strategic plan 2015 - 2018 - highland-clarksburg …...increase by 1 new signed agreement for...

Strategic Plan

2015 - 2018

April 2015

1

STRATEGIC PLAN

2015-2018

TABLE OF CONTENTS

Page(s)

INTRODUCTION AND PROCESS 2-4

MISSION, VALUES, CORE PURPOSE, VISION 5

HIGHLAND-CLARKSBURG ORGANIZATIONAL STRATEGIC IMPERATIVES 6

STRATEGIC GOALS 7-8

STRATEGIC IMPERATIVE: QUALITY OF CARE “GOAL 1” 9

STRATEGIC IMPERATIVE: QUALITY OF CARE “GOAL 2” 10

STRATEGIC IMPERATIVE: FISCAL RESPONSIBILITY “GOAL 3” 11-13

STRATEGIC IMPERATIVE: FISCAL RESPONSIBILITY “GOAL 4” 13

STRATEGIC IMPERATIVE: FISCAL RESPONSIBILITY “GOAL 5” 14

STRATEGIC IMPERATIVE: INVESTMENT IN HUMAN CAPITAL “GOAL 6” 15-16

STRATEGIC IMPERATIVE: ORGANIZATIONAL CULTURE & COMPLEXITY “GOAL 7” 17




STRATEGIC IMPERATIVE: COMMUNIATION & TECHNOLOGY “GOAL 11” 21

STRATEGIC IMPERATIVE: COMMUNIATION & TECHNOLOGY “GOAL 12” 23-23

APPENDIX 1 (Strengths –Planning Committee, Leadership, Board) 24-25

APPENDIX 2 (Weaknesses –Planning Committee, Leadership, Board) 26-27

APPENDIX 3 (Opportunities –Planning Committee, Leadership, Board) 28-29

APPENDIX 4 (Threats –Planning Committee, Leadership, Board) 30-31

APPENDIX 5 (Strengths –Staff) 32-35

APPENDIX 6 (Weaknesses –Staff) 36-40

APPENDIX 7 (Glossary of Terms) 41-42

APPENDIX 8 (Strategic Planning Team) 43

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Highland-Clarksburg Hospital

Strategic Plan

2015-2018

Introduction

Highland-Clarksburg Hospital has completed a strategic planning process designed to assist in addressing the challenges of the

future. The strategic planning process took into account the organization’s external and internal environments while helping

to define our purposes, what we intend to become, and how we will attain our goals. Ideally, a strategic plan results in the

development of direction, establishment of policy, creation of a rationale for decision-making, and a definition of what success

looks like. The strategic plan that has been developed enables us to not only to chart a course, but to successfully navigate it

and correct ourselves when we stray from that course.

Process

The Board Planning Committee and Hospital Leadership met 4 times over the last 4 months to develop the strategic plan. The first

step in the process was a SWOT analysis. During the SWOT process, we aimed to develop a current snapshot of the efforts and

results of the organization so as to:

Identify strengths to build on in the planning process

Examine weaknesses and vulnerabilities to address

Assess opportunities and threats most critical to our future success

Identify where to apply resources and attention

Put issues into perspective

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We began by identifying strengths, weaknesses, opportunities and threats that impact the main mission areas of the Highland

Hospital organization. In addressing the areas of the SWOT analysis, the following questions guided our thinking:

Strengths: What do we do exceptionally well? What valuable assets and resources do we have? Are there other strengths we need for

the future?

Weaknesses: What could we do better? Or improve upon? What are we criticized for or receive complaints about? Where are we

vulnerable?

Opportunities: Are there emerging trends on which we can capitalize?

Threats: Are any of our weaknesses likely to make us critically vulnerable? What external or internal roadblocks exist that block our

progress? Who are our competitors? Are they doing anything different?

The complete SWOT analysis was undertaken by the Planning Committee, Senior Leadership and Board Members. In addition, input

on strengths and weaknesses was sought from staff. 39 staff members participated in the process. The complete SWOT analysis,

along with the major themes that emerged are found in Appendix 1 (Strengths, Planning Committee, Leadership and Board),

Appendix 2 (Weaknesses, Planning Committee, Leadership and Board), Appendix 3 (Opportunities - Planning Committee, Leadership

and Board), Appendix 4 (Threats, Planning Committee, Leadership and Board), Appendix 5 (Strengths - Staff), Appendix 6

(Weaknesses-Staff) . Once the SWOT analysis was complete, we summarized themes from each SWOT area and used them to revisit

and update our mission and vision, our core values and purpose. We identified common goal areas based in the themes from the

SWOT analysis, which became our Strategic Imperatives. We completed the process by identifying strategic goals for each area, and

developing strategies or actions to help us attain our goals. In order to measure our success, metrics or benchmarks were identified

for each strategy, including a time for completion. Each strategy has a designated person or group responsible for assuring progress

toward meeting our goals.

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The following are the results of the Planning Session and the resultant Strengths, Weaknesses, Opportunities and Threats for

Highland-Clarksburg Hospital:

The top strengths are: 1. Location/Facility –Potential for long and short term growth 2. Dedicated Staff 3. Board and Community Support 4. High Quality Patient Care and Clinical Staff 5. Positive Relationship with State Agencies

The top weaknesses are: 1. Recruitment and Retention of physicians, RN’s, LPN’s, Therapist and Social Workers 2. Internal Communication and team work, Management’s presence on the units 3. Financial Position 4. Turnover and Staff Retention, Benefits not competitive, lack of staff 5. Information systems 6. Lack of succession plan

Top Opportunities are: 1. Ability to Grow/Expand Services/ability to add services 2. Partnership with WVU and others on interns, teaching, etc. 3. Enhance employee benefits 4. Enhance External communication 5. Training and professional skilled development 6. Grant opportunities

The top threats are: 1. Funding source pressures –State, Federal, Medicaid 2. Ability to recruit professional staff 3. Financial issues associated with not meeting financial goals (loan covenants) 4. Reputation on Admissions and relationships with referral sources 5. Competition

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Mission Statement

Our mission is to provide quality behavioral health services to children, adolescents, and adults in a

caring environment.

Values

Quality Care

Patient-centered environment Ethical treatment of all

Innovation

Fiscal Responsibility Total Well-being

Investment in our people Visibility

Core Purpose

To improve the health of the people we serve.

