Finding a Pathway to Continuous Quality Improvement Using the AHCA/NCAL National Quality Award

1. Finding a Pathway to Continuous Quality Improvement Using the AHCA/NCAL National Quality Award Jeri Reinhardt, Director, Quality - Benedictine Health System Tim Case, AHCA/NCAL National Quality Award Program Administrator Jon Frantsvog, Administrator - St. Benedict's Health Center

3. What is Baldrige???? • A National Award established by congress in 1987 • Managed by the Department of Commerce • Critical Purposes: • To help improve organizational performance practices, capabilities and results • To facilitate communication and sharing of information on best practices • To serve as a working tool for understanding and managing performance and guiding organizational planning

4. Baldrige Criteria = Evidence Based Management Processes and Systems • National Institute of Standards and Technology (NIST) review the US organizations with the highest performance • They examine the key processes and systems that are creating the high performance • Processes that are utilized by many high performing organization become the Baldrige Criteria

5. Baldrige Criteria • Three different sets: • General • Education • Health Care • Non-Prescriptive • Series of Questions • Organization must identify what is important and then explain

6. The Role of Core Values and Key Processes

7. Baldridge Core Values and Concepts • PARADIGMS • Visionary Leadership • Patient-Focused Excellence • Organizational and Personal Learning • Valuing Staff and Partners • Agility • Focus on the Future • Managing for Innovation • Management by Fact • Social Responsibility • Focus on Results • Systems Perspective

8. Driver System Results 7 Strategic Planning 2 • Business • Results: • Health Care • Patient • Satisfaction • Financial/Market • Staff & Work • System • Organizational • Effectiveness • Governance/Social • Responsibility People 5 Leadership 6 1 Process 3 Patients, Customers & Markets Measurement, Analysis & Knowledge Management 4

9. Baldridge Scoring Guidelines – Categories 1-6 • A – D – L – I • Approach – How – • What is your process? • Deployment – What is the extent? • Do all departments, units use this process? • Learning – Have you evaluated and improved? • Requires feedback loop • Integration – Is this process in harmony with other areas? • Leadership, strategy, customers, employees, measurement, process improvement

10. Baldrige Scoring Guidelines – Category 7 • Le-T-C-I • Level of performance • Trends of performance • Comparison of performance to others • Integration all important results

11. AHCA/NCAL National Quality Award • Bronze – Organizational Profile • 5-page Limit • Silver – Core Values and Concepts • 18-page Limit • Gold – Health Care Criteria for Performance Excellence • 50-page Limit

12. Bronze Requirements • Responses to 2.0 criteria in two areas: • Organizational Description • Organizational Environment • Organizational Relationships • Organizational Situations • Competitive Environment • Strategic Context • Performance Improvement System

13. Silver Requirements • Updated responses to Bronze criteria in section 2.0 (Organizational Profile). • Responses to Silver criteria 2.1-2.8 based on the 11 Baldrige core values and concepts. • Objective: To demonstrate that the organization’s leaders are able to learn the principles of performance improvement and apply them to their operating and service delivery systems using the context of the mission, characteristics, and challenges described in the Bronze (2.0) responses.

14. Visionary Leadership, Social Responsibility & Community Health Focus on the Future Customer Focused Excellence Organizational and Personal Learning Valuing Employees and Partners Agility Focus on the Future Managing for Innovation Management by Fact Public Responsibility and Citizenship Systems Perspective Focus on Results and Creating Value Baldrige Core Values & Concepts

15. AHCA/NCAL Quality Award The Eight Silver Criteria • Visionary Leadership / Social Responsibility and Community Health • Focus on the Future • Customer-Focused Excellence • Management by Fact • Workforce Engagement and Organizational/Personal Learning • Valuing Staff and Partners • Systems Perspective, Managing for Innovation & Agility • Focus on Results and Creating Value

16. The “Leap” to Silver Requires... • Commitment to learning and new way of thinking • Considerable time throughout the year • Greater staff involvement • Systems approach • Key performance results measured and improved over time

17. The “Leap” to Silver Requires... • Alignment with diverse customer requirements, business goals, strategic goals, and its performance management system. • Customer needs that are reflected in the strategic plan, performance metrics and business outcomes.

18. Leadership Strategic Planning Focus on Patients, Other Customers and Markets Measurement, Analysis, Knowledge Management Workforce Focus Process Management Results Gold Criteria: MBNQA – Health Care Criteria for Performance Excellence Categories

19. Gold Requirements • Translate the Silver (2.0) criteria response into the Baldrige “Organizational Profile.” • Address the seven Baldrige Health Care Criteria for Performance Excellence. • Host a satisfactory site visit. • Objective: To demonstrate superior performance in health care, customer satisfaction, financial, market, workforce, process, and leadership outcomes over time.

20. “I used to run a better nursing home!”

21. Bronze Award - 2001 • How we wrote the application • What we knew • What we learned • What we changed

22. Silver Award - 2003 • How we wrote the application • What we knew • What we learned • What we changed

23. Gold Award - 2005 • How we wrote the application • What we knew • What we learned • What we changed

24. “And the journey continues(In fact, it never ends)”