Department Some Key Performance Indicators

1
SOMCService Dashboard FY 07

YTD results are calculated using YTD means and
ranks report.
Safety ? Quality
? Service ?
Relationships ?
Performance
AP Action Plan ?
Explanation/Calculation BM
Benchmark
2
History

• Seven Cs
• SOMC Best Practices
• Hero Fair
• Sleigh Bells
• Press, Ganey National Conference Panel
  Discussion
• Complaint Mgt. and Service Recovery
• 2004

• Service Team
• Kendall Stewart MD Champion
• Service SOMC Strategic Value
• Service Kick off Chip Bell
• Passports
• Valuesville FAIR (PACT)
• Sleighride
• 1998

• Patient Centered Care
• Connecting the Dots
• These Hands
• National Customer Service Week - Presence
• 2006

• Leadership model
• Graceland
• Walk-awhile in my shoes
• Press, Ganey 500
• Liz
• 2000

• Taste of Chicago
• Customer Love
• 2002

• 2005
• A HEART
• Service Celebration
• You Make a Difference video

• 2001
• Tour Standard of Behavior (Bike fair)
• Just ask me
• Press, Ganey Success Story National Presentation
  

• 2003
• Drivers ED
• Fred Lee 7Cs
• 7Cs Cascade learning (2003
  2004)

• 1997
• Press, Ganey
• Partnership

• 1999
• Moments of Truth
• Reward Recognition
• Standards of Behavior
• Pathways (communication)
• Measure PG employee survey
• Fix-o-Flat

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3
Inpatient Satisfaction Explanation
Higher is Better
Why is this important? Service is what
sets us apart form other organizations

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4
Outpatient Satisfaction Explanation
Higher is Better
Why is this important?
Meeting and exceeding the indicators are our
bread and butter (on a departmental as well as
organizational level) for both inpatient and
outpatient population
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5
What is our Action Plan - Outpatient Satisfaction
updated 12/06

• What is our Plan?
• Achieve and sustain the 84th percentile rank
• How will we Do it?
• Investigation long range tracking system for
  patients to use
• Outpatient Satisfaction Team was restructured
• Retreat was held, re-education and brainstorming
  was accomplished
• Press, Ganey was asked for best practice
  hospitals
• A teleconference was held with Press, Ganey
  standard vs. non-standard questions analyzed,
  90-day rule lifted
• Recoded (titled) Outpatient surveys
• Met with Pam Partlow regarding PARS
• Amy to attend Press, Ganey conference in November

• Who will Do it?
• Amy Beinkampen and Bryan Hammond
• How will we Check to document improvement?
• Monthly scores
• How will we Act to sustain improvement?
• All departments will know overall and unit
  scores on weekly basis
• Continuously form action plans

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6
ED Patient Satisfaction Explanation
Higher is Better
Why is this important? ED is
the front door to the organization

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7
Home Health Patient Satisfaction Explanation
Higher is Better
Why is this important?
Home Care is
important to SOMC since it provides continuity of
care from the Hospital to the Home Setting. SOMC
Home Care is the oldest Home Care provider in
Scioto County

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8
Ambulatory Patient Satisfaction Explanation
Higher is Better
Why is this important?
As
we move towards Patient-Centered Care, this will
just be the final step in reaching and
maintaining customer satisfaction. With current
competition between health care facilities and
the importance of good financial stability, great
customer service is a must.
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9
What is our Action Plan Overall Ambulatory
Updated 2/07

• What is our Plan?
• Hold Department meetings
• Discuss scripting
• Back to the basics
• How will we Do it?
• Daily every staff member
• Who will Do it?
• All SDS staff

• How will we Check to document improvement?
• February PG scores and following months
• How will we Act to sustain improvement?
• Cont. to use scripting everyday

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10
Urgent Care Patient Satisfaction Explanation
Higher is Better
Why is this important?
WUCC is strategically
located in county, need quality care and service.
Increase SOMC market overall share.
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11
What is our Action Plan WUCC
Updated 1/07

• What is our Plan?
• Maintain PG of 90 or gt
• Add Registrar
• Increase call back program with set schedule
  for staff
• Revamp PI team
• Direct O/P lab and x-ray to different location
• Inform patients on all delays
• Staff cards at discharge
• How will we Do it?
• Teamwork!!!
• Hire 2 P/T Registrars
• Schedule Call back staff every Tues/Thurs for 10
  hrs
• Assign new members to PI team
• O/P lab and x-ray seating area created
• Charge nurse will make rounds every 2 hrs
• Full time staff member assigned to triage
• Three registrars to help with incoming WUCC and
  outpatient census

