Organizational Performance Tracker

Simone Lampkin, MHA, CSSGB

Methodist Le Bonheur Healthcare

Simone Lampkin

No Conflicts of Interest

About Methodist Le Bonheur Healthcare

3

2017 Financial Statistics

Our promise is to improve every life we touch

Vision

Methodist Le Bonheur Healthcare will be nationally recognized for excellence in

clinical quality, patient safety, and compassionate care to improve every life

we touch.

Methodist Le Bonheur is a great place to be…

2015 - 2018

Working very hard to provide exceptional care

What you measure is

what you get.

But how do you know you’re measuring the right things?

7

2005

9

2010

14

2012

8

2013

3

2014

Number of Quality Goals:

At just 3 quality goals, we were clearly leaving some gaps.

And there were other challenges of our measurement model

1) Setting incremental goals based on historical performance was a slow path to excellence. Our goal is top decile by 2020.

2) Certain measures, like Early Elective Deliveries, while important, engaged only 3% of physicians. What were the other 97% working to improve?

3) With goals set for incremental improvement, a 20% improvement could still be below average. Who wants to receive care from an ‘average’ hospital?

Simply put, our Balanced Scorecard model for quality was inconsistent with our vision of top decile in all clinical measures of excellence.

We needed a clearer pathway to reach our 2020 Vision

Steps taken align practice and vision:

Now all important patient safety measures have top performance goals: - Ventilator-Associated Pneumonia - Length of Stay & Readmission O:E - Patient Safety Indicators - Surgical Site & Central Line Infections - C-Section Rates & Early Elective Delivery - Emergency Department Cycle Times - Cardiovascular Metrics (PCI, Statins) - Neurology Metrics (Thrombolytic Therapy) - Failure to Intervene (Sepsis Mortality) - Hospital-Acquired: c. Difficile and MRSA - Hospital-Acquired Pressure Ulcers

Then linked all measures to management incentives

Steps taken: Translate vision into benchmarked metrics

Step 2: Build a culture that expects excellence in ALL areas

Metrics are chunked by service line to ensure natural owners

Include all metrics that support the vision

While we published data on all of these metrics; the only benchmarking was from registries

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Step 3: Identify national benchmarks for every metric

Public Reporting Sites

National Registries

Leapfrog Best Practices

Observed:Expected Ratios STS/ACC Registries

Our solution: Organizational Performance Tracker (OPT)

The OPT has 2 components: 1) Actual monthly and YTD performance results 2) Points awarded based on comparison to benchmarks

Weighting applied to direct appropriate focus

METRICS Patient harm measures more heavily weighted than process measures

FACILITY SCORE Service Lines are weighted based on strategic growth plans

SYSTEM SCORE Facilities are weighted based on annual revenue

Senior leaders can now very quickly assess performance

Composite Quality Score (2018 Goal = Score of 115)

< Threshold of 100 115 or > Between 100 - 114

Performance against benchmarks are easily viewed

Leaders can quickly see where improvements

are most needed

Dynamic graphing feature shows trends – and eliminated monthly production of > 1000 static charts

Concerns were voiced – with significant emotion

Improvements have been seen in dozens of metrics

34.4% Reduction in catheter-associated urinary tract infections

41.0% Reduction in Left Without Being Seen in the ED

56.0% Reduction in surgical site infections for colon surgery

57.0% Reduction in hospital-acquired MRSA

63.0% Reduction in clostridium difficile infections

74.6% Reduction in surgical site infections for abdominal hysterectomy

77.5% Reduction in ventilator-associated pneumonia

Sources: Infection Prevention surveillance data improvements since 2016; ED real-time ED statistics (2015 to 2017)

In summary, steps for implementation included:

Total transparency, full visibility at all levels, and clear ownership of each indicator were keys to our success. The OPT is interactively displayed on large wall monitors in C-Suites, nursing units, and even public hallways.

Impact of the Organizational Performance Tracker

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Questions