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/CEOal.faber@partnershipohio.org(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