2017-2018 Baldrige Excellence Framework Health Care

Examiner Version
Includes Criteria
Commentary
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BALDRIGE
On
EXCELLENCE
FRAMEWORK
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A systems approach to improving your
organization’s performance
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health care
in
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LEADERSHIP
STRATEGY
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CUSTOMERS
MEASUREMENT, ANALYSIS, AND
KNOWLEDGE MANAGEMENT
WORKFORCE
2017 OPERATIONS
RESULTS
2018 #Baldrige
www.nist.gov/baldrige
Baldrige Performance Excellence Program
National Institute of Standards and Technology (NIST) • United States Department of Commerce
January 2017
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The Baldrige Excellence Framework (Health Care)TM is an official publication of NIST under the authority of the Malcolm Baldrige
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Government and is not subject to copyright protection in the United States under Section 105 of Title 17 of the United States Code. The
U.S. Department of Commerce, as represented by NIST, holds copyright to the publication in all countries outside of the United States.
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CRITERIA FOR PERFORMANCE EXCELLENCE®, EDUCATION CRITERIA FOR PERFORMANCE EXCELLENCE®, HEALTH CARE
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Suggested citation: Baldrige Performance Excellence Program. 2017. 2017–2018 Baldrige Excellence Framework (Health Care):
in
A Systems Approach to Improving Your Organization’s Performance. Gaithersburg, MD: U.S. Department of Commerce,
National Institute of Standards and Technology. https://www.nist.gov/baldrige.
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The Baldrige Program and the Baldrige Foundation thank the American Hospital Association
as the lead sponsor for the Health Care Criteria for Performance Excellence.
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We also thank the following organizations for supporting the publication of this booklet.
Contents
ii About the Baldrige Excellence Framework
The Baldrige framework empowers your organization to reach its goals, improve results, and become more
competitive. The framework consists of the Criteria, the core values and concepts, and the scoring guidelines.
v How to Use the Baldrige Excellence Framework

You can use this booklet as a reference, for self-assessment, or as the basis of an external assessment.
1 Health Care Criteria for Performance Excellence Overview and Structure
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The Health Care Criteria include the Organizational Profile and seven interconnected categories. The categories
are subdivided into items and areas to address.
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3 Health Care Criteria for Performance Excellence Items and Point Values
4 Health Care Criteria for Performance Excellence
4 Organizational Profile
7 1 Leadership
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10 2 Strategy
13 3 Customers
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4 Measurement, Analysis, and Knowledge Management
19 5 Workforce
23 6 Operations
26 7 Results
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31 Scoring System
Performance against Health Care Criteria items is scored on two evaluation dimensions: process and results.
34 Process Scoring Guidelines
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35 Results Scoring Guidelines
37 How to Respond to the Health Care Criteria

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This section explains how to respond most effectively to the Health Care Criteria item requirements.
40 Core Values and Concepts

These embedded beliefs and behaviors form the foundation of the Health Care Criteria.
45 Changes from the 2015–2016 Baldrige Excellence Framework

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47 Glossary of Key Terms

The glossary includes definitions of terms in small caps in the Health Care Criteria and scoring guidelines.
55 Index of Key Terms

58 List of Contributors
On the Web
Health Care Criteria Commentary (https://www.nist.gov/baldrige/baldrige-criteria-commentary-health-care)
This commentary provides the “why” behind the Health Care Criteria, as well as additional examples and guidance.
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About the Baldrige Excellence Framework
The Baldrige Excellence Framework empowers your organization to reach its goals, improve
results, and become more competitive.
Thousands of organizations around the world use the Baldrige Excellence Framework to improve and get sustainable
results. Those recognized as national role models receive the Malcolm Baldrige National Quality Award, a Presidential
award. More than 100 recipients have broadly shared their best practices with others. Through that sharing, many
thousands of organizations have improved their operations and results, and thus their contributions to the U.S. and
global economy.
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Baldrige has a simple purpose.
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The purpose of the Baldrige framework is simply to help your organization—no matter its size or the types of health
care services it offers—answer three questions: Is your organization doing as well as it could? How do you know? What
and how should your organization improve or change?
By challenging yourself with the questions that make up the Health Care Criteria for Performance Excellence
(pages 4–30), you explore how you are accomplishing what is important to your organization. The questions (divided
into six interrelated process categories and a results category) represent seven critical aspects of managing and
performing as an organization:
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1. Leadership
2. Strategy
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3. Customers
4. Measurement, analysis, and knowledge management
5. Workforce
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6. Operations
7. Results
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Baldrige promotes a systems perspective.

A systems perspective means managing all the components of your organization as a unified whole to achieve ongoing
success. The system’s building blocks and integrating mechanism are the core values and concepts (pages 40–44),
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the seven interrelated Health Care Criteria categories (pages 4–30), and the scoring guidelines (pages 34–35).
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I see the Baldrige process as a powerful set of mechanisms for disciplined people engaged
in disciplined thought and taking disciplined action to create great organizations that
produce exceptional results.
—Jim Collins, author of Good to Great: Why Some Companies
Make the Leap . . . and Others Don’t
ii 2017–2018 Baldrige Excellence Framework (Health Care)

A focus on core values and concepts. Baldrige is based on a set of beliefs and behaviors (see pages 40–44). These
core values and concepts are the foundation for integrating key performance and operational requirements within a
results-oriented framework that creates a basis for action, feedback, and ongoing success:
• Systems perspective
• Visionary leadership
• Patient-focused excellence
• Valuing people
• Organizational learning and agility
• Focus on success
• Managing for innovation
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• Management by fact
• Societal responsibility and community health
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• Ethics and transparency
• Delivering value and results
A focus on processes. Processes are the methods your organization uses to accomplish its work. The Baldrige frame-
work helps you assess and improve your processes along four dimensions:
1. Approach: How do you accomplish your organization’s work? How effective are your key approaches?
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2. Deployment: How consistently are your key approaches used in relevant parts of your organization?
3.
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Learning: How well have you evaluated and improved your key approaches? How well have improvements been
shared within your organization? Has new knowledge led to innovation?
4. Integration: How well do your approaches align with your current and future organizational needs? How
well do your measures, information, and improvement systems complement each other across processes
and work units? How well are processes and operations harmonized across your organization to achieve key
organization-wide goals?
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A focus on results. The Baldrige framework leads you to examine your results from three viewpoints: the external
view (How do your patients, other customers, and other stakeholders view you?), the internal view (How efficient and
effective are your operations?), and the future view (Is your organization learning and growing?).
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In Baldrige, results include all areas of importance to your organization. This composite of measures ensures that your
strategies are balanced—that they do not inappropriately trade off among important stakeholders, objectives, or short-
and longer-term goals. The Baldrige framework helps you evaluate your results along four dimensions:
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1. Levels: What is your current performance on a meaningful measurement scale?

2. Trends: Are the results improving, staying the same, or getting worse?
3. Comparisons: How does your performance compare with that of other organizations and competitors, or with
benchmarks or industry leaders?
4. Integration: Are you tracking results that are important to your organization and that consider the expectations
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and needs of your key stakeholders? Are you using the results in decision making?
A focus on linkages. The linkages among the Health Care Criteria categories are an essential element of the systems
perspective provided by the Baldrige framework. Some examples of these linkages are
• the connections between your processes and the results you achieve;
• the need for data in the strategic planning process and for improving operations;
• the connection between workforce planning and strategic planning;
• the need for patient, other customer, and market knowledge in establishing your strategy and action plans; and
• the connection between your action plans and any changes needed in your work systems.
About the Baldrige Excellence Framework iii

A focus on improvement. The Baldrige framework helps you understand and assess how well you are accomplishing
what is important to your organization: how mature and how well deployed your processes are, how good your results
are, whether your organization is learning and improving, and how well your approaches address your organization’s
needs. The Baldrige scoring guidelines (pages 34–35) are based on the process and results dimensions described above.
As you respond to the Health Care Criteria questions and gauge your responses against the scoring guidelines, you
will begin to identify strengths and gaps—first within the Health Care Criteria categories and then among them. The
coordination of key processes, and feedback between your processes and your results, will lead to cycles of improve-
ment. As you continue to use the framework, you will learn more and more about your organization and begin to
define the best ways to build on your strengths, close gaps, and innovate.
Baldrige is adaptable.
The Health Care Criteria do not prescribe how you should structure your organization or its operations. In the Organi-
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zational Profile (pages 4–6), you describe what is important to your organization (its operating environment, key
relationships, competitive environment, and strategic context). The Health Care Criteria encourage you to use creative,
adaptive, and flexible approaches, which will foster incremental and breakthrough improvement through innovation.
The Health Care Criteria encourage you to choose the tools (e.g., Lean, Six Sigma, the International Organization
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for Standardization [ISO] 9000 series, a balanced scorecard, Plan-Do-Check-Act [PDCA]) that are most suitable and
effective for your organization in making improvements and achieving excellence.
Baldrige has national and global impact.

The Baldrige framework and Criteria play three roles in strengthening U.S. competitiveness:
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• They help improve organizational processes, capabilities, and results.
• They facilitate the communication and sharing of best practices among U.S. organizations through the Baldrige
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Award, the Quest for Excellence® Conference, and other educational offerings.
• They serve as a working tool for understanding and managing organizational performance, guiding your strategic
thinking, and providing opportunities to learn.
Baldrige works with public and private sector partners to address critical national needs related to long-term success
and sustainability, including cybersecurity risk management (see https://www.nist.gov/baldrige/products-services
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/baldrige-cybersecurity-initiative) and excellence in U.S. communities (see Communities of Excellence 2026,
http://www.communitiesofexcellence2026.org).
Within the United States, state, regional, sector, and organizational performance excellence programs use the Baldrige
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framework to help organizations improve their competitiveness and results. Globally, about 100 performance or
business excellence programs exist; most use the Baldrige framework or a derivative as their organizational excellence
model.
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Baldrige is here for your organization.

According to one health care leader, “It was the use of the Baldrige framework that boosted our ability to deliver bet-
ter care to our patients. And, in the end, that is the most important thing: delivering better care to our patients—and
having a greater and more positive impact on the lives of all of our customers” (Nancy Schlichting, CEO, Baldrige
Award recipient Henry Ford Health System). Why not take advantage of that opportunity? Your patients, other
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customers, workforce, community, and other stakeholders—and the nation—will be better off.
I honestly in my heart believe that because we participated in the Baldrige Program and
because it gave us that consistent feedback, there are people who are alive today who
wouldn’t have been had we not been so committed to the Baldrige process.
—Rulon Stacey, former president/CEO, Baldrige Award recipient Poudre Valley Health System
iv 2017–2018 Baldrige Excellence Framework (Health Care)

How to Use the Baldrige Excellence Framework
Whether your organization is large or small, you can use the Baldrige Excellence Framework for
improvement. Your experience with Baldrige will help you decide where to begin.
If your organization is in the business/nonprofit or education sector, you should use the business/nonprofit or
education version of this booklet, respectively. See https://www.nist.gov/baldrige/publications/baldrige-excellence
-framework to obtain a copy.
If you are just learning about the Baldrige framework . . .
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Here are some ways to begin using the Baldrige framework to improve your organization.
Scan the questions in the Organizational Profile (pages 4–6). Discerning and discussing the answers to these ques-
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tions with your senior leadership team might be your first Baldrige self-assessment.
Study the 11 Baldrige core values and concepts (pages 40–44). Consider how your organization measures up in
relation to the core values. Are there any improvements you should be making?
Answer the questions in the titles of the 17 Health Care Criteria for Performance Excellence items to reach a
basic understanding of the Criteria and your organization’s performance.
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See a simple outline of a holistic performance management system by reading the headings in purple in the
Health Care Criteria section of this booklet (pages 4–30). See if you are considering all of these dimensions in estab-
lishing your leadership system and measuring performance.
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Use the Baldrige framework and its supporting material as a general resource on organizational performance
improvement. This booklet and the materials online (https://www.nist.gov/baldrige/publications/baldrige-excellence
-framework) may help you think in a different way or give you a fresh frame of reference.
Attend the Quest for Excellence® or a state or regional Baldrige conference. These events highlight the role-
model approaches of Baldrige Award recipients. These organizations have used the Baldrige framework to improve
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performance, innovate, and achieve world-class results. Workshops on Baldrige self-assessment are often offered in
conjunction with these conferences.
Become an examiner, or attend the Baldrige Examiner Training Experience (https://www.nist.gov/baldrige
in
/products-services/baldrige-examiner-training-experience). Examiners receive valuable training, evaluate award

applications, and learn to apply the Criteria to their organizations.
Become a Baldrige Executive Fellow. Baldrige Fellows (C-suite and rising executives) participate in an executive
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development program (see https://www.nist.gov/baldrige/products-services/baldrige-executive-fellows-program),

learning from each other and from Baldrige Award recipients.
If you are ready to assess your organization using Baldrige . . .

To assess your organization with the Baldrige framework, follow one or more of the suggestions below.
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Check your progress on achieving organizational excellence and improve communication among your work-
force members and leadership team with two simple questionnaires: Are We Making Progress? (https://www.nist.gov
/baldrige/self-assessing/improvement-tools/are-we-making-progress) and Are We Making Progress as Leaders?
(https://www.nist.gov/baldrige/self-assessing/improvement-tools/are-we-making-progress-leaders).
Identify gaps in your understanding of your organization and compare your organization with others with
easyInsight: Take a First Step toward a Baldrige Self-Assessment (https://www.nist.gov/baldrige/self-assessing
/improvement-tools/easyinsight-take-first-step-toward-baldrige-self). This assessment is based on the Organizational
Profile.
Complete the Organizational Profile (pages 4–6). Have your leadership team answer the questions. If you identify
topics for which you have conflicting, little, or no information, use these topics for action planning. For many organi-
zations, this approach serves as a first Baldrige self-assessment.
How to Use the Baldrige Excellence Framework v

Answer the questions in the Baldrige Excellence Builder (https://www.nist.gov/baldrige/publications/baldrige
-excellence-builder). This assessment tool includes key questions for improving your organization’s performance. They
are the questions in black boldface in the Criteria section of this booklet.
Use the full set of Health Care Criteria questions as a personal guide to everything that is important in lead-
ing your organization. You may discover blind spots or areas where you should place additional emphasis.
Review the scoring guidelines (pages 34–35). They help you assess your organizational maturity, especially when
used in conjunction with “Steps toward Mature Processes” (page 36) and “From Fighting Fires to Innovation:
An Analogy for Learning” (page 32).
Answer the questions in one Health Care Criteria category in which you know you need improvement, either
yourself or with leadership team colleagues, referring to the item notes and Health Care Criteria Commentary (https://
www.nist.gov/baldrige/baldrige-criteria-commentary-health-care). Then assess your strengths and opportunities for
improvement, and develop action plans. Be aware, though, that this kind of assessment limits the benefits of the
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systems perspective embodied in the Baldrige framework.
Have your leadership team assess your organization. At a retreat, have your leadership team develop responses to
the Organizational Profile and the seven Health Care Criteria categories, using the Baldrige Excellence Builder (https://
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www.nist.gov/baldrige/publications/baldrige-excellence-builder), and record the responses. Then assess your strengths
and opportunities for improvement, and develop action plans.
Conduct a full Baldrige self-assessment. Set up teams within your organization to develop responses to the
Organizational Profile and Health Care Criteria categories. For details, see https://www.nist.gov/baldrige/self-assessing
and the slide presentation “Self-Assessing Your Organization with the Baldrige Excellence Framework” (https://www
.nist.gov/baldrige/community/baldrige-ambassadors).
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Contact your state, local, or sector-specific Baldrige-based program (see the Alliance for Performance Excellence,
http://www.baldrigepe.org/alliance). Many programs provide networking opportunities, training, coaching, and self-
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assessment services in addition to an award program.
Contact a Baldrige Award recipient. Organizations that receive the Baldrige Award advocate for performance
improvement, share their strategies, and serve as role models. Many undertake ongoing self-assessments of their
organizations and can share their experiences with you. See http://patapsco.nist.gov/Award_Recipients/index.cfm
for award recipients and their contact information.
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If you are ready for external feedback . . .

Here are some resources for receiving external feedback on your organization’s strengths and opportunities for
improvement.
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Apply to your state, local, or sector-specific Baldrige-based award program (see the Alliance for Performance
Excellence, http://www.baldrigepe.org/alliance). A team of experts will examine your organization objectively and
identify your organization’s strengths and its opportunities to improve.
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Arrange for a Baldrige Collaborative Assessment (https://www.nist.gov/baldrige/products-services/baldrige

-collaborative-assessment). In this on-site assessment, a team of Baldrige examiners works with your leaders and staff
to give your organization immediate, actionable feedback.
Apply for the Malcolm Baldrige National Quality Award. Once you meet eligibility requirements, apply for the
highest level of national recognition for performance excellence that a U.S. organization can receive: the Malcolm
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Baldrige National Quality Award.

Award applicants say that the Baldrige evaluation process is one of the best, most cost-effective, most comprehensive
performance assessments you can find, whether or not they receive the Baldrige Award. See https://www.nist.gov
/baldrige/baldrige-award for more information. In the Baldrige process, everyone is a learner.
vi 2017–2018 Baldrige Excellence Framework (Health Care)

Health Care Criteria for Performance
Excellence Overview and Structure
Health Care Criteria for Performance Excellence Overview: A Systems Perspective

The performance system consists of the six categories in the center of the figure. These categories define your processes and
the results you achieve.
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Performance excellence requires strong Leadership and is demonstrated through outstanding Results. Those categories are
highlighted in the figure.
The word “integration” at the center of the figure shows that all the elements of the system are interrelated.
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The center horizontal arrowheads show the critical linkage between the leadership triad (categories 1, 2, and 3) and the
results triad (categories 5, 6, and 7) and the central relationship between the Leadership and Results categories.
The center vertical arrowheads point to the Organizational Profile and the system foundation, which provide information on
and feedback to key processes and the organizational environment.
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The Organizational Profile
sets the context for your The results triad (Workforce,
organization. It serves as the Operations, and Results)
The leadership triad (Leader-
ship, Strategy, and Customers)
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background for all you do. includes your workforce-focused
processes, your key operational
emphasizes the importance of processes, and the performance
a leadership focus on strategy results they yield.
and customers.
Organizational Profile
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Strategy Workforce
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Leadership Integration RESULTS

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Customers Operations
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Measurement, Analysis, and Knowledge Management
The system All actions

foundation lead to
(Measurement, Results—a
Core s
Values and Concept
Analysis, and composite of health
Knowledge Management) care and process,
is critical to effective customer, workforce,
management and to a leadership and gover-
fact-based, knowledge- nance, and financial
driven, agile system for and market results.
improving performance The basis of the Health Care Criteria is a set of Core Values and Concepts
and competitiveness. that are embedded in high-performing organizations (see pages 40–44).
Health Care Criteria for Performance Excellence Overview and Structure 1

Health Care Criteria for Performance Excellence Structure
The seven Baldrige Health Care Criteria for Performance Excellence categories are subdivided into
items and areas to address.
Items Requirements
There are 17 Health Care Criteria items (plus 2 in the Item requirements are expressed as questions or statements
Organizational Profile), each with a particular focus. These on three levels:
items are divided into three groups according to the kinds of
• Basic requirements are expressed in the title question.
information they ask for:
• Overall requirements are expressed in the questions
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• The Organizational Profile asks you to define your
in boldface in the shaded box. These leading ques-
organizational environment.
tions are the starting point for responding to the
• Process items (categories 1–6) ask you to define your requirements.
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organization’s processes.
• Multiple requirements are the individual questions
• Results items (category 7) ask you to report results for under each area to address, including the question
your organization’s processes. in boldface. That first question expresses the most
important one in that group.
See page 3 for a list of item titles and point values.
Item Notes Key Terms
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Item notes (1) clarify terms or requirements, (2) give instruc- Terms in small caps are defined in the Glossary of Key
tions and examples for responding, and (3) indicate key Terms (pages 47–54).
linkages to other items.
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Areas to Address
Each item includes one or more areas to address (labeled
a, b, c, and so on).
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Key term in Item point value Type of information

Item number small caps to provide in response
to this item
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Item title
and basic 7.5 Financial and Market Results: What are your results for financial viability? (90 pts.)
requirements
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a. Financial and Market Results

(1) Financial PeRfoRmance What are your financial PeRfoRmance Results? What are your current levels and
RE SU LT S
trends in key measures or indicators of financial performance, including aggregate measures of financial
Area to return, financial viability, and budgetary performance, as appropriate? How do these results differ by market
segments and patient and other customer groups, as appropriate?
address
(2) Marketplace PeRfoRmance What are your marketplace PeRfoRmance Results? What are your current levels
and trends in key measures or indicators of marketplace performance, including market share or position,
market and market share growth, and new markets entered, as appropriate? How do these results differ by market
Headings segments and patient and other customer groups, as appropriate? Overall
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summarizing requirements
multiple Terms in small caps are defined in the Glossary of Key Terms (pages 47–54).
requirements
Note
7.5a(1). Measures should relate to the financial measures health care organizations, measures of performance to Multiple
you report in 4.1a(1) and the financial management budget might include additions to or subtractions from
approaches you report in item 2.2. Aggregate measures of reserve funds, cost avoidance or savings, responses to requirements
financial return might include those for return on invest- budget decreases, lowering of costs to patients or other cus-
ment (ROI), operating margins, profitability, or profitability tomers or return of funds as a result of increased efficiency,
by market segment or patient or other customer group. administrative expenditures as a percentage of budget, and
Item Measures of financial viability might include those for the cost of fundraising versus funds raised.
liquidity, debt-to-equity ratio, days cash on hand, asset
notes utilization, cash flow, bond ratings, accountable care For additional guidance on this item, see the Health Care Link to
organization or shared savings programs, and value-based Criteria Commentary (https://www.nist.gov/baldrige
purchasing financial results, as appropriate. For nonprofit /baldrige-criteria-commentary-health-care). Health Care
Criteria
Commentary
2 2017–2018 Baldrige Excellence Framework (Health Care)

Health Care Criteria for Performance
Excellence Items and Point Values
See pages 31–36 for the scoring system used with the Health Care Criteria items in a
Baldrige assessment.
P Organizational Profile
P.1 Organizational Description
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P.2 Organizational Situation
Categories and Items Point Values
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1 Leadership 120
1.1 Senior Leadership 70
1.2 Governance and Societal Responsibilities 50
2 Strategy 85
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2.1 Strategy Development 45
2.2 Strategy Implementation
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3 Customers 85
3.1 Voice of the Customer 40
3.2 Customer Engagement 45
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4 Measurement, Analysis, and Knowledge Management 90

4.1 Measurement, Analysis, and Improvement of
Organizational Performance 45
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4.2 Information and Knowledge Management 45
5 Workforce 85
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5.1 Workforce Environment 40

5.2 Workforce Engagement 45
6 Operations 85
6.1 Work Processes 45
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6.2 Operational Effectiveness 40
7 Results 450
7.1 Health Care and Process Results 120
7.2 Customer Results 80
7.3 Workforce Results 80
7.4 Leadership and Governance Results 80
7.5 Financial and Market Results 90
TOTAL POINTS 1,000
Health Care Criteria for Performance Excellence Items and Point Values 3
Health Care Criteria for Performance Excellence
Begin with the Organizational Profile
The Organizational Profile is the most appropriate starting point for self-assessment and for writing an application. It is critically
important for the following reasons:
• It helps you identify gaps in key information and focus on key performance requirements and results.
• You can use it as an initial self-assessment. If you identify topics for which conflicting, little, or no information is avail-
able, use these topics for action planning.
• It sets the context for and allows you to address unique aspects of your organization in your responses to the Health Care
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Criteria requirements in categories 1–7.
P Organizational Profile
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The Organizational Profile is a snapshot of your organization, the key influences on how it operates, and your competitive
environment.
P.1 Organizational Description: What are your key organizational characteristics?
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a. Organizational Environment
(1) Health Care Service Offerings What are your main health care service offerings (see the note on the next
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page)? What is the relative importance of each to your success? What mechanisms do you use to deliver your
health care services?
(2) Mission, Vision, and Values What are your stated mission, vision, and values? What are your organization’s
core competencies, and what is their relationship to your mission?
(3) Workforce Profile What is your workforce profile? What recent changes have you experienced in workforce
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composition or in your needs with regard to your workforce? What are
• your workforce or employee groups and segments,
• the educational requirements for different employee groups and segments, and
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• the key drivers that engage them in achieving your mission and vision?
What are your organized bargaining units (union representation)? What are your organization’s special health and
safety requirements?
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(4) Assets What are your major facilities, technologies, and equipment?
(5) Regulatory Requirements What is the regulatory environment under which you operate? What are the key appli-
cable occupational health and safety regulations; accreditation, certification, or registration requirements; industry
standards; and environmental, financial, and health care service delivery regulations?
b. Organizational Relationships
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(1) Organizational Structure What are your organizational leadership structure and governance system? What
are the reporting relationships among your governance board, senior leaders, and parent organization, as
appropriate?
(2) Patients, Other Customers, and Stakeholders What are your key market segments, patient and other
customer groups, and stakeholder groups, as appropriate? What are their key requirements and expectations for
your health care services, patient and other customer support services, and operations? What are the differ-
ences in these requirements and expectations among market segments, patient and other customer groups, and
stakeholder groups?
(Continued on the next page)
4 2017–2018 Health Care Criteria for Performance Excellence

