Week 9 Discussion
Key Performance Indicators
In the Organizational Snapshot you created for Assignment 1, your identified
Key Performance Indicators your organizations measures itself against. After
exploring the topics we have covered in this course, and reviewing the
Baldrige Excellence Framework, how do you feel about these performance
metrics? Are they the right ones? Would you make any changes or additions?
Explain.
Week 10
Your Big Idea
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You have been invited to speak at the upcoming National Leadership in
Healthcare Innovation Conference. The committee members have asked you
to give a presentation on innovative ideas that will transform your organization
and explain how these ideas could be applicable in other organizations.
What is the main innovation (AKA “Big Idea”) you would build your
presentation around and why?
What recent stories from the Wall Street Journal or other reputable publication
would you use as illustrations to support the main themes of your
presentation?
What are the costs and benefits of your Big Idea?
Organizational Snapshot
Identification of the Organization
Baylor Scott & White Holdings- BSW Holdings is a nonprofit organization that is
situated in Texas, which was created as a merger of two healthcare systems in the county. The
affiliates are the Scotts & White Healthcare (S & W) and Baylor Health Care System (BHCS).
The corporation controls important aspects and reserved powers over the material affiliates of S
& W and BHCS. It involves two flagship hospitals, the Scott & White Memorial Hospital and
the Baylor University Medical Center in combination with other twenty hospitals that are
situated in central Texas (Baylor Health Care System, n.d). The system also comprises a research
institute and five foundations. It has the Baylor Scott & White Quality Alliance (BSWQA),
which is a care organization that is accountable for performing the clinical operations, integrating
the health network of employees, hospital, physicians that are independent and other providers
that aim at delivering value-based cost-effective and high-quality care.
The organization has a strategy of changing the healthcare system for the better, which it
aims at achieving through creating a road map for the future. The strategy is aligned with the
vision, mission, and values and of the organization. Its mission is based on its foundation as a
Christian ministry of healing, where it works towards promoting the well- being of the
communities, families, and individuals. Its vision is to become a trusted innovator and educator
in the value- based care delivery, affordability and customer experience (Baylor Health Care
System, n.d). The strategy of BSW Holding is health experience, affordability and alignment
growth.
Revenue and Expense
The operating margin of BSW Holding for the first half of the fiscal year 2018 amounted
to 383.4 million dollars, which was equivalent to 8 % of the total operating revenue. In
comparison to the fiscal year 2017, during the same time, the income had increased from $ 212.5
million which was 4.7 %. The adjusted EBITDA for the first half of the fiscal year 2018 was
25.2 percent of the total operating revenue amounting to $ 730.5 million in comparison to the
10.9 % that represented $ 490.0 million for the same period in the fiscal year 2017 (Baylor
Health Care System, n.d).
The net operating revenue of the organization for the first half of the fiscal year 2018
increased by $324.5 million representing 7.2%, from $ 44891 in 2017 to $ 4813.6 million. The
net care revenue for the patient and the expenses related to bad debts of the patients increased by
$ 301.0 million representing 7.8 per cent from to $4140 million in the first half of the the fiscal
year 2018 from $ 3839.4 million in the first half of the fiscal year of 2017 (Baylor Health Care
System, n.d). These statistics reflect the higher volumes for the fiscal year 2018.
The value of premium revenue decreased from $ 476.9 million in the first half of the
fiscal year 2017 to $412.3million in the first half of the fiscal year of the fiscal year 2018, which
represented -13.5 percent. The decline in the premium revenue is explained by the decision to
leave the public exchange market, Individual ACA, which led to the organization losing about
42, 500 members that have subscribed to this product in the first six months of the fiscal year
2017.
The combined operating expenses of BSW Holding for the first six months of the fiscal
year 2018 increased by 3.6% amounting to $ 153. 7 million compared to $4276.5 million that
was recorded in the first half of the fiscal year 2017 (Baylor Health Care System, n.d). Expenses
on wages, salaries, and employee benefits increased to $2222.2 million which was by 4.1%
amounting to $.5 million in the first half of the fiscal year 2018, from $ 21337 million for the
first six months of the fiscal year 2017. The rise was estimated as 46.2 % and 47.5% of the total
operating revenue for the first half of the fiscal year 2018 and 2017 respectively. Wages, salaries
and employees’ benefits represented 49.9% and 50.2% of the expenditure of the organization for
the first six months of 2017 and 2018 respectively. The expenditure on other operating expenses
and supplies rose by 6.9% or $ 118.1 from $1700.6 in the first six months of the fiscal year 2017
to $1818.7 in the first six months of the fiscal year 2018, which represented 27.9 % and 37.8 %
for the first half of the fiscal year 2017 and 2018 respectively (Baylor Health Care System, n.d).
The supplies and operating expenses for the first half of the fiscal year 2017 and 2018
represented 39.8% and 41.1% of the total expenses respectively.
Current Metrics to Assess Financial Performance
The liquidity of BSW Holding includes unrestricted investment and cash that increased to
$ 4.5 billion as at 30 June 2017 to $ 4.7 billion as at 31 December 2017 after net gains in trading
and investment of $ 187.6 million and capital expenditure of $ 218.6 million. Unrestricted day
cash at hand increased from 194.2 days as at 30 June 2017 to 204. 7 days as at 31 December
2017. Days cash on hand totaled 241.5 days at 31 December 2017 in comparison to 22.7 days at
30 June 2017 (Baylor Health Care System, n.d). The capitalization to debt ration reduced from
40.0 % at 30 June 2017 to 38.4% at 31 December 2017. The total assets for the organization
increased from $11.1 billion at 30 June 2017 to $11.9 billion at 31 December 2017.
The BSW Holding System runs five foundations that include the Irving Healthcare
Foundation, Scott & White Healthcare Foundation Brenham, Baylor Health Care System
Foundation, and All Saint Health Foundation. The total assets of the foundations have increased
to $ 7.1 billion at 31 December 2017 from $ 6.7 billion at 30 June 2017.
Financial Issues of the Greatest Concern
Among the main financial issues of BSW Holding is revenue. This issue represents the
amount that the organization receives from all its operations and it is among the basic points in
determining the profitability, viability, and sustainability of the organization in the market. The
issue is important in determining the growth patterns of the organization and gives information to
the investors on the viability to invest in the company. For example, flat or declining revenues
have implications of limited opportunities for the growth of the company and its possibility to
dissolve.
Possible Areas of Financial Performance Improvement
BSW Holdings needs to improve the management of its operating expenses. The Salaries,
wage, and employees benefits account 46.2% of the total operating expenses, and the
expenditure has been rising, which reduces the revenue for the organization. The company can
hire more independent contractors to work on a temporary basis instead of hiring long-term
employees. This strategy can be effective in reducing the employee's benefit and overall
expenditure on operating expenses. The company can also implement a non- monetary
compensation programs to reduce the turnover on employees while maintaining their motivation
to work.
References
Baylor Health Care System. (n.d). Quarterly Disclosure Report for the Six Months Ended
December 31, 2017 (Unaudited)
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Examiner Version
Includes Criteria
Commentary
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BALDRIGE
EXCELLENCE
FRAMEWORK
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health care
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A systems approach to improving your
organization’s performance
LEADERSHIP
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STRATEGY
CUSTOMERS
MEASUREMENT, ANALYSIS, AND
KNOWLEDGE MANAGEMENT
WORKFORCE
2017
2018
OPERATIONS
RESULTS
#Baldrige
www.nist.gov/baldrige
Baldrige Performance Excellence Program
National Institute of Standards and Technology (NIST) • United States Department of Commerce
January 2017
To order copies of this publication or obtain other Baldrige Program products and services, contact
Baldrige Performance Excellence Program
Administration Building, Room A600
100 Bureau Drive, Stop 1020
Gaithersburg, MD 20899-1020
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Telephone: (301) 975-2036
Fax: (301) 948-3716
E-mail: baldrige@nist.gov
Web: https://www.nist.gov/baldrige
The Baldrige Program welcomes your comments on the Baldrige Excellence Framework and other Baldrige products and
services. Please direct your comments to the address above.
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The Baldrige Excellence Framework (Health Care)TM is an official publication of NIST under the authority of the Malcolm Baldrige
National Quality Improvement Act of 1987 (Public Law 100-107; codified at 15 U.S.C. § 3711a). This publication is a work of the U.S.
Government and is not subject to copyright protection in the United States under Section 105 of Title 17 of the United States Code. The
U.S. Department of Commerce, as represented by NIST, holds copyright to the publication in all countries outside of the United States.
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BALDRIGE CRITERIA FOR PERFORMANCE EXCELLENCE® and Design, BALDRIGE PERFORMANCE EXCELLENCE PROGRAM®,
CRITERIA FOR PERFORMANCE EXCELLENCE®, EDUCATION CRITERIA FOR PERFORMANCE EXCELLENCE®, HEALTH CARE
CRITERIA FOR PERFORMANCE EXCELLENCE®, MALCOLM BALDRIGE NATIONAL QUALITY AWARD® and Design, PERFORMANCE
EXCELLENCE®, THE QUEST FOR EXCELLENCE®, and the MALCOLM BALDRIGE NATIONAL QUALITY AWARD medal and
depictions or representations thereof are federally registered trademarks and service marks of the U.S. Department of Commerce,
National Institute of Standards and Technology. The unauthorized use of these trademarks and service marks is prohibited.
