Transcript 2009 AHCA/NCAL National Quality Award Program

2010 AHCA/NCAL National
Quality Award Program
- Silver Award Overview Session Two
Lance Reynolds
Kevin Warren
Tim Case
Silver Award Criteria
2.0 Organizational Profile
2.1 Visionary Leadership and Social Responsibility and
Community Health
2.2 Focus on the Future
2.3 Resident-Focused Excellence
2.4 Management by Fact
2.5 Organizational and Personal Learning
2.6 Valuing Staff and Partners
2
2.7 Systems Perspective, Agility, & Managing for Innovation
2.8 Focus on Results and Creating Value
The first step towards getting somewhere
is to decide that you are not going to
stay where you are.
J. Pierpont Morgan
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2.0 Organizational Profile
4
This was formerly referred to as Step I, and
remains largely based on, the Bronze Award
criteria.
Make sure you update any information you
copy from a former Bronze Award
application.
You are not bound by your previous Bronze
Award application.
2.0 establishes the foundation for the entire
application.
The Writing Process Linkages:
Organizational Profile (Key Factors)
+
Category Response
= Results
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Linkages
Example #1
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
Organizational Profile:
– Vision: “Best Nursing Home in the State as measured
by Resident, Family and Staff Satisfaction”.

Category 2.3 Response: No Resident, Family and Staff
Satisfaction processes described.

Results: No results
Linkages (continued)



Example #2
Organizational Profile:
– Vision: “Best Nursing Home in the Nation as
measured by Resident, Family and Staff
Satisfaction”.
Category 2.3 Response: Two years of conducting
surveys
Results: Results are compared to local nursing homes
only.
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Organizational Profile
Examiners use the Organizational Profile to
determine what is important to you, the
applicant, throughout their entire review
process. It is a required part of their work.
FOCUS
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Silver Award Criteria
2.0 Organizational Profile
2.1 Visionary Leadership and Social Responsibility and
Community Health
2.2 Focus on the Future
2.3 Resident-Focused Excellence
2.4 Management by Fact
2.5 Organizational and Personal Learning
2.6 Valuing Staff and Partners
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2.7 Systems Perspective, Agility, & Managing for Innovation
2.8 Focus on Results and Creating Value
2.7 Systems Perspective, Agility, &
Managing for Innovation
How does the organization effectively
interconnect the individual components of its
performance management system to view the
organization as a whole and to ensure
consistency of plans, processes, measures, and
actions in order to maximize agility, encourage
innovation, and achieve performance excellence?
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2.7 Systems Perspective, Agility, &
Managing for Innovation
How does your organization systematically:
a. Ensure alignment of processes, measures, and action plans
across departments and throughout various organizational
levels to improve performance and customer satisfaction.
• Describe key work processes.
• Describe how the organization manages these processes to
ensure that they are consistent with your strategic objectives
and action plans described in 2.2.
• Describe how action plans are integrated across departments and
organizational levels to improve performance and customer
satisfaction.
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2.7 Systems Perspective, Agility, &
Managing for Innovation
How does your organization systematically:
b. Make meaningful change to improve your services,
programs, processes, operations, care delivery
model, and business model to create new value for
your stakeholders.
• Give examples of innovative changes made in the last
year to improve resident care and quality of life,
organization of work, and business results.
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2.7 Systems Perspective, Agility, &
Managing for Innovation
How does your organization systematically:
c. Build agility—a capacity for rapid change and
flexibility.
• Describe how the workforce is cross-trained
and empowered to be flexible.
• Describe how work systems and processes
are simplified to reduce response times to
changes in customer needs and
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expectations. Give one or two examples.
Scoring Guidelines
SECTION 2.1 – 2.7
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Factor
Approach
10-25%
30-45%
No systematic approach to Item The beginning of a systematic
requirements is evident;
approach to the basic
information is anecdotal
requirements of the Item, is
evident
An effective, systematic
approach, responsive to the
basic requirements of the Item,
is evident
Deployment
Little or no deployment of any
systematic approach is evident
The approach is in the early
stages of deployment in most
areas or work units, inhibiting
progress in achieving the basic
requirements of the Item
The approach is deployed,
although some areas or work
units are in the early stages of
deployment
Learning
An improvement orientation is
not evident; improvement is
achieved through reacting to
problems
Early stages of a transition from
reacting to problems to a
general improvement orientation
are evident
The beginning of a systematic
approach to evaluation and
improvement of key processes
is evident
Integration
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0-5%
No organizational alignment is
The approach is aligned with
The approach is in early stages
evident; individual areas or work other areas or work units largely of alignment with your basic
units operate independently
through joint problem solving
organizational needs identified
in response to the
Organizational Profile and other
Process Items
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Factor
50-65%
70-85%
90-100%
Approach
An effective, systematic
approach , responsive to the
overall requirements of the Item,
is evident
An effective, systematic
approach, responsive to the
multiple requirements of the
Item, is evident
An effective, systematic
approach, fully responsive to the
multiple requirements of the
Item, is evident
Deployment
The approach is well deployed,
although deployment may vary
in some areas or work units
The approach is well deployed
with no significant gaps
The approach is fully deployed
without significant weaknesses
or gaps in any areas or work
units
Learning
A fact-based, systematic
evaluation and improvement
process and some
organizational learning are in
place for improving the efficiency
and effectiveness of key
processes
Fact-based, systematic
evaluation and improvement and
organizational learning are key
management tools; there is clear
evidence of refinement and
innovation as a result of
organizational-level analysis and
sharing
Fact-based, systematic
evaluation and improvement and
organizational learning are key
organization-wide tools;
refinement and innovation,
backed by analysis and sharing,
are evident throughout the
organization
Integration
The approach is aligned with
your organizational needs
identified in response to the
Organizational Profile and other
Process Items
The approach is integrated with
your organizational needs
identified in response to the
Organizational Profile and other
Process Items
The approach is well integrated
with your organizational needs
identified in response to the
Organizational Profile and other
Process Items
Comparisons and Scoring
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
50% to 65% (This is a strong organization)
 Some current performance levels have been
evaluated against relevant comparisons and/or
benchmarks and show good relative performance

