Joanne's Journal - February 22, 2018
Our First Six Months
People notice that I track my time here ….I do it for a specific reason. I believe that the CEO needs to provide a periodic accountability to the board, the staff and to the community, reviewing what we have accomplished over six months, one year, three years and five years. As an organization, we need to attend to both the urgent issues (staffing needs and capacity concerns with record-breaking patient volumes for example), never ignoring the longer-term strategic needs of the organization.
I have summarized below what I think we have accomplished as an organization and would certainly welcome your feedback. We still have much work to do!
Improving employee engagement is our top priority. It is critical to implementing our strategy, improving our recruitment and retention and building our future. We will measure our engagement again in April through a pulse survey, so I don’t have any hard data about the impact of our initiatives based on last year’s survey results. But to me, the organization feels different, and there are many stories being shared (like the one below from CHaD Pediatric Specialties). I have made a concerted effort to visit many of our clinical and administrative sites. People are interacting in a healthier way, making eye contact, smiling and feeling hopeful about the future. We have just begun, but the key to this is creating access to leadership, caring for and valuing our employees, creating two-way communication and promoting transparency.
Some actions we have taken include re-energizing and refreshing the charge of the Board of Governors (BoG). Dr. Brian Spence will be serving as the Vice Chair of the BoG, leading this important group with me. As part of our organizational engagement plan, we will soon be launching a Colleague Experience Council, and we are over 30 days into our Executive Leader Rounding program. As part of the rounding program, I am assigned to 1 East, 1 West and outpatient clinics in Concord. Last Tuesday night and early Wednesday morning (when we were at our maximum occupancy), I rounded on the Lebanon inpatient units. Yes…I even learned firsthand about “the Beast” a nickname for a unit here whose patients are so complex that it has become a rite of passage for many nurses to work on that unit and has helped make them the expert clinicians they are today.
Unfortunately, attracting and retaining our workforce continues to be our greatest challenge. We are discussing affordable housing, transportation, work-life balance, and compensation in service of identifying effective short-term and long-term solutions. I continue to meet employees at lunch and now for breakfast in the cafeteria. Every conversation teaches me about the organization and what we need to address in order to become an employer of choice in our region.
Financial and Operational Stability
We just completed the sale of $386 million in bonds ($83 million in tax-exempt and $303 million in corporate taxable bonds). This was the last component of our overall refinancing plan ($645 million in total) with a goal of taking advantage of favorable markets to better position D-H for the long-term. As a part of this process, we had to meet with the rating agencies and potential investors, and it is safe to say that our bond pricing greatly exceeded all of our expectations and couldn't have gone any better than it did.
The demand for our bonds and the resulting success of our pricing is a testimony to our reputation and growing strength as a health system. This has also allowed us access to additional capital funds, which will allow us to expand our footprint in the southern region and to invest in our facilities.
Our margins are strong and the demand for our services continues to grow. All of the metrics reflecting financial strength are moving in the right direction. We still have work to do, but you can sense the positive momentum.
Operationally, we have reorganized to focus on our imperatives -- Patrick Jordan has been a member of the Senior Leadership team for three months as our system Chief Operating Officer and has the team focused on operational needs that are important for both DHMC as well as the entire system.
At DHMC, we are tracking a 3.4 percent increase (since 2016) of our Case Mix Index (a measure of how sick our patients are) and a decrease in our length of stay of 5 percent over the same time period (i.e. reflects how efficiently we move people through their plan of care). We are focused on creating some inpatient capacity here at DHMC while we plan for expansion of much needed ICU space. See the Q & A below with Dr. Maria Padin, Chief Medical Officer for DHMC, and Jeff O’Brien, Senior Vice President for Clinical Operations, for more details of this important capacity and patient flow work.
“System-ness” and Executing on our Strategy
Our team has spent the last three months discussing how to organize for more effective decision making, resource allocation, revenue growth and operational effectiveness, and overall management. We are continuing to develop a future-oriented basis for action where we set and test the objectives that define and guide critical actions and performance. We have restructured our leadership team and added key talent to begin acting like a health system as we grow our footprint and move into an operating model that supports advancing risk-based payment models where it makes sense for our system.
The CEOs from our affiliate organizations meet every month to discuss system integration. We are measuring and monitoring our progress as a CEO leadership team in integrating shared services across the entire health system. Importantly, Cheshire Medical Center successfully converted their clinical systems to Epic, enabling further system clinical integration to benefit our patients.
