Transcript National Council for Performance Excellence

National Council for Performance Excellence
2004
Health Care
Baldrige
Express
Survey Process
In partnership with the Michigan Quality Council
248-370-4552 phone
[email protected]
425 B Pawley Hall
Rochester, MI 48309-4401
National Council for Performance Excellence
Introduction
The Baldrige Criteria help organizations
identify strengths and key areas for
improvement.
The Baldrige approach has been used for
approximately 16 years by tens of thousands
of organizations to stay abreast of competition
and to increase effectiveness.
55 countries throughout
the world have adopted
the Baldrige framework to
enhance competitiveness.
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5 Reasons to Choose Baldrige
The Baldrige Criteria:

Provide a framework for improvement without being
prescriptive.

Are inclusive. The Criteria describe an integrated
management framework that addresses all the factors that
define the organization, its operations, and its results.

Focus on common requirements, rather than procedures,
tools, or techniques.

Are adaptable. They can be used by large and small
businesses, and organizations with one site or worldwide
locations.

Are at the leading edge of validated management
practices.
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Baldrige Award Winners
Outperformed the S&P 500

The U.S. Department of Commerce studies the performance
of publicly held Baldrige Award winning companies.

Every year since 1991 they outperformed the Standard and
Poor’s index (S&P).

Baldrige winners outperformed the S&P 500 by 4.8 to 1.

1,101% increase in stock
performance was demonstrated,
compared to 228% from the S&P
index companies for the
same period.
National Council for Performance Excellence
It Makes Good Sense

Organizations that use a Performance Excellence process
achieve results*:

59% Higher Stock Price

111% Higher Operating Income

116% Higher Sales

114% Higher Total Asset
*Data from Singhal and Hendricks Study
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Baldrige Express eSurvey

The National Council for Performance Excellence
administers an organizational assessment survey
utilizing the Malcolm Baldrige Criteria for Performance
Excellence

The organizational assessment survey guides you
through the 7 categories, addressing each item of the
Criteria

The survey consists of 58 questions and takes
approximately 2 hours to complete online

The assessment tool uses a maturity scale to
determine the performance level

The Survey tool and Performance Indicator Feedback
Report are effective and efficient aides to
organizational assessment
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Baldrige Criteria for
Performance Excellence

Leadership

Strategic Planning

Focus on Patients, Other Customers, and
Markets

Measurement, Analysis, and Knowledge
Management

Staff Focus

Process Management

Organizational Performance Results
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Health Care Criteria for Performance Excellence
Systems Framework
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Eleven Core Values

Visionary Leadership

Patient-Focused Excellence

Organizational and Personal Learning

Valuing Staff and Partners

Agility

Focus on the Future

Managing for Innovation

Management by Fact

Social Responsibility and Community Health

Focus on Results and Creating Value

Systems Perspective
National Council for Performance Excellence
Choosing Baldrige

Your organization is facing increasing challenges
everyday.

Assess your readiness to respond to those challenges
by using the Baldrige Health Care Criteria

In the Health Care industry, organizations with worldclass results are able to achieve a score about 700
(70%) on the Baldrige scale.

Organizations early in their performance improvement
journey frequently score around 200 points.

Where would your organization score?
National Council for Performance Excellence
Benefits of the eSurvey Approach

Online, web-based, easily accessed from any PC

Accessible 24/7

Cost effective compared to alternative approaches

Technical support provided

Engage employees at all levels

Easy to use maturity scale to determine performance level

Receive internal and external feedback

Obtain high performance diagnostics from the feedback

3-day turnaround of Performance Indicator Feedback Report
upon completion of survey

Measure performance on a wide range of key organization
performance indicators

Evaluate key processes, systems and results

Identify organizational strengths, deployment gaps, and
pinpoint vital opportunities for improvement
National Council for Performance Excellence
The Performance Indicator
Feedback Report


When all survey data has been collected, an automated
Performance Indicator Feedback Report will be
generated and sent to you in three business days.
The Performance Indicator Feedback Report consists of:
 Demographic Charts
 Overall Scores
 Category-Level Scores
 Item-Level Scores
 Gap Analysis Charts
 Individual Question Scores
 Pareto Charts for each Category
 Priority Improvement Data Charts
 Approach and Deployment Comments
 Priority Improvement Comments
National Council for Performance Excellence
The Presentation

The following slides guide you through the
eSurvey process

Included with the following eSurvey snapshots
are sample reports to show how the data
collected is later represented in the Performance
Indicator Feedback Report.
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Type in your User
ID which you
received through
email (usually your
email address)
and unique
password. Click
‘Login to the
Survey’.
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Customized Demographic Profile
This is a sample of the table used to customize the Demographic Profile for your organization.
Position
Location
Function
Years of Service
Senior Management
Emergency
Medical Support
0 yrs. < 1 yr.
Other Staff
Main Bldg.
Clinician
1 yrs. < 3 yrs.
Doctor/Nurse
Outpatient
Customer Service
3 yrs. < 5 yrs.
Admin Support
5 yrs. < 10 yrs.
10+ yrs.

