2006 Baldrige National Quality Program

Health Care
Criteria for
Performance
Excellence
THE MALCOLM BALDRIGE NATIONAL QUALITY AWARD
A Public-Private Partnership Board of Overseers
Building active partnerships in the private sector—and The Board of Overseers advises the Department of Com-
among the private sector and all levels of government—is merce on the Baldrige National Quality Program. The
fundamental to the success of the Baldrige National Quality board is appointed by the Secretary of Commerce and con-
Program in improving national competitiveness. Private- sists of distinguished leaders from all sectors of the U.S.
sector support for the Program in the form of funds, vol- economy.
unteer efforts, and participation in information transfer
The Board of Overseers evaluates all aspects of the Pro-
continues to grow.
gram, including the adequacy of the Criteria and processes
To ensure the continued growth and success of these part- for determining Award recipients. An important part of the
nerships, each of the following organizations plays an im- board’s responsibility is to assess how well the Program is
portant role. serving the national interest. Accordingly, the board makes
recommendations to the Secretary of Commerce and to the
Foundation for the Malcolm Baldrige Director of NIST regarding changes and improvements in
National Quality Award the Program.

The Foundation for the Malcolm Baldrige National Quality Board of Examiners
Award was created to foster the success of the Program.
The Foundation’s main objective is to raise funds to per- The Board of Examiners evaluates Award applications and
manently endow the Award Program. prepares feedback reports. The Panel of Judges, part of the
Board of Examiners, makes Award recommendations to the
Prominent leaders from U.S. organizations serve as Foun- Director of NIST. The board consists of leading experts
dation Trustees to ensure that the Foundation’s objectives from U.S. businesses and education, health care, and non-
are accomplished. A broad cross section of organizations profit organizations. NIST selects members through a com-
throughout the United States provides financial support to petitive application process. For 2006, the board consists of
the Foundation. about 540 members. Of these, 10 (who are appointed by
the Secretary of Commerce) serve as Judges, and approxi-
National Institute of Standards and mately 110 serve as Senior Examiners. The remainder
Technology serve as Examiners. All members of the board must take
part in an Examiner Preparation Course.
The U.S. Department of Commerce is responsible for the
Baldrige National Quality Program and the Award. The In addition to reviewing applications, board members play
National Institute of Standards and Technology (NIST), an a significant role in sharing information about the Program.
agency of the Department’s Technology Administration, Their membership in hundreds of professional, trade, com-
manages the Program. NIST promotes U.S. economic munity, and state organizations helps them disseminate this
growth by working with industry to develop and deliver the information.
high-quality measurement tools, data, and services neces-
sary for the nation’s technology infrastructure. NIST also Award Recipients
participates in a unique, government/private-sector partner-
ship to accelerate the development of high-risk technologies Award recipients are required to share information on their
that promise significant commercial and economic benefits. successful performance and quality strategies with other
Through a network of technology extension centers and U.S. organizations. However, recipients are not required to
field offices serving all 50 states and Puerto Rico, NIST share proprietary information, even if such information was
helps small- and medium-sized businesses access the infor- part of their Award application. The principal mechanism
mation and expertise they need to improve their competi- for sharing information is The Quest for Excellence®
tiveness in the global marketplace. Conference, held annually.
Award recipients in the 18 years of the Award have been
American Society for Quality extremely generous in their commitment to improving U.S.
competitiveness and furthering the U.S. pursuit of perform-
The American Society for Quality (ASQ) assists in adminis-
ance excellence. They have shared information with hundreds
tering the Award Program under contract to NIST. ASQ is
of thousands of companies, education organizations, health
dedicated to the ongoing development, advancement, and
care organizations, government agencies, and others. This
promotion of quality concepts, principles, and techniques.
sharing far exceeds expectations and Program requirements.
ASQ strives to be the world’s recognized champion and
Award recipients’ efforts have encouraged many other orga-
leading authority on all issues related to quality. ASQ rec-
nizations in all sectors of the U.S. economy to undertake
ognizes that continuous quality improvement will help the
their own performance improvement efforts.
favorable positioning of American goods and services in the
international marketplace.
 Baldrige National Quality Program
National Institute of Standards and Technology • Technology Administration • Department of Commerce

To: U.S. Health Care Community

From: Harry S. Hertz, Director

Baldrige National Quality Program

Subject: Win the Baldrige Challenge

The Baldrige Health Care Criteria for Performance Excellence are about winning! They are about winning in
your health care “marketplace” every day with a high-performing, high integrity, ethical organization. Every
Baldrige Criteria user is a winner.

The Health Care Criteria help organizations respond to current challenges and address all the complexities of
delivering today’s results while preparing effectively for the future. The 2006 Health Care Criteria include 19
simple new questions, one for each of the Baldrige Health Care Criteria Items (see page 11). While the questions
are simple, providing the answers is challenging and gets at the core of how your organization operates today and
how you prepare for the future. How does your organization measure up?
Whether your organization is small or large, is involved in ambulance service or health maintenance, or has one
facility or multiple sites across the country, the Health Care Criteria provide a valuable framework that can help
you measure performance and plan in an uncertain environment. The Health Care Criteria can help you align
resources with approaches, such as Plan-Do-Study-Act cycles, a Balanced Scorecard, and Six Sigma; improve
communication, productivity, and effectiveness; and achieve strategic goals.

How to begin that first Baldrige assessment? Take a few minutes and scan the questions in the Organizational
Profile on pages 12 and 14. A discussion of the answers to these questions might be your first Baldrige assess-
ment. For additional guidance, refer to our free booklet Getting Started with the Baldrige Criteria for Performance
Excellence.

Do you need to know what your staff and your senior managers think? Do you believe you have been making
progress but want to accelerate or better focus your efforts? Try using our simple Are We Making Progress? and
Are We Making Progress as Leaders? questionnaires. Organized by the seven Baldrige Criteria Categories, they will
help you check your progress toward meeting your organizational goals and can improve communication among
your staff and your leadership team.

Even if you don’t expect to win the Baldrige Award, submitting an Award application has valuable benefits. Every
applicant receives a detailed feedback report based on an independent, external assessment conducted by a panel
of specially trained and recognized experts.

The Health Care Criteria are in your hands . . . so is an incredible opportunity. Why not take advantage of that
opportunity? When you turn these pages, you turn the corner toward performance excellence. If you want more
information, contact me at nqp@nist.gov.

Need some useful tools to meet the Baldrige challenge? Try using
• Getting Started with the Baldrige Criteria for Performance Excellence
• E-Baldrige Organizational Profile found on our Web site at
www.baldrige.nist.gov/eBaldrige/Step_One.htm
• Are We Making Progress? and Are We Making Progress as Leaders?
Contact the Baldrige National Quality Program or visit our Web site for these and other educational materials.
Baldrige National Quality Program • NIST • Administration Building, Room A600 • 100 Bureau Drive, Stop 1020 • Gaithersburg, MD 20899-1020
Telephone: (301) 975-2036 • Fax: (301) 948-3716 • E-mail: nqp@nist.gov • Web site: www.baldrige.nist.gov
THE QUEST FOR EXCELLENCE

The Quest for Excellence® XVIII Conference

Each year, The Quest for Excellence, the official confer-
ence of the Malcolm Baldrige National Quality Award,
provides a forum for Baldrige Award recipients to share
their exceptional performance practices with worldwide
leaders in business, education, health care, and nonprofit
organizations. The Quest for Excellence XVIII will
showcase the year 2005 Award recipients.
For the last 17 years, executives, managers, and quality
leaders have come to this conference to learn how these
role model organizations have achieved performance ex-
cellence. CEOs and other leaders from the Award recipi-
ent organizations give presentations covering all seven
Categories of the Baldrige Criteria, their journey to per-
formance excellence, and their lessons learned. At this
three-day conference, designed to maximize learning
and networking opportunities, attendees will be able
to interact with Award recipients.
The Quest for Excellence XVIII Conference will be
held April 23–26, 2006, at the Hilton Washington in
Washington, D.C. For further information, contact the
Baldrige Program by mail: Baldrige National Quality
Program, NIST, Administration Building, Room A600,
100 Bureau Drive, Stop 1020, Gaithersburg, MD 20899-
1020; telephone: (301) 975-2036; fax: (301) 948-3716; or
e-mail: nqp@nist.gov. For a general overview of the
Baldrige National Quality Program, visit its Web site:
www.baldrige.nist.gov.

The Malcolm Baldrige National Quality Award

The Award crystal, composed of two solid crystal prismatic
forms, stands 14 inches tall. The crystal is held in a base of
black anodized aluminum with the Award recipient’s name
engraved on the base. A 22-karat gold-plated medallion is
captured in the front section of the crystal. The medal bears
the inscriptions “Malcolm Baldrige National Quality
Award” and “The Quest for Excellence” on one side and
the Presidential Seal on the other.
The President of the United States traditionally presents
the Award at a special ceremony in Washington, D.C.
Crystal by Steuben

The Malcolm Baldrige National Quality Award logo and the phrases “The Quest for Excellence”
and “Performance Excellence” are trademarks and service marks of the
National Institute of Standards and Technology.

ii 2006 Health Care Criteria for Performance Excellence

CONTENTS 1 2006 Health Care Criteria: Core Values, Concepts, and Framework
7 Key Characteristics of the Health Care Criteria
9 Changes from the 2005 Health Care Criteria

11 2006 Health Care Criteria for Performance Excellence—Item Listing

12 2006 Health Care Criteria for Performance Excellence
12 Preface: Organizational Profile
15 1 Leadership
18 2 Strategic Planning
21 3 Focus on Patients, Other Customers, and Markets
24 4 Measurement, Analysis, and Knowledge Management
26 5 Human Resource Focus
29 6 Process Management
32 7 Results

38 Baldrige Application Self-Analysis Worksheet

40 2006 Health Care Criteria: Category and Item Descriptions
55 Scoring System
56 Scoring Guidelines
59 2006 Health Care Criteria Response Guidelines

63 Applying for the Malcolm Baldrige National Quality Award

63 Fees for the 2006 Award Cycle
65 Summary of Health Care Eligibility and Restrictions
67 How to Obtain Copies of Baldrige National Quality Program Materials

69 Glossary of Key Terms

78 Index of Key Terms

Business and education organizations should use the appropriate Criteria

booklets for their respective sectors. See pages 67–68 for ordering information.

If you plan to apply for the Award in 2006, you also will need the Baldrige Award Application
Forms, which can be downloaded at www.baldrige.nist.gov/Award_Application.htm.
The first step in the Award application process is to provide the Eligibility Certification
Package, which is due April 11, 2006. If you would like to recommend a senior member of
your organization for the Board of Examiners, the package is due March 10, 2006.
Award Application Packages are due May 25, 2006, or May 11, 2006, if submitted on a CD.
We are easy to reach. Our Web site is www.baldrige.nist.gov.

2006 Health Care Criteria for Performance Excellence iii

 Baldrige National Quality Program
Honors 2004 Award Recipients

On July 20, 2005, the four 2004 Baldrige Award recipients—

The Bama Companies, Inc. (Bama); Texas Nameplate Company,
Inc. (TNC); Kenneth W. Monfort College of Business (Monfort);
and Robert Wood Johnson University Hospital Hamilton
(RWJ)—were honored. Clockwise from the upper right, the
photographs show (1) the Award crystal; (2) U.S. Secretary of
Commerce Carlos M. Gutierrez, Bama CEO Paula Marshall-
Chapman, Bama Chairman of the Board and Founder/Owner
Lilah Marshall, TNC President and CEO R. Dale Crownover,
TNC Vice President and General Counsel John L. Darrouzet,
U.S. Vice President Richard B. Cheney, Monfort Dean Joe
Alexander, Monfort Assistant Dean Tim Jares, RWJ President
and CEO Christy Stephenson, and RWJ Chief Operating Officer
Deborah Cardello; (3) Vice President Cheney; (4) Vice President
Cheney and the Award recipients; (5) and Secretary Gutierrez.

iv 2006 Health Care Criteria for Performance Excellence

2006 HEALTH CARE CRITERIA: CORE VALUES, CONCEPTS, AND FRAMEWORK

Criteria Purposes Visionary Leadership

Your organization’s senior leaders should create a leadership
The Health Care Criteria are the basis for conducting orga-
system that includes both clinical and administrative leaders
nizational self-assessments, for making Awards, and for
and fosters the integration and alignment of business and
giving feedback to applicants. In addition, the Health Care
clinical directions.
Criteria have three important roles in strengthening U.S.
competitiveness: Your organization’s senior leaders (administrative/operational
and health care provider leaders) should set directions and
I to help improve organizational performance practices,
create a patient focus, clear and visible values, and high ex-
capabilities, and results
pectations. The directions, values, and expectations should
I to facilitate communication and sharing of best prac- balance the needs of all your stakeholders. Your leaders
tices information among health care organizations and should ensure the creation of strategies, systems, and meth-
among U.S. organizations of all types ods for achieving performance excellence in health care,
stimulating innovation, building knowledge and capabilities,
I to serve as a working tool for understanding and
and ensuring organizational sustainability. The values and
managing performance and for guiding organizational
strategies should help guide all of your organization’s activi-
planning and opportunities for learning
ties and decisions. Senior leaders should inspire and motivate
Health Care Criteria for Performance Excellence Goals your entire staff and should encourage all staff, including
any volunteers, to contribute, to develop and learn, to be
The Health Care Criteria are designed to help organiza-
innovative, and to be creative. Senior leaders should be re-
tions use an integrated approach to organizational
sponsible to your organization’s governance body for their
performance management that results in
actions and performance. The governance body should be
I delivery of ever-improving value to patients, other responsible ultimately to all your stakeholders for the ethics,
customers, and stakeholders, contributing to improved actions, and performance of your organization and its senior
health care quality and organizational sustainability leaders.
I improvement of overall organizational effectiveness Senior leaders should serve as role models through their
and capabilities as a health care provider ethical behavior and their personal involvement in planning,
communications, coaching, development of future leaders,
I organizational and personal learning
review of organizational performance, and staff recognition.
As role models, they can reinforce ethics, values, and expec-
Core Values and Concepts tations while building leadership, commitment, and initia-
The Health Care Criteria are built on the following set of tive throughout your organization.
interrelated Core Values and Concepts:
Patient-Focused Excellence
I visionary leadership
The delivery of health care services must be patient focused.
I patient-focused excellence
Quality and performance are the key components in deter-
I organizational and personal learning mining patient satisfaction, and all attributes of patient care
I valuing staff and partners delivery (including those not directly related to medical/
I agility clinical services) factor into the judgment of satisfaction and
I focus on the future value. Satisfaction and value to patients are key considera-
I managing for innovation tions for other customers as well. Patient-focused excellence
has both current and future components: understanding
I management by fact
today’s patient desires and anticipating future patient desires
I social responsibility and community health and health care marketplace offerings.
I focus on results and creating value
Value and satisfaction may be influenced by many factors
I systems perspective
during a patient’s experience participating in health care.
These values and concepts, described below, are embedded Primary among these factors is an expectation that patient
beliefs and behaviors found in high-performing organizations. safety will be ensured throughout the health care delivery
They are the foundation for integrating key performance process. Additional factors include a clear understanding of
and operational requirements within a results-oriented likely health and functional status outcomes, as well as the
framework that creates a basis for action and feedback. patient’s relationship with the health care provider and an-
cillary staff, cost, responsiveness, and continuing care and

2006 Health Care Criteria for Performance Excellence 1

 in building community health and fulfilling its societal
responsibilities.
Staff success depends increasingly on having opportunities
for personal learning and on practicing new skills. In orga-
nizations that rely on volunteers, the volunteers’ personal
learning also is important, and their learning and skill de-
velopment should be considered with the staff’s. Organiza-
tions invest in staff’s personal learning through education,
training, and other opportunities for continuing growth and
development. Such opportunities might include job rotation
and increased pay for demonstrated knowledge and skills.
On-the-job training offers a cost-effective way to train and
to better link training to your organizational needs and pri-
orities. For health care providers, personal learning includes
building discipline knowledge, discipline retraining to adjust
attention. For many patients, the ability to participate in to a changing health care environment, and enhancing
making decisions about their health care is considered an knowledge of measurement systems that influence outcome
important factor. This requires patient education for an in- assessments and clinical guidelines, decision trees, or critical
formed decision. Characteristics that differentiate one pathways. Education and training programs may benefit
provider from another also contribute to the sense of being from advanced technologies, such as computer- and Internet-
patient-focused. based learning and satellite broadcasts.
Patient-focused excellence is thus a strategic concept. It is Personal learning can result in (1) more satisfied and versa-
directed toward obtaining and retaining patient loyalty, re- tile staff who stay with your organization, (2) organizational
ferral of new patients, and market share gain in competitive cross-functional learning, (3) the building of your organiza-
markets. Patient-focused excellence thus demands rapid and tion’s knowledge assets, and (4) an improved environment
flexible response to emerging patient desires and health care for innovation.
marketplace requirements, and measurement of the factors
Thus, learning is directed not only toward better health care
that drive patient satisfaction. It demands listening to your
services but also toward being more responsive, adaptive,
patients and other customers. Patient-focused excellence
innovative, and efficient—giving your organization health
also demands awareness of new technology and new modali-
care marketplace sustainability and performance advantages
ties for delivery of health care services.
and giving your staff satisfaction and motivation to excel.
Organizational and Personal Learning
Valuing Staff and Partners
Achieving the highest levels of organizational performance
An organization’s success depends increasingly on the diverse
requires a well-executed approach to organizational and
backgrounds, knowledge, skills, creativity, and motivation of
personal learning. Organizational learning includes both
all its staff and partners, including both paid staff and vol-
continuous improvement of existing approaches and signifi-
unteers, as appropriate.
cant change, leading to new goals and approaches. Learning
needs to be embedded in the way your organization oper- Valuing staff means committing to their satisfaction, devel-
ates. This means that learning (1) is a regular part of daily opment, and well-being. Increasingly, this involves more
work; (2) is practiced at personal, department/work unit, flexible, high-performance work practices tailored to staff
and organizational levels; (3) results in solving problems at with varying workplace and home life needs. Major chal-
their source (“root cause”); (4) is focused on building and lenges in the area of valuing staff include (1) demonstrating
sharing knowledge throughout your organization; and (5) is your leaders’ commitment to your staff’s success, (2) provid-
driven by opportunities to effect significant, meaningful ing recognition that goes beyond the regular compensation
change. Sources for learning include staff’s and volunteers’ system, (3) offering development and progression within
ideas, health care research findings, patients’ and other cus- your organization, (4) sharing your organization’s knowl-
tomers’ input, best practice sharing, and benchmarking. edge so your staff can better serve your patients and other
customers and contribute to achieving your strategic objec-
Organizational learning can result in (1) enhancing value to
tives, (5) creating an environment that encourages appropri-
patients through new and improved patient care services;
ate risk taking and innovation, and (6) creating a supportive
(2) developing new health care opportunities; (3) reducing
environment for a diverse workforce.
errors, defects, waste, and related costs; (4) improving re-
sponsiveness and cycle time performance; (5) increasing Organizations need to build internal and external partnerships
productivity and effectiveness in the use of all your re- to better accomplish overall goals. Internal partnerships might
sources; and (6) enhancing your organization’s performance include cooperation among staff, physicians, independent

2 2006 Health Care Criteria for Performance Excellence

practitioners, and other staff, as well as labor-management All aspects of time performance now are more critical, and
cooperation. Partnerships with staff might entail staff devel- cycle time has become a key process measure. Other impor-
opment, cross-training, or new work organizations, such as tant benefits can be derived from this focus on time; time
high-performance work teams. Internal partnerships also improvements often drive simultaneous improvements in
might involve creating network relationships among your organization, quality, cost, patient focus, and productivity.
departments/work units to improve flexibility, responsive-
ness, and knowledge sharing and to develop processes that Focus on the Future
better meet patient care and needs. In today’s health care environment, creating a sustainable
organization requires understanding the short- and longer-
External partnerships might be with customers, suppliers,
term factors that affect your organization and health care
business associations, third-party payors; nonprofit, educa-
marketplace. Pursuit of health care excellence requires a
tion, community, and social service organizations; and other
strong future orientation and a willingness to make long-
health care providers. Strategic partnerships or alliances are
term commitments to key stakeholders—your patients and
increasingly important kinds of external partnerships. Such
families, staff, communities, employers, payors, health pro-
partnerships with other health care organizations could re-
fession students, suppliers, and partners.
sult in referrals or in shared facilities that are either capital
intensive or require unique and scarce expertise. Also, part- Your organization’s planning should anticipate many factors,
nerships might permit the blending of your organization’s such as changes in health care delivery systems, resource
core competencies or leadership capabilities with the com- availability, patient and other stakeholder expectations,
plementary strengths and capabilities of partners to address technological developments, new partnering opportunities,
common issues. External partnerships also might address staff development and hiring needs, the evolving importance
sector-wide issues, such as the need for comparative data. of electronic communication and information transfer, changes
in customer and market segments, evolving regulatory re-
Successful internal and external partnerships develop
quirements, changes in community and societal expectations
longer-term objectives, thereby creating a basis for mutual
and needs, and new thrusts by competitors and other orga-
investments and respect. Partners should address the key
nizations providing similar services. Strategic objectives and
requirements for success, means for regular communica-
resource allocations need to accommodate these influences.
tion, approaches to evaluating progress, and means for
A focus on the future includes developing staff and suppli-
adapting to changing conditions. In some cases, joint edu-
ers, accomplishing effective succession planning, creating
cation and training could offer a cost-effective method for
opportunities for innovation, and anticipating public re-
staff development.
sponsibilities and concerns.
Agility A major long-term investment associated with health care
Success in today’s ever-changing health care environment excellence is the investment in creating and sustaining an
demands agility—a capacity for rapid change and flexibility. assessment system focused on health care outcomes. This
All aspects of electronic communication and information entails becoming familiar with research findings and ongo-
transfer require and enable more rapid, flexible, and cus- ing application of assessment methods.
tomized responses. Health care providers face ever-shorter
cycles for the introduction of new/improved health care ser- Managing for Innovation
vices, as well as for faster and more flexible responses to pa- Innovation means making meaningful change to improve an
tients and other customers, and nonprofit and governmental organization’s services, programs, processes, and operations
organizations are increasingly being asked to respond rapidly and to create new value for the organization’s stakeholders.
to new or emerging social issues. Major improvements in Innovation should lead your organization to new dimensions
response times often require simplification of work units of performance. Innovation is no longer strictly the purview
and processes or the ability for rapid changeover from one of health care researchers; innovation is important for all
process to another. Cross-trained and empowered staff are aspects of your operations and all processes. For example,
vital assets in such a demanding environment. innovation can address critical pathways and practice guide-
lines, facility design, the administration of medications, the
Today’s health care environment places a heavy burden on
organization of work, or alternative therapies. Organizations
the timely design of health care delivery systems, disease
should be led and managed so that innovation becomes part
prevention programs, health promotion programs, and
of the learning culture. Innovation should be integrated into
effective and efficient diagnostic and treatment systems.
daily work and should be supported by your performance
Overall design must include the opportunity to learn for
improvement system.
continuous organizational improvement and must value the
individual needs of patients. Design also must include effec- Innovation builds on the accumulated knowledge of your
tive means for gauging improvement of health status—for organization and its staff. Therefore, the ability to rapidly
patients and populations/communities. Beneficial changes disseminate and capitalize on this knowledge is critical to
must be introduced at the earliest appropriate opportunity. driving organizational innovation.

2006 Health Care Criteria for Performance Excellence 3

Management by Fact Organizations should not only meet all local, state, and fed-
An effective health care service and administrative manage- eral laws and regulatory and accreditation requirements, but
ment system depends on the measurement and analysis of they should treat these and related requirements as oppor-
performance. Such measurements should derive from health tunities for improvement “beyond mere compliance.”
care service needs and strategy, and they should provide Organizations should stress ethical behavior in all stake-
critical data and information about key processes, outputs, holder transactions and interactions. Highly ethical conduct
and results. Many types of data and information are needed should be a requirement of and should be monitored by the
for performance management. Performance measurement organization’s governance body. Ethical conduct should ad-
should include information on health care outcomes; com- dress both business and health care practices, such as the
munity health; epidemiological data; critical pathways and need to consider nondiscriminatory patient treatment poli-
practice guidelines; administrative, payor, staff, cost, and cies and protection of patients’ rights and privacy. Public
financial performance; competitive or collaborative compar- health services and the support of the general health of the
isons; customer satisfaction; and corporate governance and community are important citizenship responsibilities of
compliance. Data should be segmented by, for example, health care organizations.
markets, health care service lines, and staff groups to facili- Practicing good citizenship refers to leadership in carrying
tate analysis. out these responsibilities—within the limits of an organiza-
Analysis refers to extracting larger meaning from data and tion’s resources—and includes influencing other organiza-
information to support evaluation, decision making, and tions, private and public, to partner for these purposes. For
improvement. Analysis entails using data to determine example, your organization might lead or participate in
trends, projections, and cause and effect that might not efforts to establish free clinics or affordable health care pro-
otherwise be evident. Analysis supports a variety of purposes, grams, to increase public health awareness programs, or to
such as planning, reviewing your overall performance, im- foster neighborhood services for the elderly. A leadership
proving operations, accomplishing change management, role also could include helping to define regional or national
and comparing your performance with competitors’, with health care issues for action by regional or national networks
similar health care organizations’, or with “best practices” or associations.
benchmarks. Managing social responsibility requires the use of appro-
A major consideration in performance improvement and priate measures and leadership responsibility for those
change management involves the selection and use of per- measures.
formance measures or indicators. The measures or indicators
you select should best represent the factors that lead to improved Focus on Results and Creating Value
health care outcomes; improved customer, operational, financial, An organization’s performance measurements need to focus
and ethical performance; and healthier communities. A compre- on key results. Results should be used to create and balance
hensive set of measures or indicators tied to patient/customer and value for your key stakeholders—patients, their families,
organizational performance requirements represents a clear basis staff, the community, payors, businesses, health profession
for aligning all processes with your organization’s goals. Through students, suppliers, partners, investors, and the public. By
the analysis of data from your tracking processes, your creating value for your key stakeholders, your organization
measures or indicators themselves may be evaluated and builds loyalty and contributes to the community. To meet
changed to better support your goals. the sometimes conflicting and changing aims that balancing
value implies, organizational strategy explicitly should in-
Social Responsibility and Community Health clude key stakeholder requirements. This will help ensure
A health care organization’s leaders should stress responsi- that plans and actions meet differing stakeholder needs and
bilities to the public, ethical behavior, and the need to foster avoid adverse impacts on any stakeholders. The use of a bal-
improved community health. Leaders should be role models anced composite of leading and lagging performance mea-
for your organization in focusing on ethics and protection sures offers an effective means to communicate short- and
of public health, safety, and the environment. Protection of longer-term priorities, monitor actual performance, and
health, safety, and the environment includes any impact of provide a clear basis for improving results.
your organization’s operations. Also, organizations should
emphasize resource conservation and waste reduction at the Systems Perspective
source. Planning should anticipate adverse impacts that may The Baldrige Health Care Criteria provide a systems per-
arise in facilities management, as well as distribution, trans- spective for managing your organization and its key pro-
portation, use, and disposal of your radiation, chemicals, and cesses to achieve results—performance excellence. The
biohazards. Effective planning should prevent problems, seven Baldrige Categories and the Core Values form the
provide for a forthright response if problems occur, and building blocks and the integrating mechanism for the
make available information and support needed to main- system. However, successful management of overall perfor-
tain public awareness, safety, and confidence. mance requires organization-specific synthesis, alignment,

4 2006 Health Care Criteria for Performance Excellence

and integration. Synthesis means looking at your organiza-
tion as a whole and builds upon key organizational require- Linkage of the Health Care Criteria to the
ments, including your strategic objectives and action plans. Baldrige Business Sector Criteria
Alignment means using the key linkages among requirements
given in the Baldrige Categories to ensure consistency of The 2006 Health Care Criteria incorporate the Core
plans, processes, measures, and actions. Integration builds Values and Concepts described on the preceding pages
on alignment, so that the individual components of your and are built upon the seven-part framework used in
performance management system operate in a fully intercon- the Business Criteria for Performance Excellence. The
nected manner. rationale for the use of the same framework is that it is
adaptable to the requirements of all organizations, in-
These concepts are depicted in the Baldrige framework cluding health care organizations. However, this adap-
below. A systems perspective includes your senior leaders’ tation does not assume that these requirements are nec-
focus on strategic directions and on your patients and other essarily addressed in the same way. This adaptation to
customers. It means that your senior leaders monitor, respond health care, then, is largely a translation of the language
to, and manage performance based on your results. A systems and basic concepts of business excellence to similarly
perspective also includes using your measures, indicators, important concepts in health care excellence. A major
and organizational knowledge to build your key strategies. practical benefit derived from using a common frame-
It means linking these strategies with your key processes work for all sectors of the economy is that it fosters
and aligning your resources to improve overall performance cross-sector cooperation and sharing of best practices
and satisfy patients, other customers, and stakeholders. information.
Thus, a systems perspective means managing your whole
organization, as well as its components, to achieve success.