• Who will Do it?
• WUCC staff/Physicians
• How will we Check to document improvement?
• PG scores and comments weekly
• How will we Act to sustain improvement?
• Inform staff daily of pts needs and desires
• NM will make rounds daily and speak to pts,
  family members and inform of any delays
• Celebrate positive accomplishments with staff

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12
Oncology Patient Satisfaction Explanation
Higher is Better
Why is this important?
Cancer Services is a
highly service-oriented dept. The level of
service and quality care provided is directly
related to the market share and business that we
provide
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13
What is our Action Plan Patient Satisfaction
with Chemotherapy AP created 5-15-07 AP
revised AP next revision due Upon red
indicator

• What is our Plan?
• Increase chemotherapy patient satisfaction
  results to 90th percentile
• How will we Do it?
• Provide an Infusion Amerities and information
  sheet for education packets of all patients
  requiring infusion. The handout will discuss
  comfort services available during treatment
  such as warm blankets, art and entertainment
  choices, and food selections for lunch
• Explain treatment schedule so that patients
  understand the time constraints related to early
  arrival
• Send welcome cards to new patients starting
  infusion the previous week along with Heathers
  business card encouraging patient contact if
  there are actions we may take to make their
  process more comfortable
• Institute follow up calls to patients the day
  after their chemotherapy cycles complete
• Who will Do it?
• Heather will prepare the infusion information
  handout for patient education packets and send
  welco9me cards to those new to infusion
• Infusion therapy nurses will explain treatment
  schedule and accommodate requests as possible
• Each Monday Heather will send welcome card to the
  previous weeks new infusion
• Infusion nursing will place follow up calls
  initially. When hours are allocated to nursing
  phone triage, these hours may be utilized for
  follow up calls

• How will we Check to document improvement?
• Continue to monitor chemotherapy patient
  satisfaction on a monthly basis.
• How will we Act to sustain improvement?
• Constant schedule review and brainstorming to
  fit patient/staff needs
• Monthly review at staff meeting
• Continue to develop scheduling processes and
  infusion comfort amenities

14
What is our Action Plan Patient Satisfaction in
Radiation Therapy AP created 9-25-06
AP revised 5-15-07 AP next revision due
Upon red indicator

• What is our Plan?
• Increase radiation therapy patient satisfaction
  results to 90th percentile
• How will we Do it?
• Provide patients and their families with puzzles
  to work while they are waiting for their
  Radiation Therapy treatment
• Have front line staff encourage patients to work
  on the puzzles and to voice any ideas they have
  for improvements to the center
• Explain treatment schedule so that patients
  understand the time constraints related to early
  arrival
• Who will Do it?
• Mary will secure a table to place in the
  treatment area waiting room to work the puzzles
  on
• Wendi will purchase puzzles for the patients t
  work
• Mary will remove a puzzle from the box and start
  the work to encourage patients to put a piece in
  the puzzle
• Mary will purchase puzzles for children and place
  them in both the Radiation Oncology waiting room
  and the main lobby childrens area

• How will we Check to document improvement?
• Continue to monitor radiation therapy patient
  satisfaction on a monthly basis.
• How will we Act to sustain improvement?
• Constant schedule review and brainstorming to
  fit patient/staff needs
• Monthly review at staff meeting

15
What is our Action Plan Overall Patient
Satisfaction with Cancer Services AP created
5-14-07 AP revised
AP next revision due Upon red indicator

• What is our Plan?
• Increase and sustain overall cancer services
  patient satisfaction results to 90th percentile
• How will we Do it?
• Ask each area to become aware of surroundings and
  organize items and posted notes
• Create queue hands to alert the clerical staff
  that patients have arrived
• Post signs in the lobby to inform the patient to
  alert the clerical personnel if they have waited
  longer than 15 minutes past their appointment
  time
• Create automated message for phone
• Work with landscaping staff to improve outside
  view of cancer center yards
• Who will Do it?
• Wendi will announce at staff meeting cancer
  center wide effort to clean up interior messages
  and organize work areas
• Wendi will work with Kim Painter to create hands
  and implement queuing process
• Wendi will order signs for the lobby
• Wendi will work with Jeff Burchett and SOMC
  staff to increase the landscaping efforts on the
  cancer center grounds

• How will we Check to document improvement?
• Continue to monitor Cancer Services patient
  satisfaction on a monthly basis.
• How will we Act to sustain improvement?
• Constant reminder of areas inside and outside
  of cancer center grounds and patient perceptions
• Hardwire new queue process at the Cancer Center

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16
Hospice Patient Satisfaction Explanation
Higher is Better
Why is this important?

