The Baldrige Award: One
Hospital’s Journey
2013 Governor’s Award
(Platinum Level) Recipient
PRESENTED BY JEANETTE SPRADLIN,
VICE PRESIDENT, QUALITY
UNION HOSPITAL, INC.
CONFLICT OF INTEREST DISCLOSURE
 NONE
OBJECTIVES:
 Clarify the link between The Partnership
for Excellence and the Malcom Baldrige
National Quality Award
 Link the components of the Baldrige
criteria to Union Inc.’s Journey to
Excellence
 Define leadership’s role in the Baldrige
journey
 Describe Union’s journey and how it
matures an organization
WHO WE ARE
UNION HOSPITAL, INC.
TERRE HAUTE, IN
UNION HOSPITAL, INC.
 Not-for-profit 350 bed




Acute Care Hospital in
Terre Haute, IN and a 25
bed Critical Access
Hospital in Clinton, IN
2400 Employees
345 Affiliated Physicians
Multiple outpatient sites/
physician offices including
Cancer Center and
Ambulatory Surgery Center
Teaching hospital with F.P.
Residency program
MALCOLM BALDRIGE
CRITERIA
ESTABLISHED BY CONGRESS IN 1987, THE
BALDRIGE PROGRAM IS MANAGED BY THE
NATIONAL INSTITUTE OF STANDARDS AND
TECHNOLOGY, AN AGENCY OF THE UNITED STATE
DEPARTMENT OF COMMERCE.
THE PROGRAM HELPS ORGANIZATIONS IMPROVE
THEIR PERFORMANCE AND SUCCEED IN THE
COMPETITIVE GLOBAL MARKETPLACE.
IT IS THE ONLY PUBLIC-PRIVATE PARTNERSHIP
AND PRESIDENTIAL AWARD PROGRAM DEDICATED
TO IMPROVING U.S. ORGANIZATIONS.
Performance
Excellence
Framework
Organizational Profile
2
1
Strategic
Planning
5
Workforce
Focus
3
Customer
Focus
6
Operations
Focus
Leadership
7
Results
4
Measurement, Analysis, and Knowledge Management
Performance
Excellence
Framework
Organizational Profile
2
1
Strategic
Planning
5
Workforce
Focus
3
Customer
Focus
6
Operations
Focus
Leadership
7
Results
4
Measurement, Analysis, and Knowledge Management
Performance
Excellence
Framework
Organizational Profile
2
1
Strategic
Planning
5
Workforce
Focus
3
Customer
Focus
6
Operations
Focus
Leadership
7
Results
4
Measurement, Analysis, and Knowledge Management
Performance
Excellence
Framework
Organizational Profile
2
1
Strategic
Planning
5
Workforce
Focus
3
Customer
Focus
6
Operations
Focus
Leadership
7
Results
4
Measurement, Analysis, and Knowledge Management
Performance
Excellence
Framework
Organizational Profile
2
1
Strategic
Planning
5
Workforce
Focus
3
Customer
Focus
6
Operations
Focus
Leadership
7
Results
4
Measurement, Analysis, and Knowledge Management
PROCESS
CATEGORIES
LOOKING FOR ADLI
APPROACH
DEPLOYMENT
LEARNING
INTEGRATION
RESULTS CATEGORY
LOOKING FOR L E TCI
LEVELS
TRENDS
COMPARISONS
INTEGRATION
BALDRIGE SECTORS
MANUFACTURING
SERVICE
SMALL BUSINESS ( < 5 0 0 E M P L O Y E E S )
EDUCATION
HEALTHCARE ( C R E A T E D I N 1 9 9 9 )
NONPROFIT/GOVERNMENT
ELIGIBILITY
REQUIREMENTS AT THE
NATIONAL LEVEL
1.
5.
ORGANIZATION A DISTINCT ORGANIZATION
OR BUSINESS UNIT HEADQUARTERED IN THE
U.S.
2. EXISTED FOR AT LEAST A YEAR
3. RESPOND TO ALL 7 CATEGORIES
4. IF ACTIVITIES OUTSIDE OF U.S. HAVE
SUFFICIENCIES FOR A FULL SITE VISIT
IF A RECIPIENT SHARE PRACTICES AT QUEST
FOR EXCELLENCE CONFERENCE
6. BEEN A BALDRIGE RECIPIENT
ELIGIBILITY
REQUIREMENTS AT THE
NATIONAL LEVEL
7. BEEN A TOP AWARD RECIPIENT FROM STATE
ORGANIZATION THAT IS A MEMBER OF THE
ALLIANCE FOR PERFORMANCE EXCELLENCE
8. PRIOR NATIONAL APPLICATION WITH A BAND
SCORE OF 8 OR HIGHER
9. RECEIVED A NATIONAL SITE VISIT
