Health Care Criteria for Performance Excellence The Satisfaction Snapshot is a monthly electronic bulletin freely available to all those involved or interested in improving the patient/ client experience. Each month the Snapshot showcases issues and ideas which relate to improving patient satisfaction and customer service, improving workplace culture and improving the way we go about our work in the healthcare industry. The Satisfaction Snapshot features: «relevant articles from healthcare industry experts «case study success stories «tips and tools for quality improvement «patient satisfaction and other industry research findings «articles with ideas to help achieve success in your role Successful healthcare organisations always strive for excellence in every facet of their operation, be it clinical care, quality, strategic planning, or financial management. What does excellence look like?, and how do you know when you have reached a standard that is acknowledged as world s best practice? A fundamental emphasis on quality is a necessity for doing business in an ever challenging environment. The internationally acknowledged Malcolm Baldrige Quality Award sets the standard of excellence that helps organisations benchmark world-class quality. Past winners of this prestigious award include Ritz-Carlton, IBM, Motorola, M and Boeing. In 00, healthcare was added as a specific evaluation category. Baptist Hospital Pensacola, Robert Wood Johnson University Hospital and Sharp Healthcare are recent winners and fantastic examples of healthcare excellence. In today s times of nursing shortages and financial pressures these organisations actually have waiting lists of people seeking employment. Do you want to improve your organisation s performance on the critical factors that drive success? Are you looking for a cost-effective way to gain a perspective on your organisation s strengths and opportunities for improvement? Do you want to improve your organisation s bottom line? Because the Baldrige Criteria is focused on what best-inclass companies do and are ever evolving, measuring yourselves against them helps you examine your organisation critically and identify strengths and opportunities to improve. The August 008 snapshot provides a selfassessment against the Baldrige criteria. How Does Your Organisation Rate? If you would like your colleagues to receive the Satisfaction Snapshot please send us their names and email addresses. The Satisfaction Snapshot is published by Press Ganey Associates Pty Ltd. All material is copyright protected. Quotation is permitted with attribution. Subscribers are permitted and encouraged to distribute copies within their organisations. Subscription to the Satisfaction Snapshot is FREE! Please direct any comments, suggestions or article submissions to: Sharon Kerr Manager of Client Relations sharon.kerr@pressganey.com.au www.pressganey.com.au P: 07 60 700 F: 07 1 90 August 008 l Volume 7 l Issue 8
page 1 The Malcolm Baldrige Quality Award is an award presented by the President of the United States to businesses, educational organisations and health care organisations that recognises achievements in quality and performance. Health care organisations can use the Baldrige Criteria as a method to define and gauge the quality of core competencies, new technologies, communication, and new alliances. The award criteria has three important roles in strengthening performance: To help improve organisational performance practices, capabilities and results; To facilitate communication and sharing of the best practice information among organisations of all types; To serve as a working tool for understanding and managing performance and for guiding planning and opportunities for learning; The criteria are designed to help organisations use an aligned approach to organisational performance management that results in: Delivery of ever-improving value to customers, contributing to success Improvement in overall organisational effectiveness and capabilities Organisational and personal learning The seven categories of the criteria are: 1. Leadership. Strategic Planning. Customer Focus. Measurement, Analysis and Knowledge Management. Workforce Focus 6. Process Management 7. Results The figure below provides the framework connecting and integrating the categories. The criteria for the Baldrige award can be found at: http://www.quality.nist.gov/pdf_files/008_healthcare_criteria.pdf August 008 l Volume 7 l Issue 8
page Examining and testing your organisation s performance against this world s best practice criteria can provide you with valuable insights into new opportunities to improve quality and organisational performance. This guide is solely intended to assist health care organisations in understanding the basic criteria of the Baldrige award, and to direct leadership attention to the areas where the organisation may have opportunities to improve performance. This Readiness Assessment can be used by senior management and board leaders to gain a quick sense of where the organisation is in relation to these quality criteria. Rating Scale This rating scale is based on the Baldrige Scoring System, which assesses an organisation s processes by evaluating approach, deployment, learning and integration. : An effective, fully responsive, systematic approach is evident; the approach if fully deployed without significant weaknesses or gaps in areas or work units; fact-based systematic evaluation and improvement and organisation learning are key organisation-wide tools; refinement and innovation are evident throughout the organisation; the approach is well integrated with organisation needs. : An effective, systematic approach is evident; the approach is deployed, although some areas or work units are in early stages of deployment; the beginning of a systematic approach to evaluation and improvement of key processes is evident; the approach is in early stages of alignment with basic organisational needs. : The beginning of a systematic approach is evident; the approach is in the early stages of deployment in most work areas; early stages of a transition from reacting to problems to a general improvement orientation are evident; the approach is aligned with other areas or work units largely through joint problem solving. 