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NIST, an agency of the U.S. Department of Commerce, manages the Baldrige Program. NIST has a 100-plus-year track record of
serving U.S. industry, science, and the public with the mission to promote U.S. innovation and industrial competitiveness by advancing
measurement science, standards, and technology in ways that enhance economic security and improve our quality of life. NIST carries
out its mission in three cooperative programs, including the Baldrige Program. The other two are the NIST laboratories, conducting
research that advances the nation’s technology infrastructure and is needed by U.S. industry to continually improve products and
services; and the Hollings Manufacturing Extension Partnership, a nationwide network of local centers offering technical and
business assistance to small manufacturers.
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Suggested citation: Baldrige Performance Excellence Program. 2017. 2017–2018 Baldrige Excellence Framework (Health Care):
A Systems Approach to Improving Your Organization’s Performance. Gaithersburg, MD: U.S. Department of Commerce,
National Institute of Standards and Technology. https://www.nist.gov/baldrige.
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The Baldrige Program and the Baldrige Foundation thank the American Hospital Association
as the lead sponsor for the Health Care Criteria for Performance Excellence.
We also thank the following organizations for supporting the publication of this booklet.
Contents
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About the Baldrige Excellence Framework
The Baldrige framework empowers your organization to reach its goals, improve results, and become more
competitive. The framework consists of the Criteria, the core values and concepts, and the scoring guidelines.
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How to Use the Baldrige Excellence Framework
You can use this booklet as a reference, for self-assessment, or as the basis of an external assessment.
Health Care Criteria for Performance Excellence Overview and Structure
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1
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The Health Care Criteria include the Organizational Profile and seven interconnected categories. The categories
are subdivided into items and areas to address.
3
Health Care Criteria for Performance Excellence Items and Point Values
4
Health Care Criteria for Performance Excellence
Organizational Profile
7
1 Leadership
10
2 Strategy
13
3 Customers
16
4 Measurement, Analysis, and Knowledge Management
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5 Workforce
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6 Operations
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7 Results
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Scoring System
Performance against Health Care Criteria items is scored on two evaluation dimensions: process and results.
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Process Scoring Guidelines
35
Results Scoring Guidelines
How to Respond to the Health Care Criteria
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37
This section explains how to respond most effectively to the Health Care Criteria item requirements.
40
Core Values and Concepts
These embedded beliefs and behaviors form the foundation of the Health Care Criteria.
Changes from the 2015–2016 Baldrige Excellence Framework
47
Glossary of Key Terms
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45
The glossary includes definitions of terms in small caps in the Health Care Criteria and scoring guidelines.
55
Index of Key Terms
58
List of Contributors
On the Web
Health Care Criteria Commentary (https://www.nist.gov/baldrige/baldrige-criteria-commentary-health-care)
This commentary provides the “why” behind the Health Care Criteria, as well as additional examples and guidance.
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About the Baldrige Excellence Framework
The Baldrige Excellence Framework empowers your organization to reach its goals, improve
results, and become more competitive.
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Thousands of organizations around the world use the Baldrige Excellence Framework to improve and get sustainable
results. Those recognized as national role models receive the Malcolm Baldrige National Quality Award, a Presidential
award. More than 100 recipients have broadly shared their best practices with others. Through that sharing, many
thousands of organizations have improved their operations and results, and thus their contributions to the U.S. and
global economy.
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Baldrige has a simple purpose.
The purpose of the Baldrige framework is simply to help your organization—no matter its size or the types of health
care services it offers—answer three questions: Is your organization doing as well as it could? How do you know? What
and how should your organization improve or change?
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By challenging yourself with the questions that make up the Health Care Criteria for Performance Excellence
(pages 4–30), you explore how you are accomplishing what is important to your organization. The questions (divided
into six interrelated process categories and a results category) represent seven critical aspects of managing and
performing as an organization:
Leadership
2.
Strategy
3.
Customers
4.
Measurement, analysis, and knowledge management
5.
Workforce
6.
Operations
7.
Results
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1.
Baldrige promotes a systems perspective.
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A systems perspective means managing all the components of your organization as a unified whole to achieve ongoing
success. The system’s building blocks and integrating mechanism are the core values and concepts (pages 40–44),
the seven interrelated Health Care Criteria categories (pages 4–30), and the scoring guidelines (pages 34–35).
I see the Baldrige process as a powerful set of mechanisms for disciplined people engaged
in disciplined thought and taking disciplined action to create great organizations that
produce exceptional results.
—Jim Collins, author of Good to Great: Why Some Companies
Make the Leap . . . and Others Don’t
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2017–2018 Baldrige Excellence Framework (Health Care)
Systems perspective
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Visionary leadership
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Patient-focused excellence
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Valuing people
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Organizational learning and agility
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Focus on success
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Managing for innovation
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Management by fact
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Societal responsibility and community health
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Ethics and transparency
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Delivering value and results
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A focus on core values and concepts. Baldrige is based on a set of beliefs and behaviors (see pages 40–44). These
core values and concepts are the foundation for integrating key performance and operational requirements within a
results-oriented framework that creates a basis for action, feedback, and ongoing success:
A focus on processes. Processes are the methods your organization uses to accomplish its work. The Baldrige framework helps you assess and improve your processes along four dimensions:
Approach: How do you accomplish your organization’s work? How effective are your key approaches?
2.
Deployment: How consistently are your key approaches used in relevant parts of your organization?
3.
Learning: How well have you evaluated and improved your key approaches? How well have improvements been
shared within your organization? Has new knowledge led to innovation?
4.
Integration: How well do your approaches align with your current and future organizational needs? How
well do your measures, information, and improvement systems complement each other across processes
and work units? How well are processes and operations harmonized across your organization to achieve key
organization-wide goals?
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A focus on results. The Baldrige framework leads you to examine your results from three viewpoints: the external
view (How do your patients, other customers, and other stakeholders view you?), the internal view (How efficient and
effective are your operations?), and the future view (Is your organization learning and growing?).
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In Baldrige, results include all areas of importance to your organization. This composite of measures ensures that your
strategies are balanced—that they do not inappropriately trade off among important stakeholders, objectives, or shortand longer-term goals. The Baldrige framework helps you evaluate your results along four dimensions:
Levels: What is your current performance on a meaningful measurement scale?
2.
Trends: Are the results improving, staying the same, or getting worse?
3.
Comparisons: How does your performance compare with that of other organizations and competitors, or with
benchmarks or industry leaders?
4.
Integration: Are you tracking results that are important to your organization and that consider the expectations
and needs of your key stakeholders? Are you using the results in decision making?
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A focus on linkages. The linkages among the Health Care Criteria categories are an essential element of the systems
perspective provided by the Baldrige framework. Some examples of these linkages are
•
the connections between your processes and the results you achieve;
•
the need for data in the strategic planning process and for improving operations;
•
the connection between workforce planning and strategic planning;
•
the need for patient, other customer, and market knowledge in establishing your strategy and action plans; and
•
the connection between your action plans and any changes needed in your work systems.
About the Baldrige Excellence Framework
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A focus on improvement. The Baldrige framework helps you understand and assess how well you are accomplishing
what is important to your organization: how mature and how well deployed your processes are, how good your results
are, whether your organization is learning and improving, and how well your approaches address your organization’s
needs. The Baldrige scoring guidelines (pages 34–35) are based on the process and results dimensions described above.
As you respond to the Health Care Criteria questions and gauge your responses against the scoring guidelines, you
will begin to identify strengths and gaps—first within the Health Care Criteria categories and then among them. The
coordination of key processes, and feedback between your processes and your results, will lead to cycles of improvement. As you continue to use the framework, you will learn more and more about your organization and begin to
define the best ways to build on your strengths, close gaps, and innovate.
Baldrige is adaptable.
Baldrige has national and global impact.
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The Health Care Criteria do not prescribe how you should structure your organization or its operations. In the Organizational Profile (pages 4–6), you describe what is important to your organization (its operating environment, key
relationships, competitive environment, and strategic context). The Health Care Criteria encourage you to use creative,
adaptive, and flexible approaches, which will foster incremental and breakthrough improvement through innovation.
The Health Care Criteria encourage you to choose the tools (e.g., Lean, Six Sigma, the International Organization
for Standardization [ISO] 9000 series, a balanced scorecard, Plan-Do-Check-Act [PDCA]) that are most suitable and
effective for your organization in making improvements and achieving excellence.
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The Baldrige framework and Criteria play three roles in strengthening U.S. competitiveness:
•
They help improve organizational processes, capabilities, and results.
•
They facilitate the communication and sharing of best practices among U.S. organizations through the Baldrige
Award, the Quest for Excellence® Conference, and other educational offerings.
•
They serve as a working tool for understanding and managing organizational performance, guiding your strategic
thinking, and providing opportunities to learn.
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Baldrige works with public and private sector partners to address critical national needs related to long-term success
and sustainability, including cybersecurity risk management (see https://www.nist.gov/baldrige/products-services
/baldrige-cybersecurity-initiative) and excellence in U.S. communities (see Communities of Excellence 2026,
http://www.communitiesofexcellence2026.org).
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Within the United States, state, regional, sector, and organizational performance excellence programs use the Baldrige
framework to help organizations improve their competitiveness and results. Globally, about 100 performance or
business excellence programs exist; most use the Baldrige framework or a derivative as their organizational excellence
model.
Baldrige is here for your organization.
