Pinckneyville Community Hospital Celebrates Accomplishments from Balanced Scorecard Development

July 2013
National Rural Health Resource Center (The Center)

Pinckneyville Community Hospital, located in Pinckneyville, Illinois, is a 25-bed critical access hospital. Services include acute care, swing beds, 24-hour emergency services, specialty clinics, ancillary & therapy services, outpatient senior behavioral health program and a hospital based rural health clinic. The mission of the hospital is:  "Leading the way to a healthier tomorrow through local access to quality care, delivered with compassion by a team of skilled healthcare professionals."

In 2012, Scott Goodspeed, Principal and Vice President, iVantage Health Analytics, assisted the hospital leadership team on a Leadership and Balanced Scorecard Development project. The project team focused on strategies to improve four areas: quality and customer service, staff and physician satisfaction, hospital growth, and hospital financial health. The hospital's executive team, which includes: Tom Hudgins, Administrator/CEO; Eva Hopp, CNE; Carla Bruns, Risk & Quality Manager; Christie Gajewski, HR Director; and, Kara Jo Carson, CFO/Compliance Officer, recently shared information about the progress of the project.

Q: Why did you choose to focus on Balance Scorecard Development for your RHPI project?

A: "We identified an opportunity to improve communication through leadership and communication style education as well as leadership team building exercises that would aid the hospital in implementing a more formalized strategic planning initiative to foster service and operational improvements designed to improve customer service and grow patient volume." The outside instruction provided by Scott Goodspeed proved highly beneficial to the hospital's leadership team and Board of Directors.

Q: What is your hospital's current status with regard to implementing the recommendations made during this project?

A: "Communication has changed." An employee newsletter is distributed every two weeks and information is shared on a timely basis as needed via group email accounts to the Board of Directors, leadership team and all employees with hospital email accounts. Furthermore, manager meetings now have a round table format resulting in more input from leadership.  Meetings are more efficient and when possible, key info is shared ahead of time so there isn't a rehash of information. Focus is on discussion rather than just sharing information. Through the leadership team development training provided by Mary Rooney Sheahan, MS, RLC, Executive Leadership Development and Coaching with The Sheahan Group, department managers and other key personnel learned more about one another's communication styles. This helped the leadership team members feel more comfortable in sharing and discussing topics with an emphasis on what is most beneficial for the hospital as a whole as opposed to just a departmental focus. The hospital also developed their own Change & Event Planning Guide communication tool to possibly aid in improving communication among departments and staff members.

"We had behavioral standards; however, they were long, not included in the evaluation process and were created based on another hospital's value program without our own employee input." Through an external employee survey evaluation process, hospital leadership knew that employees felt more staff accountability was needed. Therefore, to begin the process of developing new values and behavioral standards created with staff input, the hospital's leadership team first worked to establish a draft set of core values and corresponding behavioral standards. This information was then shared with all employees to gather their input and suggestions. Employee input was instrumental in refining and narrowing down the values and behavioral standards to a workable level at which employees could be held accountable for upholding. Once finalized, employees signed off on the new values and behavioral standards, they are presented to new hires as a way to get agreement from them prior to being hired and they are posted throughout the hospital to remind staff and patients about standards.

A new evaluation process was implemented to help enhance staff accountability. We sought out and utilized samples from other rural hospitals regarding physical demands, essential functions and merit calculations. Rather than employees typically receiving the max merit available, a new standard merit of 2.6% for meeting job expectations was established based on information from regional wage surveys. With this type of format, employees can "earn" additional merit award through their actions that go beyond job expectations and/or that stand out among other staff members. In order to help improve communication between managers and staff members for a fair and equitable evaluation process, we started providing employee self-evaluation tools mid-year so that employees have the opportunity to communicate what actions they feel are above and beyond expectations. This has been a learning process for both management and staff alike and opportunities to improve the process are underway for implementation in the next calendar year. In addition to setting high expectations for staff, the hospital also realized the increased importance of staff recognition. They developed departmental appreciation budgets that managers can use to recognize and celebrate employee and departmental accomplishments.

