The Nine Principles – A Roadmap for the Baldrige Criteria

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Published by the Studer Group
By Paul Grizzell and Lucy Crouch, R.N.
Foreword by Quint Studer

The commitment of health care organizations to the pursuit of performance excellence is unprecedented as good organizations strive to become great. Hospitals have been participating in The Malcolm Baldrige National Quality Award (MBNQA) and state and local quality awards at an increasing pace. In the 2007 Baldrige Award cycle, 42 of 84 applicants are from the healthcare sector. Most of these organizations will tell you that they’re not applying to win an award; they’re applying because it’s the best way to get feedback to accelerate their continuous improvement efforts in order drive better results.

In our effort to help organizations implement Service and Operational Excellence, I have found that the Nine Principles and the clear focus created by the Five Pillars provides that much desired prescriptive approach for organizations to achieve results. I developed the Nine Principles to provide organizations, and thus the individual, with a sequenced step-by-step process to attain the organization’s desired results-a road map to help organizations navigate the journey to develop a success-based culture, similar to a clinical pathway.

A few years back, while I was president of Baptist Hospitals, Inc. in Pensacola, Florida, I received a call from a CEO. He asked if I had ever worked with the Baldrige award. I said no and asked why. He explained that he thought the work we were undertaking according to my Nine Principles was very much in alignment with the Baldrige criteria. Later I received a call from a Baldrige examiner who also consulted with hospitals to help them prepare for the site visits.He made a similar comment. Are they 100 percent in alignment? No, but we have found that organizations that have implemented the Nine Principles, goals by Pillars, and prescriptive practices have achieved very good results in many of the Baldrige health care categories making the preparation for the Baldrige a natural follow to our process.

At Studer Group, our coaches come from a variety of health care backgrounds. But one important common trait is a passion to make a difference in health care. One of our Coaches, Lucy Crouch, is an R.N. who was the Director of Quality at Baptist Hospitals, Inc. in Pensacola, Florida, has directed that passion to become both a Baldrige Examiner and a Studer Group Coach. We also have a business partner, Paul Grizzell, who helps our partners accelerate their improvement efforts by using the Baldrige Criteria as a managemetn model. Paul is a nationally-recognized expert in applying the Baldrige Criteria. He is a Senior Examiner on the Malcolm Baldrige National Quality Award Board of Examiners where has led multiple site visits and helps train Baldrige Examiners and Senior Examiners. Paul co-authored “Insights to Performance Excellence in Healthcare, An Inside Look at the Baldrige Award Criteria for Healthcare” with Mark Blazey, published by the American Society for Quality.

Complacency is the enemy of great and we applaud those organizations that realize that health care can be a better place for our patients, physicians, and our employees. Thank you for the difference each of you makes.

Drive for Quality and Focus on Results

The Malcolm Baldrige Health Care Criteria for Performance Excellence is an outcome-focused, validated management model based on the characteristics of high-performing organizations. The ultimate goal of the Malcolm Baldrige National Quality Award (MBNQA) is to improve the quality and productivity of American business. Originally designed only for business, the Criteria have evolved from a quality system model to an overall organizational management and improvement model. In addition, the Criteria have been adapted to include both a Health Care and an Education models. The MBNQA has been awarded to nine health care organizations through the 2008 award cycle. During the current 2009 Baldrige Award cycle, about one half of the total applicants represent health care.

The Health Care Criteria are specifically designed to help health care organizations use a systematic, integrated approach to performance management that results in

  • delivery of ever-improving value to patients and other customers, contributing to improved health care quality
  • improvement of overall organizational effectiveness and capabilities as a health care provider
  • organizational and personal learning.

The Health Care Criteria are flexible and adaptable. They are applicable to a small rural hospital, a multi-state health care system, a nursing home, or any other health care organization.

