Kiel Reidenbach 7-2 Mmba 612 PDF

MMBA 612- Reidenbach
Table of Contents
Page
Organizational Profile .. 2-4
Major, Unique, and Special Technology. 4
Target Customers/Market 5
Customer Value Propositions.. 5
Key Suppliers, Partners, and Collaborators... 5-6
Strategic Situation. 6-8
Strategy Map..... 9
Balanced Scorecard Metrics Table...... 10-11
Financial Perspective..... 12-14
Customer Perspective.... 15-18
Internal Business Process Perspective. 19-22
Learning and Growth Perspective ...23-26
2
Bronson Methodist Hospital
Organizational Profile
Bronson Methodist Hospital (BMH) is the hub of the Bronson Health Care system. BMH is
a 404 bed not for profit teaching hospital located in Kalamazoo, Michigan. The city of
Kalamazoo is located in Kalamazoo County, USA and opened its doors in 1900 and serves a 9
county region in southwest Michigan as well as northern Indiana. Bronsons main campus
consists of two campuses located in close proximity to each other at 601 John Street, Kalamazoo,
Mi, 49007. In addition, Bronson Battle Creek Hospital is located at 300 North Avenue, Battle
Creek Michigan, while Bronson Lakeview Hospital is located at 408 Hazen Street, Paw Paw,
Michigan. All facilities are open 24 hours a day, 7 days a week.
Definition and Description of the Organization
As a member of Michigans healthcare system serving the southwestern region of Michigan,
BMH provides healthcare services in cardiology, orthopedics, surgery, emergency medicine,
neurology, oncology, obstetrics, and pediatrics. Specialty areas include a neonatal intensive care
unit, primary stroke center, neuro-critical care, burn center, as well as designation as the regions
only level 1 trauma center.
Health care services at BMH are delivered by a highly skilled multi-disciplinary team. This team
consists of physicians, specialists, physician assistants, nurse practitioners, centralized and decentralized pharmacists, registered nurses, dieticians, social workers, case managers, as well as
numerous ancillary staff. Through the work of this multidisciplinary team, comprehensive, high
quality care is provided to patients that seek the services provided by Bronson.
Mission, Vision, and Values

BMH has the following Mission, Vision, and Value Statements:
Mission- BMH exists to provide excellent, patient centered healthcare to the

