St. Mary's Journey Toward Becoming Exceptional - SSM Health Care

‣St. Mary’s Hospital in Centralia joined Good Samaritan RegionalHealth Center in Mt. Vernon in 1996 to form St. Mary’s GoodSamaritan (SMGSI).‣Our vision is to provide a broader array of services closer to home.‣ SMGSI serves 225,000 residents in nine southern Illinois counties.‣SMGSI has an active medical staff of 120 primary care andspecialty physicians.2

Recognition Received‣ In 2003, St. Mary’s Good Samaritan, Inc. won the Gold Awardfrom the Lincoln Foundation for Performance Excellence.‣ In 2004, St. Mary’s Hospital was the recipient of theThompson/Reuter’s Top 100 Hospital Award for PerformanceImprovement Leaders in Medium Sized Hospitals.‣ In 2005, St. Mary’s Hospital received the Gateway Chapter ofMultiple Sclerosis Employer of the Year Award for St. Mary’scompassionate treatment of individuals with disabilities,especially Multiple Sclerosis.‣ In 2007, St. Mary’s Hospital became a preceptor location forthe University of Illinois Rural Medicine Program.‣ In 2008, St. Mary’s Hospital received the Illinois Governor’sPeople are Today’s Heroes Award because it has served formore than 10 years as the lead agency to 21 counties for theIllinois Breast and Cervical Cancer Program.‣ In 2008, St. Mary’s Good Samaritan, Inc. won the Silver Awardfrom the Lincoln Foundation for Performance Excellence.Medication Safety Team1 st Year Accomplishments‣ ISMP Recommendations Implemented:‣ Created multidisciplinary Medication Safety Council‣ Hired Med Safety Officer‣ Developed and pilot tested a new supervisor’s investigationform for medication errors‣ Standardized the use of metric weights to avoid errors‣ Obtained approval to replace PDRs with AHFS DrugInformation & remove all outdated resources‣ Added Micromedex to home page for ease of access at pointof care‣ Standardized the adult and pediatric drug reference materialson code carts‣ Updated formulary on-line‣ Revised code blue form to record drug concentrations andaddressed atropine concentration error on form3

St. Mary's HospitalMedication Error with Harm0.0250.020.0150.010.00500.020 02007 2008 YTD August2009GOODMedication Error withHarm RateMedication Error withHarm trendlineSt. Mary's HospitalClinical Advisor APR-DRG Mortality Index1.210.970.910.870.80.740.60.40.202006 2007 2008 YTD July2009GOODMortality IndexMortality Indextrendline4

St. Mary's Hospital - CentraliaComposite Scores for Congestive Heart Failure10098969492908886848289.293.098.9 98.92006 2007 2008 YTD Sept2009GOODCongestive HeartFailureMHA 90%tile = 98.6Why Not the Best90%tile = 99.16CMS CHF TrendlineSt. Mary's Hospital - CentraliaComposite Scores for Pneumonia1009898.4GOOD969494.7 94.7929088868489.52006 2007 2008 YTD Sept2009PneumoniaMHA 90%tile = 98.1Why Not the Best90%tile = 98.38CMS PneumoniaTrendline5

St. Mary's Hospital - CentraliaSurgical Care Improvement Project (SCIP)100908070605040302010080.4 81.896 96.52006 2007 2008 YTD Sept2009SCIPGOODMHA 90%tile = 97.9Why Not the Best90%tile = 98.25CMS SCIP TrendlineSt. Mary's Hospital - CentraliaInpatient Patient Satisfaction100908070605040302010057 5754687889 902006 2007 2008 YTD Sept200975GOOD%tile Likelihood ofrecommending%tile StandardQuestions OverallLikelihood toRecommend Trendline6

St. Mary's Hospital - CentraliaOutpatient Satisfaction1009080706050403020100304314342006 2007 2008 YTD Sept200973847089GOOD%tile Likelihood ofrecommending%tile StandardQuestions OverallLikelihood ofRecommendingTrendlineSt. Mary's Hospital - CentraliaInpatient Behavioral Medicine Satisfaction10090807060504030201004031777398 9793902006 2007 2008 YTD Sept2009GOOD%tile Likelihood ofrecommending%tile StandardQuestions OverallLikelihood ofRecommendingTrendline7

