Transcript Session Title Here - Indiana Association for Healthcare Quality

The Baldrige Criteria:
A Design for Performance
Excellence
Katherine J. Wallace
Director, Performance Improvement
Indiana Hospital Association
[email protected]
317-423-7740
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Objectives
• Identify the history and structure of the
Baldrige Performance Excellence Program
• Learn how the Baldrige Criteria for
Performance Excellence provide a
framework for improvement of bottom-line
results
• Identify first steps to begin your journey to
becoming a role model organization
2
Death by PowerPoint
The Important Objectives
• Why are you here?
• What would you like to know when you
leave this session today?
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Is this stuff easy?
“Listen buddy, if I could
explain it in fifty words
or less, it wouldn’t be
worth a Nobel prize.”
Attributed to Robert Feynman,
1965 Nobel Laureate in Physics
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Why Baldrige?
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Why Baldrige?
• Baldrige hospitals, as a group, were about 83
percent more likely than non-Baldrige hospitals
to be awarded a 100 Top Hospitals national
award for excellence in balanced organizationwide performance.
• Baldrige hospitals were significantly more likely
than their peers to display faster five-year
performance improvement.
• Baldrige hospitals outperformed non-Baldrige
hospitals on nearly all of the individual measures
of performance used in the 100 Top Hospitals
composite score.
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A System for Improvement
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Why Baldrige?
• It is consistent with a “benchmarking”
approach
• Comprehensive view of the system
• Forces self-assessment
• Guide to create environments for
performance excellence.
• Turns the informal into formal
• Great feedback report!
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What can Baldrige do for you?
• Help you face the fact that you could be
much better
• Help you integrate all of your improvement
efforts
• Help guide you to your areas of weakness
• Provide a focus on what you are doing well
• Give you a chance to celebrate
• Elevate the pride and aspirations of your staff
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How does it compare to other regulatory
bodies and initiatives?
• Baldrige is not required.
• Baldrige is not prescriptive.
• Baldrige criteria provides a framework for
self-assessment that guides organizations to
create environments for performance
excellence.
What is it?
• Evidence-based, results-oriented criteria
aimed at improving organizational
performance
• Established by Congress in 1987 and named
after Malcolm Baldrige, Secretary of
Commerce (1981 – 1987)
• Created Award program to:
– identify/recognize role model businesses
– establish criteria for evaluating improvement
efforts
– disseminate/share best practices
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Organizations committed to a
journey to excellence focus on:
• How they meet and exceed customers’
needs
• Their strategic challenges and
advantages
• Knowing the competition
• Their systematic approach to
performance improvement
What does it look like?
A winner’s story….
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Excellent organizations…
• Have an approach to address what’s
important.
• Systematically deploy or hardwire the
approach throughout the organization
• Use data from what they learn to create
cycles of improvement
• Effectively apply what they have learned to
create improvement across the organization
that supports organization-wide goals.
• Describe performance in numerical terms
and over a period of time
• Describe how their performance compares
with other organizations
Building on the Framework….
Process Review - ADLI
Approach
Deployment
• Methods used
• Appropriateness, effectiveness
• Repeatable, based on data,
systematic
• Consistently applied
• Used by all appropriate areas
Learning
•Cycles of Evaluation &
Improvement
•Encourage Innovation
•Sharing Improvements &
Innovations
Integration
• Aligned with organizational
needs
• Complementary across
processes
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What should we expect?
• The Baldrige criteria can accelerate
performance improvement efforts of all
size hospitals, regardless where they are
in their quality journey.
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First Set of Questions – the OP*
Who are you?
What is it that you do?
• Organizational Profile
– Initial self-assessment
– Clarify operating environment and key
relationships
– Describe competitive environment
– Describe key strategic challenges and
advantages
– Describe system for performance improvement
*Organizational Profile
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Followed by …Process Questions
How do you do it?
How do you keep improving?
•
Six “process” categories:
1. Leadership
2. Strategic Planning
3. Customer Focus
4. Measurement, Analysis, and Knowledge
Management
5. Workforce Focus
6. Operations Focus
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Finally … Results Questions
How well do you do it?
How do you know?
