American College of Healthcare Executives

Succeeding in the Patient-Centered Age of Healthcare

Michael J. McBride, FACHERegional Vice President / Administrator

CHRISTUS Santa Rosa Hospital

Anthony C. Stanowski, FACHEVice President, Industry Relations

ARAMARK Healthcare

March 23 – 24, 2009

2

• Learning Objectives• Who we are• Transparency’s impact on healthcare• CHRISTUS Santa Rosa’s approach to

performance improvement• CHRISTUS Santa Rosa’s results

Agenda

3

Learning Objectives

• Understand how access to new information will enable patients to shop for healthcare

• Identify how employee satisfaction can drive patient satisfaction scores, and subsequently market share and financial performance.

4

Who We Are

5

CHRISTUS Santa Rosa Health Care

6

Our Mission

Our Mission: To extend the healing ministry of Jesus Christ.

CHRISTUS Santa Rosa Health Care

7

Strategic FocusTo enhance CHRISTUS Santa Rosa’s regional delivery system

• Strengthening and growing children’s services• Expanding non-acute services• Growing targeted adult services• Enhancing physician relationships/partnerships

SUPPORTED BY OUR JOURNEY TO EXCELLENCE

Business Literacy Service Excellence Clinical Quality Community Value

by

Expa

nsio

n/C

olla

bora

tion/

Con

solid

atio

n Marketing/

PhilanthropyMission

To extend the healing ministry of Jesus Christthrough

our

8

Our Profile – Sites

FY 2007 CSR Delivery SystemExisting locationsSuburban locationsCollaboration/consolidation

CSRH– New Braunfels

CSRH- Boerne(planned)

CSRH- Westover Hills(under construction)

CSRH- Medical Center

CSRH – City Centre

CSR Children’s

9

Only faith-based, not-for-profit health system in San AntonioServing San Antonio and South Texas since 1869Licensed for 978 bedsTotal net operating revenue $400 millionTotal assets exceeding $424 million1,850 physicians on medical staffOver 3,500 associates$158 million annual hospital payroll

Our Profile – FY 2008

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Serves 320,000 patients annually

29,254 admissions

150,393 Emergency Department visits

51 organ transplants

10,281 outpatient surgeries

141,373 outpatient visits

Our Profile – FY 2008

11

Distinguished Hospital Award for Clinical Excellence FIVE Years in a row!

Rated #1 hospital in San Antonio

Rated in the top 5% of adult hospitals nationally

Rated #1 in San Antonio for overall

•Cardiac •Pulmonary

•Gastrointestinal •Joint Replacement

12

Serves more than 1,300 hospitals and senior living communities in North America14,000 employeesFocuses on

Clinical Technology ServicesPatient and Retail Food ServicesFacility Services

ARAMARK Healthcare

13

CHRISTUS Santa Rosa and ARAMARK Healthcare

• Partnership began in 2004• ARAMARK Healthcare manages 410 employees

on site in the following:Asset Solutions Parking Management Central Transportation Plant Operations Management Customer Service Center Retail & Patient Food Services Environmental Services Uniform ServicesLinen Distribution Vending Services

Transparency: Consumerism and IT form the Eye of

the Perfect Storm

TransparencyTransparency: : Consumerism and IT form the Eye of Consumerism and IT form the Eye of

the Perfect Stormthe Perfect Storm

15

The Consumer-centric Model is Based on Choice

Cost and quality transparency will create a level playing field in healthcare. The key driver of patient satisfaction and financial success will be

16

The Consumer-centric Model is Based on Choice

Cost and quality transparency will create a level playing field in healthcare. The key driver of patient satisfaction and financial success will be customer servicecustomer service..