10. GREATER THAN 25% OF ORGANIZATION’S
WORKFORCE IS OUTSIDE OF THE
ORGANIZATION’S HOME STATE
11. THERE IS NO ALLIANCE FOR PERFORMANCE
EXCELLENCE AWARD PROGRAM AVAILABLE
Resources / Questions / Discussion
Al Faber, President/CEO
al.faber@partnershipohio.org
(614) 425-7157
Baldrige Performance Excellence Program:
www.quality.nist.gov
The Alliance for Performance Excellence:
www.baldrigepe.org
The American Society for Quality:
http://asq.org/
15th Annual Quest for Success Conference
Celebrating 15 Years of Performance Excellence!
September 15-16, 2014
Polaris Hilton, Columbus, Ohio
www.thepartnershipforexcellence.org
Our Journey
To Excellence
MILESTONE
• Aware of the
Healthcare
Criteria
• Started
learning
more about
the criteria
• Started attending
Days of Sharing at
healthcare
organizations that
were national
award recipients
• Started attending
Quest; became
examiners
• Attend VHA
offerings re.
Baldrige criteria
2006 - 2012
• Asked VHA to put
together offerings
regarding the
healthcare criteria
and “how to get
started:”
• Hired Baldrige
coaches
• Submitted national
applications from
2008 – 2012
World-class
Performance
• WORLDCLASS
HEALTHCARE OUTCOMES
• OUTSTANDING
Submit a national
PATIENT/FAMILY
application
SATISFACTION &
ENGAGEMENT
• Submitted first
TPE application
•
• Received
Platinum Award
• We continue to
prioritize our OFIs
in our feedback
reports.
• Continuing our
efforts
• We continue to
make our
approaches
systematic with
full deployment
• OUTSTANDING
WORKFORCE
OUTCOMES
• EFFICIENT AND
EFFECTIVE
PROCESSES
• OUTSTANDING
FINANCIAL
PERFORMANCE
Why Baldrige?
Impacts the entire organization;
provides integration with a
systematic approach across the
organization to reach goals to
accomplish mission/vision.
At UHI –
ANOTHER NAME FOR BALDRIGE
As we travel on our Baldrige
journey, it is known to staff as
our work to become First, Best … Always.
FIRST STEP
CREATING THE
ORGANIZATIONAL
PROFILE
PROFILE SETS THE STAGE
HELPS WITH SELF EVAL.
IDENTIFIES GAPS
 Includes:
 Offerings
 MVV
 Workforce Profile
 Assets
 Regulatory Requirements
 Structure
 Patients, Customers,
Stakeholders
 Suppliers and Partners
THE APPLICATION
FLOWS FROM THE
PROFILE
 Competitive Position
 Competitiveness Changes
 Comparative Data
 Strategic Challenges and
Advantages
 Performance Improvement
System
 Core Competencies
 All in 5 pages
Category 1
LEADERSHIP
120 POINTS
Vision
To be exceptional - as your trust ed
partner and best choice for health care
Strong Financial
Position
Strategic Collaberation/
Integration
Best Workplace
Best Health System
Critical Success Factors
Core Competency: Community Integration
Mission: We exist to serve our patients with
compassionate health care of the highest quality
BEST CHOICE Values
Key Stakeholders: Patients, Patient’s Family, Community
LEADERSHIP MODEL
j
Set and
Communicate
Direction
n Reward
and
Recognize
Mission
Vision
Th
e
k
Align
People
and
Processes
t
en
Pas
sio
n/
Co
m
Cre
ate
nm
ro
vi
En
nt
e
tm
i
m
l Execute
n
sfo
ed
nt
Values
to Achieve
Exceptional
Outcomes
O
Tra
Review,
Analyze and
Adjust
rie
m
rm
a t io
nal
Lead
er
pl
i
c
s
i
D
/
d
e
in
R
lt
u
s
e
s
LEADERSHIP
1.1 – Senior Leaders
 Organizational Rhythm
 Performance
 Listening and Learning
 Rounding
 Engagement with