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17
Medical Care Foundation Satisfaction Explanation
Higher is Better
Why is this important?

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18
What is our Action Plan Inpatient
Satisfaction
Updated 8/17/06

• What is our Plan?
• Increase patient satisfaction
• How will we Do it?
• During Review customer service expectations
  with staff performance appraisals
• Review results in monthly staff meeting
• Relocated patient information booklets to a more
  accessible area
• UC to give copy of orders with
  surgeries/procedures and radiology testing to
  nursing team leader
• Met with Jeff Gilmore and Nicki Welch dietary
  hostess will hand diet cards to patients during
  the ordering process of completing the patients
  menu, using scripting.
• Who will Do it?
• 3 North A Leadership Team
• Unit Clerks
• All staff
• Dietary Hostess

• How will we Check to document improvement?
• Monitor monthly results
• How will we Act to sustain improvement?
• Continue with action plans

19
What is our Action Plan - Inpatient Services
August/September 2006

• What is our Plan?
• Achieve and sustain the 90th percentile rank
• How will we Do it?
• The inpatient services team held a retreat
• Inpatient Leadership to meet with staff members
  to ask them to re-commit to service
• Valerie to meet with leaders of relationship
  team to work on pride
• Ask Press, Ganey for best practice hospitals
• Registration Rapid Cycle testing between ED
  Nursing and Monitor Care with admitted patients
  being greeted by admitted floor staff
• Who will Do it?
• See above

• How will we Check to document improvement?
• Monthly scores
• How will we Act to sustain improvement?
• Know overall and unit scores on a weekly basis
• Continue to take action

20
What is our Action Plan - Inpatient Satisfaction
October 2006

• What is our Plan?
• Achieve the 99thile rank
• How will we Do it?
• 1 West - scripting when rounding, encourage
  certification, e-mailing education tips,
  discharge planning ask "Is there anything else
  I can do for you". Every time enter room
  checking bathroom for half hat and placing
  patients name, reviewing plan of day at the
  start of each shift.
• Peds - 99th nurses section, continuing with
  documentation at the bedside, Malissa spending
  more time in the patient room, eliminated
  bedside comment card, laminated survey in each
  room, working with dietary "happy" meal concept.
• 3 North B - increased rounding, Proactive
  problem.
• Maternity - skill of IV - students scripting
  when approaching patients, patients have a
  choice to refuse, students to only stick once.
• Volunteer - Volunteer at registration desk,
  define roles of PARS and volunteers, three
  volunteers doing rounding Mon-Fri (2 on Days and
  1 one Eves).
• Dietary - Overall 99th, special diet - Hostess
  to review special diet, hostess to see patients
  on clear liquids, full liquids and NPO, Quality
  - changing menus, including children's menu.

• Lab - Smile school.
• Registration - Dissecting the results and
  looking at unit specific results for best
  practices for pre admission process, rapid cycle
  testing on MCU for meeting and greeting
  patients.
• Cath Lab - Angioplasty services hired additional
  staff that will educate pre test and follow up
  post test.
• Cardiac Lab - Charge person meeting and greeting
  in the hallway, taking patient back to room if
  physician running late, offering juice in
  addition to coffee.
• Maintenance - Decrease noise level in downstairs
  hallway, room PM's, room temperature - look at
  "by unit" results, standard design temps are
  70-75 degrees.
• Inpatient Rehab - Implementing rounding,
  implementing a staff card to leave with
  patients.
• MCU - Personal care focus - charge nurses
  following up, charge nurse follow up with staff
  nurse to move patients, call backs.
• Who will Do it?
• Question leaders
• How will we Check to document improvement?
• Monthly reports
• How will we Act to sustain improvement?
• Monthly meetings and action plans

