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PRATT REGIONAL MEDICAL CENTER DO WHAT IS RIGHT NOT WHAT IS EASY MANAGEMENT GUIDE 2019

PRMC MANAGEMENT RESOURCE GUIDE Welcome Before we dig in here s a glimpse of what to expect as part of the PRMC Management Team You ve just stepped into one of the most significant roles in the workforce because you have the most direct impact on employees the heart of our organization Their success and development will all be influenced by your leadership No pressure right However We tend to more often speak about what employees need from their managers to shine and not what managers need to help them get there That s why we set up this complete one stop shop for managers like you to learn how to prepare for the role like a champ and be the leader you ve always dreamed of being You ve got an incredible opportunity ahead of you and lots to do Page 1 of 49

PRMC MANAGEMENT RESOURCE GUIDE Table of Contents Tier 1 Immediate Leader Competencies 5 Ensuring your employees receive their paychecks 7 Document Examples 8 Time Clock Reconciliation Form Example 8 PTO Absence Request Example 9 Paid Time Off Request Policy 9 Time Sheet Example 1 10 Time Sheet Example 2 11 Time Sheet Example 3 12 Ensuring your employees have the supplies equipment to do their jobs 14 Capital equipment request 14 Purchasing Supplies 15 Ordering In Stock Items 15 Ordering Non Stock Items 15 How to Hire an Employee 19 Budgetary Requirements 19 Posting a Job Description 19 Viewing Applicants Position Manager 19 Dashboard 19 Requisitions Jobs 20 People 21 Steps for an Internal Transfer 25 30 day 90 day Annual Evaluations 27 Taleo Dashboard 27 New Hire Evaluations 27 30 day Meeting 27 90 day Meeting 27 Annual Evaluations 28 Building Rapport with Employees 101 30 Why round on Employees 30 Employees want five critical things from their leader 30 How to round on Employees 30 Page 2 of 49

PRMC MANAGEMENT RESOURCE GUIDE Who 30 When 30 Keywords to Use When Rounding on Employees 30 Tools 31 Related Resources 31 Tier 2 Competencies 32 Annual Budget Process 34 Financial Reports 35 Cost Center Reports 36 General Ledger GL Reports 36 Financial Board Report 37 PRMC TRAVEL 38 Hotel Reservations 38 Mode of Transportation 38 Airline 38 Hospital Vehicle 39 Meals 39 Risk Management 41 Introduction 41 How to Submit a Variance Report QDC 41 How to Investigate a Variance Report QDC 41 Quality Improvement 43 Introduction 43 Expectations 43 Meeting Attendance 43 Deliverables 43 Collaboration Synergy 44 Steps to Leading Quality Improvement 44 Research the topic or measure 44 Set a broad goal and draft a timeline 44 Build the team ad hoc group 44 Design the strategy 44 Select specific measures and define the goal 45 Page 3 of 49

PRMC MANAGEMENT RESOURCE GUIDE Educate widely and creatively 46 The kick off 46 Rapid tests of change 46 Evaluation 47 Celebrate often 47 Goal Setting 48 S Specific 48 M Measurable 48 A Attainable 48 R Relevance 48 T Timeframe 48 When to Use SMART Goals 48 LEM Leader Evaluation Manager 49 Annual Evaluation Tab 49 90 Day Plan Tab 49 Validation Matrix 49 Page 4 of 49

PRMC MANAGEMENT RESOURCE GUIDE Tier 1 Immediate Leader Competencies Ensuring Your Employees Receive Their Paychecks Ensuring Your Employees Have The Supplies Equipment To Do Their Jobs How To Hire An Employee 30 day 90 day Annual Evaluations Building Rapport With Employees 101 Rounding Being a manager is a difficult relationship fueled position A manager s role is ultimately to support and lead their people to be the best they can be It s not about the authority the control or the power If you re in it for the glory or the title it won t work out Being a manager is about bringing out the best in people That s the bottom line It s a selfless people first heart driven role and it s worth every second of the complexity if you re in it for the right reasons Page 5 of 49

PRMC MANAGEMENT RESOURCE GUIDE Start PRMC EMPLOYEE Clock In ClockOut Time Clock PTO Request Time Rec Sheets given to Manager Reminder Initial and Date any changes made to employee s payroll sheet CPSI Evident Database Weekly Wage Report Sent to All Managers Review Wage Reports PTO Slips Time Rec Sheets Does the information match actual hours woked Yes No Collect Necessary Information from Employee Payroll Process In order to ensure employees are properly paid for their working time and to comply with applicable regulations it is essential that the Medical Center s time attendance records be accurate for each employee Working while not clocked in or otherwise working off the clock is prohibited It must be understood that the ultimate responsibility for time attendance recording lies with each individual employee Resource Contact Payroll Manager Lynn Southard ext 1200 Page 6 of 49 Take to Payroll Manager for Completion End

PRMC MANAGEMENT RESOURCE GUIDE Ensuring your employees receive their paychecks Our employees get paid every two weeks Each Monday you will have timesheets in your box for the prior week s payroll This needs to be reviewed and returned to the Payroll Manager Lynn Southard in the Administration office She needs it returned no later than Tuesday by noon In case of a holiday the Payroll Manager and or the VP of Human Resources may send out an email requesting that you return the timesheets earlier This is rare but please make sure to return them as requested for payroll to be processed timely In the payroll folder you will want to go through each employee s time for the prior week look for the missed clock in outs if you have a time reconciliation for an employee please make sure to write it in on the timesheet as well as turn in the time reconciliation What this does is allows the Payroll Manager to continue processing payroll without having to go back to the folder and try and find the time rec Also make sure that you have PTO slips for any time off that they took in the folder Employees should be entering their PTO into the time clock as well as turning in a PTO slip for approval By the employee making sure their PTO is entered helps to avoid missed PTO slips and the employee not being paid appropriately On the time sheet next to the employee it will show you their Full time Equivalent FTE In Table 1 you will find the FTE Conversion Scale for reference as to how many hours the employee should have each period It is vital that the employee continues to uphold their FTE requirements as this will affect the level of benefits they qualify for FTE Conversion FTE 1 0 0 8 0 6 0 4 0 2 Hours Worked per Week Sun Sat 40 hrs 32 hrs 24 hrs 16 hrs 8 hrs Table 1 FTE Scale Once you have gone through each employee s time for the prior week you will want to sign the bottom to acknowledge that it is correct and accurate Make notes where needed and return by noon on Tuesday As managers it is our job to help payroll run smoothly by turning in all Time Reconciliations all PTO slips approving overtime and noting any changes on the time sheets Questions can be directed to the Payroll Manager Lynn Southard at extension 1200 She is located in the Administration office and is here Monday through Friday Frequent errors on the missed clock in out times may warrant additional instruction or training These errors increase the workload for others as well as the chance for error in pay Page 7 of 49

PRMC MANAGEMENT RESOURCE GUIDE Document Examples Time Clock Reconciliation Form Example Figure 1 Time Clock Reconciliation Page 8 of 49

