- Enhance understanding of the Performance Excellence program and the impact on Healthcare organizations - Be able to locate Process level and Results level items and how to begin - Identify areas in the hospital pharmacy that can be impacted by the program

1. Criteria for Performance Excellence
to Improve Pharmacy Services
Kenneth Maxik, Director of Patient Safety and Compliance
04/24/15 – TSHP Annual Seminar

2. Objectives
•Enhance understanding of the Performance
Excellence program and the impact on Healthcare
organizations
•Be able to locate Process level and Results level
items and how to begin
•Identify areas in the hospital pharmacy that can be
impacted by the program
2

3. Background
From big picture national level to what does it mean to me
at my pharmacy.
Apply
Don’t Apply
3

4. Baldrige Program History
The Malcolm Baldrige National Quality Improvement Act of
1987, Public Law 100‐107
Created Award Program to
 Establish criteria for evaluating improvement efforts
 Identify/recognize role‐model businesses
 Disseminate/share best practices
Expanded to health care and education (1999)
Expanded to nonprofit sector (2005)
No longer publicly funded (2012)

5. Breadth of the Baldrige Program
104 Baldrige Award winners 1987-2013
Number of applicants (through 2011):
 Manufacturing – 354
 Service – 187
 Small business – 361
 Education – 151 (since 1999)
 Healthcare – 288 (since 1999)
 40 out of 69 applicants in 2011 were healthcare
 Non-profit – 47 (since 2006)
Estimated number of state applicants – 10,279
 33 state quality award programs

6. Alliance for Performance Excellence
The Performance Excellence (PE) Criteria
Why is it right for Healthcare?
What is the criteria for performance excellence?
How can it produce performance excellence?
When can it serve as professional development?
(PD)

7. WHY IS PERFORMANCE
EXCELLENCE RIGHT FOR
HEALTH CARE
Results, Results, Results

8. In Today’s Environment,
You Don’t Have a Choice…
Must focus on your patients and other stakeholders – their needs,
expectations, engagement
Must focus on your people – your staff, key partners – their needs,
their capabilities, their satisfaction & engagement
Must use data to make decisions, to systematically improve key
processes
Must quickly adapt to changes in your environment and maintain
agility, innovation
Must constantly improve the way you do things – your core
processes, but also your support processes
Must rely on strong leadership – communication, transparency,
vision, and constancy of purpose
Must focus on all aspects of your organization – the system

9. Focusing Energy & Resources
Vision
Alignment
Mission
Vision
Mission

10. Truven Health Analytics (formerly Thomson Reuters) performed a study
of top performing hospitals and found…
“…hospitals that had won the Baldrige National Quality Award or been
considered for a Baldrige Award site visit, outperformed other hospitals
in nearly every metric used to determine the top 100 hospitals.”
Why is performance excellence right for
healthcare?

11. “Baldrige . . . has offered us a way to systematically evaluate
our entire organization and understand the link between the
hundreds of processes that make up the health care
experience. . . . We've spent considerable time making
improvements based on our Baldrige feedback. We've figured
out how to deploy a consistent message throughout our
organization. Our HR goals are now part of our strategic plan. .
. . We have developed a complaint management process that is
used systemwide. And we now benchmark against the
highest-performing companies, whether or not they're in
health care. Best of all, we've figured out how to translate our
mission imperative—that is, ‘exceptional health care
services’—into specific and measurable goals.”
—Sister Mary Jean Ryan, FSM, president/CEO, SSM Health Care, 2002 Award
recipient
Why is performance excellence right for
healthcare?

12. First, the Evidence…
Source: Kevin B. Hendricks and Vinod R. Singhal, “Don’t Count TQM Out,” Quality Progress, April 1999
Comparison of Award Winning Firms and Control Firms
Average % Change in Performance Measure
0
20
40
60
80
100
120
140
Stock Price Operating
Income
Sales Total
Assets
Employees Return on
Sales
Performance Measure
PercentChange
Award Winners
Control Group

13. Why is performance excellence right for
healthcare?
Core Measures
 Advocate Good Samaritan Hospital’s CMS core measure
results for pneumonia, heart failure, heart attack, and
surgical care are either approaching or exceeding the top-
decile level, and meet or exceed the levels of local
competitors.
 Atlanticare Regional Medical Center achieved CMS national
top-10 percent performance in 2008 for patient care
measures related to congestive heart failure, acute
myocardial infarction, and pneumonia.
 On 17 of 22 core measures reported for CMS, Schneck
Medical Center scored 100 percent in the second quarter
of 2011.

