


National Average for Michigan is 132 minutes. Goal for Sparrow Hospital is 115 minutes.

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Strategic Objective Improve customer satisfaction

Metric Title Percent would recommend from Loyalty Survey

What is the source data? Patients discharged from the Emergency Room utilizing a national survey tool.


The data is collected from one location.




A national data base is used to export data and then the data is recorded on Sparrow’s scorecard by the Patient Experience Department.


Patients who received care at fully hospital-based EDs will be eligible for the survey. The survey will ask patients about their experiences with arriving at the ED, during ED care, and after being admitting to the hospital or discharged from the ED. In the field testing, approximately 18,000 ED patients over the course of a three-month period were sampled from 12 hospitals, with sampled individuals randomized to three modes: mail only, telephone only, and mail with telephone follow-up. The OMB package for field testing including survey instruments and protocols.


Between the 75th percentile and the 90th percentile.

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Learning & Growth Perspective #1


Strategic Objective Increase the Job Enjoyment Score.

Metric Title Percent from the NDNQI survey related to Job Enjoyment.

What is the source data? The National Database of Nurse Quality Indicators


The data is collected from 10 inpatient units.


The data is collected one time per year.


The data is put into the system by the performance improvement specialist.


The data is captured via survey instrument. Surveys are crafted so respondents can immediately understand what is being asked and the purpose of each question. Survey development is founded on deep social science expertise and experience resulting in psychometrically sound surveys that provide useful and meaningful results. The Press Ganey Research team applies careful design and refinement of survey questions to ensure reliability (extent to which repeatedly measuring the same property produces the same result) and validity (extent to which it measures what it is supposed to measure).


Between the 75th Percentile & 90th Percentile.

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Learning and Growth Chart #1

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Strategic Objective Increase the number of patients that log into My Chart patient information system.

Metric Title Percentage of patients discharged that logged into My Chart.

What is the source data? The data comes from a report that is run from Epic.


The data is collected from one source, Sparrow Hospital.




The data is retrieved from Epic and then disseminated from an Senior Project Analyst.


The number of patients discharged from the hospital divided by the number of patients discharged from the hospital that accessed My Chart equals the percentage of patients logging into My Chart.The total number of patients discharged is tracked through Lawson. The total number of patients that log into My Chart is tracked in epic. The two numbers are divided and equal the percent of patients discharged who logged in.


75% of patients discharged from the hospital will log into My Chart

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Learning and Growth Chart #2

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Strategic Objective Increase number of caregivers that receive training related to hospital safety initiatives.

Metric Title Percent of caregivers that have completed TeamSTEPPS training.

What is the source data? The My Learning software.


The data is collected from one source.


The data is collected and reviewed monthly.


The data is taken from My Learning and entered into the TeamSTEPPS tracking spread sheet.


The number of caregivers at Sparrow Hospital divided by the number of caregivers that have completed the TeamSTEPPS training.The number of caregivers is tracked in the Lawson data base. The caregivers must take a quiz in My Learning upon completion of the TeamSTEPPS training. These two numbers are divided to provide a percent of caregivers that have completed the training.


100% completion by December 31, 2016.

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Learning & Growth Perspective Chart#3

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