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Baldrige National Quality Program 2007

Baldrige: A Roadmap for Patient Safety and Quality Improvement

Harry S. Hertz August 22, 2007

What Is Baldrige? Why Baldrige? Lessons Learned & Results Next Steps

Baldrige National Quality Program 2007

What Are the Baldrige Criteria?

A set of expectations or requirements

A structured approach to performance improvement

A framework for a systems view of performance management

Baldrige National Quality Program 2007

Basic Goals of the Criteria

delivery of ever-improving value to patients, other customers, and stakeholders, contributing to improved health care quality and organizational sustainability

improvement of overall organizational effectiveness and capabilities

organizational and personal learning ………performance excellence

To help organizations enhance their performance by focusing on

Baldrige National Quality Program 2007

Criteria Purposes

To help improve organizational performance practices, capabilities, and results

To facilitate communication and sharing of best practices

To serve as a tool for understanding and managing performance

Baldrige National Quality Program 2007

Baldrige Health CareCriteria Framework: A Systems Perspective

Baldrige National Quality Program 2007

Beginning the Journey - 2000

Organization

Situation:

Recognized Crisis:

Location:

Reason for Baldrige:

A&T PROGRAMS

Manufacturing

Troubled

Yes

Primarily One

Turnaround

AEROSPACE SUPPORT

Service

New/Emerging

No

Geographically Dispersed

Improvement

Saint Luke’s HospitalSaint Luke’s Hospital

Sustaining Performance ExcellenceSustaining Performance Excellence

Saint Luke’s HospitalSaint Luke’s Hospital

Sustaining Performance ExcellenceSustaining Performance Excellence

• Leadership drives and sustains the Leadership drives and sustains the processprocess

• Leadership at all levels is importantLeadership at all levels is important

• More difficult to change the culture More difficult to change the culture than to learn the toolsthan to learn the tools

• Valuable team building experienceValuable team building experience

• Trust is extremely important Trust is extremely important

Lessons LearnedLessons Learned

• There are no “quick fixes”There are no “quick fixes”

• Must always focus on the customerMust always focus on the customer

• Should never be satisfied with the Should never be satisfied with the present level of qualitypresent level of quality

• Decisions must be driven by data and Decisions must be driven by data and compared to “best”compared to “best”

• Employees make it happen!Employees make it happen!

Lessons LearnedLessons Learned

Saint Luke’s HospitalSaint Luke’s Hospital

Sustaining Performance ExcellenceSustaining Performance Excellence

Saint Luke’s HospitalSaint Luke’s Hospital

Sustaining Performance ExcellenceSustaining Performance Excellence

Baldrige National Quality Program 2007

Lessons Learned by Education and Health Care

Baldrige is a systems perspective Self-assessment facilitates learning Measurements and data are critical Baldrige focuses on results and outcomes Organizational “silos” are pervasive Need to improve internal communication

Baldrige National Quality Program 2007

Lessons Learned by Education and Health Care (cont.)

Many activities, few processes- “What” is not the same as “how”

The customer concept is challenging Improvement is the goal The process itself is educational

Baldrige National Quality Program 2007

Bronson Methodist Hospital: Cardiac Services % Market Share

30

3540

45

5055

60

1999 2000 2001 2002 2003 2004 Jan-Sept2005

BMH Competitor

Baldrige National Quality Program 2007

BHI: Results

Baldrige National Quality Program 2007

Organizational Knowledge

Baptist Daily• Modeled after Ritz

Carlton best practice

• Began in 2001

• Evolved into facility-specific

Baldrige National Quality Program 2007

1999 & 2000 Award Process Mean Item Percentage Scores: All Business Categories (Stage 1 and

Award Recipients)

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

1.1 1.2 2.1 2.2 3.1 3.2 4.1 4.2 5.1 5.2 5.3 6.1 6.2 6.3 7.1 7.2 7.3 7.4 7.5

Item

Mea

n P

erce

nta

ge

Sco

res

Award Recipients

Stage 1

Baldrige National Quality Program 2007

Baldrige Role Model Characteristics: 1999-2004

Visionary Leadership Guidance (1.1) Process Drive (6.1) Customer and Market Knowledge (3.1)

Baldrige National Quality Program 2007

Early Adopters: 1999-2004

Process Driven (6.1) High Performance Work Systems (5.1)

Customer and Market Knowledge (3.1) Visionary Leadership Guidance (1.1)

Baldrige National Quality Program 2007

“The next time I go to a hospital, I’d rather see a Baldrige Award on the wall than a Harvard diploma.”

Harvey Mackay

Source: Minneapolis Star Tribune 4/6/95

Harvard

Baldrige National Quality Program 2007

Next Steps

Organizational Profile

Are We Making Progress (as Leaders)?

Baldrige National Quality Program 2007

Organizational Profile

Purpose:- Describe what is relevant and important- Ensure common understanding - Guide selection of information/data- Identify gaps/lack of deployment- Serve as first Baldrige assessment

Baldrige National Quality Program 2007

Organizational Profile

Organizational Description– Organizational Environment– Organizational Relationships

Organizational Challenges – Competitive Environment – Strategic Challenges– Performance Improvement System

Baldrige National Quality Program 2007

Are We Making Progress?Are We Making Progress as

Leaders?

Employee (Leadership Team) Questionnaires Seven Category Framework 40 Statements, 5-Point Scale Compare Results Focus Improvement and Communication

for Your Organization

Baldrige National Quality Program 2007

Organizational Profile and Are We Making Progress

(as Leaders)?

Do you know the answer?

Would your organizational colleagues give the same answer?

Baldrige National Quality Program 2007

Resources for More Information

Most Baldrige National Quality Program (BNQP) documents are available both in hard copy and on the BNQP Web site.

To obtain these documents,call (301) 975-2036 orvisit www.baldrige.nist.gov.

Baldrige National Quality Program 2007

Our dilemma is that we hate change and love it at the same time; what we really want is for things to remain the same but get better.

Sydney J. Harris