PRMC MANAGEMENT RESOURCE GUIDE PTO Absence Request Example Paid Time Off Request Policy Figure 2 PTO Absence Request Page 9 of 49

PRMC MANAGEMENT RESOURCE GUIDE Time Sheet Example 1 Figure 3 Example Time Sheet 1 Page 10 of 49

PRMC MANAGEMENT RESOURCE GUIDE Time Sheet Example 2 Code Key A PTO Prior Year P PTO Current Year F Bereavement H Holiday Pay J Jury Duty M Meeting Off Site Only Note We no longer utilize a code for Lunch Not Taken Instead employees can go into their time for the day look for the Auto Meal to the right of the screen If AutoMeal shows 50 select OFF to add lunch back in Figure 4 Example Time Sheet 2 Page 11 of 49

PRMC MANAGEMENT RESOURCE GUIDE Time Sheet Example 3 Figure 5 Example Time Sheet 3 Page 12 of 49

PRMC MANAGEMENT RESOURCE GUIDE Start Capital or Supply Need Supply Non Stock or InStock Item Capital Complete Capital Equipment Request Template Non Stock In Stock Order through CPSI Complete PO Template MATERIALS MANAGEMENT Obtain budget approval through Sr Acct New or Existing Product New Existing Take to VP No Do I have Money to Pay for This Complete Order Request Yes Order Delivered to Department Take to Materials End Purchasing Supplies PO Process It is the policy of Pratt Regional Medical Center to have a procedure for the ordering and subsequent invoice approval for needed supplies and equipment These procedures should provide for the necessary documentation accountability and audit trail Resource Contacts Senior Accountant Natasha Zielke Ext 1252 Manager of Materials Management Linda Mertens Ext 1417 Page 13 of 49 Take to Product Standardization Commitee

PRMC MANAGEMENT RESOURCE GUIDE Ensuring your employees have the supplies equipment to do their jobs As leaders we need to make sure that employees have all of the tools to be successful We do not have the right to measure performance unless we are committed to giving our employees the tools to do their job Leadership resides with your people Ask them and they ll tell you what they need to be able to provide for and exceed customer expectations It is the policy of Pratt Regional Medical Center that all expenditures shall be documented and approved via the appropriate process Governing authority officers and employed managers will be authorized to incur expenses up to the limits described in the Purchasing Authorization Table Table 2 Purchasing Authorization Table Title Level 1 Manager Level 2 Director Level 3 VP Level 4 Executive Staff Amount 300 500 2500 2500 Table 2 Purchasing Authorization Table Capital equipment request Late spring of each year a Capital Minor Equipment spreadsheet will be emailed out to all department supervisors Department supervisors have approximately two weeks to complete this spreadsheet and submit it to their designated VP Keep in mind the requests will be for capital and minor equipment that the department will need within the next three years The request items will be What item How many Cost If you don t know the price of an item or where to purchase it you can work with Materials Management to acquire the information needed Replacement or New Any additional questions you can refer to the Senior Accountant Natasha Zielke ext 1152 for help The lists from each department will be summarized on one spreadsheet and sorted by department The requests are reviewed by Executive Staff and then during the budget process they will decide with the board how many dollars they will allocate to capital expenditures The list will then be prioritized it is crucial that if there is a high priority item that you communicate this with your VP before the Executive staff review Once finalized the list will be shared with the department supervisors so that they know what items were approved Although they make the approved capital list the purchases will still need to go to Executive staff for approval before being purchased during the year This is due to emergency purchases that are likely to come in other departments that will affect the budget Page 14 of 49

PRMC MANAGEMENT RESOURCE GUIDE Purchasing Supplies To order supplies you will first need to determine if the item is available as an In Stock item or needs to be special ordered Non Stock item If you need help identifying this you may direct questions to the Purchasing Manager Linda Mertens at extension 1417 Ordering In Stock Items Items you need that are stored in the hospital should be requisitioned using the Electronic requisition on CPSI Evident or by manual requisition within the Materials Department Electronic Requisition 1 Enter CPSI Evident 2 Select the department you choose to place the order for a Hospital Base Menu Change Department if necessary 3 Select Communications right hand column Requisitions Department ex ICU is 013 press enter 4 It may be easiest to sort by alphabetical description Select the item you are wanting to order and type in quantity Pay close attention to the unit in which you need to ensure proper ordering 5 When complete click Send on the upper left corner 6 Print requisition for your department if necessary Manual Requisition 1 Physically go to the Materials Department 2 Find which item you are looking for located within the location book found as you walk into the department 3 Ensure you write down the yellow sticker for the item quantity department on the requisition form attached to the clipboard Ordering Non Stock Items Items that require a particular order because they are a Non Stock item require a Master PO Template available on the Intranet under forms and Accounts Payable 1 2 3 4 5 6 7 8 9 10 11 12 13 Master PO Template Requirements Vendor Name Phone Number Unique Account Number if applicable Order Date Department Number Ordered By Quantity Unit of Measure each box case Item Number reorder ref GL number charging it to Natasha can help you with this number Description Price Signatures required based upon Purchasing Authorization Table Page 15 of 49

PRMC MANAGEMENT RESOURCE GUIDE Once the PO Template has been completed and received budget approval it can be delivered to Materials Management for ordering Samples of the following are included for your reference Master PO Template Figure 6 Capital Equipment Request Figure 7 Figure 6 Example Master PO Template Page 16 of 49

PRMC MANAGEMENT RESOURCE GUIDE Figure 7 Capital Equipment Request Page 17 of 49

PRMC MANAGEMENT RESOURCE GUIDE PRMC Hiring Flow Chart February 2019 Job Application On Line ATS Position Manager HSA Notice of Application Rec d HR Not Hiredadd to Global Notes New Rehire Eligible No Applicant notified to initiate Skill Survey No Employee Start Date Yes Not Pass to Hiring Manager Download Resume Application HSA Uncertain Snooze HSA assessment review acceptable acceptable No For Internal Transfers see pg 24 No Yes No Interest in proceeding Yes Wish to Proceed Global Notes Updated Notify HR H Visio Files Hiring Flow Chart2019 vsd Proof of License Qualifications met OnBoarding Process Welcome Letter S Page STB Booklet K 4 W 4 I 9 Form Confidentiality Form Ambassador assigned Reward Recognition Assessment Emergency Contact Form Social Media Policy Email sign on info Use of intranet Parking Policy Payroll Calendar Direct Deposit Form Doculivery Information Identity Theft Policy Code of Conduct Corporate Compliance Program Job Description Prof License CBT Fit Test Form Immunization Records Physical Drug Screen KDADS Intellilcorp Screening SSN Trace FACIS OIG Authorization Photo video form Photograph Employee Badge Interview Scheduled with Director Peer Interview Completed No On Boarding Initiated No No No Meets critera Page 18 of 49 Offer Extended Confirm rate pay grade etc Job Offer Form completed yes Resource Contacts VP and Chief of Human Resource Officer Ken Brown ext 1170 HR Administrative Assistant Vickie Moser ext 1152

