Creating Sustainable Organizations

The Baldrige Performance

Excellence Program

Sherry MartinHIV Quality of Care Advisory Committee

September 13, 2012

Improving Quality in the Face of Change

• Is change real; is health reform real?• Why consider using the Baldrige

approach?• What are the common factors that

lead to high performance?

National Health Expenditure

CMS, Office of the Actuary, July, 2011

Health Affairs, September 3, 2012

We must become:•More effective - use of evidenced-based practices• Eliminate overuse and underuse• Scale up prevention services

•More efficient – cut out waste• Streamline cinic processes• Reduce turn-around-times; wait times

•Safer – eliminate errors• Eliminate delays in medication access• Reduce suicides

•More patient- focused – methods to reach specific patients• Increase access to care

$750 Billion in unnecessary health spending in 2009 alone

What Is the Answer?THE PERFORMANCE IMPROVEMENT

IMPERATIVE

“Health care delivery organizations should develop organizational cultures that encourage continuous improvement by incorporating best practices, transparency, open communication, staff empowerment, team work, and that align incentives..

The imperatives are clear and the changes are possible”

IOM, Sept. 2012

“

Baldrige Performance Excellence ProgramWHAT IS IT?

• Formal recognition of US organizations from the President

• Established to promote performance excellence and sharing of successful practices

• Administered by National Institute of Standards and Technology

• Formerly, the Baldrige National Quality Program

What is Performance Excellence?

Integrated management approach that results in:•Delivery of continually improving value to the patient, including effective health care outcomes•Improved delivery processes, more efficient and timely•Organizational learning

Is the Baldrige Program Successful?

• Hospitals using Baldrige are 6x more likely to be among the 100 Top Hospitals– More than 27% are Baldrige users– Only 3% of non-Baldrige users are listed– Outperform the other top hospitals in every

metric used to determine list– Outperform the other top hospitals on CMS core

measures

The Baldrige ProgramHOW DOES IT WORK?

• Structured self assessment tool, that enables an organization to:– Identify challenges and barriers to achieving their

mission/vision– Develop strategies and action plans to overcome– Determine whether their approaches used to run

the organization are achieving results– Collect, analyze and use data effectively– Align the organization to achieve sustained results

The Self Assessment Core -THE CRITERIA

• Structured questions that enable you to analyze how you manage your work processes and the associated results

• Applicable to any size or type of healthcare facility

• Non-prescriptive – they don’t tell you how to establish your infrastructure or processes

Baldrige 2011-2012 Criteria Categories

• Leadership• Strategic Planning• Customer Focus• Measurement, Analysis and Knowledge

Management• Workforce Focus• Process Management• Results

Criteria ExampleLEADERSHIP

• How do senior leaders create an environment for organizational performance improvement, the accomplishment of your mission and strategic objectives, innovation, and organizational agility?

• How do senior leaders take an active role in reward and recognition programs to reinforce high performance and a customer and business focus?

Criteria ExampleSTRATEGIC PLANNING

• What are your key strategic objectives and the timetable for accomplishing them?

• How do your strategic objectives achieve the following?– Address your strategic challenges and strategic

advantages– Capitalize on your core competencies and address

the need for new core competencies– Enhance your agility to adapt to sudden shifts in

your market or regulatory conditions

Criteria ExampleCUSTOMER FOCUS

• How do you listen to patients and families and other customers to obtain actionable information? How do your listening methods vary for different customers.

• How do you determine patient satisfaction and engagement? How do your measurements capture actionable information for use in exceeding your patients’ expectations?

Criteria ExampleMEASUREMENT, ANALYSIS AND KNOWLEDGE• How do you select, collect, align and integrate

data and information for tracking daily operations and overall organizational performance, including progress relative to strategic objectives and action plans? How do you use this data to support organizational decision making ( at the front line)

• How do you use organizational performance review findings to develop priorities for continuous improvement and opportunities for innovation

Key Excellence FactorsLeadership/Strategic Planning

• Systematic setting and communication of direction, values and aggressive goal setting

• Role modeling by all leaders of values• Strong work process alignment with strategy• Demonstrated accountability and

transparency• Clear focus on plan execution and agility

Goonan, K, et al. Journey to Excellence, 2009

Sharp Health Care – 2007 Baldrige Winner

How Sharp Aligned the Organization

Schneck Medical Center – 2011 Baldrige Winner

Key Excellence FactorsCustomer Focus

• Plethora of methods to listen to patients and other customers

• Identification of patient requirements and subsequent action plans

• Sound decision making• Transparency of operations and results

Goonan, K, MD; Journey to Excellence, 2009

Southcentral Foundation – 2011 Baldrige Winner

Key Excellence FactorsMeasurement and KM

• Consistent use of fact-based decision making• Collection of actionable data• Consistent use of multiple aligned and

interlinking measures• Wide deployment and accessibility of data

and information

Goonan, K, MD; Journey to Excellence, 2009.

Key Excellence IndicatorsProcess Management

• Well-designed work systems and key business and support processes

• Strong focus on work systems and key processes that deliver customer value and organizational success and sustainability

• High levels of quality designed into key services

Goonan, K,MD: Journey to Excellence, 2009

Sharp Health Care – 2007 Baldrige Winner

Sharp Health Care Processes

RESULTS

• Healthcare - outcomes related to core business

• Customer focused – satisfaction• Workforce-focused – engagement• Process management – efficiency, cycle time• Leadership – accomplishment of strategic

plans to achieve mission

Criteria ExamplesRESULTS

• What are your current levels and trends in key measures or indicators of health care outcomes that are important to and directly serve your patients and stakeholders?

• How do these results compare with the performance of other organizations with similar offerings

• What are your current levels and trends in key measures of operational performance of your work processes, including productivity and cycle time…

Key Excellence FactorsResults

• Excellent results that fully address health care outcomes, strategy and action plans, customer requirements, workforce needs, financial status

• Beneficial levels compared to credible benchmarks

• Beneficial trends

• Goonan, K, MD: Journey to Excellence, 2009

Levels and Trends

• LEVEL – your current level of performance – enables you to compare performance with benchmarks and establish targets to achieve

• TREND – the rate of your performance improvement - enables you to determine whether your interventions are working

Southcentral Foundation – 2011 Baldrige Winner

Baldrige Self AssessmentSUCCESS FACTORS

• Comprehensive – evaluates all aspects of an organization

• Fact-based, objective assessment• Systematic – evaluates approach, deployment

and effectiveness ( results)• Identifies key opportunities on which to focus

to achieve the mission• Operates in the organizational background

Baldrige AssessmentIS IT A TOOL FOR US?

• Requires:– Data and information to answer the criteria

questions– Consensus around key identified opportunities on

which to focus– Improvement initiative cycles

The ResultImproved Quality in a Changing Environment

SUSTAINABILITY

“Knowing is not enough; we must apply. Willing is not enough; we must do”

Goethe