1. Creating Sustainable Organizations The Baldrige Performance Excellence Program Sherry Martin HIV Quality of Care Advisory Committee September 13, 2012

2. 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?

4. National Health Expenditure CMS, Office of the Actuary, July, 2011

5. Health Affairs, September 3, 2012

6. 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

7. 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 “

8. Baldrige Performance Excellence Program WHAT 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

9. 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

10. 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

11. The Baldrige Program HOW 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

12. 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

13. Baldrige 2011-2012 Criteria Categories Leadership Strategic Planning Customer Focus Measurement, Analysis and Knowledge Management Workforce Focus Process Management Results

14. Criteria Example LEADERSHIP 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?

15. Criteria Example STRATEGIC 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

16. Criteria Example CUSTOMER 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?

17. Criteria Example MEASUREMENT, 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

18. Key Excellence Factors Leadership/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

19. Sharp Health Care – 2007 Baldrige Winner How Sharp Aligned the Organization

20. Schneck Medical Center – 2011 Baldrige Winner

21. Key Excellence Factors Customer 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

22. Southcentral Foundation – 2011 Baldrige Winner

23. Key Excellence Factors Measurement 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.

24. Key Excellence Indicators Process 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

25. Sharp Health Care – 2007 Baldrige Winner Sharp Health Care Processes

26. 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

27. Criteria Examples RESULTS 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…

28. Key Excellence Factors Results 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

29. 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

30. Southcentral Foundation – 2011 Baldrige Winner

34. Baldrige Self Assessment SUCCESS 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

35. Baldrige Assessment IS 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 Result Improved Quality in a Changing Environment SUSTAINABILITY

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