Advocate Good Samaritan Hospital – Profile

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Malcolm Baldrige National Quality Award 2010 Award Recipient, Health Care

Photo courtesy of Advocate Good Samaritan Hospital.

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Highest-Ranking Official* David Fox President

Public Affairs Contact

*At time of award

For more information Advocate Good Samaritan Hospital 3815 Highland Ave. Downers Grove, IL 60515 (630) 275-2442 [email protected] http://www.advocatehealth.com/gsam Advocate Good Samaritan Hospital, an acute-care medical facility in Downers Grove, Illinois, has evolved during the past 30 years from a midsized community hospital to a nationally recognized leader in health care. By leveraging its core competency of building loyal relationships as well as the organizational transformation of "moving from good to great," the hospital has achieved exceptional clinical, service, and financial outcomes.

"Good Sam," as it is popularly known, features the highest level of trauma services and perinatal care. Good Samaritan Hospital is part of Advocate Health Care, named one of the 10 top health systems by Thomson Reuters. The hospital has a workforce of 2,700 associates, 450 volunteers, and 950 independent physicians representing 59 specialties. It has revenues of $420 million.

Highlights

 Risk-adjusted mortality (actual mortality divided by expected mortality where 1.0 equals the expected) decreased from 0.73 in 2004 to 0.25 in 2010.

 A brand preference study of Good Samaritan Hospital and its closest competitors ranked Good Samaritan Hospital as the overall most preferred hospital, as well as the top choice for its main service offerings.

 Good Samaritan Hospital has established a strategic context and vision for a synergistic hospital-physician partnership that has enabled the organization to generate some of the best clinical outcomes in the United States.

 Overall patient satisfaction levels for outpatient, emergency, ambulatory surgery, and convenient care exceed top decile.

First and Foremost a Clinical Enterprise

 Good Samaritan Hospital demonstrates high levels of performance in many process measures for clinical outcomes. Risk-adjusted mortality (actual mortality divided by expected mortality where 1.0 equals the expected) decreased from 0.73 in 2004 to 0.25 in 2010.

 The Centers for Medicare and Medicaid Services core measure results for pneumonia, heart failure, heart attack, and surgical care are either approaching or exceeding the top-decile level, and meet or exceed the levels of local competitors.

 In 2003, Good Samaritan Hospital used Six Sigma methodology to pioneer improvement of "door-to-balloon" time, the critical period for assessing and diagnosing a heart attack and delivering the needed intervention. By 2010, the hospital's average door-toballoon time was 52 minutes, among the best in Illinois. The hospital's Cardiac Alert Program has been benchmarked across the country, and the Institute for Healthcare Improvement recognized it as an international best practice.

 Using Failure Mode and Effects Analysis (FMEA) to identify opportunities to improve processes, Good Samaritan Hospital decreased the ratio of observed to expected postoperative renal failures from 3.0 in 2007 to 0.86 in 2009.

Satisfied Patients, Loyal Patients

 Creating an exceptional patient experience is the mission imperative, the ongoing vision, and is at the core of the Good Samaritan culture. Overall patient satisfaction levels at the hospital exceed top-decile ratings from Press Ganey, the largest national surveyor for patient satisfaction, for the following patient segments: outpatient, emergency, ambulatory surgery, and convenient care; the hospital also has achieved top-quartile performance for inpatient satisfaction.

 A brand preference study of Good Samaritan Hospital and its closest competitors ranked Good Samaritan Hospital as the overall most preferred hospital, as well as the top choice for its main service offerings.

Building Loyal Partnerships with Physicians: A Strategic Priority

 Good Samaritan Hospital has established a strategic context and vision for a synergistic hospital-physician partnership that has enabled the organization to generate some of the best clinical outcomes in the United States. A key element of Good Samaritan Hospital's success in advancing clinical

excellence and patient safety is its innovative Clinical Integration Program that rewards physicians for achieving superior clinical, service, and efficiency outcomes. Advocate Health Care will use the Clinical Integration Program as the centerpiece of its Accountable Care Organization (AdvocateCare) model in the transition to health care reform.

 A win-win partnership with physicians has led to breakthrough results in quality, physician satisfaction at the 97th percentile, and an increase in market share of 17 percent from 2006 to 2010.

Caring for Those Who Care

 Good Samaritan Hospital uses a 12-step process to determine key factors that affect workforce engagement and satisfaction and then to assess its effectiveness in addressing those factors. The hospital uses the results, which are segmented by job classifications and work units, to determine organizational and department-level tactics for improvement. Survey results from Morehead, an employee opinion research firm, show overall associate satisfaction at the 98th percentile in 2009 and 97th percentile in 2010, both exceeding top decile.