Vision

Highland will be the premier provider of quality behavioral health care services and improve the total

well-being of individuals and families through investment in our employees, patients and communities.

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Highland-Clarksburg Organization Strategic Imperatives

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Strategic Goals

Strategic Imperative: Quality of Care

Goal 1: Provide safe, quality, patient-centered care to every patient.

Goal 2: Grow existing services and identify new opportunities to meet the health care needs of the state and region.

Strategic Imperative: Fiscal Responsibility

Goal 3: Achieve and maintain a financially strong health care system.

Goal 4: Develop a sustainable operational plan using multiple fundraising sources, including community and government

support.

Goal 5: Maintain the physical plant to be in compliance with State and Federal requirements.

Strategic Imperative: Investment in Human Capital

Goal 6: Recruit, develop, retain and strategically manage an exemplary workforce.

Strategic Imperative: Organizational Culture and Complexity

Goal 7: Become the employer of choice for employees who seek professional fulfillment, excellence in their work and in the

organization.

Goal 8: Refine the organizational structure to insure clarity, communication, and strategic goal alignment.

Goal 9: Exceed the expectations of everyone we serve.

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Strategic Imperative: Communication and Technology

Goal 10: Invest in technology that improves the continuity and safety of care, improves documentation, makes patient

information accessible to appropriate health care providers, enhances communication, and provides decision

support.

Goal 11: Provide a reliable, well managed, and secure Information Technology environment.

Goal 12: Improve communication with patients, employees, partners, public and Board of Directors about our mission, goals,

performance, and the benefits and services we provide.

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Goal 1: Provide safe, quality patient-centered care to every patient.

Strategy Metric/Benchmark Responsible Person(s)

Develop appropriate benchmarks for patient care which conform with established national benchmarks. 1) Increase patient satisfaction 2) Increase % of satisfaction with patient knowledge of discharge meds 3) Decrease restraints/seclusion/holds 4) Complete physician discharge documentation 5) Decrease medication incidences Exceed baseline national/regional benchmarks on all additional quality and safety indicators

Benchmarks to begin on April 1, 2015 and be ongoing. In Year 1: 1) Exceed 95% patient satisfaction 2) Exceed 90% satisfaction 3) Decrease 20% quarterly 4) Exceed 90% completeness 5) Decrease 20% quarterly Exceed history by 10% year one, 15% year two and 20% year three

QA Director Clinical Managers Pharmacy Director Medical Director

Act/report on all findings from surveys and QA process in timely fashion

QA team develops plan of action within 30 days of report

QA Director Board of Directors Quality Committee

Implement employee/provider survey for feedback on areas of patient care improvement

Plan in place by April 1, 2015, training ongoing Clinical Directors and Managers

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Goal 2: Grow existing services and identify new opportunities to meet the health care needs of the state and

region.


Establish a Vision Team of administration/staff/Board of Directors

Establish Vision Team by April 1, 2015 Implement 2 new services by October 1, 2015 Increase utilization of facilities ongoing

COO Nurse Executive Board of Directors Finance

Partner with community organizations such as Health Access, etc.

Increase by 1 new signed agreement for referral process quarterly beginning April 1, 2015

Marketing Director Admissions

Maximize existing referral sources to overcome issues leading to decrease in referrals; reinvigorate existing referral sources Review existing admissions process for possible enhancement of current process

Create action plan and begin implementing June 1, 2015

Marketing Director

Maximize value in community engagement by evaluating the appropriate engagement of said community

Analysis of cost/benefit of community activities by April 1, 2015

Marketing

Representation of employees in greater community

Increase by 10% per year the number of employees serving on outside boards, community groups, state/region affiliations Capture data in employee surveys

Human Resources Nurse Executive

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Goal 3: Achieve and maintain a financially strong health care system.


Maximize patient census & payer mix through marketing outreach & state contracts.

Patient Census Goals: 2015=67 2018-95 2016=87 2017-94 Payer mix= budgeted value

CEO Marketing COO Leadership

Development of needed specialty psychiatric services and become a provider of choice

Daily/monthly census comparisons Tracking of inquiry calls for services not in CON

Admissions COO Marketing Leadership

Analyze operating costs and efficiencies

Operating surplus 2015=$528,952 2016=$2.4m 2017=$3m 2018=$2.7m

Leadership Team

Achieve loan covenants for debt service and cash on hand

D/S Ratio=above 1.2 – Annual test beginning 9/30/2015 Days Cash on Hand

2015 = 20

12/31/2015 = 22.6

3/31/2016 = 25.2

6/30/2016 = 27.8

9/30/2016 = 30

12/31/2016 = 32.6

3/31/2017 = 35.2

6/30/2017 = 37.8 After 6/30/2017=40 Annual

CEO COO Leadership Team Board of Directors

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Hold mid-level management accountable for financial planning for their service and for development of methodologies that will allow staff to participate in successful planning and interventions

Monthly census at or above budget Monthly financials at or above budget

Department Managers COO Controller

Develop early warning system for financial issues (ex: 90 day outlook) Integrate into monthly board report

System developed and functional by: April 2015

COO Leadership Team

Communicate financial goals with employees and empower them to participate and share responsibility for financial success/ loss

Monthly reports to Department Heads; quarterly reports to employees. Begin Date: March 2015

Controller COO

Maintain the following ratios Average Length of Stay 8-10- monthly Days in A/R: 55 days –quarterly Operating margin: 2.5 percent – annual Excess margin: 4.5 percent – annual Current ratio: 1.9 – quarterly Average payment period: 58 days – quarterly Bad debt as a percent of net patient revenue - 1% annually Replacement viability – 3% annually Average Age of Plant 7 years - annual Maintained Bed Occupancy – monthly Forensics – 95% Child/Adolescent – 60% HHC Adult Substance Abuse – 75%

Controller COO Leadership Team

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Goal 4: Develop a sustainable operational plan using multiple fundraising sources, including community and

government support


Develop internal capacity to identify and apply for grant opportunities

Identify one new grant opportunity quarterly beginning July 1, 2015 Review federal register, WV State purchasing register, other sources

CEO

Continued meetings with State and Government agencies to develop mutually beneficial relationships with shared risk

Ongoing CEO COO Board of Directors

Continuous evaluation of purchasing practice (i.e., cleaning supplies, office supplies, general, etc.)

