Health Care Express Survey Process .pptPresentation Transcript
National Council for Performance Excellence In partnership with the Michigan Quality Council 248-370-4552 phone [email_address] 425 B Pawley Hall Rochester, MI 48309-4401 2004 Health Care Baldrige Express Survey Process
Introduction National Council for Performance Excellence The Baldrige Criteria help organizations identify strengths and key areas for improvement. The Baldrige approach has been used for approximately 16 years by tens of thousands of organizations to stay abreast of competition and to increase effectiveness. 55 countries throughout the world have adopted the Baldrige framework to enhance competitiveness.
5 Reasons to Choose Baldrige
The Baldrige Criteria:
Provide a framework for improvement without being prescriptive.
Are inclusive. The Criteria describe an integrated management framework that addresses all the factors that define the organization, its operations, and its results.
Focus on common requirements, rather than procedures, tools, or techniques.
Are adaptable. They can be used by large and small businesses, and organizations with one site or worldwide locations.
Are at the leading edge of validated management practices.
Baldrige Award Winners Outperformed the S&P 500
The U.S. Department of Commerce studies the performance of publicly held Baldrige Award winning companies.
Every year since 1991 they outperformed the Standard and Poor’s index (S&P).
Baldrige winners outperformed the S&P 500 by 4.8 to 1.
1,101% increase in stock performance was demonstrated, compared to 228% from the S&P index companies for the same period.
It Makes Good Sense
Organizations that use a Performance Excellence process achieve results*:
59% Higher Stock Price
111% Higher Operating Income
116% Higher Sales
114% Higher Total Asset
*Data from Singhal and Hendricks Study
The National Council for Performance Excellence administers an organizational assessment survey utilizing the Malcolm Baldrige Criteria for Performance Excellence
The organizational assessment survey guides you through the 7 categories, addressing each item of the Criteria
The survey consists of 58 questions and takes approximately 2 hours to complete online
The assessment tool uses a maturity scale to determine the performance level
The Survey tool and Performance Indicator Feedback Report are effective and efficient aides to organizational assessment
Baldrige Express eSurvey
Baldrige Criteria for Performance Excellence
Focus on Patients, Other Customers, and Markets
Measurement, Analysis, and Knowledge Management
Organizational Performance Results
Health Care Criteria for Performance Excellence Systems Framework
Eleven Core Values
Organizational and Personal Learning
Valuing Staff and Partners
Focus on the Future
Managing for Innovation
Management by Fact
Social Responsibility and Community Health
Focus on Results and Creating Value
Your organization is facing increasing challenges everyday.
Assess your readiness to respond to those challenges by using the Baldrige Health Care Criteria
In the Health Care industry, organizations with world-class results are able to achieve a score about 700 (70%) on the Baldrige scale.
Organizations early in their performance improvement journey frequently score around 200 points.
Where would your organization score?
Benefits of the eSurvey Approach
Online, web-based, easily accessed from any PC
Cost effective compared to alternative approaches
Technical support provided
Engage employees at all levels
Easy to use maturity scale to determine performance level
Receive internal and external feedback
Obtain high performance diagnostics from the feedback
3-day turnaround of Performance Indicator Feedback Report upon completion of survey
Measure performance on a wide range of key organization performance indicators
Evaluate key processes, systems and results
Identify organizational strengths, deployment gaps, and pinpoint vital opportunities for improvement
The Performance Indicator Feedback Report
When all survey data has been collected, an automated Performance Indicator Feedback Report will be generated and sent to you in three business days.
The Performance Indicator Feedback Report consists of:
Gap Analysis Charts
Individual Question Scores
Pareto Charts for each Category
Priority Improvement Data Charts
Approach and Deployment Comments
Priority Improvement Comments
The following slides guide you through the eSurvey process
Included with the following eSurvey snapshots are sample reports to show how the data collected is later represented in the Performance Indicator Feedback Report.
Type in your User ID which you received through email (usually your email address) and unique password. Click ‘Login to the Survey’.
Customized Demographic Profile This is a sample of the table used to customize the Demographic Profile for your organization.
The Demographic Profile provides valuable comparative attributes within the organization.
Survey participants choose appropriate selections from the Demographic Profile to indicate their position within the organization.
Comparative charts and data are presented in the Performance Indicator Feedback Report according to the selections of the participants.
Baldrige Express e Survey Demographic Selection (Sample Participant’s View) Each different demographic attribute will appear on separate pages. Participants select the demographic value that describes their position within the organization.
