OUMS Pillar Goal Update

Report
OUMS Pillar Goal Update
February 15, 2013
OUMS – Voluntary Turnover Rate (FT/PT)
2009
2010
2011
2012
The Children’s Hospital Based
15.7%
13.6%
19.1%
20.0%
Women’s & Newborn Based
10.1%
11.1%
14.3%
14.9%
OU Medical Center Based
21.8%
22.0%
22.0%
22.6%
Outpatient & Campus-Wide
Ancillary/Support Departments
10.3%
12.4%
11.9%
12.3%
OUMC OKC Overall
15.2%
15.7%
16.9%
17.5%
OUMC Edmond Overall
19.2%
20.0%
OU Medical System
17.1%
17.8%
GOAL = Decrease OUMC-wide Voluntary FT/PT Turnover to 15% or less
OUMS – Employee Engagement
85%
80%
79%
75%
75%
74%
75%
76%
70%
65%
60%
55%
50%
2009
2010
2011
Dec. 2011
2012
GOAL = Achieve employee engagement of 75% or greater
OUMS – Employee Engagement
100%
90%
80%
70%
60%
50%
40%
Children's
Women's
OUMC
OKC Support &
Ancillary
2009
81%
84%
77%
79%
78%
2010
80%
73%
70%
76%
78%
2011
75%
76%
69%
74%
78%
74%
2012
75%
78%
72%
77%
79%
76%
Edmond
System
GOAL = Achieve employee engagement of 75% or greater
OU MEDICAL SYSTEM
HCAHPS Overall Rating (% Top 2 Box) – HCAHPS Mode Adjusted
3Q
2011
4Q
2011
1Q
2012
2Q
2012
3Q
2012
4Q
2012
75TH
90TH
Nursing Communication
75%
77%
78%
77%
76%
74%
81%
84%
Physician Communication
82%
82%
84%
82%
82%
81%
84%
88%
Responsiveness
60%
62%
61%
60%
60%
57%
71%
77%
Pain Management
70%
72%
71%
70%
73%
68%
73%
76%
Medication Communication
64%
68%
66%
67%
67%
65%
65%
70%
Cleanliness
67%
66%
68%
65%
66%
64%
77%
82%
Quietness
67%
65%
65%
65%
64%
64%
66%
73%
Discharge Information
86%
88%
90%
88%
87%
87%
86%
89%
Overall Rating (% top 2 box)
68%
70%
69%
70%
70%
66%
74%
80%
Willingness to Recommend
73%
73%
72%
72%
75%
71%
77%
82%
52%
55%
HCA % Top Box:
Care Transition
HCAHPS
50%
GOAL = Achieve 75th percentile or greater in “Overall Rating of this Hospital”
OU MEDICAL CENTER
HCAHPS Overall Rating (% Top 2 Box) – HCAHPS Mode Adjusted
3Q
2011
4Q
2011
1Q
2012
2Q
2012
3Q
2012
4Q
2012
75TH
90TH
Nursing Communication
71%
76%
77%
73%
74%
71%
81%
84%
Physician Communication
77%
77%
82%
79%
79%
76%
84%
88%
Responsiveness
53%
55%
56%
53%
54%
46%
71%
77%
Pain Management
61%
65%
70%
66%
70%
62%
73%
76%
Medication Communication
58%
68%
65%
58%
64%
62%
65%
70%
Cleanliness
64%
63%
63%
58%
62%
62%
77%
82%
Quietness
60%
52%
53%
49%
57%
54%
66%
73%
Discharge Information
85%
88%
91%
86%
86%
84%
86%
89%
Overall Rating (% top 2 box)
62%
65%
65%
63%
66%
59%
74%
80%
Willingness to Recommend
68%
71%
65%
63%
69%
66%
77%
82%
51%
51%
HCA % Top
Box: 51%
Care Transition
HCAHPS
CHILDREN’S HOSPITAL
HCAHPS Overall Rating (% Top 2 Box) – HCAHPS Mode Adjusted
HCAHPS
3Q
2011
4Q
2011
1Q
2012
2Q
2012
3Q
2012
4Q
2012
75TH
90TH
Nursing Communication
77%
81%
81%
82%
80%
81%
81%
84%
Physician Communication
82%
89%
87%
86%
85%
89%
84%
88%
Responsiveness
55%
63%
66%
63%
66%
60%
71%
77%
Pain Management
72%
71%
74%
72%
75%
75%
73%
76%
Medication Communication
66%
68%
69%
75%
70%
73%
65%
70%
Cleanliness
67%
71%
73%
71%
72%
68%
77%
82%
Quietness
65%
