NMHS: The Baldrige Journey Lee Greer, M.D., MBA Chief 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

Leadership Operations Focus Operations Focus Workforce Focus Workforce Focus Customer Focus Customer Focus Strategic Planning Strategic Planning Results Organizational Profile 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 Eight EPP Steps Deployment OCTOBER Evidence Gathering SWOT Evidence Analysis Prioritization Approve Plan Entity Plans Budget Workforce

NMHS Goals Entity/Facility Goals Work Unit Goals Employee Goals NMMC Service Line Goals Workforce Alignment

“Your calling is calling……” NMMC-Tupelo Employee Entrance

Organizational Culture RECOGNITION & 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 95 th 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 Data Evidence-based literature and current practice guidelines Selected external comparative databases Baldrige winners and other industries Above the 90 th 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

Overall Sepsis Mortality

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