The Baldrige Performance Excellence Program and Criteria Promoting

The Baldrige Performance Excellence Program and Criteria Promoting Excellence in Health Care

Objectives Today, we will cover: 1. 2. 3. 4. Background of the Baldrige Performance Excellence Program Basic concepts of the program framework How the Baldrige framework can be applied to improve your business area Lessons learned from Baldrige recipients

Program History Malcolm Baldrige National Quality Improvement Act of 1987, Public Law 100 -107 • Named after Malcolm Baldrige, Secretary of Commerce from 1981 -1987 • Advocate of quality management to improve the standing of U. S. businesses • Highest level of recognition for performance excellence in the U. S.

Program History • Created award program to - Identify/recognize role-model businesses - Establish criteria for evaluating improvement efforts - Disseminate/share best practices • Expanded to health care and education (1998) • Expanded to nonprofit sector (2005)

Baldrige Arrived! (1994 – Public Culture)

Program History • Criteria adopted / adapted by states, regions – Multiple levels – Feedback, site visit opportunities • Support through Alliance for Performance Excellence

New Eligibility at National Level • Starting in 2012, an organization must meet one of the following criteria to apply for the national Baldrige Award: o Previously won the national Baldrige Award (not within the past 5 years); o Between 2007 and 2011: • Received the top award from an award program that is a member of the Alliance for Performance Excellence; • Applied for the national Baldrige Award and earned a high score in both organizational processes and results but did not receive a site visit; • Applied for the national Baldrige Award and received a site visit; o Has more than 25 percent of its workforce outside of the home state; or o Is an organization that does not have an available Alliance for Performance Excellence award program.

Quality Texas Award Levels Baldrige National Award Process Texas Award for Performance Excellence State/Local Recognition Progress Level Commitment Level Engagement Level

The Texas Award for Performance Excellence • Four Application Levels 1. Engagement – 10 page application, feedback 2. Commitment – 15 page application , feedback 3. Progress – 25 page application, optional site visit, feedback 4. Award – 50 page application, site visit, feedback 9

What Is the Baldrige Program? • Operates as a unique public-private partnership • Identifies & recognizes role-model businesses • Forum for sharing best practices • Educates organizations on achieving performance excellence • Manages the Malcolm Baldrige National Quality Award

What is the Baldrige Framework? • Criteria-based assessment and improvement framework • Non-prescriptive • Uses a “systems perspective” to define an organization • Adaptable and scalable • Proven approach - stock & performance study

Who Uses the Criteria? • • • Manufacturing Service Small Business Education Nonprofit (includes government agencies) Health Care

Baldrige = Performance Kevin Hendricks (College of William & Mary) and Vinod Singhal (Georgia Institute of Technology)

Applications by Award Categories 12 11 10 09 08 07 06 05 Manufacturi 1 ng Service 3 2 3 2 3 1 3 2 4 5 4 4 6 Small Business Education 2 7 7 5 7 7 8 8 3 8 10 9 11 16 16 16 Health Care 25 40 54 42 43 42 45 33 Nonprofit 5 14 7 8 16 13 10 - Total 39 69 83 70 85 84 86 64

Baldrige Healthcare Applicants 2005 -2012 100 90 85 83 86 84 80 70 69 70 64 60 54 50 39 40 43 42 40 42 45 33 30 25 20 10 0 2012 2011 2010 2009 Health Care 2008 Total 2007 2006 2005

Does the Baldrige Framework Really Work? • Several studies have been done, including a comparison with Thomson Reuters 100 Top Hospitals data • Baldrige criteria categories align well with the 100 Top Hospitals performance criteria Baldrige Criteria 100 Top Hospitals Performance Criteria Leadership and governance Composite score Product and process Patient outcomes: mortality, complications, patient safety, core measures Customer focus HCAHPS score Financial and market Profitability, expenses, length of stay From: Foster, DA and Chenoweth, JC. Comparison of Baldrige Award Applicants and Recipients with Peer Hospitals on a National Balanced Scorecard. Thomson Reuters. 2011. 16

Does the Baldrige Framework Really Work? 17

The Feedback Report: Your Greatest Benefit • Written assessment of strengths/ opportunities for improvement • Compiled by a team of expert examiners – Key themes (summary) – Organization-specific comments – Individualized scoring information – Scoring distribution

