2008 AHCA/NCAL National Quality Award Program - Step III Overview - Jon Frantsvog Ira Schoenberger Tim Case

2 The 2008 Step III Criteria Leadership Strategic Planning Focus on Patients, Other Customers and Markets Measurement, Analysis, and Knowledge Management Workforce Focus Process Management Results

3 4. Measurement, Analysis, and Knowledge Management (90 pts.) Addresses Analysis, Review, and Improvement of Organizational Performance and Management of Data, Knowledge, and Information 4.1 Measurement, Analysis, and Improvement of Organizational Performance (45 pts.) 4.2 Management of Information, Information Technology, and Knowledge (45 pts.)

4 5. Workforce Focus (85 pts.) Addresses How an Organization Engages, Develops, and Manages Its Workforce and Builds an Effective Workforce Environment 5.1 Workforce Engagement (45 pts.) 5.2 Workforce Environment (40 pts.)

5 6. Process Management (85 pts.) Addresses How an Organization Designs Its Work Systems, Prepares for Emergencies, and Manages and Improves Its Work Processes 6.1 Work Systems Design (35 pts.) 6.2 Work Process Management and Improvement (50 pts.)

6 7. Results (450 pts.) Addresses Progress on Results—Including Current Performance Levels, Trends, and Comparative Data 7.1 Health Care Outcomes (100 pts.) 7.2 Patient- and Other Customer-Focused Outcomes (70 pts.) 7.3 Financial and Market Outcomes (70 pts.) 7.4 Workforce-Focused Outcomes (70 pts.) 7.5 Process Effectiveness Outcomes (70 pts.) 7.6 Leadership Outcomes (70 pts.)

7 7.1 Health Care Outcomes N1. Health care results reported in this Item should relate to the key health care features identified as patient and other customer requirements or expectations in P.1b(2), based on information gathered in Items 3.1 and 3.2. The measures or indicators should address factors that affect patient and other customer preference, such as those included in Item P.1, Note 7, and Item 3.1, Note 4. See other notes (N2 and N3) in this section.

8 7.2 Patient- and Other Customer- Focused Outcomes N1. Patient and other customer satisfaction and dissatisfaction results reported in this Item should relate to the patient and other customer groups and market segments discussed in P.1(b)2 and Item 3.1 and to the determination methods and data described in Item 3.2. Other customers might include patients’ families, the community, insurers and other third-party payers, employers, health care providers, patient advocacy groups, Department of Health, and students.

9 7.2 Patient- and Other Customer- Focused Outcomes N2. There may be several different dimensions of patient satisfaction, such as satisfaction with the quality of care, satisfaction with provider interactions, satisfaction with long-term health outcomes, and satisfaction with ancillary services. All of these areas are appropriate satisfaction indicators. N3. Measures and indicators of patients’ and other customers’ satisfaction with your services relative to their satisfaction with competitors or other organizations providing similar health care services (7.2a[1]) might include information and data from your customers and from independent organizations.

Financial and Market Outcomes Responses to 7.3a(1) might include aggregate measures of financial return, such as return on investment (ROI), operating margins, profitability, or profitability by health care market or patient and other customer segment. Responses also might include measures of financial viability, such as liquidity, debt-to-equity ratio, days cash on hand, asset utilization, cash flow, and bond ratings (if appropriate). Measures should relate to the financial measures reported in 4.1a(1) and the financial management approaches described in Item 2.2.

Workforce-Focused Outcomes N1. Results reported in this Item should relate to processes described in Category 5. Your results should be responsive to key work process needs described in Category 6 and to your organization’s action plans and human resource plans described in Item 2.2. N2. Responses to 7.4a(1) should include measures and indicators identified in response to 5.1c(1). N3. Results for paid staff, independent practitioners, volunteers, and health profession students should be included, as appropriate.

Process Effectiveness Outcomes N1. Results reported in Item 7.5 should address your key operational requirements as presented in the Organizational Profile and in Items 6.1 and 6.2. Include results not reported in Items 7.1–7.4. N2. Results reported in Item 7.5 should provide key information for analysis and review of your organizational performance (Item 4.1) and should provide the operational basis for health care outcomes (Item 7.1), patient- and other customer-focused outcomes (Item 7.2), and financial and market outcomes (Item 7.3). N3. Appropriate measures and indicators of work system performance (7.5a[1]) might include audit, just in- time delivery, and acceptance results for externally provided products, services, and processes; supplier

Leadership Outcomes N1. Measures or indicators of strategy and action plan accomplishment (7.6a[1]) should address your strategic objectives and goals identified in 2.1b(1) and your action plan performance measures and projected performance identified in 2.2a(6) and 2.2b, respectively. N2. For examples of measures of ethical behavior and stakeholder trust (7.6a[2]), see Item 1.2, Note 7. N3. Responses to 7.6a(3) might include financial statement issues and risks, important internal and external auditor recommendations, and management’s responses to these matters. For some nonprofit health care organizations, results of IRS 990 audits also might be included.

