winona health’s performance 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
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.
WH’s Performance Excellence System (PES) is designed to:
Create peace of mind by providing compassionate, personalized care
to our family, friends and neighbors.
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
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)
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
Central to WH’s Living Performance Excellence efforts is a Plan Do Check Act (PDCA) method
known by the acronym “STEP”
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
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
WH Quality Matrix
Delivery Systems Staff Setting Process
Quality Standards Safety Courtesy Performance Effectiveness
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.
Performance Excellence Journey
Minnesota Council for Quality (2003 – Present) Malcolm Baldrige Criteria (2004 – Present) Accreditation/Licensing Agencies State & National Projects Winona Health-Specific Initiatives
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
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.
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
Solution: Focus on Core Competencies
Integrated, Automated Technological Systems Strategic & Financial Planning Process Community Commitment Performance Excellence System
Lessons Learned
Commitment of Leadership Focus on Your Strengths Performance Excellence is EVERYONE’S
Responsibility There are NO Short Cuts