Comparing Performance Improvement Tools Baldrige Business results and organizational improvement and innovation systems Six Sigma, Lean, and ISO 9001 Organizational improvement and innovation processes Six Sigma and Lean Drive waste and inefficiencies from processes identified for improvement by Criteria users

Comparing Performance Improvement Tools •

Baldrige and Joint Commission Similarities • Focus on continuous improvement • Are based on a set of core values • Offer a means for self-assessment Think: Complementary

Baldrige and Joint Commission Differences Joint Commission • Focuses on patient care • Establishes minimum standards for accreditation • Looks at same things at all institutions (like audit) • Little emphasis on approach, learning, integration Baldrige • Overall organizational focus, including focus on patients • Recognizes role-model performance • Focuses on individual factors and strategic challenges and advantages (not audit) • Heavy focus on approach/process, learning, integration

Baldrige and Magnet Similarities – Both offer a systemic approach to transform the organization – Both focus on transformational leadership to achieve culture change – Both rely on self assessment supported by independent assessment – Both focus on alignment of key processes and systems

Baldrige and Magnet Similarities – Both require use of data to affect a fact-based, knowledge-driven system – Both focus on attracting, empowering, developing, retaining, engaging workforce – Both are non-prescriptive – Both focus on achieving superior outcomes (results)

Baldrige and Magnet Differences • Baldrige – 50 page application – 5 page organization profile • Magnet – No more than 15 inches in height (approx. 2500 pages) – Gather supporting evidence

Criteria in Health care • Used by: - Mayo Clinic, Johns Hopkins, UCLA, Henry Ford, Partners - Baylor, THR, HCA, Cook Children's, JPS • Compatible with - Magnet journey TJC accreditation IHI initiatives Lean/Six Sigma, PDCA, etc.

Award Recipients: Health Care • Advocate Good Samaritan Hospital (2010) • Atlanti. Care (2009) • Baptist Hospital, Inc. (2003) • Bronson Methodist Hospital (2005) • Heartland Health (2009) • Henry Ford Health System (2011) • Mercy Health System (2007) • North Mississippi Health Services (2012) • North Mississippi Medical Center (2006) • Poudre Valley Health System (2008) • Robert Wood Johnson University Hospital Hamilton (2004) • Saint Luke’s Hospital of Kansas City (2003) • Schneck Medical Center (2011) • Sharp Health. Care (2007) • Southcentral Foundation (2011) • SSM Health Care (2002)

Testimonials from Health Care Leaders “The Award Criteria provide a well-tested approach to help achieve higher levels of excellence. Health care organizations could benefit from applying its rigorous Criteria in their efforts to improve quality, lower costs, and better serve patients. ” —Robert R. Waller, former president and CEO, Mayo Foundation “Baldrige. . . has offered us a way to systematically evaluate our entire organization and understand the link between the hundreds of processes that make up the health care experience. . . recipient —Sister Mary Jean Ryan, FSM, president/CEO, SSM Health Care, 2002 Award

Steps toward Mature Processes Reacting to Problems (0– Early Systematic Approaches 25%) (30– 45%) Aligned Approaches (50 – 65%) Integrated Approaches (70– 100%)

From Fire Fighting to Innovation

The Baldrige Criteria • • • Validated set of criteria questions Regularly updated (2 year cycle) Useful as a performance assessment tool Based on core values Comprised of • • • Organizational Profile Six Process categories Results

Baldrige 2012– 2013 Criteria Categories Leadership Strategic Planning Customer Focus Measurement, Analysis, and Knowledge Management • Workforce Focus • Operations Focus • Results • •

Baldrige Criteria Framework: A Systems Perspective

Core Values and Concepts • Visionary leadership • Customer-driven excellence • Organizational and personal learning • Valuing workforce members and partners • Agility • Management by fact • Societal responsibility • Focus on results and creating value • Systems perspective • Focus on the future • Managing for innovation

The Role of Core Values and Concepts

Organizational Profile • Describes the key factors that are unique to the organization • Describes the organization’s priorities • Describes: • • • Organization Environment Organizational relationships Competitive Environment Strategic Context Performance Improvement System

The Criteria Structure

Evaluating Process: methods used and improved to address categories 1– 6 Evaluation factors • • Approach Deployment Learning Integration ADLI

Evaluating Results: Outputs and outcomes in achieving the requirements in items 7. 1– 7. 5 Evaluation factors • Levels • Trends • Comparisons • Integration Le. TCI