(3) Suppliers and Partners What are your key types of suppliers, partners, and collaborators? What role do
they play
• in your work systems, especially in producing and delivering your key health care services and patient and
other customer support services; and
• in enhancing your competitiveness?
What are your key mechanisms for two-way communication with suppliers, partners, and collaborators?
What role, if any, do these organizations play in contributing and implementing innovations in your organization?
What are your key supply-chain requirements?
Terms in small caps are defined in the Glossary of Key Terms (pages 47–54).
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Notes
P. Your responses to the Organizational Profile questions are might cover greenhouse gas emissions, carbon regulations
very important. They set the context for understanding your and trading, and energy efficiency.
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organization and how it operates. Your responses to all other
P.1b(2). Customers include the direct users and potential
questions in the Baldrige Health Care Criteria should relate
users of your health care services (patients), as well as
to the organizational context you describe in this profile.
referring health care providers and users who pay for your
Your responses to the Organizational Profile questions thus
services, such as patients’ families, insurers, and other third-
allow you to tailor your responses to all other questions to
party payors.
your organization’s uniqueness.
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P.1b(2). Patient and other customer groups might be based
P.1a(1). Health care service offerings are the services you
on common expectations, behaviors, preferences, or profiles.
offer in the marketplace. Mechanisms for delivering services
Within a group, there may be customer segments based on
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to your patients or other customers might be direct or might
be indirect, through contractors, collaborators, or partners.
differences, commonalities, or both. You might subdivide
your market into segments based on health care service
P.1a(2). If your organization has a stated purpose as well lines or features, service delivery modes, payors, volume,
as a mission, you should include it in your response. Some geography, or other defining factors.
organizations define a mission and a purpose, and some use
P.1b(2). The requirements of your patient and other
the terms interchangeably. In some organizations, purpose
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customer groups and your market segments might include
refers to the fundamental reason that the organization
patient safety; security, including cybersecurity; quality of
exists. Its role is to inspire the organization and guide its
care; affordability; care planning and continuity of care;
setting of values.
provider choice; electronic communication and access to
P.1a(2). Core competencies are your organization’s areas personal health information; easy transferability of health
in
of greatest expertise. They are those strategically important, information; billing requirements; socially responsible
possibly specialized capabilities that are central to fulfilling behavior; cultural inclusion; and multilingual services.
your mission or provide an advantage in your marketplace
P.1b(2), P.1b(3). Patient, other customer, stakeholder, and
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or service environment. Core competencies are frequently

operational requirements and expectations will drive your
challenging for competitors or suppliers and partners to
organization’s sensitivity to the risk of service, support, and
imitate and frequently preserve your competitive advantage.
supply-chain interruptions, including those due to natural
P.1a(3). Workforce or employee groups and segments disasters and other emergencies.
(including organized bargaining units) might be based on
P.1b(3). Communication mechanisms should use under-
type of employment or contract-reporting relationship, loca-
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standable language, and they might involve in-person

tion (including telework), tour of duty, work environment,
contact; email, social media, or other electronic means; or
use of certain family-friendly policies, or other factors.
the telephone. For many organizations, these mechanisms
P.1a(3). Organizations that also rely on volunteers and may change as marketplace, patient, other customer, or
unpaid staff to accomplish their work should include these stakeholder requirements change.
groups as part of their workforce.
P.1a(5). Industry standards might include industrywide For additional guidance on this item, see the Health Care
codes of conduct and policy guidance. Depending on the Criteria Commentary (https://www.nist.gov/baldrige
regions in which you operate, environmental regulations /baldrige-criteria-commentary-health-care).
Organizational Profile 5
P.2 Organizational Situation: What is your organization’s strategic situation?
a. Competitive Environment
(1) Competitive Position What is your competitive position? What are your relative size and growth in the health
care industry or the markets you serve? How many and what types of competitors and key collaborators do
you have?
(2) Competitiveness Changes What key changes, if any, are affecting your competitive situation, including changes
that create opportunities for innovation and collaboration, as appropriate?
(3) Comparative Data What key sources of comparative and competitive data are available from within the health
care industry? What key sources of comparative data are available from outside the health care industry? What
limitations, if any, affect your ability to obtain or use these data?
b. Strategic Context
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What are your key strategic challenges and advantages in the areas of health care services, operations, societal
responsibilities, and workforce?
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c. Performance Improvement System
What are the key elements of your performance improvement system, including your processes for evaluation and
improvement of key organizational projects and processes?
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Notes
P.2b. Strategic challenges and advantages might relate
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to technology; health care services; finances; operations
approaches and their deployment. This question is intended
to set an overall context for your approach to performance
(including data and information security); organizational improvement. The approach you use should be related to
structure and culture; your parent organization’s capabilities; your organization’s needs. Approaches that are compatible
patients, other customers, and markets; brand recognition with the overarching systems approach provided by the
and reputation; the health care industry; and people. Baldrige framework might include implementing a Lean
er
Strategic advantages might include differentiators such as Enterprise System, applying Six Sigma methodology, using
technology leadership, innovation rate, geographic proxim- PDCA methodology, using standards from ISO (e.g., the
ity, accessibility, health care and administrative support 9000 or 14000 series), using decision science, or employing
services, cost, reputation for service delivery, and wait times other improvement tools.
in
for service.
P.2c. The Baldrige Scoring System (pages 31–36) uses For additional guidance on this item, see the Health Care
performance improvement through learning and integration Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
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as a dimension in assessing the maturity of organizational

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1 Leadership (120 pts.)
The Leadership category asks how senior leaders’ personal actions guide and sustain your organization. It also asks about
your organization’s governance system and how your organization fulfills its legal, ethical, and societal responsibilities.
1.1 Senior Leadership: How do your senior leaders lead the organization? (70 pts.)
a. Vision and Values
(1) Setting Vision and Values How do senior leaders set your organization’s vision and values? How do
P R O C ESS
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?
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(2) Promoting Legal and Ethical Behavior How do senior leaders’ actions demonstrate their commitment to
legal and ethical behavior? How do senior leaders promote an organizational environment that requires it?
b. Communication
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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 customer, and
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health care focus, including by participating in reward and recognition programs?
c. Mission and Organizational Performance
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(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;
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• 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?
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(2) Creating a Focus on Action How do senior leaders create a focus on action that will achieve the organiza-
tion’s mission? How do senior leaders
• create a focus on action that will improve the organization’s performance;
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• 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?
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Notes
1.1. In health care organizations with separate 1.1a(1). Your organization’s vision should set the context
administrative/operational and health care provider leaders, for the strategic objectives and action plans you describe in
the term “senior leaders” refers to both sets of leaders and items 2.1 and 2.2.
the relationship between them. 1.1b. Use of social media may include delivering periodic
1.1. Your organizational performance results should be messages through internal and external websites; tweets;
reported in items 7.1–7.5. Results related to the effectiveness blogging; and electronic forums for patients, other custom-
of leadership and the leadership system should be reported ers, and the workforce, as well as monitoring external social
in item 7.4. media outlets and responding, when appropriate.
1 Leadership 7
1.1b. Organizations that rely heavily on volunteers to technological and organizational innovation to help the
accomplish their work should also discuss efforts to com- organization succeed in the future. A successful organization
municate with and engage the volunteer workforce. also ensures a safe and secure environment for its workforce
and other key stakeholders. A successful organization is
1.1c(1). A successful organization understands that some
capable of addressing risks and opportunities arising from
risk is always present, and determines and oversees its risk
data and information security and from environmental
appetite and risk tolerance. A successful organization is
considerations and climate change.
capable of addressing current business needs and, through
agility and strategic management, is capable of preparing for 1.1c(2). Senior leaders’ focus on action considers your strat-
its future business, market, and operating environment. In egy, workforce, work systems, and assets. It includes taking
creating an environment for success now and in the future, intelligent risks and implementing innovations and ongoing
leaders should consider both external and internal factors. improvements in performance and productivity. Senior
Factors might include workforce capability and capacity, leaders’ focus on action also includes the actions needed
resource availability, technology, knowledge, core competen- to achieve your strategic objectives (see 2.2a[1]), and may
cies, work systems, facilities, and equipment. Achieving
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involve establishing change management plans for major
future success may require leading transformational changes organizational change or responding rapidly to significant
in the organization’s structure and culture. Success now information from social media or other input.
and in the future might be affected by changes in the
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marketplace, in patient and other customer preferences, For additional guidance on this item, see the Health Care
in the financial markets, and in the legal and regulatory Criteria Commentary (https://www.nist.gov/baldrige
environment. In the context of ongoing success, the concept /baldrige-criteria-commentary-health-care).
of innovation and taking intelligent risks includes both
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1.2 Governance and Societal Responsibilities: How do you govern your organization and
fulfill your societal responsibilities? (50 pts.)
a. Organizational Governance
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(1) Governance System How does your organization ensure responsible governance? How does your
PROC ESS
governance system review and achieve the following?
• Accountability for senior leaders’ actions

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• Accountability for strategic plans
• Fiscal accountability
• Transparency in operations
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• Selection of governance board members and disclosure policies for them, as appropriate
• Independence and effectiveness of internal and external audits
• Protection of stakeholder and stockholder interests, as appropriate
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• Succession planning for senior leaders

(2) Performance Evaluation How do you evaluate the performance of your senior leaders and your
governance board? How do you use performance evaluations in determining executive compensation? How
do your senior leaders and governance board use these performance evaluations to advance their develop-
ment and improve both their own effectiveness as leaders and that of your board and leadership system, as
appropriate?
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b. Legal and Ethical Behavior

(1) Legal, Regulatory, and Accreditation Compliance How do you address and anticipate legal, regulatory, and
community concerns with your health care services and operations? How do you
• address any adverse societal impacts of your health care services and operations;
• anticipate public concerns with your future health care services and operations; and
• prepare for these impacts and concerns proactively, including through conservation of natural resources and
effective supply-chain management processes, as appropriate?
What are your key compliance processes, measures, and goals for meeting 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 operations?
(Continued on the next page)

(2) Ethical Behavior How do you promote and ensure ethical behavior in all 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 your workforce, patients, other c
ustomers,
partners, suppliers, and other stakeholders? How do you monitor and respond to breaches of ethical
behavior?
c. Societal Responsibilities
(1) Societal Well-Being How do you consider societal well-being and benefit as part of your strategy and daily
operations? How do you contribute to the well-being of your environmental, social, and economic systems?
(2) Community Support How do you actively support and strengthen your key communities? What are your key
communities? How do you identify them and determine areas for organizational involvement, including areas that
leverage your core competencies? How do your senior leaders, in concert with your workforce, contribute to
improving these communities and building community health?
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Notes
1.2. Societal responsibilities in areas critical to your ongoing responses to them, survey results showing workforce
marketplace success should also be addressed in Strategy perceptions of organizational ethics, ethics hotline use, and
Development (item 2.1) and Operations (category 6). Key results of ethics reviews and audits. Measures or indicators
results should be reported as Leadership and Governance of ethical behavior might also include evidence that policies,
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Results (item 7.4). workforce training, and monitoring systems are in place for
conflicts of interest; protection and use of sensitive data,
1.2. The health and safety of your workforce are not
information, and knowledge generated through synthesizing
factors in items 5.1 and 6.2, respectively.
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addressed in this item; you should address these workforce
and correlating these data; and proper use of funds.
1.2c. Areas of societal contributions might include your
1.2a(1). The governance board’s review of organizational
efforts to improve the environment (e.g., collaboration to
performance and progress, if appropriate, is addressed
conserve the environment or natural resources); strengthen
in 4.1(b).
local community services, education, health, and emergency
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1.2a(1). Transparency in the operations of your governance preparedness; and improve the practices of trade, business,
system should include your internal controls on governance or professional associations.
processes.
1.2c(2). Actions to build community health are population-
1.2a(1). In protecting stakeholder interests, the governance based services that support the general health of the
in
system should consider and sanction appropriate levels of communities in which you operate. Such services will likely
risk for the organization, recognizing the need to accept risk draw on your core competencies and might include the
as part of running a successful organization. identification of community health needs, health education
programs, immunization programs, health screenings, well-
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1.2a(2). The evaluation of leaders’ performance might be

supported by peer reviews, formal performance manage- ness and prevention programs, indigent care, and programs
ment reviews, reviews by external advisory boards, and for- to eliminate health disparities. You should report the results
mal or informal feedback from and surveys of the workforce of these services in item 7.4.
and other stakeholders.
For additional guidance on this item, see the Health Care
1.2b(2). Measures or indicators of ethical behavior might Criteria Commentary (https://www.nist.gov/baldrige
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include the percentage of independent board members, /baldrige-criteria-commentary-health-care).

instances of ethical conduct or compliance breaches and
1 Leadership 9
2 Strategy (85 pts.)
The Strategy category asks how your organization develops strategic objectives and action plans, implements them,
changes them if circumstances require, and measures progress.
2.1 Strategy Development: How do you develop your strategy? (45 pts.)
a. Strategy Development Process
(1) Strategic Planning Process How do you conduct your strategic planning? What are the key process steps?
P R O C ESS
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
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• 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
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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
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• Potential blind spots in your strategic planning process and information
• Your ability to execute the strategic plan
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(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 sys-
tems? 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?
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b. Strategic Objectives
(1) Key Strategic Objectives What are your organization’s key strategic objectives and timetable for achiev-
ing 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?
in
(2) Strategic Objective Considerations How do your strategic objectives achieve appropriate balance among
varying and potentially competing organizational needs? How do your strategic objectives
• address your strategic challenges and leverage your core competencies, strategic advantages, and
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strategic opportunities;
• balance short- and longer-term planning horizons; and
• consider and balance the needs of all key stakeholders?
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Notes
2.1. This item deals with your overall organizational might use various types of forecasts, projections, options,
strategy, which might include changes in health care service scenarios, knowledge (see 4.2b for relevant organizational
offerings and processes for patient and other customer knowledge), analyses, or other approaches to envisioning
engagement. However, you should describe the service the future in order to make decisions and allocate resources.
design and patient and other customer engagement strate- Strategy development might involve key suppliers, partners,
gies, respectively, in items 6.1 and 3.2, as appropriate. patients, and other customers.
2.1. Strategy development refers to your organization’s 2.1. The term “strategy” should be interpreted broadly.
approach to preparing for the future. In developing your Strategy might be built around or lead to any or all of the
strategy, you should consider your level of acceptable enter- following: new health care services; redefinition of key
prise risk. To make decisions and allocate resources, you patient and other customer groups or market segments;

differentiation of your brand; new core competencies; entry 2.1a(3). Your decisions about addressing strategic chal-
into retail or telemedicine; new partnerships, alliances, or lenges, changes in your regulatory and external business
acquisitions to improve access, grow revenue, or reduce environment, blind spots in your strategic planning, and
costs; and new staff or volunteer relationships. Strategy gaps in your ability to execute the strategic plan may give
might be directed toward becoming a high-reliability rise to organizational risk. Analysis of these factors is the
organization, a preferred provider, a center for clinical and basis for managing strategic risk in your organization.
service excellence, a research leader, a low-cost provider, a
2.1a(3). Blind spots arise from incorrect, incomplete, obso-
market innovator, a provider of a high-end or customized
lete, or biased assumptions or conclusions that cause gaps,
service, an integrated service provider, or an employer of
vulnerabilities, risks, or weaknesses in your understanding
choice. It might also be directed toward meeting a com-
of the competitive and collaborative environment and
munity or public health care need.
strategic challenges your organization faces. Blind spots may
2.1a(1). Organizational agility refers to the capacity for arise from new or replacement offerings or business models
rapid change in strategy. Operational flexibility refers to the coming from inside or outside your industry.
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ability to adjust your operations as opportunities or needs
2.1a(3). Your strategic planning should address your ability
arise, including as a result of strategic changes.
to mobilize the necessary resources and knowledge to
2.1a(2). Strategic opportunities are prospects for new or execute the strategic plan. It should also address your ability
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changed services, processes, business models (including to execute contingency plans or, if circumstances require,
strategic alliances), or markets. They arise from outside-the- a shift in strategy and rapid execution of new or changed
box thinking, brainstorming, capitalizing on serendipity, strategic plans.
research and innovation processes, nonlinear extrapolation
2.1a(4). Work systems refer to how your organization’s
of current conditions, and other approaches to imagining a
work is accomplished, consisting of the internal work
different future. The generation of ideas that lead to strategic
processes and external resources you need to develop and
opportunities benefits from an environment that encour-
produce health care services, deliver them to your patients
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ages nondirected, free thought. Choosing which strategic
and other customers, and succeed in your marketplace.
opportunities to pursue involves considering relative risk,
Decisions about work systems are strategic. These decisions
(“intelligent risks”).
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financial and otherwise, and then making intelligent choices
involve protecting intellectual property, capitalizing on core
competencies, and mitigating risk. Decisions about your
2.1a(3). Data and information may come from a variety of work systems affect organizational design and structure,
internal and external sources and in a variety of forms. Data size, locations, financial viability, and ongoing success. In a
are available in increasingly greater volumes and at greater generic view of an organization, for example, the organiza-
speeds. The ability to capitalize on data and information, tion might define three work systems: one that addresses
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including large datasets (“big data”), is based on the ability the clinical delivery of health care services, one that engages
to analyze the data, draw conclusions, and pursue actions, patients and other customers, and one that comprises
including intelligent risks. systems that support service delivery and patient and other
2.1a(3). Data and information might relate to patient, customer engagement.
in
other customer, and market requirements, expectations, 2.1b(1). Strategic objectives might address access and
and opportunities; your culture, policies, and procedures to locations; rapid response; customization; co-location with
ensure patient safety and avoid medical errors; your policies major partners; workforce capability and capacity; specific
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and procedures for access to and equity of care; your core joint ventures; rapid or market-changing innovation;
competencies; the competitive and collaborative environ- societal responsibility actions or leadership; social media
ment and your performance now and in the future relative and web-based management of relationships with suppliers,
to competitors and comparable organizations; technological providers, patients, and other customers; implementation of
and other key innovations or changes that might affect electronic health records and electronic care processes (e.g.,
your services and the way you operate, as well as the rate of order entry and e-prescribing); and enhancements in health
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innovation; workforce and other resource needs; your ability care service quality. Responses should focus on your specific
to capitalize on diversity; opportunities to redirect resources challenges, advantages, and opportunities—those most
to higher-priority health care services or areas; financial, important to your ongoing success and to strengthening
societal, ethical, regulatory, technological, security and your overall performance.
cybersecurity, and other potential risks and opportunities;
your ability to prevent and respond to emergencies, includ- For additional guidance on this item, see the Health Care
ing natural or other disasters; changes in the local, national, Criteria Commentary (https://www.nist.gov/baldrige
or global economy; requirements for and strengths and /baldrige-criteria-commentary-health-care).
weaknesses of your partners and supply chain; changes in
your parent organization; and other factors unique to your
organization.
2 Strategy 11
2.2 Strategy Implementation: How do you implement your strategy? (40 pts.)
a. Action Plan Development and Deployment
(1) Action Plans What are your key short- and longer-term action plans? What is their relationship to your
PR O C ESS
strategic objectives? How do you develop your action plans?
(2) Action Plan Implementation How do you deploy your action plans? How do you deploy your action
plans to your workforce and to key suppliers, partners, and collaborators, as appropriate, to ensure that
you achieve your key strategic objectives? How do you ensure that you can sustain the key outcomes of your
action plans?
(3) Resource Allocation How do you ensure that financial and other resources are available to support the
achievement of your action plans while you meet current obligations? How do you allocate these resources to
support the plans? How do you manage the risks associated with the plans to ensure your financial viability?
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(4) Workforce Plans What are your key workforce plans to support your short- and longer-term strategic
objectives and action plans? How do the plans address potential impacts on your workforce members and
any potential changes in workforce capability and capacity needs?
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(5) Performance Measures What key performance measures or indicators do you use to track the achieve-
ment and effectiveness of your action plans? How does your overall action plan measurement system
reinforce organizational alignment?
(6) Performance Projections For these key performance measures or indicators, what are your perfor-
mance projections for your short- and longer-term planning horizons? What is your projected performance
on these action plan measures or indicators compared with your projections of the performance of your
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competitors or organizations offering similar health care services and with key benchmarks, as appropriate? If
there are gaps in performance against your competitors or comparable organizations, how do you address them
in your action plans?
b. Action Plan Modification
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How do you establish and implement modified action plans if circumstances require a shift in plans and rapid
execution of new plans?
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Notes
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2.2. The development and deployment of your strategy and • Category 6: how you address changes to your work
action plans are closely linked to other Health Care Criteria processes resulting from action plans
items. The following are examples of key linkages:
• Item 7.1: specific accomplishments relative to your
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• Item 1.1: how your senior leaders set and communi- organizational strategy and action plans
cate organizational direction
2.2a(2). Action plan implementation and deployment
• Category 3: how you gather patient, other customer, may require modifications in organizational structures and
and market knowledge as input to your strategy and operating modes. The success of action plans benefits from
action plans and to use in deploying action plans visible short-term wins as well as long-term actions.
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• Category 4: how you measure and analyze data and 2.2a(6). Measures and indicators of projected performance
manage knowledge to support key information needs, might consider new ventures; organizational acquisitions or
support strategy development, provide an effective mergers; new value creation; market entry and shifts; new
basis for performance measurements, and track prog- legislative mandates, legal requirements, industry standards,
ress on achieving strategic objectives and action plans or accreditation standards; and significant anticipated
innovations in health care services and technology.
• Category 5: how you meet workforce capability and
capacity needs, determine needs and design your 2.2b. Organizational agility requires the ability to adapt to
workforce development and learning system, and changing circumstances, both internal and external.
implement workforce-related changes resulting from
action plans For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige

3 Customers (85 pts.)
The Customers category asks how your organization engages its patients and other customers for long-term marketplace
success, including how your organization listens to the voice of the customer, serves and exceeds patients’ and other
customers’ expectations, and builds relationships with patients and other customers.
3.1 Voice of the Customer: How do you obtain information

from your patients and other customers? (40 pts.)
a. Listening to Patients and Other Customers
(1) Current Patients and Other Customers How do you listen to, interact with, and observe patients and
P R O C ESS
other customers to obtain actionable information? How do your listening methods vary for different patient
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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
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from patients and other customers on the quality of health care services, patient and other customer sup-
port, 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?
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b. Determination of Patient and Other Customer Satisfaction and Engagement
(1) Satisfaction, Dissatisfaction, and Engagement How do you determine patient and other customer satisfac-
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tion, 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 informa-
er
tion 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
in
care services or to health care industry benchmarks, as appropriate?
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Notes
3.1. The voice of the customer refers to your process for monitoring comments on social media outlets you moderate
capturing patient- and other customer-related information. and on those you do not control.
Voice-of-the-customer processes are intended to be proac-
3.1a(1). Your listening methods should include all stages
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tive and continuously innovative to capture patients’ and

of your involvement with patients and other customers.
other customers’ stated, unstated, and anticipated require-
These stages might include relationship building, the active
ments, expectations, and desires. The goal is customer
relationship, and a follow-up strategy, as appropriate.
engagement. In listening to the voice of the customer,
you might gather and integrate various types of patient 3.1b. You might use any or all of the following to determine
and other customer data, such as survey data, focus group patient and other customer satisfaction and dissatisfaction:
findings, social media data and commentary, marketing surveys, including third-party surveys or surveys endorsed
information, and complaint data that affect patients’ and or required by payors, such as the Consumer Assessment
other customers’ purchasing and engagement decisions. of Healthcare Providers and Systems (CAHPS); formal
and informal feedback; health care service utilization data;
3.1a(1). Social media and web-based technologies are a
complaints; win/loss analysis; patient and other customer
growing mode of gaining insight into how patients and
referral rates; and transaction completion rates. You might
other customers perceive all aspects of your involvement
gather information on the web, through personal contact
with them. Listening through social media may include
or a third party, or by mail. Determining patient and other
3 Customers 13
customer dissatisfaction should be seen as more than organizations that deliver similar health care services in
reviewing low satisfaction scores. Dissatisfaction should your market or a noncompetitive market, or comparisons
be independently determined to identify root causes and obtained through health care industry or other organiza-
enable a systematic remedy to avoid future dissatisfaction. tions. Information obtained on relative satisfaction may also
include information on why patients and other customers
3.1b(2). Dimensions of patient satisfaction might include,
choose your competitors over you.
for example, satisfaction with provider interactions,
long-term health outcomes, ancillary services, quality of
care, cost, and ease of access. Information you obtain on For additional guidance on this item, see the Health Care
relative patient and other customer satisfaction may include Criteria Commentary (https://www.nist.gov/baldrige
comparisons with competitors, comparisons with other /baldrige-criteria-commentary-health-care).
3.2 Customer Engagement: How do you engage patients and other customers
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by serving their needs and building relationships? (45 pts.)
a. Service Offerings and Patient and Other Customer Support
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(1) Service Offerings How do you determine health care service offerings? How do you
P RO C ESS
• determine patient, other customer, and market needs and requirements for health care service offerings;
• identify and adapt service offerings to meet the requirements and exceed the expectations of your patient and
other customer groups and market segments; and
• identify and adapt service offerings to enter new markets, to attract new patients and other customers, and to
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create opportunities to expand relationships with current patients and other customers, as appropriate?
(2) Patient and Other Customer Support How do you enable patients and other customers to seek informa-
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tion and support? How do you enable them to obtain health care services from you? What are your key means
of patient and other customer support, including your key communication mechanisms? How do they vary for
different patient and other customer groups or market segments? How do you
• determine your patients’ and other customers’ key support requirements, and
• deploy these requirements to all people and processes involved in patient and other customer support?
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(3) Patient and Other Customer Segmentation How do you determine your patient and other customer
groups and market segments? How do you
• use information on patients, other customers, markets, and health care service offerings to identify current
and anticipate future patient and other customer groups and market segments;
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• consider competitors’ patients and other customers, as well as other potential patients, customers, and
markets in this segmentation; and
• determine which patient and other customer groups and market segments to emphasize and pursue for busi-
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ness growth?
b. Patient and Other Customer Relationships
(1) Relationship Management How do you build and manage relationships with patients and other customers?
How do you market, build, and manage relationships with patients and other customers to
• acquire patients and other customers and build market share;
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• manage and enhance your brand image;

• retain patients and other customers, meet their requirements, and exceed their expectations in each stage of
their relationship with you; and
• increase their engagement with you?
How do you leverage social media to manage and enhance your brand, and to enhance patient and other
ustomer engagement and relationships, as appropriate?
c
(2) Complaint Management How do you manage patient and other customer complaints? How do you resolve
complaints promptly and effectively? How does your management of those complaints enable you to recover
your patients’ and other customers’ confidence, enhance their satisfaction and engagement, and avoid similar
complaints in the future?

Notes
3.2. Customer engagement refers to your patients’ and security of patient and other customer data. Your results
other customers’ investment in or commitment to your on performance relative to key service features should
brand and health care service offerings. Characteristics of be reported in item 7.1, and those for patients’ and other
engaged patients and other customers include retention, customers’ perceptions and actions (outcomes) should be
brand loyalty, willingness to make an effort to obtain—and reported in item 7.2.
to continue to obtain—health care services from you, and
3.2a(2). The goal of patient and other customer support
willingness to actively advocate for and recommend your
is to make your organization easy to obtain health care
brand and health care service offerings.
services from and responsive to your patients’ and other
3.2a(1). Health care service offerings are the services that customers’ expectations.
you offer in the marketplace. In identifying health care
3.2b. Building relationships with patients and other custom-
service offerings, you should consider all the important
ers might include developing partnerships or alliances with
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characteristics of services that patients and other customers
them.
receive in each stage of their relationship with you. The
focus should be on features that affect patients’ and other 3.2b(1). Brand management is generally associated with
customers’ preference for and loyalty to you and your marketing to improve the perceived value of your health
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brand—for example, features that affect their view of clinical care services or brand. Successful brand management builds
and service quality and that differentiate your offerings from loyalty and positive associations on the part of patients and
those of competing or other organizations. Those features other customers, and it protects your brand and intellectual
might include extended hours, family support services, ease property.
of access to and use of your services, timeliness, cost, and
assistance with billing/paperwork processes and transporta- For additional guidance on this item, see the Health Care
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tion. Key service features might also take into account
how transactions occur and factors such as the privacy and
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3 Customers 15
4 Measurement, Analysis, and Knowledge Management (90 pts.)
The Measurement, Analysis, and Knowledge Management category asks how your organization selects, gathers, analyzes,
manages, and improves its data, information, and knowledge assets; how it uses review findings to improve its perfor-
mance; and how it learns.
4.1 Measurement, Analysis, and Improvement of Organizational Performance:

How do you measure, analyze, and then improve organizational performance? (45 pts.)
a. Performance Measurement
(1) Performance Measures How do you track data and information on daily operations and overall organiza-
P R O C ESS
tional performance? How do you
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• select, collect, align, and integrate data and information to use in tracking daily operations and overall organiza-
tional performance; and
• track progress on achieving strategic objectives and action plans?
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What are your key organizational performance measures, including key short- and longer-term financial
easures? How frequently do you track these measures?
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(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 infor-
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mation? 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?
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(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
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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
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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?
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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?
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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 work group and functional-level operations; and

• when appropriate, to your suppliers, partners, and collaborators to ensure organizational alignment?

