PREFACE: ORGANIZATIONAL PROFILE

P. 1 Organizational Description

P.1a(1) SSM Health Care was founded 130 years ago byMother Mary Odilia Berger, who migrated with four othersisters to the United States from Germany. The sistersarrived in St. Louis on November 16, 1872, during a small-pox epidemic. The Sisters of St. Mary, as they werenamed, began nursing smallpox patients the next day. In1987, the Sisters of St. Mary and the Sisters of St.Francis reunited to form the Franciscan Sisters of Mary.

Today, sponsored by the Franciscan Sisters of Mary,SSM Health Care (SSMHC) is based in St. Louis, MO,and operates as a private, not-for-profit health caresystem. SSMHC entities are located in the Midwest infour states--Missouri, Illinois, Wisconsin, and Oklahoma.

Ninety percent of SSMHC’s revenue is derived from healthcare services provided at its hospitals. Primary amongthese services are emergency, medical/surgical,oncology, mental health, obstetric, cardiology, orthopedic,pediatric, and rehabilitative care. SSMHC delivers itshealth care services in inpatient, outpatient, emergencydepartment, and ambulatory surgery settings associatedwith 17 acute care hospitals. Sixteen of the hospitals areowned and operated by SSMHC, and one is managed bythe system, but jointly owned with another health caresystem.

Secondary services, which support SSMHC’s core hospi-tal business, include physician practices, skilled nursing(long term) care, home care, and other nonpatientbusiness services. Physician diagnostic and treatmentservices are provided through the offices of SSMHC’s 209employed physicians. The physician practices referpatients to SSMHC’s hospitals. SSMHC provides skillednursing care primarily through three nursing homes, eachassociated with one of the acute care hospitals. SSMHome Care provides home care and hospice services in avariety of geographic areas. The nursing homes and SSMHome Care assure continued quality care for patients whoare discharged from the hospital.

SSMHC has structured its organization into three levels:system, network, and entity. At the system level, SystemManagement, supported by the Corporate Office staff,establishes the overall direction for the organization,ensures regulatory compliance, facilitates sharing ofknowledge, monitors organizational performance, anduses the system’s size to achieve economies of scale.SSMHC’s networks coordinate the delivery of care; facili-tate communication, cooperation, and sharing of knowl-edge and skills; and provide support services (planning,finance, human resources, physician practice manage-ment) for the entities within a specific market. The entitiesfocus on meeting their communities needs and deliveringcare to their patients.Recognizing that health care is delivered locally, SSM

Health Care has established geographically based organ-izational units serving south central Wisconsin; BlueIsland, IL, and southern Illinois; St. Louis, Jefferson City,and Maryville, MO; and central Oklahoma. Each marketarea has a board of directors and single governance struc-ture. Networks coordinate delivery of services in threemajor markets: SSM Health Care St. Louis in greater St.Louis, SSM Health Care of Oklahoma in centralOklahoma, and SSM Health Care of Wisconsin in south-ern Wisconsin. These networks integrate the hospitals,nursing homes, physician practices, clinics, managedcare organizations (where existing), and other businessunits in these areas. SSM Home Care is managedcentrally.

Three of the owned hospitals are specialty hospitals:rehabilitation (SSM Rehab/St. Louis), pediatrics (SSMCardinal Glennon Children’s Hospital/St. Louis) and ortho-pedics (Bone & Joint Hospital/Oklahoma City).

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Figure P.1-1 SSMHC Vision Statement

SSM Health Care’s Mission StatementThrough our exceptional health care services, we revealthe healing presence of God.

Figure P.1-2 SSMHC Mission Statement

SSM Health Care’s Core ValuesIn accordance with the philosophy of the FranciscanSisters of Mary, we value the sacredness and dignityof each person. Therefore, we find these five valuesconsistent with both our heritage and ministerialpriorities:� Compassion� Respect� Excellence� Stewardship� Community

Figure P.1-3 SSMHC Core Values

Figure P.1-4 SSMHC Quality Principles

SSM Health Care’s Vision StatementThrough our participation in the healing ministry ofJesus Christ, communities, especially those that areeconomically, physically and socially marginalized, willexperience improved health in mind, body, spirit andenvironment within the financial limits of the system.

SSMHC’s Quality Principles� Patients and other customers are our first

priority� Quality is achieved through people� All work is part of a process � Decision making by facts� Quality requires continuous improvement

©SSM Health Care All Rights Reserved

Cardinal Glennon provides pediatric services at its hospitalcampus as well as through Glennon Care for Kids, whichhas more than 30 sites in Missouri and Illinois, includingsix sites at SSMHC hospitals. SSM Rehab has inpatientcomprehensive medical rehab units at three SSMHChospitals and more than a dozen outpatient sites in theSt. Louis area.

P.1a(2) SSM Health Care’s culture is reflected in itsvision, mission, core values, and quality principles (Fig.P.1-1-4) The mission and core values were developed byemployees systemwide in 1999. During the recent yearsof tumultuous change and challenge in health care, thesecultural touchstones have provided constancy of purposefor SSM Health Care employees. Two of the strongestcultural influences ensuring constancy of purpose are (1)the organization’s history and tradition and (2) a long-termcommitment to continuous quality improvement.

SSMHC committed to continuous quality improvement(CQI) systemwide in 1990, and was among the first healthcare systems in the nation to do so. Sr. Mary Jean Ryan,FSM, President/CEO, and the system's senior leadershipteam made this commitment after research showed strongparallels between SSMHC's values and quality principles.The focus on CQI and assessment of progress using theCriteria for Performance Excellence has transformedSSMHC’s culture into one of teamwork, continuouslearning, innovation, breakthrough performance, andsystems thinking. SSMHC has become a national rolemodel for health care organizations across the country,even internationally, that are striving to create a culture ofcontinuous improvement. Each year, SSMHC’s seniorleaders host many visitors from other health careorganizations and share best practices at national, stateand local health care meetings.

The SSMHC culture is also characterized by consensusbuilding and decision-making at the level of greatestimpact and responsibility. SSMHC employees responsiblefor implementing decisions as well as those impacted bythose decisions work together in teams to reachconsensus on action plans. This promotes anunderstanding of the rationale for the decisions and buy-infor deployment of the action plans. The organization’sbroad-based leadership system, which includesapproximately 190 executives from across the system,facilitates consensus building and decision-making amongthe leaders. This culture is also reflected in the degree ofautonomy exercised at the local level. SSMHC carefullybalances the need for standardization with the benefits oflocal autonomy. Within SSMHC, local networks andhospitals have a great deal of authority and freedom toaddress their own market’s unique challenges. As aresult, the organization reaps the benefits of flexibility andmore rapid decision-making. In addition, each employee isconsidered a leader and expected to contribute to his or

her fullest potential, both within and beyond their jobdescription.

P1a(3) Nearly 5,000 physician partners and 22,041employees work together to provide health care services.The system’s health care staff is diverse and includesnurses (patient care and administrative), physicians,executives and managers/supervisors; support, clinicaland technical professionals; lead clinical/technicalprofessionals; allied health; support services; andadministrative assistants/coordinators/office clerical.Eighty-two percent of the employees are women, and 18percent represent minority groups. SSMHC has nounionized employee groups. Periodically, contract workersare used to supplement the workforce.

Special safety requirements for employees includeergonomics, exposure control through sharps alternatives,hazardous and biohazardous material management, lifeand environmental safety, and emergency preparedness.

P1a(4) SSM Health Care is a vast organization with ownedfacilities totaling more than 11.5 million square feet. Thesefacilities include acute care hospitals, nursing homes,outpatient care buildings, physician and other officebuildings, and clinics. SSMHC’s major medical equipmentsupports diagnostic and treatment services within itsacute care settings. This equipment includesstate-of-the-art technology, such as MRI, CT, ultrasound,diagnostic imaging, angiography, and surgical lasers. Forexample, St. Marys Hospital Medical Center in Madison,WI, and Bridge Medical Inc. received the HealthcareInnovations in Technology Systems partnership awardfrom Healthcare Informatics magazine for their creativeuse of emerging technology to improve patient carequality. St. Marys helped develop and has sinceimplemented the Bridge MedPointTM software system,which uses bar-code technology to intercept medicationand blood transfusion product errors at the bedside.

A standardized, systemwide information system supportsSSMHC’s assessment, measurement, accountability,and e-health activities. The infrastructure initiated in 1992includes local area networks (LANS); system-spanningwide-area networks (WANS); access to external,government, and commercial databases; videoteleconferencing; tele-radiology; and other services.

P1a(5) The system operates under the requirements of thefederal sector, including OSHA, EEOC, and EPA (health,safety and environmental), and within city, state, andcounty regulations. While SSMHC is not legally requiredto meet EEOC regulations, the organization has electedto do so because of its strong commitment to diversity.SSMHC is committed to exceeding regulatoryrequirements, and considers compliance a minimumstandard. All hospitals, nursing homes, care sites, and

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services are fully licensed and accredited by allappropriate federal, state and local agencies.

SSMHC is the only health care organization in the nationto qualify for and adopt the Corporate Parent ModelMaster Trust Indenture (MTI), a legal platform forcoordinating external borrowing. The MTI has givenSSMHC the ability to streamline corporate borrowingthrough tax exempt revenue bonds and to be flexible inaffiliating and building relationships with other entities.

SSMHC tracks charity care and community benefits toensure that it fulfills the organization’s Vision andmaintains tax exempt status as a nonprofit health careorganization under IRS financial regulations. TheCorporate Responsibility Process (CRP) ensures thatSSMHC’s entities comply with Medicare and Medicaidfraud and abuse requirements and regulations enforced bythe Office of Inspector General (OIG). SSMHC’s HIPAAProject is preparing the organization for U.S. Departmentof Health and Human Services’ regulations on patientconfidentiality under the Health Insurance Portability andAccountability Act of 1996 (HIPAA).

P.1b(1) SSMHC views patients and their families as itsprimary customer group. SSMHC further delineates thiscustomer group by five key patient groups: inpatient,outpatient, emergency department, home care and longterm care. Surveys have shown family members, who actin behalf of children or relatives not competent to makedecisions, have the same key requirements as patients.See Fig. P.1-5 for key customer requirements. All patientsegments expect accuracy, good communication, andpositive health care outcomes.

P.1b(2) SSMHC has selected the following key suppliersto represent and distribute supplies systemwide: CardinalHealth (pharmacy & pharmacy automation), Burrows,Owen & Minors, and Allegiance (regionalmedical/surgical), Alliant (food service), Fischer(laboratory), and Diagnostic Imaging (radiology). SSMHCuses Premier, Inc., the nation’s largest health carepurchasing group, to obtain cost savings. As one of

several hundred owners of Premier, SSMHC also receivesperiodic dividends. SSMHC’s key requirement for Premieris cost savings. SSMHC screens its suppliers, and hasestablished strict controls to monitor and ensure qualityproducts are received.

In addition to ongoing communications by telephone, mailand e-mail, an SSMHC representative meets in personwith key contacts from each of the suppliers quarterly toconduct a formal business review and planning session.The meeting is designed to review the supplier’sperformance and plan future improvements; to discussSSMHC’s goals, requests, and unresolved issuesregarding products and services; and to explore newproducts and programs. Electronic links to suppliers areprovided on the SSMHC intranet.

Physicians are critical to SSMHC’s success becausethey are the primary source of patient referrals, andessential partners in improving clinical outcomes.Therefore, SSMHC considers physicians its mostimportant partner group. All physicians who admit andtreat patients at SSMHC hospitals must apply for medicalstaff membership and be granted specific privilegesappropriate to their education, training and experience.The system’s most important supplier partners aremedical equipment and supply distributors. SSMHCidentifies partners as those with whom it has areciprocating relationship--one that carries dualrequirements. See Fig. P.1-6 for supplier-partner keyrequirements.

SSMHC seeks to make physicians clinical partners,sharing in the organization’s mission, decision making,strategic planning, and clinical performance improvementopportunities. SSMHC works closely with approximately5,000 medical staff physicians systemwide, including 209who are employed, and participates in 39 joint ventures

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� Responsiveness, Pain Management

� Wait Times, PainRelief

� Wait Times,Pain Management

� Timeliness,Accuracy

� Technical Skill

� Inpatients

� Outpatients

� Emergency Dept.

� Home Care

� Long Term Care

Key RequirementsPatients & TheirFamilies

Figure P.1-5 Key Customer Requirements

SSMHC Requirements of Suppliers� Timely availability of inventory� Invoicing accuracy� Cost savings/Sales

Supplier Requirements of SSMHC� Timely payment of bills (DSO)

SSMHC Requirements of Physicians (Partners)� Business growth/patient referrals� Resource management� Exceptional patient care/Outcomes (shared)

Physician Requirements of SSMHC� Nursing responsiveness & Reduced turnover � Administrative responsiveness & Facility

improvements

Figure P.1-6 Supplier/Partner Key RequirementsUPDATE

with physicians. One of the most successful examples ofphysician partnering is SSMHC’s long-standingrelationship with Dean Health System in Wisconsin. Since the late 1980s, DeanMedical Center, a component of Dean Health System, andSSMHC have had a 50/50 joint venture called St. MarysDean Ventures, Inc., which provides primary care servicesin rural Wisconsin through 92 physicians, 19 optometrists,and 2 podiatrists in 23 clinics, 3 ambulatory surgicalcenters, and 12 eye offices. This partnership has enabledSSMHC to be the leader in the south central Wisconsinmarket.

A systemwide Physician Leadership Council wasestablished in 2001 to coordinate activities to developphysician leaders in the organization. The Councilconsists of seven physicians representing employed,appointed and elected medical staff leaders. The Councilhas implemented monthly medical leader conferencecalls; established an intranet listserv for physicians;organized a pre-session for physicians at the annualSSMHC Leadership Conference; and planned a two-dayretreat that includes updates on the system’s goals.Physician executives also receive SSMHC’s weeklyelectronic newsletter, SSM Link . All physicians receiveSSM Network , SSMHC’s bimonthly newspaper. Moreformal communications occur in person at team or ClinicalCollaborative meetings, conferences, sharing sessions,Board and committee meetings. Physicians selected bythe medical staff serve on network/regional boards.

P.2 Organizational Challenges

P.2a(1) SSMHC is the 10th largest Catholic health caresystem in the nation ranked by staffed acute care beds. In2001, the system had $2.4 billion in assets and $1.7billion in total operating revenue. The health care industryis very competitive in SSMHC’s major markets andmanaged care penetration is high. Despite thesepressures, SSMHC is currently increasing market share inall its major markets.

SSM Health Care St. Louis competes with BJC HealthCare, the area's largest provider; Tenet, the first nationalfor-profit company to enter this health care market; andSt. John’s Mercy Medical Center. SSM Health Care St.Louis, second in size with 18 percent of the inpatientmarket share, is known as the most physician-friendlynetwork in the St. Louis area. Cardinal Glennon Children’sHospital, the nation’s only Catholic-sponsored children’shospital, is a national role model for compassionate carefor dying children through Footprints, funded by a RobertWood Johnson Foundation grant.

SSM Health Care of Oklahoma competes with Integris,the largest provider network; University Health Partners;Deaconess Hospital; and Mercy of Oklahoma. SSMHealth Care of Oklahoma, third with 17.1 percent market

share, is the fastest growing network in Oklahoma City.Bone & Joint Hospital is a national role model for kneeand hip surgery. In 2002, Bone & Joint was named one ofthe nation’s top ten orthopedic hospitals in the country byAARP and was the only facility in Oklahoma to receivetwo five-star ratings in orthopedics fromHealthgrades.com.

SSM Health Care of Wisconsin competes with MeriterHealth Services and the University of Wisconsin Hospital.Other competitors in Wisconsin include ReedsburgHospital, Sauk Prairie Hospital, and Divine SaviorHospital. SSM Health Care of Wisconsin, first with an18.8 percent market share, is the lowest cost provider inthe Madison market. In 2002, St. Marys Hospital MedicalCenter in Madison was designated a national nursing rolemodel, one of only 50 magnet hospitals in the country, bythe American Nurses Credentialing Center for its use ofthe shared governance model.

SSMHC’s key collaborators are Dean Health System, ajoint venture partner in Wisconsin; affiliated colleges anduniversities that provide physician and nurse staffing andassist in professional health care staff recruitment;affiliated hospitals that increase market share; theAmerican Hospital Association and state hospitalassociations that assist in advocacy efforts; and a varietyof local, regional and national organizations that partnerwith SSMHC entities and networks on HealthyCommunities projects.

SSM Health Care expands access to health care andreferrals through affiliation agreements with rural hospitalsin Missouri, Illinois, Wisconsin, and Oklahoma.

In addition, SSMHC participates in approximately 100clinical affiliation agreements with colleges anduniversities around the country providing internship andresidency sites for physicians and other health careprofessionals. The four primary collaborators are theUniversity of Wisconsin, Saint Louis University, OklahomaState University, and University of Oklahoma. P.2a(2) The following factors give SSMHC a competitiveedge and differentiate it in the marketplace: A culture ofcontinuous quality improvement that encouragesteamwork, learning, and innovation; use of the Criteria forPerformance Excellence to assess approach anddeployment of processes; a commitment to partneringwith physicians; systemwide Clinical Collaboratives toimprove clinical outcomes; and the Catholic tradition ofgiving compassionate health care services to all, but mostespecially to those who are poor and vulnerable.Other factors contributing to SSMHC’s success include agovernance structure that promotes rapid decisionmaking; systemwide survey processes that providein-depth insight into the needs and requirements ofSSMHC’s patients and other customers along withsoftware that enables drill-down analysis; a reputation for

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being a good partner, especially among physicians; Strategic and Financial Planning Process (SFPP) thatenables the system to focus on the future and respond toa competitive and rapidly changing environment withagility. The entities also are strengthened by being part ofSSMHC, a national system, and its regional networks,which promote sharing of knowledge and resources.SSM Health Care was one of only a small number ofhealth care systems across the country to report asubstantial financial improvement ($56 million) between1999-2001. This financial improvement enabled thesystem to pursue a $240 million bond issue to fund 2001capital expenditures for technology and hospital/nursinghome facilities and reimburse past capital expenditures.SSMHC expects these capital improvements to enhanceits health care services and result in increased marketshare.

P.2b SSM Health Care’s key strategic challenges are:� patient safety� nursing shortage� increasing financial pressures, including capital

investment costs and declining reimbursement� growing customer expectations.

P.2c SSM Health Care uses the Criteria for PerformanceExcellence as a business model and assessment tool.Thirty-six applications for state and national qualityawards have been made by SSMHC and its entities since1995. SSMHC received site visits by examiners from boththe Missouri Quality Award and the Malcolm BaldrigeNational Quality Award during 1999. SSMHC was awardedthe 1999 Missouri Quality Award. SSMHC received asecond MBNQA site visit in 2001.

The application process each spring helps theorganization to assess the effectiveness of itsapproaches. Members of the systemwide category teamsinvolved in gathering data for the application learn moreabout how the entire organization operates and how theycan improve in their own areas.

After the feedback report is received at the system level, asmall systemwide team works with consultants to analyzethe report and prioritize improvement initiatives based onavailable resources and value to the organization.Sub-teams of experts are called together whenspecialized expertise is required to define next steps.System Management (defined in 1.1a(1)) discusses theteam’s recommendations and decides whichimprovements to pursue. The Quality Resource Centerholds an educational videoconference on the feedback foremployees and physicians at the network and entity level.Special educational sessions and progress updates arepresented to System Management and the InnsbrookGroup. The feedback is also considered by the InnsbrookGroup in its February planning session for the Strategic,Financial & HR Plan. Teams are assigned to improve

existing processes or to develop and implement newprocesses. The strengths and opportunities for improvement as wellas improvement plans are communicated broadlythroughout the organization using the communicationsmethods listed in Figure 1.1-1. Sr. Mary Jean Ryan, FSM,and the regional presidents present the key feedbackfindings to the administrative councils and employees andphysicians during the January/February annual entityvisits.

Improvements are made at the entity, network and systemlevel using a continuous quality improvement (CQI)methodology. Improvement teams use the samePlan-Do-Check-Act (PDCA) steps of the CQI model, withsome modifications, for both design and redesign ofprocesses. The CQI Model-Process Design Approach isused to design new processes, and the CQIModel-Process Improvement Approach is used to redesignprocesses. (See Fig. 6.1-1)

SSMHC keeps focused on the need for improvementthrough its Performance Management Process, which isdescribed in Item 1.1 and Item 4.1.

SSMHC fosters best practice sharing throughout theorganization in the following ways.� An annual Sharing Conference highlights 40 or more

best practices from around the system� Best practices are exhibited at the system's annual

Leadership Conference� Best practices are shared at annual systemwide

meetings of functional area leaders� Quality improvement teams notify the Quality

Resource Center of new projects and send their story-books to be shared with other entities.

� Teams participating in SSMHC’s Clinical Collabora-tives share lessons learned through teleconferencesand face-to-face meetings of participants

� Information is shared through the system's intranetsite and in an e-mail newsletter, SSM Link , distributedweekly to the executive leadership group.

� Shared team learning is tied to SSMHC strategicinitiatives in the system's bimonthly newsletter, SSMNetwork , whose mission is "Sharing Ideas to AdvanceOur Common Mission." This newsletter is distributedto all employees and physicians.

SSM Health Care’s employees and physicians were delib-erate in selecting the word “exceptional” to be used in ourMission Statement: Through our exceptional health careservices, we reveal the healing presence of God. Weknow that it sets a high standard, and we are determinedto work together to reach that standard. We do it becausewe share in the commitment to give the same exceptionaland compassionate care to every person, regardless ofher or his ability to pay.

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CATEGORY 1 - LEADERSHIP

1.1 Organizational Leadership1.1a(1) SSM Health Care is committed to providingexceptional health care services to every person whocomes to us in need of care. SSMHC’s Board of Directorssets the organization’s Vision Statement (Figure P.1-1)and affirms the Mission and Core Values statements(Figures P. 1-2 and P.1-3) developed by employeesthroughout the system. The Board consists of ninemembers, both religious and lay persons, and meets fourtimes a year. Four regional boards and three local boards,operating under guidelines established by the SSMHCBoard, are responsible for medical staff credentialing andperformance assessment and improvement for SSMHCentities within their service areas. The regional/localboards meet six times a year.

Approximately 190 regional and system executives, entitypresidents and administrative council (AC) members,physicians, and corporate vice presidents make upSSMHC’s leadership system (see page xv). Physicianexecutive leaders, who are typically vice presidents ofmedical affairs, medical directors, or chief medical officersat the entities or networks, are fully participating membersof the leadership system.

The leadership system contains the following primarymandated groups: * System Management, 11 senior leaders, who meetmonthly. See page xvi.* Operations Council, 9 senior leaders, subset ofSystem Management, who meet monthly. * Innsbrook Group, 31 system, network and entity seniorleaders, who meet three times a year. The InnsbrookGroup consists of all members of System Managementand all hospital presidents, plus representative physicianorganization, network, home care, and informationsystems executives. * Network leadership consists of the networkpresident/CEO and his or her direct reports, 8 to 10people, who meet weekly or biweekly.* Entity leadership consists of presidents and membersof their leadership teams, called administrative councils,and medical staff leaders, 8 to 10 people, who meetweekly or biweekly.

Nearly 3,000 SSM Health Care employees and physiciansparticipated in focus groups across the system to definethe organization’s mission and values during 1999. Out ofthis discussion came recommended wording for a single,more concise and memorable mission statement and corevalues. During 2000, educational sessions wereconducted at each of the entities to communicate the newmission and core values to all physicians and employees.The education, designed to give definition to the mission

and values, included group discussions of the personalmeaning of the mission and values to individuals. A“Meeting in a Box” tool kit, including a video, brochuresand pocket cards was used to facilitate consistentdeployment. Educational programs conducted in 2001 forthe deployment of the 2002-4 Strategic, Financial & HRPlan (SFP) served to reinforce the mission and values.

SSMHC is a mission-and-values-driven organization. Everyexecutive leader throughout the system is responsible forensuring that SSMHC’s mission and values arecommunicated and deployed. The corporate vicepresident-mission awareness develops SSMHC’s missioninitiatives with input from the Mission Think Tank of abouta dozen employees and entity/network missionawareness representatives. System Managementrequires each entity to have a mission awareness team(MAT), made up of a cross section of employees. Theseteams sponsor an annual retreat day for their co-workersand a variety of works of mercy, for example, fundraisingfor local charities, that emulate the mission and values.Mission and values statements and Quality Principles(Figure P.1-4) are reinforced in system, network and entitypublications, such as SSM Network , SSMHC’s bimonthlynewspaper, and posted in conference rooms throughoutthe system.

The Innsbrook Group sets the organization’s short- andlong-term strategic directions and performanceexpectations through the Strategic, Financial & HRPlanning Process (SFPP) (Figure 2.1-1). They developgoals that support the Vision and Mission statements.Interactive processes occur within each entity and networkto finalize the entity/network Strategic, Financial & HRPlans (SFPs). Use of the SFPP also enables theInnsbrook Group to create and balance value for all of itsstakeholders (patients and their families; employees; allactive and associate physicians; major suppliers; andpayors) by ensuring the goals reflect each stakeholder’srequirements.

System Management translates short- and long-termdirections and deploys organizational values andperformance expectations to all employees through asystemwide tool called “Passport.” SSMHC employeesreceive a “Passport” - a card that contains the SSMHCmission and values; the characteristics of exceptionalhealth care services identified in the 2002-4 SFP; spacesfor entity, departmental, and personal goals andmeasures; and a place for the employee and managersignatures and date. The Passport creates “line of sight”from personal goals to the organization’s goals.

SSMHC’s senior leaders use communication plans (whichidentify key messages, audiences, leader spokespersons,methods, and timelines) and tools like “Meeting in a Box”

1

to ensure consistent communication of values, directions,and expectations throughout the leadership system and toall employees and employed physicians. See Figure 1.1-1for other communications methods used by senior leadersto communicate values, directions, and expectations andto facilitate the sharing of knowledge and skills.

The effectiveness of communications and deployment ofvalues, directions and performance expectations isassessed (“checked” in the PDCA) firsthand when Sr.Mary Jean Ryan and the regional presidents make theirannual entity site visits during January and February. Thevisits enable two-way discussions with entityadministrative council members, physicians, andphysician representatives as well as randomly selectedemployees. 1.1a(2) Through their unwavering commitment during thepast 12 years to a culture of continuous qualityimprovement (CQI), SSMHC’s executive leaders havecreated an environment that empowers and encourages allemployees to be innovative and to seek the knowledgethey need to anticipate and manage industry changes.The SSMHC culture fosters organizational agility bydeploying decision making to the immediate level ofimpact. This philosophy was established at the time thesystem was formed in 1986 and is based on the religiousheritage of SSMHC’s sponsors, the Franciscan Sisters of

Mary, and reinforced in governing policies. SharedAccountability, an organizational structure that givesnurses greater decision-making authority and overallaccountability for nursing practice at their entities, is anexample of deploying decision making to the immediatelevel of impact. This concept was one of several strategiesthat emerged from SSMHC’s 2000 Nursing Summit toaddress the nursing shortage. St. Marys Hospital MedicalCenter in Madison, WI, which had operated under SharedGovernance, a model of Shared Accountability, for 12years found that the structure significantly reduced itsnurse turnover rate. System Management approvedsystemwide replication of this best practice and requiredall SSMHC entities to develop a plan for implementation in2002.