17

• A clean hospital positively impact how patients perceive you

• When support services are coordinated and efficient, it makes you feel that your hospital is well run

• A well-maintained physical plant can impact patient, employee, nurse, and physician satisfaction

• The hospital environment is critical to patient outcomes

• Support services are an important contributor to patients’ view of the hospital

• Support services make a big impact on clinical care

89%

87%

82%

80%

79%

75%

Source: ARAMARK Healthcare Stakeholder Proprietary Quantitative Research

94%

76%

78%

75%

82%

79%

% Who Strongly AgreeNurses Doctors

Clinicians Affirm that Non-clinical Services Significantly Impact Clinical Care.

18

41%of a consumer’s choice is based on

non-clinical experiences(An additional 20% is based on clinical reputation.)

Source: McKinsey Study, 2008

19

Consumer’s Main Reason for Hospital Preference

Patient Perception

8%

Insurance/Cost6%

Doctor's Recommendation

5%

Tradition12%

Other/Uncertain

20%

Proximity22%

Good Medical Care27%

Source: PRC National Consumer Perception Study, 2008Reported in Hospitals and Health Networks, June 2008

20

Patients’ Perceptions Correlate with Infection Rates

Source: Press, Ganey Associates and Pennsylvania Health Care Cost Containment Council (n=87 hospitals), 2007, based on 2005 data.

21

Healthcare Executives Perceive Quality and Patient Satisfaction as Top Issues

1. Quality of Care

2. Patient Satisfaction

A Force Multiplier in the Consumer-centric Model is:

The Internet

22

23

Consumer Use of the Internet for Healthcare Information Has Grown

Source: Harris Interactive, Vol. 8, August 20, 2008n = 1,010 in 2008

24

Hospital Compare Web Hits Increased 500% following the First Public Report of HCAHPS data

CMS placed print advertisements in 58 newspapers across the US to highlight results and the Hospital Compare website

0

2

4

6

8

10

12

March April May June

Hospital Compare Web Hits (in millions)

Ad

2008

The Sea ChangeThe Sea Change

Positive customer experiences

25

Patient transaction focus

First choice provider

26

And Hospitals Will Respond to Service Expectations

27

And Hospitals Will Respond to Service Expectations

Source: Press Ganey, 1,158 hospitals reflecting 1,512,272 patients. 9/24/2008

Employee Satisfaction

The Major Driver of Patient Satisfaction Is, Simply,

28

29

Relationship of Employee to Patient Satisfaction

Source: Press Ganey, Employee and Nurse Check-Up Report, 2008 (10/14/2008)

Figure 1: 356,625 responses from employees and patients from 148 facilities.

Figure 2: 28,308 responses from employees and physicians at 26 facilities.

Figure 3: 353,893 responses by employees and patients from 147 facilities

All data is from January 1 to December 31, 2007

(1) (2)

(3)

30

Reputations are Built Over Time as Word of Mouth Spreads through a Community

• Hospitals with patient satisfaction in the 90th percentile experience nearly a one-third increase in patient volume.

• On average, this equated to an additional 1,382 patients per year.

• Hospitals at the bottom 10th

percentile saw an average volume loss of 17%

Source: Press Ganey, “Increased Patient Satisfaction – Increased Volumes,” 2005. As reported in by Mel Hall, HFMA journal, October2008

80

81

82

83

84

85

Patie

nt S

atis

fact

ion

1 2 3 4

Profitability (Quartile)

Patient Satisfaction and Hospital Profitability

Leas

t Pr

ofita

ble

Mos

t Pro

fitab

le

31

CMS’ Value Based Purchasing Program Will Have a Direct Impact on Revenues

• Incentive payment• Phased in approach

32

How Will Transparency Impact the Hospital’s Market Position?

