2011 2012 health care criteria

8/6/2019 2011 2012 Health Care Criteria

1/88


2/88


3/88

Baldrige Performance Excellence ProgramNational Institute of Standards and Technology Department of Commerce

To: U.S. H C O z

From: H S. H z, DB P Ex P

Subject: W I B I Y N ?

B B H C C P Ex ! B - , - z . B B C

q .

I B H C C ? N ! B . W H C C ? Y . W ? Y . W , , ? Y . A ?

Y .

W z ; , , ; , H C C , , . T H C C

P -D -C -A , B S , S x S .

H B ? q O z P 46. A q B . F ,

Your Guide to Performance Excellence.

D ff ? O ff ? Are We Making Progress? Are We Making Progress as Leaders?

q . O z B C , z .

E x B A , . E x .

T H C C . . . . W ? W , x . I ,

@ . .

Need some useful tools to begin the Baldrige challenge? Try using Getting Started with the Baldrige Criteria,

available on our Web site at http://www.nist.gov/baldrige/enter/self_started.cfm easyInsight: Take a First Step toward a Baldrige Self-Assessment,

available at http://www.nist.gov/baldrige/publications/easy_insight.cfm Are We Making Progress? and Are We Making Progress as Leaders?available at http://www.nist.gov/baldrige/publications/progress.cfm

Optional Self-Analysis Worksheet (Word le to download),available at http://www.nist.gov/baldrige/publications/hc_criteria.cfm

Besides using these resources from the Baldrige Performance Excellence Program, visithttp://www.baldrigepe.org to get support from Baldrige-based programs in your state or local area.

Baldrige Performance Excellence Program NIST Administration Building, Room A600 100 Bureau Drive, Stop 1020 Gaithersburg, MD 20899-1020 Telephone: (301) 975-2036 Fax: (301) 948-3716 E-Mail: [email protected] Web Site: http://www.nist.gov/baldrige
mailto:[email protected]://www.nist.gov/baldrige/enter/self_started.cfmhttp://www.nist.gov/baldrige/publications/easy_insight.cfmhttp://www.nist.gov/baldrige/publications/progress.cfmhttp://www.nist.gov/baldrige/publications/hc_criteria.cfmhttp:///reader/full/http://www.baldrigepe.orgmailto:[email protected]://www.nist.gov/baldrigemailto:[email protected]://www.nist.gov/baldrige/enter/self_started.cfmhttp://www.nist.gov/baldrige/publications/easy_insight.cfmhttp://www.nist.gov/baldrige/publications/progress.cfmhttp://www.nist.gov/baldrige/publications/hc_criteria.cfmhttp:///reader/full/http://www.baldrigepe.orgmailto:[email protected]://www.nist.gov/baldrige


4/88

THE Q UEST FOR EXCELLENCE

The 23rd and 24th Annual Quest for Excellence Conferences E , T Q Ex , ffi

M B N Q A , B A

x , , , z . T 23 Q Ex

2010 , 24 Q Ex 2011 .

S 1988, x , , -z x . C

x ffi (CEO ) z

B C , x , . A - x z ,

.

T A 36, 2011, M W P H W , D.C.,

A 1518, 2012, . F , B P :

B P Ex P , NIS , A B , R A600, 100 B D , S

1020, G , MD 20899-1020; : (301)975-2036; x: (301) 948-3716; - : @ .

. F B P ,

B W : :// . . / .

The Malcolm BaldrigeNational Quality AwardT P U S

W , D.C. T , , 14 . T z

, . A 22- - . T

T Q Ex P S .

Crystal by Steuben

The Malcolm Baldrige National Quality Award logo and the phrases The Quest for Excellence and Performance Excellence are trademarks and

service marks of the National Institute of Standards and Technology.

20112012 Health Care Criteria for Performance Excellenceii
http://www.nist.gov/baldrigehttp://www.nist.gov/baldrige


5/88


6/88

Baldrige Health Care Criteria forPerformance Excellence Framework

A Systems Perspective

2StrategicPlanning

5Workforce

Focus

Organizational Profile:Environment, Relationships, and Strategic Situation

1Leadership

7Results

4Measurement,Analysis, and Knowledge Management

3Customer

Focus

6Operations

Focus

20112012 Health Care Criteria for Performance Excellenceiv


7/88

HEALTH CARE CRITERIA FOR PERFORMANCE EXCELLENCE FRAMEWORK

T q H C C PEx , :

1 Leadership

2 Strategic Planning

3 Customer Focus

4 Measurement, Analysis, and KnowledgeManagement

5 Workforce Focus

6 Operations Focus

7 Results

T .

F ,

.

Organizational Prole Y O z P ( ) x

z . Y z , ,

, , z

.

Performance SystemT x B

.

L ( 1), S P ( 2), C F ( 3) . T z

. S z

z .

W F ( 5), O F ( 6), R ( 7) . Y

z z

.

A R , - , -

, , .

T z ,

z . F , L ( 1)

R ( 7). T - ff

.

System FoundationM , A , K M( 4) ff

z - , -

. M , , .

Criteria StructureT C

.

ItemsT 17 , q . I 3.

T 29.

Areas to AddressI ( ). O z

q .

Health Care Criteria for Performance Excellence Framework 1


8/88

Baldrige Performance Excellence ProgramHonors the 2008 Award Recipients

On December 2, 2009, at a ceremony in Washington, D.C., thethree 2008 Baldrige Award recipients were honored: Cargill CornMilling North America (CCM) o Wayzata, Minnesota (manu acturing); Iredell-Statesville Schools (I-SS) o Statesville, North Carolina(education); and Poudre Valley Health System (PVHS) o FortCollins, Colorado (health care). Clockwise rom the upper le t, thephotographs show (1) U.S. Vice President Joe Biden; (2) U.S. Secretary o Commerce Gary Locke; (3) Secretary Locke, I-SS Chairman o

the Board o Education David W. Cash, I-SS Superintendent Brady Johnson, and Foundation or the Malcolm Baldrige National Quality Award Chair Joe Alexander; (4) Malcolm Hollensteiner, nephew o Malcolm Baldrige; (5) Secretary Locke, PVHS President/CEORulon F. Stacey, PVHS Director o Process Improvement Priscilla J.Nuwash, and Joe Alexander; and (6) Secretary Locke, CCM President Alan Willits, Cargill, Inc. Chairman and Chie Executive OfcerGreg Page, and Joe Alexander.

20112012 Health Care Criteria for Performance Excellence2


9/88

HEALTH CARE CRITERIA FOR PERFORMANCE EXCELLENCE ITEM LISTING

P Preface: Organizational ProleP.1 O z D

P.2 O z S

Categories and Items Point Values

Leadership 12011.1

1.2

S L

G S R

70

50

Strategic Planning 852.1

2.2

S D

S I

40

45

Customer Focus 85

2

33.1 V C 45

3.2 C E 40

Measurement, Analysis, and Knowledge Management 904.1 M , A , I

O z P 45

4.2 M I , K , I 45

Workforce Focus 85

4

55.1 W E 40

5.2 W E 45

Operations Focus 856.1

6.2

W S

W P

45

40

Results 450

6

77.1 H C P O 120

7.2 C -F O 90

7.3 W -F O 80

7.4 L G O 807.5 F M O 80

TOTAL POINTS 1,000

Note: The scoring system used with the Criteria items in a Baldrige assessment can be found on pages 6770.

Health Care Criteria for Performance ExcellenceItem Listing 3


10/88

HEALTH CARE CRITERIA FOR PERFORMANCE EXCELLENCE

The Importance of Beginning with Your Organizational Prole

Y O z P

- ;

q ;

x j , , z ( C q z

, , , , O z P );

- . I , , , O z P , .

P Preface: Organizational ProleT Organizational Prole z , key how

, key .

P.1 Organizational Description: What are your key organizational characteristics?

Describe your organizations operating environment and your KEY relationships with PATIENTS and STAKEHOLDERS, suppliers,and PARTNERS.

W , q :a. Organizational Environment

(1) Service Offerings W z health care service ff ( 1 )? W z ? W ?

(2) V ISION and M ISSION W z ? W purpose , vision, values , mission ? W z core competencies mission ?

