Annual Operating Plan 2009 – Results Analysis Our assessment of performance against our 2009 Annual Operating Plan is inserted in the text of the ’09 AOP in the boxes labeled “Results”: Goal 1: Strengthen efforts to achieve excellence in clinical quality, safety, and the patient experience: a. Move BIDMC towards its long term goal of eliminating preventable harm in all patient care settings by 2012 by standardizing best practice in high risk processes: Priorities include: 1. In the inpatient setting, making clear the team responsible for each patient’s care at any point in time; Results: Goal has been modified with more specification of interventions based on failure mode analysis of current practice: Completed production of video training tool - Etiquette- Based Medicine including communication of MD identity/team/roles to patients, introduced as basis for medical house staff training session on improving MD-patient communication. Improved accuracy of Primary Care Physician listing in electronic record through establishment of IT/Admin/Clinical workgroup, performed iterative correction/reconciliation of electronic data set and revised registration verification of PCP of HCA patients. Supported "Be Informed" Patient Education/Communication campaign - CVI pilot, with creation of comprehensive service-based communication standards including pre-admission protocols, posters, and patient-oriented brochures; awaiting patient satisfactions survey results to assess impact. Established as future priority – clarification of team responsibility across transitions of care: plan developed for highly-specified handoff protocols for inter-service and inter-hospital transfers of care. 2. In Interventional procedure and perioperative areas, ensuring consistent practice in all as evidenced by audit of practices in 4 identified high risk areas; Results: Successfully Completed. The interventional procedure committee has developed, approved, and disseminated standardized practices for the following high risk activities that apply to all high risk areas: pre-procedure time outs, anticoagulation management, moderate sedation, and the universal protocol. 3. In the ambulatory setting: development of a strategy for better detection of preventable harm; Results: Successfully Completed. This effort, which is novel across the CRICO-affiliated institutions, was presented to the CRICO board in October ’09. The work for the year has focused on assessing perceived risks through focus groups with staff and clinicians in the ambulatory areas. The ambulatory risk manager participates in ambulatory quality and safety activities, coaches and facilitated root cause analyses and development of corrective action plans and provides education related to risk management topics in the ambulatory areas. 4. Increasing institutional capacity to rapidly solve problems by providing personnel with the training and support needed to solve local problems successfully, and a standard process for approaching larger problem solving efforts. Results: Successfully Completed. In order to develop leaders who drive a culture of real-time problem solving, a formalized training program was developed by Alice Lee and the Business Transformation department in collaboration with the Greater Boston Manufacturing Partnership (GBMP) using a Learn-Do approach. To date, 21 senior leaders have been trained through this 8-week (48 hour) Lean study group course, which includes chiefs of service, physicians, vice presidents, and directors. An additional 23 senior leaders are currently being trained including Perioperative senior leaders (chiefs of services, directors, and surgeons). These trained administrative and medical leaders will train their staff in Lean continuous improvement principles thereby spreading problem solving thinking. To further develop employees’ problem solving mindsets, a plan was developed to diffuse Lean principles throughout the organization. This plan includes targeted training for leaders in key strategic areas who will then spread their knowledge by training and coaching their staff. A support structure is being developed to create a stable foundation for improvement and a standardized improvement approach, which includes internal and external oversight committees. The internal Lean steering committee has been formed and is composed of 8 leaders who were trained in the first Lean study group. An advisory board is currently being formed and is comprised of 4 external Lean experts from a variety of industries and 2 BIDMC Board members. As we continue to learn more, we will be continuously improving the delivery of the deployment approach. b. Achieve FY09 targets of 94th percentile in Press Ganey scores for “willingness to recommend” for inpatient care and 77th percentile (mean score 93.5) for outpatient care. Priorities include: 1. Defining with greater specificity the key drivers of “willingness to recommend” and how to change them; 2. Targeting improvements in the patient experience during an unplanned admission, 3. Improving scores in performance of publicly reported inpatient measures of “responsiveness of hospital staff”, communication with physicians, and communication with nurses, 4. Enhancing performance in Press Ganey outpatient measures of “sensitivity to patients’ needs”, “cheerfulness of practice”, and "information about delays 5. Implementing patient advisory councils in 3 additional major service lines as an approach to including patients in improvement efforts