21
What is our Action Plan for Inpatient
Satisfaction - November 2006

• What is our Plan?
• Achieve the 99th percentile rank
• How will we Do it?
• 3 North A - Several attended error prevention,
  unit clerk and nurse aids rounding - give each
  patient a card from the staff, promoting
  charting at bedside, trialing admission and
  discharge nurse, celebrated 90th percentile
  with party in a box.
• MCU - SV Leadership team meeting monthly,
  trialing rapid cycle - call light champions,
  every 2 weeks scripting coaching session for
  staff, encourage staff on care notes and
  available booklets, arrange staff to spend a
  day in the Cath Lab to increase knowledge, "You
  Make A Difference" day.
• 1 West - Started meeting with nurse aids -
  setting expectations and signed agreement.
• Inpatient Services - Shift Manager has
  increased speed of admission process,
  continued rounding by shift manager in the ER,
  developed script for ER staff regarding patient
  waiting.
• Peds - Added information to our parent
  handbooks to let parents know what to expect
  when the IV is started.

• Rehab - Meeting 11 with staff - will continue
  next 6 months, addressing lessons learned and
  staff comments at staff meetings, continue
  rounding, celebrated 99thile with rehab staff.
• Dietary - Trial on 3 North - hostess hands diet
  order directly to patient with explanation,
  trialing on Peds - placemats for kids (games -
  coloring etc.).
• Pastoral Care - Developed a method to receive
  daily listing of patients who have not been
  visited by a chaplain , Plan to meet with nurse
  in charge on floor daily to identify high risk
  patients in need.
• Social Services - Home Care - begin routinely
  giving cards to all patients to assure
  understanding of services, explaining Home Care
  may not mean to the patient as skilled home
  care, Asking physicians for anticipated
  discharge date to inform patient/family.
• Patient Relations - Investigating possibility of
  rounding with floors, Place framed informational
  sheets on floor.
• Who will Do it?
• Question leaders
• How will we Check to document improvement?
• Monthly reports
• How will we Act to sustain improvement?
• Monthly meetings and action plans

22
What is our Action Plan Inpatient Satisfaction
- January 2007

• 1 West - Addressed physician complaints with one
  physician identified, increasing remote
  controls, continuing with rounding, patient info
  sheets distributed with rounding, 90-100 patient
  call backs.
• Speed of Admission Process - Calling room
  numbers to ED charge nurse, changing room
  assignment line of transfers, SDS and Cath Lab
  admits, additional Shift Mgr. during peak hours,
  rounding with patients waiting.
• Pastoral Care/Discharge Planning - Trying to
  increase volunteer pastors to support 2 FTE's,
  working on getting certified pastor training for
  existing staff, Patient Relations begin visiting
  again with input from Nurse Mgrs, re-vamping
  discharge team will focus on discharge dates,
  implementing Utilization Review Team.
• Test and Treatments Cardiac Testing - Focusing
  on patient comments, adding 3 new staff members,
  involving physicians in process improvement,
  proactively being asked "is there something else
  we can do today".
• Room Décor/Room Temp - Celebrating first time
  room décor gt90th percentile rank.
• Who will Do it?
• Question leaders
• How will we Check to document improvement?
• Monthly reports
• How will we Act to sustain improvement?
• Monthly meetings and action plans

• What is our Plan?
• Achieve the 99th percentile rank
• How will we Do it?
• Admissions - Debbie Harr contacting managers to
  improve pre admission process.
• Flat Screen TV's - Stryker working with Kurbell
  to develop digital.
• 3 North A - Bedside charting, monitoring ID
  bands.
• Pediatrics - Improved skill of the IV to
  99thile rank, focusing on scripting of checking
  your ID bands.
• MCU - Patient rounding by ANM, follow-up calls
  continue, staff members rounding (Jamie Arnett),
  patient relations rounding, met with individual
  care givers to focus on call lights, nurse aide
  champion - keeping hallway clear.
• 3 North B - Degree of Difference Campaign/moving
  4's to 5's/212 degree theme, poster of nurse
  related questions, nursing student rounding.
• Information Desk - Training seminar, coffee cart
  continues.
• Inpatient Rehab - Developed a team which
  includes dietary to address dietary needs,
  changing admission orders to address pain
  management, improving family conference process.
• Maternity - Lullaby beginning Jan 29, 2007 with
  new births.
• ICU - Volunteer role expanded to rounding at 8am
  and 11am, menu completion from dietary,
  re-commitment to service from staff, meeting
  with Dr. Horton re physician, 0.99 cent coupon
  for 99th percentile rank.