(3) W ORKFORCE Profile W workforce ? W workforce ff segments ? W ? W key mission vision ? W z workforce j diversity , z , key workforce

, q ?

(4) Assets W j , , q ?

(5) Regulatory Requirements W z ? W ; , , q ;

; , , health care service ?

b. Organizational Relationships(1) Organizational Structure W z governance ? W

governance , senior leaders , z , ?

(2) CUSTOMERS and STAKEHOLDERS W key segments patient stakeholder , ? W key q x health care services , patient

stakeholder , ? W ff q x segments patient stakeholder ?

(3) Suppliers and P ARTNERS W key , partners , collaborators ? W , partners , collaborators key health care services patient

stakeholder ? W key , partners , collaborators ? W , , z innovations z ?

W key - q ?

Organizational Profile:Environment,Relationships,and Strategic Situation

2StrategicPlanning

1Leadership

3Customer

Focus

5Workforce

Focus7

Results

6Operations

Focus




11/88

Notes:

N1. H ff (P.1 [1]) z ff .

M , , .

N2. C (P.1 [2]) z x . Y z

. C q

. A , q .

N3. M z . T z

(P.1 [3]).

N4. W ( z ; P.1 [3])

, , , , - , .

N5. S , , - , ,

, , ,

. G .

N6. P (P.1 [2]) x , , , .

W , ff . Y

, , , ,, z

.

N7. R q (P.1 [2]) ,

, , , , q , , , , .

N8. C (P.1 [3]) - , , - , W - , . F z ,

, , q .

F , 3334.

Information for Understanding All Criteria ItemsFor definitions of key terms presented throughout the Criteria and scoring guidelines text in SMALL CAPS, see theGlossary of Key Terms on pages 5766.

Frequently, several questions are grouped under one number (e.g., P.1a[3]). These questions are related and donot require separate responses. These multiple questions serve as a guide in understanding the full meaning of theinformation being requested.

The items in the Baldrige Criteria are divided into three groups: the Preface , which defines your organizationalenvironment; categories 16, which define your organizations processes ; and category 7, which contains yourresults for your organizations processes. Only responses to the last two groups are scored during a Baldrige Award evaluation of an organization; the Organizational Profile items are used to provide context for theevaluation.

Item notes serve three purposes: (1) to clarify terms or requirements presented in an item, (2) to give instructionsand examples for responding to the item requirements, and (3) to indicate key linkages to other items. In allcases, the intent is to help you respond to the item requirements.

Preface: Organizational Prole 5


12/88

P.2 Organizational Situation: What is your organizations strategic situation?

Describe your organizations competitive environment, your KEY STRATEGIC CHALLENGES and ADVANTAGES, and your systemfor PERFORMANCE improvement.

W , q :a. Competitive Environment

(1) Competitive Position W ? W z ? W key collaborators z ?

(2) Competitiveness Changes W key ff , innovation , ?

(3) Comparative Data W key ? W key ?

W , , ff ?

b. Strategic Context W key health care service , , , strategicchallenges advantages ?

c. PERFORMANCE Improvement System

W key performance , , zlearning , innovation processes ?

Notes:

N1. S (P.2 ) , , ,

, , .S ff

, , , , , ,

, .

N2. P (P.2 )

z ( 6770). T q

B x x . A

B

z S x S , P -D -C -A(PDCA) ,

. A z .

F , 34.

Page LimitF B A , O z P . T

. O z P .T Baldrige Award Application Forms, :// . . /

/ / _ . .

http:///reader/full/http://www.nist.govhttp:///reader/full/http://www.nist.gov


13/88

1

1

Leadership

F

1

Leadership

t


2StrategicPlanning

3Customer

ocus

5Workforce

Focus7

Results

6Operations

Focus


StraPlan

CusFo

Leadership (120 pts.) T Leadership x how z senior leaders

z . A x z governance how z , , key .

1.1 Senior Leadership: How do your senior leaders lead? (70 pts.)

I

Process

Describe HOW SENIOR LEADERS actions guide and sustain your organization. Describe HOW SENIOR LEADERS communicate with your WORKFORCE and encourage HIGH PERFORMANCE .

W , q :a. VISION, VALUES, and MISSION

(1) V ISION and V ALUES How senior leaders z vision values ? How senior leadersdeploy z vision values leadership system , workforce , key

partners , patients stakeholders , ? H ow senior leaders z values ?

(2) Promoting Legal and E THICAL BEHAVIOR How senior leaders ethical behavior ? How z q ?

(3) Creating a SUSTAINABLE Organization How senior leaders sustainable z ? H ow senior leaders ?

z performance , mission strategic objectives , innovation , performance , z

workforce x patients stakeholders engagement

z workforce learning z learning , , z patient

b. Communication and Organizational P ERFORMANCE (1) Communication How senior leaders workforce ? How

senior leaders ?

, - z key high performance patient

(2) Focus on Action How senior leaders z ,

performance , vision ? How senior leaders ? H ow senior leaders value patients stakeholders z

performance x ?

Notes:

N1. I z / ,

.

N2. O z (1.1 [1]) x ,

2.1 2.2.

N3. A z (1.1 [3]) z

,, . B x . I x , z

Health Care Criteria for Performance Excellence: Leadership 7


14/88

z . A z

. A z , ,

( 1.2).

N4. A (1.1 [2]) , , , z .

I

; q S x S L . I

z ( 2.2 [1]).

N5. Y z 7.17.5.

N6. F z , 1.1 (1) ff

.

F , 3435.

1.2 Governance and Societal Responsibilities: How do you govern andfulll your societal responsibilities? (50 pts.) Process

Describe your organizations GOVERNANCE system and APPROACH to leadership improvement. Describe HOW your organization ensures legal and ETHICAL BEHAVIOR , fulfills its societal responsibilities, supports its KEY communities, and contributesto community health.

W , q :

a. Organizational G OVERNANCE (1) GOVERNANCE System How z key

governance ?

governance ,

x stakeholder ,

(2) PERFORMANCE Evaluation How performance senior leaders , x ? H ow performance x ? H ow

performance governance , ? H ow senior leaders governance performance

effectiveness leadership system , ?

b. Legal and ETHICAL BEHAVIOR (1) Legal Behavior, Regulatory Behavior, and Accreditation How

health care services ? H ow ? H ow , effective - processes , ? W

key processes , measures , goals , , q , ? W key processes , measures , goals

?

(2) ETHICAL BEHAVIOR How z ethical behavior ? W key processes measures indicators ethical behavior

governance , z , patients , partners , , stakeholders ? How ethical behavior ?

c. Societal Responsibilities and Support of K EY Communities (1) Societal Well-Being How -

? H ow - , , ?

(2) Community Support How z key ? W key ? H ow z

, core competencies ? How senior leaders , workforce , ?



15/88

Notes:

N1. S z S

D ( 2.1) O F ( 6).K , q

( ); ;

, -, ; ,

, L G O ( 7.4).

N2. (1.2 [1])

.

N3. L (1.2 [2]) ,

, .

N4. M (1.2 [2])

, ,

z , , . T

, ,

.

N5. A 1.2 ff ( . .,

); , , ; , , .

N6. T 1.2; 5.1.

N7. A (1.2 [2]) - . S

, z , q

, - ( . .,

), , . Y

7.1.

F , 35.

Assessment of Item ResponsesI C q ; O z P ; , ,

. R 6770.

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.

J C , Good to Great:Why Some Companies Make the Leap . . . and Others Dont

Health Care Criteria for Performance Excellence: Leadership 9


16/8810 20112012 Health Care Criteria for Performance Excellence

2 2 Strategic Planning (85 pts.) T Strategic Planning x how z strategic objectives

action plans . A x how strategic objectives action plans q , how .

2.1 Strategy Development: How do you develop your strategy? (40 pts.) Process


2StrategicPlanning

1Leadership

3Customer

Focus

5Workforce

Focus7

Results

6Operations

Focus

4Measurement, Analysis, and Knowledge Management

Organizational ProfiEnvironEnviron Rment,R l tielation ships,ships and Str

2StrategicPlanning

rship3

CustomerFocus

Wo

Op

Describe HOW your organization establishes its strategy to address its STRATEGIC CHALLENGES and leverage its STRATEGIC ADVANTAGES. Summarize your organizations KEY STRATEGIC OBJECTIVES and their related GOALS .

