PRESENTED BY JEANETTE SPRADLIN, VICE PRESIDENT, QUALITY
UNION HOSPITAL, INC.
The Baldrige Award: One Hospital’s Journey
2013 Governor’s Award (Platinum Level)
Recipient
CONFLICT OF INTEREST DISCLOSURE
NONE
OBJECTIVES:
Clarify the link between The Partnership for Excellence and the Malcom Baldrige National Quality Award
Link the components of the Baldrige criteria to Union Inc.’s Journey to Excellence
Define leadership’s role in the Baldrige journey
Describe Union’s journey and how it matures an organization
WHO WE ARE
UNION HOSPITAL, INC.TERRE HAUTE, IN
UNION HOSPITAL, INC.
Not-for-profit 350 bed Acute Care Hospital in Terre Haute, IN and a 25 bed Critical Access Hospital in Clinton, IN
2400 Employees345 Affiliated PhysiciansMultiple outpatient sites/
physician offices including Cancer Center and Ambulatory Surgery Center
Teaching hospital with F.P. Residency program
ESTABLISHED BY CONGRESS IN 1987, THE BALDRIGE PROGRAM IS MANAGED BY THE NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, AN AGENCY OF THE UNITED
STATE DEPARTMENT OF COMMERCE. THE PROGRAM HELPS ORGANIZATIONS
IMPROVE THEIR PERFORMANCE AND SUCCEED IN THE COMPETITIVE GLOBAL MARKETPLACE. IT IS THE ONLY PUBLIC-PRIVATE PARTNERSHIP
AND PRESIDENTIAL AWARD PROGRAM DEDICATED TO IMPROVING U.S.
ORGANIZATIONS.
MALCOLM BALDRIGE CRITERIA
Organizational Profile
2 Strategic Planning
3Customer
Focus
6Operations
Focus
5 Workforce
Focus1Leadershi
p
7 Results
4Measurement, Analysis, and Knowledge
Management
PerformanceExcellenceFramework
Organizational Profile
2 Strategic Planning
3Customer
Focus
6Operations
Focus
5 Workforce
Focus1Leadershi
p
7 Results
4Measurement, Analysis, and Knowledge
Management
PerformanceExcellenceFramework
Organizational Profile
2 Strategic Planning
3Customer
Focus
6Operations
Focus
5 Workforce
Focus1Leadershi
p
7 Results
4Measurement, Analysis, and Knowledge
Management
PerformanceExcellenceFramework
Organizational Profile
2 Strategic Planning
3Customer
Focus
6Operations
Focus
5 Workforce
Focus1Leadershi
p
7 Results
4Measurement, Analysis, and Knowledge
Management
PerformanceExcellenceFramework
Organizational Profile
2 Strategic Planning
3Customer
Focus
6Operations
Focus
5 Workforce
Focus1Leadershi
p
7 Results
4Measurement, Analysis, and Knowledge
Management
PerformanceExcellenceFramework
LOOKING FOR ADLIAPPROACH
DEPLOYMENTLEARNING
INTEGRATION
PROCESS CATEGORIES
LOOKING FOR LETCI
LEVELSTRENDS
COMPARISONSINTEGRATION
RESULTS CATEGORY
MANUFACTURINGSERVICE
SMALL BUSINESS (< 500 EMPLOYEES)
EDUCATIONHEALTHCARE (CREATED IN 1999)
NONPROFIT/GOVERNMENT
BALDRIGE SECTORS
1. ORGANIZATION A DISTINCT ORGANIZATION OR BUSINESS UNIT HEADQUARTERED IN
THE U.S.2. EXISTED FOR AT LEAST A YEAR
3. RESPOND TO ALL 7 CATEGORIES4. IF ACTIVITIES OUTSIDE OF U.S. HAVE
SUFFICIENCIES FOR A FULL SITE VISIT5. IF A RECIPIENT SHARE PRACTICES AT
QUEST FOR EXCELLENCE CONFERENCE6. BEEN A BALDRIGE RECIPIENT
ELIGIBILITY REQUIREMENTS AT THE NATIONAL LEVEL
7. BEEN A TOP AWARD RECIPIENT FROM STATE ORGANIZATION THAT IS A MEMBER OF THE ALLIANCE FOR PERFORMANCE EXCELLENCE8. PRIOR NATIONAL APPLICATION WITH A
BAND SCORE OF 8 OR HIGHER9. RECEIVED A NATIONAL SITE VISIT
10. GREATER THAN 25% OF ORGANIZATION’S WORKFORCE IS OUTSIDE OF THE
ORGANIZATION’S HOME STATE11. THERE IS NO ALLIANCE FOR
PERFORMANCE EXCELLENCE AWARD PROGRAM AVAILABLE
ELIGIBILITY REQUIREMENTS AT THE NATIONAL LEVEL
Resources / Questions / Discussion
Al Faber, President/[email protected](614) 425-7157
Baldrige Performance Excellence Program:www.quality.nist.gov
The Alliance for Performance Excellence:www.baldrigepe.org
The American Society for Quality:http://asq.org/
www.thepartnershipforexcellence.org
15th Annual Quest for Success ConferenceCelebrating 15 Years of Performance Excellence!
