February 5, 2009 St. Louis, Missouri

1. AHCA Quality Symposium “Process Design and Management”“And identifying associated operational performance measures and outcomes these produce for tracking daily operations.” February 5, 2009 St. Louis, Missouri

2. while also The Duality of Work Principle Everyone has two jobs: “Working in the Process” (delivering results) “Working on the Process” (improving how we do the work) Management has the special responsibility of providing a work environment that enables, encourages, and rewards this behavior.

3. Why the Focus on Process? • “A manager’s ability to build and institutionalize the capabilities, of people, the organization, and systems requires a focus on core processes” - Craig Weatherup, Pepsi-Cola • “If you have processes that are in control, you know how the organization is working…You can’t redesign processes (systems) unless you know what you’re trying to do.” - Paul Allaire, Xerox” • “Capabilities only come by combining a competency with a reliable process” - Jan Leschly, SmithKline Beecham

4. Why the Focus on Process? • From The Harvard Business Review: How Process Enterprises Really Work • (9-1-2001) • Process enterprise structure flies in the face of most companies, which operate as fiefdoms. Product and functional teams jealously guard power and turf - - and process integration threatens their control. • New, horizontal processes pull people in one direction - - old, vertical management structures pull them in another. Confusion and conflict abound. • Process enterprises replace these turf and hierarchy battles with new approaches to leadership, performance measurement, compensation, and training, and all harmonizing with integrated, streamlined processes. • Process owners are the most visible difference - - assign a senior manager end-to-end responsibility for each process, including authority over work and budgets!!! They design the process, measure its performance, and train the frontline workers who perform it - - though employees still report to unit heads. 4

5. Why the Focus on Process? • From The Harvard Business Review: How Process Enterprises Really Work • (9-1-2001) • Traditional vertical management styles have no place in process enterprises, where lines of authority blur. Process owners manage processes - - but unit owners manage the people who perform them. With this split in authority, both kinds of managers must work differently with each other and with the front line: • Focus on customers and teamwork • Negotiate and collaborate • Exert influence rather than authority • Coach and develop (rather than control) front-line employees • Need to take a fresh look at many of the basic elements of the organizational infrastructure: • Measurement • Compensation • Facilities • Training and development • Career paths 5

6. Why the Focus on Process? “Design in” quality when the costs are the lowest Show customers a quality products right from the start 6

7. Steps Toward Mature Processes (2) Early Systematic Approaches (1) Reacting to Problems Strategic & Operational Goals Strategic & Operational Goals (3) Aligned Approaches (4) Integrated Approaches Strategic & Operational Goals Strategic & Operational Goals

8. Steps Toward Mature Processes 8

9. Process Improvement: Attributes of a Well Managed Process • Has a start time (something triggers its initiation) and a stop time (there are clear deliverables); can be periodic or highly repetitive • Has a defined flow of when and how each step adds value by transforming inputs into output for a customer • Is not constrained by artificial boundaries such as functional organizations • Uses feedback loops and tracks trendable measures in order to determine the “goodness” of the process over time • Has an owner who feels responsible for the “goodness” of the process independent of functional boundaries • Is systematic (not bureaucratic) and agile -- thus supporting dynamic change and improvement to respond to changing business needs • Process owners and performers have a strong sense of the linkage of their process with other processes in the organization

10. Process/System Approach • Underlying Premise: Everyone belongs to a process/system. All work is a process. Nothing gets done without people and a process. Process (working in a process) Input Output Supplier (internal or external to company) Customer (internal or external to the company) Feedback (working on the process; continuous improvement; this forms the basis of PDCA) This is a key ingredient of making a process “systematic”

11. Process Characterization Worksheet (SIPOC) Stakeholders: Suppliers: Inputs: Outputs: Customers: Process Name: t (start): t (done): Process Owner: Process Performers: . Key Performance Measures: Process frequency (volume):

12. Process Characterization Worksheet Stakeholders: The individuals or groups that have a vested interest in the performance of the process but do not define the requirements of the outputs. Process Name: the working name of the process Suppliers: Inputs: Outputs: Customers: The individuals or groups that provide the inputs for the process. The things necessary to perform the value-added tasks of the process. The products or services that the process delivers. The individuals or groups who receive the outputs of the process; they do define the requirements of the outputs. t (start): the most significant starting or triggering event that starts the process t (done): the most significant completion event of the process cycle Process Owner: The person who is responsible for the goodness of the process irrespective of whether they own all of the resources performing the process Process Performers: The individuals or groups who perform the value adding tasks in the process. Key Performance Measures: The measures used to determine the “goodness” of the performance of the process; i.e., quality, cost, cycle time, satisfaction, value. Process frequency (volume): The rate of repetition of the process; i.e., how often the process occurs

13. Critical To Quality The Product/Service/Cost characteristics that are important to the customer from the customer's point of view

14. Critical-to-Quality (CTQ) Attributes

15. Process Flow Chart

16. Process Flow – Swim Lane Format

17. P-D-C-AProcess Improvement

18. P-D-C-AProcess Improvement • Plan • Complete Project Scope Worksheet • Select Team Members • Determine Root Cause • Do • Develop action plan • Pilot Action Plan on a small scale • Check • Verify that results of pilot are effective • Act • Standardize the Improvement/Change • Extend to all appropriate parts of the organization