PRMC MANAGEMENT RESOURCE GUIDE How to Hire an Employee Selecting an employee is a vital part of your role To ensure the employee is a proper fit and not a daily headache takes time Budgetary Requirements On the monthly budget that you get from accounting you can review your salary line and make sure you are not spending more than you have budgeted if you are spending more than you will need to speak with your direct supervisor and evaluate if the expense is overtime that will be eliminated by the new hire There may be a need to adjust the budget Helpful Hint if you did not spend your salary budget last year it might have been reduced automatically Senior Accountant Natasha ext 1252 are a helpful resource for budget questions Posting a Job Description Review the job description in PolicyTech for the position you are hiring for Does it communicate clear expectations for the position you are hiring for Position Manager A position can be generated through the position manager by the HR Administrative Assistant Vickie Moser You may reach her at Ext 1152 o Key elements that you will need to communicate in a job requisition are Job Title FTE Full Time Equivalent Full Time Status 64 80 hr ppd Part Time Status 16 64 hr ppd PRN Status 16 hr ppd What shift this position will work Number of specified position open Job Summary Benefit Level Does additional advertising need to occur Note Some hard to hire positions should be advertised early Human Resources Assistant Vickie Moser ext 1152 and Manager of CommunityRelations Andie Dean ext 1444 can assist you with this if given proper notice Viewing Applicants Position Manager Dashboard The Applicants tab will show several categories including 1 Active candidates that have filled out an application a Internal b External c Not viewed d Viewed 2 Filed candidates that filled out an application and did not get hired for that job posting Page 19 of 49

PRMC MANAGEMENT RESOURCE GUIDE Requisitions Jobs Selecting the position title that you are hiring for will open options to view candidates FYI This is also an excellent time to review that all the position information is correctly entered as this is what the applicant will be expected when applying for the job Page 20 of 49

PRMC MANAGEMENT RESOURCE GUIDE People Application 1 Select the applicant s name 2 The document image with the Blue A will link to the application Note There are things that this application can tell you that you are not allowed to ask a candidate Special Things to Consider 1 Driver s License a If not there may be a cautionary reason e g DUI prison illegal resident 2 Education level Education should match the job requirements a Applicants that are overqualified for the position they are applying for may have a cautionary reason to be applying 3 Felony a The healthcare industry is a high risk industry and employees that cannot be trusted add to this risk Although we all are human and can make poor decisions that will follow us in life we must choose whether it is a risk that we are willing to take In some cases a felony conviction will disqualify applicant for consideration 4 Additional applications a If the candidate has applied for numerous jobs think about it carefully before the interview This may show a level of desperation that can be problematic with honest interviewing or personal life issues that may cause professional work problems Page 21 of 49

PRMC MANAGEMENT RESOURCE GUIDE Resume 1 The document image with the Grey R will link to the applicant s resume a Resumes can be a confusing piece of the hiring process they can be helpful or add positive bias into an already complex decision b Three useful recommendations when reviewing a resume i How long has the applicant stayed in previous jobs e g job hopper ii How similar was the job they applied for compared to their past jobs iii Skills that they have developed from past jobs Behavioral Screening Completed by Applicant 1 The screening status dot will be green once completed a If the assessment is incomplete do not interview them yet b The purpose of the assessment is in generating questions for the interviewing process The questions will help to target some of the cautionary areas An example of the screening is located on the next page Reminder Please add to the notes section if you interviewed the applicant this will help any future interviewers with the interviewing process Also note that some candidates may be listed as not eligible for hire Interpreting the Behavioral Assessment Response Accuracy Time Elapsed Overly fast or Overly Slow may be a cautionary consideration The average applicant takes about 20 30 minutes to complete the behavioral assessment Confidence in Results scale Inflated Response scale Overall Score Page 22 of 49

PRMC MANAGEMENT RESOURCE GUIDE Job Fit Job Performance Index Retention Index this can be artificially low in some candidates so the recommendation is to not automatically rule out the candidate for low scores in this area Service Excellence this can be a predictive indicator that they demonstrate a friendly customer service mannerism Utilization of the Behavioral Assessment The survey can and is highly recommended to be used as a tool in the interviewing process By following this guide you will begin to develop improved interviewing skills that are consistently applied during all interviews Any notes that are taken on the survey assessment become part of the employee s file and should be turned into Human Resources Page 23 of 49

PRMC MANAGEMENT RESOURCE GUIDE Skills Survey Completed by Applicant s References 1 The applicant must send at least four references for the skills survey to be distributed 2 They are distributed to the applicant s references by email so this is something to be aware of that could delay the hiring process 3 Once they are complete the Human Resources Assistant Vickie Moser will send them to you by email FYI Be sure to watch for duplicate IP addresses in instances 4 If you do not get the skills the applicant is attempting to manipulate the system survey back you usually cannot hire the person Only human resources can determine if particular circumstances would allow the applicant to be hired without a completed skill survey Interpreting the Skills Survey 1 The survey utilizes a ranking scale from 1 7 with seven being the best Something to keep in mind is that the applicant chose their references and therefore one would assume the scores to be relatively high Any ratings less than a five should be a cautionary consideration Peer Interview 1 Work with Human Resources to find three employees who have undergone peer interview training 2 Schedule a time with these three individuals and the applicants you wish to be interviewed you may schedule multiple candidates for peer interview back to back 3 Print out three copies of the unit specific Peer Interview Form for each peer interviewer If you need assistance locating your form your supervisor or Human Resources may be able to assist 4 Print out a resume if you have one for each peer interviewer 5 Meet your candidate and escort them to the peer interview room This helps them to be less nervous 6 Perform your AIDET with the candidate introducing them to the peer interview group be sure to manage up the peer interviewers 7 After the peer interview is complete escort the candidate out and explain that you will receive the scores from the peer group and be in touch with them in the future Page 24 of 49

PRMC MANAGEMENT RESOURCE GUIDE 8 Return to the peer interview room and receive any feedback from the group as well as the scores Keep the scores sheets as they will be turned in to Human Resources Hiring the EmployeeSo now you have identified the top applicant for the job and you would like to make an offer 1 Work with the Payroll Manager Lynn Southard and VP of Human Resources Ken Brown to get a pay rate that will be offered to the applicant a It is vital that you have certain information for Human Resources e g years of experience same job role education etc 2 Using the Human Resources Offer of Employment fill in the pay grade rate demographic information and expected start date 3 Call the candidate and make the offer 4 If they don t accept the offer attempt to find out why there may have been a misunderstanding that can be resolved if it is about salary it is best to tell the applicant that you will consult with Human Resources on the pay and get back with them Steps for an Internal Transfer 1 The position will be posted by the hiring manager 2 The internal candidate applies for the position just as if they were an external candidate with the additional step of notifying their supervisor 3 The hiring supervisor should seek out the current supervisor to discuss job performance Although the employee might be seen as marginally performing in one area given a different environment they might do very well this is something to take into consideration when making your hiring determination 4 The hiring manager should notify and coordinate with the current supervisor for interview scheduling and job offers 5 Upon internal candidate accepting the job offer both managers should coordinate the work schedule transfer to the new department This process should not exceed 30 days without executive staff approval Remember if they leave the organization they only have to give two weeks notice Page 25 of 49

