the executive team's role in accountability - methods to...

1 © 2008 Studer Groupwww.studergroup.com

The Executive Team’s Role in Accountability

Methods to Sustain Results Beyond TrustAudrey Meyers, MBA, FACHE

President and CEO, Valley Health System

Linda Lewis, RN, MSA, CNAA, BC, FACHEVice President/CNO, Initiative Champion

The Valley Hospital (Ridgewood, NJ)

Barbara Hotko, RN, MPA, Coach, Studer Group

What’s Right in Health CareSM | Evidence to Outcomes




Session Objectives

At the conclusion of this session you will be able to:• List key tactics that can be easily adopted to

elevate and reinforce the Executive Staff’s role in accountability to ensure a culture of execution

• Describe the value of Evidence Based tactics (Must Haves) and how they become even more critical to sustaining excellence when challenged by external environment conditions

• Implement verification methods beyond trust for sustainability


The Executive Team’s Role in Accountability Methods to Sustain Results Beyond Trust


HOSPITALAMI

TOTALJOINT HIP

LUNGCANCERSTROKE

Balanced Results!



External Environment

• Hospital Closings• State Budget Cuts• Physician Stressors• Renewal • Reimbursement Challenges

– CMS– HCAHPS

The CEO’s Role in AccountabilityAbsolute Commitment at the Top



Valley’s Mission

The Valley Hospital serves the community by healing and caring for patients, comforting their families and teaching good health. The Valley Hospital is distinguished by a commitment to:• Excellence in clinical care• Innovation in programs and technology• Providing a compassionate and respectful

environment

We are here to SERVE the patient

Results



Inpatient Satisfaction

25

35

45

55

65

75

85

95

2000 2001 2002 2003 2004 2005 2006 2007

43rd

95th %


0

10

20

30

40

50

60

70

80

90

100

2000 2001 2002 2003 2004 2005 2006 2007

Emergency Department

46th

92nd%



Same Day Surgery

0102030405060708090

100

2000 2001 2002 2003 2004 2005 2006 2007

33rd

96th %


Outpatient Satisfaction

50556065707580859095

100

2003 2004 2005 2006 2007

89th91st %



Employee Satisfaction

0

25

50

75

100

2000 2003 2006

60th

90th %


RESPONSE RATE = 45%

Mailed = 727

Returned = 330

Internet responses = 20%

Physician Satisfaction

3

• Mean Score = 81.1

• 97th percentile National Database

• 99th percentile New Jersey

• 99th percentile for AHA Region 2

January 2007 ~ The Valley Hospital ranked #3 in the National Database

of 287 facilities!!



SG Fire Starter of the Month Award, March 2007


Valley Health System Ranking

• Top 10 for the third consecutive year

• Ranked #8 among large employers

• Only Bergen County Hospital to be included as a Top Employer since inception in 2005

• Ranked first or second of all hospital or health system employers for all four years



The Valley Hospital HCAHPS Ranking

The Valley HospitalThe highest ranked hospital in

Bergen, Passaic and Rockland Counties


HCAHPS Comparative Results

Percent of patients who reported YES, they would definitely recommend the hospital

71%

73%

78%

83%

68% 70% 72% 74% 76% 78% 80% 82% 84%

Holy Name

Englewood

Hackensack

VALLEY

U.S. Average 67% State Average 64%


CEO ~ Key Tactics Methods to Sustain Results Beyond Trust


CEO ~ Key Tactics

• Leadership Institute – Accountability Grid

• Pillar Agendas– “Service Excellence” Hardwired Agenda Topic

• Executive Team• Management Forum

• Monthly review key strategies on Accountability Grid (MARK Book)



Verification Methods Beyond Trust

• Results (achieving objectives)– Monitoring progress

• Documentation (Rounding Logs)– % compliance

• Observation (AIDET observation sheets)– Competency

• Accountability Grid – Review 90 day plan


Monthly MARK Review

Leaders monthly meeting agenda items for discussion with direct supervisor:

MARK (Management Accountability Resource Kit)• Update on Goals and Objectives progress• 90-Day Plan• Accountability Grid from Leadership Institute• Rounding Logs • Recognition Logs • People Trends and Issues-Standards of Behavior




Aligning Leaders Behaviors with Desired Behaviors:

a) Review 90 Day Plan(s) with your supervisor

b) Review Scorecard with your supervisor



The Executive Staff

The Executive Team’s Role in Accountability

Hardwiring at All Levels



Hardwiring at All Levels

• The Nine Principles®

• Leadership Institutes• Leadership Accountability• Hardwiring the “Evidenced Based