Annual review by Accounting Manager Action Plan by July 2015

Fiscal Department

Develop, evaluate and communicate of denial management system of patient stays, admissions for lost days through UR

Lost Days minimized to ¼ of bad debt Utilization Review Performance Improvement Medical Executive Committee

Annual reviews of contracts 100 % contracts reviewed annually COO Quality Assurance

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Goal 5: Maintain the physical plant to be in compliance with State and Federal requirements.


Develop compliance process and assessment for State and Federal agencies

12/14 Assess current state of compliances for EOC, E.P and Life Safety 3/15 Review of standards completed 3/15 Walkthrough of completed standards 4/15 Completion of all Federal and State standards addressed and documented 5/15 Additional walkthrough of standards ( JC & OHFLAC) in anticipation of site surveys *Each Quarter review for preparedness

Director of Safety, Compliance and Emergency Preparedness Director of Facilities

Develop preventive maintenance program for equipment

11/14 Established need for NEW Preventative Maintenance (PM) and Work Order (WO) Program 12/14 Safety to work with Facilities and IT to review of possible programs 5/15 Review of suggested PM/WO programs complete 6/15 Review programs with Finance Committee 7/15 Purchase and implementation of new PM/WO program 9/15 Employee Training 12/15 PM/WO programs complete and provided to Safety for compliance

Director of Safety, Compliance and Emergency IT Facilities Finance committee COO

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Statement of Conditions (SOC-)Outline future needs of physical plant

11/14 Initiate SOC 12/14 Start SOC for hospital 3/15 Paper copy of SOC *Annual update of SOC 2016 Add PM information to SOC 2016 PM to coincide with SOC

Director of Safety, Compliance and Emergency COO

Develop Facilities/ Equipment Assessment program for ongoing needs of physical hospital environment (boilers, air handlers, roofs, grounds, current equipment, etc.)

7/15 Develop assessment plan, format and criteria 3/16 Facility/Equipment assessment complete 7/16 Development of 5 year capital program for finance

Director of Safety, Compliance and Emergency Safety Director of Facilities COO

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Strategic Imperative: Investment in Human Capital

Goal 6: Recruit, develop, retain and strategically manage an exemplary workforce.


Enhance regional Academic relationships

Identify all colleges we want to partner with by March 1, 2015 Plan in place by May 1, 2015

Nurse Executive Director of Therapy & Social Work Human Resources Staff Development

Ensure all employees have a full formal orientation to the hospital and specific department

Develop a team of all hospital functions by March 1, 2015 Develop and implement plan by June 1, 2015

Nurse Executive Director of Therapy & Social Work Staff Development Human Resources

Monitor benefit and compensation for equity and competitiveness

Source and Cost wage analysis availability by March 1, 2015 Have proposal by May 1, 2015 Review after receipt of survey with 60 days In conjunction with Charleston monitor and suggest health plan and fringe benefits other than wage

Human Resources Charleston Human Resources

Review mentoring plan for new hires and staff growth needs.

Review current preceptorship by March 1, 2015 Have all written plans in place by June 1, 2015 Develop and implement test for effectiveness of preceptor program by October 1, 2015

Nurse Executive & Assistant NE Director of Therapy & Social Work Human Resources

Employ best practices in recruitment

Review new webpage and offer suggestions when completed- ongoing Identify and plan approach going forward by May 1, 2015. Utilize current Facebook page Identify job fairs and identify attendees to participate in each

Human Resources COO Nurse Executive Marketing

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Develop continuing education Achieve status for offering CEUs for Clinical by April 1, 2015 Develop annual plan for offerings

Staff Development Nurse Executive Director of Therapy and Social Work

Develop succession plan Review tools for identifying high performers by May 1, 2015 Develop plan for succession by October 1, 2015 Implement plan January 1, 2016

CEO Human Resources COO Leadership team

Immediate rewards for performance

Pat on backs, Employee of month, Thank you notes-ongoing Human Resources Leadership Team Department Heads All employees

Develop 360 degree performance evaluation system for employees, supervisors, managers & administrators

In conjunction with Charleston develop process Identify participants for 1st year Implement January 2016

Human Resources -HCHI Human Resources -Charleston COO

Develop pay for performance model for future implementation

In conjunction with Charleston, develop award program by October 1 and implement in 2016

COO Finance Human Resources - HCHI Human Resources- Charleston

Coordinate on-site continuing education opportunities.

Develop plan to include all licensure and certification requirements by June 2015 Implement plan September 2015

Staff Development Human Resources

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Goal 7: Become the employer of choice for employees who seek professional fulfillment, excellence in their

work and in the organization.


Create a Professional Development Committee for oversight and coordination of, and recommendations for improvements for staff in career growth.

Establish committee by April 2015 Action plan by June 2015

Nurse Executive Human Resources Staff Development Committee (to consist of members from all disciplines)

Implement best practices in the “employer of choice” movement.

1. System rounds by leadership 2. Recognition programs 3. Others

Identify and establish best practices by June 2015 Implement July 2015

Leadership team

Create an environment for successful recruitment of medical providers and staff through internal initiatives and inclusion of the external community.

Develop plan by May 2015 Implement July 2015

Marketing Human Resources Finance

Develop an environment for teamwork success Develop plan for teambuilding activities and deploy to management by April 2015

Staff Development Director of Therapy & Social Work Human Resources

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Goal 8: Refine the organizational structure to insure clarity, communication, and strategic goal alignment.


Analyze organizational chart to refine as appropriate to reflect core values.

Complete review of current structure by June 2015 Introduce recommendation by July 2015

CEO COO Nurse Executive Medical Director Human Resources

Refine upper management responsibilities and tasks for prioritization of responsibilities/time/actions.

Review current JDs and responsibilities by July 2015

COO Leadership Team Human Resources

Communicate revised organizational structure and responsibilities with entire organization.

By August 2015 CEO COO Human Resources

Increase opportunities for employee communication Develop and introduce Bi annual employee feedback survey for communications by June, 2015

Human Resources IT

Increase positive employee communication via open forums, system rounds, and regular clinical leadership visits to units

Establish a plan to address employee communication. February 1, 2015

COO Medical Director Clinical Leadership group Human Resources Nurse Executive

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Goal 9: Exceed the expectations of everyone we serve.