Notes
4.1. The results of organizational performance analysis 4.1b. Organizational performance reviews should be
and review should inform the strategy development and informed by organizational performance measurement
implementation you describe in category 2. (4.1a) and by performance measures reported throughout
4.1. Your organizational performance results should be your Health Care Criteria item responses, and they should
reported in items 7.1–7.5. be guided by the strategic objectives and action plans you
identify in category 2. The reviews might also be informed
4.1a. Data and information from performance measurement by internal or external Baldrige assessments.
should be used to support fact-based decisions that set and
align organizational directions and resource use at the work 4.1b. Performance analysis includes examining performance
unit, key process, department, and organization levels. trends; organizational, health care industry, and technology
projections; and comparisons, cause-effect relationships, and
4.1a(2), 4.1a(3). The comparative and customer data and correlations. This analysis should support your performance
information you select should be used to support opera- reviews, help determine root causes, and help set priorities
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tional decision making and the overall performance reviews for resource use. Accordingly, such analysis draws on all
addressed in 4.1b. Comparative data and information are types of data: health care outcome, patient- and other
obtained by benchmarking and by seeking competitive customer-related, financial and market, operational, and
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comparisons. Benchmarking is identifying processes and competitive/comparative. The analysis should also draw on
results that represent best practices and performance for publicly mandated measures, when appropriate.
similar activities, inside or outside the health care industry.
Competitive comparisons relate your performance to that For additional guidance on this item, see the Health Care
of competitors and other organizations providing similar Criteria Commentary (https://www.nist.gov/baldrige
health care services. One source of this information might /baldrige-criteria-commentary-health-care).
be social media or the web.
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4 Measurement, Analysis, and Knowledge Management 17

4.2 Information and Knowledge Management: How do you manage your
information and your organizational knowledge assets? (45 pts.)
a. Data and Information
(1) Quality How do you verify and ensure the quality of organizational data and information? How do you
PR O C ESS
manage electronic and other data and information to ensure their accuracy and validity, integrity and reliability,
and currency?
(2) Availability How do you ensure the availability of organizational data and information? How do you make
needed data and information available in a user-friendly format and timely manner to your workforce, suppliers,
partners, collaborators, patients, and other customers, as appropriate? How do you ensure that your infor-
mation technology systems are user-friendly?
b. Organizational Knowledge
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(1) Knowledge Management How do you build and manage organizational knowledge? How do you
• collect and transfer workforce knowledge;
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• blend and correlate data from different sources to build new knowledge;
• transfer relevant knowledge from and to patients, other customers, suppliers, partners, and
collaborators; and
• assemble and transfer relevant knowledge for use in your innovation and strategic planning processes?
(2) Best Practices How do you share best practices in your organization? How do you identify organizational units
or operations that are high performing? How do you identify their best practices for sharing and implement them
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across the organization, as appropriate?
(3) Organizational Learning How do you use your knowledge and resources to embed learning in the way your
organization operates?
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Notes
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4.2a(2). Information technology systems include, for 4.2b(3). Embedding learning in the way your organization
example, physical devices and systems (hardware); software operates means that learning (1) is a part of everyday work;
platforms and applications; externally based information (2) results in solving problems at their source; (3) is focused
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systems, such as those stored in the cloud or outside your on building and sharing knowledge throughout your orga-
organization’s control; and the data and information stored nization; and (4) is driven by opportunities to bring about
within them. Your response might include information significant, meaningful change and to innovate.
related to electronic health records within your organization.
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4.2b(1). Blending and correlating data from different
sources may involve handling big data sets and disparate
types of data and information, such as data tables, video,
and text. Furthermore, organizational knowledge con-
structed from these data may be speculative and may reveal
sensitive information about organizations or individuals that
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must be protected from use for any other purposes.

5 Workforce (85 pts.)
The Workforce category asks how your organization assesses workforce capability and capacity needs and builds a
workforce environment conducive to high performance. The category also asks how your organization engages, manages,
and develops your workforce to utilize its full potential in alignment with your organization’s overall needs.
5.1 Workforce Environment: How do you build an effective and supportive

workforce environment? (40 pts.)
a. Workforce Capability and Capacity
(1) Capability and Capacity How do you assess your workforce capability and capacity needs? How do you
P R O C ESS
assess the skills, competencies, certifications, and staffing levels you need?
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(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?
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(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
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• 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;
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• capitalize on your organization’s core competencies;
• reinforce a focus on patients, other customers, and health care; and
• exceed performance expectations?
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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
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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?
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What key benefits do you offer your workforce?
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Notes
5.1. Workforce refers to the people actively involved in 5.1a. Workforce capability refers to your organization’s
accomplishing your organization’s work. It includes perma- ability to carry out its work processes through its people’s
nent, temporary, and part-time personnel, as well as any knowledge, skills, abilities, and competencies. Workforce
contract staff you supervise, independent practitioners (e.g., capacity refers to your organization’s ability to ensure
physicians, physician assistants, nurse practitioners, acu- sufficient staffing levels to carry out its work processes and
puncturists, and nutritionists not paid by your organization), successfully deliver health care services to patients, including
and health profession students (e.g., medical, nursing, and the ability to meet seasonal or varying demand levels.
ancillary). It includes team leaders, supervisors, and manag-
5.1a. Your assessment of workforce capability and capacity
ers at all levels. People supervised by a contractor should
needs should consider not only current needs but also
be addressed in categories 2 and 6 as part of your larger
future requirements based on the strategic objectives and
work system strategy and your internal work processes.
action plans you identify in category 2 and the performance
For organizations that also rely on volunteers, workforce
projections you discuss in 4.1c(1).
includes these volunteers.
5 Workforce 19
5.1a(2). This requirement refers only to new workforce changes in your external environment, culture, technology,
members. The retention of existing workforce members is or strategic objectives.
considered in item 5.2, Workforce Engagement. 5.1b(1). Workplace accessibility maximizes productivity by
5.1a(3). Preparing your workforce for changing capability eliminating barriers that can prevent people with disabilities
and capacity needs might include training, education, from working to their potential. A fully inclusive workplace
frequent communication, consideration of workforce is physically, technologically, and attitudinally accessible. You
employment and employability, career counseling, and should address workforce safety in 6.2c(1).
outplacement and other services.
5.1a(4). Organizing and managing your workforce may
involve organizing the workforce for change as you address
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5.2 Workforce Engagement: How do you engage your workforce to achieve
a high-performance work environment? (45 pts.)
a. Workforce Engagement and Performance
(1) Organizational Culture How do you foster an organizational culture that is characterized by open com-
PR O C ESS
munication, high performance, and an engaged workforce? How do you ensure that your organizational
culture benefits from the diverse ideas, cultures, and thinking of your workforce? How do you empower
your workforce?
(2) Drivers of Engagement How do you determine the key drivers of workforce engagement? How do you
determine these drivers for different workforce groups and segments?
(3) Assessment of Engagement How do you assess workforce engagement? What formal and informal assess-
ment methods and measures do you use to determine workforce engagement, including satisfaction? How
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do these methods and measures differ across workforce groups and segments? How do you also use other
indicators, such as workforce retention, absenteeism, grievances, safety, and productivity, to assess and
improve workforce engagement?
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(4) Performance Management How does your workforce performance management system support high
performance and workforce engagement? How does it consider workforce compensation, reward, recogni-
tion, and incentive practices? How does it reinforce
• intelligent risk taking to achieve innovation;
• a focus on patients, other customers, and health care; and
• achievement of your action plans?
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b. Workforce and Leader Development
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(1) Learning and Development System How does your learning and development system support the organi-
zation’s needs and the personal development of your workforce members, managers, and leaders? How does
the system
• address your organization’s core competencies, strategic challenges, and achievement of short- and
long-term action plans;
• support organizational performance improvement, organizational change, and innovation;
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• support ethical health care and ethical business practices;

• improve focus on patients and other customers;
• consider the learning and development desires of workforce members; and
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• ensure the reinforcement of new knowledge and skills on the job?

(2) Learning and Development Effectiveness How do you evaluate the effectiveness and efficiency of your
learning and development system? How do you
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• correlate learning and development outcomes with findings from your assessment of workforce engagement
and with key organizational results reported in category 7, and
• use these correlations to identify opportunities for improvement both in workforce engagement and in
learning and development offerings?
(3) Career Progression How do you manage career progression for your workforce and your future leaders?
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How do you manage career development for your workforce? How do you carry out succession planning for
management and leadership positions?
Notes
5.2. Understanding the characteristics of high-performance 5.2a(2). Drivers of workforce engagement (identified in
work environments, in which people do their utmost P.1a[3]) refer to the drivers of workforce members’ commit-
for their patients’ and other customers’ benefit and the ment, both emotional and intellectual, to accomplishing the
organization’s success, is key to understanding and building organization’s work, mission, and vision.
an engaged workforce. These characteristics are described in
detail in the definition of high performance (page 49).
5 Workforce 21
5.2a(4). Compensation, recognition, and related reward and 5.2b. Your response should include how you address any
incentive practices include promotions and bonuses that unique considerations for workforce development, learning,
might be based on performance, skills acquired, adapta- and career progression that stem from your organization.
tion to new work systems and culture, and other factors. Your response should also consider the breadth of develop-
Recognition can include monetary and nonmonetary, ment opportunities you might offer, including education,
formal and informal, and individual and group mechanisms. training, coaching, mentoring, and work-related experiences.
Recognition systems for volunteers and independent practi-
tioners who contribute to the organization’s work should be For additional guidance on this item, see the Health Care
included, as appropriate. Criteria Commentary (https://www.nist.gov/baldrige
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6 Operations (85 pts.)
The Operations category asks how your organization designs, manages, improves, and innovates its health care services
and work processes and improves operational effectiveness to deliver value to patients and other customers and to
achieve ongoing organizational success.
6.1 Work Processes: How do you design, manage, and improve your
key health care services and work processes? (45 pts.)
a. Service and Process Design
(1) Determination of Service and Process Requirements How do you determine key health care service and
P R O C ESS
work process requirements?
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(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?
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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
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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?
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(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
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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?
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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
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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
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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 opportu-
nities? How do you discontinue pursuing opportunities at the appropriate time to enhance support for higher-priority
opportunities?
6 Operations 23
Notes
6.1. The results of improvements in the performance of your 6.1b(4). To improve process performance and reduce
health care services and processes should be reported in variability, you might implement approaches such as a Lean
item 7.1. Enterprise System, Six Sigma methodology, ISO quality
system standards, PDCA methodology, decision sciences,
6.1a(1), 6.1a(2). Your key work processes are your most
or other process improvement tools. These approaches
important internal value-creation processes. They might
might be part of the performance improvement system you
include health care service design and delivery, patient and
describe in P.2c in the Organizational Profile.
other customer support, and business processes. Your key
work processes are those that involve the majority of your 6.1c. Ensuring that suppliers are positioned to meet
workforce and produce value for patients, other customers, operational needs and enhance your performance and your
and stakeholders. In contrast, projects are unique work customers’ satisfaction may involve partnering with suppliers
processes intended to produce an outcome and then go out for mutual benefit. Feedback to suppliers should involve
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of existence. two-way communication, allowing suppliers to express what
they need from you.
6.1a(3). The potential need for agility could include
changes in work processes as a result of overall work system 6.1d. Your process for managing opportunities for innova-
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changes, such as bringing a supply-chain process in-house tion should capitalize on strategic opportunities identified in
to avoid disruptions in supply due to increasing external 2.1a(2).
events triggered by climate change or other unpredictable
factors. For additional guidance on this item, see the Health Care
6.1b(3). Your key support processes should support your
value-creation processes. They might support leaders and
other workforce members engaged in health care service
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design and delivery, interactions with patients and other
customers, and business and enterprise management.
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6.2 Operational Effectiveness: How do you ensure effective management
of your operations? (40 pts.)
a. Process Efficiency and Effectiveness
How do you control the overall costs of your operations? How do you
PR O C ESS
• 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
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(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
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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?
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c. Safety and Emergency Preparedness
(1) Safety How do you provide a safe operating environment? How does your safety system address accident
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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
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secure and available to serve patients, other customers, and organizational needs?
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Notes
6.2b(2). Managing cybersecurity includes protecting against 6.2c(2). Disasters and emergencies might be related to
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the loss of sensitive information about employees, patients, weather, utilities, security, or a local or national emergency.
other customers, and organizations; protecting intellectual The extent to which you prepare for disasters or emergen-
property; and protecting against the financial, legal, and cies will depend on your organization’s environment and
reputational aspects of breaches. There are many sources for its sensitivity to disruptions of operations. Acceptable levels
general and industry-specific cybersecurity standards and of risk will vary depending on the nature of your services,
practices. Many are referenced in the Framework for Improv- supply chain, and stakeholder needs and expectations. The
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ing Critical Infrastructure Cybersecurity (https://www.nist impacts of climate change could include a greater frequency
.gov/cyberframework). The Baldrige Cybersecurity Excellence of disruptions.
Builder (https://www.nist.gov/baldrige/products-services
/baldrige-cybersecurity-initiative) is a self-assessment tool For additional guidance on this item, see the Health Care
incorporating the concepts of the Cybersecurity Framework Criteria Commentary (https://www.nist.gov/baldrige
and the Baldrige systems perspective. /baldrige-criteria-commentary-health-care).
6.2b(2). For examples of what your information technology
systems might include, see the note to 4.2a(2).
6 Operations 25
7 Results (450 pts.)
The Results category asks about your organization’s performance and improvement in all key areas—health care and
process results, customer results, workforce results, leadership and governance results, and financial and market
results. The category asks about performance levels relative to those of competitors and other organizations with similar
health care service offerings.
7.1 Health Care and Process Results: What are your health care and
process effectiveness results? (120 pts.)
a. Health Care and Customer-Focused Service Results
What are your health care results and your results for your patient and other customer service processes? What
R ESU LT S
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are your current levels and trends in key measures or indicators of health care outcomes and the performance of
services that are important to and directly serve your patients and other customers? How do these results compare
with the performance of your competitors and other organizations with similar offerings? How do these results
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differ by health care service offerings, patient and other customer groups, and market segments, as appropriate?
b. Work Process Effectiveness Results
(1) Process Effectiveness and Efficiency What are your process effectiveness and efficiency results? What
are your current levels and trends in key measures or indicators of the operational performance of your key
work and support processes, including productivity, cycle time, and other appropriate measures of process
effectiveness, efficiency, security and cybersecurity, and innovation? How do these results compare with the
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performance of your competitors and other organizations with similar processes? How do these results differ
by process types, as appropriate?
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(2) Safety and Emergency Preparedness What are your safety and emergency preparedness results? What are
your current levels and trends in key measures or indicators of the effectiveness of your organization’s safety
system and its preparedness for disasters or emergencies? How do these results differ by location or process type,
as appropriate?
c. Supply-Chain Management Results
What are your supply-chain management results? What are your results for key measures or indicators of the
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performance of your supply chain, including its contribution to enhancing your performance?
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Notes
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7. Results should provide key information for analyzing and 7.1. Results reported should include those for representative
reviewing your organizational performance (item 4.1), dem- key measures that are publicly reported and/or mandated
onstrate use of organizational knowledge (item 4.2), and by regulators, accreditors, or payors, such as the Healthcare
provide the operational basis for customer-focused results Effectiveness Data and Information Set (HEDIS), Centers
(item 7.2) and financial and market results (item 7.5). There for Medicare and Medicaid Services (CMS) quality and
is not a one-to-one correspondence between results items value-based payment model measures, outpatient measures,
and Health Care Criteria categories 1–6. Results should be
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Agency for Healthcare Research and Quality measures, and

considered systemically, with contributions to individual quality measures related to accountable care organizations,
results items frequently stemming from processes in more as appropriate.
than one Health Care Criteria category.
7.1a. Health care results and results for patient and other
7. In areas where appropriate comparisons are particularly customer service processes should relate to the key patient
important for assessing your performance, results items ask and other customer requirements and expectations you
specifically how your results compare with the performance identify in P.1b(2), which are based on information gathered
of competitors and other organizations with similar through processes you describe in category 3. The measures
offerings. In other areas, assessment of the use of com- or indicators should address factors that affect patient and
parisons relates to their importance in relation to your key other customer preference, such as those listed in the notes
organizational factors and the maturity of your performance to P.1b(2) and 3.2a.
improvement system as expressed in the Results Scoring
Guidelines (page 35).

7.1b. Results should address the key operational require- for suppliers could be training hours on new services or
ments you identify in the Organizational Profile and in processes, knowledge-sharing activities, audit hours that
category 6. vary by supplier experience or specification complexity, or
joint process and service development. For results that are
7.1b. Appropriate measures and indicators of work process numeric and trendable, you should report levels and trends.
effectiveness might include error rates, audit results, Examples for suppliers could be parts defect rates, on-time
timeliness of delivery, results for externally provided health delivery, or just-in-time delivery.
care services and processes, rates and results of health care
service and work system innovation, results for simplifica- 7.1c. Appropriate measures and indicators of supply-chain
tion of internal jobs and job classifications, waste reduction, performance might include supplier and partner audits,
work layout improvements, changes in supervisory just-in-time delivery, and acceptance results for externally
ratios, Occupational Safety and Health Administration provided services and processes. Measures and indicators of
(OSHA)-reportable incidents, response times for emergency contributions to enhancing your performance might include
drills or exercises, and results for work relocation or those for improvements in downstream supplier services
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contingency exercises. delivered directly to patients and other customers.
7.1c. Because some significant supply-chain results may be
either qualitative or not amenable to trending over time, this
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requirement does not ask for levels and trends. Examples
7.2 Customer Results: What are your customer-focused performance results? (80 pts.)
a. Patient- and Other Customer-Focused Results
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(1) Patient and Other Customer Satisfaction What are your patient and other customer satisfaction and
RESULTS
dissatisfaction results? What are your current levels and trends in key measures or indicators of patient and
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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 patient and other
customer engagement, including those for building relationships with patients and other customers? How do
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these results compare over the course of your patients’ and other customers’ relationships with you, as appropri-
ate? How do these results differ by health care service offerings, patient and other customer groups, and
market segments, as appropriate?
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Notes
7.2. Results for patient and other customer satisfaction, and indicators might include information and data from
dissatisfaction, and engagement should relate to the patient your patients, from your other customers, from competitors’
and other customer groups and market segments you customers, and from independent organizations. Results
identify in P.1b(2) and to the listening and determination from any of the CAHPS surveys should be included if your
methods you report in item 3.1. organization reports these measures.
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7.2a(1). For patients’ and other customers’ satisfaction with

your health care services relative to satisfaction with those For additional guidance on this item, see the Health Care
of competitors and comparable organizations, measures Criteria Commentary (https://www.nist.gov/baldrige
7 Results 27
7.3 Workforce Results: What are your workforce-focused performance results? (80 pts.)
a. Workforce-Focused Results
(1) Workforce Capability and Capacity What are your workforce capability and capacity results? What
R ESU LTS
are your current levels and trends in key measures of workforce capability and capacity, including appropri-
ate skills and staffing levels? How do these results differ by the diversity of your workforce and by your
orkforce groups and segments, as appropriate?
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(2) Workforce Climate What are your workforce climate results? What are your current levels and trends
in key measures or indicators of your workforce climate, including those for workforce health, security,
accessibility, and services and benefits, as appropriate? How do these results differ by the diversity of your
workforce and by your workforce groups and segments, as appropriate?
(3) Workforce Engagement What are your workforce engagement results? What are your current levels
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and trends in key measures or indicators of workforce satisfaction and workforce engagement? How
do these results differ by the diversity of your workforce and by your workforce groups and segments,
as appropriate?
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(4) Workforce Development What are your workforce and leader development results? What are your
current levels and trends in key measures or indicators of workforce and leader development? How
do these results differ by the diversity of your workforce and by your workforce groups and segments,
as appropriate?
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Notes
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7.3. Results reported in this item should relate to the 7.3a(3). Responses should include results for the measures
processes you report in category 5. Your results should and indicators you identify in 5.2a(3).
also respond to the key work process needs you report in
category 6 and to the action plans and workforce plans you For additional guidance on this item, see the Health Care
report in item 2.2. Criteria Commentary (https://www.nist.gov/baldrige
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7.3. Responses should include results for independent /baldrige-criteria-commentary-health-care).
practitioners, volunteers, and health profession students, as
appropriate.
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7.4 Leadership and Governance Results: What are your senior leadership
and governance results? (80 pts.)
a. Leadership, Governance, and Societal Responsibility Results
(1) Leadership What are your results for senior leaders’ communication and engagement with the workforce
R ESU LT S
and with patients and other customers? What are your results for key measures or indicators of senior
leaders’ communication and engagement with the workforce, patients, and other customers to deploy your
vision and values, encourage two-way communication, and create a focus on action? How do these results differ
by organizational units and patient and other customer groups, as appropriate?
(2) Governance What are your results for governance accountability? What are your key current findings
and trends in key measures or indicators of governance and internal and external fiscal accountability,
as appropriate?
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(3) Law, Regulation, and Accreditation What are your legal, regulatory, and accreditation results? What are
your results for key measures or indicators of meeting and surpassing regulatory, legal, and accreditation
requirements? How do these results differ by organizational units, as appropriate?
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(4) Ethics What are your results for ethical behavior? What are your results for key measures or indicators
of ethical behavior, breaches of ethical behavior, and stakeholder trust in your senior leaders and gover-
nance? How do these results differ by organizational units, as appropriate?
(5) Society What are your results for societal well-being and support of your key communities? What are your
results for key measures or indicators of your fulfillment of your societal responsibilities, support of your key
communities, and contributions to community health?
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b. Strategy Implementation Results
What are your results for the achievement of your organizational strategy and action plans? What are your
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results for key measures or indicators of the achievement of your organizational strategy and action plans? What
are your results for building and strengthening core competencies? What are your results for managing risk and
taking intelligent risks?
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Notes
7.4. Most of the requirements in this item do not ask for 7.4a(4). For examples of measures of ethical behavior and
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levels and trends. The reason is that some significant results stakeholder trust, see the note to 1.2b(2).
may be either qualitative in nature or not amenable to
7.4a(5). Responses should relate to the societal responsibili-
trending over time. Examples could be results of intelligent
ties you address in 1.2b(1) and 1.2c(1), as well as the support
risk taking and governance accountability. For such results,
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of the key communities and contributions to community

qualitative explanation may be more meaningful than
health you report in 1.2c(2). Measures of contributions to
current levels and trends. For results that are numeric and
societal well-being might include those for reduced energy
trendable, you should report levels and trends. Examples
consumption, the use of renewable energy resources and
could be the number of unqualified or clean audits, regula-
recycled water, reduction of your carbon footprint, waste
tory findings, or ethics hotline calls.
reduction and utilization, and alternative approaches
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7.4a(1). Responses should include results relating to the to conserving resources (e.g., increased audio- and
communication processes you identify in item 1.1. videoconferencing).
7.4a(2). Responses might include financial statement issues 7.4b. Measures or indicators of strategy and action plan
and risks, important internal and external auditor recom- achievement should relate to the strategic objectives and
mendations, and management’s responses to these matters. goals you report in 2.1b(1) and the action plan performance
7.4a(3). Legal, regulatory, and accreditation results should measures and projected performance you report in 2.2a(5)
relate to the processes and measures you report in 1.2b and 2.2a(6), respectively.
(including the results of mandated financial audits).
Workforce-related occupational safety and health results For additional guidance on this item, see the Health Care
(e.g., OSHA-reportable incidents) should be reported in Criteria Commentary (https://www.nist.gov/baldrige
7.1b(2) and 7.3a(2). /baldrige-criteria-commentary-health-care).
7 Results 29
7.5 Financial and Market Results: What are your results for financial viability? (90 pts.)
a. Financial and Market Results
(1) Financial Performance What are your financial performance results? What are your current levels and
R ESU LTS
trends in key measures or indicators of financial performance, including aggregate measures of financial
return, financial viability, and budgetary performance, as appropriate? How do these results differ by market
(2) Marketplace Performance What are your marketplace performance results? What are your current levels
and trends in key measures or indicators of marketplace performance, including market share or position,
market and market share growth, and new markets entered, as appropriate? How do these results differ by market
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Note
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7.5a(1). Measures should relate to the financial measures health care organizations, measures of performance to
you report in 4.1a(1) and the financial management budget might include additions to or subtractions from
approaches you report in item 2.2. Aggregate measures of reserve funds, cost avoidance or savings, responses to
financial return might include those for return on invest- budget decreases, lowering of costs to patients or other cus-
ment (ROI), operating margins, profitability, or profitability tomers or return of funds as a result of increased efficiency,
by market segment or patient or other customer group. administrative expenditures as a percentage of budget, and
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Measures of financial viability might include those for the cost of fundraising versus funds raised.
liquidity, debt-to-equity ratio, days cash on hand, asset
utilization, cash flow, bond ratings, accountable care
organization or shared savings programs, and value-based
Us For additional guidance on this item, see the Health Care
purchasing financial results, as appropriate. For nonprofit /baldrige-criteria-commentary-health-care).
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Scoring System
The scoring of responses to Baldrige Health Care Criteria for Performance Excellence items is based
on two evaluation dimensions: process (categories 1–6) and results (category 7).
To score Health Care Criteria responses, consider the follow- • the sharing of refinements and innovations with
ing information relative to the item requirements and the other relevant work units and processes in your
scoring guidelines (pages 34–35): organization.
• The key organizational factors presented in the See “From Fighting Fires to Innovation” on the next page,
Organizational Profile which illustrates a progression through the maturity levels
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for this scoring dimension.
• The maturity and appropriateness of the approaches,
the breadth of their deployment, and the strengths of Integration is the extent to which
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the learning and improvement process
• your approach is aligned with the organizational
• The level of performance and how results compare to needs identified in the Organizational Profile and
those of other, relevant organizations or benchmarks other process items;
• your measures, information, and improvement
Scoring Dimensions systems are complementary across processes and work
units; and
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Process
• your plans, processes, results, analyses, learning, and
Process refers to the methods your organization uses and actions are harmonized across processes and work
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improves. Processes address the requirements in categories
1–6. The four factors used to evaluate process are approach,
units to support organization-wide goals.
deployment, learning, and integration (ADLI). Baldrige-based In scoring process items, keep in mind that approach,
feedback reflects strengths and opportunities for improve- deployment, learning, and integration are linked. Descrip-
ment in these factors. A score for a process item is based on tions of approach should always indicate the deployment—
a holistic assessment of your overall performance, taking consistent with the specific requirements of the item and
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into account the four process factors. your organization. As processes mature, the description
should also show cycles of learning (including innovation),
Approach comprises as well as integration with other processes and work units
• the methods used to carry out the process, (see “Steps toward Mature Processes,” page 36).
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• the appropriateness of these methods to the item Results

requirements and your operating environment,
Results are the outputs and outcomes your organization
• the effectiveness of your use of the methods, and achieves, which address the requirements in category 7. The
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four factors used to evaluate results are levels, trends, com-

• the degree to which the approach is repeatable
parisons, and integration (LeTCI). A score for a results item is
and based on reliable data and information
based on a holistic assessment of your overall performance,
(i.e., systematic).
taking into account the four results factors.
Deployment is the extent to which
Levels are your current performance on a meaningful
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• your approach addresses item requirements that are measurement scale.

relevant and important to your organization,
Trends comprise your rate of performance improvement or
• your approach is applied consistently, and continuation of good performance in areas of importance
(i.e., the slope of data points over time).
• your approach is used by all appropriate work units.
Comparisons comprise your performance relative to that
Learning comprises
of other, appropriate organizations, such as competitors or
• the refinement of your approach through cycles of organizations similar to yours, or benchmarks.
evaluation and improvement,
Integration is the extent to which your results measures
• the encouragement of breakthrough change to your (often through segmentation) address important perfor-
approach through innovation, and mance requirements relating to patients, other customers,
Scoring System 31
From Fighting Fires to Innovation: An Analogy for Learning
1
Learning is an essential attribute of high-
performing organizations. Effective, well-deployed
organizational learning can help an organization
improve from the early stages of reacting to
problems to the highest levels of organization-
wide improvement, refinement, and innovation.
Reacting to the problem (0–5%)
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Run with the hose and put out the fire.
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2 3
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General improvement orientation (10–25%) Systematic evaluation and improvement (30–45%)
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Install more fire hoses to get to the fires quickly Evaluate which locations are most susceptible to fire. Install
and reduce their impact. heat sensors and sprinklers in those locations.
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4 5
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Learning and strategic improvement (50–65%) Organizational analysis and innovation (70–100%)
Install systemwide heat sensors and a sprinkler system Use fireproof and fire-retardant materials. Replace combustible
that is activated by the heat preceding fires. liquids with water-based liquids. Prevention is the primary
approach for protection, with sensors and sprinklers as the
secondary line of protection. This approach has been shared
with all facilities and is practiced in all locations.