SSMHC executive leaders model learning and innovationby being in the forefront of health care as, for example,with the early introduction of CQI. Sr. Mary Jean Ryan,FSM, president/CEO, was presented with the 1997Governor's Quality Leadership Award from the Governor ofMissouri. To help other systems just beginning their CQIjourney, Sr. Mary Jean and Bill Thompson, senior vicepresident-strategic development, wrote a book, CQI andthe Renovation of an American Health Care System: ACulture Under Construction, published by ASQ QualityPress in July 1997.

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Employees & PhysiciansEvery 6 monthsClinical Collaborative Learning SessionsNursesAnnualNursing Summit & Clinical SummitEmployees & PhysiciansAnnualShowcase for Sharing/Sharing Conf.Employees & PhysiciansMonthlyDepartment MeetingsPhysiciansSemiannualMedical Staff MeetingsEmployees & PhysiciansQuarterlyTown Hall MeetingsEmployees & PhysiciansMonthly or PRNEmployee CouncilsEmployees, Physicians, VolunteersAs neededMeeting in a BoxEmployees, PhysiciansContinuousEnvironmental CommitteesEmployees, Physicians, Patients & FamiliesMonthly or PRNEthics Committees

Employees, Physicians, SuppliersAnnual (S) &Quarterly (N)

Leadership Conferences (System &Network)

Employees & PhysiciansMonthlyMission Awareness Teams

Employees & PhysiciansAnnual or PRNExec Presentations at Orientations, EducForums, Functional Area Meetings

Employees, Physicians, Volunteers6X a year/ PRNPresident/CEO’s Column published inentity employee newsletters

Internal & External StakeholdersBimonthlySSM Network (print & electronic) & entitynewsletters

Executive & Physician Leaders &Directors/Managers

Weekly/ PRNSSM Link (electronic)

Entity administrative councils, Employees &Physicians

AnnualSite Visits by President/CEO & RegionalPresidents

AudienceFrFrequencyKey Methods

Figure 1.1-1 Communication and Knowledge/Skill Sharing Methods S=system, N=network, E=entity

System Management sponsors two well-attended annualsystemwide events designed to share best practicesinternally. About 40+ best practices are highlighted inbreakout sessions for 200+ SSMHC employees andphysicians at an annual Sharing Conference held for thepast six years and an annual Showcase for Sharingexhibit at the annual Leadership Conference. Cliniciansbenchmark and share their best clinical practices throughthe system’s ongoing Clinical Collaborative learningsessions and annual Clinical Summit Conferences.Eighteen SSMHC hospital teams have also participated insix clinical benchmark studies as part of the NationalInstitute for Healthcare Improvement (IHI) BreakthroughSeries.

The Opportunities for Improvement (OFI) complaintmanagement software is an example of a SharingConference best practice that is being replicated at allSSMHC hospitals (Item 3.2a(3). The OFI process andsoftware were developed by Bone & Joint Hospital inOklahoma City.

1.1b(1) SSMHC executive leaders use a systemwidePerformance Management Process to review andassess organizational performance as it relates toachieving the SFPP short- and long-term goals; and inmeeting changing health care service needs. The processfacilitates identification of the root causes of performancevariations and establishes clear accountabilities forimplementing corrective action. This PerformanceManagement Process was developed during 2000 by thesystemwide Accountability Team. The process improvesaccountability and monitoring of performance at all levelsof the organization. Figure 1.1-2 depicts the leadershipreview forums, frequency, and reports/indicators reviewed.The reports are also used to monitor competitiveperformance and to ensure regulatory compliance. Thefirst refinement made to the Performance ManagementProcess involved development of common definitions toensure consistent and accurate measurement ofperformance across the system in 2001. SSMHC isstriving to increase balance in this process by addingmore clinical indicators and competitive benchmarks atthe system level.

The Performance Management Process defines the rolesand responsibilities of leadership groups in managing the performance of SSMHC and its entites;defines a consistent set of performance reporting toolsused throughout SSMHC; and establishes standardizeddefinitions and indicators to ensure consistency in themeasurement and evaluation of performance. Theoperational process covers three general areas ofreporting: financial, customer satisfaction, and clinicalquality performance.

System Management assesses the overall health ofSSMHC monthly by examining the Combined FinancialStatements and 16 System Level Indicators on aconsolidated basis for the services of hospital operations,home health, long-term (nursing home) care, andphysician practices. The Operations Council analyzes theoperational performance of SSMHC monthly using theSSMHC Operations Performance Indicator Report(IPR), also known as the Stoplight Report, which containsthe same 16 indicators reviewed by System Management(Figure 1.1-3), plus other key measures. This reportcovers performance by network and freestandingcampuses. If an unfavorable variance occurs for one ofthese system level indicators, the Operations Councillooks at the Hospital Operations Performance Reportto determine causal factors.

The Innsbrook Group and related administrative councilsreview progress related to SFPP goals twice a year usingthe Combined Financial Statements for SSMHC, asynopsis of the system performance prepared byCorporate Finance, a report of their consolidated resultsfor their entity or network, and a report on the operatingincome (loss) and variance for all SSMHC entities.Individual entity and network leaders use OperationsPerformance Indicator Reports, which contain anexpanded set of indicators (49) as the primary tool forevaluating the performance of an individual entity ornetwork. Selected entity and network leaders are currentlypiloting a Daily or Weekly Operations Report thatmonitors productivity, staffing and patient volume. Thismechanism for the review of inprocess indicators is beingevaluated for replication systemwide.

System, network, and entity leadership groups and the regional boards assess quality improvement and patientsafety at SSMHC hospitals through the Quality Report,which will be integrated into the PIR by the end of thisyear. This quarterly electronic report contains 14indicators in four categories: customer satisfaction,employee safety, clinical quality, and patient safety. Italso contains information related to risk management,infection control and environment of care issues.Corrective action plans are required to remedy unfavorablevariances.

1.1b(2) If an unfavorable variance occurs beyond anestablished performance threshold in any of the 16System Level Indicators, a network or freestanding(non-network) entity is required to develop and implementa corrective action plan using a standardized format.Corrective action plans include a root cause analysis,detailed implementation plans, description of the supportneeded, timelines, and responsibilities. These plans arereviewed by the SSMHC’s executive vice president andthe Operations Council. The network/entity hasimplementation responsibility with oversight provided by

3

the executive vice president/COO and Operations Council.The network leadership/entity administrative council alsomonitors progress on corrective actions. The MinistryEffectiveness Analysis (MEA), also known as PortfolioAnalysis, is a tool used by SSMHC’s entities andnetworks when corrective action plans do not result in thedesired performance improvement. Correlation analysesare used to prioritize opportunities for improvement orinnovation at all levels of the organization.

SSMHC’s senior leaders deploy the organization’sperformance results to employees at the appropriatesystem, network and entity levels. They communicatesystem performance review findings, priorities forimprovement, and opportunities for innovation in theirareas at System Management, Operations Council andInnsbrook Group meetings. The network/entity presidentscommunicate findings, priorities and opportunities for theirnetwork/entity at administrative council and entitydepartment meetings. Network/entity presidents appointteams or other accountable groups to deploy thecorrective action plans. Entity presidents and otherleaders deploy performance results to physicians atmedical executive committee meetings (monthly), medicalstaff meetings (at least annually), and employed physicianboard meetings (monthly). A medical staff survey providesa steady stream of feedback that allows real timecorrections. Hospital-based physicians join with other staffin teams to develop corrective action plans. Physicians inprivate practice participate on teams within their medical

groups to improve results. The corporate vicepresident-support services shares findings with suppliers,as appropriate, during regularly scheduled meetings toleverage their capabilities to reduce supply costs.

1.1b(3) SSMHC uses its Performance ManagementProcess in combination with the systemwide LeadershipDevelopment Process to improve the effectiveness ofexecutive leaders, including senior leaders, and theleadership system as a whole. Executive leaders at alllevels monitor the PIRs to evaluate their own leadershipeffectiveness as well as organizational effectiveness.Entity leaders also monitor results from the patientsatisfaction, HR Solutions employee, and medicalstaff surveys on questions related to the entity’sadministrative performance in order to assess their ownperformance in meeting patient, physician and employeesatisfaction requirements.

SSMHC defines the line accountability (Figure 4.1-1) of itsleadership groups at all levels of the organization in thePerformance Management Process policy. As part of thesystemwide Leadership Development Process, executiveleaders, including senior leaders, are evaluated on theirability to achieve superior results in clinical, operationaland financial performance as well as their ability to ensuresatisfaction of employees, physicians and patients.

The Leadership Development Process, drawing inputfrom a 360-degree evaluation, is based on established

4

� 2� 1, 2, 3, 4� 3, 4, 5� 2, 5� 3, 4

� Network/Entity Comb Financial Stmts� Hospital PIR (49 indicators)� Entity Quality Report � Corrective Action Plans: PIR/Qlty Rpt� Complaint Reports

Monthly

Quarterly

NetworkLeadership/Entity AC

� 1, 2, 3, 4� Combined Financial StatementsTwice a yearInnsbrook Group

� 1, 2, 3, 4� 2� 2� 1, 2, 3, 4� 2, 5

� SSMHC PIR (16 indicators)� Network/Entity Comb Financial Stmts� Entity Variance Report� Hospital PIR (49 indicators)� Corrective Action Plans: PIR/Qlty Rpt

Monthly Operations Council

� 2� 1, 2, 3, 4 � 2, 4

� SSMHC Combined Financial Stmts� SSMHC PIR (16 indicators)/Qlty Rpt� Quarterly Ranking Rpt (Pat. Loyalty)

Monthly

Quarterly

System Management

� 3, 4, 5� 3, 4, 5 � 5

� Quality Report � Competency Report� CRP & HIPAA Reports

QuarterlyRegional Boards

� 2� 2, 3, 4, 5� 5

� Financial Condition of the System� Healthy Communities Report� CRP & HIPAA Reports

QuarterlyAnnuallyAnnually

SSMHC Board ofDirectors

PurposeReports Monitored Frequency Forum

Figure 1.1-2 Leadership Review Forums 1=competitive performance; 2=performance plan review; 3=changing needsevaluation; 4=organizational success; 5=regulatory compliance

performance expectations that provide a standard foraccountability and form the basis for learning. Desiredbehaviors are based on the system’s organizational valuesas well as the following seven management practices:� Superior results in clinical, operational and

financial performance� Customer focus� Continuous quality improvement� Involvement and shared accountability� Developing people� Fact-based decision making� Information sharing

Annually, executives participate in a 360-degree evaluationprocess, receiving input regarding their behavior andmanagement skills on a 1 to 3 scale. The results drive theexecutive’s annual personal development plan.Opportunities for development include participation inprofessional and community organizations, developmentseminars, mentoring, SSMHC’s Leadership Conferenceand other educational sessions. Each executivecustomizes the survey with one or more questions

designed to measure her/his particular area ofdevelopment.

The annual Baldrige feedback provides a comprehensiveevaluation of the effectiveness of the entire leadershipsystem and prompts action plans for improvements. Thisprocess is described in the Organizational Profile. Inaddition, the senior vice president-human resourcesmonitors trends in the 360-degree evaluation results fromall system executive leaders to identify systemwideleadership education/development needs.

1.2 Public Responsibility and Citizenship1.2a(1) SSMHC implemented a systemwideorganizational ethics effort called the CorporateResponsibility Process (CRP) in 1998. Designed by aCQI team, CRP includes a process and mechanism toaddress societal requirements associated with regulatory,legal, and ethical compliance in providing health careservices. The CRP aligns with the elements of the nationalOffice of Inspector General's (OIG) model complianceplan. But it goes beyond compliance with the OIG’s modelplan to ensure that SSMHC values are reflected in all workprocesses. Employees, physicians, volunteers, and keyvendors are empowered through training and a confidentialHelpline to raise questions about any part of their job. Allreported issues are investigated and appropriate actiontaken in a timely manner. KPMG has identified SSMHC’sCRP as a best practice nationwide.

The Corporate Office identifies new or modified regulationsrelated to OSHA, CMS, EEOC, EPA, CDC, and HIPAAthrough literature research, networking, and participationin the Joint Commission on Accreditation of HealthcareOrganizations (JCAHO) assessment. The CRP Teamreviews the changes, obtains legal input, andrecommends policy or procedural changes to SystemManagement. This information is shared electronicallywith the entity CRP coordinators, who share and deployrequired changes at the entity/network level. Twice a year,the Catholic Healthcare Audit Network (CHAN) performsfocused audits to assess compliance in priority areasidentified by the CRP team.

Corporate Risk Services (CRS), a Corporate Officedepartment, works with the Quality Resource Center(QRC) to ensure a safe environment for patients,employees, and visitors. Risk managers for patient andemployee safety serve as a resource to the entities. Aspart of a three-year action plan, CRS is developing animproved Risk Management Program Assessment tool.See Figure 1.2-1 for Key Processes, Measures and Goalsfor Public Responsibility and Citizenship.

1.2a(2) System Management established the SSMPolicy Institute in 1998 to keep abreast of changingtrends and proactively anticipate and address public

5

70%/70.9%

Practice Direct Operating Cost %

$33,783/$31,407

Net Revenue Per Physician

12%/9.6%Operating Margin %(Home Health)

4%/<3%Operating Margin % (SkilledNursing)

3.6%/4.5%Operating Margin % (Hospitals)

$1,343/$1,315

Operating Expense Per APD

$1,345/$1,331

Patient Revenue Per APD 214/220Unrestricted Days Cash on Hand 56%/64%Home Care Patient Loyalty Index

2%avg/8%nat’lPrevalence of Daily PhysicalRestraints

Not availableyet

Physician Satisfaction

Not availableyet

Employee Satisfaction

37,864/37,614

Acute Admissions

4.8%/4.4%31-Day Unplanned ReadmissionRate

1.3%/2.3%Operating Margin % (Consolidated)49%/54.5%Inpatient Loyalty Index

March 2002Results/Plan

System Level Indicators

Figure 1.1-3 16 System Level Indicators withMarch 2002 Monthly Results vs Plan

concerns regarding health care issues. The Institute isresponsible for researching and analyzing health andsocial welfare issues, proposals, and project possibilitiesat the national and state level; advancing SSMHCprofessionals for appointments to city, state, and federalhealth and social welfare boards and commissions; andeducating employees and physicians on current publicpolicy issues. The Institute’s president sends electronicreports on relevant and critical public policy or regulatorychanges to members of System Management, entity andnetwork presidents, and other SSMHC advocates. Reportson high level issues, such as major reimbursement orstaffing, are discussed at System Management meetingsand appropriate action taken. For example, in 2001SSMHC’s nurse executives worked with the Institute’sstaff to advocate in behalf of the Nurse Reinvestment Act.The Institute’s Board is comprised of professionals fromaround the country who provide review and feedback onkey policy directions. The Institute’s staff and SSMHC’sexecutives are active at the state and federal levels onmajor association policy committees and boards.Advocacy was a focus of the 2001 Leadership Conference.

During SSMHC’s Strategic, Financial & HR PlanningProcess (SFPP), each network and entity conducts anannual external environmental and market assessmentthat includes an analysis of public policy and regulatoryissues. This data and the surrounding discussion are usedin developing and updating the network and entity’s actionplans. SSMHC’s network and entity planners andmarketers use primary and secondary market research toanticipate concerns regarding current and future servicesand operations within the communities served. The resultsfrom focus groups are used to address the concerns ofconsumers by, for example, providing new services ormodifying existing ones. The Quality Resource Centeralso researches statutes and regulations concerningclinical practice standards to keep SSMHC executivesabreast of changes.

SSMHC entities work with local task forces and publicagencies on an ongoing basis to coordinate disasterplanning. Following the September 11, 2001, terroristattacks, SSMHC established the Bioterrorism TaskForce, a systemwide team with broad geographic andprofessional representation, to coordinate and support theentities in caring for patients who might have beenexposed to biological or chemical agents. All entitiesreviewed and revised their existing disaster plans to coverboth biological and chemical exposures working closelywith local agencies. The team distributed an “AnthraxCare Package” of articles with updated clinical informationto assist physicians and nurses in diagnosing and treatinganthrax exposure. A hot link with the Centers for DiseaseControl and Prevention web site on the SSMHC intranetand Physician Portal (single point of access for patientresults, health information and communication tools)provides employees and physicians access to reliableupdated medical information. Breaking news is publishedin SSM Link . A bioterrorism contact person was named ateach SSMHC entity.

SSMHC’s experts also served as resources within theirlocal communities by participating in communitymeetings, training sessions, media interviews, andnational, state and local teleconferences. Three SSMHChospitals hosted community disaster planning seminarsand educational forums on bioterrorism for communityleaders, emergency and medical officials, and businessmanagers.

SSMHC entities have a hazardous waste policy thatstipulates the proper disposal and/or recycling ofhazardous wastes. Entity safety committees monitorhazardous waste activities through a Hazard Report. Thepolicy is reviewed at least annually and updates areprovided to a variety of agencies, such as EPA, theNuclear Regulatory Commission (NRC), JCAHO, and

6

� 25% prior year’sOperating Margin

� Project-specific

� Cost of Charity Care (Fig. 7.4-20)

� Health Status in Selected Populationsfor Individual Projects (Fig. 7.4-19)

� Charity Care

� HealthyCommunitiesPrograms

Community Health

� 0� 0� 0� 0

� Infection Rates� Dangerous Abbreviations(Fig. 7.1-4)� Restraints (Fig. 7.1-6)� Patient Falls

� Public SafetyRisk Management� 100% � Scores (Fig. 7.4-17)� JCAHO SurveyAccreditation

� 0� 24-48 hours� Licensure

� # Govt Investigations � Turnaround Time � Licensure

� CRP� Contract Review� Licensure

Regulatory/Legal

GoalsMeasuresKey ProcessesRequirements

Figure 1.2-1 Key Requirements, Processes, Measures and Goals for Public Responsibility

state agencies. The entity leadership teams proactivelyanalyze risk through completion of a hazard vulnerabilityform and a disaster preparedness checklist.

In October 2001, SSMHC began to implement acomprehensive systemwide Patient Safety Program,developed by a team representing Risk Services and theQuality Resource Center. The program includes: a newClinical Collaborative called Achieving Exceptional Safetyin Health Care (AES); newly established Patient SafetyCouncil; and updated philosophy statement and guidelinesfor disclosing unanticipated adverse medical outcomes topatients and their families.

All of SSMHC’s entities are participating in the new AEScollaborative and have identified six entity-specific goalsfor improvement for 2002 along with the process changesrequired to achieve these goals. Sixteen safety practiceswill be implemented systemwide by 2004. In addition tothe entity-specific goals, all of SSMHC entities areworking to eliminate dangerous abbreviations; establish anentity safety center; and provide a quarterly safety reportto the entity administrative council, employee and medicalstaff, and regional/local boards.

1.2a(3) SSMHC’s religious heritage creates a culture ofhigh ethical standards for the organization. SSMHC’scontract review process ensures ethical, legal, andregulatory practices are adhered to in stakeholdertransactions and interactions. The process defines whichtypes of contracts require contract review. The remainder,those dealing with managed care, human resources, orcertain low-risk areas are reviewed by staff specializing inthose areas. Contracts considered high risk are reviewedby SSMHC’s law firms. Specialty Counsel CoordinationProtocols assist the system and its legal counsel tomanage legal and regulatory compliance.

Ethical practices are first communicated through an ethicssection in the orientation of new employees at the entities.They are reinforced by system policies such as theStandards of Ethical Behavior, Conflict of Interest,Corporate Responsibility, Equal EmploymentOpportunity/Affirmative Action, Confidentiality ofInformation, Sexual and Other Harassment, and StaffRights to Refuse to Participate in Aspects of Patient Care;CRP confidential Helpline; and employee grievanceprocess, which encourages reporting of unethicalbehaviors by management or others. Ethical practices arefurther reinforced through education required for allemployees. All employees with decision-makingcapabilities for purchasing are required to review and signan annual Conflict of Interest Questionnaire. Ethicscommittees in all the hospitals and nursing homes offer aforum for patients and their families and caregivers todiscuss and review clinical/ethical issues, includingpatient rights.

1.2b Improving the health of the community has been anSSMHC focus since 1872 when the Sisters of St. Mary(now known as Franciscan Sisters of Mary) first walkedthe streets of St. Louis giving aid to any sick or sufferingperson they encountered. SSMHC launched asystemwide Healthy Communities initiative in 1995 toleverage the system's resources with those of thecommunities it serves in support of the Vision. Theprogram was designed by a quality improvement team tobring measurable improvements in health and well-being toresidents in specific geographic areas. Each SSMHCentity is required to actively engage in one or morecommunity projects within its service area. Projects arechosen based on the identification of a community healthindicator that needs to be improved; collaboratingagencies or organizations with which to partner; and anindicator to measure the effectiveness of the intervention.The Board of Directors reviews an annual report onHealthy Communities projects and progress updates.

In keeping with SSMHC’s mission and values, anyonewho comes to its hospitals receives care regardless of theperson’s ability to pay. A system policy requires that agoal of at least 25 percent of the prior year's operatingmargin be designated for charity care at each entity.

SSMHC understands that an unhealthy environmentnegatively affects the health of the people in thecommunities we serve. Therefore, we engage in a varietyof activities focused on environmental protectionism, whichare consistent with our unwavering commitment tononviolence. Each SSMHC entity has established acommittee, typically called Preservation of the Earth(POE), to foster environmental awareness and promote ahealthy environment. Other methods of buildingcommunity health include:* Serving on community and industry boards* Actively participating in civic organizations* Supporting state and national quality award programs* Advocating through the SSM Policy Institute* Operating the Regional Poison Center in St. Louis* Providing community health programs, screenings,health and wellness education programs, and supportgroups for persons with a variety of diseases.

A systemwide Community Benefit Team was formed in2001 to review SSMHC’s charity care policy and develop acommunity benefits policy. The team has also selectedsoftware to be used to measure and track charity care andcommunity benefits across the system. The results willbe presented in an annual report to System Management,government leaders, policymakers, and the general public.The report will include the amount of charity care SSMHCentities provide to persons who are poor; unpaid costs ofprograms for the public; and other activities that respondto community need and improve community health.

7

CATEGORY 2 - STRATEGIC PLANNING

2.1 Strategy Development 2.1a(1-2) SSMHC’s Strategic, Financial & HR PlanningProcess (SFPP) combines direction setting, strategydevelopment, human resources, and financial planning.(See foldout, Figure 2.1-1.) The SFPP involves all of theorganization’s networks, entities and departments in athree-year (long-term) planning horizon, with annualupdates (short-term). The SFPP integrates QualityPrinciples and methods and stresses planning as a way oflearning more about patients and responding to theirneeds and expectations as well as market opportunities.The SFPP ensures that the networks and entities setstrategic goals clearly oriented toward performanceimprovement.

(1S) The SFPP begins in December when the VisionStatement, set by SSMHC's Board of Directors, isreviewed. The Vision and Mission statements serve asthe foundation for the planning process. (2S) EachJanuary, corporate planning, in conjunction with corporatefinance and HR, evaluates the SFPP by surveying theprevious year’s key participants.

Experience has taught SSMHC that three years provideoptimal time to implement, fully deploy, and realize theresults of its initiatives across the vast organization.Because of the rapidly changing health care industry,each year the SFPP participants study and validate thesystem's focus on patients, other stakeholders andmarkets (3.0), information and analysis (4.0), staff focus(5.0), and process management (6.0). Figure 2.1-1 depictsthe steps in the process at the system, network, entityand departmental levels. At times during the planningcycle, these steps occur concurrently.

(3S) In February, the Innsbrook Group assesses keychallenges, reviews comparative data, and sets thesystemwide goals for the next three years, using theVision and Mission Statements as a framework.

(4N&E) In March, a Governance Retreat is held for theparent, regional and local board members to provide anopportunity for input into the three-year plan. At thesystem level, during April and May, the Corporate Officedepartments, such as finance and human resources, anddivisions, such as the SSM Information Center (IC) andMaterials Management, which provide centralized servicesfor the entities and networks, establish their plans withbudgets. These department/division plans and budgets areconsolidated in the Corporate Office/Information CenterPlan (5S) and determine the annual corporate fees to bepaid by the entities.

(6S) In late May, the networks and entities receive asubmission packet with standardized forms and defini-tions to ensure a consistent format and alignment ofnetwork and entity plans with SSMHC’s goals.

Beginning in March and continuing through June, thenetworks and entities are conducting (7N&E) Internaland External Assessments based on minimum data setrequirements. This assessment is done every three yearsto develop the Strategic, Financial & HR Plan (SFP) andis validated annually. Data and information from a varietyof internal and external sources are integrated to form theminimum data set (Figure 2.1-2). The planning staff ateach entity and network gathers the information fromvarious sources, such as departmental performanceimprovement plans, patient, medical staff and employeesurveys, market research, and PIRs. This informationprovides the assurance that a comprehensive analysishas been conducted of those key elements impacting thebusiness. The minimum data set, introduced in 1998, is arobust tool that ensures SSMHC maintains a balance inaddressing stakeholder needs in a consistent manner.

During (8S) summer site visits, the networks and entitiesshare the assessment findings and preliminary strategiesand action plans with corporate planning, finance andhuman resources staff to ensure alignment. SSMHCCorporate Planning distributes the Final Plan AssumptionGuidelines (9S) to the entities and networks in July.These guidelines ensure the consistent use of financialand economic assumptions across the system bynetwork and entity staff preparing their strategic plans.The assumption guidelines contain information thataffects the entities such as centralized service fees.

The entity or network leaders analyze the minimum dataset findings to determine their organization’s strengths,weaknesses, opportunities, and challenges and toidentify gaps between current and desired performancelevels. (10 N&E) The administrative staff and physicianleaders for each entity and network then set measurable,three-year strategic goals to achieve the system goalsrelated to exceptional health care services. Localnetworks and entities involve key stakeholders, includingsuppliers and payors in goal-setting when theircapabilities impact achievement of the goals.

2.1b (1-2) SSMHC’s key strategic objectives, indicatorsand timetable are presented in Figure 2.1-3. SSMHC hasestablished five characteristics of exceptional care as itsstrategic objectives. In preparation for the 2001three-year planning session, the Innsbrook Groupcompleted a survey on what defines exceptional healthcare. The findings facilitated discussion that identifiedSSMHC’s characteristics of exceptional health careservices in light of current challenges and stakeholders

8

needs. The group then identified system level goalsneeded to achieve these strategic objectives. Thisrepresented a significant breakthrough in SSMHC’sapproach to planning and goal setting. By first definingexceptional health care services, SSMHC was able to tieplanning more closely to the Mission Statement, whichresulted in more balanced goals. Clinical outcomes andpatient, employee and physician satisfaction were placedon equal footing with financial results.

