1. Winona Health’s Performance Excellence System Kathleen Lanik Chief Quality & Safety Officer

2. Our Vision Winona Health will be a recognized leader in the revolutionary transformation of community healthcare. Our Mission Devoted to improving the health and well-being of our family, friends, and neighbors.  A service environment where people can realize their full potential.  Excellence & leadership in clinical care & service  Customer Focus  Stewardship of Resources

3. Winona Health’s Values

4. WH’s Performance Excellence System (PES) is designed to: Create peace of mind by providing compassionate, personalized care to our family, friends and neighbors.

5. WH’s Performance Excellence System (PES) has Four Quality Standards that Guide all Actions:  Safety: Do no harm  Courtesy: Be kind, caring and selfless  Performance: Deliver an excellent care experience  Effectiveness: Obtain results by design

6. WH’s Performance Excellence System (PES) includes:  Living Service Excellence (LSE) Tools and Initiatives for Staff Performance Management Provides a System-Wide Approach to Staff Excellence  Living Performance Excellence (LPE) Tools and Initiatives for Process Improvements Provides an Organization-Wide Approach to Performance Improvement (PI)

7. Winona Health’s Performance Excellence System Living Service Excellence Staff Performance Management Tools  LSE Standards/Values  Performance Evaluation  Role Summaries  LSE Award Program  Winona Health University  Employee Pride Survey  Experience Compass Living Performance Excellence Process/Performance Improvement Tools  STEP  Lean  By Design Matrix  Experience Compass  Root Cause Analysis  Fact-based Decision Making  Evidence-based Practice  Failure Mode Effects & Analysis

8. Central to WH’s Living Performance Excellence efforts is a Plan Do Check Act (PDCA) method known by the acronym “STEP”

9. The STEP/PDCA process is initiated by: 1.S – See the Opportunity Identifying Opportunities for Improvement (OFIs) and Completing an Opportunity Statement Suggesting an Improvement Initiative 2.T – Team Up Team is Developed, Goals Set, & Timeline for Development is Established 3.E – Evaluate Evaluating the Plan Through Continued Data Collection and Analysis 4.P – Proceed Proceed to Adopt Change or Determine to Study Further

10. LEAN QUALITY THINKING - A Change in the Mental Model - 1.Process Whole System Management Strategy FLOW vs. Silos 2.Quality Focus On What PATIENTS Expect Coordinated Care – Not Just Competency of Care 3.Controlling Cost Elimination of Waste

11. WH Quality Matrix Delivery Systems  Staff  Setting  Process Quality Standards  Safety  Courtesy  Performance  Effectiveness

12. WH Experience Compass Needs (North) Stereotypes (South) Emotions (East) Wants (West)

13. WH’s Performance Excellence process supports continuous pursuit of excellence, and is enhanced by: Memberships Minnesota Council for Quality (MCQ) American Society for Quality (ASQ) Institute of Clinical Systems Improvement (ICSI) Institute for Healthcare Improvement (IHI) Participation Center for Medicare/Medicaid Services (CMS) Quality Project 5 Million Lives Campaign Minnesota Hospital Association Call to Action Initiatives In recognition of its efforts, WH has been recognized by multiple local, state and national organizations.

14. Performance Excellence Journey  Minnesota Council for Quality (2003 – Present)  Malcolm Baldrige Criteria (2004 – Present)  Accreditation/Licensing Agencies  State & National Projects  Winona Health-Specific Initiatives

15. Baldrige Journey

16. Notable Strengths:  Visionary Leadership Focused on the Future  Valuing Staff and Partners  Patient-Focused Excellence  Management By Fact “Pretty Good Practices”  Systematic 6-Step Process to Manage Staff Performance  Mentoring Program Baldrige Journey

17. 2005 Opportunity for Improvement (OFI) 4.1b(1) – Winona Health does not have a fact-based, systematic process in place to evaluate and improve its systems for the review and analysis of measures and organizational performance. As a result, opportunities to improve the measurement and review systems may be missed and/or effective measurement and review practices may be misunderstood and discontinued.

18. Past Data Reporting Schedule

19. Past Data Reports

20. Question: What Do We Need?  A System That Automates Our Processes  A System That Addresses Multiple Needs Within Our Organization: Reporting to wide range of constituents Tracking of data at all levels in the organization Alignment with our strategic plan Supportive of our Performance Excellence System Web-based application for easy access

21. Solution: Focus on Core Competencies  Integrated, Automated Technological Systems  Strategic & Financial Planning Process  Community Commitment  Performance Excellence System

22. Performancesoft Data Management

23. Performancesoft Data Reports

24. Performancesoft Books

25. Lessons Learned  Commitment of Leadership  Focus on Your Strengths  Performance Excellence is EVERYONE ’ S Responsibility  There are NO Short Cuts

26. “We are what we repeatedly do. Excellence, then, is not an act, but a habit.” -- Aristotle

27. Questions?