W , q :

a. Strategy Development P ROCESS (1) Strategic Planning P ROCESS How z ? W key

process ? W key ? H ow process ? H ow core competencies , strategic challenges , strategic advantages ( O z P )? W - - z ? H ow z ? H ow process z ?

(2) Strategy Considerations How key ? H ow z process ?

z , , , , , health care services , patient stakeholder

, , , - z sustainability , core competencies , projections

performance z performance x

b. STRATEGIC O BJECTIVES (1) K EY STRATEGIC OBJECTIVES W key strategic objectives ?

W goals strategic objectives ?

(2) STRATEGIC OBJECTIVE Considerations How strategic objectives ?

strategic challenges strategic advantages innovation health care services , , z core competencies core competencies - - key stakeholders

Notes:

N1. S z . S z -

, , , , (4.2 z ), . S , , , , .

N2. T . S : ; ; ; -

; , q ,, ; ;

; ff . S

, x , , -

, , - -z , . I .

N3. Y z , , , (2.1 [2]) z , ,

: , , q , x , ; ,

, ;

q ; -; ;


17/88

z ;

ff ,

; ; z ; - ; , ,

, , , , ; , ; ; q

; z; q z .

N4. Y x (2.1 [2]) z . I z

, q , x .

N5. S (2.1 [2]) ,

, z , - , , ;

; ; W - , ,

; ( . . , - );

q . R 2.1

z .

N6. I 2.1 z , ff

. H , ; 3.2 6.1, .

F , 3637.

2.2 Strategy Implementation: How do you implement yourstrategy? (45 pts.) Process

Describe HOW your organization converts its STRATEGIC OBJECTIVES into ACTION PLANS. Summarize your organizations ACTIONPLANS, HOW they are DEPLOYED, and KEY ACTION PLAN PERFORMANCE MEASURES or INDICATORS . Project your organizations futurePERFORMANCE relative to KEY comparisons on these PERFORMANCE MEASURES or INDICATORS .

W , q :

a. ACTION PLAN Development and D EPLOYMENT (1) A CTION PLAN Development How action plans ? W key - -

action plans strategic objectives ? W key , , health care services , stakeholders ( patient ), partners , ?

(2) A CTION PLAN Implementation How deploy action plans z workforce key , partners , collaborators , , key strategicobjectives ? How key action plans ?

(3) Resource Allocation How action plans , ? H ow

? H ow z ?

(4) W ORKFORCE Plans W key workforce - - strategic objectives action plans ? How

workforce workforce capability capacity ?

(5) PERFORMANCE MEASURES W key performance measures indicators

effectiveness action plans ? How action plan z alignment ? How key deployment stakeholders ?

(6) A CTION PLAN Modification How action plans q x ?

b. PERFORMANCE PROJECTIONSF key performance measures indicators 2.2 (5), performance projections

- - z ? H performance measures indicators performance z ff healthcare services ? H key benchmarks , goals , performance , ? I

performance z , how ?

Health Care Criteria for Performance Excellence: Strategic Planning 11


18/88

Notes:

N1. S C . T

x :

1.1 z

3 , ,

4 , , ,

, ff ,

5 ,

, -

6 , , q

7.1 z

N2. M (2.2 )

; z q ; ; ;

, q , ;

.

F , 37.

Te Baldrige Award Program is still one of the best in the entire maelstrom of awards.Teres the Nobel Prize, the Oscars, and all that, but the Baldrige Award is right up there! Its inspiring. Its exciting. It makes us proud.

L B , q x , ff J q K ,

M B



19/88Health Care Criteria for Performance Excellence: Customer Focus 13

3 3 Customer Focus (85 pts.)T C ustomer Focus y x how y z patients stakeholders - . T engagement y how y z voice of its customers (y patients stakeholders) ,

customer , customer y innovation.

3.1 Voice of the Customer: How do you obtain informationfrom your patients and stakeholders? (45 pts.)

Describe how your organization listens to your patients and stakeholders and gains satisfaction and dissatisfactioninformation.

W y , q :

a. P aTienT and s TakeholDer Listening(1) Listening to Current P atients and Stakeholders How y patients stakeholders

? How y y patient , stakeholder , segments? How y W - patients

stakeholders, ? How y y patients stakeholders y ? How y patients stakeholders q y

, patient stakeholder , ?(2) Listening to Potential P atients and Stakeholders How y patients stakeholders,

patients stakeholders, patients stakeholders - y , patient stakeholder , , ?

b. Determination of P aTienT and s TakeholDer Satisfaction and e ngagemenT(1) Satisfaction and E ngagement How y patient stakeholder engagement?

How patient stakeholder segments, ? How y x y patients

stakeholders x y patients stakeholders engagement?

(2) Satisfaction Relative to Competitors How y y patients stakeholders y ? How y y patients

stakeholders levels patients stakeholders z - health care services y benchmarks, ?

(3) Dissatisfaction How y patient stakeholder ? How y y patients stakeholders q x

x ?

Process

Organizational Profile:Environment, Relationships, and Strategic Situation

2StrategicPlanning

1Leadership

3Customer

Focus

5Workforce

Focus7

Results

6Operations

Focus

4Measurement, Analysis, and Knowledge Management

Planning

ship3

CustomerFocus

F

OpeF

4Measurement, Analysis, and Knowled

Notes:

N1. T y - - .

V - - - y , ,

q , x , . T .

L y , y , , ,

.

N2. U W - (3.1 [1])

y . U y

y y z y z , , ,

y y z .

N3. D (3.1 ) y

: y , , z , , / y ,

, . I

W , y, y .D


20/88

. D

.

N4. D (3.1 [1]) , x , q ,

, - , .

N5. D (3.1 [2]) ,

z ,

z . D

.

F , 3839.

3.2 Customer Engagement: How do you engage patients and stakeholdersto serve their needs and build relationships? (40 pts.) Process

Describe HOW your organization determines HEALTH CARE SERVICE offerings and PATIENT and STAKEHOLDER communicationmechanisms to support PATIENTS and STAKEHOLDERS. Describe HOW your organization builds PATIENT and STAKEHOLDER relationships.

W , q :

a. H EALTH CARE SERVICE Offerings and P ATIENT and STAKEHOLDER Support(1) HEALTH C ARE SERVICE Offerings How patient , stakeholder , q

health care service ff ? H ow ff q x x patient stakeholder segments (

O z P )? H ow ff , patients stakeholders , x x patients stakeholders , ?

(2) P ATIENT and STAKEHOLDER Support How patients stakeholders ? H ow health care services ? W key patient stakeholder , key

? H ow ff patient stakeholder segments ? How patients stakeholders key q ? H ow

patients stakeholders q deployed processes patient stakeholder ?

(3) P ATIENT and STAKEHOLDER Segmentation How patient , stakeholder , , health careservice ff patient stakeholder segments ? How patients stakeholders patients ,

stakeholders , ? H ow patient stakeholder segments health care services ?

(4) P ATIENT and STAKEHOLDER Data Use How patient , stakeholder , , health careservice ff , patient - stakeholder - ,

innovation ?

b. Building PATIENT and STAKEHOLDER Relationships(1) Relationship Management How , , patients stakehold

ers ?

q patients stakeholders patients stakeholders , q , x x

engagement

(2) Complaint Management How patient stakeholder ? H ow patient stakeholder process effectively ?

How patient stakeholder process patients stakeholders engagement ?



21/88

Notes:

N1. C z

ff . C ,

ff

z , z

ff .

N2. H ff ff

. H ff (3.2 )

. T ff

x , ff q

ff ff z ff . B

, x , , ,

, , / . K .

Y 7.1,

( ) 7.2.

N3. T (3.2 [2]) z

x .

N4. B (3.2 )

.

F , 39.

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 wouldnt have been had we not beenso committed to the Baldrige process.

R S , CEO 2008 B P V H S

Health Care Criteria for Performance Excellence: Customer Focus 15


22/88

4 Measurement, Analysis, and4 Knowledge Management (90 pts.)

T Measurement, A NALYSIS , and Knowledge Management x how z , , z , , , ,

knowledge assets how . T xhow z performance .