patients and families that it serves.
Vision-This organization wants to be a national leader in health care quality.
Values- The workforce is expected to act with integrity, provide patient and
family centered care, demonstrate teamwork, pursue evidence driven
improvement, pursue continuous education, and demonstrate community
commitment.
Core competencies of BMH include the following:
patient and family centeredness
dignity and respect
participation and collaboration
information sharing in daily practice
Through these competencies, patients and families are involved as a partner in their care which
allows Bronson to achieve its mission of providing excellent, patient centered, healthcare to
those that the organization serves.
Workforce Profile
BMH employs 3,182 employees. Of these employees, 32% are nursing (or 1,018), 17%
are technical (or 541), 14% are professional (or 445), and 37% are categorized as other(or
1,177). Further demographical breakdown reveals that 82% of employees are female and 18%
are male, 45% finished high school, 50% finished college, and 5% finished a graduate program.
As for an approved hours break down, 74% are full time, 17% are part time, and another 9% are
on call. Of these positions, 72% are during the day shift, 17% are night shift, and 10% are
considered other. Breakdown by ethnicity reveals that 91% identify as Caucasian, 5% as
African American, 1% as Hispanic, and 3% as other. Bronson Methodist Hospital also has 412
community members that serve as volunteers within the hospital.
Medical staff breakdown includes a staff of 780 physicians and allied health
professionals. Bronson employs 50 physicians and 14 allied health professionals. The
organization contracts radiologists, anesthesiologists, pathologists, pediatric gastroenterologists,
neonatologists, emergency physicians, and trauma panel coverage.
Major, Unique, and Special Technology
BMH prides itself on providing the best care possible to its patients and families. As a
result, the American Hospital Association (AHA) recognized Bronson as a Most Wired
Hospital in 2014-2015. This award recognizes that BMH has an investment in the use of
information technology that supports quality care, patient safety, and best practice. One of the
major contributors to this recognition was the implementation of an electronic medical record
called Epic. This electronic record supports continuity of care across the Bronson system as well
as with various other hospital systems. As a result, BMH has gone almost completely paperless
when it comes to areas such as charting and medication ordering/administration. In addition,
Epic also provides a tool called Bronson MyChart that patient can access from home to help
manage and receive information about their health.
BMH also has a neuro-interventional team that treats complex stroke and other
neurological problems within the neuro-critical care unit. Due to the technology within the
neuro-intervention suites, specialized tools, and highly skilled neuro-interventional team at
Bronson, they have received the Stroke Gold Plus Quality Acheivement Award in 2015.
Patients can now receive stroke treatment and other neuro-vascular interventions that were
previously unavailable in the area.
Target Customers/Markets
BMH and its satellite hospitals serve 9 counties in southwestern Michigan. Bronson
provides healthcare services to patients of any age and across all continuums of health and
illness. BMH has both general medical, as well as intensive care units available to neonatal,
pediatric, and adult populations. The organization has a main businessto-consumer focus as
patients are the primary focus. However, the hospital depends on many venders and partnerships
so there is a business-to-business aspect as well.
Customer Value Propositions
The following customer value propositions for BMH are directly aligned with the
mission, vision, and values that are inherent in the care provided at this organization:
1. Safe, timely, effective, efficient, and equitable care.
2. Mutual goal setting and collaboration
3. Highly skilled and committed team of care providers
BMH strives to provide high quality care to patients as well as their families. By utilizing
a patient and family centered care model, Bronson providers are able to communicate and
collaborate with patients and families to ensure all questions are answered, all needs are met,
and that care is individualized for each and every patient to achieve the best possible
outcomes.
Key Suppliers, Partners, and Collaborators
Partnerships with suppliers and vendors are essential in helping Bronson reach the goal of
providing the highest quality healthcare services to their patients. Bronson has many vendors in
all areas of work. Needed supplies come from medical supply companies, food vendors, linen
services, rental companies, pharmaceutical companies, information technology companies,
construction companies, as well as many others. In order for Bronson to function on a day to day
basis, these vendors and suppliers are instrumental in meeting the needs of the organization as
well as the needs of the patients and families served.
Bronson also partners with many local schools due to the fact that it is a teaching hospital.
Western Michigan University has partnered with Bronson through its physician assistant,
nursing, and medical schools. Many area community colleges have also joined in a partnership
with Bronson through their nursing programs. This is of particular importance in todays
healthcare environment due to the shortage of providers and nursing staff across the nation. Due
to these partnerships with area schools, Bronson is able to train, attract, and retain qualified
healthcare providers to meet the needs of the populations served. Most recently, Bronson has
also partnered with Mary Free Bed Rehabilitation Hospital in order to provide care after
discharge for patients needing additional care.
Strategic Situation
Bronson currently is in an enviable competitive position. This is because of the wide
array of services that Bronson is able to offer. The organization provides specialty practices in
orthopedics, surgery, and oncology. In addition, Bronson is the regions only level 1 trauma
center, are a primary stroke center, are a chest pain emergency center, contain a birthplace with a
neonatal intensive care unit, and have the areas only childrens hospital. Bronsons nearest
competitors are Trinity Health Corporation, Ascension Health, and Borgess Health Alliance, Inc.
Although BMH already serves a 9 county region and serves a population of over 1
million, they have continued to grow over the past few years. Bronson recently acquired Bronson
Lakeview as well as Bronson Battle Creek Hospital. These mergers have helped Bronson grow
into a large regional health care system serving a much larger patient population.
BMH operates under what it calls the 3 Cs for its corporate strategy. The 3 Cs include
Clinical Excellence, Corporate Effectiveness, and Customer and Service Excellence. These three
Cs allow for BMH to identify the following strategic challenges:
1. Bronson hopes to achieve national best practice performance in clinical outcomes, be
recognized as a safe environment for patients, and use evidence based medicine to
achieve excellent patient outcomes.
2. Bronson wishes to distinguish itself as an employer of choice, be recognized for a culture
of service excellence, and foster a culture of excellence that values diversity while
encouraging teamwork, learning, and innovation.
3. Bronson hopes to provide strong financial performance to allow for capital reinvestment,
growth, and sustainability, partner with physicians, the community, and others to achieve
common objectives, and use the Baldridge Criteria for performance excellence to
improve processes and organizational performance.
Bronson has also identified strategic challenges related to the 3 Cs under which it
operates. Achieving a diverse and high quality workforce in todays healthcare environment is
becoming increasingly difficult. The new generation of nurses, for example, has a documented
high propensity for leaving their positions. In the face of a nursing shortage, it is becoming
difficult to both attract and retain qualified nurses. Maintaining profitable growth is another
example of a challenge that Bronson faces. Due to the affordable care act, decreasing
reimbursement, as well as other payment strategies such as bundled payment, Bronson must look
closely at work processes and patient outcomes to deliver high quality care that is both efficient
and cost effective. Thirdly, meeting patient and family service expectations are a strategic
challenge. Patient and family centeredness is at the core of care provided at Bronson. Customer
satisfaction is now figured into reimbursement and awards and penalties are given based on this
outcome. Bronson must continually grow in this area to ensure that patients and families are
satisfied.
One relevant strategic advantage that BMH has is its senior leadership team and their
ability to put in place forward thinking. This forward thinking is what has allowed Bronson to
achieve level 1 trauma certification, stay within recommended staffing guidelines, survive an in
hospital nursing shortage, create one of the regions only neuro-critical care units, procurement of
Bronson Battle Creek, and still stay profitable. The senior leadership team at Bronson has shown
the ability to prepare for future changes in reimbursement and process changes well before they
are implemented, and helped Bronson to be a leader in healthcare quality.
Bronson Methodist Hospital