Baldrige Health Care Criteria for Performance Excellence Framework: A Systems Perspective

Organizational Profile:
Environment, Relationships, and Challenges

2 5
Strategic Human Resource
Planning Focus

1 7
Leadership Results

3 6
Focus on Patients, Process
Other Customers, Management
and Markets

4
Measurement, Analysis, and Knowledge Management

2006 Health Care Criteria for Performance Excellence 5

Health Care Criteria for Performance Human Resource Focus (Category 5), Process Management
Excellence Framework (Category 6), and Results (Category 7) represent the results
triad. Your organization’s staff and key processes accomplish
The Core Values and Concepts are embodied in seven the work of the organization that yields your overall perfor-
Categories, as follows: mance results.
1 Leadership All actions point toward Results—a composite of health
2 Strategic Planning care, patient and other customer, and market, financial, and
internal operational performance results, including human
3 Focus on Patients, Other Customers, and Markets resource, governance, and social responsibility results.
4 Measurement, Analysis, and Knowledge
The horizontal arrow in the center of the framework links
Management
the leadership triad to the results triad, a linkage critical to
5 Human Resource Focus organizational success. Furthermore, the arrow indicates the
6 Process Management central relationship between Leadership (Category 1) and
Results (Category 7). The two-headed arrows indicate the
7 Results
importance of feedback in an effective performance manage-
The figure on page 5 provides the framework connecting ment system.
and integrating the Categories.
System Foundation
From top to bottom, the framework has the following basic
Measurement, Analysis, and Knowledge Management (Cat-
elements.
egory 4) are critical to the effective management of your
Organizational Profile organization and to a fact-based, knowledge-driven system
for improving health care and operational performance.
Your Organizational Profile (top of figure) sets the context
Measurement, analysis, and knowledge management serve as
for the way your organization operates. Your environment,
a foundation for the performance management system.
key working relationships, and strategic challenges serve as
an overarching guide for your organizational performance
management system. Criteria Structure
The seven Criteria Categories shown in the figure are sub-
System Operations divided into Items and Areas to Address.
The system operations are composed of the six Baldrige
Categories in the center of the figure that define your Items
operations and the results you achieve. There are 19 Items, each focusing on a major requirement.
Leadership (Category 1), Strategic Planning (Category 2), Item titles and point values are given on page 11. The Item
and Focus on Patients, Other Customers, and Markets format is shown on page 59.
(Category 3) represent the leadership triad. These Categories
Areas to Address
are placed together to emphasize the importance of a lead-
ership focus on strategy and patients and other customers. Items consist of one or more Areas to Address (Areas).
Senior leaders set your organizational direction and seek Organizations should address their responses to the specific
future opportunities for your organization. requirements of these Areas.

6 2006 Health Care Criteria for Performance Excellence

KEY CHARACTERISTICS OF THE HEALTH CARE CRITERIA

1. The Criteria focus on results. 3. The Criteria integrate key health care themes.
The Criteria focus on the key areas of organizational The Health Care Criteria have been adapted to be sensi-
performance given below. tive to and tolerant of the specific needs of health care
organizations. These include
Organizational performance areas:
I the different types of organizational missions (e.g.,
(1) health care and service delivery outcomes
HMOs, home health care agencies, hospitals, and/or
(2) patient- and other customer-focused outcomes teaching and research institutions);
(3) financial and market outcomes I the patient as key customer and multiple other
customers and stakeholders (e.g., the community
(4) human resource outcomes
and payors);
(5) organizational effectiveness outcomes, including I the complex leadership structure that includes both
key internal operational performance measures
administrative/operational and health care providers;
(6) leadership and social responsibility outcomes I the multiple roles that health care providers may
play as staff, supplier, and customer; and
The use of this composite of measures is intended to
ensure that strategies are balanced—that they do not I the importance of health care service delivery as the
inappropriately trade off among important stakeholders, primary focus of the organization’s processes.
objectives, or short- and longer-term goals.
4. The Criteria support a systems perspective to
2. The Criteria are nonprescriptive and adaptable. maintaining organization-wide goal alignment.
The Criteria are made up of results-oriented require- The systems perspective to goal alignment is embedded
ments. However, the Criteria do not prescribe in the integrated structure of the Core Values and
Concepts, the Organizational Profile, the Criteria, the
I how your organization should be structured;
Scoring Guidelines, and the results-oriented, cause-effect
I that your organization should or should not have linkages among the Criteria Items.
departments for quality, planning, or other
Alignment in the Criteria is built around connecting and
functions; or
reinforcing measures derived from your organization’s
I that different units in your organization should be processes and strategy. These measures tie directly to
managed in the same way. patient/customer and stakeholder value and to overall
performance. The use of measures thus channels differ-
These factors differ among organizations, and they are
ent activities in consistent directions with less need for
likely to change as needs and strategies evolve.
detailed procedures, centralized decision making, or
The Criteria are nonprescriptive for the following reasons: overly complex process management. Measures thereby
serve both as a communications tool and as a basis for de-
(1) The focus is on results, not on procedures, tools, or
ploying consistent overall performance requirements.
organizational structure. Health care organizations
Such alignment ensures consistency of purpose while also
are encouraged to develop and demonstrate creative,
supporting agility, innovation, and decentralized decision
adaptive, and flexible approaches for meeting re-
making.
quirements. Nonprescriptive requirements are
intended to foster incremental and major (“break- A systems perspective to goal alignment, particularly when
through”) improvements, as well as basic change strategy and goals change over time, requires dynamic
through innovation. linkages among Criteria Items. In the Criteria, action-
oriented cycles of learning take place via feedback be-
(2) The selection of tools, techniques, systems, and
tween processes and results.
organizational structure usually depends on factors
such as organization type and size, organizational The learning cycles have four, clearly defined stages:
relationships, your organization’s stage of develop-
(1) planning, including design of processes, selection
ment, and staff capabilities and responsibilities.
of measures, and deployment of requirements
(3) A focus on common requirements, rather than on
(2) executing plans
common procedures, fosters understanding, com-
munication, sharing, alignment, and integration, (3) assessing progress and capturing new knowledge,
while supporting innovation and diversity in taking into account internal and external results
approaches.

2006 Health Care Criteria for Performance Excellence 7

 (4) revising plans based on assessment findings, strengths and opportunities for improvement relative to
learning, new inputs, new requirements, and the 19 performance-oriented requirements and relative to
opportunities for innovation process and performance maturity as determined by the
Scoring Guidelines. In this way, assessment leads to ac-
5. The Criteria support goal-based diagnosis. tions that contribute to performance improvement in all
The Criteria and the Scoring Guidelines make up a two- areas, as described in the shaded box on page 7. This
part diagnostic (assessment) system. The Criteria are a diagnostic assessment is a useful management tool that
set of 19 performance-oriented requirements. The Scor- goes beyond most performance reviews and is applicable
ing Guidelines spell out the assessment dimensions— to a wide range of strategies, management systems, and
Process and Results—and the key factors used to assess types of organizations.
each dimension. An assessment thus provides a profile of

8 2006 Health Care Criteria for Performance Excellence

CHANGES FROM THE 2005 HEALTH CARE CRITERIA

The Health Care Criteria for Performance Excellence have The most significant changes in the Health Care Criteria
evolved significantly over time to help organizations address booklet for 2006 are summarized as follows:
a dynamic environment, focus on strategy-driven perfor- I Item Notes have been added that specifically address
mance, and, most recently, address concerns about gover-
nonprofit health care organizations.
nance, ethics, and organizational sustainability. The Criteria
have continually progressed toward a comprehensive, inte- I Each Criteria Item title now includes a simple question
grated systems perspective of overall organizational perfor- that encompasses the central concept of the Item.
mance management.
Minor wording improvements have been made throughout
Each year, the decision whether to revise the Criteria must the Criteria booklet.
balance two important considerations. On one hand, there is
a need for Criteria that are at the leading edge of validated Item Notes
management practice to help users address the increasingly Some Item Notes have been modified and some Item Notes
complex challenges they face; on the other hand, there is a have been added to specifically address concepts of impor-
desire for Criteria that are stable to allow users continuity in tance to nonprofit health care organizations.
their performance assessments. In 2005, the Baldrige Criteria
were significantly revised to address the focused demands on Criteria Item Titles
senior leaders, the need for long-term (as well as short-term) Each Criteria Item title now includes a simple question that
organizational sustainability, the great challenges of innovat- addresses the basic requirements of the Item. This question
ing organizations (not just technology), the difficulty of identifies for Criteria users the most central concept or fun-
executing new processes and strategic plans, and the benefits damental theme of the Item. Criteria users who have com-
of improved alignment of all aspects of your management pleted their Organizational Profile may choose to perform
system with your results measurements. Recognizing the their first “complete” Baldrige assessment by responding to
challenges for organizations to address these opportunities, the 19 Item title questions, using the detailed content of the
the decision was made to make no substantive revisions to Criteria Item as an educational guide to understand the cen-
the Criteria for 2006. tral concept more fully.

2006 Health Care Criteria for Performance Excellence 9

10 2006 Health Care Criteria for Performance Excellence
2006 HEALTH CARE CRITERIA FOR PERFORMANCE EXCELLENCE—ITEM LISTING

P Preface: Organizational Profile

P.1 Organizational Description
P.2 Organizational Challenges

2006 Categories and Items Point Values

1 Leadership 120
1.1 Senior Leadership 70
1.2 Governance and Social Responsibilities 50

2 Strategic Planning 85
2.1 Strategy Development 40
2.2 Strategy Deployment 45

3 Focus on Patients, Other Customers, and Markets 85

3.1 Patient, Other Customer, and Health Care Market Knowledge 40
3.2 Patient and Other Customer Relationships and Satisfaction 45

4 Measurement, Analysis, and Knowledge Management 90

4.1 Measurement, Analysis, and Review of Organizational Performance 45
4.2 Information and Knowledge Management 45

5 Human Resource Focus 85

5.1 Work Systems 35
5.2 Staff Learning and Motivation 25
5.3 Staff Well-Being and Satisfaction 25

6 Process Management 85
6.1 Health Care Processes 45
6.2 Support Processes and Operational Planning 40
7 Results 450
7.1 Health Care and Service Delivery Outcomes 100
7.2 Patient- and Other Customer-Focused Outcomes 70
7.3 Financial and Market Outcomes 70
7.4 Human Resource Outcomes 70
7.5 Organizational Effectiveness Outcomes 70
7.6 Leadership and Social Responsibility Outcomes 70

TOTAL POINTS 1,000

Note: The Scoring System used with the Criteria Items

in a Baldrige assessment can be found on pages 55–58.

2006 Health Care Criteria for Performance Excellence 11

2006 HEALTH CARE CRITERIA FOR PERFORMANCE EXCELLENCE

Importance of Beginning With Your Organizational Profile

Your Organizational Profile is critically important because
• it is the most appropriate starting point for self-assessment and for writing an application;
• it helps you identify potential gaps in key information and focus on key performance requirements and results;
• it is used by the Examiners and Judges in application review, including the site visit, to understand your organization
and what you consider important; and
• it also may be used by itself for an initial self-assessment. If you identify topics for which conflicting, little, or no
information is available, it is possible that the Organizational Profile can serve as your complete assessment, and you
can use these topics for action planning.

P Preface: Organizational Profile

The Organizational Profile is a snapshot of your organization, the KEY influences on HOW you operate, and the KEY chal-
lenges you face.

P.1 Organizational Description: What are your key organizational characteristics?

Describe your organization’s PERFORMANCE environment and your KEY relationships with PATIENTS and other
CUSTOMERS, suppliers, PARTNERS, and STAKEHOLDERS.

Within your response, include answers to the following questions:

a. Organizational Environment
(1) What are your organization’s main HEALTH CARE SERVICES? What are the delivery mechanisms used to
provide your HEALTH CARE SERVICES to your PATIENTS and other CUSTOMERS?
(2) What is your organizational culture? What are your stated PURPOSE, VISION, MISSION, and VALUES?
(3) What is your STAFF profile? What are your categories and types of STAFF? What are their educational
levels? What are your organization’s workforce and job DIVERSITY, organized bargaining units, use of
contract and privileged STAFF, and special health and safety requirements?
(4) What are your major technologies, equipment, and facilities?
(5) What is the legal and regulatory environment under which your organization operates? What are the
applicable occupational health and safety regulations; accreditation, certification, or registration
requirements; relevant health care industry standards; and environmental and financial regulations
relevant to HEALTH CARE SERVICE delivery?
b. Organizational Relationships
(1) What are your organizational structure and GOVERNANCE system? What are the reporting relationships
among your GOVERNANCE board, SENIOR LEADERS, and parent organization, as appropriate?
(2) What are your KEY PATIENT and other CUSTOMER groups, STAKEHOLDER groups, and health care market
SEGMENTS, as appropriate? What are their KEY requirements and expectations for your HEALTH CARE SERVICES
and operations? What are the differences in these requirements and expectations among PATIENT, other
CUSTOMER, and STAKEHOLDER groups, and health care market SEGMENTS?

(3) What role do suppliers and PARTNERS play in your KEY support PROCESSES? What role, if any, do they play
in your organizational INNOVATION PROCESSES? What are your most important types of suppliers and
PARTNERS? What are your most important supply chain requirements?

(4) What are your KEY supplier and partnering relationships and communication mechanisms?

12 2006 Health Care Criteria for Performance Excellence

 Notes:
N1. Health care service delivery mechanisms to your N5. Health care market segments (P.1b[2]) might be
patients and other customers (P.1a[1]) might be direct based on health care services or features, geography,
or through contractors, collaborators, or partners. health care service delivery modes, payors, business
volume, population demographics, or other factors
N2. Many health care organizations rely heavily on
that are important to your organization to define
volunteers to supplement the work of their staff. These
related market characteristics.
organizations should interpret staff (P.1a[3]) to mean
staff and volunteers. N6. Requirements for patient, other customer, and
stakeholder groups, and health care market segments
N3. Examples of the legal and regulatory environment
(P.1b[2]) might include accessibility, continuity of care,
under which your organization operates (P.1a[5]) might
electronic communication, and billing requirements.
include the regulations promulgated by the Centers
for Medicare and Medicaid Services (CMS), such as N7. Key suppliers (P.1b[3,4]) might include collabora-
the Health Insurance Portability and Accountability tors and collaborating organizations.
Act of 1996 (HIPAA) and the State Children’s Health
N8. Communication mechanisms (P.1b[4]) should be
Insurance Program (SCHIP). They also might include
two-way and might be in person, via regular mail or
“industrywide” standards, such as the standards of the
e-mail, Web-based, or by telephone. For many orga-
Joint Commission on Accreditation of Healthcare
nizations, these mechanisms may change as the re-
Organizations (JCAHO).
quirements of the marketplace, patients and other
N4. For some health care organizations, governance customers, or stakeholders change.
and reporting relationships (P.1b[1]) might include
relationships with foundation funding sources.

For additional description of this Item, see page 40.

For definitions of key terms presented throughout the Health Care Criteria and Scoring Guidelines text
in SMALL CAPS/SANS SERIF, see the Glossary of Key Terms on pages 69–76.
Frequently, several questions are grouped under one number (e.g., P.1a[3]). These questions are related
and do not require separate responses. These multiple questions serve as a guide in understanding the full
meaning of the information being requested.
Item notes serve three purposes: (1) to clarify terms or requirements presented in an Item, (2) to give
instructions on responding to the Item requirements, and (3) to indicate key linkages to other Items. In
all cases, the intent is to help you respond to the Item requirements.

2006 Health Care Criteria for Performance Excellence 13

 P.2 Organizational Challenges: What are your key organizational challenges?
Describe your organization’s competitive environment, your KEY STRATEGIC CHALLENGES, and your system for
PERFORMANCE improvement.

Within your response, include answers to the following questions:

a. Competitive Environment
(1) What is your competitive position? What is your relative size and growth in the health care industry
or markets served? What are the numbers and types of competitors and KEY collaborators for your
organization?
(2) What are the principal factors that determine your success relative to your competitors and other
organizations delivering similar HEALTH CARE SERVICES? What are any KEY changes taking place that affect
your competitive situation, including opportunities for collaboration, as appropriate?
(3) What are your KEY available sources of comparative and competitive data from within the health care
industry? What are your KEY available sources of comparative data for analogous PROCESSES outside the
health care industry? What limitations, if any, are there in your ability to obtain these data?
b. STRATEGIC CHALLENGES
What are your KEY HEALTH CARE SERVICE, operational, and human resource STRATEGIC CHALLENGES? What are your KEY
STRATEGIC CHALLENGES associated with organizational SUSTAINABILITY?

c. PERFORMANCE Improvement System

HOW do you maintain an overall organizational focus on PERFORMANCE improvement, including organizational
LEARNING? How do you achieve SYSTEMATIC evaluation and improvement of KEY PROCESSES?

Notes:
N1. Principal factors (P.2a[2]) might include differen- regulatory requirements, staff retention, an aging
tiators such as technology leadership, accessibility, workforce, or competition from new health care
health care and administrative support services offered, organizations.
cost, e-services, past reputation for service delivery,
N3. Performance improvement (P.2c) is an assessment
and wait times for service.
dimension used in the Scoring System to evaluate the
N2. Strategic challenges (P.2b) might include rapid maturity of organizational approaches and deployment
technological change, disruptive technologies that (see pages 55–58). This question is intended to help
rapidly revolutionize or make obsolete existing pro- you and the Baldrige Examiners set an overall context
cesses or health care services, reduced cycle times for for your approach to performance improvement.
health care service introduction, health care industry
N4. Overall approaches to process improvement (P.2c)
volatility, declining health care market share, the
might include applying Six Sigma methodology, im-
changing health care marketplace, mergers and acqui-
plementing Plan-Do-Study-Act (PDSA) improvement
sitions, patient and customer loyalty and retention,
cycles, or employing other process improvement tools.
changing or emerging patient and other customer or

For additional description of this Item, see pages 40–41.

Page Limit
For Baldrige Award applicants, the Organizational Profile is limited to five pages. These pages are not counted in
the overall application page limit. Typing and formatting instructions for the Organizational Profile are the same
as for the application. These instructions are given in the Baldrige Award Application Forms, which can be downloaded
at www.baldrige.nist.gov/Award_Application.htm.

14 2006 Health Care Criteria for Performance Excellence

 1 Leadership (120 pts.)
The Leadership Category examines HOW your organization’s SENIOR LEADERS guide and sustain your organization. Also
examined are your organization’s GOVERNANCE and HOW your organization addresses its ethical, legal, and community
responsibilities.

1.1 Senior Leadership: How do your senior leaders lead? (70 pts.) Process
Describe HOW SENIOR LEADERS guide and sustain your organization. Describe HOW SENIOR LEADERS communicate
with STAFF and encourage high PERFORMANCE.
Within your response, include answers to the following questions:
a. VISION and VALUES
(1) HOW do SENIOR LEADERS set organizational VISION and VALUES? HOW do SENIOR LEADERS deploy your organization’s
VISION and VALUES through your LEADERSHIP SYSTEM, to all STAFF, to KEY suppliers and PARTNERS, to PATIENTS and
other CUSTOMERS, and to stakeholders, as appropriate? HOW do their personal actions reflect a commit-
ment to the organization’s VALUES?
(2) HOW do SENIOR LEADERS promote an environment that fosters and requires legal and ETHICAL BEHAVIOR?
(3) HOW do SENIOR LEADERS create a SUSTAINABLE organization? HOW do SENIOR LEADERS create an environment for
PERFORMANCE improvement, accomplishment of your MISSION and STRATEGIC OBJECTIVES, INNOVATION, and organi-
zational agility? HOW do they create an environment for organizational and STAFF LEARNING? HOW do they
personally participate in succession planning and the development of future organizational leaders?
b. Communication and Organizational PERFORMANCE
(1) HOW do SENIOR LEADERS communicate with, empower, and motivate all STAFF throughout the organization?
HOW do SENIOR LEADERS encourage frank, two-way communication throughout the organization? HOW do
SENIOR LEADERS take an active role in STAFF reward and recognition to reinforce high PERFORMANCE and a focus
on the organization, as well as on PATIENTS and other CUSTOMERS?
(2) HOW do SENIOR LEADERS create a focus on action to accomplish the organization’s objectives, improve
PERFORMANCE, and attain your VISION? HOW do SENIOR LEADERS include a focus on creating and balancing VALUE
for PATIENTS, other CUSTOMERS, and other STAKEHOLDERS in their organizational PERFORMANCE expectations?

Notes:
N1. Senior leaders include the head of the organization N4. For health care organizations that rely on volun-
and his or her direct reports. In health care organizations teers to supplement the work of their staff, responses
with separate administrative/operational and health to 1.1b(1) also should discuss your efforts to commu-
care provider leadership, “senior leaders” refers to both nicate with, empower, and motivate the volunteer
sets of leaders and the relationships among those leaders. workforce.
N2. Organizational vision (1.1a[1]) should set the N5. A focus on action (1.1b[2]) considers both the
context for strategic objectives and action plans, which people and the hard assets of the organization. It in-
are described in Items 2.1 and 2.2. cludes ongoing improvements in productivity that may
be achieved through eliminating waste or reducing cycle
N3. A sustainable organization (1.1a[3]) is capable of
time, and it might use techniques such as Six Sigma. It
addressing current organizational needs and possesses
also includes the actions to accomplish the organiza-
the agility and strategic management to prepare suc-
tion’s strategic objectives.
cessfully for its future organizational and market envi-
ronment. In this context, the concept of innovation N6. Your organizational performance results should
includes both technological and organizational inno- be reported in Items 7.1–7.6.
vation to succeed in the future.

Item responses are assessed by considering the Criteria Item requirements; your key organizational factors pre-
sented in your Organizational Profile; and the maturity of your approaches, breadth of their deployment, and
strength of your improvement process and results relative to the Scoring System. Refer to the Scoring System
information on pages 55–58.
For additional description of this Item, see page 41.

2006 Health Care Criteria for Performance Excellence 15

 1.2 Governance and Social Responsibilities: How do you govern and
address your social responsibilities? (50 pts.) Process
Describe your organization’s GOVERNANCE system. Describe HOW your organization addresses its responsibil-
ities to the public, ensures ETHICAL BEHAVIOR, practices good citizenship, and contributes to the health of the
community.
Within your response, include answers to the following questions:
a. Organizational GOVERNANCE
(1) HOW does your organization address the following KEY factors in your GOVERNANCE system:
• accountability for management’s actions
• fiscal accountability
• transparency in operations and selection and disclosure policies for GOVERNANCE board members,
as appropriate
• independence in internal and external audits
• protection of STAKEHOLDER and stockholder interests, as appropriate
(2) HOW do you evaluate the PERFORMANCE of your SENIOR LEADERS, including both administrative and health
care leaders? HOW do you evaluate the PERFORMANCE of members of the GOVERNANCE board, as appropriate?
HOW do SENIOR LEADERS and the GOVERNANCE board use these PERFORMANCE reviews to improve both their
personal leadership EFFECTIVENESS and that of your board and LEADERSHIP SYSTEM, as appropriate?
b. Legal and ETHICAL BEHAVIOR
(1) HOW do you address any adverse impacts on society of your HEALTH CARE SERVICES and operations? HOW do
you anticipate public concerns with current and future services, and operations? HOW do you prepare
for these concerns in a proactive manner, including using resource-sustaining PROCESSES, as appropriate?
What are your KEY compliance PROCESSES, MEASURES, and GOALS for achieving and surpassing regulatory,
legal, and accreditation requirements, as appropriate? What are your KEY PROCESSES, MEASURES, and GOALS
for addressing risks associated with your HEALTH CARE SERVICES and other organizational operations?
(2) HOW does your organization promote and ensure ETHICAL BEHAVIOR in all your interactions? What are your
KEY PROCESSES and MEASURES or INDICATORS for enabling and monitoring ETHICAL BEHAVIOR in your GOVERNANCE
structure, throughout your organization, and in interactions with PATIENTS and other CUSTOMERS, stake-
holders, and PARTNERS? HOW do you monitor and respond to breaches of ETHICAL BEHAVIOR?
c. Support of KEY Communities and Community Health
HOW does your organization actively support and strengthen your KEY communities? HOW do you identify KEY
communities and determine areas of emphasis for organizational involvement and support? What are your
KEY communities? HOW do your SENIOR LEADERS and your STAFF contribute to improving these communities and
to building community health?

Notes:
N1. Societal responsibilities in areas critical to your management reviews (5.1b), and formal or informal
organization’s ongoing success also should be ad- staff and other stakeholder feedback and surveys. For
dressed in Strategy Development (Item 2.1) and in some governmental health care organizations, external
Process Management (Category 6). Key results, such advisory boards might evaluate the performance of
as results of regulatory and legal compliance (including senior leaders and the governance board.
malpractice) and accreditation, should be reported as
N4. Nonprofit health care organizations should re-
Leadership and Social Responsibility Results (Item 7.6).
port, as appropriate, how you address the legal and
N2. Transparency in operations (1.2a[1]) should in- regulatory requirements and standards (1.2b[1]) that
clude your internal controls on governance processes. govern fundraising and lobbying activities.
For nonprofit health care organizations that serve as
N5. Public concerns (1.2b[1]) might include patient
stewards of public funds, stewardship of those funds
safety, cost, equitable and timely access to providers,
and transparency in operations are areas of emphasis.
emergence of new health care threats, and the han-
N3. Leadership performance evaluation (1.2a[2]) might dling of medical waste.
be supported by peer reviews, formal performance

16 2006 Health Care Criteria for Performance Excellence

 N6. Ethical behavior (1.2b) includes business, profes- health of your community. Such services might in-
sional, health care practice, and patient rights issues. clude health education programs, immunization pro-
It also includes public accountability and disclosure of grams, unique health services provided at a financial
information about your organizational health care loss, population-screening programs (e.g., hyperten-
performance. sion), safety program sponsorship, and indigent care.
You should report the results of community health
N7. Measures or indicators of ethical behavior
services in Item 7.6.
(1.2b[2]) might include the percentage of independent
board members, measures of relationships with stock- N9. In addition to actions to build community health,
holder and nonstockholder constituencies, instances areas of community support appropriate for inclusion
of ethical conduct breaches and responses, survey in 1.2c might include your efforts to strengthen local
results on staff perceptions of organizational ethics, community services and education; the environment;
ethics hotline use, and results of ethics reviews and and practices of trade, business, or professional
audits. They also might include evidence that policies, associations.
staff training, and monitoring systems are in place
N10. The health and safety of staff are not addressed
with respect to conflicts of interest and the proper use
in Item 1.2; you should address these staff factors in
of funds.
Item 5.3.
N8. Actions to build community health (1.2c) are
population-based services supporting the general

For additional description of this Item, see pages 41– 42.

2006 Health Care Criteria for Performance Excellence 17

 2 Strategic Planning (85 pts.)
The Strategic Planning Category examines HOW your organization develops STRATEGIC OBJECTIVES and ACTION PLANS. Also
examined are HOW your chosen STRATEGIC OBJECTIVES and ACTION PLANS are deployed and changed if circumstances require, and
HOW progress is measured.

2.1 Strategy Development: How do you develop your strategy? (40 pts.) Process
Describe HOW your organization establishes its strategy and STRATEGIC OBJECTIVES, including HOW you address
your STRATEGIC CHALLENGES. Summarize your organization’s KEY STRATEGIC OBJECTIVES and their related GOALS.
Within your response, include answers to the following questions:
a. Strategy Development PROCESS
(1) HOW does your organization conduct its strategic planning? What are the KEY PROCESS steps? Who are
the KEY participants? HOW does your PROCESS identify potential blind spots? What are your short- and
longer-term planning time horizons? HOW are these time horizons set? HOW does your strategic
planning PROCESS address these time horizons?
(2) HOW do you ensure that strategic planning addresses the KEY factors listed below? HOW do you collect and
analyze relevant data and information pertaining to these factors as part of your strategic planning PROCESS:
• your organization’s strengths, weaknesses, opportunities, and threats
• early indications of major shifts in technology, health care markets, your competitive or collaborative
environment, or the regulatory environment
• long-term organizational SUSTAINABILITY and organizational continuity in emergencies
• your ability to execute the strategic plan
b. STRATEGIC OBJECTIVES
(1) What are your KEY STRATEGIC OBJECTIVES and your timetable for accomplishing them? What are your most
important GOALS for these STRATEGIC OBJECTIVES?
(2) HOW do your STRATEGIC OBJECTIVES address the challenges identified in response to P.2 in your Organizational
Profile? HOW do you ensure that your STRATEGIC OBJECTIVES balance short- and longer-term challenges and
opportunities? HOW do you ensure that your STRATEGIC OBJECTIVES balance the needs of all PATIENTS, other KEY
CUSTOMERS, and KEY STAKEHOLDERS?

Notes:
N1. “Strategy development” refers to your organiza- N3. Your organization’s strengths, weaknesses, oppor-
tion’s approach (formal or informal) to preparing for tunities, and threats (2.1a[2]) should address all factors
the future. Strategy development might utilize various that are key to your organization’s future success, in-
types of forecasts, projections, options, scenarios, or cluding the following, as appropriate: your patient and
other approaches to envisioning the future for purposes other customer and health care market needs, expec-
of decision making and resource allocation. Strategy tations, and opportunities; your culture, policies, and
development might involve key suppliers, partners, procedures to ensure patient safety and to avoid med-
patients, and other customers. ical errors; your competitive and collaborative envi-
ronment and your capabilities relative to competitors
N2. “Strategy” should be interpreted broadly. Strategy
and comparable organizations; the life cycle of your
might be built around or lead to any or all of the follow-
health care services; technological and other key inno-
ing: new health care services and/or delivery processes
vations or changes that might affect your health care
and markets; revenue growth via various approaches,
services and how you operate, as well as the rate of
including acquisitions, grants, and endowments; new
that innovation; your staff and other resource needs;
partnerships and alliances; and new staff or volunteer
your opportunities to redirect resources to higher-
relationships. Strategy might be directed toward be-
priority health care services or areas; financial, societal,
coming a center for clinical and service excellence, a
ethical, regulatory, technological, and other potential
preferred provider, a research leader, or an integrated
risks; changes in the national or global economy;
service provider.

18 2006 Health Care Criteria for Performance Excellence

 partner and supply chain needs, strengths, and weak- management; and health care service quality and
nesses; and other factors unique to your organization. enhancements. Responses to Item 2.1 should focus on
your specific challenges—those most important to
N4. Your ability to execute the strategic plan (2.1a[2])
your organizational success and to strengthening your
also should address your organizational agility based
organization’s overall performance as a health care
on contingency plans or if circumstances require a shift
provider.
in plans and rapid execution of new or changed plans.
N6. Item 2.1 addresses your overall organizational
N5. Strategic objectives that address key challenges
strategy, which might include changes in health care
(2.1b[2]) might include access and locations; rapid re-
services and programs. However, the Item does not
sponse; customization; co-location with major partners;
address service and program design; you should ad-
specific joint ventures; rapid innovation; Web-based
dress these factors in Item 6.1, as appropriate.
provider, patient, and other customer relationship

For additional description of this Item, see page 43.

2.2 Strategy Deployment: How do you deploy your strategy? (45 pts.) Process
Describe HOW your organization converts its STRATEGIC OBJECTIVES into ACTION PLANS. Summarize your orga-
nization’s ACTION PLANS and related KEY PERFORMANCE MEASURES or INDICATORS. Project your organization’s future
PERFORMANCE on these KEY PERFORMANCE MEASURES or INDICATORS.