4.1 Measurement, Analysis, and Improvement of Organizational Performance:How do you measure, analyze, and then improve organizational performance? (45 pts.)


2StrategicPlanning

1Leadership

3Customer

Focus

5Workforce

Focus7

Results

6Operations

Focus

Process

Describe HOW your organization measures, analyzes, reviews, and improves its PERFORMANCE through the use of data and information at all levels and in all parts of your organization.

W , q :

a. PERFORMANCE Measurement(1) PERFORMANCE MEASURES How , , ,

z performance , strategic objectives action plans ? W key z performance measures , key -

- measures ? H q measures ? How z innovation ?

(2) Comparative Data How effective key innovation ?

(3) P ATIENT and STAKEHOLDER Data How effective voice -of -the -customer ( ) innovation ?

(4) Measurement Agility How performance x z x ?

b. PERFORMANCE ANALYSIS and ReviewHow z performance ? H ow key z performance measures ? W analyses

? H ow z , performance , , strategic objectives action plans ? How

z z ?

c. PERFORMANCE Improvement(1) Best-Practice Sharing How performance

z work processes ?

(2) FUTURE PERFORMANCE How performance key performance ?

(3) Continuous Improvement and I NNOVATION How z performance innovation ? How deployed - z ? W

, how deployed , partners , collaborators z alignment ?

Notes:

N1. P (4.1 ) - - z , , , z .

N2. C (4.1 [2]) .

B ,



23/88


24/88


25/88


26/88

Notes:

N1. W x , ,

, , z .

N2. T - (5.2 [2] 5.2 [3]),

z , . T - 59.

N3. C , , (5.2 [3])

, q , . R

z , .

N4. I (5.2 [2]) - 7.3 - z

7 .

N5. Y z q

, , . I , 5.2 . Y

z , , , , ,

- x .

F , 4244.

Te Baldrige journey for us has really never been about winning the crystal. Its about being worthy,about accelerating our performance, about transforming our organization, making it a better place for our

physicians to practice, achieving stronger political outcomes, about creating a great work environment, and eventually getting to this vision of ours of building healthy communities.

D , CEO 2009B A A C



27/88

2 7

4

ysis, and Knowledge Managementl

6 Operations Focus (85 pts.)1

Leadership

Process


2StrategicPlanning

3Customer

Focus

5Workforce

Focus

Results

Measurement,Anal

g

er

ocus7

Result

4ysis, and Knowledge Management

T O PERATIONS F OCUS x how z , , work systems work processes patient stakeholder value

z sustainability. A x .

6.1 Work Systems: How do you design, manage, and

improve your work systems? (45 pts.)Describe HOW your organization designs, manages, and improves its WORK SYSTEMS to deliver PATIENT and STAKEHOLDER VALUE, prepare for potential emergencies, and achieve organizational success and SUSTAINABILITY .

W , q :

a. W ORK SYSTEM Design(1) Design Concepts How work systems? How z

core competencies? How processes work systems z ( key work processes) x ?

(2) W ORK S YSTEM Requirements How key work system q , patients, stakeholders, , partners, collaborators, ? W key q

work systems?

b. W ORK SYSTEM Management(1) W ORK S YSTEM Implementation W z work systems? How

work systems patient stakeholder value z sustainability ?

(2) Cost Control How work systems? How , patients? How z ,, process performance , ?

c. Emergency ReadinessHow work system ? How

, , patients , , ?

Notes:

N1. W z . W , , ,

, . Y

x , , .

N2. D (6.1 ) - ,- , - ,

, . H z - ,

, z - ( . ., , ,

/ ). E 4.2.

F , 44.

Health Care Criteria for Performance Excellence: Operations Focus 21


28/88

6.2 Work Processes: How do you design, manage, andimprove your key work processes? (40 pts.) Process

Describe HOW your organization designs, manages, and improves its KEY WORK PROCESSES to deliver PATIENT and STAKEHOLDER VALUE and achieve organizational success and SUSTAINABILITY .

W , q :

a. W ORK PROCESS Design

(1) Design Concepts How work processes key q ?How , z , - , health careservice x , processes ? How cycle time ,productivity , , ffi effectiveness processes ?

(2) W ORK PROCESS Requirements How key work process q ? W z key work processes ? W key q work processes ?

b. W ORK PROCESS Management(1) K EY W ORK PROCESS Implementation How key work processes work systems ? How

- - processes key process q ? W key performance measures indicators - measures

work processes ?

(2) P ATIENT Expectations and Preferences How patient x ? H ow health care service processes x patient x ? H ow

patient patient health care services ?

(3) Supply-Chain Management How ? H ow q performance patient stakeholder ? H ow

performance ? How ?

(4) PROCESS Improvement How work processes , performance , , health care services ?

Notes:

N1. Y (6.2 [2]) , , -

, , . Y z

.P q

x . P .

N2. (6.2 [4]) , z

L E S , S x S , P -D -C -A (PDCA) , . T P.2

O z P .

N3. T

7.1.

F , 4445.



29/88

2

t

Results (450 pts.)Organizational Profile:

Environment,Relationships,and Strategic Situation

2StrategicPlanning

3Customer

Focus

5Workforce

Focus

6Operations

Focus


rces

ionss

71

Leadership

T R ESULTS x z performance key process , customer- , workforce

, governance , .Performance levels x z

health care service ff .

7.1 Health Care and Process Outcomes: What are your health careand process effectiveness results? (120 pts.) Results

Summarize your organizations KEY health care RESULTS and its KEY PERFORMANCE and PROCESS EFFECTIVENESS and efficiency RESULTS. Include PROCESSES that directly serve PATIENTS and STAKEHOLDERS, strategy, and operations. S EGMENT your RESULTSby HEALTH CARE SERVICE offerings, by PATIENT and STAKEHOLDER groups and market SEGMENTS, and by PROCESS types and locations, as appropriate. Include and indicate your RESULTS for KEY MEASURESthat are publicly reported and/or mandated by regulatory, accreditor, or payor requirements. Include appropriate comparative data.

P q :

a. PATIENT-Focused Health Care R ESULTS W levels trends key measures indicators processperformance patients stakeholders ? H results

performance z ff ?

b. Operational P ROCESS EFFECTIVENESSRESULTS (1) Operational E FFECTIVENESS W levels trends key measures indicators

performance key work systems processes , productivity , cycle time , measures process effectiveness , ffi , innovation ?

(2) Emergency Preparedness W levels trends key measures indicators effectiveness work system ?

c. Strategy Implementation R ESULTS W results key measures indicators z action plans , core competencies ?

Notes:

N1. R 7.1 z

( 4.1); z (4.2); -

( 7.2) ( 7.5). R C M MS (CMS)

z .

N2. H 7.1 q

x P.1 (2), 3.1 3.2. T

ff , P.1, 7, 3.2, 2.

N3. R 7.1 q O z P

6.1 6.2.

N4. A ff (7.1 ) , - -, x

; ; ; ; ; ; x ;

x .

N5. M (7.1 )

2.1 (1) 2.2 (5)

2.2 , .

F , 4647.

Health Care Criteria for Performance Excellence: Results 23


30/88


31/88

7.4 Leadership and Governance Outcomes: What are yoursenior leadership and governance results? (80 pts.) Results

Summarize your organizations KEY SENIOR LEADERSHIP and GOVERNANCE RESULTS, including those for fiscal accountability,legal compliance, ETHICAL BEHAVIOR , societal responsibility, and support of KEY communities and community health.SEGMENT your RESULTS by organizational units, as appropriate. Include appropriate comparative data.

P q :

a. Leadership, G OVERNANCE, and Societal Responsibility R ESULTS (1) Leadership W results key measures indicators senior leaders workforce deploy vision values , - ,

?

(2) GOVERNANCE W key trends key measures indicators governance , x , ?

(3) Law, Regulation, and Accreditation W results key measures indicators , , q ?

(4) Ethics W results key measures indicators ethical behavior stakeholder z senior leaders governance ? W results key measures indicators ethical behavior ?