Category Point Values 1 2 3 4 5 6 7 Leadership 120 Strategic Planning 85 Customer Focus 85 Measurement, Analysis, and Knowledge Management 90 Workforce Focus 85 Operations Focus 85 Results 450 TOTAL POINTS 1, 000

Scoring of Applications, 2008– 2012 Process Band 0– 150 200 8 5 6 4 4 0 Results Band 0– 125 151– 200 10 8 6 3 0 201– 260 21 23 28 21 261– 320 47 50 39 321– 370 15 13 371– 430 2 431– 480 481– 550 2009 2010 2011 2012 2008 2009 2010 2011 2012 18 21 16 13 8 126– 170 34 29 27 17 8 16 171– 210 26 27 30 17 37 26 45 211– 255 15 19 23 17 29 22 13 39 256– 300 6 4 4 4 18 0 1 1 0 301– 345 1 0 0 0 0 346– 390 0 0 391– 450 0 0

2012 Average Category Scores 80 Service Percent Score 70 Health Care 60 50 40 30 20 Leadership Strategic Planning Customer Focus Measurement, Analysis, & Knowledge Management Category Workforce Focus Operations Focus Results

Key Excellence Indicators: Leadership Senior leaders • communicate and demonstrate clear direction and values • inspire the highest standards of legal and ethical behavior • model and encourage learning, innovation, excellence, and a focus on the future • drive strategies for performance excellence and sustainability

Key Excellence Indicators: Leadership The governance body • is informed, transparent, and accountable • takes responsibility for ethics, actions, and performance The organization • surpasses legal and regulatory compliance • stresses ethical behavior • strengthens environmental, social, and economic systems

Texas Health Resources: Alignment with our Leadership System 48

Clinical Support Services Quarterly Performance Management Tool This tool consolidates key departmental performance information into one document for quarterly review meetings. 49

FY 14 Clinical Support Services Goal Alignment This tool is used division-wide with employees to illustrates strategic goal alignment from Institutional Strategies through individual employee goals.

Mercy Health System: Leadership

Robert Wood Johnson: Leadership 5 Pillar Communicati on Direction and Plan 5 Pillar Communication Customer Groups Evaluation & Improvement 5 Pillar Communicati on Patients Employees Community Alignment & Integration 5 Pillar Communication Deployment & Measurement

Robert Wood Johnson: Leadership Staff Focus People Customer Focus Service Process Management Quality Measurement, Analysis & Knowledge Management Finance Strategic Planning Growth Five Pillars of Excellence

Key Excellence Indicators: Strategic Planning Strategy development • aims for sustained leadership • balances short- and long-term factors • anticipates the future environment • incorporates innovation, stakeholders’ needs, challenges, and advantages • aligns work systems and learning with strategic directions

Key Excellence Indicators: Strategic Planning • Develops aligned, consistent action plans • Deploys action plans to the workforce, key suppliers, and partners • Tracks the accomplishment of action plans • Develops human resource and financial plans • Uses performance projections and comparisons

THR Strategy Development and Implementation Process cascades strategic themes and objectives into the org Strategy Implementation Process • 1 Three-year cycle; yearly refresh • Strategic goals, standards of performance, timing 1 Mid-range System Strategic Plan (SSP) 2 4 System Strategy Initiatives 3 Zone / Entity Imperatives Annual Resourc e Plan (Budget, People, IT) 5 Department / Team / Personal Action Plans 10/30/2020 • Initiatives across 16 Objectives • Initiatives scoped by ELC; sponsored by ELC members 2 • Driven by Strategy Initiative Teams (SITs) • Initiatives chartered with measureable plans and goals • Develop zone- and entity-specific initiatives 3 • Align to System Strategy • Refine based on alignment to system plan and to entity budgets • Yearly resourcing process for strategy initiatives 4 • Top-down input from system; bottom-up input from entities and functions 5 • Align to Strategic Objectives and when individual is allocated against strategy initiatives or action plans • Develop individualized action plans for day-to-day operational needs Confidential And Proprietary – All Rights Reserved – For Internal Use Only Texas Health Resources 56

