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  • HENRY FORDHEALTH SYSTEM

    Detroit, Michigan

    2011 Malcolm Baldrige National Quality Award Application

  • Table of ConTenTs

    Glossary of Terms and Abbreviations

    Organizational ProfileP.1 OrganizationDescription.......................................................................................................................................i

    P.2 OrganizationalSituation......................................................................................................................................iv

    Category 1: Leadership1.1 SeniorLeadership.................................................................................................................................................1

    1.2 GovernanceandSocietalResponsibilities...........................................................................................................3

    Category 2: Strategic Planning2.1 StrategyDevelopment..........................................................................................................................................6

    2.2 StrategyImplementation......................................................................................................................................9

    Category 3: Customer Focus3.1 VoiceoftheCustomer........................................................................................................................................10

    3.2 CustomerEngagement.......................................................................................................................................12

    Category 4: Measurement, Analysis, and Knowledge Management4.1 Measurement,Analysis,andImprovementofOrganizationalPerformance......................................................15

    4.2 ManagementofInformation,Knowledge,andInformationTechnology...........................................................17

    Category 5: Workforce Focus5.1 WorkforceEnvironment.....................................................................................................................................19

    5.2 WorkforceEngagement......................................................................................................................................21

    Category 6: Operations Focus6.1 WorkSystems.....................................................................................................................................................25

    6.2 WorkProcesses...................................................................................................................................................28

    Category 7: Results7.1 HealthCareandProcessOutcomes....................................................................................................................30

    7.2 Customer-FocusedOutcomes.............................................................................................................................38

    7.3 Workforce-FocusedOutcomes...........................................................................................................................41

    7.4 LeadershipandGovernanceOutcomes..............................................................................................................44

    7.5 FinancialandMarketOutcomes.........................................................................................................................48

  • Glossary of Terms and abbreviaTions5 Million Lives Campaign IHI-sponsored national initiative to protect patients from harm; 5M refers to goaleliminate 5M harm events nation-wide100K Lives Campaign IHI-sponsored national initiative to reduce mortality through implementation of evidence-based practices in hospital care

    a

    A&CC Audit and Compliance Committee of the BOT ACC American College of CardiologyACGME Accreditation Council for Graduate Medical EducationResponsible for the accreditation of U.S. post-MD medical training programs; accomplished through a peer review process and based upon established standards and guidelinesAction Plan Collection of specific actions, resources, responsibilities, and timelines that respond to short- or long-term strategic initiatives. ADLI Approach, deployment, learning, integrationAHA American Hospital AssociationAHRQ Agency for Healthcare Research and QualityAIP Annual Incentive PlanALA Advanced Leadership Academy. 18 month formal Leadership development program/cohort for individuals selected by SL as potential successors to Performance Council. Allopathic Medical training that leads to a Doctor of Medicine degree (M.D.)AMA American Medical AssociationAmbulatory Services provided on an outpatient basisAME Annual mandatory educationAMGA American Medical Group AssociationAMI Acute Myocardial Infarction (heart attack)AOA American Osteopathic AssociationNational accrediting body for osteopathic health care organizationsAOHPH Association of Occupational Health Professionals in HealthcareAOS Available on siteAPM Action Plan MonitorAugmentation Helping labor progress by doing something to stimulate contractions.BAA Business Associate AgreementRequirement in the vendor policy for all vendors to follow all HIPAA guidelinesBBP/OPIM Blood-borne Pathogen/Other Potentially Infectious MaterialBCBSM Blue Cross and Blue Shield of MichiganBCN Blue Care NetworkBHS Behavioral Health ServicesBOB Book of BusinessBOG Board of GovernorsBOT Board of TrusteesBU Business Unit

    Bundle Set of separate but interdependent clinical processes or practices that together drive a desired outcome

    C

    CA CancerCABG Coronary Artery Bypass GraftCAHPS Consumer Assessment of Healthcare Providers and SystemsMember satisfaction survey used by HAPCAP College of American PathologistsCapitated A payment mechanism by which a health plan gives the provider a set fee per member per month (PMPM) regardless of treatment required. Care Coordination Approaches in the process of care to ensure patients needs are met and hand offs between care givers and settings are error freeCARF Commission on Accreditation of Rehabilitation FacilitiesCarePlus Classic Original version of the EMR and associated data repository of patients medical recordsCBC Complete blood countCC Community CareMarket segment which includes community-based and in-home servicesCCs core competenciesCCS Community Care ServicesCDC Center for Disease ControlCDS Corporate Data StoreA secured, comprehensive data warehouse which includes information from various clinical, revenue cycle, and business systems CE Customer EngagementCenters of Excellence Programs certified as Centers of Excellence by external agenciesCEO Chief Executive OfficerCEU Clinical Education UnitsEducation required by nurses and other Allied health professionals to maintain licensure and certificationCESC Customer Engagement Steering CommitteeChampion (Safety, Engagement, etc.) Internal consultants to individual BUs. For example, engagement champions focus on employee engagement and retention initiatives. They develop and recommend department, BU and System-wide initiatives based on Engagement Survey data to drive improved engagement scores and decreased turnover as well as create tools and resources for managers to help them build and sustain a highly engaged workforce environment. Safety Champions perform a similar role focused on safety.CHAP Community Health Accreditation ProgramCHASS Community Health and Social Services Clinic (Federally Qualified Health Centers)CHNA Community Health Needs AssessmentCHP Community Health ProgramsCHRO Chief Human Resource OfficerCIO Chief Information Officer

  • CISC Care Innovation Steering CommitteeA cross-System team focusing on innovations in prevention and chronic disease management Clinical job function Allied health, behavioral health, clinical support, nursing, physician, researchCME Continuing Medical EducationEducation required by physicians and other clinicians to maintain licensureCMO Chief Medical OfficerCMS Centers for Medicare and Medicaid ServicesFederal agency responsible for the administration of Medicare/Medicaid CNEC Corporate Nurse Executive CouncilThe Code Code of ConductExpectations for ethical and moral behavior COI Conflict of InterestCommunity Care Patient segment for all CCS services CON Certificate of needState laws and programs to restrain health care facility costs and allow coordinated planning of new services and constructionCOO Chief Operating OfficerCore Measures Standardized, or core, quality performance measures reported by The Joint Commission (TJC) accredited hospitals, aligned with measures required by CMS, and endorsed by NQF; viewed as integral to improving the quality of care provided to hospital patients and bringing value to stakeholders by focusing on evidence-based care processes for AMI, HF, pneumonia, and surgical infection preventionCOS Culture of SafetyCPM Customer Potential ManagementHFHSs customer relationship management vendors databaseCPNG Care Plus Next Generationsignificantly enhanced EMR implemented in 2011CPOE Computerized Physician/Provider Order Entry CPT Community Pillar TeamCQO Chief Quality OfficerCrimson Physician performance improvement software from the Health Care Advisory BoardCRM Customer relationship managementpatient preference databaseCrucial Conversations HFHSU class offered to leaders to improve retention and enhance conflict management CSCM Catastrophic Senior Case ManagementCSR Customer Service RepresentativeCTO Combined Time Offvacation, sick and personal timeCV Cardiovascular

    d

    Days Cash on Hand Measures the number of days that operating expenditures are covered by cash balances DME Durable medical equipmentDNV DNV Healthcarea hospital accrediting agency. DR Disaster recoveryDVT Deep Vein Thrombosisblood clot

    DVT Protocols Approaches to minimize risk of potentially fatal blood cl