PRMC MANAGEMENT RESOURCE GUIDE Start Existing Employee or New Hire New Hire 30 Day Meeting 90 Day Meeting Certification of Orientation Assessment of Performance Existing Employee Verify that all employees are listed in your Active Employees within the Taleo System Document in Taleo Continue Continue or Discontinue Employment Discontinue Termination of Employment Documented in Taleo Yes or No No Contact HR End Yes Received Email that Employee Evaluation is Due Reminder High Solid Low conversations should be a routine part of the employee s annual evaluation Notify Employee to Complete Evaluation Forms Complete Evaluation Documentation in Taleo 30 Day 90 Day Annual Evaluation A performance evaluation is an opportunity for a manager and an employee to meet and discuss organizational priorities and to set performance goals for the employee The evaluation should focus on key behaviors that management has assessed as important to the organization All performance evaluations should assist employees to meet their performance goals Appraisal may be done on a formal or informal basis but ideally it will be an ongoing process Salary review may be conducted separately from the performance appraisal Keeping lines of communication open is essential to the success of the process Resource Contacts VP and Chief Human Resources Officer Ken Brown ext 1170 Page 26 of 49 Review all Employee Requirements are completed Schedule Evaluation Meeting with the Employee Go over Taleo Documentation with Employee Print off Taleo paperwork for Employee to Sign and Turn in to HR End

PRMC MANAGEMENT RESOURCE GUIDE 30 day 90 day Annual Evaluations Taleo Dashboard Taleo is PRMC s employee performance evaluation system You can access Taleo through the following link Taleo Link Contact HR for login ID Company Code PRMC After logging in you will see your Taleo dashboard The first thing you will want to check is that your My Active Employees list is accurate You can contact HR if additions or deletions need to be made Once employees are in your My Active Employee list Taleo will generate e mails to remind you of when evaluations are due Your dashboard will show any evaluations Awaiting My Approval and will show Performance Reviews that are upcoming or past due You can click into each employees profile and view when their next evaluation due date FTE designated what grade and step they are on the pay scale You can also list out any applicable certifications you may want to keep track of Taleo can also be utilized to document comments and save documents This can be helpful for anything you may want to remember for their annual evaluation ex extra projects they have worked on additional certificates or licenses they received any warnings I also scan in and upload the file and or behavioral issues New Hire Evaluations You will be required to complete a 30 day and 90 day evaluation of each new employee that you manage You will receive e mail reminders from Taleo 30 day Meeting The main point is to touch base with the employee How do we compare with what we said in your interviewing process What s working well Have any individuals have been helpful to you Based on your prior work what ideas for improvement do you have Is there any reason that you feel this is not the right place for you 90 day Meeting 1 Certification of Orientation You will need to know dates on the review and completion of the following activities Job Description Infection Control Equipment Safety Facility Tour Confidentiality New Employee Orientation Environmental Safety Emergency Codes Time Clock Use Department Specific Orientations Page 27 of 49

PRMC MANAGEMENT RESOURCE GUIDE 2 Assessment of Performance Attendance Dependable Policy Procedures Safety Quality of Work Conduct Appearance Standards of Performance Job Knowledge Use of Time Productivity Suitability for Position 3 Recommendation to Continue Discontinue Employment Annual Evaluations You are required to complete each employee s annual evaluation Each yearly evaluation is due on the employee s hire date anniversary Note This may change in situations where the employee has received a promotion or job title change The annual evaluation is tied to the correlating merit increase in pay You will get your first Taleo e mail notification approximately 30 days before the due date for your employee s annual evaluation Before the Evaluation Employee Requirements Before the Evaluation occurs you must ensure your employee has completed all of the following Annual evaluation forms completed by the employee these are located on the PRMC Intranet o Annual job overview employee perspective review o SMART goal worksheet o Compliance pledge o Going the Extra Smile Employee Record of Activities Evaluation Form All assigned HealthStream computer based training modules are complete Staff Educator can show you how to view this TB skin test is current can contact Employee Health if unsure Respirator fit test completed if applicable CPR certification is current if applicable Before the Evaluation Supervisor Requirements After receiving your employee s annual evaluation papers you will need to do the following in Taleo 1 Designate a selection on the Standards of Performance and Job Competencies e g fully successful superior or unsuccessful These designations can be used to populate the manager comments section with pre defined sentences The performance designation you choose will correlate with a Merit Increase Recommendation The employee s merit increase you select should match the recommendation Page 28 of 49

PRMC MANAGEMENT RESOURCE GUIDE Helpful Hint To locate the pre defined comments select the icon to obtain the list of options Select each box that correlates with that employee s performance Once selected you are always welcome to edit or add as appropriate 2 Fill in your commentary on the Employee Strengths and Areas for Improvement It can be helpful to review the employee s perspective review sheet to see if you are on the same page 3 If applicable fill in any disciplinary action taken 4 Select any relevant Going the Extra Smile Award activities that the employee filled on their evaluation papers Time for the Evaluation 1 Schedule a 30 minute evaluation meeting with the employee 2 Go over the documentation you completed in the employee evaluation system Taleo with the employee and make updates if needed 3 Select submit and request approval 4 Print off a copy of the evaluation and have the employee sign the bottom 5 Scan your signed evaluation and employee packet into Taleo 6 Turn in the printed version to Human Resources 7 Merit increases are made active with the next full payroll period High Middle Low Conversations It s all too often that we devote the majority of our energy and attention towards the people that deserve it the least the low performers Unintentionally we begin to neglect the main drivers of performance our high and middle performers In 2018 PRMC began utilizing the technique high middle low to coach and develop staff The expectation is that all supervising leaders will perform high middle low conversations with their employees during their annual evaluation period This technique when used consistently helps to move organizational performance and foster a healthy workforce culture The essential tactics are to re recruit high performers coach and develop middle performers and create performance pressure for low performers to move up or out of the organization If not progress slows and PRMC will fail to reach its full potential High Middle Low Resource Guide Reminder Anything related to employees documentation must be signed and dated Page 29 of 49

PRMC MANAGEMENT RESOURCE GUIDE Building Rapport with Employees 101 Building rapport with employees involves a leader taking time each day to touch base with employees make a personal connection find out what is going well and determine what improvements can be made Quite simply it is a way to efficiently gather the information you need to do your job as a leader and do it well At Pratt Regional Medical Center we will refer to this process as Leader Rounding on Employees Why round on Employees Employees want five critical things from their leader 1 2 3 4 5 A leader who cares about them as an individual and values them as an employee Systems that work and the tools and equipment to do their job Opportunities for professional development Recognition and reward for a job well done A positive work environment Employees do not want to work with low performers By regularly rounding on our employees we can proactively address issues that arise as well as to reinforce positive behavior When Leader Rounding on Employees is implemented effectively we can expect to see increased employee engagement and decreased turnover in our organizations How to round on Employees Who Rounding should be conducted by the leader with hire terminating power the individual that the employee sees as my boss Rounding is not a delegated task When Each leader rounds with 100 of their direct reports 1 1 at a prescribed frequency o If you have less than 40 employees you will round with each employee monthly o If you have 41 80 employees you will round with each employee every other month o If you have more than 80 employees you will round with each employee quarterly or every 90 days Keywords to Use When Rounding on Employees What is working well for you today Is there a care provider I can recognize Why Is there a physician I can recognize Why Do you have the tools equipment and information needed to do your job take care of patients today Are there any systems you want to improve Do you have any ideas to fix them Are there any quality or safety issues to discuss Ideas Tough Questions Discuss any tough questions you need to address or have heard while rounding What have you done this past week month to impact patient experience If priority focus is on patient experience CAHPS Align to employee engagement survey During opening or closing of rounds you can align to employee engagement survey opportunities I e if the leader s results on include you in decisions regarding the unit are low then the leader might say Sara I would like to round on you This is a perfect time for me to hear your thoughts so you feel included in the operations of our unit Page 30 of 49