 A detailed seven-step Performance Management System promotes high performance and engagement through integration with Good Samaritan Hospital's MVP (Mission Values Philosophy), Standards of Behavior, cascaded goals from the strategic plan, and leadership competencies. Leader performance and action plans are managed through a transparent, intranet- based goal performance system. Volunteers are engaged through question- and-review sessions with leaders and an annual seven question survey.

Good Samaritan as Good Neighbor

 Community outreach programs include free wellness services, health fairs, screenings, and lectures throughout the year. Examples include a domestic violence task force; the Why Wait Program offering free mammograms and clinical breast and pelvic exams; support for parents who experience a problematic pregnancy, have a baby with special needs, or have lost a baby; and the Fun with Fitness Program that addresses childhood obesity.

 Good Samaritan Hospital actively participates in Access DuPage, an innovative community health approach through which Good Samaritan Hospital's physicians provide care to the uninsured population. The hospital provides all diagnostic tests and treatments without charge to Access DuPage patients. Good Samaritan Hospital provided over $10 million in charity care through Access DuPage as a part of its total charity care of $28 million in 2010.

Excelling at 'Funding the Future'

 With a focus on "funding the future," Good Samaritan Hospital has contributed to Advocate Health Care's system-wide AA rating representing performance in the top 10 percent in the industry. GSMA's net operating margin increased from 5.98 percent in 2007 to 7.79 percent in 2010.

 As a result of Good Samaritan Hospital's success in creating a culture of patient safety, malpractice insurance expenses declined 83 percent from 2005 to 2010, saving approximately $12 million.

 Good Samaritan Hospital has become a benchmark for gross days in accounts receivable (AR), reducing the AR cycle from 42 days in 2006 to 32 days in 2009, and generating $66 million in incremental cash.

© 2010 Advocate Health Care. All Rights Reserved.

Table of Contents Organizational Profile i

Responses Addressing All Criteria Category 1: Leadership

1.1 Senior Leadership 1

1.2 Governance and Social Responsibilities 3

Category 2: Strategic Planning

2.1 Strategy Development 6

2.2 Strategy Deployment 10

Category 3: Customer Focus

3.1 Customer Engagement 11

3.2 Voice of the Customer 13

Category 4: Measurement, Analysis, and Knowledge Management

4.1 Measurement, Analysis, and Improvement of 16 Organizational Performance

4.2 Management of Information, Knowledge, and 18 Information Technology

Category 5: Workforce Focus

5.1 Workforce Engagement 20

5.2 Workforce Environment 24

Category 6: Process Management

6.1 Work Systems 27

6.2 Work Processes 28

Category 7: Results

7.1 Health Care Outcomes 31

7.2 Customer-Focused Results 34

7.3 Financial and Market Outcomes 38

7.4 Workforce-Focused Outcomes 40

7.5 Process Effectiveness Outcomes 43

7.6 Leadership Outcomes 47

Glossary of Terms & Abbreviations 50

i

“Welcome all to this place of healing”

It’s the difference between hearing a heartbeat and listening to a suffering heart; it’s the difference between being cured and

being healed. What makes the difference is a deep

commitment to living our values and vision. We, the

associates of Advocate Good Samaritan Hospital (GSAM),

believe that human beings deserve excellent, compassionate,

and wholistic care supporting their physical, emotional, and

spiritual needs. This belief holds deeply rooted meaning for

us, and as health care associates, it gives our work purpose. As

one physician turned patient remarked, “when I was a patient

at a teaching hospital, they treated my disease; when I was a

patient at GSAM, you treated me as a whole person while

treating my disease”. This ultimate compliment gives life to

the words posted inside our front door, welcome all to this

place of healing. Our aim is to cure and to heal; the difference

rests in the depth and quality of our relationships.

Here in Downers Grove, IL, a suburb of one of America’s

great cities, Chicago, we dedicate ourselves to achieve,

sustain, and redefine health care excellence. We do so because

of our faith-based calling and because we believe that our

innovations and role model performance will inspire greater

performance in our industry.

In 2004, an epiphany that we could do better in fulfilling this

calling prompted a cultural-transformation of Moving from

Good to Great (G2G). Success of this journey, enabled by our

core competency of Building Loyal Relationships with all

stakeholders, is measured by our achievement of

superior clinical and service outcomes. Sustainability is

attained through our integrated approach to achieving results

across six (6) pillars [Figure P.1-1]. These pillars create the

framework for the alignment and deployment of our strategic

plan and the tracking of key result areas (KRAs).

