Winona Health’s Performance Excellence System Kathleen Lanik Chief Quality & Safety Officer
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Transcript of Winona Health’s Performance Excellence System Kathleen Lanik Chief Quality & Safety Officer
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Winona Health’sPerformance Excellence System
Kathleen Lanik
Chief Quality & Safety Officer
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Our VisionWinona Health will be a recognized leader in the
revolutionary transformation of community healthcare.
Our MissionDevoted to improving the health and well-being of our family, friends, and neighbors.
A service environment where people can realize their full potential. Excellence & leadership in clinical care & service Customer Focus Stewardship of Resources
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Winona Health’s Values
Integrity – We do no harm.
Service – We serve with compassion, dignity, and respect.
Loyalty – We build relationships that exceed expectations.
Excellence – We improve performance through learning and innovation.
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WH’s Performance Excellence System (PES) is designed to:
Create peace of mind by providing compassionate, personalized care
to our family, friends and neighbors.
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WH’s Performance Excellence System (PES) has Four Quality Standards that
Guide all Actions:
Safety: Do no harm
Courtesy: Be kind, caring and selfless
Performance: Deliver an excellent care experience
Effectiveness: Obtain results by design
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WH’s Performance Excellence System (PES) includes:
Living Service Excellence (LSE) Tools and Initiatives for Staff Performance Management Provides a System-Wide Approach to Staff Excellence
Living Performance Excellence (LPE) Tools and Initiatives for Process Improvements
Provides an Organization-Wide Approach to Performance Improvement (PI)
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Winona Health’s Performance Excellence System
Living Service Excellence
Staff Performance Management Tools
LSE Standards/ValuesPerformance EvaluationRole SummariesLSE Award ProgramWinona Health UniversityEmployee Pride SurveyExperience Compass
Living Performance Excellence
Process/Performance ImprovementTools
STEPLeanBy Design MatrixExperience CompassRoot Cause AnalysisFact-based Decision MakingEvidence-based PracticeFailure Mode Effects & Analysis
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Central to WH’s Living Performance Excellence efforts is a Plan Do Check Act (PDCA) method
known by the acronym “STEP”
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The STEP/PDCA process is initiated by:
1. S – See the Opportunity Identifying Opportunities for Improvement (OFIs) and Completing an Opportunity Statement Suggesting an Improvement Initiative
2. T – Team Up Team is Developed, Goals Set, & Timeline for Development is Established
3. E – Evaluate Evaluating the Plan Through Continued Data Collection and Analysis
4. P – Proceed Proceed to Adopt Change or Determine to Study Further
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LEAN QUALITY THINKING - A Change in the Mental Model -
1. Process Whole System Management Strategy
FLOW vs. Silos
2. Quality Focus On What PATIENTS Expect
Coordinated Care – Not Just Competency of Care
3. Controlling Cost Elimination of Waste
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WH Quality Matrix
Delivery Systems Staff Setting Process
Quality Standards Safety Courtesy Performance Effectiveness
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WH Experience Compass
Needs (North)
Stereotypes (South)
Emotions (East)
Wants (West)
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WH’s Performance Excellence process supports continuous pursuit of excellence, and is enhanced by:
Memberships
Minnesota Council for Quality (MCQ)
American Society for Quality (ASQ)
Institute of Clinical Systems Improvement (ICSI)
Institute for Healthcare Improvement (IHI)
Participation
Center for Medicare/Medicaid Services (CMS) Quality Project
5 Million Lives Campaign
Minnesota Hospital Association Call to Action Initiatives
In recognition of its efforts, WH has been recognized by multiple local, state and national organizations.
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Performance Excellence Journey
Minnesota Council for Quality (2003 – Present) Malcolm Baldrige Criteria (2004 – Present) Accreditation/Licensing Agencies State & National Projects Winona Health-Specific Initiatives
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Baldrige Journey
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Notable Strengths: Visionary Leadership Focused on the Future Valuing Staff and Partners Patient-Focused Excellence Management By Fact
“Pretty Good Practices” Systematic 6-Step Process to Manage Staff
Performance Mentoring Program
Baldrige Journey
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Baldrige Journey
2005 Opportunity for Improvement (OFI)
4.1b(1) – Winona Health does not have a fact-based, systematic process in place to evaluate and improve its systems for the review and analysis of measures and
organizational performance. As a result, opportunities to improve the measurement and review systems may be
missed and/or effective measurement and review practices may be misunderstood and discontinued.
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Past Data Reporting Schedule
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Past Data Reports
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Question: What Do We Need? A System That Automates Our Processes A System That Addresses Multiple Needs Within
Our Organization:Reporting to wide range of constituentsTracking of data at all levels in the organizationAlignment with our strategic planSupportive of our Performance Excellence SystemWeb-based application for easy access
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Solution: Focus on Core Competencies
Integrated, Automated Technological Systems Strategic & Financial Planning Process Community Commitment Performance Excellence System
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Performancesoft Data Management
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Performancesoft Data Reports
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Performancesoft Books
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Lessons Learned
Commitment of Leadership Focus on Your Strengths Performance Excellence is EVERYONE’S
Responsibility There are NO Short Cuts
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“We are what we repeatedly do. Excellence, then, is not an
act, but a habit.”
-- Aristotle
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Questions?