70 to 85% (This is a National Award Winner)
 Many to most trends and current performance
levels have been evaluated against relevant
comparisons and/or benchmarks and show areas
of leadership and very good relative performance
Criteria Scoring Points and Weighted
Percentages
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Criteria
Points
%
2.0
25
2.5%
2.1
180
18%
2.2
50
5%
2.3
110
11%
2.4
90
9%
2.5
75
7.5%
2.6
75
7.5%
2.7
175
17.5%
2.8
220
22%
1000
100%
18%
57.5%
39.5%
2.8 Focus on Results and Creating
Value
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
What are your organization’s key results that
create value for your key stakeholders?

Explain how you use these key measures to
drive performance improvement, or cross
reference to relevant examples in other sections
of the application.
2.8 Focus on Results and Creating
Value
a. Health care outcomes:
Give at least three (3) key clinical outcome results over appropriate
time frames. At least one of the outcomes should clearly show
improvement over time across at least three data points. Identify
the strategies and specific changes used to improve this
outcome. Assisted Living Facilities (ALFs) and Developmental
Disability Residential Services providers (DD) may choose to
substitute non-clinical process outcome results. If available, show
your outcomes in comparison to competitors or to state or
national averages, whichever seems most appropriate.
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2.8 Focus on Results and Creating
Value:
b. Government survey performance
outcomes:
Provide
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government/state survey (deficiency) results
over time (minimum of the last 3 surveys, but preferably 4
or 5 surveys). This requirement applies only to skilled
nursing, ICF/MR, and others for which compliance with
routine government compliance inspections is required. If
available, show your outcomes in comparison to
competitors or to state or national averages, whichever
seems most appropriate.
2.8 Focus on Results and Creating
Value: c. Other outcomes:
In
addition to the results reported above, provide a minimum of five (5)
additional results drawn from the areas on the next slides. The results
chosen and reported should cover the most important requirements for
your organization’s success, highlighted in your organizational profile
(section 2.0) and responses to the core values and concepts (sections
2.1 to 2.7). If possible, choose results to report for which you can provide
comparative data from competitors and other long term care facilities.
Whenever
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possible, show your outcomes in comparison to competitors
or other long term care organizations. You must at least show early
stages of efforts to gather and use comparative data. You are
encouraged to identify performance benchmarks or targets within your
results reporting.
2.8 Focus on Results and Creating
Value
Resident- and stakeholder-focused results:
Report
your current levels and trends in key
measures or indicators of resident, family and
other stakeholder and partner satisfaction and
dissatisfaction. Show how these results compare
with the performance of your competitors and
other nursing homes or long term care facilities.
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2.8 Focus on Results and Creating
Value
Financial and marketplace results:
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
Report current levels and trends in key measures or
indicators of financial performance, including financial
return, financial viability, or budgetary performance as
appropriate.

