Strategic Plan 2011 - 2013 Jefferson Healthcare Strategic Plan 2011-2013 Page 2 About Jefferson Healthcare Jefferson Healthcare (Jefferson County Public Hospital District No. 2) is the primary healthcare provider for more than 20,000 residents of Eastern Jefferson County. It is governed by a five-member elected board. We provide inpatient care at its 25-bed acute care facility and a comprehensive range of outpatient services including emergency care, diagnostic imaging, laboratory, physical therapy and rehabilitation, surgical services and sleep medicine. In addition, we operate five primary care clinics and a home health & hospice agency. By employing about 500 workers, Jefferson Healthcare provides significant economic benefit to Jefferson County as the largest employer. It also employs about 25 physicians and midlevel professionals and has agreements with specialists to provide care for the residents of our county. Jefferson Healthcare Strategic Plan 2011-2013 Page 3 Mission, Vision, Values Mission Jefferson Healthcare … excellence with compassion and innovation. Purpose Assure appropriate health care services are available to support the health of all the people of Eastern Jefferson County. Values Jefferson Healthcare is: Intentionally patient centered. Committed to the highest possible quality health care for all. An employer that recognizes the quality of its employees and helps them to reach their potential. Committed to a healthy community that encourages individual responsibility. A prudent steward of health care resources. Jefferson Healthcare Strategic Plan 2011-2013 Page 4 Quality and Patient Safety Jefferson Healthcare will provide safe, quality, patient-centered care to every patient we serve, every time we serve them. Strategy A. Achieve accreditation. Strategy B. Develop and implement the Jefferson Healthcare Quality Index. Strategy C. Develop, cultivate and promote a Culture of Safety at Jefferson Healthcare. Measurable Goals 1. 2. 3. 4. 5. Achieve accreditation by June 30, 2011. Achieve 75% compliance (green) for entire index by 4th quarter 2011. Complete Culture of Safety curriculum by 75% of staff by December 31, 2011. Complete Culture of Safety survey by June 30, 2011. Improvement in selected National Patient Safety goals by 4th quarter 2011. Jefferson Healthcare Strategic Plan 2011-2013 Page 5 Quality and Patient Safety Jefferson Healthcare will fully embrace performance improvement as the means to achieving clinical and operational excellence. Strategy A. Align quality and LEAN departments to facilitate quality and operational improvement initiatives across the enterprise. Strategy B. Fully implement evidence-based standard work for directors and leaders. Strategy C. Train and build the skills of directors and staff on the methods and tools of LEAN and performance improvement to empower utilization within departments. Measurable Goals 1. Achieve day-to-day performance improvement in 75% of measures by September 1, 2011. 2. Complete performance improvement training for directors by July 30, 2011. 3. Complete three performance improvement projects within each department by December 31, 2011. Jefferson Healthcare Strategic Plan 2011-2013 Page 6 Quality and Patient Safety Jefferson Healthcare will organize hospital-based providers and outpatient clinic services to promote tighter mission and goal alignment. Strategy A. Develop and complete operational excellence plans. Strategy B. Align incentives in quality, growth, service and financial performance. Strategy C. Identify service leaders for hospital-based provider services to identify and achieve higher standards of quality, service, growth and financial performance. Measurable Goals 1. Align all provider contracts with quality, service, growth and financial performance incentives by December 31, 2011. 2. Show consistent and progressive improvement in related Jefferson Healthcare QI indicators beginning 4th quarter 2011. 3. Meet or exceed budgeted patient volumes, revenues and expense targets by all hospital-based provider services in 2011. Jefferson Healthcare Strategic Plan 2011-2013 Page 7 Quality and Patient Safety Jefferson Healthcare will select an Electronic Health Record (EHR) that improves the continuity and safety of care, enhances communication, provides decision support, improves documentation and makes patient information readily accessible to the interdisciplinary care team throughout the Jefferson Healthcare enterprise. Strategy A. Identify EHR option(s) most capable of meeting Jefferson Healthcare performance and CMS meaningful use criteria. Strategy B. Identify plan to finance selected EHR. Measurable Goals 1. Complete EHR selection process and identify system most capable of meeting Jefferson Healthcare clinical and operational needs by October 31, 2011. 