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Baldrige Excellence Framework
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The Malcolm Baldrige, Baldrige Performance Excellence Program National Quality Award. National Institute of Standards and Technology NIST United States Department of Commerce. The Malcolm Baldrige National Quality Award created. January 2015 by Public Law 100 107 in 1987 is the highest level of. national recognition for performance excellence that a. To order copies of this publication or obtain other Baldrige Program products and services contact U S organization can receive The award promotes. Baldrige Performance Excellence Program awareness of performance excellence as an. Administration Building Room A600 increasingly important element in U S. 100 Bureau Drive Stop 1020,competitiveness and,Gaithersburg MD 20899 1020. Telephone 301 975 2036 the sharing of successful performance strategies and. Fax 301 948 3716 information on the benefits of using these strategies. E mail baldrige nist gov, Web http www nist gov baldrige The President of the United States traditionally presents. the award The award crystal composed of two solid, The Baldrige Program welcomes your comments on the Baldrige Excellence Framework and other Baldrige products and crystal prismatic forms stands 14 inches tall The crystal. services Please direct your comments to the address above is held in a base of black anodized aluminum with the. award recipient s name engraved on the base A 22 karat. The Baldrige Excellence Framework Health Care is an official publication of NIST under the authority of the Malcolm Baldrige National gold plated medallion is captured in the front section. Quality Improvement Act of 1987 Public Law 100 107 codified at 15 U S C 3711a This publication is a work of the U S Government of the crystal The medal bears the name of the award. and is not subject to copyright protection in the United States under Section 105 of Title 17 of the United States Code The U S Department and The Quest for Excellence on one side and the. of Commerce as represented by NIST holds copyright to the publication in all countries outside of the United States Presidential Seal on the other. BALDRIGE CRITERIA FOR PERFORMANCE EXCELLENCE and Design BALDRIGE PERFORMANCE EXCELLENCE PROGRAM. CRITERIA FOR PERFORMANCE EXCELLENCE EDUCATION CRITERIA FOR PERFORMANCE EXCELLENCE HEALTH CARE Organizations apply for the award in one of six eligibility. CRITERIA FOR PERFORMANCE EXCELLENCE MALCOLM BALDRIGE NATIONAL QUALITY AWARD and Design PERFORMANCE categories manufacturing service small business. EXCELLENCE THE QUEST FOR EXCELLENCE and the MALCOLM BALDRIGE NATIONAL QUALITY AWARD medal and education health care and nonprofit Up to 18 awards. depictions or representations thereof are federally registered trademarks and service marks of the U S Department of Commerce may be given annually across the six categories. National Institute of Standards and Technology The unauthorized use of these trademarks and service marks is prohibited. For more information on the award and, Cover photos courtesy of Baldrige Award winners Henry Ford Health System and Sutter Davis Hospital.
the application process see, NIST an agency of the U S Department of Commerce manages the Baldrige Program NIST has a 100 plus year track record of http www nist gov baldrige enter apply cfm. serving U S industry science and the public with the mission to promote U S innovation and industrial competitiveness by advancing. measurement science standards and technology in ways that enhance economic security and improve our quality of life NIST carries. out its mission in three cooperative programs including the Baldrige Program The other two are the NIST laboratories conducting. research that advances the nation s technology infrastructure and is needed by U S industry to continually improve products and. services and the Hollings Manufacturing Extension Partnership a nationwide network of local centers offering technical and. business assistance to small manufacturers, Suggested citation Baldrige Performance Excellence Program 2015 2015 2016 Baldrige Excellence Framework A Systems Approach. to Improving Your Organization s Performance Health Care Gaithersburg MD U S Department of Commerce National Institute of. Standards and Technology http www nist gov baldrige. The Quest for Excellence, Official conference of the Malcolm Baldrige National Quality Award. The Baldrige Program and Baldrige Foundation thank the. American Hospital Association as the lead sponsor for the 27th Annual Quest for Excellence Conference and. Health Care Criteria for Performance Excellence Award Ceremony. April 12 15 2015,Baltimore Marriott Waterfront Baltimore Maryland. 28th Annual Quest for Excellence Conference and,Award Ceremony.