Organization Demographics Vermont Council for Quality The Demographic Section is designed to provide the organization with an overall response rate relative to the total number of respondents and their percentage weight for each demographic attribute they have chosen. This chart reflects sample demographic data collected from the eSurvey and reported in the Performance Indicator Feedback Report.
e Survey Status Page (Sample Participant’s View) Once you have completed the Demographic Profile, click on the Leadership Category to begin the survey.
Click the radio button that best describes the level of development in your organization. Mouse over the levels to view the descriptors of each level. Category 1, Question 1A of the Survey
Overall Score by Question and Current-State Descriptors The Overall Score by Question and Current-State Descriptors show the overall percentage of points for a theme within each category. Refer to the Scoring Guidelines in Appendix B to see the approach/ deployment percentage scoring. The ‘Current’ text describes the maturity level of where the organization is now. The Role Model text describes where the organization could strive to be. View Appendix B
After each category, the eSurvey asks participants to identify two areas they believe needs the most improvement. This data is reported as a Pareto chart and Priority Improvement Data Chart in the Feedback Report. Priority Improvement Selections (Sample Participant’s View)
Staff members in your organization will be asked to select one or more areas in each of the seven categories, which they feel, is in most need of improvement. The concept of a Pareto chart is to show that the areas in need of improvement are usually a vital few, allowing leaders to concentrate their focus on specific improvement efforts.
We will supply you with a Pareto chart for each of the seven categories, which reference each of the seven sections of the Organization Assessment Survey.
Each chart will display the letters that correspond to the themes for each of the seven categories along the x-axis. Along the y-axis both Count and Percentages are charted. The count of staff votes (Hits) for each area they believe is most in need of improvement is represented as bars on the graph. The chart is arranged with the largest hit count on the left of the graph, indicating the area selected by staff which they feel is most in need of improvement. The line charted above the bars represents the cumulative percentages of each bar, from left to right.
Category 1 - Leadership Areas Most Needing Improvement - Pareto Chart The letters F, C, and G represent an opportunity to solve 80% of key issues in 30% of the areas (3 of 10) for the category (Leadership). In this example, the letters H, I, and J, did not receive any votes since these areas were not selected by staff as areas most in need of improvement.
Priority Improvement Counts and Percentages This chart shows priority improvement selections according to the various Demographic attributes and values. Look at “C” and “G” and you will see that Other Staff identified the need to improve these areas by a greater margin than did Senior Management and Doctors/Nurses. This tends to indicate a deployment gap and suggests that Senior Management and Doctors/Nurses are not perceived as effective as they believe themselves to be.
Approach and Deployment comments are requested for each Category priority improvement selection. Participants offer suggestions for improvement on the process. Participants offer approach/deployment comments and suggestions for improvement on their first selection. Priority Improvement Comments (Sample Participant’s View)
Participants offer approach/deployment comments and suggestions for improvement on their second selection. Priority Improvement Comments (Sample Participant’s View)
Leadership Row-Level Comments by Position Comments are provided by the respondents and can be prepared and used by examiners and organization leaders for improvement planning. The comments are sorted by each category and theme statement. Comments are reported out by one attribute, in this case, “Position”. They are then sorted by each value such as “Senior Management”, “Other Staff”, and “Doctor/Nurse”. 1A Communicating Values and Performance Expectations [Baldrige ref: 1.1a(1)] Position/Senior Management Approach & Deployment: We do a great job communicating to all. Through e-mails, town hall meetings, Intranet. Scorecards for the whole organization, sectors and local offices in place. Rules of Operation being implemented and communicated very efficiently. Approach & Deployment: We use many techniques to communicate including all hands meetings each quarter, weekly notes from the exec office, email, voice mail. Position/Other Staff Approach & Deployment: The scorecard is resented and the financial result and forecast are sometimes known. Action Steps to Improve : Get more input from contributors for the scorecard. Make the results known. Approach & Deployment: Some goals are linked to the balanced scorecard but many have not been seen as major objectives. Many goals are very ad hoc and changeable, leaving staff unsure on direction. Many times effort is expended only to see that it has been wasted because of a change in direction or emphasis. Position/Doctor/Nurse Approach & Deployment: The issue in the local office is that most of the top management has left the organization and is now not fully replaced. There are still some gaps in the organization, which create some lack of communication. The checking of the effectiveness to focus on patients does not seem to be done often.
Completed Survey Status Page When you have entered answers to every question for each category, you can submit your survey.
Summary Results Overall Category-Level Totals The Overall Category-Level Totals table explains the amount of points scored for each category, the total possible points to score in a category and the percentage of total points for each category.