Actively promote vision of one organization through making the vision visible in every place of business and using consistent branding.

By September 2015 Marketing COO CEO

Enhance partnering with community agencies by developing an annual plan of contacts and actions.

By July 2015 Board Members COO CEO Marketing

Education of all organization members about internal and external communication excellence.

Develop plan by June 2015 Communicate by July 2015

IT Human Resources COO CEO

Analyze expectations of those we serve through survey/personal contact.

Analysis completed by July 2015

Marketing COO Quality Assurance Admissions

Develop satisfaction collection methods for internal and external customers.

By July 2015 Marketing COO Human Resources

Develop and implement an employee survey system to evaluate employee expectations.

By July 2015 Human Resources Leadership Team

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Goal 10: Invest in technology that improves the continuity and safety of care, improves

documentation, makes patient information accessible to appropriate health care

providers, enhances communication and provides decision support

Strategy Metric/Benchmark Responsible Person(s) Implementation of full EMR system including development and staff training

Training set for January and February 2015 Go live 30 days after Charleston Implantation 60 days after going live Develop Policies and Procedures for EMR

IT HCHI and Charleston EMR teams

Develop a Health Information System Plan for HCHI software needs

Meeting with IT committee on 1- 22-15 Team Formed and Kickoff Feb 2, 2015 Review with Finance committee June 2015

IT Committee IT

Intranet – Website Looking into Share Point program -presentation is set for 1-24-15 Review with Charleston new website in March 2015 Changes made for Clarksburg April 2015

Marketing IT

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Goal 11: Provide a reliable, well managed and secure information technology environment

Strategy Metric/Benchmark Responsible Person(s) Development and enforcement of Policy, Procedures, Standards for securing and maintaining hospital information

Meet with IT committee to develop policies & procedures on securing hospital information Jan 22, 2015 Policy Creation May 2015-July 2015 Completion September 2015

IT- Committee members IT Charleston -EMR

Social Media – positive and educational service for community and staff

Facebook to be set in a secure environment completion April 2015 Increase traffic –ongoing Improve functionality and feedback –ongoing

Marketing IT

Off site – Disaster Recovery Plan – HOT SPOT

Develop Disaster Recovery Plan by July 2015 Hot Spot Completion September 2015

HCHI and Charleston IT Alpha Technology

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Goal 12: Improve communication with patients, employees, partners, public and Board of

Directors about our mission, goals, performance and the benefits and services we

provide.

Strategy Metric/Benchmark Responsible Person(s) Develop & improve orientation for staff, patients and families to include hospital admission, vision, strategies & values

Identify coordinator of orientation by February 2015 Materials reviewed February-June 2015 Implemented by June 15, 2015

Orientation staff Staff Development COO Human Resources

Develop annual marketing & outreach plan, and an annual report that meets federal regulations for non-profits

Revise and update marketing plan 2015-2016 by April 1, 2015

Marketing COO

Develop website/Facebook that is consumer friendly & provides detailed information about services and support

Review Charleston Website enhancements March 2015 Develop Plan for additional work May 2015

Marketing Outside Assistance (Pikewood)

Increase communication with the Board of Directors

Education topics finalized by April 2015 Presenters notified and scheduled for Board Meetings

COO Leadership Team

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HIGHLAND-CLARKSBURG HOSPITAL APPENDIX 1

2015 STRATEGIC PLAN DEVELOPMENT STRENGTHS - BOARD, LEADERSHIP AND PLANNING COMMITTEE

TOP 5 STRENGTHS LOCATION/FACILITY - POTENTIAL FOR GROWTH DEDICATED STAFF AND LEADERSHIP BOARD AND COMMUNITY SUPPORT QUALITY PATIENT CARE RELATIONSHIP WITH STATE AGENCIES

SURVEY RESPONSES LOCATION DEDICATED STAFF COMMUNITY SUPPORT QUALITY PATIENT CARE DEDICATED STAFF ROOM TO GROW/EXPAND OPERATIONS RELATIONSHIP WITH STATE AGENCIES CLINICAL EXPERTISE MOTIVATED LEADERSHIP AUTONOMY SPACE AND OPPORTUNITIES ARE ENDLESS INITIATIVE TO GROW CURRENT LEADERSHIP SKILLS. WELL EDUCATED AND EXPERIENCED LEADERS GROWTH POTENTIAL COMAPSSION AND WILLINGNESS OF STAFF COMMUNITY SUPPORT STAFF FACILITIES LOCATION

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COLLABORATES WITH THE COMMUNITY NEW FACILITY LOCATION SERVICES OFFERED ROOM FOR EXPANSION INVOLVEMENT WITH THE COMMUNITY NEW FACILITY COMMITTED TO THE MENTAL HEALTH NEEDS OF WV POSITIVE ENVIRONMENT FOR STAFF AND PATIENTS BOARD AND COMMUNITY SUPPORT EXCITED AND DYNAMIC LEADERSHIP PHYSICAL PLANT LOCATION EXPANDABLE SPACE GOOD RELATIONSHIP WITH THE STATE GOOD PLANNING AND LEADERSHIP POTENTIAL FOR GROWTH BEAUTIFUL FACILITY DEDICATED STAFF ACTIVE INTERESTED BOARD OF DIRECTORS FACILITY AND LOCATION KNOWLEDGE AND LEADERSHIP OF MANAGEMENT

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2015 STRATEGIC PLAN DEVELOPMENT WEAKNESSES - BOARD , LEADERSHIP AND PLANNING COMMITTEE

TOP WEAKNESSES RECRUITMENT OF DOCTORS AND PROFESSIONAL STAFF INTERNAL AND EXTERNAL COMMUNICATION FINANCIAL POSITION STAFF RETENTION REGULATORY ISSUES THAT INHIBIT GROWTH LACK OF TECHNOLOGY

