Using Baldrige to Create Organizational Alignment & Integration Sonja Wulff, Manager, Performance Excellence

Overview Performance Excellence Journey Role of the Application Addressing OFIs

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

The Baldrige Journey Leadership: Find an improvement model Decision: Baldrige National Quality Program

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

The Early Years (2000-2003) 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

A Turning Point (2004) 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

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

Role of the Application Goal: Accurate, actionable feedback to help PVHS provide world-class healthcare Self-assessment External assessment by highly trained team of examiners Craig Trauma patient

Step One: What Is Important to You? Organizational Profile 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 2: How Do You Run Your Organization? Process Categories (1-6) Can you answer the Criteria questions? Do you address ADLI?

What Is ADLI? 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?

An Example Employee Performance Review 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

Step 3: What Are Your Results? 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?

What Is LeTCI? 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?

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

Addressing OFIs Senior Management Retreat Performance Excellence Teams Prioritize improvements Performance Excellence Teams Develop & implement action plans Quality Improvement Department Develop integrated action plan Coordinate improvement efforts

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

Making It How We Do Business Integration with Strategic Plan Communication through Quarterly Performance Excellence Meetings Accountability to PVHS Board of Directors

Learning Patience 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 PVHS CEO Rulon Stacey at Quest for Excellence, 2009

Our Vision To provide world-class health care Molly 4th generation treated at PVH