Using Baldrige to Create Organizational Alignment & Integration

Sonja Wulff, Manager, Performance Excellence

• Performance Excellence Journey• Role of the Application• Addressing OFIs

Overview

Poudre Valley Health System• Private, locally owned, not-for-profit• Full spectrum of healthcare services

– 2 tertiary hospitals, outpatient campus, numerous satellite clinics

– Regional medical hub for cardiac, trauma, neonatal intensive care & bariatric surgery

Poudre Valley Health System• Service area: Northern Colorado, Wyoming & Nebraska• 4,200 employees, 550 independent physicians & 800

volunteers• $1 billion in annual revenue

Where Our Journey Started• Community hospital serving Fort

Collins, Colorado• 24% annual employee turnover• 5 CEOs in 4 years• Changing healthcare market• Demand for physician integration

• Leadership: Find an improvement model• Decision: Baldrige National Quality Program

The Baldrige Journey

Baldrige National Quality Program• Presidential award to recognize high-performing organizations in manufacturing, service, small business, education, health care & nonprofit (1987)

• Criteria for Performance Excellence– Tool for organizational assessment, based on evidence-based practices from high-performing organizations

• Baldrige Process– Submit annual application for review by highly trained examiners– Receive feedback report to drive organizational improvement

• Commitment as recipient: Share best practices

• Category teams met just to write Application• Application focused on warm-fuzzy stories & lists of

accomplishments, including futures• Results selection based on what looked good and where we had

benchmarks• Baldrige happened outside of “normal” work• Submitted 1st application in 2000• Took a year off “to work on improvements”• Applied again, expecting “success”• Score dropped

The Early Years (2000-2003)

• Made Baldrige how we do business• Established Quality Improvement Department

– Role: Coordinate performance excellence across Categories

• Established performance excellence teams– Role: Use Criteria to identify & address gaps

A Turning Point (2004)

Performance Excellence Teams• Criteria-based steering committees that drive

improvements across system• Senior management leadership & participation• Representation from all facilities, disciplines &

customer groups

Performance Excellence Cycle

• Goal: Accurate, actionable feedback to help PVHS provide world-class healthcare

• Self-assessment• External assessment by highly trained

team of examiners

Role of the Application

CraigTrauma patient

• Define who you are & what is important to you– Vision, core competencies– Products, customers– Workforce, facilities– Competitors, strategic challenges/advantages

• Road map for the rest of the application & the way you run your business (key factors, key themes)

Step One: What Is Important to You?Organizational Profile

• Can you answer the Criteria questions? • Do you address ADLI?

Step 2: How Do You Run Your Organization?Process Categories (1-6)

• APPROACH: How do you do it? What are the steps in your process? How repeatable is it?

• DEPLOYMENT: Is your approach consistently applied across your organization? Who uses it?

• LEARNING: Do you refine your approach through systematic evaluation and improvement?

• INTEGRATION: Is your approach aligned with your organizational needs? How is it linked to other approaches/processes?

What Is ADLI?

• APPROACH: Annual process with standardized tool

• DEPLOYMENT: Every employee, all levels of the organization, all facilities

• LEARNING: Annual evaluation & improvement by Workforce Team & HR

• INTEGRATION– Behavior Standards, Values, Key Customer Requirements, Core

Competencies, Personal Goal Cards

– Building Blocks of Leadership

– Balanced scorecard: Timely completion of performance reviews

An ExampleEmployee Performance Review

• What are your key measures? • Are you measuring what you should be

measuring to support the Organizational Profile and Process Categories?

• Do you address LeTCI?

Step 3: What Are Your Results?

• LEVELS: What is your current performance?

• TRENDS: How have you performed over time?

• COMPARISONS: How does your performance compare to other organizations?

• INTEGRATION: Do you segment your results? Do you show results for important customers, products/services, markets, processes?

What Is LeTCI?

An Example: Staff Voluntary Turnover

Weaving a Thread

Org Profile Category 2 Category 3 Category 7

Customer Groups & Key Requirements

Input into strategic planning

Listening to customers

Healthcare outcomes,

satisfaction & dissatisfaction

measures

Weaving a Thread

Org Profile Category 1 Category 5 Category 7

Workforce Groups & Key Requirements

Deploying Vision,

Mission & Values

Performance management,

workforce development,

climate, capability &

capacity

Measures of satisfaction &

dissatisfaction, development,

climate, capability &

capacity

Performance Excellence Cycle

• Senior Management Retreat– Prioritize improvements

• Performance Excellence Teams– Develop & implement action plans

• Quality Improvement Department– Develop integrated action plan– Coordinate improvement efforts

Addressing OFIs

An Example: Integrated Action Plan

• Physician Engagement– Leadership: Fully deploy Vision to physicians– Strategy: Identify new ways to involve physicians in strategic

planning– Customer Service Steering Committee: Engage physicians in

improving patient satisfaction– Knowledge Management: Implement physician balanced

scorecards– Workforce: Support action plan from physician engagement

survey– Process Improvement: Support physician-led PDCA teams – Key Measures: Improve reporting of key measures to

physicians

• Integration with Strategic Plan• Communication through Quarterly

Performance Excellence Meetings• Accountability to PVHS Board of

Directors

Making It How We Do Business

• 8 national apps + 6 state apps• 4 national site visits + 3 state visits• Colorado Performance Excellence

Peak Award, 2004, 2008• Baldrige National Quality Award, 2008

Learning Patience

PVHS CEO Rulon Stacey at Quest for

Excellence, 2009

Our Vision

To provide

world-class

health care

Molly 4th generation treated at

PVH