(5) Society W results key measures indicators z , z key , ?

Notes:

N1. R 7.4 (1) 1.1.

N2. R 7.4 (2) , x

, .

N3. R , , (7.4 [3]) q 1.2 . W -

( . ., O S H A [OSHA] )

7.3 (2).

N4. F x (7.4 [4]), 1.2, 4.

N5. R 7.4 (5) z 1.2 (1) 1.2 (1),

1.2 (2). M

- ; ,

, ( . ., ); .

F , 48.

Baldrige is a commitment to excellence that never ends. . . . We want to learn every day, we want to be better every day, and Baldrige gave us the framework . . . to pursue that journey of excellence.

M L , CEO 2009B A H H

Health Care Criteria for Performance Excellence: Results 25


32/88

7.5 Financial and Market Outcomes: What are your nancial andmarketplace performance results? (80 pts.) Results

Summarize your organizations KEY financial and marketplace PERFORMANCE RESULTS by market SEGMENTS or PATIENT and STAKEHOLDER groups, as appropriate. Include appropriate comparative data.

P q :

a. Financial and Market R ESULTS

(1) Financial P ERFORMANCE W levels trends key measures indicators performance , measures , , performance , ?

(2) Marketplace P ERFORMANCE W levels trends key measures indicators performance , , ,

, ?

Notes:

N1. R 7.5 (1) , (ROI),

, , . R , q , - - q

, , z , , , . M 4.1 (1) 2.2.

F , 48.

Embracing the Baldrige Criteria as a framework to bring excellence to our industry [makes] good business sense, and more important, its the right thing to do for our patients.

F J. S , CEO 2005B A B M H



33/88

CHANGES FROM THE 20092010 H EALTH CARE CRITERIA

T H C C P Ex z , - ,

, , , - z . T C

, z .

T - - B C . H , B P

20 , C . T

q z , ,

. W C , B P

. O , C

x ; , C

. S 2009, B P - C .

S - C ,

, 20112012 H C C P Ex .

T C : (1) x , (2) .

C x z . , , , z x . T B C x

z x. H , C

. W C q x , z

, , . H

x q x ffi .

O z x . E

q ( ) z . W

, , , C

x . A , q

. W the line of sight from strategic challenges and advantages to core competencies, tostrategy, and then to work systems and work processes . T

z x

q . W x, x . S q ,

2011 C .

T z

. W z

. T z

z . W

- - . L

- . T q z

.

T C C z :

T 41 40, C 18 17, 2 P : O z P

. T q

H CC . T

z , .

Preface: Organizational Prole I P.1, Organizational Description,

.S - 6.2.

I P.2, Organizational Situation, .

Category 1: Leadership I 1.1, Senior Leadership ,

.

I 1.2, Governance and Societal Responsibilities ,

x .

Changes from the 20092010 Health Care Criteria 27


34/88

Category 2: Strategic Planning T z

. I 2.1, Strategy Development,

. T q

. I 2.2, Strategy Implementation,

.

Category 3: Customer Focus T

.

I 3.1, Voice of the Customer ,

, , .

I 3.2, Customer Engagement , ff , , , . T

, .

Category 4: Measurement, Analysis,and Knowledge Management

I 4.1, Measurement, Analysis, and Improvement of Organizational Performance , -

- z . U -

3. P q -

.

Category 5: Workforce Focus T

. I 5.1, Workforce Environment ,

.

I 5.2, Workforce Engagement ,

.

Category 6: Operations Focus T , Operations Focus ,

ff .

I 6.1, Work Systems , x ,

. I 6.2, Work Processes ,

.T -

.

Category 7: Results T

16 x

. I 7.1, Health Care and Process Outcomes ,

. T

: (1) -

, q z

; (2) - ff

. I 7.3, Workforce-Focused Outcomes ,

5. I 7.4, Leadership and Governance Outcomes,

x

. I 7.5, Financial and Market Outcomes ,

z .

Glossary of Key Terms S G K

. T ff .

Results Scoring Guidelines T

z , , q . A , x 90100%

.



35/88

HEALTH CARE CRITERIA RESPONSE GUIDELINES

T ff C ff q

17 C . F z B A ,

q 50 .

T :

(1) C ,

(2)

(3)

o respond most effectively to the Criteria items, your organizationalso will find it important to refer to the scoring guidelines (pages 6869), which describe how organizations can demonstrate increas ing accomplishment and improvement relative to the requirements of the Criteria items.

General Guidelines1. Read the entire Criteria booklet.

T C , - B x . Y

: H C C P Ex ( 426) S S ( 6770)

G K ( 5766) C I D ( 3348)

2. Review the item format and understand how torespond to the item requirements.T ( ) ff

, , . I q .

T q . E C

I D ( 3348).

E process esults, q . G 3031. G

3132.

I q q . S q

q . R q ; , q . R q

, z . T q q .

Item Format

B qx

O qx

A

S z

q

I :

q

/

I I I

M qx C q

L

x

Summarize your organizations KEY health care RESULTS and its KEY PERFORMANCE and PROCESS EFFECTIVENESS and efficiency RESULTS. Include PROCESSES that directly serve PATIENTS and STAKEHOLDERS , strategy, and operations. S EGMENT your RESULTSby HEALTH CARE SERVICE offerings, by PATIENT and STAKEHOLDER groups and market SEGMENTS, and by PROCESS types and locations, as appropriate. Include and indicate your RESULTS for KEY MEASURESthat are publicly reported and/or mandated by regulatory, accreditor, or payor requirements. Include appropriate comparative data.

P q :

a. PATIENT-Focused Health Care R ESULTS W levels trends key measures indicators processperformance patients stakeholders? H results

performance z ff ?

b. Operational P ROCESS EFFECTIVENESSRESULTS(1) Operational E FFECTIVENESS W levels trends key measures indicators

performance key work systems processes, productivity, cycle time, measures process effectiveness, ffi , innovation?

(2) Emergency Preparedness W levels trends key measures indicators effectiveness work system ?

c. Strategy Implementation R ESULTS W results key measures indicators z action plans, core competencies?

N1. R 7.1 z

( 4.1); z (4.2); -

( 7.2) ( 7.5). R C M MS (CMS)

z .

N2. H 7.1 q

x P.1 (2),

ff , P.1, 7, 3.2, 2.

N3. R 7.1 q O z P

6.1 6.2.

Notes:

N4. A ff (7.1 ) , - -, x

; ; ; ; ; ; x ;

x .

N5. M (7.1 )

2.1 (1) 2.2 (5)

2.2 , .

F , 46.

7.1 Health Care and Process Outcomes: What are your health careand process effectiveness results? (120 pts.) Results

Health Care Criteria Response Guidelines 29


36/88

3. Refer to the scoring guidelines.Te ev u tion of ro e nd re u t ite re on ein ude review of the Criteri ite require ent ino bin tion with the oring guide ine ( ge 6770).S e i y, o e ent to require ent of thero e ite ( tegorie 16), the oring guide ineddre the turity of your ro he , the bre dth of de oy ent, the extent of e rning, nd integr tion withother e e ent of your erfor n e n ge ent y te .Si i r y, o e ent to require ent of the re u tite ( tegory 7), the oring guide ine fo u on thetu erfor n e eve , the igni n e of the re u t

trend , re ev nt o r tive d t , integr tion withi ort nt e e ent of your erfor n e n ge enty te , nd the trength of the i rove ent ro e .Terefore, you need to on ider both the Criteri ndthe oring guide ine you re re your re on e to

ite .

4. Understand the meaning of key terms.M ny of the ter u ed in the Criteri h ve e ning th ty differ o ewh t fro t nd rd denition or denition

u ed in your org niz tion. er rinted in small caps nbe found in the G o ry of Key er beginning on ge57. Under t nding the e ter n he you ur te y e f-

e your org niz tion nd o uni te your ro e e ndre u t to tho e reviewing your re on e nd nning youri rove ent effort .

5. Start by preparing the Organizational Prole.Te Org niz tion Pro e i the o t ro ri te t rtingoint. Te Org niz tion Pro e i intended to heeveryonein uding org niz tion u ing the Criteri for e f-

e ent, i tion writer , nd reviewer under t nd wh t i o t re ev nt nd i ort nt to your org niz tioni ion nd to it erfor n e he th re rovider.Te que tion in the Org niz tion Pro e re on ge 46.Te Org niz tion Pro e i de ribed in gre ter det i onge 3334.

