Accountability, One First Down at a Time- Leads to a ......Please do not quote or disseminate...

Copyright © 2015 Studer Group. Please do not quote or disseminate without Studer Group authorization

Accountability, One First Down at a Time-

Leads to a Winning Team!Michael Hansen, FACHE, President/CEO

Suszanne Deyke, MSN, RN, CEN Emergency Department Director

Sue Hrnicek, MSN, RN, Surgical Services Director

Chad Van Cleave, CFO

Columbus Community Hospital

Columbus, Nebraska


Our Stadium

Introduction


• Our Mission – is to improve the health of the

communities we serve

• Our Vision – is to deliver the states highest quality

patient care

• Values - ICARE

• Columbus Community Hospital | We are an Acute

Care Facility

3

Mission and Vision

CCH Fight Song


4


• Create the Right Environment

• Assume good intentions

• Be supportive

• Communicate openly – explain the WHY

• Be fair and consistent

* Goal – Build Trust

5

Looking Inward

1st and 10


• Skills Lab – AIDET®

• Engaging in EBP

• Communication Board – UBC

6

Validation

7

Emergency

Department

Communication

Board

Cleanliness /Quietness

Comm w/ NursesComm w/Providers

Discharge Info Overall Rating Pain Mgmt Recommend

Jul - Sep 2014N = 96

85 56 49 63 79 11 68

Oct - Dec 2014N = 101

72 72 62 32 87 50 76

Jan-Mar 2015N = 84

46 8 28 33 20 36 14

Apr-Jun 2015N = 99

80 31 14 60 34 68 40

Jul-Sep 2015N = 76

94 96 70 73 75 93 51

Oct-Dec 2015N = 99

98 78 61 49 72 61 67

Jan-Mar 2016N = 84

95 76 83 90 62 44 50

Apr-Jun 2016N = 26

98 99 89 84 92 84 81

0

10

20

30

40

50

60

70

80

90

100

Yardage obtained

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• Experienced leader gaining trust of staff and MD’s

• 25+ years experience and humility are not enough

• Differences between current practice and evidence

based/best practice

• Beginning a culture of accountability

• Mentoring your leadership team-it’s ok to fumble

9

Breaking into Leadership

2nd and 7


• Video of Dr. Kurt Kapels, Hospitalist

10

Rounding with Providers

3rd and 12


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• Encourage the heart and find their passion

• Successfully deliver the message

12

Punt or Go For it

4th and 1


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14

Leader Evaluation Manager® (LEM)

Like Offensive Coordinators, hospital Senior Leaders must

develop and execute a game plan to be successful.


• Key factors to achieve high performance

• Alignment

• Readiness for Change

• Fundamentals

• Self Awareness

• Consistency

• Accountability

15

LEM Organizational Goal Development


• Top Mistakes in Setting Goals

#1: Inappropriately assigning organization-wide goals to middle

managers.

#3: All leaders share the same weights for a goal, even when their

responsibilities don't affect the weights.

#6: Some leaders fail to accept responsibility for far-reaching

organizational goals they directly affect.

#8: Leaders tend to "cherry pick" the easiest goals to meet instead of the

most important.

Source: Top 10 Mistakes in Setting Hospital Goals By Bill Bielenda

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Studer Group provides the coaching and tools necessary to be successful

in goal development, implementation and accountability.


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• Process begins 60-90 days prior to fiscal year begin

• Involvement from all key stakeholders (e.g. clinical,

finance, compliance, physicians, Board Members)

• CCH focus for FY2017

60% Patient Satisfaction- 30% Inpatient (i.e. HCAHPS)

- 30% Outpatient (e.g. ER, Rehab, Lab, etc.)

20% Employee/Physician Satisfaction (biennial)

20% Finance - 10% Wages, Salaries and Benefits

- 10% Operating Margin

19

CCH Organizational Goal Development


• Focus on Inpatient and Outpatient Services with

highest volumes

• Goals scored based on percentile rankings using

the National Research Corporation (NRC) database

• Top box scores developed using 12-month rolling

averages

• Top box scores compared to a static percentile

ranking from prior year when entering into LEM

20

CCH Patient Satisfaction Goal Development


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• Scoring based upon LEM goal template offered through Studer Group


23

CCH Patient Satisfaction Goal Alignment

• Top box scores compared to a static percentile ranking from prior year


24

CCH Physician Satisfaction Goal Development


25

LEM Accountability Tools

• 90-day Action Plans

• Monthly Report Cards

• Monthly Meeting Model

• Validation Matrix


26

CCH 90-Day Goal Example


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CCH 90-Day Goal Example


28

CCH Validation Matrix Example


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CCH Validation Matrix Example


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CCH Validation Matrix Examples


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Patient Satisfaction Monitoring & Improvement

• On-demand reports from the NRC

• Breakdown of percentile ranking

• Drill down capabilities for patient comments


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• Real-time access to patient comments

• Recognize and reward staff

• Service recovery

• Development of 90-day action plans


34

Touchdown!


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Touchdown!

CCH Earns ‘Top Performer’ Recognition

for 5th Consecutive Year!

In November 2015, The Joint Commission announced that Columbus

Community Hospital (CCH) was again being recognized as a Top

Performer on Key Quality Measures®.

CCH was recognized for attaining and sustaining excellence in

accountability measure performance for the Surgical Care and

Immunization measure sets.

This is the fifth year we have been recognized as a Top Performer and CCH

is 1 of only 117 hospitals to achieve the Top Performer distinction for

five consecutive years. We know what matters most to patients is the

quality and safety of the care they receive.


36

Touchdown!


37

Touchdown!


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Touchdown!

Thank You!

Michael Hansen, FACHE, President/CEO

[email protected]

Suszanne Deyke, MSN, RN, CEN Emergency Department Director

[email protected]

Sue Hrnicek, MSN, RN, Surgical Services Director

[email protected]

Chad Van Cleave, CFO

[email protected]

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mailto:[email protected]




Accountability, One First Down at a Time- Leads to a ......Please do not quote or disseminate...

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