Criteria for Performance Excellence to Improve Pharmacy ServicesKenneth Maxik, Director of Patient Safety and Compliance04/24/15 – TSHP Annual Seminar

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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

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Background

From big picture national level to what does it mean to me at my pharmacy.

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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)

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

Alliance for Performance Excellence

The Performance Excellence (PE) CriteriaWhy 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)

WHY IS PERFORMANCE EXCELLENCE RIGHT FOR HEALTH CARE

Results, Results, Results

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

Focusing Energy & Resources

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Alignment

Mission

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Mission

Baldrige Assessme

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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?

“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?

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 FirmsAverage % Change in Performance Measure

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Stock Price OperatingIncome

Sales TotalAssets

Employees Return onSales

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Control Group

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.

Why is performance excellence right for healthcare?

WHAT IS THE CRITERIA FOR PERFORMANCE EXCELLENCE

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

JCAHONCQA 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.

What are the criteria for performance excellence?

What are the criteria for performance excellence?

Understand the Linkages

Processes and Results Achieved

Need for Data to Improve Operations

What are the criteria for performance excellence?

Linkage Between WorkforcePlanning and Strategic Plan

Patient, Customer, and MarketKnowledge in EstablishingStrategy

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HOW CAN IT PRODUCE PERFORMANCE EXCELLENCE

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Core Values

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

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

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.

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.

How can it produce performance excellence?

Self Assessment > Holistic ViewExternal Evaluation > Critical ReviewFeedback Report > Improvement Priorities

State Award Program

Level 1Interest Recognition

Level 2CommitmentAward

Level 3AchievementAward

Level 4Excellence Award

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

Getting Started: Option 1

Self‐assessment

Price is Free

Well Worth the Money!

Getting Started: Option 2

Guided Approach

Level 1 Application – Abbreviated Organizational Profile and self assessment questionnaire

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?

Level 2 – Complete Organizational Profile 7 Categories 15 page max.

Continuing The Journey

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.

ProcessSAMPLEa. VISION, VALUES, and MISSION

(1) VISION and VALUES HOW do SENIOR LEADERS set your organization’s VISION and VALUES? HOW do SENIORLEADERS DEPLOY the VISION and VALUES through your LEADERSHIP SYSTEM; to the WORKFORCE; to KEY suppliers andPARTNERS; 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 tolegal 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 successfulnow 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 KEYCUSTOMERS? 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 inmotivating 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’sMISSION? HOW do SENIOR LEADERS• create a focus on action that will improve the organization’s PERFORMANCE, achieve INNOVATION and INTELLIGENTRISK 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?

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

SAMPLEItem Number

Item Title

Points

Basic Requirement

Level 3 - Organizational Profile 7 Categories 17 Items 35 page max.

Continuing The Journey

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.

ProcessSAMPLEa. VISION, VALUES, and MISSION

(1) VISION and VALUES HOW do SENIOR LEADERS set your organization’s VISION and VALUES? HOW do SENIORLEADERS DEPLOY the VISION and VALUES through your LEADERSHIP SYSTEM; to the WORKFORCE; to KEY suppliers andPARTNERS; 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 tolegal 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 successfulnow 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 KEYCUSTOMERS? 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 inmotivating 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’sMISSION? HOW do SENIOR LEADERS• create a focus on action that will improve the organization’s PERFORMANCE, achieve INNOVATION and INTELLIGENTRISK 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?

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.

Within your response, include answers to the following questions:

Process

a.

Vision and ValuesHow do senior leaders set organizational vision and values?

HOW do SENIOR LEADERS’ actions demonstrate their commitment tolegal and ETHICAL BEHAVIOR?

HOW do SENIOR LEADERS’ actions build an organization that is successfulnow and in the future?

HOW do SENIOR LEADERS communicate with and engage the entire WORKFORCE and KEYCUSTOMERS?

HOW do SENIOR LEADERS create a focus on action that will achieve the organization’sMISSION?

(1)

(2)

(3)

SAMPLE

b.

Communication and Organizational Improvement

(1)

(2)

Overall Requirements

Level 4 – Organizational Profile 7 Categories 17 Items 35 Areas 50 page max.

Continuing The Journey

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.

ProcessSAMPLEa. VISION, VALUES, and MISSION

(1) VISION and VALUES HOW do SENIOR LEADERS set your organization’s VISION and VALUES? HOW do SENIORLEADERS DEPLOY the VISION and VALUES through your LEADERSHIP SYSTEM; to the WORKFORCE; to KEY suppliers andPARTNERS; 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 tolegal 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 successfulnow 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 KEYCUSTOMERS? 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 inmotivating 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’sMISSION? HOW do SENIOR LEADERS• create a focus on action that will improve the organization’s PERFORMANCE, achieve INNOVATION and INTELLIGENTRISK 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?

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

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