SURVEY RESPONSES LOCATION ESPECIALLY FOR RECRUITING DOCS AND NURSES BENCH STRENGTH - NO SUCCESSION PLAN OR FORMAL MGNT DEVELOPMENT RESTRICTIONS IN THE CON PROCESS ON ABILITY TO ADD SERVICES AND BUSINESS LINES ATTRACTING AND HIRING OF KEY STAFF AND PSYCHIATRISTS LACK OF BENCH STRENGTH/SUCCESSION PLANNING NEW FACILITY - LACK OF FUNDS AND ACCESS TO CAPITAL FOR GROWTH TECHNOLOGY ADVANCES STALLED - ERM, HRIS, ETC FRAGMENTED COMMUNICATION BETWEEN LEADERSHIP, NOT CONSISTENT COMMUNICATION STATE PROCESSES AND RESTRICTIONS FOR EXPANSIONS COMPETITION KNOWLEDGE OF MARKETING OF OUR SERVICES ACCESS TO DOCTORS STAFF RETENTION (BENEFITS, EDUCATION) STAFF NOT ADHERING TO P&PS DEFINITION AND ACKNOWLEDGEMENT OF ROLES AND RESPONSIBILITIES CENSUS/PATIENT COUNT

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OVERHEAD AND COST STRUCTURE RN COMPETITION STAFF RETENTION AND TURNOVER LACK OF SUPPORT FOR FRONT LINE PATIENT CARE STAFF EMPLOYEE BENEFITS TECHNOLOGY ADVANCES STALLED - ERM, HRIS, ETC LEADERSHIP NEEDS TO BE ACCESSIBLE AND FREQUENT VISITORS TO THE UNITS LACK OF STAFF PSYCHIATRISTS WAITING PERIOD TO CHANGE CON LACK OF PSYCHIATRISTS NEED TO STREAMLINE THE ADMISSION PROCESS TECHNOLOGY ADVANCES THAT WE ARE NOT ABLE TO USE COMMUNITY UNAWARE OF OUR SERVICES LIMITED ORGANIZATIONAL LIFE/DEVELOPMENT DIFFICULITY WITH PROBLEM SOLVING AND REMOVAL OF BARRIERS INADEQUATE BOTTOM UP AND TOP DOWN COMMUNICATIONS AVAILABLE MONEY VERSUS DEBT STATE CON PROCESS ATTRACTING QUALIFIED STAFF MAINTAINING CENSUS AND INCOME NEW TO NORTH CENTRAL WV WILL EVOLVE AS FOLKS KNOW HCHI LACK OF UNDERSTANDING OF WHAT HCHI SERVICES ARE PROVIDED EXPANSION OF SERVICES EXPANSION OF SERVICE AREA LACK OF A DRESS CODE/PERSONAL APPEARANCE FINANCIAL POSITION - LACK OF EQUITY AND CASH RESERVES PHYSICAN RECRUITMENT LEADERSHIP STABILITY FINANCIAL STATUS PREVIOUS COO DID NOT USE CHARLESTON EXPERIENCE SO FACILITY GOT OFF ON WRONG FOOT GETTING OUR MESSAGE OUT TO THE COMMUNITY

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ABILITY TO COMPETE FOR AND RETAIN STAFF DUE TO BENEFIT PACKAGE


2015 STRATEGIC PLAN DEVELOPMENT OPPORTUNITIES - BOARD, LEADERSHIP AND PLANNING COMMITTEE

TOP OPPORTUNITIES

ABILITY TO GROW/EXPAND SERVICES/ADD SERVICES PARTNERSHIPS WITH WVU AND OTHERS ON INTERNS, TEACHING, ETC. ENHANCE EMPLOYEE BENEFITS

SURVEY RESPONSES GROW CURRENT SERVICES AND DEVELOP NEW ONES PARTNERSHIP WITH WVU SCHOOL OF MEDICINE I HIRING DOCS COMMUMITY INVOLVEMENT TO MARKET OUR SERVICES HIRE HOSPITALISTS DEVELOP RELATIONSHIPS WITH SCHOOLS OF NURSING FOR RECRUITMENT AND HIRING MAINTAIN AND NURTURE RELATIONSHIPS WITH REFERRAL SERVICES LOOK FOR GRANT OPPORTUNITIES LONG TERM ALCOHOL/SA LONG TERM TREATMENT FACILITY BECOME A TEACHING HOSPITAL Step Down Units/Services

PRTF – Waiver to entry Longer Outpatient Services Telemedicine – USDA funding grant (See Attachment) 28 Day Program

Geriatric Unit Residential Adult IDD Veterans

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NEW SERVICES LIKE PRTF, JUVENILE FORENSIC, ADULT SERVICES, OUTPATIENT, ETC

INVESTMENT IN HEALTH PREMIUMS FOR EMPLOYEES

PROFESSIONAL AND SKILLS DEVELOPMENT

EXPANSION OF SERVICES EXPANSION OF SERVICE AREA STREAMLINE THE ADMISSIONS PROCESS - MEDICAL CLEARANCES, ETC

MEDICAL OFFICE BUILDING

EXPANSION OF SERVICES AS WE HAVE ABUNDANT SPACE

PARTNERSHIPS WITH COLLEGES AND UNIVERSITIES

BECOMING A TEACHING HOSPITAL

GROWTH IN FORENSICS

PARTNERSHIPS IN GEOGRAPHIC AREA

ABILITY TO EXPAND SERVICES

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HIGHLAND-CLARKSBURG HOSPITAL APPENDIX 4 2015 STRATEGIC PLAN DEVELOPMENT

THREATS - BOARD, LEADERSHIP AND PLANNING COMMITTEE

TOP THREATS FUNDING SOURCES PRESSURES - STATE, FEDERAL, FORENSICS, MEDICAID ABILITY TO RECRUIT PROFESSIONAL STAFF FINANCIAL ISSUES ASSOCIATED WITH NOT MEETING FINANCIAL GOALS (LOAN COVENANTS) REPUTATION ON ADMISSIONS AND RELATIONSHIP WITH REFERRAL SOURCES COMPETITION