2. Have finance plan in place at time of selection. Jefferson Healthcare Strategic Plan 2011-2013 Page 8 People Jefferson Healthcare will recruit and retain a clinically exceptional staff. Strategy A. Implement best practices for effective recruitment to assure the hiring and development of exceptional staff. Strategy B. Revise the current hiring, orientation and onboarding programs to assist in the recruitment and retention of most talented candidates. Strategy C. Revise job descriptions to clearly state qualifications, expectations and accountability and set a high standard for performance. Strategy D. Revise the current performance evaluation system to improve the process of measuring employee performance improvement and engagement. Strategy E. Develop a People & Engagement Committee to assist leadership in policy and goal development and employee engagement programs. Measurable Goals 1. Reduce turnover during probationary period by 50% by December 31, 2011. 2. Decrease the time from position posted to time of hire to an average of 60 days by September 31, 2011. 3. Develop a tool to determine the effectiveness of orientation of new employees at 90 days by September 30, 2011. 4. Increase patient satisfaction and reduce number of complaints about employee’s performance by December 31, 2011. 5. Complete job description revisions by December 31, 2011. 6. Complete performance evaluation revisions by December 31, 2011. Jefferson Healthcare Strategic Plan 2011-2013 Page 9 People Jefferson Healthcare will be the employer of choice for employees who seek professional fulfillment and want excellence in their work and the work of the organization. Strategy A. Seek employee involvement; be transparent and deliberate in communications and consistent and equitable in the application of human resource policies and procedures. Strategy B. Establish new intentional employee recognition programs to recognize employee contributions that support Jefferson Healthcare initiatives. Strategy C. Provide employees with professional opportunities for growth through internal and external programs. Strategy D. Develop lateral career and career ladder job enrichment opportunities for all staff positions. Strategy E. Balance ratio of full-time to part-time employees to assure continuity and commitment that supports excellence and balanced workloads. Strategy F. Develop open lines of communication between administration and staff. Measurable Goals 1. Improve Press Ganey scores related to engagement to 40th percentile in 2011. 2. Develop and implement two new employee recognition programs by August 31, 2011. 3. Increase number of full-time employees in relation to part-time employees by 10% in 2011 and by an additional 10% in 2012. 4. Hold quarterly employee open forums and provide timely communications to staff to improve communication and seek feedback by September 1, 2011. Jefferson Healthcare Strategic Plan 2011-2013 Page 10 People Jefferson Healthcare will promote and maintain an effectively organized, goalaligned medical group. Strategy A. Explore the viability of creating Jefferson Providers, a tighter, more cohesive multi-specialty medical group. Strategy B. Hold meetings of employed and contractual providers to discuss external and internal challenges, improved communications between providers, and other ways to improve continuity of care by increasing intra-system referrals. Strategy C. Explore innovative primary care delivery concepts such as medical home and implement strategies that are financially responsible and would be supported within the framework of our organization and community. Measurable Goals 1. Establish baseline patient satisfaction with clinic/contractual medical service using Press Ganey by 2nd quarter 2011. 2. Establish baseline provider satisfaction by June 1, 2011 and have response measures in place by June 30, 2011. 3. Establish quarterly meetings with employed, contracted and other community providers beginning 2nd quarter 2011. 4. Begin exploration of innovative primary care models in 2012. 5. Increase intra-system (Jefferson Healthcare to Jefferson Healthcare) referrals by 10% in 2011 and 25% in 2012. 6. Complete an analysis and submit recommendation to Provider Leadership Group on the advantages of evolving employed and contracted providers into Jefferson Providers, a multi-specialty medical group in 2011. Jefferson Healthcare Strategic Plan 2011-2013 Page 11 Service Excellence Jefferson Healthcare will become a high-performing organization focused on providing patient-centered care and services. Strategy A. Identify and research innovative collaborative partnership models (Planetree, IHI) with the intent of determining a model that will dramatically improve the patient experience at Jefferson Healthcare. Strategy B. Adopt the IHI’s definition of “patient-centered care” to be used as a standard in planning, facility design, program development and integration of services across the continuum of care. Strategy C. Adopt “right patient in right place” to deliver responsible and equitable use of resources in balancing patient expectations and system needs. Measurable Goals 1. Complete IHI self-assessment of patient-centered care by July 31, 2011. 