Eleven core values serve as the foundation of the Health Care Criteria. These are the fundamental underpinnings of the Criteria. In the same way that a set of values drives focuses for an organization, the Baldrige Core Values ensure that the Criteria focus on those characteristics that are the proven foundation of high-performing organizations. These Core Values align closely with the Studer Group Nine Principles that form the foundation of the Studer Group. The Baldrige Core Values are:

  • Visionary Leadership
  • Patient-Focused Excellence
  • Organizational and Personal Learning
  • Valuing Staff and Partners
  • Agility
  • Focus on the Future
  • Managing for Innovation
  • Management by Fact
  • Societal Responsibility and Community Health
  • Focus on Results and Creating Value
  • Systems Perspective

In designing a format for evaluation and system improvement, the Baldrige Health Care Criteria for Performance Excellence are organized into seven categories, plus an Organizational Profile that describes your organization and the context in which it operates. Anything your organization does can be positioned within the framework of the Baldrige Criteria. They are:

  • Organizational Profile
  • Leadership
  • Strategic Planning
  • Customer Focus
  • Measurement, Analysis, and Knowledge Management
  • Workforce Focus
  • Process Management
  • Results

There are several key characteristics of the Health Care Criteria:

  • The Criteria focus on organizational performance results. A composite set of measures ensures a balanced view of results that ensures that all stakeholder needs are addressed.
  • The Criteria are non-prescriptive and adaptable – The Criteria focus on results – it is up to the organization to determine the most appropriate path to accomplish those results. Each organization is different and will approach Criteria requirements in a manner that is most appropriate to their health care system/facility.
  • The Criteria integrate key health care themes – the Health Care Criteria have been adapted to be sensitive to specific needs of health care organizations.
  • The Criteria support a systems perspective to maintaining organization-wide goal alignment

The Baldrige Criteria asks how an organization demonstrates well-deployed, systematic processes leading to a balanced set of business results. While it is easy for a health care organization to embrace the values and the well-documented success of organizations that have effectively applied the Criteria, organizations are looking for more prescriptive advice and feedback within each category as they navigate the road to performance excellence. The Baldrige Criteria ask for systematic processes and results; the Studer Group provides many of the answers to Criteria questions with prescriptive tools to hardwire excellence. To “hardwire” means much the same thing as “systematic.” These prescriptive tools have been shown to lead to improved results.

The Tools to Great Organizational Performance

Following is a description of the alignment of Studer Group principles to the Baldrige Criteria. The prescriptive Studer Group tools provide many of the answers to the questions that are asked by the Baldrige Criteria. The effective implementation of the Nine Principles, the Six Must Haves and the Pillars will accelerate your Baldrige improvement efforts. The Baldrige Criteria provide a framework for all of your improvement efforts as you make your organization a better place for employees to work, physicians to practice medicine, and patients to receive care.

Organizational Profile

The Organizational Profile provides a snapshot of your organization, the key influences on how you operate, and the key challenges you face. The Organizational Profile helps you identify the most important characteristics of and challenges facing your organization. It asks for two areas of focus:

Organizational Description – you are asked to describe the organizational environment, which includes your main services and delivery mechanisms, your culture, staff profile, major technologies and equipment, and your legal and regulatory environment. It also asks about your Organizational Relationships, which include your structure, your key patient groups, and the role of suppliers and partners.

Organizational Situation – you are asked to describe your competitive environment, including your competitive position, your principal success factors, and your sources of comparative and competitive data. It also asks you to identify your key health care, operational, and human resource strategic challenges and your performance improvement system.

The Organizational Profile fills several roles:

  • it is a starting point for self-assessment and for writing an application
  • it helps identify gaps in key information and performance results
  • it is used by Examiners to understand your organization and what you consider important
  • it is a tool that can help align senior leaders as you prepare for strategic planning and other activities that require alignment of thought among leaders.

Studer Group principles will help align the culture of your organization. The measurements that are driven by Studer Group tools can help you identify the strategic challenges of your organization.

Category 1 – Leadership

Category 1 – Leadership – focuses on how your senior leaders guide and sustain your organization, including developing and communicating values and setting directions and expectations. It also examines your governance structure and how you address ethical, legal, and community service and public health.

The ”no secrets” culture promoted by the Studer Group’s Nine Principles serves as the basis for many processes that demonstrate the communication of values, directions, and performance expectations and include Departmental communication boards organized according to the Pillars, quarterly employee forums and Leadership Development Institutes that are CEO-led and organized according to the Pillars, and consistent departmental/staff meetings organized according to the Pillars.