Report current levels and trends in key measures or
indicators of marketplace performance, including market
share or position, market and market share growth, and
new markets entered, as appropriate.
2.8 Focus on Results and Creating
Value: Workforce-focused results
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• Report staff turnover and/or retention rates (minimum of 3, but
preferably 4-5 years). Show how these results compare with the
performance of your competitors and other nursing homes or long
term care facilities.
• Report current levels and trends in key measures of employee
satisfaction for the past four to five years. Show how these results
compare with the performance of your competitors and other nursing
homes or long term care facilities.
• Report current levels and trends in key measures of workforce and
leadership development.
• Report current levels and trends in key measures of workforce health,
safety and security, and workforce services and benefits, as
appropriate. Include worker’s compensation claims and grievances
over a four to five year period.
2.8 Focus on Results and Creating
Value: Process effectiveness results
• Report current levels and trends in key measures of
occupancy.
• Report current levels and trends in key measures of
work system performance such as supplier and
partner performance, job simplification, changing
supervisory ratios, med-pass, and cycle time
reduction.
• Report current levels and trends in key measures of
preparedness for disasters or emergencies.
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2.8 Focus on Results and Creating
Value: Leadership results
• Report results for your key measures of
accomplishment for your strategic and action plans
outlined in 2.2.
• Report results for key measures of ethical behavior.
• Report results for key measures of promoting or
supporting community health and services.
And, Other results
• As deemed appropriate for the applicant’s individual
organization.
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Guidelines for Responding to the
Results Items
1.
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Focus on the most critical organizational
performance results.
Guidelines for Responding to the
Results Items
1.
Focus on the most critical organizational performance
results.
2.
Note the meaning of four key requirements for
effective reporting of results data:
1.
2.
3.
4.
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Performance Levels
Trends
Comparisons
Integration: To show that all important results are
included, segmented (e.g. by important resident or
stakeholder, workforce, process and healthcare service
groups), and as appropriate, related to key performance
projections.
Guidelines for Responding to the
Results Items
1.
2.
Focus on the most critical organizational performance
results.
Note the meaning of four key requirements for
effective reporting of results data.
a.
b.
c.
d.
3.
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Performance Levels
Trends
Comparisons
Integration
Include trend data covering actual periods for
tracking trends.
Guidelines for Responding to the
Results Items
1.
2.
Focus on the most critical organizational performance
results.
Note the meaning of four key requirements for effective
reporting of results data.
a.
b.
c.
d.
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Performance Levels
Trends
Comparisons
Integration
3.
Include trend data covering actual periods for
tracking trends.
4.
Use a compact format – graphs and tables.
Graphs and Tables
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October 2007
October 2008
67%
71%
82%
2/1/2008
2/1/2007
October 2006
12/1/2007
12/1/2006
10/1/2007
10/1/2006
8/1/2007
8/1/2006
6/1/2006
6/1/2007
4/1/2007
4/1/2006
2/1/2007
2/1/2006
12/1/2005
12/1/2006
10/1/2005
10/1/2006
8/1/2005
8/1/2006
6/1/2005
6/1/2006
4/1/2005
4/1/2006
2/1/2005
2/1/2006
12/1/2004
12/1/2005
Graphs and Tables
“Quality of Dining Experience”
Incidental Overtime
100
80
60
40
20
0
Graphs and Tables
20
15
2003
10
2004
2005
5
2006
0
Percent of
Falls
Nursing Staff Data
100
NAR without
turnover
90
NAR stability
80
NARs without
Absenteeism
70
60
RN / LPN
Turnover
50
RN /LPN
Stability
40
30
RN / LPN
Withou
Absenteeism
20
10
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Jan. 07
Dec. 06
Nov. 06
Oct. 06
Sep. 06
Aug.06
July 06
June 06
May 06
Apr. 06
Mar. 06
Feb. 06
Jan. 06
0
Graphs and Tables
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12%
10%
8%
Facility
State
6%
USA
4%
-06
Se
p06
-0
6
Ma
r-0
6
Ma
y06
2%
0%
-06
No
v
J F M A MJ J A S ON D
Ju
l
2008
16%
14%
Ja
n
14%
13%
12%
11%
10%
9%
8%
6%
5%
4%
3%
2%
1%
Graphs and Tables
Year
2003
2004
2005
2006
2007
2008
Year
2001
2002
2003
2004
2005
2006
YTD Census
(%)
68
60
72
89
89
86
YTD Census
(%)
6
8
10
13
13
10
Table 2.8a Year to Date Census
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Table 2.8b Year to Date Medicare Census
Graphs and Tables
2004
37
2005
2006
2007
2008
Guidelines for Responding to the
Results Items
1.
Focus on the most critical organizational performance results.
2.
Note the meaning of four key requirements for effective
reporting of results data.
a.
b.
c.
d.
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Performance Levels
Trends
Comparisons
Integration
3.
Include trend data covering actual periods for tracking trends.
4.
Use a compact format – graphs and tables
5.
Integrate results into the body of the text and
interpret where appropriate.
Guidelines for Responding to the
Results Items
1.
2.
Focus on the most critical organizational performance results.
Note the meaning of four key requirements for effective
reporting of results data.
a.
b.
c.
d.
3.
4.
5.
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6.
Performance Levels
Trends
Comparisons
Integration
Include trend data covering actual periods for tracking
trends.
Use a compact format – graphs and tables.
Integrate results into the body of the text and interpret
where appropriate.
Interpret the graphed results.
Good Performance Levels





