Goals and Objectives for Fiscal Year 2014 · 2. New Care Models Admission Medication Reconciliation...
Transcript of Goals and Objectives for Fiscal Year 2014 · 2. New Care Models Admission Medication Reconciliation...
Goals and Objectives for
Fiscal Year 2014
1
Summary of Significant (Top 10) FY14 Goals
2
1. Spread of Care Coordination Model: Expand on pilot experience with refining team membership, improving team
communication and engaging patients and families.
2. Palliative Care: Improve nursing knowledge of and comfort with facilitating End of Life goal setting with patients and
families.
3. HCAHPS: The patient experience of care is publically reported and will become influential in reputational benchmarking.
UPMC is committed to achieving the highest levels of patient satisfaction.
4. Flow: A high level focus on the flow of patients through our organization assures access to the care we provide and
regularly demonstrates operational performance improvement opportunities.
5. Service Line Enhancement: Focus on developing key employed and private physician service lines to assure innovative
growth of necessary patient volumes.
6. Employee Engagement: Improve employee engagement through adoption of My Voice “TLC” paradigm and through the
utilization of the Just Culture survey.
7. Redesign and optimize physician documentation: Leverage our sophisticated eRecord to improve physician
satisfaction, prepare for ICD-10, improve depth of documentation to support quality and coding initiatives.
8. Implementation of Optum CAC and CDI: Leverage new technologies to optimize coding in support of quality and
revenue generation.
9. Implementation of board approved security enhancements: In response to the March 8, 2012, shooting at WPIC and
other events around the country, full deployment of recommended enhancements to hospital security is a priority.
10. Operational Efficiencies: Improve operational and financial efficiencies through georgraphic consolidation allowing
enabling projects for the eventual demolition of the former CHP and through partnering with Supply Chain on leveraging
system buying power on high volume, low cost items.
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Objective: Primary Care
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Virtual Group 1. Integrated Payer/
Provider Model
2. New Care Models
1. Pursue VG1 expansion of
physician base and usage
of APPs
2. Expand VG concept to
other practices
3. Review/align incentive
plans
4. Expand concept to other
payers
New model for primary care
for interested physician
groups
2. New Care Models
5. Access
Support enhanced access
through non-traditional office
hours; growth in outpatient
encounters; improved quality.
Create a master plan for
Bethel Park and West Mifflin
to allow for enhanced
primary care presence in
accordance with the South
Hills strategy
5. Access Create 'carepoint' portals for
UPMC in the South Hills that
both feed into surgery/
imaging, but also higher level
care in Oakland and uptown.
4
Objective: Ambulatory Care
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Front desk standardization
project
5. Access Improve patient experience
in HBCs
Explore opportunities for
enhanced infusion therapy in
the outpatient setting
1. Integrated Payer/ Provider
Model
Incorporate "Orthopedic
Specialists - UPMC" into
South Hills Surgery Center
5. Access
6. Diversified Revenue
Increased Surgical and
Imaging volumes
Grow Surgical Volumes at
South Hills Surgery Center
5. Access
6. Diversified Revenue
Greater utilization of existing
capacity, increased revenue,
etc.
5
Objective: Ambulatory Care
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Grow Surgical Volumes at
South Hills Surgery Center
5. Access
6. Diversified Revenue
Greater utilization of existing
capacity, increased revenue,
etc.
Grow Imaging Volume at
UPMC West Mifflin
5. Access
6. Diversified Revenue
Establish greater utilization of
existing capacity, increased
revenue, etc…
Explore Creation of Imaging
Center at South Hills Surgery
Center
5. Access
6. Diversified Revenue
Prevent patient leakage and
improve patient experience
as services grow at South
Hills Surgery Center.
Open Presbyterian
Prescription Shop
2. New Care Models
5. Access
6. Diversified Revenue
Demonstrate the ability to
capture employee and
patient prescriptions which
will enhance the patient
experience while developing
new revenue streams.
6
Objective: New Models of Care
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Spread Care Coordination
Model
2. New Care Models Complete roll out at
Presbyterian Campus.
Complete plan for
deployment at Shadyside
Campus.
Patient Mobility 2. New Care Models Implement patient mobility
project. Expected outcome
is to decrease LOS through
coordinating, refining, and
deploying mobility initiatives
at all PUH SHY units.