Mission- BMH exists to provide excellent, patient centered healthcare to the patients and families that it serves.
Vision- This organization wants to be a national leader in health care quality.
Values- The workforce is expected to act with integrity, provide patient and family centered care, demonstrate
teamwork, pursue evidence driven improvement, pursue continuous education, and demonstrate community
commitment.
Financial
Maximize CMS reimbursement
Decrease un-reimbursed cost
Perspective
Metric- Total cost savings from Medicares
Bundled Payment Program
Customer
Perspective
Internal Business
Perspective
Increase satisfaction with

services.
Decrease preventable
adverse patient events
Decrease readmission rates
Metric- Percentage of
patients that would
recommend Bronson to a
friend or family member.
Metric- Total number of

patients that develop a
hospital acquired pressure
ulcer (HAPU)

unplanned readmissions
Innovation
Operations
Post Sale Services
Include patients and

families in
multidisciplinary rounds
patients and families
that state they were
included in their plan of
care
Learning and
Growth
Perspective
Metric- Total dollars lost to nonreimbursable events
Employee Capabilities
Ensure admission to
appropiate unit of care
Increase volume and

efficiency of post discharge
follow-up

patients admitted to offservice units of care
Metric- Percentage of all

discharged patients who
received a follow-up phone
call within 2 weeks of
discharge
Information Systems
Capabilities
Motivation, Empowerment,
and Alignment Capabilities
Invest in employee
development/ education
(certification, degrees,
tuition assistance, bonus
incentives)
Customize EMR to
meet demands of day to
day processes of all end
users
nurses holding a
bachelors degree or
higher
employees trained on
new technology within
the EMR
Utilize shared
governance structure to
incorporate staff driven
initiatives
Metric- Number of
employee suggestions for
improvement that are
implemented
10
Balanced Scorecard Metrics Table

Perspective
Strategic Objective
Leading
Metric
Lagging
Metric
Financial
Perspective
Total cost savings
from Medicare
Bundled payment
program.
Maximize CMS
Reimbursement
Decrease UnReimbursed Costs
Customer
Perspective
Increase satisfaction with

services
Decrease preventable
adverse patient events
Decrease readmission
rates
Internal
Business
Process
Perspective
Total dollars lost