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Performance levels permit evaluation relative to past
performance, projections, goals and appropriate
comparisons
Goals refer to a future condition or performance level
that one intends to attain
Quantitative goals – “targets”
Targets might be projected on comparative or
competitive data
Benchmarks refer to results that represent best
performance inside or outside an organization’s industry
Relevant Comparisons and
Benchmarks
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
Your organization is not unique

Review Baldrige Winners

Seek advice from AHCA Winners

Think outside the box
Scoring System




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Levels – meaningful scale
Trends – appropriate time period
Comparisons – appropriate, similar,
benchmarks
Integration – measures identified in your
Organizational Profile and Process Items;
harmonized to support goals
Scoring Guidelines Results
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Results
Results are 22% of the possible score so…

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Start Early!!
What results support our Key Strategic
Objectives and Action Plans?

Do we clearly understand what each Item calls
for?

Where do we get comparative data?
Silver Award Requirements to
Recommend
1.Score a minimum of 358 total points.
2.Have no less than 88 (40%) points in
sections 2.8.
3.Have no criterion in Band A and no more
than two criteria in Band B.
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Technical Requirements
Due electronically March 31, 2010
18-page limit
1” Margins
12-pt Times New Roman font
$500 application fee
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Resources
AHCA/NCAL National Quality Award program
requirements and application information
(www.ahcancal.org).
Baldrige National Quality Award Program
To order a free copy of the Baldrige Health Care Criteria
for Performance Excellence:
Tel: 301-975-2036
Website: www.baldrige.nist.gov.
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More Resources



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Scoring guidelines at www.baldrige21.com
Scroll past Baldrige Excellence Tools list to
More Baldrige Excellence Tools, Services
and Resources
Scroll down to the line Scoring Guidelines
2010 Integrated Versions and click on Health
Care
More Resources
Books available at www.ahcapublications.org:
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•
Conducting Satisfaction-Based Customer Surveys: A Guidebook
for Long Term Care Providers by Vivian Tellis-Nayak, Ph.D.
•
Continuous Quality Improvement: Using the Regulatory
Framework by Barbara Baylis
•
Developing a Quality Management System: The Foundation for
Performance Excellence in Long Term Care by Bernie Dana
•
Quality Management Integration in Long-Term Care: Guidelines
for Excellence by Maryjane Bradley and Nancy Thompson
Final Review





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
Best done with “Walk the Wall” (remember the “war
room”)
Ensure all sections are addressed
Remember: Examiners cannot assume, the
document must stand on its own
Reconfirm page limits, page numbering and
formatting instructions
E-mail some copies to ensure nothing lost in
transmission.
And remember……
Writing Do’s and Don’ts
DON’TS!
1.
2.
3.
4.
5.
6.
7.
8.
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9.
10.
Do not start until you have full agreement on budget, timeline and
application team
Do not waste space with anecdotal glorification
Do not begin writing until the Organizational Profile is clear and
complete
Do not allow anyone who does not understand the criteria, no matter
how senior, write any part of the application
Do not stray from the criteria questions
Do not stray from ADLI
Do not “write forward” (We will be…)
Do not get behind schedule
Do not rely on a consultant to do it all for you
DO NOT GIVE UP!
You are an Original!
Applications must be original, not supplied by
external entities, whether it be corporate office
or consultants.
Speak to what you know best……you know
better than ANYONE why the facility should be
a Silver Award Winner
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Tell the Story!
Sell the Story!