14. Why is performance excellence right for
healthcare?

15. WHAT IS THE CRITERIA FOR
PERFORMANCE EXCELLENCE

16. What are the criteria for
performance excellence?
“form of inquiry and discussion between
individuals, based on asking and answering
questions to stimulate critical thinking and
to illuminate ideas”
National Performance Excellence Criteria
JCAHO
NCQA DNV
Lean Six SigmaISO
“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, best-selling author
of Good to Great.

17. What are the criteria for
performance excellence?

18. What are the criteria for
performance excellence?
Understand the Linkages
Processes and Results
Achieved
Need for Data to Improve
Operations

19. What are the criteria for
performance excellence?
Linkage Between Workforce
Planning and Strategic Plan
Patient, Customer, and Market
Knowledge in Establishing
Strategy

20. Whatarethecriteriaforperformance
excellence?

21. Whatarethecriteriaforperformance
excellence?

22. Whatarethecriteriaforperformance
excellence?

23. Whatarethecriteriaforperformance
excellence?

24. Whatarethecriteriaforperformance
excellence?

25. HOW CAN IT PRODUCE
PERFORMANCE EXCELLENCE

26. Whatisthecriteriaforperformanceexcellence?

27. Whatisthecriteriaforperformanceexcellence?

28. Core Values

29. Core Values
• Systems perspective
• Visionary leadership
• Patient-focused excellence
• Valuing people
• Organizational learning and agility
• Focus on success
• Managing for innovation
• Management by fact
• Societal responsibility and
community health
• Ethics and transparency
• Delivering value and results

30. Core Values
• Systems perspective: A
systems perspective means
managing all the components of
your organization as a unified
whole to achieve your mission,
ongoing success, and
performance excellence.
• Visionary leadership: Should
set a vision for the organization,
create a focus on patients and
other customers, demonstrate
clear and visible organizational
values and ethics, and set high
expectations for the workforce

31. Core Values
• Patient-focused excellence:
must consider all features and
characteristics of patient care
delivery (including those not
directly related to medical,
clinical, and health services) and
all modes of customer access and
support that contribute value to
your patients and other customers
• Management by fact:
Management by fact requires you
to measure and analyze your
organization’s performance, both
inside the organization and in
your competitive environment.

32. Core Values
• Delivering value and results:
balancing value implies, your
organizational strategy should
explicitly include key stakeholder
requirements.
• Stakeholder: All groups that are or might
be affected by your organization’s actions
and success.

33. How can it produce performance
excellence?
Self Assessment > Holistic View
External Evaluation > Critical Review
Feedback Report > Improvement Priorities

34. State Award Program
Level 1
Interest
Recognition
Level 2
Commitment
Award
Level 3
Achievement
Award
Level 4
Excellence
Award

35. Getting Started: Option 1
Self‐assessment
 Who are we?
 What do we do?
 How do we do what we do?
 How well are we doing?
 How do we know how well we are doing?
Help think and act strategically
Help align processes and resources
Self‐identify opportunities for improvement

36. Getting Started: Option 1
Self‐assessment
Price is Free
Well Worth the Money!

37. Getting Started: Option 2
Guided Approach
Level 1 Application – Abbreviated Organizational Profile and
self assessment questionnaire

38. Getting Started
Simplified Organizational Profile
1. What key products and services do you provide to your
customers?
2. What is your organization's mission or purpose?
3. How many employees do you have in your workforce?
4. What are your key employee groups and their key
requirements?
5. How do you communicate with your employees?
6. Who are your key customers and why do they buy,
secure, or use your products or services?