The Demographic Profile provides valuable comparative attributes within the organization.

Survey participants choose appropriate selections from the Demographic Profile to
indicate their position within the organization.

Comparative charts and data are presented in the Performance Indicator Feedback
Report according to the selections of the participants.
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Baldrige Express eSurvey
Demographic Selection (Sample Participant’s View)
Each different
demographic attribute
will appear on separate
pages. Participants
select the demographic
value that describes
their position within the
organization.
Vermont Council for Quality
Organization Demographics
The Demographic
Section is
designed to
provide the
organization with
an overall
response rate
relative to the
total number of
respondents and
their percentage
weight for each
demographic
attribute they
have chosen.
Attribute/Value
Number
Responded
Response as
% of Total
Position
Senior Management
Other Staff
Doctor/Nurse
Total
7
28.0
10
40.0
8
32.0
25
100%
This chart reflects sample demographic data collected
from the eSurvey and reported in the Performance
Indicator Feedback Report.
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eSurvey Status Page (Sample Participant’s View)
Once you have
completed the
Demographic
Profile, click on the
Leadership
Category to begin
the survey.
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Category 1, Question 1A of the Survey
Click the radio
button that best
describes the level
of development in
your organization.
Mouse over the
levels to view the
descriptors of each
level.
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Overall Score by Question and Current-State Descriptors
The Overall Score by Question and Current-State Descriptors show the overall percentage of points for
a theme within each category. Refer to the Scoring Guidelines in Appendix B to see the approach/
deployment percentage scoring. The ‘Current’ text describes the maturity level of where the organization
is now. The Role Model text describes where the organization could strive to be.
%
Row
%
1A
56
Current
Role Model
%
1B
56
Current
Role Model
%
1C
38
Current
Role Model
Description
Communicating Values and Performance Expectations [Baldrige ref: 1.1a(1)]
Mature - Often done well by many. Effectiveness is sometimes checked.
Nearly always done well. Effectiveness is regularly checked and improvements are constant.
Leadership Commitment to Providing Maximum Value for Patients and Other Customers [Baldrige ref: 1.1a(1)]
Mature - Often done well by many. Effectiveness is sometimes checked.
Nearly always done well. Effectiveness is regularly checked and improvements are constant.g improvements.
Empowering Staff and Establishing a Climate for Empowerment, Innovation, Organizational Agility, and Ethical
Behavior [Baldrige ref: 1.1a(2)]
Basically Effective - Occasionally done well by some.
Nearly always done well. Effectiveness is regularly checked and improvements are constant.
View
Appendix B
National Council for Performance Excellence
Priority Improvement Selections
(Sample Participant’s View)
After each category,
the eSurvey asks
participants to identify
two areas they believe
needs the most
improvement. This
data is reported as a
Pareto chart and
Priority Improvement
Data Chart in the
Feedback Report.
National Council for Performance Excellence
Pareto Charts

Staff members in your organization will be asked to select one or more
areas in each of the seven categories, which they feel, is in most need
of improvement. The concept of a Pareto chart is to show that the
areas in need of improvement are usually a vital few, allowing leaders
to concentrate their focus on specific improvement efforts.

We will supply you with a Pareto chart for each of the seven
categories, which reference each of the seven sections of the
Organization Assessment Survey.