Results: We fell short of the 09 AOP goal for both inpatient and ambulatory willingness to recommend. The inpatient goal was to be at the 94th %tile, and we dropped to the 85th %tile. For ambulatory the goal was the 77th %tile, or mean score of 93.5. Ambulatory ended the year at the 50th %tile, mean score 92. Despite much effort, we did not move willingness to recommend, and so did not identify which key drivers influence that score - so efforts in 1.b.1., 1.b.2., and 1.b.3. were not successful. In ambulatory, there was improvement in the 3rd quarter for "sensitivity to patient needs", "cheerfulness of practice" and "information about delays", though these dropped a bit in the 4th quarter. With respect to patient involvement, we did successfully launch an ICU advisory council, added 2 patients to the Ethics Advisory Council, and began planning for a hospital-wide, and DPH mandated, Patient and Family Advisory Council. Goal 2: Ensure a respectful & safe workplace environment that provides satisfying work, recognition for great performance, and opportunities for career development: a. Conduct an employee survey follow up in Q2, 2009 with a goal of moving 20% of Tier 3 (lowest scoring units) to Tier 2 (mid level) and 15% of Tier 2 units to Tier 1 (the highest scoring) while achieving at least an 80% response rate from employees. Results: Successfully Completed. The employee survey had an 84% response rate. 40% of Tier 3 work units moved to Tier 2 and 33% of Tier 2 units moved to Tier 1. We attribute this positive movement to the efforts of managers who developed action plans targeting the areas where the survey showed issues and concerns. b. Create and implement programs to recruit and retain an outstanding and diverse workforce including competitive benefits and compensation programs, career development programs to prepare employees for jobs in areas facing skills shortages, and leadership development programs to enhance the strength and capabilities of our managers. To be measured by annual voluntary turnover of 10% or less and filling at least 18% of management openings from underrepresented minorities. Results: FY 2009 was a challenging year both internally and in the general economy. There were a limited number of layoffs and employees were asked to forego merit increases, reduce their earned time off and do without a 401(k) match on their savings. BIDMC’s voluntary turnover rate was relatively low, coming in at 8.4%. Only 13.5% of new supervisors, managers and directors were from underrepresented minorities, although overall representation at those levels was at 15.1%. c. Implement a program to improve employee safety that reduces slip & fall injuries by 10%, lift injuries by 5%, and exposure to blood or bodily fluids by 10% through better compliance with Personal Protective Equipment requirements, achieving an overall BLS employee injury incidence benchmark score of 8.7. Review, and change as necessary, current policies and procedures to prevent staff injury from violent patients. Results: FY 08 FY 09 FY 09 Difference Difference Actual Goal Actual From FY 08 From FY 09 Goal All Incidents 891 N/A 896 0.561% N/A ALL Handling AOP GOAL: 5% 135 128 183 35.56% 43% DECREASE Fall, Slip, Trip AOP GOAL: 10% 125 113 116 -7.20% 3% DECREASE Exposures AOP GOAL: 10% 332 299 326 -1.81% 9% DECREASE BLS (Incidence Rate) AOP GOAL: 7.6 6.5 7.14 -6.05% 10% changed to 6.5 Work Place Violence: We launched a Reducing Workplace Violence work group in FY 2009, which implemented a system wide survey of employee perceptions of workplace safety with respect to violence. Goal 3: Strengthen financial performance by achieving our volume goals and improving productivity: a. Achieve a 2% operating margin, and identify, plan and implement efficiency and growth initiatives to restore a 4% operating margin: 1. Engage clinical and administrative leadership in a structured review of BIDMC strategic challenges and opportunities; 2. Evaluate clinical programs to determine whether to maintain, grow or eliminate. 3. Improve net margins in key strategic programs by reducing costs and enhancing revenue. Results: Goal of 2% operating margin not met in FY09. In the face of declining revenue, management took action to reduce expenses in order to achieve a BIDMC operating margin of 1.3%. Efforts to restore a 4% margin continue. FY10 budget includes a BIDMC operating margin of 3.1% without including any potential positive impact from an affiliation with Atrius Health. b. Raise $70 million in new gifts and pledges, with a goal of $8 million in cash to support operations and $12 million in cash to support capital, and continue capital campaign efforts by achieving a cumulative campaign total of $170M in 2009 towards the overall $600 million goal. Results: Raised $37 million in very difficult economic climate in total gifts and pledges. With extraordinary push with board members, raised $8.1 million in cash to support operations – an increase of 60% over last year’s total. c. Maximize usage of our existing clinical, research, and administrative space to ensure adequate capacity while developing a new metric driven space allocation model by: 1. Achieving 75% utilization of perioperative rooms; 2. Achieving the interim main campus aggregate goal of 48% of all ambulatory kept visits. In moving towards the 2016 goal to fit ambulatory visit volume growth on main campus, ALL clinics must be at 50% utilization or more. 3. Continuing to improve overall throughput, including a 5% reduction