Stakeholders
Team Integration
Orientation
Legal and Ethical
Environment
Sustainability






Improvement
Align People and
Processes
Board Quality
Committee
Workforce Engagement
Robust Learning
Leadership Development
Innovation and
Intelligent Risk Taking
OPERATIONAL
RHYTHM
LEADERSHIP
Responsibility
1.2 – Governance & Societal
 Board Governance





Processes
How its members
represent the community
Self Assessments
Performance Eval. CEO
Charter, Bylaws and
Policies
Hold SLs responsible –
performance goals tied to
compensation
 Community Integration
 Compliance
 Address Public Concern
 Community Support
 Commitment to Ethical
Behavior
 Caring for the Indigent
 Environmental Stewards
Category 2
STRATEGIC
PLANNING
85 POINTS
3 YEAR
STRATEGIC PLANNING
j
Develop/Refine
Objectives and Goals
•Critical Success Factors
• Objectives and Goals
• All factors from APP plus
• Industry Assessment
• Community Needs
• Competitor Assessment
• Detailed Stakeholder
Analysis
l
•Mission/Vision/Values
•Critical Success Factors
•Advantages and Challenges
•Core Competencies
o
1 YEAR
ANNUAL PLANNING
k
Assess and Set
Strategic Direction
Align People and
Processes
•Work Systems
•EPM & Key Processes
•Action Plans
m
Allocate Resources
n
Evaluate &Improve
3-YR Financial Plan
Operational Rhythm
Assess and Set Annual Direction
• Economic Trends
• Political and Regulatory Issues
• Technology Assessment
• Competitor Review
• Organizational Capacity & Capability
• Workforce Satisfaction / Engagement
• Patient Satisfaction / Engagement
• Quality Assessment
•Mission/Vision/Values
•Refined Core Competencies
•Advantages/Challenges
p
Reaffirm /Revise Strategic Objectives
q
Align Processes/People,
r
Allocate Resources
Annual Budget
s
Evaluate & Improve
Operational Rhythm
•Refined CSFs
•Refined Objectives and Goals
• EPM and Key Processes
•Action Plans and goals
STRATEGIC PLANNING
Development
 Focus Groups:
 Employee
 Physicians
 Board Members
 Employers
 Vendors
 Patients/Patients’
Families
 Community
2.1 – Strategy
 SWOT Analysis
 Strategic Challenges and