to nonreimbursable
events.
Percentage of
patients that
would
recommend
Bronson to a
friend or family
member.
Total number of
patients that
develop a hospital
acquired pressure
ulcer (HAPU).
Total number of
unplanned
readmissions.
Why Leading or
Lagging?
This is a lagging metric
because it provides financial
information on past events
with little future orientation
and no predictive power. It
will simply show the effect of
other measures put into place
in other areas to maximize
reimbursement from those
areas participating in bundled
payment.
because it will show after-thefact data on those hospital
acquired events/conditions
that will not be reimbursed by
insurance carriers.
This is a leading metric. The
results of the Press Ganey
survey will be predictive in
nature as it pertains to repeat
customers as well as market
growth. It will show more real
time feedback of how the
hospital is performing in
order to identify and make
needed adjustments.
This is a lagging metric. It is a
reflection of historical data
that is collected after the fact.
It holds no predictive
properties.
This is a lagging metric as it

shows data that is historical
and there is no opportunity to
make changes before the
event in order to influence its
outcome. There are no
predictive properties on
performance here.
Innovation
Include patients and

families in
multidisciplinary
rounds
Percentage of
patients and
families that state
they were
included in their
plan of care

because it shows data from
past events for tracking
purposes. It holds no
predictive value on future
performance.
11
Operations
Ensure admission to
appropiate unit of
care
Total number of
patients admitted
to off-service
units of care

because it shows data from
past events for tracking
purposes. It holds no
predictive value on future
performance.
Post Sale Services
Increase volume and

efficiency of post
discharge follow-up
Learning and
Growth
Perspective
Invest in employee
development/ education
(certification, degrees,
tuition assistance, bonus
incentives)
Information System
Capabilities
Customize EMR to meet
demands of day to day
processes of all end users
Percentage of all
discharged
patients who
received a
follow-up phone
call within 2
weeks of
discharge
This is a leading metric

because it will improve
performance in the discharge
process and have a direct
effect on decreasing
readmission, patient
satisfaction, and ultimately
financial objectives.
Percentage
of nurses
holding a
bachelors
degree or
higher
This is a leading metric.

Hospitals with a larger
population of nurses holding
a bachelors degree or higher
have been shown to have
better patient outcomes. This
will be predictive of patient
outcomes.
Percentage of
employees trained
on new
technology within
the EMR
This is a lagging metric. It is

an after the fact measurement
of employee training. It is not
predictive.
Number of
employee
suggestions for
improvement that
are implemented
This is a lagging metric. It

simply shows the number of
employee suggestions and
holds no predictive value
Motivation,
Empowerment, and
Alignment capabilities
Utilize shared
governance structure
to incorporate staff
driven initiatives
12
Financial Perspective
Financial Metric 1
Metric information
Metric
Strategic Objective
Metric Title
What is the source data?
Maximize CMS reimbursement

Total cost savings from Medicare Bundled payment program.
The data in this metric will come from Bronson Methodist
Hospitals billing and finance department. The billing and finance
department will collect data on cost savings for those patient
populations that are enrolled in Medicare bundled payment
programs and provide trends in reimbursement, penalties, and
incentives.
From how many locations
Data is collected from the 4 units with patient populations
is the source data
participating in Medicares bundled payment initiative. These units
collected?
include the ortho-surgical unit, both inpatient and outpatient
surgery units, as well as the general-surgical unit.
What is the source data
This data will be collected monthly and reported to unit directors
collection frequency?
and managers, as well as the executive team for review.
How is source data inputted The data is inputted by the billing and finance department for each
into the information
patient encounter via ICD-10 codes. Reports are then generated
system?
monthly for review using the financial software for those patients
enrolled in Medicare Bundled Payment Programs.
Which mathematical
Through the bundled payment program, a lump sum is paid to
function is used to
Bronson for services that are bundled. Based on performance for
hierarchically aggregate the these populations, Bronson stands to make money, break even, or
source data? Explain in
lose money depending on the cost to the organization for providing
detail how the calculation
these services. Data will be collected on the cost of providing
takes place.
services vs the lump sum provided by CMS to track performance
and revenue from these patient populations. It is the goal of the
organization to provide better care with less cost through evidence
based practice, collaboration, and excellent outcomes.
What is the numeric
The target for this metric is no less than $2.5 million dollars
TARGET for this metric?
monthly in incentives paid from Medicare through the bundled
payment program.
13
Financial Chart- Metric 1
$2.90
$2.18
$2.30
$2.65
$2.62
$2.24
$2.53
$1.65
$0.80
$1.40
$1.60
$3.50
$3.00
$2.50
$2.00
$1.50
$1.00
$0.50
$0.00
$1.00
Dollars (in Millions)
Total Cost Savings from Medicare