39. Level 2 – Complete Organizational Profile
 7 Categories
 15 page max.
Continuing The Journey

40. Criteria for Performance
Excellence1.1 Senior Leadership (70 points)
Describe how senior leaders guide and sustain your organization. Describe your senior
leaders communicate with staff and encourage high performance.
Process
a. VISION, VALUES, and MISSION
(1) VISION and VALUES HOW do SENIOR LEADERS set your organization’s VISION and VALUES? HOW do SENIOR
LEADERS DEPLOY the VISION and VALUES through your LEADERSHIP SYSTEM; to the WORKFORCE; to KEY suppliers and
PARTNERS; and to PATIENTS, other CUSTOMERS, and other STAKEHOLDERS, as appropriate? HOW do SENIOR LEADERS’
personal actions reflect a commitment to those VALUES?
(2) Promoting Legal and ETHICAL BEHAVIOR HOW do SENIOR LEADERS’ actions demonstrate their commitment to
legal and ETHICAL BEHAVIOR? HOW do they promote an organizational environment that requires it?
(3) Creating a Successful Organization HOW do SENIOR LEADERS’ actions build an organization that is successful
now and in the future? HOW do they
• create an environment for the achievement of your MISSION, improvement of organizational PERFORMANCE,
PERFORMANCE leadership, organizational LEARNING, and LEARNING for people in the WORKFORCE; • create a WORKFORCE
culture that delivers a consistently positive experience for PATIENTS and other CUSTOMERS and that fosters CUSTOMER
ENGAGEMENT; • create an environment for INNOVATION and INTELLIGENT RISK taking, achievement of your STRATEGIC
OBJECTIVES, and organizational agility; • participate in succession planning and the development of future organizational
leaders; and • create and promote a culture of PATIENT safety?
b. Communication and Organizational PERFORMANCE
(1) Communication HOW do SENIOR LEADERS communicate with and engage the entire WORKFORCE and KEY
CUSTOMERS? HOW do they
• encourage frank, two-way communication, including EFFECTIVE use of social media, when appropriate; • communicate KEY
decisions and needs for organizational change; and • reinforce HIGH PERFORMANCE and a PATIENT, other CUSTOMER, and
health care focus by taking a direct role in
motivating the WORKFORCE, including by participating in reward and recognition programs?
(2) Focus on Action HOW do SENIOR LEADERS create a focus on action that will achieve the organization’s
MISSION? HOW do SENIOR LEADERS
• create a focus on action that will improve the organization’s PERFORMANCE, achieve INNOVATION and INTELLIGENT
RISK taking, and attain its VISION; • identify needed actions; and • in setting expectations for organizational PERFORMANCE,
include a focus on creating and balancing VALUE for PATIENTS, other CUSTOMERS, and other STAKEHOLDERS?

41. Criteria for Performance
Excellence
1.1 Senior Leadership (70 points)
Describe how senior leaders guide and sustain your
organization. Describe how your senior leaders
communicate with staff and encourage high
performance.
Process
Item Number
Item Title
Points
Basic Requirement

42. Level 3 - Organizational Profile
 7 Categories
 17 Items
 35 page max.
Continuing The Journey

43. Criteria for Performance
Excellence1.1 Senior Leadership (70 points)
Describe how senior leaders guide and sustain your organization. Describe your senior
leaders communicate with staff and encourage high performance.
Process
a. VISION, VALUES, and MISSION
(1) VISION and VALUES HOW do SENIOR LEADERS set your organization’s VISION and VALUES? HOW do SENIOR
LEADERS DEPLOY the VISION and VALUES through your LEADERSHIP SYSTEM; to the WORKFORCE; to KEY suppliers and
PARTNERS; and to PATIENTS, other CUSTOMERS, and other STAKEHOLDERS, as appropriate? HOW do SENIOR LEADERS’
personal actions reflect a commitment to those VALUES?
(2) Promoting Legal and ETHICAL BEHAVIOR HOW do SENIOR LEADERS’ actions demonstrate their commitment to
legal and ETHICAL BEHAVIOR? HOW do they promote an organizational environment that requires it?
(3) Creating a Successful Organization HOW do SENIOR LEADERS’ actions build an organization that is successful
now and in the future? HOW do they
• create an environment for the achievement of your MISSION, improvement of organizational PERFORMANCE,
PERFORMANCE leadership, organizational LEARNING, and LEARNING for people in the WORKFORCE; • create a WORKFORCE
culture that delivers a consistently positive experience for PATIENTS and other CUSTOMERS and that fosters CUSTOMER
ENGAGEMENT; • create an environment for INNOVATION and INTELLIGENT RISK taking, achievement of your STRATEGIC
OBJECTIVES, and organizational agility; • participate in succession planning and the development of future organizational
leaders; and • create and promote a culture of PATIENT safety?
b. Communication and Organizational PERFORMANCE
(1) Communication HOW do SENIOR LEADERS communicate with and engage the entire WORKFORCE and KEY
CUSTOMERS? HOW do they
• encourage frank, two-way communication, including EFFECTIVE use of social media, when appropriate; • communicate KEY
decisions and needs for organizational change; and • reinforce HIGH PERFORMANCE and a PATIENT, other CUSTOMER, and
health care focus by taking a direct role in
motivating the WORKFORCE, including by participating in reward and recognition programs?
(2) Focus on Action HOW do SENIOR LEADERS create a focus on action that will achieve the organization’s
MISSION? HOW do SENIOR LEADERS
• create a focus on action that will improve the organization’s PERFORMANCE, achieve INNOVATION and INTELLIGENT
RISK taking, and attain its VISION; • identify needed actions; and • in setting expectations for organizational PERFORMANCE,
include a focus on creating and balancing VALUE for PATIENTS, other CUSTOMERS, and other STAKEHOLDERS?