health care services, markets, processes, action plans, and
organization-wide goals identified in your Organizational
How to Score an Item Response
Profile and in process items. Follow these steps in assigning a score to an item response.
In the scoring of results items, look for data on performance Read the scoring guidelines (pages 34–35).
levels, trends, and relevant comparisons for key measures Choose the scoring range (e.g., 30–45%, 50–65%, or
and indicators of your organization’s performance, as well 70–85%) that is most descriptive of the organization’s
as integration with your organization’s key requirements. achievement level as presented in the item response.
Results items should also show data on the breadth of the
performance results reported. This is directly related to Choose this range based on a holistic view of either the four
deployment and organizational learning; if improvement process factors (ADLI) or the four results factors (LeTCI) in
processes are widely shared and deployed, there should be aggregate. In this holistic view, the scoring range to assign
corresponding results. is the one that best reflects the applicant’s response as a
whole; do not tally or average independent assessments of
each of the four factors. No one evaluation factor serves as a
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“Importance” as a “gate” that keeps the score out of a higher range.
Scoring Consideration The “most descriptive” range is not necessarily a perfect
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A critical consideration in Baldrige evaluation and feedback fit. It often reflects some gaps between the response and
is the importance of your reported process and results to the description of one or more of the factors in the chosen
your key business factors. The areas of greatest importance scoring range.
should be identified in your Organizational Profile and
Read the next higher and the next lower scoring ranges.
in items such as 2.1, 2.2, 3.2, 5.1, 5.2, and 6.1. Your key
Assign a score (e.g., 55% or 60%) within the chosen range
customer requirements, competitive environment, workforce
by evaluating whether the item response as a whole is
needs, key strategic objectives, and action plans are particu-
closer to the statements in the next higher or the next lower
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larly important. Us scoring range.
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Scoring System 33
Process Scoring Guidelines (For Use with Categories 1–6)
SCORE DESCRIPTION
• No systematic approach to item requirements is evident; information is anecdotal. (A)

• Little or no deployment of any systematic approach is evident. (D)
0% or 5%
• An improvement orientation is not evident; improvement is achieved by reacting to problems. (L)
• No organizational alignment is evident; individual areas or work units operate independently. (I)
• The beginning of a systematic approach to the basic requirements of the item is evident. (A)
• The approach is in the early stages of deployment in most areas or work units, inhibiting progress in
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10%, 15%, achieving the basic requirements of the item. (D)
20%, or 25% • Early stages of a transition from reacting to problems to a general improvement orientation are
evident. (L)
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• The approach is aligned with other areas or work units largely through joint problem solving. (I)
• An effective, systematic approach, responsive to the basic requirements of the item, is evident. (A)
• The approach is deployed, although some areas or work units are in early stages of deployment. (D)
30%, 35%, • The beginning of a systematic approach to evaluation and improvement of key processes is
40%, or 45% evident. (L)
• The approach is in the early stages of alignment with the basic organizational needs identified in
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response to the Organizational Profile and other process items. (I)
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• An effective, systematic approach, responsive to the overall requirements of the item, is
evident. (A)
• The approach is well deployed, although deployment may vary in some areas or work units. (D)
50%, 55%, • A fact-based, systematic evaluation and improvement process and some organizational learning,
60%, or 65% including some innovation, are in place for improving the efficiency and effectiveness of
key processes. (L)
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• The approach is aligned with your overall organizational needs as identified in response to the
Organizational Profile and other process items. (I)
• An effective, systematic approach, responsive to multiple requirements in the item, is evident. (A)

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• The approach is well deployed, with no significant gaps. (D)

• Fact-based, systematic evaluation and improvement and organizational learning, including
70%, 75%,
innovation, are key management tools; there is clear evidence of refinement as a result of
80%, or 85%
organizational-level analysis and sharing. (L)
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• The approach is integrated with your current and future organizational needs as identified in
• An effective, systematic approach, fully responsive to the multiple requirements of the item, is
evident. (A)
• The approach is fully deployed without significant weaknesses or gaps in any areas or work units. (D)
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90%, 95%, • Fact-based, systematic evaluation and improvement and organizational learning through
or 100% innovation are key organization-wide tools; refinement and innovation, backed by analysis and
sharing, are evident throughout the organization. (L)
• The approach is well integrated with your current and future organizational needs as identified in

Results Scoring Guidelines (For Use with Category 7)
SCORE DESCRIPTION
• There are no organizational performance results, or the results reported are poor. (Le)
• Trend data either are not reported or show mainly adverse trends. (T)
0% or 5% • Comparative information is not reported. (C)
• Results are not reported for any areas of importance to the accomplishment of your organization’s
mission. (I)
• A few organizational performance results are reported, responsive to the basic requirements of the
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item, and early good performance levels are evident. (Le)
10%, 15%, • Some trend data are reported, with some adverse trends evident. (T)
20%, or 25% • Little or no comparative information is reported. (C)
• Results are reported for a few areas of importance to the accomplishment of your organization’s
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mission. (I)
• Good organizational performance levels are reported, responsive to the basic requirements of the
item. (Le)
30%, 35%, • Some trend data are reported, and most of the trends presented are beneficial. (T)
40%, or 45% • Early stages of obtaining comparative information are evident. (C)
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• Results are reported for many areas of importance to the accomplishment of your organization’s
mission. (I)
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• Good organizational performance levels are reported, responsive to the overall requirements of
the item. (Le)
• Beneficial trends are evident in areas of importance to the accomplishment of your organization’s
50%, 55%, mission. (T)
60%, or 65% • Some current performance levels have been evaluated against relevant comparisons and/or
benchmarks and show areas of good relative performance. (C)
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• Organizational performance results are reported for most key patient and other customer, market,
and process requirements. (I)
• Good-to-excellent organizational performance levels are reported, responsive to multiple

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requirements in the item. (Le)

• Beneficial trends have been sustained over time in most areas of importance to the accomplishment of
your organization’s mission. (T)
70%, 75%,
• Many to most trends and current performance levels have been evaluated against relevant
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80%, or 85%
comparisons and/or benchmarks and show areas of leadership and very good relative
performance. (C)
• Organizational performance results are reported for most key patient and other customer, market,
process, and action plan requirements. (I)
• Excellent organizational performance levels are reported that are fully responsive to the multiple
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requirements of the item. (Le)

• Beneficial trends have been sustained over time in all areas of importance to the accomplishment of
90%, 95%,
your organization’s mission. (T)
or 100%
• Industry and benchmark leadership is demonstrated in many areas. (C)
• Organizational performance results and projections are reported for most key patient and other
customer, market, process, and action plan requirements. (I)
Scoring System 35
Steps toward Mature Processes
An Aid for Assessing and Scoring Process Items
Reacting to Problems Strategic

(0–25%) and Operational
Goals
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Operations are characterized by activities rather than by processes, and
they are largely responsive to immediate needs or problems. Goals are
poorly defined.
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Early Systematic
Strategic and
Approaches Operational
(30–45%)
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The organization is beginning to carry out operations with repeatable

processes, evaluation, and improvement, and there is some early coordination
among organizational units. Strategy and quantitative goals are being defined.
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Aligned Strategic
Approaches and Operational
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(50–65%) Goals
Operations are characterized by repeatable processes that are regularly

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evaluated for improvement. Learnings are shared, and there is coordination

among organizational units. Processes address key strategies and goals.
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Integrated Strategic
Approaches and Operational
Goals
(70–100%)
Operations are characterized by repeatable processes that are regularly

evaluated for change and improvement in collaboration with other affected
units. The organization seeks and achieves efficiencies across units through
analysis, innovation, and the sharing of information and knowledge.
Processes and measures track progress on key strategic and operational goals.

How to Respond to the Health Care Criteria
These guidelines explain how to respond most effectively to the requirements of the 17 process and
results Health Care Criteria items. This information is intended mainly for applicants for Baldrige-
based awards, but it is also useful to organizations that are using the Health Care Criteria for self-
assessment. See also the Scoring System, including the scoring guidelines (pages 34–35), which
describes how to assess responses and determine your organization’s performance accomplishments.
the extent of their deployment, the extent of learning,

First Steps
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and the extent of integration with other elements of your
performance management system.
1. Learn about the Baldrige framework.
Similarly, in responding to the questions in the results items
Become familiar with the following sections, which provide
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(category 7), include information on the results evaluation
a full orientation to the Baldrige framework:
factors in the scoring guidelines: the actual performance
• Health Care Criteria for Performance Excellence levels, the significance of the results trends, relevant com-
(pages 4–30) parative data, integration with important elements of your
performance management system, and the results of the
• Scoring System (pages 31–36)
improvement process.
• Glossary of Key Terms (pages 47–54)
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• Category and Item Commentary (https://www.nist.gov
4. Understand the meaning of key terms.
/baldrige/baldrige-criteria-commentary-health-care) Many terms in the Criteria and scoring guidelines have
Us meanings that may differ somewhat from common mean-
ings. Terms printed in small caps are defined in the Glos-
2. Understand how to read and
respond to a Criteria item. sary of Key Terms (pages 47–54). Understanding these terms
can help you accurately self-assess your organization and
Review the Health Care Criteria for Performance Excellence
communicate your processes and results to those reviewing
Structure (page 2), which shows the types of items, the
your responses and planning your improvement efforts.
different parts of the items, and the role of each part. Pay
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particular attention to the multiple requirements within the

areas to address and the notes.
5. Start with the Organizational Profile.
The Organizational Profile (pages 4–6) is the most appropri-
Item requirements are presented as questions. Some ate starting point. Whether you are using the Criteria for
in
requirements in the areas to address include multiple self-assessment, writing an application, or reviewing either
questions. To fully respond to the requirements, address all of these, the Organizational Profile helps you understand
the questions, as missing information will be interpreted as what is most relevant and important to your organization’s
a gap in your performance management system. However,
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business, mission, and performance.

you do not need to answer each question separately. Taken
together, the multiple questions express the full meaning of
the area to address. In responding, you may want to group Responding to Process Items
responses to these questions in a way that is appropriate to Although the Criteria focus on key organizational
your organization. performance results, these results by themselves offer little
diagnostic value. For example, if some results are poor or are
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To increase your understanding of the Health Care Criteria,

you may want to trace various concepts that are woven improving at rates slower than your competitors’ or compa-
throughout. This interweaving ensures a systems approach rable organizations’ results, you need to understand why this
to organizational performance management. Examples of is so and what you might do to accelerate improvement.
these concepts include core competencies, innovation, use Your responses to process items (categories 1–6) permit
of data and information to review performance and create you or those who are reviewing your responses to diagnose
knowledge, and change readiness and management. your organization’s most important processes—the ones
that contribute most to organizational performance
3. Review the scoring guidelines. improvement and result in key outcomes or performance
Consider both the Criteria and the scoring guidelines results. This diagnosis and the quality of the feedback you
(pages 34–35) as you prepare your responses. In responding receive depend heavily on the content and completeness of
to the questions in the process items (categories 1–6), your responses. For this reason, respond to these items by
include information on the process evaluation factors in providing information on your key processes. Guidelines for
the scoring guidelines: the maturity of your approaches, organizing and reviewing such information follow.
How to Respond to the Health Care Criteria 37

1. Understand the meaning of how. some performance measures, and some results in category 7
are expected to relate to those strategic objectives.
In responding to questions in process items that begin with
how, give information on your key processes with regard
to approach, deployment, learning, and integration (ADLI; Responding to Results Items
see the Scoring System, page 31). Responses lacking such
information, or merely providing an example, are referred to 1. Focus on your organization’s
in the scoring guidelines as anecdotal information. most critical performance results.
Show that approaches are systematic. Systematic Report results that cover the most important requirements
approaches are repeatable and use data and information to for your organization’s success, as highlighted in the
enable learning. In other words, approaches are systematic Organizational Profile and in the Leadership, Strategy,
if they build in the opportunity for evaluation, improvement, Customers, Workforce, and Operations categories.
innovation, and knowledge sharing, thereby enabling a gain
in maturity. 2. Report levels, trends, and
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comparisons, and show integration.
Show deployment. In your responses, summarize how
your approaches are implemented in different parts of your Report performance levels on a meaningful measurement
organization. scale.
On
Show evidence of learning. Give evidence of evaluation Report trends to show the directions of results and rates of
and improvement cycles for processes, as well as the change in areas of importance. A minimum of three histori-
potential for innovation. Show that process improvements cal data points is generally needed to ascertain a trend.
are shared with other appropriate units of your organization Trends should represent historic and current performance
to enable organizational learning. and not rely on projected (future) performance.
There is no minimum period for trend data; time intervals
e
Show integration. Integration is alignment and harmoniza-
tion among processes, plans, measures, actions, and results. between data points should be meaningful for the
This harmonization generates organizational effectiveness measure(s) you report. Trends might span five or more years
and efficiencies.
Us or less than one year, depending on what is meaningful. For
important results, include new data even if trends are not
Showing alignment in the process items and tracking yet well established. Explain trends that show a significant
corresponding measures in the results items should improve beneficial or adverse change.
organizational performance. In your responses, show align-
ment in four areas: Report comparisons to show how your results compare
with those of other, appropriately selected organizations or
er
• In the Organizational Profile, make clear what is benchmarks.

important to your organization.
Show integration by including all results that are important
• In Strategy (category 2), including the strategic objec- to your organization, and segmenting them appropriately
in
tives, action plans, and core competencies, highlight (e.g., by important patient, other customer, workforce,
your organization’s areas of greatest focus and process, and service line groups).
describe how you deploy your strategic plan.
Responding Efficiently
am
• In describing organizational-level analysis and review

(item 4.1), show how you analyze and review perfor-
mance information as a basis for setting priorities. 1. Cross-reference when appropriate.
• In Strategy (category 2) and Operations (category 6), Ensure that each item response is as self-contained as
highlight the work systems and work processes that possible and that responses to different items are mutually
are key to your organization’s overall performance. reinforcing. To accomplish this, refer to other responses
Ex
rather than repeat information. In such cases, give key pro-

2. Understand the meaning of what. cess information in the item requesting that information. For
example, you would describe workforce development and
Two types of questions in process items begin with what.
learning systems in item 5.2. Discussions about workforce
The first requests basic information on key processes and
development and learning elsewhere in your application
how they work. Although it is helpful to state who performs
would then reference but not repeat details given in
the work, diagnosis or feedback also requires a description
item 5.2.
of how the process works.
The second type of what question asks you to report key 2. Use a compact format.
findings, plans, objectives, goals, or measures. These ques- To make the best use of space, use flowcharts, tables, and
tions set the context for showing alignment and integration lists to present information concisely. Page limits for Baldrige
in your performance management system. For example, Award and Baldrige-based award applications are designed
when you identify key strategic objectives, your action plans,

to force your organization to consider what is most impor- • The organization projects improved performance,
tant in managing your enterprise and reporting your results. including discontinuous or breakthrough improvement
in 2017 relative to prior performance for hospital B.
3. Use graphs and tables. The text should explain this breakthrough change and
You can report many results compactly by using graphs might refer to critical learning from hospital A as the
and tables. When you report results over time or compare basis for the projected change.
them with others, “normalize” them (i.e., present them in Interpreting the graph with the scoring guidelines in mind
a way—for example, as ratios—that takes size factors into would result in the following observations on the organiza-
account). For example, if the number of employees has tion’s performance and maturity level:
varied over the period or if you are comparing your results
to those of organizations differing in size, safety trends will • The current overall organizational performance level
be more meaningful if you report them as lost workdays per is excellent. This conclusion is supported by the
100 employees rather than as total lost workdays. comparison with the best competitor and a national
benchmark level.
ly
The graph below shows one part of a possible response to
item 7.1, Health Care and Process Results. The organization • The overall organization shows beneficial improve-
has identified use of beta-blockers with acute myocardial ment trends sustained over time.
On
infarction (AMI) as a key requirement. • Hospital A is the current performance leader—
The graph illustrates a number of characteristics of clear and showing sustained high performance and a slightly
effective results reporting: beneficial trend since 2013. Hospital B shows rapid
improvement. Its performance is close to that of the
• Both axes and units of measure are clearly labeled. best competitor but trails hospital A.
• Levels and trends are reported for a key • Hospital C—identified in the text as a new
e
requirement—use of beta-blockers for AMI. acquisition—is having early problems with ensuring
• Results are presented for several years. beta-blocker use but is projecting a turnaround. (The
organization should briefly explain these problems.)
this measure.
Us
• An arrow indicates that an upward trend is good for
• The organization has projected improvements in
beta-blocker use for all of its hospitals. Hospital C
• Appropriate comparisons are shown clearly. continues to lag behind the others; hospital A is
• In a single graph, the organization shows that projected to reach the benchmark level by 2017.
it tracks all three of its hospitals separately for
er
beta-blocker use.
Figure 7.1-3 Beta-Blocker Use

in
Good Hospital A
am
90
Hospital B
85
AMI beta blocker use (%)
80 Hospital C
Ex
75
Overall organization
70
Best competitor
65
60 National benchmark
2012 2013 2014 2015 2016 2017 2018
(proj.)
(proj.)
Year
How to Respond to the Health Care Criteria 39

Core Values and Concepts
These beliefs and behaviors are embedded in high-performing organizations. They are the
foundation for integrating key performance and operational requirements within a results-oriented
framework that creates a basis for action, feedback, and ongoing success.
The Baldrige Health Care Criteria are built on the following

set of interrelated core values and concepts: Visionary Leadership
Your organization’s senior leaders should create a leader-
• Systems perspective ship system that includes both health care provider and
• Visionary leadership administrative/operational leaders. This system should foster
ly
• Patient-focused excellence the integration and alignment of health care and business
directions.
• Valuing people
On
Your organization’s senior leaders should set a vision for the
• Organizational learning and agility
organization, create a focus on patients and other customers,
• Focus on success demonstrate clear and visible organizational values and eth-
• Managing for innovation ics, and set high expectations for the workforce. The vision,
• Management by fact values, and expectations should balance the needs of all your
stakeholders. Your leaders should also ensure the creation of
• Societal responsibility and community health
strategies, systems, and methods for building knowledge and
e
• Ethics and transparency capabilities, stimulating innovation, managing risk, requir-
• Delivering value and results ing accountability, achieving performance excellence, and
thereby ensuring ongoing organizational success.
Systems Perspective
Us The values and strategies leaders define should help guide
A systems perspective means managing all the components all of your organization’s activities and decisions. Senior
of your organization as a unified whole to achieve your mis- leaders should inspire and encourage your entire workforce
sion, ongoing success, and performance excellence. to contribute, to develop and learn, to be innovative, and
Successfully managing overall organizational performance to embrace meaningful change. Senior leaders should be
er
requires realization of your organization as a system with responsible to your organization’s governance body for their
interdependent operations. Organization-specific synthesis, actions and performance, and the governance body should
alignment, and integration make the system successful. be responsible ultimately to all your stakeholders for your
Synthesis means looking at your organization as a whole. organization’s and its senior leaders’ ethics, actions, and
in
It incorporates key organizational attributes, including performance.

your core competencies, strategic objectives, action plans, Senior leaders should serve as role models through their
work systems, and workforce needs. Alignment means ethical behavior and their personal involvement in planning,
am
using key organizational linkages to ensure consistency providing a supportive environment for innovation, commu-
of plans, processes, measures, and actions. Integration nicating, coaching and motivating the workforce, developing
builds on alignment, so that the individual components of future leaders, reviewing organizational performance, and
your performance management system operate in a fully recognizing workforce members. As role models, they can
interconnected, unified, and mutually beneficial manner to reinforce ethics, values, and expectations while building lead-
deliver anticipated results. ership, commitment, and initiative throughout your organi-
Ex
These concepts are depicted in the Baldrige Health Care zation. Senior leaders should demonstrate authenticity and
Criteria overview (page 1). When your organization takes a admit to their missteps and opportunities for improvement.
systems perspective, your senior leaders focus on strategic
directions and on patients and other customers. Your senior Patient-Focused Excellence
leaders monitor, respond to, and manage performance based Your patients and other customers are the ultimate judges
on your results. With a systems perspective, you use your of your performance and the quality of your health care ser-
measures, indicators, core competencies, and organizational vices. Thus, your organization must consider all features and
knowledge to build your key strategies, link these strategies characteristics of patient care delivery (including those not
with your work systems and key processes, manage risk, and directly related to medical, clinical, and health services) and
align your resources to improve your overall performance all modes of customer access and support that contribute
and your focus on patients, other customers, and stakehold- value to your patients and other customers. Such behavior
ers. The core values and concepts, the seven Health Care leads to patient and other customer acquisition, satisfaction,
Criteria categories, and the scoring guidelines are the preference, and loyalty; positive referrals; and, ultimately, the
system’s building blocks and integrating mechanism. ongoing success of your business. Patient-focused excellence

has both current and future components: understanding the patient-focused excellence demands a patient-focused
desires of patients and other customers today and anticipat- culture and organizational agility.
ing future desires and health care marketplace potential.
Many factors may influence value and satisfaction over the Valuing People
course of your patients’ and other customers’ experience with An organization’s success depends on an engaged workforce
your organization. Primary among these factors is the degree that benefits from meaningful work, clear organizational
of patient safety throughout the health care delivery process. direction, the opportunity to learn, and accountability for
An additional factor is your organization’s management of performance. That engaged workforce must also have a
patient and other customer relationships, which helps build safe, trusting, and cooperative environment. The successful
trust, confidence, and loyalty. Additional factors include organization has a culture of inclusion that capitalizes on the
the availability of clear information on likely health and diverse backgrounds and characteristics, knowledge, skills,
functional status outcomes, the responsiveness of health creativity, and motivation of its workforce and partners. Such
care providers and ancillary staff members, cost, and the an organization values all people who have a stake in the
organization, including customers, community members, and
ly
quality and availability of continuing care. For many patients,
an important factor is the ability to participate in decisions other people affected by the organization’s actions.
about their health care. This leads to the requirement for Valuing the people in your workforce means committing to
developing systems and processes to ensure that patients
On
their engagement, development, and well-being. Increas-
and family members are fully involved in the care team, ingly, this may involve offering flexible work practices that
educated so they fully understand their condition and the are tailored to varying workplace and life needs. Major
plan of care, and supported in making the medical decisions challenges in valuing your workforce members include
that are best for them. (1) demonstrating your leaders’ commitment to their success,
Patient-focused excellence means much more than reducing (2) providing motivation and recognition that go beyond the
errors, merely meeting accreditation specifications, or reduc- regular compensation system, (3) offering development and
e
ing complaints. Nevertheless, these factors contribute to your progression within your organization, (4) sharing your orga-
patients’ and other customers’ view of your organization and nization’s knowledge so that your workforce can better serve
your patients and other customers and contribute to achiev-
Us
thus are also important parts of patient-focused excellence.
In addition, your success in recovering from accidents, service ing your strategic objectives, (5) creating an environment
errors, and mistakes is crucial for retaining patients and other that encourages intelligent risk taking to achieve innovation,
customers and engaging them for the long term. Patient- (6) developing a system of workforce and organizational
focused excellence also involves increasing the efficiency and accountability for performance, and (7) creating an inclusive
effectiveness of the services and care provided and working environment for a diverse workforce.
er
to ensure that care is provided in the most appropriate The success of your workforce members—including
setting. The security and privacy of patient information are your leaders—depends on their having opportunities to
necessary attributes for customer retention. learn. This learning includes preparing people for future
A patient-focused organization addresses not only the organizational core competencies. On-the-job training offers
in
health care service characteristics that meet basic patient and a cost-effective way to cross-train and to link training more
other customer requirements but also those unique features closely to your organization’s capacity needs and priorities.
and characteristics that differentiate the organization from Workforce members’ learning includes building discipline
competitors. This differentiation may be based on innovative knowledge and retraining to adjust to a changing health care
am
health care service offerings, combinations of offerings, price, environment, and enhancing knowledge of measurement
customized offerings, multiple access and outward commu- systems that influence outcome assessments and clinical
nication mechanisms, time to appointment, rapid response, guidelines, decision trees, care bundles, or critical pathways.
innovative patient conveniences (e.g., valet parking, gourmet If your organization relies on volunteers, their personal
menus, or hotel accommodations), or special relationships. development and learning are also important to consider.
To accomplish their overall goals, successful organizations
Ex
A major long-term investment associated with health

care excellence is investment in creating and sustaining build internal and external partnerships with people and
an assessment system focused on health care outcomes. with other organizations. Internal partnerships might
This entails becoming familiar with research findings and include cooperation among administrators, staff, physicians,
ongoing application of assessment methods. Patient-focused and independent practitioners, as well as between labor
excellence is thus a strategic concept. It is directed toward and management. Internal partnerships might also involve
patient and other customer retention and loyalty, referral of creating network relationships among people across work
new patients, stronger brand recognition, market share gain, units and locations, between physicians and other caregivers,
and growth. It demands constant sensitivity to changing or between employees and volunteers to improve flexibility,
and emerging patient, other customer, and market require- responsiveness, and knowledge sharing, as well as to support
ments and to the factors that drive customer engagement. the effective flow of patients through the health care system.
It demands close attention to the voice of the customer. It External partnerships might be with customers, such
demands anticipating changes in the marketplace. Therefore, as third-party payors; suppliers; business associations;
Core Values and Concepts 41

e ducation, community, or social service organizations; and innovation, leading to new goals, approaches, health care
other health care providers. All of these people can contrib- services, and markets.
ute to your organization’s ongoing success.
Learning needs to be embedded in the way your organiza-
tion operates. This means that learning (1) is a regular
Organizational Learning and Agility part of daily work; (2) results in solving problems at their
Success in today’s ever-changing, globally competitive source (root cause); (3) is focused on building and sharing
environment demands continual organizational learning knowledge throughout your organization; and (4) is driven
and agility. Agility requires a capacity for rapid change by opportunities to effect significant, meaningful change and
and for flexibility in operations. Health care organizations to innovate. Sources for learning include employees’, physi-
face ever-shorter cycles for introducing new or improved cians’, and volunteers’ ideas; health care research findings;
health care services, as well as for faster and more flexible patients’ and other customers’ input; best-practice sharing;
responses to patients and other customers, and nonprofit competitors’ performance; and benchmarking.
and government organizations are increasingly being
asked to respond rapidly to new or emerging social issues. Organizational learning can result in (1) enhanced value to
ly
Disruptive events are occurring more frequently. They can be patients through new and improved health care services;
triggered by innovative technologies or service introductions, (2) the development of new health care business opportuni-
economic upheaval or stress, major weather events, or social ties; (3) the development of evidence-based approaches to
On
or societal demands. Organizations must be capable of medicine and new health care delivery models; (4) reduced
managing risk and making transformational changes on an errors, defects, waste, and related costs; (5) increased pro-
ever-shorter cycle time. Major improvements in response ductivity and effectiveness in the use of all your resources;
times often require new work systems, the simplification (6) enhanced performance in fulfilling your organization’s
of work processes, or the ability for rapid changeover from societal responsibilities and building community health;
one process or one location to another. A cross-trained and (7) greater agility in managing change and disruption.
and empowered workforce and effective management of Today’s health care environment places a heavy burden
e
up-to-date organizational knowledge are vital assets in such on organizations to ensure the timely design of health
a demanding environment. care delivery systems, disease prevention programs, health
Organizational learning includes both continuous improve-

Us promotion programs, and effective and efficient diagnostic
and treatment systems. Their design must allow the oppor-
ment of existing approaches and significant change or tunity to learn for continuous organizational improvement
The Role of Core Values and Concepts

er
The Baldrige Health Care

rship and Gover
Criteria build on Leade nan
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core values and concepts... esu
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(Criteria categories 1–6)

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ts
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Cu W rce
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rR kfo
yielding tom
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performance results
ults
(Criteria category 7).