April 3 6 2016,Baltimore Marriott Waterfront Baltimore Maryland. We also recognize the Lippincott Solutions team at Wolters Kluwer for. sponsoring the Health Care Criteria Each year at The Quest for Excellence Baldrige Award. recipients share their exceptional performance practices. with leaders of business education health care and. nonprofit organizations and inspire attendees to apply the. insights they gain within their own organizations Plan to. attend and learn about the recipients best management. practices and Baldrige journeys participate in educational. presentations on the Baldrige Excellence Framework and. network with Baldrige Award recipients and other attendees. For more information on The Quest for Excellence see. http www nist gov baldrige qe,ii About the Baldrige Excellence Framework. The Baldrige framework empowers your organization to reach its goals improve results and become more. competitive The framework consists of the Criteria the core values and concepts and the scoring guidelines. v How to Use the Baldrige Excellence Framework, You can use this booklet as a reference for self assessment or as the basis of an external assessment. 1 Health Care Criteria for Performance Excellence Overview and Structure. The Criteria include the Organizational Profile and seven integrated interconnected categories The categories. are subdivided into items and areas to address, 3 Health Care Criteria for Performance Excellence Items and Point Values. 4 Health Care Criteria for Performance Excellence,4 Organizational Profile.
7 1 Leadership,10 2 Strategy,13 3 Customers, 16 4 Measurement Analysis and Knowledge Management. 19 5 Workforce,22 6 Operations,25 7 Results,30 Scoring System. Performance against Criteria items is scored on two evaluation dimensions process and results. 34 Process Scoring Guidelines,35 Results Scoring Guidelines. 36 How to Respond to the Criteria, This section explains how to respond most effectively to the Health Care Criteria item requirements. 39 Core Values and Concepts, These embedded beliefs and behaviors form the foundation of the Health Care Criteria.
44 Changes from the 2013 2014 Criteria,47 Glossary of Key Terms. The glossary includes definitions of terms presented in SMALL CAPS in the Criteria and scoring guidelines. 55 Index of Key Terms,58 List of Contributors,On the Web. Category and Item Commentary http www nist gov baldrige publications hc criteria cfm. This commentary on the Health Care Criteria provides additional examples and guidance. About the Baldrige Excellence Framework, The Baldrige Excellence Framework empowers your organization to reach its goals improve. results and become more competitive, Thousands of organizations around the world use the Baldrige Excellence Framework the core values and concepts. pages 39 43 the Health Care Criteria for Performance Excellence pages 4 29 and the scoring guidelines pages. 34 35 to improve and get sustainable results Those recognized as national role models receive the Malcolm Bald. rige National Quality Award a Presidential award More than 100 recipients have broadly shared their best practices. with others Through that sharing many thousands of organizations have improved their operations and results and. thus their contributions to the U S and global economy. Baldrige has a simple purpose, The purpose of the Baldrige framework is simply to help your organization no matter its size or the type of health.
care services it offers answer three questions Is your organization doing as well as it could How do you know What. and how should your organization improve or change. By challenging yourself with the questions that make up the Health Care Criteria for Performance Excellence you. explore how you are accomplishing what is important to your organization The questions divided into six inter. related process categories and a results category represent seven critical aspects of managing and performing as an. organization,1 Leadership,2 Strategy,3 Customers,4 Measurement analysis and knowledge management. 5 Workforce,6 Operations,Baldrige promotes a systems perspective. A systems perspective means managing all the components of your organization as a unified whole to achieve ongoing suc. cess The system s building blocks and integrating mechanism are the core values and concepts the seven interrelated. Health Care Criteria categories and the scoring guidelines. I honestly in my heart believe that because we participated in the Baldrige Program and. because it gave us that consistent feedback there are people who are alive today who. wouldn t have been had we not been so committed to the Baldrige process. Rulon Stacey former president CEO Baldrige Award recipient Poudre Valley Health System. ii 2015 2016 Baldrige Excellence Framework Health Care. A focus on core values and concepts Baldrige is based on a set of beliefs and behaviors see pages 39 43 These. core values and concepts are the foundation for integrating key performance and operational requirements within a. results oriented framework that creates a basis for action feedback and ongoing success. Systems perspective,Visionary leadership,Patient focused excellence. Valuing people,Organizational learning and agility. Focus on success,Managing for innovation,Management by fact.
