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Quality and Experience Pillars

Creating an inspiring place to work, practice, and receive care.

Addressing High-Impact Areas of Opportunity

Objectives

1a. Evaluate Opportunity and Need for Surgical Journey Technology

1b. Hire PX Data Analyst

1c. Analyze Facility Environment for Improvements Across the First Floor

1d. Customer Service and Training Collaboration with Billing/Registration

1e. Integrate Family/Patient Into Care Delivery/Quality Improvement Projects

1f. Re-Imagine Experience Department Roles, Duties, and Impact on both Patient and Families

1g. Evaluate and Enhance PX Recognition Programs

1h. Collaborate with Growth Pillar on Urgent Care PX Initiatives and Journey Mapping

Metrics

Hardwire Service Excellence & Sustain a Culture of High Performance

Objectives

2a. LEM Accountability Project

2b. Enhance Leadership Development Institutes with Education to Equip Leaders with Skills for Success

2c. Collaborate with People and Growth to Review and Improve Communication Around Vision, Values, Pillars, and Strategic Objectives Across the Organization

Metrics

Promote an Organization of Continuous Well-being, Volunteerism, and Engagement

Objectives

3a. Launch EAC Evaluation Survey for Feedback

3b. Enhance Wellness Committee Offerings

3c. Partner with Marketing for EAC/Wellness Collaboration on MCH Events

3d. Collaborate to Enhance Volunteer Program in Alignment with System Experience Initiatives

3e. Expand Caring Paws Program

Metrics

Integrated Healthcare Delivery System

Objectives

4a. Continued CDI/Coding Collaboration for Best Practice and Physician Education / Implementation Billing Hold

4b. Identify and Educate on Mortality Trends

4c. Compliance with CMS IPPS 2025 Final Rule

4d. Enhance Navigator Program

4e. Increase Transparency, Discipline Collaboration and Patient Safety with Patient Electronic Care Boards

4f. Relaunch and Re-Brand MCH Alignment Room and Project Prioritization

4g. Build and Trend Reports Around Non-Medical Drivers of Health

4h. Launch Organization Wide Safety Huddle

Metrics

Just Culture

Objectives

5a. Analyze and Disseminate Safety Survey Results

5b. Increase Safety Rounds (Focus: CAUTI, CLABSI, Falls)

Metrics

Survey Ready Culture

Objectives

6a. Grow Internal Audit Program

6b. Enhance Hospital Risk Program Process

6c. ISO Education

6d. Refine QMS/QMR

Metrics

Best Practices

Objectives

7a. Pathway Submission

7b. Magnet Implementation

Metrics

We’re Here for You

Your Health Journey Begins with  
the Right Team in the Right Place