Question

There are three imperative steps that need to be taken. The first is a strong commitment by leadership to this very high level of safety and quality. The leadership must set the goal and example for everyone in order to achieve high reliability. The second is to embed all of the principles and practice of a culture of safety throughout the organization which emphasizes trust, reporting of unsafe conditions, and highly effective improvement over time. The third step is to utilize powerful Robust Process Improvement tools like Six Sigma, Lean, and change management to create near perfect processes, similar to the tools that we see in industries like commercial aviation today, and sustain very high levels of safety over long periods of time.

—Dr. Mark R. Chassin

These three steps: commitment by leadership, development of a culture of safety, and the use of process improvement tools, are the core recommendations made by Dr. Chassin, the president of The Joint Commission and the president of the Joint Commission Center for Transforming Healthcare. A first step in identifying whether these recommendations are being met is to compare elements of an organization to criteria which have been identified as essential to high-reliability organizations.

To prepare for this Assignment:

Consider the three steps described by Dr. Chassin and the seven major criteria of the Baldridge Performance Excellence Program, and reflect on how these recommendations can apply to health care organizations, specifically to long-term care facilities.

The Assignment:

In this Assignment you will identify major elements of high-reliability organizations providing long-term care. According to the Baldrige Performance Excellence Program (MBNQA), the criteria are as follows:

• Leadership
• Strategic planning
• Customer and market focus
• Measurement, analysis, and knowledge management
• Human resource focus
• Process management
• Business/organizational performance results

Using the Highly Reliable Organization Matrix located in this week’s Learning Resources, complete the matrix by typing in the elements which meet the criteria in rows and columns. Describe each element briefly, give an example as to how this can be met in a long-term care facility, and explain the expected impact on patient care.

Based on the results of the Highly Reliable Organization Matrix, write a 1- to 2-page executive summary to the board of directors of the long-term care organization, describing elements which meet the criteria from the matrix and how any missing elements of the criteria for excellence can be met.

Chart needed

Highly Reliable Organization Matrix
Criteria for Performance Excellence*	Inpatient	Skilled Nursing	Ambulatory Care	Public Hospitals	Private/Not for Profit
Leadership
Strategic planning
Customer and market focus
Measurement, analysis, and knowledge management
Human resource focus	Example: The staffing ratio of nurses to patients is lower in highly reliable health care organizations.
Process management
Business/organizational performance results

Answer 1

The Malcolm Baldrige Performance Excellence Program’s mission is to improve the competitiveness and performance of U.S. organizations through organizational assessment and development for the benefit of all U.S. residents. The Baldrige Performance Excellence Program is a customer-focused federal change agent that develops and disseminates evaluation criteria, manages the Malcolm Baldrige National Quality Award, promotes performance excellence and provides global leadership in the learning and sharing of successful strategies and performance practices, principles, and methodologies.

Baldrige assessment criteria:

• Leadership—Examines how senior executives guide the organization and how the organization addresses its responsibilities to the public and practices good citizenship.
• Strategic planning—Examines how the organization sets strategic directions and how it determines key action plans.
• Customer focus—Examines how the organization determines requirements and expectations of customers and markets; builds relationships with customers; and acquires, satisfies, and retains customers.
• Measurement, analysis, and knowledge management—Examines the management, effective use, analysis, and improvement of data and information to support key organization processes and the organization’s performance management system.
• Workforce focus—Examines how the organization enables its workforce to develop its full potential and how the workforce is aligned with the organization’s objectives.
• Process management—Examines aspects of how key production/delivery and support processes are designed, managed, and improved.
• Results—Examines the organization’s performance and improvement in its key business areas: customer satisfaction, financial and marketplace performance, human resources, supplier and partner performance, operational performance, and governance and social responsibility. The category also examines how the organization performs relative to competitors.

Leadership:

a. Vision and Values

(1) Setting Vision and Values How do senior leaders set your organization’s vision and values? How do senior leaders deploy the vision and values through your leadership system; to the workforce; to key suppliers and partners; and to patients, other customers, and other stakeholders, as appropriate? How do senior leaders’ personal actions reflect a commitment to those values?