Fully deploy our Pharmacy
MEDS Program on both
campuses
2. New Care Models
Admission Medication
Reconciliation > 90%ile,
HCAHPS scores around
medications > 50th %ile and
discharge prescription
capture rate >20%
Achieve spread of nursing
face to face report and
rounding with physicians
2. New Care Models Enhance collaboration and
communication between care
providers.
7
Objective: New Models of Care
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Palliative Care: Expand end
of life training for nursing
2. New Care Models
4. Good Science
1. Achieving spread across
oncology units
2. Increased number of
consults to palliative care
Standardize Palliative Care
Social Work roles at
Campuses
2. New Care Models
4. Good Science
Complete Phase II Advanced
Research Study.
Complete Phase II Advanced
Research Study
2. New Care Models
4. Good Science
Increase patient involvement
in care through pain
medication self-
administration.
8
Objective: Clinical Service Line Management
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Further enhancements to
Cardiothoracic Service Line
through standardization
2. New Care Models
4. Good Science
1. Decrease ventilator times
2. Decrease CT ICU length
of stay
3. Maintain 3 star SDS
ranking
Develop program initiative for
Neurosurgical Service Line
5. Access
6. Diversified Revenue
1. Grow neurosurgical
volume at PUH SHY
2. Retain key surgeons
3. Develop young leaders
(Jankowitz, Sekula,
Richardson, Gardner,
Okonkwo, etc.)
Facilitate transitions of care
between Hillman Cancer
Center and UPMC
Shadyside
2. New Care Models
3. Smart Technology
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Objective: Clinical Service Line Management
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Optimize Clinical Labs
Building
3. Smart Technology
4. Good Science
7. Corporate Citizenship
Work with Spine VAT
Leaders to standardize on 4
Implant Providers
4. Good Science
7. Corporate Citizenship
Savings of >$600K plus
streamlined OR daily
operations
Develop model for pre-
authorization/patient billing of
specialty molecular/genomic
testing
3. Smart Technology
6. Diversified Revenue
Develop an electronic pre-op
questionnaire at SHY
3. Smart Technology
4. Good Science
Enhanced patient
satisfaction; decreased nurse
time spend on pre-op phone
calls
Achieve Magnet
Redesignation/submission of
Magnet redesignation
documents
4. Good Science Magnet redesignation
documents to be submitted
April 1, 2014
10
Objective: Physician Alignment
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Redesign and optimize
physician documentation
3. Smart Technology
6. Diversified Revenue
Complete design and deploy
Collaborate with Corporate
CVO to refine and deploy
Morrissey administrative
modules for appointment and
reappointment
3. Smart Technology Streamlined appointment and
reappointment processes
11
Objective: Ring Hospitals
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Transplant 8. Best-in-Class Governance 1. Maintain UNOS
administrative scorecard
results at 94% or > for all
UPMC adult transplant
programs
2. Maintain and/or improve
patient and graft survival
rates for all UPMC adult
transplant programs at
the expected outcomes
for the intervals of 1-
month, 1-year and 3-year
Pursue lab opportunities
specifically within anatomic
pathology
3. Smart Technology
6. Diversified Revenue
12
Objective: Financial and Operating Performance
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Achieve LOS Target FY14 budgeted LOS
Achieve Budgeted
Controllable Operating
Margin
7. Corporate Citizenship
Achieve Stage 2 Meaningful
Use objectives
3. Smart Technology Maintains UPMC's eligibility
to receive additional federal
incentive funds
7 South Tower Integration 7. Corporate Citizenship Finalize relocation plans
Complete phases 2 & 3 of
Radiology Renovation
3. Smart Technology
5. Access
7. Corporate Citizenship
1. Improved efficiency,
patient experience,
technology
2. Elimination of 5 short stay
unit, etc.
Complete Surgical Services
Renovation Project
7. Corporate Citizenship Increased room capacity, full
deployment of Responder 5,
Impress, etc.