September 15-16, 2014Polaris Hilton, Columbus, Ohio
Late 1990s
2004 - present
20132014 forward
• Aware of the Healthcare Criteria
• Started learning more about the criteria
• OUTSTANDING FINANCIAL PERFORMANCE
World-class Performance
• OUTSTANDING PATIENT/FAMILY SATISFACTION & ENGAGEMENT
• WORLDCLASS HEALTHCARE OUTCOMES
• EFFICIENT AND EFFECTIVE PROCESSES
• OUTSTANDING WORKFORCE OUTCOMES
INPUTS
• Defined
processes
• Measures
• Benchmarks
• Improvements
• Stakeholder
Engagement
OUTPUTS
• Assessment
• Training
• Tools
• Benchmarking
• Support
2006 - 2012• Started attending Days of Sharing at healthcare organizations that were national award recipients
• Started attending Quest; became examiners
• Attend VHA offerings re. Baldrige criteria
• Asked VHA to put together offerings regarding the healthcare criteria and “how to get started:”
• Hired Baldrige coaches
• Submitted national applications from 2008 – 2012
• Submitted first TPE application
• Received Platinum Award
• Continuing our efforts
• Submit a national application
• We continue to prioritize our OFIs in our feedback reports.
• We continue to make our approaches systematic with full deployment
Why Baldrige?Impacts the entire
organization; provides integration with a systematic
approach across the organization to reach goals to
accomplish mission/vision.
Our JourneyTo Excellence
MILESTONE
At UHI – ANOTHER NAME FOR BALDRIGE
As we travel on our Baldrige journey, it is known to staff as
our work to become - First, Best … Always.
CREATING THE ORGANIZATIONA
L PROFILE
FIRST STEP
HELPS WITH SELF EVAL.IDENTIFIES GAPS
THE APPLICATION FLOWS FROM THE PROFILE
Includes:OfferingsMVVWorkforce ProfileAssetsRegulatory RequirementsStructurePatients, Customers,
StakeholdersSuppliers and Partners
Competitive PositionCompetitiveness ChangesComparative DataStrategic Challenges and
AdvantagesPerformance
Improvement SystemCore Competencies
All in 5 pages
PROFILE SETS THE STAGE
LEADERSHIP120 POINTS
Category 1
LEADERSHIP MODEL
LEADERSHIP 1.1 – Senior Leaders
Organizational RhythmListening and Learning RoundingEngagement with
StakeholdersTeam IntegrationOrientationLegal and Ethical
EnvironmentSustainability
Performance Improvement
Align People and Processes
Board Quality Committee
Workforce EngagementRobust LearningLeadership
DevelopmentInnovation and
Intelligent Risk Taking
OP
ER
AT
ION
AL
RH
YT
HM
LEADERSHIP 1.2 – Governance & Societal Responsibility
Board Governance Processes
How its members represent the community
Self AssessmentsPerformance Eval. CEOCharter, Bylaws and
PoliciesHold SLs responsible –
performance goals tied to compensation
Community Integration
ComplianceAddress Public
ConcernCommunity SupportCommitment to
Ethical BehaviorCaring for the
IndigentEnvironmental
Stewards
STRATEGIC PLANNING85 POINTS
Category 2
ST
RA
TE
GIC
PLA
NN
ING
3 Y
EA
RAssess and Set
Strategic Direction
• All factors from APP plus • Industry Assessment• Community Needs• Competitor Assessment• Detailed Stakeholder Analysis
Develop/Refine Objectives and Goals
Evaluate &Improve
•Critical Success Factors• Objectives and Goals
Assess and Set Annual Direction
Reaffirm /Revise Strategic Objectives
Align Processes/People,
• Economic Trends• Political and Regulatory Issues