2.2 Strategic Deployment2.2a(1) Following the setting of goals and objectives, eachentity or network team (10E&N) defines strategies andaction plans, with key measures, to support its three-yeargoals. They finalize their plans by allocating resources tosupport achievement of their goals and objectives. TheCapital Allocation Process represents a system levelapproach to capital allocation. This process ensures thedeployment of resources to projects that supportachievement of SSMHC’s strategic objectives. Figure2.2.1 presents actions plans that are consistent amongthe system’s networks and entities.

The Operations Council determines the maximum amountof available resources that may be spent on capital

expenditures below $500K. Networks and freestandingentities allocate their under $500K to their entities at theirdiscretion. The entities allocate their own resourcesinternally through a top down and bottom up approach.Each department is required to develop preliminary goalsand action plans, including budgets, to support theentity’s overall goals and objectives. These budgets areaggregated and evaluated relative to the entity’s totalavailable resources. With this information, entity leadersdevelop action plans with input from appropriatedepartment staff, including physicians. The action plansincorporate identified champions, completion dates,expected results, and, if appropriate, volume projections,human resource needs, and capital requirements. Theyare approved by the entity leadership group and trackedby an administrative champion. The departments monitortheir action plans using inprocess measures, enablingearly identification of performance gaps. Root causeanalyses and improvement plans are used to close gaps.

As a result of this process, each entity has a defined setof goals, objectives, strategies and action plans that arealigned with the system’s goals, objectives, strategiesand action plans while tailored for the individual marketthe entity serves. If the entity is a member of a network,

11

Figure 2.1-2: Minimum Data Set: Examples of External & Internal Data Collected & Analyzed to Develop theSFPP (Examples are provided because of space limitations.)

Clinical Quality AnalysisQuality Report, Clinical Collaborative results, Departmentalperformance improvement plans, Regulatory survey feedback

Public Policy/Legislative/Accred. AnalysisFederal and state legislative and reimbursementtrends, JCAHO and other regulatory standards

Financial AnalysisNet revenue, expense & operating margin, use of agencystaff, payor mix trends; contract profitability

Payor AnalysisInventory of payors, payment rates, payorsatisfaction/issues

Human Resource Analysis Employee satisfaction survey results, Market analysis ofcompensation and benefits, turnover and diversity rates, train-ing needs

Emerging Technologies/Trends/Growth Oppor-tunities AnalysisLiterature review, IC plan, Networking withcolleagues in SSMHC’s and other markets

Physical Plant/Technology Analysis Major plant infrastructure and equipment assessment, ICplan, regulatory requirements

Competitor AnalysisInventory of competitors, market share trends,marketing/advertising/competitive position

Product Line AnalysisProfitability, volume and consumer perception of key productlines

Demographic/Socieoeconomic AnalysisPopulation trends by age, ethnic origin; Popula-tion- based use rates, Discharges by zip code

Medical Staff AnalysisMedical staff survey results, supply by specialty compared tomarket needs, geographic distribution

Consumer Information AnalysisPatient satisfaction survey results, Marketresearch, market share by product line

Internal DataExternal Data

3.3%3.0%2.5%Operating MarginExceptional Financial Performance2.63%3.06%3.49%Unplanned Readmission rateExceptional Clinical Outcomes 75.0%74.0%73.0%Employee SatisfactionExceptional Employee Satisfaction81.9%80.9%79.9%Physician SatisfactionExceptional Physician Satisfaction60.1%56.1%53.1%Inpatient LoyaltyExceptional Patient Satisfaction2004 Goals2003 Goals2002 GoalsIndicatorsStrategic Objectives

Figure 2.1-3 Strategic Objectives, Indicators, Timeline & Goals

the network leadership ensures the action plans also alignwith the network.

(11N&E & freestanding hospitals ) SSMHC implementeda systemwide Capital Allocation Process in 1998 tobalance the operating needs and goals of the system,networks and entities. If the capital cost of a projectexceeds $500K, the network or freestanding entity (entitynot affiliated with a network) develops a strategic andfinancial analysis and completes a standardized CapitalProject Application Form (CPAF) and submits it to theCorporate Office. Entities affiliated with networks submittheir CPAFs to the network leadership group. (12S)Corporate finance and planning staff analyze the CPAFs toensure that a project is strategically and financially sound.This analysis is submitted to the systemwide CapitalAllocation Council for consideration. The Councilprioritizes projects based on the strategic and financialbenefit to the system as a whole. (13S) Approved projectsare communicated by approval letter to the networks andfreestanding entities, who adjust their baseline projections.

(14E) Entities within networks finalize and submit theirstrategic and financial plans to the network planning,finance and HR staff for review. (15N&freestanding entities)The networks and freestanding entities then finalize andsubmit their plans to the Corporate Office and SSMInformation Center staff for review (16S) and SystemManagement’s final approval (17S). The plans areconsolidated into a single financial plan for the entiresystem by Corporate Office staff. The SSMHC Board ofDirectors (18S) reviews the system's overall financial planand key network and entity strategies for approval. TheSFP is reviewed by the Board of Directors each

December, and SSMHC's president/CEO communicates(19S) the Board's approval to entity and networkpresidents via letter. During this time, entity and networkdepartments and service-line levels (20D) finalize theirgoals, operating plans and budgets with physicians,department managers, and staff. (21E) The entity leadersreview and approve department plans.

Each entity president (22E) initiates ongoingcommunication about his or her entity’s specific strategicand financial plan to department managers and MedicalStaff leaders. To reach all levels of the organization, avariety of communication vehicles are used, includingmemos, newsletters, department meeting agenda items,and presentations. The strategic plan is also shared withregional boards. (23N) Networks do their PDCA evaluationof their SFPP at the end of the year.

(24D) Throughout SSMHC, specific goals and objectivesfrom the department planning process are posted in thedepartment on a poster. Posters provide a visual line ofsight connection from SSMHC’s Mission to thedepartment goals. The departmental goals tie directly tothe key department inprocess and outcome indicators.SSMHC uses its Passport Program to deploy strategicgoals and action plan goals to all employees and to alignnetwork, entity, department and individual plans withoverall organizational strategy. The Passport links theemployee’s work to the goals of the entity, network, andsystem. “Passport to Exceptional Health Care Services,”a “Meeting in a Box,” was presented in fall 2001 to entityadministrative councils, vice presidents, and departmentsupervisors and managers. This box contained a video bySr. Mary Jean; overheads and speaker notes; and

� Operating margin % (Fig. 7.2-3) Operating Revenue & Expense per APD(Fig. 7.2-4)

� Admissions (Fig. 7.4-1)� Net revenue per physician (Fig. 7.2-6)

� Paid Hours/Adjusted patient day(Fig. 7.4-3)

� Average Length of Stay (Fig. 7.4-2)

� Increase revenue and reduceexpenses

� Achieve growth� Reduce financial support to

employed physicians� Improve staff productivity amid

labor pressures� Improve medical management

Exceptional financialperformance

� Inpatient loyalty (Fig. 7.1-7)� Nurse turnover rate (Fig. 7.3-3)� Physician satisfaction (Fig. 7.3-8)� Employee satisfaction (Fig.7.3-1) � # Minorities in managerial professional

ranks (Fig. 7.3-12)

� Improve patient satisfaction withpain management

� Implement Nursing SharedAccountability Model

� Increase diversity representationwithin leadership

Exceptional patient,employee and physiciansatisfaction

� Unplanned readmission rate (Fig. 7.1-1)� Medication event rate� Dangerous Abbreviations (Fig. 7.1-4)

� Use Clinical Collaboratives toimprove health care outcomes

� Ensure patient safety

Exceptional clinicaloutcomes

Key IndicatorsSystem Action Plans 2002Strategic Objectives

12

2.2-1 Strategic Objectives, System Action Plans and Key Indicators

posters showing the linkage between department andentity goals. The presentation helped managers identifydepartment goals to support entity goals and to assistemployees in developing individual goals to supportdepartment goals on their Passports.

2.2.a (2) Figure 2.2-1 shows systemwide action plans tosupport the strategic objectives. These plans typicallyhave short- and long-term goals associated with them, asappropriate. Progress on these plans is monitored throughkey indicators on the PIR and Quality Report. SSMHC isfocused on providing exceptional health care services.Unplanned readmission rate has been identified as a keyindicator of exceptional clinical outcomes. As part of thestrategy to decrease unplanned readmissions, theorganization is engaged in identifying the primary drivers ofthe unplanned readmission rate and will use thisinformation to expand and enhance the number of clinicalmeasures in the Performance Management Process.

2.2.a (3) Human resource planning is integrated into thesystem’s SFPP as a result of process improvements in2000. Entity and network human resource and nurseexecutives provide data for the planning process as part ofthe Minimum Data Set and actively participate in strategicplanning sessions. At the entity and network levels, HRneeds and financial impact are tied to each action plan

during the SFPP to ensure adequate resources areallocated to support strategies.

The key systemwide HR action plans for 2002 focus onimplementing Shared Accountability and ensuring adiverse staff. Every SSMHC entity is beginning theimplementation of a shared accountability model fornurses and plans to increase the number of minorities inprofessional and managerial positions.

2.2a(4) See Figure 2.2-2 for indicators that track progressin achieving system action plans. Annual evaluation ofthe Performance Management Process (PIR) to monitorthe goals and action plans set through the SFPP ensuresalignment. The entire Performance Management Processis evaluated annually using Baldrige feedback.

2.2.b Figure 2.2-2 reflects performance projections ofSSMHC’s key system level indicators and comparisonswith other organizations. Benchmark sources are given inCategory 7.

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58.64%61.55%67.30%Physician Direct OperatingExpense

$32,971$36,593$32,971Net Revenue per physician

52.7%71.0%64.0%Home Care Patient LoyaltyIndex

15.0%8.4%7.1%Home Care Operating Margin

5%00Nursing Home Prevalence ofDaily Physical Restraints

<3.0%4.29%-2.29%Nursing Home OperatingMargin

93.0%81.9%79.9%Physician SatisfactionIndicator

74%75.0%73.0%Employee SatisfactionIndicator

52.3%60.1%53.1%Inpatient Loyalty Index

2.42%2.63%3.49%31- Day Unplanned Readmis-sion Rate

$1,508$1,506$1,434Operating Expense/APD$1,805$1,486$1,399Patient Revenue/APD

N/A155,800145,200Acute Admissions190-220 days235 days220 daysUnrestricted Days Cash

3.0-4.0%3.3%2.5%Consolidated OperatingMargin (Hospitals Included)

BenchmarkLong Term Goals2004

Short Term Goals2002

Figure 2.2-2 Key Performance Indicators, Short/Long Term Goals and Benchmarks

CATEGORY 3 - FOCUS ON PATIENTS,OTHER CUSTOMERS, AND MARKETS

3.1 Patient/Customer and Health Care MarketKnowledge3.1a(1) During the Strategic, Financial & HR PlanningProcess (SFPP), which is applied at system, network andentity levels, environmental scanning is used to identifypotential customers, customers of competitors and futuremarkets every three years with annual update assess-ments for validation. The minimum data set for this scanincludes market research; market share by product line;population trends by age and ethnic origin; population-based use rates; discharges by zip code; an inventory ofcompetitors; market share trends; andmarketing/advertising/competitive positions.

To learn specifically about customers of competitors,network and entity planners and marketers monitor datafrom the annual medical staff surveys and physiciancontacts and conduct literature searches, telephonesurveys, and focus groups of competitors’ customers.Collaborations with area nursing homes and call lines forfamilies and visitors provide additional opportunities tolearn of potential customers. The data are fed into theplanning process at the appropriate organizational level.

For example, through environmental scanning, planners atSt. Anthony Hospital learned that in their market demandfor cardiology procedures had increased dramatically; acardiology physician group was breaking up; and acompetitor was considering opening a heart hospital. With

this knowledge, St. Anthony recruited a staff of cardiolo-gists and enhanced its cardiac services by developing aheart hospital within the existing facility. St. Anthonyopened Oklahoma City’s first heart hospital in February2002. The local business newspaper awarded St. Anthonyits Innovator of the Year award for utilizing existingresources by creating a hospital within the main hospital.

SSMHC has defined patients and their families as its keycustomer group. SSMHC further delineates this customergroup into five categories based on site of care: inpatient,outpatient, emergency department, home care, and longterm care patients. Entities further segment each of thesecustomer groups based on community needs as well asinternal and competitor assessments. The inpatient caresetting represents 90 percent of SSMHC’s revenue.Accordingly, primary emphasis is given to this caresetting with respect to key requirements, processes, andmeasures. Physicians are SSMHC’s key partner group,but are recognized to have many of the characteristics ofcustomers. In fact, it is common for employees to treatphysicians as customers in their daily work relationships.

3.1a(2) A robust set of listening and learning tools areused to determine as well as define and differentiate therequirements, expectations, and preferences of former,current and potential customers. The data collected fromthese listening and learning methods (Figure 3.1-1) areaggregated, analyzed, and used in the SFPP each year toupdate strategies and action plans and by quality improve-ment teams on an ongoing basis to improve the organiza-tion’s services to customers. SSMHC’s corporate planning

14

Network/Entity� Planning/Marketing� Planning/Marketing� Planning/Marketing� Planning/Marketing� PR/Marketing� Planning/Marketing

� Primary-Secondary Market Research (Annual/PRN)� Survey Research (Annual & PRN)� Published Studies (Annual & PRN)� Community Contact Telephone Lines (PRN)� Internet-Web Pages Response System (Continuous)� Professional Associations, Courses, Journals, and

E-mail Newsletter Subscriptions & News AbstractServices (Continuous)

Potential Patients &Future Markets

(1)(2)(3(4)

Corporate Planning

Network/Entity� Planning/Marketing� Hospitality/Quality� Quality/Risk� Departments� PR/Marketing

� Satisfaction Surveys: Inpatients, Outpatients, ED,Rehab, Ambulatory Surgery, Home Care, & Long TermCare (Continuous)� Primary-Secondary Market Research (Annually/PRN)� Comment Cards (Continuous)� Complaint System & Informal Feedback (Continuous)� Selected Patient Followup Calls (Continuous)� Internet-Web Pages Response System (Continuous)

Former & CurrentPatients & Families

(1)(3)(4)

Primary OwnersListening & Learning Tools & FrequencyCustomer & Use

Figure 3.1-1 Tools Used to Determine Customer Needs & Contact Requirements Use of Information: (1) healthcare service planning (2) marketing (3) making improvements (4) other business development

staff relies on the semiannual regression analysis ofpatient satisfaction survey data to validate theserequirements.

The network and entity leadership groups are the primaryfocal point for information gathered through the listeningand learning methods. The breadth of the methods enablethe collection of information reflecting current and formerpatients/customers views. From this basis, the factorscontributing to patient loyalty have been determined andthis indicator is monitored as one of 16 system levelindicators in the PIR. In addition, the patient satisfactionsurvey is structured to gather information from each of thepatient care settings. This information is segmented andanalyzed using the patient satisfaction software.

In 2001 and 2002, the corporate planning staff performedcorrelation analysis of key system level indicators tofurther define which key system level indicators stronglycorrelate, positively or negatively, with inpatient loyaltyand satisfaction. The results of the analyses werepresented at the Innsbrook Group planning sessions. Thistype of insight provides further guidance for planning effortsby clarifying the cause and effect relationship betweenSSMHC system strategies and business performance.

3.1a(3) SSMHC has found most listening and learningtools add the greatest value when used and managed atthe local level. Network and entity owners of these toolscontinuously evaluate them and make improvements atleast annually. Evaluation is done primarily throughcustomer surveys and validation of results using alterna-tive tools and literature research. Improvements are madewhen the results are found to be no longer applicable ornot actionable by internal users. As health care servicesare added or significantly modified, consideration is alsogiven to the best approach to gain feedback from theappropriate stakeholders. This effort may drive the additionor expansion of current approaches to listening andlearning.

The corporate planning staff evaluates the systemwidepatient satisfaction survey through:� Review of survey questions for relevancy and validity� Literature and web-based research� Monitoring of regulatory guidance� Baldrige and state quality award feedback�Input from entity patient satisfaction coordinators andother entity staff with responsibility for functional areas.This is done formally on an annual basis and informally onan ongoing basis.

3.2 Patient/Customer Relationships and Satisfaction3.2a(1) Physicians have an essential role in meeting thekey customer requirements of patients and in improving

clinical outcomes. The physician relationship with SSMHCand with the patient, therefore, is considered critical to theorganization’s success. SSMHC develops partnershipand loyalty with physicians through the physician partner-ing process and by meeting their key requirements. (SeeItem 6.2 for more detail on the physician partneringprocess, which includes relationship building strategies.)SSMHC’s networks and entities have physician liaisonsand other staff members who focus on physician relations,recruitment and retention.

SSMHC’s Healthy Communities projects facilitate relation-ship building with local communities, businesses and civicleaders. SSMHC also builds relationships with freestand-ing hospitals and nursing homes within its communitiesas a key way of acquiring new patients. These relation-ships are often formalized through affiliation or manage-ment agreements. (See P.2a(1))

SSMHC’s key customer requirements are those factorsdetermined by correlation analysis of patient satisfactiondata to most strongly correlate with patient loyalty. Thecorporate planning staff provides monthly reports to theentity and network patient satisfaction coordinators and aQuarterly Ranking Report for System Management thatdepicts trends and gaps between current performance andgoals in measures of patient loyalty for each entity. Todevelop loyal patient relationships, the networks, entitiesand system monitor customer requirements and takeaction to improve areas of dissatisfaction identified throughthe surveys, and patient/physician complaints. Entitydepartments or customer satisfaction/patient satisfaction

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Obtain ServicesEntity & physician locations or officesHealthy Community projectsClinics & outreach programs

Seek InformationDirect contact with hospital staff, senior execu-tives & physiciansSSMHC caregivers & patients rights brochureInternet sitesEthics committeesEducational programs & support groupsSpeakers bureausPoison CenterHealth Information & Referral Line

Make ComplaintsDirect contact with hospital staff, senior execu-tives & physiciansEntity complaint processesCRP HelplinePatient satisfaction surveys

Key Access Mechanisms

Figure 3.2-1 Key Access Mechanisms

teams have responsibility for addressing issues identifiedthrough the patient satisfaction surveys, SFPP, or focusgroups.

To build loyal patient relationships, Clinical Collaborativesand other improvement projects are structured in responseto key drivers of patient loyalty. Fourteen entity processimprovement teams, for example, are participating in thesystemwide Clinical Collaborative Using Patient Informa-tion to Improve Care and Achieve Success (UPI). Theteams used patient satisfaction survey data to identifyspecific areas of improvement in patient/caregiver commu-nications and to measure progress. In addition, entityclasses, support groups, and e-health informationempower patients to proactively manage theirdisease/condition and, in the process, builds loyalty. Asanother means to enhance patient loyalty, SSMHC’sambulatory surgery departments make follow-up phonecalls to patients who have gone home.

3.2a(2) SSMHC uses the results of customer satisfactionsurveys and other listening and learning tools (Figure

3.1-1) to identify customer contact requirements. Thecorporate planning staff conducts impact analyses on theresults of the patient satisfaction survey to determine andprioritize the contact requirements of each of SSMHC’sfive key patient groups, which receive customized surveyquestions. In addition, at the local level, the network andentity owners of other listening and learning tools analyzedata gathered through these tools to validate customercontact requirements. Even though SSMHC’s patientcare settings are different, the contact requirements for allpatient care groups have been found to be basically thesame: responsiveness, accuracy, good communication,and good health care outcomes.

Deployment is reinforced through job descriptions and thePassport. Job descriptions at SSMHC entities includeservice standard competencies. Most entities also includetheir service standards on individual employee Passports,which contain the SSMHC core values. The Passport toolis introduced during employee orientations and tied toemployee performance evaluations. At the system level,customer satisfaction with service contact is trackedthrough related questions on the patient satisfactionsurveys. See Figure 3.2-1 for key access mechanisms.

3.2a(3) Each SSMHC entity has implemented aComplaint Management Process (Figure 3.2-2) thatprovides timely resolution, follow-up with patients/families,and complaint tracking. Patients/families are given infor-mation about how to make complaints upon arrival at theentity. SSMHC employees are empowered and trained toevaluate a breakdown in service and when possible to “fixit now” or refer the patient to someone who can.

SSMHC has learned from experience that a complaintmanagement process is most effective at the entity level.To ensure consistent handling, resolution, and tracking ofcomplaints throughout the organization, SSMHC’s QualityResource Center is implementing standard definitions andcommon software for tracking complaints at the entitylevel. The process and software, called Opportunities forImprovement (OFI), were developed by a process designteam at Bone & Joint Hospital in Oklahoma City in 1994and underwent several cycles of improvement. OFI, whichwas shared, recognized as a best practice, and piloted atseveral entities, is now being implemented systemwide.The entity staff follow up with patients within establishedtime frames to make sure complaints have been resolvedto the patients’ satisfaction. Entity quality staff aggregatecomplaint data and send it to the QRC for system-levelaggregation. Entity leaders monitor the aggregatedcomplaint reports at least quarterly to identity systemiccomplaint issues and appoint teams to improve the relatedprocesses. The entity presidents feed complaint issuesthat may be systemic to the network leadership group.The network presidents in turn bring any potential

16

Complaint Raised

Addresses / Resolves & Follows Up with Customer

Resolved

YES

Complaint Entered into OFI Software

Report to QRC for System Level Aggregation

Issue Referred

Data Aggregated

Entity Leadership Review

Systemic Issue

END

Initiate CQI

Process

NO

YES

NO

Figure 3.2-2 Complaint Management Process

systemwide issues for discussion at the monthlymeetings of System Management, of which they aremembers. The System Management team determineswhether complaint issues brought forward will beaddressed systemwide or within a network/region. 3.2a(4) During the Internal and External Assessment stepin the SFPP (Item 2.1), SSMHC evaluates its approachesto building relationships and to providing patient/customeraccess. Network and entity finance officers, planners,human resources and quality staff work with the medicalstaff leadership to conduct an external and an internalanalysis using the minimum standard data set (Item2.1a(2)).Patient Access: The external consumer informationanalysis asks: What do consumers think about ourproducts and services compared to those of our competi-tors? What do our customers expect? What do markettrends tell us about consumer behavior? Exploratoryresearch on unmet consumer needs (for example,out-migration) is conducted as part of this analysis.Local Communities Relationship: The externaldemographic/socio-economic analysis asks: Who are wecurrently serving? What are the needs of the customersthat we are serving? How will we change over the next fiveyears to meet those needs? The external public policy/legislative analysis asks: How will emerging legislativeissues impact us as an employer? How will emerginglegislative issues impact us as a provider?Physician Partnering Relationship: The internalmedical staff analysis includes data collection on physi-cian expectations for the various types of network andentity relationships. A key question in the medical staffanalysis is: How does our medical staff perceive theproducts and services we provide compared to ourcompetitors? The key question on the external physiciananalysis is: What is the trend in physician practicesrelative to their relationships with competitors?

If factors are detected that require a change in how werelate to and/or work with others in the marketplace orcommunities we serve, these changes are incorporatedinto the Strategic, Financial & HR Plan strategies andaction plans. The MEA and focus groups are used whenmore detailed analysis of external/internal changes isneeded.

3.2b(1) SSMHC surveys patients and, when appropriate,their families for satisfaction/dissatisfaction and opportuni-ties for improvement, using both formal and informalmethods. SSMHC employees at all levels of the organiza-tion use the results from these various methods to makefact-based decisions regarding, for example, the need fornew services or enhanced delivery processes.

The survey methods include a formal standardizedpatient satisfaction survey and entity complaintmanagement process as well as informal discussions thatoccur between caregivers and patients and their families;executive leader visits with patients in the hospital; partici-pation in community organizations; and suggestions frommedical staff members on behalf of their patients. Focusgroups are used to obtain additional data needed to furtherrefine and understand patient responses. Impact analysesprioritize patient satisfaction improvement efforts. Theowners of the various survey methods provide their findingsto the entity/network leadership groups that are responsi-ble for making ongoing operational improvements orsystemic changes through the SFPP. The leadershipgroups appoint teams to make ongoing operationalimprovements. Through the Plan-Do-Check-Act/CQIModel, the teams identify opportunities, design and imple-ment improvements, track the results and evaluate theimpact of the improvement, and then standardize or adjustthe improvement.

The corporate planning staff conducts the formal patientsatisfaction survey, which is standardized systemwideand customized for all five patient segments. Analysis ofthe survey data is done monthly by the corporate planningstaff to identify each entity’s percentage of “loyal” patients.The survey and data analyses are designed to giveSSMHC the ability to predict the future loyalty of itspatients and anticipated interactions with them. Surveyquestions specifically draw out the patient’swillingness/unwillingness to recommend the organizationto others. Inpatient loyalty is one of the 16 system levelperformance indicators.

Based on semiannual impact analyses of patient satisfac-tion survey results, SSMHC’s corporate planning staffvalidates the most important patient requirements drivingsatisfaction at each entity. Online analytical processingsoftware facilitates detailed segmentation of patient satis-faction data with almost unlimited drill-down capabilities.Users can look at inpatient loyalty results for a particularnursing unit, for example, and compare those results toother units within the entity or any other entity withinSSMHC. The patient satisfaction data are also cross refer-enced with Trendstar clinical and financial data enablingpatient satisfaction coordinators to further segment thedata by race, gender, age, DRG procedures, primarypayor, and physician. Network and entity planning andmarketing staff use primary market research, such asfocus groups or telephone surveys, to further examine thesurvey findings when greater clarity is required.

The corporate planning staff analyzes the patient satisfac-tion survey results and electronically publishes:� Semiannual survey improvement matrices that identifyspecific improvements that will result in the greatest gains

17

in patient satisfaction. These reports go to entity andnetwork executives and entity patient satisfaction coordi-nators for review and discussion with impacted areas.� Patient satisfaction survey results for all entities isupdated monthly and available via WebDiver on the intra-net to track the impact of improvements. This resource isavailable to entity and network directors and managerswithin a week of the close of a month. � Monthly electronic executive summary reports showhigh level results of each entity’s patient satisfactionsurveys on a single page. This report also contains resultsfrom all SSMHC entities, which facilitates internal bench-marking. Summary reports are distributed to a broadaudience of entity and network executives, and depart-ment directors, and managers for actionable followup.

Because SSMHC has used a consistent and reliableformat for its patient satisfaction survey since 1993, theorganization’s entities have 10 years of patient satisfactiondata available to them to use in improving trends andmonitoring patient satisfaction. A statistician with theSSM Information Center and professor at Saint LouisUniversity provides checks on the validity and reliability ofsurvey event items and consults on statistical issuesregarding the analysis of survey results.