SURVEY RESPONSES COMPETITION FINANCING ISSUES - LOAN CONVENANTS, DEBT PAYMENTS, ETC REPUTATION ON ADMISSIONS INABILITY TO RECRUIT MEDICAL CLINICAL PERSONNEL EXTERNAL POTENTIAL FOR UNIONS TO TARGET US EMPLOYEE TURNOVER AND MORALE ISSUES COMPETITION LOSS OF STAFF TO OTHER FACILITIES FINANCIAL STABILITY CHARLESTON - CLARKSBURG RELATIONSHIP LEADERSHIP INVOLVEMENT WITH THE LINE STAFF REFERRAL SERVICE FRUSTRATION WITH ADMISSION PROCESS NO WEEKEND ADMISSIONS TO THE 5N UNIT DEPENDENCE ON STATE HOSPITALS FOR FUNDING FOR FORENSICS FUTURE OF MEDICAID RISING COST OF BENEFITS AND WAGES NOT BECOMING AN EMPLOYER OF CHOICE

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PATIENT CARE DUE TO STAFF TURNOVER LACK OF INFORMATION TECHNOLOGY STAFF COMPETITION WITH THE VA, STATE AND OTHER HOSPITALS SHARPE HOSPITAL EXPANSION PERCEPTION THAT PATIENTS WILL STAY HERE AND CONTRIBUTE TO HOMELESS POPULATION NOT MEETING THE LOAN COVENANTS AND DEBT PAYMENTS NOT HAVING A WORKABLE, EASY TO USE EMR LACK OF STATE/FEDERAL FUNDING FOR MEDICAID AND FORENSICS MEDICAID MANAGED CARE STATE BUDGET DEFICITS MAINTAINING POSITIVE COMMUNITY RELATIONS FEDERALLY FUNDED REIMBURSEMENTS

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2015 STRATEGIC PLAN DEVELOPMENT STRENGTHS - STAFF

TOP STAFF STRENGTHS EXCELLENT STAFF WHO ARE COMMITTED TO PATIENT CARE OUR FACILITY AND THE ABILITY TO GROW AND EXPAND

SURVEY RESPONSES ALLOW STAFF TO BE CREATIVE AND ACTIVE IN HOSPITAL PROGRAMS QUALITY PATIENT CARE OVERALL WORK ENVIRONMENT WHERE STAFF ARE WELCOMED AND APPRECIATED INCREASE CASUAL ATTIRE FOR ALL DAYS COMMITTED STAFF OUR FACILITY TRAINING IS EXCELLENT 4 SOUTH NIGHT SHIFT WORKS AS A TEAM STAFF HAS GOOD RELATIONSHIP WITH PATIENTS TEAMWORK PATIENT SCHEDULE PAPERWORK - CHARTING GOOD TRAINING BY PRECEPTOR TINA LOWE PEOPLE I WORK WITH ARE LIKE FAMILY LOVE THE 3 - 12 HOUR SHIFTS AS I HAVE TIME FOR MY FAMILY ORIENTSTIONS ARE BETTER PAY IS GETTING BETTER OPEN DOOR POLICY FOR MANAGEMENT WORKING TOGETHER

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CURRENT ORG STRUCTURE WITH MED DIRECTOR, NURSE EXEC, COO WORKING TOGETHER ABILITY TO GROW CORE GROUP OF EMPLOYEES WHO ARE VESTED IN OUR SUCCESS WILLINGNESS TO CHANGE OUR PEOPLE WE ARE NEW, TIME TO PUT THINGS INTO PLACE HELPING THE LIVES OF OUR PATIENTS LINE STAFF ROOM TO GROW AND EXPAND CARING PEOPLE AND ORGANIZATION LOT OF POTENTIAL - NEED TO WORK ON THE KINKS FLOOR STAFF VERY GOOD CLINICAL/NURSING/PSYCHIATRIC TEAMS COMMITTED EMPLOYEES RESPONSIVNESS TO FEEDBACK CARING MANAGEMENT FOR THE PATIENTS TRAINING GOOD EMPLOYEES PROVIDING QUALITY PATIENT CARE MANAGEMENT(MOST) ENSURES THAT HCHI IS A FRIENDLY PLACE TO WORK ORGANIZATION WORKS TO REWARD THOSE WHO WORK HARD DIRECT CARE STAFF ABILITY TO MOVE FORWARD DESPITE HIGH TURNOVER EMPLOYEES ADAPTING TO CHANGING WORK NEEDS HR WORKING TO RESOLVE DIFFERENCES GREAT POTENTIAL GREAT BOND FOR RMPLOYEES OTHER THAN BEING AFRAID OF UPPER MANAGEMENT NOTHING REAL POSITIVE TO SAY SADLY BUT HEY IT’S A JOB QUALITY LINE STAFF CARING ABOUT THE PATIENTS GREAT POTENTIAL TO HELP THE COMMUNITY (HAVE NOT SEEN IT YEST) NOTHING MORE TO SAY WAITING ON IT TO GET BETTER CLINICAL SKILLS AND EXPERTITSE

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TEAMWORK AND COLLABORATION IN CLINICAL LEADERSHIP POTENTIAL FOR GROWTH AND DEVELOPMENT THE FACT THEAT HCHI EXISTS. OUR TRANSFORMER FACILITY IS TRULY A BLESSING EDUCATIONAL OPPORTUNITIES CARING STAFF CARING STAFF LOOKING FOR WAYS TO IMPROVE QUALITY OF CARE POTENTIAL TO BE GREAT OUR STAFF THE TRUE CARE, CONCERN AND POSITIVE LEADERSHIP MIKE CADORPH PROVIDED GREGG HALL'S COMMITMENT TO THE HOSPITAL OUR FACILITY GREAT PEOPLE WORK HERE PAY IS NOT BAD GREAT STAFF WITH GOOD ATTITUDES CO WORKERS WILLING TO HELP ONE ANOTHER FIXING PROBLEMS WHEN THEY ARISE GREAT STAFF WORKING WELL TOGETHER STAFF MAKES NEW EMPLOYEES FEEL WELCOME NEW COO IS OUTGOING. MAKES YOU FEEL LIKE PART OF THE TEAM STAFF WORKS WELL TOGETHER PAYCHECKS ARE ALWAYS ON TIME AND ACCURATE MANY BHTS GO ABOVE AND BEYOND WORK UNITS ARE LIKE FAMILY NEW FACILITY - GROWTH HARD WORKING FLOOR STAFF FORENSIC UNIT - AMBER DAVIS - GREAT UNIT ROOM TO GROW AND EXPAND NEW MANAGEMENT GOOD PEOPLE TO WORK WITH ROOM TO GROW AND EXPAND

