4 references check the attachment Sutter Davis Hospital in the modules readings, along with ?supplement these with Marketlin

HENRY FORD HEALTH SYSTEM

Detroit, Michigan

2011 Malcolm Baldrige National Quality Award Application

Table of ConTenTs

Glossary of Terms and Abbreviations

Organizational Profile P.1  Organization Description ………………………………………………………………………………………………………………………i

P.2  Organizational Situation ……………………………………………………………………………………………………………………..iv

Category 1: Leadership 1.1  Senior Leadership ……………………………………………………………………………………………………………………………….1

1.2  Governance and Societal Responsibilities ……………………………………………………………………………………………..3

Category 2: Strategic Planning 2.1  Strategy Development …………………………………………………………………………………………………………………………6

2.2  Strategy Implementation ……………………………………………………………………………………………………………………..9

Category 3: Customer Focus 3.1  Voice of the Customer ……………………………………………………………………………………………………………………….10

3.2  Customer Engagement ………………………………………………………………………………………………………………………12

Category 4: Measurement, Analysis, and Knowledge Management 4.1  Measurement, Analysis, and Improvement of Organizational Performance ………………………………………………15

4.2  Management of Information, Knowledge, and Information Technology …………………………………………………..17

Category 5: Workforce Focus 5.1  Workforce Environment …………………………………………………………………………………………………………………….19

5.2  Workforce Engagement ……………………………………………………………………………………………………………………..21

Category 6: Operations Focus 6.1  Work Systems …………………………………………………………………………………………………………………………………..25

6.2  Work Processes …………………………………………………………………………………………………………………………………28

Category 7: Results 7.1  Health Care and Process Outcomes……………………………………………………………………………………………………..30

7.2  Customer-Focused Outcomes ……………………………………………………………………………………………………………..38

7.3  Workforce-Focused Outcomes ……………………………………………………………………………………………………………41

7.4  Leadership and Governance Outcomes ………………………………………………………………………………………………..44

7.5  Financial and Market Outcomes………………………………………………………………………………………………………….48

Glossary of Terms and abbreviaTions 5 Million Lives Campaign IHI-sponsored national initiative to protect patients from harm; 5M refers to goal— eliminate 5M harm events nation-wide 100K 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 Cardiology ACGME Accreditation Council for Graduate Medical Education—Responsible for the accreditation of U.S. post- MD medical training programs; accomplished through a peer review process and based upon established standards and guidelines Action Plan Collection of specific actions, resources, responsibilities, and timelines that respond to short- or long- term strategic initiatives. ADLI Approach, deployment, learning, integration AHA American Hospital Association AHRQ Agency for Healthcare Research and Quality AIP Annual Incentive Plan ALA 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 Association Ambulatory Services provided on an outpatient basis AME Annual mandatory education AMGA American Medical Group Association AMI Acute Myocardial Infarction (heart attack) AOA American Osteopathic Association—National accrediting body for osteopathic health care organizations AOHPH Association of Occupational Health Professionals in Healthcare AOS Available on site APM Action Plan Monitor Augmentation Helping labor progress by doing something to stimulate contractions. BAA Business Associate Agreement—Requirement in the vendor policy for all vendors to follow all HIPAA guidelines BBP/OPIM Blood-borne Pathogen/Other Potentially Infectious Material BCBSM Blue Cross and Blue Shield of Michigan BCN Blue Care Network BHS Behavioral Health Services BOB Book of Business BOG Board of Governors BOT Board of Trustees BU Business Unit

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

C

CA Cancer CABG Coronary Artery Bypass Graft CAHPS Consumer Assessment of Healthcare Providers and Systems—Member satisfaction survey used by HAP CAP College of American Pathologists Capitated 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 free CARF Commission on Accreditation of Rehabilitation Facilities CarePlus Classic Original version of the EMR and associated data repository of patients’ medical records CBC Complete blood count CC Community Care—Market segment which includes community-based and in-home services CCs core competencies CCS Community Care Services CDC Center for Disease Control CDS Corporate Data Store—A secured, comprehensive data warehouse which includes information from various clinical, revenue cycle, and business systems CE Customer Engagement Centers of Excellence Programs certified as Centers of Excellence by external agencies CEO Chief Executive Officer CEU Clinical Education Units—Education required by nurses and other Allied health professionals to maintain licensure and certification CESC Customer Engagement Steering Committee Champion (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 Program CHASS Community Health and Social Services Clinic (Federally Qualified Health Centers) CHNA Community Health Needs Assessment CHP Community Health Programs CHRO Chief Human Resource Officer CIO Chief Information Officer