PRMC MANAGEMENT RESOURCE GUIDE Tools Rounding Log this will be provided to you by PRMC s Studer Champions o Questions to include on your rounding log should trigger responses that will harvest the information of the employee Relationship What did I learn about this person What was working well for this care provider What care provider can I recognize Are there other departments areas I can recognize Physicians I can recognize Did this person have all the tools and equipment they needed to do their job today Are there things that I learned about systems that are or are not working well in my area or other areas How would I recommend they be fixed Have I validated behaviors that have been introduced for example AIDET Stoplight Report o The Stoplight Report is a valuable tool to communicate follow up actions that originate during rounding The report demonstrates that the leader heard employee feedback and sought action based upon that feedback The Stoplight Report is organized into three sections The green section of the report highlights manage ups and wins and also ideas areas for improvement that were implemented The yellow section represents those opportunities for improvement that were identified but not able to be addressed right away and why The red section of the report communicates the ideas opportunities that were harvested and not acted upon and the reason why they were unable to be implemented Related Resources Leader Rounding on Employees Toolkit can be accessed through the following link LEADER ROUNDING WITH EMPLOYEES TOOLKIT pdf Page 31 of 49

PRMC MANAGEMENT RESOURCE GUIDE Tier 2 Competencies Budget Management Travel Off site Meeting Risk Management Quality Improvement Goal Setting LEM Page 32 of 49

PRMC MANAGEMENT RESOURCE GUIDE Budget Management Early June Request to complete Capital Request Minor Equipment Timeline June July Begin Revision 1 Budget July August Edit Revision 1 Budget with any known changes or missing elements Mid August Begin Revision 2 Budget Late August Early September Executive Staff sits down to determine areas needing adjustment VP will work with Director Manager to adjust Revision 2 Budget Helpful Hint Budget Amount YTD Actual Amount of Budget Remaining September Completed Revision 3 Budget is taken to the Board of Directors for approval Any open PO This will be the amount PRMC is authrorized to spend for the fiscal year October Each month the expectation is that all leaders will manage their budgets by closely monitoring expenditures and adjusting if needed Page 33 of 49 Actual Budget Remaining

PRMC MANAGEMENT RESOURCE GUIDE Budget Management Now that you re part of the PRMC Management Team one of your many responsibilities will be to manage your department s budget and spending It is quite possible that this will be your first time preparing a budget The budget is the best tool to see how your department is doing financially As someone once said If you fail to plan you plan to fail Budget is often seen as a burdensome and time consuming exercise but it is a crucial element of financial management and is a huge contributor to PRMC s overall success The time spent on planning and budgeting is a time well spent The budget typically consists of four major pieces Budget for People Means reviewing current staffing in your department the skills they exist and looking to the future for what you would like to accomplish as a department and what will be needed You can determine if the current staffing levels are ok and if you need to hire additional staff with different skills Budget for Operating Expenses Means predicting how much money you will need for the day to day operations of your department Things like salaries overtime supplies software licenses travel expense training conferences etc Budget for Capital Expenses Relates to costs associated with a single item whose price is at least 5 000 and has a useful life of at least two years Multiple items may be considered capital if they share a common link and cost at least 10 000 combined Budget for Revenue is typically non existent if you run a support department such as IT HR Finance Accounting etc These departments provide support and usually don t generate revenue Annual Budget Process The annual budget process is one of the most critical things financially we do together as a facility To start the budget process each leader will receive an initial draft for each department managed based on nine months of expenses annualized to twelve months This draft will be known as your Rev 1 budget Your job as a leader of a department is to review this draft for accuracy and completeness If you have any budgeting questions the Sr Accountant Natasha Zielke is an excellent resource as well as our Chief Financial Officer Alan Waites Please remember there are no stupid questions During the review of this draft you will want to make sure you account for any additional resources needed in the following year i e New staff Replacement staff that might not have been in place during the full 9 months prior new service contracts or other items that you didn t purchase the year before Additionally you will want to include any known cost increases in service contract costs that might take effect in the following year Once your Revision 1 Budget has been reviewed you will turn it into the Chief Financial Officer Alan Waites who will then begin compiling the Revision 2 Budget to include the edits and additions provided by each leader Keep in mind that just because you created a budget for the year it can change if the organization is below target This is where the Executive team will evaluate the facility wide budget and decide whether cuts need to be made Leaders may expect questions during this determination phase Once the Executive team gives the rubber stamp of approval this will be known as the Final Revision 3 Budget that will be taken to the Board of Directors for approval Once budgets are finalized the total in your department is what you must work with for the year You can move money from one line to another freely but you should not exceed your budget in total Page 34 of 49

PRMC MANAGEMENT RESOURCE GUIDE Financial Reports Bi weekly each department supervisor will receive a payroll report that displays your FTE s overtime hours and call back hours against prior year average The reports act as a point of reference to help manage the FTE s in your budget and explain any differences to your supervisor if asked Staying informed and attentive to your staffing budget is one implemented practice to ensure PRMC maintains effective financial practices Additionally each month around the 10th business day separate emails are sent from the accounting department that will include the following reports Cost Center Report General Ledger Financial Board Report Page 35 of 49

PRMC MANAGEMENT RESOURCE GUIDE Cost Center Reports A cost center reports are sent for each department in the facility The primary function of a cost center is to track expenses improve operational efficiencies and maximize profit within your specific areas You should expect to receive two cost center reports Cost Center Report Comparing Budgeted Expenses to Current Expenses Cost Center Report Comparing Prior Year Expenses to Current Year Expens Note Not all departments generate revenue General Ledger GL Reports The general ledger report provides you with a summary of all the transactions for the current month This report will display your beginning balance ending balance and all of the transactions for the period organized by account FYI Auto Tran Exp Report entries represent items purchased from Materials Management If you have inquries related to this entry you may contact the Sr Accountant For detail about any other items can be found by contacting Accounts Payable Page 36 of 49