Strategic Objectives are broken down into “Initiatives, ” and Initiatives are broken down into “Action Plans” “Strategy on a page” Describes all Strategic Objectives “Blue Sheet” Describes each Strategic Objective and all “Initiatives” 10/30/2020 “Green Sheet” Describes each Initiative in full detail Confidential And Proprietary – All Rights Reserved – For Internal Use Only Texas Health Resources “Purple Sheet” Describes each Action Plan associated with an initiative 57

What we’ve learned from our Category 2 efforts • The “right people” and the “right process” produce the “right strategy” − We transformed the Texas Health strategy team by bringing in people with a skill for inductive insight and by developing and deploying a data-rich process − We base all of our strategic decisions on insights developed from data-rich research • Strategic execution is a team sport and it requires a scoreboard to win − Effective deployment of any strategy involved the coordinated efforts of many people—from the strategists, to the deployment teams, to the process owners − Tracking the execution of all of our strategic initiatives requires consistent oversight, which occurs best if there are clear lines of accountability • Strategy is never done − Strategy is not a static event—a one-time set of decisions − Strategy is dynamic and requires adaptability to remain relevant − The market and competitors are constantly moving, so systemic refreshes of the strategy are required 10/30/2020 Confidential And Proprietary – All Rights Reserved – For Internal Use Only Texas Health Resources 58

Clinical Support Services Annual Strategic Planning Process 59

FY 14 Division of Clinical Support Services Strategic Goals The CSS strategic plan captures 3 years of strategic objectives, goals, and action plans at a time and is: • Directly aligned with institutional strategies and goals • Updated annually • Organized around the 5 pillars of People, Service, Quality, Finance, and Growth 60

FY 14 Clinical Support Services Strategic Planning Timeline Includes concurrent strategic planning activities: • FS = Facilitated Sessions to walk division leaders through the planning process activities • Finishing out the current FY 12 -FY 14 plan Developing the incoming FY 15 -FY 17 plan D = Deliverable(s) Due 61

Sharp Health. Care: Strategic Planning

Bronson: Strategic Planning Spring Long-Term Planning Strategic Managemen t Model 4 Review previous performance, SID and determine key services & processes 5 Review/revise PFE, LT objectives, and LT capital assumptions 6 Develop key themes and preliminary ST assumptions Winter Evaluation & Input 1 Process Effectiveness Review Summer Budget & Short-Term Planning CONTINUOUS 12 Organizational performance reviews Progress updates Current information 2 SID compiled by BDD 7 SOT’s present ST objectives, tactics and resources required to ET 3 Gather input from stakeholders regarding ST/LT challenges and opportunities 8 Resources allocated by Fall Approval & Deployment 9 Annual strategic plan, budget, and staffing plans approved by ET and BOD 10 SOT’s finalize scorecard measures 11 Deployment: SOT Action Plans, Strategic Plan Cascade, SPMS, Three C’s Communications ET through capital planning retreat, budget, LT financial plan, and staffing plans

Key Excellence Indicators: Customer Focus • Proactively captures the voice of the customer • Gathers information on customer desires and marketplace potential • Listens to current, former, and potential customers • Collects actionable information on engagement, satisfaction, and dissatisfaction

Key Excellence Indicators: Customer Focus • Innovates product offerings and services to exceed expectations • Refines and innovates support and communication • Builds trust, confidence, and loyalty • Resolves complaints promptly and eliminates the causes

Defining our Customers

Deployment - Providing optimal patient-centered care Accessing a Network of Care Getting Out Acute/ Emergent Getting In Patients & Families Ambulatory Getting Treatment Finding My Way Keep people informed Value people’s time and energy Treat the whole person Chronic Elective/ Procedural

Clinical Support Services Customer Rounding Process • CSS leaders (VP, Directors, Associate Directors, Managers, and Supervisors) use standardized rounding forms to round on 2 to 4 key customers per quarter • Rounding forms are reviewed at the department level and follow-up is provided on any identified issues • Rounding data are analyzed at the division level for trends and opportunities for department and/or division-wide improvement • Engagement question scores are reported on department and division scorecards

Clinical Support Services High-Level Customer Complaint Management System

Heartland Health: Customer Focus Evaluation and (5) Improvement SPP Step 1 Review customer inputs and analyze processes to refine feedback mechanisms, relationship strategies, and action plans (annual/ongoing) Voice of the Customer(2) Listening, inputs and methods Analysis and Decision Making (3) SPP Steps 2– 6: Customer Groups (1) Patients Members Community—Region Deployment of Strategy and (4) Action Plans SPP Step 8: Deploy improvements through the Balanced Scorecard and action plans. Conduct reviews to determine customer requirements and assess if services, processes, and improvements are meeting customer needs. Translate results of analysis into priorities for improvement Customer Relationship Management