72%
72%
68%
65%
63%
66%
73%
Discharge Information
91%
92%
93%
91%
91%
92%
86%
89%
Overall Rating (% top 2 box)
72%
75%
72%
69%
76%
71%
74%
80%
Willingness to Recommend
79%
81%
77%
80%
83%
82%
77%
82%
57%
59%
Care Transition
HCA % Top
Box: 51%
WOMEN’S
HCAHPS Overall Rating (% Top 2 Box) – HCAHPS Mode Adjusted
3Q
2011
4Q
2011
1Q
2012
2Q
2012
3Q
2012
4Q
2012
75TH
90TH
Nursing Communication
78%
77%
77%
79%
77%
76%
81%
84%
Physician Communication
85%
84%
84%
85%
82%
80%
84%
88%
Responsiveness
67%
74%
66%
72%
66%
69%
71%
77%
Pain Management
74%
78%
70%
73%
77%
72%
73%
76%
Medication Communication
71%
74%
72%
76%
68%
63%
65%
70%
Cleanliness
68%
63%
69%
68%
68%
63%
77%
82%
Quietness
75%
75%
73%
77%
73%
74%
66%
73%
Discharge Information
84%
85%
89%
90%
87%
87%
86%
89%
Overall Rating (% top 2 box)
72%
72%
71%
76%
73%
71%
74%
80%
Willingness to Recommend
74%
73%
75%
78%
77%
71%
77%
82%
51%
57%
HCA % Top
Box: 51%
Care Transition
HCAHPS
OUMC EDMOND
HCAHPS Overall Rating (% Top 2 Box) – HCAHPS Mode Adjusted
3Q
2011
4Q
2011
1Q
2012
2Q
2012
3Q
2012
4Q
2012
75TH
90TH
Nursing Communication
77%
70%
77%
72%
76%
65%
81%
84%
Physician Communication
84%
82%
81%
80%
81%
83%
84%
88%
Responsiveness
70%
58%
59%
52%
57%
51%
71%
77%
Pain Management
78%
69%
74%
70%
69%
67%
73%
76%
Medication Communication
59%
58%
55%
60%
64%
59%
65%
70%
Cleanliness
74%
69%
66%
68%
65%
64%
77%
82%
Quietness
64%
60%
66%
70%
60%
61%
66%
73%
Discharge Information
85%
84%
84%
86%
86%
85%
86%
89%
Overall Rating (% top 2 box)
70%
69%
66%
72%
67%
65%
74%
80%
Willingness to Recommend
74%
67%
74%
67%
70%
61%
77%
82%
52%
51%
HCA % Top
Box: 50%
Care Transition
HCAHPS
OUMS – Risk Adjusted Mortality Index
Risk Adjusted Mortality Index OUMS 4Q11 - 3Q12
1.3
1.18
1.2
1.11
1.09
1.1
1.06
1.03
1.01
1
1.01
0.9
0.82
0.8
Risk adjustment methodology
changed in 1Q12 to incorporate
POA flag and Increase number of
0.7
0.6
4Q11
1Q12
Quarterly Index
12 Month Index
2Q12
System Benchmark
3Q12
GOAL = Decrease mortality rate to CHOIS benchmark or less
DOWNTOWN - Core Measures
CORE MEASURES
OUMC
Acute Myocardial Infarction (AMI)
Heart Failure
Pneumonia
Surgical Care Improvement (SCIP)
Immunizations
Outpatient SCIP
TCH /Womens
Asthma Care: Composite Score
Immunizations TCH
Perinatal Core Measure
No Elective Delivery: 37-39 Wks
Antenatal Steroids
Exclusive Breast Milk Feedings
Ceasarean Section Rate (HCA Avg)
Immunizations: Women's
90th Percentile
1Q12
2Q12
3Q12
4Q12
100%
100%
99.10%
99.47%
97.5%
100%
99.38%
99.30%
97.82%
95%
100%
99.23%
97.47%
99.20%
100%
100%
99%
100.0%
98.54%
96.7%
100%
100%
97.1%
98.58%
99.2%
99.5%
97.97%
99.4%
100%
99.3%
90th Percentile
1Q12
2Q12
3Q12
4Q12
NA
97.5%
98.3%
51.2%
98.6%
NA
92.7%
33.0%
97.7%
98.0%
100%
100%
80%
50.62%
97.5%
100%
100%
32.4%
29.5%
0%
94%
100%
45.5%
9.4%
59%
92%
100%
32.4%
15.1%
0%
100%
100%
38.7%
17.8%
98%
GOAL = Maintain performance at top 10th percentile on publicly reported Core Measures
EDMOND - Core Measures
