STRATEGIC GOAL # 1: SERVICES
Quality services are
improved, expanded and delivered in an integrated manner.
By the end of
FY 2005, at least 85% of ECRH consumers will indicate that ECRH services
have met or exceeded their expectations.
Addressed by Strategy(s): 1 – 9, 11 – 13, 16
Yield Outcomes: A, B, C, D, E
Performance Measure: Consumer Satisfaction
Survey results
By the end of
FY 2005, ECRH will improve consumer safety by:
Reducing the incidence
of all types of consumer-focused
“serious and unusual incidents” – as defined in DMHDDAD
policy by 50% (from FY 04 rate).
Addressed by Strategy(s): 1 – 4, 7 – 9
Yield Outcomes: B, C
Performance Measure: Rate of SUIR’s
b. Reducing the utilization of restraint – both for total time in
restraints and for number of consumers restrained at least
once – by 50% (from FY 04 data).
Addressed by Strategy(s): 1 – 4, 7 – 9, 13
Yield Outcomes: A, B, D
Performance Measure: ORYX Restraint Measures
By the end of
FY 2005, ECRH will improve consumer services by the enhancements listed
below:
Increase
number of consumers enrolled for ≥ 6
months in the Work Therapy/Consumer Employment
Program by 25% (from FY04 enrollment).
Addressed by Strategy(s): 1, 4, 6, 7
Yield Outcomes: D
Performance Measure: Number of Consumers
enrolled in WT/CE Program ≥ 6 months
Enhance programmatic
services so that MH consumers are engaged in prescribed and/or generic
therapeutic activities at least 4hrs per day (average).
Addressed by Strategy(s): 1, 4 – 8, 13
Yield Outcomes: A, B, C, D
Performance Measure: Daily average (in hours/day/
MH consumer) of active treatment/programming
engagement
Enhance and
increase consumer-centered, community-focused active treatment programs
by completing Person Centered Planning for all consumers with lengths
of stay ≥ 60 days.
Addressed by Strategy(s): 1, 4, 6, 9, 10
Yield Outcomes: D
Performance Measure: Percentage of applicable
consumers who have had least one PCP meeting
Increase the number
of direct care staff that are C.N.A.’s – in areas serving
physically/medically challenged
Consumers
– by 50% (from FY04 data).
Addressed by Strategy(s): 16
Yield Outcomes: A, B, D
Performance Measure: Percentage of direct care staff
serving physically/medically challenges
consumers who are C.N.A.s.
By the end of
FY 2005, ECRH will enhance community services for DD consumers by:
Increasing number
of community consumers completing the Judevine program – training
& education program for family members et al of consumers with autistic
spectrum disorders – by 50% (from FY 04).
Addressed by Strategy(s): 12
Yield Outcomes: E
Performance Measure: Number of consumer families
who completed the Judevine Program
Developing at least
one program funded by the Medicaid
Waiver Program for community consumers.
Addressed by Strategy(s): 11
Yield Outcomes: E
Performance Measure: Development of Program
By the end of
FY 2005, ECRH will reduce the incidence of recidivism by 25% in Psychiatric
Services (from FY 2004 rate for 30-Day Readmissions).
Addressed by Strategy(s): 1 – 9, 13, 14, 15
Yield Outcomes: A, D
Performance Measure: ORYX measure for 30-Day
Readmission Rate
Develop treatment
delivery model that incorporates Person Centered Planning methodologies.
Certify all staff,
who work with consumers, in Mandt System© training.
Develop a comprehensive
plan to reduce the use of restrictive interventions by structuring the
treatment environment and by enhancing staff competencies in use of
alternative strategies.
Develop an integrated
and comprehensive process for training consumers in the skills that
will enable each to have a better and safer experience in the community,
i.e. community competence.
Enhance and expand
the Phoenix Center for inpatient MH and MH/DD consumers.
Enhance and expand
the Work Therapy & Consumer Employment Program.
Develop an integrated
and comprehensive program of Programmatic Day Services for inpatient
MH and MH/DD customers, e.g. Treatment Mall.