Effective communication of values, directions, and performance expectations can be demonstrated by several of the Must Haves. One example is Senior Leader Rounding and other leaders rounding in their own area and the areas they serve. Rounding with staff encourages frank, two-way communication. 90-Day Plans enable an organization to communicate and manage performance expectations. These plans are written by all leaders every 90 days and are reviewed by senior leaders with a focus on Pillar alignment and actions driving to results.

Empowerment, innovation, and agility are demonstrated by Service Action Teams, the Employee Bright Idea Program, and Service Recovery. Service Action Teams are primarily made up of front-line staff that are empowered to review patient satisfaction data and make recommendations for improvement. Many of the improvements are evidence of innovation. Frequent review of survey scores and performance results enable the Service Action Teams to be agile in their responses. Bright Ideas program is a powerful and effective example of both empowerment and innovation as employees have the opportunity to identify and make improvements related to all aspects of the business: clinical, operational, and support services. Service Recovery, when implemented according to Studer Group recommendations, provides for the empowerment of all employees to own complaints and is consistent with the Baldrige core value of agility. Employees address the complaining by the patient or family immediately and on the spot.

Responsibilities to the public and communities served are addressed by both the Growth and Community Pillars. Goals and related action steps for these two Pillars serve to enhance other organizational efforts related to corporate compliance, codes of conduct, regulatory compliance, etc. In addition, departmental 90-Day Plans that include both departmental growth and community goals and actions demonstrates that the commitment to serve the community cascades down to each employee.

Category 2 – Strategic Planning

Category 2 – Strategic Planning – focuses on how an organization develops strategic objectives and action plans. It also addresses how the objectives and action plans are deployed and changed if required, and how progress is measured.

The Pillars serve as the basis for the strategic plan, with each Pillar having measurable goals. Each Pillar should have one-two year goals for short-term planning and three-five year goals for longer-term planning. Once goals are established for the organization, department goals can be created from this starting point ensuring alignment throughout the organization – from the CEO to each individual contributor.

Contribution to success in reaching Pillar objectives is cascaded through the organization by 90-Day Plans, which are organized by the Pillars. This cascading accountability method demonstrates both strategic deployment and measurement of progress. 90-day Plans are also consistent with the Baldrige core value of Agility by enabling leaders to frequently check and quickly adjust their action steps to ensure the accomplishment of strategic objectives. The leader performance evaluation, one of the Six Must Haves, is also organized according to the Pillars and further demonstrates how progress is measured.

Category 3 – Customer Focus

Category 3 – Customer Focus – addresses how you determine requirements, expectations, and preferences of patients, other customers, and the markets in which you operate. Also included in this category is how you build relationships with patients and other customers and how you determine and assess the key factors that lead to patient and other customer acquisition, satisfaction, and retention and to health care service expansion and sustainability.

The goals and actions taken related to the Pillar of Service are based on customer requirements, expectations, and preferences. The organizational goals for service that are deployed at the department and staff level by leader performance evaluations and 90-Day Plans serve as an effective response to this category of criteria. In addition, a description of each of Service Action Team and its accomplishments to date provide further supportive evidence of processes addressing a focus on patients and other customers.

A key tool from Studer Group is Individualized Patient Care. This tool acknowledges that, while there are overarching requirements of all patients, each individual patient and their families have specific requirements that, if met, will increase their level of satisfaction significantly. If physicians, nurses, and other staff are aware of the individual requirements, they can be addressed on an on-going basis, ensuring a “customized” health care experience for the patient and the patient’s family.

Inpatient, Outpatient, and ED Teams should be focused on patient requirements and include a listing of their respective implemented improvements. The Standards Team, along with a description of the standards of performance, how they were developed, implemented, and used to direct consistent employee behavior towards a focus on the customer, further supports the Criteria of Category 3. Additionally, this is consistent with the Baldrige core value of Managing for Innovation. The Physician Satisfaction Team and a description of its accomplishments supports the criteria directed at other customers.