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According to one health care leader, “It was the use of the Baldrige framework that boosted our ability to deliver better care to our patients. And, in the end, that is the most important thing: delivering better care to our patients—and
having a greater and more positive impact on the lives of all of our customers” (Nancy Schlichting, CEO, Baldrige
Award recipient Henry Ford Health System). Why not take advantage of that opportunity? Your patients, other
customers, workforce, community, and other stakeholders—and the nation—will be better off.
I honestly in my heart believe that because we participated in the Baldrige Program and
because it gave us that consistent feedback, there are people who are alive today who
wouldn’t have been had we not been so committed to the Baldrige process.
—Rulon Stacey, former president/CEO, Baldrige Award recipient Poudre Valley Health System
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2017–2018 Baldrige Excellence Framework (Health Care)
How to Use the Baldrige Excellence Framework
Whether your organization is large or small, you can use the Baldrige Excellence Framework for
improvement. Your experience with Baldrige will help you decide where to begin.
If your organization is in the business/nonprofit or education sector, you should use the business/nonprofit or
education version of this booklet, respectively. See https://www.nist.gov/baldrige/publications/baldrige-excellence
-framework to obtain a copy.
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If you are just learning about the Baldrige framework . . .
Here are some ways to begin using the Baldrige framework to improve your organization.
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Scan the questions in the Organizational Profile (pages 4–6). Discerning and discussing the answers to these questions with your senior leadership team might be your first Baldrige self-assessment.
Study the 11 Baldrige core values and concepts (pages 40–44). Consider how your organization measures up in
relation to the core values. Are there any improvements you should be making?
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Answer the questions in the titles of the 17 Health Care Criteria for Performance Excellence items to reach a
basic understanding of the Criteria and your organization’s performance.
See a simple outline of a holistic performance management system by reading the headings in purple in the
Health Care Criteria section of this booklet (pages 4–30). See if you are considering all of these dimensions in establishing your leadership system and measuring performance.
Use the Baldrige framework and its supporting material as a general resource on organizational performance
improvement. This booklet and the materials online (https://www.nist.gov/baldrige/publications/baldrige-excellence
-framework) may help you think in a different way or give you a fresh frame of reference.
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Attend the Quest for Excellence® or a state or regional Baldrige conference. These events highlight the rolemodel approaches of Baldrige Award recipients. These organizations have used the Baldrige framework to improve
performance, innovate, and achieve world-class results. Workshops on Baldrige self-assessment are often offered in
conjunction with these conferences.
Become an examiner, or attend the Baldrige Examiner Training Experience (https://www.nist.gov/baldrige
/products-services/baldrige-examiner-training-experience). Examiners receive valuable training, evaluate award
applications, and learn to apply the Criteria to their organizations.
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Become a Baldrige Executive Fellow. Baldrige Fellows (C-suite and rising executives) participate in an executive
development program (see https://www.nist.gov/baldrige/products-services/baldrige-executive-fellows-program),
learning from each other and from Baldrige Award recipients.
If you are ready to assess your organization using Baldrige . . .
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To assess your organization with the Baldrige framework, follow one or more of the suggestions below.
Check your progress on achieving organizational excellence and improve communication among your workforce members and leadership team with two simple questionnaires: Are We Making Progress? (https://www.nist.gov
/baldrige/self-assessing/improvement-tools/are-we-making-progress) and Are We Making Progress as Leaders?
(https://www.nist.gov/baldrige/self-assessing/improvement-tools/are-we-making-progress-leaders).
Identify gaps in your understanding of your organization and compare your organization with others with
easyInsight: Take a First Step toward a Baldrige Self-Assessment (https://www.nist.gov/baldrige/self-assessing
/improvement-tools/easyinsight-take-first-step-toward-baldrige-self). This assessment is based on the Organizational
Profile.
Complete the Organizational Profile (pages 4–6). Have your leadership team answer the questions. If you identify
topics for which you have conflicting, little, or no information, use these topics for action planning. For many organizations, this approach serves as a first Baldrige self-assessment.
How to Use the Baldrige Excellence Framework
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Answer the questions in the Baldrige Excellence Builder (https://www.nist.gov/baldrige/publications/baldrige
-excellence-builder). This assessment tool includes key questions for improving your organization’s performance. They
are the questions in black boldface in the Criteria section of this booklet.
Use the full set of Health Care Criteria questions as a personal guide to everything that is important in leading your organization. You may discover blind spots or areas where you should place additional emphasis.
Review the scoring guidelines (pages 34–35). They help you assess your organizational maturity, especially when
used in conjunction with “Steps toward Mature Processes” (page 36) and “From Fighting Fires to Innovation:
An Analogy for Learning” (page 32).
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Answer the questions in one Health Care Criteria category in which you know you need improvement, either
yourself or with leadership team colleagues, referring to the item notes and Health Care Criteria Commentary (https://
www.nist.gov/baldrige/baldrige-criteria-commentary-health-care). Then assess your strengths and opportunities for
improvement, and develop action plans. Be aware, though, that this kind of assessment limits the benefits of the
systems perspective embodied in the Baldrige framework.
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Have your leadership team assess your organization. At a retreat, have your leadership team develop responses to
the Organizational Profile and the seven Health Care Criteria categories, using the Baldrige Excellence Builder (https://
www.nist.gov/baldrige/publications/baldrige-excellence-builder), and record the responses. Then assess your strengths
and opportunities for improvement, and develop action plans.
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Conduct a full Baldrige self-assessment. Set up teams within your organization to develop responses to the
Organizational Profile and Health Care Criteria categories. For details, see https://www.nist.gov/baldrige/self-assessing
and the slide presentation “Self-Assessing Your Organization with the Baldrige Excellence Framework” (https://www
.nist.gov/baldrige/community/baldrige-ambassadors).
Contact your state, local, or sector-specific Baldrige-based program (see the Alliance for Performance Excellence,
http://www.baldrigepe.org/alliance). Many programs provide networking opportunities, training, coaching, and selfassessment services in addition to an award program.
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Contact a Baldrige Award recipient. Organizations that receive the Baldrige Award advocate for performance
improvement, share their strategies, and serve as role models. Many undertake ongoing self-assessments of their
organizations and can share their experiences with you. See http://patapsco.nist.gov/Award_Recipients/index.cfm
for award recipients and their contact information.
If you are ready for external feedback . . .
Here are some resources for receiving external feedback on your organization’s strengths and opportunities for
improvement.
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Apply to your state, local, or sector-specific Baldrige-based award program (see the Alliance for Performance
Excellence, http://www.baldrigepe.org/alliance). A team of experts will examine your organization objectively and
identify your organization’s strengths and its opportunities to improve.
Arrange for a Baldrige Collaborative Assessment (https://www.nist.gov/baldrige/products-services/baldrige
-collaborative-assessment). In this on-site assessment, a team of Baldrige examiners works with your leaders and staff
to give your organization immediate, actionable feedback.
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Apply for the Malcolm Baldrige National Quality Award. Once you meet eligibility requirements, apply for the
highest level of national recognition for performance excellence that a U.S. organization can receive: the Malcolm
Baldrige National Quality Award.
Award applicants say that the Baldrige evaluation process is one of the best, most cost-effective, most comprehensive
performance assessments you can find, whether or not they receive the Baldrige Award. See https://www.nist.gov
/baldrige/baldrige-award for more information. In the Baldrige process, everyone is a learner.
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2017–2018 Baldrige Excellence Framework (Health Care)
Health Care Criteria for Performance
Excellence Overview and Structure
Health Care Criteria for Performance Excellence Overview: A Systems Perspective
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The performance system consists of the six categories in the center of the figure. These categories define your processes and
the results you achieve.
Performance excellence requires strong Leadership and is demonstrated through outstanding Results. Those categories are
highlighted in the figure.
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The word “integration” at the center of the figure shows that all the elements of the system are interrelated.
The center horizontal arrowheads show the critical linkage between the leadership triad (categories 1, 2, and 3) and the
results triad (categories 5, 6, and 7) and the central relationship between the Leadership and Results categories.
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The center vertical arrowheads point to the Organizational Profile and the system foundation, which provide information on
and feedback to key processes and the organizational environment.
The Organizational Profile
sets the context for your
organization. It serves as the
background for all you do.
The leadership triad (Leadership, Strategy, and Customers)
emphasizes the importance of
a leadership focus on strategy
and customers.
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Organizational Profile
Strategy
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Leadership
The system
foundation
(Measurement,
Analysis, and
Knowledge Management)
is critical to effective
management and to a
fact-based, knowledgedriven, agile system for
improving performance
and competitiveness.
The results triad (Workforce,
Operations, and Results)
includes your workforce-focused
processes, your key operational
processes, and the performance
results they yield.
Workforce
RESULTS
Integration
Customers
Operations
Measurement, Analysis, and Knowledge Management
s
Core
Values and Concept
The basis of the Health Care Criteria is a set of Core Values and Concepts
that are embedded in high-performing organizations (see pages 40–44).
Health Care Criteria for Performance Excellence Overview and Structure
All actions
lead to
Results—a
composite of health
care and process,
customer, workforce,
leadership and governance, and financial
and market results.
1
Health Care Criteria for Performance Excellence Structure
The seven Baldrige Health Care Criteria for Performance Excellence categories are subdivided into
items and areas to address.
Items
Requirements
There are 17 Health Care Criteria items (plus 2 in the
Organizational Profile), each with a particular focus. These
items are divided into three groups according to the kinds of
information they ask for:
Item requirements are expressed as questions or statements
on three levels:
• Basic requirements are expressed in the title question.