Within your response, include answers to the following questions:

a. ACTION PLAN Development and DEPLOYMENT
(1) HOW do you develop and deploy ACTION PLANS to achieve your KEY STRATEGIC OBJECTIVES? HOW do you allocate
resources to ensure accomplishment of your ACTION PLANS? HOW do you ensure that the KEY changes
resulting from your ACTION PLANS can be sustained?
(2) HOW do you establish and deploy modified ACTION PLANS if circumstances require a shift in plans and
rapid execution of new plans?
(3) What are your KEY short- and longer-term ACTION PLANS? What are the KEY changes, if any, in your HEALTH
CARE SERVICES and programs, your CUSTOMERS and markets (including PATIENT populations), and how you will
operate?
(4) What are your KEY human resource plans that derive from your short- and longer-term STRATEGIC
OBJECTIVES and ACTION PLANS?

(5) What are your KEY PERFORMANCE MEASURES or INDICATORS for tracking progress on your ACTION PLANS? HOW do
you ensure that your overall ACTION PLAN measurement system reinforces organizational ALIGNMENT? HOW
do you ensure that the measurement system covers all KEY DEPLOYMENT areas and STAKEHOLDERS?
b. PERFORMANCE PROJECTION
For the KEY PERFORMANCE MEASURES or INDICATORS identified in 2.2a(5), what are your PERFORMANCE PROJECTIONS for
both your short- and longer-term planning time horizons? How does your projected PERFORMANCE compare
with the projected PERFORMANCE of your competitors or comparable organizations providing similar HEALTH
CARE SERVICES? How does it compare with KEY BENCHMARKS, GOALS, and past PERFORMANCE, as appropriate? If there
are current or projected gaps in PERFORMANCE against your competitors or comparable organizations, HOW will
you address them?

Notes:
N1. Strategy and action plan development and deploy- • Category 3 for gathering patient, other customer,
ment are closely linked to other Items in the Criteria. and health care market knowledge as input to your
The following are examples of key linkages: strategy and action plans and for deploying action
• Item 1.1 for how your senior leaders set and com- plans;
municate directions;

2006 Health Care Criteria for Performance Excellence 19

 • Category 4 for measurement, analysis, and knowl- • Item 7.6 for specific accomplishments relative to
edge management to support your key information your organizational strategy and action plans.
needs, to support your development of strategy, to
N2. Deployment of action plans (2.2a[1]) might in-
provide an effective basis for your performance
clude key partners, collaborators, and suppliers.
measurements, and to track progress relative to
your strategic objectives and action plans; N3. Measures and indicators of projected performance
• Category 5 for your work system needs and staff (2.2b) might include changes resulting from new
education, training, and development needs, and ventures; organizational acquisitions or mergers;
for implementing staff-related changes resulting health care market entry and shifts; new legislative
from action plans; mandates, legal requirements, or industry standards;
and significant anticipated innovations in health care
• Category 6 for process requirements resulting
service delivery and technology.
from your action plans; and

For additional description of this Item, see pages 43– 44.

20 2006 Health Care Criteria for Performance Excellence

 3 Focus on Patients, Other Customers, and Markets (85 pts.)
The Focus on PATIENTS , Other CUSTOMERS , and Markets Category examines HOW your organization determines the re-
quirements, needs, expectations, and preferences of PATIENTS, other CUSTOMERS, and markets. Also examined is HOW your
organization builds relationships with PATIENTS and other CUSTOMERS and determines the KEY factors that lead to the acquisition,
satisfaction, loyalty, and retention of patients and other customers and to HEALTH CARE SERVICE expansion and SUSTAINABILITY.

3.1 Patient, Other Customer, and Health Care Market Knowledge: How do you use
patient, other customer, and health care market knowledge? (40 pts.) Process
Describe HOW your organization determines requirements, needs, expectations, and preferences of
PATIENTS, other CUSTOMERS, and markets to ensure the continuing relevance of your HEALTH CARE SERVICES and to
develop new HEALTH CARE SERVICE opportunities.
Within your response, include answers to the following questions:
a. PATIENT, Other CUSTOMER, and Health Care Market Knowledge
(1) HOW do you identify PATIENTS, other CUSTOMERS, CUSTOMER groups, and health care market SEGMENTS? HOW do
you determine which PATIENTS, other CUSTOMERS, CUSTOMER groups, and market SEGMENTS to pursue for
current and future HEALTH CARE SERVICES? HOW do you include CUSTOMERS of competitors and other potential
CUSTOMERS and markets in this determination?

(2) HOW do you listen and learn to determine KEY PATIENT and other CUSTOMER requirements, needs, and changing
expectations (including HEALTH CARE SERVICE features) and their relative importance to PATIENTS’ and other
CUSTOMERS’ health care purchasing or relationship decisions? How do your determination methods vary
for different PATIENTS, other CUSTOMERS, or CUSTOMER groups? HOW do you use relevant information and
feedback from current and former PATIENTS and other CUSTOMERS, including marketing information, PATIENT
and other CUSTOMER loyalty and retention data, win/loss ANALYSIS, and complaint data for PURPOSES of planning
HEALTH CARE SERVICES, marketing, making PROCESS improvements, and developing new business opportunities?
HOW do you use this information and feedback to become more PATIENT- and other CUSTOMER-focused and
to better satisfy PATIENT and CUSTOMER needs and desires?
(3) HOW do you keep your listening and LEARNING methods current with HEALTH CARE SERVICE needs and directions,
including changes in your health care marketplace?

Notes:
N1. Patients, as a key customer group, are frequently differentiate your organization’s services from other
identified separately in the Criteria. Other customer providers offering similar services. Beyond specific
groups could include patients’ families, the commu- health care provisions leading to desired health care
nity, insurers and other third-party payors, employers, outcomes, those features might include factors such as
health care providers, patient advocacy groups, De- extended hours, family support services, cost, timeli-
partments of Health, and students. Generic references ness and ease of use of your services, assistance with
to customers include patients. billing/paperwork processes, and transportation assis-
tance. Key health care service features and purchasing
N2. Your responses to this Item should include the
or relationship decisions (3.1a[2]) might take into ac-
patients and other customer groups and the market
count how transactions occur and factors such as con-
segments identified in P.1b(2).
fidentiality and security.
N3. “Health care service features” (3.1a[2]) refers to
N4. The determination of health care service features
all the important characteristics of your health care
and their relative importance (3.1a[2]) should take
services that patients and other customers receive.
into account the potentially differing expectations of
This includes all customers’ interactions with you and
patients and other customers.
their service experiences. The focus should be on fea-
tures that affect customer health care-related prefer- N5. Listening and learning (3.1a[2]) might include
ence and loyalty and the customers’ view of clinical gathering and integrating survey data, focus group
and service quality—for example, those features that findings, Web-based data, and other data and

2006 Health Care Criteria for Performance Excellence 21

 information that affect health care purchasing and needs and directions (3.1a[3]) also might include use
relationship decisions. Keeping your listening and of newer technology, such as Web-based data gathering.
learning methods current with health care service

For additional description of this Item, see pages 44–45.

3.2 Patient and Other Customer Relationships and Satisfaction: How do you build
relationships and grow customer satisfaction and loyalty? (45 pts.) Process
Describe HOW your organization builds relationships to acquire, satisfy, and retain PATIENTS and other
CUSTOMERS and to increase customer loyalty. Describe also HOW your organization determines PATIENT and
other CUSTOMER satisfaction.
Within your response, include answers to the following questions:
a. PATIENT and Other CUSTOMER Relationship Building
(1) HOW do you build relationships to acquire PATIENTS and other CUSTOMERS, to meet and exceed their
expectations, to increase loyalty and secure their future interactions with your organization, and to
gain positive referrals?
(2) HOW do your KEY access mechanisms enable PATIENTS and other CUSTOMERS to seek information, obtain
services, and make complaints? What are your KEY access mechanisms? HOW do you determine KEY
contact requirements for each mode of PATIENT and other CUSTOMER access? HOW do you ensure that these
contact requirements are deployed to all people and PROCESSES involved in the CUSTOMER response chain?
(3) HOW do you manage PATIENT and other CUSTOMER complaints? HOW do you ensure that complaints are
resolved EFFECTIVELY and promptly? HOW do you minimize PATIENT and other CUSTOMER dissatisfaction to
secure future interactions? HOW are complaints aggregated and analyzed for use in improvement
throughout your organization and by your PARTNERS?
(4) HOW do you keep your APPROACHES to building relationships and providing PATIENT and other CUSTOMER
access current with HEALTH CARE SERVICE needs and directions?
b. PATIENT and Other CUSTOMER Satisfaction Determination
(1) HOW do you determine PATIENT and other CUSTOMER satisfaction and dissatisfaction? How do these deter-
mination methods differ among PATIENT and other CUSTOMER groups? HOW do you ensure that your
measurements capture actionable information for use in securing your PATIENTS’ and other CUSTOMERS’
future interactions with your organization, and gaining positive referrals, as appropriate? HOW do you
use PATIENT and other CUSTOMER satisfaction and dissatisfaction information for improvement?
(2) HOW do you follow up with PATIENTS and other CUSTOMERS on the quality of HEALTH CARE SERVICES and trans-
actions to receive prompt and actionable feedback?
(3) HOW do you obtain and use information on PATIENTS’ and other CUSTOMERS’ satisfaction relative to their
satisfaction with your competitors, other organizations providing similar HEALTH CARE SERVICES, and/or
health care industry BENCHMARKS?
(4) HOW do you keep your APPROACHES to determining satisfaction current with HEALTH CARE SERVICE needs and
directions?

Notes:

N1. Customer relationship building (3.2a) might in- win/loss analysis, and information on timeliness of
clude the development of partnerships or alliances service delivery. Information might be gathered on the
with customers. Internet, through personal contact or a third party, or
by mail.
N2. Determining patient and other customer satisfac-
tion and dissatisfaction (3.2b) might include use of any N3. Patient and other customer satisfaction measure-
or all of the following: surveys, formal and informal ments (3.2b[1]) might include both a numerical
feedback, customer account histories, complaints, rating scale and descriptors for each unit in the scale.

22 2006 Health Care Criteria for Performance Excellence

 Actionable satisfaction measurements provide useful with which you don’t compete but which provide ser-
information about specific service features, delivery, vices in different geographic areas or to different pop-
relationships, and transactions that affect the custo- ulations of people.
mers’ future actions—choice of health care provider
N5. Your patient and other customer satisfaction and
and positive referral.
dissatisfaction results should be reported in Item 7.2.
N4. Other organizations providing similar health care
services (3.2b[3]) might include other organizations

For additional description of this Item, see page 45.

2006 Health Care Criteria for Performance Excellence 23

 4 Measurement, Analysis, and Knowledge Management (90 pts.)
The Measurement, ANALYSIS , and Knowledge Management Category examines HOW your organization selects, gathers,
analyzes, manages, and improves its data, information, and KNOWLEDGE ASSETS. Also examined is HOW your organization
reviews its PERFORMANCE.

4.1 Measurement, Analysis, and Review of Organizational Performance: How do you

measure, analyze, and review organizational performance? (45 pts.) Process
Describe HOW your organization measures, analyzes, aligns, reviews, and improves its PERFORMANCE as a
health care provider at all LEVELS and in all parts of your organization.
Within your response, include answers to the following questions:
a. PERFORMANCE Measurement
(1) HOW do you select, collect, align, and integrate data and information for tracking daily operations and
for tracking overall organizational PERFORMANCE, including progress relative to STRATEGIC OBJECTIVES and
ACTION PLANS? What are your KEY organizational PERFORMANCE MEASURES? HOW do you use these data and
information to support organizational decision making and INNOVATION as a health care provider?
(2) HOW do you select and ensure the EFFECTIVE use of KEY comparative data and information to support
operational and strategic decision making and INNOVATION?
(3) HOW do you keep your PERFORMANCE measurement system current with HEALTH CARE SERVICE needs and
directions? HOW do you ensure that your PERFORMANCE measurement system is sensitive to rapid or
unexpected organizational or external changes?
b. PERFORMANCE ANALYSIS and Review
(1) HOW do you review organizational PERFORMANCE and capabilities? HOW do your SENIOR LEADERS participate in
these reviews? What ANALYSES do you perform to support these reviews and to ensure that conclusions
are valid? HOW do you use these reviews to assess organizational success, competitive PERFORMANCE, and
progress relative to STRATEGIC OBJECTIVES and ACTION PLANS? HOW do you use these reviews to assess your
organization’s ability to rapidly respond to changing organizational needs and challenges in your
operating environment?
(2) HOW do you translate organizational PERFORMANCE review findings into priorities for continuous and
breakthrough improvement and into opportunities for INNOVATION? HOW are these priorities and oppor-
tunities deployed to work group- and functional-level operations throughout your organization to
enable EFFECTIVE support for their decision making? When appropriate, HOW are the priorities and oppor-
tunities deployed to your suppliers, PARTNERS, and collaborators to ensure organizational ALIGNMENT?

Notes:
N1. Performance measurement is used in fact-based published and public studies, participation in indicator
decision making for setting and aligning organiza- programs, or other sources. These data may be drawn
tional directions and resource use at the work unit, from local or national sources.
key process, departmental, and whole organization
N3. Organizational performance reviews (4.1b[1])
levels.
should be informed by organizational performance
N2. Comparative data and information (4.1a[2]) are measurement and guided by the strategic objectives
obtained by benchmarking and by seeking competitive and action plans described in Items 2.1 and 2.2. The
comparisons. “Benchmarking” refers to identifying reviews also might be informed by internal or external
processes and results that represent best practices and Baldrige assessments.
performance for similar activities, inside or outside the
N4. Analysis includes examining trends; organizational,
health care industry. Competitive comparisons relate
health care industry, and technology projections; and
your organization’s performance to that of competi-
comparisons, cause-effect relationships, and correla-
tors and other organizations providing similar health
tions intended to support your performance reviews,
care services. Comparative data might include data
help determine root causes, and help set priorities for
from similar organizations and health care industry
resource use. Accordingly, analysis draws on all types
benchmarks. Such data might be derived from surveys,
of data: patient- and other customer-related, health

24 2006 Health Care Criteria for Performance Excellence

 care outcomes, financial and market, operational, and N6. Your organizational performance results should
competitive/comparative. be reported in Items 7.1–7.6.
N5. The results of organizational performance analy-
sis and review should contribute to your organiza-
tional strategic planning in Category 2.

For additional description of this Item, see pages 45–47.

4.2 Information and Knowledge Management: How do you manage organizational

information and knowledge? (45 pts.) Process
Describe HOW your organization ensures the quality and availability of needed data and information for
STAFF, suppliers, PARTNERS, collaborators, and PATIENTS and other CUSTOMERS. Describe HOW your organization
builds and manages its KNOWLEDGE ASSETS.
Within your response, include answers to the following questions:
a. Data and Information Availability
(1) HOW do you make needed data and information available? HOW do you make them accessible to STAFF,
suppliers and PARTNERS, and PATIENTS and other CUSTOMERS, as appropriate?
(2) HOW do you ensure that hardware and software are reliable, secure, and user-friendly?
(3) HOW do you ensure the continued availability of data and information, including the availability of
hardware and software systems, in the event of an emergency?
(4) HOW do you keep your data and information availability mechanisms, including your software and
hardware systems, current with HEALTH CARE SERVICE needs and directions and with technological changes
in your operating environment?
b. Organizational Knowledge Management
HOW do you manage organizational knowledge to accomplish the following:
• the collection and transfer of STAFF knowledge
• the transfer of relevant knowledge from and to PATIENTS and other CUSTOMERS, suppliers, PARTNERS,
and collaborators
• the rapid identification, sharing, and implementation of best practices
c. Data, Information, and Knowledge Quality
HOW do you ensure the following properties of your data, information, and organizational knowledge:
• accuracy
• integrity and reliability
• timeliness
• security and confidentiality

Notes:
N1. Data and information availability (4.2a) are of N2. Data and information access (4.2a[1]) might be
growing importance as the Internet, electronic com- via electronic or other means.
munication and information transfer, and e-business
N3. Given the increase in availability of data and in-
are used increasingly for provider, provider-to-patient/
formation, your organization’s efforts to ensure the
customer, business-to-business, and organization-to-
quality of your data, information, and knowledge are
organization interactions and as intranets become
of growing importance. Of particular concern to
more important as a major source of organization-
health care organizations is the need to ensure the
wide communications.
confidentiality of patient records.

For additional description of this Item, see pages 47–48.

2006 Health Care Criteria for Performance Excellence 25

 5 Human Resource Focus (85 pts.)
The Human Resource Focus Category examines HOW your organization’s WORK SYSTEMS and your STAFF LEARNING and motiva-
tion enable all STAFF to develop and utilize their full potential in ALIGNMENT with your organization’s overall objectives,
strategy, and ACTION PLANS. Also examined are your organization’s efforts to build and maintain a work environment and
STAFF support climate conducive to PERFORMANCE EXCELLENCE and to personal and organizational growth.

5.1 Work Systems: How do you enable staff to accomplish

the work of your organization? (35 pts.) Process
Describe HOW your organization’s work and jobs enable all STAFF and the organization to achieve HIGH
PERFORMANCE.
Describe HOW compensation, career progression, and related workforce practices enable STAFF
and the organization to achieve HIGH PERFORMANCE.
Within your response, include answers to the following questions:
a. Organization and Management of Work
(1) HOW do you organize and manage work and jobs, including skills, to promote cooperation, initiative,
EMPOWERMENT, INNOVATION, and your organizational culture? HOW do you organize and manage work and
jobs, including skills, to achieve the agility to keep current with HEALTH CARE SERVICE needs and to achieve
your ACTION PLANS?
(2) HOW do your WORK SYSTEMS capitalize on the diverse ideas, cultures, and thinking of your STAFF and the
communities with which you interact (your STAFF recruitment and your PATIENT and other CUSTOMER
communities)?
(3) HOW do you achieve EFFECTIVE communication and skill sharing across health care professions, depart-
ments and work units, jobs, and locations?
b. STAFF PERFORMANCE Management System
HOW does your STAFF PERFORMANCE management system, including feedback to STAFF, support HIGH-PERFORMANCE
WORK and contribute to the achievement of your ACTION PLANS? HOW does your STAFF PERFORMANCE management
system support a PATIENT and other CUSTOMER and HEALTH CARE SERVICE focus? HOW do your compensation, recog-
nition, and related reward and incentive practices reinforce HIGH-PERFORMANCE WORK and a PATIENT and other
CUSTOMER and HEALTH CARE SERVICE focus?

c. Recruitment and Career Progression

(1) HOW do you identify characteristics and skills needed by potential STAFF?
(2) HOW do you recruit, hire, and retain new STAFF? HOW do you ensure STAFF members represent the diverse
ideas, cultures, and thinking of your recruitment community?
(3) HOW do you accomplish EFFECTIVE succession planning for leadership and management positions,
including senior administrative/operational and health care leadership positions, as appropriate? HOW
do you manage EFFECTIVE career progression for all STAFF throughout the organization?

Notes:

N1. “Staff” refers to all people who contribute to the N2. “Your organization’s work” refers to how your
delivery of your organization’s services, including paid staff are organized or organize themselves in formal
staff (e.g., permanent, temporary, and part-time per- and informal, temporary, or longer-term units. This
sonnel, as well as any contract employees supervised might include work teams, process teams, project
by your organization), independent practitioners (e.g., teams, patient/customer action teams, problem-
physicians, physician assistants, nurse practitioners, solving teams, centers of excellence, functional units,
acupuncturists, and nutritionists not paid by the orga- remote workers (e.g., at home), cross-functional
nization), volunteers, and health profession students teams, and departments—self-managed or managed
(e.g., medical, nursing, and ancillary). Staff includes by supervisors.
team leaders, supervisors, and managers at all levels.
“Jobs” refers to responsibilities, authorities, and tasks
Contract employees supervised by a contractor should
of individuals. In some work systems, jobs might be
be addressed in Category 6.
shared by a team.

26 2006 Health Care Criteria for Performance Excellence

 N3. “Recruitment” refers to how potential staff are acquired, and other factors. Recognition includes
hired and brought into the organization. This in- monetary and nonmonetary, formal and informal, and
cludes paid staff, privileged staff, and volunteers. individual and group mechanisms. Recognition systems
for volunteers and independent practitioners who
N4. Compensation, recognition, and related reward
contribute to the work of the organization should be
and incentive practices (5.1b) include promotions and
included, as appropriate.
bonuses that might be based on performance, skills

For additional description of this Item, see page 48.

5.2 Staff Learning and Motivation: How do you contribute to

staff learning and motivate staff? (25 pts.) Process
Describe HOW your organization’s STAFF education, training, and career development support the achieve-
ment of your overall objectives and contribute to HIGH PERFORMANCE. Describe HOW your organization’s
education, training, and career development build STAFF knowledge, skills, and capabilities.
Within your response, include answers to the following questions:
a. STAFF Education,Training, and Development
(1) HOW do STAFF education and training contribute to the achievement of your ACTION PLANS? HOW do your
STAFF education, training, and development address your KEY needs associated with organizational
PERFORMANCE measurement, PERFORMANCE improvement, and technological change? HOW does your educa-
tion and training APPROACH balance short- and longer-term organizational objectives with STAFF needs
(including licensure and recredentialing requirements) for development, ongoing LEARNING, and career
progression?
(2) HOW do STAFF education, training, and development address your KEY organizational needs associated
with new STAFF orientation, DIVERSITY, ethical health care and business practices, and management and
leadership development? HOW do STAFF education, training, and development address your KEY organiza-
tional needs associated with STAFF, workplace, and environmental safety?
(3) HOW do you seek and use input from STAFF and their supervisors and managers on education, training,
and development needs? HOW do you incorporate your organizational LEARNING and KNOWLEDGE ASSETS into
your education and training?
(4) HOW do you deliver education and training? HOW do you seek and use input from STAFF and their
supervisors and managers in determining your delivery APPROACHES? HOW do you use both formal and
informal delivery APPROACHES, including mentoring and other APPROACHES, as appropriate?
(5) HOW do you reinforce the use of new knowledge and skills on the job and retain this knowledge for
long-term organizational use? HOW do you SYSTEMATICALLY transfer knowledge from departing or retiring
staff?
(6) HOW do you evaluate the EFFECTIVENESS of education and training, taking into account individual and
organizational PERFORMANCE?
b. Motivation and Career Development
HOW do you motivate STAFF to develop and utilize their full potential? HOW does your organization use
formal and informal mechanisms to help STAFF attain job- and career-related development and LEARNING
objectives? HOW do managers and supervisors help STAFF attain job- and career-related development and
LEARNING objectives?

Note:

Education and training delivery (5.2a[4]) might occur on-the-job, classroom, computer-based, distance learn-
inside or outside your organization and involve ing, or other types of delivery (formal or informal).

For additional description of this Item, see page 49.

2006 Health Care Criteria for Performance Excellence 27

 5.3 Staff Well-Being and Satisfaction: How do you contribute to
staff well-being and grow staff satisfaction? (25 pts.) Process
Describe HOW your organization maintains a work environment and STAFF support climate that contribute
to the well-being, satisfaction, and motivation of all STAFF.
Within your response, include answers to the following questions:
a. Work Environment
(1) HOW do you ensure and improve workplace health, safety, security, and ergonomics in a proactive
manner? HOW do STAFF take part in these improvement efforts? What are your PERFORMANCE MEASURES or
improvement goals for each of these KEY workplace factors? What are the significant differences in
these workplace factors and PERFORMANCE MEASURES or targets if different STAFF groups and work units have
different work environments?
(2) HOW do you ensure workplace preparedness for disasters or emergencies?
b. STAFF Support and Satisfaction
(1) HOW do you determine the KEY factors that affect STAFF well-being, satisfaction, and motivation? HOW are
these factors SEGMENTED for a diverse workforce and for different categories and types of STAFF?
(2) HOW do you support your STAFF via services, benefits, and policies? HOW are these tailored to the needs
of a diverse workforce and different categories and types of STAFF?
(3) What formal and informal assessment methods and MEASURES do you use to determine STAFF well-being,
satisfaction, and motivation? How do these methods and MEASURES differ across a diverse workforce and
different categories and types of STAFF? HOW do you use other INDICATORS, such as STAFF retention, absen-
teeism, grievances, safety, and PRODUCTIVITY, to assess and improve STAFF well-being, satisfaction, and
motivation?
(4) HOW do you relate assessment findings to KEY organizational PERFORMANCE RESULTS to identify priorities for
improving the work environment and STAFF support climate?

Notes:

N1. Specific factors that might affect your staff’s well- N3. Measures and indicators of well-being, satisfac-
being, satisfaction, and motivation (5.3b[1]) include tion, and motivation (5.3b[3]) might include data on
effective staff problem or grievance resolution; safety safety and absenteeism; the overall turnover rate; the
factors; staff’s views of management; staff training, de- turnover rate for patient/customer contact staff; staff’s
velopment, and career opportunities; staff preparation charitable contributions; grievances, strikes, other job
for changes in technology or the work organization; actions; insurance costs; workers’ compensation
the work environment and other work conditions; claims; and results of surveys. Survey indicators of
management’s empowerment of staff; information satisfaction might include staff knowledge of job roles,
sharing by management; workload; cooperation and staff knowledge of organizational direction, and staff
teamwork; recognition; services and benefits; com- perception of empowerment and information sharing.
munications; job security; compensation; and equal Your results relative to such measures and indicators
opportunity. should be reported in Item 7.4.
N2. Approaches for staff support (5.3b[2]) might in- N4. Identifying priorities (5.3b[4]) might draw on
clude providing counseling, career development and your human resource results presented in Item 7.4
employability services, recreational or cultural activi- and might involve addressing staff problems based on
ties, nonwork-related education, day care, job rotation their impact on your organizational performance
or sharing, special leave for family responsibilities or results.
community service, home safety training, flexible
work hours and location, outplacement, and retire-
ment benefits (including extended health care).

For additional description of this Item, see pages 49– 50.

28 2006 Health Care Criteria for Performance Excellence

 6 Process Management (85 pts.)
The PROCESS Management Category examines the KEY aspects of your organization’s PROCESS management, including KEY
health care, business, and other support PROCESSES for CREATING VALUE for PATIENTS, other CUSTOMERS, and the organization. This
Category encompasses all KEY PROCESSES and all departments and work units.

6.1 Health Care Processes: How do you identify and manage

your key health care processes? (45 pts.) Process
Describe HOW your organization identifies and manages its KEY PROCESSES for delivering HEALTH CARE SERVICES.
Within your response, include answers to the following questions:
a. Health Care PROCESSES
(1) HOW does your organization determine its KEY HEALTH CARE SERVICES and service delivery PROCESSES? What are
your organization’s KEY health care PROCESSES? How do these PROCESSES contribute to improved HEALTH CARE
SERVICE outcomes?

(2) HOW do you determine KEY health care PROCESS requirements, incorporating input from PATIENTS and other
CUSTOMERS, suppliers, PARTNERS, and collaborators, as appropriate? What are the KEY requirements for these
PROCESSES?

(3) HOW do you design these PROCESSES to meet all the KEY requirements, including PATIENT safety, regulatory,
accreditation, and payor requirements? HOW do you incorporate new technology, organizational
knowledge, and the potential need for agility into the design of these PROCESSES? HOW do you incorpo-
rate health care outcomes, CYCLE TIME, PRODUCTIVITY, cost control, and other efficiency and EFFECTIVENESS
factors into the design of these PROCESSES? HOW do you implement these PROCESSES to ensure they meet
design requirements?
(4) HOW are PATIENTS’ expectations addressed and considered? HOW are HEALTH CARE SERVICE delivery PROCESSES and
likely outcomes explained to set realistic PATIENT expectations? HOW are PATIENT decision making and
PATIENT preferences factored into the delivery of HEALTH CARE SERVICES?

(5) What are your KEY PERFORMANCE assessments and MEASURES or INDICATORS used for the control and improve-
ment of your health care PROCESSES? HOW does your day-to-day operation of your health care PROCESSES
ensure meeting KEY PROCESS requirements, including PATIENT safety, regulatory, accreditation, and payor
requirements? HOW are in-process MEASURES used in managing these PROCESSES? HOW is PATIENT and other
CUSTOMER, supplier, PARTNER, and collaborator input used in managing your health care PROCESSES, as
appropriate?
(6) HOW do you minimize overall costs associated with inspections, tests, and PROCESS or PERFORMANCE audits,
as appropriate? HOW do you prevent errors and rework?
(7) HOW do you improve your health care PROCESSES to achieve better PERFORMANCE, to reduce variability, to
improve HEALTH CARE SERVICES and health care outcomes, and to keep them current with HEALTH CARE SERVICE
needs and directions? HOW are improvements and lessons learned shared with other organizational
units and PROCESSES to drive organizational LEARNING and INNOVATION?

Notes:
N1. “Health care processes” refers to patient and N2. Key processes for the conduct of health care re-
community service processes for the purpose of pre- search and/or a teaching mission should be reported
vention, maintenance, health promotion, screening, in either Item 6.1 or 6.2, as appropriate to your orga-
diagnosis, treatment/therapy, rehabilitation, recovery, nization’s mission.
palliative care, or supportive care. This includes ser-
N3. Process requirements should include all appropri-
vices delivered to patients through other providers
ate components of health care service delivery. In a
(e.g., laboratory or radiology studies). Responses to
group practice, this might be the making of appoint-
Item 6.1 should be based on the most critical require-
ments, presentation, evaluation of risk factors, health
ments for successful delivery of your services.

2006 Health Care Criteria for Performance Excellence 29

 education, and appointment closures. Depending on might deal with some aspects of health care provider
the health care service, this might include a significant services if there is a customer-supplier relationship.
focus on technology and patient-specific considerations. Health care staff should still be addressed in Item 1.1
and Category 5.
N4. To achieve better process performance and re-
duce variability, you might implement approaches N6. Performance measures and indicators (6.1a[5])
such as the PDSA process, Six Sigma methodology, should address health care outcomes, patient and
or other process improvement tools. other customer requirements, and health care service
features that affect patient and other customer
N5. To provide as complete and concise a response as
preferences.
possible for your key health care processes, you might
want to use a tabular format identifying the key pro- N7. The results of improvements in health care out-
cesses and the attributes of each as called for in ques- comes and health care service performance should be
tions 6.1a(1)–6.1a(7). Depending on the structure of reported in Item 7.1. All other process performance
your health care staff, your response to Item 6.1 results should be reported in Item 7.5.

For additional description of this Item, see pages 50–51.