1: There is no systematic approach evident; little or no evidence of an approach is evident; improvement is achieved through reacting to problems; individual areas or work units operate independently. N/S: Not Sure. I don t have enough information to make a judgment about performance in this area. : An effective, systematic approach is evident; the approach is well deployed, although deployment may vary in some areas or work units; a fact-based systematic evaluation and improvement process and some organisational learning are in place for improving the efficiency and effectiveness of key processes; the approach is aligned with organisational needs. August 008 l Volume 7 l Issue 8
page 1. ORGANISATIONAL LEADERSHIP Senior Leadership Direction Sets and deploys organisational values, short-and longer-term directions and performance expectations Creates and balances value for patients and other customers and stakeholders in their performance expectations Communicates organisational values, directions, and expectations through the leadership system to all staff, and to key suppliers and partners Effectively practices two-way communication Creates an environment for empowerment, innovation, and organisational agility Creates an environment for organisational and staff learning Creates an environment that fosters legal and ethical behaviour Organisational Governance Displays management accountability for the organisation s actions Shows fiscal accountability Provides independence in internal and external audits Protects stockholder and stakeholder interests, as appropriate August 008 l Volume 7 l Issue 8
page Organisational Performance Review Reviews organisational performance and capabilities Regularly assesses organisational success, competitive performance, and progress relative to short- and longer-term goals Uses organisational reviews to assess the hospital s ability to address changing health care service needs Regularly reviews key performance measures Translates organisation performance review findings into priorities for continuous and breakthrough improvement of key organisational performance results and into opportunities for innovation Deploys priorities and opportunities throughout the organisation Effectively aligns with suppliers and partners, when appropriate Uses organisational performance review findings to improve both their own leadership effectiveness and board leadership effectiveness. SOCIAL RESPONSIBILITY Responsibilities to the Public Considers the impact of the hospital s health care services and operations on society Guarantees that key processes, measures and goals for achieving and surpassing regulatory, legal and accreditation requirements are addressed Guarantees that key processes, measures and goals for addressing risks associated with the management of health care services and other organisational operations are addressed Anticipates public concern with current and future services and operations Proactively prepares for concerns regarding current and future services and operations August 008 l Volume 7 l Issue 8
page Ethical Behaviour Exhibits ethical behaviour in all stakeholder transactions and interactions Uses key processes and measures or indicators for monitoring ethical behaviour throughout the organisation, with key partners and collaborators, and in the governance structure Support of Key Communities Actively supports and strengthens key communities Identifies key communities and determines areas of emphasis for organisational involvement and support Encourages senior leaders and staff to contribute to improving key communities and building community health August 008 l Volume 7 l Issue 8
page 6. STRATEGY DEVELOPMENT Strategy Development Process Effectively directs the strategic planning process and involves key participants Strategically addresses short- and longer-term planning time horizons Strategically addresses patient, other customer, and health care market needs, expectations and opportunities Strategically addresses the competitive environment and/or the collaborative environment to conserve community resources and the hospital s capabilities relative to competitors Strategically addresses technological and other key innovations or changes that may affect the hospital s health care services and how it operates Strategically addresses organisational strengths and weaknesses, including staff and other resources Strategically addresses organisational opportunities to redirect resources to higher priority health care services or areas Strategically addresses financial, societal and ethical, regulatory, and other potential risks Strategically addresses changes in the local, regional, or national economic environment Strategically addresses factors unique to the organisation, including partner and supply chain needs, strengths and weaknesses Strategic Objectives Accomplishes key strategic objectives in a timely manner Balances short- and longer-term challenges and opportunities Ensures that strategic objectives balance the needs of patients and other key customers and stakeholders August 008 l Volume 7 l Issue 8
