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

2. Overview Performance Excellence Journey Role of the Application
Addressing OFIs

3. 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

4. Poudre Valley Health System
Service area: Northern Colorado, Wyoming & Nebraska
4,200 employees, 550 independent physicians & 800 volunteers
$1 billion in annual revenue

5. 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

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

7. 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

8. The Early Years ( )
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

9. 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

10. Performance Excellence Teams
Criteria-based steering committees that drive improvements across system
Senior management leadership & participation
Representation from all facilities, disciplines & customer groups

11. Performance Excellence Cycle

12. 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

13. 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)

14. Step 2: How Do You Run Your Organization? Process Categories (1-6)
Can you answer the Criteria questions?
Do you address ADLI?

15. 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?

16. 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

17. 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?

18. 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?

19. An Example: Staff Voluntary Turnover

20. 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

21. 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

22. Performance Excellence Cycle

23. 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

24. 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

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

26. 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

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