and must value patients’ individual needs. Design must also
include effective means of gauging the improvement of Managing for Innovation
health status—for patients and populations or for communi- Innovation means making meaningful change to improve
ties. To meet the demands of rapidly changing markets, your your organization’s health care services, programs, processes,
organization needs to carry out stage-to-stage integration of operations, health care delivery model, and business model,
activities from research or concept to implementation. with the purpose of creating new value for stakeholders.
Innovation should lead your organization to new dimensions
All aspects of time performance are now more critical, and of performance. Innovation requires a supportive environ-
cycle time is a key process measure. Other important benefits ment, a process for identifying strategic opportunities, and
can be derived from this focus on time; time improvements the pursuit of intelligent risks. Innovation and continuous
often drive simultaneous improvements or changes in your incremental improvement are different, but complementary,
work systems, organization, quality, cost, supply-chain inte- concepts. Successful organizations use both approaches to
gration, productivity, and ongoing success in a challenging improve performance.
economy.
Innovation is no longer strictly the purview of health care
ly
Organizational learning and agility can also be achieved researchers; innovation is important for all aspects of your
through strategic partnerships or alliances with other health operations and all work systems and work processes. Your
care organizations, which might offer complementary core organization should be led and managed so that identifying
On
competencies that allow entry into new markets or a basis strategic opportunities and taking intelligent risks become
for new health care services or result in referrals or shared part of the learning culture. Innovation should be integrated
facilities. Partnerships might also permit you to address com- into daily work and be supported by your performance
mon issues by blending your organization’s core competen- improvement system. Systematic processes for identifying
cies or leadership capabilities with partners’ complementary strategic opportunities should reach across your entire
strengths and capabilities, creating a new source of strategic organization.
advantage. External partnerships might address sectorwide
e
issues, such as the need for longitudinal care, equity of and Innovation may arise from adapting innovations in other
access to care, and comparative performance data. industries to achieve a breakthrough in the health care
industry. It builds on the accumulated knowledge of your
Focus on Success
Us organization and its people and the innovations of competi-
tors. It may involve collaboration among people who do
Ensuring your organization’s success now and in the future
not normally work together and are in different parts of the
requires an understanding of the short- and longer-term
organization. Therefore, the ability to rapidly disseminate
factors that affect your organization and its marketplace.
and capitalize on new and accumulated knowledge is critical
Ensuring this ongoing success requires managing uncertainty
to driving organizational innovation and should explore
er
in the environment, as well as balancing some stakeholders’
strategic alliances with complementary organizations.
short-term demands with the organization’s and stakehold-
ers’ needs to invest in long-term success. The pursuit of
sustained growth and performance leadership requires a Management by Fact
Management by fact requires you to measure and analyze
in
strong future orientation and a willingness to make long-

term commitments to key stakeholders—your customers, your organization’s performance, both inside the organiza-
such as patients and their families; your workforce, suppliers, tion and in your competitive environment. Measurements
partners, and community; the public; and employers, payors, should derive from organizational needs and strategy, and
am
and health profession students. It also requires the agility to they should provide critical data and information about
modify plans when circumstances warrant. key processes, outputs, results, outcomes, and competitor
and industry performance. Organizations need many
Your organization’s planning and resource allocation should types of data and information to effectively manage their
anticipate many factors, such as changes in health care performance. Data and information may come in many
delivery models; resource availability; patients’ and other forms, such as numerical, graphical, or qualitative, and from
customers’ short- and long-term expectations; new business
Ex
many sources, including internal processes, surveys, and the

and partnering opportunities; potential crises, including Internet (including social media). Performance measurement
changing economic conditions; workforce capacity and should include measurement of health care outcomes;
capability needs; the competitive health care marketplace; patient, other customer, service, and process performance;
technological developments; security and cybersecurity risks; comparisons of operational, market, and competitive
changes in patient, other customer, and market segments; performance; supplier, workforce, partner, cost, and financial
evolving regulatory requirements; changes in community performance; governance and compliance results; and
and societal expectations and needs; and strategic moves by accomplishment of strategic objectives.
competitors. Your strategic objectives and resource allocations
need to accommodate these influences. A focus on success A major consideration in performance improvement and
includes developing your leaders, workforce, and suppliers; change management is the selection and use of performance
accomplishing effective succession planning; creating a measures or indicators. The measures or indicators you select
supportive environment for taking intelligent risks and should best represent the factors that lead to improved health
encouraging innovation; and anticipating societal responsi- care outcomes; improved patient, other customer, operational,
bilities and concerns. financial, and societal performance; and healthier communities.
Core Values and Concepts 43

A comprehensive yet carefully culled set of measures or indicators Managing societal responsibilities requires your organization
tied to patient/other customer and organizational performance to use appropriate measures and your leaders to assume
requirements provides a clear basis for aligning all processes with responsibility for those measures.
your organization’s goals. You may need measures and indica-
tors to support you in making decisions in a rapidly changing Ethics and Transparency
environment. By analyzing data from your tracking processes, Your organization should stress ethical behavior in all
you can evaluate the measures or indicators themselves and stakeholder transactions and interactions. Your organization’s
change them to better support your goals. governance body should require highly ethical conduct and
Analysis means extracting larger meaning from data monitor all conduct accordingly. Ethical conduct should
and information to support evaluation, decision making, address both business and health care practices, such
improvement, and innovation. It entails using data to deter- as nondiscriminatory patient treatment policies and the
mine trends, projections, and cause-and-effect relationships protection of patients’ rights and privacy. Your senior leaders
that might not otherwise be evident. Analysis supports a should be role models of ethical behavior and make their
variety of purposes, such as planning, reviewing your overall expectations of the workforce very clear.
ly
performance, improving operations, comparing your perfor- Your organization’s ethical principles are the foundation
mance with competitors’ or with best-practice benchmarks, for your culture and values. They distinguish right from
and managing change. To facilitate analysis, data may need
On
wrong. Clearly articulated ethical principles, along with
to be aggregated from various sources. Data may also need your organizational values, empower your people to make
to be segmented by, for example, markets, health care service effective decisions and may serve as boundary conditions for
lines, and workforce groups to gain deeper understanding. determining organizational norms and prohibitions.
Societal Responsibility and Transparency is characterized by consistently candid and

open communication on the part of leadership and manage-
Community Health ment and by the sharing of clear and accurate information.
e
Your organization’s leaders should stress responsibilities to the The benefits of transparency are manifold. Transparency is a
public, the consideration of societal well-being and benefit, key factor in workforce engagement and allows people to see
and the need to foster improved community health. Leaders
Us
should be role models for your organization and its workforce
why actions are being taken and how they can contribute.
Transparency also is important in interactions with customers
in the protection of public health, safety, and the environment. and other stakeholders, giving them a sense of involvement,
This protection applies to any impact of your organization’s engagement, and confidence in your organization.
operations. Also, your organization should emphasize resource
Ethical behavior and transparency build trust in the
conservation and waste reduction at the source. Planning
organization and its leaders and engender a belief in the
er
should anticipate adverse impacts from facilities management,
organization’s fairness and integrity that is valued by all key
as well as from distribution, transportation, use, and disposal
stakeholders.
of medical waste, radiation waste, chemicals, and biohazards.
Effective planning should reduce or prevent problems; provide
Delivering Value and Results
in
for a forthright response if problems occur; and make avail-

able the information and support needed to maintain public By delivering and balancing value for key stakeholders,
awareness, safety, and confidence. your organization builds loyalty, contributes to growing the
economy, and contributes to society. To meet the sometimes
Your organization should meet all local, state, and federal
am
conflicting and changing aims that balancing value requires,

laws and regulatory requirements and should also treat these your organizational strategy should explicitly include key
and related requirements as opportunities to excel beyond stakeholder requirements. This will help ensure that plans
minimal compliance. Considering societal well-being and and actions meet differing stakeholder needs and avoid
benefit means leading and supporting—within the limits of adverse impacts on any stakeholders. A balanced composite
your resources—the environmental, social, and economic of leading and lagging performance measures is an effective
systems in your organization’s sphere of influence. Public
Ex
means to communicate short- and longer-term priorities,

health services and the support of the general health of the monitor actual performance, and provide a clear basis for
community are important societal responsibilities of health improving results.
care organizations. Such leadership and support might
include efforts to establish free clinics or affordable health Your organization’s performance measurements need to
care programs, increase public health awareness programs, focus on key results. Results should be used to deliver and
or foster neighborhood services for the elderly. It also might balance value for your key stakeholders—your patients and
involve being a role model for socially important issues, their families; payors; other customers; your workforce,
practicing resource conservation, reducing your carbon foot- suppliers, and partners; health profession students; investors;
print, improving health care industry practices, and sharing the public; and the community. Thus results need to be a
nonproprietary information. composite of measures that include not just financial results,
but also health care and process results; patient, other cus-
For a role-model organization, leadership also entails influ-
tomer, and workforce satisfaction and engagement results;
encing other organizations to partner for these purposes.
and leadership, strategy, and societal performance.

Changes from the 2015–2016
Baldrige Excellence Framework
Revisions have one overarching purpose: for the framework and the Criteria to reflect the leading
edge of validated leadership and performance practice.
As the drivers of competitiveness and long-term success organizations; protecting intellectual property; and protect-
have evolved, so, too, have the Baldrige Excellence Frame- ing against the financial, legal, and reputational aspects of
work and the Criteria for Performance Excellence. The Cri- breaches.
ly
teria for Performance Excellence initially helped the nation
Enterprise risk management. No organization is risk free.
address the quality crisis of the 1980s by enabling and
Intelligent risk management requires an enterprise to decide
encouraging businesses to adopt a robust, leadership-driven,
when and how risks should be taken and managed. Such
On
customer-focused quality management system. Through
management can mean the difference between extinction,
significant and intentional evolution, today the B
aldrige
survival, or role-model performance. Through a systems
Excellence Framework offers organizations of all kinds a
perspective of organizational performance management, the
nonprescriptive leadership and management guide that
Baldrige framework has long addressed ERM, defined by
facilitates a systems approach to achieving organization-
ISO 31000: Risk Management—Principles and Guidelines as
wide excellence.
an organization’s coordinated activities to direct and control
As the Baldrige framework and the Criteria evolve, they the effect of uncertainty on achieving its objectives. The
e
must balance two important considerations. On the one future competitive advantage that will flow from good ERM
hand, the Criteria need to reflect a national standard for is based on the holistic addressing of risk and the actions
Us
performance excellence, educating organizations in all
aspects of establishing an integrated performance manage-
taken—including the pursuit of intelligent risks—as part of
an overall strategic approach to managing organizational
ment system. On the other hand, the Criteria need to be performance. In this revision, some Health Care Criteria
accessible and user-friendly for a variety of organizations at requirements and notes have been revised to highlight
varying levels of maturity. (1) that risk is inherent in everything organizations do
and (2) that the challenge is to balance the level of risk
To strike this balance, changes to the 2017–2018 Baldrige
er
taken with the sustainability of the organization and the
Excellence Framework (Health Care) focus on strengthening
opportunity for innovation.
two areas of growing importance to organizations’ long-
term success and on making the Health Care Criteria more The most significant changes to the Health Care Criteria
logical from the users’ perspective. The two areas that have items and related sections are summarized as follows.
in
been strengthened are cybersecurity and enterprise risk

management (ERM). To address the consideration of making Category 1: Leadership
the Health Care Criteria more accessible and logical from Item 1.1, Senior Leadership, now presents leaders’ actions
am
the users’ perspective, several items have been simplified, to guide and sustain the organization in three areas to
and some requirements have been moved, removed, or the address: vision and values, communication, and mission and
wording changed to aid understanding. Also, in 2015, the organizational performance. This change addresses Health
Baldrige Program for the first time published an abridged Care Criteria users’ questions about the logical relationship
version of the Baldrige framework, the Baldrige Excellence of leaders’ actions.
Builder, consisting of the most important questions for
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organizations seeking to improve their performance. A new

Category 2: Strategy
Baldrige Excellence Builder based on the 2017–2018 Baldrige
Excellence Framework will be published in early 2017. In item 2.1, Strategy Development, questions about strategy
considerations now emphasize these considerations as
Cybersecurity. There were an estimated 300 million elements of managing strategic risk in your organization.
cyberattacks in 2015—only 90 million of which were Questions on work systems are now organized to empha-
detected—and such attacks are increasing at an annual rate size the fundamental decisions that lead to decisions on
of approximately 40 percent. For health care organizations work processes and effective work systems.
of all kinds, managing and reducing cyber risks to data,
information, and systems have become a necessity. While Category 4: Measurement, Analysis, and
the Health Care Criteria have addressed the security of Knowledge Management
information systems and the confidentiality of information
Item 4.1, Measurement, Analysis, and Improvement of
since 2001, requirements and notes now reflect the grow-
Organizational Performance, has been revised to improve
ing importance of protecting against the loss of sensitive
clarity and focus. Several requirements were reduced or
information about employees, patients, other customers, and
Changes from the 2015–2016 Baldrige Excellence Framework 45

combined to remove redundancy. The requirement related to Category 7: Results
best practices has been moved to item 4.2 as part of manag-
Item 7.1, Health Care and Process Results, now asks for
ing organizational knowledge.
results related to your security and cybersecurity processes
Item 4.2, now Information and Knowledge Management, and your safety system. This again recognizes not only the
has been reordered and realigned to focus on the quality importance of these processes but also the importance of
and availability of data and information and on organiza- monitoring results of their performance as a basis for further
tional knowledge, including the sharing of best practices. action.
Requirements around cybersecurity and management of
Items 7.2 and 7.3 are now called Customer Results and
information systems have been moved to item 6.2, since
Workforce Results, respectively.
they are key components of operational effectiveness.
Item 7.4, Leadership and Governance Results, now asks
Category 5: Workforce for your results for managing risk and taking intelligent
Item 5.1, Workforce Environment, now asks how you ensure risks, recognizing that risk is inherent in delivering ongoing
ly
that new workforce members fit your organizational culture, organizational success.
recognizing that your culture is a driver of the workforce
engagement addressed in item 5.2. Scoring System
On
The Scoring System section continues to emphasize that the
Item 5.2, Workforce Engagement, now asks how you
importance of individual item requirements is dependent on
consider the learning and development desires of workforce
the organization’s key factors and is a critical consideration
members in your learning and development system.
in scoring. In addition, no one evaluation factor should
serve as a “gate” that automatically keeps the score out of a
Category 6: Operations higher range.
Item 6.1, Work Processes, now asks about your key work
e
processes as an overall requirement, in recognition of the In the Process Scoring Guidelines and the Results Scor-
importance of clearly articulating these processes. It also ing Guidelines, the descriptors in the 70–85% range for
asks about your consideration of risk in health care service Approach and for Levels have been reworded. This revision
and process design. Supply-chain management is now
Us is intended to clarify the difference between the 70–85%
ranges for Approach and for Levels (now “responsive to
addressed in this item, reflecting its importance as a key
work process. multiple requirements in the item”) and the 90–100%
ranges (“fully responsive to the multiple requirements of the
Item 6.2, Operational Effectiveness, now asks about your item”). To score in the 70–85% range for Approach or Levels,
management of information systems, including how you an organization does not need to be responsive to all of the
er
ensure their reliability, security, and cybersecurity during multiple requirements.
normal operations and as part of organizational continuity
during disasters or emergencies. Core Values and Concepts
The description of visionary leadership now refers to leaders’
in
authenticity and willingness to share missteps and oppor-

tunities for improvement. These are valuable contributors to
building trust in leaders.
am
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Glossary of Key Terms
The terms below are those in small caps in the Baldrige Health Care Criteria for Performance
Excellence and scoring guidelines. Each term is followed by a definition in boldface. The rest of
the first paragraph elaborates on this definition. The paragraphs that follow provide examples,
descriptive information, or key linkages to other information about the Baldrige framework.
ACTION PLANS. Specific actions that your organization Although individual facts and data are important, they do not
ly
takes to reach its short- and longer-term strategic usually provide an effective basis for acting or setting priorities.
objectives. These plans specify the resources committed to Effective actions depend on an understanding of relationships,
and the time horizons for accomplishing the plans. Action which is derived from the analysis of facts and data.
On
plan development is the critical stage in planning when
you make strategic objectives and goals specific so that you ANECDOTAL. In a response to a Health Care Criteria
can effectively deploy them throughout the organization item, information that lacks specific methods; measures;
in an understandable way. In the Health Care Criteria, deployment mechanisms; and evaluation, improvement,
deploying action plans includes creating aligned measures and learning factors. Anecdotal information frequently
for all affected departments and work units. Deployment consists of examples and describes individual activities
might also require specialized training for some workforce rather than systematic processes. For example, in an anec-
e
members or recruitment of personnel. dotal response to how senior leaders deploy performance
expectations, you might describe a specific occasion when a
For example, a strategic objective for a health care system senior leader visited all of your organization’s facilities. On
Us
in an area with an active business alliance focusing on
cost and quality of care might be to become the low-cost
the other hand, in properly describing a systematic process,
you might include the methods all senior leaders use to
provider. Action plans could entail designing efficient communicate performance expectations regularly to all
processes to optimize the length of hospital stays, reduce locations and workforce members, the measures leaders use
rework resulting from patient injuries and treatment errors, to assess the effectiveness of the methods, and the tools and
analyze resource and asset use, and analyze the most com- techniques you use to evaluate and improve the methods.
er
monly encountered diagnosis-related groups with a focus
on prevention in those areas. To deploy the action plans, See also systematic.
the system might need to train department and work-unit
caregivers in setting priorities based on costs and benefits. APPROACH. The methods your organization uses to
in
Organizational-level analysis and review would likely carry out its processes. Besides the methods themselves,
emphasize process efficiency, cost per patient, and health approach refers to the appropriateness of the methods to
care quality. the item requirements and your organization’s operating
environment, as well as how effectively your organization
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See also strategic objectives. uses those methods.

ALIGNMENT. A state of consistency among plans, Approach is one of the factors considered in evaluating pro-
processes, information, resource decisions, workforce cess items. For further description, see the Scoring System
capability and capacity, actions, results, and analyses (pages 31–36).
that support key organization-wide goals. Effective align-
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ment requires a common understanding of purposes and BASIC REQUIREMENTS. The most central concept of a
goals. It also requires the use of complementary measures Health Care Criteria item, as presented in the item title
and information for planning, tracking, analysis, and question. For an illustration, see Health Care Criteria for
improvement at three levels: the organizational level, the Performance Excellence Structure (page 2).
key process level, and the departmental or work unit level.
BENCHMARKS. Processes and results that represent
See also integration.
the best practices and best performance for similar
activities, inside or outside your organization’s industry.
ANALYSIS. The examination of facts and data to provide Organizations engage in benchmarking to understand the
a basis for effective decisions. Analysis often involves current dimensions of world-class performance and to
determining cause-effect relationships. Overall organiza- achieve discontinuous (nonincremental) or “breakthrough”
tional analysis guides you in managing work systems and improvement.
work processes toward achieving key organizational results
and attaining strategic objectives. Benchmarks are one form of comparative data. Other forms
include health care data collected by a third party (e.g., CMS,
Glossary of Key Terms 47

accrediting organizations, and commercial organizations), of engaged customers include retention, brand loyalty,
data on competitors’ and other organizations’ performance willingness to make an effort to obtain—and to continue to
obtained from sharing or from external reference databases, obtain—health care services from you, and willingness to
comparisons with similar organizations that are in the same actively advocate for and recommend your brand and service
geographic area or that provide similar health care services, offerings.
and information from the open literature (e.g., outcomes of
research studies and practice guidelines). CYCLE TIME. The time required to fulfill commitments
or complete tasks. Cycle time refers to all aspects of time
CAPABILITY, WORKFORCE. See workforce capability. performance, such as time to report test results, fulfill orders,
or introduce new health care technology; length of hospital
CAPACITY, WORKFORCE. See workforce capacity. stays; call-line response and billing time; and other key
measures of time. Improvement in cycle time might involve
COLLABORATORS. Organizations or individuals who any or all of these.
cooperate with your organization to support a particular
ly
Time performance and speed are important to improving
activity or event or who cooperate intermittently when
competitiveness and overall performance.
their short-term goals are aligned with or are the same
as yours. Typically, collaborations do not involve formal
DEPLOYMENT. The extent to which your organization
On
agreements or arrangements.
applies an approach in addressing the requirements of
See also partners. a Health Care Criteria item. Evaluation of deployment
considers how broadly and deeply the approach is applied
CORE COMPETENCIES. Your organization’s areas of in relevant work units throughout your organization.
greatest expertise; those strategically important, pos-
Deployment is one of the factors considered in evaluating
sibly specialized capabilities that are central to fulfilling
process items. For further description, see the Scoring
e
your mission or that provide an advantage in your
System (pages 31–36).
marketplace or service environment. Core competencies
are frequently challenging for competitors or suppliers
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and partners to imitate, and they may provide an ongoing
DIVERSITY. Personal differences among workforce
members that enrich the work environment and are
competitive advantage. The absence of a needed core
representative of your hiring and patient communities.
competency may result in a significant strategic challenge or
These differences address many variables, such as race,
disadvantage for your organization in the marketplace.
religion, color, gender, national origin, disability, sexual ori-
Core competencies may involve technological expertise, entation, age and generation, education, geographic origin,
er
unique service offerings, a marketplace niche, or business and skill characteristics, as well as ideas, thinking, academic
acumen in a particular area (e.g., health care delivery disciplines, and perspectives.
start-ups).
The Health Care Criteria refer to valuing and benefiting
from the diversity of your workforce hiring and patient com-
in
CUSTOMER. An actual or potential user of your

munities. Capitalizing on both in building your workforce
organization’s health care services. Customers include
increases your opportunities for high performance; patient,
the direct users of your health care services (patients), as
other customer, workforce, and community satisfaction; and
well as others who pay for your services, such as patients’
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patient, other customer, and workforce engagement.

families, insurers, and other third-party payors. The Baldrige
framework addresses customers broadly, referencing your
EFFECTIVE. How well a process or a measure addresses
current and future patients and other customers, as well as
its intended purpose. Determining effectiveness requires
your competitors’ patients and other customers.
(1) evaluating how well the process is aligned with the
Patient-focused excellence is a Baldrige core value embed- organization’s needs and how well it is deployed, or
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ded in the beliefs and behaviors of high-performing (2) evaluating the outcome of the measure as an indicator of
organizations. Patient focus impacts and should be a factor process or service performance.
in integrating your organization’s strategic directions, work
systems and work processes, and organizational perfor- EMPOWERMENT. Giving people the authority and
mance results. responsibility to make decisions and take actions. When
people are empowered, decisions are made closest to
See also stakeholders for the relationship between
patients and other customers (the front line), where work-
customers and others who might be affected by your health
related knowledge and understanding reside.
care services.
The purpose of empowering people is to enable them to
CUSTOMER ENGAGEMENT. Your patients’ and other satisfy patients and other customers on first contact,
customers’ investment in or commitment to your brand improve processes and increase productivity, and improve
and health care service offerings. It is based on your your organization’s health care and other performance
ongoing ability to serve their needs and build relationships results, as well as to encourage collaboration. An empow-
so that they will continue using your services. Characteristics ered workforce requires information to make appropriate

decisions; thus, your organization must provide that See also performance projections.
information in a timely and useful way.
GOVERNANCE. The system of management and controls
ENGAGEMENT, CUSTOMER. See customer engagement. exercised in the stewardship of your organization. Gov-
ernance includes the responsibilities of your organization’s
ENGAGEMENT, WORKFORCE. See workforce owners/shareholders, board of directors, and senior leaders
engagement. (administrative/operational and health care). Corporate or
organizational charters, bylaws, and policies document the
ETHICAL BEHAVIOR. The actions your organization rights and responsibilities of each of the parties and describe
takes to ensure that all its decisions, actions, and how they will direct and control your organization to ensure
stakeholder interactions conform to its moral and pro- (1) accountability to owners/shareholders and other stake-
fessional principles of conduct. These principles should holders, (2) transparency of operations, and (3) fair treat-
support all applicable laws and regulations and are the ment of all stakeholders. Governance processes may include
foundation for your organization’s culture and values. They the approval of strategic direction, the monitoring and
ly
distinguish right from wrong. evaluation of the CEO’s performance, the establishment of
executive compensation and benefits, succession planning,
Senior leaders should be role models for these principles financial and other fiduciary auditing, risk management,
On
of behavior. The principles apply to all people involved in disclosure, and shareholder reporting. Ensuring effective
your organization, from temporary workforce members to governance is important to stakeholders’ and the larger
members of the board of directors. These principles benefit society’s trust and to organizational effectiveness.
from regular communication and reinforcement. Although
the Baldrige framework does not prescribe a particular
HEALTH CARE SERVICES. All services delivered by your
model for ensuring ethical behavior, senior leaders have the
organization that involve professional clinical/medical
responsibility for the alignment of your organization’s mis-
judgment, including those delivered to patients and to
e
sion and vision with its ethical principles. Ethical behavior
the community. Health care services also include services
encompasses interactions with all stakeholders, including
that are not considered clinical or medical, such as admis-
your workforce, patients and their family members, insurers,
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payors, other customers, other partners, suppliers, and local
sions, food services, and billing.
community. HIGH PERFORMANCE. Ever-higher levels of overall
Well-designed and clearly articulated ethical principles organizational and individual performance, including
empower people to make effective decisions with great quality, productivity, innovation rate, and cycle time.
confidence. In some organizations, ethical principles also High performance results in improved service and value for
er
serve as boundary conditions restricting behavior that patients, other customers, and other stakeholders.
otherwise could have adverse impacts on your organization Approaches to high performance vary in their form, their
and/or society. function, and the incentive systems used. High performance
See also the related core value, Ethics and Transparency stems from and enhances workforce engagement. It involves
in
(page 44). cooperation between the administration/management and

the workforce, which may involve workforce bargaining
EXCELLENCE. See performance excellence. units; cooperation among work units, often involving
am
teams; empowerment of your people, including personal

GOALS. Future conditions or performance levels that accountability; and workforce input into planning. It may
your organization intends or desires to attain. Goals can involve learning and building individual and organizational
be both short and longer term. They are ends that guide skills; learning from other organizations; creating flexible
actions. Quantitative goals, frequently referred to as targets, job design and work assignments; maintaining a flattened
include a numerical point or range. Targets might be desired organizational structure, where decision making is decen-
tralized and decisions are made closest to patients and other
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performance based on comparative or competitive data.

Stretch goals are goals for desired major, discontinuous customers (the front line); and effectively using performance
(nonincremental) or “breakthrough” improvements, usually measures, including comparisons. Many organizations
in areas most critical to your organization’s future success. encourage high performance with monetary and nonmon-
etary incentives based on factors such as organizational
Goals can serve many purposes, including performance, team and individual contributions, and skill
• clarifying strategic objectives and action plans to building. Also, approaches to high performance usually seek
indicate how you will measure success, to align your organization’s structure, core competencies,
work, jobs, workforce development, and incentives.
• fostering teamwork by focusing on a common end,
• encouraging out-of-the-box thinking (innovation) to HOW. The systems and processes that your organization
achieve a stretch goal, and uses to achieve its mission requirements. In responding
to “how” questions in Health Care Criteria categories 1–6,
• providing a basis for measuring and accelerating you should include information on approach (methods and
progress. measures), deployment, learning, and integration.