Societal responsibility and community health,Ethics and transparency. Delivering value and results, A focus on processes Processes are the methods your organization uses to accomplish its work The Baldrige frame. work helps you assess and improve your processes along four dimensions. 1 Approach designing and selecting effective processes methods and measures. 2 Deployment implementing your approach consistently across the organization. 3 Learning assessing your progress and capturing new knowledge including looking for opportunities for improve. ment and innovation, 4 Integration aligning your approach with your organization s needs ensuring that your measures information and. improvement systems complement each other across processes and work units and harmonizing processes and. operations across your organization to achieve key organization wide goals. A focus on results The Baldrige framework leads you to examine your results from three viewpoints the external. view How do your patients other customers and other stakeholders view you the internal view How efficient and. effective are your operations and the future view Is your organization learning and growing. In Baldrige results include all areas of importance to your organization This composite of measures ensures that your. strategies are balanced that they do not inappropriately trade off among important stakeholders objectives or short. and longer term goals The Baldrige framework helps you evaluate your results along four dimensions. 1 Levels your current performance on a meaningful measurement scale. 2 Trends the direction and rate of change of your results. 3 Comparisons your performance relative to that of other appropriate organizations such as competitors or organi. zations similar to yours and to benchmarks or health care industry leaders. 4 Integration the extent to which the results you track are important to your organization and the extent to which. you are using them to support your organizational goals and revise plans. A focus on linkages The linkages among the Health Care Criteria categories are an essential element of the systems. perspective provided by the Baldrige framework Some examples of these linkages are. the connections between your processes and the results you achieve. the need for data in the strategic planning process and for improving operations. the connection between workforce planning and strategic planning. the need for patient other customer and market knowledge in establishing your strategy and action plans and. the connection between your action plans and any changes needed in your work systems. About the Baldrige Excellence Framework iii, A focus on improvement The Baldrige framework helps you understand and assess how well you are accomplishing. what is important to your organization how mature and how well deployed your processes are how good your results. are whether your organization is learning and improving and how well your approaches address your organization s. needs The Baldrige scoring guidelines pages 34 35 are based on the process and results dimensions described above. As you respond to the Health Care Criteria questions and gauge your responses against the scoring guidelines you. will begin to identify strengths and gaps first within the Health Care Criteria categories and then among them. When you use the Baldrige framework to manage your organization s performance the coordination of key processes. and feedback between your processes and your results lead to cycles of improvement As you continue to use the. framework you will learn more and more about your organization and begin to define the best ways to build on your. strengths close gaps and innovate,Baldrige is adaptable.
The Health Care Criteria do not prescribe how you should structure your organization or its operations In the Baldrige. Organizational Profile pages 4 6 you describe what is important to your organization its operating environment. key relationships competitive environment and strategic context The Health Care Criteria encourage you to use. creative adaptive and flexible approaches which will foster incremental and breakthrough improvement through. innovation The Health Care Criteria encourage you to choose the tools e g Lean Six Sigma International Organi. zation for Standardization ISO 9000 a balanced scorecard Plan Do Check Act PDCA that are most suitable. and effective for your organization in making improvements Properly utilized such tools are a contributor to. achieving excellence,Baldrige has national and global impact. The Baldrige framework and Criteria play three roles in strengthening U S competitiveness. They help improve organizational processes capabilities and results. They facilitate the communication and sharing of best practices among U S organizations through the Baldrige. Award the Quest for Excellence Conference and other educational offerings. They serve as a working tool for understanding and managing organizational performance guiding your strategic. thinking and providing opportunities to learn, Within the United States state regional sector specific and organization specific performance or business excel. lence programs use the Baldrige framework and Criteria to help organizations improve their competitiveness and. results Many accreditation systems and certifications are also based on the Criteria Globally about 100 performance. or business excellence programs exist most use the Baldrige framework or a derivative as their organizational. excellence model,Baldrige is here for your organization. According to one health care leader It was the use of the Baldrige framework that boosted our ability to deliver better. care to our patients And in the end that is the most important thing delivering better care to our patients and. having a greater and more positive impact on the lives of all of our customers Nancy Schlichting CEO Baldrige. Award recipient Henry Ford Health System Why not take advantage of that opportunity Your patients other. customers workforce community and other stakeholders and the nation will be better off. 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 author of Good to Great Why Some Companies. Make the Leap and Others Don t, iv 2015 2016 Baldrige Excellence Framework Health Care.