PRMC MANAGEMENT RESOURCE GUIDE Financial Board Report The board packet will include financial information for PRMC as well as the status of each department compared to their allotted budget The budgets are displayed on a fiscal year to date timeframe Annually in July it is this information that will be used to annualize the following year s budget numbers Example Our Fiscal Year begins October 1st so at the end of December you should have at least 9 months of your budget remaining 75 If you ever have questions or need clarification on any of the financial information we provide please reach out to any of the contacts below Staff Accountant Taryn Renneker ext 1466 Accounts Payable Clerk Rhonda Dipman ext 1435 Sr Accountant Natasha Zielke ext 1252 Chief Financial Officer Alan Waites ext 1432 Page 37 of 49

PRMC MANAGEMENT RESOURCE GUIDE PRMC TRAVEL Business Travel Expense Reporting Policy Complete the Request to Request to Attend Meeting Form located on the PRMC Intranet It is essential to ensure all information is completed including when the registration and reservations are due whether they should be paid by check or credit card if any reservations or registrations have already been paid correct addresses to send payment whether or not a PRMC car is needed see policy below if airline or hotel reservations are required any specific airline or hotel reservations requested Submit the Request to Attend Meeting with a copy of the meeting brochure information and a completed PO to your supervisor for approval NOTE PO s do not have to be exact if you do not know the amount for sure price them on the internet to get a general idea for approval All travel is subject to the approval of one s supervisor and executive staff and the Request to Attend Meeting and ALL PO s should be approved before making reservations or registrations Hotel Reservations To ensure accuracy and completion the preferred method of making hotel reservations for business trips is through the Administrative Assistants in the Administration Office Hotel reservations are usually made at the hotel where the conference is being held or where they have blocked rooms for a discount If the hotel where the rooms were blocked is full or the rate cannot be obtained due to late registration PRMC may make a reservation at another hotel and while every effort will be made to make it as close to the venue as possible it may not be as convenient If the rate for the blocked rooms at a hotel is not within budget we will make reservations at another hotel as close to the venue as possible with a less expensive rate Once a reservation has been made it is not acceptable to request an upgrade all upgrades are the responsibility of the employee at the hotel Mode of Transportation Airline When airline travel is necessary the preferred method is again through the assistance of the Administrative Assistants Keep in mind that when flying on hospital business or attending seminars and meetings we choose the most economical flight possible All PO s should be approved before making the reservation Page 38 of 49

PRMC MANAGEMENT RESOURCE GUIDE Hospital Vehicle Per PRMC Policy if a hospital vehicle is available employees are required to use them for business travel and mileage will not be reimbursed If a hospital vehicle is not available and the employee has prior approval mileage is reimbursed Keep in mind if you will be flying out of an airport we recommend that the employee use their personal vehicle or have a fellow employee drop them off and pick them up from the airport to allow the availability of the vehicle to other hospital employees and mileage will be reimbursed Meals PRMC will pay for meals up to 30 per day for each employee anything higher than this allowance will be at the employee s expense This does NOT include alcohol This amount cannot be carried over from day to day resulting in one large meal on the trip PRMC will also cover expenses that have a reasonable and necessary relationship to the purpose of the activity or meeting i e lodging public transportation tolls parking etc PRMC will NOT cover personal expenses such as upgrades phone calls movies dry cleaning etc that are not necessary to participate in the purpose of the travel When you submit a Request to Attend Meeting form a credit card is usually reserved for you to use for these expenses unless there are multiple meeting attendees and in that case one designee would be assigned the credit card The credit card can be checked out from the Administration Office the afternoon before you leave and should be returned within 24 hours of your return accompanied by an Expense Report and ALL receipts Page 39 of 49

PRMC MANAGEMENT RESOURCE GUIDE START Variance Submitted Risk Manager Notified of NEW Incident Risk Manager reviews the incident details Risk Manager Assigns the QDC to the appropriate reviewers Reviewers will receive an email notification of a NEW incident review Risk Manager reviews the incident and investigation findings and assigns to the appropriate peer review committee After completion of the investigation the reviewer will select investigation complete Investigation Document investigation findings Interview involved personnel Assign initial SOC Give recommended follow up plan Risk Management Risk management in healthcare comprises the clinical and administrative systems processes and reports employed to detect monitor assess mitigate and prevent risk By employing risk management PRMC can proactively and systematically safeguard patient safety as well as the organization s assets market share reimbursement levels brand value and community standing Resource Contact Risk Manager Mike Miller ext 1270 Page 40 of 49

PRMC MANAGEMENT RESOURCE GUIDE Risk Management Introduction The current software PRMC uses for Risk Management program is called Quality Data Check QDC The policy and procedure to fill out a QDC for a variance complaint grievance or workman s compensation injury are explained in the policy titled Variance Reports It is used any time there is an incident or occurrence defined as Any event not consistent with the desired operation of this facility or the care of patients Variance Report Policy and Procedure This definition along with the added use of Workman s Compensation events as well as grievances makes for a variety of purposes which will vary widely from nuisance complaints up to and including the death of a patient For enterprise wide tracking to be effective the use of the variance reporting system QDC should be encouraged and supported Likewise we should also promote the use of the chain of command as much as possible to make sure that users don t see the tool as either a complaint box or a punitive measure The state law demands that certain reportable events be reported through the risk management department to ensure serious events get reported to the appropriate agencies and the Kansas State authorities These events are rare likely not more than a handful of instances in a year For all but the reportable events required by law or statute quality initiatives and training are the results of the Risk Management system At its best it is to provide attention for tracking for quality initiatives to help identify trends in the patient environment and to provide some consistency in the collection of data The QDC involvement records are deleted regularly at approximately two years after the final evaluation of an event except for the handful of reportable incidents How to Submit a Variance Report QDC The Variance Report policy outlines the entire procedure for entering a QDC Access to the QDC system can take place from the QDC desktop icon on any network computer either in the hospital or clinics It can also be done anonymously without logging in or using the anonymous button for those already logged in There is also a 19 minute video available while logged into the QDC system under the help dropdown tab For each of the drop down categories in the QDC system a helpful definition will appear if hovered over with the mouse pointer How to Investigate a Variance Report QDC If you are assigned as a reviewer you ll receive an email notification which will provide a link to the QDC incident You can click the link and log in The initial screen will have a button under the red bar which says My Pending Reviews Clicking on the button will show the reviews which also require clicking to open the incident report The incident will be read only but the review field will allow editing of your review work Any other review done previously will also only be read only The investigation should include any necessary tasks to provide you with enough information to determine if the standard of care was met Some of these tasks may include but are not limited to interviews with those involved or a thorough review of the electronic medical record Each reported incident shall be assigned an appropriate standard of care determination under the jurisdiction of a designated risk management committee Separate standard of care determinations shall be made for each involved provider and each clinical issue reasonably presented by the facts Page 41 of 49