Heartland Health: Customer Focus Key Customer Requirements Key Satisfaction Priorities/Examples Patient Customer Segment Patients Inpatient Satisfiers/Priorities Comfort • Response to • Pain concerns/complaints • Personal needs • Emotional needs • Compassion addressed • Included in decisions Listening and Input Methods • Patient surveys (D, M) • Discharge calls (D) • Key words (D) • Rounding (D) Key: Frequency: A–annual, B-Biennial, D-Daily, M-Monthly, P-Periodic, AN–As Needed Voice of the Customer

Poudre Valley Health System: Customer Focus

Sharp Health. Care: Customer Focus

RWJ: Customer Focus Beyond Satisfaction. . . Customer Loyalty Employees Patients Community l Circles l Greeters l CHW l On-line benefits l Free TV and phone l Family Giving l CHW discounts l Food on demand l Soup kitchen l Bonus programs l Integrative therapy l CAB l l Hearts Apart Employee Sat. Committee l l Education Comfort in clothing l Health Fairs

Saint Luke’s: Customer Focus

Key Excellence Indicators: Measurement, Analysis, and Knowledge Management • Creates a balanced composite of measures tied to needs, strategy, and goals • Collects and uses data to determine trends, projections, and cause and effect • Uses performance analyses in decision making, improvement, and innovation

Key Excellence Indicators: Measurement, Analysis, and Knowledge Management • Maintains and safeguards information systems • Shares and transfers critical knowledge • Provides knowledge needed for work, improvement, and innovation • Leverages knowledge of workforce, customers, suppliers, collaborators, and partners • Captures and shares knowledge to drive innovation

Objective #1 The Performance Measurement Process Key Process Steps Sub-Processes Select Indicators Collect Data & Publish Results Convert Results to Action June 25, 2013 79

Clinical Support Services Scorecard Clinical Support Services has integrated division and department-level scorecards with relevant and actionable metrics and appropriate benchmarks. 80

Clinical Support Services Patient Flow Scorecard Performance Ranges Measurement Under Performing Threshold Patient Access: Patients coming into MD Anderson A 1 Monthly Average Daily Bed Vacancy: Daily Bed Vacancy = 100% - % of Beds Occupied each day. Patient Throughput: Patient Flow Through MD Anderson Target Stretch • How CSS monitors CSS department contributions to patient flow <4 4. 0%-4. 9% 5. 0%-5. 9% >6 PT 1 Case Management e. PNA Response Time: Percent inpatient e. PNAs responded to within 1 business day <80% 80%-85% 86%-95% >95% PT 2 Social Work e. PNA Response Time: Percent e. PNAs responded to within 2 days < 90%-94% 95%-99% 100% Bed Turnaround Time: Getting Bed Ready for the Next Patient B 1 Transportation- Median Turnaround Time: Time elapsed between request and completion Key Stretch: Requires significant effort or improvement to achieve. Target: At or slightly above external or historical benchmark performance. • Includes metrics and performance ranges for CSS services that are critical to patient flow > 38 min 36. 1 - 38 min 33. 1 - 36 min < 33 min Threshold: Slightly below target level performance. May indicate a change in the process that requires corrective action to address. Underperforming : Performance is in a state of emergency. Requires immediate corrective action. 81

Atlanti. Care: Measurement, Analysis, and Knowledge Management

PVHS: Measurement, Analysis, and Knowledge Management

BHI: Measurement, Analysis, and Knowledge Management

Key Excellence Indicators: Workforce Focus • Optimizes capability and capacity • Organizes and manages the workforce to serve customers and achieve strategy • Designs proactive processes and policies to ensure safety and security • Offers practices and policies tailored to workforce members’ needs

Key Excellence Indicators: Workforce Focus • Engages the workforce through meaningful work, clear direction, and accountability • Ensures a trusting, effective, and cooperative environment • Supports, recognizes, and rewards high performance • Optimizes workforce and leader development