INDICATORS. See measures and indicators. KEY. Major or most important; critical to achieving
your intended outcome. The Health Care Criteria, for
INNOVATION. Making meaningful change to improve example, refer to key challenges, plans, work processes, and
health care services, processes, or organizational measures—those that are most important to your organiza-
effectiveness and create new value for stakeholders. tion’s success. They are the essential elements for pursuing
Innovation involves adopting an idea, process, technology, or monitoring a desired outcome. Key is generally defined
service, or business model that is either new or new to as around the most significant five (e.g., around five key
its proposed application. The outcome of innovation is a challenges).
discontinuous or “breakthrough” improvement in results,
services, or processes. Innovation benefits from a supportive KNOWLEDGE ASSETS. Your organization’s accumulated
environment, a process for identifying strategic opportuni- intellectual resources; the knowledge possessed by
ties, and a willingness to pursue intelligent risks. your organization and its workforce in the form of
information, ideas, learning, understanding, memory,
Successful organizational innovation is a multistep process
insights, cognitive and technical skills, and capabilities.
ly
of development and knowledge sharing, a decision to
These knowledge assets reside in your workforce, software,
implement, implementation, evaluation, and learning.
patents, databases, documents, guides, and policies and
Although innovation is often associated with health care
procedures. Knowledge assets also reside within patients,
On
research and technological innovation, it is applicable to all
other customers, suppliers, and partners.
key organizational processes that can benefit from change
through innovation, whether breakthrough improvement or Knowledge assets are the know-how that your organiza-
a change in approach or outputs. Innovation could include tion has available to use, invest, and grow. Building and
fundamental changes in an organization’s structure or busi- managing knowledge assets are key components of creating
ness model to accomplish work more effectively or improve value for your stakeholders and sustaining a competitive
critical pathways and practice guidelines, facility design, the advantage.
e
administration of medications, the organization of work, or
alternative therapies. LEADERSHIP SYSTEM. The way leadership is exercised,
formally and informally, throughout your organization;
See also intelligent risks and strategic opportunities.
Us the basis for key decisions and the way they are made,
communicated, and carried out. A leadership system
INTEGRATION. The harmonization of plans, processes,
includes structures and mechanisms for making decisions;
information, resource decisions, workforce capability
ensuring two-way communication; selecting and developing
and capacity, actions, results, and analyses to support
leaders and managers; and reinforcing values, ethical behav-
key organization-wide goals. Effective integration goes
ior, directions, and performance expectations. In health
er
beyond alignment and is achieved when the individual
care organizations with separate administrative/operational
components of an organizational performance management
and health care provider leadership, the leadership system
system operate as a fully interconnected unit.
includes both sets of leaders and the relationship between
Integration is one of the factors considered in evaluating them.
in
both process and results items. For further description, see

An effective leadership system respects workforce members’
the Scoring System (pages 31–36).
and other stakeholders’ capabilities and requirements, and
See also alignment. it sets high expectations for performance and performance
am
improvement. It builds loyalties and teamwork based

INTELLIGENT RISKS. Opportunities for which the poten- on your organization’s vision and values and the pursuit
tial gain outweighs the potential harm or loss to your of shared goals. It encourages and supports initiative,
organization’s future success if you do not explore them. innovation, and appropriate risk taking; subordinates
Taking intelligent risks requires a tolerance for failure and organizational structure to purpose and function; and avoids
an expectation that innovation is not achieved by initiating chains of command that require long decision paths. An
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only successful endeavors. At the outset, organizations must effective leadership system includes mechanisms for leaders
invest in potential successes while realizing that some will to conduct self-examination, receive feedback, and improve.
lead to failure.
LEARNING. New knowledge or skills acquired through
The degree of risk that is intelligent to take will vary by the
evaluation, study, experience, and innovation. The
pace and level of threat and opportunity in the health care
Baldrige framework refers to two distinct kinds of learning:
sector. In a rapidly changing environment with constant
organizational learning and learning by the people in your
introductions of new health care services, processes, or
workforce. Organizational learning is achieved through
business models, there is an obvious need to invest more
research and development, evaluation and improvement
resources in intelligent risks than in a stable environment. In
cycles, ideas and input from the workforce and stakeholders,
the latter, organizations must monitor and explore growth
the sharing of best practices, and benchmarking. Workforce
potential and change but, most likely, with a less significant
learning is achieved through education, training, and devel-
commitment of resources.
opmental opportunities that further individual growth.
See also strategic opportunities.

To be effective, learning should be embedded in the way PARTNERS. Key organizations or individuals who are
your organization operates. Learning contributes to a working in concert with your organization to achieve a
competitive advantage and ongoing success for your organi- common goal or improve performance. Typically, partner-
zation and workforce. ships are formal arrangements for a specific aim or purpose,
For further description of organizational and personal learn- such as to achieve a strategic objective or deliver a specific
ing, see the related core values and concepts: Valuing People, health care service.
and Organizational Learning and Agility (pages 41–43). Formal partnerships usually last for an extended period and
Learning is one of the factors considered in evaluating pro- involve a clear understanding of the partners’ individual and
cess items. For further description, see the Scoring System mutual roles and benefits.
(pages 31–36). See also collaborators.
LEVELS. Numerical information that places or positions PATIENT. The person receiving health care, including
your organization’s results and performance on a preventive, promotional, acute, chronic, rehabilitative,
ly
meaningful measurement scale. Performance levels permit and all other services in the continuum of care. Other
evaluation relative to past performance, projections, goals, terms used for patient include member, consumer, client, and
and appropriate comparisons. resident.
On
MEASURES AND INDICATORS. Numerical information PERFORMANCE. Outputs and their outcomes obtained
that quantifies the input, output, and performance from health care services, processes, patients, and other
dimensions of processes, programs, projects, services, customers that permit you to evaluate and compare
and the overall organization (outcomes). Measures and your organization’s results to performance projections,
indicators might be simple (derived from one measurement) standards, past results, goals, and other organizations’
or composite. results. Performance can be expressed in nonfinancial and
e
The Health Care Criteria do not distinguish between financial terms.
measures and indicators. However, some users of these The Health Care Criteria address four types of performance:
Us
terms prefer “indicator” (1) when the measurement relates (1) health care process and outcome, (2) patient- and other
to performance but does not measure it directly (e.g., customer-focused, (3) operational, and (4) financial and
the number of complaints is an indicator but not a direct marketplace.
measure of dissatisfaction), and (2) when the measurement
is a predictor (“leading indicator”) of some more significant Health care process and outcome performance is perfor-
performance (e.g., increased patient satisfaction might mance relative to measures and indicators of characteristics
er
be a leading indicator of retention of health maintenance of health care service delivery that are important to patients
organization members). and other customers. Examples include hospital readmission
rates, mortality and morbidity rates, measures of patient
MISSION. Your organization’s overall function. The harm associated with the health care system, and length
in
mission answers the question, “What is your organization of hospital stays, as well as measures of functional status,
attempting to accomplish?” The mission might define out-of-hospital treatment of chronic conditions, culturally
patients, other customers or markets served, distinctive or sensitive care, and patient compliance and adherence. Health
care performance might be measured at the organizational
am
core competencies, or technologies used.

level, the diagnosis-related-group level, or the patient seg-
MULTIPLE REQUIREMENTS. The details of a Health Care ment level.
Criteria item, as expressed in the individual questions Patient- and other customer-focused performance is
under each lettered area to address. The first question in performance relative to measures and indicators of patients’
a set of multiple requirements expresses the most important and other customers’ perceptions, reactions, and behaviors.
Ex
question in that group. The questions that follow expand on Examples include patient and other customer retention,
or supplement that question. For an illustration, see Health complaints, and survey results.
Care Criteria for Performance Excellence Structure (page 2).
Operational performance is workforce, leadership, and
Even high-performing, high-scoring users of the Baldrige organizational performance (including ethical and legal
framework are not likely to be able to address all the compliance) relative to measures and indicators of effective-
multiple requirements with equal capability or success. ness, efficiency, and accountability. Examples include cycle
time, productivity, waste reduction, workforce turnover,
OVERALL REQUIREMENTS. The most important features workforce cross-training rates, accreditation, regulatory
of a Health Care Criteria item, as elaborated in the first compliance, fiscal accountability, strategy accomplishment,
question (the leading question in boldface) in each community involvement, and contributions to community
paragraph under each lettered area to address. For an health. Operational performance might be measured at the
illustration, see Health Care Criteria for Performance Excel- work-unit, key work process, and organizational levels.
lence Structure (page 2).

Financial and marketplace performance is performance sequence is critical, the process needs to include information
relative to measures of cost, revenue, and market position, that helps customers understand and follow the sequence.
including asset utilization, asset growth, and market share. Such service processes also require guidance for service
Examples include returns on investments, value added providers on handling contingencies related to customers’
per employee, bond ratings, debt-to-equity ratio, returns possible actions or behaviors.
on assets, operating margins, performance to budget, the
In knowledge work, such as strategic planning, research,
amount in reserve funds, days cash on hand, other profit-
development, and analysis, process does not necessarily
ability and liquidity measures, and market gains.
imply formal sequences of steps. Rather, it implies general
understandings of competent performance in such areas
PERFORMANCE EXCELLENCE. An integrated approach
as timing, options to include, evaluation, and reporting.
to organizational performance management that results
Sequences might arise as part of these understandings.
in (1) delivery of ever-improving value to patients, other
customers, and stakeholders, contributing to improved Process is one of the two dimensions evaluated in a
health care quality and ongoing organizational success; Baldrige-based assessment. This evaluation is based on four
ly
(2) improvement of your organization’s overall effective- factors: approach, deployment, learning, and integration. For
ness and capabilities; and (3) learning for the organiza- further description, see the Scoring System (pages 31–36).
tion and for people in the workforce. The Baldrige
On
Organizational Profile, Health Care Criteria, core values PRODUCTIVITY. Measures of the efficiency of resource
and concepts, and scoring guidelines provide a framework use. Although the term is often applied to single factors,
and assessment tool for understanding your organization’s such as the workforce (labor productivity), machines, mate-
strengths and opportunities for improvement and, thus, for rials, energy, and capital, the concept also applies to the total
guiding your planning toward achieving higher performance resources used in producing outputs. Using an aggregate
and striving for excellence. measure of overall productivity allows you to determine
whether the net effect of overall changes in a process—
e
PERFORMANCE PROJECTIONS. Estimates of your possibly involving resource trade-offs—is beneficial.
organization’s future performance. Projections should
be based on an understanding of past performance, rates
of improvement, and assumptions about future internal
Us PROJECTIONS, PERFORMANCE. See performance
projections.
changes and innovations, as well as assumptions about
changes in the external environment that result in internal RESULTS. Outputs and outcomes achieved by your
changes. Thus, performance projections can serve as a key organization. Results are evaluated based on current
tool in managing your operations and in developing and performance; performance relative to appropriate com-
er
implementing your strategy. parisons; the rate, breadth, and importance of performance
improvements; and the relationship of results measures to
Performance projections state your expected future
key organizational performance requirements.
performance. Goals state your desired future performance.
Performance projections for your competitors or similar Results are one of the two dimensions evaluated in a
in
organizations may indicate challenges facing your organiza- Baldrige-based assessment. This evaluation is based on four
tion and areas where breakthrough performance or innova- factors: levels, trends, comparisons, and integration. For
tion is needed. In areas where your organization intends further description, see the Scoring System (pages 31–36).
am
to achieve breakthrough performance or innovation, your

performance projections and your goals may overlap. SEGMENT. One part of your organization’s patient,
See also goals. other customer, market, health care service offering, or
workforce base. Segments typically have common charac-
teristics that allow logical groupings. In Health Care Criteria
PROCESS. Linked activities with the purpose of produc-
results items, segmentation refers to disaggregating results
ing a service for a customer (user) within or outside
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data in a way that allows for meaningful analysis of your

your organization. Generally, processes involve combina-
organization’s performance. It is up to each organization to
tions of people, machines, tools, techniques, materials,
determine the factors that it uses to segment its patients,
and improvements in a defined series of steps or actions.
other customers, markets, services, and workforce.
Processes rarely operate in isolation and must be considered
in relation to other processes that impact them. In some Understanding segments is critical to identifying the distinct
situations, processes might require adherence to a specific needs and expectations of different patient, other customer,
sequence of steps, with documentation (sometimes formal) market, and workforce groups and to tailoring health care
of procedures and requirements, including well-defined service offerings to meet their needs and expectations. For
measurement and control steps. example, you might segment your market based on distribu-
tion channels, service volume, geography, or technologies
In the delivery of services, particularly those that directly
employed. You might segment your workforce based on
involve patients and other customers, process is used more
geography, skills, needs, specialties, work assignments, or
generally to spell out what delivering that service entails,
job classifications.
possibly including a preferred or expected sequence. If a

SENIOR LEADERS. Your organization’s senior manage- STRATEGIC OBJECTIVES. The aims or responses that
ment group or team. In many organizations, this consists your organization articulates to address major change
of the head of the organization and his or her direct reports. or improvement, competitiveness or social issues, and
In health care organizations with separate administrative/ health care advantages. Strategic objectives are generally
operational and health care provider leadership, “senior focused both externally and internally and relate to signifi-
leaders” refers to both sets of leaders. cant patient, other customer, market, health care service,
or technological opportunities and challenges (strategic
STAKEHOLDERS. All groups that are or might be challenges). Broadly stated, they are what your organization
affected by your organization’s actions and success. must achieve to remain or become competitive and ensure
Key stakeholders might include customers, the community, its long-term success. Strategic objectives set your organiza-
employers, health care providers, patient advocacy groups, tion’s longer-term directions and guide resource allocation
departments of health, students, the workforce, partners, and redistribution.
collaborators, governing boards, stockholders, donors, sup-
See action plans for the relationship between strategic
pliers, taxpayers, regulatory bodies, policy makers, funders,
ly
objectives and action plans and for an example of each.
and local and professional communities.
See also customer. STRATEGIC OPPORTUNITIES. Prospects for new or
On
changed services, processes, business models (including
STRATEGIC ADVANTAGES. Those marketplace benefits strategic alliances), or markets. They arise from outside-
that exert a decisive influence on your organization’s the-box thinking, brainstorming, capitalizing on serendipity,
likelihood of future success. These advantages are research and innovation processes, nonlinear extrapolation
frequently sources of current and future competitive success of current conditions, and other approaches to imagining a
relative to other providers of similar health care services. different future.
Strategic advantages generally arise from either or both of
The generation of ideas that lead to strategic opportunities
e
two sources: (1) core competencies, which focus on building
benefits from an environment that encourages nondirected,
and expanding on your organization’s internal capabilities,
free thought. Choosing which strategic opportunities to
and (2) strategically important external resources, which
Us
your organization shapes and leverages through key external
pursue involves consideration of relative risk, financial and
otherwise, and then making intelligent choices (intelligent risks).
relationships and partnerships.
See also intelligent risks.
When an organization realizes both sources of strategic
advantage, it can amplify its unique internal capabilities
SYSTEMATIC. Well-ordered, repeatable, and exhibiting
by capitalizing on complementary capabilities in other
the use of data and information so that learning is
er
organizations.
possible. Approaches are systematic if they build in the
See strategic challenges and strategic objectives opportunity for evaluation, improvement, and sharing,
for the relationship among strategic advantages, strategic thereby permitting a gain in maturity. To see the term in use,
challenges, and the strategic objectives your organization refer to the Process Scoring Guidelines (page 34).
in
articulates to address its challenges and advantages.

TRENDS. Numerical information that shows the direc-
STRATEGIC CHALLENGES. Those pressures that exert tion and rate of change of your organization’s results
am
a decisive influence on your organization’s likelihood or the consistency of its performance over time. Trends
of future success. These challenges are frequently driven show your organization’s performance in a time sequence.
by your organization’s anticipated collaborative environ-
Ascertaining a trend generally requires a minimum of three
ment and/or competitive position in the future relative to
historical (not projected) data points. Defining a statistically
other providers of similar health care services. While not
valid trend requires more data points. The cycle time of the
exclusively so, strategic challenges are generally externally
process being measured determines the time between the
Ex
driven. However, in responding to externally driven strategic

data points for establishing a trend. Shorter cycle times
challenges, your organization may face internal strategic
demand more frequent measurement, while longer cycle
challenges.
times might require longer periods for a meaningful trend.
External strategic challenges may relate to patient, other
Examples of trends called for by the Health Care Criteria and
customer, or market needs or expectations; health care
scoring guidelines include data on health care outcomes and
service or technological changes; or financial, societal, and
other health care service performance; results for patient,
other risks or needs. Internal strategic challenges may relate
other customer, and workforce satisfaction and dissatisfac-
to capabilities or human and other resources.
tion; financial performance; marketplace performance; and
See strategic advantages and strategic objectives operational performance, such as cycle time and productivity.
for the relationship among strategic challenges, strategic
advantages, and the strategic objectives your organization VALUE. The perceived worth of a program, service, pro-
articulates to address its challenges and advantages. cess, asset, or function relative to its cost and possible
alternatives.

Organizations frequently use value considerations to deter- deliver your health care services and carry out your business
mine the benefits of various options relative to their costs, and support processes.
such as the value of various health care service combinations
Decisions about work systems are strategic. These decisions
to patients and other customers. Your organization needs
involve protecting and capitalizing on core competencies
to understand what different stakeholder groups value and
and deciding what should be procured from or produced
then deliver value to each group. This frequently requires
outside your organization in order to be efficient and
balancing value among customers and other stakeholders,
sustainable in your marketplace.
such as your workforce and the community.
WORKFORCE. All people actively supervised by your
VALUES. The guiding principles and behaviors that
organization and involved in accomplishing your
embody how your organization and its people are
organization’s work, including paid employees (e.g.,
expected to operate. Values influence and reinforce your
permanent, part-time, temporary, and telecommuting
organization’s desired culture. They support and guide the
employees, as well as contract employees supervised
decisions made by every workforce member, helping your
ly
by your organization), resident physicians, independent
organization accomplish its mission and attain its vision
practitioners not paid by the organization (e.g.,
appropriately. Examples of values include demonstrating
physicians, physician assistants, nurse practitioners,
integrity and fairness in all interactions, exceeding patients’
acupuncturists, and nutritionists), health care students
On
and other customers’ expectations, valuing individuals
(e.g., medical, nursing, and ancillary), and volunteers, as
and diversity, protecting the environment, and striving for
appropriate. Your workforce includes team leaders, supervi-
performance excellence every day.
sors, and managers at all levels.
VISION. Your organization’s desired future state. The
WORKFORCE CAPABILITY. Your organization’s ability
vision describes where your organization is headed, what it
to accomplish its work processes through its people’s
intends to be, or how it wishes to be perceived in the future.
e
knowledge, skills, abilities, and competencies.
VOICE OF THE CUSTOMER. Your process for capturing Capability may include the ability to build and sustain
patient- and other customer-related information. Voice-
of-the-customer processes are intended to be proactive
Us relationships with patients, other customers, and the com-
munity; to innovate and transition to new technologies; to
and continuously innovative to capture stated, unstated, develop new health care services and work processes; and to
and anticipated patient and other customer requirements, meet changing health care, market, and regulatory demands.
expectations, and desires. The goal is to achieve customer
engagement. Listening to the voice of the customer might WORKFORCE CAPACITY. Your organization’s ability
er
include gathering and integrating various types of patient to ensure sufficient staffing levels to accomplish its
and other customer data, such as survey data, focus group work processes and deliver your health care services to
findings, social media data and commentary, and complaint patients and other customers, including the ability to
data, that affect students’ and other customers’ relationship meet varying demand levels.
in
and engagement decisions.

WORKFORCE ENGAGEMENT. The extent of workforce
WORK PROCESSES. Your organization’s most important members’ emotional and intellectual commitment to
internal value-creation processes. They might include accomplishing your organization’s work, mission, and
am
health care service design, production, and delivery; patient vision. Organizations with high levels of workforce engage-
support; supply-chain management; business; and support ment are often characterized by high-performance work
processes. They are the processes that involve the majority of environments in which people are motivated to do their
your organization’s workforce. utmost for their patients’ and other customers’ benefit and
the organization’s success.
Your key work processes frequently relate to your core
Ex
competencies, the factors that determine your success rela- In general, workforce members feel engaged when they find
tive to competitors and organizations offering similar health personal meaning and motivation in their work and receive
care services, and the factors your senior leaders consider interpersonal and workplace support. An engaged workforce
important for business growth. Your key work processes are benefits from trusting relationships, a safe and cooperative
always accomplished by your workforce. environment, good communication and information flow,
empowerment, and accountability for p erformance. Key
WORK SYSTEMS. How your organization’s work is factors contributing to engagement include training and
accomplished, consisting of the internal work processes career development, effective recognition and reward
and external resources you need to develop and systems, equal opportunity and fair treatment, and
produce services, deliver them to your patients and family-friendliness. Workforce engagement also depends
other customers, and succeed in your marketplace. on building and sustaining relationships between your
Work systems involve your workforce, your key suppliers administrative/operational leadership and independent
and partners, your contractors, your collaborators, and other practitioners.
components of the supply chain needed to produce and

Index of Key Terms
Page numbers in boldface indicate definitions in the Glossary of Key Terms (pages 47–54).
A comparisons, iii, 6, 11, 12, 14, 16, 17, 26, environment

27, 31, 33, 35, 37, 38, 39, 43, 44, 47, competitive/collaborative, iv, 4, 6, 11,
About the Baldrige Excellence 48, 49, 51, 52 33, 43, 53
Framework, ii–iv competitors, iii, 5, 6, 11, 12, 13, 14, 16, organizational/operating, iv, 1, 2, 4,
accreditation, 4, 8, 12, 29, 41, 51 17, 26, 27, 31, 37, 39, 41, 42, 43, 44, 5, 7, 8, 16, 20, 25, 31, 41, 44, 47, 48,
action plans, iii, v, vi, 4, 7, 10, 12, 16, 17, 48, 52, 54 50, 52
ly
19, 21, 28, 29, 33, 35, 38, 40, 47, 49, 53 complaints, management of, 14, 16, 41, protection of, 9, 24, 43, 54
achievement of, 12, 21, 28 51 regulatory, 4, 5, 8, 10, 11
deployment of, 12 compliance, legal and regulatory, 8, 9, workforce, 3, 5, 8, 11, 19, 20, 21, 40,
development of, vi, 12, 47
On
43, 44, 51 41, 46, 50, 53, 54
ADLI (approach, deployment, learning, core competencies, 4, 5, 8, 9, 10, 11, 19, ethics
integration). See Scoring System and 21, 29, 37, 38, 40, 41, 43, 48, 49, 51, and ethical behavior, 7, 8, 9, 11, 21,
individual terms 53, 54 29, 40, 44, 49, 50, 51
agility, iii, 7, 8, 10, 11, 12, 16, 23, 24, 40, Core Values and Concepts, 40–44 and transparency, iii, 40, 42, 44
41, 42, 43, 51 cost control, 25, 42, 47 evaluation factors, iii, 31, 30–31, 33,
alignment, iii, 12, 16, 17, 19, 31, 34, 36, culture, organizational, 6, 7, 8, 11, 16, 37–38
e
38, 40, 44, 46, 47, 48, 49, 50 19, 20, 21, 22, 41, 43, 44, 46, 49, 54 excellence. See performance excellence
analysis, 1, 3, 10, 11, 12, 13, 16, 17, 25, customer (meaning of), 48. See also
26, 31, 32, 34, 36, 38, 42, 43, 44, 45, patients and other customers F
47, 50, 52
Us
customer engagement, 3, 7, 10, 11, 13,
feedback, iii, iv, vi, 1, 9, 13, 23, 24, 31,
anecdotal, 34, 38, 47 14, 15, 27, 41, 48, 54
approach, iii, iv, 6, 31, 32, 34, 36, 37, 38, Customers (category 3), ii, 1, 2, 3, 12, 33, 37, 38, 40, 50
46, 47, 48, 49, 52, 53 13–15, 26, 38, 42 focus on success, iii, 40, 42, 43
area to address, 2, 37, 51 cybersecurity, 5, 11, 24, 25, 26, 43, 45, From Fighting Fires to Innovation, 32
46
er
B cycle time, 25, 26, 42, 43, 48, 49, 51, 53 G

basic requirements, 2, 34, 35, 47 Glossary of Key Terms, 47–54
benchmarks, iii, 12, 13, 17, 31, 35, 38, D goals, ii, iii, 8, 10, 19, 29, 31, 33, 36, 38,
in
39, 42, 44, 47, 50 data 41, 42, 44, 47, 48, 49, 50, 51, 52
best practices, ii, iv, 17, 18, 42, 44, 46, analysis and use of, iii, 6, 9, 10, 11, governance, 1, 3, 4, 7, 8, 9, 16, 26, 29,
47, 50 12, 13, 15, 16, 17, 18, 25, 26, 27, 31, 40, 42, 43, 44, 46, 49
33, 37, 38, 43, 44, 47, 52, 53, 54
am
C comparative/competitive, iii, 6, 11, H

12, 14, 16, 17, 26, 27, 31, 33, 35, 37, Health Care Criteria for Performance
capability and capacity, workforce, 8,
38, 39, 43, 44, 47, 48, 49, 51, 52 Excellence, 4–30
11, 12, 19, 20, 28, 43, 47, 50, 54
delivering value and results, iii, 40, 42, items and point values, 3
Changes from the 2015–2016 Baldrige
44 overview and structure, 1–2
Excellence Framework, 45–46
deployment, iii, iv, 6, 7, 12, 14, 16, 29, health care outcomes, 14, 17, 23, 26, 41,
Ex
collaborators, 5, 6, 12, 16, 18, 48, 53, 54