Leading Indicators: Employee Sat = Patient Sat = Market Share

Mar

ket

Shar

e

Patient Satisfaction

AC

B

D

F

Low

Low

High

High Cat Bird Seat

GrowthResumeWriters

At Risk

Source: SRK Solutions

33

Pre-Implementation Status

34

CHRISTUS Santa Rosa: Pre-Partnership State• Some departments managed internally, some

managed by separate external vendorsUncoordinated approach to service response

• Poor inter-departmental communication• Multiple cultures in departments outsourced to

disparate organizations Duplication of efforts among support departments

35

CHRISTUS Santa Rosa: Pre-Partnership State

• Silo approach to work• Lack of tracking system for work orders• Lack of one system to call to place work orders, resulting

in numerous calls• Leadership turnover• Low skill level in Maintenance Associates• Culture of “it’s not my job” and finger-pointing among

departments• Reluctance to change• Lack of credibility of support departments within

organization

36

CHRISTUS Santa Rosa: Rationale for Comprehensive Partnership

• “Best Practice-Touchstone Award Winner” at CHRISTUS St. Michael Health System

• Skilled in integrating support departments for a seamless delivery of care.

• Expertise in management of multiple support departments• Establishment of Central Transportation and automated

Call CenterSeamless, one-call approach for multiple services

37

CHRISTUS Santa Rosa: Rationale for Comprehensive Partnership

• Cost savings realization.• Revenue growth opportunities• Innovation• Improvement in employee satisfaction• Coordination, coordination, coordination

38

CHRISTUS Santa Rosa: Rationale for Comprehensive Partnership

• Transform the culture from the bottom up.• Set the tone of a true partnership• Treat associates in ways consistent with our values• Experience in culture changes

39

CHRISTUS Santa Rosa: Rationale for Comprehensive Partnership

• Allow long term associates to remain as CSR Associates.

• Benefit transition• Capital improvements

Call centerRetail food serviceEnergy saving software and equipment

40

CSRHC Challenged ARAMARK Healthcare to Impact Its Clinical Support Services by Creating

Patient-focused and Cost-effective Solutions:

• Seamless support of the healthcare continuum.Provide expert managementDaily execution of integrated support services

• Patient, visitor, physician, and associate satisfactionDining experiencesMaintenance and cleanlinessCustomer-focused services.

41

CSRHC Challenged ARAMARK Healthcare to Impact Its Clinical Support Services by Creating

Patient-focused and Cost-effective Solutions:

• Implement technical and programmatic solutionsImprove operational efficiencyImprove financial outcomes within support services.

• Increase morale among support service staffProvide broader career development opportunitiesAccess ARAMARK Healthcare’s competitive benefit offerings.

42

Implementation Approach

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Philosophy: The Healthcare Environment is a Healing Atmosphere Supported by a Broad Network of People Who Are All Connected.

44

We Expanded The Definition of Patient Care.

45

We Focused on the Patient ExperiencePatient-Centered Culture

• Patient Engagement• Respect• Personal Touch• Patient-centeredness

Physician Relations

Capacity

Nurse Shortage

Personnel Shortages

P4P

Reimbursement

Quality

Patient Safety

Patient Sat

Regulatory

46

Service Was Aligned With Overall Vision, Mission, Values, and Goals.

Programs

• Room Service

• OrganizationalDevelopment

• HospitalityAssociate

• MultiServiceAssociate

Evidence-based Behaviors

• Rounding onStaff

• Thank You Notes• Key Words/

AIDET• Rounding on

Customers

• Peer Interviews • High-Middle-Low

Creates a culture of:• Patient Engagement• Respect• Personal Touch• Patient-centeredness

Enhanced Patient and Client Satisfaction

Vision, Mission, Values, Goals

47

• Establish a preventive maintenance minded culture in facility services

Increased preventive maintenance completion rates from 320 preventive work orders per year to more than 1,200 work orders per month

• Implemented ARAMARK Healthcare’s Integrated Service Information System (ISISpro)

Improve coordination of work ordersMonitor service response timesRecord compliance with regulatory standardsAssess productivity

Operational Efficiency and Service Excellence

48

Operational Efficiency and Service Excellence

• Customer Service Center“One-call” handles requests with patient transport, environmental, maintenance, biomedical, and linen servicesMore than 16,000 calls per monthAverage call answer time: 20 seconds.

