1. Minneapolis VAMC Steven P. Kleinglass Medical Center Director Why We do What We do Our continuous quest for quality and journey towards excellence.

2. 2 Overview Introduction to the VAMC, Minneapolis MN Medical Center Statistics Background of Why We Took on Carey How We Started Years of Work Where We Are Today Where Are We Going “Why We Do What We Do”

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5. 5 Medical Center Statistics 287 Operating Beds; 88 CLC Beds (Rehab) 3,000 FTEE $500 Million Operating Budget $30 Million Funded Research 686,000 Outpatient visits/year 85,000 Unique Patients Polytrauma Site Highly Affiliated with the University of Minnesota Medical School 7 Community Based Outpatient Clinics New 30 Bed Spinal Cord Injury & Disorder Center

6. Why we began the journey: Great staff – inconsistent processes Many committees, but not systematically structured with some gaps and redundancies across the organization. Did not have our own strategic plan & goals, but an operational one year plan based upon the VISN strategic plan. Tools for process improvement were limited. Use of data disjointed, tracking, trending, and analysis variable. 6

7. Our Quest for Quality Began in 2005 with our first application to the Robert W. Carey Organization Excellence Program, which aligns with the Baldrige National Quality Program. Thru this annual process, we received valuable feedback that allowed us to critically look at, and systematically improve our systems. Received the Robert W. Carey Award for Excellence in 2008, and the Circle of Excellence in 2009. Applied to the MN Quality Council Award in 2010 looking for external (from VA) feedback and to continue our process for improvement. 7

8. 8 Nurse Executive Chief of Staff Associate Director Medical Center Director

9. 9 Executive Leadership Board Governing Board Executive Leadership Board CouncilsStrategic Management ↕ Executive Comm. of the Medical Staff ↕ Environment of Care ↕ Compliance & Ethics ↕ Patient Service ↕ Workforce Engagement ↕ Quality Manage ment ↕ Academic Excellence ↕ Committees bold Subcommittees italics Resource Management Strategic Planning Administrative Applications Informatics Infection Control Peer Review Transfusion Pharmacy & Therapeutics (P&T) Invasive Procedures* and Moderate Sedation Medical Records Advance Directive Operating Room Clinical Bar Code Emergency Management Radiation Safety GEMS Pandemic Flu SMART Laser Safety Injury Prevention Compliance Integrated Ethics Leadership Preventive Ethics Ethics Consultation Consumer Advisory Committee (CAC) Seamless Transition Patient Behavior Diversity Partnership Voluntary (VAVS) Pain Manage ment Systems Redesign Cancer Patient Safety Skin Integrity CPR Falls Prevent. Graduate Medical Education Research & Development

10. 10 One of the most important reasons for establishing an internal team is to provide a “power plant” to help drive implementation of the improvement plans. Minneapolis VAMC

11. 11 Restructuring and re-staffing only changes the players. In order to change the way work is done, the system must be changed. Minneapolis VAMC

12. 12 Anyone who has learned to see the organization as a system can never again feel satisfied with “improvement” initiatives that simply change staffing and the organization chart but do not tackle the system itself. Minneapolis VAMC

13. 13 Using assessments just for measurement purposes is like buying a Ferrari for grocery shopping. Minneapolis VAMC

14. 14 The secret of effective data gathering is to create a situation where the interviewees want to tell you everything. Minneapolis VAMC

15. 15 Some leadership teams just don’t have what it takes to pull this off. Minneapolis VAMC

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17. 17 Thanks!

18. Where Are We Going Thru the Baldrige process, we continue to obtain feedback and learn about ways we can improve our processes and systems. Submitting an application to the Baldrige National Quality Program to continue this process. 18

19. Why We Do What We Do To care for him who shall have borne the battle, and for his widow, and his orphan…..Abraham Lincoln Ultimately, we are doing this so we can give the best care possible to our veterans, it is what they deserve. 19