Guidelines for Responding to Process Items

A though the Criteri fo u on key org niz tion erfor n ere u t , the e re u t by the e ve offer itt e diagnostic v ue.For ex e, if o e re u t re oor or re i roving t r teower th n your o etitor or o r b e org niz tion , it i

i ort nt to under t nd why thi i o nd what ight be doneto e er te i rove ent.

Te ur o e of ro e ite i to er it di gno i of yourorg niz tion most important ro e e the one th tontribute o t to org niz tion erfor n e i rove entnd ontribute to key out o e or erfor n e re u t .Di gno i nd feedb k de end he vi y on the ontent ndo etene of your ite re on e . For thi re on, it ii ort nt to re ond to the e ite by roviding your key ro e infor tion. Guide ine for org nizing nd reviewingu h infor tion fo ow.

1. Understand the meaning of how.Pro e ite in ude que tion th t begin with the wordhow. Responses should outline your key process information

that addresses approach, deployment, learning, and integration(see Scoring System, page 67).Re on e king u h infortion, or ere y roviding n ex e, re referred to in theoring guide ine ne dot infor tion.

2. Understand the meaning of what.wo ty e of que tion in ro e ite begin with the wordwh t. Te r t ty e of que tion reque t b i infor tionon key ro e e nd how they work. A though it i he futo in ude who erfor the work, ere y t ting whodoenot er it di gno i or feedb k. Te e ond ty e of que tionreque t infor tion on what your key nding , n ,

obje tive , go , or e ure re. Te e tter que tion etthe ontext for howing ign ent nd integr tion in yourerfor n e n ge ent y te . For ex e, when you

identify key tr tegi obje tive , your tion n , o e of yourerfor n e e ure , nd o e re u t re orted in tegory 7re ex e ted to re te to the t ted tr tegi obje tive .

3. Write and review responses with the following guidelinesand comments in mind.

Show th t approaches re y te ti .Sy te ti ro he re re e t b e ndu e d t nd infor tion to en b e e rning.In other word , ro he re y te tiif they bui d in the o ortunity forev u tion, i rove ent, innov tion, ndknow edge h ring, thereby en b ing g inin turity.

Show deployment .De oy ent infor tion hou d u rizehow your ro he re i e entedin different rt of your org niz tion.De oy ent n be hown o t y by u ing t b e .



37/88

Show eviden e of learning.Pro e e hou d in ude ev u tion nd i rove ent y e , we the otenti for bre kthrough h nge. Pro e

i rove ent hou d be h red with other ro ri te unitof the org niz tion to en b e org niz tion e rning.

Show integration.Integr tion how ign ent nd h r oniz tion ongro e e , n , e ure , tion , nd re u t th tgener te org niz tion effe tivene nd effi ien ie .

Show fo u nd on i ten y.Tere re four i ort nt on ider tion reg rding fo und on i ten y: (1) the Org niz tion Pro e hou dke e r wh t i i ort nt to your org niz tion; (2) the

Str tegi P nning tegory ( tegory 2), in uding thetr tegi obje tive , tion n , nd ore o eten ie ,hou d high ight re of gre te t fo u nd de ribehow de oy ent i o i hed; (3) the de ri tion of org niz tion - eve n y i nd review (ite 4.1) hou dhow how your org niz tion n yze nd review erforn e infor tion to et rioritie ; nd (4) the O er tion

Fo u tegory ( tegory 6) hou d high ight the work y te nd work ro e e th t re key to your overerfor n e. Showing focus and consistency in the process items and tracking corresponding measures in the results items should improve organizational performance.

Re ond fu y to ite require ent .Mi ing infor tion wi be inter reted g in yourerfor n e n ge ent y te . A re to ddrehou d be ddre ed. Individu que tion within nre to ddre y be ddre ed individu y or together.

4. Cross-reference when appropriate. A u h o ib e, e h ite re on e hou d be e f-ont ined. However, re on e to different ite o hou dbe utu y reinfor ing. It i ro ri te to refer to the otherre on e r ther th n re e t infor tion. In u h e , key ro e infor tion hou d be given in the ite reque tingthi infor tion. For ex e, workfor e deve o ent nde rning y te hou d be de ribed in ite 5.2. Di u ionbout workfor e deve o ent nd e rning e ewhere in your

i tion wou d then referen e but not re e t det i givenin your ite 5.2 re on e.

5. Use a compact format.

A i nt hou d ke the be t u e of the 50 i tionge er itted. A i nt re en our ged to u e ow h rt ,

t b e , nd bu et to re ent infor tion on i e y. Te50- ge i tion i it i de igned to for e your org niztion to on ider wh t i o t i ort nt in n ging yourenter ri e nd re orting your re u t .

Guidelines for Responding to Results Items

Te Criteri e jor e h i on re u t . Te fo owinginfor tion, guide ine , nd ex e re te to effe tive ndo ete re orting of re u t .

1. Focus on the most critical organizationalperformance results.Re u t re orted hou d over the o t i ort nt require entfor your org niz tion u e , high ighted in your Org niztion Pro e nd in the Le der hi , Str tegi P nning, Cuto er Fo u , Workfor e Fo u , nd O er tion Fo u tegorie .

2. Note the meaning of the four key requirementsfrom the scoring guidelines for effective reportingof results data:

performance levels th t re re orted on e ningfu e ure ent e

trends to how dire tion of re u t , r te of h nge, ndthe extent of de oy ent

comparisons to how how re u t o re with tho e of other, ro ri te y e e ted org niz tion

integrationto how th t i ort nt re u t re in udednd eg ented (e.g., by i ort nt tient or t keho der,

workfor e, ro e , nd he th re ervi e grou )

3. Include trend data covering actual periods fortracking trends.No ini u eriod of ti e i e ied for trend d t .However, ini u of three hi tori d t oint gener y i needed to ert in trend. rend ight n ve orore ye r for o e re u t . rend hou d re re ent hi torind urrent erfor n e nd not re y on roje ted (future)erfor n e. i e interv between d t oint hou dbe e ningfu for the e i e ure( ) re orted. Fori ort nt re u t , new d t hou d be in uded even if trendnd o ri on re not yet we e t b i hed.

Health Care Criteria Response Guidelines 31


38/88

Figure 7.13 Beta-Blocker Use

Good 90 Hospital A

) 85 Hospital B % ( e s u

80 Hospital C

c k e r

o l 75 b

Overall organiza on e t a

b 70 I M A Best compe tor

65

Benchmark60 from na onal hospital

2006 2007 2008 2009 2010 2011 2012 associa on Year

4. Use a compact formatgraphs and tables.M ny re u t n be re orted o t y by u ing gr h ndt b e . Gr h nd t b e hou d be be ed for e y inter ret tion. Re u t over ti e or o red with other hou d benor ized (i.e., re ented in w y, u h u ing r tio ,th t t ke into ount ize f tor ). For ex e, re ortingfety trend in ter of need e ti k er 100 t ff e ber

wou d be ore e ningfu th n tot need e ti k if thenu ber of t ff e ber h v ried over the ti e eriod or

if you re o ring your re u t to tho e of org niz tiondiffering in ize.

5. Incorporate results into the body of the text.Di u ion of re u t nd the re u t the e ve hou dbe o e together in B drige Aw rd i tion. Trends that show a significant beneficial or adverse change should be explained.U e gure nu ber th t orre ond to ite . Forex e, the third gure for ite 7.1 wou d be gure 7.13.(See the ex e in the gure on thi ge.)

Te gr h hown on thi ge i u tr te d t th t he thre y te with u ti e ite ight re ent rt of

re on e to ite 7.1, He th C re nd Pro e Out o e . Inthe Org niz tion Pro e, the org niz tion h indi ted u eof bet -b o ker with ute yo rdi inf r tion (AMI) key tient nd t keho der require ent.