Strategic Advantages
Develop Objectives,
Measures and Goals
Allocate Resources
Use of Innovation
Key Work Systems
Align People and
Processes
Core Competencies
STRATEGIC PLANNING
Implementation
 Action Plans
 Corporate,
Department,
Employee
Goals Cascade
 Benchmarks
 Projections
2.2 – Strategy
Category 3
CUSTOMER
FOCUS
85 POINTS
VOICE OF THE CUSTOMER
Capture Voice of
Patient / Stakeholders
(Figure 3.1-2)
Improve through
PDCA /
Six Sigma
Engage
Workforce to
Develop Action
Plans
Analyze VOC
Patients
and
Families
Prioritize
Oppurtunities for
Improvement
Category 4
MEASUREMENT,
ANALYSIS, AND
KNOWLEDGE
MANAGEMENT
90 POINTS
PERFORMANCE MEASUREMENT,
ANALYSIS AND REVIEW SYSTEM
Strategic Priorities,
Goals and
j
Measures
Aggregate n
and Review
Performance
BSC
Process
Measures
Flow down k
Strategic
Priorities
and Measures
Functional Measures
Department Measures
Individual Measures
Analyze m
and Take
Action
Execute l
and Measure
Performance
Proposed
Measure
Measurement Selection Process
Actionable?
Yes
No
No
Supports
Breakthrough
SPP Goal?
Yes
Selected Change
the Business
Measure
Not Selected
No
Stakeholder*/
Regulatory
Requirement?
No
Critical to
Run the
Business?
Yes
Ye
Selected Run the
Business Measure
Yes
LEVEL 1 = External and world class
LEVEL 2 = External but not world
class
LEVEL 3 = Internal comparison
Optimal
Comparative
Database Exists
ESTABLISHING BENCHMARKS
LEVEL 4 = No comparison
Is it
External?
yes
If World Class – Level 1
Evaluate for: 1) Size, Validity,
Reliability; 2)Comparable in
structure; 3) Relevance to
competitors 4)Ability to segment
and statistically analyze; 5)
Cost/benefit
If not World Class – Level 2
Set Target at Top 10%
(or interim goal if gap is
large)
no
Select most meaningful comparison –
Level 3
Determine who to compare to: 1)
Inter-entity; 2) Inter-departmental; 3)
Historical performance
No comparison – Level 4
Set Stretch Goal
KNOWLEDGE MANAGEMENT,
INFORMATION and IT
Sharing the Message Workfor ce Knowledge
Data Management
Requirements
 Emails, scorecards,
 Accuracy
screen savers, State of
the Union, Weekly
Briefings
 Leadership meetings,
Shared Governance
 Daily Check In
 Storytelling
 Integrity/Reliability
 Timeliness
 Safety/Confidentiality
 Data Center Elements;
software and hardware
requirements
 Technology Today
Category 5
WORKFORCE
FOCUS
85 POINTS
WORKFORCE SYSTEM
j
Pas
sio
n
/C
Set and
Communicate
Direction
recognition
Reward
and
Recognize
Mission
Vision
nt
me
on
vir
nt
e
n Manage
itm
compensation,
m
om
benefits
and
Develop and
Cre workforce
Deploy
ate
Th to
strategies
eE
achieve CSF
n
Align
People
and
Processes
k Define/Manage
a
Tr
m Evaluate
ns
and
fo
rm
improve workforce
atio
n al
performance
Lead
te
Execute
to Achieve
Exceptional
Values
Outcomes
ri
O
l Select, hire,
lts
develop workforce - esu
R
Ensure safe ined /
ip l
environment
Disc
en
Review,
Analyze and
Adjust
d
Capability and
Capacity needs
er
Workforce Environment
Effective and Supportive
Capability/Capacity;
New WF Members
 Quarterly C/C reports
Accomplishments;
Change; Environment
 Alignment of goals –
 Grow Our Own
 Electronic employment
forms
 Preceptor and mentors
 Onboarding for
retention; 60 day touch
base





electronic tracking tied to
performance evaluations
Transparent and
collaborative culture
Employee wellness
program; incentive on
insurance premiums
Disease Management
Pt. Safety and Satisfaction
Ambassadors
Concierge, 26 Fund
Workforce Engagement
Organization and Personal Success
Engagement; Culture;
Performance Mgmt.
Learning/Development;
Career Progression
 Surveys
 Performance Manager
 Action Plans
 Succession Planning
 Recognition and Rewards
 Leadership Team –




