Winona Health Accomplishments 2008

2008 Key Initiatives WINONA HEALTH-WINONA CLINIC MERGER Goal: Integrate Winona Health and Winona Clinic processes to achieve the shared goals of improved community access to healthcare, successful physician recruitment and growth in healthcare services On January 1, 2008, Winona Health and Winona Clinic merged, creating a unified organizational structure. Since then, several support departments have integrated, including clinic billing, transcription, credentialing and switchboard services, and others are working on integration, including laboratory services. In addition, both organizations continue to focus on improving systems to benefit patients, as demonstrated by combining clinic patient registration and check-in processes. Most importantly, the merged health system has recruited a record number of providers in 2008, including physicians, nurse practitioners and physician assistants. Adding these new providers allowed for expansion of hours in the Urgent Care Clinic and additional appointment availability in Family Practice, Pediatrics, Internal Medicine and the Center for Women’s Health. COMPUTERIZED PROVIDER ORDER ENTRY (CPOE) Goal: Deploy fully Computerized Provider Order Entry (CPOE) in all Community Memorial Hospital (CMH) clinical departments A team of physicians, nurses and other healthcare providers worked throughout the year to deploy CPOE in all CMH departments, after its successful pilot in the Emergency Department last year. Nationwide, only 5% of all hospitals have implemented CPOE, which creates a safer, more reliable healthcare system by standardizing orders around best practices and eliminating steps in the ordering process. It also eliminates potential errors that result from transcribing providers’ written orders. As part of its work, the CPOE Team created 192 standard order sets for patients with specific conditions and 14 alerts reminding providers of important steps within an order or warning them of potential complications. The team’s goal was to have 80% of all hospital provider orders submitted electronically; thanks to 100% participation by the medical staff, this goal was exceeded.

Cornerstone #1:

Customer Focus Strategic Objective #1: Anticipate and exceed patient and resident needs and expectations • Based on customer feedback, Winona Health will move to a new paper satisfaction survey in 2009 for its clinics, hospital and senior services. • Lake Winona Manor received its second consecutive 5-Star rating -- the highest given -- from the Minnesota Department of Health’s Nursing Home Report Card, which surveys long-term care residents about their satisfaction with services. • Assisted living residents and their families were 100% satisfied with overall services received at Watkins, Adith Miller and Roger Metz Manors. • Winona Health Home Care patients rated their overall satisfaction with services at 92.7%.; with nurses, 91%; home health aides, 96%; therapy, 97%; and comfort at home, 100%. • Community Memorial Hospital patients rated the respect and courtesy shown by their physicians at 96.37%, better than the peer group rating of 93.07%. Outpatient Surgery patients rated their doctors’ care at 86.34%, with the peer score at 81.64%; Emergency Department patients rated their physician care at 76.2%, compared to the peer score of 70.01%. • The Emergency Department received top performer scores in nine categories, including overall quality, sensitivity to patient needs, patient involvement in care and nurse communications. • The Outpatient Surgery Department was ranked a top performer in 16 of 23 patient satisfaction categories, including overall quality, wait times, pain management, patient-centeredness and nurse and provider overall ratings. • Overall patient satisfaction in the hospital’s Behavioral Health unit was a 2.69 on a 3-point scale. • Ninety percent of dialysis patients rated their care as very good or excellent, up from 85% in 2007. • Physical/Occupational Therapy patients rate their satisfaction with quality of care and obtaining results at the 90th percentile. Cardiac Rehab patients rate their satisfaction as “excellent.” • Community Memorial Hospital’s Room Service staff achieved a 96% satisfaction score for their food and service delivery. One patient commented, “I’d rate the food a 10. Better than a café or restaurant!” • A Valet and Guest Services program was launched in 2008 at the south clinic entrance. In its first year, staff greeted more than 335,000 patients and visitors, assisted 44,000 and transported 1,900 people, and parked more than 2,700 cars. • More Winona Health customers turned to its website, which had a 59.9% increase in unique visitors from 2007 to 2008 and a 46% increase in visits. • Winona Health chaplains initiated a No One Dies Alone program that provides a volunteer companion for patients and residents nearing the end of life. • Lake Winona Manor expanded, relocated and redecorated its Transitional Care Unit, which now accommodates 38 residents -- 17 more than previously. It also expanded its rehabilitation gym. • Lake Winona Manor decentralized its social workers and therapeutic recreation staff, moving them closer to the residents, and added weekend and evening programming. • Winona Health now offers a driver assessment service, thanks to a grant from the Winona Health Foundation’s Quality & Excellence Program.

