Use Baldrige criteria to meet your goals and patient ... - Quality Texas

healthcareNarrowthcare’sQualityChasmby William Denney,Cynthia St. John andLiz Youngbloodtoday’s healthcare leadersface the need to effectively manage both the clinicaland business sides of their operations. This includesdemonstrating cost reductions, overall organizationalimprovement and long-term sustainability.Added to these responsibilities are the societal expectationsthat these leaders make radical changes tothe healthcare infrastructure while it still consistentlymeet the needs of patients and that these leaders doso in a field that is quite complex. The bottom line isthat hospitals have no choice but to move from basiccompliance to organizational excellence.May 2009 • QP 39

Implementing the Baldrige Healthcare Criteria forPerformance Excellence 1 within a healthcare organizationcan drive high-quality outcomes and improvefinancial performance. The Baldrige criteria provide astructure to help align and focus all areas of an organizationwith key stakeholder needs and expectations. Inshort, the criteria can transform healthcare.In the midst of striving for organizational excellence,healthcare institutions are faced with a variety of challenges.For example, no one can deny that healthcareis a highly regulated industry. Staying up to date withchanging requirements is costly in time and resourcesthat don’t generate additional revenue.An organization that does not maintain compliance,however, will lose money in the form of penalties, decreasesin payments, required reimbursement of fundsreceived and even failure to qualify to serve certainpayer categories.Another challenge faced by full-service, acute carehospitals is providing healthcare to all, regardless ofability to pay. Emergency and subsequent healthcareservices are provided regardless of whether a patientcan pay for the services.Many healthcare consumers cannot afford insurance.Others have insurance but cannot pay the increasingco-pay amounts and other consumer-fundedportions of healthcare plans. This added financial burdenon hospitals, along with the increasing regulatorycompliance requirements, is cause for concern. Hospitalsthat are unable to meet these challenges end upclosing their doors because they can’t financially sustaintheir operations.Additionally, consumers (patients) are much moreinvolved in making healthcare decisions, and expectationsfor transparency have become the norm. Patientconsumers decide what healthcare services they wantto receive and where they want to receive them. Thesedecisions are based on accessible information relatedto services, quality and other outcomes.Furthermore, high-quality, cost-effective care withpositive outcomes is expected. For consumers, this is agiven; therefore, patient satisfaction has become a keydriver in determining where patients will go to receiveservices.All these factors create a challenging environmentfor healthcare institutions. Addressing these challengesand moving beyond them to create organizationalexcellence are critical to success and sustainability.Quality and the IOM aimsInitial efforts to achieve improvement have frequentlybeen associated with the Institute of Medicine (IOM)aims. In its landmark report Crossing the QualityChasm, IOM acknowledged the existence of a pervasivequality gap and called for the urgent redesign ofthe U.S. healthcare system. 2The report set forth the following six aims for focusedimprovement:• Safety—avoiding injuries to patients from the careintended to help them.• Effectiveness—providing services based on scientificknowledge to all who could benefit while refrainingfrom providing services to those unlikely tobenefit.• Patient-centered care—providing care that is respectfulof and responsive to individual patient preferences,needs and values, and ensuring that patientvalues guide all clinical decisions.• Timeliness—reducing wait times and sometimesharmful delays for those who receive and those whogive care.• Efficiency—avoiding waste, including unusedequipment and supplies, ignored ideas and unnecessaryexpenditures of energy.• Equitable care—providing care that does not varyin quality because of personal characteristics suchas gender, ethnicity, geographic location and socioeconomicstatus.Intended to result in care that is safer, more reliable,more responsive, more integrated and more available,these aims became the focus of many healthcare institutions’quality efforts.Since the report’s release, some gains have beenachieved. These topics continue to cause unrest withinthe healthcare industry, however—opportunities forimprovement persist. In a time when great leaps forwardare needed, progress is too often measured insmall, incremental improvements. Leaders find themselvessupporting and financing many seemingly good,but random, acts of improvement. Despite best intentions,costs continue to rise, patients remain dissatisfied,and process failures are widespread.What is needed is a systematic way to align hospitalimprovement activities with strategic goals andto track focused measures that result in real change.Since its availability in 1999, the Baldrige healthcarecriteria have been used by many hospitals to accom-40QP • www.qualityprogress.com