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NICE FACILITY PATIENT ORIENTED AND GOOD CARE NIGHT TIME DIFFERENTIAL PHARMACY TEAM UNITS FOCUSED ON PATIENT NEEDS PHARMACY COMMUNICATION 12 HOUR SHIFTS GOOD STAFF. MOTIVATED THERAPIST AND CASE MANAGERS ROOM TO GROW AND EXPAND NEED IN THE COMMUNITY JOB SECURITY

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HIGHLAND-CLARKSBURG HOSPITAL APPENDIX 6 2015 STRATEGIC PLAN DEVELOPMENT WEAKNESSES - STAFF

TOP STAFF WEAKNESSES TURNOVER AND RETENTION OF EMPLOYEES COMMUNICATION TO EMPLOYEES BENEFITS NOT COMPETITIVE LACK OF STAFF MANAGEMENT PRESENCE ON THE UNITS

SURVEY RESPONSES CHALLENGE OF PATIENT CARE AND THE NEED TO FILL BEDS STAFF TURNOVER ONGOING STRUGGLE TO BEAT THE CLOCK - DOCUMENTATION, THERAPY, PLAN DEVELOPMENT, LACK OF STAFF POOR BENEFITS - NOT COMPETITIVE WITH OTHER HOSPITALS SAFETY - OUTDOOR LIGHTING SENIOR STAFF STAFF TURNOVER DANGEROUS ITEMS ON THE FORENSIC FLOOR - PATIENT ROOMS DON'T LOCK COMMUNICATION ATTITUDES NOT ABLE TO GET BREAKS DUE TO LACK OF STAFF NOT HONORING PROMISES SENIORITY/RECOGNIZED FOR A JOB WELL DONE PEOPLE NOT APPRECIATED PROMISES NOT HONORED PASSING OF THE BUCK BY MANAGEMENT - NOT ANSWERING QUESTIONS SENIORITY/RECOGNIZED FOR A JOB WELL DONE PEOPLE NOT APPRECIATED NOT ENOUGH STAFF - ALL WE HEAR IS FILL THE BEDS THE HOSPITAL IS DIRTY - BHTS ARE DOING THE CLEANING TRAINING ON PSYCH MATTERS LACK OF SOLID ORIENTATION FOR WORKING WITH PSYCHIATRIC PATIENTS

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PTO NOT SUFFICIENT (VACATIONS, SICK, PERSONAL) MORE MANAGEMENT PRESENCE ON THE FLOORS ARE NEEDED UNIT STAFF NEED TO BE WITH PATIENTS MORE PAY RATES TO MATCH OTHER HOSPITALS SYSTEMS AND PROCESS NEED TO BE SET UP PEOPLE DON'T KNOW THEIR JOB DESCRIPTIONS AND REQUIREMENTS PTO AND BENEFITS ARE HORRIBLE - HAPPY EMPLOYEES = BETTER WORK ENVIRONMENT MANAGEMENT NO ONE ASKS OUR OPINION OR IF THEY DO NOTHING HAPPENS WORKING ON UNITS WE ARE NOT TRAINED FOR NEED TO HIRE QUALITY AND HARD WORKERS WAY TO MANY CALL OFFS - PEOPLE ARE ABUSING IT NOT A GOOD WORK ENVIRONMENT - LOT OF NEGATIVITY UNPROFESSIONAL ADMINISTRATIVE STAFF - NOT TREATING STAFF EQUALLY UNPROFESSIONAL INTERACTION BETWEEN STAFF AND C/A PATIENTS - PROVOKING, DISRESPECT LACK OF STAFF ON THE UNITS STAFF BEING PULLED TO WORK ON DIFFERENT UNITS RECRUITING GOOD TO GREAT TALENT DUE TO BENEFITS MORE STAFF IN MAINTENANCE/HOUSEKEEPING/KITCHEN STAFF TURNOVER EMPLOYEE BENEFITS 401K PLAN SHOULD HAVE AN EMPLOYER MATCH PTO AS VACATION AND SICK ARE TOGETHER MANAGEMENT PROVIDING DIRECTION TRUST IN SOME DEPARTMENTS STAFF TURNOVER POLICIES NOT BEING ENFORCED INCONSISTENCY IN APPLICATION OF RULES AND POLICIES CALL OFF POLICY NEEDS CHANGED - TOO MANY CALL OFFS LACK OF COMMUNICATION RESULTING IN CONFUSION AT THE LOWER LEVELS THE BLAME GAME WHICH RESULTS IN THE WRONG PEOPLE BEING TARGETTED NEED FOR MANAGEMENT TO BE ON THE UNITS MORALE IS LOW DUE TO LOW STAFF AND HIGH TURNOVER NEED TO DEFINE ROLES OF NURSE EXEC AS SHE CAN FIRE UOU OR YOU GO ON HER HIT LIST;

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OTHERS ALWAYS WITH THE NURSE EXEC. NEED TO TALK TO THE NURSE EXEC NEED TO MAKE SURE THE HOSPITAL IS CLEAN BEETER JOB BY HOUSEKEEPING UPPER MANAGEMENT LEAVES A LOT TO BE DESIRED. SOME ARE HATEFUL. NEVER KNOW IF YOU HAVE A

