1. Managing Performance from
All Angles
Susan McGann, Chief Performance Officer and
Mary C. Magee, MSN, RN; Administrative Director of
Quality & Regulatory Affairs
2
New Targeted/
Measureable Approach
• 3 Campus Health System
• 485 Beds
• 4500+ Employees
• 850+ Medical Staff
• 127,000+ Annual ED Visits
• 146,000+ Outpatient Visits
Aria Health

2. 3
New Targeted/
Measureable Approach
• Decentralized
• Department Specific
• Connectivity to Strategic Goals
• Alignment
• Coordination & Oversight
• Measures & Formatting
Scorecards
4
New Targeted/
Measureable Approach
• Strategic Initiatives
• Campus Initiatives
• Regulatory Initiatives / Tracers
• Rounding Activity
• Projects: Task Force or Formal Team
• Data du jur
Initiatives & Projects

3. 5
New Targeted/
Measureable Approach
“A journey of a thousand miles
begins with a single step.”
Lau-Tzo
Aha Moment
•The Board Room Visual
6
New Targeted/
Measureable Approach
• Campus Administrator
• Information
– Campus Initiatives
– Projects: Task Force or Formal
– Regulatory
• Sources of information
• Mechanics of gathering information
• Pulling it all together
• A NEW Day in the Life……..
A Day in the Life…

4. 7
New Targeted/
Measureable Approach
8
New Targeted/
Measureable Approach
Scorecards
ARIA
Scorecard
QTOPS
BC FC TC
Strategic
Initiatives
Scorecard
Built w/
project
Quality/Professional
Committee
Scorecard

5. 9
New Targeted/
Measureable Approach
Scorecards
• QTOPS ARIA Health
– BC
– FC
– TC
• Quality & Professional
Board
• Missed Opportunity
• Patient Safety
• Strategic Initiatives
– Best Place to Work
– Medical Staff
Development
– Environment of Clinical
Excellence
10
New Targeted/
Measureable Approach
Scorecards

6. 11
New Targeted/
Measureable Approach
Header
LSS Projects
Built
Mammography
Credentialing
Pre-Employment
O.R. Flow TC
ED Flow
12
New Targeted/
Measureable Approach
Header

7. 13
New Targeted/
Measureable Approach
Header
Projects
Built
ARIA
Suicide
Assessment
& Prevention
Food
for
Thought Medical Staff
&
Hospital Initiative
Aligning Unit
Measures
to Campus Level
Crimson Initiative
DOH
Projects (2)
Patient Safety
Education
14
New Targeted/
Measureable Approach
Frankford Campus
Projects
Built
FC
Digital
Mammography
ICARE
Hourly Rounding
Visitor
Management
Community
Outreach
Plant
Operations
CAUTI –
On the CUSP

8. 15
New Targeted/
Measureable Approach
2010 Timeline
LSS
Kickoff
Jan Feb March April May June July
Meetings
w/
Strategic
Initiative
Teams
Built
LSS
Projects
Admin
Training
Created
new
HR
QTOPS
Planning
Meetings
Review
Verification
of QTOPS
Metrics
ASE
Kickoff
Senior
Leadership
Finalize HR
Metrics &
Built
Scorecard
Built Quality/
Professional
Scorecard
Finalized SI
Environment
of Clinical
Excellence
Objectives,
Measures in
progress
Attended
the Client
Conference
Aug Sept
Tim S -
SLT
Training
Finance
Trainin
g
FC Scorecard
Oct
Nursing Measures
data loading
Missed
Opportunity
Scorecard
Training Additional
Employees
Med Staff
SI
Projects
Presented
to
Nursing
Leadership
Tim S-SL
Meeting
BC Scorecard
Planning
Discussions
FC using
ASE in meetings
Turnover of Staff
Visual
Maps
Briefing
Books - Dan
SI Clinical
Excellence
Pt Safety
projects
Patient Safety
scorecard
Infection
Prevention
Scorecard
FC Nursing
Scorecards
Nov Dec
TC Nursing
Scorecards
BC Nursing
Scorecards
16
New Targeted/
Measureable Approach
2011 Timeline
Shared
drive
FC
Jan Feb March April May June July
Client
Conference
BC Nurse
Managers
Training
IROUND
Training
IP Dept
ASE
presented
to BC
Managers
Meeting
Alignment
of unit
measures
to campus
level
Nurse
Managers
FC Training
Created
Templates VR
FC
Projects
Aug Sept Oct
DOH
Scorecard
created
Regulatory
Projects
CORE Measure
Campus
Level
SLT
Training
Nov
Projects FC
Dec
FC Nurse
Managers
Feb data
reports
BC campus
level data
BC Nurse
Managers
Training
Hosp wide
shared drive
created
IP Nursing
measures
connected
to campus
level
IRound = Active DC
Tracers

9. 17
New Targeted/
Measureable Approach
• How is it used?
– Board Mtgs: phasing out the paper
– Senior Leadership: key metrics, variance & status reports
• Campus Administrator: key metrics, projects, initiatives, variance
& status reports
– Committee Mtgs: dashboards, results, progress
– Campus “Coffee & Scores”: results, discussion
– LSS Report Outs
– NEW – under construction: Regulatory Compliance
Nitty Gritty
18
New Targeted/
Measureable Approach
• Turning Rounds and Tracers
into real-time usable data
• Easy
• Efficient
• Cost Effective
ActiveDC

10. 19
New Targeted/
Measureable Approach
• Infection Prevention
– Hand Hygiene
– Ventilator Associated Pneumonia
– Infection Prevention Tracer
• Safe Haven
• Physician Satisfaction “Ask Me Three”
Pilot
20
New Targeted/
Measureable Approach
• Paper world: 78.2 hrs/quarter - 5 people doing
data entry & analysis and 15 people doing the
monitoring per hour
• Averaged 850 observations per quarter
• As of 4.21.11: 220 observations, 6 people, 0
data entry hours
• Updated stats to be presented at conference
Hand Hygiene

11. 21
New Targeted/
Measureable Approach
• Standard of care “bundle” for patients on
ventilators
• Challenges with paper audits
• Audits performed
• ActiveDC Results= clear picture of opportunities
• Campus Administrators / Nursing Directors
• “Real Time” feedback & interventions in ICU on
existing patients!
VAP
22
New Targeted/
Measureable Approach
• ASE
– Total number of scorecards
– Total number of measures
– Total number of projects / initiatives
– Nursing Measures Created, Data Loaded & Unit Scorecards Created
– Briefing Books, Falls Dashboard – Used with Task Force
– Projects loaded into Medical Staff Dev-SI
– Project loaded into Clinical Excellence-SI
– Two of three campuses with scorecards, projects, & initiatives
– FC – Expanded metrics, using in meetings
– Additional training of staff & leadership
– Patient Safety, Infection Prevention Scorecards, Missed Opportunity, DoH
– Visual Maps, Templates for VR and Status reports
– Rapid Deployment
• iROUND/ActiveDC
– Adoption of concept / idea
– Rapid deployment
– Training
– Pilot Testing
– Real Audits / Tracers
Major Accomplishments

12. 23
New Targeted/
Measureable Approach
• Directional Building – it does matter!
• Measure Inventory
• Data Definitions
• Nomenclature & Labeling
• Buy-in
• Ownership & Accountability
• It’ll take off!
• Usage brings out new ideas Support Team
Major Lessons
24
New Targeted/
Measureable Approach
Contact Information
Susan McGann, CPO
smcgann@ariahealth.org
Mary C. Magee, Admin. Dir. of Quality
mmagee@ariahealth.org
Q&A THANK YOU!