3.2b(2) The entities have developed processes, such asthe following, for prompt and actionable feedback frompatients. Senior executives take part in daily rounds ofhospitalized patients to ask them how the hospital’sservices can be improved. Patient concerns are addressedpromptly with a follow-up report made to the patient.Comment cards and customer service hotlines are avail-able to patients. Nurses and others who give bedside careask the patient “Is there anything else I can do for you?”before leaving the room. This question enables caregiversto respond immediately to a patient’s needs and reducesthe number of calls for assistance. Patients often receivefollow-up telephone calls, as appropriate to their level ofcare, after they leave the hospital.

3.2b(3) SSMHC gathers information on customer satis-faction relative to competitors and other health careorganizations primarily during the SFPP. This informationis analyzed and used to identify needed improvementsand to develop entity/network goals and action plans.

As part of the minimum data set, the networks/entitiescompile a consumer information survey and analysis thatfocuses on consumer perceptions of SSMHC’s productsand services compared to those of competitors. This infor-mation is also collected through the physician satisfactionsurveys, focus groups, and telephone surveys. SSMHCalso benefits from the broader physician perspective onpatient care. The physician satisfaction survey containsspecific questions to elicit feedback on the performance of

SSMHC entities as compared to other hospitals in thecommunity.

SSMHC obtains benchmark data from National ResearchCorporation’s Health Care Market Guide (HCMG) for theinpatient, emergency department, ambulatorysurgery/outpatient, and home care patient satisfactionsurveys. The HCMG is an ongoing tracking study thatfocuses on the key drivers of patient satisfaction for morethan 2,500 hospitals. SSMHC entities in Wisconsin,Illinois, and the St. Louis area use privately or publiclyproduced studies that compare all health care providers ina geographic area on issues relative to reputation andimage as well as performance.

SSMHC sets its goals for patient satisfaction based onthe benchmark and competitive data collected from thesesources. When System Management detects gaps inpatient satisfaction between current performance andgoals, it drills down to understand root cause issues.Networks, entities and departments use a similar approach and tools. Established thresholds in the PIRprocess indicate when corrective action plans are requiredat the system, network or entity levels. Improvementteams are activated and use the CQI Model to redesigncare delivery processes when process improvement isindicated.

3.2b(4) The corporate planning staff closely collaborateswith the entity patient satisfaction coordinators on anongoing basis to evaluate and improve the content of thepatient satisfaction surveys. An annual evaluation includesstatistical tests for validity and reliability by an outsidestatistician; feedback from entity patient satisfactioncoordinators; trade and literature research; and anaccreditation/regulatory requirements audit. Based on thefindings, the planning staff makes proposed changes inthe surveys and shares the survey drafts with entitypatient satisfaction coordinators (who share them withother hospital staff) for feedback. The draft survey isrevised based on entity feedback and then pilot testedwith patients. The corporate planning staff makes anynecessary refinements and the improved surveys areimplemented.

Evaluation and improvement of internal customer andhealth care service needs have resulted in major improve-ments in SSMHC’s patient satisfaction survey since 1985,including an electronic reporting system for the monthlysurvey data using DI-Diver software; an executivesummary report to show high level results of each hospi-tal’s survey results compared to other SSMHC hospitals;and pain management questions added to the ED andambulatory surgery surveys to further understand this keydriver of patient satisfaction.

18

CATEGORY 4-INFORMATION ANDANALYSIS

4.1 Measurement and Analysis of OrganizationalPerformance4.1a(1) The SSM Information Center (SSMIC or IC)supports SSMHC’s approach of gathering and integratingdata for performance measurement through a robustinformation system based on common platforms that aresystematically deployed across the organization. Indicatordata are published in Performance Indicator Reports(PIR) (Figure 1.1-2) as part of the PerformanceManagement Process.

Data for the indicators are gathered at the department leveland consolidated at the entity level using a variety ofsystems. The entities use the General Financial andMaterials Management System to integrate finance andmaterials management systems to provide real-timeaccess and sharing of data across the organization. ThePatient Satisfaction and Loyalty System and EmployeeSatisfaction System provide satisfaction data to determinesatisfaction/dissatisfaction for each of these key groups.The Patient Resource Utilization and Analysis System andMaryland Hospital Assn. (MHA) are the primary sourcesfor clinical quality data. These automated systems feedthe entity data into the Performance Management Processreporting system.

The SSMIC publishes and distributes monthly electronicPIRs that roll up data on 49 indicators from the departmentto system level. System Management, OperationsCouncil, network leadership and entity presidents and theiradministrative councils use these reports to monitor andmanage organizational performance. Each PIR contains acolor coded stoplight report that visually reflects if anindicator is within specifically defined parameters. ThePIRs also include a detailed format that shows currentmonth vs year-to-date data. If an indicator reveals anunfavorable variance outside defined parameters, correctiveaction plans are developed to recover. In addition to acutecare hospitals, reports are available for SSMHC’slong-term care (skilled nursing) facilities, home care, andphysician practices.

Entity administrative councils monitor the Hospital(Long-Term Care, Physician Practice or Home Care)Operations Performance Indicator Report containing49 indicators monthly. The integration of the entity leveldata provides entity leaders with the information they needto determine whether corrective action plans are needed atthe entity level. Network leaders review the SSMHCOperations Performance Indicator Report monthly,which rolls up the same 49 indicators for all the entitieswithin a network. It facilitates the identification of systemicissues requiring networkwide corrective action.

The Operations Council reviews an SSMHC OperationsPerformance Indicator Report Summary monthly. Thisreport includes a rollup of the same 49 indicators for allSSMHC networks/freestanding acute care hospitals. TheOperations Council uses this report to monitor theperformance of each network and entity. Entities andnetworks with a significant unfavorable variance in any keyindicator are required to submit and implement a correctiveaction plan to bring the indicator on plan (Item 1.1). Actionplans are coordinated with the department leader(s) andput into place to adjust daily operations.

Sixteen indicators from the SSMHC OperationsPerformance Indicator Report are rolled up and refinedfor System Management and the Operations Council in thePIR System Level Indicators report (Figure 1.1-3). The16 indicators include eight for hospital operations, two fornursing home (long-term care), two for home care, two forphysician practices, and two consolidated operationsindicators (profitability and liquidity). This report allowssenior level leaders of SSMHC to evaluate the system’sperformance and identify areas where more detailedanalysis and action followup is required. Daily or WeeklyOperations Reports enable some entities/networks tomonitor such indicators as productivity, staffing and patientvolume. Figure 4.1-1 gives an example of the rollup ofindicators from the department to system level.

19

System/Network/Freestanding Campus Interface

Accountability: RegionalPresident/Network President

to System COO

Network and FreestandingCampus/Entity Interface

Accountability: Entity Presidentto Network VP/Network

President

Entity/Department Interface Accountability: AC Members to

Entity President Department Mgrs. To AC

Members

System Indicator:i.e. Operating

margin(SSMHC PIR)

Entity Indicator:i.e. Expense peradjusted patient

day(Hospital PIR)

DepartmentalIndicators:

i.e. Expenseper unit

(DepartmentReport)

Figure 4.1-1 Example: Perf. Indicator Rollup

The SSMIC also publishes and electronically distributesthe Quality Report quarterly. The Quality Report contains14 indicators in four categories: clinical quality, patientsafety, employee safety, and customer satisfaction.System, network and entity leaders and regional boardmembers monitor this report to evaluate the system’sperformance in quality of care as well as patient andemployee safety. Corrective action plans are required toremedy unfavorable variances. A team was appointed in2002 to bring greater balance to the PIR process byintegrating the Quality Report and additional clinical qualityindicators into the PIRs.

4.1a(2) Performance results are tracked by patient;employee and physician satisfaction; clinical; quality; andfinancial indicators. The categories of indicators areidentified through the SFPP ( Item 2.1). Each entity’sperformance is monitored on the same set of indicators,which aligns the entities with the network, and systemgoals and objectives. The Performance ManagementProcess is formalized and deployed through the SystemPolicies & Procedures. To further align and deploy thisprocess the system has adopted a standard set ofdefinitions for all key indicators for performance reporting.These definitions and the sources of information used intheir preparation are outlined in the Standard AccountingPolicies and Procedures, available on the SSMHCintranet.

Further deployment and alignment of the system’s goalsand objectives is accomplished with the Passport. Eachemployee fills out her/his Passport, which outlines themission, vision, goals, and measures, with the departmentmanager. This tool, along with a department poster,creates line of sight from the employee level to the systemlevel.

4.1a(3) SSMHC uses comparative information, bothcompetitive and benchmark, to improve overallperformance. Comparative information is used to assessthe system’s performance relative to other similarorganizations, either competitors or through nationaldatabases, and to set stretch goals.

The need for and priority of comparative data aredetermined by answering these questions:� Does the comparative/benchmarking effort relate to the

strategies and action plans of the SFPP?� Is the data available and reliable?� Does the comparative/benchmarking effort relate to the

department level indicators?Criteria for seeking sources of appropriate comparativeinformation and data or benchmarking partners include: � Organizations similar in size and/or providing similar

services (e.g., health care systems)� Organizations that compete in SSMHC markets� Organizations known to excel in the process.

SSMHC uses the International BenchmarkingClearinghouse’s four-step benchmarking process. Step 1: Planning the Study. Form a sharing network;decide what to benchmark; and determine how informationwill be collected and shared.Step 2: Collecting Information. Collect information aboutSSMHC’s process; seek out benchmarking partners;investigate how superior performance is achieved with theother organization’s process.Step 3: Analyzing Results. Compare own process toperformance of others; analyze to find gaps; and uncoverinnovative approaches to close gaps.Step 4: Adapting and Improving. Adapt the best practiceor implement specific improvements to existing process;measure results after implement action.

This process is contained in The SSM Health CareBenchmarking Guide, available to employees in hard copyand on the intranet. The Guide also provides suggestedbenchmarking references in specific functional areas, i.e.,readmission, surgery and pharmacy. SSMHC usessystemwide electronic benchmarking tools, includingMcKessonHBOC Trendstar, HBSI Action, HBSIExplore/EIS, HBSI Fathom, and MHA QI Project.

External visits are key to the benchmarking process. Forexample, the K.I.D.S. RULE customer service program atCardinal Glennon Children’s Hospital in St. Louis wasdeveloped and implemented through benchmarking withthe Disney Corporation. The hospital’s leadership groupcommissioned the Customer Service Team to takecustomer service from good to exceptional at Glennon.Disney was selected because, like Glennon, children areprimary customers. Members of the team attended DisneyInstitute training and visited two other hospitals that haveused the Disney approach. The team selected one ofthese hospitals to assist in designing an employeecustomer training curriculum. The team revised employeeperformance appraisals to include a customer satisfactionsegment worth 40 percent and developed classes in BasicCustomer Service Training and Phone Management; anemployee recognition and reward program for excellentcustomer service; and a new patient admission packet.They also publish a newsletter highlighting satisfactionsurvey results/comments and hold focus groups withpatients and the parents of patients to clarify theirconcerns. The team closely monitors Glennon’s inpatientloyalty results, which trended up after K.I.D.S. RULE wasimplemented late in 1999.

4.1a(4) System Management is responsible formanagement of the PIRs. Through the rigorous annualassessment, SSMHC receives feedback on opportunitiesto improve its measurement system. Following anevaluation of the state and Baldrige feedback, SystemManagement engages appropriate teams to define andmake any necessary enhancements. An Accountability

20

Task Force of senior system/network executives andentity presidents was formed in early 2000 to better alignindicators at all levels of the organization and establishgreater accountability for performance results. Their workresulted in the current PIR system, which was improved in2001 to reflect the new 2002-4 goals. A sub-team of seniorexecutives is working in 2002 to better integrate clinicalquality indicators into the PIRs. Changes are implementedby System Management, which revises related policies,and the SSMIC, which updates the reports. Changes inthe reports are made in a way that preserves prior yearcomparisons.

4.1b(1) SSMHC uses a variety of methods to analyzedifferent categories of data for review by executive leadersand for use in organizational planning. (Figure 4.1-2)Regression/impact analysis, for example, is used toidentify opportunities for improvement from the patientsatisfaction surveys. Through this statistical tool, theareas with the lowest satisfaction and highest importanceto the customer can be determined. This helps SSMHC'semployees understand, prioritize and address areas ofimportance to patients and their families. The percentageof loyal vs. at-risk customers and an impact index analysisis also obtained from patient satisfaction surveys to give a“Loyal Customer Index.” SSMHC’s patient satisfactionsoftware is used at the entities to analyze and comparepatient satisfaction data for more detailed understanding ofpatient needs.

4.1b(2) Analytical results are packaged in the PerformanceManagement Process reports, which become thefoundation for reviews as described in Item 1.1b.(1).Operating indicator data are analyzed and integrated viathe tools described in Figure 4.1-2 for monthly operationalreviews and the SFPP. SSMHC improvement teams usethese methods to improve department, entity, network orsystem processes. During the entity leadership reviews ofthe Hospital Operations Performance IndicatorReport, administrative council members discuss results,as appropriate, and present performance improvementinitiatives undertaken between review sessions. Year-endresults and analyses are included in the SFPP during theStrategic Development phase. Systemwide progress iscommunicated to all employees by senior leaders inmessages crafted to ensure understanding and to allowopportunities for two-way conversations.

In early 2002, the corporate planning staff conducted acorrelation analysis of key system level indicators tovalidate which indicators strongly correlate, positively ornegatively, to inpatient loyalty. The results were presentedat the annual Innsbrook Group planning session to providea basis for planning decisions and priorities.

Analysis via the tools identified in Figure 4.1-2 isconducted to provide information related to the system’sstrategic initiatives. In addition, line graphs and controlcharts are used to analyze trends in financial, clinicalquality, and customer data. Comparative data is used ongraphs and charts to provide an opportunity to assessSSMHC on a relative basis.

4.1b.(3) During the SFPP, SSMHC’s organizational goalsand measures are established. The PerformanceManagement Process is intentionally designed to providepredictive insight into organizational level achievement ofkey strategic objectives as defined through the SFPP.(Figure 4.1-1 provides an example of department tosystem level indicator alignment.) Analysis methodsfacilitate reconciliation of strategic and tactical data andprovide a basis for prioritizing initiatives. Continuous andbreakthrough improvements occur through correctiveaction plans and the built-in annual improvement cycles ofthe planning process. The SFPP both drives and drawsfrom the Performance Management Process through thecomparison of current performance to anticipated (or plan)performance. The gap between current performance anddesired levels of performance provide the basis for actionplans directed at incremental improvement. Breakthroughperformance improvement needs are identified through use

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� Mission Effectiveness Analysis (MEA)

� Regression/Impact Analysis

� Focus group

� Syndicated customer research

� Root cause analysis

� Variation analysis

� Segmentation

� Literature research� Complaint management

Performance Review

� External/Market Analysis (consumer, demographic, competitor, emergingtechnologies, payor, public policy & physician)� Internal Analysis(medical staff, product line, HR, physicalplant/technology, financial, supplier and partner, &quality analyses

� Public Perception� SWOT� Capital Review� Market Basket� Development Needs� Correlation

� Financial RiskAsssessment

� Gap� Sensitivity� Feasibility� Business Development� Credit

Planning (SFPP)

Figure 4.1-2 Key Analyses to Support PerformanceReview & Strategic Planning

of comparative data and are the basis for keyorganizational strategies.4.2 Information ManagementSSMHC’s Information Management Council (IMC)determines the data and information needed by entity,network and system staff, suppliers/partners,stakeholders, and patients/customers through aninformation management planning process (Figure4.2-1) that is part of the overall SFPP. The IMC is amulti-disciplinary subcommittee of System Managementthat represents the system, networks and entities. TheIMC consists of approximately 20 System Managementmembers, entity presidents, physicians andrepresentatives from operations, finance, nursing, planning,and information systems. The information management(IC) plan is developed by the IMC and implemented by theSSM Information Center.

4.2a(1) Common information systems platforms aredeployed in each entity via SSMHC’s network. Keyclinical, financial, operational, customer and marketperformance data for all entities and SSMHC as a wholeare provided in automated information systems that allowfor significant reporting capability. Based on best practicesat several entities, the ePMI (Exceptional PerformanceManagement Initiative) Team in 2002 recommended asystemwide model for redesigning the Financial and

Decision Support services within SSMHC. The new modelenables improved monitoring of performance, additionaldecision support for executive leaders, and more rapidresponse to strategic opportunities.

Based on the needs of the organization, the IMC followsestablished criteria to classify its information systems intothree categories: Required (standardized across thesystem and must be implemented at each facility);Standard (standardized systems that entities implementaccording to their needs); and Non-Standard (notstandardized across the system and entities mayimplement according to their needs). There is a focus onstandardizing information systems to ensure that standarddata and information will be available for reporting at aregional and system level. The SSMIC workscollaboratively with key functional areas (e.g., corporatefinance) to ensure its systems meet common datadefinitions as, for example, with the systemwidePerformance Indicator Reporting process. The required andstandard information systems are deployed throughout thesystem by the SSMIC. The SSMIC has also implementeda sophisticated technical infrastructure that allows thephysician partners to access data and information neededfor their practice from any location at any time frommultiple devices, including PCs, PDAs, pagers, and fax.

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Figure 4.2-1 IS Planning & Management Process

Plan / Check

Do / Act

SSM Information CenterIS Planning & Management

SSM Information Center

List

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Network / Entity IMC

Vendors / Consultants

Nursing Informatics

Medical Informaticse-Health / Web IMC

HIPAA

Revenue Cycle

ePMI

User Groups

Network / Entity IMC

Vendors / Consultants

Nursing Informatics

Medical Informaticse-Health / Web IMC

HIPAA

Revenue Cycle

ePMI

User Groups

System IMC

Tactical Teams

Operational Teams

ProjectOffice

Tactical Teams

Operational Teams

ProjectOffice

Entity Membership

Capital AllocationCommittee

Entity ServiceLevel

Agreements

Plan / Check

Do / Act

SSM Information CenterIS Planning & Management

SSM Information Center

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Network / Entity IMC

Vendors / Consultants

Nursing Informatics

Medical Informaticse-Health / Web IMC

HIPAA

Revenue Cycle

ePMI

User Groups

Network / Entity IMC

Vendors / Consultants

Nursing Informatics

Medical Informaticse-Health / Web IMC

HIPAA

Revenue Cycle

ePMI

User Groups

System IMC

Tactical Teams

Operational Teams

ProjectOffice

Tactical Teams

Operational Teams

ProjectOffice

Entity Membership

Capital AllocationCommittee

Entity ServiceLevel

Agreements

The SSMIC has a technology management function thatmonitors its information systems to ensure high availabilityand access of data and information. This is accomplishedthrough the Operations Center and the use of systemmonitoring tools such as Spectrum and ITO. A variety offile servers are monitored for disk and CPU utilization andsystem uptimes. This data is used for forecasting andplanning server upgrades. Additionally, networkperformance is monitored to ensure access to theapplication systems. As appropriate, the SSMIC hasimplemented redundancy for specific systems and withinits network infrastructure for high availability.

4.2a(2) The SSMIC’s Compliance Administration Group(CAG) has developed Security Policies and Proceduresthat document the system’s intentions and staffresponsibilities regarding information confidentiality,privacy, and security. The policies and procedures coverall employees of SSMHC and physicians who use SSMHCinformation or information processing services during thecourse of their work. They also cover all consultants,payors, contractors, contract and resident physicians,external service providers, volunteers, andsuppliers/vendors who use SSMHC information orinformation processing services.

To ensure data and information security andconfidentiality, the SSMIC has established a departmentfor Compliance Administration and Security, which isresponsible for ensuring appropriate authorized access toits computer systems. A formal Computer Authorizationprocess for granting access to systems and a process ofroutinely requiring passwords to be changed have beenimplemented. The department leader also is working withthe project manager for HIPAA compliance and heads upthe HIPAA Technical Security team to ensure that theconfidentiality of electronic patient records is incompliance with federal standards.

Data integrity, reliability and accuracy is addressedthrough a multidimensional approach. The SSMIC’sDecision Support department works with entity customersto audit the data and information loaded into its databasesfor accuracy. For electronic business partners, such aspayors, the SSMIC has established checks and balancesin the control process to validate the timely receipt andintegrity of submissions for payroll direct deposit andelectronic claims submissions. The SSMIC uses theCatholic Healthcare Audit Network (CHAN) to performaudits of information systems and processes for integrity,reliability, accuracy, timeliness, security andconfidentiality. Hospitals also complete the MHAConformance Assessment Surveys to check the accuracyand validity of clinical data and improve data reporting.

4.2a(3) SSMHC keeps its data and information systemscurrent through the SFPP and IS Planning & Management

Process. Technology needs are assessed through theinternal and external assessment step of the SFPP. Theexternal emerging technologies analysis addresses thecurrent situation in the industry and marketplace. Theinternal physical plant/technology analysis assesses thetechnology needs of SSMHC’s entities and networks tosupport achievement of goals and action plans. The IMCuses the information collected through anSSMIC-sponsored IMC Education Day, and the SFPP andits own listening posts and learning tools to develop theinformation management (IC) plan, which incorporatesnetwork and entity information systems needs. Followingapproval by the IMC, the IC plan is incorporated into thesystem’s SFP. The SSMIC communicates its goals andobjectives to each entity and network through a ServiceLetter Agreement that details the products and servicesthe SSMIC will provide to that entity and network duringthe year. A measurement system for evaluating theSSMIC’s performance is a key component of theagreement.

The SSMIC also contracts with and participates in externalindustry research and educational groups, including theGartner Group, Meta Group, Washington University’s CAITprogram, HIMMS/CHIME, and INSIGHT (participation byindividual and board membership) as a way of keepingcurrent with health care service needs and directions.

4.2b(1) The SSMIC has deployed Uninterrupted PowerSupply (UPS) systems and is protected by its own powergenerator to ensure availability of hardware and software.The financial and payroll systems are covered under ahot-site backup disaster recovery program. The Network(LAN, WAN, & Internet) Security policy outlines theprocedures, responsibilities of IS staff, and standards forsafeguarding the hardware, software, and the Internet. TheSSMIC also formally tests software product enhancementsprior to implementing them into a production environmentto make certain they are reliable and user friendly.Quarterly survey results and comments are shared withthe leadership team and action plans for improvement aredeveloped. The leaders monitor the initial survey resultsand comments as well as the action plans, insuring thatorganizationwide issues are appropriately addressed. Theyalso ensure that each respondent receives feedbackrelative to their ratings and comments. Feedback from theCustomer Satisfaction Program described above alsohelps to ensure that hardware and software are reliableand user friendly.

4.2b(2) Software and hardware systems are kept currentthrough the SFPP and IS Planning and ManagementProcess as described in 4.2a(3). For example, the SSMIChas assisted the organization to meet its patient safetyinitiative by implementing software designed to preventmedication errors, such as Electronic Signature andBedside Medication Administration.

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CATEGORY 5-STAFF FOCUS

5.1 Work Systems5.1a(1) SSMHC organizes and manages its health careservices through an organizational structure designed tobe flexible and responsive to the needs of customers andpartners. Work and jobs are organized and managed at allorganizational levels (system, network and entity)according to functional responsibility, usually bydepartments. Each position has a clearly defined jobdescription. Individual and department goals are alignedwith entity, network and system goals through thePassport, creating a common focus.

As CQI has become a cultural norm, SSMHC has beentransformed into a team-driven organization seeking toconstantly improve. Teams are commissioned on a short-or long-term basis to achieve specific initiatives or todesign or redesign work processes. Use of teams givesSSMHC the flexibility to pull together individuals withspecial expertise to quickly address changing customer,operational, and health care service requirements.

Employees and physicians throughout SSMHC participateon teams to design, organize, manage, and improve theirwork processes. CQI teams can be systemwide,networkwide or entity-specific. Systemwide teamsaddress universal work-related issues. Networkwide teamsdeal with issues common to a particular region. Theentities use teams as well as informal work groups tointegrate the mission into work, provide patient care,problem solve, and so on. Employees validated “work” and“teamwork” as their two main satisfiers in the most recentemployee survey as well as on surveys for the past threeyears. The satisfaction with teamwork reflects the impactthe CQI management paradigm has had on the SSMHCculture.

SSMHC’s long-standing commitment to CQI Principlesand teamwork promotes communication and cooperationas well as knowledge and skill-sharing within and acrossthe work units, departments, and entities. CQI hascreated a common language and common set of toolsenabling people to work together on entity, networkwideand systemwide teams and to share information, lessonslearned, and methodologies. Team members share bestpractices within their departments.

SSMHC brings together system, network, and entityleaders for knowledge sharing at annual meetings,conferences, teleconferences, and learning sessions.Nursing executives (like other functional area leaders)meet annually to discuss systemwide nursing issues anddevelop policies and initiatives related to nursing. Anannual Nursing Sharing Conference enables nurses fromacross the system to share improvement and bestpractices and gain indepth knowledge on issues from a

national expert. The 2002 Nursing Sharing Conferencefocused on Shared Accountability. Other methods ofeffective communication and knowledge/skills sharingamong employees are depicted in Figure 1.1-1.

5.1a(2) SSMHC is in the early stages of implementingShared Accountability, an accountability-basedprofessional practice model, at all entities to fosterempowerment and to give nurses and other employeesgreater decision-making authority. Shared Accountabilitybuilds on CQI and SSMHC’s commitment to placedecision-making and accountability at the level wherework is performed.

The SSMHC Quality Principle “Quality is achieved throughpeople” is the bedrock of the organization’s culture. One ofthe seven management practices considered essential forsuccess within SSMHC’s leadership system is“developing people.” This practice is defined as facilitatingthe development of others; having high expectations ofindividual skills and abilities; investing in employeedevelopment; and valuing and modeling lifelong learning.These behaviors are part of the Leadership DevelopmentProcess (Item 1.1a(1)).

SSMHC utilizes mentoring at all levels to engage anddevelop new professionals. SSMHC launched a pilotDiversity Mentoring Program in 2000 with ten minorityemployees in professional and management ranks servingas mentorees and ten executive leaders serving asmentors. The program is now implemented systemwideand has been expanded to 20 pairs. The program supportsone of SSMHC’s diversity goals: To increase the numberof minorities in the professional and managerial ranks bypreparing them for upward mobility.

5.1a(3) An annual staff evaluation process gives SSMHC’semployees an opportunity to discuss development needswith their supervisors and to identify opportunities to learnand gain new job skills. The performance of SSMHCclinicians is evaluated based on job-specific competencystandards. Each entity and network has a performancereview process in place for all other employees andemployed physicians. Through the Passport programemployees identify personal goals that are linked toorganizational goals and are then evaluated on theirperformance in achieving these goals.