CORE MEASURES
OUMC-Edmond
Acute Myocardial Infarction (AMI)
Heart Failure
Pneumonia
Surgical Care Improvement (SCIP)
Hospital Based Inpatient Psych
Immunizations
Outpatient AMI
Outpatient SCIP
90th Percentile
1Q12
2Q12
3Q12
4Q12
100%
100%
99.10%
99.47%
100%
96.77%
100%
98.33%
97.35%
95%
100%
94.74%
100%
100%
100%
98.81%
98.05%
100%
85.71%
100.0%
100%
93%
100%
99.55%
98.48%
92%
100%
100.0%
100%
100%
100%
99.35%
100%
94.44
100%
98.8%
97.5%
100.0%
99.5%
GOAL = Maintain performance at top 10th percentile on publicly reported Core Measures
DOWNTOWN – Hospital Acquired Conditions
Hospital Acquired Conditions
OUMC
Retained Foreign Body
Air Embolism
Blood Incompatibility
Pressure Ulcers - Stage III & IV
Falls and Trauma
Glycemic Control
Vascular Catheter Associated Infections
Catheter Associated Urinary Tract Infection
TCH
Retained Foreign Body
Air Embolism
Blood Incompatibility
Pressure Ulcers - Stage III & IV
Falls and Trauma
Glycemic Control
Vascular Catheter Associated Infections
Catheter Associated Urinary Tract Infection
Goal
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1Q12
0
0
0
2
3
1
0
1
1Q12
0
0
0
0
0
0
1
0
2Q12
0
0
0
1
1
1
2
0
2Q12
0
0
0
0
0
0
2
0
3Q12
1
0
0
2
2
2
8
0
3Q12
0
0
0
0
0
0
6
0
4Q12
0
0
0
5
1
0
15
1
4Q12
0
0
0
0
1
0
2
0
GOAL = Maintain Composite HAC rates to the target level or lower
EDMOND – Hospital Acquired Conditions
Hospital Acquired Conditions
OUMC-Edmond
Retained Foreign Body
Air Embolism
Blood Incompatibility
Pressure Ulcers - Stage III & IV
Falls and Trauma
Glycemic Control
Vascular Catheter Associated Infections
Catheter Associated Urinary Tract Infection
0
0
0
0
0
0
0
0
1Q12
0
0
0
0
1
0
0
0
2Q12
0
0
0
0
1
0
0
1
3Q12
0
0
0
0
0
0
0
0
4Q12
0
0
0
0
3
0
0
1
GOAL = Maintain Composite HAC rates to the target level or lower
OUMS – Hospital Adjusted Admissions
Admissions
Budget
50,000
49,130
49,000
48,000
47,000
46,475
46,000
45,000
44,333
44,000
43,000
42,000
2010
2011
2012
Goal = Increase Adjusted Hospital Admissions to 100% of budget or greater
Result = 101.6%
OUMS – Hospital Adjusted Admissions
60,000
50,000
40,000
6,585
5,979
30,000
11,708
6,840
6,144
13,330
Women's
Children
Adult
20,000
10,000
Edmond
22,203
22,816
2011
2012
0
Goal = Increase Adjusted Hospital Admissions to 100% of budget or greater
Result = 101.6%
*Adult Includes Women’s Admissions
OUMS – Budgeted EBITDA
OKC
Edmond
2010
2011
2012
2012 Budget
114,546
118,546
101,340
110,438
7,168
7,171
7,502
8,781
Goal = To Achieve 100% of Budgeted EBITDA
Result = 86.9%
Earnings Before Interest, Taxes, Depreciation and Amortization
2012 YTD
OUMS - Key 2013 Response
• Better Aligned Organizational Structure
• Retooled Process for Leadership Engagement
• Redeployed & Restructured Excel Program
• Enhanced, Structured, and Transparent Focus on
Culture of Quality & Safety
• System-Coordinated, but Hospital-Driven
Strategic Growth Plans

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