Leadership Outcomes N4. Accreditation, assessment, and regulatory and legal compliance results (7.6a[4]) should address requirements described in 1.2b. If your organization has received sanctions or adverse actions under law (including malpractice), regulation, accreditation, or contract during the past three years, briefly describe the incident's) and current status. If settlements have been negotiated in lieu of potential sanctions or adverse actions, give explanations. Workforce-related occupational health and safety results (e.g., Occupational Safety and Health Administration [OSHA] reportable incidents) should be reported in 7.4a(3). N5. Organizational citizenship and community health results (7.6a[5]) should address support of the key communities discussed in 1.2c.

The Step III (Baldrige) Application Tackling the Beast

16 The Project Team Project leader who ensures that the outline and eventual application stays on target, both for timeline and content. Management team and select floor staff provide input. Strong business writer has to bring together the input of the staff. A camel is a horse designed by a committee.

17 Writing the Application Be very thorough in response to the criteria. Address every section of each criterion. Make sure you are referring to the footnotes after each question to ensure you are linking to other sections. Provide examples to illustrate your point. When addressing questions referred to the scoring grid make sure you share with us how your organization approaches, deploys, aligns and integrates processes for each section as applicable. Prioritize what is most important to your organization. Remember you only have 44 pages. Plan ahead, outline before writing. Write in complete narrative sentences. Say enough, say it well, then stop.

18 Suggested Work Plan Start now Review application materials (AHCA/NCAL and Baldrige). Note that from year to year questions and requirements may change. Identify what each criterion requires. October - November - Develop a Plan of Attack Review Section 7 and refer back to footnote sections as applicable link to other sections. Review all sections and footnotes and link as applicable to other sections. Gather information. Farm out information gathering to department heads and other staff. Develop a strong outline for each section (watch space budget!

19 Suggested Work Plan December - March Write the sections and review weekly with team. Develop strong draft before 2/28. Solicit guidance as needed, the sooner the better. Check request, if necessary. March Polish. Study requirements and submittal instructions. Submit by March 31, 2008.

20 Engage Others in Learning Step III will engage staff with leaders in growing and learning Set up teams and divide work Work with employees who embrace it Establish meeting times and requirements Communicate across teams Celebrate achievement

21 Step III Keys to Success Articulate systematic processes, not just anecdotal evidence Systems and processes aligned and deployed with mission-driven strategic and operational goals Strong evidence of a quality management system with focus on the customer Demonstrate measurement, analysis, and action on performance results of key processes Performance results show improvement over time, but need not be always best in class

22 Step III Keys to Success Applicants who address all criteria thoroughly and specifically, according to the criteria, are likely to be successful.

23 Step III Award Recipients Step III Award recipients: Demonstrate an effective, systematic approach to all of the requirements in each category that is well deployed with evidence of fact-based and systematic evaluation, improvement, learning and innovation. Show how each approach is aligned or integrated with the organization’s needs as described in the Organizational Profile and other process areas. Are able to effectively demonstrate by approach, deployment, and level and consistency of results that they are “best-in-class.”

24 Receiving the Award… Reaping the Benefits Press releases Family letters Pins and plaques Marketing and advertising (using the logo) Community and Recognition Events Laying the groundwork for the next step

25 AHCA/NCAL Quality Award Eligibility Member of AHCA/NCAL No substandard quality of care or immediate jeopardy on standard or (substantiated) complaint surveys within the last three years Applicants at Step II and Step III levels must have a 3-year weighted average survey deficiency score that is no higher than 3-year weighted average in their state Step III applicants must have previously received the Step I and Step II Awards

26 Technical Requirements Due electronically March 31, page limit 1” Margins 12-pt Times New Roman font $475 application fee

Quality Award Schedule Step I Award Application DeadlineFebruary 28, 2008 Step II and III Award Application DeadlineMarch 31, 2008 Application Assessment/ScoringApril – July 2008 Step II Award Recipient NotificationJune 30, 2008 Step I Award Recipient NotificationJuly 31, 2008 Step III Award Recipient NotificationAugust 15, 2008 Feedback Report Distribution DeadlineSeptember 30, 2008 AHCA/NCAL Convention and Award Ceremony October 5-8, 2008

28 Resources AHCA/NCAL Quality Award program requirements and application information ( Baldrige National Quality Program To order a free copy of the Baldrige Health Care Criteria for Performance Excellence: Tel: Website:

29 More Resources Books available at Conducting Satisfaction-Based Customer Surveys: A Guidebook for Long Term Care Providers by Vivian Tellis-Nayak, Ph.D. Continuous Quality Improvement: Using the Regulatory Framework by Barbara Baylis Developing a Quality Management System: The Foundation for Performance Excellence in Long Term Care by Bernie Dana Quality Management Integration in Long-Term Care: Guidelines for Excellence by Maryjane Bradley and Nancy Thompson

For more information... For more information about the AHCA/NCAL Quality Award Program, please contact Wendy Vernon at or