30 2006 Health Care Criteria for Performance Excellence

 6.2 Support Processes and Operational Planning: How do you identify and manage
your support processes and accomplish operational planning? (40 pts.) Process
Describe HOW your organization manages its KEY business and other support PROCESSES. Describe your
PROCESSES for financial management and continuity of operations in an emergency.

Within your response, include answers to the following questions:

a. Business and Other Support PROCESSES
(1) HOW does your organization determine its KEY business and other support PROCESSES? What are your KEY
PROCESSES for supporting your health care PROCESSES?

(2) HOW do you determine KEY support PROCESS requirements, incorporating input from internal and external
CUSTOMERS, suppliers, PARTNERS, and collaborators, as appropriate? What are the KEY requirements for these
PROCESSES?

(3) HOW do you design these PROCESSES to meet all the KEY requirements? HOW do you incorporate new tech-
nology, organizational knowledge, and the potential need for agility into the design of these PROCESSES?
HOW do you incorporate CYCLE TIME, PRODUCTIVITY, cost control, and other efficiency and EFFECTIVENESS factors
into the design of the PROCESSES? HOW do you implement these PROCESSES to ensure they meet design
requirements?
(4) What are your KEY PERFORMANCE MEASURES or INDICATORS used for the control and improvement of your
support PROCESSES? HOW does your day-to-day operation of KEY support PROCESSES ensure meeting KEY
PERFORMANCE requirements? HOW are in-process MEASURES used in managing these PROCESSES? HOW is PATIENT
and other CUSTOMER, supplier, PARTNER, and collaborator input used in managing these PROCESSES, as
appropriate?
(5) HOW do you minimize overall costs associated with inspections, tests, and PROCESS or PERFORMANCE audits,
as appropriate? HOW do you prevent errors and rework?
(6) HOW do you improve your KEY business and support PROCESSES to achieve better PERFORMANCE, to reduce
variability, and to keep the PROCESSES current with HEALTH CARE SERVICE needs and directions? HOW are
improvements and lessons learned shared with other organizational units and PROCESSES to drive
organizational LEARNING and INNOVATION?
b. Operational Planning
(1) HOW does your organization ensure adequate financial resources are available to support your operations?
HOW do you determine the resources needed to meet current financial obligations? HOW do you ensure
adequate resources are available to support major new business investments, as appropriate? HOW do
you assess the financial risks associated with your current business operations and major new business
investments?
(2) HOW do you ensure continuity of operations in the event of an emergency?

Notes:
N1. Your key business processes (6.2a) are those non- organization’s health care service design and delivery
health care service processes that are considered most processes, staff, and daily operations. These might
important to business growth and success by your include key patient support processes (e.g., house-
organization’s senior leaders. These might include keeping and medical records) and key administrative
processes for innovation, technology acquisition, in- support processes (e.g., facilities management, legal,
formation and knowledge management, supply chain human resource, and project management).
management, supplier partnering, outsourcing, mergers
N3. An emergency (6.2b[2]) might be weather-related,
and acquisitions, project management, and sales and
utility-related, or due to a local or national emergency.
marketing. The key business processes to be included
in Item 6.2 are distinctive to your organization and N4. Your financial management results should be re-
how you operate. ported in Item 7.3. Other results related to your key
business and support processes and operational plan-
N2. Your other key support processes are those that
ning should be reported in Item 7.5.
are considered most important for support of your

For additional description of this Item, see pages 51–52.

2006 Health Care Criteria for Performance Excellence 31

 7 Results (450 pts.)
The R ESULTS Category examines your organization’s PERFORMANCE and improvement in all KEY areas—health care and
Results
service delivery, PATIENT and other CUSTOMER satisfaction, financial and marketplace PERFORMANCE, human resource outcomes,
operational PERFORMANCE, and leadership and social responsibility. PERFORMANCE LEVELS are examined relative to those of
competitors and other organizations providing similar HEALTH CARE SERVICES.

7.1 Health Care and Service Delivery Outcomes: What are your health
care and service delivery results? (100 pts.) Results
Summarize your organization’s KEY health care PERFORMANCE RESULTS. SEGMENT your RESULTS by patient and other
CUSTOMER groups and market SEGMENTS, as appropriate. Include appropriate comparative data. Indicate
those MEASURES that are mandated by regulatory, accreditor, or payor requirements.
Provide data and information to answer the following questions:
a. Health Care RESULTS
What are your current LEVELS and TRENDS in KEY MEASURES or INDICATORS of health care outcomes, HEALTH CARE SERVICE
delivery RESULTS, PATIENT safety, and PATIENTS’ functional status that are important to your PATIENTS and other
CUSTOMERS? How do these RESULTS compare with the PERFORMANCE of your competitors and other organizations
providing similar HEALTH CARE SERVICES?

Notes:
N1. Health care results reported in this Item should preference, such as those included in Item P.1, Note 3,
include the key health care service features identified and Item 3.1, Note 3.
as patient and other customer requirements or expec-
N2. Key health care results should be tailored to your
tations in P.1b(2), based on information gathered in
organization and might include both mandated and
Items 3.1 and 3.2. The measures or indicators should
nonmandated results.
address factors that affect patient and other customer

For additional description of this Item, see pages 52–53.

32 2006 Health Care Criteria for Performance Excellence

 7.2 Patient- and Other Customer-Focused Outcomes: What are your
patient- and other customer-focused performance results? (70 pts.) Results
Summarize your organization’s KEY PATIENT- and other CUSTOMER-focused RESULTS, including PATIENT/CUSTOMER
satisfaction and PATIENT/CUSTOMER-perceived VALUE. SEGMENT your RESULTS by program or service types or
groups, CUSTOMER groups, and market SEGMENTS, as appropriate. Include appropriate comparative data.
Provide data and information to answer the following questions:
a. PATIENT- and Other CUSTOMER-Focused RESULTS
(1) What are your current LEVELS and TRENDS in KEY MEASURES or INDICATORS of PATIENT and other CUSTOMER satisfac-
tion and dissatisfaction? How do these RESULTS compare with the customer satisfaction levels of your
competitors and other organizations providing similar HEALTH CARE SERVICES?
(2) What are your current LEVELS and TRENDS in KEY MEASURES or INDICATORS of PATIENT- and other CUSTOMER-
perceived VALUE, including PATIENT and other CUSTOMER loyalty and retention, positive referral, and other
aspects of building relationships with PATIENTS and other CUSTOMERS, as appropriate?

Notes:
N1. Patient and other customer satisfaction and with the long-term health outcomes, and satisfaction
dissatisfaction results reported in this Item should with ancillary services. All of these areas are appropri-
relate to the patient and other customer groups and ate satisfaction indicators.
market segments discussed in P.1(b)2 and Item 3.1
N3. Measures and indicators of your patients’ and
and to the determination methods and data described
other customers’ satisfaction relative to satisfaction
in Item 3.2.
with your services with competitors or other organiza-
N2. There may be several different dimensions of tions providing similar health care services (7.2a[1])
patient satisfaction, such as satisfaction with quality of might include objective information and data from
care, satisfaction with provider interaction, satisfaction your customers and from independent organizations.

For additional description of this Item, see page 53.

7.3 Financial and Market Outcomes: What are your financial

and market results? (70 pts.) Results
Summarize your organization’s KEY financial and health care marketplace PERFORMANCE RESULTS by patient or
other CUSTOMER or market SEGMENTS, as appropriate. Include appropriate comparative data.
Provide data and information to answer the following questions:
a. Financial and Market RESULTS
(1) What are your current LEVELS and TRENDS in KEY MEASURES or INDICATORS of financial PERFORMANCE, including
aggregate MEASURES of financial return and economic VALUE or budgetary MEASURES, as appropriate?
(2) What are your current LEVELS and TRENDS in KEY MEASURES or INDICATORS of health care marketplace PERFOR-
MANCE, including market share or position, growth, and new markets entered, as appropriate?

Note:
Responses to 7.3a(1) might include aggregate measures should relate to the financial management approaches
such as return on investment (ROI), asset utilization, described in Item 6.2. For nonprofit health care orga-
operating margins, profitability, profitability by market nizations, additional measures might include perfor-
or customer segment, liquidity, debt-to-equity ratio, mance to budget, reserve funds, and the amount of
value added per staff member, bond ratings (if appro- charitable contributions.
priate), and financial activity measures. Measures

For additional description of this Item, see page 53.

2006 Health Care Criteria for Performance Excellence 33

 7.4 Human Resource Outcomes: What are your
human resource results? (70 pts.) Results
Summarize your organization’s KEY human resource RESULTS, including WORK SYSTEM PERFORMANCE and STAFF LEARN-
ING, development, well-being, and satisfaction. SEGMENT your RESULTS to address the DIVERSITY of your workforce
and the different types and categories of STAFF, as appropriate. Include appropriate comparative data.
Provide data and information to answer the following questions:
a. Human Resource RESULTS
(1) What are your current LEVELS and TRENDS in KEY MEASURES or INDICATORS of WORK SYSTEM PERFORMANCE and
EFFECTIVENESS?

(2) What are your current LEVELS and TRENDS in KEY MEASURES of STAFF LEARNING and development?
(3) What are your current LEVELS and TRENDS in KEY MEASURES or INDICATORS of STAFF well-being, satisfaction, and
dissatisfaction?

Notes:

N1. Results reported in this Item should relate to ac- N3. Appropriate measures and indicators of staff
tivities described in Category 5. Your results should learning and development (7.4a[2]) might include
be responsive to key process needs described in Cate- innovation and suggestion rates, courses completed,
gory 6 and to your organization’s action plans and learning, on-the-job performance improvements,
human resource plans described in Item 2.2. credentialing, and cross-training rates.
N2. Appropriate measures and indicators of work sys- N4. For appropriate measures of staff well-being and
tem performance and effectiveness (7.4a[1]) might in- satisfaction (7.4a[3]), see Item 5.3 Notes.
clude simplification of jobs and job classifications, job
N5. Results for paid staff, independent practitioners,
rotation, work layout improvement, staff retention
volunteers, and health profession students should be
and internal promotion rates, and changing super-
included, as appropriate.
visory ratios.

For additional description of this Item, see pages 53–54.

34 2006 Health Care Criteria for Performance Excellence

 7.5 Organizational Effectiveness Outcomes: What are your
organizational effectiveness results? (70 pts.) Results
Summarize your organization’s KEY operational PERFORMANCE RESULTS that contribute to the improvement of
organizational EFFECTIVENESS. SEGMENT your RESULTS by HEALTH CARE SERVICE types and groups and by market
SEGMENTS, as appropriate. Include appropriate comparative data.

Provide data and information to answer the following questions:

a. Organizational EFFECTIVENESS RESULTS
(1) What are your current LEVELS and TRENDS in KEY MEASURES or INDICATORS of the operational PERFORMANCE of your
KEY health care PROCESSES? Include PRODUCTIVITY, CYCLE TIME, supplier and PARTNER PERFORMANCE, and other
appropriate MEASURES of EFFECTIVENESS and efficiency.
(2) What are your current LEVELS and TRENDS in KEY MEASURES or INDICATORS of the operational PERFORMANCE of your
other KEY PROCESSES? Include PRODUCTIVITY, CYCLE TIME, supplier and PARTNER PERFORMANCE, and other appropri-
ate MEASURES of EFFECTIVENESS and efficiency.

Notes:

N1. Results reported in Item 7.5 should address your organizational performance (Item 4.1) and should
key operational requirements as presented in the Or- provide the operational basis for health care and ser-
ganizational Profile and in Items 6.1 and 6.2. Include vice delivery outcomes (Item 7.1), patient- and other
results not reported in Items 7.1–7.4. customer-focused outcomes (Item 7.2), and financial
and market outcomes (Item 7.3).
N2. Results reported in Item 7.5 should provide
key information for analysis and review of your

For additional description of this Item, see page 54.

2006 Health Care Criteria for Performance Excellence 35

 7.6 Leadership and Social Responsibility Outcomes: What are your
leadership and social responsibility results? (70 pts.) Results
Summarize your organization’s KEY GOVERNANCE, SENIOR LEADERSHIP, and social responsibility RESULTS, including
evidence of ETHICAL BEHAVIOR, fiscal accountability, legal compliance, and organizational citizenship. SEGMENT
your RESULTS by organizational units, as appropriate. Include appropriate comparative data.
Provide data and information to answer the following questions:
a. Leadership and Social Responsibility RESULTS
(1) What are your RESULTS for KEY MEASURES or INDICATORS of accomplishment of your organizational strategy
and ACTION PLANS?
(2) What are your RESULTS for KEY MEASURES or INDICATORS of ETHICAL BEHAVIOR and of STAKEHOLDER trust in the SENIOR
LEADERS and GOVERNANCE of your organization? What are your RESULTS for KEY MEASURES or INDICATORS of
breaches of ETHICAL BEHAVIOR?
(3) What are your KEY current findings and TRENDS in KEY MEASURES or INDICATORS of fiscal accountability, both
internal and external, as appropriate?
(4) What are your RESULTS for KEY MEASURES or INDICATORS of organizational accreditation, assessment, and
regulatory and legal compliance?
(5) What are your RESULTS for KEY MEASURES or INDICATORS of organizational citizenship in support of your KEY
communities, including contributions to the health of your community?

Notes:

N1. For examples of measures of ethical behavior and received sanctions or adverse actions under law (includ-
stakeholder trust (7.6a[2]), see Item 1.2, Note 6. ing malpractice), regulation, accreditation, or contract
during the past three years, briefly describe the inci-
N2. Responses to 7.6a(3) might include financial
dent(s) and current status. If settlements have been
statement issues and risks, important internal and ex-
negotiated in lieu of potential sanctions or adverse
ternal auditor recommendations, and management’s
actions, give explanations. Staff related occupational
responses to these matters. For some nonprofit health
health and safety results (e.g., Occupational Safety and
care organizations, results of IRS 990 audits also
Health Administration [OSHA]-reportable incidents)
might be included.
should be reported in 7.4a(3).
N3. Accreditation, assessment, and regulatory and
N4. Organizational citizenship and community health
legal compliance results (7.6a[4]) should address re-
results (7.6a[5]) should address support of the key
quirements described in 1.2b. If your organization has
communities discussed in 1.2c.

For additional description of this Item, see page 54.

36 2006 Health Care Criteria for Performance Excellence

2006 Health Care Criteria for Performance Excellence 37
BALDRIGE APPLICATION SELF-ANALYSIS WORKSHEET (OPTIONAL)
(not to be submitted with your Baldrige application)

While insights gained from external Examiners or reviewers are always helpful, you know your organization better than they
will. You are currently in an excellent position to identify your organization’s key strengths and key opportunities for improve-
ment (OFIs). Having just completed your responses to the Baldrige Criteria questions, you can accelerate your improvement
journey by doing a self-analysis.
Use this optional worksheet to list your key strengths and key OFIs. Start by identifying one or two strengths and one or two
OFIs for each Criteria Category. For those of high importance, establish a goal and a plan of action.
An electronic copy of this worksheet is available in Microsoft Word format at www.baldrige.nist.gov/Word_files/
Optional_Worksheet_HC.doc.

Importance For High-Importance Areas

Criteria Category
High, Medium, Low Stretch (Strength) or Improvement (OFI) Goal What Action Is Planned? By When? Who Is Responsible?

Category 1—Leadership

Strength

1.

2.

OFI

1.

2.

Category 2—Strategic Planning

Strength

1.

2.

OFI

1.

2.

Category 3—Focus on Patients, Other Customers, and Markets

Strength

1.

2.

OFI

1.

2.

38 2006 Health Care Criteria for Performance Excellence

 Importance For High-Importance Areas
Criteria Category
High, Medium, Low Stretch (Strength) or Improvement (OFI) Goal What Action Is Planned? By When? Who Is Responsible?

Category 4—Measurement, Analysis, and Knowledge Management

Strength

1.

2.

OFI

1.

2.

Category 5—Human Resource Focus

Strength

1.

2.

OFI

1.

2.

Category 6—Process Management

Strength

1.

2.

OFI

1.

2.

Category 7—Results

Strength

1.

2.

OFI

1.

2.

2006 Health Care Criteria for Performance Excellence 39

2006 HEALTH CARE CRITERIA: CATEGORY AND ITEM DESCRIPTIONS

Preface: Organizational Profile clearly identify which functions are performed by senior
leaders and, as applicable, by your governance board and
The Organizational Profile provides an overview of your
your parent organization. Board independence and ac-
organization. The profile addresses your operating environ-
countability frequently are key considerations in the gov-
ment, your key organizational relationships, your competi-
ernance structure.
tive and collaborative environment and strategic challenges,
and your approach to performance improvement. Your Or- I In supplier-dependent organizations, suppliers play criti-
ganizational Profile provides a context for understanding cal roles in processes that are important to running the
your organization and for guiding and prioritizing the in- organization and to maintaining or achieving overall
formation you present in response to the Criteria Items in organizational performance success. Supply chain re-
Categories 1–7. quirements might include accessibility, continuity of care,
on-time or just-in-time delivery, flexibility, variable staff-
P.1 Organizational Description: What are your key ing, research and design capability, and customized man-
organizational characteristics? ufacturing or services.
Purpose
P.2 Organizational Challenges: What are your key
This Item addresses the key characteristics and relationships organizational challenges?
that shape your organizational environment. It also addresses
your organization’s governance system. The aim is to set Purpose
the context for your organization and for your responses to This Item addresses the competitive and collaborative envi-
the Criteria requirements in Categories 1–7. ronment in which your organization operates and the key
strategic challenges that your organization faces. It also ad-
Comments dresses how you approach performance improvement and
I The Organizational Profile provides your organization organizational learning. The aim is to understand your key
with critical insight into the key internal and external organizational challenges and your system for maintaining a
factors that shape your operating environment. These sustainable advantage.
factors, such as the mission, vision, values, competitive
and collaborative environment, and strategic challenges, Comments
impact the way that your organization is run and the de- I Knowledge of an organization’s strengths, vulnerabilities,
cisions you make. As such, the Organizational Profile and opportunities for both improvement and growth is
helps your organization better understand the context in essential to the success and sustainability of the organiza-
which it operates; the key requirements for current and tion. With this knowledge, you can identify those health
future organizational success and sustainability; and the care service and program offerings, processes, and perfor-
needs, opportunities, and constraints placed on your or- mance attributes that are unique to your organization;
ganization’s performance management system. those that set you apart from other organizations; and
those that help you to sustain your competitive position.
I Use of such terms as “purpose,” “vision,” “mission,” and
“values” varies depending on the organization, and some I Understanding who your competitors and collaborators
organizations may not use one or more of these terms. are, how many you have, and their key characteristics is
Nevertheless, you should have a clear understanding of the essential for determining what your competitive position
essence of your organization, why it exists, and where your is and what your collaborative opportunities are in the
senior leaders want to take the organization in the future. health care industry and marketplace. Leading organiza-
This clarity enables you to make and implement strategic tions have an in-depth understanding of their current
decisions affecting the future of your organization. competitive and what your collaborative environment, in-
cluding the factors that affect day-to-day performance
I The legal and regulatory environment in which you op-
and factors that could impact future performance.
erate places requirements on your organization and im-
pacts how you run your organization. Understanding this I Sources of comparative and competitive data might include
environment is key to making effective operational and external organizations (e.g., CMS, the National Commit-
strategic decisions. Further, it allows you to identify tee for Quality Assurance [NCQA], JCAHO, and the
whether you are merely complying with the minimum Maryland Quality Indicator Project), health care industry
requirements of applicable laws, regulations, and stan- journals and other publications, benchmarking activities
dards of practice or exceeding them, a hallmark of lead- (comparative data also can be obtained from organizations
ing organizations. outside of the health care sector, particularly in areas
related to patient and other customer satisfaction, staff
I Leading organizations have well-defined governance sys-
satisfaction, and organizational effectiveness [e.g., cycle
tems with clear reporting relationships. It is important to

40 2006 Health Care Criteria for Performance Excellence

 values, and performance expectations. Attention is given to
how your senior leaders communicate with staff, develop
future leaders, and create an environment that encourages
ethical behavior and high performance. The Category also
includes your organization’s governance system, its legal and
ethical responsibilities to the public, how your organization
supports its community, and how your organization con-
tributes to the health of its community.

1.1 Senior Leadership: How do your senior leaders lead?

Purpose
This Item examines the key aspects of your senior leaders’
responsibilities. It examines how your senior leaders set and
communicate the organization’s vision and values. It focuses
on your senior leaders’ actions to create and sustain a high-
time]), annual reports for publicly traded companies and performance organization.
public organizations, conferences, local networks, and in-
dustry associations. Comments
I Operating your organization in today’s highly competitive I Senior leadership’s central role in setting values and direc-
marketplace means you are facing many strategic chal- tions, communicating, creating and balancing value for all
lenges that can affect your ability to sustain performance stakeholders, and creating an organizational bias for action
and maintain your competitive position. These challenges are the focus of this Item. Success requires a strong orien-
might include your operational costs (e.g., pharmaceuti- tation to the future and a commitment to improvement,
cals, labor, or medical technology); expanding or decreas- innovation, and organizational sustainability. Increasingly,
ing markets; mergers or acquisitions both by your organi- this requires creating an environment for empowerment,
zation and by your competitors; economic conditions, agility, and learning.
including fluctuating demand and economic downturns; I An important aspect of leadership in health care organi-
needs for public health and bioterrorism preparedness; zations is the relationship and collaboration between ad-
HIPAA compliance; the introduction of new or substitute ministrative and health care provider leadership in orga-
health care services, possibly based on a disruptive tech- nizations with separate administrative and health care
nology; rapid technological changes; or emergence of leadership.
e-health care delivery technology. In addition, your orga-
nization may face challenges related to the recruitment, I In highly respected organizations, senior leaders are com-
hiring, and retention of qualified staff or volunteers. mitted to the development of the organization’s future
leaders and to the reward and recognition of staff perfor-
I A particularly significant challenge, if it occurs to your mance. Senior leaders personally participate in the devel-
organization, is being unprepared for a disruptive tech- opment of future leaders, in succession planning, and in
nology that threatens your competitive position or your staff recognition opportunities and events. Development
marketplace. Examples of such technologies include activities for future leaders might include personal men-
MRIs replacing myelograms and orthoscopic surgery re- toring or participating in leadership development courses.
placing more invasive types of surgery. Today, organiza-
tions need to be scanning the environment inside and 1.2 Governance and Social Responsibilities: How do you
outside their immediate industry to detect such chal- govern and address your social responsibilities?
lenges at the earliest possible point in time.
Purpose
I One of the many issues facing organizations today is how This Item examines key aspects of your organization’s
to manage, use, and share their ever-increasing organiza- governance system. It also examines how your organization
tional knowledge. Leading organizations already benefit fulfills its public responsibilities, how your senior leaders
from the knowledge assets of their staff, patients and ensure that you behave legally and ethically, and how your
other customers, suppliers, collaborators, and partners, senior leaders and staff encourage and practice good
who together drive organizational learning and improve citizenship.
performance.
Comments
Leadership (Category 1) I The organizational governance requirement is intended
Leadership addresses how your senior leaders guide and to address the need for a responsible, informed, and
sustain your organization, setting organizational vision, accountable governance or advisory body that can protect

2006 Health Care Criteria for Performance Excellence 41

 the interests of key stakeholders (including stockholders)
in publicly traded, private, and nonprofit organizations. It
should have independence in review and audit functions.
It also should have a performance evaluation function that
monitors organizational and senior leader performance.
I An integral part of health care delivery, performance
management, and improvement is proactively addressing
(1) the need for ethical behavior; (2) legal, regulatory, and
accreditation requirements; and (3) risk factors. Address-
ing these areas requires establishing appropriate measures
or indicators that senior leaders track in their performance
reviews. Your organization should be sensitive to issues of
public concern related to your health care services and
operations, whether or not these issues are currently em-
bodied in laws and regulations. Role model organizations The Baldrige Health Care Criteria emphasize three key
look for opportunities to exceed requirements and to aspects of organizational excellence. These aspects are
excel in areas of legal and ethical behavior. important to strategic planning:
I This Item addresses the use of resource-sustaining pro- I Patient-focused quality and health care performance
cesses. These processes might include the use of “green” provide a strategic view of quality. The focus is on the
technologies, replacement of hazardous chemicals with drivers of patient satisfaction, patient loyalty, patient
water-based chemicals, energy conservation, use of health status, and health care service improvement—
cleaner energy sources, or recycling of by-products or key factors in organizational sustainability.
wastes.
I Operational performance improvement contributes to
I Social responsibility implies going beyond a compliance short- and longer-term productivity growth and cost
orientation. Good citizenship opportunities are available containment. Building operational capability—
to organizations of all sizes. These opportunities might including speed, responsiveness, and flexibility—
include encouraging and supporting your staff’s commu- represents an investment in strengthening your
nity service. organizational fitness.
I Examples of organizational community involvement in- I Organizational and personal learning are necessary
clude partnering with other health care providers, busi- strategic considerations in today’s fast-paced environ-
nesses, and professional associations to engage in benefi- ment. The Criteria emphasize that improvement and
cial cooperative activities, such as providing education learning need to be embedded in work processes. The
and volunteer services and sharing best practices to im- special role of strategic planning is to align work pro-
prove overall U.S. health status and health care. Levels of cesses and learning initiatives with your organization’s
involvement and leadership are dependent upon your strategic directions, thereby ensuring that improvement
organization’s size and available resources. and learning prepare you for and reinforce organiza-
I This Item addresses actions to build and improve com- tional priorities, especially health care priorities.
munity health, including the consideration of partnering The Strategic Planning Category examines how your
with other local organizations (public and business) and organization
health care providers. The community health services
offered by your organization will be dependent upon
I determines its key strengths, weaknesses, opportunities,
your mission, including service requirements for tax- and threats, and its ability to execute your strategy.
exempt organizations. I optimizes the use of resources, ensures the availability
of trained staff, and bridges short- and longer-term
Strategic Planning (Category 2) requirements that may entail capital expenditures,
technology development or acquisition, supplier
Strategic Planning addresses strategic and action planning,
development, and new health care partnerships and
deployment of plans, how plans are changed if circum-
collaborations.
stances require a change, and how accomplishments are
measured and sustained. The Category stresses that long- I ensures that deployment will be effective—that there
term organizational sustainability and your competitive or are mechanisms to communicate requirements and
collaborative environment are key strategic issues that need achieve alignment on three levels: (1) the organization
to be integral parts of your organization’s overall planning. and the senior leader level, (2) the key process level, and
(3) the department/work unit and individual job level.

42 2006 Health Care Criteria for Performance Excellence

The requirements in the Strategic Planning Category en- markets. How it competes and/or collaborates presents many
courage strategic thinking and acting—to develop a basis options and requires that you understand your organiza-
for an appropriate competitive and collaborative position in tion’s and your competitors’/collaborators’ strengths and
the marketplace. These requirements do not imply formalized weaknesses. Although no specific time horizons are in-
plans, planning systems, departments, or specific planning cycles. cluded, the thrust of this Item is sustained performance
They also do not imply that all your improvements could or leadership.
should be planned in advance. An effective improvement I An increasingly important part of strategic planning is
system combines improvements of many types and degrees
projecting the future competitive and collaborative envi-
of involvement. This requires clear strategic guidance, par-
ronment. Such projections help to detect and reduce
ticularly when improvement alternatives, including major
competitive threats, to shorten reaction time, and to
change, compete for limited resources. In most cases, set-
identify opportunities. Depending on the size and type of
ting priorities depends heavily on health care market de-
organization, maturity of health care markets, pace of
mands and a cost rationale. However, you also might have
change, and competitive/collaborative parameters (such
critical requirements, such as incorporating new health care
as cost or innovation rate), organizations might use a va-
technology or community health and public responsibilities,
riety of modeling, scenarios, or other techniques and
that are not driven by cost considerations alone.
judgments to anticipate the future environment.
2.1 Strategy Development: How do you develop your I While many organizations are increasingly adept at stra-
strategy? tegic planning, plan execution is still a significant challenge.
Purpose This is especially true given market demands to be agile
and to be prepared for unexpected change, such as dis-
This Item examines how your organization sets strategic
ruptive technologies that can upset an otherwise fast-paced
directions and develops your strategic objectives to guide
but more predictable marketplace. This Item and Item 2.2
and strengthen your overall performance as a health care
highlight the need to place a focus not only on develop-
provider and your performance relative to other organiza-
ing your plans but also on your capability to execute them.
tions providing similar health care services.
2.2 Strategy Deployment: How do you deploy your strategy?
Comments
I This Item calls for basic information on the planning Purpose
process and for information on all the key influences, This Item examines how your organization converts your
risks, challenges, and other requirements that might strategic objectives into action plans to accomplish the
affect your organization’s future opportunities and direc- objectives. It also examines how your organization assesses
tions—taking as long term a view as appropriate and pos- progress relative to these action plans. The aim is to ensure
sible from the perspectives of your organization and your that your strategies are successfully deployed for goal
industry or marketplace. This approach is intended to achievement.
provide a thorough and realistic context for the develop-
ment of a patient-, other customer-, and health care Comments
market-focused strategy to guide ongoing decision mak- I This Item asks how your action plans are developed and
ing, resource allocation, and overall management. deployed. Accomplishment of action plans requires re-
sources and performance measures, as well as the align-
I This Item is intended to cover all types of health care or-
ment of department/work unit and supplier and partner
ganizations, competitive/collaborative situations, strategic
plans. Of central importance is how you achieve align-
issues, planning approaches, and plans. The requirements
ment and consistency—for example, via key processes and
explicitly call for a future-oriented basis for action but do
key measurements. Also, alignment and consistency are
not imply planning departments, specific planning cycles,
intended to provide a basis for setting and communicat-
or a specified way of visualizing the future. Even if your
ing priorities for ongoing improvement activities—part of
organization is seeking to create an entirely new health
the daily work of all departments/work units. In addition,
care service or business situation, it is still necessary to set
performance measures are critical for tracking performance.
and to test the objectives that define and guide critical
actions and performance. I Key changes in your services or patients and other custo-
mers and health care markets might include Web-based
I This Item emphasizes health care industry leadership,
or electronic communication/information transfer initia-
which usually depends on health care service delivery and
tives integrated within or separate from your current
operational effectiveness. This leadership requires a view
health care and other services.
of the future that includes not only the health care markets
or segments in which your organization provides services I Action plans should include human resource plans that
but also how it competes and/or collaborates in these are aligned with and support your overall strategy.