Figure P.1-1 Sustainability through Six Integrated Pillars

Our pillar results and numerous external awards validate

integrated success, that we are fulfilling our mission, being a

place of healing, and building loyal relationships.

P.1a(1) Main Health Care Services / Delivery Mechanisms:

GSAM offers a broad spectrum of health care services to our

communities. Our main service offerings are general

medicine, surgery, cardiac, and mother/baby care. Figure P.1-

2 illustrates GSAM’s market and patient segments and main

health care services. Diagnostics (e.g. lab, x-ray) span across

all main services. The mechanism to deliver health care to

patients and stakeholders is through the collaboration between

patients, families, multi-disciplinary teams, and physicians.

GSAM is a regional Level I Trauma Center; this program

represents 1% of our total volumes. Our Women and

Children’s division includes a Perinatal Level III program,

highest state designation, with a state-of-the-art Neonatal

Intensive Care Unit (NICU).

Figure P.1-2 Market/Patient Segments and Main Services

P.1a(2) Organizational Culture: The G2G culture is

characterized by a collective effort to continuously challenge

the status quo. We strive to create a culture where everyone

lives the values and feels ownership for the pursuit of the

vision. The cultural shifts of our G2G journey are fostered

through processes and behaviors integrated into our

Leadership System [Figure 1.1-1]. G2G cultural shifts include:

 Integration at all levels, from department to individual associates through the cascading of pillar goals [2.2a(2)];

 Accountability and transparency of results through the Performance Management System [Figure 5.1-2]

 Service embodied in Standards of Behavior [3.1b(1)];  Patient Safety driven by goals and training [1.1a(4)];  Continuous improvement driven by the performance

improvement system [P.2c] and systematic review of

measures [Figure 4.1-3]; and

 Engagement of patients, associates, and physicians, fostered through our leadership competencies and defined

relationship-building strategies [Figures 3.1-3; 3.1-4].

Our culture is grounded in our Mission, Values, and

Philosophy (MVP), and in our Vision. Our core competency

is essential to fulfilling our mission of healing through

wholistic care. Our values serve as an internal compass to

guide relationships and decisions. Our core beliefs, along with

our heart-felt vision, result in a culture where exceptional

outcomes are achieved [Figure P.1-3].

Figure P.1-3 GSAM’s Vision, Values, Mission

Mission (our purpose of being a place of healing): serve the health needs of individuals, families, and communities through a wholistic approach.

Values: Compassion, Equality, Excellence, Partnership, and Stewardship

Philosophy: care is rooted in the principles of human ecology, faith, and community-based health care believing that human beings are created in the image of God

Vision: to provide an exceptional patient experience marked by superior health outcomes and service

Core Competency: Building Loyal Relationships

Mother / Baby

Cardiac

Surgery

General Medicine

Inpatient (IP) Outpatient (OP)

Emergency Department (ED)

Primary Service Area (PSA)

Secondary Service Area (SSA)

7.2 (Loyalty/

Satisfaction)

7.3 (Revenue)

7.5 (Process)

7.1

7.2a(1)

7.2a(2)

7.3

2.1, 3.1a, 7.1

7.2, 7.3, 7.5

P.1b(2),

3.1,6.1,

7.1, 7.2

3.2

P.1-7

Measures

Criteria

© 2010 Advocate Health Care. All Rights Reserved.

ii

P.1a(3) Workforce Profile: Building loyal relationships with

GSAM’s workforce of associates and physicians is a strategic

priority. There are no unions. The 2727 Associates (1740

FTEs) represent clinical and support staff, other professionals,

and leaders. Sixty-three percent of our nursing staff with direct

patient care responsibilities have achieved BSN or above.

Nine hundred and fifty three (953) dedicated independent

physicians make up the medical staff. This includes

contractual arrangements for physician services in the

Emergency, Pathology, Anesthesia, and Radiology

Departments. GSAM’s Advocate Physician Partners Clinical

Integration Program (APP), described in P.2b, represents a

national best practice. The APP contracts for and collaborates

with physicians to provide clinically integrated care for a

broad base of patients. In addition to working through APP,

GSAM collaborates with its physicians through its medical

staff committee structure and credentialing process.

More than 500 volunteers contribute time and energy to serve

patients and families. They provide non-clinical services such

as concierge, assisting in fundraising, and supporting the

operations of the Gift Shop and Resale Shop.

