Transcript The AHCA Quality Award

2008 AHCA/NCAL National
Quality Award Program
- Step III Overview Jon Frantsvog
Ira Schoenberger
Tim Case
The 2008 Step III Criteria
Leadership
Strategic Planning
Focus on Patients, Other Customers and Markets
Measurement, Analysis, and Knowledge Management
Workforce Focus
Process Management
Results
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4. Measurement, Analysis, and
Knowledge Management (90 pts.)
Addresses Analysis, Review, and Improvement of
Organizational Performance and Management of
Data, Knowledge, and Information
4.1 Measurement, Analysis, and Improvement of
Organizational Performance (45 pts.)
4.2 Management of Information, Information
Technology, and Knowledge (45 pts.)
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5. Workforce Focus (85 pts.)
Addresses How an Organization Engages,
Develops, and Manages Its Workforce and Builds
an Effective Workforce Environment
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5.1
Workforce Engagement (45 pts.)
5.2
Workforce Environment (40 pts.)
6. Process Management (85 pts.)
Addresses How an Organization Designs Its
Work Systems, Prepares for Emergencies, and
Manages and Improves Its Work Processes
6.1 Work Systems Design (35 pts.)
6.2 Work Process Management and
Improvement (50 pts.)
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7. Results (450 pts.)
Addresses Progress on Results—Including Current
Performance Levels, Trends, and Comparative Data
7.1 Health Care Outcomes (100 pts.)
7.2 Patient- and Other Customer-Focused Outcomes (70 pts.)
7.3 Financial and Market Outcomes (70 pts.)
7.4 Workforce-Focused Outcomes (70 pts.)
7.5 Process Effectiveness Outcomes (70 pts.)
7.6 Leadership Outcomes (70 pts.)
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7.1 Health Care Outcomes
N1. Health care results reported in this Item should
relate to the key health care features identified as
patient and other customer requirements or
expectations in P.1b(2), based on information
gathered in Items 3.1 and 3.2. The measures or
indicators should address factors that affect patient
and other customer preference, such as those
included in Item P.1, Note 7, and Item 3.1, Note 4.
See other notes (N2 and N3) in this section.
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7.2 Patient- and Other CustomerFocused Outcomes
N1. Patient and other customer satisfaction and
dissatisfaction results reported in this Item should
relate to the patient and other customer groups and
market segments discussed in P.1(b)2 and Item 3.1
and to the determination methods and data described
in Item 3.2. Other customers might include patients’
families, the community, insurers and other third-party
payers, employers, health care providers, patient
advocacy groups, Department of Health, and students.
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7.2 Patient- and Other CustomerFocused Outcomes
N2. There may be several different dimensions of
patient satisfaction, such as satisfaction with the quality
of care, satisfaction with provider interactions,
satisfaction with long-term health outcomes, and
satisfaction with ancillary services. All of these areas
are appropriate satisfaction indicators.
N3. Measures and indicators of patients’ and other
customers’ satisfaction with your services relative to
their satisfaction with competitors or other
organizations providing similar health care services
(7.2a[1]) might include information and data from your
customers and from independent organizations.
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7.3 Financial and Market Outcomes
Responses to 7.3a(1) might include aggregate
measures of financial return, such as return on
investment (ROI), operating margins, profitability, or
profitability by health care market or patient and
other customer segment. Responses also might
include measures of financial viability, such as
liquidity, debt-to-equity ratio, days cash on hand,
asset utilization, cash flow, and bond ratings (if
appropriate). Measures should relate to the financial
measures reported in 4.1a(1) and the financial
management approaches described in Item 2.2.
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7.4 Workforce-Focused Outcomes
N1. Results reported in this Item should relate to processes
described in Category 5. Your results should be responsive to
key work process needs described in Category 6 and to your
organization’s action plans and human resource plans
described in Item 2.2.
N2. Responses to 7.4a(1) should include measures and
indicators identified in response to 5.1c(1).
N3. Results for paid staff, independent practitioners, volunteers,
and health profession students should be included, as
appropriate.
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7.5 Process Effectiveness Outcomes
N1. Results reported in Item 7.5 should address your key
operational requirements as presented in the Organizational
Profile and in Items 6.1 and 6.2. Include results not reported in
Items 7.1–7.4.
N2. Results reported in Item 7.5 should provide key information for
analysis and review of your organizational performance (Item 4.1)
and should provide the operational basis for health care outcomes
(Item 7.1), patient- and other customer-focused outcomes (Item
7.2), and financial and market outcomes (Item 7.3).
N3. Appropriate measures and indicators of work system
performance (7.5a[1]) might include audit, just in- time delivery,
and acceptance results for externally provided products, services,
and processes; supplier
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7.6 Leadership Outcomes
N1. Measures or indicators of strategy and action plan
accomplishment (7.6a[1]) should address your strategic
objectives and goals identified in 2.1b(1) and your action plan
performance measures and projected performance identified in
2.2a(6) and 2.2b, respectively.
N2. For examples of measures of ethical behavior and
stakeholder trust (7.6a[2]), see Item 1.2, Note 7.
N3. Responses to 7.6a(3) might include financial statement
issues and risks, important internal and external auditor
recommendations, and management’s responses to these
matters. For some nonprofit health care organizations, results of
IRS 990 audits also might be included.