healthcareplish this alignment and tracking. The criteria representa systems approach to improvement that is composedof six process categories and a seventh categoryfor associated results:1. Leadership.2. Strategic planning.3. Focus on patients, other customers and markets.4. Measurement, analysis and knowledge management.5. Workforce focus.6. Process management.7. Results.The criteria have also been referred to as a leadershipsystem and a sustainability model. But what theyreally represent is an integrated approach to improvinga diverse and complicated organization and achievingsustainable results.Baldrige and the IOM aimsWhile the criteria address key processes in an effectivemanagement system and are increasingly recognizedas a framework to create and sustain quality outcomes,the greatest emphasis is placed on the outcomesachieved by these processes. Table 1 (p. 42) summarizesthe Baldrige results criteria relative to the IOM aims.Systematic application of the criteria often correspondswith significant gains in IOM aim achievement.Following are examples of results from Baldrige recipientsthat impact IOM aims:Safety: The provision of safe care is dependent ona variety of factors. It therefore follows that safety alsotouches many of the Baldrige results items. Most directly,the healthcare outcomes criteria (7.1) ask forlevels, trends and comparative results relative to patientsafety.Also relevant, however, are workforce-focusedoutcomes due to the human factors often associatedwith medical errors. Workforce capability and capacity,including staffing levels and appropriate skills, areaddressed by the workforce-focused outcomes criteria(7.4).In addition, safe care is aligned with the Baldrigeprocess effectiveness outcomes (7.5) and leadershipoutcomes (7.6). Key work-process measures, includingthose directly and indirectly related to the provisionof safe care, are addressed in 7.5. Leadership sets theinstitution’s strategic objectives and priorities and isresponsible for monitoring progress toward these priorities(7.6), of which safe care should be paramount.Patient safety cultureexample / figure 1Percentage of staff thatview issue as a problem302520151050Specificprocess toreviewperformanceagainstdefinedtraining goalsAccreditation results (such as Joint Commission requirements)are also addressed in the leadership outcomescriteria.Given the relation between the Baldrige results criteriaand the IOM safety aim, it is not surprising thatBaldrige award recipients often demonstrate strongerpatient safety outcomes compared with their peers.In Figure 1 from Baldrige award recipient NorthMississippi Medical Center, as patient safety improvementbecomes part of an organization’s processes andculture, staff recognizes that actions to improve safetyare visible and well implemented.Figure 2 from St. Luke’s Hospital of Kansas Cityshows that mortality rates were lower, which impactsother important measurements compared with nationalaverages.SLHRewardedfor takingquick actionto identifya seriousmistakeNorth Mississippi Medical CenterSelect group top 10%Lower mortalityrates / figure 2National averageMedical mortality 13.1% 15.3%Surgical mortality 1.8% 15.3%Physician rating 86% 33%Accreditation score 92 91Overall score 7669 5418St. Luke’s Hospital (SLH) Rank = 35 of 4,500hospitals in United StatesGoodProvidesteamworktraining toimprovepatient careperformanceand safetyMay 2009 • QP 41

Baldrigeresults ⇒7.1HealthcareoutcomesEffectiveness: Evidence-based medicine has experiencedcontinued refinement, with specific treatmentstrategies demonstrating consistently better results forpatients with specific presenting conditions.The delivery of effective care, as defined by the IOM,relates to providing services to all who could benefit,while refraining from providing services to those notlikely to benefit—in other words, the effective use ofevidence-based medicine as available and appropriate.These practices and their corresponding results are addressedin the healthcare outcomes criteria (7.1).In addition to patient safety outcomes identifiedearlier, the healthcare outcomes criteria ask for levels,trends and comparative results relative to healthcareoutcomes and patients’ functional status.An additional means by which overall effectivenessis achieved is through the effective design, implementationand improvement of healthcare delivery processes.These processes are measured by item 7.5,process effectiveness outcomes. In particular, 7.5 asksfor current levels and trends for the operational performanceof key work processes, including productivity,cycle time and other appropriate measures of processeffectiveness.Table 1 also identifies the workforce-focused item(7.4) as relevant to the IOM effectiveness aim. Thisconnection is based on the importance of workplaceclimate and engagement, particularly related to opennessto new ideas, approaches and improvement opportunitiesto ensure ongoing gains in effectiveness.Baldrige award recipients generally demonstrateBaldrige results and IOM aims / Table 17.2Patient7.3Financial7.4and other and marketcustomerfocusedoutcomesoutcomesWorkforcefocusedoutcomes7.5 7.6Process LeadershipeffectivenessoutcomesoutcomesIOM aims⇓Care is:1. Safe • • • •2. Effective • • • •3. Patientcentered•4. Timely •5. Efficient • • •6. Equitable • •IOM = Institute of Medicinestronger effectiveness-related outcomes comparedwith their peers. Looking to clinical measures of effectiveness(see Online Figure 1 at www.qualityprogress.com), one Baldrige award recipient shows results thatare better than measurements from the Centers forMedicare and Medicaid Services (CMS). As shown inOnline Figure 2, the recipient performed better than localcompetitors and as good as the best in the country,as measured by the Agency for Healthcare Researchand Quality (AHRQ).Patient-centered care: The IOM aim of patientcenteredcare emphasizes responsiveness to patientpreferences, needs and values. Similarly, category 3of the Baldrige criteria and corresponding item 7.2 inthe results section address patient and other customerfocusedprocesses and outcomes.In particular, the results criteria ask for levels,trends and comparative data relative to patient/customersatisfaction and dissatisfaction, perceived value,retention and positive referral. These measuresprovide an indication of how a healthcare institution isperforming relative to patient-centered care.Similar to the aims already discussed, Baldrigeaward recipients tend to demonstrate stronger patientcenteredoutcomes compared with their peers. Figure3 shows high scores for patient loyalty at BronsonMethodist Hospital, a Baldrige recipient. Table 2 showsa comparison of customer value at award recipientBaptist Hospital Inc. in Pensacola, FL, and comparableinstitutions.Timeliness: In Baldrige terminology, timeliness isone aspect of the process effectiveness outcomes criteria(7.5).In addition to the general operational performanceof work systems and key work processes, time-basedmeasures play a large role in the criteria, given thesignificance of time performance to improving overallperformance. Appropriate measures and indicatorsof work system performance may include just-in-timedelivery of healthcare and related services, plus otherindicators that demonstrate responsiveness, such ascycle times, turnaround times, time to new healthcareservice introduction and order fulfillment time.Given the inherent emphasis on time-based measuresof performance, Baldrige award recipients regularlydemonstrate reduced times on key measuresas compared with their peers. For example, OnlineFigure 3 shows process speed improvement at Rob-42QP • www.qualityprogress.com