• Five results items
– Each process category is linked to an
associated results item, although process
categories and results items are not in the
same order
– Results are expected to be summarized and
segmented as appropriate for all key areas
and key processes, including comparative
data
– Measure the things that are important to
your success
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Baldrige Health Care Criteria
Framework: A Systems Perspective
22
Another Look at the Baldrige
Framework
Ingredients to Optimum Performance
Requirements
Patients/
Customers
Leadership
Meet
Delight
Motivated
people
Get results
Be valued
Strategy
Efficient
Processes
Data and scorecard to monitor progress
Predict Outcomes
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Criteria Structure
• Categories (1, 2, …)
–Items (1.1, 1.2, 2.1, …)
• Areas to Address (a, b, c, …)
– Questions
» Explanatory Notes
“Anatomy” of the Criteria
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Criteria book – pg 29
Category 1: Leadership (120 pts.)
Addresses Senior Leaders’ Actions,
Governance, and Societal Responsibilities
1.1 Senior Leadership (70 pts.)
1.2 Governance and Societal
Responsibilities
(50 pts.)
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The Leadership Category
•
•
•
•
•
•
•
•
•
Vision, Mission, and Values
Promoting Legal and Ethical Behavior
Creating a Sustainable Organization
Communication
Focus on Action
Governance System
Performance Evaluation
Societal Well Being
Community Support
The Importance of the Vision and
Mission
• Begin with the end in
mind. – Stephen
Covey
• People often say that
motivation doesn't
last. Well, neither
does bathing - that's
why we recommend it
daily. - Zig Ziglar
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Does your Organization have an
Effective Vision and Mission
Statement?
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Category 2: Strategic Planning (85 pts.)
Addresses Strategic and Action Planning and
Deployment of Plans
2.1 Strategy Development (40 pts.)
2.2 Strategy Deployment (45 pts.)
30
Strategic Planning Category
• Strategic Planning Process
• Strategic Objectives
• Action Plan Development & Implementation
• Resource Allocation
• Workforce Plan
• Performance Measures
• Performance Projections
The Importance of Strategic
Planning
• If you don't know
where you are going,
you will wind up
somewhere else. Yogi Bera
• Meticulous planning
will enable everything
a man does to appear
spontaneous. -Mark
Caine
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Category 3: Customer Focus (85 pts.)
Addresses How an Organization Engages Its
Customers and Listens to the Voice of the Customer
3.1 Voice of the Customer (45 pts.)
3.2 Customer Engagement (40 pts.)
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Customer Focus Category
• Quantification of
customer needs is
the key.
Customerdefined value
Satisfaction Determination
Map and
understand
value stream
Percent Satisfaction with Product, Service Attributes
100
ers
% OnmTime
9 9
All
Cu
sto
BA
R
BA
R
SE
RV
ICE
9 8
Non-egg Supplier
Claims
2002
2003
2004
2005
9 7
BAR 2002
BAR 2003
9 6
9 5
'01
'02
SFF OTD
2
1
0
D
T
Y
'0 1
•
•
•
•
Segmentation
Data Use
Relationship Management
Complaint Management
'03
'04
'05
3
.
2001
All
Cu
sto
me
rs
QU
AL
ITY
40
A
Continuous
process
improvement
1 00
60
vg
• Use feedback
and analyses
to improve
On Time Delivery
80
P ounds P roduc e d
Make value
stream flow
• Performance
measures, and
analyses
C om pla ints pe r M illion
• Listening to
Patients and
Stakeholders –
Current and
Potential
• Engagement
• Satisfaction
and
Dissatisfaction
'0 2
'0 3
'0 4
'0 5
'0 6 Y T D
BAR OTD
'06 YTD
The Importance of the Customer
• Whoever understands
the customer best
wins. - Mike Gospe
• 95% of companies
collect customer
feedback. Yet only
10% use the
feedback to improve,
and only 5% tell
customers what they
are doing in response
to what they heard.
- Gartner Group
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Category 4: Measurement, Analysis,
and Knowledge Management (90 pts.)
Addresses Analysis, Review, and Improvement of
Organizational Performance and Management of
Data, Knowledge, and Information Resources
4.1 Measurement, Analysis, and Improvement
of Organizational Performance (45 pts.)