Te gr h i u tr te nu ber of h r teri ti of e r ndeffe tive re u t re orting: A gure nu ber i rovided for referen e to the gr h in

the text. Both xe nd unit of e ure re e r y be ed. D t eve nd trend re re orted for key tient nd

t keho der require entu e of bet -b o ker with AMI.

Re u t re re ented for ever ye r . An rrow indi te th t n u w rd trend i good for thi

e ure. A ro ri te o ri on re hown e r y. Te org niz tion how , u ing ing e gr h, th t three

of it ho it re e r te y tr ked for bet -b o ker u e. Te org niz tion roje t i roved erfor n e,

in uding di ontinuou or bre kthrough i rove entre tive to rior erfor n e for ho it B. Te texthou d ex in thi bre kthrough h nge nd ight referto riti e rning fro ho it A the b i for theroje ted h nge.

o he inter ret the oring guide ine ( ge 69), the fo owing o ent on the gr hed re u t wou d be ro ri te: Te urrent over org niz tion erfor n e eve i

good. Ti on u ion i u orted by the o ri on with o etitor nd with ben h rk eve .

Te over org niz tion how bene i i rove enttrend u t ined over ti e.

Ho it A i the urrent erfor n e e der howing ut ined high erfor n e nd ight y bene i trend in e2007. Ho it B how r id i rove ent. It erfor n ei ne r th t of the be t o etitor but tr i ho it A.

Ho it Cidentied in the i tion new qui itioni h ving e r y rob e with en uring

bet -b o ker u e but i roje ting turn round. (Teorg niz tion hou d briey ex in the e rob e .)

Te org niz tion h roje ted i rove ent in bet -b o ker u e for of it ho it . Ho it C ontinue tog behind the other ; ho it A i roje ted to eet it

go by 2012.



39/88

CATEGORY AND ITEM DESCRIPTIONS

Preface: Organizational Prole

T O z P w z . T

, z , x ,

. Y O zP w

z . I B x ww w

. I z C

17.

T O z P z w x

. T , , , , , ,

, w z . A , O z P z x

w ; z ; ,

, z .

P.1 Organizational Description: What are your key organizational characteristics?

PurposeT

z. I z

. T x z C

17.

Comments T ,

, , ,

z , z .

N , z , w x , w w z

. T ff z .

A z z

. Ex

w ff . K w

,

. T w

z w z . U ff .

F , w w w

w , , x, z .

L z w - w . I

w , ,

z . B .

I - z ,

z . S -

Category and Item Descriptions 33


40/88

, , - - , x , ffi ,

, , z .

P.2 Organizational Situation: What is your organizations strategic situation?

Purpose

T w z , . I w , z . T

z .

Comments K w z , ,

w z . W w , ff, , , z ; z ; ;

. U w

, w , w

w . L z -

, .

S x z ( . ., CMS, N C Q A [NCQA], J C , M Q I P ),

, ,

z , , w , . C ,

, ff , z ff ( . .,

), z .

O z

ff . T ( . ., , ,

); x ; z

; , w ;

; w H

I P A A (HIPAA); w ; ; -

. I , z , ,

w . A ,

z ,

. I , MRI , ,

. , z

.

Leadership (Category 1)

L w z , z , ,

x . A w w w , , z , ,

. T z w z ,

, ; ; .

1.1 Senior Leadership: How do your senior leaders lead?

Purpose

T x . I x w

z w . I

, - z w , , .

Comments S ,

, , z

. S

, , z . I , w , , .

I z w / ,

w w .

I z , , z , z



41/88

w w . S

. T z , , ,

w . D

.

1.2 Governance and Societal Responsibilities: How do you governand fulll your societal responsibilities?

PurposeT x

z , . I x

w z z

w z ,

, .

Comments T z

,, ,

( ). T

w , w

z CEO ff .

A , ,

(1) ; (2) ,

, ; (3) .E

. Y z

,

w w . R - z x x

. T .

C , z w

w - , , , - w .

S . O w -

, , z z . T w z z .

Y z

.Ex z w , ,

, , U.S. .

A w z ( ) . T

ff z w , x- xz .



42/88

Strategic Planning (Category 2)

S P , , w

, w , w

. T - z

z . D z z

.

W z , x . T

x , w

- . T

, x .

T B H C C z z x . T

: P - x w x .

T , , w ,

z . O

- - w . B , , x z .

O z - . T

C z w . T

w w z ,

z .

T S P x w z , w , ,

; ; x

z ,

w , - - x , , , w

w ff

: (1) z x

, (2) w w , (3) /w

T S P

. T . T

. A ff

. T , w

, , . I ,

. H w , ,

w ,

.

2.1 Strategy Development: How do you develop your strategy?

PurposeT x w z

, , . T

, z , .

Comments T

, , , ff

z - w

z . T

x -, -, - , , .

T z , / , , , . T

x - ,

, w z .E z w

, .

T z , w

ff . H w

w z w .

H w / z



43/88


44/88

T C ,

z . H w ,

z . S , , - , , , , , . A

z ff x .

3.1 Voice of the Customer:How do you obtain information from your patients and stakeholders?

PurposeT x z

. I x . T x x .

Comments S - - -

z . I , z . S

w , w

, w w

, w / z , .

T z w . I

ff

z .

I , , , , ff

x w . T

. ff , w

z . C

. T

- . A

z . O z w .



45/88

K w , ,

w z ff, ,

- - w, w , z

. I

, w , ff , / z

. S w . T

ff - z .

3.2 Customer Engagement:How do you engage patients and stakeholders to serve their needs and build relationships?

PurposeT x z ff

, , ; ; ,, , ff

. T x w w

w . T ff , - -

, , .

Comments C

w z ff . A -

- w

. A w

w . T ff

. T ff

w .

C , , ff

. S ff z .

Measurement, Analysis, and KnowledgeManagement (Category 4)

T M , A , K w M w C ff , z ,

z w z . I ,

4 z , , w

. C . F , , ,

w w , .

4.1 Measurement, Analysis, and Improvement of Organizational Performance: How do you measure,analyze, and then improve organizational performance?

PurposeT x z

, , w z

. T ff ( . .,

, , ). T

,

. T , ,w, z

w z

, x z x , .

Comments A

. T w x ff

x . A w z w

z -w . A w

, w , -

z -w .

T z . T (1) z w w

, , , (2)



46/88

( ) , (3)

, (4)

z w w

. C z

,, .

Y ff

(1) , (2)

w z

, (3)

, ( )

z .

C z . L

(1) z x ( . ., ), (2) ( . ., ), (3)

z ( . ., CMS z NCQA J C ,

z ) . T z w

. T .

I w w

z , , , . T ,

z w

w z , , , .

A z w z , z , , . Ex

w : w w

, ,,

- - ff

, , ( . .,

, , w , ), w, z , ,

, z, ff

w

, , w ,

-

w zw

w w

w w w , ,



47/88


48/88

Workforce Focus (Category 5) W F w

w - w w w

z . T w . Y w

w , , , w

w ( . ., w z ).

w w , C w SP ( 2).

5.1 Workforce Environment: How do you build an effective and supportive workforce environment?

PurposeT x z w ,

w , w w z ,

w w . T ff w w .

Comments A z , z ,

w ; w ,- z

. T , w

w , w . M z , z ,

w . S x ,, ,

, , ,

, w - , , ,

x w , , , x

.

5.2 Workforce Engagement: How do you engage your workforce to achieve organizational and personal success?

PurposeT x z ,

, w , w w ff

. T , ,

z .

Comments A z

ff z . T

ff, ,, . T

W F . H - w z x ,

, w , w, w z

, , z

. T w .

M w w , z

. R z w ;

z ; , , ff ,

w . I z , w w w w . I z , w

w /

. F

z . U w , , , x w w

w . C

w . ff , ,

, / .

C ; w x

; , z ,

z . D z

, w , z , w

. T ;

w , , w , ; ; x ; ; w

; HIPAA w ; w w ;



49/88

- . E

w , , w ,, , .

L z - - ,

, - , , w , , .

z , z w .

A ff w w ,

. I w w : ,

, ; w ; w ;

w ff x x .

A z w w

z - w . E z

w w . T w ( . .,w w ).