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Pediatrician Craig Anderson, MD, interacts with Patrick, 15 months, during a well-baby exam in the Pediatric/Adolescent Medicine Department at Winona Clinic. Dr. Anderson joined Winona Health’s medical team in 2008.

• The Assisted Living staff adopted the Minnesota Health & Housing Association’s Code of Ethics and Guiding Principles for Dementia Care. • The Winona Clinic simplified its registration and check-in processes by relocating them to the departments where a patient is seen. This change benefitted more than 48,000 patient visits in the first six months. • With support from 17 community partners, Healthy Kids Club, designed for children ages 6-11, completed its first year with the following impact: - 693 Wellness Journals were given to area children thanks to funding from the Winona Health Foundation. - Three special events attended by about 625 individuals promoted children’s health and wellness, while providing resources for parents. - Chris Stoltman, registered dietitian, coordinated an “In the Kitchen with Healthy Kids Club” class with Winona Volunteer Services, showing children and their families healthy and easy tips to make more nutritious meals. • The second annual Winona Health Celebrates Women provided a fun-filled, educational morning for approximately 100 area women. Strategic Objective #2: Achieve strategic unity with community and tertiary providers • Winona Clinic and Winona Health fully integrated their Human Resources departments and their provider credentialing, transcription, switchboard and clinic billing systems. • Urgent Care services were expanded at the Sarnia Square location, providing care to more than 18,000 patients and exceeding previous year visits by 564%. • Winona Health Hospice Services increased its average daily census from 21 patients in 2007 to more than 30 in 2008. • Community Memorial Hospital’s market share for primary cases grew to almost 70% -- an 11% increase in five years. In the 55987 zip code area, CMH has a 74% market share for primary cases, a 12% increase in five years.

• Winona State University Student Health Services implemented Winona Health’s electronic medical record, so students’ health records and tests are available online at the campus and in clinics and the hospital. • Staff completed the re-credentialing process for Winona Health physicians and other providers, verifying their educational, licensure and board certifications and reviewing their quality results. At the end of fiscal year 2008, Winona Health’s medical staff included: - 40 physicians on its “active” medical staff (current practicing). - 6 on its “honorary” staff (retired physicians). - 62 on its “clinical” staff (physician assistants, nurse practitioners, certified registered nurse anesthetists and surgical assistants). - 179 on the “courtesy” staff (physicians, podiatrists, dentists and others who are qualified for membership but make only limited use of the hospital). • Winona Health recruited a record number of new providers in 2008, including: - Craig Anderson, MD, Pediatrics - Angela Fink, NP, Urgent Care Clinic - Holly Fratzke, NP, Center for Women’s Health - Mary Funk, NP, Long-term Care - Bob Giese, PA-C, Urgent Care Clinic - Howard Gorder, PA-C, Urgent Care Clinic - David Lofgren, MD, Family Practice - Nicholas Modjeski, MD, Family Practice - starting Fall, 2009 - Douglas Orlich, OD, Eye Care Center - Scott Pastryk, OD, Eye Care Center - Sima Rad, MD, Emergency Medicine - Bryan Reed, DO, Internal Medicine - Elie Richa, MD, Hospitalist - Susan Smith, NP, Urgent Care Clinic - Tara Suffrins, NP, Center for Women’s Health - Kevin Vanderveen, MD, Emergency Medicine - Hans Zinnecker, MD, General Surgery - starting January, 2009

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Cornerstone #2:

People

Strategic Objective #3: Become the employer of choice for top regional talent • Winona Health’s staff increased by 30% in 2008, both from the Winona Clinic merger and from other service growth. • Continued efforts to reduce musculoskeletal injuries led to a 15% decrease in injuries. • The health system decreased its staffing vacancy rate by 60% from 2007 to 2008 or from 5.7% to 2.57%. • More than 81% of staff participated in the 2008 Employee Pride Survey, with overall satisfaction increasing for the third consecutive survey. • Winona Health’s self-insurance program introduced an account-based plan, resulting in about 70% of all plan dollars being spent locally, a 10% increase. • The Winona Health University Leadership Academy was launched, providing management team educational programming on key organizational processes. • Integration of Employee Health with Occupational Health Services was begun. • Winona Health physicians now have a “one stop shop” for needed materials, thanks to a medical staff Intranet site deployed this year. • Winona Health continues its Malcolm Baldrige quality improvement journey: Brian Zmolek and Mary Miller-Hyland completed national examiner training, while Kathleen Lanik and Loretta Bronson completed Minnesota Council for Quality examiner training. Rachelle Schultz completed training and serves as a judge for the Minnesota Quality Award. • Five Winona Health employees were selected by their peers to receive Living Service Excellence Awards in 2008: - Barb Kujak, Environmental Services - Corrie Searles, Rehabilitation Services - Autumn Herber, Volunteer Services - Xaisoua Xiong, Environmental Services - Donna Hoffman, Lake Winona Manor

• Winona Health staff were recognized for their special skills and talents throughout 2008, including: - Autumn Herber, volunteer coordinator, received the Heart of Minnesota Award from the Healthcare Auxiliary of Minnesota. - Kathy Redig and Bill Flesch, chaplains, presented their work on Godly Play at the Minnesota Homes and Housing Alliance annual Institute. - Ryan Goergen, Materials Management, presented on Winona Health’s Lean supply efforts at the Cerner national conference. - Kathleen Lanik, chief quality and safety officer, spoke about Winona Health’s use of the Baldrige quality framework at a meeting of the Rochester Area Quality Council. She and Brian Zmolek, director of quality resources, presented Winona Health’s quality journey at the Minnesota Quality Award conference. - Frank A. Bures, MD, is a four-time recipient of the Minnesota Medical Association’s Physician Communicator Award for his weekly newspaper column, Healthful Hints. - Michal Roskos, Health Information Management Department, was recognized by the United States Consumer Product Safety Commission for outstanding work in providing vital product safety information extracted from our patient database. - Ruth Moes, MD, and Loretta Boyer, RN, worked with Institute for Clinical Systems Improvement teams on pre-operative evaluation protocols and skin safety, respectively. - Rachelle Schultz, president/CEO, was named to the Institute for Clinical Systems Improvement Board of Directors and was invited by Gov. Tim Pawlenty to participate in the AcademyHealth and Commonwealth Fund’s State Quality Improvement Institute. • Winona Health staff strengthened their work-related skills by receiving advanced degrees and certifications in 2008, including: - Satya Gorty, MD, anesthesiologist, passed his oral examinations and is now board-certified by the American Society of Anesthesiologists. - Shawn Delton and Jody Doebbert, RNs, Emergency Department, received Certification as Emergency Nurses (CEN). - Rita Nesler, Jane Dittrich and Cindy Byerly, RNs, Intensive Care Unit, received Critical Care certification, earning the credentials CCRN. - Heidi Ferris, RD, CDE, achieved re-certification by the National Certification Board for Diabetes Educators. - Julie Gregory, Rehab, obtained certification as a Pilates instructor. - Brianna Frisch, Rehab, completed certification as an Advanced Clinical Instructor. - Jennifer Carpenter, Marketing, completed her Master’s in Educational Leadership. - Cheryl Krage and Jennifer Ready, Assisted Living, became site surveyors for the Minnesota Health & Housing Alliance’s Confident Choices Program. - Lynn Sprain, Cardiac Rehab, received certification as an Exercise Physiologist.

Each year during National Hospital and Long-term Care Week, Winona Health recognizes some of its outstanding employees. These employees (pictured) were selected by their peers to receive Service Excellence Awards in 2008: Back row, L-R: Barb Kujak, Environmental Services; Corrie Searles, Rehabilitation Services; Autumn Herber, Volunteer Services. Front row, L-R: Xaisoua Xiong, Environmental Services; Donna Hoffman, Adith Miller Manor.