JOB IF YOU ARE NOT A YES PERSON UPPER MANAGEMENT WILL HOUND YOU UNTIL YOU QUIT OR FIRE YOU MARKETING INFORMATION IS INACCURATE WHEN PRESENTED TO PUBLIC TEAMWORK AND COLLABORATION FROM ADMINISTRATION RECRUITING AND RETENTION OF STAFF FRUSTRATIONS WITH LOSING APPLICATIONS SUBMITTED ONLINE MORALE IS LOW. BUDGETARY CONCERNS? FINE TUNING THE PAGING SYSTEM. RESIGNATIONS ARE OCCURING DUE TO HOW HOSPITAL IS MANAGED POOR REPUTATION IN THE NURSING COMMUNITY ONGOING STRUGGLE TO FILL BEDS BALANCED WITH PROVIDING SERVICES DISCONNECT FROM ADMINISTRATIVE TO DIRECT CARE STAFF LACK OF COMMUNICATION RESULTING IN CONFUSION AT THE LOWER LEVELS LACK OF PROBLEM SOLVING ADOLESCENTS NOT RECEIVING INDIVIDUAL THERAPY NOT HIRING STAFF FOR C/A LACK OF TEAMWORK WITH ADMINISTRATION AND DIRECT CARE STAFF. NOT FEELING APPRECIATED NOT ENOUGH STAFF BENEFITS/SCHEDULE. I HAVE TO WORK EVERY WEEKEND TOO MANY PEOPLE OVERSTEP THEIR AUTHORITY LEVEL TOO MANY PEOPLE THINK THEY ARE THE BOSS COMMUNICATION BETWEEN ROTATING SHIFTS NEED TO IMPROVE C/A IS ALWAYS UNDERSTAFFED NURSE MANAGER SHOULD WORK A NIGHT SHIFT OPTION TO WORK 8 HOUR SHIFTS AS I HAVE BABY SITTER ISSUES STAFFING AND TURNOVER NO RAISES NO CONSISTENCY WITH MANAGEMENT NO LUNCH AFTER 12 1/2 HOURS MANDATED OVERTIME

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DAILY FLOAT TO COVER BREAKS BHTS RUN THERAPY AND NURSE GROUPS NO ONE ON ONE TIME FOR PATIENTS (CHILD/ADOL.) BHTS HAVE TO CLEAN ROOMS NO GLOVES AVAILABLE FOR BHTS. PATIENTS ADMITTED WITH CONTAGIOUS DISEASES FILLING OF BEDS WITH NO STAFF AVAILABLE DRS AND NURSES ARE RUDE WHEN APPROACHED BY HBTS WITH QUESTIONS DRS AND NURSES NEED TO LISTEN TO THE BHTS UPPER MANAGEMENT DOES NOT KNOW THEIR ROLE OR MAKE DECISIONS LACK OF STAFF INACCURATE INFORMATION IN ORIENTATION STAFF PULLED TO OTHER FLOORS FOCUS APPEARS TO BE ON INSIGNIFICANT ISSUES RATHER THAN THE BIG ONES LOW STAFF MORALE SOME UNITS ARE HELD TO HIGHER STANDARDS SOME PEOPLE HAVE BEEN INDIVIDUALLY TARGETTED SOME PEOPLE GO UNNOTICED IN THEIR CURRENT POSITIONS THERAPY DIR. NEEDS TO BE SEEN ON THE UNITS. NEVER CAN FIND HER.NO DIRECTION. PROGRAMS SUFFERING

COMMUNICATIONS

MAJOR ISSUE STAFF TURNOVER. WHY IS THIS HAPPENING???

HOW UPPER MANAGEMENT IS TREATING STAFF

UPPER MANAGEMENT NOT BEING VISIBLE ON THE UNITS

BEING TOLS TO EMAIL, TEXT OR CALL BECAUSE THEY DON'T HAVE TIME TO VISIT THE UNIT

PULLED TO OTHER UNITS WITHOUT TRAINING

EXPECTED TO WORK YOUR DAY OFF AND MANDATED OT

STAFF RETENTION

5 NORTH STAFF HAVE HAD LITTLE GUIDANCE. THERAPY MANAGEMENT HAVE NOT BEEEN APPROACHABLE

TOO MANY ADMINISTRATIVE POSITIONS THAT TAKE AWAY FROM FLOOR STAFF

NOTHING EVER DONE WHEN YOU RAISE A CONCERN

HIRING PRACTICES

PULLING STAFF TO OTHER UNITS

MANDATED OT OR WORKING DAYS OFF

UNABLE TO LEAVE FLOOR FOR BREAKS OR LUNCH DUE TO LACK OF STAFF

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BAD REPUTATION FOR TREATMENT OF EMPLOYEES. YOU ARE REPLACEABLE!!

LACK OF STAFF

ORGANIZATION

BEING PREPARED

LACK ODF STAFF

PULLING OF STAFF TO OTHER UNITS

NOT BEING PROACTIVE ON SCHEDULING AND CALL OFF COVERAGE

BAD MORALE DUE TO STAFF TURNOVER

LACK OF EDUCATIONAL OPPORTUNITIES

MINIMAL TRAINING

DISCONNECT BETWEEN UPPER MANAGEMENT AND STAFF

VERY LITTLE POSITIVE FEEDBACK

UPPER MANAGEMENT NOT ON THE UNITS

SUGGESTIONS MADE BY STAFF ARE LARGELY IGNORED

NURSING NOT HELD IN MUCH ESTEEM

NO OPEN COMMUNICATION

LOT OF "BUS THROWING"

STAFF SHOULD WEAR SCRUBS/UNIFORMS TO BE DISTINGUSISHED FROM PATIENTS

STREAMLINE ORGANIZATION STRUCTURE

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Appendix 7: Glossary of Abbreviations

ACHC Accreditation Commission for Health Care

CEO Chief Executive Officer

CEU Continuing Education Unit

CFO Chief Financial Officer

CMO Chief Medical Officer

CNO Chief Nursing Officer

COO Chief Operating Officer

C/O Complaints of

DOP Director of Pharmacy

D/S Debt Service

EAP Employee Assistance Program

EMR Electronic Medical Records

HR Human Resources

IS Information Systems

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IT Information Technology

IV Intravenous

IV RPh Intravenous (Infusion) Registered Pharmacist

QA Quality Assurance

RPh Registered Pharmacist

RN Registered Nurse

Rx Pharmacy

SW Social Work(ers)

UR Utilization Review

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Appendix 8: Highland-Clarksburg Hospital Strategic Planning Team

Board Planning Committee Highland-Clarksburg Leadership

Cynthia Persily-Chair Marilou Patalinjug Tyner

Paul Howe –Vice Chair Paula Herndon

Martin Howe Shelly Giaquinto

James Dissen Shannon Putnam

Michael Casdorph Cynthia Drury

Lisa Layden – Advisor Deborah Childers

Kathy Burr – Recorder Rae Ann Davenport-Johnson

Board Members

James H. Dissen

Michael Casdorph

Margaret Bailey

Cynthia Persily

Greg Gordon

Martin Howe

Paul Howe

Gary McCallister

strategic plan 2015 - 2018 - highland-clarksburg …...increase by 1 new signed agreement for...

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