Within the SSMHC culture, we understand that anemployee’s primary motivation comes from an intrinsicdesire to perform well in her or his work. Therefore,creating an environment that supports and enablesemployees is important. We accomplish this by providingthe information and tools employees need to do their workindividually and in teams. At a more fundamental level,managers motivate employees primarily through twonon-monetary approaches--coaching and recognition.

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Formal coaching is built into the employee developmentprocess, although informal coaching is an ongoingprocess at all levels of the organization.

A comprehensive Employee Recognition Policy wasdeveloped and implemented in early 2000. All SSMHCentities have a formal process to recognize employees,physicians, and volunteers for their years of service, teamcontributions, and CQI efforts. Each entity also has aprocess in place to recognize individuals who live out theSSMHC mission in a way that goes above and beyondtheir job description. Formal and informal recognition isgiven to both individual employees and to teams. Theprimary method of recognizing teams as well as sharingresults is through the annual Showcase for Sharingconference, a systemwide recognition event held inconjunction with SSMHC’s annual Leadership Conference.Teams that have made effective use of the CQI processare also eligible to receive a plaque from the QualityResource Center.

In keeping with its mission and values and the humanresources strategic goal of competitive compensation,SSMHC develops compensation policies to be fair andequitable for all employees. Annual market surveys areconducted and pay ranges adjusted as necessary toensure competitive compensation for all jobs within all thecommunities served by SSMHC. The compensationsystem also is evaluated annually and the results reportedto the parent Board of Directors.

5.1a(4) Throughout the organization, including senioradministrators and executive leaders, employees areencouraged through coaching to develop to their fullestpotential on their career path within SSMHC. Whenopenings occur, internal candidates are given a strongpreference. Forty-nine percent of SSMHC’s executivesand 1,064 employees were promoted from within in 2001.

SSMHC’s succession planning for executive leaders iscalled the Executive Career Development Program.The process is defined in the SSMHC ExecutiveLeadership Handbook. Through this process, futureleaders are identified and developed. The program beginswith a leadership behavior assessment through a psychometric tool, such as Calipers or similar psychologicaltesting, and use of a personal development plan within thefirst six months of employment. The program alsoincludes an executive orientation; CQI training; and aCorporate Responsibility Process training session forexecutives within the first six months of employment.Executive leaders have mentors available to them and areexpected to mentor others.

5.1a(5) SSMHC’s executive leaders consider it essentialto be the employer of choice because of the shortage ofhealth care workers nationwide. The American Hospital

Association recognized SSMHC in 2002 as an exemplaryemployer and the St. Louis Business Journal named SSMHealth Care St. Louis as one of two nonprofit employers ofchoice in the St. Louis area.

Caliper Profiles, or similar assessment tools, are usedacross the system to assess the personalitycharacteristics of potential managers. This profile helpsensure SSMHC hires individuals that are a good fit with itsvalues, core behavior expectations, CQI culture, andstrategic initiatives. Key performance requirements arecommunicated to potential staff during the interviewprocess.

SSMHC’s human resources staff have identified generalcharacteristics of successful and valued employeesthrough institutional knowledge and many years ofemployee focus groups and surveys. Successful SSMHCemployees are interested in good benefits and competitivewages; encouraged by being a team player; motivated bythe intrinsic value of providing patient care; comfortableasking for needed information; honest; nonviolent; andresponsive to patients and co-workers.

SSMHC human resources staff interview potentialemployees to assess whether they have thecharacteristics necessary for a good fit with the cultureand the skills to fulfill the job requirements. If a decision tohire is made, extensive background checks areconducted, followed by a physical and drug screen.SSMHC human resources staff also check to verifycredentials and post secondary education. They confirmthe most recent five years of work history of candidates forprofessional and managerial positions and identify thecause of any gaps in employment history.

SSMHC uses a wide variety of recruitment methods. Therecruitment efforts focus on SSMHC’s commitment toquality and culture of teamwork to interest candidates whohave the potential to be valued employees. SSMHCscreens advertising outlets and sources of job candidatesbased on the SSMHC valued employee profile. Thesystem also recruits electronically, both on its externalWeb site and from all SSMHC intranet pages. Openingsare also posted on wall bulletin boards at the entities.During 2001, SSMHC recruited 2,459 employees via theweb. An online application is available. Information aboutall applicants, including online applicants, is trackedelectronically. (Figure 7.4-12) This tracking program helpsHR staff to better focus their recruiting efforts.

SSMHC has addressed the industry’s critical nursingshortage by bringing together nurse and human resourcesexecutives to develop innovative recruitment and retentionstrategies. System Management is taking the followingactions based upon the recommendations of the fivesystemwide nursing recruitment and retention teams: (1)

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implementing nursing shared accountability models at theentities, (2) improving nursing education and orientationprograms offered within the system, (3) improving nursingaccess to technology, (4) developing programs to fostercollaborative relationships between nurses andphysicians, (5) offering a variety of benefits such asimproved tuition reimbursement and bonuses foremployees who recruit a peer.

Other recruiting strategies are student nurse internshipsand post-graduate clinical teaching site experiences.These programs are designed to give student nurses andpostgraduate nurses an opportunity to work side-by-sidewith experienced nurses. As an example, in 2001, 84percent of the student nurses stayed on as SSMHC St.Louis employees.

SSMHC’s entities celebrate their diversity in many ways,including events that feature ethnic foods; observances ofethnic holidays and other events celebrating racial, ethnic,and religious significance.

5.2 Staff Education, Training, and DevelopmentContinuous learning is considered essential for employeesto stay abreast of changing health care technology,industry trends, market forces, and governmentalregulations. Education and training is designed to supportthe goals and action plans of the system, networks andentities to meet these challenges.

5.2a(1) System Management determines whethereducational topics support the organization’s short- orlong-term strategic objectives. Education programs thatsupport long-term objectives and meet a a requirement forconsistency are offered systemwide. Those that supportshort-term strategic objectives and specific goals andaction plans, for example, supporting use of new medicalequipment, are offered locally.

Education and training in CQI, for example, are deployedsystemwide to support SSMHC’s Quality Principles andteam and individual quality-in-daily-life approach to work.Teams are typically used to complete action plansthroughout the system. SSMHC’s CQI classes prepareemployees and physicians to participate effectively asteam members and team leaders (group dynamics) and touse the proper tools of analysis. When action plansinvolve systemwide processes or initiatives, such asHIPAA, specific training programs are designed andimplemented systemwide. Other examples of systemwidetraining include Corporate Responsibility (CRP) andcomputer skill training.

All SSMHC hospitals assess staff development needs forclinicians on a hospitalwide, departmental, and individuallevel and use these assessments to plan staff education.For each employee, the human resources staff verifies

that education and training are consistent with applicablelegal and regulatory requirements and hospital policy.They also verify that the individual’s knowledge andexperience are appropriate for his or her assignedresponsibilities, including job-specific competencies. Theprimary assessment of individual knowledge and skills iscompleted each year with the performance review, whichidentifies future training needs. The entity humanresources staff analyze trends and identify neededimprovements in staff education. A summary of theaggregated data regarding competency of employees;analysis of patterns or trends; identification of trainingneeds; and actions taken to address the needs arereported annually to SSMHC’s regional boards of directorsin the Competency Report.

5.2a(2) SSMHC’s entities and networks conduct a humanresource analysis and competency assessment, as partof the SFPP, to identify the training and education theiremployees will need to meet systemwide goals. Data arecollected and analyzed by the entity/network staffs andincorporated into resource plans supporting thesystem/network/entity goals and strategies.

The results of this survey are combined with other sourcesof input, including performance review plans, employeesatisfaction levels, formal needs assessments, directrequests, staff meetings, and direct observation. Ananalysis is conducted and educational priorities are set.Employees are surveyed to assess learning sites, coursecontent, and delivery alternatives.

5.2a(3) The organizational training needs generated bythe strategic objectives and system action plansdeveloped during the SFPP are addressed at theappropriate system, network and/or entity levels.

Technology. System level technology education andtraining needs are driven and defined by the SFPP and theSSMIC. System level strategies, such as the conversionto ERP, that require the implementation and use of newtechnology are supported through the deployment ofappropriate learning opportunities.Management/Leadership Development. TheLeadership Development Process is an approach to thedevelopment of people at many levels. Input from a varietyof sources is used to identify appropriate learning andgrowth opportunities for employees who are or desire toserve in a leadership role.New Staff Orientation. Initial education and training aredelivered through a tailored orientation that includessystem and entity-specific information. Executive leadersparticipate and welcome new employees into theorganization, sharing the mission, vision, and philosophy.Topics typically covered include the Passport program(which includes strategic initiatives), patient rights, ethicalconcerns in patient care, CRP policies, principles of

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quality improvement, and much more. Orientation to theindividual work area is provided by the department.Employee Safety. Required safety training is focused atthe entity level on ergonomics (especially patient lifts andtransfers), exposure control through sharps alternatives,hazardous and biohazardous material management, lifeand environmental safety, and emergency preparedness,including bioterrorism.Performance Measurement/Improvement. Allemployees receive an orientation to CQI as part of theirnew employee orientation. Five CQI principles arediscussed, including why and how every employee isexpected to continuously improve their work. Employeesalso receive an orientation to their work unit and theirspecific responsibilities are identified. As part of theirorientation, Passport goals and performance and skillstandards for their own position are described. Throughthe employee development process, employees receivetraining from their supervisor about the development ofperformance improvement goals for their own position. Therequirement for executive leaders regarding CQI trainingand personal development plans are outlined in theexecutive handbook. The Leadership DevelopmentProcess includes assessment of individual strengths anddevelopment needs with subsequent education. Diversity. A video on SSMHC’s commitment to creatingan inclusive environment and culture called “Experiencethe Difference Diversity Makes” is shown to new hires.Mandatory training related to diversity and sexualharassment policies is held annually for all employees.

5.2a(4) These include special systemwide educationprograms; entity, network, and system level orientationprograms for new employees; on-the-job training; ongoingCQI classes and so on.

Education and training and the methods of delivery aretailored to meet the varied needs related to learningstyles, locations, and subject matter. Lecture,computer-based/web-based training and simulation, skilldemonstrations and testing, videotape, discussion,videoconferencing, self-learning modules, individualinstruction, and group learning activities are all also usedin meeting these needs. Software “super users,” onlinehelp, and “train the trainer” classes are used fortechnology training. Skill-based training, such ascardiopulmonary resuscitation, requires hands-on learningand competency assessment through returndemonstrations. Principles of adult learning are applied.

Specific individuals or dedicated education departmentshave been assigned responsibility for delivering educationat the entities. Staff education is provided to employeeson all shifts, 24 hours a day, 7 days a week. SSMHCemployees are a diverse group of people. Some staff areprofessionals with graduate degrees, others have less

than a high school diploma. These factors are consideredwhen tailoring delivery methods and course content.

General education, training and development programs arecontinuously evaluated and improved in accordance withSSMHC’s CQI philosophy. Systemwide education thatsupports SSMHC’s strategic objectives, such as CQI andCRP courses, are evaluated at the system level.Continuous quality improvement training is evaluated bystudent and team evaluations. CRP training is evaluatedusing feedback surveys and post tests. Both types ofevaluations are used as input for periodic trainingrevisions. Learning Management System software trackstraining participation and cost across the system.

Internal training is evaluated at the entity level by (1)evaluations immediately following the training, and (2)annual competency/performance review. Educators followup informally with supervisors to assess whether trainingprograms have met objectives and if employeeperformance is improved. Employees evaluate the contentand presentation after formal educational programs. Theentities aggregate findings and tabulate and trend them todetermine improvement opportunities in program designand delivery, and the evaluation and outcomes are used torevise the education program.

5.2a(5) Job skills and knowledge are reinforced at theentities through observation of day-to-day performance bypreceptors, supervisors, managers, mentors, and peers.Preceptors provide continuous and immediatereinforcement to staff following training. Educatorsreinforce training and job skills by providing informal followup with supervisors, assessing whether training programshave met departmental objectives and employeeperformance has improved.

Supervisors and managers are trained to reinforce the useof quality improvement tools and techniques on the job. Tomaintain the highest quality patient care and customersatisfaction, entities assure that employees achieveexpected levels of performance through ongoingcompetency assessments of patient care staff, withsummaries of these assessments reported to the Boardannually. Completed training is tracked through a learningmanagement system and linked to personnel files.

5.3 Staff Well-Being and Satisfaction5.3a The cornerstone for SSMHC’s focus on staffwell-being and satisfaction is the understanding thatemployee well-being and satisfaction are directlycorrelated to patient and physician satisfaction.

SSMHC has retained Marsh Risk Consulting Strategies, arisk control consultant, to make entity site visits toassess employee safety programs and loss preventionprograms at least annually. A report on the assessment

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with recommendations for improvement is provided toentity safety officers and the corporate risk manager foremployee safety. The entity’s leadership group approvesany capital expenditure or appoints teams to make thenecessary improvements to processes that impactemployee safety. See Figure 5.3-1 for measures ofenvironmental factors and safety.

5.3b(1) SSMHC determines the key factors affectingemployee satisfaction, motivation, and well-being throughanalysis of results from an annual systemwide employeesurvey known as the HR Solutions Survey. An analysisis done based on the normative differential score, whichcompares SSMHC’s scores with the National HealthcareNormative Data. The survey is administered primarily bypaper, but has phone and Internet capability. It allows foruniform collecting and reporting across the system, rapidturnaround time from assessment to results; and providesactionable results summaries. Survey data is segmentedaccording to SSMHC’s main job categories: Nurses(patient care and administrative), physicians, executivesand managers/supervisors; support, clinical and technicalprofessionals; lead clinical/technical professionals; alliedhealth; support services; and administrativeassistants/coordinators/office clerical. SSMHC hascustomized the survey, which contains 124 questions, toprovide segmented data on satisfaction among minorityemployees. The HR staff can drill down for survey resultsby ethnicity, pay status, gender, tenure, age, anddepartment.

5.3b(2) Employees within SSMHC are employed full-time,part-time, occasional, and by contract, meeting both theirneeds and the system’s need for flexibility because ofchanging patient volumes.

Some systemwide approaches used to enhance the workenvironment for SSMHC employees include flexible hours(seventy-two hours semimonthly is considered full-timewith full-time benefits); work at home; SSMHC-sponsored

retreats (one day to reflect on the mission andreenergize); wellness programs; environment of respect;and job postings for internal recruitment. For example,employees may choose to work between 9 a.m. and 3p.m., while their children are in school, and job sharingexists where needed. Entities commonly rely on internalfloat pools, as preferred to agency use, to providesupplemental on-call staffing and flexibility. Employeescan also easily transfer between SSMHC entities withingeographical areas.

SSMHC determines staff needs for services, benefits, andpolicies through the SFPP, with data collected,aggregated and analyzed through the human resourceanalysis step. Sources of input include the HR Solutionsemployee survey, market studies, employee councils,suggestion boxes, Town Hall meetings, etc.

Flexible Benefits Program: Employees select benefitsthat most closely meet their individual and family needs.The benefit structures are uniform across the system forcomparable hospital, nursing home (long-term care), orphysician. Executives and employees receive the samehealth insurance benefits plan, including choice of medicalinsurance plans, including indemnity and HMO options,with prescription drug coverage; dental insurance plan;vision care plan; life insurance and dependent term life;accidental death and dismemberment; LDAcoverage-Legally Domiciled Adult; Long Term CareInsurance-insurance to provide coverage for times ofextended care; Long-term disability; Health andDependent Care pre-tax spending accounts; andTax-Deferred Match Savings Plan. Employee Assistance Program (EAP): Entities provide,at no cost to the employee, this confidential program ofcounseling for employees with personal, family, legal,financial, substance abuse and/or work-related problems.Employee Emergency Fund: Many entities offerconfidential monetary support to employees facing suddenfinancial crisis.

SSMHC also has systemwide policies providing: extendedmedical benefits (short-term disability); retirement plan;supplemental tax-deferred match savings plan; directdeposit; discounts for cafeteria and gift shop; credit union;tuition reimbursement / educational assistance; leave ofabsence programs for family medical, personal,educational, or military service; and adoptionreimbursement. In 2001, SSMHC introduced a phasedretirement option as a way of retaining older employees.Under this option, an employee 60 or older who has fiveyears of vesting service can receive pension benefits whilecontinuing to work for SSMHC, full- or part-time, and willalso be eligible to receive any other benefit provided for theparticular status.

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� Number of minorities inprofessional and managementpositions (Fig. 7.3-12)

� Employee Satisfaction

Diversity

� Employee Turnover(Fig. 7.3-3)� Nurse Turnover (Fig. 7.3-3)� Employee Satisfaction (Fig.

7.3-1)

EmployeeSatisfaction/Motivation

� Employee Satisfaction StaffWell-being

� Lost-time injuries (Fig. 7.3-4) � OSHA incidents (Fig.7.4-18)� Back injuries (Fig. 7.3-6)

EnvironmentalFactors/Safety

MeasuresFactors

Figure 5.3-1 Key Measures for Staff Safety,Well-Being & Satisfaction/Motivation

SSMHC employee benefits are tailored to represent thediversity of the work force, specifically women whorepresent 82 percent of the workforce. This commitment towomen prompted the implementation of PTO/EMTO,Family Medical Leave policies, day care benefits, and thecafeteria plan for employees. Eighteen percent ofemployees represent minority groups. The promotion andcelebration of gender and ethnic diversity within SSMHC’sculture has been one of several key organizationalcommitments since the system was organized in 1986.This commitment is reflected in SSMHC’s 2002-2004SFP, which includes four diversity goals:�Increase the number of minorities in professional andmanagerial positions systemwide by 51 in 2002�All SSMHC entities support at least threecommunity-based activities each year in partnership withorganizations that rigorously pursue fairness and equality�All SSMHC entities provide annual diversity training totheir employees and managers �Increase annual discretionary spending with minoritybusiness enterprises (MBE) to 10 percent in 2002. SSMHC created the position of corporate vicepresident-human resources & system diversity to assistSSMHC’s networks and entities in achieving diversityinitiatives and goals. All entities have action plans tosupport the systemwide diversity goals. SSMHC’sdiversity initiative was recognized as a national bestpractice in 2002 by the American Hospital Association.

The materials used for employee CRP trainingsystemwide are available in both English and Spanish.Some SSMHC entities offer literacy and languageprograms for their employees. St. Mary’s Hospital MedicalCenter and St. Marys Care Center in Madison, WI, forexample, offer English-As-A-Second-Language classes foremployees during work hours. An SSM Diversity Forum,composed of persons of color, different ethnicity or withdisabilities holding professional and managementpositions within SSMHC in the St. Louis area, was pilotedin St. Louis. During 2002, SSMHC will begin replicatingthe forums in other SSMHC regions.

5.3b(3) SSMHC assesses employee well-being,motivation, and satisfaction with the work environmentsystemwide and develops action plans for improvements.Corporate Risk Services collects, aggregates andanalyzes systemwide data on employee health, safetyand ergonomics. The corporate human resources staffcollects, aggregates and analyzes systemwide data ondiversity and harassment, grievances, harassment reports,work place violence, and labor activity. These data areintegrated with other employee-related data, for example,employee satisfaction and turnover rates.

The annual HR Solutions survey process is the primarymethod used to determine staff well-being, satisfactionand motivation. Results can be analyzed by job groups

across an entity, network or the entire system. Follow-upfeedback sessions are conducted with employee groupsto clarify and validate survey results. The results from thesurvey and feedback sessions are compiled andintegrated into reports on the system as a whole forSystem Management and the network/entity presidents.An interim written survey called “Short Form” is used toevaluate improvements made in the response to employeefeedback.

Employee input also is solicited during exit interviews.This information helps trend why people leave and identifyissues of concern. All of the results measured areanalyzed and used by human resources executives andexecutives at the entity and network level to improve thosefactors that have been identified as drivers of staffwell-being, satisfaction, and motivation. Figure 5.3-1shows the key measures and indicators used to trackstaff safety, well-being, and satisfaction/motivation. EachSSMHC entity has an employee council withcross-functional employee representation that serves as aforum for discussion and resolution of issues of concern toemployees.

5.3b(4) SSMHC’s executives monitor key indicators ofemployee satisfaction and well-being along with other keyorganizations performance indicators through the PIRsand Quality Report (Item 1.1). Correlation analysis, rootcause analysis, literature research and other quality toolsare used to analyze the performance results and identifyopportunities for improvement. Action plans at the system,network or entity level are implemented to make thenecessary improvements. For example, SSMHC’sexecutive leaders noted a correlation in 1999 between adrop in inpatient loyalty and dissatisfaction among asingle group of SSMHC employees--nurses. Furtheranalysis revealed that the early impact of a nursingshortage at some SSMHC hospitals was impacting notonly labor costs but also nursing staff morale, SSMHCorganized the two-day Nursing Recruitment and RetentionSummit in January 2000. Since 1999, inpatient loyalty andnurse satisfaction have both increased. The nursingturnover rate declined in 2001 and is projected to decreasefurther in 2002 (Figure 7.3-3).

SSMHC implemented the HR Solutions Survey in 2002 onthe recommendation of a systemwide team. The surveywas piloted during 2001 at St. Francis Hospital & HealthCenter in Blue Island, IL. The new survey replaces asystemwide focus group survey instrument that thesystem had used since 1997. The HR Solutions Surveyimproves SSMHC’s ability to correlate its employee andpatient satisfaction; benchmark results with otherorganizations; and collect data related to special initiativessuch as diversity.

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CATEGORY 6- PROCESS MANAGEMENT

6.1 Health Care Service Processes6.1a(1) Guided by the five SSMHC Quality Principles,teams design health care services and their related deliv-ery processes using the CQI Model - Process DesignApproach (Figure 6.1-1). The CQI Model incorporates thePlan-Do-Check-Act (PDCA) cycle and includes substepsor questions that serve as checkpoints to ensure processdesigners consider, at minimum, requirements such ascustomer expectations, best practices, potential designproblems, measurement systems, etc. The model isintended to be used in its entirety when, for example, newcomplex health care service processes need to bedesigned, or in a streamlined PDCA cycle when theprocess is less complex or quick action is required. ACQI Model-Process Improvement Approach, similar tothe Process Design Approach, is used to make improve-ments to existing processes.

6.1a(2) When network and entity leaders identify an oppor-tunity to launch a new or modified health care service,they appoint a team to determine the feasibility of offeringthe new service. This team or a subsequent design teamis appointed to design the new process(es) for the service.This team, composed of stakeholders in theprocess/service, including employees of all levels, physi-cians, and suppliers and customers, as appropriate,conducts an Analysis as part of the Plan phase of the CQIModel and makes a recommendation to the network/entityleadership group. The entity administrative council (AC) ornetwork leadership group discusses the team’s findingsand decides whether or not to move forward to the next

step, Implement New Process, in the Do phase of the CQIModel. When a new process will impact the system as awhole, this decision is made in consultation withSSMHC’s senior leaders.

Opportunities for a new service are generally discoveredthrough the Strategic, Financial & HR PlanningProcess (SFPP). As part of the SFPP, networks andentities identify needs for new services based oncustomer-focused studies, stakeholder input, communityassessment data, and so forth. All new services arerequired under the CQI Model’s Identify Opportunity stepto link to the system/network/entity strategic goals. Theneed for a new or modified service may also stem fromnew regulatory issues, quality control (performancemeasurement data) for key processes, patient/customerinput from tools described in Item 3.1, or an individualemployee or employee team suggestion.

When the projected cost of a new service exceeds $500K,the network or entity develops a strategic and financialanalysis and submits the project to the Capital Planningand Allocation Process (2.2a1) for review and approval atthe system level. A cost-benefit analysis is alsoconducted by the network or entity staff for those new orsignificantly modified health care services with a projectedcost of less than $500K.

6.1a(3) Customer requirements, expectations and priori-ties constantly change, with the advent of new technologyand health care delivery systems. During the annualSFPP, the networks and entities review information aboutchanging patient/customer and market requirements, suchas changing demographics, the consumerism movement,

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Figure 6.1-1 CQI Model: Process Design Approach

IdentifyOpportunity

Team members?Process to design? Why process chosen?How links to SFP?Identify benchmarking opportunities

Conceptual Design

AnalysisImplement

New Process

ResultsStandard-ization

FuturePlans

Customers' expected outcomes?"Best way" to meet customer needs?Research from other organizations?

How design to avoid problems?How can the impact of problems on customers be reduced?Indicators designed into process to measure performance?

Implement new processHow to change process if not meeting customer needs?

Initial results meet or exceed customer needs?Results demonstrate new process' ability to meet or exceed customer needs?

Methods to be used to make new process permanent?How can team's work be shared with others across the system?

What other changes could improve process?How can team improve to work more effectively in the future?

Plan Do Check Act Plan

and available technology. Also analyzed are data from avariety of customer listening and learning methodsdescribed in Item 3.1. These data are also monitored bynetwork and entity staff on an ongoing basis and byexecutives at least monthly.

During the Planning phase of the CQI Model, ConceptualDesign step, the team addresses the question “What arethe customers’ expected outcomes from the process”? toensure that patient/customer requirements are incorpo-rated into the new or modified service. This is accom-plished by reviewing many sources of existingpatient/customer feedback data, conducting specializedcustomer surveys or focus groups, and including custom-ers on the design team. Customer needs are validatedduring the Check phase.

6.1a (4) Data on emerging medical and informationtechnologies are collected, analyzed, and reviewed as partof the SFPP (Figure 2.1-2). The Information ManagementCouncil plan (Item 4.2) focuses on emerging informationtechnologies. The networks and entities incorporate theselearnings about new technology into health care serviceprocesses through process design teams. The teams doa technology assessment in the Planning phase, Concep-tual Design step, to evaluate new technology, includinge-technology capabilities, that will best support the idealprocess design and achieve customer performance expec-tations. E-technology is considered for incorporation inany process involving education and communication withpatients and the public, results reporting and communica-tion with physicians, and supply chain management.Examples of e-technology applications within SSMHC areWeb-enabled physician access to results of diagnostictesting and electronic collection and distribution of clinicalquality data through the Quality Report. Technologyoptions for the introduction of a new health care serviceoften exceed $500K and, therefore, are evaluated at thesystem level as part of the Capital Allocation Process.This ensures technology resources are aligned to supportSSMHC’s strategic objectives.

6.1a(5) The CQI Model has a built-in focus on improvingthe design process, transfer of team learnings, and suchfactors as quality, cycle time, cost control, new technol-ogy, productivity, and efficiency/effectivenss.

Design teams build into new processes improved healthcare outcomes, reduced cost, new technology, enhancedproductivity, and greater effectiveness through higherquality and reduced cycle time during all steps of thePlanning phase. This is done by research and benchmark-ing, examining SSMHC’s strategic objectives and goals,reviewing customer expectations, establishing appropriateperformance measures and goals, doing a cost-benefitanalysis, and determining the impact on customers. Team

members evaluate the performance of the process inthese areas during the Check phase, Results step, andensure continued improvement in the Act phase,Standardization step.

