Women & Children’s Division Quality Department Business Plan Proposal July 20, 2014 Karen Fugate Women & Children’s Quality Department Manager kfugate@tgh.org

Postpartum Antepartum 11/28/2018 Business Summary New program focused on quality and safety within a not-for-profit organization affiliated with a teaching university Full service Women & Children’s Division including: Labor & Delivery (high risk and low risk) High risk antepartum Postpartum Transition Nursery Level III NICU Pediatrics PICU Pediatric Day Surgery Quality Safety Transition Nursery NICU PICU Pediatrics L&D Postpartum Antepartum

11/28/2018 Mission Statement To develop hospital systems that consistently deliver efficient, equitable, safe, high quality, evidence-based healthcare to all pregnant and recently delivered women, infants and children. Aligns with organization mission

11/28/2018 Goals and Objectives 1 To identify and develop processes that decrease medical errors 2 To develop a process to adopt and maintain evidence-based clinical practice guidelines 3 To document and report monitoring activities, data analysis, and recommendations for improvement 4 To ensure compliance with all regulatory requirements and certifications 5 To ensure appropriate resources are available to support the program

Benefits to the organization 11/28/2018 Benefits to the organization Decrease medical errors Develop “Harm Across the Board” (HAB) dashboard for division Work with Informatics Dept to extract “meaningful” data from EMR Collaborate with interdisciplinary teams to develop improvement plans Regulations and Certifications CMS Recommended Pediatric Core Measures The Joint Commission – Perinatal Care Core Measures CMS Obstetric Adverse Events Evaluate compliance with all regulatory requirements within division Data Analysis Evaluate results relative to established goals, regulations and benchmarks Communicate data in a useable format Evidence-based practice Help identify EBP opportunities Assist with EBP projects Develop EBP guidelines Cost Increase efficiency Analyze high cost patient populations Eliminate “non-value added” processes

Gap Analysis Current situation Challenges Action required 11/28/2018 Gap Analysis Current situation Increasing focus on quality and safety Project increase in regulatory requirements Transparency of quality metrics – public reporting Cost impact – Pay for performance Not meeting quality metrics Challenges Current staff task-saturated Current healthcare climate requires individuals skilled in quality methodology Action required Strategically placed professional quality staff

Meeting the needs of the organization 11/28/2018 Meeting the needs of the organization Provide cutting edge, evidence-based care with an outcomes focus Improved efficiency, decreased waste Improve patient experience Prototype for other divisions Increase market share Increase visibility – speaking and publication opportunities

Marketing Strategy: Selling the program 11/28/2018 Marketing Strategy: Selling the program Program managed by Quality professional with proven track record within organization Focus on collaborative, interdisciplinary team work and decision making Results driven Collaborative goals Project management Increased focus on quality attracts the “best and brightest” Professional growth for all disciplines Reputation – increase pride

Marketing budget No marketing costs 11/28/2018 Marketing budget No marketing costs Engage stakeholders at quality committee meetings Report results/success to leadership (nursing and medical) Advertise program internally in newsletters Create program website on organization intranet

Start up costs: 2014 Total $310,000 Operating expense 11/28/2018 Start up costs: 2014 Operating expense Program director salary $90,000 Quality staff salary (x 2 RNs) $140,000 Business Intelligence staff salary x 1 $45,000 Benefits $20,000 Office supplies $1000 Computers and software $4000 Staff orientation and training $10,000 Total $310,000

Statement of Operations: Fiscal year ending September 30, 2014 11/28/2018 Statement of Operations: Fiscal year ending September 30, 2014 Revenues Dollars saved from eliminating preventable harm (direct costs) $150,000 Reduced financial penalties (Medicare/Medicaid) Total $300,000 Expenses Wages and benefits $295,000 Office supplies $1000 Education and training $2000 Total $298,000 Operating income $2,000 *This is a revenue saving department, not revenue generating

Reporting structure *CEO reports to Board of Directors CNO 11/28/2018 Reporting structure Quality Department Staff Director Reports to VP of Women’s & Children’s Service VP of Women’s & Children’s Services reports to CNO CNO reports to COO who reports to *CEO CNO VP of Women & Children’s Services Director of Women & Children’s Quality Dept RN Staff Business Intelligence Staff *CEO reports to Board of Directors

Collaboration with leadership team 11/28/2018 Collaboration with leadership team Director of Women & Children’s Quality reports directly to VP of Women & Children’s Services; however Director also has close working relationship with CQO Projects, focus areas, and goals are determined collaboratively with input from Director, VP, and CQO. Consideration is given to ensure projects align with hospital initiatives.

Salary Determination/Considerations 11/28/2018 Salary Determination/Considerations Dependent upon budget determination Depends on how organization values position and what it can afford Define the job as clearly as possible Write a job description and don’t use title only to determine salary Basing salary on title only can be very unreliable Helps to ensure you are comparing “apples to apples” when researching salaries Do a market analysis once job is clearly defined Seek assistance from HR to do analysis Set a salary range Entry level is based on experience Annual evaluation determine raises Bundle pay and “perks” Flex time, work from home, benefits, etc. Work with HR to define “perks” and benefits

Hiring Plan Advertise for positions with assistance from HR 11/28/2018 Hiring Plan Advertise for positions with assistance from HR Prior to interview, applicants are screened by HR HR can assist with finding the right employee to fit into the organization culture which is “patient first” Behavioral assessment survey prior to consideration for interview Conduct interviews to fill positions Candidates should interview with Director Peer-to-peer interview if applicable Use consistent, structured interview process defined by HR to identify potential employees that are a “good fit” for culture of the organization

Ready, set, GO Fill positions Orient 11/28/2018 Ready, set, GO Fill positions Orient Discuss projects, goals, and focus areas Outline roles, responsibilities, and expectations Assign projects commensurate with experience Allow opportunities for professional growth Determine metrics to measure success Meet with team on a regular basis to discuss progress and metrics Director will assume responsibility for some projects and will always be available for assistance/consult and as a mentor Open door policy