The Board and Executive Leadership of Dartmouth-Hitchcock Health (D-HH) have initiated a health system strategic planning process, which will:
(a) Establish an objective current state assessment (internal and external environment)
(b) Clarify future aspirations and test the current mission and vision for D-HH
(c) Determine D-HH’s high-level goals and approach to differentiation in the marketplace, considering potential future-state scenarios
(d) Identify strategic requirements and enablers for success
(e) Develop an implementation plan with tactics, measures of success, and resource requirements
Quality, Safety and Value
As a system leadership team, we will decide what we need to be “tight” on (i.e. totally aligned) and what we can be “loose” on (i.e. site-based autonomy). For example, we need to be tight on quality and safety standards of care. We have established a System Quality and Safety Committee that is focused on driving standardization, as well as monitoring and measuring care outcomes and patient experience. Components of the organization have had stunning improvements in serious safety events …outcomes that are far better than national benchmarks. Our infection prevention activities have resulted in best practice performance. In addition, we experienced almost three months of relentless survey activities but have survived and exceeded The Joint Commission and CMS standards. At the end of this year, we will have successfully implemented daily safety briefings in all of our system’s hospitals.
Research and Education
We have begun in earnest to work toward the transition of our clinical research grants and contracts, which will happen later this year. The work to build the necessary infrastructure to not only support the work we are doing, but importantly, position us to grow our research efforts into the future is underway. Our educational programs continue to bring hundreds of learners to our organization every year and by all evaluated measures, the quality of the educational experience we are producing across the various programs is high. We have also begun to explore ways to enhance and expand our programs that bring us critical members of our workforce, such as medical assistants and licensed nursing assistants.
Building a thriving health system is hard work….and we have just begun. Much of this depends on building healthy relationships across the state and here in our back yard. We have made crafting a healthy relationship with the Geisel School of Medicine a priority. Dean Duane Compton and I meet weekly to make decisions together about the academic and research enterprise we share. John Kacavas, Chief Legal Officer and General Counsel, and the Communications and Marketing team are getting us out of the Upper Valley, so we can share with the rest of the state the great work that is happening here. It also gives us an opportunity to be important partners on initiatives that affect everyone in our region.
None of this would be possible without the committed group of employees and caregivers across our organization. Each of you have contributed to these outcomes in many ways. We are certainly becoming stronger and better able to withstand the buffeting that is part of the drill for health care organizations today. Thank you!
Looking forward, I am excited about the opportunities we have to build on our successes, create a health system where the whole is greater than the sum of its parts, and strengthen our ability to continue providing great care, service and health outcomes for the patients and communities we serve in Vermont and New Hampshire.
As always, I welcome your feedback. Feel free to reply to this email or send a note to: Office.of.the.CEO@hitchcock.org.
Your Voice Matters: Employee Engagement Action Plans – Showcasing CHaD's Pediatric Specialties
In an effort to improve employee engagement, Dartmouth-Hitchcock conducted an Employee Engagement Survey last year to measure the relationship between the organization and its employees, to better understand what matters to employees and how improvements can be made at the local and organizational level.
In this series, we are highlighting departments who are successfully executing against their follow-up action plans from the Employee Engagement Survey results. Children's Hospital at Dartmouth-Hitchcock's (CHaD's) Pediatric Specialties is featured in this article and is comprised of fifteen individual specialty sections. D-H Today interviewed Ericka Bergeron, RN, BSN, nurse manager, Jim Judd, MA, Operations Practice Manager, and Jill Grodan, MBA, practice manager, Business and Finance, about their engagement action planning success.
What is your department/team focused on in your action plan?
Bergeron: For our nursing staff, we identified five areas to work on. The first is recognition—it is easy to say ‘thank you’ every once in a while, but being recognized and feeling valued consistently is important. The next area is incentives—things like good attendance and positive attitudes should be celebrated, and we want to reward people who are consistently going above and beyond. Another area is to have time to do something fun together as a group — like hosting a potluck lunch, having staff yoga sessions, things that give our team time to connect. Another area is communication, not just in our peer groups, but having nursing staff connect with secretaries and providers, and having a whole loop of communication. The last area is establishing a shared governance group where we have both staff and leadership working together to solve problems.
Judd: Right now, one of my responsibilities is overseeing the outpatient secretaries and Ericka focuses on the nurses, but we collaborate all the time to make sure we are on the same page. Interestingly, even with this delineation of the responsibilities of each group, we found many items in the engagement survey spanned both nursing and secretaries, as well as leadership. This has allowed us to work together to address the issues.
Safety Everyday: Using a High-Reliability Framework
Across the Dartmouth-Hitchcock system, leaders and staff are focused on assuring that patients visiting any one of our locations have the best possible experience. This means ensuring their care is of the highest possible quality and safety. To do so means adopting the principles and practices of a high-reliability organization.
But what is a high-reliability organization? A high-reliability organization is one that continuously operates under very complex conditions and yet manages to have fewer than their fair share of accidents. Some examples of such organizations include commercial aviation and nuclear power. The three key capabilities of high-reliability organizations are that: a) leaders make quality and safety the organization’s highest priority; b) they use a robust model for continuous improvement; c) and they establish a culture that values reliability and consistency and they sustain it. To become a high-reliability organization, Dartmouth-Hitchcock has been focused on building these capabilities over the last few years.