• Technology Assessment• Competitor Review
• Organizational Capacity & Capability
• Workforce Satisfaction / Engagement
• Patient Satisfaction / Engagement• Quality Assessment
j
Allocate Resources
q
p
o
Align People and Processes
•Refined CSFs•Refined Objectives and Goals
•Mission/Vision/Values•Critical Success Factors•Advantages and Challenges•Core Competencies
•Work Systems•EPM & Key Processes•Action Plans
3-YR Financial Plan
Operational Rhythmn
m
l
k
• EPM and Key Processes•Action Plans and goals
Allocate Resources
Evaluate & Improve
r
s Operational Rhythm
Annual Budget
•Mission/Vision/Values•Refined Core Competencies•Advantages/Challenges
AN
NU
AL
PL
AN
NIN
G
1 Y
EA
R
STRATEGIC PLANNING 2.1 – Strategy Development
Focus Groups:EmployeePhysiciansBoard MembersEmployersVendorsPatients/Patients’
FamiliesCommunity
SWOT AnalysisStrategic Challenges
and Strategic Advantages
Develop Objectives, Measures and Goals
Allocate ResourcesUse of InnovationKey Work SystemsAlign People and
ProcessesCore Competencies
STRATEGIC PLANNING 2.2 – Strategy Implementation
Action PlansCorporate, Department, Employee Goals Cascade
BenchmarksProjections
CUSTOMER FOCUS
85 POINTS
Category 3
VOICE OF THE CUSTOMER
MEASUREMENT, ANALYSIS, AND
KNOWLEDGE MANAGEMENT
90 POINTS
Category 4
PERFORMANCE MEASUREMENT, ANALYSIS AND REVIEW SYSTEM
Stakeholder*/Regulatory
Requirement?
Critical to Run the
Business?
Selected Run the Business Measure
Actionable?
SupportsBreakthrough
SPP Goal?
Selected Changethe Business
Measure
Not Selected
ProposedMeasure
No
No No
Ye
No No
Yes
Yes Yes
Yes
No
Measurement Selection Process
Optimal Comparative
Database Exists
If World Class – Level 1
Evaluate for: 1) Size, Validity, Reliability; 2)Comparable in structure; 3) Relevance to competitors 4)Ability to segment and statistically analyze; 5) Cost/benefit
If not World Class – Level 2
Select most meaningful comparison – Level 3
Determine who to compare to: 1) Inter-entity; 2) Inter-departmental; 3) Historical performance
No comparison – Level 4
yes no
Set Target at Top 10%(or interim goal if gap
is large)
Set Stretch Goal
Is it External?
ESTABLISHING BENCHMARKS
LEVEL 1 = External and world class
LEVEL 2 = External but not world class
LEVEL 3 = Internal comparison
LEVEL 4 = No comparison
Sharing the Message - Workfor ce Knowledge
Data Management Requirements
Emails, scorecards, screen savers, State of the Union, Weekly Briefings
Leadership meetings, Shared Governance
Daily Check InStorytelling
AccuracyIntegrity/ReliabilityTimelinessSafety/
ConfidentialityData Center
Elements; software and hardware requirements
Technology Today
KNOWLEDGE MANAGEMENT, INFORMATION and IT
WORKFORCE FOCUS
85 POINTS
Category 5
WORKFORCE SYSTEM
Capability/Capacity; New WF Members
Accomplishments; Change; Environment
Quarterly C/C reports
Grow Our OwnElectronic
employment formsPreceptor and
mentorsOnboarding for
retention; 60 day touch base
Alignment of goals – electronic tracking tied to performance evaluations
Transparent and collaborative culture
Employee wellness program; incentive on insurance premiums
Disease ManagementPt. Safety and Satisfaction
AmbassadorsConcierge, 26 Fund
Workforce Environment Effective and Supportive
Engagement; Culture; Performance Mgmt.