Engagement is Critical • We believe that highly engaged and satisfied employees work together like family to comfort and provide the best care to our patients Engagement Mechanism Purpose In-person meetings, forums and conferences Share ideas, best practices, concerns and feedback Intranet Share company news and program highlights Social Media Engagement via Yammer, Facebook, Twitter, You. Tube, etc. Surveys, focus groups, Reveals engagement quick polls, rounding, and satisfaction town halls and exit interviews

The Complete Voice of the Workforce Text Analytics (themes, sentiment) Statistical Analysis (correlation, regression) Information THR Structured Data THR Unstructured Data External Data Targeted, Datadriven Action

Clinical Support Services Employee Rounding Process • CSS leaders (VP, Directors, Associate Directors, Managers, and Supervisors) use standardized rounding forms to round on at least 25% of direct reports per quarter • Rounding forms are reviewed at the department level and follow-up is provided on any identified issues • Rounding forms are analyzed at the division level for trends and opportunities for department and/or division-wide improvement • Engagement question scores are reported on department and division scorecards

Clinical Support Services FY 14 Badge Cards • Trifold card • Includes the Clinical Support Services vision and key goal alignment information 91

Atlanti. Care: Workforce Focus Workforce Capacity and Capability

Atlanti. Care: Workforce Focus Performance Management Process

Heartland Health: Workforce Focus Satisfaction Driver Examples Workforce Segment E P V Participation • Work teams • Process improvement methodologies • Communication methods X X X X X Job fulfillment • • • Retention levels Competitive rewards Family-like relationships Orientation/education Recognition programs X X X X Work environment • State-of-the-art facilities X X X X X Staffing/ teamwork • Various shift lengths X X X X X • Supplies and equipment • Technology • Telecommuting • Staggered start times • Productivity and labor measures X E = employee, P = physician, V = volunteer

Mercy Health System: Workforce Focus • Inform • Involve • Celebrate

Mercy Health System: Workforce Focus Inform Involve • Meaningful Mission • Cruise and Connect • Communicate Goals • Partnership • Feedback • Workforce Strategies Celebrate • Celebrate People • Celebrate Ideas • Celebrate Achievements

Key Excellence Indicators: Operations Focus • Designs and innovates work systems to capitalize on core competencies • Designs agile work systems • Optimizes work systems to deliver value for customers • Establishes a comprehensive emergency preparedness system

Key Excellence Indicators: Operations Focus • Designs and innovates work processes to meet requirements • Designs work processes for agility, excellence, efficiency, and effectiveness • Manages, measures, and improves work processes • Manages the supply chain to improve suppliers’ and partners’ performance

Clinical Support Services Performance Improvement Model Maintain improved performance Revise or Fully implement solution(s) Identify and define the problem & AIM ACT PLAN Study the results (post data) STUDY DO Implement (pilot test) your solution(s) Develop Solution(s) Assess the current situation: process flow, cause & effect, baseline data

Clinical Support Services Process Flows Template

North Mississippi Medical Center: Operations Focus

Key Excellence Indicators: Results • Performance levels are excellent in areas that are important to accomplishing the mission. • Results reflect offerings with superior value as viewed by customers and the marketplace.

Key Excellence Indicators: Results • Operational, workforce, legal, ethical, societal, and financial indicators reflect benchmark performance. • Actionable results are used to evaluate and improve performance in alignment with strategy.

Clinical Performance Improvement (Core Measures) 0 7

HCAHPS Inpatient 100 90 Percentile Rank - PG All Hospital Database 80 70 60 50 40 30 20 10 0 1 Q 2009 2 Q 2009 3 Q 2009 4 Q 2009 1 Q 2010 2 Q 2010 Overall Score 3 Q 2010 4 Q 2010 1 Q 2011 2 Q 2011 3 Q 2011

Clinical Support Services: Results Overall, results at the division level have exceeded the 70% favorable target for FY 13 in all categories of the Are We Making Progress Survey Clinical Support Services Are We Making Progress Survey Comparative Results Employee Engagement 100 90 80 Target ≥ 70% Favorable 70 60 50 40 30 20 10 0 Leadership Strategic Planning Customer Focus FY 08 Knowledge Management FY 09 FY 11 Workforce Focus Operations Focus Business Results FY 13 108

Advocate Good Samaritan Hospital: Mortality Index Results (Actual/Expected) GOOD 20. 5% 22. 3% 21. 4% 23. 1% GOOD Inpatient Market Share, 2007 -2010 Physician Loyalty (Percentile)