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• Overall requirements are expressed in the questions
in boldface in the shaded box. These leading questions are the starting point for responding to the
requirements.
• The Organizational Profile asks you to define your
organizational environment.
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• Process items (categories 1–6) ask you to define your
organization’s processes.
• Multiple requirements are the individual questions
under each area to address, including the question
in boldface. That first question expresses the most
important one in that group.
• Results items (category 7) ask you to report results for
your organization’s processes.
See page 3 for a list of item titles and point values.
Key Terms
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Item Notes
Terms in small caps are defined in the Glossary of Key
Terms (pages 47–54).
Item notes (1) clarify terms or requirements, (2) give instructions and examples for responding, and (3) indicate key
linkages to other items.
Areas to Address
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Each item includes one or more areas to address (labeled
a, b, c, and so on).
Key term in
small caps
Item number
address
(1) Financial PeRfoRmance What are your financial PeRfoRmance Results? What are your current levels and
trends in key measures or indicators of financial performance, including aggregate measures of financial
return, financial viability, and budgetary performance, as appropriate? How do these results differ by market
segments and patient and other customer groups, as appropriate?
(2) Marketplace PeRfoRmance What are your marketplace PeRfoRmance Results? What are your current levels
and trends in key measures or indicators of marketplace performance, including market share or position,
market and market share growth, and new markets entered, as appropriate? How do these results differ by market
segments and patient and other customer groups, as appropriate?
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Headings
a. Financial and Market Results
summarizing
multiple
requirements
Terms in small caps are defined in the Glossary of Key Terms (pages 47–54).
Note
Item
notes
2
7.5a(1). Measures should relate to the financial measures
you report in 4.1a(1) and the financial management
approaches you report in item 2.2. Aggregate measures of
financial return might include those for return on investment (ROI), operating margins, profitability, or profitability
by market segment or patient or other customer group.
Measures of financial viability might include those for
liquidity, debt-to-equity ratio, days cash on hand, asset
utilization, cash flow, bond ratings, accountable care
organization or shared savings programs, and value-based
purchasing financial results, as appropriate. For nonprofit
RE SU LT S
Area to
to provide in response
to this item
7.5 Financial and Market Results: What are your results for financial viability? (90 pts.)
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Item title
and basic
requirements
Type of information
Item point value
Overall
requirements
health care organizations, measures of performance to
budget might include additions to or subtractions from
reserve funds, cost avoidance or savings, responses to
budget decreases, lowering of costs to patients or other customers or return of funds as a result of increased efficiency,
administrative expenditures as a percentage of budget, and
the cost of fundraising versus funds raised.
Multiple
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
Link to
Health Care
Criteria
Commentary
requirements
2017–2018 Baldrige Excellence Framework (Health Care)
Health Care Criteria for Performance
Excellence Items and Point Values
See pages 31–36 for the scoring system used with the Health Care Criteria items in a
Baldrige assessment.
Organizational Profile
P.1
Organizational Description
P.2
Organizational Situation
3
4
Strategy
85
1.1
Senior Leadership
1.2
Governance and Societal Responsibilities
2.1
Strategy Development
2.2
Strategy Implementation
3.1
Voice of the Customer
3.2
Customer Engagement
40
45
45
Information and Knowledge Management
45
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Workforce
5.1
Workforce Environment
40
5.2
Workforce Engagement
45
Operations
6.1
Work Processes
45
6.2
Operational Effectiveness
40
Results
7.1
Health Care and Process Results
7.2
Customer Results
80
7.3
Workforce Results
80
7.4
Leadership and Governance Results
80
7.5
Financial and Market Results
90
90
85
85
450
120
TOTAL POINTS
Health Care Criteria for Performance Excellence Items and Point Values
85
40
Measurement, Analysis, and Improvement of
Organizational Performance
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7
45
Measurement, Analysis, and Knowledge Management
4.2
6
50
Customers
4.1
5
70
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2
120
Leadership
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1
Point Values
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Categories and Items
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P
1,000
3
Health Care Criteria for Performance Excellence
Begin with the Organizational Profile
The Organizational Profile is the most appropriate starting point for self-assessment and for writing an application. It is critically
important for the following reasons:
• It helps you identify gaps in key information and focus on key performance requirements and results.
• You can use it as an initial self-assessment. If you identify topics for which conflicting, little, or no information is available, use these topics for action planning.
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• It sets the context for and allows you to address unique aspects of your organization in your responses to the Health Care
Criteria requirements in categories 1–7.
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P Organizational Profile
The Organizational Profile is a snapshot of your organization, the key influences on how it operates, and your competitive
environment.
a. Organizational Environment
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P.1 Organizational Description: What are your key organizational characteristics?
(1) Health Care Service Offerings What are your main health care service offerings (see the note on the next
page)? What is the relative importance of each to your success? What mechanisms do you use to deliver your
health care services?
(2) Mission, Vision, and Values What are your stated mission, vision, and values? What are your organization’s
core competencies, and what is their relationship to your mission?
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(3) Workforce Profile What is your workforce profile? What recent changes have you experienced in workforce
composition or in your needs with regard to your workforce? What are
• your workforce or employee groups and segments,
• the educational requirements for different employee groups and segments, and
• the key drivers that engage them in achieving your mission and vision?
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What are your organized bargaining units (union representation)? What are your organization’s special health and
safety requirements?
(4) Assets
What are your major facilities, technologies, and equipment?
(5) Regulatory Requirements What is the regulatory environment under which you operate? What are the key applicable occupational health and safety regulations; accreditation, certification, or registration requirements; industry
standards; and environmental, financial, and health care service delivery regulations?
Ex
b. Organizational Relationships
(1) Organizational Structure What are your organizational leadership structure and governance system? What
are the reporting relationships among your governance board, senior leaders, and parent organization, as
appropriate?
(2) Patients, Other Customers, and Stakeholders What are your key market segments, patient and other
customer groups, and stakeholder groups, as appropriate? What are their key requirements and expectations for
your health care services, patient and other customer support services, and operations? What are the differences in these requirements and expectations among market segments, patient and other customer groups, and
stakeholder groups?
(Continued on the next page)
4
2017–2018 Health Care Criteria for Performance Excellence
(3) Suppliers and Partners
they play
What are your key types of suppliers, partners, and collaborators? What role do
• in your work systems, especially in producing and delivering your key health care services and patient and
other customer support services; and
• in enhancing your competitiveness?
What are your key mechanisms for two-way communication with suppliers, partners, and collaborators?
What role, if any, do these organizations play in contributing and implementing innovations in your organization?
What are your key supply-chain requirements?
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Terms in small caps are defined in the Glossary of Key Terms (pages 47–54).
Notes
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might cover greenhouse gas emissions, carbon regulations
and trading, and energy efficiency.
P.1b(2). Customers include the direct users and potential
users of your health care services (patients), as well as
referring health care providers and users who pay for your
services, such as patients’ families, insurers, and other thirdparty payors.
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P. Your responses to the Organizational Profile questions are
very important. They set the context for understanding your
organization and how it operates. Your responses to all other
questions in the Baldrige Health Care Criteria should relate
to the organizational context you describe in this profile.
Your responses to the Organizational Profile questions thus
allow you to tailor your responses to all other questions to
your organization’s uniqueness.
P.1a(1). Health care service offerings are the services you
offer in the marketplace. Mechanisms for delivering services
to your patients or other customers might be direct or might
be indirect, through contractors, collaborators, or partners.
P.1b(2). The requirements of your patient and other
customer groups and your market segments might include
patient safety; security, including cybersecurity; quality of
care; affordability; care planning and continuity of care;
provider choice; electronic communication and access to
personal health information; easy transferability of health
information; billing requirements; socially responsible
behavior; cultural inclusion; and multilingual services.
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P.1a(2). If your organization has a stated purpose as well
as a mission, you should include it in your response. Some
organizations define a mission and a purpose, and some use
the terms interchangeably. In some organizations, purpose
refers to the fundamental reason that the organization
exists. Its role is to inspire the organization and guide its
setting of values.
P.1b(2). Patient and other customer groups might be based
on common expectations, behaviors, preferences, or profiles.
Within a group, there may be customer segments based on
differences, commonalities, or both. You might subdivide
your market into segments based on health care service
lines or features, service delivery modes, payors, volume,
geography, or other defining factors.
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P.1a(2). Core competencies are your organization’s areas
of greatest expertise. They are those strategically important,
possibly specialized capabilities that are central to fulfilling
your mission or provide an advantage in your marketplace
or service environment. Core competencies are frequently
challenging for competitors or suppliers and partners to
imitate and frequently preserve your competitive advantage.
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P.1a(3). Workforce or employee groups and segments
(including organized bargaining units) might be based on
type of employment or contract-reporting relationship, location (including telework), tour of duty, work environment,
use of certain family-friendly policies, or other factors.
P.1a(3). Organizations that also rely on volunteers and
unpaid staff to accomplish their work should include these
groups as part of their workforce.
P.1a(5). Industry standards might include industrywide
codes of conduct and policy guidance. Depending on the
regions in which you operate, environmental regulations
Organizational Profile
P.1b(2), P.1b(3). Patient, other customer, stakeholder, and
operational requirements and expectations will drive your
organization’s sensitivity to the risk of service, support, and
supply-chain interruptions, including those due to natural
disasters and other emergencies.