Learning/Development; Career
ProgressionSurveysAction PlansRecognition and RewardsLeadership Team –
minutes out to allState of the Union Doc Talks, Weekly
BriefingsStandards of ExcellenceTeamwork
Performance ManagerSuccession PlanningLeaders on the
HorizonLDIClinical EducatorsElectronic EducationTuition
Reimbursement
Workforce EngagementOrganization and Personal Success
OPERATIONS FOCUS
85 POINTS
Category 6
PROCESS BASED MANAGEMENT (PBM)
Union Hospital Enterprise Process Model (Revised August 22, 2013)
1.0 Lead the Organization
1.1 Perform Strategic Planning 1.1.1 Set strategic direction1.1.2 Set objectives and goals1.1.3 Align systems to deploy strategy1.1.4 Evaluate and Improve
1.2 Deliver Organizational Excellence1.2.1 Ensure Safety and Deliver Quality1.2.2 Innovate Purposefully
1.2.3 Ensure Knowledge Management1.3 Recruit, Engage, and Align Physicians 1.4 Communicate effectively
1.5 Ensure Legal, Ethical Behavior and Regulatory Compliance
1.6 Ensure organizational governance1.7 Develop and maintain government and industry
relationships
3.1 Understand markets, customers and capabilities
3.2 Develop health care services and service lines3.2.1 Reinforce service line Infrastructure3.2.2 Balance Goals3.2.3 Link Care Continuum3.2.4 Engage Physicians
3.2.5 IntegrateReferral Sources
3.2.6 Strengthen Customer Service
3.2.7 Build Brand Strategy
3.3 Manage and align the health care services portfolio and service lines
3.4 Develop marketing strategy, forecast, and plans
5.1 Provide information on service availability and cost
5.2 Admit / Place5.2.1 In-patient and OP admissions
5.2.2 In-patient and OP external source admissions
5.2.3 Emergency Department admissions
5.2.4 Mother/Baby admissions
6.1 Clinically assess patient and develop plan of care
6.2 Conduct discharge planning6.3 Manage and provide
treatment and care6.2.1 In-Patient 6.2.2 Ambulatory
Surgical6.3.3 Out-patient 6.3.4 Emergency6.3.4 Home/Health
Hospice6.4 Provide Case Management6.5 Provide in-patient
non-direct services (food, chaplain, cleaning etc.)
6.6 Educate patients and families6.7 Manage patient medical information
7.1 Discharge / Exit7.2 Transfer7.2.1 Inpatient7.2.2 Ambulatory/ Surgical 7.2.3 Outpatient 7.2.4 Emergency 7.2.5 Home Health, Hospice7.3 Maintain relationships7.3.1 Inpatient7.3.2 Ambulatory/ Surgical7.3.3 Outpatient7.3.4 Emergency7.3.5 Home Health/ Hospice
2.0 Create Strategic Alignments for Health
Services
2.1 Conduct SWOT to identify continuum of services offered
2.2 Determine which services will be delivered within Union
2.3 Determine which services will be provided through strategic alignments
2.4 Identify potential strategic alignments
2.5 Develop and sustain strategic alignments
2.6 Support Key Communities2.6.1 Improve health of the community2.6.2 Provide community support and volunteerism
7.0 Transition of Care
6.0 Deliver Health Care
5.0 Provide Entry to Health Care
3.0 Assess, Develop Service Lines &
Market
4.0 Build and Sustain Patient /
Stakeholder Relationships
4.1 Develop customer service strategy
4.2 Deploy customer service strategy
4.3 Measure and evaluate customer service
Union Hospital Enterprise Process Model (Revised August 22, 2013)
10.0 Deliver IT8.0 Deliver Human Resource Services
9.0 Deliver Financial Services
11.0 Provide & Manage Facilities &
Equipment
12.0 Deliver Supplier Chain Management
13.0 Manage Organizational Risk
8.1 Develop and manage HR planning, policies, and strategies
8.2 Recruit, select and onboard workforce
8.3 Develop, coach and counsel workforce
8.4 Reward, Recognize and retain workforce8.4.1 Provide benefits8.4.2 Manage
workforce satisfaction/ engagement processes
8.5 Manage promotion/ reassignment and separation process
8.6 Manage employee information8.6.1 Manage employee licensure and certifications8.6.2 Manage employee competency
8.7 Ensure workforce safety, security and wellness
8.8 Provide administrative duties
10.1 Manage IT strategy and governance (Dir. Of IT)
10.2 Develop & manage IT service relations
10.3 Develop & manage IT vendor relations
10.4 Manage business resiliency and risk
10.5 Manage organization information
10.6 Develop & deploy Business solutions (Controller)