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7.6 Leadership Outcomes
N4. Accreditation, assessment, and regulatory and legal
compliance results (7.6a[4]) should address requirements
described in 1.2b. If your organization has received sanctions or
adverse actions under law (including malpractice), regulation,
accreditation, or contract during the past three years, briefly
describe the incident's) and current status. If settlements have
been negotiated in lieu of potential sanctions or adverse actions,
give explanations. Workforce-related occupational health and
safety results (e.g., Occupational Safety and Health
Administration [OSHA] reportable incidents) should be reported in
7.4a(3).
N5. Organizational citizenship and community health results
(7.6a[5]) should address support of the key communities
discussed in 1.2c.
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The Step III (Baldrige)
Application
Tackling the Beast
The Project Team
Project leader who ensures that the outline and
eventual application stays on target, both for timeline
and content.
Management team and select floor staff provide
input.
Strong business writer has to bring together the input
of the staff.
A camel is a horse designed by a committee.
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Writing the Application
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Be very thorough in response to the criteria. Address every
section of each criterion.
Make sure you are referring to the footnotes after each
question to ensure you are linking to other sections.
Provide examples to illustrate your point.
When addressing questions referred to the scoring grid make
sure you share with us how your organization approaches,
deploys, aligns and integrates processes for each section as
applicable.
Prioritize what is most important to your organization.
Remember you only have 44 pages.
Plan ahead, outline before writing.
Write in complete narrative sentences. Say enough, say it
well, then stop.
Suggested Work Plan
Start now
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Review application materials (AHCA/NCAL and Baldrige).
Note that from year to year questions and requirements
may change.
Identify what each criterion requires.
October - November - Develop a Plan of Attack
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Review Section 7 and refer back to footnote sections as
applicable link to other sections.
Review all sections and footnotes and link as applicable to
other sections.
Gather information. Farm out information gathering to
department heads and other staff.
Develop a strong outline for each section (watch space
budget!
Suggested Work Plan
December - March
• Write the sections and review weekly with team.
• Develop strong draft before 2/28.
• Solicit guidance as needed, the sooner the better.
• Check request, if necessary.
March
• Polish.
• Study requirements and submittal instructions.
• Submit by March 31, 2008.
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Engage Others in Learning
Step III will engage staff with leaders in
growing and learning
Set up teams and divide work
Work with employees who embrace it
Establish meeting times and requirements
Communicate across teams
Celebrate achievement
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Step III Keys to Success
Articulate systematic processes, not just anecdotal
evidence
Systems and processes aligned and deployed with
mission-driven strategic and operational goals
Strong evidence of a quality management system
with focus on the customer
Demonstrate measurement, analysis, and action on
performance results of key processes
Performance results show improvement over time,
but need not be always best in class
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Step III Keys to Success
Applicants who address all criteria
thoroughly and specifically,
according to the criteria, are likely
to be successful.
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Step III Award Recipients
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Step III Award recipients:
Demonstrate an effective, systematic approach to all
of the requirements in each category that is well
deployed with evidence of fact-based and
systematic evaluation, improvement, learning and
innovation.
Show how each approach is aligned or integrated
with the organization’s needs as described in the
Organizational Profile and other process areas.
Are able to effectively demonstrate by approach,
deployment, and level and consistency of results
that they are “best-in-class.”
Receiving the Award…
Reaping the Benefits
Press releases
Family letters
Pins and plaques
Marketing and advertising (using the logo)
Community and Recognition Events
Laying the groundwork for the next step
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AHCA/NCAL Quality Award
Eligibility
Member of AHCA/NCAL
No substandard quality of care or immediate
jeopardy on standard or (substantiated) complaint
surveys within the last three years
Applicants at Step II and Step III levels must have a
3-year weighted average survey deficiency score
that is no higher than 3-year weighted average in
their state
Step III applicants must have previously received the
Step I and Step II Awards
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Technical Requirements
Due electronically March 31, 2008
44-page limit
1” Margins
12-pt Times New Roman font
$475 application fee
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2008 Quality Award Schedule
Step I Award Application Deadline
Step II and III Award Application Deadline
Application Assessment/Scoring
Step II Award Recipient Notification
Step I Award Recipient Notification
Step III Award Recipient Notification
Feedback Report Distribution Deadline
AHCA/NCAL Convention and Award Ceremony
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February 28, 2008
March 31, 2008
April – July 2008
June 30, 2008
July 31, 2008
August 15, 2008
September 30, 2008
October 5-8, 2008
Resources
AHCA/NCAL Quality Award program
requirements and application information
(www.ahcancal.org).
Baldrige National Quality 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
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.
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Continuous Quality Improvement: Using the Regulatory
Framework by Barbara Baylis
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Developing a Quality Management System: The Foundation for
Performance Excellence in Long Term Care by Bernie Dana
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Quality Management Integration in Long-Term Care: Guidelines
for Excellence by Maryjane Bradley and Nancy Thompson
For more information...
For more information about the
AHCA/NCAL Quality Award
Program, please contact Wendy
Vernon at [email protected] or
202-898-2853.
www.ahcancal.org