healthcareert Wood Johnson University Hospital Hamilton, NJ,a Baldrige winner, compared with Joint Commissionresults. Online Figure 4 shows a comparison betweenthe timeliness of antibiotics given and length of stay atBronson Methodist Hospital.Efficiency: Also closely related to the timely deliveryof care and services is the efficiency with whichhealthcare processes are delivered. Efficiency encompassesall forms of waste avoidance, including equipment,supplies, human resources and even ignoredideas.The aim of providing efficient care is related to multipleBaldrige results items:• Financial and market outcomes (item 7.3) addressesfinancial performance measures, including levelsand trends for budget performance—a measure offinancial efficiency.• Workforce-focused outcomes (7.4) take into considerationthe concept of avoiding waste in the formof ignored ideas. As noted earlier in reference tothe IOM effectiveness aim, the importance of workplaceclimate and workforce engagement—particularlyrelated to openness to new ideas, approachesand improvement opportunities—can also significantlyimpact efficiency.• Process effectiveness outcomes (7.5) address theoperational performance of work systems and keywork processes, including productivity and efficiencymeasures. Indicators of process efficiency mightinclude work system performance that demonstratesincreased cost savings, higher productivityor waste reduction, such as the reduction of repeatdiagnostic tests and cost reduction.Baldrige award recipients tend to demonstratestronger efficiency-related outcomes compared withtheir peers. Figure 4 (p. 44) shows how St. Luke’s Hospitalof Kansas City increased its profit margins byeliminating internal inefficiencies. In Online Figure 5,despite increases in volume, Baptist Hospital Inc. tendedto create the capacity for fast response times andbest-in-class performance.Equitable care: Healthcare results (7.1) addresskey measures of healthcare outcomes, including functionalstatus.Although many Baldrige recipients serve lower incomeand rural patients, their healthcare outcomes aregenerally equal to or better than facilities serving moreaffluent communities. Results such as these supportLoyalty and likelinessto return / figure 3Mean score54321Inpatient ER OPsurgeryBronson MethodistHospital (BMH) baselineGallupER = emergency room; OP = outpatientthe aim of equitable care.In addition, leadership results (7.6) measure a varietyof factors, including support of key communitiesand contribution to the health of the community theinstitution serves, regardless of its characteristics.Customer survey scores / Table 2Baptist Hospital Inc. (BHI)Issue BHI A BCare/servicesPatients are kept sufficiently informed about theircondition/treatment.Pain is well controlled.Personnel show concern for patients’ well-being.Overall quality of health care provided is excellent.Phone representatives at hospital are helpful.Sufficient personal attention is given to patients.Patient needs are met promptly.Waiting time for tests and treatment is reasonable.+8484+88+83+84+83+79+7779807878777773717677737473707068EmotionalPatient needs are understood. +78 71 62Location/environmentParking is convenient. +76 62 49NursesNurses show good attitide toward patient requests. +89 79 78PhysiciansOverall quality of care provided by physician is excellent. 83 80 80+ = Significantly above competition (A and B)OPtestingGood100806040200Percentile rankingBMH 1Q ‘05 projectedBMH baseline percentileMay 2009 • QP 43