Improvement of the design process occurs in the FuturePlans step. Each team analyzes its use of the CQI Modeland shares this and the team’s other learnings system-wide through methods shown in Figure 1.1-1. Thisimproves future use of the CQI Model and assists SSMHCin evaluating and improving the overall organizationalapproach to the CQI Model. The CQI Model, introduced in1990, is evaluated by the QRC staff on an onging basis toensure design quality and timeliness. They provideguidance, oversight and education to teams using the CQIModel. The CQI Model and related education wereimproved in 1998 to enable teams to design and improveprocesses more rapidly. A team is currently revising CQIeducation to focus on ways to use the PDCA CQI Modelto further shorten design cycle time and offer a greatervariety of learning venues.

6.1a(6) Early in the Planning phase, the team ensuresthat the process being designed supports SSMHC’s(system/network/entity) strategic objectives. In the thirdstep, Analysis, the team answers the question “Whatindicators are being designed into the process to measureits performance?” In designing the measurement systemfor the new process, the team researches key operationalperformance requirements, including regulatory andaccreditation, and expected results.

6.1a(7) Implementation of the new process occurs withcompletion of an action plan assigning responsibility andgoal dates for each step to optimize timely and success-ful implementation. Completion of an annual Failure Modeand Effects Analysis and incorporation of preventativemeasures in the process design, as described in 6.1a(5),provide a more error-free process and trouble-free imple-mentation. In complex or critical processes, the recom-mendations from teams are tested, using pilot projects, forexample, for a period of time to ensure the new process isworking as designed. This gives customers and stake-holders of the proposed change the opportunity to learnthe new process and to suggest modifications to enhancethe chance of success. In the Check phase, Results step,the team confirms that the piloted process is meeting orexceeding established performance requirements. For keyrequirements not met or unintended problems, the teamgoes back to the Implement New Process step andcontinues the PDCA cycle, implementing necessaryactions to achieve goals. In the Act phase, Standardiza-tion step, the team develops implementation and deploy-ment plans. They establishes written policies andprocedures, guidelines, and orientation systems to ensure

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the service or process continues to function as designedon an ongoing basis.

6.1b(1) As a health care delivery system with a variety ofentities and care settings, the key or core health careservice delivery processes relate to care provided toindividual customers whose needs may vary. Despite thediversity in patient diagnoses and treatment needs, thekey processes/functions in the delivery of patient care andservices are the same at each entity throughout thesystem. Figure 6.1-2 depicts the four key deliveryprocesses of admission/registration, assessment, caredelivery/treatment, and discharge and the their relatedprincipal performance requirements. 6.1b(2) Patient expectations feed into the CQI Model(Figure 6.1-1) in Planning phase and are considered inCheck phase in evaluating the results of the change inprocess. SSMHC uses a number of listening and learningtools (Figure 3.1-1) to understand patient expectations.

On a daily basis, during the health care service deliveryexperience, entities utilize a variety of methods to addresspatients’ expectations and preferences, involve them indecision making, and explain likely outcomes:� Each patient is informed of likely risks and outcomes tohelp establish realistic expectations through an informedconsent process.� The patient and family have input into the treatment planand setting of goals.� The initial and ongoing patient assessment includesdetermining patient preferences regarding spiritual, educa-tion, nutrition, and pain management needs, as well asneeds relating to other aspects of care.� CARE PATHWAYS, protocols, and guidelines “map” theplan of care based on practice standards for specificdiagnoses, procedures, or patient types. � Case Management coordinates patient care across thecontinuum of care. Case managers work closely withpatients, families, payors, and each other to facilitate thetimely delivery of appropriate services.

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§Discharge instructions documented and provided to patient (Fig. 7.1-11)§Response rate on patient satisfaction survey

Assistance &Clear directions

Discharge fromsetting of care

§ Average Length of Stay (ALOS) (Fig. 7.4-2)§ Payment denials §Unplanned readmits (Fig. 7.1-1)

Appropriate utiliza-tion

CaseManagement

Discharge

§Clear documentation of informed surgical and anesthesia consent§ Perioperative mortality§ Surgical site infection rates

Professional skill,competence/comunication

SurgicalServices/Anes-thesia

§Use of dangerous abbreviations in medication orders (Fig. 7.1-4)§Med error rate or adverse drug events resulting from med errors

Accuracy Pharmacy/Medication Use

§Response rate on patient satisfaction (Fig. 7.1-9) & medical staff surveyquestions (Fig. 7.3-8)§Wait time for pain medications §% CHF patients received med instructions/weighing (Fig. 7.1-2a,b,c)§% Ischemic heart patients discharged on proven therapies (Fig. 7.1-3)§Unplanned readmits/Returns to ER or Operating Room (Fig. 7.1-1)§Mortality (Fig. 7.1-5)

NurseresponsivenessPain management

Successful ClinicalOutcomes

Provision of clini-cal care

Care Delivery/Treatment

§Quality control results/Repeat rates§ Turnaround time (Fig. 7.4-5)§Response rate on Medical Staff satisfaction survey

Accuracy &Timeliness

Clinical labora-tory & radiologyservices

§% of histories & physicals charted within 24 hrs &/or prior to surgery§ Pain assessed at appropriate intervals, per hospital policy

Timeliness Patientassessment

Assess

§ Time to admit patients to the setting of care § Timeliness in admitting/registration rate on patient sat. survey questions

Timeliness Admitting/Regis-tration

AdmitKey MeasuresKey RequirementsProcess

Figure 6.1-2 Key Health Care Delivery Processes in the Continuum of Care

6.1b(3) Key patient and applicable accreditation, regula-tory and payor requirements are used by teams anddepartments or services within each entity to establishinprocess operational, quality control, and outcomesmeasures. Data are systematically collected for use inmanaging processes by: establishing a baseline when aprocess is designed, implemented or redesigned; describ-ing process performance or stability; describing thedimensions of performance relevant to the functions, processes or outcomes; identifying areasfor improvement; or determining whether designs/ changesin a process have met objectives. Dimensions of perform-ance are evaluated, making changes as necessary tomeet customer needs, regulatory requirements or advanc-ing health care technologies.

6.1b(4) Performance assessments (daily, weekly,monthly or quarterly basis) provide an opportunity toreview and manage process measures, as appropriate.Performance assessments occur at the department, entityand system level as outlined in Figure 1.1-2. On a day-to-day basis, these same measures enable caregivers tomonitor and manage the delivery of patient care. Perform-ance measures for health care service delivery processesare listed in Figure 6.1-2. Many of the department andentity-level measures used to monitor day-to-day opera-tions include inprocess measures, such as computer editchecks, for both detecting and measuring potential errorsbefore they impact the patient.

Real time patient/family and physician partner input issought through continuous interaction between thepatient/family, caregiver staff, and physician throughoutthe patient needs assessment, care planning and caredelivery experience. Input is also obtained throughcomment cards, patient visits by nursing supervisors andexecutives, entity complaint processes, and patient andphysician participation on CQI teams (Item 3.1).

6.1b(5) SSMHC believes that medical errors occur primar-ily because of a breakdown in processes. It is vital thatdesign teams minimize errors and rework by implementingprocesses that prevent errors and problems fromoccurring. The CQI Model requires that design teamsfocus in the Planning phase, Analysis step, on designinga process that avoids problems and the need for rework. In2001, SSMHC introduced a comprehensive systemwidePatient Safety Program, which aims to expand prevention-based processes and approaches. All entities have teamsparticipating in the AES Clinical Collaborative, focused onimplementing evidence-based processes to reducemedical errors and improve patient safety. Following areexamples of existing patient safety prevention-basedprocesses or mechanisms.� In the Pharmacy, a computerized process flags dupli-cate medication therapies, medication allergies, drug

interactions, and high risk drug alerts to minimize adversedrug reactions.� The Pyxis medication distribution system is interfacedwith the Medication Administration Record (MAR) toprevent nurses from removing an incorrect drug, therebypreventing wrong drug errors, the highest risk error topatients.� Computerized laboratory systems utilize a delta check-ing system to flag widely varying lab results and potentialerrors.� Quality control testing in the laboratory and in Radiologydetect potential problems prior to reporting results.�Individualized patient assessment for falls and implemen-tation of fall prevention practices for the fall-prone patientdecreases the likelihood of patient injury.

6.1b(6) SSMHC employs a two-pronged approach toimproving health care service delivery processes. Oneapproach is proactive and draws from the creativity of ouremployees and physicians. It is based on our fifth QualityPrinciple, “Quality requires continuous improvement.” Astrong culture of continuous quality improvement,reinforced by our mission to deliver exceptional healthcare services, empowers SSMHC employees to proac-tively strive to improve their own work processes, individu-ally or on teams. Suggestions for improvement come fromemployees who, for example, serve on Employee Councilsor who have attended a Sharing Conference or simply seea better way of doing their work. In addition, the CQIModel is designed to uncover new opportunities forimprovement as teams in the Future Plans step answerthe question: “What other changes could be made toimprove the process?”

The second approach responds to a demonstrated needfor improvement and draws from various data monitoringprocesses. SSMHC evaluates health care service deliverysystems and processes through the collection and analy-sis of process performance measures (Figure 6.1-2) andthe Quality Report and PIRs described in Item 1.1 andItem 4.1. An intensive assessment, including a root causeanalysis, is promptly initiated when adverse critical eventsoccur or when statistical analysis detects undesirablevariation in performance.

When either the proactive or responsive approachindicates that improvements are needed in system,network, or entity processes, teams are created that usethe CQI Model-Process Improvement Approach tomake the appropriate changes. This model is similar tothe CQI Model-Process Design Approach, except for aCurrent Situation step in the Planning phase, whichreplaces Conceptual Design, and a Proposed Solutionsstep in the Do phase, which replaces Implement NewProcess. Transfer of team learning occurs using the samemethods listed in Figure 1.1-1.

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SSMHC’s Clinical Collaborative process is a systemwideimprovement approach using our CQI methodology thatencourages rapid cycle improvement in clinical processesand the sharing of improvement ideas and results throughlearning sessions and monthly teleconference calls. Forexample, the Near Miss Team at St. Joseph HospitalWest in Lake St. Louis, MO, participating in a patientsafety Clinical Collaborative, developed a reportingprocess that includes a simple form and recognition ofemployees who report potential medical errors. The NearMiss reporting process, which led to 43 process improve-ments at the hospital within one year and no errorsreported in any of the improved processes, was sharedthroughout the system and is one of 15 patient safetypractices selected for replication throughout SSMHCwithin the next two years.

6.2 Business Processes 6.2a(1) SSMHC considers its Physician Partnering andSupply Chain Management processes to be mostimportant to its business growth and achievement ofstrategies. Physicians are considered SSMHC’s mostimportant partners because they are critical to achievingexceptional health care outcomes and for growth throughadmissions. In addition, industry research has shown thatphysician orders account for the single largest usage ofhospital resources. Reduction of expenses through controlof supply costs, a key SSMHC action plan for 2002, isessential to offset decreasing reimbursement, rising laborcosts caused by the shortage of nurses and other skilledhealth care professionals, and the growth of uninsured/underinsured patients.

6.2a(2) SSMHC’s business relationships carry dualrequirements. SSMHC’s key requirements for theseprocesses are determined primarily through the SFPP andbusiness area planning. Input from customers of theprocesses is gathered during the internal and externalassessment step of the SFPP (Item 2.1). A medical staffsurvey is the primary method of identifying the keyrequirements of physicians. Formal contracts and frequentbusiness reviews define supplier requirements. These keybusiness processes, their key requirements, and perform-ance measures are provided in Figure 6.2-1.

6.2a(3) Business processes are designed by teams usingthe CQI Model.

Physician Partnering ProcessThe Physician Partnering Process consists of threeprimary steps: � Recruitment and appointment to staff� Integration into the organization� Full participation as a partner in delivering exceptional

health care outcomes

Recruitment. Before recruiting physicians, SSMHC’sentities first identify their future needs for medical staffusing the minimum data set within the annual SFPP andthen develop a physician recruitment and retention plan.During the recruiting process, the entities seek to attractphysicians who meet the entities’ service line needs andare qualified to provide exceptional health care. All physi-cians undergo a rigorous application and appointmentprocess, defined in the Medical Staff Bylaws, Rules andRegulations, that determines whether or not they aregranted clinical privileges. To attract highly skilled physi-cians, SSMHC leverages its reputation for physicianpartnering and willingness to provide state-of-the-art clini-cal technology and information systems, updated facili-ties, and skilled and responsive staff that physiciansrequire in order to give exceptional patient care. Physicianliaisons on the entity staffs assist with physician recruit-ment and maintain ongoing contact with physicians toensure that their requirements and needs are met.

Integration. SSMHC integrates physicians into theorganization and its key processes through orientations,strategic communications (Figure 1.1-1), and the MedicalLeadership Enrichment Program, and other education anddevelopment opportunities. Following are examples of keyprocesses and programs in which physicians participate:� Leadership System � Leadership Development Process� Regional Boards� Strategic & Financial Planning Process & Governance

Planning Retreat� Ministry Effectiveness Analysis (MEA)� Performance Improvement Process� Development of mission & values� Corporate Responsibility Process (CRP)� Enterprise Resource Planning (ERP) process� User groups giving input on supplies and technology

purchases� Physician Leadership Conference

Partner in Delivering Exceptional Health CareOutcomes. Physicians have a key role within SSMHC inclinical improvement at the system, network and entitylevels. In 1998, SSMHC began its own series of ClinicalCollaboratives based on the National Institute for Health-care Improvement (IHI) Breakthrough Series. Thesecollaboratives are designed to make rapid improvements inclinical areas that result in better outcomes for patientsand improved value and patient safety, while satisfyingexternal agency regulatory requirements. Physicians worktogether with other caregivers, administrators, and staff,often as a team leader. SSMHC currently has four ClinicalCollaboratives under way involving more than 75 improve-ment teams. Topics are secondary prevention of ischemic

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heart disease, prescribing practices, patient safety, andcongestive heart failure.

Since 1990, when CQI was first introduced systemwide,physicians have attended CQI courses and participated onteams to design and redesign health care deliveryprocesses. Physicians receive just-in-time training beforeparticipating on teams or collaboratives. Physicians alsoparticipate in case management and in developing CAREPATHWAYS and protocols.A medical staff reappointment process is used to ensurethat physicians remain competent within their specialtiesto deliver high quality care. An ongoing peer reviewprocess ensures that physicians are performing to meetSSMHC’s quality standards.

Supply Chain Management ProcessSSMHC’s materials management process is designed toachieve economies of scale and reduced prices byconsolidating purchasing and contracting with preferredsuppliers and partners. This supplier partnership enablesSSMHC and its suppliers to align their strategic goals.

SSMHC is an owner and participating member of Premier,one of the two largest group purchasing organizations inthe nation serving health care. Through this relationship,the system derives a significant economic benefit--6 to 15percent savings over prevailing market prices.

SSMHC has chosen the following distribution partners:Cardinal Health (pharmacy & pharmacy automation);Allegiance, Burrows, Owen & Minors (regionalmedical/surgical); Alliant (food service); and DiagnosticImaging (radiology).

6.2a(4) Key performance measures/indicators, includinginprocess measures, monitored to manage the two keybusiness processes are listed in Figure 6.2-1. Eachmedical staff member is required to reapply every twoyears, and data from peer review is considered in therecredentialing process. SSM Materials Management setsgoals to support the system’s strategic initiatives in anannual planning process. Systemwide user groupscomposed primarily of department directors have been

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Figure 6.2-1 Key Business Processes, Requirements & Measures

§ Fill Rate (Fig. 7.4-7)§ Zack – turn around time for EDI (PO to EDI vendor § Acknowledgement cycle (timeliness)§ SAP Goods Receipt /Invoice Receipt Accuracy (GR/IR) §Days Sales Outstanding (DSO) (Cash Flow) (Fig. 7.4-10)§ Sales /Cost Savings (Fig. 7.4-9)

Timely InventoryAvailability

Invoicing Accuracy

Cost Savings/Sales

Distribution ManagementSupply Chain Management

§Capital $ Spent (Fig. 7.2-2)§ # Equipment Upgrades§ Satisfaction with Admin, facility & equipment rate on MD

survey (Fig. 7.3-9b)

AdministrativeResponsiveness& FacilityImprovements(MD Requirement)

§Nurse Turnover Rate (Fig. 7.3-3)§Nurse responsiveness rate on satisfaction survey (Fig.

7.1-9)§ # Agency Hours § Satisfaction w/Nursing Care rate on MD survey §Overall Physician Satisfaction (Fig. 7.3-8)

Exceptional Nursing:Responsiveness &Reduced Turnover(MD Requirement)

§% Pathway use § Supply & Total Expense Per AEA § Aver. Length of Stay (ALOS) Reduction (Fig. 7.4-2)

Resource Mgmt/Mgmt of care deliveryprocesses(SSM Requirement)

§ # physicians in Clinical Collaboratives (Fig. 7.3-11)§Clinical Outcome Results

Exceptional PatientCare/Outcomes(Shared Requirement)

Medical Staff Integration& Partner in Health CareDelivery

§ # Total Physicians on Staff § #Pt. Referrals/Physician (Admits/physician) § Admissions Growth (Figs. 7.2-9, 7.2-10, 7.2-11)

Business Growth/Patient Referrals(SSM Requirement)

RecruitmentPhysician Partnering

Key MeasuresKey RequirementsKey Business Process

formed to provide customer input on supply needs;consensus on preferred products; and clinical acceptabil-ity. Disciplines represented in key user groups includeradiology, lab, dietary, operating room, and pharmacy.

The Supply Chain Management Processes is managedthrough a multilevel materials management organizationthat coordinates systemwide purchasing and maintainseffective ongoing communication with internal customersas well as suppliers. Each SSMHC entity or network hasa designated materials management office and staff.SSMHC’s materials managers meet every two weeks byvideo/teleconferencing as a committee to brainstorm newideas, discuss strategy, review contract offerings, partici-pate in supplier presentations, discuss distribution issues,and review supplier performance. The meetings offer acollaborative process for supply chain discussions anddecision making, ensuring a consistent approach anddeployment of supplies throughout the system.

SSMHC has formal corporate agreements that define thepartnerships with Cardinal Health, Burrows/Owen&Minors, Alliant, Fischer, and Diagnostic Imaging. Theseorganizations represent the major sources of supplies.They have agreed to collaborate with SSMHC to developinnovative methods of enhancing the quality and cost-effectiveness of patient care services; to improve patientoutcomes and satisfaction; and to enhance the financialsuccess of both. Within Cardinal Health, the umbrellaagreement covers the Cardinal Distribution, Pyxis, andAllegiance units. The contact persons meet quarterly withSSMHC to conduct formal business reviews and planningsessions. The purpose of these sessions is to reviewperformance; discuss reciprocal goals, requests, andunresolved issues; and identify and present futurebusiness opportunities.

6.2a(5) The networks and entities have minimized costsand increased efficiency in the Physician Partneringprocess through a retention strategy based on integratingphysicians into the organization and satisfying theirrequirements. In the Supply Chain Management Process,user groups give management support for standardizationand product deployment, which controls consistency ofthe process. By standardizing and consolidating distribu-tion, the system realizes the benefits of delivery accordingto user needs, including just in time, vendor managedinventory and, often, on consignment.

6.2a(6) Leaders at the system, network or entity levelevaluate the Physician Partnering and Supply ChainManagement processes by monitoring the PIR results andfeedback from the patient, physician, employee and payorsurveys and other listening and learning methods.

Premier provides SSMHC with an annual scorecard detail-ing its performance and comparing SSMHC’s purchasingefforts against its peers within the group purchasingorganization. A scorecard was developed in 2000 and2001 by Cardinal and SSMHC with input from thesystem’s internal customers to measure the performanceof Cardinal Distribution, Pyxis, and Allegiance andSSMHC. Scorecards for each Cardinal unit are reviewed ateach quarterly business review and planning session.SSMHC has extended the scorecards in 2002 to the otherkey suppliers. User group input is also considered inevaluating supplier performance.

When corrective actions are indicated by the PIRs, score-cards, or customer/partner input, SSMHC’s leaderscommission teams to improve the processes. The teamsuse the CQI Model: Process Improvement Approach. Inthe Act phase, teams consider how to best share theirimprovements across the system. Key communicationmethods are listed in Figure 1.1-1.

6.3 Support Processes 6.3a(1-2) SSMHC’s key processes supporting daily opera-tions and staff in the delivery of care and their customerand operational requirements are listed in Figure 6.3-1.When designing or improving key support processesSSMHC teams determine key requirements of internal andexternal customers in the Planning phase, Identify Oppor-tunity step, of the CQI Model. Requirements may alsoderive from the SFPP and are determined through internalcustomer surveys, patient and physician satisfactionsurveys, regulatory or accreditation requirements, andoperational and financial requirements.

6.3a(3) Because SSMHC understands that the effectivefunctioning of support processes is critical to the effectivedelivery of health care services processes, key supportprocesses are designed using the CQI Model: ProcessDesign Approach. The design team ensures that theprocess supports SSMHC’s strategic initiatives early inthe Planning phase. It next determines customer require-ments and benchmarks within SSMHC or outside, ifappropriate. In the Analysis step, the team designs ameasurement system to track fulfillment of key customerrequirements. Inprocess measures are included to facili-tate rapid identification and correction of potentialproblems.

6.3a(4-5) Performance measures include both outcomeand inprocess measures that are used by process ownersto manage day-to-day process performance and to assessresults. Performance measures used to determine ifsupport processes meet the key customer and operationalrequirements are listed in Figure 6.3-1. Internal customerfeedback from daily interactions and employee

36

satisfaction survey results are also used by processowners to manage and improve support processes.

6.3a(6) Prevention-based methods are used withinSSMHC to minimize costs associated with inspections,errors and rework in key support processes. Methodsinclude computerized edit and validation checks for billing,accounting, and human resources; extensive preventivemaintenance for clinical equipment; and proactive safetyprograms.

6.3a(7) SSMHC evaluates and improves supportprocesses in a proactive way as a result of its CQI cultureand supporting tools and in response to performancemeasurement data or to keep current with changing organ-izational or industry needs. The PIRs contain establishedthresholds for performance for 16 indicators at the system,network and entity level. At the department level, inproc-ess measures are monitored based on establishedperformance thresholds. A negative variance from thesethresholds activates the formation of teams and correctiveaction plans to make process redesign/improvements.

Benchmarking data and employee suggestions are otheractivators for improving support services.

When an opportunity for improvement is identified in theperformance of a key support process, entities use theCQI Model Process Improvement Approach (Figure6.1-1). Results are shared with staff, through storyboardsand entity/system newsletters and are also communi-cated through the transfer of learning methods depicted inFigure 1.1-1.

37

Figure 6.3-1 Key Support Processes, Requirements, & Measures

§ Transcription turnaround time & error rate§Medical record delinquency rate§Response rate on medical staff surveys

Timely & accurate medical recordcompletion

HIM (medical records)

§ Issue Resolution Time§User satisfaction scores (Fig. 7.4-13)

Timeliness, Efficiency of informationInformation SystemsInformation Systems Management

§% of preventive maintenance (PM)completed within established time frame§Response rate to satisfaction surveys §Deficiencies from state health department

or JCAHO (Fig. 7.4-17)

Appropriate physical condition &proactive maintenance

Maintenance /ClinicalEngineering Services

§Results of Quality inspection rounds§Response rate to satisfaction surveys

Facility cleanlinessHousekeepingFacilities Management

§% separated employees w/exit interview§Results of internal customer manager

surveys/manager training hours§ Turnover (Fig. 7.3-3)§ Employee Satisfaction (Fig. 7.3-1)

Recruitment and retentionEmployee Satisfaction

Human ResourcesHuman Resources

§Revenue & Expense/APD (Fig. 7.2-4)§ Admissions (Figs. 7.2-9 to 7.2-11)§Operating margin % (Fig. 7.2-3)§ Bad debts %§ Insurance cash collections (Fig. 7.4-15)§ Suspense days (days to billing)§Net days accounts receivable (Fig. 7.4-16)

Exceptional financial performance

Accurate billing

Timeliness of billing/cash flow

Finance/PatientAccts/Collections

Finance

Key MeasuresKey Customer & OperationalRequirements

Support Process

CATEGORY 7 - ORGANIZATIONAL PERFORMANCE RESULTS

7.1 Patient and Other Customer-Focused Results7.1-1 Unplanned readmissions within 31 days is a systemlevel indicator for health care outcomes. Review of thisindicator helps SSMHC prioritize process improvementopportunities in order to address the drivers ofreadmissions and variations in care delivery. Asystemwide team is working to identify best practices bystandardizing data collection and assisting entities inimplementing improvements. Causal factors contributing toreadmissions can be DRG-specific (patients that haveillnesses which are likely to recur, such as congestiveheart failure (CHF) and ischemic heart disease), as well asprocess-specific (i.e., consistent discharge instructions toimprove post-discharge compliance).

7.1-2 CHF is a primary driver of SSMHC readmissions.SSMHC launched a Clinical Collaborative for CHF patientcare in November, 2000 to enable patients to benefit fromthe best evidenced-based interventions possible. SSMHChospitals are performing at or above national benchmarksbased on studies published by the American HeartJournal, The Journal of the American Medical Association,and The Quality Management and Health Care Journal.Research has shown that behavioral drivers (such asweighing and/or medication instructions) andtherapy-based drivers (such as Coumadin use) are primaryfactors that contribute to unplanned readmissions.SSMHC’s efforts to focus on these drivers of readmissionwill contribute to reducing unplanned readmissions.Participating physicians and employees recognize thatthese collaborative efforts are a unique benefit of being partof SSM Health Care.

7.1-3 SSMHC launched another Clinical Collaborative toreduce the incidence of secondary ischemic heart disease(likelihood of a second heart attack). National studies haveshown that daily aspirin use, lipid lowering agents (LLA’s)and other therapies reduce the incidence of second heart

38

1999

2000 20

01

Rea

dmis

sion

Rat

e

MHA Top 25thpercentile

SSMHC

MHA Avg.

Goodê

Figure 7.1-1

Unplanned Readmissions Within 31 Days

11/00 6/01 12/01

% o

f CH

F P

ts w

/ Med

Inst

r.

SSMHC

Benchmarkdata

Goodé

Figure 7.1-2c

CHF Patients w/ Medication Instructions

1/994/99

6/999/99

6/0012/00

3/017/01

12/01

% M

I pts

dis

ch. o

n A

SA

SSMHC

Univ.MichiganBenchmark

Goodé

Figure 7.1-3a

Secondary Prevention of Ischemic Heart DiseasePatients discharged on aspirin/antiplatelet meds

1/994/99

6/999/99

6/0012/00

3/017/01

12/01% M

I pts

trea

ted

w/ L

LA's

SSMHC

Univ.MichiganBenchmark

NRMI ave.