In addition to the self-evaluation forms provided to employees, we have also implemented additional measures to help create a more engaged workforce. Managers now gather information from employees to help them get to know one another better as well as how the employee prefers to communicate and be rewarded. The hospital will also conduct a leadership survey in June 2013 that will be useful for the leadership team in building and improving leadership and communication skills that will benefit the hospital's overall culture.

"We have recently created a "PCH Pride" program designed to: communicate and reinforce the positives of being a Pinckneyville Community Hospital (PCH) employee; help promote and foster a sense of pride among staff; and, to help bolster employee morale." The program is beginning by expanding the current "Hospital Pride Wednesday" when we wear our blue hospital logo shirts by encouraging staff to wear hospital logo apparel on a more regular basis for a chance to win additional hospital logo merchandise.

There have been a number of patient-focused improvements, which include: establishing a call back program for ER patients within 48 hours; improved communication between nursing and medical staff through joint Case Manager/Physician rounds and implementation of scribes; pharmacist and nurse collaboration regarding electronic medication reconciliation; pharmacist one-on-one discussions with patients to educate them on high-risk medications; and, expansion of the community education program to include more frequent events. Case Managers implemented a variety of process improvements related to patient discharge planning, whereby they have been asked by the Illinois Critical Access Hospital Network (ICAHN) Nurse Leader Group to give a presentation on those process improvements. The collaboration and increased communication by our Case Managers with discharge planners at other hospitals so that patients from our area are referred back to our facility has been very successful in growing our swing bed patient activity. This was an instrumental part of the positive financial growth achieved during the hospital's fiscal year that ended 04/30/13. The hospital created a patient satisfaction team and expanded it to include ancillary departments. The hospital also began conducting outpatient surveys since that represents a large portion of the patients. They have already used patient feedback to tweak policies such as dress code and professionalism standards. The hospital has worked to include staff in the improvements. When they began addressing revenue cycle improvement, Performance Improvement Champions for Registration Accuracy and Collections were created. This approach has improved communication and cooperation between departments to improve information collection, improve registration accuracy, decrease rework and revamp the financial need process.

Q: What were the expected outcomes of this project? Has your hospital been able to document any of these outcomes?

A: The hospital has been tracking a number of measures. Staff turnover is less than 1%. Days in accounts receivable are less than the established goals, including below the average experienced by their peers per benchmarking data available through the ICAHN and Quality Health Indicators (QHI) Quality & Financial Scorecard program. Swing bed numbers are up and there has been a 2.8% increase in net revenue from calendar year 2011 to 2012.

Inpatient satisfaction scores improved significantly but still tend to fluctuate. Areas that have shown steady improvement include "Response of Staff", which improved from 69% in January to 78% in May. "Doctors treating patients with courtesy and listening carefully" has been maintained in the 90th percentile since January. "Pain Management" went from 68% in January to 81% as of May. "Discharge Information" has been held in the high 80's-90's, which corresponds with the improvements made to the patient discharge process. We have been focusing on timely answering of call lights and assuring that patient pain is managed. The next focus of the hospital's Patient Satisfaction Improvement Team will involve "Quietness of the Environment". Of significant note, the hospital's increased attention to communication has paid off. Per Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey results from July 2011 to June 2012, PCH was recognized by Becker's Clinical Quality & Infection Control July 13, 2012 publication as being 1 of 61 Hospitals With the Best Nurse Communication out of 3,851 total hospitals reporting via HCAHPS. With a score of 88%, PCH was ranked as the 28th non-specialty, acute-care hospital with the highest percentage of patients who reported that their nurses "always" communicate well.

Q: What are the expected next steps towards adopting your consultants' recommendations? Is there a sustainability plan?

A: The hospital will continue to focus on stabilizing the inpatient quality measures and to use trended outpatient satisfaction data to identify and implement new improvements designed to enhance patient experience with the services being provided. A follow-up employee satisfaction survey is planned for late 2013/early 2014 in order to help gauge staff perception of the activities, programs and changes implemented in 2012/2013. Physician satisfaction measures will be addressed in the future.

The "PCH Pride" program will be expanded to include showcasing employees who win the monthly drawings for wearing hospital logo apparel. The winners will be asked to share why they love working at PCH and this will be shared with employees, visitors and guests via a public display board. We will develop displays that promote and celebrate the great things about being a PCH employee, including favorable/competitive insurance, pension and education benefits; surveying employees as to their thoughts on "PCH positives" and why they love to work here; and, possibly showcasing a department each month to share what services their department provides and any recent accomplishments achieved.

