STORIES AND TOOLS FOR
ALIGNING THE PUBLIC HEALTH
ACCREDITATION BOARD AND
THE BALDRIGE PERFORMANCE
EXCELLENCE PROGRAM
David Klater, Dave Klater Consultants Inc.
Marni Mason, MarMason Consulting
Susan Ramsey, WA State Department of Health
David Klater, Dave Klater Consultants Inc.
Marni Mason, MarMason Consulting
Susan Ramsey, WA State Department of Health
COPPHI Open Forum
June 19, 2012
PHAB standards and Baldrige Criteria
Overview of Tool
WA State Health Department’s
Experience



Narrative description
Appendices
Crosswalks
◦ PHAB
◦ Baldrige

Baldrige
PHAB
Four sample applications

“The health department must provide a
completed performance management selfassessment that reflects the extent to which
performance management practices are being
used…Self-assessment tools are available
through the Baldrige Performance Excellence
Program…”
PHAB Measure 9.1.2 A

Similarities
◦ Self-assessment
◦ Site Visits
◦ Reports that detail areas for improvement

Differences
◦
◦
◦
◦
◦
Required documentation
Criteria selection
Award status
State-based programs
Organizational leadership, performance
comparisons, and results



High level alignment
Many expectations and subtleties of the
intent of PHAB’s measures
Health departments’ clients = entire
communities
Baldrige Program
The Baldrige Criteria Framework
Evaluation Factor
For Categories 1 to 6
Approach (A)
Deployment (D)
Leaning (L)
Description

the methods used to accomplish the process

the appropriateness of the methods to the Criteria item
requirements and the organization’s operating environment

the effectiveness of your use of the methods

the degree to which the approach is repeatable and based on
reliable data and information (i.e., systematic)

your approach is applied in addressing Criteria item
requirements relevant and important to your organization

your approach is applied consistently

your approach is used (executed) by all appropriate work units

refining your approach through cycles of evaluation and
improvement

encouraging breakthrough change to your approach through
innovation

sharing refinements and innovations with other relevant work
units and processes in your organization
your approach is aligned with your organizational needs
identified in the Organizational Profile and other process items

Integration (I)

your measures, information, and improvement systems are
complementary across processes and work units