2006 Health Care Criteria for Performance Excellence 43

I Examples of possible human resource plan elements are contribute to the sustainability of your organization in the
marketplace.
• a redesign of your work organization and jobs to in-
crease staff empowerment and decision making; Throughout the Criteria, patients frequently are identified
separately from other customer groups. This is done to
• initiatives to promote better collaboration and cooper-
stress the importance of this customer group (i.e., patients)
ation between health care providers and administrative
to health care organizations. However, Item requirements
staff;
also address other customers (or refer to customers generi-
• initiatives to promote greater labor-management coop- cally) to ensure inclusion of all customer groups in the orga-
eration, such as union partnerships; nization’s customer focus and performance management
system. Other customers could include patients’ families, the
• initiatives to foster knowledge sharing and organiza-
community, insurers and other third-party payors, employ-
tional learning;
ers, health care providers, patient advocacy groups, Depart-
• modification of your compensation and recognition ments of Health, and students. A key challenge to health
systems to recognize team, organizational, patient and care organizations frequently may include balancing the dif-
other customer satisfaction, or other performance fering expectations of patients and other customer groups.
attributes; or
3.1 Patient, Other Customer, and Health Care
• education and training initiatives, such as developmen- Market Knowledge: How do you use patient, other
tal programs for future leaders, partnerships with customer, and health care market knowledge?
universities to help ensure the availability of future
staff, and establishment of training programs on new Purpose
technologies important to your future success. This Item examines your organization’s key processes for
gaining knowledge about your current and future patients,
I Projections and comparisons in this Item are intended to
other customers, and markets, with the aim of offering rele-
improve your organization’s ability to understand and
vant health care services; understanding longer-term or
track dynamic, competitive performance factors.
emerging patient/customer needs, requirements, and expec-
Through this tracking process, your organization should
tations; and keeping pace with marketplace changes and
be better prepared to take into account its rate of im-
changing ways of doing business.
provement and change relative to that of competitors and
other organizations providing similar health care services Comments
and relative to its own targets or stretch goals. Such I In a rapidly changing technological and competitive health
tracking serves as a key diagnostic management tool.
care environment, many factors may affect patient and
I In addition to improvement relative to past performance other customer preference and loyalty and your interface
and to the projected performance of competitors and with patients and other customers in the marketplace.
comparable organizations, projected performance might This makes it necessary to continually listen and learn.
include changes resulting from new business ventures, To be effective, listening and learning need to be closely
entry into new health care markets, introduction of new linked with your organization’s overall strategy.
technologies, innovations, or other strategic thrusts. I Knowledge of patient and other customer groups and
health care market segments allows your organization to
Focus on Patients, Other Customers, and tailor listening and learning strategies and marketplace
Markets (Category 3) offerings, to support and tailor your marketing strategies,
Focus on Patients, Other Customers, and Markets addresses to develop new health care service opportunities, and to
how your organization seeks to understand the voices of ensure organizational sustainability.
patients, other customers, and the marketplace, with a focus I A relationship strategy may be possible with some cus-
on meeting patients’ and other customers’ requirements, tomers but not with others. Differing relationships may
needs, and expectations; delighting them; and building loy- require distinctly different listening and learning strate-
alty and positive referrals. The Category stresses relation- gies. The use of electronic communication and the Inter-
ships as an important part of an overall listening, learning, net (e.g., Web-based scheduling, support group, and
and performance excellence strategy. Your patient and other health care information) is rapidly changing many mar-
customer satisfaction and dissatisfaction results provide vital ketplaces and may affect your listening and learning
information for understanding your customers and the strategies, as well as your definition of patient and other
health care marketplace. In many cases, such results and customer groups and health care market segments.
trends provide the most meaningful information, not only
on your patients’ and other customers’ views but also on
I Selection of listening and learning strategies depends on
their marketplace behaviors—patient/customer loyalty and your key organizational factors. Increasingly, organiza-
positive referrals—and how these views and behaviors may tions interact with customers via multiple modes. Some

44 2006 Health Care Criteria for Performance Excellence

 frequently used modes include focus groups with key health care services. Such information might be derived
customers; close integration with patients and other key from your own comparative studies or from independent
customers; interviews with lost and potential customers studies. The factors that lead to patient and other customer
about their health care purchase or relationship decisions; preference are of critical importance in understanding
use of the patient and other customer complaint process factors that drive health care markets and potentially
to understand key service attributes; win/loss analysis rel- affect longer-term success in the health care marketplace.
ative to competitors and other organizations providing I Changing health care service needs and directions might
similar health care services; and survey or feedback infor-
include changing modes of patient and other customer
mation, including information collected on the Internet.
access, such as the Internet. In such cases, key contact re-
quirements might include privacy and access to personal
online assistance.

Measurement, Analysis, and Knowledge

Management (Category 4)
The Measurement, Analysis, and Knowledge Management
Category is the main point within the Criteria for all key
information about effectively measuring, analyzing, and re-
viewing performance and managing organizational knowl-
edge to drive improvement and organizational competitive-
ness, with specific attention to performance as a health care
provider. In the simplest terms, Category 4 is the “brain
center” for the alignment of your organization’s health care
and administrative operations and its strategic objectives.
Central to such use of data and information are their quality
and availability. Furthermore, since information, analysis,
and knowledge management might themselves be primary
3.2 Patient and Other Customer Relationships and
sources of competitive advantage and productivity growth,
Satisfaction: How do you build relationships and
the Category also includes such strategic considerations.
grow customer satisfaction and loyalty?
Purpose 4.1 Measurement, Analysis, and Review of Organizational
Performance: How do you measure, analyze, and review
This Item examines your organization’s processes for building
organizational performance?
patient and other customer relationships and determining pa-
tient and other customer satisfaction, with the aim of acquiring Purpose
new patients and other customers, retaining existing custo- This Item examines your organization’s selection, manage-
mers, ensuring positive patient and other customer experi- ment, and use of data and information for performance
ences and comments, and developing new health care market measurement, analysis, and review in support of organiza-
opportunities. tional planning and performance improvement as a health
care provider. This performance improvement includes
Comments
efforts to improve health care results and outcomes (e.g.,
I This Item emphasizes how you obtain actionable infor- through the selection of statistically meaningful indicators,
mation from patients and other customers. Information the risk adjustment of data, and the linking of outcomes to
that is actionable can be tied to key health care service processes and provider decisions). The Item serves as a
and organizational processes and be used to determine central collection and analysis point in an integrated perfor-
cost implications for setting improvement goals and pri- mance measurement and management system that relies on
orities for change. clinical, financial, and nonfinancial data and information.
I Complaint aggregation, analysis, and root cause determi- The aim of measurement, analysis, and review is to guide
nation should lead to effective elimination of the causes your organization’s process management toward the achieve-
of complaints and to the setting of priorities for process ment of key organizational performance results and strategic
and service improvements. Successful outcomes require objectives, and to anticipate and respond to rapid or unex-
effective deployment of information throughout the pected organizational or external changes.
organization.
Comments
I In determining patients’ and other customers’ satisfac- I Alignment and integration are key concepts for successful
tion, a key aspect is their comparative satisfaction with implementation of your performance measurement system.
competitors and/or other organizations providing similar

2006 Health Care Criteria for Performance Excellence 45

 outcomes of research studies and practice guidelines), and
(3) data gathering and evaluation by independent organi-
zations (e.g., CMS, accrediting organizations [NCQA
and JCAHO], and commercial organizations).
I The organizational review called for in this Item is in-
tended to cover all areas of performance. This includes
not only how well you currently are performing but also
how well you are moving toward the future. It is antici-
pated that the review findings will provide a reliable
means to guide both improvement and opportunities for
innovation that are tied to your organization’s key ob-
jectives, success factors, and measures. Therefore, an
important component of your organizational review is
the translation of the review findings into an action
agenda sufficiently specific for deployment throughout
your organization and to your suppliers, partners, col-
laborators, and key customers.
I Analyses that your organization conducts to gain an un-
derstanding of performance and needed actions may vary
They are viewed in terms of extent and effectiveness of
widely depending on your type of organization, size,
use to meet your performance assessment needs. Align-
competitive environment, and other factors. Examples of
ment and integration include how measures are aligned
possible analyses include
throughout your organization and how they are integrated
to yield organization-wide data and information. Alignment • how health care service quality improvement correlates
and integration also include how performance measure- with key patient and other customer indicators, such as
ment requirements are deployed by your senior leaders to satisfaction, loyalty, and market share
track departmental, work group, and process-level perfor-
• cost and revenue implications of patient- and other
mance on key measures targeted for organization-wide
customer-related problems and effective problem
significance or improvement.
resolution
I The use of comparative data and information is impor-
• interpretation of market share changes in terms of
tant to all organizations. The major premises for use are
patient and other customer gains and losses and
(1) your organization needs to know where it stands rela-
changes in patient and other customer satisfaction
tive to competitors, to other providers, and to best prac-
tices; (2) comparative information and information ob- • improvement trends in key operational performance
tained from benchmarking often provide the impetus for indicators, such as productivity, cycle time (e.g., length
significant (“breakthrough”) improvement or change; and of stay, turnaround times, wait times, and billing de-
(3) comparing performance information frequently leads lays), waste reduction, utilization rates, error rates, and
to a better understanding of your processes and their cost per case
performance. Comparative information also may support
• relationships among staff and organizational learning
analysis and decisions relating to core competencies,
and value added per staff member
alliances, and outsourcing.
• financial benefits derived from improvements in staff
I Your effective selection and use of comparative data and
safety, absenteeism, and turnover
information require (1) determination of needs and prior-
ities, (2) criteria for seeking appropriate sources for com- • benefits and costs associated with education and
parisons—from within and outside the health care indus- training, including Internet-based or e-learning
try and your organization’s markets, and (3) use of data opportunities
and information to set stretch goals and to promote
• benefits and costs associated with improved organiza-
major, nonincremental (“breakthrough”) improvements
tional knowledge management and sharing
in areas most critical to your organization’s strategy.
• the relationship between knowledge management and
I Sources of comparative data and information might in-
innovation
clude (1) information obtained from other organizations
through sharing or contributing to external reference • how the ability to identify and meet staff requirements
databases (e.g., the Maryland Quality Indicator Project), correlates with staff retention, motivation, and
(2) information obtained from the open literature (e.g., productivity

46 2006 Health Care Criteria for Performance Excellence

 • cost and revenue implications of staff-related problems
and effective problem resolution
• individual or aggregate measures of productivity and
quality relative to competitors’ performance
• cost trends relative to competitors’ trends (e.g., cost/
case for key diagnosis-related groups [DRGs])
• compliance with preventive screenings compared to
similar health care providers
• relationships among patient health care quality, opera-
tional performance indicators, and overall financial
performance trends as reflected in indicators such as
operating costs, revenues, asset utilization, and value
added per staff member
• allocation of resources among alternative improvement
projects based on cost/benefit implications or environ-
mental and community impact
• net earnings or savings derived from quality, opera-
tional, and human resource performance improvements
• comparisons among cost centers showing how quality
and operational performance improvement affect
financial performance (e.g., impacts of HMO preven- and their results may have many resource implications.
tive care versus diagnostic expenses and treatment of Organizations have a critical need to provide an effective
potentially preventable illnesses) analytical basis for decisions because resources for im-
provement are limited and cause-effect connections often
• contributions of improvement activities to cash flow,
are unclear.
working capital use, and shareholder and community
value 4.2 Information and Knowledge Management: How do you
• financial impacts of customer retention (e.g., retention manage organizational information and knowledge?
of third-party payors) Purpose
• cost and revenue implications of new health care This Item examines how your organization ensures the
market entry availability of high-quality, timely data and information for
all your key users—staff, suppliers and partners, collabora-
• cost and revenue, patient and other customer, and pro-
tors, and patients and other customers. It also examines how
ductivity implications of engaging in or expanding
your organization builds and manages its knowledge assets.
electronic communication/information transfer and use
The aim is to improve organizational efficiency, effective-
of the Internet and intranets
ness, and innovation.
• health care market share versus profits/financial returns
Comments
• trends in economic, market, and stakeholder indicators

Managing information can require a significant commit-
of value and the impact of these trends on organiza-
ment of resources as the sources of data and information
tional sustainability
grow dramatically. The expanding use of electronic infor-

Individual facts and data do not usually provide an effec- mation within organizations’ operations, as part of orga-
tive basis for setting organizational priorities. This Item nizational knowledge networks, from the Internet, and in
emphasizes that close alignment is needed between your electronic communication/information transfer, chal-
analysis and your organizational performance review and lenges organizational abilities to ensure reliability, confi-
between your analysis and your organizational planning. dentiality, and availability in a user-friendly format.
This ensures that analysis is relevant to decision making

Data and information are especially important in alliances
and that decision making is based on relevant data and
and supply chains. Your responses to this Item should
information.
take into account this use of data and information and

Action depends on understanding cause-effect connec- should recognize the need for rapid data validation and
tions among processes and between processes and organi- reliability assurance, given the increasing use of electronic
zational performance results or outcomes. Process actions data transfer.

2006 Health Care Criteria for Performance Excellence 47

I Organizations should carefully plan how they will continue and requirements of the health care marketplace. The
to provide data and information in the event of either a focus of this Item is on a workforce capable of achieving
natural or man-made disaster. These plans should con- high performance. In addition to enabled staff and proper
sider the needs of all of the organization’s stakeholders, work system design, high-performance work requires on-
including staff, patients and other customers, suppliers/ going education and training, as well as information sys-
partners, and collaborators. The plans also should be co- tems that ensure proper information flow.
ordinated with the organization’s overall plan for business I Work and job factors for your consideration include sim-
continuity (Item 6.2).
plification of job classifications, cross-training, job rota-
I The focus of an organization’s knowledge management is tion, use of teams (including self-directed teams), and
on the knowledge that people need to do their work; im- changes in work layout and location to facilitate patient-
prove processes and health care services; keep current focused processes. Also important is effective communi-
with changing business needs and directions; and develop cation across functions and work units to ensure a focus
innovative solutions that add value for the patient/customer on patient and other customer requirements and to en-
and the organization. sure an environment of trust, knowledge sharing, and
mutual respect. Job design should address the organiza-
Human Resource Focus (Category 5) tion’s credentialing and privileging of its health care
practitioners, as appropriate.
Human Resource Focus addresses key human resource
practices—those directed toward creating and maintaining a
high-performance workplace and toward developing staff to
enable them and your organization to adapt to change. The
Category covers human resource development and manage-
ment requirements in an integrated way (i.e., aligned with
your organization’s strategic objectives and action plans).
Your human resource focus includes your work environment
and your staff support climate. A particular challenge in some
health care organizations is the breadth of staff relationships—
the variety of people contributing to the delivery of the orga-
nization’s services. This might include paid staff, indepen-
dent practitioners, volunteers, and students. All appropriate
contributions must be considered in the Human Resource
Focus Category.
To reinforce the basic alignment of human resource man-
agement with overall strategy, the Criteria also cover human
resource planning as part of overall planning in the Strategic
Planning Category (Category 2). I Compensation and recognition systems should be matched
to your work systems. To be effective, compensation and
5.1 Work Systems: How do you enable staff to accomplish
recognition might be tied to demonstrated skills, to peer
the work of your organization?
evaluations, and/or to collaboration among departments
Purpose and health care practitioners.
This Item examines your organization’s systems for work and I Compensation and recognition approaches also might
jobs; communication; and staff compensation, career pro- include bonuses/profit sharing, and rewards for exemplary
gression, performance management, recognition, and team or unit performance. Compensation and recognition
hiring, with the aim of enabling and encouraging all staff to might be linked to patient and other customer satisfaction
contribute effectively and to the best of their ability. These and loyalty measures and the achievement of organiza-
systems are intended to foster high performance, to result tional strategic objectives or other key organizational
in individual and organizational learning, and to enable objectives.
adaptation to change, contributing to organizational sustain-
ability. I The requirements of high-performance work, coupled
with the challenges of labor markets, necessitate attention
Comments to succession planning and hiring profiles. This should
I High-performance work is characterized by flexibility, in- include and capitalize on diversity factors. Staff recruit-
novation, knowledge and skill sharing, alignment with or- ment and career progression planning should consider
ganizational objectives, patient and other customer focus, both internal and external candidates, with a focus on the
and rapid response to changing health care service needs future sustainability and growth of the organization.

48 2006 Health Care Criteria for Performance Excellence

5.2 Staff Learning and Motivation: How do you contribute systematic processes for sharing this information. This is
to staff learning and motivate staff? particularly important for implicit knowledge (i.e., knowl-
edge personally retained by your staff).
Purpose
This Item examines the education, training, and on-the-job I To help staff realize its full potential, many organiza-
reinforcement of knowledge and skills of your organization’s tions use individual development plans prepared with
workforce. It also examines your organization’s systems for each staff member that address his or her career and
motivation and staff career development, with the aim of meet- learning objectives.
ing the ongoing needs of staff, licensure and recredentialing I Factors inhibiting motivation should be understood and
requirements, and a high-performance workplace. addressed by your organization. Further understanding of
these factors could be developed through staff surveys or
Comments
exit interviews with departing staff members.
I Depending on the nature of your organization’s health
care services, staff responsibilities, and the stage of orga- 5.3 Staff Well-Being and Satisfaction: How do you
nizational and personal development, education and contribute to staff well-being and grow staff
training needs might vary greatly. These needs might in- satisfaction?
clude continuing clinical education; gaining skills for
Purpose
knowledge sharing, communication, teamwork, and prob-
lem solving; interpreting and using data; meeting patient This Item examines your organization’s work environment,
and other customer requirements; accomplishing process your staff support climate, and how you determine staff sat-
analysis and simplification; reducing waste and cycle time; isfaction, with the aim of fostering the well-being, satisfac-
applying HIPAA regulations and concepts in daily work; tion, and motivation of all staff while recognizing their di-
working with and motivating volunteers; and setting pri- verse needs. It also examines your organization’s capabilities
orities based on strategic alignment or cost/benefit analy- for handling emergencies or disasters, with the aim of staff
sis. Education needs also might include advanced skills in protection and workplace safety.
new technologies or basic skills, such as reading, writing,
Comments
language, arithmetic, and, increasingly, computer skills.
I Most organizations, regardless of size, have many oppor-
I Education and training delivery might occur inside or tunities to contribute to staff’s well-being, satisfaction, and
outside your organization and could involve on-the-job, motivation. Some examples of services, facilities, activities,
classroom, computer-based, or distance learning, as well and other opportunities are personal and career counsel-
as other types of delivery. Training also might occur ing; career development and employability services;
through developmental assignments within or outside recreational or cultural activities; formal and informal
your organization. recognition; nonwork-related education; day care; special
I When you evaluate education and training, you should leave for family responsibilities and community service;
seek effectiveness measures as a critical part of the evalua- flexible work hours and benefits packages; outplacement
tion. Such measures might address the impact on individ- services; and retiree benefits, including extended health
ual, department, unit, and organizational performance; care and access to staff services.
the impact on customer-related performance; the impact I All organizations, regardless of size, are required to meet
on health care outcomes; and a cost/benefit analysis of minimum regulatory standards for workplace safety; how-
the training. ever, high-performing organizations have processes in
I Although this Item does not specifically ask you about place to ensure that they not only meet these minimum
training for patient and other customer contact staff, such standards but go beyond a compliance orientation. This
training is important and common. It frequently includes includes designing proactive processes, with input from
learning critical knowledge and skills in the following employees directly involved in the work, to ensure a safe
areas: health care services and patients and other custo- working environment.
mers; how to listen to patients and other customers; how I Although satisfaction with pay and satisfaction with pro-
to recover from problems or failures; and how to effec- motion are important to paid staff, these two factors gen-
tively manage or meet patient and other customer erally are not sufficient to ensure overall staff satisfaction,
expectations or needs. motivation, and high performance. Some examples of
I An organization’s knowledge management system should other factors to consider are effective staff problem and
provide the mechanism for sharing the knowledge of staff, grievance resolution; staff development and career oppor-
privileged physicians, and the organization to ensure tunities; work environment and management support;
high-performance work is maintained through transitions. workplace safety and security; workload; effective com-
Each organization should determine what knowledge is munication, cooperation, and teamwork; job security; ap-
critical for its operations and should then implement preciation of the differing needs of diverse staff groups;

2006 Health Care Criteria for Performance Excellence 49

 novel partnering arrangements. Flexibility might demand
special strategies, such as sharing facilities, cross-training,
and providing specialized training. Cost and cycle time re-
duction often involve agile process management strategies.
It is crucial to utilize key measures for tracking all aspects of
your overall process management.

6.1 Health Care Processes: How do you identify and

manage your key health care processes?
Purpose
This Item examines your organization’s key health care
service design and delivery processes, with the aim of creat-
ing value for your patients, other customers, and other key
stakeholders, and improving your marketplace and opera-
tional performance.

Comments
I This Item calls for information on the management and
improvement of key health care processes. The informa-
and organizational support for serving patients and other tion required includes a description of the key processes,
customers. their specific requirements, and how performance relative
to these requirements is determined and maintained. In-
I In addition to direct measures of staff satisfaction and creasingly, these requirements might include the need for
well-being through formal or informal surveys, some agility—speed and flexibility—to adapt to change.
other indicators include safety, absenteeism, turnover,
grievances, strikes, OSHA reportables, and workers’ com- I Design processes might address (1) modifications and
pensation claims. For health care staff, indicators might variants of existing health care services that might result
include patient referrals to other organizations or institu- from the shift of a service from an inpatient to an outpa-
tions and willingness to serve on committees. tient setting, the introduction of new technology for an
existing service, or the institution of critical pathways;
(2) new health care services resulting from research;
Process Management (Category 6)
(3) new/modified facilities to meet performance require-
Process Management is the focal point within the Criteria ments; and (4) significant redesigns of processes to im-
for all key work processes—health care processes and those prove patient focus, productivity, or both. You should
processes that support the delivery of health care. As appro- consider the key requirements for your health care ser-
priate to an organization’s mission, key processes might vices. Factors that might need to be considered in design
include the conduct of health care research and/or the include desired health care outcomes; safety and risk
teaching of medical/nursing students or allied health care management; timeliness, access, coordination, and conti-
professionals. Built into the Category are the central require- nuity of care; patient involvement in care decisions; mea-
ments for efficient and effective process management: effec- surement capability; process capability; variability in cus-
tive design; a prevention orientation; linkage to patients and tomer expectations requiring health care service options;
other customers, suppliers, partners, and collaborators; and availability or scarcity of staff with critical skills; availabil-
a focus on creating value for all key stakeholders; opera- ity of referral sources; technology; facility capacity or uti-
tional and financial performance; cycle time; and evaluation, lization; supplier capability; regulatory requirements; and
continuous improvement, and organizational learning. documentation. Effective design also must consider cycle
time and productivity of health care service delivery pro-
Agility, cost efficiencies, and cycle time reduction are in-
cesses. This might involve detailing critical pathways and
creasingly important in all aspects of process management
redesigning (“re-engineering”) those delivery processes to
and organizational design. In the simplest terms, “agility”
achieve efficiency, as well as to meet changing require-
refers to your ability to adapt quickly, flexibly, and effec-
ments.
tively to changing requirements. Depending on the nature
of your organization’s strategy and markets, agility might I This Item calls for information on the incorporation of
mean rapid change to a new technology or treatment pro- new technology. This could include e-technology for
tocol, rapid response to changing payor requirements, or sharing information with partners and collaborators,
the ability to produce a wide range of patient-focused ser- communicating with patients and other customers, and
vices. Agility also increasingly involves shared facilities, giving them continuous (24/7) access and automated in-
decisions to outsource, agreements with key suppliers, and formation transfer.

50 2006 Health Care Criteria for Performance Excellence

I Coordination of design and delivery processes involves the opportunity for patients to participate on an informed
all departments/work units and/or individuals who will basis in decision making relative to their own health care.
take part in delivery and whose performance materially I This Item also calls for information on how processes are
affects overall process outcome. This might include re-
improved to achieve better performance. Better perfor-
searchers, health care providers, facilities engineering,
mance means not only better quality from your patients’
and administration.
and other customers’ perspectives and better health care
I Specific reference is made to regulatory and payor re- outcomes, but also better financial and operational per-
quirements, in-process measurements/assessments, and formance—such as productivity—from your other stake-
patient and other customer and supplier interactions. holders’ perspectives. A variety of process improvement
These measurements and interactions require the identi- approaches are commonly used. These approaches include
fication of critical points in processes for measurement, (1) sharing successful strategies across your organization
observation, or interaction. These activities should occur to drive learning and innovation, (2) conducting research
at the earliest points possible in processes to minimize and development, (3) benchmarking, (4) using alternative
problems and costs that may result from deviations from technology, and (5) using information from patients and
expected performance. Achieving expected performance other customers—within and outside your organization.
frequently requires setting in-process performance levels
or standards to guide decision making. When deviations 6.2 Support Processes and Operational Planning: How do
occur, corrective action is required to restore the perfor- you identify and manage your support processes and
mance of the process to its design specifications. Depend- accomplish operational planning?
ing on the nature of the process, the corrective action Purpose
could involve technical and human considerations. Proper
This Item examines your organization’s key business and
corrective action involves changes at the source (root
other support processes and your operational planning with
cause) of the deviation. Such corrective action should
respect to financial management and planning for the conti-
minimize the likelihood of this type of variation occurring
nuity of operations. The aim is to improve your overall op-
again or elsewhere in your organization. When patients’
erational performance.
and other customers’ interactions are involved, differences
among patients and other customers must be considered Comments
in evaluating how well the process is performing. This I Your key business processes are those nonhealth care ser-
might entail allowing for specific or general contingencies,
vice processes that are considered most important to
depending on the patient and other customer information
growth and success by your senior leaders. These processes
gathered. Key process cycle times in organizations may
frequently relate to an organization’s strategic objectives
be a year or longer, which may create special challenges
and critical success factors. Key business processes might
in measuring day-to-day progress and in identifying op-
include processes for innovation, technology acquisition,
portunities for reducing cycle times where appropriate.
information and knowledge management, supply chain
I Critical to health care service delivery are the considera- management, supplier partnering, outsourcing, mergers
tion of patient expectations, the setting of realistic patient and acquisitions, project management, and sales and mar-
expectations relative to likely health care outcomes, and keting. Given the diverse nature of these processes, the
requirements and performance characteristics might vary
significantly for different processes.
I Your other key support processes are those that support
your daily operations and your health care service deliv-
ery but are not usually designed in detail with the health
care services. The support process requirements usually
do not depend significantly on health care service charac-
teristics. Support process design requirements usually
depend significantly on your internal requirements, and
they must be coordinated and integrated to ensure effi-
cient and effective linkage and performance. Support
processes might include processes for housekeeping,
medical records, facilities management, legal services,
human resource services, public relations, community re-
lations, and other administrative services.
I For many organizations, supply chain management is a
growing factor in achieving productivity and profitability

2006 Health Care Criteria for Performance Excellence 51

 goals and overall organizational performance success.
Suppliers and partners are receiving increasing strategic
attention as organizations re-evaluate their core func-
tions. Supplier processes should fulfill two purposes: to
help improve the performance of suppliers and partners
and also, on specific actions, to help them contribute to
your organization’s improved performance. Supply chain
management might include processes for supplier selec-
tion, with the aim of reducing the total number of suppli-
ers and increasing preferred supplier and partnering
agreements.
I This Item calls for information on how your organization
evaluates and improves the performance of your key busi-
ness and other support processes and shares information
with other organizational units to drive learning and in-
novation. Four approaches frequently used are (1) process focus encompasses your objective evaluation and your pa-
analysis and research, (2) benchmarking, (3) use of alter- tients’ and other customers’ evaluation of your organiza-
native technology, and (4) use of information from patients tion’s health care outcomes and service delivery results, your
and other customers of the processes. Together, these overall financial and health care market performance, your
approaches offer a wide range of possibilities, including leadership system and social responsibility results, your
minor process modification and complete redesign (“re- human resource results, and the results of all your key pro-
engineering”) of processes. cesses and process improvement activities. Through this
I Many types of analyses can be performed to ensure ade- focus, the Criteria’s purposes—superior health care quality
quate financial resources are available to support current and value as viewed by your patients and other customers
operations and new business investments and to assess and the marketplace; superior organizational performance
their financial risks. For current operations, these efforts as reflected in your clinical, operational, human resources,
might include the analysis of cash flows, net income legal, ethical, and financial indicators; and organizational
statements, and current liabilities versus current assets. and personal learning—are maintained. Category 7 thus
For business investments, the efforts might include analy- provides “real-time” information (measures of progress) for
sis of discounted cash flows, return on investment (ROI), evaluation and improvement of health care outcomes and
or return on invested capital (ROIC). The specific types all key processes, in alignment with your overall organiza-
of analyses will vary from organization to organization. tional strategy. Item 4.1 calls for analysis and review of
These analyses should help your organization assess the clinical and operational results data and information to de-
financial viability of your current operations and the termine your overall organizational performance and set
potential viability of and risks associated with your new priorities for improvement.
business initiatives. 7.1 Health Care and Service Delivery Outcomes: What are
I Efforts to ensure the continuity of operations in an emer- your health care and service delivery results?
gency should consider all facets of your organization’s op- Purpose
erations that are needed to provide health care services to
patients and other customers. You should consider both This Item examines your organization’s key health care and
your health care delivery and your key business and other service delivery results that lead to patient and other cus-
support processes in your planning. The specific level of tomer satisfaction, loyalty, and positive referral.
service that you will need to provide will be guided by Comments
your mission and your patient and other customer needs
and requirements. Health care providers will likely have a
I This Item addresses those measures that best reflect your
higher need for services than organizations that do not organization’s success in delivering on its mission as a
provide an essential function. Your continuity of opera- health care provider. The Item calls for the use of key
tions efforts should be coordinated with your efforts to data and information to establish your organization’s per-
ensure data and information availability (Item 4.2) and formance in delivering health care. Overall, this is the
workplace preparedness (Item 5.3). most important Item in the Criteria, as it focuses on
demonstrating improving health care results over time.
Results (Category 7) I This Item addresses the use of comparative data. Com-
parative data from external organizations (e.g., CMS,
The Results Category provides a results focus for meeting
NCQA, JCAHO, and the Maryland Quality Indicator
your organization’s mission as a health care provider. This

52 2006 Health Care Criteria for Performance Excellence

 Project) for your patient population are useful in demon- of patients and other customers and patient and other cus-
strating superior results relative to other organizations tomer accounts; patient and other customer complaints
that provide similar health care services. and complaint management; effective complaint resolution;
patient- and other customer-perceived value based on
I This Item places an emphasis on measures of health care
health care quality, outcomes, and cost; patient and other
service performance that serve as indicators of patients’
customer assessment of access and ease of use (including
and other customers’ views and health care decisions rela-
courtesy in-service interactions); and awards, ratings, and
tive to continuing interactions with your organization
recognition from patients and other customers and inde-
and/or positive referral. These measures of service perfor-
pendent rating organizations.
mance are derived from patient- and other customer-
related information gathered in Items 3.1 and 3.2. I This Item places an emphasis on patient- and other
customer-focused results that go beyond satisfaction
I The correlation among health care service performance
measurements because loyalty, retention, positive referral,
and patient/customer indicators is a critical management
and longer-term patient and other customer relationships
tool with multiple uses: (1) defining and focusing on key
are better indicators and measures of future success in the
quality and patient/customer requirements; (2) identifying
health care marketplace and organizational sustainability.
service differentiators in the health care marketplace; and
(3) determining cause-effect relationships among your 7.3 Financial and Market Outcomes: What are your
health care services attributes and evidence of customer financial and market results?
satisfaction and loyalty, as well as positive referrals. The
correlation might reveal emerging or changing market Purpose
segments, the changing importance of requirements, or This Item examines your organization’s key financial and
even the potential obsolescence of health care and other health care market results, with the aim of understanding
patient/customer services. your financial sustainability and your marketplace challenges
and opportunities.
7.2 Patient- and Other Customer-Focused Outcomes: What
are your patient- and other customer-focused perfor- Comments
mance results? I Measures reported in this Item are those usually tracked
Purpose by senior leadership on an ongoing basis to assess your
organization’s financial performance.
This Item examines your organization’s patient- and other
customer-focused performance results, with the aim of I Appropriate financial measures and indicators might in-
demonstrating how well your organization has been satisfy- clude revenues, budgets, profits, net assets, market posi-
ing your patients and other customers and has developed tion, cash-to-cash cycle time, earnings per share, and fi-
loyalty, repeat business, and positive referrals, as appropriate. nancial returns. Marketplace performance measures might
include market position, market share, measures of
Comments growth, new markets entered, entry into e-services for pa-
I This Item focuses on all relevant data used to determine tients and other customers, new populations served, and
and help predict your organization’s performance as the percentage of income derived from new health care
viewed by your patients and other customers. Relevant services and programs.
data and information include patient and other customer
satisfaction and dissatisfaction; retention, gains, and losses 7.4 Human Resource Outcomes: What are your human
resource results?
Purpose
This Item examines your organization’s human resource
results, with the aim of demonstrating how well your orga-
nization has been creating and maintaining a productive,
learning, and caring work environment for all staff.