How to Use the Baldrige Excellence Framework, Whether your organization is large or small you can use the Baldrige Excellence Framework for. improvement Your experience with Baldrige will help you decide where to begin. If your organization is in the business nonprofit or education sector you should use the business nonprofit or educa. tion version of this booklet respectively See http www nist gov baldrige publications criteria cfm to obtain a copy. If you are just learning about the Baldrige framework. Here are some ways to begin using the Baldrige framework to improve your organization. Scan the questions in the Organizational Profile pages 4 6 and see if you can answer them Discussing the. answers to these questions with your senior leadership team might be your first Baldrige self assessment. Study the 11 Baldrige core values and concepts pages 39 43 Consider how your organization measures up in. relation to the core values Are there any improvements you should be making. Answer the questions in the titles of the 17 Health Care Criteria for Performance Excellence items to reach a. basic understanding of the Criteria and your organization s performance. See a simple outline of a holistic performance management system by reading the headings in purple in the. Health Care Criteria section of this booklet pages 4 29 See if you are considering all of these dimensions in estab. lishing your leadership system and measuring performance. Use the Baldrige framework and its supporting material as a general resource on organizational performance. improvement This booklet and the materials online http www nist gov baldrige publications hc criteria cfm may. help you think in a different way or give you a fresh frame of reference. Attend the Quest for Excellence or a Baldrige regional conference These events highlight the role model. approaches of Baldrige Award recipients These organizations have used the Baldrige framework to improve. performance innovate and achieve world class results Workshops on Baldrige self assessment are often offered in. conjunction with these conferences, Become an examiner or attend the Baldrige Examiner Training Experience see http www nist gov baldrige. Examiners receive valuable training evaluate award applications and learn to apply the Criteria to their organizations. Become a Baldrige Executive Fellow Baldrige Fellows C suite and rising executives participate in an executive. development program see http www nist gov baldrige fellows index cfm learning from each other and from. Baldrige Award recipients, If you are ready to assess your organization using Baldrige. To assess your organization with the Baldrige framework follow one or more of the suggestions below. Check your progress on achieving organizational excellence and improve communication among your work. force members and leadership team with two simple questionnaires Are We Making Progress http www. nist gov baldrige publications progress cfm and Are We Making Progress as Leaders http www nist gov baldrige. publications progress leaders cfm, Identify gaps in your understanding of your organization and compare your organization with others with. easyInsight Take a First Step toward a Baldrige Self Assessment http www nist gov baldrige publications. easy insight cfm This assessment is based on the Organizational Profile. Complete the Organizational Profile pages 4 6 Have your leadership team answer the questions If you identify. topics for which you have conflicting little or no information use these topics for action planning For many organi. zations this approach serves as a first Baldrige self assessment. Answer the questions in the Baldrige Excellence Builder http www nist gov baldrige publications builder cfm. This abridged version of the Baldrige framework consisting of the questions in black boldface in the Criteria section. of this booklet represents the overall features of organizational performance excellence. How to Use the Baldrige Excellence Framework v, Use the full set of Health Care Criteria questions as a personal guide to everything that is important in lead.
ing your organization You may discover blind spots or areas where you should place additional emphasis. Review the scoring guidelines pages 34 35 They help you assess your organizational maturity especially when. used in conjunction with Steps toward Mature Processes page 32 and From Fighting Fires to Innovation An. Analogy for Learning page 31, Answer the questions in one Health Care Criteria category in which you know you need improvement either. yourself or with leadership team colleagues referring to the item notes and Category and Item Commentary http. www nist gov baldrige publications hc criteria cfm Then assess your strengths and opportunities for improvement. and develop action plans Be aware though that this kind of assessment loses the benefits of the systems perspective. embodied in the Baldrige framework, Have your leadership team assess your organization At a retreat have your leadership team develop responses to. the Organizational Profile and the seven Health Care Criteria categories using the Baldrige Excellence Builder http. www nist gov baldrige publications builder cfm and record the responses Then assess your strengths and opportuni. ties for improvement and develop action plans, Conduct a full Baldrige self assessment Set up teams within your organization to develop responses to the. Organizational Profile and Health Care Criteria categories For details see the slide presentation Self Assessing Your. Organization with the Baldrige Criteria http www nist gov baldrige community baldrige ambassadors cfm. Contact your state local or sector specific Baldrige based program see the Alliance for Performance Excellence. http www baldrigepe org alliance Many programs provide networking opportunities training coaching and self. assessment services in addition to an award program. Contact a Baldrige Award recipient Organizations that receive the Baldrige Award advocate for performance. improvement share their strategies and serve as role models Many undertake ongoing self assessments of their. organizations and can share their experiences with you See http www nist gov baldrige for award recipients and. their contact information,If you are ready for external feedback. Here are some resources for receiving external feedback on your organization s strengths and opportunities for. improvement, Apply to your state local or sector specific Baldrige based award program see the Alliance for Performance.