Overall Category-Level Percent Scores The Overall Category-Level Percent Scores show the aggregate percent score of each Category according to the Baldrige Scoring Guidelines. This helps determine the overall strengths and weaknesses of the organization.
Overall Item-Level Percent Scores View Appendix A The Overall Item-Level Percent Scores show the percent of points on a 0 to 100 scale, for each Item. This helps users determine, at a glance, the strengths and weaknesses by item for each category. The Items and Point Values are explained in Appendix A.
Overall Category-Level Point Scores Position Point Scores by Category The Category-Level Point Scores show the cumulation of total points for each demographic view within each category. This is a sample of one demographic view.
Item-Level Percent Scores by Position Position Percent Scores by Item This chart shows the ratings by demographic attribute, in this case, Position. On the previous graph, Item 1.1, Leadership System, reflected a rating of 50%. However, according to the breakout above, Sr. Mgmt. believe the processes are much stronger (69 percent) than Other Staff (less than 38 percent) and Doctors/Nurses (45 percent). This typically indicates incomplete systems development or poor deployment of existing systems and processes required by the Item. View Appendix A Notice the gap between Senior Management and Other Staff and Doctors/Nurses in Item 1.1. This suggests an area to examine further. However, Item 7.4 shows a high degree of agreement indicating a consistent deployment of results information.
Additional Performance Indicator Feedback Reports can be extracted from the demographic profile. For example: Reports can be generated for each organizational site or department identified in the demographic profile.
The data that is entered into the survey is available in an ASCII Text File to create additional charts.
Comparative data at the Category-level is available from previous assessments from the same organization.
Additional copies of the Performance Indicator Feedback Report are available.
Michigan Quality Council
In cooperation with
National Council for Performance Excellence
Appendix A: Assessment Themes and Values The point values of the scoring system are linked directly to the points and scoring system of the Malcolm Baldrige Criteria for Performance Excellence. Each item and the questions included in the items are also derived from the Baldrige Criteria.
2004 Categories, Items, and Point Values
1.0 Leadership 120 points
1.1 Organizational Leadership 80 points
1A Communicating Values and Performance Expectations [Baldrige ref: 1.1a(1)]
1B Leadership Commitment to Providing Maximum Value for Patients and Other Customers and Stakeholders [Baldrige ref: 1.1a(1)]
1C Empowering Staff and Establishing a Climate for Empowerment, Innovation, Org. Agility, and Ethical Behavior [Baldrige ref: 1.1a(2)]
1D Ensuring Mgmt Accountability To Protect Stockholder and Stakeholder Interests through Effective Governance [Baldrige ref: 1.1b]
1E Assessing Organizational Performance and Progress Relative to Goals [Baldrige ref: 1.1c(1)]
1F Setting Priorities and Making Improvements Based on Progress Reviews [Baldrige ref: 1.1c(3)]
1G Improving Leadership Effectiveness Throughout the Organization [Baldrige ref: 1.1c(4)]
1.2 Social Responsibility 40 points
1H Following Laws and Regulations and Reducing Public Risks and Concerns [Baldrige ref: 1.2a(1&2)]
1I Ensuring Ethical Behavior [Baldrige ref: 1.2b]
1J Providing Community Support [Baldrige ref: 1.2c]
2.0 Strategic Planning 85 points
2.1 Strategy Development 40 points
2A Developing Strategic Plans Based on Health Care Service Performance Data [Baldrige ref: 2.1a(1&2)]
2B Developing Clear Strategic Objectives and Timetables for Meeting the Objectives [Baldrige ref: 2.1b(1)]
2C Ensuring that Strategic Objectives Address Challenges and Balance the Needs of Key Patients, Other Customers and Stakeholders
[Baldrige ref: 2.1b(2)]
2.2 Strategy Deployment 45 points
2D Developing and Deploying Action Plans Based on Strategic Objectives [Baldrige ref: 2.2a(1)]
2E Developing Staffing Plans Based on Strategic Objectives and Action Plans [Baldrige ref: 2.2a(3)]
2F Developing Appropriate Goals and Allocating Resources to Achieve Them [Baldrige ref: 2.2a(4) and 2.2b]
2G Aligning Work to Achieve Strategic Goals, Objectives, and Action Plans [Baldrige ref: 2.2a]
Back to Overall Item Scores Back to Gap Analysis
Appendix B: Scoring Guidelines for Categories 1-6: The overall percentage of points for 1A on the previous slide is 56%, indicating the above Approach and Deployment guideline. Back to Survey - Priority Imp