Each chart will display the letters that correspond to the themes for
each of the seven categories along the x-axis. Along the y-axis both
Count and Percentages are charted. The count of staff votes (Hits) for
each area they believe is most in need of improvement is represented
as bars on the graph. The chart is arranged with the largest hit count
on the left of the graph, indicating the area selected by staff which they
feel is most in need of improvement. The line charted above the bars
represents the cumulative percentages of each bar, from left to right.
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Category 1 - Leadership
Areas Most Needing Improvement - Pareto Chart
50
45
100
98
96
100
100
100
Count
Cumulative
88
40
80
100
90
80
70
30
60
58
25
50
20
40
36
15
30
10
20
5
10
0
0
F
C
G
B
E
A
D
H
I
Letter Key for Category 1 - Leadership - Areas Most Needing Improvement
A
Communicating Values and Performance Expectations
[Baldrige ref: 1.1a(1)]
F
Setting Priorities and Making Improvements Based on
Progress Reviews [Baldrige ref: 1.1c(3)]
B
Leadership Commitment to Providing Maximum Value for
Patients and Other Customers [Baldrige ref: 1.1a(1)]
G
Improving Leadership Effectiveness Throughout the
Organization [Baldrige ref: 1.1c(4)]
C
Empowering Staff and Establishing a Climate for
Empowerment, Innovation, Organizational Agility and Ethical
Behavior [Baldrige ref: 1.1a(2)]
H
Following Laws and Regulations and Reducing Public
Risks and Concerns [Baldrige ref: 1.2a(1&2)]
D
Ensuring Management Accountability To Protect Stockholder
and Stakeholder Interests through Effective Governance
[Baldrige ref: 1.1b]
I
Ensuring Ethical Behavior [Baldrige ref: 1.2b]
E
Assessing Organizational Performance and Progress Relative to
Goals [Baldrige ref: 1.1c(1)]
J
Providing Community Support [Baldrige ref: 1.2c]
J
Hit Percentage
35
Hit Count
The letters F, C,
and G represent
an opportunity to
solve 80% of
key issues in
30% of the areas
(3 of 10) for the
category
(Leadership). In
this example, the
letters H, I, and
J, did not receive
any votes since
these areas
were not
selected by staff
as areas most in
need of
improvement.
National Council for Performance Excellence
Priority Improvement Counts and Percentages
Category 1 - Leadership - Priority Improvement Counts and Percentages - Position
Count
Percentage
F
C
G
B
E
A
D
H
I
J
Total
F
C
G
B
E
A
D
H
I
J
Senior Management
6
1
2
1
2
1
1
0
0
0
14
43
7
14
7
14
7
7
0
0
0
Other Staff
4
9
7
0
0
0
0
0
0
0
20
20
45
35
0
0
0
0
0
0
0
Doctor/Nurse
8
1
2
3
2
0
0
0
0
0
16
50
6
13
19
13
0
0
0
0
0
Total
18
11
11
4
4
1
1
0
0
0
50
36
22
22
8
8
2
2
0
0
0
This chart shows priority improvement selections according to the various
Demographic attributes and values. Look at “C” and “G” and you will see that Other
Staff identified the need to improve these areas by a greater margin than did Senior
Management and Doctors/Nurses. This tends to indicate a deployment gap and
suggests that Senior Management and Doctors/Nurses are not perceived as
effective as they believe themselves to be.
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Priority Improvement Comments
(Sample Participant’s View)
Participants offer
approach/deployment
comments and
suggestions for
improvement on their
first selection.
Approach and
Deployment
comments are
requested for
each Category
priority
improvement
selection.
Participants offer suggestions for
improvement on the process.
National Council for Performance Excellence
Priority Improvement Comments
(Sample Participant’s View)
Participants offer
approach/deployment
comments and
suggestions for
improvement on their
second selection.
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Leadership Row-Level Comments by Position
1A Communicating Values and Performance Expectations [Baldrige ref: 1.1a(1)]
Position/Senior Management
Approach & Deployment: We do a great job communicating to all. Through e-mails, town hall meetings, Intranet. Scorecards for
the whole organization, sectors and local offices in place. Rules of Operation being implemented and communicated very efficiently.
Approach & Deployment: We use many techniques to communicate including all hands meetings each quarter, weekly notes from
the exec office, email, voice mail.
Position/Other Staff
Approach & Deployment: The scorecard is resented and the financial result and forecast are sometimes known.
Action Steps to Improve: Get more input from contributors for the scorecard. Make the results known.
Approach & Deployment: Some goals are linked to the balanced scorecard but many have not been seen as major objectives.
Many goals are very ad hoc and changeable, leaving staff unsure on direction. Many times effort is expended only to see that it has
