Using the Baldrige Model as a Framework for Achieving ... · Framework for Achieving Performance...

2015 ACHE-SETC Conference on Healthcare Leadership

INSIGHTS FOR HEALTHCARE PROFESSIONALS(A partnership with Medical World Americas)

Using the Baldrige Model as a Framework for Achieving Performance Excellence

(An ACHE Qualified Education (Cat II), 1.0 Hour CEU)

Emily Padula, FACHEExecutive Director of Integration and OutreachHill Country Memorial Hospital


Learning Objectives

• How the Baldrige model can be applied to achieve highly reliable outcomes

• Understanding the need for transparency and accountability that supports the Baldrige core value of patient-focused excellence


Agenda

• Overview

• Introduction

• Topics for Discussion:

Baldrige Review

Leveraging Core Competencies and Criteria

Values-Driven Culture (Category 5)

Relationship-Building (Categories 3, 5)

Execution (Categories 1, 2)

• Conclusion


Biography

Emily Padula, RN, MHI, FACHE is the Executive Director of Integration and Outreach at Hill Country Memorial Healthcare in Fredericksburg, Texas. HCM has been a Truven 100 Top Hospital for the last four consecutive years and is one of two healthcare recipients of the 2014 Malcolm Baldrige National Quality Award.

Emily has provided leadership for the Baldrige process and the quality department, and her role also includes executive oversight for the hospital’s “outside the walls” departments, including hospice, home care, and outpatient rehabilitation programs. She has stewardship of the organization’s vision and action to create a healthy community. Her experience includes clinical analytics, healthcare leadership, clinical staff education, and patient care.

Contact:

[email protected] to download tools


Hill Country Memorial (HCM)


HCM Patients: Average Daily Census by Location

Inpatient6%

Outpatient30%

Outside the Walls64%


Our “Climb” of Performance Excellence


Malcolm Baldrige National Quality Award

• Named for Malcolm Baldrige, Secretary of Commerce 1981-1987

• Awarded by the President of the United States

• Six sectors

• Service• Manufacturing• Small Business• Health Care (Added in 2001)• Education (Added in 2001)• Not-for-Profit (Added in 2006)


Malcolm Baldrige National Quality Award

“I see the Baldrige process as a powerful set of mechanisms for disciplined people engaged in disciplined thought and taking disciplined action to create great organizations that produce exceptional results.”

—Jim Collins, bestselling author of Good to Great: Why Some Companies Make the Leap ... and Others Don’t


Baldrige Process Scoring

Category 1

Leadership

120 Points

Category 2

Strategy

85 Points

Category 3

Customer

85 Points

Category 4

Measurement

90 Points

Category 5

Workforce

85 Points

Category 6

Operations

85 Points


Baldrige Results Scoring

Category 7.1

Overall Outcomes

120 Points

Category 7.2

Customer

85 Points

Category 7.3

Workforce

85 Points

Category 7.4

Leadership

80 Points

Category 7.5

Financial

80 Points


Leadership

• Vision, Mission, Values

• How Senior Leaders Lead

• Communication

• Innovation

• Sustainability

Core Competencies are strategically important capabilities that are:

• Central to fulfilling your mission or

• Provide an advantage in your marketplace or service environment.

• Challenging for others to imitate – strategic advantage if leveraged, strategic challenge if not.


Leadership at HCM


Category 5: Building an effective and supportive workforce environment. Engaging your workforce to achieve organizational and personal success.


Values-Driven Hiring


Quarterly Values Evaluation


Values-Driven Culture Results


Category 3: Process for listening to customers to determine needs, engagement, dissatisfaction. Meeting customer needs and building relationships.

• Systematic Listening

• Systematic Acetion on Findings

Relationship-Building


Systematic Listening


Systematic Action: SBI Process

Strategic-level work

Diverse teams 1 Quarter

Weekly meetings Standard Tools PDCA process

Defined deliverables and

measures of success

War Room Accountability &

Coaching


Systematic Action: SBI War Room

• Charter

• Timeline

• Weekly Report

• Data (MOS)

• Best Practices

• Process Map

• Handoff Plan


Systematic Action: SBI for Patient Satisfaction

60

65

70

75

80

85

90

95

100

Q42011

Q12012

Q22012

Q32012

Q42012

Q12013

Q22013

Q32013

Q42013

Q12014

Q22014

Q32014

Q42014

Pe

rce

nti

le R

ank

Quietness of Environment


Execution

Strategic Planning

Cascading Goals

Category 1: Process whereby Senior Leaders lead.

Category 2: Converting Strategy to Action.


ExecutionHow We Align For Results

28

Execution


Cascading Goals


Alignment Board Huddle


Examples of Alignment for Execution

Employee QCP Goal100% Contract Compliance

Materials Management Department GoalDecrease Supply Expense

Strategic ObjectiveStrengthen Financial Independence


Supply Expense as a Percent of Net Revenue

14.0%

14.5%

15.0%

15.5%

16.0%

16.5%

17.0%

17.5%

2011 2012 2013 2014

Bet

ter

Top QuartileTop Decile

*CMI Adjusted

Examples of Alignment for Execution


Intradepartmental Alignment Example

Surgical Site Infection Team GoalImprove Surgical Site Infections to Top Decile

Patient Safety Council GoalAchieve 0 Hospital Acquired Conditions

Strategic ObjectiveEliminate Preventable Harm


Interdepartmental Alignment Example

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jul 2014 Oct 2014 Jan 2015 Apr-15

Bett

er

Surgical Site Infection NSQIP Percentile Ranking (mo. received)


2013 PERFORMANCE VERSUS RATE OF IMPROVEMENT

HOSPITAL KEY

Quintile Performance Key:

QuintilePercentile

Range

Performance

Level

1 >80 to 100 Best

2 >60 to 80

3 >40 to 60

4 >20 to 40

5 > 0 to 20 Worst

100 Top Study – Overall Performance compared to recent Baldrige winners

1 HILL COUNTRY MEMORIAL

2 Winner 2

3 Winner 3

4 Winner 4

5 Winner 5

6 Winner 6

7 Winner 7

8 Winner 8

12

3

4

5

6

7

8

0

20

40

60

80

100

0 20 40 60 80 100

2013 Performance

20

09

-2

01

3 R

ate

of

Imp

rove

me

nt


0

1

2

3

4

5

1.1

1.2

2.1

2.2

3.1

3.2

4.1

4.2

5.15.2

6.1

6.2

7.1

7.2

7.3

7.4

7.5

Scoring Comparison

2014 HCM

2014 Baldrige Mean

2014 Site VisitedOrganizations Mean

Ring Range0 0%-5%1 10%-25%2 30%-45%3 50%-65%4 70%-85%5 90%-100%

Seven Items Outperformed Site Visit Median

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