Key factors that engage the workforce and motivate them to

accomplish the mission are summarized in Figure P.1-5 and

were determined through the approaches described in 5.1a(1).

Benefits. GSAM offers its associates a broad array of benefits

[Figure 5.2-4] including an on-site Wellness Center and the

award-winning Good Health for Good Life wellness program.

Health and Safety. Job descriptions outline position-

dependent health and safety requirements [5.2b(1)], and the

creation of a safe environment is addressed through the

deployment of health and safety standards practices.

P.1a(4) Major Facilities, Technologies & Equipment:

GSAM is located on a 76-acre campus. The 5-story main

hospital occupies over 520,000 square feet. An 89,000 square

foot state-of-the-art Health and Wellness Center is also located

on the main campus. The hospital’s main campus facilities

also include a joint venture surgery center and two Physician

Office Buildings (POB) connected to the hospital. Off-campus facilities include two (2) outpatient/immediate care centers

and a second joint venture surgery center.

In addition to building a stronger culture, an essential

component of the G2G strategy included a capital

reinvestment in facilities, technology, and equipment. The

capital reinvestment of $136M [Figure P.1-6] was driven by

the strategic imperatives of long-term organizational

sustainability, the priority of physician engagement, and the

vision to achieve outstanding clinical outcomes. Additional

major investments in technology include an electronic medical

record (EMR), remote computer access for physicians, and a

campus that is wireless for associates, patients, and visitors.

P.1a(5) Legal/Regulatory Environment: GSAM operates in

the heavily regulated health care environment. Processes are in

place to keep current with, comply with, and exceed the

required laws, regulations, and standards established by key

regulatory organizations [Figure 1.2-2]. GSAM has never been

fined or sanctioned by any regulatory agency. In our pursuit of

excellence, GSAM also has achieved voluntary accreditations

through The Joint Commission (TJC) (Advanced Primary

Stroke Center), American Nurses Credentialing Center

(Magnet), and American Society for Metabolic and Bariatric

Surgery (ASMBS). Results are shown in 7.6-6.

P.1b(1) Organizational Structure and Governance System:

GSAM is one of Advocate Health Care’s (AHC’s) ten (10)

Figure P.1-4 GSAM Workforce Segments & Profile

S e g

m e n

ts 2727

Associates RN – 34% Non-Nursing – 66%

953 Physicians

Independent; 59 Specialties

500 Volunteers

88% Adults 12% Teens

Gender 18% Male 82% Female

Tenure (years)

< 1 =16% 1–5 = 31% 5-10 =24%

10 – 20 = 18% >20 =11%

Status 39% FT 43% PT 18% registry

Ethnicity White

69% Asian 14%

African American

8%

Hispanic 7%

Other 2%

P.1-5 Key Workforce Satisfaction & Engagement Factors Workforce Segments

Satisfaction Factors

Engagement Factors

Results

Associate: Nursing

 Fulfilling Work  A caring patient environment

Satisfaction – 7.4-4

 Fulfilling work Engagement- 7.4-5, 7.4-7

 Commitment to quality improvement

Both – 7.4-6

All Other Associates

(Non- Nursing)

 Confidence in Senior Leaders

 A Caring patient environment

Satisfaction-7.4-8, 7.4-9

Engagement – 7.4-11  Fulfilling Work

 To be treated with respect Both – 7.4-10

Physicians

 Quality and consistent nursing care  Administration

skill  Patient safety  Efficient

operations

 Quality and consistent nursing care  Administration

skill

Satisfaction – 7.4-13, 7.4-14

Engagement – 7.4-15

Volunteers  Personal satisfaction- contribution  Flexible scheduling

Both – 7.4-3

Figure P.1-6 G2G Reinvestment Strategy Summary

Year Investment

2005 101,000 sq foot, 44-bed, all private room, state-of-the-art Critical Care Pavilion (CCP) and e-ICU

2006 27-bed, private room, mother baby unit

2008 90,000 sq foot Surgical Pavilion with 15 fully integrated/technologically advanced operating suites

2008 2

nd Outpatient Center in South Downers Grove

Centralized telemetry monitoring

2009 17,000 square foot Endoscopy and Ambulatory Center with 30 private rooms and seven (7) state-of-the-art procedure rooms

iii

acute care hospitals. A guiding principle of AHC/GSAM is

that health care needs are best met through local governance

and management and enhanced through system collaboration.

