Winona Health’s Performance Excellence System Kathleen Lanik Chief Quality & Safety Officer

1. Winona Health’s Performance Excellence System Kathleen Lanik Chief Quality & Safety Officer

2. Our Vision • Winona Health will be a recognized leader in the revolutionary transformation of community healthcare. Our Mission • Devoted to improving the health and well-being of our family, friends, and neighbors. • A service environment where people can realize their full potential. • Excellence & leadership in clinical care & service • Customer Focus • Stewardship of Resources

3. Winona Health’s Values Integrity– We do no harm. Service– We serve with compassion, dignity, and respect. Loyalty– We build relationships that exceed expectations. Excellence– We improve performance through learning and innovation.

4. WH’s Performance Excellence System (PES) is designed to: Create peace of mind by providing compassionate, personalized care to our family, friends and neighbors.

5. WH’s Performance Excellence System (PES) has Four Quality Standards that Guide all Actions: • Safety: Do no harm • Courtesy: Be kind, caring and selfless • Performance: Deliver an excellent care experience • Effectiveness: Obtain results by design

6. WH’s Performance Excellence System (PES) includes: • Living Service Excellence (LSE) Tools and Initiatives for Staff Performance Management Provides a System-Wide Approach to Staff Excellence • Living Performance Excellence (LPE) Tools and Initiatives for Process Improvements Provides an Organization-Wide Approach to Performance Improvement (PI)

7. Winona Health’s Performance Excellence System • Living Service Excellence • Staff Performance Management • Tools • LSE Standards/Values • Performance Evaluation • Role Summaries • LSE Award Program • Winona Health University • Employee Pride Survey • Experience Compass • Living Performance Excellence • Process/Performance Improvement • Tools • STEP • Lean • By Design Matrix • Experience Compass • Root Cause Analysis • Fact-based Decision Making • Evidence-based Practice • Failure Mode Effects & Analysis

8. Central to WH’s Living Performance Excellence efforts is a Plan Do Check Act (PDCA) method known by the acronym “STEP”

9. The STEP/PDCA process is initiated by: • S – See the Opportunity Identifying Opportunities for Improvement (OFIs) and Completing an Opportunity Statement Suggesting an Improvement Initiative • T – Team UpTeam is Developed, Goals Set, & Timeline for Development is Established • E – Evaluate Evaluating the Plan Through Continued Data Collection and Analysis • P – Proceed Proceed to Adopt Change or Determine to Study Further

10. LEAN QUALITY THINKING - A Change in the Mental Model - Process Whole System Management Strategy FLOW vs. Silos Quality Focus On What PATIENTS Expect Coordinated Care – Not Just Competency of Care Controlling Cost Elimination of Waste

11. WH Quality Matrix • Delivery Systems • Staff • Setting • Process • Quality Standards • Safety • Courtesy • Performance • Effectiveness

12. WH Experience Compass Needs (North) Stereotypes (South) Emotions (East) Wants (West)

13. WH’s Performance Excellence process supports continuous pursuit of excellence, and is enhanced by: Memberships Minnesota Council for Quality (MCQ) American Society for Quality (ASQ) Institute of Clinical Systems Improvement (ICSI) Institute for Healthcare Improvement (IHI) Participation Center for Medicare/Medicaid Services (CMS) Quality Project 5 Million Lives Campaign Minnesota Hospital Association Call to Action Initiatives In recognition of its efforts, WH has been recognized by multiple local, state and national organizations.

14. Performance Excellence Journey • Minnesota Council for Quality (2003 – Present) • Malcolm Baldrige Criteria (2004 – Present) • Accreditation/Licensing Agencies • State & National Projects • Winona Health-Specific Initiatives

15. Baldrige Journey

16. Baldrige Journey Notable Strengths: • Visionary Leadership Focused on the Future • Valuing Staff and Partners • Patient-Focused Excellence • Management By Fact “Pretty Good Practices” • Systematic 6-Step Process to Manage Staff Performance • Mentoring Program

17. Baldrige Journey 2005 Opportunity for Improvement (OFI) 4.1b(1) – Winona Health does not have a fact-based, systematic process in place to evaluate and improve its systems for the review and analysis of measures and organizational performance. As a result, opportunities to improve the measurement and review systems may be missed and/or effective measurement and review practices may be misunderstood and discontinued.

18. Past Data Reporting Schedule

19. Past Data Reports

20. Question: What Do We Need? • A System That Automates Our Processes • A System That Addresses Multiple Needs Within Our Organization: • Reporting to wide range of constituents • Tracking of data at all levels in the organization • Alignment with our strategic plan • Supportive of our Performance Excellence System • Web-based application for easy access

21. Solution:Focus on Core Competencies • Integrated, Automated Technological Systems • Strategic & Financial Planning Process • Community Commitment • Performance Excellence System

22. Performancesoft Data Management

23. Performancesoft Data Reports

24. Performancesoft Books

25. Lessons Learned • Commitment of Leadership • Focus on Your Strengths • Performance Excellence is EVERYONE’S Responsibility • There are NO Short Cuts

26. “We are what we repeatedly do. Excellence, then, is not an act, but a habit.” -- Aristotle

27. Questions?