CISC Care Innovation Steering Committee—A cross- System team focusing on innovations in prevention and chronic disease management Clinical job function Allied health, behavioral health, clinical support, nursing, physician, research CME Continuing Medical Education—Education required by physicians and other clinicians to maintain licensure CMO Chief Medical Officer CMS Centers for Medicare and Medicaid Services— Federal agency responsible for the administration of Medicare/Medicaid CNEC Corporate Nurse Executive Council The Code Code of Conduct—Expectations for ethical and moral behavior COI Conflict of Interest Community Care Patient segment for all CCS services CON Certificate of need—State laws and programs to restrain health care facility costs and allow coordinated planning of new services and construction COO Chief Operating Officer Core 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 prevention COS Culture of Safety CPM Customer Potential Management—HFHS’s customer relationship management vendor’s database CPNG Care Plus Next Generation—significantly enhanced EMR implemented in 2011 CPOE Computerized Physician/Provider Order Entry CPT Community Pillar Team CQO Chief Quality Officer Crimson Physician performance improvement software from the Health Care Advisory Board CRM Customer relationship management—patient preference database Crucial Conversations HFHSU class offered to leaders to improve retention and enhance conflict management CSCM Catastrophic Senior Case Management CSR Customer Service Representative CTO Combined Time Off—vacation, sick and personal time CV Cardiovascular

d

Days Cash on Hand Measures the number of days that operating expenditures are covered by cash balances DME Durable medical equipment DNV DNV Healthcare—a hospital accrediting agency. DR Disaster recovery DVT Deep Vein Thrombosis—blood clot

DVT Protocols Approaches to minimize risk of potentially fatal blood clots

e

EA Environmental assessment EAG Employee Advisory Group EAP Employee Assistance Program EC Executive Cabinet ED Emergency Department EDS Electronic Data Systems EEOC Equal Employment Opportunity Commission EHS Employee Health Services EMR Electronic Medical Record e-Nancy Direct email access system to the HFHS CEO EOS Employee Opinion Survey EPA Environmental Protection Agency ePrescribe/ePrescribing Software that allows creation and distribution of prescriptions electronically e-Visits Structured online clinical interviews between patients and their physicians; physicians to make clinical judgments and recommend next steps/treatments

f

FCR First Call Resolution FMEA Failure Modes and Effects Analysis—Structured method to identify, prioritize, and address potential failures in high-risk processes with the aim of preventing them FQHC Federally Qualified Health Center

G

Gallup Q12 An evidence-based survey tool of 12 questions most highly correlated with employee satisfaction and organizational productivity Gantz Wiley Employee Opinion Survey vendor used by HFHS prior to 2008 Governance Institute conducts research studies, tracks healthcare industry trends, and showcases governance practices of leading health care boards across the country.

H

HAP Health Alliance Plan Harm Any unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment) that requires additional monitoring, treatment or hospitalization, or that results in death. Such injury is considered harm whether or not it is considered preventable, resulted from a medical error, or occurred within a hospital. HCAB Healthcare Advisory Board—Research organization which provides industry data and literature HbA1c Glycosylated hemoglobin, measured in a blood test commonly used to assess blood sugar control in diabetic patients HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems—CMS’s national inpatient satisfaction survey