Physician Satisfaction Teams that conduct physician satisfaction surveys and have implemented physician suggestion boxes or hotlines further demonstrate processes for determining expectations, implementing improvements, and building relationships with other customer groups. The weekly reporting and review of patient satisfaction results support the Category 3 Criteria and is consistent with the Baldrige core value of Agility.

The organization’s process for complaint management can be addressed by the Service Recovery Process recommended by Studer Group. Service Recovery, when implemented well, is immediate, owned by all employees, and tracked to identify opportunities for system improvements. . In addition, tracking and trending of system issues further supports the criteria by demonstrating an on going systematic process for improving approaches to improving relationships, another requirement of the Category 3 criteria.

The Reward & Recognition Team can be described in this section as a process for reinforcing behaviors that support high service and rewarding results in order to promote sustaining those results.

Finally, three of the six Must Haves are processes that address the requirements of Category 3:

  1. Nurse leader rounding on patients is an effective process for gaining additional feedback from patients regarding their expectations as well as the organizations performance in meeting/exceeding those expectations. It is also the basis of individualized patient care.
  2. Post-discharge phone calls are a systematic method of receiving feedback regarding expectations and the organization’s ability to meet or exceed them. Effective post-discharge phone calls go beyond gathering feedback to ensuring patient safety in the post-hospital environment.
  3. Key Words at Key Times meet the criteria requirements in that organizations use them to help patients better understand how we are committed to meeting or exceeding their expectations.

Category 4 – Measurement, Analysis, and Knowledge Management

Category 4 – Measurement, Analysis, and Knowledge Management – focuses on how you select, gather, analyze, mange and improve your data, information, and knowledge assets. It also examines how you review organizational performance.

Principle 2, Measure the Important Things, drives organizations to openly and frequently review key results of the organization using the Pillars as a means to organize and focus. Information is shared throughout the organization via the work of the Measurement Team. Employee forums and department and organization communication boards are effective methods by which information is shared throughout the organization to enable support for decision making.

The Baldrige core value of Management by Fact is supported by various Studer Group solutions. The Studer Group has brought several solutions to health care partners to help gather data in a manner that enables effective decision-making. Studer Group software solutions such as the Leadership Evaluation Manager, Rounding Manager, Discharge Call Manager, and Idea Express help automate data-gathering processes. This systematic process for aggregating data allows effective analysis, review, and performance improvement.

Category 5 – Workforce Focus

Category 5 – Workforce Focus – asks how your work system and your workforce learning and motivation enable the entire workforce to develop and utilize their full potential in alignment with overall objectives, strategy, and action plans. It also examines your efforts to build and maintain a work environment and support climate that leads to performance excellence and to personal and organizational growth.

Studer Group solutions put a great deal of emphasis on staff, their development, and their work performance. The Studer Group Health Care Flywheel’s hub is Purpose, Worthwhile Work, and Making a Difference. Ensuring that work systems align with providing these three areas will help accelerate the Flywheel.

Alignment of activities with the Pillar of People ensures that leader’s 90-Day Plans include actions that will improve the staff performance in an overall culture of staff improvement.

Studer Group initiatives tools help address many of the Workforce Focus areas. Recruitment and career progression is addressed using multiple Studer Group solutions: Peer Interviewing, 30- and 90-day questions, and assistance in the first 90 days of employment help ensure that the right employees are brought on whose behavior is going to align with the expectations of the organization. Employee performance management is addressed through High-Medium-Low Performer Conversations. Standards of Behavior help in the selection of employees as well s ongoing performance coaching. In addition, focused teams, such as an Employer of Choice Team, help drive actions that improve staff satisfaction and reduce turnover.

Development and improvement of staff capabilities is addressed through multiple Studer Group workforce development solutions. Leadership Development Institutes are quarterly development opportunities that focus and align leaders across the organization. Employee Forums allow employees to hear about the organization as a whole and receive opportunities for development.

Workforce well-being and satisfaction is addressed using multiple Studer Group tools, including Rounding for Outcomes that helps identify issues that are of concern to employees as well as those things that are positives in the view of employees. Systematic assessment of employee satisfaction that segments appropriate employee groups and resulting action plans allows the organization to make specific changes within employee groups that help increase satisfaction and decrease turnover. Reward and recognition helps reinforce appropriate behavior. Exit interviews help the organization understand and address the actions that may be driving workforce turnover.