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Community Memorial Hospital received a Minnesota Hospital Association Patient Safety Excellence Award for prevention of patient falls. Winona Health’s Safe from Falls Team includes, from left to right: Joann Tingum, nursing assistant; Robin Hoeg, RN, MS, director of Inpatient Services; Jodi Haag, LPN; Judy Bunke, RN; Beth Krage, nursing assistant; Missy Barnholtz, administrative assistant of Inpatient Services; and Elizabeth Burns, physical therapist. Not pictured: Kathy Green-Kaminsky, RN.

Cornerstone #3:

Care and Service Strategic Objective #4: Use integrated systems, lean principles and technology to achieve optimum clinical outcomes and operational efficiencies • Computerized Provider Order Entry (CPOE) was deployed throughout Community Memorial Hospital, ensuring better patient outcomes by standardizing physician orders around best practices. More than 80% of all hospital orders were submitted electronically in the first weeks after its launch. • Winona Health is one of 3,700 hospitals nationwide participating in the Institute for Healthcare Improvement’s 5 Million Lives campaign, whose goal is to protect patients from incidents of medical harm. Winona Health participates in all six initiatives, with the following results: - Prevent Harm from High-Alert Medications - 0 incidents - Reduce Surgical Complications - 97% compliance rate; top 20% in nation - Prevent Pressure Ulcers - fewer than 1% of hospital patients develop ulcers, better than the best-in-class rate of 2.3% - Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) Infections - met national goal to reduce transmission, lowering the rate from 0.65% to 0.32% in one year - Deliver Reliable, Evidence-based Care for Congestive Heart Failure - 89.5% compliance rate; top 20% in the nation - Get Boards on Board - Quality & Safety Committee of the Board actively engaged in monitoring clinical quality and safety metrics

• Winona Clinic was recognized by the MN Community Measurement (MNCM) as a “high performing clinic” for its care of cardiovascular patients. MNCM also recognized the clinic for showing “the greatest improvement over the last five years” in breast cancer screenings. • Winona Health Physician Clinics established best practice targets for treating patients with chronic diseases: In the first three quarters of 2008, asthma and hypertension targets were exceeded in every quarter, while diabetes was exceeded in two quarters. The clinics bi-annual audit for best practice preventive care showed all three screenings -- breast cancer, cervical cancer and colon cancer -exceeded targets. • Winona Health’s Home Care services ranked in the 89th percentile compared to others in the state on national quality measures. • A Palliative Care program was piloted in Lake Winona Manor, which also received one of ten grants from Stratis Health to bring palliative care programs to rural communities. Palliative Care offers patients living with chronic and incurable conditions better relief from their symptoms. • A new protocol was developed and deployed that standardizes the approach to Patient Controlled Analgesia. This new protocol enhances safety for patients receiving intravenous narcotics. • Ninety-six percent of Winona Health dialysis patients receive adequate dialysis treatments, 11% points better than the best practice benchmark of 85%.

• Lake Winona Manor exceeded all of its quality improvement goals reported on the National Nursing Home Star Network. LWM monitors its measures related to • Community Memorial Hospital was named a top performer in a Center for Medicare pressure ulcers, depression, chronic care pain and three other items. & Medicaid Services-Premier project that rewards hospitals for delivering high • Lake Winona Manor had an excellent Minnesota Department of Health survey, quality care. Based on third-year results, CMH ranked in the top 10% for overall receiving only five minor citations that were corrected immediately. quality for heart attack patients and in the top 20% in caring for Congestive Heart Failure patients. • Winona Clinic’s Internal Medicine Department is piloting a Pre-Visit Planning • The Minnesota Department of Health completed its survey of Community Memorial program for patients with diabetes, ensuring they leave each appointment with the tests needed and self-management recommendations to adopt before the next Hospital, noting only two minor deficiencies -- that were quickly corrected -- out of physician visit. 478 items.