Excellence http www baldrigepe org alliance When you apply a team of experts will examine your organization. objectively and identify your organization s strengths and its opportunities to improve. Arrange for a Baldrige Collaborative Assessment http www nist gov baldrige enter baldrige collab assess cfm. In this on site assessment a team of Baldrige examiners works with your leaders and staff to give your organization. immediate actionable feedback, Apply for the Malcolm Baldrige National Quality Award Once you meet eligibility requirements apply for the. highest level of national recognition for performance excellence that a U S organization can receive the Malcolm. Baldrige National Quality Award, Award applicants say that the Baldrige evaluation process is one of the best most cost effective most comprehensive. performance assessments you can find whether or not they receive the Baldrige Award See http www nist gov. baldrige enter apply cfm for more information In the Baldrige process everyone is a learner. vi 2015 2016 Baldrige Excellence Framework Health Care. Health Care Criteria for Performance,Excellence Overview and Structure. Health Care Criteria for Performance Excellence Overview A Systems Perspective. The performance system consists of the six categories in the center of the figure These categories define your processes and. the results you achieve, Performance excellence requires strong Leadership and is demonstrated through outstanding Results Those categories are. highlighted in the figure, The word integration at the center of the figure shows that all the elements of the system are interrelated.
The center horizontal arrowheads show the critical linkage between the leadership triad categories 1 2 and 3 and the. results triad categories 5 6 and 7 and the central relationship between the Leadership and Results categories. The center vertical arrowheads point to and from the system foundation which provides information on and feedback to key. processes and the organizational environment,The Organizational Profile. sets the context for your The results triad Workforce. organization It serves as the Operations and Results. The leadership triad Leader includes your workforce focused. ship Strategy and Customers background for all you do. processes your key operational, emphasizes the importance of processes and the performance. a leadership focus on strategy results they yield,and customers. Organizational Profile,Strategy Workforce,Leadership. p Integration RESULTS,Customers Operations,Measurement Analysis and Knowledge Management.
The system All actions,foundation lead to,Measurement Results a. Analysis and,Values and Concept,composite of health. Knowledge Management care and process,is critical to effective customer focused. management and to a workforce focused,fact based knowledge leadership and gover. driven agile system for, improving performance The basis of the Health Care Criteria is a set of Core Values and Concepts and market results.
and competitiveness that are embedded in high performing organizations see pages 39 43. Health Care Criteria for Performance Excellence Overview and Structure 1. Health Care Criteria for Performance Excellence Structure. The seven Baldrige Health Care Criteria for Performance Excellence categories are subdivided into. items and areas to address,Items Requirements, There are 17 Health Care Criteria items plus 2 in the Item requirements are expressed as questions or statements. Organizational Profile each with a particular focus These on three levels. items are divided into three groups according to the kinds of. Basic requirements are expressed in the title question. information they ask for, Overall requirements are expressed in the questions. The Organizational Profile asks you to define your. in boldface in the shaded box These leading ques,organizational environment. tions are the starting point for responding to the. Process items categories 1 6 ask you to define your requirements. organization s processes, Multiple requirements are the individual questions. Results items category 7 ask you to report results for under each area to address including the question. your organization s processes in boldface That first question expresses the most. important one in that group, See page 3 for a list of item titles and point values.
Item Notes Key Terms, Item notes 1 clarify terms or requirements 2 give instruc Terms in SMALL CAPS are defined in the Glossary of Key. tions and examples for responding and 3 indicate key Terms pages 47 54. linkages to other items,Areas to Address, Each item includes one or more areas to address labeled a. b c and so on,Type of information, Item number Item point value Key term in to provide in response. small caps to this item,Item title,and basic 7 5 Financial and Market Results. requirements marketplace performance results 90 pts. Provide data and information to answer the following questions. Area to a Financial and Market RESULTS,R ES ULT S, 1 Financial PERFORMANCE What are your financial PERFORMANCE RESULTS What are your current LEVELS and.