minutes out to all
State of the Union
Doc Talks, Weekly
Briefings
Standards of Excellence
Teamwork
 Leaders on the Horizon
 LDI
 Clinical Educators
 Electronic Education
 Tuition
Reimbursement
Category 6
OPERATIONS
FOCUS
85 POINTS
PROCESS BASED MANAGEMENT (PBM)
Define the
Process
Establish
Metrics
Determine
Performance
Stabilize the
Process
Improve
Improvement
Plans
Develop
Improvement
Plans
Set
Goals
Union Hospital Enterprise Process Model (Revised August 22, 2013)
1.0 Lead the Organization
1.1 Perform Strategic Planning
1.1.1 Set strategic direction
1.1.2 Set objectives and goals
1.1.3 Align systems to deploy strategy
1.1.4 Evaluate and Improve
2.0 Create Strategic
Alignments for Health
Services
2.1 Conduct SWOT to
identify continuum of
services offered
2.2 Determine which
services will be
delivered within Union
2.3 Determine which
services will be
provided through
strategic alignments
2.4 Identify potential
strategic alignments
2.5 Develop and sustain
strategic alignments
2.6 Support Key
Communities
2.6.1 Improve health
of the
community
2.6.2 Provide
community
support and
volunteerism
1.2 Deliver Organizational Excellence
1.2.1 Ensure Safety and Deliver Quality
1.2.2 Innovate Purposefully
1.2.3 Ensure Knowledge Management
1.3 Recruit, Engage, and Align Physicians
1.4 Communicate effectively
3.0 Assess, Develop
Service Lines & Market
3.1
Understand markets,
customers and
capabilities
3.2 Develop health care
services and service
lines
3.2.1 Reinforce
service line
Infrastructure
3.2.2 Balance Goals
3.2.3 Link Care
Continuum
3.2.4 Engage
Physicians
3.2.5 Integrate
Referral Sources
3.2.6 Strengthen
Customer Service
3.2.7 Build Brand
Strategy
3.3 Manage and align the
health care services
portfolio and service
lines
3.4 Develop marketing
strategy, forecast, and
plans
4.0 Build and Sustain
Patient / Stakeholder
Relationships
4.1 Develop customer
service strategy
4.2 Deploy customer
service strategy
4.3 Measure and
evaluate customer
service
5.0 Provide Entry to
Health Care
5.1 Provide information
on service
availability and cost
5.2 Admit / Place
5.2.1 In-patient and
OP admissions
5.2.2 In-patient and OP
external source
admissions
5.2.3 Emergency
Department
admissions
5.2.4 Mother/Baby
admissions
1.5 Ensure Legal, Ethical Behavior and Regulatory
Compliance
1.6 Ensure organizational governance
1.7 Develop and maintain government and industry
relationships
6.0 Deliver Health Care
6.1 Clinically assess
patient
and develop plan of
care
6.2 Conduct discharge
planning
6.3 Manage and provide
treatment and care
6.2.1 In-Patient
6.2.2 Ambulatory
Surgical
6.3.3 Out-patient
6.3.4 Emergency
6.3.4 Home/Health
Hospice
6.4 Provide Case
Management
6.5 Provide in-patient
non-direct services
(food, chaplain,
cleaning etc.)
6.6 Educate patients and
families
6.7 Manage patient
medical information
7.0 Transition of Care
7.1 Discharge / Exit
7.2 Transfer
7.2.1 Inpatient
7.2.2 Ambulatory/
Surgical
7.2.3 Outpatient
7.2.4 Emergency
7.2.5 Home Health,
Hospice
7.3 Maintain
relationships
7.3.1 Inpatient
7.3.2 Ambulatory/
Surgical
7.3.3 Outpatient
7.3.4 Emergency
7.3.5 Home Health/
Hospice
Union Hospital Enterprise Process Model (Revised August
8.0 Deliver Human
Resource Services
8.1 Develop and manage
HR planning, policies,
and strategies
8.2 Recruit, select and
onboard workforce
8.3 Develop, coach and
counsel workforce
8.4 Reward, Recognize
and retain workforce
8.4.1 Provide benefits
8.4.2 Manage
8.5
8.6
8.7
8.8
workforce
satisfaction/
engagement
processes
Manage promotion/
reassignment and
separation process
Manage employee
information
8.6.1 Manage
employee
licensure and
certifications
8.6.2 Manage
employee
competency
Ensure workforce
safety, security and
wellness
Provide administrative
duties
9.0 Deliver
Financial Services
9.1 Perform planning &
management
accounting
(Controller)
9.2 Perform revenue
cycle management
9.3 Perform general
accounting &
reporting
9.4 Manage fixed
assets and capital
project accounting
9.5 Manage payroll
9.6 Process accounts
payable and
expense
reimbursements
9.7 Manage treasury
operations
9.8 Manage internal
control
9.9 Manage taxes
9.10 Medicare/Medicaid
cost reporting
10.0 Deliver IT
10.1 Manage IT
strategy and
governance
(Dir. Of IT)
10.2 Develop & manage
IT service relations
10.3 Develop & manage
IT vendor relations
10.4 Manage business
resiliency and risk
10.5 Manage
organization
information
10.6 Develop & deploy
Business solutions
(Controller)
10.7 Maintain business
solutions
10.8 Deliver & support
IT service
10.9 Manage IT
knowledge
11.0 Provide &
Manage Facilities &
Equipment
11.1 Design, construct,
and/or acquire
facilities (Dir. Of
Plant)
11.2 Maintain facilities
and equipment
11.3 Perform biomedical
testing / preventive
maintenance
11.4 Monitor and manage
environmental health
and safety
11.5 Dispose of facilities
22, 2013)
12.0 Deliver Supplier
Chain Management
12.1 Develop sourcing
strategies
12.2 Select
suppliers/partners
12.3 Negotiate and
manage contracts
12.4 Procure materials
and services
12.5 Evaluate material /
service and provide
feedback to
suppliers/partners
12.6 Receive, and
distribute materials
/ services
12.7 Manage logistics
and warehousing
13.0 Manage
Organizational Risk
13.1 Establish
organizational risk
framework
13.2 Manage operational
risk
13.5 Manage liability
coverage
13.6 Ensure emergency /
disaster
preparedness
13.7 Credentialing and
privileging
13.8 Conduct Peer
Review
SWIMLANE CORRIDOR
150 feet of
process
maps
31 key
processes
SWIMLANES
Category
7
RESULTS
450 POINTS
7.1 Healthcare & Patient Focus Results;
Work Process Effectiveness Results;
Supply-Chain Mgmt. Results
 40 Graphs
 CMS Indicators
 Risk Adjusted Complication