page 7. STRATEGY DEPLOYMENT Action Plan Development and Deployment Develops and deploys action plans to achieve key strategic objectives Allocates resources to ensure accomplishment of action plans Ensures that key changes resulting from action plans can be sustained Identifies key short- and longer-term action plans, taking into consideration any key changes in the hospital s health care services and programs, customers, and markets Identifies key performance measures or indicators for tracking progress on action plans Guarantees that they overall action plan measurement system reinforces organisational alignment Guarantees that the measurement system covers all key deployment areas and stakeholders. PATIENT, OTHER CUSTOMERS, AND HEALTH CARE MARKET KNOWLEDGE Patient/Customer and Health Care Market Knowledge Effectively determines patients, other customers, customer groups and health care market segments to target Listens and learns to determine key patient/customer requirements and expectations and their relative importance to patients /customers health purchasing decisions Uses relevant information from current and former patients/ customers or customer groups, including marketing information, patient/customer loyalty and retention data, win/loss analysis, and complaints, for purposes of health care service planning, marketing, process improvements and other business development Guarantees that listening and learning methods stay current with health care service needs and directions August 008 l Volume 7 l Issue 8
page 8 6. PATIENT AND OTHER CUSTOMER RELATIONSHIP AND SATISFACTION Patient/Customer Relationship Building Builds relationships to acquire patients and other customers, to meet and exceed their expectations, to increase loyalty and secure their future interactions with the organisation, and to gain positive referrals Provides key access mechanisms for patients and other customers to seek information, obtain services, and make complaints Offers a complain management process and ensures that complaints are resolved effectively and promptly Uses aggregated and analysed complaints for improvement throughout the organisation Patient/Customer Satisfaction Determination Determines patient and other customers satisfaction and dissatisfaction Guarantees that measurements capture actionable information for use in exceeding patients and other customers expectations, securing their future interactions with your organisation, and gaining positive referrals Uses patient and other customer satisfaction and dissatisfaction information for improvement Follows-up with patients and other customers on health care services and transaction quality to receive prompt and actionable feedback Obtains and uses information on patients and other customers satisfaction relative to satisfaction with your competitors, other organisations providing similar health care services, and/or benchmarks Maintains approaches to determining satisfaction that are current with health care service needs and directions August 008 l Volume 7 l Issue 8
page 9 7. MEASUREMENT AND ANALYSIS OF ORGANIZATIONAL PERFORMANCE Performance Measurement Selects, collects, aligns and integrates data and information for tracking daily operations and for tracking overall organisational performance Effectively uses key comparative data and information to support operational and strategic decision making and innovation Maintains a performance measurement system that is current with health care service needs and directions and is sensitive to rapid or unexpected organisational or external changes Performance Analysis Performs analysis to support senior leaders organisational performance review Performs analysis to support the organisation s strategic planning Communicates results of organisational-level analysis to work groups and functional-level operations to enable effective support for decision making 8. INFORMATION AND KNOWLEDGE MANAGEMENT Data and Information Availability Provides data and information to staff, suppliers and partners, and patients and other customers, as appropriate Guarantees that hardware and software are reliable, secure, and user friendly Guarantees that data and information availability mechanisms, including software and hardware systems, are current with health care service needs and directions August 008 l Volume 7 l Issue 8
page 10 Organisational Knowledge Manages the collection and transfer of staff knowledge Assists the transfer of relevant knowledge from patients and other customers, suppliers and partners Manages the identification and sharing of best practices Guarantees that data, information and organisational knowledge maintain integrity, timeliness, reliability, security, accuracy and confidentiality 9. WORK SYSTEMS Organisation and Management of Work Organises and manages work and jobs to promote cooperation, initiative, empowerment, innovation and organisational culture Capitalises on the diverse ideas, cultures and thinking of staff and the communities with which the organisation interacts Achieves effective communication and skill sharing across health care professions, departments and work units, jobs and locations Staff Performance Management System Provides a staff performance management system, including feedback to staff, that supports high-performance work Guarantees that the staff performance management system supports a patient/customer and health care service focus Guarantees that the compensation, recognition and related reward and incentive practices reinforce high-performance work and a patient/customer and health care service focus August 008 l Volume 7 l Issue 8
