MERCY HEALTH SYSTEM providing exceptional health care services resulting in healing in the broadest sense Malcolm Baldrige 2007 NATIONAL QUALITY PROGRAM APPLICATION Mercy Health System Table of Contents Organizational Profile .................................................................................................................. Page i P.1 Organizational Description .......................................................................................... Page i P.2 Organizational Challenges ........................................................................................... Page iii Category 1.0: Leadership ............................................................................................................ Page 1 1.1 Senior Leadership .......................................................................................................... Page 1 1.2 Governance and Social Responsibilities ..................................................................... Page 4 Category 2.0: Strategic Planning................................................................................................ Page 7 2.1 Strategy Development.................................................................................................... Page 7 2.2 Strategy Deployment...................................................................................................... Page 9 Category 3.0: Focus on Patients, Other Customers, and Markets........................................ Page 12 3.1 Patient, Other Customer, and Health Care Market Knowledge ............................ Page 12 3.2 Patient and Other Customer Relationships and Satisfaction.................................. Page 13 Category 4.0: Measurement, Analysis, and Knowledge Management ................................. Page 17 4.1 Measurement, Analysis, and Improvement of Organizational Performance....... Page 17 4.2 Management of Information, Information Technology, and Knowledge ............. Page 20 Category 5.0: Workforce Focus ................................................................................................. Page 22 5.1 Workforce Engagement................................................................................................. Page 22 5.2 Workforce Environment ............................................................................................... Page 25 Category 6.0: Process Management .......................................................................................... Page 28 6.1 Work Systems Design .................................................................................................... Page 28 6.2 Work Process Management and Improvement......................................................... Page 30 Category 7.0: Results ................................................................................................................... Page 32 7.1 Health Care Outcomes .................................................................................................. Page 32 7.2 Patient- and Other Customer-Focused Outcomes .................................................... Page 35 7.3 Financial and Market Outcomes ................................................................................. Page 38 7.4 Workforce-Focused Outcomes..................................................................................... Page 40 7.5 Process Effectiveness Outcomes................................................................................... Page 43 7.6 Leadership Outcomes .................................................................................................... Page 47 Mercy Health System Malcolm Baldrige National Quality Award Application P.1 Organizational Description Figure P-1, MHS Core Services Mercy Health System (MHS) is an integrated healthcare Hospital-Based Services system organized to provide comprehensive services to • Mercy Hospital Janesville (MHJ) is a 325,000 sq. ft. residents in southern Wisconsin and northeastern Illinois. facility with 240 beds, 24/7 emergency services, While Mercy Alliance, Inc. (MAI) is the parent company and inpatient/outpatient surgery, and diagnostic services. legal name of the organization, Mercy Health System is the • Mercy Harvard Hospital (MHH), is a 79,500 sq. ft. recognized name and refers to all operating units included in critical access hospital with 32 beds, this application. MAI consists of three legal entities. 24/7 emergency services, and outpatient surgery. Mercy Walworth Hospital and Medical Center (MWH), a. Organizational Environment • expanded from a multi-specialty clinic into a critical a(1) MHS established its roots in 1895 when Dr. Henry Palmer created Janesville’s first hospital by organizing a team access hospital in December 2005, is a 60,000 sq. ft. of 12 physicians in what had been a private home. In 1907, facility with 6 beds, 24/7 emergency services, outpatient surgery, physician clinics, and diagnostics. the Sisters of Mercy, a Catholic religious order, purchased the 30-bed hospital. In 1972, the Sisters transferred control of the Clinic-Based Services charitable corporation to a self-perpetuating volunteer board • 38 community clinics located in six counties in WI and of directors. In 1989, the board of directors recruited a new IL, ranging from single-physician practices to large, president and CEO, Javon R. Bea. Together with the hospital multi-specialty centers with outpatient surgery, urgent staff and BOD, he developed a vision to create a vertically care services, and diagnostics (1,500 to 60,000 sq. ft.). integrated healthcare system that would partner with Post-Acute Care/Retail Services physicians to deliver patient-focused, high quality care; • Mercy Manor Transition Center (MMTC), a 28-bed, provide excellence in patient care services through conven- subacute unit located on the Janesville hospital campus. iently located medical centers; provide complementary care • Mercy Harvard Care Center (MHCC), a 45-bed, long- through post-acute care and retail health services; and offer term care unit located at MHH. this range of care through an integrated insurance plan. • Home health services and durable medical equipment. • Residential hospice facility in Janesville, WI. Today, MHS maintains an unwavering commitment to quality • Community-based residential facility in Janesville, WI. and cost-effective healthcare. In 2003, MHS received the • Mercy Health Mall Governor’s Forward Award of Excellence, the state of • Six retail pharmacies in Wisconsin and Illinois. Wisconsin’s equivalent to the Malcolm Baldrige Award. Insurance Products MHS is a national leader in the integration of healthcare • MercyCare Insurance Company (MCIC) offers Health services, and has ranked in the top quartile of Verispan’s top Maintenance Organization (HMO) products, Point-of- 100 integrated healthcare networks for the past six years. Service (POS) products, Medicaid HMO products, and MHS’s network of care includes four core services (Figure Medicare supplement plans to employers. P-1) providing a complete spectrum of healthcare services, from the most basic—preventive medicine and health vision statement and all levels of performance accountability, education—to the most complex—open heart surgery and aligning partners with organizational strategies. neurosurgery. The integration of physicians as partners creates a collaborative atmosphere that enables MHS to a(3) MHS employs a diverse workforce of over 3,700 staff provide a wide array of healthcare services convenient to partners as summarized in Figure P-3. The average age of patients. MHS also strategically positions itself for financial MHS partners is 42 years and the average length of stability through standardization of support processes and employment is 7.5 years. The employee composition is 7% growth of diverse, comprehensive services and programs. minority, which reflects community demographics. MHS has a bargaining unit located at one clinic, which was in place at a(2) MHS’s success has been guided by its mission and acquisition, and its members comprise 4% of the workforce. vision, which are reviewed annually and modified to reflect As needed, MHS contracts for temporary staff with staffing new strategies as appropriate. The mission, vision, and values agencies. A number of contract labor service agreements are mirror key patient requirements and provide consistent ongoing, such as those for select housekeeping and security organizational guidance in a changing healthcare industry. services. MHS also has an association of volunteers serving The vision is aligned with the Four Pillars of Excellence as MHJ and MHH with 905 active members. The key shown in Figure P-2. Central to the vision statement objective requirements and expectations of the MHS workforce include: to assure excellence in patient care is the Culture of a safe and healthy work place; competitive compensation and Excellence (COE). The COE provides the foundation for benefits; development and career mobility; effective commun- fostering a supportive, entrepreneurial spirit, empowering ication; and involvement and recognition. staff to suggest changes, continually improve performance, and better serve customers. This culture is reinforced by Physicians are essential MHS collaborators in improving MHS’s Servant Leadership Philosophy (Figure 1.1-2). clinical outcomes. A key MHS strategy is partnering with Because all employees embody MHS’s mission, they are physicians through its employment model. MHS employs 275 referred