Index
Patient Safety Results
Risk Adjusted Mortality Index
LOS
VAT Savings
Door to Doc Times
Ortho Implant Spend
Pharmacy Supply Fill Rate
Clinical Pharmacy
Interventions
Lab TATs
Uptime for Critical IT Systems
Emergency Preparations
 Go back to the profile
and think about your
main services, CSFs, core
competencies, key
stakeholders
 Data must be segmented
and appropriate
comparisons given
 Data must include trends
over time
7.2 Patient and Other Customer-Focused
Results; Healthcare & Patient Focus Results
 31 Graphs
 Best
 HCAHPS Results
Image/Reputation Results
 Satisfaction
Scores per
Service Line
 Other
Satisfaction
Results
7.3 Workforce Results – Capability, Capacity,
Climate, Engagement, Development Results
 34 Graphs
 Competency Pattern and
 Retention/Turnover

 Absenteeism
 Vacancy Rate
 Internal Mgr. Fill Rates
 Time to Fill
 Health Benefit
Costs/Employee
 Employee/Physician/
Volunteer/Student
Satisfaction










Trends
Alignment to Critical Success
Factors
Timely Appraisals
OSHA Recordable Incident
Rate
Lost Time Case Rate
DART Rate
Lifting Injuries
Worker’s Comp
Employee, Physician,
Volunteer Engagement
Grievances
Education Dollars/ Employee
% Leaders in Leadership
Training
7.4 Leadership/Governance Results;
Strategy Implementation Results
 21 Graphs
 Focus on Improvement
 Communication







Contributions
Foundation Contributions
BOD Self Assessment
Leadership Compliance
with COI
Audit Findings
RAC Appeal Success Rate
Compliance Training, COI
Strategic Planning Results
 Workplace Perceptions of









Compliance
Accreditations/Certifications
Awards and Recognition
Perception of Ethics
Charity Care to Gross
Revenue
United Way Contributions
Scholarship $ Awarded
Donations and
Sponsorships
Project Search
Environmental Impact
7.5 Financial and Market Results
 18 Graphs
 Days Cash on Hand
 Total Operating
 Net Days in A/R





Revenue
Total Margin Ratio
Operating Margin
EBIDA Margin
Age of Plan
Debt Service
Coverage Ratio
 Occasions of
Service
 PSA Market Share
 SSA Market Share
 Total 144 Graphs for
Results Section.
Platinum Level – Governor’s Award
TEAM CELEBRATION
A Journey to Ohio
HOW WE PROCESS THE
BALDRIGE WORK
 Core Team made up of




SLs and other key
leaders (Cat Leads)
Core Team meets every
month
Each Cat has a team; a
SL sponsors each team
Work done through the
teams
Feedback reports
utilized to prioritize
work
 3S for Success Teams




drive the education
First, Best… Always is
the umbrella
Each Cat Team
responsible for
contents of application
Site Visit preparation
works much the same –
three day visit requires
much prep time
Celebrate and wait for
the Feedback Report
ON THE ROAD AGAIN!
DEDICATION PRAYER