P.1b(3). Communication mechanisms should use understandable language, and they might involve in-person
contact; email, social media, or other electronic means; or
the telephone. For many organizations, these mechanisms
may change as marketplace, patient, other customer, or
stakeholder requirements change.
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
5
P.2 Organizational Situation: What is your organization’s strategic situation?
a. Competitive Environment
(1) Competitive Position What is your competitive position? What are your relative size and growth in the health
care industry or the markets you serve? How many and what types of competitors and key collaborators do
you have?
(2) Competitiveness Changes What key changes, if any, are affecting your competitive situation, including changes
that create opportunities for innovation and collaboration, as appropriate?
(3) Comparative Data What key sources of comparative and competitive data are available from within the health
care industry? What key sources of comparative data are available from outside the health care industry? What
limitations, if any, affect your ability to obtain or use these data?
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b. Strategic Context
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What are your key strategic challenges and advantages in the areas of health care services, operations, societal
responsibilities, and workforce?
c. Performance Improvement System
What are the key elements of your performance improvement system, including your processes for evaluation and
improvement of key organizational projects and processes?
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Terms in small caps are defined in the Glossary of Key Terms (pages 47–54).
Notes
approaches and their deployment. This question is intended
to set an overall context for your approach to performance
improvement. The approach you use should be related to
your organization’s needs. Approaches that are compatible
with the overarching systems approach provided by the
Baldrige framework might include implementing a Lean
Enterprise System, applying Six Sigma methodology, using
PDCA methodology, using standards from ISO (e.g., the
9000 or 14000 series), using decision science, or employing
other improvement tools.
P.2c. The Baldrige Scoring System (pages 31–36) uses
performance improvement through learning and integration
as a dimension in assessing the maturity of organizational
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
Ex
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P.2b. Strategic challenges and advantages might relate
to technology; health care services; finances; operations
(including data and information security); organizational
structure and culture; your parent organization’s capabilities;
patients, other customers, and markets; brand recognition
and reputation; the health care industry; and people.
Strategic advantages might include differentiators such as
technology leadership, innovation rate, geographic proximity, accessibility, health care and administrative support
services, cost, reputation for service delivery, and wait times
for service.
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2017–2018 Health Care Criteria for Performance Excellence
1 Leadership (120 pts.)
The Leadership category asks how senior leaders’ personal actions guide and sustain your organization. It also asks about
your organization’s governance system and how your organization fulfills its legal, ethical, and societal responsibilities.
1.1 Senior Leadership: How do your senior leaders lead the organization? (70 pts.)
a. Vision and Values
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P R O C ESS
(1) Setting Vision and Values How do senior leaders set your organization’s vision and values? How do
senior leaders deploy the vision and values through your leadership system; to the workforce; to key
suppliers and partners; and to patients, other customers, and other stakeholders, as appropriate? How do
senior leaders’ personal actions reflect a commitment to those values?
(2) Promoting Legal and Ethical Behavior How do senior leaders’ actions demonstrate their commitment to
legal and ethical behavior? How do senior leaders promote an organizational environment that requires it?
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b. Communication
How do senior leaders communicate with and engage the entire workforce, patients, and other key customers?
How do they
• encourage frank, two-way communication, including use of social media, when appropriate;
• communicate key decisions and needs for organizational change; and
c. Mission and Organizational Performance
(1) Creating an Environment for Success
the future? How do they
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• take a direct role in motivating the workforce toward high performance and a patient, other customer, and
health care focus, including by participating in reward and recognition programs?
How do senior leaders create an environment for success now and in
• create an environment for the achievement of your mission and for organizational agility;
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• cultivate organizational learning, learning for people in the workforce, innovation, and intelligent risk
taking;
• create a workforce culture that fosters patient and other customer engagement;
• participate in succession planning and the development of future organizational leaders; and
• create and promote a culture of patient safety?
(2) Creating a Focus on Action How do senior leaders create a focus on action that will achieve the organization’s mission? How do senior leaders
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• create a focus on action that will improve the organization’s performance;
• identify needed actions;
• in setting expectations for organizational performance, include a focus on creating and balancing value for
patients, other customers, and other stakeholders; and
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• demonstrate personal accountability for the organization’s actions?
Terms in small caps are defined in the Glossary of Key Terms (pages 47–54).
Notes
1.1. In health care organizations with separate
administrative/operational and health care provider leaders,
the term “senior leaders” refers to both sets of leaders and
the relationship between them.
1.1. Your organizational performance results should be
reported in items 7.1–7.5. Results related to the effectiveness
of leadership and the leadership system should be reported
in item 7.4.
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Leadership
1.1a(1). Your organization’s vision should set the context
for the strategic objectives and action plans you describe in
items 2.1 and 2.2.
1.1b. Use of social media may include delivering periodic
messages through internal and external websites; tweets;
blogging; and electronic forums for patients, other customers, and the workforce, as well as monitoring external social
media outlets and responding, when appropriate.
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1.1c(2). Senior leaders’ focus on action considers your strategy, workforce, work systems, and assets. It includes taking
intelligent risks and implementing innovations and ongoing
improvements in performance and productivity. Senior
leaders’ focus on action also includes the actions needed
to achieve your strategic objectives (see 2.2a[1]), and may
involve establishing change management plans for major
organizational change or responding rapidly to significant
information from social media or other input.
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
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1.1c(1). A successful organization understands that some
risk is always present, and determines and oversees its risk
appetite and risk tolerance. A successful organization is
capable of addressing current business needs and, through
agility and strategic management, is capable of preparing for
its future business, market, and operating environment. In
creating an environment for success now and in the future,
leaders should consider both external and internal factors.
Factors might include workforce capability and capacity,
resource availability, technology, knowledge, core competencies, work systems, facilities, and equipment. Achieving
future success may require leading transformational changes
in the organization’s structure and culture. Success now
and in the future might be affected by changes in the
marketplace, in patient and other customer preferences,
in the financial markets, and in the legal and regulatory
environment. In the context of ongoing success, the concept
of innovation and taking intelligent risks includes both
technological and organizational innovation to help the
organization succeed in the future. A successful organization
also ensures a safe and secure environment for its workforce
and other key stakeholders. A successful organization is
capable of addressing risks and opportunities arising from
data and information security and from environmental
considerations and climate change.
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1.1b. Organizations that rely heavily on volunteers to
accomplish their work should also discuss efforts to communicate with and engage the volunteer workforce.
1.2 Governance and Societal Responsibilities: How do you govern your organization and
fulfill your societal responsibilities? (50 pts.)
a. Organizational Governance
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• Accountability for senior leaders’ actions
• Accountability for strategic plans
• Fiscal accountability
• Transparency in operations
• Selection of governance board members and disclosure policies for them, as appropriate
• Independence and effectiveness of internal and external audits
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• Protection of stakeholder and stockholder interests, as appropriate
• Succession planning for senior leaders
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(2) Performance Evaluation How do you evaluate the performance of your senior leaders and your
governance board? How do you use performance evaluations in determining executive compensation? How
do your senior leaders and governance board use these performance evaluations to advance their development and improve both their own effectiveness as leaders and that of your board and leadership system, as
appropriate?
b. Legal and Ethical Behavior
(1) Legal, Regulatory, and Accreditation Compliance How do you address and anticipate legal, regulatory, and
community concerns with your health care services and operations? How do you
• address any adverse societal impacts of your health care services and operations;
• anticipate public concerns with your future health care services and operations; and
• prepare for these impacts and concerns proactively, including through conservation of natural resources and
effective supply-chain management processes, as appropriate?
What are your key compliance processes, measures, and goals for meeting and surpassing regulatory, legal, and
accreditation requirements, as appropriate? What are your key processes, measures, and goals for addressing
risks associated with your health care services and operations?
(Continued on the next page)
8
2017–2018 Health Care Criteria for Performance Excellence
PROC ESS
(1) Governance System How does your organization ensure responsible governance? How does your
governance system review and achieve the following?
(2) Ethical Behavior How do you promote and ensure ethical behavior in all interactions? What are your
key processes and measures or indicators for enabling and monitoring ethical behavior in your governance
structure; throughout your organization; and in interactions with your workforce, patients, other c
ustomers,
partners, suppliers, and other stakeholders? How do you monitor and respond to breaches of ethical
behavior?
c. Societal Responsibilities
(1) Societal Well-Being How do you consider societal well-being and benefit as part of your strategy and daily
operations? How do you contribute to the well-being of your environmental, social, and economic systems?
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(2) Community Support How do you actively support and strengthen your key communities? What are your key
communities? How do you identify them and determine areas for organizational involvement, including areas that
leverage your core competencies? How do your senior leaders, in concert with your workforce, contribute to
improving these communities and building community health?
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Terms in small caps are defined in the Glossary of Key Terms (pages 47–54).
Notes
responses to them, survey results showing workforce
perceptions of organizational ethics, ethics hotline use, and
results of ethics reviews and audits. Measures or indicators
of ethical behavior might also include evidence that policies,
workforce training, and monitoring systems are in place for
conflicts of interest; protection and use of sensitive data,
information, and knowledge generated through synthesizing
and correlating these data; and proper use of funds.
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1.2. Societal responsibilities in areas critical to your ongoing
marketplace success should also be addressed in Strategy
Development (item 2.1) and Operations (category 6). Key
results should be reported as Leadership and Governance
Results (item 7.4).
1.2. The health and safety of your workforce are not
addressed in this item; you should address these workforce
factors in items 5.1 and 6.2, respectively.