Establish a residential
living unit within Psychiatric Services to address the unique needs
of dually diagnosed consumers (MH/DD).
Implement the new
DD Behavioral Guidelines by revising policies and procedures, training
staff concerning P/P changes, etc.
Develop strategies
for DD consumers for the consolidation of the IPP and the
ISP into one.
Establish Gracewood
Community Day Habilitation Services Center for selected consumers from
state operated group homes as well as other qualifying DD consumers
from community.
Enhance Judevine
Program to more fully address the need for training for families and
providers of consumers with autistic spectrum disorders by additional
staff.
Reorganize Psychiatric
Services and Forensic Services by restructuring the service delivery
system.
Improve effectiveness
of Admission Office by increasing presence of Social Work –
especially during “peak hours.”
Explore feasibility
of operating a “23-Hours Observation Unit.”
Explore feasibility
of operating a C.N.A. Certification Training Program at ECRH.
A. Improved mental
health
status for
consumers.
B. Improved safety
for
consumers.
C. Fewer consumers
being
abused,
neglected
or
exploited.
D. Improved overall
health
&
emotional
status
for
consumers.
E. Improved quality
community
services.
STRATEGIC GOAL # 2: WORKPLACE
Workplace
environment is enhanced and maintained to attract and support highly
motivated, well-trained, consumer-focused employees and to develop future
leaders in the workplace.
By the end of
FY 2005, ECRH will improve the efficiency and effectiveness of Human
Resource Management by:
Enhancing the screening
and selection function so that the “application to hire” time period
– in business days – is reduced by 50% (from FY 04).
Addressed by Strategy(s): 1 – 3
Yield Outcomes: A, B, C
Performance Measure: Application to Hire Interval
Increasing the number
of transactions that are “error-free” by 50% (from the FY04 rate).
Addressed by Strategy(s): 1 – 4
Yield Outcomes: A, B, C
Performance Measure: Transactions Error-free Rate
Increasing by 50%
the number of employees that indicate that HRM services have met or
exceeded their expectations (from baseline survey FY05, 1st
Qtr).
Addressed by Strategy(s): 3 – 9
Yield Outcomes: A, B, C
Performance Measure: Staff Satisfaction Survey
–
Results for Human Resources
By the end of
FY 2005, ECRH will improve the efficiency and effectiveness of Human
Resource Development by:
Improving the effectiveness
of orientation of new employees and of on-going competency programs
for veteran employees – as part of their individual Employee Development
Plans – by developing “Basic Skills Programs” for identified employee
populations.
Addressed by Strategy(s): 1, 8
Yield Outcomes: A, D
Performance Measure: Development of applicable
Basic Skills Programs
Enhancing competency
and improving retention of clinical employees by developing job specific
“Essential Skills Programs” for current and future employees in
identified employee populations.
Addressed by Strategy(s): 1, 9 , 12
Yield Outcomes: A, D
Performance Measure: Development of applicable
Essential Skills Programs
Enhancing competency
and improving retention of clinical staff by enrolling applicable
employees – either as a result of current position or as part of individual
Employee Development Plans – in “First Line Supervision” course.
Addressed by Strategy(s): 4, 6, 10
Yield Outcomes: A, B, C, D
Performance Measure: Percentage of applicable
employees that have completed FLS course
Improving the framework
for data collection concerning learning needs and efficaciousness, effectiveness
and efficiency of HRD training initiatives.
Addressed by Strategy(s): 10, 11
Yield Outcomes: A, D
Performance Measure: Development of indicators that
capture interface between training & competency in
ways that are “actionable” for management purposes.
By the end of
FY 2005, ECRH will improve employee retention so that turnover (excluding
retirements) is reduced by:
Increasing “filling
from within” for clinical positions (excluding Health Care Workers
and health care professionals, e.g. physicians, dentists, nurses, pharmacists,
dietitians, therapists – occupational, physical, speech) by 25% (from
FY04).