13
Objective: Financial and Operating Performance
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
CSI - Operational Efficiencies
1. Decrease regulated
medical red bag waste
2. Implement reusable
sleeve project for SCDs
3. Expand equipment depot
to include critical care and
bariatric beds/supply
4. Reduction of linen misuse
8. Best-in-Class Governance 1. Decrease waste and
dollars spent and
efficiency of operations
2. Achieve related system
savings of $750,000
3. Achieve related system
savings of $1 million
4. Achieve linen expense
benchmarks
Increase use of recycling and
reprocessing of single use
items in SHY surgical
services
4. Good Science
7. Corporate Citizenship
Expense reduction
Complete TUG
implementation
3. Smart Technology 1. Completion of
Implementation for TUG
Linen - FY14 Q1
2. Completion of
implementation for TUG
trash collection - FY14
14
Objective: Financial and Operating Performance
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Implement badge readers at
PUH & SHY parking facilities
1. Standardization
2. Equipment upgrade
Implement trial of K9 security
service at PUH
Security enhancement
Implementation of board
approved security
enhancements
Security enhancement
Implementation of Optum
CAC and CDI
3. Smart Technology
6. Diversified Revenue
Complete the pharmacy
optimization project
7. Corporate Citizenship Close MUH pharmacy to
streamline operations with
calculated FTE savings
Create CV IT platform for
UPMC HVI
3. Smart Technology Continue partnership with
ISD to implement the CVIS
platform across all UPMC
facilities and CV modalities
15
Objective: Financial and Operating Performance
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Transition from use of white
board to electronic smart
board for patient flow in
PACU
3. Smart Technology 1. Improve communication
2. Improve workflow
Grow and expand
Neurodiagnostic Services at
Shadyside
3. Smart Technology
5. Access
Create a program
comparable to the
Presbyterian Campus, 24
hour EEG capability,
Outpatient services/revenue
Collection Manager 3. Smart Technology 1. Improve patient safety by
introducing positive
patient identification at
the point of care
2. Expand Collection
Manager to MUH ED,
PACU & Dialysis
3. Expand Collection
Manager to include SHY
ED and DAS and GI lab
16
Objective: Financial and Operating Performance
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Implement Rauland Borg
Nurse Call Spectralink
integration on applicable
units at SHY
3. Smart Technology
Increase ability to trend to
address and mitigate call bell
responses times
Assume responsibility for and
improve engagement with
local community groups
7. Corporate Citizenship Succession planning for
former VP of Community
Relations position
Observation Patients 2. New Care Models
6. Diversified Revenue
1. Decrease LOS
2. Decrease Utilization
3. Optimize Observation
Units
17
Objective: Clinical Quality and Safety
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
HCAHPS
1. Improve at least 75% of
HCAHPS domain scores
2. Improve environment of
Care scores
3. Expand Patient and
Family Advisory Council
(PFAC) to allow real-time
process for feedback to
associates and
physicians
1. Improvement in at least 6
of 8 domain scores
2. De-cluttering of rooms
with standardization of
receptacles.
Improvement of HCAHPS
related to noise and
environment
3. Monthly meetings with at
least 2 patient or family
attendees. Attendees
would be nominated by
the Unit Directors and
clinical leaders. Video
PFAC for staff educators
and vignettes for Infonet
1. Decrease serious events
and HACs, fall rates with
injuries, and hospital
acquired pressure ulcers
4. Good Science 1. Decrease serious events
and HACs
2. Achieve benchmarked fall
rate of < 4%
18
Objective: Clinical Quality and Safety
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Optimize STEMI Programs at
HVI Locations
2. New Care Models
4. Good Science
Partnership between
Interventional Cardiology,
Emergency Medicine and
EMS providers to enhance
"first medical contact to
intervention" throughout
UPMC Cardiology programs.