"We have also been reviewing options for a formalized culture improvement and customer service training program for all employees. We want to create a culture that recognizes the value of everyone no matter the job title - a "pride of ownership culture" where each employee knows and is confident about their own self-worth and contribution. We are considering a program that is more about helping employees overcome personal challenges that are weighing them down, preventing them from being able to take pride in their work and live by established values. Through these concepts, every employee will learn how to think like an owner - to take ownership in being committed to contribute to the hospital's success. The ultimate goal of this employee education initiative will be to improve the quality of customer service and to be the provider of choice, through fostering a "PCH Pride" program that instills personal ownership in the hospital's success by assisting employees with personal development through connecting personal values with that of the organization.

PCH is also undertaking an internal wellness effort to aid in preparing how the hospital will play a role in helping improve the general health of its community through population health management. "We feel that the best approach for this initiative is to start with our own employees - to really start living and promoting our hospital mission: 'Leading the Way to a Healthier Tomorrow'." This effort began with the creation of the PCH Heart & Sole program whereby various employees get together to participate in regional run/walk events and has recently grown to include an Employee Wellness Committee whose primary objective is to promote healthy lifestyle choices. PCH will also be conducting a local community health needs assessment in July 2013 as an opportunity to look at its community health needs, how they can measure progress to date in addressing those issues and to begin to address what still needs to be done. ICAHN has designed a cost and time efficient process that will assist the hospital in gathering current meaningful information about local health care needs.

Other goals of the hospital for the upcoming year include: the possibility of developing a patient advocacy focus group designed to get patient and family input on ideas for customer service, safety and quality improvement; creating a provider development plan that will aid in building the primary care base; improving physician retention (reduce turnover) by recruiting physicians with an interest in what the local community has to offer and making new physicians feel like they are part of the community; involve providers more in the strategic planning process; implementing provider contracts that align expectations and incentives with the quality and reimbursement factors hospitals are facing with health care changes; developing a succession plan for a general surgeon; growing specialty clinic services and working with local providers to address concerns on utilization of mid-levels in certain specialty clinics; developing a financial dashboard report including key performance indicators and comparative financial ratio data and providing corresponding board education on understanding and analyzing ratio performance trends; and mentoring the Upfront Collection Performance Improvement Champions and the team of department representatives to help foster increased cash collections, reduction in bad debt and improved financial need process.

Q: Is there anything your hospital would do differently if you were able to repeat this experience?

A: "Implementing the new evaluation process has been challenging. You never know how that is going to work for your particular facility until it is actually put into action. We've made certain to communicate the changes and rationale to employees along the way; however, implementing any type of change can be somewhat unsettling. If we could do something different with the process, it probably would have been good to get the new evaluation formats completed earlier in calendar year (CY) 12 so that we could implement trial runs prior to effective implementation in CY13." Despite the short-term challenges, the hospital does feel the process is much improved and will help them achieve our underlying goals. The leadership team recently held a discussion meeting to share manager and employee feedback to work towards potential evaluation process improvements for the upcoming CY.

Q: Aside from the measurable outcomes, what has been the impact of this project on your community?

A: We have noticed a much more positive outlook among community members about the hospital and the services provided. Community members are now actively and routinely engaging hospital staff regarding updates on the replacement facility project. The expansion of the hospital's community education program and a letter campaign in 2012 designed to communicate support for the new replacement facility project appear to have helped initiative this growth in community interest. There is a new sense of excitement regarding the replacement facility project and the benefits it will provide to our community, not only from a health care perspective in helping secure local access to emergency and health care services well into the future but also as an improvement to the community's overall economic outlook.

Staff and leadership as a whole are more engaged and willing to take risks and share ideas for improvement.  Rather than being stagnant, there is a focus on growth, change, and improvement as well as increased creativity to design solutions. There is much better communication across all levels of the organization and there is more awareness and focus on the celebration of accomplishments. This type of culture development is reflected in our employees' attitudes and interactions with fellow co-workers, patients and visitors, which will continue to nurture the positive connection with our community.