31, 32, 33, 34, 37, 38, 47, 48, 49, 52 43, 44, 51, 53
communication
diversity, 11, 19, 21, 28, 41, 48, 54 health care providers, 5, 7, 11, 14, 40,
with patients and other customers, 5,
14, 29, 41 41, 42, 50, 53
by senior leaders, 7, 8, 12, 20, 29, 40, E health care services, ii, 4, 5, 6, 8, 10, 11,
44, 45, 47, 49, 50 effective (meaning of), 48 12, 13, 14, 15, 19, 23, 24, 26, 27, 33,
with suppliers, partners, and emergency preparedness, 5, 9, 11, 25, 40, 41, 42, 43, 44, 48, 49, 50, 51, 52,
collaborators, 5, 24 26, 27, 46 53, 54
with the workforce, 7, 8, 12, 20, 21, empowerment, 21, 42, 44, 48, 49, 54 design of, 14, 23, 24, 42, 54
29, 40, 44, 47, 49, 50, 54 engagement improvement of, 11, 12, 15, 23, 24,
communities, key, 9, 29 of patients and other customers, 3, 7, 42, 43
community health, iii, 9, 29, 40, 42, 44, 10, 11, 13, 14, 15, 27, 41, 48, 54 requirements for, 4, 14, 23, 41
51 of workforce, 3, 4, 19, 20, 21, 28, 41, high performance, 1, 7, 19, 21, 39, 40,
community support, 9, 29, 44, 51 44, 46, 48, 49, 54 48, 49, 51, 54
Index of Key Terms 55

how (meaning of), 38, 49 legal and regulatory compliance, 8, 43, groups (segments), 4, 5, 10, 13, 14,
How to Respond to the Health Care 44, 51 26, 27, 28, 30, 38, 43, 52
Criteria, 37–39 LeTCI (levels, trends, comparisons, listening to, 13, 27, 54. See also voice
How to Use the Baldrige Excellence integration). See Scoring System and of the customer
Framework, v–vi individual terms loyalty of, 15, 40, 41, 44, 48
levels (evaluation factor), iii, 26, 27, 28, relationships with, 11, 13, 14, 15, 27,
I 29, 30, 31, 33, 35, 37, 38, 39, 46, 49, 41, 48 54
51, 52 requirements of, 4, 5, 11, 13, 14, 26,
improvement 35, 41, 54
breakthrough, iv, 31, 39, 43, 47, 49,
M retention of, 14, 15, 41, 48, 51
50, 52 satisfaction of, 13, 14, 23, 24, 27, 40,
continuous, 16, 42, 43 management by fact, iii, 40, 42, 43–44 41, 44, 48, 53
cycles of, iv, 31, 38, 50 managing for innovation, iii, 40, 42, 43 support of, 4, 5, 13, 14, 15, 24, 40, 54
of health care services, 11, 12, 15, 23, maturity (organizational), vi, 6, 30, 31, performance, 51–52
ly
24, 42, 43 36, 37, 38, 39, 45, 53 financial and marketplace, 16, 17, 30,
opportunities for, vi, 21, 31, 38, 40, Measurement, Analysis, and 43, 51, 53
46, 52 Knowledge Management health care process and outcome, 51
of performance, v, vi, 1, 3, 6, 7, 8, 16, (category 4), ii, 1, 2, 3, 12, 16–18, 42,
On
improvement of, v, vi, 1, 3, 6, 7, 8, 16,
21, 23, 24, 26, 31, 37, 38, 40, 43, 44, 45 21, 23, 24, 26, 31, 37, 38, 40, 43, 44,
45, 48, 50, 51, 52 measurement of performance, iii, v, 3, 45, 48, 50, 51, 52
tools for, iv, 6, 24 12, 16, 17, 31, 38, 42, 43, 44, 45, 49 management of, v, 9, 21, 37, 38, 40,
indicators. See measures and indicators measures and indicators of 45, 50, 52
of performance performance, iii, 8, 9, 10, 12, 16, 17, measures and indicators of, iii, 8, 9,
information technology, 18, 24 19, 21, 23, 26, 27, 28, 29, 30, 31, 33, 10, 12, 16, 17, 19, 21, 23, 26, 27, 28,
e
innovation, iii, iv, v, 5, 6, 7, 8, 10, 11, 12, 36, 38, 40, 43, 44, 47, 48, 49, 50, 51, 52 29, 30, 31, 33, 36, 38, 40, 43, 44, 47,
13, 16, 18, 21, 23, 24, 26, 27, 31, 32, mission, 4, 5, 7, 21, 35, 37, 40, 45, 48, 48, 49, 50, 51, 52
34, 36, 37, 38, 40, 41, 42, 43, 44, 45, 49, 51, 54
49, 50, 52, 53, 54
Us
multiple requirements, 2, 34, 35, 37,
operational, 26, 43, 51, 53
patient- and other customer-focused,
managing for, iii, 40, 42, 43 46, 51 27, 51
integration, iii, 1, 6, 31, 33, 37, 38, 40, projections of, 10, 12, 16, 17, 19, 29,
43, 49, 50, 52 O 35, 38, 44, 51, 52, 53
intelligent risks, 7, 8, 10, 11, 21, 23, 29, workforce, 21, 43, 51
41, 43, 45, 46, 50, 53 Operations (category 6), ii, 1, 2, 3, 9, 12,
er
19, 23–25, 28, 38, 42, 46 performance excellence, v, vi, 1, 40, 45,
items (Criteria), v, 2, 3 52, 54
requirements of, 2, 4, 29, 31, 34, 35, opportunities for improvement, vi, 21,
31, 38, 40, 46, 52 physicians, 19, 41, 42, 54
37, 45, 46, 47, 48, 51 process (meaning of), iii, 31, 52
organizational learning, iii, 7, 18, 32, 33,
in
34, 38, 39, 40, 42–43, 50 Process Scoring Guidelines, 34

K organizational learning and agility, iii, processes. See also support processes;
key (meaning of), 50 40, 42–43, 51 work processes
knowledge, organizational, 10, 18, 23, Organizational Profile, iv, v, vi, 1, 2, 3, design of, 23, 47
am
26, 40, 41, 43, 45, 46 4–6, 24, 27, 31, 33, 34, 37, 38, 52 improvement of, iii, iv, 6, 23, 24, 31,
knowledge assets, 16, 18, 50 overall requirements, 2, 34, 35, 46, 51 32, 33, 34, 38, 41, 42, 43, 47, 48, 49
knowledge management, ii, 1, 3, 12, 16, management of, 23
18, 41, 42, 45, 46 P requirements for, 23, 31, 52
productivity, 8, 20, 21, 25, 26, 42, 43, 48,
partners, 5, 7, 9, 10, 11, 15, 16, 18, 24, 49, 51, 52, 53
L
Ex
25, 27, 41, 43, 44, 48, 49, 50, 51, 53, 54 projections of performance, 10, 12, 16,
leaders. See senior leaders patient (meaning of), 51. See also 17, 19, 29, 35, 38, 44, 51, 52, 53
leadership, visionary, iii, 40, 42, 46 patients and other customers
Leadership (category 1), ii, 1, 2, 3, 7–9, patient-focused excellence, iii, 40–41, R
38, 42, 45 42, 48
leadership system, v, 7, 8, 40, 50 patient safety, 5, 7, 11, 41 recruitment of workforce, 19, 47
learning, iii, iv, 6, 7, 12, 18, 21, 22, 31, patients and other customers, iii, iv, 4, regulatory and legal compliance, 8, 43,
32, 34, 36, 37, 38, 39, 41, 42, 43, 46, 5, 6, 7, 8, 9, 10, 11, 12, 13–15, 16, 17, 44, 51
47, 49, 50–51, 52, 53 18, 19, 21, 23, 24, 25, 26, 27, 29, 30, requirements
organizational, iii, 7, 18, 32, 33, 34, 31, 38, 40, 41, 42, 43, 44, 45, 48, 49, basic (item), 2, 34, 35, 47
38, 39, 40, 42–43, 50 50, 51, 52, 53, 54 for health care services, 4, 14, 23, 41
learning and development, workforce, dissatisfaction of, 13, 27, 51, 53 item, 2, 4, 29, 31, 34, 35, 37, 45, 46,
7, 12, 21, 22, 28, 38, 41, 46, 49, 50, 54 engagement of, 3, 7, 10, 11, 13, 14, 47, 48, 51
15, 27, 41, 48, 54

legal and regulatory, 4, 8, 9, 29, 43, Scoring System, 31–36 V
44, 54 segment, 4, 5, 10, 13, 14, 19, 21, 26, 27,
multiple (item), 2, 34, 35, 37, 46, 51 28, 30, 31, 38, 43, 44, 51, 52 value, iii, 7, 12, 15, 23, 24, 26, 30, 37, 40,
overall (item), 2, 34, 35, 46, 51 senior leaders, v, 3, 4, 7, 8, 9, 12, 16, 29, 41, 42, 43, 44, 49, 50, 52, 53–54
of patients and other customers, 4, 5, 40, 44, 45, 47, 49, 53, 54 delivering, iii, 40, 42, 44
11, 13, 14, 26, 35, 41, 43, 54 social media, 5, 7, 8, 11, 13, 14, 16, 17, values, 4, 5, 7, 29, 40, 44, 45, 49, 50, 54
for processes, 23, 31, 52 43, 54 valuing people, iii, 40, 41, 42, 51
resource allocation, 10, 12, 43, 53 societal responsibilities, iii, 3, 6, 7, 8, 9, vision, 4, 7, 21, 29, 40, 45, 49, 50, 54
results, 52. See also performance 11, 29, 40, 42, 43, 44, 45 visionary leadership, iii, 40, 42, 46
financial and market, 1, 3, 26, 30, 42, societal responsibility and community voice of the customer, 3, 13, 16, 40, 45,
44 health, iii, 40, 42, 44 54
health care and process, 1, 3, 23, 26, stakeholders, iii, iv, 4, 5, 7, 8, 9, 10, 24, volunteers, 5, 8, 11, 19, 22, 28, 41, 42, 54
39, 42, 44 25, 29, 40, 43, 44, 48, 49, 50, 52, 53, 54
leadership and governance, 1, 3, 7, 9, Steps toward Mature Processes, 36 W
ly
26, 29, 42, 44, 46 strategic advantages, 6, 10, 42, 53 what (meaning of), 38
patient and other customer, 1, 3, 15, strategic challenges, 6, 10, 11, 21, 48, 53 work processes, 3, 11, 12, 19, 23, 24, 25,
26, 27, 42, 44, 46 strategic objectives, 7, 8, 10, 11, 12, 16, 26, 27, 28, 38, 42, 43, 45, 46, 47, 48,
On
workforce, 1, 3, 25, 27, 41, 43, 46 17, 20, 29, 34, 38, 40, 41, 43, 47, 49, 50, 51, 54
Results (category 7), ii, 1, 2, 3, 21, 51, 53 work systems, iii, 5, 8, 10, 11, 16, 19, 22,
26–30, 31, 38, 42, 46 strategic opportunities, 10, 11, 23, 24, 24, 27, 38, 40, 42, 43, 45, 47, 48, 54
Results Scoring Guidelines, 35 43, 50, 53 workforce, ii, iii, iv, v, 1, 3, 4, 5, 6, 7, 8,
retention strategic planning process, iii, 10, 11, 9, 11, 12, 18, 19–22, 23, 24, 26, 28, 29,
patient and other customer, 14, 15, 18, 52 34, 40, 41, 42, 43, 44, 46, 47, 48, 49,
41, 48, 51 Strategy (category 2), ii, 1, 2, 3, 10–12, 50, 51, 52, 53, 54
e
workforce, 19, 20, 21 17, 19, 38, 42, 45 capability and capacity of, 8, 11, 12,
risk, 5, 7, 8, 9, 10, 11, 12, 23, 25, 29, 40, strengths, iv, vi, 9, 11, 31, 43, 52 19, 20, 28, 43, 47, 50, 54
42, 43, 45, 46, 49, 50, 53
intelligent, 7, 8, 10, 11, 21, 23, 29, 41,
Us
succession planning, 7, 8, 21, 43, 49
suppliers and supply chain, 5, 7, 8, 10,
engagement of, 3, 4, 19, 20, 21, 27,
28, 41, 44, 46, 48, 49, 54
43, 45, 46, 50, 53 11, 12, 16, 18, 23, 24, 25, 26, 27, 41, learning and development of, 7, 12,
43, 44, 46, 48, 49, 50, 53, 54 21, 22, 28, 38, 41, 46, 49, 50, 54
S support processes, 23, 26, 54 performance of, 21, 43, 51
systematic, 14, 31, 32, 34, 36, 38, 42, 43, retention and turnover of, 19, 20, 21,
safety
er
47, 53 51
of patients, 5, 7, 11, 41 systems perspective, ii, iii, vi, 1, 25, 40,
of workforce and workplace, 4, 5, 8, Workforce (category 5), ii, 1, 2, 3, 12,
42, 45 19–22, 28, 38, 42, 46
9, 21, 25, 26, 27, 29, 39, 44, 46, 54
Scoring Guidelines workforce environment, 3, 5, 8, 11,
T
in
Process, 34 19–20, 21, 40, 41, 43, 46, 48, 49, 53, 54
Results, 35 trends, iii, 17, 26, 27, 28, 29, 30, 31, 33,
35, 37, 38, 39, 44, 52, 53
am
Ex
Index of Key Terms 57

List of Contributors
The Baldrige Program thanks the following groups and individuals for contributing to the
development of the 2017–2018 Baldrige Excellence Framework.
Alliance for Performance Excellence Eric Fletcher Kevin McManus

Susan Allred Chris Gallegos Elizabeth Menzer
Deborah Ameen Dawn Garcia Sharon Muret-Wagstaff
Peggy Bailey Janice Garfield Joe Muzikowski
Jackie Beede Linda Parker Gates Gary Nesteby
ly
Michael Belter Steve George Marta Nichols
Mark Blazey Douglas Gilbert Gordon Payne
Board of Examiners of the Malcolm Brenda Grant MaryAnn Pranke
On
Baldrige National Quality Award Paul Grizzell Barry Ross
Board of Overseers of the Malcolm Baldrige Glenn Hamamura C. W. Russ Russo
National Quality Award Denise Haynes Diane Schmalensee
Glenn Bodinson Ed van den Heever Liza Nickerson Seltzer
David Boulay Deanna Herwald Doug Serrano
Sherry Bright Margot Hoffman Karen Shepard
e
Mark Graham Brown Rob Humrickhouse Denise Shields
LaWanda Burwell Barry Johnson Patricia Skriba
Bernard Carrier David Jones Jean A. Smith
Timothy Clark
Us
Judges Panel of the Malcolm Baldrige Larry Smith
Adam Cohen National Quality Award Vicki Spagnol
Sandra Cokeley Noureen Kahn Diane Springer
William Craddock Kay Kendall Paul Steel
Catherine Craver Laura Kinney Rona Suzuki
Glenn Crotty Kevin Kreitman Jack Swaim
er
David Crowell Bruce LaDuke Steven T. Thompson

Patricia Curtis Pat Lapekas Sam Turner
Kevin Dellsperger Brian Lassiter John Vinyard
in
William Denney Donald Lighter Jim Walker

Margaret Dospiljulian Brian Lindsey Brook Ward
Midge Duncan Geri Markley Paul Wilkinson
Joel Ettinger Anita Marx Jeffrey Worthington
am
Joshua Ettinger Donald McCary Suzanna Wright

Donald Fisher Mac McGuire James Youngquist
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2017–2018 Baldrige Performance Excellence Framework (Health Care)
Health Care Criteria Commentary

This commentary provides brief summaries of the Baldrige Health Care Criteria for Performance Excellence
categories and items. It also includes examples and guidance to supplement the notes that follow each item in
the Baldrige Excellence Framework (Health Care) booklet. For additional free content, and to purchase the
booklet, see https://www.nist.gov/baldrige/publications/baldrige-excellence-framework.
Organizational Profile
Your Organizational Profile provides a framework for understanding your organization. It also helps you guide and
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prioritize the information you present in response to the Health Care Criteria items in categories 1–7.
The Organizational Profile gives you critical insight into the key internal and external factors that shape your operating
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environment. These factors, such as your organization’s vision, values, mission, core competencies, competitive
environment, and strategic challenges and advantages, impact the way your organization is run and the decisions you
make. As such, the Organizational Profile helps you better understand the context in which you operate; the key
requirements for current and future success; and the needs, opportunities, and constraints placed on your management
systems.
P.1 Organizational Description
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Purpose
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This item addresses the key characteristics and relationships that shape your organizational environment. The aim is to set
the context for your organization.
Commentary
Understand your organization. The use of such terms as vision, values, mission, and core competencies varies depending on
the organization, and you may not use one or more of these terms. Nevertheless, you should have a clear understanding of
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the essence of your organization, why it exists, and where your senior leaders want to take it in the future. This clarity
enables you to make and implement strategic decisions affecting your organization’s future.
Understand your core competencies. A clear identification and thorough understanding of your organization’s core
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competencies are central to success now and in the future and to competitive performance. Executing your core
competencies well is frequently a marketplace differentiator. Keeping your core competencies current with your strategic
directions can provide a strategic advantage, and protecting intellectual property contained in your core competencies can
support your organization’s future success.
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Understand your regulatory environment. The regulatory environment in which you operate places requirements on your
organization and affects how you run it. Understanding this environment is key to making effective operational and
strategic decisions. Furthermore, it allows you to identify whether you are merely complying with the minimum
requirements of applicable laws, regulations, and standards of practice or exceeding them, a hallmark of leading
organizations and a potential source of competitive advantage.
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Identify governance roles and relationships. Role-model organizations—whether they are publicly or privately held, or
are for-profit or nonprofit—have well‐defined governance systems with clear reporting relationships. It is important to
clearly identify which functions are performed by your senior leaders and, as applicable, by your governance board and
parent organization. Board independence and accountability are frequently key considerations in the governance structure.
Understand the role of suppliers. In most organizations, suppliers play critical roles in processes that are important to
running the organization and to maintaining or achieving a sustainable competitive advantage. Supply‐chain requirements
might include accessibility, continuity of care, on-time or just-in-time delivery, flexibility, variable staffing, research and
design capability, process and health care service innovation, and customized services.
2017–2018 Baldrige Excellence Framework (Health Care): Criteria Commentary A-1

P.2 Organizational Situation
Purpose
This item asks about the competitive and collaborative environment in which your organization operates, including your
key strategic challenges and advantages. It also asks how you approach performance improvement and learning. The aim
is to help you understand your key organizational challenges and your system for establishing and preserving your
competitive advantage.
Commentary
Know your competitors. Understanding who your competitors are, how many you have, and their key characteristics is
essential for determining your competitive advantage in the health care industry and marketplace. Leading organizations
have an in‐depth understanding of their current competitive environment, including key changes taking place.
Sources of comparative and competitive data might include external organizations (e.g., the Centers for Medicare and
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Medicaid Services [CMS], the National Committee for Quality Assurance [NCQA], and the Joint Commission); health care
industry journals and other publications; benchmarking activities; annual reports for publicly traded companies and public
organizations; conferences; local networks; and industry associations. Particularly in areas related to patient and other
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customer satisfaction, staff satisfaction, and organizational effectiveness (e.g., cycle time), comparative data can also be
obtained from organizations outside the health care sector.
Know your strategic challenges. Operating in today’s highly competitive marketplace means facing strategic challenges
that can affect your ability to sustain performance and maintain your competitive position. These challenges might include
the following:
 Your operational costs (e.g., pharmaceuticals, labor, or medical technology)
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 Expanding or decreasing markets
 Mergers or acquisitions by your organization and your competitors
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Economic conditions, including fluctuating demand and local and global economic downturns
Needs for public health and bioterrorism preparedness
 Compliance with the Health Insurance Portability and Accountability Act (HIPAA)
 The introduction of new or substitute health care services
 Rapid technological changes
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 Data and information security, including cybersecurity
 New competitors entering the market
 The availability of a skilled workforce
 The retirement of an aging workforce
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Know your strategic advantages. Understanding your strategic advantages is as important as understanding your
strategic challenges. They are the sources of competitive advantage to capitalize on and grow while you continue to
address key challenges. These advantages might include the following:
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 Reputation for health care service quality

 Innovation leadership
 Customer service recognition
 Brand recognition
 Agility
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 Supply-chain integration
 Price leadership
 Environmental (“green”) stewardship
 Societal responsibility and community involvement
Prepare for disruptive technologies. A particularly significant challenge, if it occurs to your organization, is being
unprepared for a disruptive technology that threatens your competitive position or your marketplace. In the past, such
technologies have included magnetic resonance imaging replacing myelograms; laparoscopic surgery replacing more
invasive types of surgery; and e-mail, social media, and smart phones challenging all other means of communication.
Today, organizations need to be scanning the environment inside and outside the health care industry to detect such
challenges at the earliest possible point in time.

Leadership (Category 1)
This category asks how senior leaders’ personal actions and your governance system guide and sustain your organization.
1.1 Senior Leadership

Purpose
This item asks about the key aspects of your senior leaders’ responsibilities, with the aim of creating an organization that is
successful now and in the future.
Commentary
The role of senior leaders. Senior leaders play a central role in setting values and directions, communicating, creating and
balancing value for all stakeholders, and creating an organizational focus on action, including transformational change in
the organization’s structure and culture, when needed. Success requires a strong orientation to the future; an
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understanding that risk is a part of planning and conducting operations; a commitment to improvement, innovation, and
intelligent risk taking; and a focus on organizational sustainability. Increasingly, this requires creating an environment for
empowerment, agility, and learning. In health care organizations with separate administrative/operational and health care
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leadership, an important aspect of leadership is the relationship between and the collaboration of these two sets of leaders.
Role-model senior leaders. In highly respected organizations, senior leaders are committed to establishing a culture of
patient and other customer engagement, developing the organization’s future leaders, and recognizing and rewarding
contributions by workforce members. They personally engage with patients and other key customers. Senior leaders
enhance their personal leadership skills. They participate in organizational learning, the development of future leaders,
succession planning, and recognition opportunities and events that celebrate the workforce. Development of future leaders
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might include personal mentoring, coaching, or participation in leadership development courses. Role-model leaders
recognize the need for transformational change when warranted and then lead the effort through to full fruition. They
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demonstrate authenticity, admit to missteps, and demonstrate accountability for the organization’s actions.
1.2 Governance and Societal Responsibilities

Purpose
This item asks about key aspects of your governance system, including the improvement of leaders and the leadership
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system. It also asks how the organization ensures that everyone in the organization behaves legally and ethically, how it
fulfills its societal responsibilities, how it supports its key communities, and how it builds community health.
Commentary
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Organizational governance. This item addresses the need for a responsible, informed, transparent, and accountable
governance or advisory body that can protect the interests of key stakeholders in publicly traded, private, and nonprofit
organizations. This body should have independence in review and audit functions, as well as a function that monitors
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organizational, CEOs’/chief administrators’, and medical staff leaders’ performance.

Legal compliance, ethics, and risks. An integral part of health care delivery, performance management, and performance
improvement is proactively addressing (1) the need for ethical behavior; (2) all legal, regulatory, and accreditation
requirements; and (3) risk factors. Ensuring high performance in these areas requires establishing appropriate measures or
indicators that senior leaders track. You should be sensitive to issues of public concern, whether or not these issues are
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currently embodied in laws and regulations. Role‐model organizations look for opportunities to excel in areas of legal and
ethical behavior. Role‐model organizations also recognize the need to accept risk, identify appropriate levels of risk for the
organization, and make and communicate policy decisions on risk.
Public concerns. Public concerns that charitable and government organizations should anticipate might include the cost of
programs and operations, timely and equitable access to their offerings, and perceptions about their stewardship of
resources.
Conservation of natural resources. Conservation might be achieved through the use of “green” technologies, reduction of
your carbon footprint, replacement of hazardous chemicals with water‐based chemicals, energy conservation, use of
cleaner energy sources, or recycling of by‐products or wastes.
Societal responsibility. Societal responsibility implies going beyond a compliance orientation. Opportunities to contribute
to the well-being of environmental, social, and economic systems and opportunities to support key communities are

available to organizations of all sizes. The level and breadth of these contributions will depend on the size of your
organization and your ability to contribute. Increasingly, decisions to engage with an organization include consideration of
its social responsibility.
Community support. Your organization should consider areas of community involvement that are related to its core
competencies. Examples of organizational community involvement include partnering with other health care providers,
businesses, and professional associations to engage in beneficial, cooperative activities, such as increasing equity and
access to care and sharing best practices to improve overall U.S. health status and health care.
Community health. Actions to build community health might include partnering with local organizations (public entities
and businesses) and health care providers. The community health services you offer will depend on your mission,
including the service requirements of tax-exempt organizations.
Strategy (Category 2)
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This category asks how you develop strategic objectives and action plans, implement them, change them if circumstances
require, and measure progress.
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The category stresses that your organization’s long‐term organizational success and competitive environment are key
strategic issues that need to be integral parts of your overall planning. Making decisions about your organization’s core
competencies and work systems is an integral part of ensuring your organization’s success now and in the future, and
these decisions are therefore key strategic decisions.
While many organizations are increasingly adept at strategic planning, executing plans is still a significant challenge. This
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is especially true given market demands to be agile and be prepared for unexpected change, such as volatile economic
conditions or disruptive technologies that can upset an otherwise fast‐paced but more predictable marketplace. This
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category highlights the need to focus not only on developing your plans, but also on your capability to execute them.
The Baldrige framework emphasizes three key aspects of organizational excellence that are important to strategic planning:
 Patient-focused excellence is a strategic view of excellence. The focus is on the drivers of customer engagement,
patient health status, new markets, and market share—key factors in competitiveness and long-term
organizational success.
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 Operational performance improvement and innovation contribute to short‐ and longer‐term productivity growth
and cost containment. Building operational capability—including speed, responsiveness, and flexibility—is an
investment in strengthening your organizational fitness.
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Organizational learning and learning by workforce members are necessary strategic considerations in today’s
fast‐paced environment. The Health Care Criteria emphasize that improvement and learning need to be
embedded in work processes. The special role of strategic planning is to align work systems and learning
initiatives with your organization’s strategic directions, thereby ensuring that improvement and learning prepare
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you for and reinforce organizational priorities.

This category asks how you
 consider key elements of risk in your strategic planning process, including strategic opportunities, challenges, and
advantages, and the potential need for transformational change in organizational structure or culture;

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optimize the use of resources, ensure the availability of a skilled workforce, and bridge short‐ and longer‐term
requirements that may entail capital expenditures, technology development or acquisition, supplier development,
and new health care partnerships or collaborations; and
 ensure that implementation will be effective—that there are mechanisms to communicate requirements and
achieve alignment on three levels: (1) the organization and executive level, (2) the key work system and work
process level, and (3) the work unit and individual job level.
The requirements in this category encourage strategic thinking and acting in order to develop a basis for a distinct
competitive and collaborative position in the marketplace. These requirements do not imply the need for formal planning
departments, specific planning cycles, or a specified way of visualizing the future. They do not imply that all your
improvements could or should be planned in advance. An effective improvement system combines improvements of many
types and degrees of involvement. This requires clear strategic guidance, particularly when improvement alternatives,

including major change or innovation, compete for limited resources. In most cases, setting priorities depends heavily on a
cost, opportunity, and threat rationale. However, you might also have critical requirements, such as the incorporation of
new health care technology and community health or other societal responsibilities, that are not driven by cost
considerations alone.
2.1 Strategy Development

Purpose
This item asks how you establish a strategy to address your organization’s challenges and leverage its advantages and how
you make decisions about key work systems and core competencies. It also asks about your key strategic objectives and
their related goals. The aim is to strengthen your overall performance, competitiveness, and future success.
Commentary
A context for strategy development. This item calls for basic information on the planning process and for information on
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all key influences, risks, challenges, and other requirements that might affect your organization’s future opportunities and
directions—taking as long term a view as appropriate and possible from the perspectives of your organization, the health
care industry, and your marketplace. This approach is intended to provide a thorough and realistic context for developing
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a patient-, other customer-, and market-focused strategy to guide ongoing decision making, resource allocation, and overall
management.
A future-oriented basis for action. This item is intended to cover all types of health care organizations,
competitive/collaborative situations, strategic issues, planning approaches, and plans. The requirements explicitly call for a
future‐oriented basis for action. Even if your organization is seeking to create an entirely new health care service or
business, you still need to set and test the objectives that define and guide critical actions and performance.
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Competitive leadership. This item emphasizes competitive leadership in health care services, which usually depends on
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operational effectiveness. Competitive leadership requires a view of the future that includes not only the markets in which
you provide health care services but also how it competes and collaborates in providing services. How to compete and
collaborate presents many options and requires that you understand your organization’s and your competitors’ and
collaborators’ strengths and weaknesses. Deciding how to compete and collaborate also involves decisions on taking
intelligent risks in order to gain or retain market leadership. Although no specific time horizons are included, the thrust of
this item is sustained competitive leadership.
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Work systems. Efficient and effective work systems require

 effective design;
 a prevention orientation;
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 linkage to patients, other customers, suppliers, partners, and collaborators; and

 a focus on value creation for all key stakeholders; operational performance improvement; cycle time reduction;
and evaluation, continuous improvement, innovation, and organizational learning; and
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 regular review to evaluate the need for fundamental changes in the way work is accomplished.
Work systems must also be designed in a way that allows your organization to be agile and protect intellectual property. In
the simplest terms, agility is the ability to adapt quickly, flexibly, and effectively to changing requirements. Depending on
the nature of your strategy and markets, agility might mean the ability to change rapidly from one health care service to
another, adopt a new technology or treatment protocol, respond rapidly to changing demands or market conditions,
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respond rapidly to payor requirements, or produce a wide range of customized services. Agility and protection of
intellectual property also increasingly involve decisions to outsource, agreements with key suppliers, and novel partnering
arrangements.
2.2 Strategy Implementation

Purpose
This item asks how you convert your strategic objectives into action plans to accomplish the objectives and how you assess
progress relative to these action plans. The aim is to ensure that you deploy your strategies successfully and achieve your
goals.