• Quarterly improvement plan for employee safety100 percent reduction in service employee slips, trips, and fallaccidents in the first quarter following program implementationOverall reduction of incidents and accidents by 75 percent from the prior year

• Enhancements to indoor air quality and comfortARAMARK Healthcare’s comprehensive Asset Solutions Program

49

Operational Efficiency and Service Excellence

• Central Transportation ProgramImpacts patient throughput and clinical productivityManages more than 100,000 patient moves and 1,000 equipment moves per yearNearly 90 percent of transport requests are completed within 30 minutes of the request.

• Combine internal management and external vendors into a “one in-house team”

Brings current contractor expertise in houseEstablished a synergy of purpose

50

Outcomes Outcomes

51

Improvements in Clinical Quality PerformanceClinical

Quality Percentile*

Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Goal

AMI 100 100 100 100 100 100 100 100 97 95 94 100 100

Heart Failure 100 93 86 89 89 91 92 93 94 94 95 100 100

Pneumonia 100 85 88 90 90 91 90 91 90 90 91 100 100

Discharge Instructions for HF

89 90 88 85 85 84 85 85 83 84 83 81 87

Blood Culture for Pneumonia

94 96 95 94 94 95 95 95 93 94 94 89 93

Initial atb Selection for Pneumonia

89 92 91 92 91 91 91 93 91 91 90 100 89

Pre-op atb Timing for SIP

90 91 90 90 90 91 91 91 92 91 91 94 93

Post-op atb Timing for SIP

86 82 82 81 81 82 82 83 83 83 83 96 96

All numbers are percents

52

Employee Safety Claim Rates Improved

14.1

9.5

4.6

02468

10121416

2006 2007 2008

Source: CSR Internal Reporting

53

Employee Satisfaction Improved

• Sustained a culture of employee engagement during a workforce conversion of 410 service workers from hospital to ARAMARK Healthcare payroll

Established regular round-table sessionsOpened key lines of communication.Maintained employee satisfaction levels

• 79.5% in 2007; 80.8% in 2008

• Supported an organizational culture changeHosted a highly received leadership retreat facilitated by ARAMARK Healthcare’s Organization Development experts.

54

Improvements In Associate Satisfaction

POM Associate Satisfaction

0

20

40

60

80

100

2005 2006 2007 2008

55

Improvements in Associate Satisfaction

Dietary Associate Satisfaction

0

20

40

60

80

100

2006 2007 2008

56

Improvements In Employee Turnover

POM Turnover

0

10

20

30

40

50

2006 2007 2008

57

Nurse and Physician Satisfaction Improved• Improved nurse satisfaction with support services

Implemented ARAMARK Healthcare’s I Impact behaviors• Manager-to-manager conversations uncover “what’s working well”• Nurse manager preferences for improved collaboration.

• Improved surgical department satisfaction and productivityInstalled a “super-cooling” system in 13 operating suites which enables surgeons to rapidly alter room temperatures during procedures.

58

Visitor Satisfaction Improved • Retail dining experience improved

Added menu varietyIntroduced a Java City coffee barRenovated dining seating areasImproved dining room cleanlinessImproved dining room air temperature control.

• Enhanced visitor satisfactionImplemented ARAMARK Healthcare’s Facility Operations Management and Environmental Services ProgramsImproved temperature control in roomsImproved cleanliness in rooms