23
What is our Action Plan - Inpatient Services
Updated 02/07

• What is our Plan?
• Achieve and sustain the 99th percentile rank
  overall
• How will we Do it?
• Ask existing patients to be mystery shoppers and
  offer a token of appreciation in return
• Implement construction fun bags construction
  stress ball, post card, earplugs
• MCU will investigate the purchase of CD players
  and head sets
• 1 West will decide on geographic vs. acuity
  assignments
• Cardiac Testing Lab will educate staff on
  teaching booklets and bring booklets to patients
  when they are obtaining consent
• ED registration testing each component of the
  admission process
• Cath Lab extended staff hours doing patient
  education and checking for HPs
• Dietary placing a dietician on the tray line to
  look at the process and taming the anything you
  want monster
• Impatient rehab increasing the use of the
  Watching Over You Program. Sub team working
  with dietary and leadership staff holding one on
  one meetings with staff
• Maintenance and housekeeping implementing new
  room PM process May 1, 2007

• Pediatrics taking the MacDonalds approach to
  placements. Contingent unit clerk hired to help
  with adult patients
• Maternity evaluating the pain ball a new
  approach to pain management for C section
  patients. Also purchasing new pull out beds for
  family members
• 3 North B implementing patient call backs
• 3 North A focusing on promptness and response to
  call light
• Who will Do it?
• Members of the inpatient satisfaction team
• How will we Check to document improvement?
• Monthly results
• How will we Act to sustain improvement?
• Act upon results

24
What is our Action Plan - Inpatient Satisfaction
Updated 3/07

• What is our Plan?
• Achieve the 99thile rank
• How will we Do it?
• Inpatient Services - working on speed of
  admission process, Valerie stated - looking at
  new patient guidebook - pocket for information,
  questions note pad, nominee form, envelope with
  information about your care - will be taken to
  next Patient Rights Team.
• Volunteers - have placed volunteer in MCU to
  help with call lights.
• 3 North B - started patient call backs,
  developed own script and call back card.
• 3 North A - patient care card (kept in room)
  starts upon admission for family to review -
  discharge process, pamphlet to be given to ortho
  patients to address issues private room, pain,
  rehab, discharge, email sent regarding call back
  issues on ortho patient concerns.
• ICU - Service Team addressing issues, WOW
  scripting workshop has helped with quarterly
  reports for frontline staff.
• Patient Relations - using patient care cards,
  have started visiting units again for patient
  needs/questions, will hand out "Construction
  Bag" to patients, bringing back to patients -
  service line, Department let Pt. Rep. know when
  trialing equipment, etc so they can identify
  problems.
• Maternity - Malissa and Jone looking into out
  patient bili checks, Valerie congratulated
  Maternity on OHA Survey Award.
• Pediatrics - Celebrated February 99thile
  results.
• MCU - February 97ile Celebration, volunteer
  helping with answering call lights

• Inpatient Rehab - revisiting patient guidelines,
  Team conference/weekly - every patient has
  family conference to discuss questions.
• 1 West - Continue with call backs, e-mail out
  for more staff to volunteer to help, continue
  11 meetings - review dashboard in depth, first
  Vent Event (monthly) was held with very
  successful results.
• Maintenance - requested funding for mixing
  boxes, will be working on heating and cooling
  starting May.
• Bio Med - will trial four flat screen TVs, will
  e-mail managers regarding what is to be tagged
  by Bio Med.
• Social Services - increasing hospitalists to
  four on evening shift, PDCA team focusing on
  discharge planning, back up to full staff in
  Pastoral Care, focus on what pastoral care can
  do differently for patient/family.
• Registration - looking at timing and tracking
  issues regarding ED to admission on inpatients,
  Julie to provide information to Patient
  Placement Team.
• Lab - focus on outpatients - complaints with
  changes/construction, several staff attended WOW
  and will present to other staff, any patient
  concerns staff to address to Patty or Dawn.
• Who will Do it?
• Question leaders
• How will we Check to document improvement?
• Monthly reports
• How will we Act to sustain improvement?
• Monthly meetings and action plans

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25
Inpatient Satisfaction Retreat

• Staying In The Game
• Achieving and Sustaining Our Success
• August 23, 2006

26
Breakfast of Champions Celebrating our Successes

• 90th Percentile Rank FY 2006

27
What are our accomplishments?

• Increase in Reward Rec.
• Pain Ease Peds IV's
• Maternity celebrate 5yrs at 90th
• Rehab 6 service expectations
• MCU call back program
• Registration explain more about delays
• Hospitality cart Volunteer
• Patient Relations dept address concerns quicker
• ICU call backs on discharge
• Lab Increase number of glucometers due to 3N
  Grant
• Nsg Adm sitters
• 1 West developed a card for patients that can't
  be reached on call backs
• Peds gifts for patients from Coterie
• Mat script in triage regarding patient privacy
• Rehab Rehab team meets monthly instead of
  quarterly
• MCU Patient Centered Care Retreats
• Reg goodie bags for children in registration,
  ER and HCC