1.2c. Areas of societal contributions might include your
efforts to improve the environment (e.g., collaboration to
conserve the environment or natural resources); strengthen
local community services, education, health, and emergency
preparedness; and improve the practices of trade, business,
or professional associations.
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1.2a(1). The governance board’s review of organizational
performance and progress, if appropriate, is addressed
in 4.1(b).
1.2a(1). Transparency in the operations of your governance
system should include your internal controls on governance
processes.
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1.2a(1). In protecting stakeholder interests, the governance
system should consider and sanction appropriate levels of
risk for the organization, recognizing the need to accept risk
as part of running a successful organization.
1.2a(2). The evaluation of leaders’ performance might be
supported by peer reviews, formal performance management reviews, reviews by external advisory boards, and formal or informal feedback from and surveys of the workforce
and other stakeholders.
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1.2b(2). Measures or indicators of ethical behavior might
include the percentage of independent board members,
instances of ethical conduct or compliance breaches and
1
Leadership
1.2c(2). Actions to build community health are populationbased services that support the general health of the
communities in which you operate. Such services will likely
draw on your core competencies and might include the
identification of community health needs, health education
programs, immunization programs, health screenings, wellness and prevention programs, indigent care, and programs
to eliminate health disparities. You should report the results
of these services in item 7.4.
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
9
2 Strategy (85 pts.)
The Strategy category asks how your organization develops strategic objectives and action plans, implements them,
changes them if circumstances require, and measures progress.
2.1 Strategy Development: How do you develop your strategy? (45 pts.)
a. Strategy Development Process
• organizational agility, including operational flexibility?
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• transformational change and prioritization of change initiatives; and
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(2) Innovation How does your strategy development process stimulate and incorporate innovation? How
do you identify strategic opportunities? How do you decide which strategic opportunities are intelligent
risks to pursue? What are your key strategic opportunities?
(3) Strategy Considerations How do you collect and analyze relevant data and develop information for your
strategic planning process? In this collection and analysis, how do you include these key elements of risk?
• Your strategic challenges and strategic advantages
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• Potential changes in your regulatory and external business environment
• Potential blind spots in your strategic planning process and information
• Your ability to execute the strategic plan
b. Strategic Objectives
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(4) Work Systems and Core Competencies How do you decide which key processes will be accomplished by
your workforce and which by external suppliers and partners? How do those decisions consider your core
competencies and the core competencies of potential suppliers and partners? What are your key work systems? How do you make work system decisions that facilitate the accomplishment of your strategic objectives?
How do you determine what future organizational core competencies and work systems you will need?
(1) Key Strategic Objectives What are your organization’s key strategic objectives and timetable for achieving them? What are your most important goals for these strategic objectives? What key changes, if any, are
planned in your health care services, customers and markets, suppliers and partners, and operations?
(2) Strategic Objective Considerations How do your strategic objectives achieve appropriate balance among
varying and potentially competing organizational needs? How do your strategic objectives
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• address your strategic challenges and leverage your core competencies, strategic advantages, and
strategic opportunities;
• balance short- and longer-term planning horizons; and
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• consider and balance the needs of all key stakeholders?
Terms in small caps are defined in the Glossary of Key Terms (pages 47–54).
Notes
2.1. This item deals with your overall organizational
strategy, which might include changes in health care service
offerings and processes for patient and other customer
engagement. However, you should describe the service
design and patient and other customer engagement strategies, respectively, in items 6.1 and 3.2, as appropriate.
might use various types of forecasts, projections, options,
scenarios, knowledge (see 4.2b for relevant organizational
knowledge), analyses, or other approaches to envisioning
the future in order to make decisions and allocate resources.
Strategy development might involve key suppliers, partners,
patients, and other customers.
2.1. Strategy development refers to your organization’s
approach to preparing for the future. In developing your
strategy, you should consider your level of acceptable enterprise risk. To make decisions and allocate resources, you
2.1. The term “strategy” should be interpreted broadly.
Strategy might be built around or lead to any or all of the
following: new health care services; redefinition of key
patient and other customer groups or market segments;
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2017–2018 Health Care Criteria for Performance Excellence
P R O C ESS
(1) Strategic Planning Process How do you conduct your strategic planning? What are the key process steps?
Who are the key participants? What are your short- and longer-term planning horizons? How are they addressed
in the planning process? How does your strategic planning process address the potential need for
2.1a(3). Your strategic planning should address your ability
to mobilize the necessary resources and knowledge to
execute the strategic plan. It should also address your ability
to execute contingency plans or, if circumstances require,
a shift in strategy and rapid execution of new or changed
strategic plans.
2.1a(4). Work systems refer to how your organization’s
work is accomplished, consisting of the internal work
processes and external resources you need to develop and
produce health care services, deliver them to your patients
and other customers, and succeed in your marketplace.
Decisions about work systems are strategic. These decisions
involve protecting intellectual property, capitalizing on core
competencies, and mitigating risk. Decisions about your
work systems affect organizational design and structure,
size, locations, financial viability, and ongoing success. In a
generic view of an organization, for example, the organization might define three work systems: one that addresses
the clinical delivery of health care services, one that engages
patients and other customers, and one that comprises
systems that support service delivery and patient and other
customer engagement.
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2.1a(2). Strategic opportunities are prospects for new or
changed services, processes, business models (including
strategic alliances), or markets. They arise from outside-thebox thinking, brainstorming, capitalizing on serendipity,
research and innovation processes, nonlinear extrapolation
of current conditions, and other approaches to imagining a
different future. The generation of ideas that lead to strategic
opportunities benefits from an environment that encourages nondirected, free thought. Choosing which strategic
opportunities to pursue involves considering relative risk,
financial and otherwise, and then making intelligent choices
(“intelligent risks”).
2.1a(3). Blind spots arise from incorrect, incomplete, obsolete, or biased assumptions or conclusions that cause gaps,
vulnerabilities, risks, or weaknesses in your understanding
of the competitive and collaborative environment and
strategic challenges your organization faces. Blind spots may
arise from new or replacement offerings or business models
coming from inside or outside your industry.
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2.1a(1). Organizational agility refers to the capacity for
rapid change in strategy. Operational flexibility refers to the
ability to adjust your operations as opportunities or needs
arise, including as a result of strategic changes.
2.1a(3). Your decisions about addressing strategic challenges, changes in your regulatory and external business
environment, blind spots in your strategic planning, and
gaps in your ability to execute the strategic plan may give
rise to organizational risk. Analysis of these factors is the
basis for managing strategic risk in your organization.
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differentiation of your brand; new core competencies; entry
into retail or telemedicine; new partnerships, alliances, or
acquisitions to improve access, grow revenue, or reduce
costs; and new staff or volunteer relationships. Strategy
might be directed toward becoming a high-reliability
organization, a preferred provider, a center for clinical and
service excellence, a research leader, a low-cost provider, a
market innovator, a provider of a high-end or customized
service, an integrated service provider, or an employer of
choice. It might also be directed toward meeting a community or public health care need.
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2.1a(3). Data and information may come from a variety of
internal and external sources and in a variety of forms. Data
are available in increasingly greater volumes and at greater
speeds. The ability to capitalize on data and information,
including large datasets (“big data”), is based on the ability
to analyze the data, draw conclusions, and pursue actions,
including intelligent risks.
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2.1a(3). Data and information might relate to patient,
other customer, and market requirements, expectations,
and opportunities; your culture, policies, and procedures to
ensure patient safety and avoid medical errors; your policies
and procedures for access to and equity of care; your core
competencies; the competitive and collaborative environment and your performance now and in the future relative
to competitors and comparable organizations; technological
and other key innovations or changes that might affect
your services and the way you operate, as well as the rate of
innovation; workforce and other resource needs; your ability
to capitalize on diversity; opportunities to redirect resources
to higher-priority health care services or areas; financial,
societal, ethical, regulatory, technological, security and
cybersecurity, and other potential risks and opportunities;
your ability to prevent and respond to emergencies, including natural or other disasters; changes in the local, national,
or global economy; requirements for and strengths and
weaknesses of your partners and supply chain; changes in
your parent organization; and other factors unique to your
organization.
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Strategy
2.1b(1). Strategic objectives might address access and
locations; rapid response; customization; co-location with
major partners; workforce capability and capacity; specific
joint ventures; rapid or market-changing innovation;
societal responsibility actions or leadership; social media
and web-based management of relationships with suppliers,
providers, patients, and other customers; implementation of
electronic health records and electronic care processes (e.g.,
order entry and e-prescribing); and enhancements in health
care service quality. Responses should focus on your specific
challenges, advantages, and opportunities—those most
important to your ongoing success and to strengthening
your overall performance.
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
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2.2 Strategy Implementation: How do you implement your strategy? (40 pts.)
a. Action Plan Development and Deployment
(2) Action Plan Implementation How do you deploy your action plans? How do you deploy your action
plans to your workforce and to key suppliers, partners, and collaborators, as appropriate, to ensure that
you achieve your key strategic objectives? How do you ensure that you can sustain the key outcomes of your
action plans?
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(3) Resource Allocation How do you ensure that financial and other resources are available to support the
achievement of your action plans while you meet current obligations? How do you allocate these resources to
support the plans? How do you manage the risks associated with the plans to ensure your financial viability?
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(4) Workforce Plans What are your key workforce plans to support your short- and longer-term strategic
objectives and action plans? How do the plans address potential impacts on your workforce members and
any potential changes in workforce capability and capacity needs?
