Leadership for Clinical Excellence Massachusetts Coalition for the Prevention of Medical Errors – Patient Safety Forum March 30, 2017 Nancy Palmer, Chair, Board of Trustees Paul Lundberg, Chair, Quality Care Committee of the Board of Trustees Philip Cormier, Chief Executive Officer

Who we are – a community hospital system QUALITY – CARING – COMMUNITY …...Together, we CREATE the best place to give and receive care Northeast Health System was formed in the 80’s and 90’s to provide a full continuum of care to residents of the greater North Shore Acute Care Division 4 main sites – community hospitals Senior Health Division Nursing Homes Assisted Living VNA Senior Daycare Programs Behavioral Health / Addiction Services Inpatient Residential Outpatient Programs Other Services

Beverly Hospital, Beverly, MA Addison Gilbert Hospital, Gloucester, MA Four main sites – 364 licensed beds, 329 staffed Beverly Hospital, Beverly, MA Campus – 223 bed hospital Inpatient Medical / Surgical Inpatient Behavioral Health Outpatient Behavioral Health ED – 48,000 Visits Addison Gilbert Hospital, Gloucester, MA (13 miles from BH) Campus – 44 bed hospital Inpatient Medical / Surgical Outpatient Services (Oncology, Radiology, etc.) ED – 15,000 visits

BayRidge Hospital, Lynn, MA Lahey Outpatient Center, Danvers, MA BayRidge Hospital, Lynn, MA (13 miles from BH) Satellite – 62 bed psychiatric hospital Inpatient Behavioral Health & Dual Diagnosis Outpatient Behavioral Health Outpatient Services (Oncology, Radiology, etc.) Lahey Outpatient Center, Danvers (LOCD) (6 miles from BH) Outpatient Satellite Services Surgery Other Outpatient (Radiology, Pain, Disease Management, various other clinics)

Key Statistics 2016 Number of Employees – 2,600+ Number of Medical Staff – 800+ Total Inpatient Volume Discharges Patient Days Med/Surg, Pedi, Crit Care 14,450 61,700 Observations 6,100 7,000 Maternity/Nursery/SCN 4,600 10,150 Psychiatric 2,900 31,150 Total 28,250 110,110 Key Outpatient Volume Emergency Department 62,500 Surgical Cases and SDC 12,000

Lahey Health System In 2012, Northeast Health System joined Lahey Clinic to form Lahey Health System Lahey Clinic Northeast Health System Winchester Health System (2014) Governance & Administration Equal Board Representation Independent Medical Staff Specialty Approved Process Autonomy PHO Community Hospital Support & Value Shared Services but Independent Operations Finance, IT, HR, Legal, Business Development & Philanthropy Right Care, Right Place, Right Time

Leadership Context Facilitating and mentoring teamwork, improvement, respect and psychological safety.

Guiding Principles – Boards on Board (BoB)

Role of the Board of Trustees In Practice Quality top priority; focus; drive key values Zero patient harm; Just Culture; Transparency; High reliability What we pay attention to Patient stories…. the good and the bad Progress toward quality goals Colleague engagement / physician engagement Patient and family centeredness Harm reduction (patient and colleague) How we spend our time Patient Safety Leadership Walkrounds Team training Board presence and visibility at every opportunity BoB Elements Setting Aims Getting data and hearing stories Establishing and monitoring system level measures Changing the environment, policies and cultures Learning Establishing executive accountability

Role of the Board of Trustees BoB Elements Setting Aims Getting data and hearing stories Establishing and monitoring system level measures Changing the environment, policies and cultures Learning Establishing executive accountability Lessons learned, surprises, advice Staff pay attention to what leaders attend to; visibility and behaviors are high value Colleague engagement and clinical excellence inextricably linked Value of independent medical staff representation

Role of the Board Quality Care Committee In Practice Quality top priority; annual goals; accountability Review and recommend annual goals Our behaviors must support learning and a just culture; press for transparency and high reliability What we pay attention to Patient stories…. the good and the bad Performance data Status of improvement work Colleagues’ wellbeing SREs/RCAs, SQRs, FMEAs, harm reduction LIP credentialing How we spend our time Project review; dive into the detail Continuous learning: QCC role, and science of quality, safety and improvement – exploring the “Quadruple Aim” Participating in organization’s quality and safety initiatives (Patient Safety Rounds, CREATE, Crucial Conversations) BoB Elements Setting Aims Getting data and hearing stories Establishing and monitoring system level measures Changing the environment, policies and cultures Learning Establishing executive accountability

Role of the Board Quality Care Committee Lessons learned, surprises, advice Benefit of hearing from managers and colleagues at the “sharp end” of care Credentialing is serious work Physicians have stepped up to address behavior issues that could impact safety BoB Elements Setting Aims Getting data and hearing stories Establishing and monitoring system level measures Changing the environment, policies and cultures Learning Establishing executive accountability

Role of Executive Leadership In Practice Quality top priority; setting the right balance of leaders’ focus on quality and cost Holding leaders accountable for results Working “top down” and “bottom up” What we pay attention to Goals Right people, right priorities, right resources Continuous improvement What we can learn from others in the system How we spend our time Understanding our metrics and performance Planning and executing Rounding; walking the talk Engaging with colleagues and providers in achieving goals BoB Elements Setting Aims Getting data and hearing stories Establishing and monitoring system level measures Changing the environment, policies and cultures Learning Establishing executive accountability

Role of Executive Leadership BoB Elements Setting Aims Getting data and hearing stories Establishing and monitoring system level measures Changing the environment, policies and cultures Learning Establishing executive accountability Lessons learned, surprises, advice Staff pay attention to what leaders attend to; visibility and behaviors are high value Achieving the right balance between attention to quality and focus on the bottom line is not easy Colleague engagement and clinical excellence and patient experience are inextricably linked Communication needs to be succinct, easy to understand and less formal; stories and examples are key

Clinical Excellence at the “Sharp End” Colleague engagement and working “bottom up”

Lessons learned, surprises, advice Engaging colleagues to contribute their ideas is powerful CREATE workshops feedback and learning Culture change/enhancement is not easy, takes time, AND is well worth the investment

Organizational Performance Results

Organizational Performance Results Thank you! Questions?