Margin comparison / figure 41816Better141210864201999 2000 2001 2002 2003St. Luke’s Hospital (SLH)Top quartileCouncil of Teaching Hospitals and Health Systems*SLH data represent best 5% of comparative groupPercentageUncompensated costcomparison / figure 512%10%8%6%4%2%0%Percentage of total expenses2002 2003 2004 2005 2006 yearto dateNorth Mississippi Medical Center actualNational, per American Hospital AssociationBaldrige recipients tend to be able to spend moreon uncompensated and charity care than comparableinstitutions. Figure 5 shows how Baldrige recipientNorth Mississippi Medical Center posted uncompensatedexpenses above a national average. Online Figure6 shows how setting a percentage of operating marginin an environment of increased efficiency and financialimprovement resulted in increased charity care at Baldrigeaward recipient SSM Healthcare.Getting startedAn organization can start using the Baldrige criteria tocreate a change in culture leading to an improvementin quality by completing two steps: the organizationalprofile and the self-assessment.Step one—organizational profile: The profileserves as the DNA for an organization. It provides clarityabout who you are, what you do, for whom you do it,what they expect, with whom you are competing and collaborating,your key strategic challenges and advantages,and the approach you use to improve performance.Although the questions that must be answered areseemingly straightforward, within many organizationsthe responses have traditionally been treated asimplicit assumptions rather than explicit assertions.Arriving at a collective and uniform response to eachquestion provides focus to the leadership team and organization.This collective consciousness becomes thecontext within which the organization operates andagainst which it manages its performance.Step two—self-assessment: The profile describeswho you are and the environment in which you operate.The self-assessment describes how you currentlyperform relative to the Baldrige criteria.Current practices are reviewed and summarized inthe areas of leadership, strategic planning, customerfocus, measurement/analysis, knowledge management,workforce focus, process management and results.Although often an impressive document in its ownright, the true value of this process comes from usingthe information to identify the organization’s strengthsand opportunities for improvement, which are basedon its responses to the criteria and placed in the contextof what it stated was important in its profile. Theopportunities for improvement represent gaps that canbe prioritized, translated into goals and integrated intothe organization’s strategic planning and performancemanagement processes.Completing the profile and self-assessment help anorganization readily see its gaps and current barriers tosuccess. Systematically using this information in the strategicplanning process will enable the development andachievement of meaningful goals and improvements.Baldrige resultsAre you interested in learning more about the exceptional businessresults achieved by Baldrige recipients? Go to www.quality.nist.gov/Contacts_Profiles.htm (case sensitive).Not just an awardThe Baldrige criteria are not about receiving anaward. In healthcare and hospitals, there are manyquality awards and recognitions, but few nationally44QP • www.qualityprogress.com

healthcarerecognized systematic and integrated approaches forsustainable improvement.There is a misconception that the criteria are difficultto use and understand, are costly or that it takesa long time to see benefit. In fact, the criteria are easyto understand. But changing an organization’s culture touse the criteria can be a challenge. It requires leadershipcommitment to drive excellence. A committed leadershipteam can effectively create the culturechange required to begin using the criteriawithin the organization. If this is done, thepayoff can be almost immediate.There is a growing recognition withinhealthcare of the value of the Baldrige criteria.In 2008, 50% of the applicants thatapplied for feedback from the Baldrige programwere from the healthcare sector. Thesame is true for many state programs. MostBaldrige award recipients prepared themselvesto succeed at the national level byparticipating in their state program.Whatever the route taken, the resultsshow that the Baldrige criteria can providea structured way for healthcare institutionsto meet many of the seemingly overwhelmingchallenges they face today. QPCYNTHIA ST. JOHN is director ofjourney to excellence for Texas HealthResources in Houston. She earneda doctorate in psychology, with aresearch emphasis on organizationallearning and improvement, from theUniversity of Houston. She receivedthe 2008 Carroll Morrison ExaminerAward for outstanding leadership and service to QualityTexas.References1. Baldrige Healthcare Criteria for Performance Excellence,National Institute of Standards and Technology, 2008.2. Crossing the Quality Chasm, Institute of Medicine, 2001.ResourcesTo learn more about the Baldrige criteria, go to www.quality.nist.gov.For more information about state Baldrige-based programs,go to www.baldrigepe.org/alliance.Baldrige recipient information is available at www.quality.nist.gov/Contacts_Profiles.htm (case sensitive).WILLIAM DENNEY is CEO of the QualityTexas Foundation. He earned a doctoratein history from Miami University inOxford, OH. Denney is a senior memberof ASQ and is a certified qualitymanager and auditor. He has been aBaldrige examiner for 10 years and ischair of the ASQ Quality ManagementDivision’s Baldrige technical committee.LIZ YOUNGBLOOD, a registered nurse,is vice president of patient caresupport services for the Baylor HealthCare System in Dallas. She earnedan MBA from Southern MethodistUniversity in Dallas.May 2009 • QP 45