Category 6 – Process Management

Category 6 – Process Management – looks at the key aspects of your process management, including key health care, business, and other support processes for creating value for patients, other customers, and your organization overall. This category encompasses all key processes and all departments and work units.

A key focus of the Studer Group is helping organizations hardwire excellence. When processes are hardwired, delivery of healthcare becomes reliable, consistent, and is continuously improved over time. No matter who may be hired or leave the company, excellence in the delivery of health care will be sustained and improved. The Baldrige Criteria look for systematic processes, defined as approaches that are well-ordered, repeatable, and use data and information so learning and continuous improvement are possible. Studer Group’s ability to help organizations hardwire processes helps address the Baldrige requirement of systematic processes.

In addition to the Studer Group’s overall ability to help hardwire excellence through consistent processes, specific approaches that address Criteria requirements include Patient and Employee Rounding as a method to identify process improvement opportunities. Rounding of both patients and staff ensure a balanced look at the organization from the people who are closest to the care being provided.

Processes can be aligned around the Pillars, with 90-Day Plans that are aligned with Pillar goals that address Baldrige Process Management Criteria. The systematic use of 90-Day Plans ensures timely accomplishment of process improvement.

Discharge Phone Calls are an opportunity to extend health care processes beyond discharge. Discharge Phone Calls have been shown to have an impact on key patient outcomes, including reducing medication errors and identifying adverse reactions. For this reason, Discharge Phone Calls can also be seen as a means to identify and reduce errors.

Support Services Evaluations are a method to ensure that support services are meeting the requirements of those on the front line of health care. These evaluations are a method to identify opportunities for improvement, as well as a way to identify best practices that can be shared with others.

Category 7 – Results

Category 7 – Results – examines your performance results in key areas from a balanced perspective. Performance levels and trends are examined relative to those of competitors and other organizations providing similar health care services. In Baldrige scoring, Category 7 accounts for 450 out of 1000 total points. This reinforces that the ultimate goal of performance excellence is to improve results across the organization. The Baldrige results categories and their aligned Studer Group Pillars are:

  • Health Care Outcomes (Pillar of Quality)
  • Customer-Focused Outcomes (Pillar of Service)
  • Finance and Market Outcomes (Pillars of Finance and Growth)
  • Workforce-Focused Outcomes (Pillar of People)
  • Process Effectiveness Outcomes (all of the Pillars)
  • Leadership Outcomes (Pillar of Community).

By focusing on the key Success Drivers and Strategic Challenges in the Organizational Profile and the Processes in Categories 1-6, organizational performance Results will improve. If they don’t, the organization should review its Organizational Profile, its Processes, and its Opportunities for Improvement from Baldrige assessments in order to find those “levers” that can be pulled to ensure that results do improve.

Summary

The Baldrige Award process is a method to identify role model organizations across the country and to share those role model practices to help others improve. Baldrige winning organizations will tell you that the value is not in winning the Baldrige Award. The value is in the process of becoming better during their quality journey.

The Studer Group solutions, when aligned with the Baldrige Criteria for Performance Excellence, will help to focus, align and accelerate your organization’s overall improvement efforts. Those improvement efforts will make your organization a better place for employees to work, physicians to practice medicine, and patients to receive care.

Reference: Health Care Criteria for Performance Excellence, 2007, Baldrige National Quality Program, National Institute of Standards and Technology, Gaithersburg, MD.

Studer Group ©Copyright 2007

Baldrige Studer Group Alignment: The Baldrige Criteria asks how an organization demonstrates well-deployed, systematic processes leading to a balanced set of business results. While it is easy for a health care organization to embrace the values and the well-documented success of organizations that have effectively applied the Criteria, organizations are looking for more prescriptive advice and feedback within each category as they navigate the road to performance excellence. The Baldrige Criteria ask for systematic processes and results; the Studer Group provides many of the answers to Criteria questions with prescriptive tools to hardwire excellence. To “hardwire” means much the same thing as “systematic.” These prescriptive tools have been shown to lead to improved results.

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