The governance system for GSAM [1.2a(1)] is integrated with

the governance of AHC. GSAM’s governance system

includes, 1) a Governing Council (GC) with responsibilities

to: a] oversee the quality of care, b] function as the final

authority for medical staff credentialing, and c] provide input

into strategic/tactical plans and budgets; 2) GC committees

with oversight of finance, clinical excellence, and

executive/board affairs. Processes from the top down and

audits at both the AHC and GSAM level ensure governance

effectiveness. GSAM works synergistically with AHC to

optimize resources and achieve economies of scale. AHC

provides supply chain services, IT, finance, legal/risk, and

system HR policies/programs.

P.1b(2) Key Patient/Customer Groups and Market

Segments: GSAM’s market consists of 28 communities in DuPage County and western Cook County, broken into the

Primary Service Area (PSA) and Secondary Service Area

(SSA) [Figure P.1-7].

Key customer segments and stakeholder requirements for our

health care service offerings, support services, and operations

are obtained from listening posts [Figure 3.2-1]. Figure P.1-8

summarizes these requirements determined by the processes

described in 3.1a(2) and 5.1a(1).

P.1b(3) Suppliers, Partners & Collaborators: GSAM

depends on strong, synergistic relationships with suppliers,

partners, and collaborators. Their roles in GSAM’s key work

systems, health care offerings, and support services, affect the

quality of care and the effectiveness of care delivery. An

established systematic mechanism for communicating and

managing relationships with these key groups contributes to

GSAM exceeding customer requirements. These roles and

mechanisms are outlined in Figure P.1-9. AHC Supply Chain

requirements include on-time delivery, electronic

communication, savings for the organization, and accuracy.

P.2a(1) Competitive Position: GSAM serves patients in a

highly competitive market with eleven (11) hospitals within

20 miles of GSAM; three (3) of these hospitals are considered

primary competitors [Figure P.2-1]. The primary competitors

are all not-for-profit hospitals ranging from 311 to 427

licensed beds and either have, or have plans to add, private

rooms. Private rooms have become a differentiator in our

marketplace; however, GSAM is constrained by limited

availability of private rooms in the Medical/Surgical areas. To

respond to this disadvantage, we leverage our core

competency of building loyal relationships and have launched

a redesigned model of care both of which create an

environment that makes GSAM the hospital of choice. While

each of these competitive hospitals has a stronghold in the

community in which they are located, many of the

surrounding communities have loyalties that are shared with at

least one other hospital. In addition to hospitals, large multi

and single specialty physician groups provide competition for

outpatient and ambulatory services

throughout the market.

This highly competitive environment

creates intense and beneficial

competition between hospitals in

DuPage County to provide superior

health care outcomes and service. It

also results in large competitive

capital expenditures. Yet despite this

intense competition, GSAM:

 Continues to be the market share leader in its primary service area

(PSA) and has grown market

share over the last three (3) years

[Figure P.2-1]. ‘Market Share’

measures the increase, decrease,

and total number of inpatient

cases in our PSA for each

hospital.

Figure P.1-8 Key Market Segments, Patient and Stakeholder Groups & Requirements

Segment Requirements Performance Satisfaction

Dissatisfaction Loyalty

P a ti

e n

ts Inpatient

(IP) Outpatient (OP) Emergency (ED)

High quality/safe care 7.1-(1,6,10)

7.2-(1-15) 7.2-17

7.2-19 Friendly staff 3.1b(1)

Prompt services 7.5-(16,18)

Inform/Involve in care decisions 6.2b(2)

O th

e r

S ta

k e h

o ld

e rs

Associates

Fulfilling work 5.1a(2) 7.4-11

P.1-4 (tenure)

A caring patient environment 7.2 7.4-11

A commitment to quality 7.1 7.4-6

Confidence in Senior Leaders 1.1b(1) 7.4-9, 7.6-8

To be treated with respect 1.1a(1) 7.4-10

Physicians

Quality and consistent nursing care 7.1-17 7.2-17, 7.4-15

7.2-22 Patient safety 7.1-(6,10) 7.2-17, 7.4-12

Administration skill 7.6-13 7.2-17, 7.4-15

Efficient operations 7.5-7 7.4-14, 7.5-8

Third Party Payors

Efficiency 7.1-(1-2) 7.5-23

7.1-5, 7.1-2 7.1-5 High quality care

Community Access to care 7.5-12

7.2-10 7.3-11

High quality care 7.1-(1,4)

Figure P.1-7 Key Market Segments

Key Market Segments # of Communities /

Residents Annual

Admissions

Primary Service Area (PSA) 17 / 681,000 + 75%

Secondary Service

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