Addressed by Strategy(s): 4 – 9
Yield Outcomes: A, B, C, D
Performance Measure: Percentage of applicable
positions that are filled by current employees
Recommending and
sponsoring at least 8 managers for participation in DHR Leadership Development
Institute annually – beginning with FY05.
Addressed by Strategy(s): 13
Yield Outcomes: D
Performance Measure: Number of ECRH employees
enrolled in DHR-LDI
Developing and implementing
an internal transfer procedure for employees that work “shifts”
rather than during “business hours” (e.g. direct care staff, nurses)
Addressed by Strategy(s): 3, 4
Yield Outcomes: B, C
Performance Measure: Development/implementation
of internal transfer procedure
Developing formal
succession strategies including a system to help managers identify,
prepare and track candidates for promotion.
Addressed by Strategy(s): 13
Yield Outcomes: A, D
Performance Measure: Development/implementation
of succession strategies
By the end of
FY 2005, ECRH will improve the workplace by holding managers, e.g. Service
Directors, accountable for the workplace environments they create and
maintain – as measured by the indicators listed below
– by:
Reducing frequency
of “pulling” i.e. last minute employee reassignment to another living
area within the unit or facility to accommodate either employee driven
causes (e.g. call-ins, late arrivals, early departures) or consumer
driven causes (e.g. changing acuity, accommodating unanticipated consumer
off-campus activities) by 50% (from FY04,4th Qtr)
Addressed by Strategy(s): 4, 6
Yield Outcomes: B, C
Performance Measure: “Pull Rate”
Compensating employees
for overtime work promptly – in accordance with DRH policy – by
maintaining a “late overtime payment rate” of ≤ 5%
Addressed by Strategy(s): 2, 4
Yield Outcomes: B, C
Performance Measure: Late Payment Rate for
Overtime compensation
Enhancing the workplace
environment so that number of employees that indicate that their ECRH
workplace has met or exceeded their expectations is increased by 50%
for the following indicators: Employees are – (1) treated fairly;
(2) treated with dignity and respect; and (3) kept appropriately informed
(from baseline survey FY05, 1st Qtr).
Addressed by Strategy(s): 3 – 9
Yield Outcomes: B
Performance Measure: Staff Satisfaction Survey
–
Results for Workplace Environment
Perform competency-based
training needs analysis for targeted jobs or job groups.
Develop a competency-based
ECRH Training Plan for identified jobs or job groups – including but
not limited to:
(a) Non-HRM staff that
perform HRM tasks, i.e. Timekeepers, (b) HRM staff
Streamline the hiring
process.
Develop 2 – 4
strategies to address facility wide concerns identified on February
2004 Staff Satisfaction Survey in the following areas:
Communication –
including access of employees to information as well as policies and
procedures;
Recognition of employees
– including recognizing and rewarding good performance and effective
teamwork;
Treatment of employees
– including basic requirement that each employee be treated with dignity
and respect at all times.
Establish “Harmony
Council” of staff peers to assist and advise employees as they work
to constructively resolve differences between themselves and supervisors,
peers and subordinates.
Establish
“Direct Care Staff Practice Council” to assist and support DCS to
proactively and professionally address issues concerning consumer care
and staff needs.
Hold a “HST Forum”
at regular and periodic intervals between direct care staff and the
RHA.
Develop “Basic
Skills Programs” (BSP) for identified employee populations, including
but not limited to (a) “Consumer-centered” BSP for those that work
directly with consumers and (b) “Office-centered” BSP for those
that work primary in an office setting.
Develop job specific
“Essential Skills Programs” (ESP) for identified employee populations,
including by not limited to (a) CNA Certification & Re-certification
Program, (b) Professional Discipline Program, (c) QMRP/Team Leader Program
(DD only) and (d) “Standards” Program (e.g. ICF/MR, LTC, JCAHO).
Enhance learning
needs assessment process so that aggregate data concerning prevalent
topics identified from individual employee development plans are included.
Develop key indicators
for HRD function.
Develop competencies
for QMPR/Team Leader job.