28
What are our accomplishments?

• Volunteer patient e-mail
• ICU implement family pet visit
• Nsg Adm InterQual guidelines implemented
• 1W Celebrate employees passing boards
• Peds Stars of the month program
• Mat address pain management by changing
  physician orders
• Rehab Quarterly drawing for name mentioned in
  surveys
• MCU - High 5 Award
• Registration - Celebrate pats on the back for
  scores
• Volunteer gift shop delivery to patients
• 3NB .99 cent Coupon and Pizza Hut given to
  employees for 99itle
• ICU implement dedicated phone line for patient
  information
• Guest Service Line
• Lab staffing to increase earlier results
• Nsg Adm try to get patients to the floor
  quicker from ER

29
What are our accomplishments?

• 1 West first year anniversary - fishing for 5
  celebration
• Peds monthly theme celebrations
• Mat visual reminder on clipboard re patient ID
• Rehab Hero cards - staff identifies great
  service
• MCU Great Complaint Meltdown Celebration
• Registration tissue paper flowers to
  celebration patients Birthday
• Volunteers in navy smocks
• ICU Service stars staff recognition
• Maternity staff thank you card box
• Rehab Brag board
• MCU card on beds - room cleaned
• REG Wal-Mart card to staff when mentioned in PG
• ICU Staff recognition for extra effort
• Nsg Adm service recovery - snack bar cert, etc.
  for patient complain
• Registration service stories in staff meetings
• PIN number

30
What is our current reality?

• 78th percentile rank July 2006
• Target 90th
• What score would have to 94.1 score each month to
  sustain

31
What will we do to achieve and sustain the 90th
percentile rank?

• Set spec guidelines of admission to bed
• Feedback and Involved in process to satisfaction
• New Employee orient to survey results e-mail
• script priorities of patient needs each month
  Script of the Month
• Make employees feel pride for facility
• Explain to staff exact expectations of 90th
  percentile
• Campaign for employee/pts to recommend facility
  Liz - "Hospital of Choice"
• Snappy line for campaign - "Just Ask Me"
• Look at employee/patient verbatim comments
• Response rate (sustain)
• Communicate with every department represented on
  team. Ignore incidents instead of addressing it
• Volunteer or Nurse Resident make routine rounds
  to patient rooms to meet pt. needs
• Hold staff accountable challenge staff to
  challenge each other
• Prior to low census PRN NA make rounds,
  increase staff accountability
• SOMC teach customer service to Nursing schools

32
What will we do to achieve and sustain the 90th
percentile rank?

• Wait time for patient tests or treatment
  delays
• ICU take EKG machine to RRT calls for chest pain
• Volunteer nurse program for retired nurses -
  answer call lights, etc.
• Get the word out Dietary short staffed nurse
  ask patients about diet
• Hand diet card to patient regarding dietary needs
  not on tray
• Take extra minute to explain to patient regarding
  care instead of appearing to be in a hurry
• Weekly message SMILE get the staff engaged -
  everyone needs to know and hear repeat everyday
• Sevice team or SV team get their input
• Education provided to staff - help to answer
  questions of patients - Implement the Goal of the
  Day
• Script the discharge why its taking so long

33
What will we do to achieve and sustain the 90th
percentile rank?

• Test and treatment increase communication UC
  take test order to nurse, communicate to pt.
  before xray tech comes for patient, explanation
  of test
• Keeping You Informed form
• Implementing our patient centered care brainstorm
  list assign priorities
• Test treatment explaination scripting for Lab
  why they are having test or tx.
• Purchased bibles, books for family room staff
  start day in good mood. voluntary devotions
  and prayer
• 3North divided restructure Patient Satisfaction
  Teams to energize staff
• Make rounding a priortiy
• Staff does good things improve relationship
  between manager and ANMs
• Flip chart what rate did you give customer
  service today? Staff rate each other staff .
  Staff see all the stories. Explain what did you
  see staff do. These Hands
• Lack of space for Staff recognition (3North)
  bulletin board visible for visitors - enclose
  in glass