St. Mary's Hospital - CentraliaOutpatient Surgery Satisfaction100908070605040302010056 577262658274932006 2007 2008 YTD Sept2009GOOD%tile Likelihood ofrecommending%tile StandardQuestions OverallLikelihood ofRecommendingTrendlineExceptional Patient Care‣ Enhancing Patient Safety Team‣ Medication Safety Team‣ Falls Team‣ CMS: concurrent queries‣ Service Excellence Director‣ Customer Service Teams‣ Implementation of AEPC initiatives‣ Private patient rooms‣ Bi-weekly quality measure review meeting‣ CQI Plus teams to improve patient flow8

PHYSICIANSJames Stiehl, MDOrthopedic SurgeryNiranjan Shrestha, MDFamily PracticeAbel Garibaldi, MDGeneral & Vascular SurgeryVikram Agrawal, MDPediatricsBashar Oustwani, MDFamily PracticeSt. Mary's Hospital Physician Satisfaction:Overall, how satisfied are you with this hospital?10090807060504030201009788 9078562005 2006 2007 2008 2009GOODOverall SatisfactionpercentileOverall SatisfactionTrendline9

100908070605040302010041St. Mary's Hospital Physician Satisfaction:Administration's responsiveness in addressingissues important to patient care?616687922005 2006 2007 2008 2009GOODOverall SatisfactionpercentileOverall SatisfactionTrendlineSt. Mary's Hospital Physician Satisfaction:Overall, how satisfied are you with nursing care?100908070605040302010095 949872542005 2006 2007 2008 2009GOODOverall SatisfactionpercentileOverall SatisfactionTrendline10

St. Mary's Hospital Employee Satisfaction:My Supervisor Recognizes My Ideas100908092GOOD7064605040304050My supervisorrecognizes my ideas20100My supervisorrecognizes my ideastrendline2006 2007Pulse2008 2009St. Mary's Hospital Employee Satisfaction:Recommend as a Good Place to Work100908070667592GOOD605450403020100Recommend as agood place to workRecommend as agood place to worktrendline2006 2007Pulse2008 200912

St. Mary's Hospital Employee Satisfaction:Overall Satisfaction with Organization1009080707392GOOD605550403044Overall Satisfactionwith Organization20100Overall Satisfactionwith OrganizationTrendline2006 2007Pulse2008 200913

Exceptional Commitment‣ Annual medical staff interviews‣ Follow through on issues‣ Transparency – “no secrets”‣ Open communication at all levels‣ Corrective action plans if below 50th‣ Shared Governance‣ Reward & Recognition team‣ Increased employee accountability‣ Management education & development14

St. Mary's Hospital Productivity:Paid Hours Per Adjusted Equivalent Patient Day2726.52625.52524.52423.52322.52226.82523.923.32006 2007 2008 YTD Sept2009GOODHours Per AEPDHours Per AEPDTrendlineSt. Mary's Hospital Productivity:Paid Hours Per Adjusted Equivalent Admission105104.71009595.892.7GOODHours Per AEA9087.2Hours Per AEATrendline852006 2007 2008 YTD Sept200915

am1St. Mary's Hospital Operating Expense Per AEA$5,700$5,500$5,497$5,300$5,100$4,900$5,094$4,953$4,857GoodOperating ExpensePer AEA$4,700$4,5002006 2007 2008 YTDAugust2009Operating Expenseper AEA Trendline7.0%6.0%5.0%St. Mary's Hospital - CentraliaOperating Margin6.0%Good4.0%3.9%3.8%Operating Margin3.0%2.0%1.0%2.6%Operating MarginTrendlineS&P “AA” Rating3.3% to 4.5%0.0%2006 2007 2008 YTD Sept200916

ExceptionalFinance/Growth‣ JA Thomas‣ Executive Health Resources‣ Cross campus integration‣ Management accountability‣ Improved charge capture‣ Physician RecruitmentA Valuable Lesson17

Congratulations to theSt. Mary’s team on theirperformance!18