2. Develop methodology to achieve patient-centered care by September 30, 2011. 3. Existing models of high-performing patient-centered care will be identified by September 30, 2011. Jefferson Healthcare Strategic Plan 2011-2013 Page 12 Service Excellence Jefferson Healthcare will become an organization which reliably exceeds the service expectations of our patients, guests and community. Strategy A. Train, support and expect staff to practice service excellence in all interactions with patients and others, including co-workers. Strategy B. Design and implement patient advocacy program that will help lead improvement in service excellence as well as respond to the individual concerns of patients. Measurable Goals 1. Develop service excellence standards by June 30, 2011. 2. Develop Jefferson Healthcare University by October 31, 2011. 3. Incrementally train all Jefferson Healthcare staff (10% in 2011, 50% in 2012, all others in 2013) and train newly hired staff at the next available service excellence program. 4. Train high impact departments (admitting, ED, clinics) in Jefferson Healthcare service excellence standards by September 30, 2011. 5. Increase patient satisfaction to the 60th percentile by December 2011, 75th percentile by December 2012 and 90th percentile by December 2013. Jefferson Healthcare Strategic Plan 2011-2013 Page 13 Finance Jefferson Healthcare will achieve and maintain a financially strong, locally owned community health care system. Strategy A. Achieve best practice operating performance by implementing operational improvements and financial management tools/reports within all hospital departments and clinics. Strategy B. Achieve best practice revenue cycle management performance. Strategy C. Maintain competitive patient charges. Strategy D. Explore the possibility of developing a charitable foundation for Jefferson Healthcare. Measurable Goals 1. Jefferson Healthcare cash flow will be 60 days cash on hand by December 31, 2011, and will increase by a minimum of five days annually. 2. Reduce and maintain accounts receivable days at 45 days or less by December 31, 2011, and at 40 days or the 75th percentile, whichever is less, as measured for critical access hospitals by December 31, 2012. Jefferson Healthcare Strategic Plan 2011-2013 Page 14 Finance Jefferson Healthcare will develop a robust operating budget development and compliance system. Strategy A. Implement a monitoring system based on management and financial reports that requires accountability for variances. Strategy B. Provide budget development and management training for leadership and directors to build competence and accountability. Strategy C. Establish user friendly management reports and consultation to those responsible for budgets. Measurable Goals 1. Begin budget process no later than August of each budget year. 2. Achieve budgeted operating margin target by December 31, 2011. 3. Achieve 75% compliance (green) on Jefferson Healthcare financial flash report by December 31, 2011. 4. Achieve 95% labor productivity performance for entire organization by October 31, 2011. 5. Complete monthly financial reports for hospitals, home health & hospice, clinics and five largest ancillary services by December 31, 2011. Jefferson Healthcare Strategic Plan 2011-2013 Page 15 Finance Jefferson Healthcare will maximize financial reserves for operational contingency, capital reinvestment and routine facility improvement. Strategy A. Develop and annually update a three-year financial projection that forecasts revenue growth, expense management and capital needs. Strategy B. Build reserves through revenue growth, astute financial management and cost-effective expense management. Strategy C. Establish capital acquisition process. Strategy D. Develop a five-year capital budget that includes medical equipment and facility improvement. Measurable Goals 1. Financial reserves grow at rate of 5-10% per year. 2. Develop external benchmarking tool to compare Jefferson Healthcare financial performance, productivity and expense management by December 31, 2011. Jefferson Healthcare Strategic Plan 2011-2013 Page 16 Growth Jefferson Healthcare will be the preferred health care provider for all residents of Eastern Jefferson County. Strategy A. Complete a market share analysis for Jefferson County inpatient services, including a drill-down analysis for surgery, orthopedics, cardiology and gynecology services. Strategy B. Encourage all Jefferson Healthcare employees to utilize Jefferson Healthcare services. Strategy C. Organize and promote Jefferson Healthcare to better capture outmigration to services that are available locally through Jefferson Healthcare. Strategy D. Educate the community on local care options and promote the advantages of seeking quality care closer to home. Strategy E. Develop primary care and/or satellite services in Eastern Jefferson County. Strategy F. Explore affiliation with a large metropolitan medical center to provide continuity of care of local services to and from services not provided in Jefferson Healthcare and additional specialists placed in the community to provide local services. Strategy G. Outreach to local businesses about ways to improve access to local services, including becoming preferred providers. Measurable Goals 1. Meet or exceed budgeted volume targets in 75% of all service areas in 2011. 