PRMC MANAGEMENT RESOURCE GUIDE Standard of Care SOC Standard of Care SOC Definition SOC 1 Standard of care met even if an injury occurred to the patient Care provided met the standards of care Policies if applicable were followed SOC 2 Standard of care not met but with no reasonable probability of causing injury No Reasonable Probability means may be possible but is not probable Injury defined to mean an incident that requires significant medical intervention or causes disability or death o Significant Medical Intervention may include a more intensive level of care surgical intervention significant change in medications and or increased length of stay due to unexpected additional diagnostic or treatment measures SOC 3 Standard of care not met with injury occurring or reasonably probable A reportable standard of care not met means a deviation from the standard of care that has a known and direct adverse outcome impact on patient care and causes injury or there is a reasonable probability more likely than not of causing injury to that patient SOC 4 Possible grounds for disciplinary action by the appropriate licensing agency A reportable incident with possible grounds for disciplinary action by the appropriate licensing agency SOC 5 Non Clinical Incident often used for internal trending purposes and does not meet requirements for reporting to regulatory agencies HELPFUL TIPS Here are a few tips to help make the process easier for you and valuable for all involved Be sure ONLY to include the facts rather than opinions In particular it is critical to avoid blaming statements and use neutral rather than emotional language o For example OPINION BLAME The CNA on duty didn t take vital signs for the patient all night long This is dangerous and should be addressed FACT When I checked the patient s chart at 0200 I did not find evidence of charted vital signs from the hours of 1800 0600 on 4 25 2018 Keep in mind that the investigation should uncover the reasons for the event Perhaps the CNA recorded the vitals on the wrong account number and can correct the error The first example uses language that blames or implies wrongdoing By recording the facts only the language is neutral and the information specific This also takes out the perception that someone is being written up An incident report should never blame but should clearly state what happened Remember if you have multiple incidents to report they each warrant the full diligence of an investigation Be sure to place a separate QDC report for each incident If you are unable to do so due to time constraints please reach out for assistance from your supervisor Page 42 of 49

PRMC MANAGEMENT RESOURCE GUIDE Quality Improvement Introduction At Pratt Regional Medical Center we believe that the healthcare needs and expectations of the customer will be met through a commitment to safety and continuous quality improvement on the six domains of healthcare quality defined by the Institute of Medicine Report Safe Avoiding harm to patients from the care that is intended to help them Effective Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit avoiding underuse and misuse respectively Patient centered Providing care that is respectful of and responsive to individual patient preferences needs and values and ensuring that patient values guide all clinical decisions Timely Reducing waits and sometimes harmful delays for both those who receive and those who give care Efficient Avoiding waste including waste of equipment supplies ideas and energy Equitable Providing care that does not vary in quality because of personal characteristics such as gender ethnicity geographic location and socioeconomic status As a PRMC supervising leader your responsibility is to support QI activities through the planned coordination and communication of the results of measurement activities related to QI initiatives and overall efforts to continually improve the quality of care provided Expectations Meeting Attendance Your voice is important to the overall success of our Quality Assurance Performance Improvement program Your involvement is critical in ensuring that we design an intervention that we can effectively implement together that we provide the necessary tools and support for you to implement that intervention and that we take into account the demands on your time and help minimize the disruption to your workflow The invitations for the Quality Assurance Quality Improvement Meetings will be distributed through your outlook calendar and it is the expectation of PRMC that you will attend and actively participate Deliverables Action Items A basic underlying principle of Quality Improvement is that it is a continuous activity not a one time thing As you implement changes there will always be issues to address and challenges to manage things are never perfect You can learn from your experiences and then use those lessons to shift strategy and try new interventions as needed so you continually move incrementally toward your improvement goals Documentation An essential element of Quality Improvement activity is to have some form of written documentation that states your goals lists your overall strategies to achieve those goals and then delineates the specific actions you will take to implement the interventions you have selected to address the identified problems In addition to your written action plan it is important to monitor the progress of your implemented intervention Most monitoring takes place on a monthly or quarterly basis The purpose of this effort is to get some sense of what worked what did not work and what further or new interventions may be needed All of this documentation should be submitted to the Quality Coordinator Niki Griffith in a timely fashion for regulatory required documentation Page 43 of 49

PRMC MANAGEMENT RESOURCE GUIDE Collaboration Synergy The quality and safety of care and the need to contain costs require that all professions work together in an environment of respect When a team of professionals do not communicate and collaborate the organization s performance suffers Effective teamwork and good working relationships can reduce errors and improve outcomes Another reason collaboration is important is that it promotes coordination of care across the continuum of healthcare in all settings Working as a team ensures that we share knowledge and work towards a common goal all the while learning about one another s roles and responsibilities Steps to Leading Quality Improvement Once a decision has been made to focus on a topic for quality improvement it is helpful to follow a consistent series of steps to guide the work The following are suggested steps to conducting a quality improvement project Depending on the type of quality improvement effort steps might be combined or eliminated Research the topic or measure It is important to understand the background and rationale behind changes being made to improve patient safety or quality to buy in and gain enthusiasm on the part of the staff and providers being asked to change For other quality and patient safety topics a quick google search often will garner a wealth of resources Keep an eye out for credible national sources Research will also help in developing a list of potential best practice ideas for implementation consideration and potential measures to track in order to determine whether the work being done is successful Consider involving a clinician early in the process If there is a willing and enthusiastic provider that will assist with or review the research and contribute throughout the project the effort will be a worthy investment towards ease of implementation Set a broad goal and draft a timeline Having researched the topic or measure being implemented it is helpful to articulate a broad goal and come up with a drafted timeline to present to the group of people that will participate in the improvement efforts Don t be afraid to be ambitious in terms of deadlines With creative meeting alternatives and a commitment to keeping work flowing it is entirely possible to bring a change to full implementation in two or three months Build the team ad hoc group In deciding who will be needed to bring about a change in improvement it is helpful to start by drawing a rough flowchart of the processes involved and include a representative from every point in the process As representatives are being invited it is a good idea to check with them to make sure all stakeholders are represented It is important to find a way to obtain input from patients on changes that will impact their care It may not be realistic to include a patient or family member on every quality improvement activity but there are other ways to include the patient voice such as simply asking several patients for input as projects unfold Design the strategy Ask the team or ad hoc group to think through what must be done to achieve the general goal Drawing a rough flow chart of the process in question with the group and identifying points in the process where changes need to be made helps structure the discussion Brainstorming activities to gather implementation ideas are also helpful Page 44 of 49