(2) Promoting Legal and Ethical Behavior How do senior leaders’ actions demonstrate their commitment to legal and ethical behaviour? How do senior leaders promote an organizational environment that requires it?

b. Communication How do senior leaders communicate with and engage the entire workforce, patients, and other key customers? How do they • encourage frank, two-way communication, including use of social media, when appropriate; • communicate key decisions and needs for organizational change; and • take a direct role in motivating the workforce toward high performance and a patient, other customers, and health care focus, including by participating in reward and recognition programs?

Strategic Planning:

a. Strategy Development Process

(1) Strategic Planning Process How do you conduct your strategic planning? What are the key process steps? Who are the key participants? What are your short- and longer-term planning horizons? How are they addressed in the planning process? How does your strategic planning process address the potential need for • transformational change and prioritization of change initiatives; and • organizational agility, including operational flexibility?

(2) Innovation How does your strategy development process stimulate and incorporate innovation? How do you identify strategic opportunities? How do you decide which strategic opportunities are intelligent risks to pursue? What are your key strategic opportunities?

(3) Strategy Considerations How do you collect and analyze relevant data and develop information for your strategic planning process? In this collection and analysis, how do you include these key elements of risk? • Your strategic challenges and strategic advantages • Potential changes in your regulatory and external business environment • Potential blind spots in your strategic planning process and information • Your ability to execute the strategic plan

(4) Work Systems and Core Competencies How do you decide which key processes will be accomplished by your workforce and which by external suppliers and partners? How do those decisions consider your core competencies and the core competencies of potential suppliers and partners? What are your key work systems? How do you make work system decisions that facilitate the accomplishment of your strategic objectives? How do you determine what future organizational core competencies and work systems you will need?

b. Strategic Objectives

(1) Key Strategic Objectives What are your organization’s key strategic objectives and timetable for achieving them? What are your most important goals for these strategic objectives? What key changes, if any, are planned in your health care services, customers and markets, suppliers and partners, and operations?

(2) Strategic Objective Considerations How do your strategic objectives achieve an appropriate balance among varying and potentially competing for organizational needs? How do your strategic objectives • address your strategic challenges and leverage your core competencies, strategic advantages, and strategic opportunities; • balance short- and longer-term planning horizons; and • consider and balance the needs of all key stakeholders?

c. Mission and Organizational Performance

(1) Creating an Environment for Success How do senior leaders create an environment for success now and in the future? How do they • create an environment for the achievement of your mission and for organizational agility; • cultivate organizational learning, learning for people in the workforce, innovation, and intelligent risk-taking; • create a workforce culture that fosters patient and other customer engagement; • participate in succession planning and the development of future organizational leaders; and • create and promote a culture of patient safety?

(2) Creating a Focus on Action How do senior leaders create a focus on the action that will achieve the organization’s mission? How do senior leaders • create a focus on the action that will improve the organization’s performance; • identify needed actions; • in setting expectations for organizational performance, include a focus on creating and balancing value for patients, other customers, and other stakeholders; and • demonstrate personal accountability for the organization’s actions?

Customer and market focus:

a. Listening to Patients and Other Customers

(1) Current Patients and Other Customers How do you listen to, interact with, and observe patients and other customers to obtain actionable information? How do your listening methods vary for different patient groups, other customer groups, or market segments? How do you use social media and web-based technologies to listen to patients and other customers, as appropriate? How do your listening methods vary across the stages of patients’ and other customers’ relationships with you? How do you seek immediate and actionable feedback from patients and other customers on the quality of health care services, patient and other customer support, and transactions?

