Cottage Health 2019 Culture Audit

Strategy and goals move the organization forward and are central to its continued success. Each year, top organizational goals are identified by the executive team and approved by the CH Board of Directors. These goals touch areas throughout the organization and are summarized in a one-page document for ongoing reference and progress checks throughout the year. The goals document is distributed at the monthly department directors meeting and shared with all employees. Metrics for measuring success are outlined in the goals summary. Department leaders set annual goals to support the organizational top goals at a department level, and these are tied to a management incentive program. Within departments, each employee sets individual goals that are part of annual performance evaluation tied to merit increases. Progress toward goals is monitored throughout the year, and each year at employee forums our CEO presents a look back at goals accomplished and a look forward at new goals set for the coming year. Accomplishments are also summarized in a year-end letter from our CEO to express appreciation to employees and connect their hard work to measurable successes. Last year, financial performance enabled the Board to approve a monetary gift to accompany this year-end letter for non-executive level employees. In addition to annual goals, a five-year strategic plan is developed with involvement of leaders across the organization, based on assessment of community needs, blue-sky brainstorming, environmental scans, current economic and healthcare climate and evolving competition and market drivers. The next five-year strategic plan is currently under development with five task forces formed to develop proposals in areas like digital health, clinical service line development, financial stewardship and patient scheduling. Listening tours, focus groups and consumer surveys are conducted regularly within our community and region to provide data on community needs and market conditions, helping to inform strategic planning and top goals. Employee feedback and employee engagement surveys also play an important role and employee engagement is included as a focus in top goals every year. 6.22 Please describe your executive team’s current short and long-term strategy and philosophy for ensuring a successful business. Describe the process for developing it, and specific examples of how you communicate it across all levels of the business. TOP GOALS ClinicalQuality • Achieve5-StarorbetterCMSHospital CompareRating forSBCHandGVCH. Implementplan toachieve4-Starorbetter in2019atSYVCH • AdvanceCHasaHighReliability Organization (HRO) - Gapanalysis forSafePractices in handoffs,medicaldevicealarms, IT - DevelopanddelivercoreHROcurriculum - Implement“GoodCatch”quarterly recognitionprogram - Increaseworkgroupsabove thenational median foroverallCultureofSafety, from 20% to50% • ReduceSeriousSafetyeventsby20% from the2017aggregate inareasofCAUTI, CLABSI,C.diff,MRSA,SSI,Ventilator-Assoc Events,Fallswith Injury,PressureUlcers, Post-OpSepsis,Post-Oppulmonary embolismordeepvein thrombosis, allother reportedpatienteventswith significance levelsEorhigher • Achieve JCcertification forComprehensive Stroke (SBCH),StrokeReady (SYVCH), AdvancedHipandKnee (SBCH),Wound Care (GVCH) • Improveaccuracyofclinical documentation,achievingaconcurrent coverage (chart review) rateof85% ofMedicarepatientsandaphysician response rateof90% • Initiate thecollectionanduseof race, ethnicity, languageandgenderpreference data to identifypotentialhealthcare disparities incurrentqualityand safety metrics • Assure thatbyyearend100%ofallpatients inneedhave interpreter services forall criticalcommunication • Achieveand/or sustain topquartile ranking forallPressGaneyOverallPatient Satisfaction surveys PhysicianAlignment • Implementacollaborativemodel for the CHGroupHealthPlanwithSantaBarbara PreferredHealthPartnersandSansumClinic • Implementacomprehensiveprogramof educationand training forCHmedical staff leadersbyprovidingat least3 in-house conferencesand sponsoringat least10 leaders toattendoff-siteconferences • ImplementCoastalOneHealthPartners ACOwithSansumClinic • ImplementPrescribeSafe Initiative: - Letterofnotice toprescribingphysicians on the statusofpatientwithoverdose - ConcludeoperatingagreementwithSB NeighborhoodClinics forMedication AssistedTreatmentClinic - Complete3educational sessionswith medicalandhospital staffonopioid addictionandmedicationordering • Implementyear threeof theCottage Research Institute strategicplan: - Attain15newly fundedclinical studies - Develop research initiatives that support CCMC’sCaliforniaChildren’sService (CCS) TertiaryCenterdesignation - Develop research initiatives that support SBCHLevel ITraumaCenterdesignation - Increaseclinician research to90new sponsoredandnon-sponsoredclinical studies EmployeeEngagement • Achieve>90%participation in the 2018CultureofSafetySurvey • Train100%of identified staff forSBCH move intoPhase6 • Train100%of identified staff forCottage Compass FinancialStrength • Achieveoperatingmarginof3.4% • Develop3-yearmanagedcare strategy • ImplementCottageCompass Mission Toprovide superiorhealth care forand improve the healthofourcommunities throughacommitment toourcorevaluesof excellence, integrity,and compassion. Vision CottageHealth, through partnershipwithphysicians andourcommunities, is recognizedasa California leader inquality care, safety,patient experience, transparency, costeffectiveness,and communityhealth. Values Excellence– Whatwedo Integrity– Howwedo it Compassion– Whywedo it COTTAGE HEALTH 2018 Supplemental Materials 2018 Cottage Health Top Goals PDF • General Information 6.22 28/94 Start | Contents | Highlights | General Information | Hiring & Welcoming | Inspiring | Speaking | Listening | Thanking | Developing | Caring | Celebrating | Sharing