NMHS: The Baldrige Journey

Lee Greer, M.D., MBAChief Quality & Safety Officer

“To continuously improve the health of

the people of our region”

• NMMC- Tupelo• 5 Community Hospitals

–Eupora (38 beds) plus LTC–Hamilton, AL (57 beds) plus LTC – Iuka (48 beds)–Pontotoc (25 bed CAH) plus LTC –West Point (60 beds)

• 34 Clinics • Preferred Provider Organization

• 90,000 lives – 114 payer groups• 2,929 physicians & 48 hospital network

VISION

“The provider of the best patient centered care and

health services in America”

NMHS’ Commitment to the Baldrige Framework

LeadershipLeadershipOperations

FocusOperations

Focus

WorkforceFocus

WorkforceFocus

CustomerFocus

CustomerFocus

StrategicPlanningStrategicPlanning

ResultsResults

Organizational ProfileOrganizational Profile

Measurement, Analysis and Knowledge Management

Measurement, Analysis and Knowledge Management

“Every successful quality revolution has included participation of upper

management. We know of no exceptions.”

Joseph Juran

• Servant Leadership Philosophy

• Leadership Development• Employee/Physician

Engagement• Leader Rounding• New Employee Orientation• Extensive Community

Outreach

Leadership

“Ninety-five percent of what leaders like you do is pursue operational efficiency. What about strategic positioning?”

Dr. Michael Porter – HBS

Alignment

Evidence Gathering

SWOT

Approve Plan

Prioritization

Evidence Analysis Workforce

Budget

Entity Plans

Development

EightEPP

Steps

EightEPP

Steps

Deployment

OCTOBER

Evidence Gathering

SWOT

Evidence Analysis

Prioritization

Approve Plan Entity Plans

Budget

Workforce

NMMC Service Line Goals

Workforce Alignment

“Your calling is calling……”

NMMC-Tupelo Employee Entrance

Organizational CultureRECOGNITION & REWARD•Excel – Pay for performance•Team Incentive Plan

– Service/Quality– Financial/Growth

•CSF – Rewards– Stars Online – More than

5,000 awarded in 2012

“The best way to find yourself is to

lose yourself in the service of others.”

Mahatma Gandhi

Relentless Pursuit of Excellent Customer Service

1. Establish a goal of 95th percentile in patient satisfaction.

2. Ensure employees understand the survey questions & the required behaviors.

3. Ensure employees know and understand the top three drivers of satisfaction for their area & the required behaviors.

“In God we trust; all others must bring

data”

W. Edwards Deming

Comparative DataEvidence-based literature and

current practice guidelinesSelected external comparative

databasesBaldrige winners and other

industriesAbove the 90th percentile or top

10%

“We are what we repeatedly do. Excellence, then, is not

an act, but a habit.”

Aristotle

Population-focused Work Systems & Collaborative Work Groups

Work System Implementation• Trial & scale up• Training • Clinical Educators• Policies, Guidelines & Protocols• Hard-wired order sets & prompts

“The achievement of an organization are the results

of the combined effort of each individual.”

Vince Lombardi

Workforce Engagement

• Employee Opinion Survey

• Leader Rounding• Ideas for Excellence• 99th percentile in

Communication

Evidence-Based Care

75

80

85

90

95

100

Com

posi

te C

are

Sco

re

Evidence -Based Care -NMMCQUEST Top Performing Threshold

Overall Sepsis Mortality

0

5

10

15

20

25

30

35

Ove

rall M

ort

ality

Rate

Ideas for Excellence & Clinical Process Improvement

NMHS Heart Failure Care Transition (30-day readmission rates)

Competitor Satisfaction• HCAHPS

• Market Share 40.7%

• Kaiser Health News – Sixth happiest market in United States

It’s All in the Number

“To continuously improve the health of

the people of our region”

HealthWorks!• Interactive children’s

health education center

• School-based curriculum &

community-based programs

• Served >78,000 in first three years

• Improved diet & health knowledge