1. Women & Children’s Division Quality Department
Business Plan Proposal
July 20, 2014
Karen Fugate
Women & Children’s Quality Department Manager

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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.

14. 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

15. 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

16. 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