Recently, George Blike, MD, chief quality and safety officer at Dartmouth-Hitchcock (D-H), presented an update to leaders on how the system is performing locally, regionally, and nationally. He reported that DHMC has improved its overall quality, safety, and patient experience ratings such that it have moved from three to four stars, according to the Centers for Medicare & Medicaid Services (CMS) Hospital Compare. Cheshire Medical Center has also achieved a four star rating; New London, three; Mt. Ascutney Memorial Hospital and Alice Peck Day are not currently rated.
“That achievement is something to be proud of. We are particularly proud of the performance of both our academic and our mid-size community hospitals compared to other similar hospitals in Vermont and New Hampshire,” Blike says.
Blike also reviewed DHMC’s progress on numerous goals they had set for the year. He also reviewed five system-wide priorities:
- To establish an IT connectivity solution that supports sharing and collaboration by getting everyone under the same firewall to protect patient confidentiality and to improve coordination of care.
- To continue to leverage and expand the Value Institute Learning Center and build a community of practice around improvement.
- To build relationships, and have people get to know each other across the system and strengthen engagement and accountability.
- To keep driving the basics and aligning each part of the system with standards and the ability to monitor and measure—checking daily, weekly and monthly safety briefs. You can not improve what you don’t measure, monitor and track.
- To have an enduring focus on taking care of not just our patients but also our hard-working staff by reducing work-related employee injuries.
The work continues, but Blike says the system is well positioned for success moving forward. According to Blike, “We’ve made progress and built strong relationships. We need to continue engaging people in the workforce in all different roles and continue having our leaders fully aligned to drive all the dimensions of quality.”
Addressing Patient Flow: Work of ACT (Access, Capacity and Transfers) Committee
At the heart of Dartmouth-Hitchcock’s mission statement is to “provide each person the best care, in the right place, at the right time, every time.” To do that effectively and efficiently, D-H has taken a collaborative, multi-disciplinary approach with the work of the ACT (Access, Capacity and Transfers) Committee to leverage our partnerships with our affiliate hospitals, reorganize our inpatient structure and patient flow processes, and re-invigorate the work of the D-H Transfer Center.
Maria Padin, MD, chief medical officer for DHMC, and Jeff O’Brien, senior vice president for Clinical Operations for DHMC, outline the work of this committee in a conversation with Joanne’s Journal.
Managing patient access at the medical center is important to make sure D-H is caring for the most acute patients in the right setting. But often this is a challenge. Can you explain?
O'Brien: We continue to struggle with demand for patient care that is greater than the resources we have. We need to continue to improve access for the patients in our region who need the level of care we provide at DHMC—these are the highly acute patients who can’t get that type of care in other places, unless they go to Boston. We have to continue to prioritize this work so we are meeting the greatest demands. For patients who don’t need the high-level of care we offer, they are best served at one of our affiliate hospitals so they can get the high-quality care offered there and can possibly be closer to home. Under the umbrella of our ACT (Access, Capacity and Transfers) Committee, we are deploying a number of strategies to help us better manage patient access, flow and transfers so that we can more effectively meet our mission statement – to provide each person the best care, in the right place, at the right time, every time.
Can you tell us more about these strategies to improve patient access, flow and transfers?
Padin: One of our patient flow strategies involves actual construction and redesign of our physical facility here on the Lebanon campus at DHMC. It is important for people to know that these decisions to embark on these initiatives have been driven by data as we continue to prioritize the greatest needs. Our committee has worked with the Analytics Institute and inpatient unit leadership on the following initiatives:
- Redesign of CHaD Inpatient Unit: On March 6, the Children’s Hospital at Dartmouth-Hitchcock’s (CHaD) will open a redesigned CHaD Inpatient Unit on 5 East, which will house both the Pediatric Critical Care Unit (PICU) and the Pediatric & Adolescent Unit (Pedi). This newly renovated space will include critical care, intermediate care, and standard medical-surgical care for children and adolescents, all in one integrated unit. It will eventually have 21 beds encircling its new central therapeutic play space, with nursing stations located closer to patient rooms.
- Additional Adult Critical Care Beds: Because of the PICU transition, we will be able to reuse the previous PICU space on the third floor for adult critical care beds.
- Birthing Pavilion: Expansion is underway to add three beds to the Birthing Pavilion to accommodate an increase in the number of expectant mothers to deliver at DHMC. This has been a part of our integration planning with Alice Peck Day for a number of years and is expected to come to fruition in July of this year.
- Neuro-ICU: We are beginning the planning for a Neuro-ICU to care for this particular patient population.