Goodé

Figure 7.1-3b

Patients treated with lipid lowering agents (LLA's)

baseline 11/006/01

12/01%C

HF

Pts

. w/ w

eigh

ing

Ins.

SSMHC

Benchmarkdata

Goodé

Figure 7.1-2a

Improving the Care of CHF PatientsPercent of patients rec'd weighing instructions

11/00 6/01 12/01

% C

HF

Pts

. on

Cou

mad

in

SSMHC

Benchmarkdata

Goodé

Figure 7.1-2b

Percent of CHF Patients on Coumadin

attacks and the development of CHF. SSMHC’s ClinicalCollaborative to reduce the incidence of second heartattacks promotes the increasing use of proven therapies.SSMHC’s process improvements have resulted in reducedvariation through the application of evidence-basedtreatment protocols. Based on benchmark studies by theUniversity of Michigan and the National Registry forMyocardial Infarctions, SSMHC entities are performing ator above national benchmark levels.

7.1-4 Patient safety is a primary focus of SSMHC’simprovement activity. A three-year Clinical Collaborative isunder way, titled Achieving Exceptional Safety in HealthCare, to address this issue. This collaborative is designedto have all SSMHC entities adopt and implement 16 safetypractices that are recommended by national safetyauthorities. The collaborative started in January, 2002 withan initial focus to eliminate dangerous abbreviations usedin prescribing medications. A review of the medicalliterature failed to identify appropriate benchmark data, sowe are comparing ourselves to best practices internally.

7.1-5 Mortality rate is an overall indicator of quality of careand services provided and can be stratified to adjust forseverity of illness and to identify select groups of patientsfor improvement opportunities. SSMHC tracks its overallmortality rate compared to Solucient’s top 25th quartile toassess performance on a relative basis and to prioritizeimprovement initiatives. The overall goal is 0% mortality,and we continue to make progress toward this goal.SSMHC intends to continue its emphasis on ClinicalCollaborations, concentrating on high risk and/or highvolume disease states, to reduce variation and increasethe use of proven therapies to ultimately impact mortality.

7.1-6 Prevalence of physical restraints is a systemwideindicator of patient safety and preservation of patientdignity. There are times when the use of physicalrestraints is necessary to protect the patient from harmingthemselves or others. To reduce the use of restraints,SSMHC has commissioned CQI teams to ensureappropriateness of restraint use and has adopted restraintuse protocols which outline progressive alternatives torestraint use. As a result, use of restraints hassignificantly declined from 1999-1Q2002.

39

1999 2000 2001 1Q02

% R

estr

aint

s U

se

St. MarysCare Center

St.ClareMeadows

Villa Marie

Wisconsin

MO

Nat'l

Goodê

Figure 7.1-6

Nursing Home (LTC) Physical Restraints

1/02 3/02% o

rder

s w

/dan

gero

us a

bbre

v.

SSMHC

Best inSSMHC

Goal

Goodê

Figure 7.1-4

Achieving Exceptional SafetyPercent of orders w/ dangerous abbreviations

'99 '00 '01 1Q02 '03 '04

% o

f Res

pons

es

LoyalIn-playAt riskNRC Top 10%SSMHC Goal

Goodé

Figure 7.1-7a

Patient Loyalty IndexInpatient Satisfaction

'99 '00 '01 1Q02

% o

f Res

pons

es

Loyal

In-play

At risk

NRC Top 10%

Goodé

Figure 7.1-7b

Emergency Department Satisfaction

'99 '00 '01 1Q02

% o

f Res

pons

es

Loyal

In-play

At risk

NRC Top10%

Goodé

Figure 7.1-7c

Outpatient Surgery Satisfaction

1999 2000 2001

% M

orta

lity

Rat

es

SSMHC

50%Solucient

Top 25%Solucient

Goodê

Figure 7.1-5

Mortality Rates

7.1-7 The systemwide patient satisfaction and loyaltysurvey process provides in-depth insight into the needsand requirements of SSMHC’s patients. Loyalty is a keymeasure for SSMHC because it indicates a patient'swillingness to recommend our services. Inpatient loyalty isa system level indicator of exceptional patient satisfaction.

A word-of-mouth referral from a friend or neighbor is a keyfactor in a person's selection of a health care provider.Loyalty is calculated monthly from patient satisfactionsurvey responses for inpatients, emergency departmentpatients, outpatient surgery patients, and home carepatients. Long term care (nursing home) satisfaction isassessed annually. The loyalty indices are calculatedfrom key summary questions in the surveys addressingthe respondents’ overall satisfaction, willingness torecommend to others, and overall performance relative totheir expectations. Respondents are placed into one ofthree categories, “loyal”, “in-play”, and “at risk”. SSMHCuses impact analysis to engage in process improvementsto increase “loyal” and decrease “at risk” and “inplay” respondents.

Loyal - Respondents who are very highly satisfied, verywilling to recommend, and found the service to be morethan they expected. In-play - Respondents give inconsistent ratings--neitherhigh or low--to the summary questions. At-risk - Respondents who were dissatisfied, not willing torecommend, and found the service to be less thanexpected. National benchmarks for patient loyalty are taken from theNRC Health Care Market Guide. SSMHC uses the scoresof hospitals performing in NRC’s top 10% (best in class).

SSMHC inpatient loyalty increased from 47.5% in 1999 to50.0% in 2001, nearing NRC’s top 10% nationalbenchmark of 51.6% In 2000 and 2001, SSMHC rankedabove the national benchmarks for patient loyalty inemergency department services, outpatient surgery, andhome care.

7.1-8 & 7.1-9 Pain management and nurseresponsiveness are two key customer requirements forSSMHC patients in the inpatient care setting. Researchsupports the correlation of these key patient requirementswith patient loyalty. Data from patient satisfaction surveysshow high levels of patient satisfaction with painmanagement and nurse responsiveness for SSMHC. TheSSMHC internal benchmark (highest scoring hospital in2002) is 97.3% for Pain and 95.9% for Responsiveness.

7.1-10 First quarter 2001 Emergency Department (ED)Satisfaction results are the highest to date. The increaseis a result of entity-specific focus on the key patientrequirements of responsiveness and wait times. Forexample, two hospitals in the St. Louis region introduced aguarantee that all patients, regardless of the severity oftheir illness or injury, will be seen by a physician within 30minutes of their arrival in the ED. This 30-minuteguarantee has resulted in consistent improvement inpatient satisfaction at the entity and system level.SSMHC’s internal benchmark (highest scoring hospital in2002) is 97.9%. Our 2003 goal is to replicate these

40

'99 '00 '01 1Q02 '03 '04

% o

f Res

pons

es

Loyal

In-play

At risk

NRC Top10%

Best inSSMHC

SSMHCGoal

Goodé

Figure 7.1-7d

Home Care Satisfaction

1999 2000 2001 1Q02

% "

Yes

"

SSMHC

Best inSSMHC

Goodé

Figure 7.1-8

Staff Did All Possible to Control Pain

improvement efforts systemwide through best practicesharing and required benchmarking.

7.1-11 Good communication is another key patientrequirement. Inpatients, emergency, and outpatientsurgery patients are asked this question on thesatisfaction survey. This indicator demonstrates SSMHC’sability to maintain good hospital-based communication andpatient education across all patient segments. TheSSMHC internal comparisons (highest scoring hospitals in2002) average 99% for inpatient, 100% for the emergencydepartment, and 100% for outpatient surgery.Communication is also assessed for home care and longterm care patients using questions specific to the needs ofthese patient groups.

7.2 Financial and Market Results

As a result of its commitment to CQI, SSMHC was one ofonly a small number of health care systems across thecountry to be able to report a substantial financialimprovement, enabling the system to pursue continuedinvestment and growth opportunities.

7.2-1 For the fourth consecutive year, two of the majornational credit rating agencies have placed SSMHC in the“AA” credit rating category. The “AA” category is thehighest rating given to health care providers. Less than 2percent of all U.S hospitals and only 13% of those rated byS&P carry this exceptional rating. The rest are considerednon-investment grade (NIG). SSMHC was rated by bothFitch IBCA and Standard and Poor’s in early 2001 and hasmaintained its high rating in 2002. This strong positioning

has facilitated investing in facilities through access toinexpensive debt financing.

7.2-2 SSMHC’s core business is hospitals. In the lastfour years, SSMHC has approved increasing capitalinvestments in its institutions, facilities and services.SSMHC approved to spend $173 million in 2002 on severallarge capital projects to support the system’s strategicinitiatives. This includes improvements to add capacity forthe provision of product/service line enhancements incardiology in Oklahoma and Illinois and expanded medicaland intensive care in Wisconsin and St. Louis.

7.2-3 Operating margin for SSMHC, its nursing homesand home care are system level indicators. SSMHC usedits MEA process in a multi-year turnaround plan between1999-2001 that resulted in a $56 million dollarimprovement. The MEA process uncovered strategic andoperational improvements necessary to addressperformance shortfalls in 1999 resulting from capitatedmanaged care arrangements, high physician practiceacquisition & operational costs, and decliningreimbursement from Medicare. SSMHC processimprovements led to improved volume, decreasedphysician practice losses, enhanced reimbursement, andimproved operational efficiencies.

41

1999 2000 2001 1Q02

Per

cent

"Y

es"

Inpatient

Emergency

OP Surgery

Goodé

Figure 7.1-11

Were Adequate Directions Given About TakingMedications or Follow-up Care?

1999 2000 2001 2002

Milli

ons

Goodé

Figure 7.2-2

Approved Capital Investment

1%

4% 4%

90%

"AA" * "A" "BBB" NIG* SSMHC

% o

f Hos

pita

ls

U.S.Hospitals

Goodé

Figure 7.2-1

Not-for-Profit Health Care Ratings

'99'00

'011Q02

Plan02Plan03

Plan04

% O

pera

ting

Mar

gin SSMHC

Composite"AA"

CHS Top25%

Goodé

Figure 7.2-3

Overall Operating Margin Percentage

7.2-4 Revenue and expense per adjusted patient day(APD) is an indicator of patient service volume and is a predictor of operating margin. As a result of CQI andprocess improvements related to revenue enhancementand expense reduction, SSMHC began exiting unprofitableinsurance contracts and renegotiating with key payors. Inaddition, SSMHC’s public advocacy efforts influenced anincrease in Medicare reimbursement (BIPA). Theseinitiatives led to the overall improvement in revenue perpatient day in 2000 and 2001. Labor-related expensesrepresent over 50% of our operating costs andcompensation has increased 4% to 6% annually for manyyears. Despite this financial pressure, SSMHC haseffectively managed the revenue/cost implications ofproviding health care to its patients.

7.2-5 The home care industry has gone throughtremendous consolidation and reimbursement changes inthe last few years. In addition to changes in the industry,SSM Home Care underwent a change from decentralized,hospital-owned agencies to a centrally managed structure.SSM Home Care also changed clinical and patientfinancial information systems during this same time periodand recorded significant accounts receivable reserveadjustments during the latter part of 2001. Operationalissues which led to this adjustment have been correctedand SSM Home Care has returned to a strong financialposition through the 1st quarter of 2002.

7.2-6 Net revenue per physician is a system levelproductivity indicator. SSMHC works in partnership withits physicians to effectively deliver health care services. As such, it has restructured many of its physiciancompensation agreements to be productivity based, andhas assisted physicians in increasing net revenue andreducing expenses at the practice level through accountsreceivable improvements resulting from billing cycle timeenhancements.

7.2-7 Physician practice direct operating costs as apercent of net revenue is a system level efficiencyindicator. SSMHC assists its employed physicians withpractice management strategies to reduce direct operatingcosts to improve efficiency. Initiatives include restructuredgroup purchasing arrangements to reduce supply costsand consolidation of physician practice locations to reduceoverhead expenses. SSMHC’s performance stretch goal isto reach the top 25th percentile of MGMA, which iscurrently at 58.6%.

42

1999 2000 2001 1Q02

Dol

lars

OperatingRevenue/APD

OperatingExpense/APD

Figure 7.2-4

Operating Revenue and Expense per APD

2001 1Q02

$ T

hous

ands

SSMHCTop 25thPercentileMGMA

Goodé

Figure 7.2-6

Monthly Net Revenue Per Physician

2001 1Q02

% o

f Net

Rev

enue SSMHC

Top 25thPercentileMGMA

Goodê

Figure 7.2-7

Physician Practice Direct Operating Costs

1999 2000 2001 1Q02

% O

pera

ting

Mar

gin

SSM HomeCare

Benchmark

Goodé

Figure 7.2-5

SSM Home Care Operating Margin Percentage

1999 2000 2001 1Q02

Day

s

SSMHC

Composite"AA"

CHS Top25%

Goodé

Figure 7.2-8

Days Cash on Hand

7.2-8 SSMHC has maintained an average of 211 dayscash on hand while increasing capital spending throughoutthe system. The reliance on government payors greatlyreduces SSMHC’s ability to effectively manage the timingof payments. The reduction of 9 days in accountsreceivable in 2001 represents $36 million in additionalcash on hand. Not-for-profit health care providers aredependent upon their own financial outcomes to fund theircapital needs since the stock markets are unavailable tothem. SSMHC is the industry benchmark for AA-ratedhealth systems.

7.2-9 SSMHC-St. Louis is the fastest growing network inSt. Louis, with a market share of 18%. Dischargesjumped 13% in 2001 which also marked the fourthconsecutive year of growth for the network. These resultsare largely attributable to the effective use of PhysicianPartnering, resulting in an increase in total discharges.

7.2-10 SSMHC-WI has the top market share in its15-county service area due to growth in discharges for thefourth straight year. Market share in 2001 was 19.2%, upfrom 18.5%. In its primary service area of Dane County, St.Marys has a 35.5% market share. In Sauk County, St.Clare’s primary service area, the hospital has a 50.0%market share. SSMHC-WI is well-positioned to continueas the market leader. The network’s successful physicianpartnerships are clearly demonstrated by a strongphysician and rural hospital referral network.

43

14%

16%17%

18%

1998 1999 2000 2001

% M

arke

t Sha

re

Goodé

Figure 7.2-9

Inpatient Market Share

26%

19% 17%

10% 9% 8% 7% 5%

IntegrisOU Med. Center

SSMHC-OKMercy

NormanMidwest City

DeaconessOther

Source: Oklahoma Hospital Association

Mar

ket S

hare

199920002001

Goodé

Figure 7.2-11

SSMHC-OK Competitive Position

1998 1999 2000 2001

Tot

al D

isch

arge

s (0

00s)

Goodé

Figure 7.2-11

Oklahoma Discharges

14% 14%

16%

17%

1998 1999 2000 2001

% M

arke

t Sha

re

Goodé

Figure 7.2-11

Inpatient Market Share

19%14% 13%

8%

46%

SSMHC-WIMeriter

U.W.Mercy

Other

Source: WI Bureau of Health Care Info.

Mar

ket S

hare

199920002001

Goodé

Figure 7.2-10

SSMHC-WI Competitive Position

1998 1999 2000 2001

Tot

al D

isch

arge

s (0

00s)

Goodé

Figure 7.2-10

Wisconsin Discharges

18%18%19%

19%

19981999

20002001

18%

20%

% M

arke

t Sha

re

Goodé

Figure 7.2-10

Inpatient Market Share

29%

18%

11%7%

10%

24%

BJCSSMHC STL

TenetSt. John's Mercy

St. Anthony'sOther

* Interim HIDI data release

Mar

ket S

hare

199920002001*

Goodé

Figure 7.2-9

SSMHC St. Louis Competitive Position

1998 1999 2000 2001

Tot

al D

isch

arge

s (0

00s)

Goodé

Figrue 7.2-9

St. Louis Discharges

7.2-11 SSMHC of Oklahoma’s successful use of thePhysician Partnership Process has facilitated St.Anthony’s recruitment of oncologists and orthopedicsurgeons from competitors. In addition, sustainedimplementation of SFPP growth initiatives andrestructuring of key contracts have resulted in 4 straightyears of increasing discharges leading to market sharegrowth.

7.3 Staff and Work System Results

Employee satisfaction is a system level indicator.SSMHC strives to be the employer of choice to ensureemployee satisfaction and well-being and is one of only 49hospitals across the country to be named by AHA as anexemplary employer. SSMHC has analyzed the drivers toemployee satisfaction and the data indicate that the workitself, teamwork, the role of managers, opportunities foradvancement/growth and work-life balance are primaryfactors contributing to employee satisfaction. The ability tosegment the employee data and stratify by function,department or national origin allows us the flexibility toprovide more in-depth analysis to identify improvementsneeded in any of these critical drivers of satisfaction anddissatisfaction.

7.3-1 Employee satisfaction is extremely important inrecruitment and retention efforts. Systemwide focusgroups, since 1997, have provided feedback to promptchanges in areas such as employee benefits. In 2000 thetotal average system score was 71%, comparing favorablyto the IRI average of 64% and best in class at 74%. Focusgroups were done every 18 months with interim progressevaluations to assess the effectiveness of the action plansgenerated from the focus group information. SSMHC

recognized the importance of stratification of data and theability to review data by employee populations, thusprompting a change away from the focus groups to awritten survey with a new surveying vendor in 2001. Due tothe vendor change, pilot results are shown for one hospital;entire system results are expected in summer of 2002.Results can be stratified by function, department,ethnicity, tenure, gender and employee classification.SSMHC goal for 2004 at 75.8% is well above the 69%national normative data.

7.3-2 Employee education plays an important role in ourability to deliver exceptional health care services, meetaccrediting agency criteria, maintain a safe workenvironment, enhance employee satisfaction, andcontinually develop employees. This graph representsinternal training hours by employees and excludes tuitionreimbursement hours/dollars sought outside SSMHC. Assuch, SSMHC’s training investment is significantly abovethe health care benchmark (18.7) provided by the 2002ASTD State of the Industry.

44

1999 2000 2002 2003 2004

% E

mpl

oyee

Sat

isfa

ctio

n SSMHC

IRI Avg.

IRI Best

Projected

Employee Satisfaction

18.7

40.8 44.8 45.1

1999 2000 2001 ASTD

Tra

inin

g H

ours

SSMHCASTD

Goodé

Figure 7.3-2

Total Training Hours Per Employee

Tot

al FT PT

Mgr

sA

dmin

RN

'sC

lin P

rof

Reh

abR

adF

inan

ceC

ardi

o

Whi

teB

lack

His

p.

% F

avor

able

HRSolutionsTop 25%

Goodé

Figure 7.3-1

2002 New Employee Satisfaction AssessmentPilot Hospital Results Overall Job Satisfaction

19992000

20011Q2002

AvgTop 25%

% T

urno

ver

SSMHCMSA

Goodê

Systemwide Turnover - All Employees

19992000

20011Q2002

AONEBNA

0%

5%

10%

15%

20%

25%

% T

urno

ver

RN'sBenchmarks

Goodê

Figure 7.3-3

Systemwide Turnover - RN

7.3-3 With a nationwide shortage of nurses and otherhealth care workers, retention of employees is critical forSSMHC. With the increased focus on retention in 2001,including changes to enhance the benefit package (tuitionreimbursement, legally domiciled adult coverage, LTCinsurance) and more focused efforts in recruitment,turnover decreased to 20%, which is close to the top 25%of reported turnover rates from Management ScienceAssociates (MSA). Annualizing the current turnover to date(5.05% as of April, 2002), SSMHC anticipates furtherimprovement in turnover by year end.Nursing Turnover: With the increasing shortage ofnurses, SSMHC has made special efforts to decrease RNturnover. These efforts include expanding the deploymentof Shared Accountability systemwide and development of aNursing Recruitment and Retention Team to addressnursing concerns that impact our ability to implementcurrent and future strategies. For example, the team isevaluating a centralized approach for the use of nursetechnology by SSMHC’s Nursing Informatics Team.SSMHC has successfully maintained lower reported RNturnover rates than benchmark comparisons. Annualizingthe current year-to-date turnover (3.45% as of April, 2002),SSMHC should also see a positive decline in turnoverresults by year end.

7.3-4 The occurrence of employee injuries resulting in lostwork time is a key measure of environment of care andsafety management processes and is critical to worksystem performance. Transitional duty programs havebeen implemented to reduce the number of lost timeclaims, resulting in less discomfort and disruption to theinjured worker while realizing reduced costs. Lost-timeinjury rates compare favorably to OSHA rates.

7.3-5 The frequency of workers’ compensation claims isanother key measure of environment of care and safetymanagement processes. Safety training and focusedpatient handling initiatives have been implemented toreduce the number of workers’ compensation claims.Systemwide data reflect improvement in work-relatedinjuries. Current performance compares favorably withrates for other health care organizations according to RiskAssist, Inc.

7.3-6 Back injuries are a primary area of risk in the healthcare environment. Focused patient lifting initiatives havebeen implemented to reduce the number of back injuries.Systemwide data show sustained performance whichcompares favorably to other health care organizations, asreported by Risk Assist, Inc.

7.3-7 SSMHC’s commitment to continuous qualityimprovement is supported by the requirement that eachemployee receive an introduction to CQI during theirorientation session. This requirement applies to all20,000+ employees to teach them how to innovate andachieve work system improvement. In addition, advancedCQI training is available for all administrative councilmembers and all employees who are involved in orinterested in team participation. This graph illustratescumulative employee training in advanced courses such asteam member, team leader, and team facilitator classes.In 1998 an automated systemwide tracking system wasimplemented to better monitor participation in CQI training.The data shows that advanced CQI coursework continuesto increase each year.

45

1999 2000 2001 2002

Rat

es p

er 1

00 F

TE

's

SSMHCOSHA

Goodê

Figure 7.3-4

Lost Time Injuries

1999 2000 2001

Inci

dent

s P

er 1

00 F

TE

s

SSMHCRiskAssist

Goodê

Figure 7.3-6

Back Incidents

1998 1999 2000 2001

# of

Em

p. T

rain

ed

Goodé

Figure 7.3-7

Advanced CQI Training

1999 2000 2001

Rat

es p

er 1

00 F

TE

's

SSMHCRiskAssist

Goodê

Figure 7.3-5

Workers Compensation Claims

7.3-8 Physicians are an essential partner in the delivery ofhealth care and in addressing and caring for patient needs.They also have a very influential role in directing a patientto a particular hospital. Physician satisfaction is a keysystem level indicator and is measured through an annualwritten survey. The SSMHC internal comparison (highestscoring hospital) in 2001 is 84.6%. According to theAARP the “best hospital in America” is NorthshoreUniversity Hospital in Manhasset, NY, with an overallsatisfaction score of 93%.

7.3-9 Key drivers of physician satisfaction include nursingand administrative responsiveness. Impact analysisindicates that addressing these primary influencing factorswill positively impact satisfaction ratings. As such,SSMHC is engaging in initiatives such as monitoring nursecall light response time and reducing agency use toincrease physician satisfaction with nursing. In addition,hospitals are increasing efforts to engage physicians inClinical Collaboratives and facility enhancement projects toproactively address administrative responsivenessconcerns.

7.3-10 SSMHC believes that education and training arekey essentials to employee demonstrated skills andcompetency. A strong emphasis is placed on continuoustraining and development for all employees. This includesjob-specific and industry training needs and assessments.Each spring, hospitals compile a summary report for theBoard of Directors which demonstrates the previous yearsemployee competency and satisfactory evaluations. Theresults are tabulated and used to assess, modify, andadjust training needs. Of the performance evaluationsreceived in 2001, 93% demonstrated competency andadequate training. Many of those not assessed as satisfactory received additional training and coaching orwere terminated. Bone and Joint Hospital provided theinternal benchmark for best overall percentage withinSSMHC.

7.3-11 In 1999, SSMHC began a Clinical Collaborativeseries to achieve rapid improvement in key clinical areasbased on evidenced-based medicine, study of internalimprovement efforts, and best practices identified inliterature resources. In early 2002, four Collaboratives with75 teams were in progress. All entities have participatedin at least one collaborative, with 80% of the teamsachieving their goals. This indicates progress in achievinginnovation in our work system design. Comparatively, theInstitute for Healthcare Improvement's Breakthrough SeriesCollaboratives show approximately 65% of their teamsreach their goals. Teams participating in the SSMHCClinical Collaboratives accelerate patient careimprovements and improve outcomes by working together.For SSMHC, this creates a network of experts on specificclinical topics that serve as valuable resources for thesystem. Participating physicians and employeesrecognize these collaborative efforts as a unique benefit of

46

1998 1999 2000 2001

% "

Yes

"

Pt Care

Non PtCare

Goodé

Figure 7.3-9b

Administration Responsive to Needs

1999 2000 2001

% "

Yes

"

Goodé

Figure 7.3-9a

Nursing Response to Pat. in Reasonable Time

14

43

6675

1999 2000 2001 1Q02

Num

ber o

f Tea

ms

Goodé

Figure 7.3-11

Clinical Collaborative Participation

1999 2000 2001

Eva

ls R

ecei

ved

% S

atis

fact

ory

SSMHC

Best InSSMHC

Goodé

Figure 7.3-10

Training EffectivenessEmployee-Demonstrated Competency and Skills

19992000

20012002

20032004

% S

atis

fact

ion SSMHC

Best in SSMHC

Best in U.S.

SSMHC GoalGoodé

Figure 7.3-8

SSMHC Medical Staff Satisfaction SurveyOverall Satisfaction with Hospital

being part of SSM Health Care. The collaboratives arecontinuously open to new teams joining. SSMHC is theforefront of health care systems engaging in clinicalcollaboratives in partnership with physicians to facilitateimprovements in health care delivery and to improve healthcare outcomes.

7.3-12 SSMHC has achieved a 26.7% increase in minorityrepresentation in management and professional positionsin the past 5 years. This demonstrates results of thesystem's focus on increasing workforce diversity.Minorities in professional and managerial positionsincreased from 7.9% to 9.2% from 1997 to 2001.These results are better than the health care industrybenchmark of 2% and moving positively toward theNational Benchmark of 13.2%

7.4 Organizational Effectiveness Results

7.4-1 From 1998 to annualized 2002, acute admissions, asystem level indicator, has grown 32%. SSMHCexperienced a growth in admissions in 2001 largely due toincreases in ED volume and service utilization. Thissignificant increase in inpatient and outpatient utilizationdrove part of the financial turnaround in 2000 and 2001 asSSMHC was able to cover fixed costs more effectively.This trend has continued into the first quarter 2002.SSMHC’s admission growth on an annual basis has beengreater than the top 25% of performers from HBSI.

7.4-2 Average acute length of stay (ALOS), a hospital,network and operations performance indicator, hasremained consistently below the comparison data for theaverage of the top 26 not-for-profit hospital systems. ALOSis important since most payors reimbursehospitals/providers on a per case (per admission) basis,not per day. Reducing the length of stay reducesexpenses per case/admission and positively influencesoperating margin. The “best in class” is provided by KaiserPermanente.

