Baldrige Performance Excellence Program DB4
4 2015–2016 Health Care Criteria for Performance Excellence
Health Care Criteria for Performance Excellence
The Organizational Profile is the most appropriate starting point for self-assessment and for writing an application. It is criti- cally 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 avail- able, use these topics for action planning.
• 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.
P The Organizational Profile is a snapshot of your organization, the KEY influences on HOW it operates, and your competitive environment.
P.1 Organizational Description: What are your key organizational characteristics?
In your response, answer the following questions:
a. Organizational Environment
(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?
(3) WORKFORCE What is your WORKFORCE profile? What recent changes have you experienced in WORKFORCE composition or your WORKFORCE needs? 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?
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?
b. Organizational Relationships
(1) Organizational Structure What are your organizational 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 of your HEALTH CARE SERVICES, PATIENT and other CUSTOMER support services, and operations? What are the differ- ences in these requirements and expectations among market SEGMENTS, PATIENT and other CUSTOMER groups, and STAKEHOLDER groups?
(Continued on the next page)
From Baldrige Performance Excellence Program. 2015. 2015–2016 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. http://www.nist.gov/baldrige.
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(3) Suppliers and PARTNERS What are your KEY types of suppliers, PARTNERS, and COLLABORATORS? What role do they play
• 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?
Notes 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 might be direct or might be indirect, through contractors, collaborators, or partners.
P.1a(2). Core competencies are your organization’s areas of greatest expertise. They are those strategically important 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.
P.1a(2). Core competencies are one example of concepts that are woven throughout the Health Care Criteria to ensure a systems approach to organizational performance management. Other such concepts include innovation, use of data and information to review performance and create knowledge, and change readiness and management.
P.1a(3). Workforce or employee groups and segments (including organized bargaining units) might be based on type of employment or contract-reporting relationship, loca- tion (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
might cover greenhouse gas emissions, carbon regulations and trading, and energy efficiency.
P.1b(2). Customers include the users and potential users of your health care services. They are the direct 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 third-party payors.
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 and commonalities. You might subdivide your market into market segments based on health care service lines or features, service delivery modes, payors, volume, geography, or other factors that you use to define a market segment.
P.1b(2). The requirements of your patient and other customer groups and your market segments might include accessibility, continuity of care, safety, security, leveraging of technology, billing requirements, socially responsible behavior, community service, cultural preferences, and multilingual services.
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, e-mail, social media, 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 Category and Item Commentary (http://www.nist.gov/baldrige /publications/hc_criteria.cfm).
Terms in SMALL CAPS are defined in the Glossary of Key Terms (pages 47–54).
6 2015–2016 Health Care Criteria for Performance Excellence
P.2 Organizational Situation: What is your organization’s strategic situation?
In your response, include answers to the following questions:
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?
b. Strategic Context
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?
Terms in SMALL CAPS are defined in the Glossary of Key Terms (pages 47–54).
Notes P.2b. Strategic challenges and advantages might relate to technology; health care services; finances; operations; orga- nizational 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 sup- port services, cost, reputation for service delivery, and wait times for service.
P.2c. The Baldrige Scoring System (pages 30–35) uses performance improvement through learning and integration as a dimension in assessing the maturity of organizational 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., 9000 or 14000), using decision science, or employing other improve- ment tools.
For additional guidance on this item, see the Category and Item Commentary (http://www.nist.gov/baldrige /publications/hc_criteria.cfm).