Leadership Practices”• Aligning Organizational Goals• Service Excellence Teams• Reward and Recognition

The Executive Staff ~ Key Tactics Methods to Sustain Results Beyond Trust



The Executive Staff ~ Key Tactics

Evidence Based LeadershipDirections:• Evaluate how well the following Evidence

Based Leadership Practices have been hardwired using the following scale:– 1 = Never – 2 = Sometimes (at least 25% of the time)– 3 = Usually (at least 50% of the time)– 4 = Always (greater than 90% of the time)


Leadership EvaluationsAll leaders have goals aligned with the

organization’s goalsLeaders are held accountable for consistent

performance during the evaluation periodResults affect evaluations90-day action plans are current.Performance is reviewed monthly during 1:1

supervisory meetings

ScoreEvidence Based Leadership Practices

Evidence Based Leadership SurveySemi-annual self-assessment tool



Rounding for OutcomesSenior Leader Rounding Rounding on StaffRounding on PatientsRounding on Internal CustomersRounding Logs are discussed with supervisorsCommunication of findings to all employees

ScoreEvidence Based Leadership Practices

Evidence Based Leadership SurveySemi-annual self-assessment tool


Evidence Based Leadership Self-Assessment Results: How Hardwired is Rounding?

53

3322

55

2842

0102030405060708090

100

Department leaders havedefined parameters forrounding on patients

Outcomes from rounding aredocumented and reviewed

during supervisory sessions

Compliance with roundingparameters are compiled andreported on a regular basis

% Always

% Usually

Information collected from an Evidence Based Leadership survey: data reflects “% Always” answered when Rounding on Patients

Goal



Evidence Based Leadership Self-Assessment Comparative Results

2.12

3.05

0

1

2

3

4

20072008

Information collected from a 2007 and 2008 Evidence Based Leadership survey: data reflects data reflects overall score

There is communication to all employees on the outcomes from rounding including newsletters, employee forums,

department communication boards


Evidence Based Leadership Self-AssessmentComparative Results

2.63.05

0

1

2

3

4

20072008

Information collected from a 2007 and 2008 Evidence Based Leadership survey: data reflects data reflects overall score

Rounding logs and outcomes are reviewed during each supervisory session

Documentation is an important method of verification



Rounding on Patients - 1Q08 “Did a Nurse Manager Visit You During Your Stay?”

95 99 98 99

6347

32

51

0

10

20

30

40

50

60

70

80

90

100

Overall Nurses Section Response toConcerns/Complaints

Likelihood toRecommend

Perc

entil

e R

anki

ng

YesNo

Leader Rounding

Tactic and Tool Implemented:

N= 396

N= 95

N= 393 N= 334 N= 380

N= 95

N= 74

N= 94


Valley Results: Patient SatisfactionThe Executive Staff’s Role in Accountability

0102030405060708090

100

1st Qtr2007

2nd Qtr2007

3rd Qtr2007

4th Qtr2007

1st Qtr2008

IPEDAmb SurgOP

Above the 90th

percentile



Inpatient Units above the 90th percentile 1Q08

99 99 99 99 99 99 99 9892 90

0

10

20

30

40

50

60

70

80

90

100

Maternity CCU CS1 Wmnhelt C.4A

Per

cent

ile

Above the 90th

percentile

ICU IMC CS2 P.3WP.2E


0102030405060708090

100

1Q07 2Q07 3Q07 4Q07 1Q08

No EDYes EDOverall

99% 99% 99% 99% 99%

The Executive Staff’s Role in AccountabilityDeeper Diagnostic Analysis

Impact of ED Admissions on Inpatient Satisfaction



The Executive Staff’s Role in AccountabilityIt Takes a Team to Tackle Top Patient Priorities


The Executive Staff’s Role in AccountabilityDeeper Diagnostic Analysis



Key Lessons Learned

• Trust, then Verify– Verification methods . . .

• Do not have to be complex• Create discipline • Reinforce what you want • Can easily be replicated• Drill down and diagnose your data• Facilitate outcomes and sustain results


Valley’s 2008 Service Excellence Legends



What Truly Creates Results that Last?

“Leadership that is consistently excellent from

leader to leader, department to department, division to

division.”

Results that Last, Quint Studer, Introduction, Page xiii

Thank You!Audrey Meyers, MBA, FACHE

President and CEO, Valley Health System

Linda Lewis, RN, MSA, CNAA, BC, FACHEVice President/CNO, Initiative Champion

The Valley Hospital (Ridgewood, NJ)

Barbara Hotko, RN, MPACoach, Studer Group

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