Comments
I Results measures reported for work system performance
might include improvement in job classification, job rota-
tion, work layout, and working relationships among health
care providers, administrators, and support staff. Results
reported might include input data, such as the extent of
training, but the main emphasis should be on data that
show effectiveness or outcomes. An example of such an

2006 Health Care Criteria for Performance Excellence 53

 outcome measure might be the productivity enhance- 7.6 Leadership and Social Responsibility Outcomes: What
ments or cost savings resulting from the redesign of work are your leadership and social responsibility results?
processes by work teams.
Purpose
I Results reported might include generic or organization- This Item examines your organization’s key results in the
specific factors. Generic factors might include safety, ab- areas of leadership and societal responsibilities, with the aim
senteeism, turnover, satisfaction, and complaints (griev- of maintaining a fiscally sound, ethical organization that is a
ances). For some measures, such as absenteeism and good citizen in its communities.
turnover, local or regional comparisons might be appro-
priate. Organization-specific factors are those you assess Comments
for determining your work system performance and your I Because of a lack of appropriate measures, a key challenge
staff’s well-being and satisfaction. These factors might in- for many organizations is measuring their progress in
clude the extent of training or cross-training or the extent accomplishing their strategic objectives. Frequently, these
and success of self-direction. progress measures can be discerned by first defining the
results that would indicate end-goal success in achieving
7.5 Organizational Effectiveness Outcomes: What are your
the strategic objective and then using that measure to
organizational effectiveness results?
define intermediate measures.
Purpose I Independent of an increased national focus on issues of
This Item examines your organization’s other key opera- governance, ethics, and leadership accountability, it is
tional performance results not reported in Items 7.1–7.4, important for organizations to practice and demonstrate
with the aim of achieving organizational effectiveness and high standards of overall conduct. Governance bodies and
process efficiency. senior leaders should track relevant performance measures
on a regular basis and emphasize this performance in
Comments
stakeholder communications.
I This Item encourages your organization to develop and
include unique and innovative measures to track key pro- I Results reported should include key accreditation and
cesses and operational improvement. All key areas of regulatory review findings, patient safety data, staff licen-
health care service delivery and operational performance sure and recredentialing determinations, external audits,
should be evaluated by measures that are relevant and im- proficiency testing results, and utilization review results,
portant to your organization. as appropriate.

I Measures and indicators of operational effectiveness and I Results reported should include environmental, legal, and
efficiency might include internal responsiveness indica- regulatory compliance; results of oversight audits by gov-
tors, such as cycle times and turnaround times; utilization ernment or funding agencies; and noteworthy achieve-
rates; waste reduction, such as reducing repeat diagnostic ments in these areas, as appropriate. Results also should
tests; cost reduction; strategic indicators, such as innova- include indicators of support for key communities and
tion rates, time to new health care service introduction, other public purposes, including contributions to improv-
and increased use of e-technology; and supply chain indi- ing community health.
cators, such as reductions in inventory, increases in qual- I If your organization has received sanctions or adverse
ity and productivity, such as Six Sigma initiative results, actions under law (including malpractice), regulation,
improvements in electronic data exchange, and reductions accreditation, or contract during the past three years, the
in supply chain management costs. incidents and their current status should be summarized.

54 2006 Health Care Criteria for Performance Excellence

SCORING SYSTEM
The scoring of responses to Criteria Items (Items) and Award widely deployed and shared) of your performance
applicant feedback are based on two evaluation dimensions: improvements
(1) Process and (2) Results. Criteria users need to furnish I your performance relative to appropriate comparisons
information relating to these dimensions. Specific factors and/or benchmarks
for these dimensions are described below. Scoring Guide- I linkage of your results measures (often through seg-
lines are given on pages 56–57.
mentation) to important customer, product and service,
market, process, and action plan performance require-
Process ments identified in your Organizational Profile and in
“Process” refers to the methods your organization uses and Process Items
improves to address the Item requirements in Categories
1–6. The four factors used to evaluate process are Approach, Item Classification and Scoring Dimensions
Deployment, Learning, and Integration (A-D-L-I). Items are classified according to the kinds of information
“Approach” refers to and data you are expected to furnish relative to the two
evaluation dimensions given above.
I the methods used to accomplish the process

I the appropriateness of the methods to the Item The two types of Items are designated as
requirements 1. Process Process
I the effectiveness of your use of the methods
2. Results Results
I the degree to which the approach is repeatable

and based on reliable data and information (i.e., In Process Items, Approach-Deployment-Learning-
systematic) Integration are linked to emphasize that descriptions of ap-
proach should always indicate the deployment—consistent
“Deployment” refers to the extent to which
with the specific requirements of the Item. As processes mature,
I your approach is applied in addressing Item require-
their description also should indicate how cycles of learning,
ments relevant and important to your organization as well as integration with other processes and work units,
I your approach is applied consistently occur. Although the Approach-Deployment-Learning-
I your approach is used by all appropriate work units Integration factors are linked, feedback to Award applicants
reflects strengths and opportunities for improvement in any
“Learning” refers to
or all of these factors.
I refining your approach through cycles of evaluation

and improvement Results Items call for data showing performance levels,
I encouraging breakthrough change to your approach
improvement rates, and relevant comparative data for key
measures and indicators of organizational performance.
through innovation
Results Items also call for data on breadth of performance
I sharing refinements and innovations with other
improvements. This is directly related to deployment and
relevant work units and processes in your organization organizational learning; if improvement processes are
“Integration” refers to the extent to which widely shared and deployed, there should be correspond-
I your approach is aligned with your organizational ing results. A score for a Results Item is thus a composite
needs identified in other Criteria Item requirements based on overall performance, taking into account the rate
I your measures, information, and improvement systems
and breadth of improvements and their importance to the
Item requirements and your organization or mission. (See
are complementary across processes and work units
next paragraph.)
I your plans, processes, results, analyses, learning, and

actions are harmonized across processes and work units

“Importance” as a Scoring Consideration
to support organization-wide goals
The two evaluation dimensions described previously are
Results critical to evaluation and feedback. However, another
critical consideration in evaluation and feedback is the
“Results” refers to your organization’s outputs and outcomes
importance of your reported process and results to your key
in achieving the requirements in Items 7.1–7.6. The four
business factors. The areas of greatest importance should be
factors used to evaluate results are
identified in your Organizational Profile and in Items such
I your current level of performance as 2.1, 2.2, 3.1, 5.1, and 6.1. Your key patient and other cus-
I rate (i.e., slope of trend data) and breadth (i.e., how tomer requirements, competitive environment, key strategic
objectives, and action plans are particularly important.

2006 Health Care Criteria for Performance Excellence 55

Assignment of Scores to Your Responses statements in the next higher or next lower scoring
range.
The following guidelines should be observed in assigning
scores to Item responses. I A Process Item score of 50 percent represents an
approach that meets the overall requirements of the
I All Areas to Address should be included in your Item Item, that is deployed consistently and to most work
response. Also, responses should reflect what is impor- units covered by the Item, that has been through some
tant to your organization. cycles of improvement and learning, and that addresses
I In assigning a score to an Item, first decide which the key organizational needs. Higher scores reflect
scoring range (e.g., 50 percent to 65 percent) is most greater achievement, demonstrated by broader deploy-
descriptive of the organization’s achievement level as ment, significant organizational learning, and increased
presented in the Item response. “Most descriptive of integration.
the organization’s achievement level” can include some I A Results Item score of 50 percent represents a clear
gaps in one or more of the A-D-L-I (process) factors or indication of improvement trends and/or good levels of
results factors for the chosen scoring range. An organi- performance with appropriate comparative data in the
zation’s achievement level is based on a holistic view of results areas covered in the Item and important to the
either the four process or four results factors in aggre- organization. Higher scores reflect better improvement
gate and not on a tallying or averaging of independent rates and/or levels of performance, better comparative
assessments against each of the four factors. Assigning performance, and broader coverage and integration
the actual score within the chosen range requires with health care requirements.
evaluating whether the Item response is closer to the

SCORING GUIDELINES
For Use With Categories 1– 6

SCORE PROCESS

I No SYSTEMATIC APPROACH is evident; information is ANECDOTAL. (A)

I Little or no DEPLOYMENT of an APPROACH is evident. (D)
0% or 5% I An improvement orientation is not evident; improvement is achieved through reacting to problems. (L)
I No organizational ALIGNMENT is evident; individual areas or work units operate independently. (I)

I The beginning of a SYSTEMATIC APPROACH to the BASIC REQUIREMENTS of the Item is evident. (A)
I The APPROACH is in the early stages of DEPLOYMENT in most areas or work units, inhibiting progress in achieving the
10%, 15%, BASIC REQUIREMENTS of the Item. (D)
20%, or 25% I Early stages of a transition from reacting to problems to a general improvement orientation are evident. (L)
I The APPROACH is ALIGNED with other areas or work units largely through joint problem solving. (I)

I An EFFECTIVE, SYSTEMATIC APPROACH, responsive to the BASIC REQUIREMENTS of the Item, is evident. (A)
30%, 35%, I The APPROACH is DEPLOYED, although some areas or work units are in early stages of DEPLOYMENT. (D)
40%, or 45% I The beginning of a SYSTEMATIC APPROACH to evaluation and improvement of KEY PROCESSES is evident. (L)
I The APPROACH is in early stages of ALIGNMENT with your basic organizational needs identified in response to the
other Criteria Categories. (I)

I An EFFECTIVE, SYSTEMATIC APPROACH, responsive to the OVERALL REQUIREMENTS of the Item, is evident. (A)
I The APPROACH is well DEPLOYED, although DEPLOYMENT may vary in some areas or work units. (D)
50%, 55%,
60%, or 65%
I A fact-based, SYSTEMATIC evaluation and improvement PROCESS and some organizational LEARNING are in place for
improving the efficiency and EFFECTIVENESS of KEY PROCESSES. (L)
I The APPROACH is ALIGNED with your organizational needs identified in response to the other Criteria Categories. (I)

I An EFFECTIVE, SYSTEMATIC APPROACH, responsive to the MULTIPLE REQUIREMENTS of the Item, is evident. (A)
I The APPROACH is well DEPLOYED, with no significant gaps. (D)
70%, 75%,
80%, or 85%
I Fact-based, SYSTEMATIC evaluation and improvement and organizational LEARNING are KEY management tools; there is
clear evidence of refinement and INNOVATION as a result of organizational-level ANALYSIS and sharing. (L)
I The APPROACH is INTEGRATED with your organizational needs identified in response to the other Criteria Items. (I)

I An EFFECTIVE, SYSTEMATIC APPROACH, fully responsive to the MULTIPLE REQUIREMENTS of the Item, is evident. (A)
I The APPROACH is fully DEPLOYED without significant weaknesses or gaps in any areas or work units. (D)
90%, 95%, or 100% I Fact-based, SYSTEMATIC evaluation and improvement and organizational LEARNING are KEY organization-wide tools;
refinement and INNOVATION, backed by ANALYSIS and sharing, are evident throughout the organization. (L)
I The APPROACH is well INTEGRATED with your organizational needs identified in response to the other Criteria Items. (I)

56 2006 Health Care Criteria for Performance Excellence

SCORING GUIDELINES
For Use With Category 7

SCORE RESULTS

I There are no organizational PERFORMANCE RESULTS or poor RESULTS in areas reported.

I TREND data are either not reported or show mainly adverse TRENDS.
0% or 5% I Comparative information is not reported.
I RESULTS are not reported for any areas of importance to your KEY MISSION or organizational requirements.

I A few organizational PERFORMANCE RESULTS are reported; there are some improvements and/or early good PERFORMANCE
LEVELS in a few areas.
10%, 15%, I Little or no TREND data are reported.
20%, or 25% I Little or no comparative information is reported.
I RESULTS are reported for a few areas of importance to your KEY MISSION or organizational requirements.

I Improvements and/or good PERFORMANCE LEVELS are reported in many areas addressed in the Item requirements.
30%, 35%, I Early stages of developing TRENDS are evident.
40%, or 45% I Early stages of obtaining comparative information are evident.
I RESULTS are reported for many areas of importance to your KEY MISSION or organizational requirements.

I Improvement TRENDS and/or good PERFORMANCE LEVELS are reported for most areas addressed in the Item requirements.
I No pattern of adverse TRENDS and no poor PERFORMANCE LEVELS are evident in areas of importance to your KEY MISSION
50%, 55%, or organizational requirements.
60%, or 65% I Some TRENDS and/or current PERFORMANCE LEVELS—evaluated against relevant comparisons and/or BENCHMARKS—show
areas of good to very good relative PERFORMANCE.
I Organizational PERFORMANCE RESULTS address most KEY PATIENT and other CUSTOMER, market, and PROCESS requirements.

I Current PERFORMANCE is good to excellent in most areas of importance to the Item requirements.
I Most improvement TRENDS and/or current PERFORMANCE LEVELS are sustained.
70%, 75%, I Many to most reported TRENDS and/or current PERFORMANCE LEVELS—evaluated against relevant comparisons and/or
80%, or 85%
BENCHMARKS—show areas of leadership and very good relative PERFORMANCE.
I Organizational PERFORMANCE RESULTS address most KEY PATIENT and other CUSTOMER, market, PROCESS, and ACTION PLAN
requirements.

I Current PERFORMANCE is excellent in most areas of importance to the Item requirements.

90%, 95%, or 100%
I Excellent improvement TRENDS and/or sustained excellent PERFORMANCE LEVELS are reported in most areas.
I Evidence of health care sector and BENCHMARK leadership is demonstrated in many areas.
I Organizational PERFORMANCE RESULTS fully address KEY PATIENT and other CUSTOMER, market, PROCESS, and ACTION PLAN
requirements.

2006 Health Care Criteria for Performance Excellence 57

 Steps Toward Mature Processes
An Aid for Scoring Process Items

(1) Reacting to Problems (2) Early Systematic Approaches

Strategic Strategic and

and Operational Operational
Goals Goals

Operations are characterized by activities rather than by The organization is at the beginning stages of conducting
processes, and they are largely responsive to immediate operations by processes with repeatability, evaluation and
needs or problems. Goals are poorly defined. improvement, and some early coordination among
organizational units. Strategy and quantitative goals are
being defined.

(3) Aligned Approaches (4) Integrated Approaches

Strategic Strategic
and Operational and Operational
Goals Goals

Operations are characterized by processes that are Operations are characterized by processes that are
repeatable and regularly evaluated for improvement, repeatable and regularly evaluated for change and improve-
with learnings shared and with coordination among ment in collaboration with other affected units. Efficien-
organizational units. Processes address key strategies cies across units are sought and achieved through analysis,
and goals of the organization. innovation, and sharing. Processes and measures track
progress on key strategic and operational goals.

58 2006 Health Care Criteria for Performance Excellence

2006 HEALTH CARE CRITERIA RESPONSE GUIDELINES
The guidelines given in this section are offered to assist 2. Review the Item format and understand how to
Criteria users in responding most effectively to the require- respond to the Item requirements.
ments of the 19 Criteria Items. Writing an application for The Item format (see figure below) shows the different
the Baldrige Award involves responding to these require- parts of Items, the role of each part, and where each part
ments in 50 or fewer pages. is placed. It is especially important to understand the
The guidelines are presented in three parts: multiple requirements contained in the Areas to Address.
The Item Notes are an aid to help you understand the
(1) General Guidelines regarding the Criteria booklet, Areas to Address. Each Item and Area to Address is
including how the Items are formatted described in greater detail in the Category and Item
(2) Guidelines for Responding to Process Items Descriptions section (pages 40–54).
(3) Guidelines for Responding to Results Items Each Item is classified as either Process or Results,
depending on the type of information required. Guide-
General Guidelines lines for responding to Process Items are given on pages
60–61. Guidelines for responding to Results Items are
1. Read the entire Criteria booklet. given on pages 61–62.
The main sections of the booklet provide a full orienta-
tion to the Criteria, including how responses are to be Item requirements are presented in question format.
evaluated for self-assessment or by Award Examiners. Some of the requirements in the Areas to Address in-
You should become thoroughly familiar with the follow- clude multiple questions. Responses to an Item should
ing sections: contain responses that address all questions; however,
each question need not be answered separately. Re-
I Health Care Criteria for Performance Excellence sponses to multiple questions within a single Area to
(pages 12–36) Address may be grouped, as appropriate to your organi-
I Scoring System (pages 55–58) zation. These multiple questions serve as a guide in un-
derstanding the full meaning of the information being
I Glossary of Key Terms (pages 69–76) requested.
I Category and Item Descriptions (pages 40–54)

Item Format
Item number Item title Item point value Types of information users are expected to
provide in response to this Item
1.1 Senior Leadership: How do your senior leaders lead? (70 pts.) Process
Describe HOW SENIOR LEADERS guide and sustain your organization. Describe HOW SENIOR LEADERS communicate
Basic Item requirements with STAFF and encourage high PERFORMANCE.
expressed in Item title Within your response, include answers to the following questions:
a. VISION and VALUES
(1) HOW do SENIOR LEADERS set organizational VISION and VALUES? HOW do SENIOR LEADERS deploy your organization’s
VISION and VALUES through your LEADERSHIP SYSTEM, to all STAFF, to KEY suppliers and PARTNERS, to PATIENTS and
other CUSTOMERS, and to stakeholders, as appropriate? HOW do their personal actions reflect a commit-
Overall Item requirements ment to the organization’s VALUES?
expressed as specific topics (2) HOW do SENIOR LEADERS promote an environment that fosters and requires legal and ETHICAL BEHAVIOR?
users need to address (3) HOW do SENIOR LEADERS create a SUSTAINABLE organization? HOW do SENIOR LEADERS create an environment for
PERFORMANCE improvement, accomplishment of your MISSION and STRATEGIC OBJECTIVES, INNOVATION, and organi-
zational agility? HOW do they create an environment for organizational and STAFF LEARNING? HOW do they
personally participate in succession planning and the development of future organizational leaders?
Multiple requirements
Areas to Address b. Communication and Organizational PERFORMANCE expressed as individual
(1) HOW do SENIOR LEADERS communicate with, empower, and motivate all STAFF throughout the organization? Criteria questions
HOW do SENIOR LEADERS encourage frank, two-way communication throughout the organization? HOW do
SENIOR LEADERS take an active role in STAFF reward and recognition to reinforce high PERFORMANCE and a focus
on the organization, as well as on PATIENTS and other CUSTOMERS?
(2) HOW do SENIOR LEADERS create a focus on action to accomplish the organization’s objectives, improve
Notes have the PERFORMANCE, and attain your VISION? HOW do SENIOR LEADERS include a focus on creating and balancing VALUE

following purposes: for PATIENTS, other CUSTOMERS, and other STAKEHOLDERS in their organizational PERFORMANCE expectations?

– clarify key terms Notes:

and requirements N1. Senior leaders include the head of the organization N4. For health care organizations that rely on volun-
and his or her direct reports. In health care organizations teers to supplement the work of their staff, responses
– give instructions with separate administrative/operational and health to 1.1b(1) also should discuss your efforts to commu-
care provider leadership, “senior leaders” refers to both nicate with, empower, and motivate the volunteer
– indicate/clarify sets of leaders and the relationships among those leaders. workforce.

important linkages N2. Organizational vision (1.1a[1]) should set the

context for strategic objectives and action plans, which
N5. A focus on action (1.1b[2]) considers both the
people and the hard assets of the organization. It in-
are described in Items 2.1 and 2.2. cludes ongoing improvements in productivity that may
be achieved through eliminating waste or reducing cycle
N3. A sustainable organization (1.1a[3]) is capable of
time, and it might use techniques such as Six Sigma. It
addressing current organizational needs and possesses
also includes the actions to accomplish the organiza-
the agility and strategic management to prepare suc-
tion’s strategic objectives.
cessfully for its future organizational and market envi-
ronment. In this context, the concept of innovation N6. Your organizational performance results should
Location of Item includes both technological and organizational inno- be reported in Items 7.1–7.6.
description vation to succeed in the future.

For additional description of this Item, see page 41.

2006 Health Care Criteria for Performance Excellence 59

 merely providing an example, are referred to in the
Scoring Guidelines as “anecdotal information.”

2. Understand the meaning of “what.”

Two types of questions in Process Items begin with the
word “what.” The first type of question requests basic in-
formation on key processes and how they work. Although
it is helpful to include who performs the work, merely
stating who does not permit diagnosis or feedback. The
second type of question requests information on what
your key findings, plans, objectives, goals, or measures
are. These latter questions set the context for showing
alignment and integration in your performance manage-
ment system. For example, when you identify key strate-
gic objectives, your action plans, human resource devel-
opment plans, some of your performance measures, and
some results reported in Category 7 are expected to re-
late to the stated strategic objectives.

3. Write and review response(s) with the following

guidelines and comments in mind.
I Show that approaches are systematic.

3. Start by preparing the Organizational Profile. Systematic approaches are repeatable and use data and
The Organizational Profile is the most appropriate start- information to enable learning. In other words, ap-
ing point. The Organizational Profile is intended to help proaches are systematic if they build in the opportu-
everyone—including organizations using the Criteria for nity for evaluation, improvement, innovation, and
self-assessment, application writers, and reviewers—to sharing, thereby permitting a gain in maturity.
understand what is most relevant and important to your
I Show deployment.
organization’s performance as a health care provider. The
questions to address in responding to the Organizational Deployment information should summarize how your
Profile are on pages 12–14. The Organizational Profile is approaches are implemented in different parts of your
described in greater detail on pages 40– 41. organization. Deployment can be shown compactly by
using tables.
Guidelines for Responding to Process Items I Show evidence of learning.
Although the Criteria focus on key organizational perfor- Processes should include evaluation and improvement
mance results, these results by themselves offer little diag- cycles, as well as the potential for breakthrough
nostic value. For example, if some results are poor or are im- change. Process improvements should be shared with
proving at rates slower than your competitors’ or comparable other appropriate units of the organization to enable
organizations’, it is important to understand why this is so organizational learning.
and what might be done to accelerate improvement. I Show integration.
The purpose of Process Items is to permit diagnosis of your Integration shows alignment and harmonization
organization’s most important processes—the ones that yield among processes, plans, measures, and actions that
fast-paced organizational performance improvement and generate organizational effectiveness and efficiencies.
contribute to key outcomes or performance results. Diagnosis
and feedback depend heavily on the content and complete-
I Show focus and consistency.
ness of your Item responses. For this reason, it is important There are four important considerations regarding
to respond to these Items by providing your key process in- focus and consistency: (1) the Organizational Profile
formation. Guidelines for organizing and reviewing such in- should make clear what is important; (2) the Strategic
formation follow. Planning Category, including the strategic objectives
and action plans, should highlight areas of greatest
1. Understand the meaning of “how.” focus and describe how deployment is accomplished;
Process Items include questions that begin with the word (3) descriptions of organizational-level analysis and
“how.” Responses should outline your key process information review (Item 4.1) should show how your organization
that addresses approach, deployment, learning, and integration analyzes and reviews performance information to set
(see page 55). Responses lacking such information, or priorities; and (4) the Process Management Category

60 2006 Health Care Criteria for Performance Excellence

 should highlight processes that are key to your overall
performance. Showing focus and consistency in the Process
Items and tracking corresponding measures in the Results
Items should improve organizational performance.
I Respond fully to Item requirements.
Missing information will be interpreted as a gap in
your process. All Areas to Address should be addressed.
Individual questions within an Area to Address may be
addressed individually or together.

4. Cross-reference when appropriate.

As much as possible, each Item response should be self-
contained. However, responses to different Items might
be mutually reinforcing. It is then appropriate to refer to
the other responses rather than to repeat information. In
such cases, key process information should be given in
the Item requesting this information. For example, staff
education and training should be described in detail in
Item 5.2. Discussions about education and training else-
where in your application would then reference but not
repeat details given in your Item 5.2 response.

5. Use a compact format.

Applicants should make the best use of the 50 application I trends to show directions of results and rates of change
pages permitted. Applicants are encouraged to use I comparisons to show how results compare with those of
flowcharts, tables, and “bullets” to present information other, appropriately selected organizations
concisely.
I breadth and importance of results to show that all impor-
6. Refer to the Scoring Guidelines. tant results are included and segmented (e.g., by patient/
Considerations in the evaluation of Process Item responses customer, staff, process, and health care service)
include the Criteria Item requirements and the maturity
3. Include trend data covering actual periods for
of your approaches, breadth of deployment, extent of
tracking trends.
learning, and integration with other elements of your
performance management system, as described in the No minimum period of time is specified for trend data.
Scoring Guidelines (page 56). Therefore, you need to Trends might span five years or more for some results.
consider both the Criteria and the Scoring Guidelines. Time intervals between data points should be meaningful
for the specific measure(s) reported. For important re-
sults, new data should be included even if trends and
Guidelines for Responding to Results Items
comparisons are not yet well established.
The Health Care Criteria place a major emphasis on re-
sults. The following information, guidelines, and example 4. Use a compact format—graphs and tables.
relate to effective and complete reporting of results. Many results can be reported compactly by using graphs
and tables. Graphs and tables should be labeled for easy
1. Focus on the most critical organizational interpretation. Results over time or compared with others
performance results. should be “normalized” (i.e., presented in a way, such as
Results reported should cover the most important re- use of ratios, that takes into account various size factors).
quirements for your organization’s success, highlighted in For example, reporting safety trends in terms of needle
your Organizational Profile and in the Strategic Plan- sticks per 100 staff members would be more meaningful
ning; Focus on Patients, Other Customers, and Markets; than total needle sticks if the number of staff has varied
and Process Management Categories. over the time period or if you are comparing your results
to organizations differing in size.
2. Note the meaning of the four key requirements
from the Scoring Guidelines for effective reporting 5. Integrate results into the body of the text.
of results data: Discussion of results and the results themselves should be
I performance levels that are reported on a meaningful close together in an Award application. Trends that show a
measurement scale significant positive or negative change should be explained.

2006 Health Care Criteria for Performance Excellence 61

 Figure 7.1-3 Beta Blocker Use
The current overall organizational performance level is
good. This conclusion is supported by the comparison
2005 benchmark from with competitors and with a benchmark level.
Good
national hospital
The organization shows excellent improvement trends.
90 association
Hospital A
Hospital A is the current performance leader—showing
Acute Myocardial Infarction

sustained high performance and a slightly positive

85 Overall trend. Hospital B shows rapid improvement. It is near
Beta Blocker Use (%)

Organization
that of the best competitor but trails the benchmark
80 Best Competitor level.

Hospital C—identified as a new acquisition in the ap-
75 2005 plication—is having early problems with ensuring beta
Regional blocker use. (The organization should explain briefly
Average
70 Hospital B these early problems.)
Hospital C
65
6. Refer to the Scoring Guidelines.
Considerations in the evaluation of Results Item responses
include the Criteria Item requirements and the signifi-
2001 2002 2003 2004 2005 cance of the results trends, actual performance levels,
Year relevant comparative data, alignment with important
elements of your performance management system, and
strength of the improvement process relative to the Scor-
Use figure numbers that correspond to Items. For exam- ing Guidelines. Therefore, you need to consider both the
ple, the third figure for Item 7.1 would be Figure 7.1-3. Criteria and the Scoring Guidelines (page 58).
(See the example in the figure above.)
The graph shown above illustrates data an organization
might present as part of a response to Item 7.1, Health
Care and Service Delivery Outcomes. In the Organiza-
tional Profile, the organization has indicated use of beta
blockers with acute myocardial infarction as a key
requirement.
The graph shown above illustrates a number of charac-
teristics of clear and effective results reporting.

A figure number is provided for reference to the graph
in the text.