2. Achieve 45% inpatient market share for residents of Eastern Jefferson County in 2011. Achieve 50% inpatient market share for residents of Eastern Jefferson County in 2012. Jefferson Healthcare Strategic Plan 2011-2013 Page 17 Growth Jefferson Healthcare will grow existing services, and identify new businesses and service opportunities to better meet the health care needs of Eastern Jefferson County. Strategy A. Implement Business Development Committee to identify new business opportunities and monitor existing services. Strategy B. Jefferson Healthcare Clinics will grow primary care services as a method to increase activity in all service areas. Strategy C. Develop and grow Ancillary Services Committee comprised of diagnostic imaging, laboratory, rehab, sleep and other designated services to stimulate departmental growth, share best marketing practices, and monitor growth goals and objectives. Strategy D. Work with hospital quality department, clinics, home health and hospice to identify patients with frequent admissions to the ED or hospital for chronic disease management. Strategy E. Explore aligning with orthopedic services outside the area to provide a broader range of local orthopedic services that meet the community’s needs. Measurable Goals 1. Identify one new business opportunity (generating $500,000) by September 30, 2011. 2. Increase primary care visits by 10% in 2011. 3. Meet or exceed budgeted volume targets by 75% of all ancillary services in 2011. 4. Increase joint replacement market share to 50% in 2011 and 60% in 2012. 5. Establish Business Development Committee by May 31, 2011. 6. Establish Grow Ancillary Services Committee by April 30, 2011. Jefferson Healthcare Strategic Plan 2011-2013 Page 18 Mission Jefferson Healthcare will become the full expression of its mission. Strategy A. Develop and report to the community the index of contribution to the well-being of the community (charity care, subsidies to medical care, employment, people served, etc.). Measurable Goals 1. Develop a community index of contribution by June 30, 2011. 2. Make two community group/media presentations by December 31, 2011. Jefferson Healthcare Strategic Plan 2011-2013 Page 19 Mission Jefferson Healthcare will manage its future by open communication, careful analysis and comprehensive planning. Strategy A. Develop a strong and flexible planning process that focuses resources and provides for resiliency in an environment of health industry changes (strategic plan, campus renewal plan, community relations plan). Measurable Goals 1. Three-year strategic plan update finalized by March 1, 2011. 2. Master Site Plan in place by June 30, 2011. 3. EHR plan in place by June 30, 2011. Jefferson Healthcare Strategic Plan 2011-2013 Page 20 Mission Jefferson Healthcare will provide access to necessary care to all residents of Eastern Jefferson County. Strategy A. Define access parameters of necessary care by the Board and administration. Strategy B. Develop a community responsive and fiscally responsible policy on meeting the non or under-reimbursed (defined focus) care needs of Jefferson County. Measurable Goals 1. The Board reviews and adopts a service access policy by September 30, 2011. 2. Develop and initiate access policy implementation plan within 30 days of board direction. Jefferson Healthcare Strategic Plan 2011-2013 Page 21 Mission Jefferson Healthcare will be an active partner in matters that impact the health and vitality of the community at large. Strategy A. Assume a visible interest and role in the community by Jefferson Healthcare leadership. Strategy B. Reach out to community groups to provide support to their programs for community wellness such as providing staff for health fairs or collaborating in program development. Strategy C. Develop planned outreach to local businesses. Strategy D. Be an active member of the community in emergency response. Measurable Goals 1. Establish membership/involvement in community groups by 100% of SLG in 2011. 2. Participate in five community health fairs or events in 2011. Jefferson Healthcare Strategic Plan 2011-2013 Page 22
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