Bundled Payment Program
Month and Year
Financial Metric 2
Metric
Strategic Objective
Metric Title
Metric information
Decrease un-reimbursed cost
Total dollars lost to non-reimbursable events
The source data will come from units self reported events that
qualify as non-reimbursable. There will also be reports run through
the electronic medical record to identify healthcare associated
events that will not be reimbursed. The billing and finance
department will track reimbursement vs. the cost of treating these
events, and provide statements, per unit, of total dollars lost to
such events.
The source data will be collected on all inpatient floors as well as
is the source data
for all outpatient services. Events such as falls, pressure ulcers,
collected?
healthcare acquired pneumonia, healthcare acquired blood stream
infections, and others, will be self reported by units at each
occurrence. This information will be utilized by the billing and
finance department to pull billing statements on un-reimbursed
costs.
Source data will be collected real time in terms of occurrence of
events on each unit. However, financial information will not be
available until billing and reimbursement take place. Therefore,
financial information will be reported monthly via unit reports.
How is source data inputted Data is inputted into the system through incident reports by unit
based personnel involved in the incident. This information will
14
then go to Bronsons Profession Practice Department to track

events and generate reports for leader and unit based review, and
also to the financial department to manually pull billing statements
of effected patients. These reports will become part of every
departments individual unit based scorecard.
Which mathematical
Un-reimbursable events are tracked for every unit and outpatient
function is used to
practice in the Bronson system including 26 units. The billing and
hierarchically aggregate the finance department will be able to acquire the cost of such events
by first identifying the reimbursed amount per patient with an undetail how the calculation
reimbursable event. Subtracted from this data will be the average
takes place.
cost of the event using data from the Agency for Healthcare
Quality and Research (AHRQ). The sum of dollars lost for each
non-reimbursable event will be the data used to generate a monthly
total for non-reimbursed events. Units will also be able to drill
down into which type of event is most prevalent, or most costly, in
order to devise strategies and identify gaps in care.
What is the numeric
The target for this metric no more than $2 million in unreimbursed
hospital events per month.
system?
Financial Chart- Metric 2
$2.50
$2.00
$1.50
$0.00
Month and Year
$1.45
$2.10
$1.20
$2.15
$1.90
$1.40
$1.65
$2.30
$2.18
$1.80
$0.50
$2.20
$1.00
$2.10
Dollars (in Millions)
Total Dollars Lost to NonReimbursable Events
15
Customer Perspective
Customer Metric 1
Metric information
Metric
Strategic Objective
Metric Title

is the source data
collected?
Increase satisfaction with services

Percentage of patients that would recommend Bronson to a friend
or family member.
The source data will come from a partnership with Press Ganey.
This company provides patient experience surveys for the
healthcare industry and provides data and reports to Bronson
Methodist Hospital.
The source data is collected from all 21 nursing units as well as the
19 other ancillary departments.
Surveys are sent out 6 weeks post discharge, or post service, for all
patients receiving care at Bronson Methodist Hospital. The source
data is collected monthly for each of these units and departments
and will be received by the end of the first week of each month.
How is source data inputted Press Ganey will input the data into their information system in
order to generate reports. It is the responsibility of Bronsons
system?
professional practice department to input this data into unit and
service based scorecards for review.
Which mathematical
Total responses to the survey question of Would you recommend
function is used to
Bronson Methodist Hospital to a friend or family member? is
hierarchically aggregate the determined. Next, on a scale of 1-5, 5 being most likely, those
responding either a 4 or a 5 are totaled. This number is then
divided by the total number of responses in order to get the total
takes place.
percentage of those recommending Bronson to friends and/or
family.
What is the numeric
The target for this metric is no less than 92%.
16
Customer Chart- Metric 1
92%
85%
90%
94%
93%
89%
83%
90%
87%
94%
91%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
84%
Percentage
Percentage of Patients that Would