your plans, processes, results, analyses, learning, and actions
are harmonized across processes and work units to support
organization-wide goals
Evaluation Factor
For Category 7 Results
Description
Levels (Le)
 your current level of performance
Trends (T)
 the rate of your performance improvements or the
sustainability of good performance (i.e., the slope of
trend data)
Comparisons (C)
 the breadth (i.e., the extent of deployment) of your
performance results
 your performance relative to appropriate
comparisons, such as competitors or organizations
similar to yours
Integration (I)
 your performance relative to benchmarks or
industry leaders
 your results measures (often through segmentation)
address important customer, product, market,
process, and action plan performance requirements
identified in your Organizational Profile and in
process items
 your results include valid indicators of future
performance
 your results are harmonized across processes and
work units to support organization-wide goals
Baldrige Criteria - Possible Points by Category
Leadership
Strategic planning
Customer focus
Measurement, analysis,
and knowledge management
Workforce focus
Operations focus
Results
Total possible
120 points
85 points
85 points
90 points
85 points
85 points
450 points
1000 points
The PDCA of Baldrige
What?
Profile
How?
Key Factors
Criteria
Categories 1 to 6
Performance
Measures
Results
Category 7
Evaluate &
Improve
Lead to Actions
Crosswalks
Alignment: High, Medium, Low
PHAB
Description
Measure
Baldrige Area to
Address
Statement of Baldrige Criteria and Description of Alignment
Domain 1: Conduct and disseminate assessments focused on population health status and public health issues facing
the community
Standard 1.1 Participate in or Conduct a Collaborative Process Resulting in a Comprehensive Community Health
Assessment
1.1.1
Participate in or 3.2a1
Product Offerings: HOW do you identify CUSTOMER and market
conduct a
requirements for product offerings and services? HOW do you
partnership that
identify and innovate product offerings to meet the requirements
develops a
and exceed the expectations of your CUSTOMER groups and
comprehensive
market SEGMENTS (identified in your Organizational Profile)?
community health
HOW do you identify and innovate product offerings to enter new
assessment of the
markets, to attract new CUSTOMERS, and to provide opportunities
population
for expanding relationships with existing CUSTOMERS, as
appropriate?
4.1a3
CUSTOMER Data: HOW do you select and ensure the EFFECTIVE
use of VOICE-OF-THE-CUSTOMER data and in-formation (including
complaints) to support operational and strategic decision making
and INNOVATION?
Category 1 - Leadership
Baldrige Description
Area to
Address
Alignment: High, Medium, Low or none
PHAB
Statement of PHAB What health
Documentation
Measure
measure and
departments can do to required by
Description of
address this area for the PHAB that
Alignment
Baldrige application
could be used
in the Baldrige
application
Item 1.1 Senior Leadership: How do your senior leaders lead?
1.1a1
1.1a2
Vision and Values: How do
3.2.1, 5.3.1,
senior leaders set your
5.3.2
organization’s vision and values?
How do senior leaders deploy
your organization’s vision and
values through your leadership
system, to the workforce, to key
suppliers and partners, and to
customers and other
stakeholders, as appropriate?
How do senior leaders’ actions
reflect a commitment to the
organization’s values?
Promoting Legal and Ethical
Behavior: How do senior
leaders’ actions demonstrate
their commitment to legal and
ethical behavior? How do they
promote an organizational
environment that requires it?
3.2.1A Provide
Senior Leaders should Communication
information ton public implement a systematic of health
health mission, roles, communications process department
processes…. to
to ensure
mission and
improve the public's communication of
vision internally
health. 5.3.1A Conduct mission, vision, values to to workforce
a strategic planning
workforce and
and externally
process. 5.3.2A Adopt community.
to community
a strategic plan. PHAB
and public.
does not require
demonstration of
senior leadership
development.
Senior Leaders should
implement a process to
communicate and role
model the importance of
legal and ethical
behavior by the entire
workforce.
Related Baldrige Results:
7.4a2
GOVERNANCE: What are your KEY current
findings and TRENDS in KEY MEASURES or
INDICATORS of GOVERN-ANCE and fiscal
accountability, internal and external, as
appropriate?
7.4a3
Law and Regulation: What are your RESULTS
for KEY MEASURES or INDICATORS of achieving
and surpassing regulatory and legal
requirements?
7.4a4
7.4a5
Related PH Outcomes and Indicators:
Environme
ntal PH
outcomes
or
indicators
Ethics: What are your RESULTS for KEY
MEASURES or INDICATORS of ETHICAL
BEHAVIOR and of STAKEHOLDER trust in your
organization’s SENIOR LEADERS and
GOVERNANCE? What are your RESULTS for KEY
MEASURES or INDICATORS of breaches of
ETHICAL BEHAVIOR?
Society: What are your RESULTS for KEY
SocioMEASURES or INDICATORS of your organization’s economic
fulfillment of its societal responsibilities and
and social
your organization’s support of its KEY
justice
communities?
types of
outcomes
and
indicators
Results from monitoring PH outcomes or
indicators related to compliance with
environmental health regulations such as
the Food Rule and others
Results from monitoring indicators related
to Socio-economic and social justice issues
such as income levels, high school
graduation rates and others
Lite Assessment Application
2008
Why Did We
Choose WSQA?
• Legislatively mandated for all cabinet agencies
• Must apply every 3 years
• First application in 2008
• Due to budget constraints statewide postponed
2012 application
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Quality Improvement
• Based on Baldrige Performance Excellence which is
a nationally recognized performance management
framework
Why Did We
Choose PHAB Accreditation?
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Quality Improvement
• Prior History of Public Health Standards - 1999
• 85 percent of Washington State standards adopted
by PHAB
• Increase credibility
• Assess how well our public health system is working
overall
• Describe what every public health agency in
Washington should be able to do regardless of size
or location
• Build a stronger and better public health system
• Define, measure, and facilitate the improvement of
public health protection throughout the state
How has WSQA influenced
PHAB Accreditation?
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Quality Improvement
• In our case our public health standards
influenced our WSQA Application
• WSQA used as a management framework
• Public Health Standards used as a capacity
framework
• Many areas overlapped
• WSQA Results category forced showing the
return on investment
Advice for Either WSQA or
PHAB Accreditation
•
•
•
•
•
Quality Improvement
Manage records
Make clear assignments
Communication key
Identify a team of resources
Provide training on Categories or
Standards/Measures
• Make this a journey and not a one time
event
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What Worked Well?
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Quality Improvement
• Great team
• Leadership Support
• IT System in place for document
collection
• Assignment of Categories/Domains
• Creating “Read Me” files for each
measure
• Team of Internal Reviewers
• Communications staff as team members
Key Lessons Learned
Quality Improvement
• Plan ahead 9 – 12 month process
• Crosswalk from public health standards to
Baldrige criteria difficult
• Competing priorities
• Assign a Champion for each category
• Create a team to Champion this work
throughout the agency
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Contact Information
Quality Improvement
Susan Ramsey, Director
Office of Performance and Accountability
Washington State Department of Health
360-236-4013 – susan.ramsey@doh.wa.gov
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