4.2 Management of Information, Knowledge, and
Information Technology (45 pts.)
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•
•
•
•
•
•
•
Measurement, Analysis, and Knowledge
Management Category
Performance
Measures
Comparative
Data
Patient and
Stakeholder Data
Measurement
Agility
Best Practice
Sharing
Future
Performance
Continuous
Improvement &
Innovation
• Data, Information,
& Knowledge
Management
• Property
• Availability
• Information
Resources &
Technology
• Hardware &
Software
• Emergency
Availability
The Importance of Measurement
• An acre of performance
is worth a whole world
of promise. - William
Dean Howells
• Measurement is the
first step that leads to
control and eventually
to improvement. If you
can't measure
something, you can't
understand it. If you
can't understand it, you
can't control it. If you
can't control it, you
can't improve it.
- H. James Harrington
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Category 5: Workforce Focus (85 pts.)
Addresses How an Organization Engages,
Develops, and Manages Its Workforce and Builds
an Effective Workforce Environment
5.1 Workforce Environment (40 pts.)
5.2 Workforce Engagement (45 pts.)
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Workforce Focus Category
100
95
90
85
80
75
70
65
60
55
50
Employee Engagement
85.6
79.9
70.2
56.7
2005
59.6
2006
2007
2008
2009
• Workforce Capability and Capacity
• Workforce Climate
• Workforce Performance
• Measurement of Workforce Engagement
• Workforce and Leader Development
The Importance of the Workforce
• “Turned on” people
figure out how to beat
the competition.
“Turned off” people
only complain about
being beaten by the
competition. - Ben
Simonton
• We treat our people
like royalty. If you
honor and serve the
people who work for
you, they will honor
and serve you. –
Mary Kay Ash
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Category 6: Operations Focus (85 pts.)
Addresses How an Organization Designs Its Work
Systems; Prepares for Emergencies; and Designs,
Manages, and Improves Its Work Processes
6.1 Work Systems (45 pts.)
6.2 Work Processes (40 pts.)
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Operations Focus Category
• Work System Design
• Work System Management
• Emergency Readiness
Cpk=1.25
n'
Ja
02
Process Avg
LCL
• Work Process Design
• Work Process Management
n'
Ja
03
Spec Target
Upper Spec Limit
Cpk= 4.42
r
Ma
'05
UCL
Lower Spec Limit
The Importance of Operations
• If you can't describe
what you are doing as
a process, you don't
know what you are
doing. - W. Edwards
Deming
• A company can seize
extra-ordinary
opportunities only if it
is very good at the
ordinary operations. Marcel Telles
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Category 7: Results (450 pts.)
Addresses an Organization’s Performance and Improvement in Key Areas and
Includes
Current Performance Levels, Trends, and
Comparative Data
7.1 Health Care & Process Outcomes (120
pts.)
7.2 Customer-Focused Outcomes (90 pts.)
7.3 Workforce-Focused Outcomes (80 pts.)
7.4 Leadership & Governance Outcomes
(80 pts.)
7.5 Financial and Market Outcomes (80
pts.)
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Results Category
Baldrige addresses all results—process,
leadership, product, customer, financial,
and workforce.
Results: Drop-Out Rates
Drop-Out Rate
7.00%
6.00%
5.00%
4.00%
3.00%
2.00%
1.00%
0.00%
1999
2000
2001
2002
School Year
2003
2004
Building on the Framework….
Outcomes Review - LeTCI
Levels
•Current performance
Trends
•Improvement
•Sustainability
• Appropriate
• Industry Leader
• Benchmarks
Comparative
Integration
•Aligned with organizational needs
•Address measures important to
patient, health care service, market,
process, and action plans
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The Importance of Results
• Don't rate potential
over performance. - Jim Fassel
• An acre of
performance is worth
a whole world of
promise. - William
Dean Howells
Baldrige Application Components
Organizational
Profile
What’s important?
Passion
Process
What do we do and How
do we do it?
Results
Were we successful?
Principles
Results
Linkage and Alignment Across your Organization
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If we don’t do it, it’s only a few of the
1,000 points! Is it that important?
