SSM Health Care Category 4: Information and Analysis

Information and Analysis The MBNQA Information & Analysis criteria The MBNQA Information & Analysis criteria SSM’s approach to information management and measurement SSM’s approach to information management and measurement –Information systems infrastructure –Performance Management Process –Use of comparative data

MBNQA Categories 1.Leadership 2.Strategic Planning 3.Focus on Patients, Other Customers, and Markets 4.Information and Analysis 5.Staff Focus 6.Process Management 7.Results

Malcolm says…..

4: Measurement, Analysis and Knowledge Management 3: Focus on Patients, Other Customers and Markets 6: Process Management 2: Strategic Planning 5: Staff Focus 7: Organizational Performance Results 1: Leadership Organizational Purpose: Environment, Relationships and ChallengesFramework

MBNQA Category 4 INFORMATION AND ANALYSIS Performance Measurement/Analysis Select and align measures Select and align measures Gather/integrate data to support daily operations/decision making Gather/integrate data to support daily operations/decision making Ensure effective use of comparative data Ensure effective use of comparative data Analyses to support leaders’ review and strategic planning Analyses to support leaders’ review and strategic planning Communicate results to enable effective decision-making Communicate results to enable effective decision-making Align results of analysis Align results of analysis

Make needed information available to all stakeholders Make needed information available to all stakeholders Ensure data integrity, reliability, accuracy, timeliness, security, confidentiality Ensure data integrity, reliability, accuracy, timeliness, security, confidentiality Ensure hardware/software reliability and user-friendliness Ensure hardware/software reliability and user-friendliness Keep system current with health care needs Keep system current with health care needs MBNQA Category 4 INFORMATION AND ANALYSIS Information Management

SSM Information Center (SSMIC) 2002 recipient of the Missouri Quality Award Compliance Administration Group Information technology Applications development Client Response Center Decision support

IS Planning and Management SSMHC System Strategy Network / Entity IMC Vendors / Consultants Nursing Informatics Medical Informatics e-Health / Web IMC HIPAA Revenue Cycle ePMI Network/User Group Teams System IMC Tactical Teams Operational Teams Project Office Entity Membership Capital Allocation Committee Entity Service Level Agreements Plan / Check Do / Act LISTENINGPOSTNEEDSASSESSMENTSLISTENINGPOSTNEEDSASSESSMENTS INPUTSINPUTS SSM Information Center

Access Anytime, Anywhere… Physician Connectivity

Our Mission Exceptional patient, employee, and physician satisfaction Exceptional clinical outcomes Exceptional financial performance

Performance Management Process Unplanned re- admission rate within 31 days of discharge Inpatient loyalty Overall employee satisfaction Overall physician satisfaction Operating margin % Growth indicators Reimburse -ment indicators Productivity/ expense indicators Liquidity indicators Profitability indicators Inpatient loyalty indicators Employee satisfaction indicators Physician satisfaction indicators Service & quality indicators Exceptional financial performance Exceptional patient, employee & physician satisfaction Exceptional clinical outcomes Through our exceptional health care services, we reveal the healing presence of God. Alignment of Indicators

Gathering, Integrating and Presenting Data Performance Indicator Reports (PIR) Different Source Systems - General Financial (ERP) - Materials Management (ERP) - Human Resources - Clinical Systems - Satisfaction Systems Data Warehouse

Performance Indicator Report (PIR) Rollup Operations PIR System- Level Indicators (SSMHC PIR) Hospital Operations PIR

Hospital Operations Performance Indicator Report

Operations Performance Indicator Report – System

Performance Analysis – System-Level Indicators Year to Date Performance Initiative Indicators Actual Plan To Plan > 5% favorable Within 5% of plan > 5% unfavorable Hospital Operations GrowthAcute Admissions ReimbursementPatient Revenue Per APD Producitvity/CostOperating Expense Per APD ProfitabilityOperating Margin % Clinical31 Day Acute Readmission Rate Service & QualityInpatient Loyalty Index SatisfactionEmployee Satisfaction Indicator Satisfaction Physician Satisfaction Indicator 137,656 $1,410 $1, % 4.5% 49.5% 74.1% 77.6% Consolidated Operations ProfitabilityOperating Margin % 1.5% 2.4% Liquidity Unrestricted Days Cash on Hand Skilled Nursing Home ProfitabilityOperating Margin % Service & Quality Daily Physical Restraints Prevalence Home Health ProfitabilityOperating Margin % Service & QualityHomecare Patient Loyalty Index Physician ProfitabilityNet Revenue Per Physician ProductivityPractice Direct Operating Cost % 136,884 $1,336 $1, % 4.2% 52.9% 71.8% 73.6% 1.4% 3.9%. 12.0% 56.9%. $35, % -1.9% 5.1%. 8.4% 64.0%. $33, % Year to Date Performance Initiative Indicators Actual Plan To Plan

Corrective Action Plans IndicatorVariance Inpatient loyalty index< 70% of entity goal Operating margin %> 5% unfavorable to YTD Plan 31-day acute readmission rate160% of entity goal Acute admissions> 5% unfavorable to YTD Plan Employee satisfaction< 60% of entity goal Physician satisfaction< 60% of entity goal Hospitals and networks use them frequently … for virtually every red light that exists on the PIR. Hospitals and networks use them frequently … for virtually every red light that exists on the PIR. Required by policy for certain indicators: Required by policy for certain indicators:

Inprocess Measures Category 6: Inprocess measures used to manage day to day processes? Category 6: Inprocess measures used to manage day to day processes? In-process indicators: Measurements that indicate how a process is working. Also called leading indicators. Provide early warning signals to tell us if we are moving towards/away from our goals. Category 4: Gather/integrate data to support daily operations/ decision-making Category 4: Gather/integrate data to support daily operations/ decision-making

Functional Groups’ Inprocess Measures ER – Time from door to treatment or physician time (whichever is earlier) ER – Time from door to treatment or physician time (whichever is earlier) Surgery - % limbs marked: Surgery - % limbs marked: –Correctly –Incorrectly –Not marked Radiology turnaround time Radiology turnaround time Pharmacy- Drug cost/patient day (measured daily) Pharmacy- Drug cost/patient day (measured daily)

Deploying the Plan  Departmental Posters  Passport Program

Comparative Data National health care database Patient-level information Departmental-level information Improved clinical outcomes Cost reduction Opportunities

Clinical Indicators with Statistically Significant Variation

Direct Cost Opportunities by Service Line

Lessons Learned Lessons Learned Measurement is essential to improvement Measurement is essential to improvement Don’t compare yourself to just averages - - unless you want to be average Don’t compare yourself to just averages - - unless you want to be average Attention to inprocess (leading) indicators as well as to outcome (lagging) indicators Attention to inprocess (leading) indicators as well as to outcome (lagging) indicators Alignment of measures and strategic goals is essential Alignment of measures and strategic goals is essential Measure what is important Measure what is important Measurement is essential to improvement Measurement is essential to improvement Don’t compare yourself to just averages - - unless you want to be average Don’t compare yourself to just averages - - unless you want to be average Attention to inprocess (leading) indicators as well as to outcome (lagging) indicators Attention to inprocess (leading) indicators as well as to outcome (lagging) indicators Alignment of measures and strategic goals is essential Alignment of measures and strategic goals is essential Measure what is important Measure what is important