HE Health Engagement HEART Hear, Empathize, Apologize, Respond, and Thank—HFHS’s service recovery model HEDIS Health Employer Data and Information Set—Tools used by U.S. health plans to measure performance on care and service; widely accepted as measures for ambulatory care Henry HFHS’s intranet HF Heart Failure HFH Henry Ford Hospital HFHS Henry Ford Health System HFHS-employed physicians Physicians employed by HFHS on contract for specific clinical or administrative services HFHSU Henry Ford Health System University HFKH Henry Ford Kingswood Hospital HFLS Henry Ford Leadership System HFMC Henry Ford Medical Center(s) Fairlane (FRL) Sterling Heights (SH) West Bloomfield (WB) HFMG Henry Ford Medical Group HFMG physicians Members of the HFMG multi- specialty, salaried group practice, one of HFHS’s BUs HFMH or HFMH-CT Henry Ford Macomb Hospital HFMH-WC Henry Ford Macomb Hospital-Warren Campus HFPN Henry Ford Physician Network HFWBH Henry Ford West Bloomfield Hospital HFWH Henry Ford Wyandotte Hospital HFWH-CHS Henry Ford Wyandotte Hospital-Center for Health Services (ambulatory site) HHC Home Health Care HICS Hospital Incident Command System HIHCP HAP In-Home Care Program HIPAA Health Insurance Portability and Accountability Act HR Human Resources HR Business Partner BU HR Professional whose primary job function is to work closely with leadership to analyze data and drive strategy. The role aligns HR work with BU and system strategy. HR and business data are key drivers, focusing efforts in areas such as workforce planning, retention and engagement. HRA Health Risk Assessment HRET Human Resources Executive Team HRIC Human Resources Investment Center Hyperlipidemia Hyperlipidemia is a condition where there is an elevation of lipids, or fats, in the blood. This could be due to an increase in triglycerides, cholesterol, or both. Untreated hyperlipidemia may lead to heart disease.

i

ICU Intensive Care Unit IDP Individual Development Plan IHI Institute for Healthcare Improvement—Not-for-profit organization leading global health care improvement iMDSoft Software tool for tracking patient care in intensive care units

Induction Induction of labor: involves using artificial means to assist the mother in delivering her baby INR International Normalized Ratio—Blood test to assess the effect of oral anticoagulation therapy Integrated system management models and structures that allow for coordination of care experience for patients and their families and teamwork among care givers and employees IOM Institute of Medicine IP Inpatient IPA Independent Practice Association IRB Institutional Review Board—Approves, monitors, and reviews biomedical and behavioral research involving humans with the aim to protect the rights and welfare of the research subjects IT Information Technology ITDR IT disaster recovery IVR Interactive Voice Response

J

JIT Just-in-time Just Culture “Just Culture” policy and training is a best practice, standardized approach to manage employee behaviors toward open communication (“speak up”), safety, and high performance.

K

Keystone project State collaborative on patient safety, nationally recognized for excellence Kirkpatrick Four levels of training results including:

Reaction of student—what they thought and felt about the training; Learning—the resulting increase in knowledge or ca- pacity; Behavior—extent of behavior and capability improve- ment and implementation/application; and Results—the effects on the business or environment resulting from the trainee’s performance

KW Knowledge Wall

l

LA Leadership Academy. Year-long development program/ cohort for individuals identified through Talent Review process as potential successors to LEAP. Focus is on Pillars and strategic objectives Lasting Impressions Service Excellence framework adopted by all HFHS BUs Lean Improvement methodology focused on eliminating waste and reducing cycle time LEAP Leadership Execution and Planning Team Leapfrog Group Voluntary employer membership program to recognize and reward big leaps in health care safety, quality, and customer value LOS Length of Stay—The number of days a patient stays in an inpatient facility; often used as a measure of efficiency and effectiveness

1.

2.

3.

4.

LT Long term

m

Market Measurement Vendor used by HAP to conduct telephone surveys of patients about their satisfaction with HAP physicians and networks MC Metrics Committee MDCH Michigan Department of Community Health MEC Medical Executive Committee MHA Michigan Health and Hospital Association MI Michigan MIOSHA Michigan Occupational Safety and Health Administration MI-STAAR MI State Action on Avoidable Rehospitalizations Model for Improvement HFHS approach to process design and improvement based in PDCA Morbidity Rate Measures the incidence rate or prevalence of a disease or medical condition Mortality Rate Measures the number of deaths in a given population MQC Michigan Quality Council—Michigan’s Baldrige- based award program. Their Leadership Award is the highest honor given MFI Model for Improvement M/S or Med/Surg Medical/Surgical—Refers to patients admitted for medical and/or surgical care MTM Medication Therapy Management MVV Mission, Vision, Values MyHealth Consumer Health Portal