(5) Performance Measures What key performance measures or indicators do you use to track the achievement and effectiveness of your action plans? How does your overall action plan measurement system
reinforce organizational alignment?
b. Action Plan Modification
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(6) Performance Projections For these key performance measures or indicators, what are your performance projections for your short- and longer-term planning horizons? What is your projected performance
on these action plan measures or indicators compared with your projections of the performance of your
competitors or organizations offering similar health care services and with key benchmarks, as appropriate? If
there are gaps in performance against your competitors or comparable organizations, how do you address them
in your action plans?
How do you establish and implement modified action plans if circumstances require a shift in plans and rapid
execution of new plans?
Notes
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Terms in small caps are defined in the Glossary of Key Terms (pages 47–54).
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2.2. The development and deployment of your strategy and
action plans are closely linked to other Health Care Criteria
items. The following are examples of key linkages:
• Item 1.1: how your senior leaders set and communicate organizational direction
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• Category 3: how you gather patient, other customer,
and market knowledge as input to your strategy and
action plans and to use in deploying action plans
• Category 4: how you measure and analyze data and
manage knowledge to support key information needs,
support strategy development, provide an effective
basis for performance measurements, and track progress on achieving strategic objectives and action plans
• Category 5: how you meet workforce capability and
capacity needs, determine needs and design your
workforce development and learning system, and
implement workforce-related changes resulting from
action plans
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• Category 6: how you address changes to your work
processes resulting from action plans
• Item 7.1: specific accomplishments relative to your
organizational strategy and action plans
2.2a(2). Action plan implementation and deployment
may require modifications in organizational structures and
operating modes. The success of action plans benefits from
visible short-term wins as well as long-term actions.
2.2a(6). Measures and indicators of projected performance
might consider new ventures; organizational acquisitions or
mergers; new value creation; market entry and shifts; new
legislative mandates, legal requirements, industry standards,
or accreditation standards; and significant anticipated
innovations in health care services and technology.
2.2b. Organizational agility requires the ability to adapt to
changing circumstances, both internal and external.
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
2017–2018 Health Care Criteria for Performance Excellence
PR O C ESS
(1) Action Plans What are your key short- and longer-term action plans? What is their relationship to your
strategic objectives? How do you develop your action plans?
3 Customers (85 pts.)
The Customers category asks how your organization engages its patients and other customers for long-term marketplace
success, including how your organization listens to the voice of the customer, serves and exceeds patients’ and other
customers’ expectations, and builds relationships with patients and other customers.
3.1 Voice of the Customer: How do you obtain information
from your patients and other customers? (40 pts.)
a. Listening to Patients and Other Customers
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P R O C ESS
(1) Current Patients and Other Customers How do you listen to, interact with, and observe patients and
other customers to obtain actionable information? How do your listening methods vary for different patient
groups, other customer groups, or market segments? How do you use social media and web-based technologies
to listen to patients and other customers, as appropriate? How do your listening methods vary across the stages
of patients’ and other customers’ relationships with you? How do you seek immediate and actionable feedback
from patients and other customers on the quality of health care services, patient and other customer support, and transactions?
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(2) Potential Patients and Other Customers How do you listen to potential patients and other customers
to obtain actionable information? How do you listen to former, potential, and competitors’ patients and other
customers to obtain actionable information on your health care services, patient and other customer support,
and transactions, as appropriate?
b. Determination of Patient and Other Customer Satisfaction and Engagement
(1) Satisfaction, Dissatisfaction, and Engagement How do you determine patient and other customer satisfaction, dissatisfaction, and engagement? How do your determination methods differ among your patient and
other customer groups and market segments, as appropriate? How do your measurements capture actionable
information to use in exceeding your patients’ and other customers’ expectations and securing your patients’ and
other customers’ engagement for the long term?
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(2) Satisfaction Relative to Competitors How do you obtain information on your patients’ and other
customers’ satisfaction with your organization relative to other organizations? How do you obtain information on your patients’ and other customers’ satisfaction
• relative to their satisfaction with your competitors; and
• relative to the satisfaction of patients and other customers of other organizations that provide similar health
care services or to health care industry benchmarks, as appropriate?
Notes
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Terms in small caps are defined in the Glossary of Key Terms (pages 47–54).
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3.1. The voice of the customer refers to your process for
capturing patient- and other customer-related information.
Voice-of-the-customer processes are intended to be proactive and continuously innovative to capture patients’ and
other customers’ stated, unstated, and anticipated requirements, expectations, and desires. The goal is customer
engagement. In listening to the voice of the customer,
you might gather and integrate various types of patient
and other customer data, such as survey data, focus group
findings, social media data and commentary, marketing
information, and complaint data that affect patients’ and
other customers’ purchasing and engagement decisions.
3.1a(1). Social media and web-based technologies are a
growing mode of gaining insight into how patients and
other customers perceive all aspects of your involvement
with them. Listening through social media may include
3
Customers
monitoring comments on social media outlets you moderate
and on those you do not control.
3.1a(1). Your listening methods should include all stages
of your involvement with patients and other customers.
These stages might include relationship building, the active
relationship, and a follow-up strategy, as appropriate.
3.1b. You might use any or all of the following to determine
patient and other customer satisfaction and dissatisfaction:
surveys, including third-party surveys or surveys endorsed
or required by payors, such as the Consumer Assessment
of Healthcare Providers and Systems (CAHPS); formal
and informal feedback; health care service utilization data;
complaints; win/loss analysis; patient and other customer
referral rates; and transaction completion rates. You might
gather information on the web, through personal contact
or a third party, or by mail. Determining patient and other
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customer dissatisfaction should be seen as more than
reviewing low satisfaction scores. Dissatisfaction should
be independently determined to identify root causes and
enable a systematic remedy to avoid future dissatisfaction.
3.1b(2). Dimensions of patient satisfaction might include,
for example, satisfaction with provider interactions,
long-term health outcomes, ancillary services, quality of
care, cost, and ease of access. Information you obtain on
relative patient and other customer satisfaction may include
comparisons with competitors, comparisons with other
organizations that deliver similar health care services in
your market or a noncompetitive market, or comparisons
obtained through health care industry or other organizations. Information obtained on relative satisfaction may also
include information on why patients and other customers
choose your competitors over you.
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
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3.2 Customer Engagement: How do you engage patients and other customers
by serving their needs and building relationships? (45 pts.)
How do you determine health care service offerings? How do you
• determine patient, other customer, and market needs and requirements for health care service offerings;
• identify and adapt service offerings to meet the requirements and exceed the expectations of your patient and
other customer groups and market segments; and
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• identify and adapt service offerings to enter new markets, to attract new patients and other customers, and to
create opportunities to expand relationships with current patients and other customers, as appropriate?
(2) Patient and Other Customer Support How do you enable patients and other customers to seek information and support? How do you enable them to obtain health care services from you? What are your key means
of patient and other customer support, including your key communication mechanisms? How do they vary for
different patient and other customer groups or market segments? How do you
• determine your patients’ and other customers’ key support requirements, and
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• deploy these requirements to all people and processes involved in patient and other customer support?
(3) Patient and Other Customer Segmentation
groups and market segments? How do you
How do you determine your patient and other customer
• use information on patients, other customers, markets, and health care service offerings to identify current
and anticipate future patient and other customer groups and market segments;
• consider competitors’ patients and other customers, as well as other potential patients, customers, and
markets in this segmentation; and
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• determine which patient and other customer groups and market segments to emphasize and pursue for business growth?
b. Patient and Other Customer Relationships
(1) Relationship Management How do you build and manage relationships with patients and other customers?
How do you market, build, and manage relationships with patients and other customers to
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• acquire patients and other customers and build market share;
• manage and enhance your brand image;
• retain patients and other customers, meet their requirements, and exceed their expectations in each stage of
their relationship with you; and
• increase their engagement with you?
How do you leverage social media to manage and enhance your brand, and to enhance patient and other
ustomer engagement and relationships, as appropriate?
c
(2) Complaint Management How do you manage patient and other customer complaints? How do you resolve
complaints promptly and effectively? How does your management of those complaints enable you to recover
your patients’ and other customers’ confidence, enhance their satisfaction and engagement, and avoid similar
complaints in the future?
Terms in small caps are defined in the Glossary of Key Terms (pages 47–54).
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2017–2018 Health Care Criteria for Performance Excellence
P RO C ESS
(1) Service Offerings
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a. Service Offerings and Patient and Other Customer Support
Notes
3.2a(2). The goal of patient and other customer support
is to make your organization easy to obtain health care
services from and responsive to your patients’ and other
customers’ expectations.
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3.2b. Building relationships with patients and other customers might include developing partnerships or alliances with
them.
3.2b(1). Brand management is generally associated with
marketing to improve the perceived value of your health
care services or brand. Successful brand management builds
loyalty and positive associations on the part of patients and
other customers, and it protects your brand and intellectual
property.
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
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3.2a(1). Health care service offerings are the services that
you offer in the marketplace. In identifying health care
service offerings, you should consider all the important
characteristics of services that patients and other customers
receive in each stage of their relationship with you. The
focus should be on features that affect patients’ and other
customers’ preference for and loyalty to you and your
brand—for example, features that affect their view of clinical
and service quality and that differentiate your offerings from
those of competing or other organizations. Those features
might include extended hours, family support services, ease
of access to and use of your services, timeliness, cost, and
assistance with billing/paperwork processes and transportation. Key service features might also take into account
how transactions occur and factors such as the privacy and
security of patient and other customer data. Your results
on performance relative to key service features should
be reported in item 7.1, and those for patients’ and other
customers’ perceptions and actions (outcomes) should be
reported in item 7.2.