(2) Potential Patients and Other Customers How do you listen to potential patients and other customers to obtain actionable information? How do you listen to former, potential, and competitors’ patients and other customers to obtain actionable information on your health care services, patient and other customer support, and transactions, as appropriate?

b. Determination of Patient and Other Customer Satisfaction and Engagement

(1) Satisfaction, Dissatisfaction, and Engagement How do you determine patient and other customer satisfaction, dissatisfaction, and engagement? How do your determination methods differ among your patient and other customer groups and market segments, as appropriate? How do your measurements capture actionable information to use in exceeding your patients’ and other customers’ expectations and securing your patients’ and other customers’ engagement for the long term? (2) Satisfaction Relative to Competitors How do you obtain information on your patients’ and other customers’ satisfaction with your organization relative to other organizations? How do you obtain information on your patients’ and other customers’ satisfaction • relative to their satisfaction with your competitors; and • relative to the satisfaction of patients and other customers of other organizations that provide similar health care services or to health care industry benchmarks, as appropriate?

Measurement, analysis and knowledge management:

a. Performance Measurement

(1) Performance Measures How do you track data and information on daily operations and overall organizational performance? How do you • select, collect, align, and integrate data and information to use in tracking daily operations and overall organizational performance; and • track progress on achieving strategic objectives and action plans? What are your key organizational performance measures, including key short- and longer-term financial measures? How frequently do you track these measures?

(2) Comparative Data How do you select comparative data and information to support fact-based decision making?

(3) Patient and Other Customer Data How do you select voice-of-the-customer and market data and information? How do you select voice-of-the-customer and market data and information (including aggregated data on complaints and, as appropriate, data and information from social media) to build a more patient-focused culture and to support fact-based decision making? (4) Measurement Agility How do you ensure that your performance measurement system can respond to rapid or unexpected organizational or external changes?

b. Performance Analysis and Review: How do you review your organization’s performance and capabilities? How do you use your key organizational performance measures, as well as comparative and customer data, in these reviews? What analyses do you perform to support these reviews and ensure that conclusions are valid? How do your organization and its senior leaders use these reviews to • assess organizational success, competitive performance, financial health, and progress on achieving your strategic objectives and action plans; and • respond rapidly to changing organizational needs and challenges in your operating environment, including any need for transformational change in organizational structure and work systems? How does your governance board review the organization’s performance and its progress on strategic objectives and action plans, if appropriate?

c. Performance Improvement

(1) Future Performance How do you project your organization’s future performance? How do you use findings from performance reviews (addressed in 4.1b) and key comparative and competitive data in your projections? How do you reconcile any differences between these projections and those developed for your key action plans (addressed in 2.2a[6])? (2) Continuous Improvement and Innovation How do you use findings from performance reviews (addressed in 4.1b) to develop priorities for continuous improvement and opportunities for innovation? How do you deploy these priorities and opportunities • to workgroup and functional-level operations; and • when appropriate, to your suppliers, partners, and collaborators to ensure organizational alignment?

Human REsource Focus:

a. Workforce Capability and Capacity

(1) Capability and Capacity How do you assess your workforce capability and capacity needs? How do you assess the skills, competencies, certifications, and staffing levels you need?

(2) New Workforce Members How do you recruit, hire, place, and retain new workforce members? How do you ensure that your workforce represents the diverse ideas, cultures, and thinking of your hiring and patient community? How do you ensure the fit of new workforce members with your organizational culture?

(3) Workforce Change Management How do you prepare your workforce for changing capability and capacity needs? How do you • manage your workforce, its needs, and your organization’s needs to ensure continuity, prevent workforce reductions, and minimize the impact of such reductions, if they become necessary; • prepare for and manage any periods of workforce growth; and • prepare your workforce for changes in organizational structure and work systems, when needed?

(4) Work Accomplishment How do you organize and manage your workforce? How do you organize and manage your workforce to • accomplish your organization’s work; • capitalize on your organization’s core competencies; • reinforce a focus on patients, other customers, and health care; and • exceed performance expectations?

b. Workforce Climate

(1) Workplace Environment How do you ensure workplace health, security, and accessibility for the workforce? What are your performance measures and improvement goals for your workplace environmental factors? For your different workplace environments, what significant differences are there in these factors and their performance measures or targets?

(2) Workforce Benefits and Policies How do you support your workforce via services, benefits, and policies? How do you tailor these to the needs of a diverse workforce and different workforce groups and segments? What key benefits do you offer your workforce?

