THE LONG & WINDING ROAD or How to approach Leadership and Board reporting – One Hospital’s Ongoing Journey -

1. THE LONG & WINDING ROAD or How to approach Leadership and Board reporting – One Hospital’s Ongoing Journey - J. Mark Randolph RN, CCM, CPHQ BSN, MA, Psy.D. (cand) Director – Quality/Risk Management Cookeville Regional Medical CenterCookeville, Tennessee

2. Cookeville Regional Medical Center Is a 247- all private bed, national award winning, regional referral center in the heart of the Upper Cumberland region of Middle Tennessee. This facility has been serving the surrounding population since 1950, and has grown over the years to provide inpatient, outpatient, rehabilitation, and emergency care in addition to a host of highly recognized specialty services and programs in both Cardiovascular and Cancer care. With over 140 physicians providing care in 36 specialties, CRMC is dedicated to bringing the best quality care to our patients and their families.

3. Awards & Recognition

4. OBJECTIVES • Using a Electronic Quality Management system to aid in the collection, management, and analysis of data. • Using Core Measures and Benchmarking data to build clinical performance feedback reports. • Using clinical performance data for performance improvement (i.e. improving outcomes), management decision making, aiding long-term planning, setting strategies, etc. • Using various techniques to communicate information and data across a organization to change behaviors and culture. • Showing how Board education & involvement in Quality & Safety makes a difference.

5. Informatics The value of a overall Quality Information System (QIS) can’t be overly emphasized, as the data needed for such detailed reporting requires the use of Informatics solutions to properly collect, analyze, and report it. At CRMC we use a system called MIDAS+ Care Management a product of MIDAS/ACS. This system went live in 1998.

6. Informaticscont. The MIDAS+ system has “modules” in use for the following areas (with their respective databases/repositories). • Risk Management • Quality Management • Performance Improvement • Patient Relations • Hospital Case Management • Infection Control • Surgery • Medical Records QA • Focus Studies • RCA’s, etc… And all of this data can be pulled together to produce reports that are very detailed as to the performance of staff and patient outcomes in our facility.

7. Education & Training In 2007 one of our Board of Trustee members – Mr. Richard Grogan assisted a THA working committee in the development of a training program for Tennessee Hospital Trustee members that allowed them to become certified Board Members. Once this program was established, all of our Board members completed the necessary training and became certified by THA. To this day, this training is required of all our new Board members, and our entire board maintains a certified status. This gives our Board the knowledge base to provide the oversight for our organization to continue it’s climb to excellence.

8. Education & Training cont. Since training and education for the Board and Leadership is crucial in this ever changing field of healthcare. CRMC has chosen Estes Park as the provider of choice for this ongoing, extended training. All Sr. Managers, Medical Executive members, and Board of Trustee members are sent to a week long Estes Park training session. Topics covered include: Reforming the hospital board structure, Using the hospital board to improve care, Board organization for the future, Payment reform to encourage more effective care, Advocating health policy that directs better delivery of care, etc…

9. Organization Over the last few years, we have had a complete restructuring of our Performance Improvement plan and various reporting structures. This was done to stream line both process and time requirements. As noted in the partial view of the CRMC Organizational chart below there are now 2 Quality “entities” in our organization: The Board Quality Committee and the CRMC Quality Council. Both of these allow for Quality related data and discussion to be held at the highest level of leadership and management. This along with the information shared with Department directors (and then with their staff) allow for both bottom up and top down interaction as we proceed on the course toward a culture of Safety and Quality.

10. Tools Also with the restructuring in the PI plan came a variety of new forms and tools that would allow for reporting PI data and projects, but would avoid unnecessary length and unwieldy formats which tended to foster tardiness, uncertainty, frustration, and hesitancy in sharing.

11. Leadership Reports On a monthly basis the “Quality Dashboard” report is provided to both Sr. and mid-level management during our regular scheduled directors meetings. This report covers key facility care indicators such as core measures, mortality rates, readmits, LOS, Falls, Med Errors, Return to Surgery, etc.

12. Leadership Reports cont. In addition, on a Quarterly basis the “Quality Dashboard” report is also printed in a “stoplight” (red, yellow, green) format, with spark line trend graphs. These are distributed to all departments for review, discussion, and posting in their areas. This allows the staff to know where we are in our quality journey, and also allows them input into the process.

13. Facility-wide Committee • On a Quarterly basis the CRMC Quality Council meets to review and discuss quality related matters in the facility. Departmental PI projects are reviewed, and data/reports from key programs & committees reported. • This group is chaired by the Director of Quality with the following members: • CCO, • VP Ancillary, • Dir – Med Rec, • Dir – Case Mgt, • Dir – Education, • Risk Mgr, • Infection Prevention Mgr, • Safety Coord, • Chief of Staff, • Board Chairperson

14. Board-level Committee Also on a Quarterly basis the CRMC Board Quality Committee meets (usually the week after Quality Council) to review and discuss high level quality related activities & matters in the organization. Topics covered include items such as; Medical Staff quality efforts, National Patient Safety Goals, TN Patient Safety Initiative, ACS NSQIP project, HCAHPS and Core Measure Public Scores, etc. This allows the Board members to keep up to date on these matters and the ability to offer oversight.

15. CRMC Housewide PI Projects for 2008 - 2010(including CMS 9th SOW) • Core • Acute Myocardial Infarction (AMI) • Heart Failure (HF) • Pneumonia (PNEU) • Surgical Care Improvement Program (SCIP) • Others • IHI Ventilator Associated Pneumonia (VAP) • IHI Rapid Response Teams (RRT’s) • TN Patient Safety Initiative • Central Line Infections • MRSA Prevention • SCIP • ACS NSQIP

16. Example of Board Involvement & Support During a recent Board Quality Meeting, a dramatic improvement was reported in our VAP (ventilator associated pneumonia) rate/project in which our rate dropped 60-70%. After the meeting, Gail Stearman RN, FNP – Vice Chairperson CRMC Board of Trustees decided that she wanted to thank our ICU staff for all their hard work in achieving this excellent outcome for our patients. So, she came up to the unit on her own time, and brought cookies to celebrate this achievement with staff members. Sometimes it’s just the simple things that count…

17. Challenges • Reliable data abstraction & entry for performance indicators • Cultural Change – “we must work as a team for success” • Recognition for Excellence not just negative outliers • Maintain updated Data systems in today’s $$$ environment • Recognition that behavior change will not happen overnight • Development of staff level involvement and ownership in Performance Improvement efforts • Exploring the use of other PI methodologies to gain further improvement in behavior (i.e. Positive Deviance, etc)

18. Software Tools Used for Quality & Safety Reporting MIDAS+ Care Management ACS/MIDAS www.MidasPLUS.com Microsoft Excel 2003 sp3 Microsoft Corporation www.microsoft.com Bissantz SparkMaker Basic v 4.0.4.0 Bissantz & Company GmbH Nordring 98 D-90409 Nuernberg Germany www.bissantz.com/sparkmaker

20. Contact Information J. Mark Randolph – MRandolph@crmchealth.org 931-783-2481