page 11 Recruitment and Career Progression Identifies characteristics and skills needed by potential staff Guarantees that staff members represent the diverse ideas, cultures, and thinking of the community served Accomplishes effective succession planning for leadership and management positions, including senior administrative and health care leadership, as appropriate Effectively manages career progress for all staff throughout the organisation 10. STAFF LEARNING AND MOTIVATION Staff Education, Training and Development Guarantees that staff education and training contribute to the achievement of action plans Guarantees that staff education, training and development address you key needs associated with organisational performance measurement, performance improvement and technological change Guarantees that the employee education and training approach balance short- and longer-term organisational objectives with staff needs, including licensure and recredentialing requirements, development, learning and career progression Guarantees that staff education, training and development address key organisational needs associated with new staff orientation, diversity ethical health care and business practices, and management and leadership development Seeks and uses input from staff and supervisors/managers on education and training needs Incorporates you organisational earning and knowledge assets into your education and training Seeks and uses input from staff and their supervisors and managers on options for the delivery of education and training Uses both formal and informal delivery approaches, including mentoring and other approaches, as necessary Reinforces the use of new knowledge and skills on the job Evaluates the effectiveness of education and training, taking into account individual and organisational performance August 008 l Volume 7 l Issue 8
page 1 Motivation and Career Development Encourages and motivates staff to develop and utilise their full potential Uses formal and informal mechanisms to help staff attain joband career-related development and learning objectives Allows managers and supervisors to help staff attain job- and career-related development and learning objectives 11. STAFF WELL-BEING AND DEVELOPMENT Work Environment Addresses workplace health, safety, security and ergonomics and allows staff to take part in improving these key workplace factors Guarantees workplace preparedness for emergencies or disasters Guarantees health care service and business continuity for the benefit of patients, other customers, and staff Staff Support and Satisfaction Identifies key factors that affective staff well-being, satisfaction and motivation for a diverse workforce and for different categories and types of staff Supports staff services, benefits and policies and tailors services, benefits and policies to the needs of a diverse workforce and different categories and types of staff Utilises formal and information assessment methods and measures to determine staff well-being, satisfaction and motivation Relates assessment finding to key organisational performance results to identify priorities for improving the work environment and staff support climate August 008 l Volume 7 l Issue 8
page 1 1. HEALTH CARE PROCESSES Identifies and manages its key health care process (health care processes refers to patient and community service process for the purpose of prevention, maintenance, health promotion, screening, diagnosis, treatment/therapy, rehabilitation, recovery, palliative care or supportive care) Guarantees that key health care processes create value for the organisation, its patients and other customers, and other key stakeholders Determines key health care process requirements, incorporating input from patients and other customers, suppliers, and partners, as appropriate Designs key health care process to meet all the key requirements, including patient safety, regulatory accreditation, and payor requirements Incorporates improved health care outcomes, cycle time, productivity, cost control, and other efficiency and effectiveness factors into the design of health care processes Addresses and considers patients expectations and uses health care deliver processes and likely outcomes to set realistic patient expectations Incorporates new technology and organisational knowledge into the design of health care process Guarantees that day-to-day operation of health care processes meet key process requirements, including patient safety, regulatory, accreditation, and payor requirements Guarantees that patient and other customer, supplier and partner input is used in managing your health care processes, as appropriate Attempts to minimise overall costs associated with inspections, tests, and process or performance audits, as appropriate Strives to improve health care processes to achieve better performance, to reduce variability, to improve health care services and health care outcomes, and to keep the processes current with health care service needs and direction August 008 l Volume 7 l Issue 8
page 1 1. SUPPORT PROCESSES Identifies and manages the key business and other support process that support the health care processes Incorporates new technology and organisational knowledge into the design of key health care process Uses key performance measures or indicators for the control and improvement of support process Strives to improve support process to achieve better performance, to reduce variability, and to keep the processes current with health care service needs and directions NOTES: August 008 l Volume 7 l Issue 8