Process Management:

a. Service and Process Design

(1) Determination of Service and Process Requirements How do you determine key health care service and work process requirements?

(2) Key Work Processes What are your organization’s key work processes? What are the key requirements for these work processes?

(3) Design Concepts How do you design your health care services and work processes to meet requirements? How do you incorporate new technology, organizational knowledge, evidence-based medicine, health care service excellence, patient and other customer value, consideration of risk, and the potential need for agility into these services and processes?

b. Process Management and Improvement

(1) Process Implementation How does your day-to-day operation of work processes ensure that they meet key process requirements? What key performance measures or indicators and in-process measures do you use to control and improve your work processes? How do these measures relate to the quality of outcomes and the performance of your health care services?

(2) Patient Expectations and Preferences How do you address and consider each patient’s expectations? How do you explain health care service delivery processes and likely outcomes to set realistic patient expectations? How do you factor patient decision making and patient preferences into the delivery of health care services?

(3) Support Processes How do you determine your key support processes? What are your key support processes? How does your day-to-day operation of these processes ensure that they meet key organizational requirements?

(4) Service and Process Improvement How do you improve your work processes to improve health care services and performance, enhance your core competencies, and reduce variability?

c. Supply-Chain Management How do you manage your supply chain? How do you • select suppliers and ensure that they are qualified and positioned to not only meet operational needs but also enhance your performance and your customers’ satisfaction; • measure and evaluate your suppliers’ performance; • provide feedback to your suppliers to help them improve, and • deal with poorly performing suppliers?

d. Innovation Management How do you pursue your opportunities for innovation? How do you pursue the strategic opportunities that you determine are intelligent risks? How do you make financial and other resources available to pursue these opportunities? How do you discontinue pursuing opportunities at the appropriate time to enhance support for higher-priority opportunities?

Business or organizational performance result:

a. Process Efficiency and Effectiveness How do you control the overall costs of your operations? How do you • incorporate cycle time, productivity, and other efficiency and effectiveness factors into your work processes; • prevent rework and errors, including medical errors; • minimize the costs of inspections, tests, and process or performance audits, as appropriate; and • balance the need for cost control with the needs of your patients and other customers, when they differ?

b. Management of Information Systems

(1) Reliability How do you ensure the reliability of your information systems?

(2) Security and Cybersecurity How do you ensure the security and cybersecurity of sensitive or privileged data and information? How do you manage electronic and physical data and information to ensure confidentiality and only appropriate access? How do you • maintain your awareness of emerging security and cybersecurity threats; • identify and prioritize information technology systems to secure from cybersecurity attacks; • protect these systems from cybersecurity attacks; and • detect, respond to, and recover from cybersecurity breaches?

c. Safety and Emergency Preparedness

(1) Safety How do you provide a safe operating environment? How does your safety system address accident prevention, inspection, root-cause analysis of failures, and recovery?

(2) Business Continuity How do you ensure that your organization is prepared for disasters or emergencies? How does your disaster and emergency preparedness system consider prevention, continuity of operations, and recovery? How does your disaster and emergency preparedness system take your reliance on your workforce, suppliers, and partners into account? How do you ensure that information technology systems continue to be secure and available to serve patients, other customers, and organizational needs?

a. Patient- and Other Customer-Focused Results

(1) Patient and Other Customer Satisfaction What are your patient and other customer satisfaction and dissatisfaction results? What are your current levels and trends in key measures or indicators of the patient and other customer satisfaction and dissatisfaction? How do these results compare with those of your competitors and other organizations providing similar health care services? How do these results differ by health care service offerings, patient and other customer groups, and market segments, as appropriate?

(2) Patient and Other Customer Engagement What are your patient and other customer engagement results? What are your current levels and trends in key measures or indicators of the patient and other customer engagement, including those for building relationships with patients and other customers? How do these results compare over the course of your patients’ and other customers’ relationships with you, as appropriate? How do these results differ by health care service offerings, patient and other customer groups, and market segments, as appropriate?