59

Patient Satisfaction Improved

• Improved patient satisfactionIncreased the quality and variety of patient mealsImproved the cleanliness and maintenance of patient care areasResult: within 12 months, went from the 51st percentile to the 90th

percentile

60

Patient Satisfaction by Quarter

0102030405060708090

100

2004

2005

2006

2007

2008

Perc

entil

e

Overall Room Meals Nursing Personal

Source: CHRISTUS Santa Rosa Press Ganey Results 2004-2008

61

Patient Satisfaction by Quarter

0102030405060708090

100

2004

2005

2006

2007

2008

Perc

entil

e

Admission Tests/Trt Vistors/fa Discharge Ov Asses

Source: CHRISTUS Santa Rosa Press Ganey Results 2004-2008

62

Statistical Summary of Patient Satisfaction Trends

Patient Satisfaction Category Regression Coefficient R2 ValueMeals 2.0070 0.4502Tests/Treatment 1.9281 0.4464Overall Assessment 1.6386 0.1988Personal 1.2772 0.1154Overall 1.1649 0.1157Discharge 0.8982 0.0622Visitors/Family 0.7789 0.0843Room 0.4474 0.0364Nursing 0.1491 0.0020Admission -0.2368 0.0089

63Source: CMS, Sept 2008

HCAHPS Results 2007

64

11.0% 11.0% 10.9%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0%1.2% 1.8%

11.3% 11.0%11.7%12.9%13.3%

13.9%14.6%14.2%14.4%14.4%

30.4% 29.3%31.1%

29.2% 28.7%30.8% 30.9%

32.5% 32.7% 33.5%

34.8%34.3%34.4%34.6%35.3%36.2%35.7%34.4%36.6%36.9%

11.8% 12.8% 12.9%12.0% 12.4% 11.7% 11.5%

2.0%1.9%

7.8%8.8%8.7%8.9%9.0%8.9%8.5%7.4%6.9%6.4%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

1998(n=147,713)

1999(n=154,229)

2000(n=163,653)

2001(n=175,035)

2002(n=181,568)

2003(n=185,144)

2004(n=189,957)

2005(n=191,233)

2006(n=193,693)

2007(n=200,342)

CSRHC Baptist Methodist University TexSAn Other

Market Share 1998 - 2007

65

At Risk

Resume Writers

Cat BirdSeat

Growth

Methodist

University

Baptist

TexSanHeart

CHRISTUSSanta Rosa

Size of bubble designates number of beds.

Market Opportunity Grid

66

CSRHC Operating Margin and Operating Income Steadily Improved

Operating Margin

0%2%4%6%

FY03 FY04 FY05 FY06 FY07 FY08

$2,617$6,903

$9,095 $10,016

$14,663

$22,300 $20,501

$0

$5,000

$10,000

$15,000

$20,000

$25,000

Net

Ope

ratin

g In

com

e (m

illio

ns)

FY03 FY04 FY05 FY06 FY07 FY08 FY09 Budget

Net Operating Income

Source: CHRISTUS Financial Reports

67

Relative to Market Competitors CHRISTUS Operating Margin Improved

Percent Change in Operating Margin From Prior Year

-50%

0%

50%

100%

150%

FY04 FY05 FY06 FY07 FY08

Perc

ent C

hang

e in

Ope

ratin

g M

argi

n %

CHRISTUS Santa Rosa* Methodist Baptist University Texsan Heart

Source: CHRISTUS Financial Reports, American Hospital Directory

68

Summary

69

In Review:

• Transparency effects the health care marketConsumerism and availability of dataThe Internet as a force multiplier

• We implemented programs that:targeted clinical process improvementtargeted employee satisfaction, physician satisfaction, and ultimately, patient satisfaction

70

• These programs resulted in:Improved patient and visitor satisfactionDecreased employee turnoverImproved clinical performanceStabilized market share; poised for growthGrew financial performance.

In Review:

71

Questions/Comments

72

Contact Information

Michael J. McBride, FACHERegional Vice President / Administrator

CHRISTUS Santa Rosa HospitalPhone: (210) 704-3336

michael.mcbride@christushealth.org

Anthony C. Stanowski, FACHEVice President, Industry Relations

ARAMARK HealthcarePhone: 215-238-3550

stanowski-anthony@aramark.com