in ED LOS; 4. Establishing targeted growth goals for IDR/sq. ft. and implementing appropriate growth goals in 2009; 5. Defining and implementing metrics to be used and overall approach for prioritizing space allocation for clinical, inpatient and research purposes. Results: Successfully Completed. (OR Utilization - 75%). This metric doesn't capture actual OR efficiency - however, we launched a process this year where both utilization and net margin are considered when allocating OR block - this process has involved the chiefs of service and has led to better decision-making regarding block allocation - in particular, we have reduced cosmetic block substantially this fiscal year. d. Identify opportunities to maximize residency coverage and reallocate residents to ensure optimal mix of coverage at BIDMC and educational value to residents. Results: Goal not met. This was a joint effort with Dianne Anderson. The project was postponed with her departure from BIDMC, and it will be addressed in FY 10 as part of the “refresh” strategic review for education. e. Continue to implement network development initiatives and physician outreach efforts that support volume growth and build community physician and hospital relationships including: 1. Completing of the 3 year approved plan to add a total of 30 APG PCP's in Needham and BIDMC as well as continuing to implement the establishment of an APG practice in Milton, Results: Successfully Completed. There are now a total of 78 PCPs employed through APG at BIDMC and Needham as well as 6 at Milton (another 25 are employed in Brockton) 2. Developing 2 strategic relationships that enhance BIDMC’s presence and reputation in the community through hospital affiliations, BIDPO participation , CVI relationships or HMFP practices; Results: Successfully Completed: a. Whittier IPA (140 member Physician organization serving greater Newburyport area and Anna Jaques Hospital) formally affiliated with BIDPO b. Definitive agreement signed between CVI, through Heart Center of Metrowest, and Southboro Medical Associates, a member of Atrius Health, for the provision of comprehensive cardiovascular services c. Greater Lawrence initiative- 3 cardiologists and 10 PCPs affiliated with BIDPO. Cardiologists (New England Cardiology) have become an affiliate of CVI. Agreement reached with Lawrence General hospital to become tertiary sponsor of their cardiac cath, to provide QA oversight and assist with professional staffing. d. The two major GI groups in the greater Lowell area (11 physicians) have affiliated with BIDPO e. Suburban Cardiology and Internal medicine, a primary care and cardiology group in Natick, have affiliated with with BIDPO and CVI. f. One of the 2 major cardiology groups on Cape Cod (Cardiovascular Consultants of Cape Cod) affiliated with BIDPO and CVI. g. Completing of a western community cancer strategy recommendation that includes relocation of the Waltham linac; Results: Planning effort which includes HMFP and Atrius Health (Dedham Medical Associates and Vanguard Medical Associates) far along although not completed. With Atrius and HMFP as partners plan is to jointly develop a comprehensive Cancer Center in the Needham business park area or its immediate vicinity. Program planning essentially complete. Final location and deal structure being worked out but would include a BIDMC licensed medical and radiation oncology program. h. Growing inpatient medical/surgical discharges tracked to established and new external community based relationships by 3.5%. Results: Successfully Completed. Med/Surg volume tracked to BID-Needham, Brockton initiative, AIM, Emerald Physicians, Metrowest, Nashoba Valley, Whittier IPA, Northeast Health System (Beverly Hospital) and St Vincent Hospital rose 8.3 % (an increase of 354 cases to a total of 4628) Goal 4: Continue to strengthen the academic mission of BIDMC Elements in Support of our Education Mission: a. Continue Graduate Medical Education Programs Assessment: Phase 1: Student recruitment Having established a dashboard for assessing the quality of students recruited into our residency programs, begin annual collection of data and share with chiefs and hospital administration. Develop instructional materials for programs/faculty on marketing and interviewing Based on information obtained from student and resident surveys, develop department specific plans for enhancing recruitment. Results: The Center for Education has begun the annual collection of recruitment data. The director of GME visited each program to discuss post-match student survey information and to provide assistance in addressing concerns expressed by students who chose to match elsewhere. The Center for Education/GME Office provided an instructional session on interviewing for program directors and interested faculty members. We developed and distributed a slide presentation for use by all programs in recruitment activities beginning November 2009; this presentation highlights the institutional strengths of BIDMC as a site for residency training. Phase 2: Resident performance Medical knowledge outcomes: track in-service exams and board certification rates. Develop mechanism for tracking patient satisfaction data as it relates to resident performance/communication. Develop and implement standardized assessment tool for one of the ACGME competencies (professionalism, communication, practice-based improvement, or systems-based practice). Results: The GME office presented data at a COEC meeting in April 2009 