Recommend Bronson to a Friend or
Family Member
Month and Year
Customer Metric 2
Metric information
Metric
Strategic Objective
Metric Title
Decrease preventable adverse patient events

Total number of patients that develop a hospital
acquired pressure ulcer
(HAPU).
The source data will come from unit reported, as well as medical
record generated reports of hospital acquired pressure ulcers.
This source data is collected for all 21 nursing units. Data is
is the source data
collected from each of these units first through self reporting
collected?
through incident reports. In addition, HAPUs that are missed via
self reporting will be caught through a report generated by the
electronic medical record that is reviewed by the wound and
ostomy nurses that are involved with treating and/or
recommending treatment for these ulcers.
The source data will be collected ideally in real time through self
reporting. Reports are run by the wound nurses weekly. A final
report of total HAPUs by unit is run monthly.
How is source data inputted The source data is inputted into the system by front line workers
via self reporting, and also via the wound and ostomy nurse when
system?
a new pressure ulcer is identified. Units will receive a monthly
total on their unit based scorecard after data is inputted onto these
17
scorecards by the nursing professional practice department.

Which mathematical
The aggregate source data is simply a total count of pressure
function is used to
ulcers, that are, hospital acquired during a patients length of stay.
hierarchically aggregate the Occurrence of these ulcers is tracked throughout the month and
totaled at the end of each month. This total is the data that is
reported on each units scorecard.
takes place.
What is the numeric
The target for this metric is no more than 8 HAPUs per month.
Total Number of Patients that Develop a

Hospital Acquired Pressure Ulcer (HAPU)
12
10
8
6
12
10
11
12
Monthly total of HAPU's
14
Month and Year
Customer Metric 3
Metric information
Metric
Strategic Objective
Metric Title
Decrease preventable adverse patient events

Total number of unplanned readmissions.
The source data is the number of patients that are readmitted
within 30 days after discharge from the hospital that are not
planned readmissions. These readmissions are only counted if they
are identified as being related to the patients previous admission.
Those that are not will be excluded.
18

is the source data
collected?
This source data is collected for all 21 nursing units at Bronson

Methodist Hospital. This data will be collected by the billing and
finance department. The question of have you been admitted to
the hospital within the previous 30 days will be asked on all
admission screens for every patient admitted to Bronson. This will
flag the system to include, or exclude, patients in the report.
The source data will be collected monthly.

How is source data inputted Source data is inputted into the information system through
automatic posting. The answer to the admission screen question
system?
will flag a patient to either be included, or excluded from the
reports generated by the electronic medical record. These reports
will go directly to the executive team as well as unit managers and
directors.
Which mathematical
This data is a total count of those patients being readmitted within
function is used to
30 days after discharge. The medical record will automatically
hierarchically aggregate the generate this report monthly as a result of patients being flagged
by the system from the admission screen question.
takes place.
What is the numeric
The target for this metric is no more than 35 patients per month
Total Number of Unplanned Readmissions

50
40
35
30
25
20
15
Month and Year
36
31
45
43
35
31
37
43
29
32
42
10
39
Number of Patients
45
19
Internal Business Process

Innovation Metric
Metric information
Metric
Strategic Objective
Metric Title

is the source data
collected?
Include patients and families in multidisciplinary rounds

Percentage of patients and families that state they were included in
their plan of care
This data will be collected from the Press Ganey generated survey
results. The question of interest is Were you included in your plan
of care through involvement in physician rounds?. Survey
responses of Always would be included in this metric.
Locations for this data would include all 21 inpatient nursing units.
Surveys are sent out 6 weeks post discharge, or post service, for all
patients receiving care at Bronson Methodist Hospital. The source
data is collected monthly for each of these units and departments
and will be received by the end of the first week of each month.
How is source data inputted Press Ganey will input the data into their information system in
order to generate reports. It is the responsibility of Bronsons
system?
professional practice department to input this data into unit and
service based scorecards for review.
Which mathematical
The response of Always will be tallied for the question of Were
function is used to
you included in your plan of care through involvement in
hierarchically aggregate the physician rounds?. This number would be divided by the total
responses received for this survey question.
takes place.
What is the numeric
The target for this metric is no less than 82%
20
Internal Business Process Chart- Innovation Metric
76%
82%
85%
84%
78%
72%
83%
81%
79%
71%
68%
100%
80%
60%
40%
20%
0%
72%
Percentage
Percentage of patients and families

