HENRY FORD HEALTH SYSTEM Detroit, Michigan 2011 Malcolm Baldrige National Quality Award Application TABLE OF CONTENTS Glossary of Terms and Abbreviations Organizational Profile P.1 Organization Description .......................................................................................................................................i P.2 Organizational Situation ......................................................................................................................................iv Category 1: Leadership 1.1 Senior Leadership .................................................................................................................................................1 1.2 Governance and Societal Responsibilities ...........................................................................................................3 Category 2: Strategic Planning 2.1 Strategy Development ..........................................................................................................................................6 2.2 Strategy Implementation ......................................................................................................................................9 Category 3: Customer Focus 3.1 Voice of the Customer ........................................................................................................................................10 3.2 Customer Engagement .......................................................................................................................................12 Category 4: Measurement, Analysis, and Knowledge Management 4.1 Measurement, Analysis, and Improvement of Organizational Performance ......................................................15 4.2 Management of Information, Knowledge, and Information Technology ...........................................................17 Category 5: Workforce Focus 5.1 Workforce Environment .....................................................................................................................................19 5.2 Workforce Engagement ......................................................................................................................................21 Category 6: Operations Focus 6.1 Work Systems .....................................................................................................................................................25 6.2 Work Processes ...................................................................................................................................................28 Category 7: Results 7.1 Health Care and Process Outcomes....................................................................................................................30 7.2 Customer-Focused Outcomes .............................................................................................................................38 7.3 Workforce-Focused Outcomes ...........................................................................................................................41 7.4 Leadership and Governance Outcomes ..............................................................................................................44 7.5 Financial and Market Outcomes.........................................................................................................................48 GLOSSARY OF TERMS AND ABBREVIATIONS 5 Million Lives Campaign IHI-sponsored national Bundle Set of separate but interdependent clinical initiative to protect patients from harm; 5M refers to goal— processes or practices that together drive a desired outcome eliminate 5M harm events nation-wide C 100K Lives Campaign IHI-sponsored national initiative to reduce mortality through implementation of evidence- CA Cancer based practices in hospital care CABG Coronary Artery Bypass Graft CAHPS Consumer Assessment of Healthcare Providers A and Systems—Member satisfaction survey used by HAP A&CC Audit and Compliance Committee of the BOT CAP College of American Pathologists ACC American College of Cardiology Capitated A payment mechanism by which a health plan ACGME Accreditation Council for Graduate Medical gives the provider a set fee per member per month (PMPM) Education—Responsible for the accreditation of U.S. post- regardless of treatment required. MD medical training programs; accomplished through a peer Care Coordination Approaches in the process of care review process and based upon established standards and to ensure patients’ needs are met and hand offs between care guidelines givers and settings are error free Action Plan Collection of specific actions, resources, CARF Commission on Accreditation of Rehabilitation responsibilities, and timelines that respond to short- or long- Facilities term strategic initiatives. CarePlus Classic Original version of the EMR and ADLI Approach, deployment, learning, integration associated data repository of patients’ medical records AHA American Hospital Association CBC Complete blood count AHRQ Agency for Healthcare Research and Quality CC Community Care—Market segment which includes AIP Annual Incentive Plan community-based and in-home services ALA Advanced Leadership Academy. 18 month formal CCs core competencies Leadership development program/cohort for individuals CCS Community Care Services selected by SL as potential successors to Performance CDC Center for Disease Control Council. CDS Corporate Data Store—A secured, comprehensive Allopathic Medical training that leads to a Doctor of data warehouse which includes information from various Medicine degree (M.D.) clinical, revenue cycle, and business systems AMA American Medical Association CE Customer Engagement Ambulatory Services provided on an outpatient basis Centers of Excellence Programs certified as Centers of AME Annual mandatory education Excellence by external agencies AMGA American Medical Group Association CEO Chief Executive Officer AMI Acute Myocardial Infarction (heart attack) CEU Clinical Education Units—Education required by AOA American Osteopathic Association—National nurses and other Allied health professionals to maintain accrediting body for osteopathic health care organizations licensure and certification AOHPH Association of Occupational Health Professionals CESC Customer Engagement Steering Committee in Healthcare Champion (Safety, Engagement, etc.) Internal AOS Available on site consultants to individual BUs. For example, engagement APM Action Plan Monitor champions focus on employee engagement and retention Augmentation Helping labor progress by doing initiatives. They develop and recommend department, BU and something to stimulate contractions. System-wide initiatives based on Engagement Survey data to drive improved engagement scores and decreased turnover as BAA Business Associate Agreement—Requirement in the well as create tools and resources for managers to help them vendor policy for all vendors to follow all HIPAA guidelines build and sustain a highly engaged workforce environment. BBP/OPIM Blood-borne Pathogen/Other Potentially Safety Champions perform a similar role focused on safety. Infectious Material CHAP Community Health Accreditation Program BCBSM Blue Cross and Blue Shield of Michigan CHASS Community Health and Social Services Clinic BCN Blue Care Network (Federally Qualified Health Centers) BHS Behavioral Health Services CHNA Community Health Needs Assessment BOB Book of Business CHP Community Health Programs BOG Board of Governors CHRO Chief Human Resource Officer BOT Board of Trustees CIO Chief Information Officer BU Business Unit CISC Care Innovation Steering Committee—A cross- DVT Protocols Approaches to minimize risk of System team focusing on innovations in prevention and potentially fatal blood clots chronic disease management E Clinical job function Allied health, behavioral health, clinical support, nursing, physician, research EA Environmental assessment CME Continuing Medical Education—Education required EAG Employee Advisory Group by physicians and other clinicians to maintain licensure EAP Employee Assistance Program CMO Chief Medical Officer EC Executive Cabinet CMS Centers for Medicare and Medicaid Services— ED Emergency Department Federal agency responsible for the administration of EDS Electronic Data Systems Medicare/Medicaid EEOC Equal Employment Opportunity Commission CNEC Corporate Nurse Executive Council EHS Employee Health Services The Code Code of Conduct—Expectations for ethical and EMR Electronic Medical Record moral behavior e-Nancy Direct email access system to the HFHS CEO COI Conflict of Interest EOS Employee Opinion Survey Community Care Patient segment for all CCS services EPA Environmental Protection Agency CON Certificate of need—State laws and programs to ePrescribe/ePrescribing Software that allows creation restrain health care facility costs and allow coordinated and distribution of prescriptions electronically planning of new services and construction e-Visits Structured online clinical interviews between COO Chief Operating Officer patients and their physicians; physicians to make clinical Core Measures Standardized, or “core,” quality judgments and recommend next steps/treatments performance measures reported by The Joint Commission (TJC) accredited hospitals, aligned with measures required by F CMS, and endorsed by NQF; viewed as integral to improving FCR First Call Resolution the quality of care provided to hospital patients and bringing FMEA Failure Modes and Effects Analysis—Structured value to stakeholders