Achieve accreditation as
STEMI receiving center
Collaborate with Corporate
Quality and Analytics to
develop and Deploy
physician OPPE/FPPE tab in
Crimson
3. Smart Technology
7. Corporate Citizenship
Physician access for their
own data on regular
schedule
Implement reliable and
variable rounder model in
PUH ICUs
2. New Care Models Improved workflow and
increase patient satisfaction
related to responsiveness of
staff
Decrease Readmissions 1. Integrated Payer/
Provider Model
2. New Care Models
4. Good Science
Increase access to private
PCPs and specialists at
discharge
19
Objective: Clinical Quality and Safety
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Implement wireless
temperature tracking for
refrigerators and freezers in
the CLB and PUH building
3. Smart Technology Meet regulatory requirements
for monitoring temperature
tracking for medication and
specimen refrigerators
Pilot Rothman Index 3. Smart Technology Decrease LOS and ECG
utilization
Improve efficiency and
accuracy of surgical
specimen labeling process at
SHY
3. Smart Technology
4. Good Science
Increased accuracy and
efficiency
Spread biometric login for
McKesson at PUH
3. Smart Technology Safe and efficient log in to
McKesson
Fully deploy scan on re-stock
at all McKesson Accudose
Cabinets
3. Smart Technology
4. Good Science
Decrease medication errors
related to wrong stocked
medication drawers
Create a compounding
pharmacy at PUH that will
serve the health system
2. New Care Models
4. Good Science
6. Diversified Revenue
Annual drug outsource cost
savings of >$1M
20
Objective: Clinical Quality and Safety
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Reduce Radiation exposures
in nuclear cardiology
2. New Care Models
4. Good Science
Reduce radiation dose and
overall scan time for nuclear
patients by shifting to stress
only imaging on low CAD
probability patients
Implement SHY house-wide
sepsis response program
4. Good Science Reduce sepsis mortality rate
Risk/Patient Safety
standardization
7. Corporate Citizenship
Achieve Highmark Objectives 6. Diversified Revenue Achieve benchmarks
21
Objective: Workforce
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Utilization of Just Culture
process for human resource
situations
Integrate MyVoice
recommendations focused
on the TLC paradigm
7. Corporate Citizenship
8. Best-in-Class Governance
Enhance staff engagement
Integration of Environment
service staff & other support
staff in UB PPC
4. Good Science
7. Corporate Citizenship
Increase HCAHPS scores
related to environment
Address absence
management thorough
management education, time
reporting pilot at SHY, and
targeted staff education
7. Corporate Citizenship
8. Best-in-Class Governance
Create integrated approach
to employee safety and
wellness resulting in reduced
days away from work and
reduced costs
Integrate inclusion practices
into HR processes through
programming which focuses
on developing and retaining a
diverse workforce
7. Corporate Citizenship
8. Best-in-Class Governance
Develop pathways for service
workers to move to
supervisory roles. Increase
overall diverse
representation in workforce
and within supervisory and
management roles
22
Objective: Workforce
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Decrease RN turnover to
below 10%
Current RN turnover = 9.58%
Further develop volunteer
services program across BU
Implement oncology
education modules for
Kazakhstan nurses
Educate 10 Kazakhstan
nurses in preparation for
Oncology Hospital
development
Create a standard for
Nursing Assistant (NA)
training
Decrease NA/PCT turnover
by 10%. Current turnover =
24.78%
23
Objective: Other Hospital or Community Services Specific
Objectives
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Flow
1. Maintain or Improve ED
Flow metrics
2. Address opportunities in
transport Process
3. Implement Teletracking
Upgrade
4. Implement same day PCI
discharge Program at
SHY campuses
5. Align physician teaching
services by unit at SHY
campuses
6. Improve OR efficiency
and turnover time
processes at SHY
1. Integrated Payer/Provider
Model
2. New Models of Care
3. Smart Technology
5. Access
7. Corporate Citizenship
1. Achieve Benchmarks
2. Decrease Wait Times
3. -
4. Reduce overnight
observation admissions
by discharging
appropriate patients same
day. Start at PUH and
SHY; spread to system
Cath programs through
HVI Leadership Council
initiatives
5. Enhance collaboration
between care providers
6. Operational efficiencies;
physician and patient
satisfaction
24
Objective: Other Hospital or Community Services Specific
Objectives
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Implement Dragon (Voice
Recognition) functionality in
SHY and PUH
3. Smart Technology Decrease reliance on
transcription services
Integration of UPMC Bedford
HIM functions
3. Smart Technology
7. Corporate Citizenship
Explore efficiencies in certain
surgical specialties across
various UPMC hospitals
• Improve the utilization of
GI space
Consolidation of services and
cooperation to improve
operational efficiency
Support system Engineering
& Maintenance Directors
through the monthly Facility
& Engineering Council
meetings
7. Corporate Citizenship 1. Improved facility
operations and reliability
2. Creation of Hospital
Division building system
standard specifications
which will reduce 1st time
construction cost
Long Term Goals and Objectives
FY2014 – FY2016
25
Summary of Significant (Top 10) Long-Term Goals for FY14 – FY16
26
1. Patient Mobility: Expand on pilot experience of increasing and maintaining mobility of hospitalized patients in all
settings, including ICUs to decrease complications of immobility.
2. Palliative Care: Improve nursing knowledge of and comfort with facilitating End of Life goal setting with patients and
families.