10.7 Maintain business solutions
10.8 Deliver & support IT service
10.9 Manage IT knowledge
9.1 Perform planning & management accounting (Controller)
9.2 Perform revenue cycle management
9.3 Perform general accounting & reporting
9.4 Manage fixed assets and capital project accounting
9.5 Manage payroll9.6 Process accounts
payable and expense reimbursements
9.7 Manage treasury operations
9.8 Manage internal control
9.9 Manage taxes9.10 Medicare/Medicaid
cost reporting
11.1 Design, construct, and/or acquire facilities (Dir. Of Plant)
11.2 Maintain facilities and equipment
11.3 Perform biomedical testing / preventive maintenance
11.4 Monitor and manage environmental health and safety
11.5 Dispose of facilities
12.1 Develop sourcing strategies
12.2 Select suppliers/partners
12.3 Negotiate and manage contracts
12.4 Procure materials and services
12.5 Evaluate material / service and provide feedback to suppliers/partners
12.6 Receive, and distribute materials / services
12.7 Manage logistics and warehousing
13.1 Establish organizational risk framework
13.2 Manage operational risk
13.5 Manage liability coverage
13.6 Ensure emergency / disaster preparedness
13.7 Credentialing and privileging
13.8 Conduct Peer Review
SWIMLANE CORRIDOR
150 feet of process maps
31 key processes
SWIMLANES
RESULTS450 POINTS
Category 7
7.1 Healthcare & Patient Focus Results; Work Process Effectiveness Results; Supply-Chain Mgmt. Results 40 Graphs CMS Indicators Risk Adjusted Complication
Index Patient Safety Results Risk Adjusted Mortality
Index LOS
VAT Savings Door to Doc Times Ortho Implant Spend Pharmacy Supply Fill Rate Clinical Pharmacy
Interventions Lab TATs Uptime for Critical IT
Systems Emergency Preparations
Go back to the profile and think about your main services, CSFs, core competencies, key stakeholders
Data must be segmented and appropriate comparisons given
Data must include trends over time
7.2 Patient and Other Customer-Focused Results; Healthcare & Patient Focus Results
31 GraphsHCAHPS Results
Other Satisfaction Results
Best Image/Reputa-tion Results
Satisfaction Scores per Service Line
7.3 Workforce Results – Capability, Capacity, Climate, Engagement, Development Results
34 Graphs Retention/Turnover Absenteeism Vacancy Rate Internal Mgr. Fill Rates Time to Fill Health Benefit
Costs/Employee Employee/Physician/ Volunteer/Student Satisfaction
Competency Pattern and Trends
Alignment to Critical Success Factors
Timely Appraisals OSHA Recordable Incident
Rate Lost Time Case Rate DART Rate Lifting Injuries Worker’s Comp Employee, Physician,
Volunteer Engagement Grievances Education Dollars/ Employee % Leaders in Leadership
Training
7.4 Leadership/Governance Results; Strategy Implementation Results
21 Graphs Focus on Improvement Communication
Contributions Foundation
Contributions BOD Self Assessment Leadership Compliance
with COI Audit Findings RAC Appeal Success
Rate Compliance Training,
COI Strategic Planning
Results
Workplace Perceptions of Compliance
Accreditations/Certifi-cations
Awards and Recognition Perception of Ethics Charity Care to Gross
Revenue United Way
Contributions Scholarship $ Awarded Donations and
Sponsorships Project Search Environmental Impact
7.5 Financial and Market Results
18 GraphsTotal Operating
RevenueTotal Margin
RatioOperating
MarginEBIDA MarginAge of PlanDebt Service
Coverage Ratio
Days Cash on Hand
Net Days in A/ROccasions of
ServicePSA Market
ShareSSA Market
Share
Total 144 Graphs for Results Section.
Platinum Level – Governor’s Award
TEAM CELEBRATION A Journey to Ohio
HOW WE PROCESS THE BALDRIGE WORK
Core Team made up of SLs and other key leaders (Cat Leads)
Core Team meets every month
Each Cat has a team; a SL sponsors each team
Work done through the teams
Feedback reports utilized to prioritize work
3S for Success Teams drive the education
First, Best… Always is the umbrella
Each Cat Team responsible for contents of application
Site Visit preparation works much the same – three day visit requires much prep time
Celebrate and wait for the Feedback Report
ON THE ROAD AGAIN!
DEDICATION PRAYER
OUR BUILDINGSOUR EMPLOYEESOUR COMMUNITY