44. Criteria for Performance Excellence
1.1 Senior Leadership (70 points)
Describe how senior leaders guide and sustain your organization. Describe your senior
leaders communicate with staff and encourage high performance.
Within your response, include answers to the following questions:
Process
a. Vision and Values
How do senior leaders set organizational vision and values?
HOW do SENIOR LEADERS’ actions demonstrate their commitment to
legal and ETHICAL BEHAVIOR?
HOW do SENIOR LEADERS’ actions build an organization that is successful
now and in the future?
HOW do SENIOR LEADERS communicate with and engage the entire WORKFORCE and KEY
CUSTOMERS?
HOW do SENIOR LEADERS create a focus on action that will achieve the organization’s
MISSION?
(1)
(2)
(3)
b. Communication and Organizational
Improvement
(1)
(2)
Overall
Requirements

45. Level 4 – Organizational Profile
 7 Categories
 17 Items
 35 Areas
 50 page max.
Continuing The Journey

46. Criteria for Performance
Excellence1.1 Senior Leadership (70 points)
Describe how senior leaders guide and sustain your organization. Describe your senior
leaders communicate with staff and encourage high performance.
Process
a. VISION, VALUES, and MISSION
(1) VISION and VALUES HOW do SENIOR LEADERS set your organization’s VISION and VALUES? HOW do SENIOR
LEADERS DEPLOY the VISION and VALUES through your LEADERSHIP SYSTEM; to the WORKFORCE; to KEY suppliers and
PARTNERS; and to PATIENTS, other CUSTOMERS, and other STAKEHOLDERS, as appropriate? HOW do SENIOR LEADERS’
personal actions reflect a commitment to those VALUES?
(2) Promoting Legal and ETHICAL BEHAVIOR HOW do SENIOR LEADERS’ actions demonstrate their commitment to
legal and ETHICAL BEHAVIOR? HOW do they promote an organizational environment that requires it?
(3) Creating a Successful Organization HOW do SENIOR LEADERS’ actions build an organization that is successful
now and in the future? HOW do they
• create an environment for the achievement of your MISSION, improvement of organizational PERFORMANCE,
PERFORMANCE leadership, organizational LEARNING, and LEARNING for people in the WORKFORCE; • create a WORKFORCE
culture that delivers a consistently positive experience for PATIENTS and other CUSTOMERS and that fosters CUSTOMER
ENGAGEMENT; • create an environment for INNOVATION and INTELLIGENT RISK taking, achievement of your STRATEGIC
OBJECTIVES, and organizational agility; • participate in succession planning and the development of future organizational
leaders; and • create and promote a culture of PATIENT safety?
b. Communication and Organizational PERFORMANCE
(1) Communication HOW do SENIOR LEADERS communicate with and engage the entire WORKFORCE and KEY
CUSTOMERS? HOW do they
• encourage frank, two-way communication, including EFFECTIVE use of social media, when appropriate; • communicate KEY
decisions and needs for organizational change; and • reinforce HIGH PERFORMANCE and a PATIENT, other CUSTOMER, and
health care focus by taking a direct role in
motivating the WORKFORCE, including by participating in reward and recognition programs?
(2) Focus on Action HOW do SENIOR LEADERS create a focus on action that will achieve the organization’s
MISSION? HOW do SENIOR LEADERS
• create a focus on action that will improve the organization’s PERFORMANCE, achieve INNOVATION and INTELLIGENT
RISK taking, and attain its VISION; • identify needed actions; and • in setting expectations for organizational PERFORMANCE,
include a focus on creating and balancing VALUE for PATIENTS, other CUSTOMERS, and other STAKEHOLDERS?

47. Benefits of Using The Criteria
Improve organizational performance practices, capabilities,
and results by:
 Creating systematic approaches
 Aligning organizational performance toward the vision
 Integrating resources to improve communication,
productivity, and effectiveness and achieve the
organization’s goals
 Focusing on holistic performance

48. Open Dialogue
"I honestly in my heart believe that because we
participated in the Baldrige program and because it
gave us that consistent feedback, there are people
who are alive today who wouldn't have been had we
not been so committed to the Baldrige process."
—Rulon Stacey, President, Poudre Valley Health System