PRMC MANAGEMENT RESOURCE GUIDE Ideas can be categorized into themes and prioritized by a group Implementation ideas and best practices identified in your research can also be reviewed for applicability to your setting Encourage participants to gather co worker input frequently throughout the project so that potential challenges can be detected early Once an implementation strategy has been identified a plan of action can be established Policies order sets implementation bundles staff education and patient education might need to be created adopted or adapted Take time to assess whether your implementation strategies are weak or strong and consider the balance between strength of the intervention and the resources needed to support implementation A sampling of strategies follows o EHR templates can be a powerful way to hardwire adherence to assessment or practice changes Such templates make it difficult to do or document the wrong thing thus EHR template changes would be qualified as a strong strategy o Staff education although important might be qualified as a weak strategy if it is the only support for implementation In rural hospitals where staff do not typically work in the same area every day and low volumes are not conducive to repetition information is likely to be forgotten o Checklists are very helpful in driving consistency of care but are only as strong as the frequency with which they are utilized Discharge checklists surgical checklists shift to shift report templates and charge nurse duty checklists are examples of situations where checklists can help staff to deliver consistent care Strive to keep implementation strategies as simple as possible to help staff navigate changes coming from various simultaneous improvement efforts Simplicity is the driving force behind bundling where several key changes to accomplish a goal are promoted rather than a long list of changes Select specific measures and define the goal Measure Selection Standardized measures have been established for many quality and patient safety topics and it is wise to align with them to be consistent with state and national efforts and allow for comparisons with other hospitals The National Quality Forum NQF maintains an inventory of current measures and is a great place to start looking for established measures on various hospital quality and patient safety topics o It is also important to consider what type of measure s to utilize in order to support implementation and measure improvement Process measures are measures that reflect consistency in staff adherence to tasks assessments or treatments associated with providing care Process measures are often more effective as a feedback tool for staff because improvements will be reflected sooner than in outcome measures especially in low volume settings Outcome measures reflect patient outcomes such as morbidity mortality healthcare associated infections or readmission rates In rural hospitals low volumes can diminish the usefulness of outcome measures since the occurrences measured such as death or readmissions can be rare in any specific subset of the population HCAHPS the Hospital Consumer Assessment of Healthcare Providers and Systems surveys are a measure of patient perception which do not fit into either the process or outcome measure category but provide a valuable view of quality from the patient perspective Setting Goals Broadly speaking goals should ultimately be the right care for every patient every time which for process measures translates into 100 or below benchmark time medians for every measure The median is the middle number in a set of values half the numbers are less and half the numbers are greater It is helpful to have this Page 45 of 49

PRMC MANAGEMENT RESOURCE GUIDE in mind for a general long term goal but to initially focus on measurable improvement Any improvement translates into one more patient that received high quality care and that is an encouraging message for staff Educate widely and creatively Staff education is a challenge given the pace of change and the amount of information that must be shared to keep staff current in terms of quality and patient safety To support the mindset and expectation of continuous improvement it is a fruitful investment to develop a consistent system of staff education that combines periodic in person education sessions with monthly updates that include feedback to communicate receipt and review Determine whether there are other groups that can influence the success of the project or topic implementation as education is being planned Other departments healthcare settings hospital leadership and boards and community members are potential considerations as well as patients and family members However staff education is delivered there are some concepts that are important to keep in mind o Enthusiasm is an insightful prediction of change success and can be generated early in the quality improvement process by soliciting stakeholder input formally or informally and continued throughout the course of the project o The inclusion of pertinent compelling patient stories or sharing goals and progress using real numbers of lives or harm averted helps to generate enthusiasm o Sharing baseline hospital performance metrics with national and state comparisons and benchmarks provides a sense of direction for the project o Simplicity in the design and delivery of staff education will help them to learn and remember the information Consider what staff absolutely need to know to support the change and design education around that core o Critical project implementation steps should be hardwired into paper or electronic documentation systems to provide just in time guidance The kick off Timelines should be arranged so that the launch of the project sometimes termed kick off or go live begins shortly after staff education has been completed when the information and inclination are fresh Project leaders should review the new process beforehand to make sure that staff have everything they need to ensure success A fun kick off mini event such as a pizza party can be an inexpensive and positive way to bring attention to the project Rapid tests of change It is important to evaluate the changes being made which aids in guiding the documentation communication and correction of unforeseen technical or process errors It is helpful for members of the project team or ad hoc group to be available to answer questions document issues and communicate frequently to respond to complications during initial implementation Daily or weekly huddles can be held to communicate with staff about the new processes Rapid tests of change continue until it appears that the new process is running smoothly and implementation can be considered complete Page 46 of 49

PRMC MANAGEMENT RESOURCE GUIDE Evaluation The best way to build momentum on quality efforts is to actively monitor staff adherence to process measures as close to real time as possible and provide feedback to staff and providers individually or during regular communications As audits or observations are being done catching people doing right and thanking them personally and or publicly builds morale and encourages a continuation of the behavior When interventions are missed a timely and friendly conversation to learn more about potential barriers and elicit suggestions can lend valuable insight into process improvement Staff and provider performance feedback at least monthly is extremely important in the beginning stages of project implementation Once improvement has plateaued a decision must be made whether to move the project into sustain mode and monitor less frequently or to reconvene the group for a discussion on how to improve further Celebrate often It is very exciting when quality improvement efforts pay off and run charts begin to show an improvement in process and outcome measures Frequent and prominent displays of run charts or graphs that acknowledge and celebrate great work foster pride and encourage staff to continue to improve Administrative involvement in celebratory communications staff meetings and events reinforces the message that quality improvement is a high organizational priority Page 47 of 49

PRMC MANAGEMENT RESOURCE GUIDE Goal Setting SMART goals are an effective goal setting process to ensure you are making attainable and measurable goals instead of focusing on tactics and goals that cannot be defined S Specific The employee should describe the goal in detail so the objective is clear The mission statement for your goal o Who What When Where Which or Why M Measurable The employee should describe how the success of the goal will be measured What metrics is the employee going to use to determine if they meet this goal This makes the goal more tangible because it provides a way to measure progress A Attainable The employee should list challenges obstacles opportunities strategies for achieving this goal This focuses on what the employee can do to make it an attainable goal The goal should be meant to inspire motivation and if the employee has the tools skills needed to accomplish the goal R Relevance The employee should relate to competencies organizational and personal development Relevance refers to how the goal will help the employee grow professionally within the organization T Timeframe The employee should identify the timeframe for achieving this goal Providing a target date for deliverables is essential for goal setting When to Use SMART Goals Every PRMC employee is required to do a SMART goal annually with their evaluation This goal allows the individual to work on a personal growth goal alongside the organizational goals Any manager in the LEM will use SMART goals as a part of their annual evaluation and 90 day plan SMART GOAL FORM Page 48 of 49

PRMC MANAGEMENT RESOURCE GUIDE LEM Leader Evaluation Manager The LEM is a tool that allows us as leaders to have a clear view of the organizational goals and how they relate to your departmental goals PRMC uses the annual evaluation 90 day plan and validation matrix to ensure you as a leader are ready for your monthly meetings and making progress towards your goals Annual Evaluation Tab The annual evaluation tab is where you can assign and view what organizational goals you are working towards There are goals created by each pillar Service Quality People Growth and Community Leaders can copy goals created by others or create their own goals here Helpful Links Adding Goals to an Evaluation Editing Goals on an Evaluation Copying Goals from the Past Evaluations Aligning Overarching Goals Entering Evaluation Results 90 Day Plan Tab The 90 day plans act as a roadmap to follow in order to make progress towards the annual goals The 90 day plan will help to simplify the annual goal into smaller actionable steps Helpful Link Creating a 90 Day Plan Validation Matrix The Validation Matrix allows us to be accountable to the monthly tasks required of each manager in the LEM Updated 90 Day Action Plan Leader Rounding on Employees and Thank You Notes Introduction to the Validation Matrix a Introduction to the Validation Matrix b Validation Matrix 90 Day Action Plan Updated Yes No top box is yes Leader Rounding on Employees Thank You Notes Actual Goal Page 49 of 49 Example