M ff ffi w

, , z ; -

- ; - . A w w

, w ffi w . S

x ff ; ;

w ; w ; w ; ff ,

, w ; ;



50/88

ff w ; z .

I w , , , , .

Operations Focus (Category 6)

O F w w z . I x w z ,

, w w w . I w z z . I

.

Effi ff w ff ; ; , , ,

, , w ; ; ; ; ,

, , z .

W w w z . I , , x , ff

. D z , ,

w , ,

, w z . A

, w , .

C L . T w

S x S. I z .

6.1 Work Systems: How do you design, manage, and improve your work systems?

PurposeT x z w

, , , z , w , ,

z .

Comments T w w

w z w ff . I w

, w z , ,

.

M z , , w

w . O , ff . I z

, , ff

w .

Eff z

. T w w z . F x ,

w z . Y

ff w ff ( 4.2).

6.2 Work Processes: How do you design, manage, and improve your key work processes?

PurposeT x , , w , w , ffi ff

, z .

Comments Y w - -

- - - z w . T

z , , . K , , , .

K , , ,

, w ,- , , , , , . F z ,

, , . G ,

ff . Y w

w .

T . S

,



51/88

ffi ff .S ,

, , , , , ,

, . Y ff

ff w w, ,

w . M x ,

w x , w . Y

. F w ;

; , , , ;

; x ;

; ; ; ff w ; ; ;

; z ; ; . Eff

. T ( )

ffi , w .

S - w , , . T

, ,

. T z

x . A x

- . W ,

. D ,

/ .P ( ) . S

z w z . W

, ff w w

. T w , . T . K z

, w - -

, w . F z , -

z . S, ,

z . S w :

, ,

z . S - ,

w .

C - x ,

x , w .

T w . B

. A . Ex (1) z

w , (2) z , (3)

( . ., , zx , ), (4)

, (5) , (6) , (7)

ff w z . P

z . , ff w

, () .

Results (Category 7)

T R

z ff , w

; - ; w ; , ,

; . T , H C C

ff w , , ;

z ,, w , , , , ; z

. C 7 - ( )

, w z . I 4.1

w z .



52/88

7.1 Health Care and Process Outcomes: What are your health care and process effectiveness results?

PurposeT z

, w , ,

. T x z

7.27.5, w w w ff ffi .

Comments T

z . T

z

. O , H C C ,

.

T I . C x z ( . ., CMS, , NCQA, J C , M

Q I P ) z .

T

w . T - -

3.1 3.2. H

w : , , , w ,

, , , ,

, .



53/88

P , ,

w , , , - .

T w

w : (1) ; (2)

ff ; (3) - ff w

. T ,

, ff .

M ff ffi w

/ x ; , ; z ;

w , ; ; , , w , - ; - ,

, ,S x S , x , - .

T z . U

- ff w .

A , z ,

z . B z ffi

, . F , w -

- .

7.2 Customer-Focused Outcomes: What are your patient- and stakeholder-focused performance results?

PurposeT x z - -

, w w w z - , .

Comments T

z w . R

; , , ; ,

, ff ;- -

, , ; (

); ff ; w , ,

z .

T - - ,

z .

7.3 Workforce-Focused Outcomes: What are your workforce- focused performance results?

Purpose

T x z w - , w w w z

, , , w .



54/88

Comments R z -

. G , , , , ( ).

F , , . O z -

w . T

x , , - ; x - ; x - ; x .

R w ffi z

. A z , w

.

R w

, z

- , z , w w

. I , w , , w ff . F x ,

w

z .

7.4 Leadership and Governance Outcomes: What are your senior leadership and governance results?

PurposeT x z , w

, z , ,

.

Comments I

, ,

, z .

G z .

R w , , ff

, x ,

, z w , . R , ,

; ; w

, . R z w - ,

, .

I z w ( ), , ,

, z .

7.5 Financial and Market Outcomes: What are your nancial and marketplace performance results?

PurposeT x z

, w .

Comments M

z .

I 7.5, 1,

, , , , , , - - ,

, ffi ( , ,), . M

z w , , w

, w , w .



55/88

CORE VALUES AND CONCEPTS

Criteria Purposes

T H C C z - , B Aw ,

. I , C U.S. :

z ,,

z

U.S. z w

z

Health Care Criteria for Performance

Excellence Goals T H C C

z w z

- , z

z ff

z

Core Values and Concepts

T H C C w :

- x z w

T , w, - z .

T

w - w .

Visionary Leadership Y z

/

.

T , z , x

w . T , , x . Y , ,

x , , w , z

. T z . S w

, , , . S z .

T , ,

z .

S ,

, w , , w z , z w . A , , , x w ,

, z .

Core Values and Concepts 49


56/88


57/88

P - x . I w , w ,

. I , ,

( ) . I . I . T , - x

- - z .

Organizational and Personal Learning A z

w - x z w .

O z x , w . L w z . T

(1) w ; (2) ,/w , z ; (3)

( ); (4) w z ;

(5) ff , . S ff

, , , - , .

O z (1) w ;

(2) w ;(3) - w ; (4) ; (5)

ff ; (6) z .

T w w . L

, w . I z , ,

w ff . O z , , w

. S

w . O - - ff - ff w - z . F

, w

, w w

, , , w . E ,

- W - .

P (1) , , w w z ;

(2) z - ; (3) z w ; (4)

.

T , w w , ,, ffi z

w x .

Valuing Workforce Members and Partners A z w w , z

, , , . A ,

z z ,w , , , w .

V w , , , w - .

I , x , - w w

. M w (1)

, (2) , (3) ff w z , (4)

z w w

, (5) , (6)

w .

O z x . I

, ff, , , w -

. P w w , - , w z - w . I

w /w , w

, w x , , w .

Ex w ; ; ; - ; , ,

z ; .S x . S w

z x .

A , z w

. Ex w, ,

, . S z .



58/88

S x -,

. P , ,

, . I , ff - ff w .

AgilityS -

x .H -

w/ , w x ,

z w .

M w w , w ,

. A - w w

.

, , , ff

ffi . O z

. D ff

. B

.

A w , . O ; w ,z , , , , -

, , .

Focus on the FutureE z

- - ff z . T w

w -

; w ,

, , ; , , .

Y z , ; ; x ;

; w ; ; w ;

; , , ;

w ; ; x ; w z

. S . A

, w , ; ff ;

; .

A - w x

. T w .

Managing for InnovationI

z , , , , ,

w z . I z w .

I . I w ;

w w . O z

. I w .

S z .

I w z . T ,

z w z .

Management by Fact

A ff

. S ,

, , . M . P

; ; ; w , , ;

, , w , , , , ; ; ;

. D , x , , , w .

A x , , ,

. A ,, ff w

. A , , w , ,

, w , w z ,

w - .



59/88

A

. The measures or indicators you select should best represent the factors that lead to improved health care outcomes;improved patient and stakeholder, operational, financial, and societal

performance; and healthier communities. A comprehensive set of measures or indicators tied to patient/stakeholder and organizational

performance requirements provides a clear basis for aligning all processes with your organizations goals . M

. T

, .

Societal Responsibility and Community Health A z

, , w - , .

L z , ,

. T , , z .

A , z z

w . P , w

, , , w , w , , z . Eff

, ,

w , , .

O z , , w ,

x . O z .

H z . E

, .

S w - w z

, , z . P



60/88

z . S ff

ff , w ,

, .F - z ,

w .

M z .

Focus on Results and Creating Value A z

. R

, w , , , , , , , ,

. B , z

. , z

x . T w ff

.T

ff ff - - , ,

.

Systems PerspectiveT B H C C

z x . T B C , ,

. H w , z -

, , . S z w

z , , , , w . A

B C ,

, , . I ,

.

T B C w . A . I

, , . A

, , , z w . I w w

.

T , w z , w , .

Linkage of the Health Care Criteria to the Business/Nonprot Criteria

T H C C

- w B /N C . T w

z , z . H w ,

w . T , , z x

x . A

w - .



61/88

KEY CHARACTERISTICS OF THE HEALTH CARE CRITERIA

1. The Criteria focus on results.T C z

w.

Organizational performance areas:(1)

(2) -

(3) w -

(4)

(5)

T

2011 2012 health care criteria

Documents