19. P-D-C-AProcess Design

20. P-D-C-AProcess Design • Plan • Determine Team: SME’s, Process Owners, Those Who Control Resources, Those Impacted • Complete Statement of Work • Compile “critical-to-quality” (CTQ) customer requirements • Review Evidence and Best practices • Do • Develop New Design - Simulate • Pilot on an appropriate scale • Check • Evaluate effectiveness of design, Does it meet CTQ? • Act • Standardize the change on a wide scale

21. Work Systems & Processes • Key Work Systems • 1. Health Care 2. Business 3. Support

22. Process Characterization

23. Applicable Baldrige Criteria

24. Strengths Opportunities for Improvement (OFI) 6.1 Work Systems Design Evaluation 0% - 100% In the Baldrige Criteria, this Item asks the applicant to: Describe how your organization designs its work systems and determines its key processes to deliver patient and stakeholder value, prepare for potential emergencies, and achieve organizational success and sustainability. Strongly Strongly Disagree Agree 6.1.a 1. The organization designs and innovates your overall work systems? How you decide which processes within your overall work systems are internal to the organization (your key work processes), and which will use external resources? 6.1.a 2. How do your work systems and key work processes relate to and capitalize on your core competencies?. 6.1.b 1. What are you organization’s key work processes? How do these processes contribute to delivering patient and stakeholder value, profitability or financial return, organizational success, and sustainability? 6.1.b 2.How do you determine key work process requirements, incorporating input form patients, stakeholders, suppliers, partners, and collaborators, as appropriate? What are the key requirements for these processes? 6.1.c.How do you ensure work system and workplace preparedness for disasters or emergencies? How does your disaster and emergency preparedness system consider prevention, management, continuity of operations for patients and the community, evacuation and recovery? 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

25. Strengths Opportunities for Improvement (OFI) 6.2 Work Process Management and Improvement Evaluation 0% - 100% In the Baldrige Criteria, this Item asks the applicant to: Describe how your organization implements, manages, and improves its key work processes to deliver patient and stakeholder value and achieve organizational success and sustainability. Strongly Strongly Disagree Agree 6.2.a How do you design and innovate your work processes to meet all the key requirement? How do you incorporate new technology, organization knowledge, and the potential nee for agility into the design of these processes? How do you incorporate cycle time, productivity, cost control, and other efficiency and effectiveness factors into the design of these processes? 6.2.b 1. How do you implement and manage your work processes to ensure that they meet design requirements. How does your day-to-day operation of these processes ensure that they meet key process requirements? How is workforce, patient and stakeholder, supplier, partner, and collaborator input used in managing these processes? What are your key performance measures or indicators and in-process measures used for the control and improvement of your work processes? 6.2.b 2. How do you address and consider each patient's expectations? Howe are health care service delivery processes and likely outcomes explained to set realist patient expectations? How are patient decision making and patient preferences factored into the delivery of health care services? 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

26. Strengths Opportunities for Improvement (OFI) 6.2 Work Process Management and Improvement Evaluation 0% - 100% In the Baldrige Criteria, this Item asks the applicant to: Describe how your organization implements, manages, and improves its key work processes to deliver patient and stakeholder value and achieve organizational success and sustainability. Strongly Strongly Disagree Agree 6.2.b 3. How do you control the overall costs of your work processes? How do you prevent rework and errors, including medical errors? How do you minimize the costs of inspections, tests, and process or performance audits, as appropriate? 6.2.c How do you improve your work processes to achieve better performance, to reduce variability, to improve health care services and health care outcomes, and to keep the processes current with health care service and business needs and directions? How do you incorporate the results of the organizational performance reviews discussed in response to Item 4.1 into the systematic evaluation and improvement of your work processes? How are work process improvements and lessons learned shared with other organizational units and processes to drive organizational learning and innovation? 1 2 3 4 5 1 2 3 4 5 26

27. Strengths Opportunities for Improvement (OFI) 7.5 Process Effectiveness Outcomes Evaluation 0% - 100% In the Baldrige Criteria, this Item asks the applicant to: Summarize your organization’s key operational performance results that contribute to the improvement of organizational effectiveness, including your organization’s readiness for emergencies. Segment your results by health care service offerings, by patient and stakeholder groups and market segments, and by processes and locations , as appropriate. Include appropriate comparative data. Strongly Strongly Disagree Agree 7.5.a1. What are you current levels and trends in key measures or indicators of the operational performance of your work systems, include work system and workplace preparedness for disasters or emergencies? 7.5.a2. What are your current levels and trends in key measures or indicators of the operational performance of your key work processes, including productivity, cycle time, and other appropriate measures of process effectiveness, efficiency, and innovation? 1 2 3 4 5 1 2 3 4 5

28. Thank You! Questions? Jon Frantsvog, Administrator/CEO St. Benedict’s Health Center & Benedict Court 851 4th Avenue East Dickinson, ND 58601 701·456·7242 jon.frantsvog@bhshealth.org