about students matching at BIDMC; these data were gleaned from the NRMP match system as well as from internal metrics with respect to our match. In addition, we instituted a system for collecting and tracking in-service exam scores, and pass rates on specialty certification exams. We initiated a pilot program for teaching residents the most effective means for doing sign- outs/handoffs (competency: communication) and assessing resident performance in this domain. The program is continuing with two departments in FY 10. b. Undergraduate Medical Education Program Assessment: Assess utility of skills log and patient log by examining correlation with other outcome measures for students. Results: The Office of Undergraduate Medical Education within the Center for Education implemented a system for collecting data on student skills. These data were analyzed at the mid-point of the year for third-year students in the Principal Clinical Experience. Those students who did poorly were counseled; each showed significant progress in the second half of the year. Data are now being analyzed to determine possible correlations between performance on the skills/procedure logs and grades in third year clerkships and scores on national clerkship exams. c. Develop and implement program for assessment of and improvement in resident performance in family meetings: Develop and implement instrument to be completed by families following family meetings. Develop and implement pilot program for teaching residents how to conduct family meetings. Training will include: didactic sessions and simulation sessions (to include use of trustees as “standardized families”). Results: The Center for Education developed a curriculum for teaching communication skills to residents; the focus was on those skills necessary to conduct high quality family meetings. Staff designed and implemented a pilot program in May and June of 2009 in which the training (including didactics, role plays, and simulation) was implemented. Based on that experience, a formal training program was initiated for residents in the department of medicine in July 2009. d. Obtain recertification as Level 1 simulation program from American College of Surgeons and obtain accreditation from American Society of Anesthesiology. Results: The American College of Surgeons performed an accreditation site visit of the Shapiro Simulation and Skills Center in September 2009. The immediate feedback was positive; we are awaiting final word from the ACS about accreditation. We completed and submitted our application for accreditation to the American Society of Anesthesiology and are awaiting their decision as well. Elements in Support of our Research Mission: a. Ensure the quality and safety of our human subject research programs by achieving accreditation by the Association for the Accreditation of Human Research Protection Programs (AAHRPP). Results: Successfully Completed b. Achieve the FY09 budgeted IDC projection by recruitment of new investigators, mentoring recent recruits to apply for funding, encouraging cross-disciplinary proposals, and optimizing use of current research space. Results: FY09 Budgeted IDC not achieved, though target research P and L forecast was met as a result of reduced expenses. c. Finalize all research laboratory relocations in Dana/SL/RW, Research North, HIM-1 and CLS. Results: Successfully Completed d. Work with DFCI to convert the Research North Animal Facility into a barrier facility by August 2009. Results: N/A, DFCI pulled out of this deal. e. Perform an inventory of basic, clinical and administrative research space and determine related space costs: Review and implement space allocation policy after a review of research finances and the setting of new goals for IDC recovery. Results: Space fully inventoried; substantial progress in FY09 towards new space allocation policy, with implementation expected in calendar 2010. f. Research Philanthropy: Revise BoDRAC charter to reflect the needs for research philanthropy and engage BoDRAC members in these efforts. Results: Successfully Completed Chief Academic Officer (CAO) will work with senior management, the development office, senior academic leadership, the Technologies Ventures Office and BoDRAC to identify research project opportunities for fundraising, define financial targets for these and align these with institutional budget relief and RAC priorities. Results: Successfully Completed CAO to form a “Young Investigators Think Tank” to energize recent recruitments and leverage BIDMC’s investment in them: mentorship, defining unsolved problems, pointing to grant opportunities, etc. Results: Successfully Completed Publicize funding and other opportunities from the Harvard-wide Clinical and Translational Science Center (CTSC) and the Harvard University Science and Engineering Committee to BIDMC investigators. Results: Successfully Completed CAO will assist hospital in determining which research recruitments it should support based on strategic priorities. Results: Successfully Completed Expand programs for nursing and allied health research by supporting on –site discipline based research and NIH funding applications by nursing and allied health researcher. Results: Successfully Completed. We had a nurse scientist on site supporting research - several studies in process including one study on using simulation to develop critical thinking in new nurses, another on maternal - newborn infant attachment based on specific nursing behaviors.