Both axes and units of measure are clearly labeled.

Trend lines report data for a key patient/customer re-
quirement—use of beta blockers with acute myocardial
infarction.

Results are presented for several years for this three-
hospital system.

An arrow indicates that an upward trend is good for
this measure.

Appropriate comparisons are clearly shown.

The organization shows, using a single graph, that its
three hospitals are separately tracked for beta blocker
use.
To help interpret the Scoring Guidelines (page 58), the
following comments on the graphed results would be
appropriate:

62 2006 Health Care Criteria for Performance Excellence

APPLYING FOR THE MALCOLM BALDRIGE NATIONAL QUALITY AWARD
The Malcolm Baldrige National Quality Award is an I education organizations
annual Award to recognize U.S. organizations for
I health care organizations
performance excellence.
Copies of the Business and Education Criteria booklets are
Award Purpose available, and ordering information can be found on pages
The Award promotes 67–68.
I awareness of performance excellence as an increasingly Up to three awards may be given in each category each year.
important element in competitiveness Depending on the number of staff, up to five subunits of a
single parent may apply for the Award during the same
I information sharing of successful performance strategies
Award cycle.
and the benefits derived from using these strategies
To participate in the Award process, an organization must
Award Participation submit an application package that addresses the Health
The Award eligibility categories include Care Criteria for Performance Excellence (pages 12–36).
I manufacturing businesses Application Requirements
I service businesses Applying for the Award is a two-step process. A brief
description of these steps is provided on page 64. Detailed
I small businesses
information on the requirements and contents of the
Eligibility Certification Package and the Application

FEES FOR THE 2006 AWARD CYCLE

Supplemental Site Visit Fee
Eligibility Application Section Fee Usual Range
Award Category Fee Fee* (if applicable)** (if applicable)***
Manufacturing $150 $5,000 $2,000 $20,000–$35,000
Service $150 $5,000 $2,000 $20,000–$35,000
Small Business $150 $2,000 $1,000 $10,000–$17,000
Education $150 $ 500 $ 250 $ 1,500
Nonprofit
Education $150 $5,000 $2,000 $20,000–$35,000
For-profit >500 faculty/staff
Education $150 $2,000 $1,000 $10,000–$17,500
For-profit 500 or fewer faculty/staff
Health Care $150 $5,000 $2,000 $20,000–$35,000
>500 staff
Health Care $150 $2,000 $1,000 $10,000–$17,500
500 or fewer staff

* An additional processing fee of $1,250 is required for applications submitted on a CD.

** Supplemental sections are not applicable for applicants with (a) a single performance system that supports all of their
product and/or service lines and (b) products and services that are essentially similar in terms of customers and/or users,
technology, types of employees, and planning.
*** Site Visit Review Fee
This fee is paid only by applicants receiving site visits. The fee is set when visits are scheduled and is dependent on a number
of factors, including the number of sites to be visited, the number of Examiners assigned, and the duration of the visit.
The site visit fee for applicants with more than 500 employees in the manufacturing, service, for-profit education, and
health care sectors usually ranges between $20,000 and $35,000. The site visit fee for small businesses, for-profit education
organizations with 500 or fewer faculty/staff, and health care organizations with 500 or fewer staff is approximately one-
half that rate. In 2006, the site visit fee for nonprofit education organizations is $1,500. The site visit fee for all organiza-
tions is due to ASQ two weeks after completion of the site visit.

2006 Health Care Criteria for Performance Excellence 63

Package, due dates, and fees is provided in the Baldrige
Award Application Forms, which can be downloaded at Feedback to Applicants
www.baldrige.nist.gov/Award_Application.htm. Each Award applicant receives a feedback report at the
conclusion of the review process. The feedback report
Step 1, Eligibility Certification Package is a written assessment by an evaluation team of leading
Organizations filing an Eligibility Certification Package may U.S. experts.
nominate one senior member of their staff to serve on the
Board of Examiners. Organizations that wish to reserve a The feedback report contains an applicant-specific list-
place on the board for a staff member must submit their ing of strengths and opportunities for improvement
Eligibility Certification Packages by March 10, 2006. If an based on the Criteria. Used by companies, education
organization chooses not to nominate someone to the organizations, and health care organizations as part of
board, the due date for the Eligibility Certification Package their strategic planning processes, the feedback report
is April 11, 2006. helps organizations focus on their customers and im-
prove overall performance. Feedback is one of the
Step 2, Application Package most important parts of the Baldrige Award process; it
The Application Package may be submitted in either provides a pathway for improvement.
CD/PDF format or on paper. Feedback reports are mailed at various times during
If submitted in CD/PDF format, the Application Package the Award cycle, based on the stage of review an appli-
must be postmarked no later than May 11, 2006. If submit- cation reaches in the evaluation process. Strict confiden-
ted on paper, 25 copies of the Application Package must be tiality is observed at all times and in every aspect of
postmarked no later than May 25, 2006. application review and feedback.

Application Review Award Recipients

Applications are reviewed and evaluated by members of the Award recipients may publicize and advertise their
Board of Examiners, who adhere to strict rules regarding Awards. Recipients are expected to share information
conflict of interest, using the following process: about their successful performance strategies with
other U.S. organizations.
Stage 1 - independent review and evaluation by at least
six members of the board
Stage 2 - consensus review and evaluation for applicants
that score well in Stage 1
Stage 3 - site visits to applicants that score well in Stage 2
Judges’ review and recommendations of
Award recipients

Eligibility Certification Packages with a nomination

to the Board of Examiners due—March 10, 2006
Eligibility Certification Packages without a nomination
to the Board of Examiners due—April 11, 2006
Award Application Packages submitted on a CD due—May 11, 2006
Award Application Packages submitted on paper due—May 25, 2006

If your organization is applying in either the business or education category, refer to the
appropriate sector-specific Criteria booklet and the Baldrige Award Application Forms. (See
pages 67–68.)

64 2006 Health Care Criteria for Performance Excellence

SUMMARY OF HEALTH CARE ELIGIBILITY AND RESTRICTIONS
Important Facts About Applying for the Award self-sufficient enough to be examined in all seven Criteria
Categories, and it must be a discrete entity that is readily
I Criteria contained in this booklet should be used only for
distinguishable from other parts of the parent organization.
the health care eligibility category. Applicants in the busi-
It cannot be primarily a support function (e.g., housekeep-
ness (manufacturing, service, and small business) and edu-
ing, radiology, member services, finance and accounting,
cation eligibility categories should use the Criteria for
billing, human resources, purchasing, legal services, and
Performance Excellence and the Education Criteria for Per-
health care research).
formance Excellence booklets, respectively.
I The following is a summary of the eligibility rules for the Other Restrictions on Eligibility
health care category. Summaries of the eligibility rules for
the business and education categories are in their respec- Location: An applicant is eligible only if the operational
tive Criteria booklets. For-profit education or health care practices associated with all of its major organizational func-
organizations may apply under the service or small busi- tions are examinable in the United States or its territories.
ness categories, as appropriate, using these Criteria or For eligibility purposes, overseas U.S. military installations
under the health care or education categories, using their and embassies do not constitute U.S. territories. If some of
respective Criteria. If there is a question on eligibility, an applicant’s activities are performed outside its immediate
check the complete eligibility rules in the Baldrige Award organization (e.g., by overseas components, a parent organi-
Application Forms or call the Baldrige National Quality zation, or other subunits), the applicant must ensure that
Program Office at (301) 975-2036. I in the event of a site visit, the appropriate personnel
I Whatever your Award eligibility category, you will need and materials will be available for examination in the
the Baldrige Award Application Forms before proceeding. United States to document operational practices in all
You can download the document from our Web site at major organizational functions; and
www.baldrige.nist.gov/Award_Application.htm. I in the event the applicant receives the Award, the applicant
will be able to share information on the seven Criteria
Basic Eligibility Categories at The Quest for Excellence Conference
and at its U.S. facilities. Sharing beyond The Quest for
Public Law 100-107 includes provisions to expand or modify
Excellence Conference is on a voluntary basis.
the list of Award categories. Beginning with the 1999 Award
cycle, two new eligibility categories—education and health Multiple-Application Restrictions: A subunit and its par-
care—were added. Participation is open to for-profit and ent may not both apply for the Award in the same year. In
nonprofit public and private organizations, government or- some cases, more than one subunit of a parent may apply. If
ganizations, and some subunits—including U.S. subunits of the parent organization, including all of its subunits, has
foreign organizations—located in the United States and its I 0–1,000 employees, one applicant per parent per
territories—that are primarily engaged in furnishing med-
eligibility category may apply
ical, surgical, or other health services directly to persons.
I 1,001–20,000 employees, two applicants per parent per
Eligibility is intended to be as open as possible. For example,
eligibility category may apply
eligible organizations include hospitals, HMOs, long-term
care facilities, health care practitioner offices, home health I more than 20,000 employees, two applicants per parent
agencies, and dialysis centers. Organizations that do not per eligibility category for the first 20,000, plus one per
provide health services directly to persons, such as social 20,000 or fraction thereof above 20,000 per parent per
service agencies, health insurance companies, or medical/ category, may apply
dental laboratories, are ineligible to apply for the Award
In no case can more than five applications (all Award cate-
under the health care category. However, such organiza-
gories combined) be submitted from the same parent orga-
tions—if they are for-profit organizations—may be eligible
nization in the same year.
to apply for the Award under the small business or service
categories. Future Eligibility Restrictions: If an organization or a sub-
unit that has over 50 percent of the total employees of the
Eligibility of Subunits parent receives an Award, the organization and all its sub-
units are ineligible to apply for another Award for a period
A subunit is a unit or division of a larger organization. The of five years. If a subunit receives an Award, that subunit
larger organization that owns, holds, or has organizational and all its subunits are ineligible to apply for another Award
or financial control of a subunit is the “parent.” A parent is for a period of five years. After five years, Award recipients
the highest level of an organization that would be eligible to are eligible to reapply for the Award or to apply “for feed-
apply for the Award. To be eligible, the subunit must be back only.”

2006 Health Care Criteria for Performance Excellence 65

Eligibility Forms 2006. In order to reserve a place on the Board of Examiners
for a member of your organization’s senior staff, the pack-
Potential applicants must certify their eligibility prior to ap-
age must be submitted no later than March 10, 2006. The
plying for the Award. Potential applicants for the 2006
forms and necessary information are contained in the
Award are encouraged to submit their Eligibility Certifica-
Baldrige Award Application Forms.
tion Packages as soon as possible but no later than April 11,

66 2006 Health Care Criteria for Performance Excellence

HOW TO OBTAIN COPIES OF BALDRIGE NATIONAL QUALITY PROGRAM MATERIALS
Note: If you are planning to apply for the Award, orders must be drawn on a U.S. financial institution. All
you will need the Baldrige Award Application Forms international orders must be prepaid. Please make checks
in addition to the Criteria booklet. payable to ASQ.

Individual Copies Shipping Fees

Individual copies of the Criteria booklets may be The following shipping and processing schedule applies to
obtained free of charge from all orders within the United States and Canada.
Baldrige National Quality Program Order Amount U.S. Charges Canadian Charges
National Institute of Standards and Technology
Administration Building, Room A600 Up to $34.99 $ 4.25 $ 9.25
100 Bureau Drive, Stop 1020 $35.00–$99.99 6.50 11.50
Gaithersburg, MD 20899-1020 Over $100.00 12.50* 17.50*
Telephone: (301) 975-2036
I There is a shipping and processing charge of 25 percent
Fax: (301) 948-3716
E-mail: nqp@nist.gov of the total order amount for shipments outside the
United States and Canada.
In addition, the Criteria booklets and the Baldrige
I Orders shipped within the continental United States and
Award Application Forms may be downloaded from our
Web site at www.baldrige.nist.gov/Criteria.htm and Canada where UPS service is available will be shipped by
www.baldrige.nist.gov/Award_Application.htm, UPS.
respectively. I Please allow one to two weeks for delivery. International
customers, please allow six to eight weeks for delivery.
Bulk Orders I Your credit card will not be charged until your items are
Multiple copies of the 2006 Criteria for Performance Excel- shipped. Shipping and processing are charged one time,
lence booklets may be ordered in packets of 10 for $39.95 up front, for the entire order.
plus shipping and handling from the American Society for
* If actual shipping charges exceed $12.50 ($17.50 Canadian),
Quality (ASQ).
ASQ will invoice the customer for the additional expense.
2006 Business Criteria—Item Number T1510
2006 Education Criteria—Item Number T1511 Baldrige Educational Materials
2006 Health Care Criteria—Item Number T1512
Each year, the Baldrige National Quality Program develops
materials for training members of the Board of Examiners
How to Order and for sharing information on the successful performance
ASQ offers four convenient ways to order: excellence strategies of the Award recipients. The following
items are samples of the educational materials that are
I For fastest service, call toll free (800) 248-1946 in the
available.
United States and Canada (in Mexico, dial toll-free
95-800-248-1946). Have item numbers, your credit Case Studies
card or purchase order number, and (if applicable)
Case study packets contain a case study and five additional
ASQ member number ready.
documents: an executive summary, the related Criteria for
I Or fax your completed order form to ASQ at Performance Excellence booklet, the case study scorebook, the
(414) 272-1734. case study feedback report, and a blank Baldrige Scorebook.
The case studies, when used with the Criteria, are valuable
I Or mail your order to ASQ Customer Care Center,
resources to Award applicants and other users of the Crite-
P.O. Box 3005, Milwaukee, WI 53201-3066.
ria. They illustrate the Award application and review pro-
I Or order online by accessing ASQ’s Web site at cess and provide examples of how to respond to the Criteria
www.asq.org. requirements and format an application. Together, the case
study packet documents furnish information on scoring, the
Payment examination processes, and much more. A variety of case
study packets are available. The 2002, 2003, 2004, and 2005
Your payment options include check, money order, U.S. case study packets are available only online. Case study
purchase order, VISA, MasterCard, or American Express. packets from prior years are available online and in hard
Payment must be made in U.S. currency; checks and money copy. For ordering information, see the next page.

2006 Health Care Criteria for Performance Excellence 67

 2005 Business Case Study Packet: Landmark Dining, Award Recipients DVD
Inc. (based on the 2005 Criteria for Performance Excellence) The Award recipients DVD is a valuable resource for gain-
Available in e-format (PDF version) at ing a better understanding of performance excellence and
www.baldrige.nist.gov/Landmark.htm quality achievement. The DVD provides background infor-
mation on the Baldrige National Quality Program, high-
2004 Education Case Study Packet: Sandy Hill lights from the annual Award ceremony, and interviews with
School District (based on the 2004 Education Criteria for representatives from the Award recipients’ organizations.
Performance Excellence) Information on the 2005 Award recipients DVD is provided
Available in e-format (PDF version) at below.
www.baldrige.nist.gov/Sandy_Hill.htm 2005—Item Number T1513 $35.00
2003 Business Case Study Packet: GeoOrb (Available May 2006)
Polymers, North America (based on the 2003 Criteria
for Performance Excellence) How to Order Educational Materials
Available in e-format (PDF version) at To order a case study packet developed prior to 2002, bulk
www.baldrige.nist.gov/GeoOrb.htm orders of the 2006 Criteria booklets, or the Award recipi-
ents DVD, contact
2002 Health Care Case Study Packet: CapStar
Health System (based on the 2002 Health Care Criteria ASQ Customer Care Center
for Performance Excellence) P.O. Box 3005
Milwaukee, WI 53201-3066
Available in e-format (PDF version) at
Telephone: (800) 248-1946
www.baldrige.nist.gov/CapStar.htm
Fax: (414) 272-1734
1998 Business Case Study Packet: Gemini Home E-mail: asq @ asq.org
Health Service (based on the 1998 Criteria for Web site: www.asq.org
Performance Excellence)
Item Number T1083: $49.95 plus shipping and handling

The Baldrige National Quality Program welcomes your comments on the Criteria
or any of the Baldrige Award processes. Please address your comments to
2006 Health Care Criteria for Performance Excellence or E-mail: nqp@nist.gov
Baldrige National Quality Program
or Web site: www.baldrige.nist.gov
National Institute of Standards and Technology
Administration Building, Room A600
100 Bureau Drive, Stop 1020
Gaithersburg, MD 20899-1020

68 2006 Health Care Criteria for Performance Excellence

GLOSSARY OF KEY TERMS

This Glossary of Key Terms defines and briefly describes Despite their importance, individual facts and data do not
terms used throughout the Health Care Criteria booklet usually provide an effective basis for actions or setting prior-
that are important to performance management. As you may ities. Effective actions depend on an understanding of rela-
have noted, key terms are presented in SMALL CAPS/SANS SERIF tionships, derived from analysis of facts and data.
every time they appear in the Categories and Scoring
Guidelines sections of this Criteria booklet. Anecdotal
The term “anecdotal” refers to process information that
Action Plans lacks specific methods, measures, deployment mechanisms,
The term “action plans” refers to specific actions that re- and evaluation/improvement/learning factors. Anecdotal in-
spond to short- and longer-term strategic objectives. Action formation frequently uses examples and describes individual
plans include details of resource commitments and time activities rather than systematic processes.
horizons for accomplishment. Action plan development
An anecdotal response to how senior leaders deploy perfor-
represents the critical stage in planning when strategic ob-
mance expectations might describe a specific occasion when
jectives and goals are made specific so that effective, organi-
a senior leader visited all of the organization’s facilities. On
zation-wide understanding and deployment are possible. In
the other hand, a systematic process might describe the
the Criteria, deployment of action plans includes creating
communication methods used by all senior leaders to deliver
aligned measures for all departments and work units. De-
performance expectations on a regular basis to all staff loca-
ployment also might require specialized training for some
tions, the measures used to assess effectiveness of the meth-
staff or recruitment of personnel.
ods, and the tools and techniques used to evaluate and im-
An example of a strategic objective for a health system in an prove the communication methods.
area with an active business alliance focusing on cost and
quality of health care might be to become the low-cost pro- Approach
vider. Action plans could entail designing efficient processes
to minimize length of hospital stays, analysis of resource and The term “approach” refers to the methods used by an orga-
asset use, and analysis of the most commonly encountered nization to address the Baldrige Criteria Item requirements.
DRGs with a focus on preventive health in those areas. Approach includes the appropriateness of the methods to
Deployment requirements might include department/work the Item requirements and the effectiveness of their use.
unit and staff training in setting priorities based on costs Approach is one of the dimensions considered in evaluating
and benefits. Organizational-level analysis and review likely Process Items. For further description, see the Scoring
would emphasize process efficiency, cost per member, and System on pages 55–58.
health care quality.
See also the definition of “strategic objectives” on page 75. Basic Requirements
The term “basic requirements” refers to the topic Criteria
Alignment users need to address when responding to the most central
The term “alignment” refers to consistency of plans, pro- concept of an Item. Basic requirements are the fundamental
cesses, information, resource decisions, actions, results, and theme of that Item (e.g., your approach for strategy devel-
analysis to support key organization-wide goals. Effective opment for Item 2.1). In the Criteria, the basic requirements
alignment requires a common understanding of purposes of each Item are presented as the Item title question. This
and goals. It also requires the use of complementary mea- presentation is illustrated in the Item format shown on page
sures and information for planning, tracking, analysis, and 59.
improvement at three levels: the organizational level, the
key process level, and the department or work unit level. Benchmarks
See also the definition of “integration” on page 72. The term “benchmarks” refers to processes and results that
represent best practices and performance for similar activities,
Analysis inside or outside an organization’s industry. Organizations
engage in benchmarking to understand the current dimen-
The term “analysis” refers to an examination of facts and sions of world-class performance and to achieve discontinu-
data to provide a basis for effective decisions. Analysis often ous (nonincremental) or breakthrough improvement.
involves the determination of cause-effect relationships.
Overall organizational analysis guides the management of Benchmarks are one form of comparative data. Other com-
processes toward achieving key organizational performance parative data organizations might use include information
results and toward attaining strategic objectives. obtained from other organizations through sharing or

2006 Health Care Criteria for Performance Excellence 69

contributing to external reference databases, information Deployment
obtained from the open literature (e.g., outcomes of re-
The term “deployment” refers to the extent to which an
search studies and practice guidelines), data gathering and
approach is applied in addressing the requirements of a
evaluation by independent organizations (e.g., CMS, accred-
Baldrige Criteria Item. Deployment is evaluated on the basis
iting organizations, and commercial organizations) regard-
of the breadth and depth of application of the approach to
ing industry data (frequently industry averages), data on
relevant departments and work units throughout the
competitors’ performance, and comparisons with other or-
organization.
ganizations providing similar health care services.
Deployment is one of the dimensions considered in evaluat-
Creating Value ing Process Items. For further description, see the Scoring
System on pages 55–58.
The term “creating value” refers to processes that produce
benefit for your patients and other customers and for your
organization. For example, vaccinations and health screenings
Diversity
might be key processes for creating value for a community The term “diversity” refers to valuing and benefiting from
health center. They are the processes most important to personal differences. These differences address many vari-
“running your organization”—those that involve the majority ables including race, religion, color, gender, national origin,
of your staff and generate your health care services and posi- disability, sexual orientation, age, education, geographic
tive organizational performance results for your patients, origin, and skill characteristics, as well as differences in
other customers, and key stakeholders. ideas, thinking, academic disciplines, and perspectives.
The Baldrige Criteria refer to the diversity of your staff
Customer recruitment and patient and other customer communities.
The term “customer” refers to actual and potential users of Capitalizing on both provides enhanced opportunities for
your organization’s services or programs. Patients are the high performance; patient and other customer, staff, and
primary customers of health care organizations. Other cus- community satisfaction; and patient, customer, and staff
tomers could include patients’ families, the community, in- loyalty.
surers and other third-party payors, employers, health care
providers, patient advocacy groups, Departments of Health, Effective
and students. The Criteria address customers broadly, refer-
The term “effective” refers to how well a process or a mea-
encing current customers, future customers, as well as cus-
sure addresses its intended purpose. Determining effective-
tomers of your competitors and other organizations provid-
ness requires (1) the evaluation of how well the approach is
ing similar health care services or programs.
aligned with the organization’s needs and how well the ap-
Patient-focused excellence is a Baldrige Core Value embed- proach is deployed or (2) the evaluation of the outcome of
ded in the beliefs and behaviors of high-performance orga- the measure used.
nizations. Customer focus impacts and should integrate an
organization’s strategic directions, its health care processes, Empowerment
and its organizational performance results.
The term “empowerment” refers to giving staff the authority
See the definition of “stakeholders” on page 75 for the and responsibility to make decisions and take appropriate
relationship between customers and others who might be actions. Empowerment results in decisions being made clos-
affected by your organization’s services or programs. est to the patient or the business “front line,” where patient
and customer needs and work-related knowledge and under-
Cycle Time standing reside.
The term “cycle time” refers to the time required to fulfill Empowerment is aimed at enabling staff to satisfy patients
commitments or to complete tasks. Time measurements play and customers on first contact, to improve processes and in-
a major role in the Criteria because of the great importance crease productivity, and to improve the organization’s health
of time performance to improving overall performance. care and other performance results. Empowered staff re-
“Cycle time” refers to all aspects of time performance. quire information to make appropriate decisions; thus, an
Cycle time improvement might include test results report- organizational requirement is to provide that information in
ing time, time to introduce new health care technology, a timely and useful way.
order fulfillment time, length of hospital stays, billing time,
and other key measures of time. Ethical Behavior
The term “ethical behavior” refers to how an organization
ensures that all its decisions, actions, and stakeholder

70 2006 Health Care Criteria for Performance Excellence

interactions conform to the organization’s moral and profes- establishment of executive compensation and benefits, suc-
sional principles. These principles should support all applic- cession planning, financial auditing, risk management,
able laws and regulations and are the foundation for the or- disclosure, and shareholder reporting. Ensuring effective
ganization’s culture and values. They define “right” from governance is important to stakeholders’ and the larger
“wrong.” society’s trust and to organizational effectiveness.
Senior leaders should act as role models for these principles
of behavior. The principles apply to all individuals involved Health Care Services
in the organization, from staff to members of the board of The term “health care services” refers to all services deliv-
directors, and need to be communicated and reinforced on a ered by the organization that involve professional clinical/
regular basis. Although there is no universal model for ethi- medical judgment, including those delivered to patients and
cal behavior, senior leaders should ensure that the organiza- those delivered to the community.
tion’s mission and vision are aligned with its ethical principles.
Ethical behavior should be practiced with all stakeholders, High-Performance Work
including patients and other customers, staff, partners, sup-
pliers, and the organization’s local community. The term “high-performance work” refers to work pro-
cesses used to systematically pursue ever-higher levels of
While some organizations may view their ethical principles overall organizational and individual performance, including
as boundary conditions restricting behavior, well-designed quality, productivity, innovation rate, and cycle time perfor-
and clearly articulated ethical principles should empower mance. High-performance work results in improved service
people to make effective decisions with great confidence. for patients and other customers and other stakeholders.

Goals Approaches to high-performance work vary in form, function,

and incentive systems. High-performance work frequently
The term “goals” refers to a future condition or perfor- includes cooperation between administration/management
mance level that one intends to attain. Goals can be both and the staff, which may involve workforce bargaining units;
short- and longer-term. Goals are ends that guide actions. cooperation among department/work units, often involving
Quantitative goals, frequently referred to as “targets,” in- teams; self-directed responsibility and staff empowerment;
clude a numerical point or range. Targets might be projec- staff input to planning; individual and organizational skill
tions based on comparative or competitive data. The term building and learning; learning from other organizations;
“stretch goals” refers to desired major, discontinuous (non- flexibility in job design and work assignments; a flattened
incremental) or “breakthrough” improvements, usually in organizational structure, where decision making is decen-
areas most critical to your organization’s future success. tralized and decisions are made closest to the patient or the
Goals can serve many purposes, including business “front line”; and effective use of performance mea-
sures, including comparisons. Many high-performance work
I clarifying strategic objectives and action plans to systems use monetary and nonmonetary incentives based on
indicate how you will measure success factors such as organizational performance, team and individ-
I fostering teamwork by focusing on a common end ual contributions, and skill building. Also, high-performance
I encouraging “out-of-the-box” thinking to achieve a work usually seeks to align the organization’s structure,
stretch goal work, jobs, staff development, and incentives.
I providing a basis for measuring and accelerating progress
How
Governance The term “how” refers to the processes that an organization
The term “governance” refers to the system of management uses to accomplish its mission requirements. In responding
and controls exercised in the stewardship of your organiza- to “how” questions in the Process Item requirements, pro-
tion. It includes the responsibilities of your organization’s cess descriptions should include information such as approach
owners/shareholders, board of directors, senior leaders, and (methods and measures), deployment, learning, and integra-
administrative/operational and health care leaders. Corpo- tion factors.
rate or organizational charters, by-laws, and policies docu-
ment the rights and responsibilities of each of the parties Innovation
and describe how your organization will be directed and The term “innovation” refers to making meaningful change
controlled to ensure (1) accountability to stakeholders and to improve services, programs, processes, or organizational
other owners/shareholders, (2) transparency of operations, effectiveness and to create new value for stakeholders.
and (3) fair treatment of all stakeholders. Governance pro- Innovation involves the adoption of an idea, process, tech-
cesses may include the approval of strategic direction, the nology, or product that is either new or new to its proposed
monitoring and evaluation of senior leader performance, the application.

2006 Health Care Criteria for Performance Excellence 71

Successful organizational innovation is a multistep process Leadership System
that involves development and knowledge sharing, a decision
The term “leadership system” refers to how leadership is
to implement, implementation, evaluation, and learning.
exercised, formally and informally, throughout the organiza-
Although innovation is often associated with health care re-
tion; it is the basis for and the way key decisions are made,
search and technological innovation, it is applicable to all
communicated, and carried out. It includes structures and
key organizational processes that would benefit from change,
mechanisms for decision making; selection and development
whether through breakthrough improvement or change in
of leaders and managers; and reinforcement of values, ethical
approach or outputs. It could include fundamental changes
behavior, directions, and performance expectations. In health
in organizational structure to more effectively accomplish
care organizations with separate administrative/operational
the organization’s work. It could address, for example, critical
and health care provider leadership, the leadership system
pathways and practice guidelines, facility design, the admin-
also includes the relationships among those leaders.
istration of medications, the organization of work, or alter-
native therapies. An effective leadership system respects the capabilities and
requirements of staff and other stakeholders, and it sets high
Integration expectations for performance and performance improve-
ment. It builds loyalties and teamwork based on the organi-
The term “integration” refers to the harmonization of plans, zation’s vision and values and the pursuit of shared goals. It
processes, information, resource decisions, actions, results, encourages and supports initiative and appropriate risk tak-
and analyses to support key organization-wide goals. Effec- ing, subordinates organizational structure to purpose and
tive integration goes beyond alignment and is achieved function, and avoids chains of command that require long
when the individual components of a performance manage- decision paths. An effective leadership system includes
ment system operate as a fully interconnected unit. mechanisms for the leaders to conduct self-examination,
See also the definition of “alignment” on page 69. receive feedback, and improve.
Integration is one of the dimensions considered in evaluat-
ing Process Items. For further description, see the Scoring
Learning
System on pages 55–58. The term “learning” refers to new knowledge or skills ac-
quired through evaluation, study, experience, and innovation.
Key The Baldrige Criteria include two distinct kinds of learning:
organizational and personal. Organizational learning is
The term “key” refers to the major or most important ele- achieved through research and development; evaluation and
ments or factors, those that are critical to achieving your in- improvement cycles; the ideas and input of staff, patients,
tended outcome. The Baldrige Criteria, for example, refer other customers, and stakeholders; best practice sharing; and
to key challenges, key patient/customer groups, key plans, benchmarking. Personal learning is achieved through educa-
key processes, and key measures—those that are most im- tion, training, and developmental opportunities that further
portant to your organization’s success. They are the essen- individual growth.
tial elements for pursuing or monitoring a desired outcome.
To be effective, learning should be embedded in the way an
Knowledge Assets organization operates. Learning contributes to organiza-
tional performance success for the organization and its staff.
The term “knowledge assets” refers to the accumulated in- For further description of organizational and personal learn-
tellectual resources of your organization. It is the knowledge ing, see the related Core Value and Concept on page 2.
possessed by your organization and its staff in the form of
information, ideas, learning, understanding, memory, in- Learning is one of the dimensions considered in evaluating
sights, cognitive and technical skills, and capabilities. Staff, Process Items. For further description, see the Scoring
databases, documents, guides, policies and procedures, and System on pages 55–58.
software and patents are repositories of an organization’s
knowledge assets. Knowledge assets are held not only by an Levels
organization but reside within its patients and other custo- The term “levels” refers to numerical information that
mers, suppliers, and partners as well. places or positions an organization’s results and performance
Knowledge assets are the “know how” that your organiza- on a meaningful measurement scale. Performance levels
tion has available to use, to invest, and to grow. Building permit evaluation relative to past performance, projections,
and managing your knowledge assets are key components goals, and appropriate comparisons.
for your organization to create value for your stakeholders
and to help sustain overall organizational performance
success.