been wasted because of a change in direction or emphasis.
Position/Doctor/Nurse
Approach & Deployment: The issue in the local office is that most of the top management has left the organization and is now not
fully replaced. There are still some gaps in the organization, which create some lack of communication. The checking of the
effectiveness to focus on patients does not seem to be done often.
Comments are provided by the respondents and can be prepared and used by examiners and
organization leaders for improvement planning. The comments are sorted by each category and
theme statement. Comments are reported out by one attribute, in this case, “Position”. They are
then sorted by each value such as “Senior Management”, “Other Staff”, and “Doctor/Nurse”.
National Council for Performance Excellence
Completed Survey Status Page
When you have entered
answers to every
question for each
category, you can
submit your survey.
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Summary Results
Overall Category-Level Totals
Baldrige Criteria
Total
Points
Points
Scored
% of
Total
Pts.
120
65
54
2. Strategic Planning
85
34
40
3. Focus on Patients, Other Customers, and Markets
85
34
40
4. Measurement, Analysis, & Knowledge Mgmt
90
25
28
5. Staff Focus
85
34
39
6. Process Management
85
30
35
450
205
45
1000
427
43%
1. Leadership
7. Organizational Performance Results
Totals
The Overall Category-Level Totals table explains the amount of points scored for
each category, the total possible points to score in a category and the percentage of
total points for each category.
National Council for Performance Excellence
Overall Category-Level Percent Scores
100
The Overall Category-Level Percent Scores show the
aggregate percent score of each Category according
to the Baldrige Scoring Guidelines. This helps
determine the overall strengths and weaknesses of
the organization.
90
80
Percent of Possible Points
70
60
54
50
45
40
40
39
40
35
28
30
20
10
0
Leadership
Strategic Planning Focus on Patients,
Measurement,
Other Customers,
Analysis, &
and Markets
Knowledge Mgmt
Staff Focus
Process
Management
Organizational
Performance
Results
National Council for Performance Excellence
Overall Item-Level Percent Scores
100
The Overall Item-Level Percent Scores show the
percent of points on a 0 to 100 scale, for each Item.
This helps users determine, at a glance, the strengths
and weaknesses by item for each category. The Items
and Point Values are explained in Appendix A.
90
80
Percent of Possible Points
70
62
60
60
53
50
51
53
50
45
40
45
44
36
36
35
29
30
27
45
36
33
27
26
View
Appendix A
20
10
0
Item
1.1
Item
1.2
Item
2.1
Item
2.2
Item
3.1
Item
3.2
Item
4.1
Item
4.2
Item
5.1
Item
5.2
Item
5.3
Item
6.1
Item
6.2
Item
7.1
Item
7.2
Item
7.3
Item
7.4
Item
7.5
Item
7.6
National Council for Performance Excellence
Overall Category-Level Point Scores
Position Point Scores by Category
1000
900
Total Possible Points
800
700
The Category-Level Point Scores show the cumulation
of total points for each demographic view within each
category. This is a sample of one demographic view.
600
500
400
300
200
100
0
Senior Management
Other Staff
Doctor/Nurse
Leadership
84
53
61
Strategic Planning
55
19
31
Focus on Patients, Other Customers, and
Markets
41
30
32
Measurement, Analysis, and Knowledge Mgmt
37
17
28
Staff Focus
43
29
34
Process Management
37
26
28
Organizational Performance Results
237
190
181
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Item-Level Percent Scores by Position
Position Percent Scores by Item
100
90
80
Notice the gap between Senior Management and Other
Staff and Doctors/Nurses in Item 1.1. This suggests an
area to examine further.
However, Item 7.4 shows a high degree of agreement
indicating a consistent deployment of results information.
Senior Management
Other Staff
Doctor/Nurse
Percent of Possible Points
70
60
50
40
30
View
Appendix A
20
10
0
Item 1.1 Item 1.2 Item 2.1 Item 2.2 Item 3.1 Item 3.2 Item 4.1 Item 4.2 Item 5.1 Item 5.2 Item 5.3 Item 6.1 Item 6.2 Item 7.1 Item 7.2 Item 7.3 Item 7.4 Item 7.5 Item 7.6
This chart shows the ratings by demographic attribute, in this case, Position. On the previous graph, Item 1.1,
Leadership System, reflected a rating of 50%. However, according to the breakout above, Sr. Mgmt. believe the
processes are much stronger (69 percent) than Other Staff (less than 38 percent) and Doctors/Nurses (45 percent).
This typically indicates incomplete systems development or poor deployment of existing systems and processes
required by the Item.
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Other Services