address TRENDS in KEY MEASURES or INDICATORS of financial PERFORMANCE including aggregate MEASURES of financial. return financial viability and budgetary PERFORMANCE as appropriate HOW do these RESULTS differ by market. SEGMENTS and PATIENT and other CUSTOMER groups as appropriate. Headings Overall, 2 Marketplace PERFORMANCE What are your marketplace PERFORMANCE RESULTS What are your current LEVELS. summarizing and TRENDS in KEY MEASURES or INDICATORS of marketplace PERFORMANCE including market share or position. requirements, market and market share growth and new markets entered as appropriate HOW do these RESULTS differ by market. multiple SEGMENTS and PATIENT and other CUSTOMER groups as appropriate. requirements, Terms in SMALL CAPS are defined in the Glossary of Key Terms pages 47 54. requirements, 7 5a 1 Aggregate measures of financial return might as appropriate Measures should relate to the financial mea. include those for return on investment ROI operating sures you report in 4 1a 1 and the financial management. margins profitability or profitability by market segment approaches you report in item 2 2. or patient or other customer group Measures of financial. Item viability might include those for liquidity debt to equity For additional guidance on this item see the Category. ratio days cash on hand asset utilization and cash flow and Item Commentary http www nist gov baldrige Link to. notes bond ratings and value based purchasing financial results publications hc criteria cfm Category. Commentary, 2 2015 2016 Baldrige Excellence Framework Health Care.
Health Care Criteria for Performance,Excellence Items and Point Values. See pages 30 35 for the scoring system used with the Health Care Criteria items in a. Baldrige assessment,P 1 Organizational Description. P 2 Organizational Situation,Categories and Items Point Values. 1 Leadership 120,1 1 Senior Leadership 70,1 2 Governance and Societal Responsibilities 50. 2 Strategy 85,2 1 Strategy Development 45,2 2 Strategy Implementation 40.
3 Customers 85,3 1 Voice of the Customer 40,3 2 Customer Engagement 45. 4 Measurement Analysis and Knowledge Management 90. 4 1 Measurement Analysis and Improvement of,Organizational Performance 45. 4 2 Knowledge Management Information and,Information Technology 45. 5 Workforce 85,5 1 Workforce Environment 40,5 2 Workforce Engagement 45. 6 Operations 85,6 1 Work Processes 45,7 Results 450.
7 1 Health Care and Process Results 120,7 2 Customer Focused Results 80. 7 3 Workforce Focused Results 80,7 4 Leadership and Governance Results 80. 7 5 Financial and Market Results 90,TOTAL POINTS 1 000. Health Care Criteria for Performance Excellence Items and Point Values 3. Health Care Criteria for Performance Excellence, The Organizational Profile is the most appropriate starting point for self assessment and for writing an application It is criti. cally important for the following reasons, It helps you identify gaps in key information and focus on key performance requirements and results.
You can use it as an initial self assessment If you identify topics for which conflicting little or no information is avail. able use these topics for action planning, It sets the context for and allows you to address unique aspects of your organization in your responses to the Health Care. Criteria requirements in categories 1 7, The Organizational Profile is a snapshot of your organization the KEY influences on HOW it operates and your competitive. environment, P 1 Organizational Description What are your key organizational characteristics. In your response answer the following questions,a Organizational Environment. 1 HEALTH CARE SERVICE Offerings What are your main HEALTH CARE SERVICE offerings see the note on the next. page What is the relative importance of each to your success What mechanisms do you use to deliver your. HEALTH CARE SERVICES, 2 MISSION VISION and VALUES What are your stated MISSION VISION and VALUES What are your organization s.
CORE COMPETENCIES and what is their relationship to your MISSION. 3 WORKFORCE What is your WORKFORCE profile What recent changes have you experienced in. WORKFORCE composition or your WORKFORCE needs What are. your WORKFORCE or employee groups and SEGMENTS, the educational requirements for different employee groups and SEGMENTS and. the KEY drivers that engage them in achieving your MISSION and VISION. What are your organized bargaining units union representation What are your organization s special health and. safety requirements, 4 Assets What are your major facilities technologies and equipment. 5 Regulatory Requirements What is the regulatory environment under which you operate What are the KEY. applicable occupational health and safety regulations accreditation certification or registration requirements. industry standards and environmental financial and HEALTH CARE SERVICE delivery regulations. b Organizational Relationships, 1 Organizational Structure What are your organizational structure and GOVERNANCE system What are the. reporting relationships among your GOVERNANCE board SENIOR LEADERS and parent organization as appropriate. 2 PATIENTS Other CUSTOMERS and STAKEHOLDERS What are your KEY market SEGMENTS PATIENT and other. CUSTOMER groups and STAKEHOLDER groups as appropriate What are their KEY requirements and expectations. of your HEALTH CARE SERVICES PATIENT and other CUSTOMER support services and operations What are the differ. ences in these requirements and expectations among market SEGMENTS PATIENT and other CUSTOMER groups and. STAKEHOLDER groups,Continued on the next page, 4 2015 2016 Health Care Criteria for Performance Excellence. 3 Suppliers and PARTNERS What are your KEY types of suppliers PARTNERS and COLLABORATORS What role do. in your WORK SYSTEMS especially in producing and delivering your KEY HEALTH CARE SERVICES and PATIENT and. other CUSTOMER support services and,in enhancing your competitiveness.