3. Further enhancements to cardiothoracic service line through standardization: Capitalize on quality and clinical
leadership in this key clinical service line.
4. Service Line Enhancement: Focus on developing key employed and private physician service lines to assure innovative
growth of necessary patient volumes.
5. Develop succession plan for high volume physicians at SHY: Maintain key service lines, in particular those anchored
by private practice physician leaders.
6. Explore efficiencies in certain surgical specialties across various UPMC hospitals: As health care changes
progress, we are challenged to aggressively steward system resources to preserve assess to all care for our patients.
7. Employee Engagement: Improve employee engagement through adoption of My Voice “TLC” paradigm and through the
utilization of the Just Culture survey.
8. Integrate MyVoice recommendations focused on the TLC paradigm: We recognize that an engaged workforce
treated with dignity and respect delivers the highest quality care to our patients.
9. Meet organ donation consent rates of 75: As a leader in the national and international transplant communities, UPMC
is committed to supporting local donation rates known to improve transplant access for patients.
10. Develop operational plan for use of new Luna Parking garage at SHY: Opening of new parking facility will ease
congestion on SHY campuses, decrease shuttle expenses, improve associate satisfaction and improve onsite parking
access for patients and families.
11. Begin construction of UPMC Lemieux Sports Complex: Create an Orthopedic Sports Medicine program franchise in
the North Hills to match our Southside complex.
27
Objective: Primary Care
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Virtual Group 1. Integrated Payer/
Provider Model
2. New Care Models
1. Pursue VG1 expansion of
physician base and usage
of APPs
2. Expand VG concept to
other practices
3. Review/ align incentive
plans
4. Expand concept to other
payers
28
Objective: Ambulatory Care
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Begin construction of UPMC
Lemieux Sports Complex
5. Access
6. Diversified Revenue
Create an Orthopedic Sports
Medicine program franchise
in the North Hills to match
our Southside complex
Explore Creation of Imaging
Center at South Hills Surgery
Center
5. Access
6. Diversified Revenue
Prevent patient leakage and
improve patient experience
as services Grow at South
Hills Surgery Center
29
Objective: New Models of Care
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Patient Mobility 2. New Care Models Coordinate, refine and
deploy mobility initiatives at
all PUH SHY units
Palliative Care: Expand end
of life training for nursing
2. New Care Models
4. Good Science
1. Achieving spread across
oncology units
2. Increased number of
consults to palliative care
30
Objective: Clinical Service Line Management
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Further enhancements to
cardiothoracic service line
through standardization
2. New Care Models
4. Good Science
Maintain 3 star SDS ranking
Develop program initiative for
Neurosurgical Service Line
5. Access
6. Diversified Revenue
1. Grow neurosurgical
volume at PUH SHY
2. Retain key surgeons
3. Develop young leaders
(Jankowitz, Sekula,
Richardson, Gardner,
Okonkwo, etc.)
Continue development of
Magnet goals; implement
shared governance structural
model among councils
4. Good Science Further develop shared
governance structure to
prepare for Magnet
application
31
Objective: Physician Alignment
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Develop succession plan for
high volume physicians at
Shadyside
5. Access
7. Corporate Citizenship
Work with physicians and
their groups to assure
continuity and volume
32
Objective: Ring Hospitals
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
33
Objective: Financial and Operating Performance
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Develop operational plan for
use of new Luna Parking
garage at SHY
Smooth transition into use of
new garage
34
Objective: Clinical Quality and Safety
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Meet organ donation consent
rates of 75%
8. Best-in-Class Governance Meet organ donation consent
benchmarks
35
Objective: Workforce
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Utilization of Just Culture
process for Human Resource
situations
Integrate MyVoice
recommendations focused
on the TLC
7. Corporate Citizenship
8. Best-in-Class Governance
Enhance staff engagement
36
Objective: Other Hospital or Community Services Specific
Objectives
Goal
Strategic
Framework Focus
(If applicable)
Target/Expected
Outcomes Results
Explore efficiencies in certain
surgical specialties across
various UPMC hospitals
• Improve the utilization of
GI space
Consolidation of services and
cooperation to improve
operational efficiency
Support system Engineering
& Maintenance Directors
through the monthly Facility
& Engineering Council
meetings
7. Corporate Citizenship 1. Improved facility
operations and reliability
2. Creation of Hospital
Division building system
standard specifications
which will reduce 1st time
construction cost