Implement ‘gap
analysis management” that:
projects the differences
between the current skill sets and what is needed for the future
identifies potential
leaders in the consolidated organization structure as well as skills
that current leaders need to polish or acquire.
Competent
employees
delivering
compassionate
care to
consumers.
Satisfied, committed
employees and consumers.
An organization
that is committed to treating its staff and consumers with dignity and
respect.
A prepared candidate
pool for key positions in the facility.
STRATEGIC GOAL # 3: OPERATIONS
Efficiency
and effectiveness of ECRH operations are improved.
By the end of
FY 2005, ECRH will achieve and maintain full compliance with all applicable
regulatory entities or requirements, i.e. ORS/ CMS, JCAHO, HIPAA, OIG.
Addressed by Strategy(s): 1 – 9
Yield Outcomes: A
Performance Measure: Maintenance of accreditation,
certification.
By the end of
2nd Quarter of FY 2005, ECRH will enhance clinical
service delivery models and processes by implementing the
“Matrix Model” of service delivery for all inpatient clinical services.
Addressed by Strategy(s): 3, 5, 6
Yield Outcomes: A, B, D
Performance Measure: Full implementation of Matrix
Model
By the
end of FY 2005, ECRH will improve the efficiency and effectiveness of
Information Management by:
Redesigning the
framework for Quality Management and Performance Improvement data collection,
analysis, trending for clinical and management purposes.
Addressed by Strategy(s): 2, 3
Yield Outcomes: A, C, D
Performance Measure: Implementation of Redesigned
System
Streamlining clinical
documentation requirements and reducing volume of paper forms by initiating
or converting to “e-forms” in order to decrease Medical Record
Review Delinquency Rate (from FY04)
Addressed by Strategy(s): 7 – 9
Yield Outcomes: A, C, D
Performance Measure: Medical Record Review
Delinquency Rate
Appointment of HIPAA
Officer and OIG Officer.
Development and
implementation of “Tracer Methodology” as a management tool.
Modify organizational
structure and redefine roles, responsibilities and relationships
of key clinical departments, disciplines and functions.
Improve utilization
of available space to support changes in service delivery model and
enhancements of existing and new services.
Hire and place key
management staff for Psychiatric Services, e.g. Unit Director, Team
Leaders and Shift Supervisors.
Review and revise
or develop, as needed, necessary and supporting procedures for key functions
(and sub-functions) and processes (and sub-processes).
Streamlining policies,
procedures and forms and promoting use of “E files” whenever possible.
Explore feasibility
of physician electronic order entry process.
Review and revise,
as needed, procedures and safeguards concerning the security of data
and information.
Timely and satisfactory
compliance with critical Federal and state regulations.
Streamlined service
delivery processes.
Improved data management
of consumers’ personal health information.
Improved efficiency
and effectiveness of clinical and support functions.
STRATEGIC GOAL # 4: STAKEHOLDERS
Positive stakeholder
relationships are developed and nurtured.
By the end of
FY 2005, ECRH will improve the image of the facility in the CSRA by
increasing by 50% the incidence of positive or neutral media coverage
(from FY04).
Addressed by Strategy(s): 1, 2, 4, 5
Yield Outcomes: A
Performance Measure: Incidence of Positive or
Neutral Media Coverage
By the end of
FY 2005, at least 85% of families of ECRH clients will indicate that
ECRH services have met or exceeded their expectations.
Addressed by Strategy(s): 1, 3, 5
Yield Outcomes: B
Performance Measure: Family Satisfaction Survey
Results
Develop a proactive
Communications Plan for promoting positive communication lines with
key stakeholders, including the media.
Promote DHR and
ECRH successes and accomplishments to the general public.
Develop a coordinated
facility-wide process and tool to track and respond to customer inquires
more efficiently and effectively.
Establish a baseline
of positive and negative media reports.
Continue to design
and develop ways the facility can interact with and provide needed information
to stakeholders.
Improved public
image.
Improved responsiveness
to stakeholders and the public.
East Central
Regional Hospital – Strategic Plan FY05
Objectives
Strategies
Long-Term
Outcomes
June 23, 2004 Page of 9