72 2006 Health Care Criteria for Performance Excellence

Measures and Indicators Formal partnerships are usually for an extended period of
time and involve a clear understanding of the individual and
The term “measures and indicators” refers to numerical in-
mutual roles and benefits for the partners.
formation that quantifies input, output, and performance
dimensions of processes, programs, services, and the overall
organization (outcomes). The Health Care Criteria place Patient
particular focus on measures of health care outcomes, health The term “patient” refers to the person receiving health
care service delivery, and patients’ functional status. Measures care, including preventive, promotional, acute, chronic,
and indicators might be simple (derived from one measure- rehabilitative, and all other services in the continuum of
ment) or composite. care. Other terms organizations use for “patient” include
The Criteria do not make a distinction between measures member, consumer, client, or resident.
and indicators. However, some users of these terms prefer
the term “indicator” (1) when the measurement relates to Performance
performance but is not a direct measure of such performance The term “performance” refers to output results and their
(e.g., the number of complaints is an indicator of dissatisfac- outcomes obtained from processes and services that permit
tion but not a direct measure of it) and (2) when the mea- evaluation and comparison relative to goals, standards, past
surement is a predictor (“leading indicator”) of some more results, and other organizations. Performance can be ex-
significant performance (e.g., increased patient satisfaction pressed in nonfinancial and financial terms.
might be a leading indicator of a gain in HMO member
retention). The Baldrige Health Care Criteria address four types of
performance: (1) health care outcomes and service delivery,
Mission (2) patient- and other customer-focused, (3) financial and
marketplace, and (4) operational.
The term “mission” refers to the overall function of an or-
ganization. The mission answers the question, “What is this “Health care outcomes and service delivery performance”
organization attempting to accomplish?” The mission might refers to performance relative to measures and indicators of
define patients, other customers, or markets served; distinc- health care service important to patients and other customers.
tive competencies; or technologies used. Examples of health care performance include reductions in
hospital admission rates, mortality and morbidity rates,
nosocomial infection rates, length of hospital stays, and
Multiple Requirements patient-experienced error levels. Other examples include
The term “multiple requirements” refers to the individual increases in outside-the-hospital treatment of chronic ill-
questions Criteria users need to answer within each Area to nesses, and patient compliance and adherence. Health care
Address. These questions constitute the details of an Item’s performance might be measured at the organizational level
requirements. They are presented in black text under each and at the DRG-specific level.
Item’s Area(s) to Address. This presentation is illustrated in
“Patient- and other customer-focused performance” refers
the Item format shown on page 59.
to performance relative to measures and indicators of
patients’ and other customers’ perceptions, reactions, and
Overall Requirements behaviors. Examples include patient loyalty, customer reten-
The term “overall requirements” refers to the topics tion, complaints, customer survey results, and service re-
Criteria users need to address when responding to the sponse time.
central theme of an Item. Overall requirements address the “Financial and marketplace performance” refers to perfor-
most significant features of the Item requirements. In the mance using measures of cost, revenue, and market position,
Criteria, the overall requirements of each Item are pre- including asset utilization, asset growth, and market share.
sented in one or more introductory sentences printed in Examples include returns on investments, value added per
bold. This presentation is illustrated in the Item format staff member, bond ratings, debt-to-equity ratio, returns on
shown on page 59. assets, operating margins, performance to budget, amount
of reserve funds, other profitability and liquidity measures,
Partners and market gains.
The term “partners” refers to those key organizations or in- “Operational performance” refers to staff, leadership, orga-
dividuals who are working in concert with your organization nizational, and ethical performance relative to effectiveness,
to achieve a common goal or to improve performance. Typi- efficiency, and accountability measures and indicators. Ex-
cally, partnerships are formal arrangements for a specific amples include cycle time, productivity, waste reduction, staff
aim or purpose, such as to achieve a strategic objective or turnover, staff cross-training rates, accreditation results, legal/
deliver a specific service. regulatory compliance, fiscal accountability, community

2006 Health Care Criteria for Performance Excellence 73

involvement, and contributions to community health. Oper- In knowledge work, such as health care assessment and diag-
ational performance might be measured at the department nosis, strategic planning, research, development, and analysis,
and work unit level, key process level, and organizational process does not necessarily imply formal sequences of steps.
level. Rather, process implies general understandings regarding
competent performance, such as timing, options to be in-
Performance Excellence cluded, evaluation, and reporting. Sequences might arise as
part of these understandings.
The term “performance excellence” refers to an integrated
approach to organizational performance management that In the Baldrige Scoring System, process achievement level is
results in (1) delivery of ever-improving value to patients, assessed. This achievement level is based on four factors
other customers, and stakeholders, and contributing to im- that can be evaluated for each of an organization’s key pro-
proved health care quality and organizational sustainability; cesses: Approach, Deployment, Learning, and Integration.
(2) improvement of overall organizational effectiveness and For further description, see the Scoring System on pages
capabilities as a health care provider; and (3) organizational 55–58.
and personal learning. The Baldrige Health Care Criteria
for Performance Excellence provide a framework and an Productivity
assessment tool for understanding organizational strengths
The term “productivity” refers to measures of the efficiency
and opportunities for improvement and thus for guiding
of resource use.
planning efforts.
Although the term often is applied to single factors such as
Performance Projections staffing (labor productivity), machines, materials, energy,
and capital, the productivity concept applies as well to the
The term “performance projections” refers to estimates of total resources used in producing outputs. The use of an ag-
future performance. Projections may be inferred from past gregate measure of overall productivity allows a determina-
performance, may be based on competitors’ or similar orga- tion of whether the net effect of overall changes in a pro-
nizations’ performance or the performance of other organi- cess—possibly involving resource tradeoffs—is beneficial.
zations providing similar health care services that must be
met or exceeded, may be predicted based on changes in a
Purpose
dynamic health care environment, or may be goals for
future performance. Projections integrate estimates of your The term “purpose” refers to the fundamental reason that
organization’s rate of improvement and change, and they an organization exists. The primary role of purpose is to in-
may be used to indicate where breakthrough improvement spire an organization and guide its setting of values. Purpose
or change is needed. Thus, performance projections serve as is generally broad and enduring. Two organizations provid-
a key management planning tool. ing different health care services could have similar pur-
poses, and two organizations providing similar health care
Process services could have different purposes.

The term “process” refers to linked activities with the pur-

Results
pose of producing a product or service for patients and
other customers within or outside the organization. Gener- The term “results” refers to outputs and outcomes achieved
ally, processes involve combinations of people, machines, by an organization in addressing the requirements of a
tools, techniques, and materials in a defined series of steps Baldrige Criteria Item. Results are evaluated on the basis of
or actions. In some situations, processes might require ad- current performance; performance relative to appropriate
herence to a specific sequence of steps, with documentation comparisons; the rate, breadth, and importance of perfor-
(sometimes formal) of procedures and requirements, includ- mance improvements; and the relationship of results mea-
ing well-defined measurement and control steps. sures to key organizational performance requirements. For
further description, see the Scoring System on pages 55–58.
In many service situations, such as health care treatment,
particularly when customers are directly involved in the ser-
vice, process is used in a more general way (i.e., to spell out Segment
what must be done, possibly including a preferred or ex- The term “segment” refers to a part of an organization’s
pected sequence). If a sequence is critical, the service needs overall patient, other customer, market, health care service,
to include information to help customers understand and or staff base. Segments typically have common characteris-
follow the sequence. Such service processes also require tics that can be logically grouped. In Results Items, the term
guidance to the providers of those services on handling con- refers to disaggregating results data in a way that allows for
tingencies related to the possible actions or behaviors of meaningful analysis of an organization’s performance. It is
those served. up to each organization to determine the specific factors

74 2006 Health Care Criteria for Performance Excellence

that it uses to segment its patients and other customers, responding to externally driven strategic challenges, an or-
markets, health care services, and staff. ganization may face internal strategic challenges.
Understanding segments is critical to identifying the distinct External strategic challenges may relate to patient and other
needs and expectations of different patient and other cus- customer or health care market needs or expectations;
tomer, market, and staff groups and to tailoring health care health care service or technological changes; or financial,
services and programs to meet their needs and expectations. societal, and other risks or needs. Internal strategic chal-
As an example, market segmentation might be based on ge- lenges may relate to an organization’s capabilities and its
ography, distribution channels, health care service volume, human and other resources.
or technologies employed. Staff segmentation might be
See the definition of “strategic objectives” that immediately
based on geography, specialties, skills, needs, work assign-
follows for the relationship between strategic challenges and
ments, or job classifications.
the strategic objectives an organization articulates to address
key challenges.
Senior Leaders
The term “senior leaders” refers to an organization’s senior Strategic Objectives
management group or team. In many organizations, this
The term “strategic objectives” refers to an organization’s
consists of the head of the organization and his or her direct
articulated aims or responses to address major change or
reports. In health care organizations with separate adminis-
improvement, competitiveness or social issues, and health
trative/operational and health care provider leadership,
care advantages. Strategic objectives generally are focused
“senior leaders” refers to both sets of leaders and the rela-
both externally and internally and relate to significant pa-
tionships among those leaders.
tient and other customer, market, service, or technological
opportunities and challenges (strategic challenges). Broadly
Staff stated, they are what an organization must achieve to remain
The term “staff” refers to all people who contribute to the or become competitive and ensure long-term sustainability.
delivery of an organization’s services, including paid staff Strategic objectives set an organization’s longer-term direc-
(e.g., permanent, part-time, temporary, and contract em- tions and guide resource allocations and redistributions.
ployees supervised by the organization), independent practi- See the definition of “action plans” on page 69 for the rela-
tioners (e.g., physicians, physician assistants, nurse practi- tionship between strategic objectives and action plans and
tioners, acupuncturists, and nutritionists not paid by the for an example of each.
organization), volunteers, and health profession students
(e.g., medical, nursing, and ancillary). Staff includes team
Sustainability
leaders, supervisors, and managers at all levels.
The term “sustainability” refers to your organization’s abil-
Stakeholders ity to address current business needs and to have the agility
and strategic management to prepare successfully for your
The term “stakeholders” refers to all groups that are or future organizational, market, and operating environment.
might be affected by an organization’s services, actions, and Both external and internal factors need to be considered.
success. Examples of key stakeholders might include patients The specific combination of factors might include health
and other customers (e.g., patients’ families, insurers and care-wide and organization-specific components.
other third-party payors, employers, health care providers,
patient advocacy groups, Departments of Health, and stu- In addition to responding to changes in the organizational,
dents), staff, partners, governing boards, investors, charita- market, and operating environment, sustainability also has a
ble contributors, suppliers, taxpayers, policymakers, and component related to preparedness for real-time or short-
local and professional communities. term emergencies.

See also the definition of “customer” on page 70.

Systematic
Strategic Challenges The term “systematic” refers to approaches that are well-
ordered, repeatable, and use data and information so learn-
The term “strategic challenges” refers to those pressures ing is possible. In other words, approaches are systematic if
that exert a decisive influence on an organization’s likeli- they build in the opportunity for evaluation, improvement,
hood of future success. These challenges frequently are dri- and sharing, thereby permitting a gain in maturity. For use
ven by an organization’s future collaborative environment of the term, see the Scoring Guidelines on pages 56–57.
and/or competitive position relative to other providers of
similar health care services. While not exclusively so, strate-
gic challenges generally are externally driven. However, in

2006 Health Care Criteria for Performance Excellence 75

Trends Values
The term “trends” refers to numerical information that The term “values” refers to the guiding principles and be-
shows the direction and rate of change for an organization’s haviors that embody how your organization and its people
results. Trends provide a time sequence of organizational are expected to operate. Values reflect and reinforce the
performance. desired culture of the organization. Values support and
guide the decision making of every staff member, helping
A minimum of three data points generally is needed to
the organization to accomplish its mission and attain its
begin to ascertain a trend. More data points are needed to
vision in an appropriate manner. Examples of values might
define a statistically valid trend. The time period for a trend
include demonstrating integrity and fairness in all interac-
is determined by the cycle time of the process being mea-
tions, exceeding patient and other customer expectations,
sured. Shorter cycle times demand more frequent measure-
valuing staff and diversity, protecting the environment, and
ment, while longer cycle times might require longer time
striving for performance excellence every day.
periods before meaningful trends can be determined.
Examples of trends called for by the Criteria include data Vision
related to health care outcomes and other health care ser-
vice results, patient/customer and staff satisfaction and The term “vision” refers to the desired future state of your
dissatisfaction results, financial performance, health care organization. The vision describes where the organization is
marketplace performance, and operational performance, headed, what it intends to be, or how it wishes to be per-
such as cycle time and productivity. ceived in the future.

Value Work Systems

The term “value” refers to the perceived worth of a product, The term “work systems” refers to how your staff members
service, process, asset, or function relative to cost and possi- are organized into formal or informal units to accomplish
ble alternatives. your mission and your strategic objectives; how job respon-
sibilities are managed; and your processes for communica-
Organizations frequently use value considerations to deter- tion and staff hiring, performance management, compensa-
mine the benefits of various options relative to their costs, tion, recognition, and succession planning. Organizations
such as the value of various product and service combina- design work systems to align their components to enable
tions to patients and other customers. Organizations need and encourage all staff to contribute effectively and to the
to understand what different stakeholder groups value and best of their ability.
then deliver value to each group. This frequently requires
balancing value for customers and other stakeholders, such
as patients, third-party payors, investors, staff, and the
community.

76 2006 Health Care Criteria for Performance Excellence

2006 Health Care Criteria for Performance Excellence 77
INDEX OF KEY TERMS
Note: Page number references to “C2” and “C3” refer to inside front cover and inside back cover, respectively.

A continuous improvement, 2, 50 H
access, C2, 16, 19, 22, 25, 45, 49–50, 53 core competencies, 3, 46 health care category, 65
accreditation, 4, 12–13, 16, 29, 36, 42, Core Values and Concepts, 1, 5–6, 7 Health Care Criteria for Performance
54, 73 Criteria for Performance Excellence, i, Excellence, i, 1, 5–6, 9, 11–12, 59, 63,
achievement level, 56, 74 5, 65, 67–68, C3 68, 74
action plans, 5, 15, 18–20, 24, 26–27, 34, Criteria Response Guidelines, 59 health care outcomes, 3–4, 21, 29–30,
36, 43, 48, 55, 60, 69, 71, 75 critical success factors, 51 32, 49–52, 73, 76
actionable information, 22, 45 customer health care services, 1–3, 12–14, 16,
agility, 1, 3, 7, 15, 19, 26, 29, 31, 41, 50, – key contact requirements, 22, 45 18–19, 21–24, 29, 32–33, 41–45, 48–53,
75 – loyalty and retention, 14, 21, 33 70–71, 74–75
alignment, 1, 4–5, 7, 9, 19, 24, 26, 42–43, – satisfaction, 4, 22–23, 32–33, 40, high performance, 2–3, 15, 26–27, 41,
45–49, 52, 56, 60, 62, 69, 72 44–46, 52–53 48–49, 62, 70, 71
American Society for Quality (ASQ), cycle time, 2–3, 14–15, 29, 31, 35, 40, 46, “how,” 60, 71
C2, 67 49–50, 51, 53, 54, 70–71, 73, 76
analysis, 4, 6, 11, 20–22, 24–25, 35,
38–39, 45–47, 49, 52, 56, 58, 60, 69, 74 I
anecdotal, 56, 60, 69 D improvement
approach, i, 1–2, 3, 7, 14, 15, 18, 27, 28, “deployment,” 7, 11, 14–15, 19–20, – breakthrough, 7, 24, 46, 69, 71–72,
30, 40, 43, 48, 51–52, 55–56, 58, 60, 61, 42–43, 45–46, 55–56, 60–61, 69–71, 74 74
69–72, 74–75 distance learning, 27, 49 – discontinuous (nonincremental),
“Areas to Address” (Areas), 6, 56, 59, 61 diversity, 7, 12, 27, 34, 48, 70, 76 69, 71
assessment, i, 3, 8–9, 11–12, 14, 28, 36, individual development plan (IDP), 49
46, 53, 59–60, 64, 74, C3 information transfer, C2, 3, 25, 43, 47,
E 50
Award cycle, 63–65
e-technology, 50, 54 integration, 1, 5, 7, 45–46, 55–56, 60–61,
Award recipients, C2, ii, iv, 64–65, C3
Education Criteria for Performance 69, 71–72, 74
Excellence, 65, 68 Item requirements, 13, 15, 44, 55, 57,
B eligibility, 63–66 59, 61, 62, 69, 71, 73
basic requirements, 56 employee, see staff Items, i, 6–7, 11, 13, 15, 19, 24–25, 32,
benchmarking, 2, 24, 40, 46, 51–52, 69, empowerment, 26, 28, 41, 44, 70–71 35, 40, 53–56, 58–62, 67, 69–70, 72, 74
72 ethics (ethical behavior), 1, 4, 9, 15–17,
best practices, 1, 4–5, 24–25, 42, 46, 69 36, 41–42, 54, 70–72
Board of Examiners, C2, 64, 66, 67, C3 K
Board of Overseers, C2 key factor, 8, 16, 18, 21, 28, 42
F knowledge assets, 2, 24–25, 27, 41, 47,
feedback, C2, i, 1, 6, 7, 16, 21–22, 26, 45, 72
C 55, 60, 64–65, 67, 72 knowledge management, 6, 20, 24–25,
categories, ii, 4–6, 11–12, 28, 34, 40, fees, 63–64, 67 31, 45–49, 51
55–56, 61, 63, 65, 69, C3 financial performance, 4, 33, 47, 50, 53,
change management, 4 76
citizenship, 4, 16, 36, 41–42 fiscal accountability, 16, 36, 73 L
community focus on results and creating value, 1, 4 linkages, 5, 7, 13, 19, 59
– service, 17, 28–29, 42, 49 focus on the future, 1, 3, 48 listening and learning methods, 21–22
comparative data, 3, 14, 24, 32–36, 40, Foundation for the Malcolm Baldrige listening and learning strategies, 44
46, 52, 55–56, 62, 69 National Quality Award, C2, C3
compensation and recognition, 44, 48
M
competitors, 3–4, 14, 18–19, 21–22, 24,
G Malcolm Baldrige National Quality
32–33, 40–41, 43–47, 60, 62, 70, 74
gap, 12, 19, 56, 61 Award, C2, ii, 63, C3
complaint, 21–22, 45, 53–54, 73
goals, i, 1–2, 4, 7–8, 16, 18–19, 28, 38–39, management by fact, 1, 4
compliance
43–46, 52, 54–55, 58, 60, 69, 71–74 managing for innovation, 1, 3
– legal, 16, 36
governance, 1, 4, 6, 9, 12–13, 15–16, 36, maturity (organizational learning), 2, 8,
– regulatory, 54, 73
40–41, 54, 71 14–15, 27, 29, 31, 40–41, 43–44, 46, 48,
confidentiality, 21, 25, 47, 64
50, 55–56, 60–61, 72, 75

78 2006 Health Care Criteria for Performance Excellence

measurement, C2, 2, 4, 6, 9, 19–20, – health care service, 31, 51 staff
22–23, 24, 27, 39, 43, 45–46, 50–51, 53, – support, 2, 12, 29, 31, 51–52 – education and training, 27, 61
61, 70, 72–74, 76 productivity, i, 3, 15, 28–29, 31, 35, 42, – independent practitioner, 26–27, 34,
mentoring, 27, 41 45–47, 50–51, 54, 70–71, 73–74, 76 48, 75
mission, 7, 12, 15, 29, 40, 42, 50, 52, 55, provider, 1–2, 7, 15, 16, 18–19, 21, 24, 25, – performance management, 26
57, 71, 73, 76 29, 30, 33, 41–43, 45, 52, 60, 72, 74–75 – students, 3–4, 21, 26, 34, 44, 48, 50,
multiple requirements, 56, 59, 73 Public Law 100-107, 65, C3 70, 75
– turnover, 28, 46, 50, 54, 73
– volunteers, 1–2, 13, 15, 26–27, 34,
N Q 41, 48–49, 75
National Institute of Standards and quantitative goals, 58, 71 stakeholders, 1, 3–5, 7, 12–13, 15–16,
Technology, C2, i–ii, 67–68 The Quest for Excellence Conference, 18–19, 36, 41–42, 47–48, 50–51, 54,
C2, ii, 65 70–72, 74–76
strategic challenges, 6, 14, 18, 40–41, 75
O strategic objectives, 2–3, 5, 15, 18–20,
opportunities for improvement (OFIs), R 24, 43, 45, 48, 51, 54–55, 60, 69, 71, 73,
8, 38, 40, 55, 64, 74; see also strengths recruitment, 26–27, 41, 48, 69–70
75–76
organizational regulatory environment, 12–13, 18, 40
strengths, 3, 8, 15–19, 38–40, 42–43, 55,
– and personal learning, 1–2, 42, 52, requirements
62, 74; see also opportunities for
72, 74 – basic, 9, 56, 69
improvement (OFIs)
– citizenship, 36 – Item, 13, 15, 44, 55, 57, 59, 61–62,
stretch goals, 44, 46, 71
– culture, 12, 26 69, 71, 73
succession planning, 3, 15, 26, 41, 48,
– knowledge, 5, 25, 29, 31, 41, 45, 46, 47 – multiple, 56, 59, 73
71, 76
Organizational Profile, i, 5, 6–7, 9, 11, – overall, 56, 73
suppliers, 3–4, 12–13, 15, 18, 20, 24–25,
12–14, 15, 18, 35, 40, 55, 60–62 resource allocation, 3, 18, 43, 75
29, 31, 40–41, 46–48, 50, 52, 71–72, 75
overall requirements, 56, 73 resource conservation, 4
supply chain management, 31, 51–52, 54
results
sustainability, 1–2, 9, 14, 18, 21, 40–42,
– health care, 32, 45, 52
P 44, 47–48, 53, 74–75
– organizational effectiveness, 35, 54
partners, C2, 1–4, 12–13, 15–16, 18–20, sustainable, 3, 15, 40
– patient- and other customer-
22, 24–25, 29, 31, 35, 41–44, 46–48, systematic, 14, 27, 49, 55–56, 58, 60, 69,
focused, 33, 53
50–52, 71–73, 75 71, 75
rework, 29, 31
patient, systematic approach, 56, 58, 60
risks, 16, 18, 31, 36, 43, 52, 75
– health care services, 29 systems perspective, 1, 4–5, 7, 9
role model organization, ii, 42
– patient-focused excellence, 1–2, 70
– rights, 17
T
payor, 3–4, 7, 13, 21, 29, 32, 44, 47, S trend data, 55, 57, 61
50–51, 70, 75–76 safety
performance, C2, i–ii, 1–9, 11–12, 14–17, – environmental, 27
19–20, 24–35, 40–57, 60–64, 67–74, 76, – patient, 1, 16, 18, 29, 32, 54 V
C3 – staff, 49 value, 1–4, 7, 15, 29, 33, 41, 47–48, 50,
– excellence, C2, i–ii, 1, 4, 5, 9, 26, 44, – workplace, 49 52–53, 59–60, 70–72, 74, 76
63, 67–68, 74, 76, C3 sanctions, 36, 54 value added, 33, 46–47, 73
– financial and marketplace, 32, 73 Scoring Guidelines, 7–8, 13, 55–57, value creation, see creating value
– health care, 17, 32, 42, 73 60–62, 69, 75 values, 1, 4, 6–7, 11–12, 15, 40–41,
– key, 1, 12, 19, 29, 31 scoring range, 56 71–72, 74, 76
– management, 1, 4–6, 9, 16, 26, 40, Scoring System, 11, 14–15, 55, 59, 60, valuing staff and partners, 1, 2–3
42, 44, 48, 60–62, 69, 72, 74, 76 70, 72, 74 vision, 12, 15, 40–41, 71–72, 76
– operational, 6–7, 32, 35, 42, 46–47, segment, 3–4, 12–13, 21, 28, 32–36, visionary leadership, 1
50–51, 54, 73–74, 76 43–44, 53, 61, 74–75
– patient- and other customer- self-directed team, 48
focused, 33, 53, 73 senior leaders, 1, 5–6, 9, 12, 15–16, 19, W
– projections, 19, 72, 74 24, 31, 36, 40–42, 46, 51, 54, 69, 71, 75 waste reduction, 4, 46, 54, 73
process management, 6–7, 11, 16, Six Sigma, i, 14–15, 30, 54 “what,” 60
29–32, 39, 45, 50, 60–61 social responsibility and community work systems, 26, 48, 71, 76
processes health, 1, 4, 6–7, 11, 16, 32, 36, 42, 52,
– health care delivery, 1 54

2006 Health Care Criteria for Performance Excellence 79

NOTES

80 2006 Health Care Criteria for Performance Excellence

THE BALDRIGE NATIONAL QUALITY PROGRAM AND ITS IMPACTS

The Malcolm Baldrige National Quality Award was created by Public Law 100-107 and signed into law on August 20, 1987.
Public Law 100-107 led to the creation of a new public-private partnership. Principal support for the Program comes from the
Foundation for the Malcolm Baldrige National Quality Award, established in 1988.
The Award is named for Malcolm Baldrige, who served as Secretary of Commerce from 1981 until his death in 1987. His man-
agerial excellence contributed to long-term improvement in efficiency and effectiveness of government.

On August 20, 1987, President Ronald Reagan signed the modeled to some degree after the Baldrige National
“Malcolm Baldrige National Quality Improvement Act of Quality Program, and their award criteria are based on the
1987,” establishing a program that many credit with making Criteria for Performance Excellence.
quality a national priority and helping to revitalize the U.S.
• From 1996 to 2004, 28 of the 38 Baldrige Award recipi-
economy during the 1990s. Today, the Baldrige National
ents were previous winners in state award programs.
Quality Program and the Baldrige Award recipients are
imitated and admired worldwide. More than 40 states and • Since 1991, there have been nearly 9,000 applications for
many countries, including Japan, have programs modeled state and local quality awards.
after Baldrige. In particular, the Baldrige Criteria for
• Over the past 18 years of its existence, the Baldrige
Performance Excellence are widely used as an assessment
Program has trained more than 2,000 Examiners. Since
and improvement tool. Millions of print and electronic
1991, the state and local programs have trained more
copies of the Criteria have been distributed. In 1999, cate-
than 25,000 Examiners.
gories for education and health care were added to the
original three categories: manufacturing, service, and small • The Award recipients have presented to tens of thousands
business. Impacts of the Program have been far reaching: of organizations at conferences worldwide. For example,
Operations Management International, Inc. (OMI), an
• Since the Baldrige Program began until 2005, there have
international service business with 1,400 employees, has
been 1,063 applicants for the Malcolm Baldrige National
made presentations to more than 17,000 people since
Quality Award. These applicants have received vigorous
becoming an Award recipient in November 2000.
evaluations by the Board of Examiners using the Criteria
Branch-Smith Printing Division, a small family-owned
for Performance Excellence.
business with 68 employees, has given presentations to
• Through 2004, 62 Award recipients have been selected more than 2,000 people since becoming an Award
across five categories: 25 manufacturing companies, 13 recipient in November 2002. The Quest for Excellence
service companies, 15 small businesses, 5 education conferences have reached more than 17,000 attendees
organizations, and 4 health care organizations. over the Program’s history.
• As of June 2005, there were 44 active state and local
quality award programs in 41 states. All 44 programs are

The Baldrige National Quality Program thanks the following 2003 and 2004 Award recipients for the use of the photographs in this
booklet: Baptist Hospital, Inc. (Pensacola, Florida), Saint Luke’s Hospital of Kansas City, and Robert Wood Johnson University Hospital
Hamilton.
Baldrige National Quality Program
Baldrige National Quality Program
National Institute of Standards and Technology
Technology Administration
United States Department of Commerce
Administration Building, Room A600
100 Bureau Drive, Stop 1020
Gaithersburg, MD 20899-1020

The National Institute of Standards and Technology (NIST), an agency of the U.S. Com-
merce Department’s Technology Administration, manages the Baldrige National Quality
Program (BNQP). For more than a century, NIST has helped to lay the foundation for
the innovation, economic growth, and quality of life that Americans have come to expect.
NIST technology, measurements, and standards help U.S. industry invent and manufac-
ture superior products reliably, provide critical services, ensure a fair marketplace for
consumers and businesses, and promote acceptance of U.S. products in foreign markets.
NIST also partners with the private sector to accelerate the development of innovative
technologies that promise significant commercial payoffs and widespread benefits for the
nation. Through a network of nearly 400 assistance centers that serve all 50 states and
Puerto Rico, NIST provides technical and business assistance to help smaller manufac-
turers overcome barriers to productivity and competitiveness.
Call BNQP or visit our Web site for
• information on improving the performance of your organization
• information on eligibility requirements for the Baldrige Award
• information on applying for the Baldrige Award
• information on becoming a Baldrige Examiner
• information on the Baldrige Award recipients
• individual copies of the Criteria for Performance Excellence—Business, Education,
and Health Care (no cost)
• information on BNQP educational materials
• case studies

Telephone: (301) 975-2036; Fax: (301) 948-3716; E-mail: nqp@nist.gov

Web site: www.baldrige.nist.gov

American Society for Quality

600 North Plankinton Avenue
P.O. Box 3005
Milwaukee, WI 53201-3005
By making quality a global priority, an organizational imperative, and a personal ethic, the
American Society for Quality (ASQ) becomes the community for everyone who seeks
quality technology, concepts, or tools to improve themselves and their world. ASQ
administers the Malcolm Baldrige National Quality Award under contract to NIST.
Call ASQ to order
• bulk copies of the Criteria
• Award recipients DVD
Telephone: (800) 248-1946; Fax: (414) 272-1734; E-mail: asq@asq.org
Web site: www.asq.org

T1512 printed on recycled paper