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• The electronic STEP form was launched, offering a more efficient way to gather and access quality improvement ideas from staff. In the first month, 223 STEP Opportunity Statements were submitted, almost equivalent to all those submitted in the previous year. • Health Information Management staff have decreased turnaround time for emergency dictations from two hours to less than 15 minutes. For all services, they decreased turnaround from 24 hours to less than eight hours. • Winona Health garnered numerous awards and honors in 2008, including: - Most Wired-Small & Rural Hospitals Award from Hospitals & Health Networks. - Patient Safety Excellence Awards for prevention of falls and prevention of pressure ulcers from the Minnesota Hospital Association (MHA). - MHA’s Patient Safety Improvement Award for its efforts to prevent pressure ulcers. - Minnesota Quality Award - Achievement Level from the Minnesota Council for Quality. - The Minnesota Bridges to Excellence Award to Winona and Lewiston Clinics for optimal care of patients with diabetes and cardiovascular disease. - Top 25% Home Care Agency recognition from HomeCare Elite, which compiles a list of the most successful Medicare-certified home healthcare providers in the U.S. based on quality outcomes, quality improvement and financial performance. - Recognition from EnhanceMed as having a best practice for training new providers in the Emergency Department. - Best in Class designation from Dictaphone for Health Information Management’s use of speech recognition protocols. HIM reached 90% speech recognition proficiency, with a targeted goal of 60%. - The American Diabetes Association’s Education Recognition Certificate for Winona Health’s Diabetes Education Program geared to patient self-management. - Quality Respiratory Care Recognition for Community Memorial Hospital’s respiratory care services. - Blue Cross/Blue Shield of Minnesota’s Recognizing Excellence program praised Winona Clinic for its provision of quality care to its cardiovascular patients.

- The American Hospital Association published a feature article on Winona Health’s response to the 2007 flooding. - A special article on Winona Health’s Valet Services staff was published in HeartBeat magazine, Sodexo’s national staff publication. - A case study was published by Actuate Corporation about Winona Health’s use of technology to track performance excellence. - Rachelle Schultz, President/CEO, was interviewed for a story on how Winona Health uses technology to improve efficiency; this case study was published in Exec-Digital. - An American Hospital Association article was published on Winona Health’s collaborative agreement to provide around-the-clock psychiatric coverage.

Cornerstone #4:

Stewardship Strategic Objective #5: Maintain an independent, locally controlled, community healthcare system • The Winona Health-Winona Clinic merger was completed, with the clinic budget incorporated into the Winona Health operating budget in fiscal year 2008. • Operating expenses were within 2% of budget for the sixth consecutive year. • Winona Health opened its Urgent Care Clinic seven days a week based on customer feedback. This service level change saved community members about $500,000 in medical expenses by switching from emergency department care to clinic services. • Community Memorial Hospital’s Laboratory, Dialysis Department, Physical Therapy and CT Scans all showed volume growth in 2008.

• As part of its commitment to the community, Winona Health: - Provided free screening and medical information at eight community • Winona Health staff and services received local, state and national media coverage health fairs. in 2008, including: - Conducted nine free depression screenings and 126 prostate cancer screenings. - A PBS NewsHour with Jim Lehrer feature segment broadcast on National Public - Held an open house for community members to showcase services at Sarnia Television for the health system’s unique advancements in its community-wide, Square. Free blood pressure and glucose checks were available. integrated electronic medical record. - Shared information with 544 students through high school career fairs and - Healthcare Financial Management magazine interviewed Mike Allen, CFO, for an field trips. article on financial management in healthcare systems in an ever-changing - Spoke to approximately 593 community members as part of our Speakers world. Bureau.

PBS NewsHour health correspondent, Susan Dentzer (left), with her PBS news team and Winona resident Richard Etnier. The PBS NewsHour team was in Winona in March to tell the story of healthcare providers in Winona collaborating to use technology to streamline processes, improve healthcare quality and safety and help people manage their health. The story is available on the Winona Health website: winonahealth.org/pbs.

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The Winona Health Auxiliary’s Fabulous Fifties Follies helped raise $31,000 toward replacing dialysis machines in Community Memorial Hospital’s Dialysis Department. The performance featured a cast and crew of more than 90 volunteers, community members and Winona Health staff.