It’s all about linkages and integration…..
Organizational Profile
Results
Leadership
Strategic Planning
Operations Focus
Customer Focus
Workforce Focus
Measurement, Analysis, &
Knowledge Management
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Steps Toward Mature Processes
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The Baldrige Criteria, Six Sigma, and Lean are complementary, not
mutually exclusive. Many organizations use Baldrige to develop an overall
performance map to identify areas that need improvement, and then they
may use one or more of these tools to design operations or improve
processes within the organization.
.
Baldrige Health Care
Award Recipients
•
•
•
•
•
2002 SSM, St. Louis, MO
2003 St. Luke’s, Kansas City, MO
2003 Baptist Hospital, Pensacola, FL
2004 RWJ Hospital, Hamilton, NJ
2005 Bronson Methodist Hospital,
Kalamazoo, MI
• 2006 North Mississippi Medical Center,
Tupelo, MS
• 2007 Mercy Health System, Janesville, WI
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Baldrige Health Care
Award Recipients
• 2007 Sharp Healthcare, San Diego, CA
• 2008 Poudre Valley Health System, Fort
Collins, CO
• 2009 Atlanticare, Egg Harbor, NJ
• 2009 Heartland Health, St. Joseph, MO
• 2010 Advocate Good Samaritan, Downers
Grove, IL
• 2011 Schneck Medical Center, Seymour, IN
• 2011 Henry Ford Health System, Detroit, MI
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Baldrige lessons from a CEO:
•
•
•
•
•
The senior team has to drive it
Get on the train--don’t wait
Send people to Examiner Training
Executive Team as Category Leaders
The first feedback report and your next
application is when the real learning begins
• Write to describe how you actually work
rather than what you think they want to hear
56
Baldrige lessons from a CEO:
The objective is to improve,
not to win.
57
Getting Started
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How Do Organizations Use the
Baldrige Criteria?
• National Baldrige Application
– New Criteria for Applying
• State Award Program
– The Performance Excellence Program
• Internal Management System
– Focused, internal effort
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How do you get Started?
• Commit to the journey.
• Complete the Organizational Profile as the
first step in a full self-assessment.
• Answer the 18 Baldrige Criteria Item title
questions for a fuller understanding of the
Criteria and your organization’s performance.
• Finally, conduct a full self-assessment using
the seven Baldrige Criteria Categories.
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How do you get Started?
The
Partnership
for
Excellence
Helping organizations
see improved results
* Ohio * Indiana * West Virginia *
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Started in 1998
• Ohio Award for Excellence
Ohio Partnership for Excellence
The Partnership for Excellence
• Uses Baldrige Criteria for Performance
Excellence
– Advising - Organizational Profile only
– Partnering
• Profile and abbreviated application
• Address “overall” level of the criteria
– Examining
• Full application – Bronze, Silver, Gold, Platinum
recognition levels
• Address “multiple” requirements
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How do you get Started?
Baldrige Examiners
• Help you understand the Criteria and how
to apply them in your self-assessment and
action efforts.
• Coach the Executive Team
• Facilitate internal efforts
63
How do you get Started?
•
•
•
•
Baldrige Award Recipients
Honor their responsibility to serve as
performance improvement advocates
Share their strategies, and serve as role
models.
Host Baldrige sharing days
Many undertake ongoing self-assessments
of their organizations and can share their
experiences with you.
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How do you get Started?
• Attend a conference and learn how
organizations achieve role model
performance:
– TPE Conference
– The Quest for Excellence
– Regional Conferences
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Resources for More Information
• Most Baldrige National Quality Program
(BNQP) documents are available both in
printed form and on the BNQP Web site.
• To obtain documents, call (301) 975-2036,
e-mail [email protected] , or visit
www.nist.gov/baldrige
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“I see the Baldrige process as a powerful set
of mechanisms for disciplined people engaged
in disciplined thought and taking disciplined
action to create great organizations that
produce exceptional results.”
- Jim Collins, Good to Great
Thank you
Katherine J. Wallace
Director, Performance Improvement
Indiana Hospital Association
[email protected]
317-423-7740
68