Additional Performance Indicator Feedback Reports can be
extracted from the demographic profile. For example:
Reports can be generated for each organizational site or
department identified in the demographic profile.

The data that is entered into the survey is available in an
ASCII Text File to create additional charts.

Comparative data at the Category-level is available from
previous assessments from the same organization.

Additional copies of the Performance Indicator Feedback
Report are available.
National Council for Performance Excellence
Thank you!
Michigan Quality Council
[email protected]
248-370-4552
In cooperation with
National Council for Performance Excellence
National Council for Performance Excellence
Appendix A: Assessment Themes and Values
The point values of the scoring system are linked directly to the points and scoring system of the
Malcolm Baldrige Criteria for Performance Excellence. Each item and the questions included in the
items are also derived from the Baldrige Criteria.
2004 Categories, Items, and Point Values
1.0 Leadership
120 points
1.1 Organizational Leadership
80 points
1A Communicating Values and Performance Expectations [Baldrige ref: 1.1a(1)]
1B Leadership Commitment to Providing Maximum Value for Patients and Other Customers and Stakeholders [Baldrige ref: 1.1a(1)]
1C Empowering Staff and Establishing a Climate for Empowerment, Innovation, Org. Agility, and Ethical Behavior [Baldrige ref: 1.1a(2)]
1D Ensuring Mgmt Accountability To Protect Stockholder and Stakeholder Interests through Effective Governance [Baldrige ref: 1.1b]
1E Assessing Organizational Performance and Progress Relative to Goals [Baldrige ref: 1.1c(1)]
1F Setting Priorities and Making Improvements Based on Progress Reviews [Baldrige ref: 1.1c(3)]
1G Improving Leadership Effectiveness Throughout the Organization [Baldrige ref: 1.1c(4)]
1.2 Social Responsibility
40 points
1H Following Laws and Regulations and Reducing Public Risks and Concerns [Baldrige ref: 1.2a(1&2)]
1I Ensuring Ethical Behavior [Baldrige ref: 1.2b]
1J Providing Community Support [Baldrige ref: 1.2c]
2.0 Strategic Planning
85 points
Back to
Overall Item
Scores
2.1 Strategy Development
40 points
2A Developing Strategic Plans Based on Health Care Service Performance Data [Baldrige ref: 2.1a(1&2)]
2B Developing Clear Strategic Objectives and Timetables for Meeting the Objectives [Baldrige ref: 2.1b(1)]
2C Ensuring that Strategic Objectives Address Challenges and Balance the Needs of Key Patients, Other Customers and Stakeholders
[Baldrige ref: 2.1b(2)]
2.2 Strategy Deployment
45 points
2D Developing and Deploying Action Plans Based on Strategic Objectives [Baldrige ref: 2.2a(1)]
2E Developing Staffing Plans Based on Strategic Objectives and Action Plans [Baldrige ref: 2.2a(3)]
Back to Gap
2F Developing Appropriate Goals and Allocating Resources to Achieve Them [Baldrige ref: 2.2a(4) and 2.2b]
Analysis
2G Aligning Work to Achieve Strategic Goals, Objectives, and Action Plans [Baldrige ref: 2.2a]
National Council for Performance Excellence
Appendix B: Scoring Guidelines for Categories 1-6:
SCORE
0% or 5%
10%, 15%,
20%, or 25%
30%, 35%,
40%, or 45%
50%, 55%,
60%, or 65%
PROCESS
 No systematic approach is evident; information is anecdotal. (A)
 Little or no deployment of an approach is evident. (D)
 No evidence of an improvement orientation; improvement is achieved through reacting to
problems. (L)
 No organizational alignment is evident; individual areas or work units operate independently. (I)
 The beginning of a systematic approach to the basic requirements of the Item is evident. (A)
 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. (D)
 Early stages of a transition from reacting to problems to a general improvement orientation are
evident. (L)
 The approach is aligned with other areas or work units largely through joint problem solving. (I)
 An effective, systematic approach, responsive to the basic requirements of the Item, is evident. (A)
 The approach is deployed, although some areas or work units are in early stages of deployment. (D)
 The beginning of a systematic approach to evaluation and improvement of key processes is evident.
(L)
 The approach is in early stages of alignment with your basic organizational needs identified in
response to the other Criteria Categories. (I)
 An effective, systematic approach, responsive to the overall requirements of the Item, is evident.
(A)
 The approach is well deployed, although deployment may vary in some areas or work units. (D)
 A fact-based, systematic evaluation and improvement process and some organizational
LEARNING are in place for improving the efficiency and effectiveness of key processes. (L)
 The approach is ALIGNED with your organizational needs identified in response to the other
Criteria Categories. (I)
The overall percentage of points for 1A on the previous slide is 56%, indicating
the above Approach and Deployment guideline.
Back to
Survey Priority Imp