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3.2. Customer engagement refers to your patients’ and
other customers’ investment in or commitment to your
brand and health care service offerings. Characteristics of
engaged patients and other customers include retention,
brand loyalty, willingness to make an effort to obtain—and
to continue to obtain—health care services from you, and
willingness to actively advocate for and recommend your
brand and health care service offerings.
3
Customers
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4 Measurement, Analysis, and Knowledge Management (90 pts.)
The Measurement, Analysis, and Knowledge Management category asks how your organization selects, gathers, analyzes,
manages, and improves its data, information, and knowledge assets; how it uses review findings to improve its performance; and how it learns.
4.1 Measurement, Analysis, and Improvement of Organizational Performance:
How do you measure, analyze, and then improve organizational performance? (45 pts.)
a. Performance Measurement
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• select, collect, align, and integrate data and information to use in tracking daily operations and overall organizational performance; and
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• track progress on achieving strategic objectives and action plans?
What are your key organizational performance measures, including key short- and longer-term financial
easures? How frequently do you track these measures?
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(2) Comparative Data
making?
How do you select comparative data and information to support fact-based decision
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(3) Patient and Other Customer Data How do you select voice-of-the-customer and market data and information? How do you select voice-of-the-customer and market data and information (including aggregated data
on complaints and, as appropriate, data and information from social media) to build a more patient-focused culture
and to support fact-based decision making?
(4) Measurement Agility How do you ensure that your performance measurement system can respond to rapid
or unexpected organizational or external changes?
b. Performance Analysis and Review
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How do you review your organization’s performance and capabilities? How do you use your key organizational
performance measures, as well as comparative and customer data, in these reviews? What analyses do you
perform to support these reviews and ensure that conclusions are valid? How do your organization and its senior
leaders use these reviews to
• assess organizational success, competitive performance, financial health, and progress on achieving your
strategic objectives and action plans; and
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• respond rapidly to changing organizational needs and challenges in your operating environment, including any
need for transformational change in organizational structure and work systems?
How does your governance board review the organization’s performance and its progress on strategic objectives
and action plans, if appropriate?
c. Performance Improvement
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(1) Future Performance How do you project your organization’s future performance? How do you use findings
from performance reviews (addressed in 4.1b) and key comparative and competitive data in your projections?
How do you reconcile any differences between these projections and those developed for your key action plans
(addressed in 2.2a[6])?
(2) Continuous Improvement and Innovation How do you use findings from performance reviews (addressed
in 4.1b) to develop priorities for continuous improvement and opportunities for innovation? How do you
deploy these priorities and opportunities
• to work group and functional-level operations; and
• when appropriate, to your suppliers, partners, and collaborators to ensure organizational alignment?
Terms in small caps are defined in the Glossary of Key Terms (pages 47–54).
16
2017–2018 Health Care Criteria for Performance Excellence
P R O C ESS
(1) Performance Measures How do you track data and information on daily operations and overall organizational performance? How do you
Notes
4.1a. Data and information from performance measurement
should be used to support fact-based decisions that set and
align organizational directions and resource use at the work
unit, key process, department, and organization levels.
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
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4.1a(2), 4.1a(3). The comparative and customer data and
information you select should be used to support operational decision making and the overall performance reviews
addressed in 4.1b. Comparative data and information are
obtained by benchmarking and by seeking competitive
comparisons. Benchmarking is identifying processes and
results that represent best practices and performance for
similar activities, inside or outside the health care industry.
Competitive comparisons relate your performance to that
of competitors and other organizations providing similar
health care services. One source of this information might
be social media or the web.
4.1b. Performance analysis includes examining performance
trends; organizational, health care industry, and technology
projections; and comparisons, cause-effect relationships, and
correlations. This analysis should support your performance
reviews, help determine root causes, and help set priorities
for resource use. Accordingly, such analysis draws on all
types of data: health care outcome, patient- and other
customer-related, financial and market, operational, and
competitive/comparative. The analysis should also draw on
publicly mandated measures, when appropriate.
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4.1. Your organizational performance results should be
reported in items 7.1–7.5.
4.1b. Organizational performance reviews should be
informed by organizational performance measurement
(4.1a) and by performance measures reported throughout
your Health Care Criteria item responses, and they should
be guided by the strategic objectives and action plans you
identify in category 2. The reviews might also be informed
by internal or external Baldrige assessments.
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4.1. The results of organizational performance analysis
and review should inform the strategy development and
implementation you describe in category 2.
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Measurement, Analysis, and Knowledge Management
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4.2 Information and Knowledge Management: How do you manage your
information and your organizational knowledge assets? (45 pts.)
a. Data and Information
(2) Availability How do you ensure the availability of organizational data and information? How do you make
needed data and information available in a user-friendly format and timely manner to your workforce, suppliers,
partners, collaborators, patients, and other customers, as appropriate? How do you ensure that your information technology systems are user-friendly?
(1) Knowledge Management
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b. Organizational Knowledge
How do you build and manage organizational knowledge? How do you
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• collect and transfer workforce knowledge;
• blend and correlate data from different sources to build new knowledge;
• transfer relevant knowledge from and to patients, other customers, suppliers, partners, and
collaborators; and
• assemble and transfer relevant knowledge for use in your innovation and strategic planning processes?
(3) Organizational Learning
organization operates?
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(2) Best Practices How do you share best practices in your organization? How do you identify organizational units
or operations that are high performing? How do you identify their best practices for sharing and implement them
across the organization, as appropriate?
How do you use your knowledge and resources to embed learning in the way your
Notes
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Terms in small caps are defined in the Glossary of Key Terms (pages 47–54).
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4.2a(2). Information technology systems include, for
example, physical devices and systems (hardware); software
platforms and applications; externally based information
systems, such as those stored in the cloud or outside your
organization’s control; and the data and information stored
within them. Your response might include information
related to electronic health records within your organization.
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
Ex
4.2b(1). Blending and correlating data from different
sources may involve handling big data sets and disparate
types of data and information, such as data tables, video,
and text. Furthermore, organizational knowledge constructed from these data may be speculative and may reveal
sensitive information about organizations or individuals that
must be protected from use for any other purposes.
4.2b(3). Embedding learning in the way your organization
operates means that learning (1) is a part of everyday work;
(2) results in solving problems at their source; (3) is focused
on building and sharing knowledge throughout your organization; and (4) is driven by opportunities to bring about
significant, meaningful change and to innovate.
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2017–2018 Health Care Criteria for Performance Excellence
PR O C ESS
(1) Quality How do you verify and ensure the quality of organizational data and information? How do you
manage electronic and other data and information to ensure their accuracy and validity, integrity and reliability,
and currency?
5 Workforce (85 pts.)
The Workforce category asks how your organization assesses workforce capability and capacity needs and builds a
workforce environment conducive to high performance. The category also asks how your organization engages, manages,
and develops your workforce to utilize its full potential in alignment with your organization’s overall needs.
5.1 Workforce Environment: How do you build an effective and supportive
workforce environment? (40 pts.)
a. Workforce Capability and Capacity
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(3) Workforce Change Management
capacity needs? How do you
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(2) New Workforce Members How do you recruit, hire, place, and retain new workforce members? How
do you ensure that your workforce represents the diverse ideas, cultures, and thinking of your hiring and patient
community? How do you ensure the fit of new workforce members with your organizational culture?
How do you prepare your workforce for changing capability and
• manage your workforce, its needs, and your organization’s needs to ensure continuity, prevent workforce
reductions, and minimize the impact of such reductions, if they become necessary;
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• prepare for and manage any periods of workforce growth; and
• prepare your workforce for changes in organizational structure and work systems, when needed?
(4) Work Accomplishment How do you organize and manage your workforce? How do you organize and
manage your workforce to
• accomplish your organization’s work;
• capitalize on your organization’s core competencies;
• reinforce a focus on patients, other customers, and health care; and
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• exceed performance expectations?
b. Workforce Climate
(1) Workplace Environment How do you ensure workplace health, security, and accessibility for the
workforce? What are your performance measures and improvement goals for your workplace environmental
factors? For your different workplace environments, what significant differences are there in these factors and their
performance measures or targets?
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(2) Workforce Benefits and Policies How do you support your workforce via services, benefits, and policies?
How do you tailor these to the needs of a diverse workforce and different workforce groups and segments?
What key benefits do you offer your workforce?
Terms in small caps are defined in the Glossary of Key Terms (pages 47–54).
Notes
5.1. Workforce refers to the people actively involved in
accomplishing your organization’s work. It includes permanent, temporary, and part-time personnel, as well as any
contract staff you supervise, independent practitioners (e.g.,
physicians, physician assistants, nurse practitioners, acupuncturists, and nutritionists not paid by your organization),
and health profession students (e.g., medical, nursing, and
ancillary). It includes team leaders, supervisors, and managers at all levels. People supervised by a contractor should
be addressed in categories 2 and 6 as part of your larger
work system strategy and your internal work processes.
For organizations that also rely on volunteers, workforce
includes these volunteers.
5 Workforce
5.1a. Workforce capability refers to your organization’s
ability to carry out its work processes through its people’s
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