34
What will we do to achieve and sustain the 90th
percentile rank?

• Certificate frames in hallway staff pictures
  and credentials
• Video patient pre-op, stay, Rehab, home
  utilize staff to make video
• Teach class on hip replacement, etc.
• Pictures of staff from various departments
• Share best practices - Organization wide
• Changing mindset within staff opportunties for
  improvement
• Physician rounds to avoid family members
  notify family member about physician
  rounds/schedule
• Need a physician rounding champion Physician
  for Service leadership team
• Script for physician how to improve their
  perceptions of nurses
• Physician satisfaction revisit with the
  executives
• Staff unsure - guidelines or tool for staff
  basic information given to patient help be
  better communicators
• Most complaints from lack of communication.

35
What will we do to achieve and sustain the 90th
percentile rank?

• Patient progress notes, chart at bedside or take
  in room - script what to say no secrets
• Staff watch negative comments in front of
  patients/visitors
• Speed of discharge wait time for test resultes
• Staff family a burden opportunities regarding
  visitors and include in patient care
• Challenge one another department to department
  to change schedule
• Rounding unannounced on other shifts noise
  level at lunch time on nights
• New Shades and cubicle curtains, wallpaper on
  nursing units
• Listen to housekeeping staff regarding
  suggestions

36
What are our next steps?

• Mail survey to staff how are we going to turn
  percentile rank around? Include coupon also. We
  have to be 91.1 for the rest of the year let
  staff know.
• Manger have personal conversation regarding
  accountability with survey scores motivate
  staff
• More frontline staff involved accountable
• Guest Services person
• Get brainstorming list out
• Print off Solucient starters focus on 1 or 2
  things to have staff implement.

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37
What is our Action Plan ED
Updated 9/11/06

• What is our Plan?
• Improve and Maintain the 90th percentile rank or
  greater in Emergency Services
• How will we Do it?
• Meeting with Emergency physicians to discuss
  physician-related questions
• August 2006 int3erview candidates for vacant
  part-time ED Patient Representative on evening
  and night shift
• ED to develop comment cards to give to patients.
  same prototype as used at the HCC that thanked
  the patient for choosing SOMC and list the
  staff on duty each day
• Continue to run weekly Press, Ganey reports and
  to share them with the key leaders in medicine,
  nursing, registration, lab, x-ray and nursing
  staff in general
• Monitor lower scoring areas such as Physicians
  and Test Treatments and to hone in on key
  words and key questions
• Who will Do it?
• Medical Director, Assistant Medical Director,
  Director of Nursing, nurse Manager, Assistant
  Nurse Manager and all staff and related
  departments

• How will we Check to document improvement?
• Monitor monthly results
• How will we Act to sustain improvement?
• Continue with action plans

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What is our Action Plan ED
Updated 10/22/06

• What is our Plan?
• Increase ED patient satisfaction
• How will we Do it?
• Review customer comments for trends
• Run weekly PG reports share with key
  stakeholders staff
• Meet with ED Medical Director since ED Physician
  score is lowest scoring area
• Re-assess ED physician staffing
• Meet with ED DR group at monthly meeting/review
  key works in ED DR questions
• Use key words in patient interaction
• Who will Do it?
• ED Medical Director ED Asst. Medical Director
  DON/NM/ANMs
• All Staff

• How will we Check to document improvement?
• Monitor weekly and monthly PG results
• How will we Act to sustain improvement?
• Patient Centered Care principles
• Celebrate Service gains
• Weekly PG reports

39
What is our Action Plan ED
Updated 1/07

• What is our Plan?
• Increase ED patient satisfaction
• Implement triage Team with mid-level, 2p to 2a,
  beginning 1/22/07
• A 4 hour Patient Rep in the Main Department on
  day shift
• How will we Do it?
• Review customer comments for trends
• Run weekly PG reports share with key
  stakeholders staff
• Meet with ED Medical Director since ED Physician
  score is lowest scoring area
• Re-assess ED physician staffing
• Meet with ED DR group at monthly meeting/review
  key works in ED DR questions
• Use key words in patient interaction
• Who will Do it?
• ED Medical Director ED Asst. Medical Director
  DON/NM/ANMs
• All Staff

• How will we Check to document improvement?
• Monitor weekly and monthly PG results
• How will we Act to sustain improvement?
• Patient Centered Care principles
• Celebrate Service gains
• Weekly PG reports