What are your KEY mechanisms for two way communication with suppliers PARTNERS and COLLABORATORS What. role if any do these organizations play in contributing and implementing INNOVATIONS in your organization What. are your KEY supply chain requirements, Terms in SMALL CAPS are defined in the Glossary of Key Terms pages 47 54. P Your responses to the Organizational Profile questions are might cover greenhouse gas emissions carbon regulations. very important They set the context for understanding your and trading and energy efficiency. organization and how it operates Your responses to all other. P 1b 2 Customers include the users and potential users of. questions in the Baldrige Health Care Criteria should relate. your health care services They are the direct users of your. to the organizational context you describe in this profile. health care services patients as well as referring health. Your responses to the Organizational Profile questions thus. care providers and users who pay for your services such as. allow you to tailor your responses to all other questions to. patients families insurers and other third party payors. your organization s uniqueness, P 1b 2 Patient and other customer groups might be based. P 1a 1 Health care service offerings are the services you. on common expectations behaviors preferences or profiles. offer in the marketplace Mechanisms for delivering services. Within a group there may be customer segments based. to your patients might be direct or might be indirect. on differences and commonalities You might subdivide. through contractors collaborators or partners, your market into market segments based on health care. P 1a 2 Core competencies are your organization s areas service lines or features service delivery modes payors. of greatest expertise They are those strategically important volume geography or other factors that you use to define a. capabilities that are central to fulfilling your mission or market segment. provide an advantage in your marketplace or service. P 1b 2 The requirements of your patient and other, environment Core competencies are frequently challenging. customer groups and your market segments might include. for competitors or suppliers and partners to imitate and. accessibility continuity of care safety security leveraging. frequently preserve your competitive advantage, of technology billing requirements socially responsible.
P 1a 2 Core competencies are one example of concepts behavior community service cultural preferences and. that are woven throughout the Health Care Criteria to multilingual services. ensure a systems approach to organizational performance. P 1b 2 P 1b 3 Patient other customer stakeholder and. management Other such concepts include innovation use. operational requirements and expectations will drive your. of data and information to review performance and create. organization s sensitivity to the risk of service support and. knowledge and change readiness and management, supply chain interruptions including those due to natural. P 1a 3 Workforce or employee groups and segments disasters and other emergencies. including organized bargaining units might be based on. P 1b 3 Communication mechanisms should use, type of employment or contract reporting relationship loca. understandable language and they might involve in, tion including telework tour of duty work environment. person contact e mail social media or the telephone. use of certain family friendly policies or other factors. For many organizations these mechanisms may change. P 1a 3 Organizations that also rely on volunteers and as marketplace patient other customer or stakeholder. unpaid staff to accomplish their work should include these requirements change. groups as part of their workforce, P 1a 5 Industry standards might include industrywide For additional guidance on this item see the Category. codes of conduct and policy guidance Depending on the and Item Commentary http www nist gov baldrige. regions in which you operate environmental regulations publications hc criteria cfm. P 2 Organizational Situation What is your organization s strategic situation. In your response include answers to the following questions. a Competitive Environment, 1 Competitive Position What is your competitive position What are your relative size and growth in the health.