that state they were included in their
plan of care
Month and Year
Operations Metric
Metric information
Metric
Strategic Objective
Metric Title

is the source data
collected?
Ensure admission to appropiate unit of care

Total number of patients admitted to off-service units of care
The source data is the number of patients admitted to off -service
units. Off service units are defined as being a unit that does not
specialize in the type of diagnosis the patient is admitted to treat.
An example would be a Cardiology patient going to the General
Surgical floor.
This source data is collected from all 21 inpatient units.
The source data is collected daily. Although it is collected daily, it

is reported out in monthly reports. However, the end user of this
data does have the capability to drill down into weekly, as well as
daily, measures if needed
How is source data inputted Source data is already inputted into the system, at each admission,
by the house supervisor for every admission into the hospital. The
system?
epic, who builds audits and reports within the medical record
system, has the capability to build a report that will screen
admissions against their diagnosis code in order to automatically
generate reports.

Which mathematical
function is used to
hierarchically aggregate the
takes place.
What is the numeric
21
The data used in this metric is simply a monthly sum of all patients
whose diagnosis code is not consistent with the unit to which they
are admitted.
The target for this metric is no more than 32 patients a month.
Internal Business Process Chart- Operations Metric
39
37
30
34
41
52
38
36
29
31
45
60
50
40
30
20
10
0
42
Number of Patients
Total number of patients admitted to

off-service units of care
Month and Year
Post Sale Services Metric

Metric information
Metric
Strategic Objective
Metric Title
Increase volume and efficiency of post discharge follow-up

Percentage of all discharged patients who received a follow-up
phone call within 2 weeks of discharge
The source data is the total number of patients that receive a
follow up call from a nurse navigator within 2 weeks of discharge
All 21 inpatient units have a nurse navigator. These 21 inpatient

is the source data
collected?
How is source data inputted
system?
22
units are the locations that will be used for source data collection.
The source data collection frequency is monthly.
The source data is inputted into the system by the nurse navigators
that are making the phone calls by hand. For each phone call, they
will fill out the follow-up phone call spreadsheet that is located in
a shared H:drive on the computer system.
Which mathematical
The nursing professional practice committee will handle
function is used to
combining the information from the 21 spreadsheets, and
hierarchically aggregate the combining it into a monthly report. This monthly report will
consist of the total sum of follow-up phone calls made for the 21
inpatient units divided by the total number of discharges to get the
takes place.
percentage.
What is the numeric
The target for this metric is no less than 75%
Internal Business Process Chart- Post Sale Services
Month and Year
70%
72%
77%
73%
68%
76%
74%
67%
71%
65%
62%
100%
80%
60%
40%
20%
0%
51%
Percentage of Patients
Percentage of all discharged patients

who received a follow-up phone call
within 2 weeks of discharge
23
Learning and Growth

Metric information
Metric
Strategic Objective
Metric Title
Invest in employee development/ education (certification, degrees,

tuition assistance, bonus incentives)
Percentage of nurses holding a bachelors degree or higher
The source data is from the employee records kept in the Human
Resources department.
The source data will come from all 21 inpatient units that employ
registered nurses, as well as the 14 ancillary departments with RN
FTEs.
The source data collection frequency will be monthly.

is the source data
collected?
How is source data inputted The source data is inputted into the system by HR representatives
whenever an RN is hired. This system is then updated by HR
system?
whenever an employee enrolls in or graduates from an institution
with a higher degree.
Which mathematical
This data is a percentage of the entire pool of RNs at BMH that
function is used to
hold a bachelors degree or higher in nursing. The total number of
hierarchically aggregate the RNs meeting this criteria within the HR system will be divided by
the total number of RNs employed at BMH to give the final
percentage of those that have a bachelors degree or higher.
takes place.
What is the numeric
The target for this metric is 90%
24
Learning and Growth Perspective Chart- Employee Capabilities Metric
100%
80%
60%
88%
86%
82%
83%
81%
79%
74%
76%
73%
71%
20%
64%
40%
62%
Percentage of Nurses
Percentage of Nurses Holding a