n

NCQA National Committee on Quality Assurance—Not- for-profit organization dedicated to improving health plan quality through accreditation, certification, and recognition NDNQI National Database of Nursing Quality Indicators NHSC No Harm Steering Committee NHSN National Health Safety Network (formerly NNIS) NIH National Institutes of Health NIMS National Incident Management System NLA New Leaders Academy. Formal leadership development program/cohort for all new leaders based on promotion/hire. 40 hours classroom and 20 hours online training in the first 6 months. Focus is on HFHS Leadership Competencies. Non-clinical job functions Admin. support, business, facility/security/support services, information technology, leadership/management, vision center NQF National Quality Forum—non-profit organization to develop and implement a national strategy for health care quality measurement and reporting NRC National Research Corporation NSQIP National Surgical Quality Improvement Program, a national collaborative focusing on reducing surgical mortality and complications

o

OASIS Outcomes and Assessment Information Set— National database of quality indicators for home health care OB Obstetrics OMB Circular A133 Office of Management and Budget audit of federal research awards OP Outpatient OPR Organizational Performance Review OR Operating Room OSHA Occupational Safety and Health Administration Osteopathic Medical training that leads to a Doctor of Osteopathy degree (D.O.) OWD Office of Workforce Diversity

P

PC Performance Council PCP Primary Care Physician/Provider PCTC Patient Centered Team Care Performance Measures Metric used to quantify performance Performance Targets Short- and long-term goals based on projected performance PDCA Plan Do Check Act (improvement cycle); HFHS adds a “debrief” step (PDCAd) PG Press Ganey: Supplier of patient and physician satisfaction surveys, research, and improvement tools PI Performance Improvement Pillars, The pillars The 7 pillar strategic framework PLI Physician Leadership Institute PMP Performance Management Process PN Pneumonia Post-Acute Ambulatory Premier Membership organization of not-for-profit health care organizations; serves as HFHS’s Group Purchasing Organization Press Ganey (PG) Supplier of patient and physician satisfaction surveys, research, and improvement tools Private-Practice Physicians Independent physicians who have practice privileges at HFHS community hospitals

Q

QA Quality Assurance Quality Expo Annual week-long improvement project exhibit and live team presentations

r

RadicaLogic (RL) On-line patient/stakeholder risk and feedback reporting and tracking system R&E Research & Education Revenue Cycle Systems Inpatient and outpatient registration, scheduling, real-time eligibility verification, charge capture, and billing systems

s

SC System Communications

SCIP Surgical care improvement program SCM Supply Chain Management SE Service Excellence SEM (SE MI or SE) Southeast Michigan—Includes the three counties of HFHS’s primary service area (Wayne, Oakland, and Macomb) as well as Livingston, Washtenaw, St. Clair, and Monroe counties Sentinel Event Defined by the Joint Commission (TJC) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient’s illness. SESF System Employee Safety Forum Sg2 Health care membership organization, providing clinical and technology research and consulting SHC Self-Health Coach SI Strategic Initiative—A project designed to achieve our strategic objectives and related goals/targets Six Clinic Group Group of large, employed physician practices across the U.S. who share research and process improvements—HFHS is a member Six Sigma Improvement methodology and an associated set of tools to reduce variability and eliminate defects SL Senior Leadership SMART Specific, measurable, attainable, relevant, time- bound SO Strategic Objective—Projected future state of the organization resulting from implementation of strategic initiatives SPP Strategic Planning Process SQF System Quality Forum—The Quality/Safety Pillar Team ST Short term Strategic Advantage A significant aspect of the operation that is done exceedingly well. Advantages that we have that make it easier to succeed. Strategic Challenge A weakness or inadequacy in a major activity or resource that reduces the organization’s ability to achieve its strategic objectives. Factor that makes it harder to succeed. SWOT Strengths, Weaknesses, Opportunities, and Threats System The Henry Ford Health System

System Integration Linking services together to provide coordinated experiences for patients System Net Income Operating gain including investments for the whole System System Operating Net Income Operating gain (does not include investments) for the whole System

T

TAT Turn-around-time TB Tuberculosis Team Member Standards The Team Member Standards of Excellence (P.1a(2)) which apply to all employed staff and leaders THFE The Henry Ford Experience Thomson Reuters An international company specializing in information and decision support tools for healthcare TJC The Joint Commission—National accrediting body for many different types of health care organizations Trainees Those in physician training programs at HFHS at all levels, including students, residents, and fellows. Tri-county Area Wayne, Oakland, and Macomb counties in SEM TS Talent Selection