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What is our Action Plan Patient Satisfaction
Home Care updated 9/25/06

• What is our Plan?
• Sustain the 90th percentile rank on patient
  satisfaction
• Improve the Press, Ganey measure Helpfulness
  of the Phone Personnel to the 90th percentile
  rank
• How will we Do it?
• Attend teleconference entitled Winning
  Strategies Turn Unqualified Leads into New
  Business on 09/19/06
• Develop PI team to investigate improvements to
  the Home Care phone system, guidelines for
  phone etiquette and transferring calls
• Review with staff the importance of taking time
  to talk to patients after they have received 3-4
  weeks of services regarding the care they are
  receiving and inquiring regarding any problems
  during staff meeting on 09/20/06.
• Use Key Words at Key Times
• Encourage patients to fill out their Press,
  Ganey survey and inquire what Home Care staff
  could do if they feel they could not mark all
  5s on the survey
• Respond to complaints and follow up with the
  appropriate person
• Who will Do it?
• Home Care Staff

• How will we Check to document improvement?
• Patient Satisfaction scores
• Hand written comments on surveys
• Verbal comments from customers
• How will we Act to sustain improvement?
• Reevaluate action plan quarterly
• Share and celebrate successes with staff

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What is our Action Plan Home Care
Updated 1/07

• What is our Plan?
• Sustain the 90th percentile rank on patient
  satisfaction
• Improve the Press, Ganey measure Helpfulness
  of the Phone Personnel to the 90th percentile
  rank
• How will we Do it?
• Review standards of behavior with all staff
• Adjust phone system to ring into a certain
  extension first, add voice mail to all PSTAs
  phones, add phone extension in Chart room, and
  encourage all staff to answer phone when walking
  by a ringing phone
• Designate times of day when PSTAs take turns to
  work on schedule and the other answers phone
• Coordinate a stress management course for all
  staff
• Investigate developing a patient profile to
  assist staff in scheduling visits and providing
  care
• Develop scheduling flowchart for High Frequency
  patients
• Who will Do it?
• Home Care Staff

• How will we Check to document improvement?
• Patient Satisfaction scores
• Hand written comments on surveys
• Verbal comments from customers
• How will we Act to sustain improvement?
• Reevaluate action plan monthly
• Share and celebrate successes with staff

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42
Accomplishments

• Patient Centered Care poster session July 06
• Service ideas awards WUCC Outpatient Testing
  form and HCC AIC computerized scheduler
• National Customer Service Week Celebration with
  Cea Cohen Elliott presentation, 10/4 and 10/5/06
  Attendance 1346
• Customer satisfaction PI team redeveloped 9/06
  with plan to focus upon improving Press, Ganey
  measure Helpfulness of the Phone Personnel to
  the 90th percentile rank
• Home care office staff attended teleconference
  entitled Winning Strategies Turn Unqualified
  Leads in New Business 9/06
• Clinical Support Manager reviewed with staff
  during team meeting the importance of taking
  time to talk to patients after they have received
  3-4 weeks of service regarding the care they are
  receiving and inquire regarding any problems,
  using key works at key times, encouraging
  patients to complete the Press, Ganey survey, and
  responding appropriately to complaints was also
  reviewed 9/06
• Home care staff attended Customer Service
  Celebration with a presentation by Cea Cohen
  Elliott 10/06
• Organization Wide Service Action plan
  presented to Home Care staff 11/06
• Press, Ganey patient satisfaction at the 95th
  percentile for Q3 05 and the 99th percentile
  rank for 9/06 and 12/06
• Standards of behavior reviewed during staff
  meeting 1/07
• Call back Program At HCC
• Customer cards printed daily at HCC
• Increase Patient Representative hours rounding
  in the ED
• Initiate Triage/Treatment team 2pm to 2am

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Accomplishments

• Submit 4 nominations to OhioHealth Service 2007
• Ambulatory Surgery, Maternity, Dietary Hostess
  Program, Anticoagulation Clinic
• Organizational wide service action plan 11/06
• Cea Cohen Elliott 10/06
• Inpatient satisfaction 92 YTD
• HCAHPS Dry Run at or better than always
  compared to OhioHealth
• Guest service Line on all inpatient units
• OhioHealth Inpatient Success Story winner -
  inpatient
• Jone Stone (Maternity) Kathy Cross (SDS) to
  resubmit the application for PG Success Story
  2007 completed April 07

44
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