Atlanti. Care: Results Workforce Survey

Heartland Health: Results Customer Satisfaction Willingness to Recommend

Heartland Health: Results Complaint Event Management Respond Complaints per 100 Adjusted Patient Days Resolve Track Prevent Complaint Management

Heartland Health: Results Caregiver Engagement

Poudre Valley Health System: Results Prompt Service and Friendly Staff Low-Cost Provider Top-Box Patient Satisfaction Scores

Mercy Health System: Results Workforce Turnover Workforce Engagement

Sharp Health. Care: Results Perception of Quality Top-of-Mind Awareness of County Hospital Systems Likeliness to Recommend Patient Satisfaction

Bronson Methodist Hospital: Results Cardiac Service Line Market Share (%)

North Mississippi Medical Center: Results Tracheostomy with Chronic Ventilation

North Mississippi Medical Center: Results Financial Care-Based Cost Management: Making the Business Case for Quality

Getting Started Self-assessment • The first step toward achieving organizational improvement and performance excellence • A “results-oriented” review • Adaptable to the needs of each organization

Why Self-Assess? • • • Maintain a leadership position Enhance organizational learning Align actions with organization’s values Create a sustainable organization Improve performance Address a customer, competitor, regulatory, or budget-driven need to change

Benefits of Self-Assessment • Identify successes and opportunities for improvement • Jump-start a change initiative • Energize improvement initiatives • Energize the workforce • Focus your organization on common goals • Assess performance against the competition • Align resources with strategic objectives

Step 1: the Organizational Profile • A series of questions to help you identify – the key influences on your organization – the key challenges your organization faces • Describe what is relevant and important • Guide selection of information/data • Identify gaps/lack of deployment

Prepare the Organizational Profile • Organizational Description – Organizational Environment – Organizational Relationships • Organizational Situation – Competitive Environment – Strategic Context – Performance Improvement System

Your Organizational Profile: Organizational Environment • What are your stated PURPOSE, VISION, VALUES, and MISSION? • What are your organization’s CORE COMPETENCIES and what is their relationship to your MISSION? • What is the regulatory environment under which you operate?

Your Organizational Profile: Organizational Relationships • What are your reporting relationships among your GOVERNANCE board and SENIOR LEADERS? • What are your key market SEGMENTS, PATIENT and other CUSTOMER / s. TAKEHOLDER groups? • What are the differences in the requirements and expectations among these groups?

Your Organizational Profile: Organizational Situation • What is your competitive position? • What are your KEY STRATEGIC CHALLENGES and ADVANTAGES IN THE AREAS OF SERVICES, operations, workforce? • What are the key elements of your PERFORMANCE improvement system?

Step 2: Self-Assessment: Six Basic Steps 1. Identify the boundaries/scope of the assessment. 2. Select six champions, one for each process Criteria category. 3. Select category teams to collect data and information to answer Criteria questions.

Step 2: Self-Assessment: Six Basic Steps 4. Share answers to Criteria questions among category teams. 5. Create and communicate an action plan for improvement. 6. Evaluate the self-assessment process for future improvements.

Assessment Plan for Beginners UTSW 2013 §Select Sponsor & Category Champions §Complete Organizational Profile §Review/Address gaps §Complete category assessment 2014 • Address gaps • Apply to TAPE (Commitment) • Receive feedback 2015 • Address gaps • Apply to TAPE (Progress) • Receive feedback • Address gaps

Assessment Teams - UTSW Assessment Team Executive Sponsor Leadership M/V/V Communication Governance Results 7. 4 Strategic Planning SP Process Time horizons Advantages Challenges Results 7. 5 Customer Focus Customer segments Market position Satisfaction Complaints Results 7. 2 Information Analysis Measurement systems Comparisons Results Workforce Focus Performance measurement Workforce development Results 7. 3 Process Management Work systems Work Processes Improvement Process Results 7. 1

Resources for More Information Baldrige Performance Excellence Program: → Phone (301) 975 -2036 → E-mail baldrige@nist. gov → Website www. nist. gov/baldrige Quality Texas Foundation: → Phone (214) 565 -8550 → E-mail Ltomaszewski@texas-quality. org → Website www. texas-quality. org/ 136

“Perfection is unattainable, but if we chase it, we can catch Excellence. ” - Vince Lombardi