U

UAT User-acceptance testing

v

VAP Ventilator Associated Pneumonia VATs Value Analysis Teams—Teams of operational leaders who work with Supply Chain Management to address supply costs through standardization and innovation VOC Voice of the Customer Vodcast Video communication available to all workforce members via Henry

W

WHO World Health Organization WPM Work Process Measures WSU Wayne State University

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Preface: OrganizatiOnal PrOfile P.1 Organizational Description A century ago, pioneer automaker Henry Ford recognized the need for health care for the growing city of Detroit. He brought to health care the same drive that made him a visionary leader in transportation. He committed to building Henry Ford Hospi- tal (HFH) in the heart of Detroit, staffed with employed physi- cians (later the Henry Ford Medical Group (HFMG)), to serve the average person. He encouraged research and professional education, creating a tradition of innovation and learning that continues today.

Our history is one of overcoming great obstacles while never wavering in our commitment to our community. With financial losses due to unreimbursed care, and suburban patients unwill- ing to go downtown, HFH and HFMG could have left Detroit for the suburbs. Instead, we committed to Detroit by creating partnerships with the city and adding ambulatory centers in the suburbs. Today, although Detroit faces one of the worst econo- mies in the U.S. with nearly half its children living in poverty, Henry Ford Health System (HFHS) remains committed to De- troit while serving all Southeast Michigan (SEM), over 4.7M residents in 2010.

Fragmented, high-cost service delivery is a well-known failing of U.S. health care, yet HFHS has long focused on integrating services. Early leaders recognized that patients and families need services linked together to ensure coordinated, high-qual- ity, safe, personal care. From HFH’s opening in 1915, we in- tegrated inpatient (IP) and outpatient (OP) departments under one innovative management structure. As we grew, we contin- ued to lead the industry in spreading and advancing models to integrate care delivery. We were early adopters of electronic medical records (EMR), an essential tool for coordinating care. To integrate financing and delivery, we added a health insur- ance plan (Health Alliance Plan, HAP) that encourages low- cost and high-quality care. Today, HFHS is one of the nation’s leading comprehensive, integrated health systems, with a full spectrum of services.

HFHS supports research and education to ensure discovery and delivery of state-of-the-art care, contribute to the well-being of our communities, attract talent, and through innovation and knowledge sharing, set an example of leadership for the health care industry. We rank in the top 6% of institutions granted funding by the National Institutes of Health (NIH). Integration of patient care with research, education, community health, and insurance offers significant competitive advantages. HFHS has received numerous awards and recognitions for contributions to SEM and the U.S. that exemplify the ongoing Ford tradi- tions of innovation, excellence, and learning (Fig.7.4-2).

P.1a(1) Service Offerings. HFHS is a not-for-profit integrated health care delivery and insurance system (Fig. P.1-1). We of- fer services across the care continuum through nine business units (BUs) with a diverse network of facilities (Fig. P.1-2). Our key customer groups and associated health care service delivery mechanisms include:

Patients. Service is delivered through direct collaboration with our clinicians and multi-disciplinary teams, hospital stays, ambulatory and home visits, and educational programs. Our online interactions with patients include e-visits, results reporting through health information portals, and online ap- pointment scheduling and prescription renewals (3.2a(2)). Community. Service is delivered through interactions in our facilities, our Web site, print media, and educational TV, and programs at community locations, often delivered jointly with partners or collaborators. We contribute to community health care service delivery through community leadership, collaborative arrangements, and funding, especially for the un- and under-insured (1.2c(1,2), Figs. 7.5-4, 7.4-8). Purchasers. Service is delivered through HAP’s health in- surance products for individuals and employers, which of- fer coverage for health-promotion and disease-management

•

•

•

F�g. P.1-1: HFHS Integrated System

Continuum of Care Provides state-of-the-art, coordinated services throughout

the System and into the Community  HFH  Community Hospitals  Ambulatory Centers

 Community Care Services (CCS)  Community Health Programs (CHP)* HFMG Physicians, HFHS Employed Physicians, Private Practice Physicians

Health

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