7.4-3 Despite significant growth in volume, SSMHC hasengaged in a disciplined approach to staffing and, as aresult, has been able to successfully manage paid hoursper adjusted patient day at a slower rate of increase thanthe increase in patient volume. This has resulted inefficiencies in staffing while accommodating volume growthwithout compromising patient care. Productivity ismanaged daily at SSMHC at the department level to betterpredict and anticipate volume changes which impactstaffing needs. Improved daily management resulting frommore stringent monitoring has contributed to SSMHC’sability to manage this critical component of expensemanagement.

47

1999 2000 2001 1Q02

Pai

d hr

s pe

r Adj

. Pat

. Day

SSMHC

CHS top 25 %

Goodê

Figure 7.4-3

Paid Hrs Per Adjusted Patient Day

1999 2000 2001

Num

ber

of D

ays SSMHC

NFPHospitalsBest inClass-Kaiser

Goodê

Figure 7.4-2

Average Acute Length of Stay

7.9% 8.2% 8.4% 8.8% 9.2%

19971998

19992000

2001

% M

inor

ity

SSMHC

NationalBenchmark

HealthCare

Benchmark Goodé

Figure 7.3-12

Percentage of Minorities in Professionaland Managerial Positions

7.4-4 The satisfaction survey for outpatients wasimplemented in October 2001. Total outpatient visit time isa component of overall wait time, which is a keyrequirement of outpatients. Wait times has been validatedthrough research to positively influence patientsatisfaction. While the length of a visit is clearly impactedby many factors, SSMHC designs its processes to be asefficient as possible in completing the primary care ortreatment for which the visit was scheduled.

7.4-5 In response to physician satisfaction survey results,SSMHC radiology departments have initiated efforts toreduce turnaround time (patient check-in to report release)for mammogram reports. The pilot hospitals of this project,St. Joseph Health Center in St. Charles and St. JosephHospital-West, Lake St. Louis, MO were able to reduceturnaround time from more than four days to just over theirgoal of one day by changing a computer interface and thereport release process when waiting for comparative films.

7.4-6 Physician connectivity is an important element inimproving the timeliness of diagnostic test results reporting

and in fostering loyalty with our physicians. SSM Connectenables more effective and timely communication withphysicians using internet, pager, fax, or PDA’s, based oneach physician’s preference. Physician input is routinelysought regarding enhancements or new solutions.Connected physicians allow SSMHC to deploy informationregarding patient care more quickly, thereby satisfyingphysicians and enhancing process efficiencies.

7.4-7 SSMHC works collaboratively with suppliers toaddress key requirements of availability of inventory,invoice accuracy, and cost savings. Through thecooperation of Burrows, Allegiance, Cardinal and O&M,SSMHC has been able to keep an increasing demand forinventory available in the warehouse for nearly on-demandshipment. The internal benchmark is 98%.

7.4-8 Through continued cooperation between SSMHCand its vendors, SSMHC has been able to decrease theinvoice error rate by adhering to strict standards withrespect to the placement and filling of orders.

48

1999 2000 2001

Dol

lars

(Mill

ions

)

Goodé

Figure 7.4-9

Purchasing Savings from Premier

J F M A M J J A S O N D

Invo

ice

Err

or R

ate

(%) 1999

2000

2001

Goodê

Figure 7.4-8

Fischer Invoice Error Rate

Q1 Q2 Q3 Q4

% F

ill R

ate

Burrows

Allegiance

O&M

Cardinal

Benchmark

Goodé

Figure 7.4-7

Availability of Inventory

12/9903/00

06/0009/00

12/0003/01

06/0109/01

12/0103/02

No.

of P

hysi

cian

s

Actual

Goal

Projection

Goodé

Figure 7.4-6

IDN/Connected Physicians

1-01 6-01 12-01 3-02 4-02

Hou

rs

SJHC

SJH-West

GoalGoodê

Figure 7.4-5

Average Mammogram Reporting TurnaroundSt. Joseph Health Center, St. Joseph Hospital-West

2Q01 3Q01 4Q01 1Q02

Hou

rs

Lab

Radiology

Endoscopy

Goodê

Figure 7.4-4

Total Outpatient Visit Time

7.4-9 SSMHC has achieved significant savings through itsaffiliation with Premier. Premier is a Group PurchasingOrganization (GPO), which provides access topre-negotiated discount arrangements with distributors andsupply vendors. Through aggressively negotiatedcontracts, SSMHC and Premier have been able toincrease the standardized use of key purchased items,which, in turn, channels volume and decreases cost perunit and increases cost savings.

7.4-10 The key requirement of SSMHC by its keysuppliers is fast payment of invoices, as reflected by dayssales outstanding. This graph demonstrates the measureused to track the key requirement of fast payment forSSMHC’s four top suppliers. The performance goal isbased on payment terms of the contract (30 days or less).Prompt payment (paying more frequently) gives SSMHCaccess to discounted rates, which benefits SSMHC byreducing total costs. This also helps the vendor byreducing its administrative costs by lowering accountsreceivable (days sales outstanding). Scorecards reflectcurrent benchmarks.

7.4-11 SSMHC’s internal auditor, Catholic Health AuditNetwork (CHAN), helps SSMHC generate significant costsavings and revenue enhancements. During the yearended June 30, 2001, CHAN identified potential revenueenhancements and cost savings in SSMHC’s keyoperational areas of focus including managed care,revenue charge capture, physician practice billing andother areas of operational improvement. Continuedrealization of savings will be recovered in the next 12 to 18months.

7.4-12 Employment applications received via the intranetstreamline the process internally by automaticallyprocessing applicants through our applicant trackingsystem. Applications submitted electronically haveincreased 500% since the second quarter of 2000.

7.4-13 Through a disciplined customer relationshipmanagement program and the IS Planning andManagement Process displayed in Figure 4.2-1, SSMHCassures that IS systems and infrastructure are keptup-to-date and provide a high level of reliability anddependability. In the 3rd quarter 2001, SSMHC’s networkperformance was severely impacted by viruses whichaffected many organizations’ information technologyoperations. These problems were corrected in the 4thquarter of 2001 and 1st quarter 2002 results reflect thetrend of increasing satisfaction. A key inprocessmeasurement of dependability is wide area networkavailability, which has an availability rate exceeding 99.5%since 1999.

49

1999 2000 2001 1Q02

% S

atis

fact

ion

Goodé

Figure 7.4-13

Customer Satisfaction - Information SystemsReliability and Dependability

Q1-00Q2-00

Q3-00Q4-00

Q1-01Q2-01

Q3-01Q4-01

Q1-02

% T

otal

Cla

ims

% ofTotal

Claims

Goal

Goodé

Figure 7.4-14

EDI Claim Transmission Volumes

2Q003Q00

4Q001Q01

2Q013Q01

4Q011Q02

% re

c'd

elec

troni

cally

Goodé

Figure 7.4-12

SSMHC Electronic Applicant Tracking

7.4-14 The SSMHC electronic claims vendor, SSI, wasinstalled in 1999 and 2000. Electronic transmission ofclaims speeds cash flow. Payors increasingly requireelectronic claim transmission to reduce their cost ofprocessing claims. However, some of our more complexmanaged care payors have recently reduced the number ofclaims which can be sent electronically by requiringincreasing numbers of rebills and attachments. SSMHCcontinues to work with key payors to identify alternativeways to transmit required information rapidly.

7.4-15 To improve rate of reimbursement which positivelyimpacts cash on hand, SSMHC improved the quality ofinformation sent to third-party payors. SSMHC installed anadvanced claim editing and transmission system. Thisgraph demonstrates the improved insurance cashcollections after SSI was implemented in 1999-2000. Aftera year of significant improvement in third party payments,the level of improvement has slowed. The next majorincrease will come after further EDI transactions (ClaimStatus Inquiry) are implemented late in 2002.

7.4-16 While the industry benchmarks have been rising onaverage, SSMHC’s net days in accounts receivable havebeen decreasing. A systemwide Revenue Cycle CQI teamhas been implementing process changes to achieve thisimprovement.

7.4-17 All SSMHC hospitals are JCAHO accredited andare surveyed every three years. This graph demonstratesthat the survey scores are above the JCAHO averagescore of all hospitals. SSMHC hospitals have consistentlyperformed better than the JCAHO average. In the 2000survey, the JCAHO recognized eight SSMHC hospitals forbest practices. SSMHC will be surveyed again in 2003.

7.4-18 Safety training and focused patient handlinginitiatives have been implemented to reduce the number ofOSHA reportable incidents. Reportable incident rateshave declined by more than 40% since 1999 and comparefavorably to OSHA hospital rates.

7.4-19 All SSMHC entities engage in activities to improvecommunity health and measure effectiveness of theirinitiatives. Since results are project-specific, these resultsrepresent one example of SSMHC’s Healthy Communitiesinitiatives. St. Marys Health Center in Jefferson City, MOdeveloped prenatal partnerships with three county healthdepartments beginning with Cole County in 1996, andMiller and Morgan Counties in 2000. Success is measured

50

Cole Miller Morgan

Tota

l # p

rena

tal v

isits

2000

2001

Goal

Goodé

Figure 7.4-19

SMHC-Jefferson City Tri-County OB PartnershipGoal: Increase prenatal assistance in tri-county area

1999 2000 2001

Rat

e P

er 1

00 F

TEs

SSMHCOSHA

Goodê

Figure 7.4-18

OSHA Reportable Incidents

1999 2000 2001 1Q02

# D

ays

Out

stan

ding

SSMHC

Composite"AA"

CHS Top25%

Goodê

Figure 7.4-16

Net Account Receivable Days

4Q991Q00

2Q003Q00

4Q001Q01

2Q013Q01

4Q011Q02

$Milli

ons

Goodé

Figure 7.4-15

Insurance Cash Collections

by increases in prenatal visits, indicating the counties'improved rate of prenatal care. In Cole County, the risk fornot receiving adequate prenatal care decreased from12.3% to 9.8% in 1999. Annual goals through 2003 havebeen established for each county.

7.4-20 Over 20,000 SSMHC physicians and staff arecommitted to participating in the healing ministry of JesusChrist, delivering health care services to our community,especially the economically, physically and sociallymarginalized. SSMHC provides a significant amount ofcharity care in order to improve the health of thecommunities it serves. SSMHC’s commitment isevidenced by a $29 million-dollar investment in theprovision of charity care. A minimum of 25% of netoperating margin ( before deductions) is spent annually oncharity care. No one in need is turned away from ourdoors.

51

1999 2000 2001 1Q02

Milli

ons

FormulaGoal

CharityCare

Provided

Figure 7.4-20

Charity Formula Goals & Charity Care Provided

GLOSSARY OF TERMS ANDABBREVIATIONS

360 Degree Evaluation - tool used to conduct individualperformance evaluations of executive leaders

AA Composite - combined ratings from top financial ratingagencies including S&P, Fitch, Moodys, top 25% ofCHIPs, and top 25% of CHS to form best in classcomparisons

AA system - an organization rated “AA” by bond-ratingagencies (AA is the highest rating for not-for-profit healthcare organizations)

AARP - American Association of Retired Persons

AC / Administrative Council - entity leadership groupcomposed of the entity president, vice presidents as wellas the controller and some directors from the operationalareas of each entity. Some entities call this body their“Leadership Team.”

ACHE - American College of Healthcare Executives

Acuity - severity of patient illness

AEA--Adjusted Equivalent Admissions, a growth indicatorof the full range of patient services, with an adjustment foracuity; It uses average gross revenue per acute admission,adjusted by the acute Case Mix Index (CMI) to convertnonacute and outpatient services into acute inpatientequivalent units.

AES - Achieving Exceptional Safety

AONE - American Organization of Nurse Executives

APS - Enhancing Patient Safety

APD--Adjusted Patient Days, a measure of patient servicevolume; It uses average gross revenue per acute inpatientday to convert nonacute and outpatient services revenueinto units equivalent to acute patient days.

Acute care--services provided to inpatients of a hospitalunit certified and licensed by state and/or federalregulatory agencies to provide diagnostic and nursingservices to patients, based on the orders of the patients’physicians, during an acute episode of illness.

Advisory Board - group of community representatives thatassist SSMHC entities in an advisory capacity. Eachentity has such a group although a few may be called by adifferent name.

AHA - American Hospital Association

ALOS / Average Length of Stay - average number of dayspatients are in the hospital; ALOS is used to analyzepopulations of patients with common characteristics.

Ambulatory Services / Care - care or service rendered inan outpatient setting without an overnight stay; not aninpatient

ASTD- American Society of Training & Development

Behavioral Medicine - psychiatric, mental health, chemicaldependency, mental retardation, developmentaldisabilities, and cognitive rehabilitation services

Board of Directors - parent board of SSM Health Care

BJH - Bone & Joint Hospital, Oklahoma City, OK, amember of SSMHC

BNDD - Bureau of Narcotics and Dangerous Drugs

CGCH - SSM Cardinal Glennon Children’s Hospital, St.Louis, MO, a member of SSMHC

Caliper Profiles - tools to assess personalitycharacteristics of potential managers

Campus - grouping of all SSMHC services and sitesassociated with an acute care entity

Capital Allocation Council - SSM Committee thatprioritizes projects based on strategic and financial benefitto the system as a whole

CAG - SSM Information Center’s ComplianceAdministrative Group which is responsible for systemconfidentiality, privacy and security

Capital Planning and Allocation Process (CAP) - thesystemwide process by which SSMHC entities submitproposals for funding of capital projects costing more than$500,000

CARE PATHWAYS ® - practice guidelines; descriptivetools for care of the typical individual in the typicalsituation, developed through a formal process thatincorporates the best scientific evidence of effectivenessand expert opinion

CARF- Commission on Accreditation of RehabilitationFacilities

Case Management - coordination of patient care tofacilitate the timely delivery of appropriate services in themost effective manner

Case Mix Index - the comparison of a hospital’s cost forits type of patients to the national or regional averagehospital cost for a similar type of patient

CDC - Centers for Disease Control

CHAN - Catholic Healthcare Audit Network

CHF - Congestive Heart Failure

CHIPS - Center for Healthcare Industry PerformanceStudies

CHS - Catholic Healthcare Systems ratio analysis fromArthur Andersen, LLP

Clinical Collaboratives--a series of teams, based on theNational Institute for Healthcare Improvement (IHI)Breakthrough Series, that SSMHC has established tomake breakthrough improvements in clinical areas

CMS - Centers for Medicare and Medicaid Services

COBRA - Consolidated Omnibus Budget ReconciliationAct of 1985.

Continuum of Care - matching an individual's ongoingneeds with the appropriate level and type of medical,psychological, health or social care or service within anorganization or across multiple organizations; careprovided over an extended time, in various settings,spanning the illness-wellness continuum

COO - Chief Operating Officer

CPAF - Capital Project Application Form

CQI / Continuous Quality Improvement - a managementtool used throughout SSMHC to involve all employees inmonitoring, managing and improving processes andoutcomes

CRC - Client Response Center

CRP - Corporate Responsibility Process, a systemwideSSMHC process to manage regulatory, legal and ethicalcompliance

Dean Health System - Physician joint venture partner inSSM Healthcare of Wisconsin

Di-Diver/Web-Diver - Software system that providesdetailed segmentation of patient satisfaction data

DPHC - SSM DePaul Health Center, Bridgeton, MO, amember of SSMHC

DRG / Diagnostic-Related Group - a classification forpatients based on diagnosis, length of hospital stay andtherapy received; Adopted by Medicare as a mechanismfor paying hospitals, changing from a cost-based,retrospective-reimbursement system to a prospectivepayment system giving hospitals a financial incentive forreducing health care costs

DSO - Days Sales Outstanding

EAP/Employee Assistance Program - programs thatprovide counseling, alcohol and substance abuse andoften mental health services to employees

ED - emergency department, sometimes called “ER”

EEOC - Equal Employment Opportunity Commission

EIT - Entity Implementation Team

Employee Council - a council made up of a variety ofemployee representatives who investigate and address awide range of issues

Entity - an operating unit within SSM Health Care; Mayrefer to an individual hospital, nursing home, etc.

ePMI - Electronic Performance Monitoring Improvement

EPA - Environmental Protection Agency

ERP - Enterprise-wide Resource Planning to analyzeSSMHC’s business practices and requirementsassociated with finance, materials management, andHR/payroll operations

Executive leader - SSMHC employee who is a member ofSystem Management, the Innsbrook Group, networkleadership, entity administrative council, or is a corporatevice president

FDA - Food and Drug Administration

Fee-for-Service - an insurance plan that reimburses thehospital based on total billed charges with or withoutpercentage discounts (see also Indemnity Plans).

FMEA - Failure Mode and Effect Analysis. Analyticalprocess in which potential problems are identified andevaluated for severity so that design modifications can bemade.

FSM - Franciscan Sisters of Mary congregational initials

FTE / Full-Time Equivalent - the amount of time worked bythe combined full- and part-time staff, divided by the timeworked by a full-time employee (40 hours)

GSRHC - Good Samaritan Regional Health Center, Mt.Vernon, IL, a member of SSMHC

HBOC - Patient-level software system providing clinical,financial and decision support information

HBSI - Healthcare Benchmarking Systems International.Provides external operational and clinical data used to

benchmark departmental operations and isolate

performance improvement opportunities.

HIPAA - Health Insurance Portability and AccountabilityAct of 1996

HCAB - Health Care Advisory Board

HCFA - Health Care Finance Administration

HCMG - National Research Corporation’s Health CareMarket Guide is a comparative database containingconsumer-reported assessments of hospitals, healthsystems and health plans representing data on more than2,500 hospitals and 600 health plans.

HMO / Health Maintenance Organization - managed carebusiness that organizes health care services for itsmembers. HMOs have three distinct features: (1) they useprimary care providers to coordinate patient care; (2) theyhave specific providers and facilities members must use;and (3) they have a fixed fee structures

HR Solutions Survey - annual SSM employee satisfactionsurvey

HME/IV- Home medical equipment/intravenous

Healthy Communities - an SSMHC systemwide initiative toimprove the health of people who live in the communitiesserved by SSMHC entities. Each entity has at least oneHealthy Communities project.

Home Health Care - refers to services provided to patientsin their own homes.

IHI - National Institute for Healthcare Improvement

IMC - Information Management Council

Indemnity Insurance Plans - an insurance plan that paysfor the cost of services after the services have been given,as long as the service is in the benefit package. See alsoFee-for-service.

Innsbrook Group - a leadership group within SSMHCconsisting of the members of System Management, allhospital presidents, plus representative physician

organization, network, home care, and informationsystems executives.

Inpatient (IP) - inpatient acute services, in a suitablyequipped setting to provide services to persons whorequire 24-hour care (overnight) treatment or rehabilitation

International Benchmarking Clearinghouse - a division ofthe American Productivity & Quality Center (APQC) whichprovides information on benchmarking, knowledgemanagement, measurement, customer satisfaction,productivity and quality

IRI- a management consulting firm specializing in humanresources, customer satisfaction and labor relations ISM - Information Services Manager

JCAHO / Joint Commission on Accreditation of HealthcareOrganizations; an independent, not-for-profit nationalorganization dedicated to improving the quality of care inorganized health care settings. Major functions includedeveloping accreditation standards, awarding accreditationdecisions, and providing education and consultation. Alsocalled “Joint Commission.”

JOA - joint operating agreement

KPMG - SSMHC’s auditor

LANS - local area network of information systems

LDA - Legally Domiciled Adult

LLA - Lipid Lowering Agent

LOS - Length of Stay; the number of days a patient is inthe hospital.

LTC - Long Term Care

Managed Care - an organized system of heath careservices characterized by a primary care provider thatmanages and coordinates the patient's access to services;the doctor's approval prior to admitting a patient to thehospital or performing a surgical procedure is frequentlyrequired.

MAR - Medication Administration Record

MAT - Mission Awareness Team

MCO - Managed Care Organization

MEA - Ministry Effectiveness Analysis; Process used bySSMHC to evaluate market potential and makeimprovements

Medical Staff - a body that has overall responsibility for thequality of the professional services provided by individualswith clinical privileges and responsibility of accounting tothe governing body. The medical staff includes fullylicensed physicians and may include other licensedindividuals permitted by law and by the organization toprovide patient care independently (without clinicaldirection or supervision within the hospital). Members havedelineated clinical privileges that allow them to providecare within the scope of their clinical privileges.

MGMA- Medical Group Management Association

MHA - Maryland Hospital Association; Group whichmaintains a national comparative database of health careoutcomes representing more than 1,000 hospitals as partof its QI Project. SSMHC uses the top 25% forbenchmarking.Mission Think Tank - SSMHC employees andentity/network mission awareness representatives thatprovide input on mission and values deploymentthroughout SSMHC.

MTI - A master trust indenture (“MTI”) is the legal platformfor coordinating external borrowing, primarily the proceedsfor tax exempt revenue bonds. The MTIprovides (i) a mechanism for linking separate organizationsinto a single credit, (ii) a uniform set of covenants to whichall participants will adhere, and (iii) a structure for reportingresults to the external creditors.

Mortality Rate - measures the death rate based on paststatistical measures. Mortality is usually measured by sexor age, among other factors.

MSA - Management Science Associates, an organizationthat monitors health care compensation and othernumerics for over 370 organizations and 733,500employees. Multidisciplinary Team - a group of clinical staff memberscomposed of representatives of a range of professions,disciplines or services areas.

Network - grouping of SSMHC entities within a community

Network Leadership - Network president/CEO and his/herdirect reports

NRC -Nuclear Regulatory Commission

NRC - National Research Corporation

OIG - Office of the Inspector General

OP / Outpatient - program that provides services topersons who generally do not need the level of care

associated with the more structured environment of aninpatient or residential program

Operations Council - subset of System Managementsenior leaders who review and address the system’soperational performance

Operations Performance Indicators--a set of 49systemwide performance indicators for hospitals that arerolled up for review by SSMHC’s Operations Council.Home Health, Long-term Care and the Physician Practicesalso each have a set of operations performance indicators.These indicators are aggregated into the PerformanceIndicator Report, a color coded report.

OSHA - Occupational Safety & Health Act

Passport - a card carried by SSMHC employees thatincludes the mission and values of SSMHC and otherinformation to provide “line of sight” from personal goals toorganizational goalsPayors - third parties who make all or partial payment ofcharges on behalf of the patient. Includes indemnity plans,HMOs, PPOs, Medicare, Medicaid, Champus, etc.

PDA - Personal Digital Assistant (handheld device)

PDCA - Plan, Do, Check, Act; a cycle for monitoring andimproving processes, functions and outcomes. Sometimes called Plan, Do, Study, Act (PDSA)

PI - performance improvement

PIR - Performance Indicator Report containing keyperformance indicators; also known as the PI Report, PIRand Stoplight Report

Physician--a person legally qualified to practice medicine.

Physician Portal - access to reliable, updated medicalinformation

PO - Physician Organization

PPC - Post Process Change

PPO / Preferred Provider Organization - a health plan thatgives patients lower rates if they use physicians in thepreferred group of providers. Patients may still use doctorsoutside that list, but usually pay more to do so.

PRC - Professional Research Consultants

Premier - the nation’s largest group purchasingorganization

Premier Insurance Company - one of Wisconsin’s largestHMOs, in which SSMHC owns an interest

Preservation of the Earth Committee - SSMHC entitieshave a committee of employees devoted to environmentalprotection

Primary Care Providers - physicians who practice in theareas of pediatrics, family practice, internal medicine whotreat primary care needs of patients.

PRN - As needed

PTO/EMTO - Paid Time Off/Extended Medical Time Off

QI Project ® - External health care database provided bythe Maryland Hospital Association. Data are supplied byindividual facilities and aggregated by the QI Project.Aggregate QI Project data represent the averages of allrates and are intended for the internal use of Projectparticipants.

QRC / Quality Resource Center - department located atSSMC's Corporate Office providing support to entitiesthroughout the system

Readmission - patient returns to the hospital within 31days, for the same or related condition as previousadmission.

Regional Board - the Board of Directors responsible forreviewing medical staff credentialing and quality reviewactivities. A Board of Directors may be responsible for anIndividual entity, or a group of entities within a geographicarea

REMEDY - complaint tracking software

RN - registered nurse

SAPP-Define - SSMHC Intranet based application thatincludes Standard Accounting Policies and Procedures

SAH - St. Anthony Hospital, Oklahoma City, OK, amember of SSMHC

S&P - Standard & Poors Index

SAP--cutting edge software selected by SSMHC for itsEnterprise Resource Planning (ERP) project. SAP integrates finance, materials management and HR/Payrollinformation systems to provide real-time access andsharing of data across the organization

SCH - St. Clare Hospital and Health Services, Baraboo,WI, a member of SSMHC

SFHHC - St. Francis Hospital & Health Center, BlueIsland, IL, a member of SSMHC

SFHHS- St. Francis Hospital & Health Services, Maryville,MO, a member of SSMHC

SFP - Strategic, Financial and HR Plan

SFPP - Strategic, Financial and HR Planning Processused by SSMHC

Shared Accountability - an organizational structure thatgives nurses greater decision-making authority as part ofoverall accountability for nursing practice

Shared Governance - a model of Shared Accountability

SJHC/HW - SSM St. Joseph Health Center, St. Charles,MO, and SSM St. Joseph Hospital West, Lake SaintLouis, MO, members of SSMHC

SJHK - SSM St. Joseph Hospital of Kirkwood, Kirkwood,MO, a member of SSMHC

SMH - St. Michael Hospital, Oklahoma City, OK, amember of SSMHC

SMCC - St. Marys Care Center, Madison, WI, a memberof SSMHC

SMHC-JC - St. Marys Health Center, Jefferson City, MO, amember of SSMHC

Solucient - clinical information system

SMHC-STL - SSM St. Mary’s Health Center, St. Louis,MO, a member of SSMHC

SSMHC - SSM Health Care; also called “system”throughout this application

SSMIC - SSM Information Center

SSM Health Care St. Louis - network of SSMHC entities inthe greater St. Louis, Missouri metropolitan area

SSM Health Care of Oklahoma- network of SSMHCentities in the Oklahoma City area

SSM Health Care of Wisconsin - network of SSMHCentities in the southern Wisconsin area

SSM Policy Institute - an SSMHC 501(c)(4) organizationwhose mission is to enhance the public awareness ofthose matters relevant to the design and delivery of healthservices that provide best quality, access and overall bestpractices. Also, to work toward improving communityhealth status in a variety of venues.

SWOT - Strengths, Weaknesses, Opportunities andThreats

System Management - a group of 11 senior leaders thatprovides direction to entity and network leaders throughoutSSMHC

System Level Indicators - a set of 16 performancemeasures selected by SSMHC to be reviewed systemwideand by System Management & the Operations Council

VMSNF - Villa Marie Skilled Nursing Facility, JeffersonCity, MO, a member of SSMHC

WANS- wide area network information system

WAHSA - Wisconsin Association of Homes and Servicesfor the Aging

WIITTS - Wisconsin regional integrated informationtechnology and telemedicine system