- Served on the committee to bring activities to the Winona Community Center for parents and their children living in low income neighborhoods. Monthly programming started in September, with more than 35 children attending a free “healthy snack” presentation. - Offered seven free Community Health Talks on topics such as eye health, dementia and breast cancer. A total of 154 people attended these educational sessions. - Exceeded its $22,500 fundraising goal for the Greater Winona Area United Way. - Supported Ten Days of Giving, Gifts for Winona and the American Cancer Society’s Daffodil Sales. - Served as a training site for Winona State University and Minnesota State College - Southeast Technical students as they learned about nursing, radiology, sports medicine and social work.

• The Winona Health Foundation awarded $21,200 through its Community Engagement Grant program, including $12,000 to sustain the MediAppS program at Catholic Charities.

• The Winona Health Auxiliary gifted $52,834 to Winona Health for patient overhead lift systems, flood relief items for Lake Winona, Adith Miller and Roger Metz Manors. In addition, $20,000 were awarded in scholarships to 21 healthcare students, totaling $72,834 in Auxiliary gifts.

• The Winona Health Foundation assisted 254 Rushford residents affected by the August 2007 flood with their medical bills via a grant from the Medtronic Foundation. The Ben & Adith Miller Patient Care Fund also assisted flood victims.

• The Winona Health Auxiliary’s 389 volunteers contributed a total of 30,419 hours -or $570,964 of service -- to Winona Health. Five volunteers contributed more than 500 hours in the last year: Dana Jonsgaard, Mary Brenno, Jan Wanek, Jenny Kahl and Marlene Mulrooney. Seven volunteers have contributed a cumulative total of 5,000 or more hours: Jenny Kahl (9600 hours), Haryette Newman (9500 hours), Jan Wanek (6400 hours), Diane Barge (6400 hours), Carole Forest (5800 hours), Mary Brenno (5400 hours) and Grace Miner (5300 hours).

• In 2008, 100% of the Winona Health Foundation Board, the Winona Health Board and the Winona Health Senior Leadership Team contributed to the Winona Health Foundation. Ninety-six percent of the 26 directors contributed.

• The Auxiliary conducted several successful events in 2008: Its third annual Garage Sale raised more than $11,000; the Used Book Sale, Victorian Tea, $5 Jewelry Sale and Birthday Ball all raised record-breaking amounts.

• The Winona Health Foundation awarded $13,819 through its competitive Quality & Excellence Grant program, which awards grants to Winona Health staff projects: - Cardiac Rehabilitation received funding for an audio-headphone system to improve patient education. - Physical Therapy received funding for enhanced Pilates equipment and expanded patient education software. - The hospital’s Medical/Surgical patients’ laptop program was funded. - The Department of Behavioral Medicine received funding for a program that engages patients in work-related activities. - Watkins Manor received a Wii game console for resident use.

• Individuals, families and businesses contributed more than $2.1 million to the Winona Health Foundation in 2008.

• The number of staff contributing to the Winona Health Foundation’s Family Giving Campaign tripled in 2008, with 184 -- 15.5% -- making a donation. Their collective gifts and pledges totaled more than $22,300. • Sixty-three Winona Health employees were recognized by patients and families during the first year of the Foundation’s Guardian Angel program.

• The Ben & Adith Miller Classic golf tournament raised $170,000 for the Ben & Adith Miller Patient Care Fund, a $5,000 increase over 2007. The fund covered $744,377 of medical expenses for 294 patients in 2008.

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2009 Key Initiatives PATIENT/RESIDENT SATISFACTION Goal: Strengthen satisfaction scores throughout Winona Health to ensure a positive patient/resident experience in all services -- clinics, hospital, ambulatory and senior services Target: Achieve 80th percentile ranking in an index created for all service lines by the end of 2009

DOCUMENTATION/CODING Goal: Strengthen the capture and communication of our patient/resident health issues by using technology and training to improve clinical documentation and coding processes that align with industry best practices. Target: Align 75% of identified measures with industry best practices

PROVIDER-BASED BILLING Goal: Reorganize Winona Health's legal entities, clinical and business processes, ultimately simplifying patient/resident bills and improving patient/resident-centered care Target: Achieve 100% reorganization by the end of 2009

Community Memorial Hospital ~ Winona Senior Services ~ Physician Clinics Parkview Pharmacy ~ Winona Health Foundation 855 Mankato Avenue ~ Winona, Minnesota 507.454.3650 ~ winonahealth.org