care industry or the markets you serve How many and what types of competitors and KEY COLLABORATORS do. 2 Competitiveness Changes What KEY changes if any are affecting your competitive situation including changes. that create opportunities for INNOVATION and collaboration as appropriate. 3 Comparative Data What KEY sources of comparative and competitive data are available from within the health. care industry What KEY sources of comparative data are available from outside the health care industry What. limitations if any affect your ability to obtain or use these data. b Strategic Context, What are your KEY STRATEGIC CHALLENGES and ADVANTAGES in the areas of HEALTH CARE SERVICES operations societal. responsibilities and WORKFORCE,c PERFORMANCE Improvement System. What are the KEY elements of your PERFORMANCE improvement system including your PROCESSES for evaluation and. improvement of KEY organizational projects and PROCESSES. Terms in SMALL CAPS are defined in the Glossary of Key Terms pages 47 54. P 2b Strategic challenges and advantages might relate to to set an overall context for your approach to performance. technology health care services finances operations orga improvement The approach you use should be related to. nizational structure and culture your parent organization s your organization s needs Approaches that are compatible. capabilities patients other customers and markets brand with the overarching systems approach provided by the. recognition and reputation the health care industry and Baldrige framework might include implementing a Lean. people Strategic advantages might include differentiators Enterprise System applying Six Sigma methodology using. such as technology leadership innovation rate geographic PDCA methodology using standards from ISO e g 9000 or. proximity accessibility health care and administrative sup 14000 using decision science or employing other improve. port services cost reputation for service delivery and wait ment tools. times for service, P 2c The Baldrige Scoring System pages 30 35 uses For additional guidance on this item see the Category. performance improvement through learning and integration and Item Commentary http www nist gov baldrige. as a dimension in assessing the maturity of organizational publications hc criteria cfm. approaches and their deployment This question is intended. 6 2015 2016 Health Care Criteria for Performance Excellence. 1 Leadership 120 pts, The Leadership category asks HOW SENIOR LEADERS personal actions guide and sustain your organization It also asks about. your organization s GOVERNANCE system and HOW your organization fulfills its legal ethical and societal responsibilities. 1 1 Senior Leadership How do your senior leaders lead the organization 70 pts. In your response include answers to the following questions. a VISION VALUES and MISSION,P R O C ESS, 1 VISION and VALUES HOW do SENIOR LEADERS set your organization s VISION and VALUES HOW do SENIOR.
LEADERS DEPLOY the VISION and VALUES through your LEADERSHIP SYSTEM to the WORKFORCE to KEY suppliers and. PARTNERS and to PATIENTS other CUSTOMERS and other STAKEHOLDERS as appropriate HOW do SENIOR LEADERS. personal actions reflect a commitment to those VALUES. 2 Promoting Legal and ETHICAL BEHAVIOR HOW do SENIOR LEADERS actions demonstrate their commitment to. legal and ETHICAL BEHAVIOR HOW do they promote an organizational environment that requires it. 3 Creating a Successful Organization HOW do SENIOR LEADERS actions build an organization that is successful. now and in the future HOW do they, create an environment for the achievement of your MISSION improvement of organizational PERFORMANCE. PERFORMANCE leadership organizational LEARNING and LEARNING for people in the WORKFORCE. create a WORKFORCE culture that delivers a consistently positive experience for PATIENTS and other CUSTOMERS. and that fosters CUSTOMER ENGAGEMENT, create an environment for INNOVATION and INTELLIGENT RISK taking achievement of your STRATEGIC OBJECTIVES. and organizational agility, participate in succession planning and the development of future organizational leaders and. create and promote a culture of PATIENT safety,b Communication and Organizational PERFORMANCE. 1 Communication HOW do SENIOR LEADERS communicate with and engage the entire WORKFORCE and KEY. CUSTOMERS HOW do they, encourage frank two way communication including EFFECTIVE use of social media when appropriate.
communicate KEY decisions and needs for organizational change and. reinforce HIGH PERFORMANCE and a PATIENT other CUSTOMER and health care focus by taking a direct role in. motivating the WORKFORCE including by participating in reward and recognition programs. 2 Focus on Action HOW do SENIOR LEADERS create a focus on action that will achieve the organization s. MISSION HOW do SENIOR LEADERS, create a focus on action that will improve the organization s PERFORMANCE achieve INNOVATION and INTELLIGENT. RISK taking and attain its VISION,identify needed actions and. in setting expectations for organizational PERFORMANCE include a focus on creating and balancing VALUE for. PATIENTS other CUSTOMERS and other STAKEHOLDERS, Terms in SMALL CAPS are defined in the Glossary of Key Terms pages 47 54. 1 1 In health care organizations with separate administra 1 1a 1 Your organization s vision should set the context. tive operational and health care provider leaders the term for the strategic objectives and action plans you describe in. senior leaders refers to both sets of leaders and the items 2 1 and 2 2. relationship between them, 1 1a 3 A successful organization is capable of addressing. 1 1 Your organizational performance results should be current organizational needs and through agility and. reported in items 7 1 7 5 Results related to the effectiveness strategic management is capable of preparing for its future. of leadership and the leadership system should be reported business market and operating environment Achieving. in item 7 4 future success may require leading transformational changes.


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