Bachelor's Degree or Higher
0%
Month and Year
Information System Capabilities

Metric information
Metric
Strategic Objective
Metric Title
is the source data
collected?
system?
Customize EMR to meet demands of day to day processes of all

end users
Percentage of employees trained on new technology within the
EMR
The source data is from training sign in sheets that are under the
control of the education department at BMH.
The source data is collected from all 21 inpatient units, as well as
the 18 ancillary departments that use the Epic EMR
The source data collection frequency is after each monthly training

session.
Source data is inputted manually into the tracking system, Net
Learning, that Bronson uses to track employee education. This will
show on employee transcripts and allow for a report to be
generated specific to these training sessions.
Which mathematical
This metric is a percentage of all Bronson employees that use the
function is used to
Epic EMR that have completed monthly training sessions. This
hierarchically aggregate the metric is derived from taking the number of those employees
completing training and dividing it by the total number of
employees that use the Epic system.

takes place.
What is the numeric
25
The target for this metric is 100% by December 2016
Learning and Growth Perspective Chart- Information System Capabilities Metric
100%
80%
60%
86%
81%
79%
74%
76%
71%
67%
70%
72%
70%
20%
67%
40%
65%
Percentage of Employees
Percentage of Employees Trained on

new Technology within the EMR
0%
Month and Year
Motivation, Empowerment, and Alignment Capabilities

Metric information
Metric
Strategic Objective
Metric Title
is the source data
collected?
system?
Utilize shared governance structure to incorporate staff driven

initiatives
Number of employee suggestions for improvement that are
implemented
The number of suggestions that are implemented throughout the
Bronson System
This data is collected from all 21 inpatient units, as well as the 19
other ancillary departments within BMH.
The source data collection frequency is bi-monthly.
The source data is inputted into the system by Unit managers in to
the master excel spreadsheet that is the property of the executive
team.

Which mathematical
function is used to
hierarchically aggregate the
takes place.
What is the numeric
26
This metric is simply the total sum of suggestions that come from
front line employees that are implemented for improvement
purposes.
The target for this metric is 10 per 2 month period.
Learning and Growth Perspective Chart- Motivation, Empowerment, and Alignment Capabilities
Month(s) and Year
10
8
6
4
2
0
Number of Suggestions
Number of Employee Suggestions for

Improvement that are Implemented

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MMBA 612- Reidenbach

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MMBA 612- Reidenbach

Mission, Vision, and Values

Mission- BMH exists to provide excellent, patient centered healthcare to the

Vision-This organization wants to be a national leader in health care quality.

Core competencies of BMH include the following:

patient and family centeredness

dignity and respect

participation and collaboration

information sharing in daily practice

MMBA 612- Reidenbach

MMBA 612- Reidenbach

MMBA 612- Reidenbach

MMBA 612- Reidenbach

MMBA 612- Reidenbach

MMBA 612- Reidenbach

Bronson Methodist Hospital

Increase satisfaction with

Decrease readmission rates

Metric- Total number of

Metric- Total number of

Post Sale Services

Include patients and

Metric- Total dollars lost to nonreimbursable events

Increase volume and

Metric- Total number of

Metric- Percentage of all

MMBA 612- Reidenbach

Balanced Scorecard Metrics Table

Decrease UnReimbursed Costs

Increase satisfaction with

Total dollars lost

This is a lagging metric as it

Include patients and

This is a lagging metric

MMBA 612- Reidenbach

This is a lagging metric

Post Sale Services

Increase volume and

This is a leading metric

This is a leading metric.

This is a lagging metric. It is

This is a lagging metric. It

MMBA 612- Reidenbach

Maximize CMS reimbursement

MMBA 612- Reidenbach

Financial Chart- Metric 1

Dollars (in Millions)

Total Cost Savings from Medicare

Month and Year

MMBA 612- Reidenbach

then go to Bronsons Profession Practice Department to track

Financial Chart- Metric 2

Month and Year

Dollars (in Millions)

Total Dollars Lost to NonReimbursable Events

MMBA 612- Reidenbach

What is the source data?

From how many locations

Increase satisfaction with services

MMBA 612- Reidenbach