Commentary
Developing and deploying action plans. Accomplishing action plans requires resources and performance measures, as
well as alignment among the plans of your departments/work units, suppliers, and partners. Of central importance is how
you achieve alignment and consistency—for example, via work systems, work processes, and key measurements. Also,
alignment and consistency provide a basis for setting and communicating priorities for ongoing improvement activities—
part of the daily work of all departments/work units. In addition, performance measures are critical for tracking
performance.
Performing analyses to support resource allocation. You can perform many types of analyses to ensure that financial
resources are available to support the accomplishment of your action plans while you meet current obligations. For current
operations, these efforts might include the analysis of cash flows, net income statements, and current liabilities versus
current assets. For investments to accomplish action plans, the efforts might include analysis of discounted cash flows,
return on investment, or return on invested capital.
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Analyses also should evaluate the availability of people and other resources to accomplish your action plans while
continuing to meet current obligations. Financial resources must be supplemented by capable people and the necessary
facilities and support.
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The specific types of analyses performed will vary from organization to organization. These analyses should help you
assess the financial viability of your current operations and the potential viability of and risks associated with your action
plan initiatives.
Creating workforce plans. Action plans should include human resource or workforce plans that are aligned with and
support your overall strategy. Examples of possible plan elements are
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 a redesign of your work organization and jobs to increase workforce empowerment and decision making;
 initiatives to promote greater labor‐management cooperation, such as union partnerships;
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consideration of the impacts of outsourcing on your current workforce and initiatives;
initiatives to prepare for future workforce capability and capacity needs;
 initiatives to foster knowledge sharing and organizational learning;
 modification of your compensation and recognition systems to recognize team, organizational, patient, other
customer, or other performance attributes; and

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education and training initiatives, such as developmental programs for future leaders, partnerships with
universities to help ensure the availability of an educated and skilled workforce, and training programs on new
technologies important to the future success of your workforce and organization.
Projecting your future environment. An increasingly important part of strategic planning is projecting the future
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competitive and collaborative environment. This includes the ability to project your own future performance, as well as
that of your competitors. Such projections help you detect and reduce competitive threats, shorten reaction time, and
identify opportunities. Depending on your organization’s size and type, the potential need for new core competencies, the
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maturity of markets, the pace of change, and competitive parameters (e.g., costs or the innovation rate), you might use a
variety of modeling, scenarios, or other techniques and judgments to anticipate the competitive and collaborative
environment.
Projecting and comparing your performance. Projections and comparisons in this item are intended to improve your
organization’s ability to understand and track dynamic, competitive performance factors. Projected performance might
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include changes resulting from new business ventures, entry into new markets, the introduction of new technologies,
service innovations, or other strategic thrusts that might involve a degree of intelligent risk.
Through this tracking, you should be better prepared to take into account your organization’s rate of improvement and
change relative to that of competitors or comparable organizations and relative to your own targets or stretch goals. Such
tracking serves as a key diagnostic tool for you to use in deciding to start, accelerate, or discontinue initiatives and to
implement needed organizational change.

Customers (Category 3)
This category asks how you engage patients and other customers for long‐term marketplace success, including how you
listen to the voice of the customer, serve and exceed patients’ and other customers’ expectations, and build relationships
with patients and other customers.
The category stresses customer engagement as an important outcome of an overall learning and performance excellence
strategy. Your satisfaction and dissatisfaction results for patients and other customers provide vital information for
understanding your patients, your other customers, and the marketplace. In many cases, the voice of the customer
provides meaningful information not only on your patients’ and other customers’ views but also on their marketplace
behaviors and on how these views and behaviors may contribute to your organization’s current and future success in the
marketplace.
Throughout the Health Care Criteria, patients are referred to specifically to stress their importance to health care
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organizations. The item requirements also refer to other customers to ensure that your customer focus and performance
management system include all customers. Other customers might include patients’ families, the community, insurers and
other third-party payors, employers, health care providers, patient advocacy groups, departments of health, and students.
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A key challenge to health care organizations may be balancing the differing expectations of patients and other customers.
3.1 Voice of the Customer

Purpose
This item asks about your processes for listening to your patients and other customers and determining their satisfaction
and dissatisfaction. The aim is to capture meaningful information in order to exceed your patients’ and other customers’
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expectations.
Commentary
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Customer listening. Selection of voice-of-the-customer strategies depends on your organization’s key business factors.
Most organizations listen to the voice of the customer via multiple modes. Some frequently used modes include focus
groups with patients and other key customers, close integration with patients and other key customers, interviews with
lost and potential patients and other customers about their health care purchasing or relationship decisions, comments
posted on social media by patients and other customers, win/loss analysis relative to competitors and other organizations
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providing similar health care services, and survey or feedback information.
Actionable information. This item emphasizes how you obtain actionable information from patients and other customers.
Information is actionable if you can tie it to key health care service offerings and business processes and use it to determine
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the cost and health care quality implications of setting particular improvement goals and priorities for change.
Listening/learning and organizational strategy. In a rapidly changing technological, competitive, economic, and social
environment, many factors may affect patients’ and other customers’ expectations and loyalty and your interface with
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patients and other customers in the marketplace. This makes it necessary to continually listen and learn. To be effective,
listening and learning need to be closely linked with your overall organizational strategy.
Social media. Customers are increasingly turning to social media to voice their impressions of your health care services
and patient and other customer support. They may provide this information through social interactions you mediate or
through independent or customer‐initiated means. All of these can be valuable sources of information for your
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organization. Negative commentary can be a valuable source for improvement, innovation, and immediate service
recovery. Organizations need to become familiar with vehicles for monitoring and tracking this information.
Customer and market knowledge. Knowledge of patients and other customers, patient and other customer groups, market
segments, former patients and other customers, and potential patients and other customers allows you to tailor health care
service offerings, support and tailor your marketing strategies, develop a more patient- and other customer-focused
workforce culture, gain patients and other customers, evolve your brand image, and ensure long-term organizational
success.
Customers’ satisfaction with competitors. A key aspect of determining patients’ and other customers’ satisfaction and
dissatisfaction is determining their comparative satisfaction with competitors, competing or alternative health care service
offerings, and/or organizations providing similar health care services. Such information might be derived from your own
comparative studies or from independent studies. The factors that lead to patients’ and other customers’ preference are

critically important in understanding factors that drive health care markets and potentially affect your organization’s
longer‐term competitiveness and success.
3.2 Customer Engagement

Purpose
This item asks about your processes for determining and customizing health care service offerings that serve your patients,
other customers, and markets; for enabling patients and other customers to seek information and support; and for
identifying patient and other customer groups and market segments. The item also asks how you build relationships with
your patients and other customers and manage complaints. The aim of these efforts is to improve marketing, build a more
patient- and other customer-focused culture, and enhance patient and other customer loyalty.
Commentary
Engagement as a strategic action. Customer engagement is a strategic action aimed at achieving such a degree of loyalty
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that the patient or other customer will advocate for your brand and health care service offerings. Achieving such loyalty
requires a patient- and other customer-focused culture in your workforce based on a thorough understanding of your
business strategy and your patients’ and other customers’ behaviors and preferences.
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Customer relationship strategies. A relationship strategy may be possible with some patients and other customers but not
with others. The relationship strategies you do have may need to be distinctly different for each patient group, customer
group, and market segment. They may also need to be distinctly different during the different stages of patients’ and other
customers’ relationships with you.
Brand management. Brand management is aimed at positioning your health care service offerings in the marketplace.
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Effective brand management leads to improved brand recognition and customer loyalty. Brand management is intended to
build patients’ and other the customers’ emotional attachment for the purpose of differentiating yourself from the
competition and building loyalty.
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Complaint management. Complaint aggregation, analysis, and root‐cause determination should lead to effective
elimination of the causes of complaints and to the setting of priorities for process and health care service improvements.
Successful outcomes require effective deployment of information throughout your organization.
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Measurement, Analysis, and Knowledge Management (Category 4)
In the simplest terms, category 4 is the “brain center” for the alignment of your operations with your strategic objectives. It
is the main point within the Health Care Criteria for all key information on effectively measuring, analyzing, and
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improving performance and managing organizational knowledge to drive improvement, innovation, and organizational
competitiveness. Central to this use of data and information are their quality and availability. Furthermore, since
information, analysis, and knowledge management might themselves be primary sources of competitive advantage and
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productivity growth, this category also includes such strategic considerations.
4.1 Measurement, Analysis, and Improvement of Organizational Performance

Purpose
This item asks how you select and use data and information for performance measurement, analysis, and review in
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support of organizational planning and performance improvement. The item serves as a central collection and analysis
point in an integrated performance measurement and management system that relies on clinical, financial, and other data
and information. The aim of performance measurement, analysis, review, and improvement is to guide your process
management toward the achievement of key organizational results and strategic objectives, anticipate and respond to rapid
or unexpected organizational or external changes, and identify best practices to share.
Commentary
Aligning and integrating your performance management system. Alignment and integration are key concepts for
successfully implementing and using your performance measurement system. The Health Care Criteria view alignment
and integration in terms of how widely and how effectively you use that system to meet your needs for organizational
performance assessment and improvement and to develop and execute your strategy.

Alignment and integration include how measures are aligned throughout your organization and how they are integrated
to yield organization‐wide data and information. Organization-wide data and information are key inputs to organizational
performance reviews and strategic decision making. Alignment and integration also include how your senior leaders
deploy performance measurement requirements to track departmental, work group, and process‐level performance on key
measures that are targeted for their organization‐wide significance or for improvement.
The case for comparative data. The use of comparative data and information is important to all organizations. The major
premises for their use are the following:
 Your organization needs to know where it stands relative to competitors and to best practices.
 Comparative information and information obtained from benchmarking often provide the impetus for significant
(“breakthrough”) improvement or transformational change.
 Comparing performance information frequently leads to a better understanding of your processes and their
performance.
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 Comparative performance projections and competitors’ performance may reveal organizational advantages as
well as challenge areas where innovation is needed.
Comparative information may also support organizational analysis and decisions relating to core competencies,
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partnering, and outsourcing.
Selecting and using comparative data. Effective selection and use of comparative data and information require you to
determine needs and priorities and establish criteria for seeking appropriate sources for comparisons—from within and
outside the health care industry and your markets.
Comparative data might include data from similar organizations or health care industry benchmarks. Local or national
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sources of such data might include
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other organizations through sharing or contributing to external reference databases (e.g., indicator projects),
the open literature (e.g., outcomes of research studies and practice guidelines), and
 independent organizations (e.g., CMS, accrediting organizations such as the NCQA and the Joint Commission,
and commercial organizations) that gather and evaluate data.
Effective use of comparative data and information allows you to set stretch goals and to promote major nonincremental
(“breakthrough”) improvements in areas most critical to your competitive strategy.
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Reviewing performance. The organizational review called for in this item is intended to cover all areas of performance.
This includes not only current performance but also projections of your future performance. The expectation is that the
review findings will provide a reliable means to guide both improvements and opportunities for innovation that are tied to
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your key objectives, core competencies, and measures of success. Review findings may also alert you to the need for
transformational change in your organization’s structure and work systems. Therefore, an important component of your
organizational review is the translation of the review findings into actions that are deployed throughout your organization
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and to appropriate suppliers, partners, collaborators, and key customers.

Analyzing performance. Analyses that you conduct to gain an understanding of performance and needed actions may
vary widely depending on your organization’s type, size, competitive environment, and other factors. Here are some
examples of possible analyses:
 How health care service improvements or new health care services correlate with key patient and other customer
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indicators, such as satisfaction, loyalty, and market share

 Return on investment for intelligent risks that you pursue
 Cost and revenue implications of patient- and other customer-related problems and effective problem resolution
 Interpretation of market share changes in terms of gains and losses in patients and other customers and changes in
their engagement
 Trends in key operational performance indicators, such as productivity, cycle time, waste reduction, utilization
rates, error rates, and cost per case
 Relationships among learning by workforce members, organizational learning, and the value added per staff
member
 Financial benefits derived from improvements in workforce capacity, safety, absenteeism, and turnover
 Benefits and costs associated with education and training

 Benefits and costs associated with improved organizational knowledge management and sharing
 The relationship between knowledge management and innovation
 How the ability to identify and meet workforce capability and capacity needs correlates with retention,
motivation, and productivity
 Cost and revenue implications of workforce‐related problems and effective problem resolution
 Individual or aggregate measures of productivity and quality relative to competitors’ performance
 Cost trends relative to competitors’ trends
 Compliance with preventive screenings compared with that of similar health care providers
 Relationships among health care service quality, operational 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
environmental and societal impact
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 Net earnings or savings derived from improvements in quality, operational, and workforce performance
 Comparisons among cost centers showing how quality and operational performance affect financial performance
(e.g., impacts of health maintenance organization [HMO] preventive care versus diagnostic expenses and
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treatment of potentially preventable illnesses)
 Contributions of improvement activities to cash flow, working capital use, and shareholder value
 Impacts of patient and other customer loyalty on profit
 Cost and revenue implications of entry into new health care markets, including service-line and geographic
expansion
 Market share versus profits
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 Trends in economic, market, and stakeholder indicators of value and the impact of these trends on long-term
organizational success
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Aligning analysis, performance review, and planning. Individual facts and data do not usually provide an effective basis
for setting organizational priorities. This item emphasizes the need for close alignment between your analysis and your
organizational performance review and between your performance review and your organizational planning. This ensures
that analysis and review are relevant to decision making and that decisions are based on relevant data and information. In
addition, your historical performance, combined with assumptions about future internal and external changes, allows you
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to develop performance projections. These projections may serve as a key planning tool.
Understanding causality. Action depends on understanding causality among processes and between processes and
results. Process actions and their results may have many resource implications. Organizations have a critical need to
provide an effective analytical basis for decisions because resources for innovation and improvement are limited.
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4.2 Information and Knowledge Management

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Purpose
This item asks how you build and manage your organization’s knowledge assets and ensure the quality and availability of
data and information. The aim of this item is to improve organizational efficiency and effectiveness and stimulate
innovation.
Commentary
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Information management. Managing information can require a significant commitment of resources as the sources of data
and information grow dramatically. The continued growth of information within organizations’ operations—as part of
organizational knowledge networks, through the web and social media, in organization-to-organization communications,
and in electronic communication/information transfer—challenges organizations’ ability to ensure reliability and
availability in a user‐friendly format. In addition, the ability to blend and correlate disparate types of data, such as video,
text, and numbers, provides opportunities for a competitive advantage.
Data and information quality and availability. Data and information are especially important in organizational networks,
partnerships, and supply chains. You should take into account this use of data and information and recognize the need for
rapid data validation and quality assurance.,

Knowledge management. The focus of your knowledge management is on the knowledge that your people need to do
their work; improve processes and health care services; and innovate to add value for patients, other customers, and your
organization.
Your organization’s knowledge management system should provide the mechanism for sharing your people’s and your
organization’s knowledge to ensure that high performance is maintained through transitions. You should determine what
knowledge is critical for your operations and then implement systematic processes for sharing this information. This is
particularly important for implicit knowledge (i.e., knowledge personally retained by workforce members).
Organizational learning. One of the many issues facing organizations today is how to manage, use, evaluate, and share
their ever‐increasing organizational knowledge. Leading organizations benefit from the knowledge assets of their
workforce, customers, suppliers, collaborators, and partners, who together drive organizational learning and innovation.
Workforce (Category 5)
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This category addresses key workforce practices—those directed toward creating and maintaining a high‐performance
environment and toward engaging your workforce to enable it and your organization to adapt to change and succeed.
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To reinforce the basic alignment of workforce management with overall strategy, the Health Care Criteria also cover
workforce planning as part of overall strategic planning in category 2.
5.1 Workforce Environment

Purpose
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This item asks about your workforce capability and capacity needs, how you meet those needs to accomplish your
organization’s work, and how you ensure a supportive work climate. The aim is to build an effective environment for
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accomplishing your work and supporting your workforce.
Commentary
Workforce capability and capacity. Many organizations confuse the concepts of capability and capacity by adding more
people with incorrect skills to compensate for skill shortages or by assuming that fewer highly skilled workers can meet
capacity needs for processes requiring less skill or different skills but more people to accomplish. Having the right number
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of workforce contributors with the right skill set is critical to success. Looking ahead to predict those needs for the future
allows for adequate training, hiring, relocation times, and preparation for work system changes.
Workforce support. Most organizations, regardless of size, have many opportunities to support their workforce. Some
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examples of services, facilities, activities, and other opportunities are personal and career counseling; career development
and employability services; recreational or cultural activities; formal and informal recognition; non‐work‐related
education; child and elder care; special leave for family responsibilities and community service; flexible work hours and
benefits packages; outplacement services; and retiree benefits, including ongoing access to services.
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Workforce groups. In some health care organizations, the variety of workforce groups—such as paid staff, independent
practitioners, volunteers, and students—contributing to delivering the organization’s services is a challenge. You should
consider each of these groups in responding to this category.
5.2 Workforce Engagement

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Purpose
This item asks about your systems for managing workforce performance and developing your workforce members to
enable and encourage all of them to contribute effectively and to the best of their ability. These systems are intended to
foster high performance, to address your core competencies, and to help accomplish your action plans and ensure your
organization’s success now and in the future.
Commentary
High performance. The focus of this item is on a workforce capable of achieving high performance. High performance is
characterized by flexibility, innovation, empowerment and personal accountability, knowledge and skill sharing, good
communication and information flow, alignment with organizational objectives, customer focus, and rapid response to
changing organizational needs and health care marketplace requirements.

Workforce engagement and performance. Many studies have shown that high levels of workforce engagement have a
significant, positive impact on organizational performance. Research has indicated that engagement is characterized by
performing meaningful work; having clear organizational direction and accountability for performance; and having a safe,
trusting, effective, and cooperative work environment. In many organizations, employees and volunteers are drawn to and
derive meaning from their work because it is aligned with their personal values. In health care organizations, workforce
engagement also depends on building and sustaining relationships between administrative/operational leaders and
independent practitioners.
Drivers of workforce engagement. Although satisfaction with pay and pay increases are important, these two factors
generally are not sufficient to ensure workforce engagement and high performance. Some examples of other factors to
consider are effective problem and grievance resolution; development and career opportunities; the work environment and
management support; workplace safety and security; the workload; effective communication, cooperation, and teamwork;
the degree of empowerment; job security; appreciation of the differing needs of diverse workforce groups; and
organizational support for serving patients and other customers.
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Factors inhibiting engagement. It is equally important to understand and address factors inhibiting engagement. You
could develop an understanding of these factors through workforce surveys, focus groups, blogs, or exit interviews with
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departing workforce members.
Compensation and recognition. Compensation and recognition systems should be matched to your work systems. To be
effective, compensation and recognition might be tied to demonstrated skills, peer evaluations, and/or collaboration among
departments and health care practitioners. Compensation and recognition approaches also might include profit sharing;
mechanisms for expressing simple “thank-yous”; rewards for exemplary team or unit performance; and linkage to patient
and other customer engagement measures, achievement of organizational strategic objectives, or other key organizational
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Other indicators of workforce engagement. In addition to direct measures of workforce engagement through formal or
informal surveys, other indicators include absenteeism, turnover, grievances, and strikes.
Workforce development needs. Depending on the nature of your organization’s health care services, workforce
responsibilities, and stage of organizational and personal development, workforce development needs might vary greatly.
These needs might include participating in continuing clinical education and gaining skills for knowledge sharing,
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communication, teamwork, and problem solving; interpreting and using data; exceeding patients’ and other customers’
requirements; analyzing and simplifying processes; reducing waste and cycle time; applying HIPAA regulations and
concepts in daily work; working with and motivating volunteers; and setting priorities based on strategic alignment or
cost‐benefit analysis.
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Education needs might also include advanced skills in new technologies or basic skills, such as reading, writing, language,
arithmetic, and computer skills.
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Learning and development locations and formats. Learning and development opportunities might occur inside or outside
your organization and could involve on‐the‐job, classroom, e‐learning, or distance learning, as well as developmental
assignments, coaching, or mentoring.
Individual learning and development needs. To help people realize their full potential, many organizations prepare an
individual development plan with each person that addresses his or her career and learning objectives and desires.
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Customer contact training. Although this item does not specifically ask you about training staff members who have direct
contact with patients and other customers, such training is important and common. It frequently includes gaining critical
skills and knowledge about your health care services, your patients and other customers, how to listen to them, how to
recover from problems or failures, and how to effectively manage and exceed patients’ and other customers’ expectations.
Learning and development effectiveness. Measures to evaluate the effectiveness and efficiency of your workforce and
leader development and learning systems might address the impact on individual, departmental/unit, and organizational
performance; the impact on patient- and other customer-related performance; and costs versus benefits.

Operations (Category 6)
This category asks how you focus on your organization’s work, the design and delivery of health care services, innovation,
and operational effectiveness to achieve organizational success now and in the future.
6.1 Work Processes

Purpose
This item asks about the management of your key health care services, your key work processes, and innovation, with the
aim of creating value for your patients and other customers and achieving current and future organizational success.
Commentary
Work process requirements. Your design approaches could differ appreciably depending on the nature of your health care
service offerings—whether they are entirely new, are variants, are customized, or involve major or minor work process
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changes. Your design approaches should consider the key requirements for your services. Factors that you might need to
consider in work process design include desired health care outcomes; safety and risk management; timeliness of, access
to, coordination of, and continuity of care; patient involvement in care decisions; variability in patients’ and other
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customers’ expectations of health care service options; environmental impact, your carbon footprint, and use of “green”
technology; measurement capability; process capability; availability of referral sources; supplier capability; technology;
facility capacity or utilization; regulatory requirements; and documentation.
Effective design must also consider the cycle time and productivity of health care service delivery processes. This might
involve detailed mapping of service delivery processes and the redesign (“reengineering”) of those processes to achieve
efficiency, as well as to meet changing patient and other customer requirements.
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Key health care service-related and business processes. Your key work processes include your health care service-related
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processes and those business processes that your senior leaders consider important to organizational success and growth.
These processes frequently relate to your organization’s core competencies, strategic objectives, and critical success factors.
Key health care processes might include assessment, screening, treatment, and therapy. Key business processes might
include physician integration, research and development, technology acquisition, information and knowledge
management, supply-chain management, supplier partnering, outsourcing, mergers and acquisitions, project management,
and sales and marketing. Given the diverse nature of these processes, the requirements and performance characteristics
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might vary significantly for different processes.
Work process design. Many organizations need to consider requirements for suppliers, partners, and collaborators at the
work process design stage. Overall, effective design must take into account all stakeholders in the continuum of care.
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If many design projects are carried out in parallel or if your organization’s health care services use equipment and facilities
that are used for other services, coordination of resources might be a major concern, but it might also offer a means to
significantly reduce costs and time to design and implement new services.
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In‐process measures. This item refers specifically to in‐process measurements. These measurements require you to identify
critical points in processes for measurement and observation. These points should occur as early as possible in processes to
minimize problems and costs that may result from deviations from expected performance.
Process performance. Achieving expected process performance frequently requires setting in‐process performance levels
or standards to guide decision making. When deviations occur, corrective action is required to restore the performance of
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the process to its design specifications. Depending on the nature of the process, the corrective action could involve
technology, people, or both. Proper corrective action involves changes at the source (root cause) of the deviation and
should minimize the likelihood of this type of variation occurring again or elsewhere in your organization.
When interactions with patients or other customers are involved, evaluation of how well the process is performing must
consider differences among patient and other customer groups. This might entail allowing for specific or general
contingencies, depending on the patient or other customer information gathered. In some organizations, cycle times for key
processes may be a year or longer, which may create special challenges in measuring day‐to‐day progress and identifying
opportunities for reducing cycle times, when appropriate.
Key support processes. Your key work processes include those processes that support your daily operations and the
delivery of your health care services but are not usually designed in detail with them. Support process requirements do not

usually depend significantly on health care service characteristics. Such requirements usually depend significantly on
internal requirements, and they must be coordinated and integrated to ensure efficient and effective linkage and
performance. Support processes might include processes for housekeeping, medical records, finance and accounting,
facilities management, legal services, human resource services, public and community relations, and other administrative
services.
Patient expectations. Critical to patient-focused delivery of health care are the consideration of patient expectations, the
setting of realistic patient expectations for likely health care outcomes, and the opportunity for patients to participate in
making informed decisions about their own health care.
Process improvement. This item calls for information on how you improve processes to achieve better performance. Better
performance means not only better quality from your patients’ and other customers’ perspectives, but also better financial
and operational performance—such as productivity—from your other stakeholders’ perspectives. A variety of process
improvement approaches are commonly used. Examples include
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 using the results of organizational performance reviews;
 sharing successful strategies across your organization to drive learning and innovation;
 performing process analysis and research (e.g., process mapping, optimization experiments, error proofing);
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 conducting technical and business research and development;
 using quality improvement tools like Lean, Six Sigma, and Plan‐Do‐Check‐Act (PDCA);
 benchmarking;
 using alternative technology; and
 using information from customers of the processes—within and outside your organization.
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Process improvement approaches might use financial data to evaluate alternatives and set priorities. Together, these
approaches offer a wide range of possibilities, including a complete redesign (“reengineering”) of processes.
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Supply‐chain management. For many organizations, supply‐chain management has become a key factor in achieving
productivity and profitability goals and overall organizational success. Suppliers, partners, and collaborators are receiving
increasing strategic attention as organizations reevaluate their core competencies. Supplier processes should fulfill two
purposes: to help improve the performance of suppliers and partners and to help them contribute to improving your
overall operations. Supply‐chain management might include processes for selecting suppliers, with the aim of reducing the
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total number of suppliers and increasing preferred supplier and partner agreements.
Innovation management. In an organization that has a supportive environment for innovation, there are likely to be many
more ideas than the organization has resources to pursue. This leads to two critical decision points in the innovation cycle:
(1) commensurate with resources, prioritizing opportunities to pursue those opportunities with the highest likelihood of a
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return on investment (intelligent risks) and (2) knowing when to discontinue projects and reallocate the resources either to
further development of successful projects or to new projects.
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6.2 Operational Effectiveness

Purpose
This item asks how you ensure effective operations in order to have a safe workplace environment and deliver customer
value. Effective operations frequently depend on controlling the overall costs of your operations and maintaining the
reliability, security, and cybersecurity of your information systems.
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Commentary
Cost control. Cost and cycle-time reduction may be achieved through Lean process management strategies. The
elimination of waste may involve Six Sigma projects. It is crucial to utilize key measures for tracking all aspects of your
operations management.
Managing cybersecurity. Given the frequency and magnitude of electronic data transfer and storage, the prevalence of
cybersecurity attacks, and patient, other customer, and business requirements around securing information, managing
cybersecurity is an essential component of operational effectiveness. Proper management of cybersecurity requires a
systems approach that focuses on using key business factors to guide cybersecurity activities and integrating cybersecurity
with your overall leadership and management approaches. In a dynamic and challenging environment of new threats,
risks, and solutions, managing cybersecurity means taking into account your organization’s unique threats, vulnerabilities,
and risk tolerances. It means determining activities that are important to critical service delivery and to your patients and

other customers, and prioritizing investments to protect them. Cybersecurity may involve training workforce members not
directly involved in information technology matters and educating patients, other customers, suppliers, and partners. It
may also involve communicating with these stakeholders to inform them of potential cyber threats, inform them of
breaches, and report recovery efforts in order to maintain their confidence in your organization.
Workplace safety. All organizations, regardless of size, are required to meet minimum regulatory standards for workplace
and workforce safety; however, high‐performing organizations have processes in place to ensure that they not only meet
these minimum standards but also go beyond a compliance orientation to a safety-first commitment. This includes
designing proactive processes, with input from people directly involved in the work, to ensure a safe working
environment.
Organizational continuity. Efforts to ensure the continuity of operations in an emergency should consider all facets of
your operations that are needed to provide your health care services to patients, including supply-chain availability. The
specific level of operations that you will need to provide will be guided by your mission and your patients’ and other
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customers’ needs and requirements. Health care providers are likely to have a higher need for continuity of services than
organizations that do not provide an essential function. You should also coordinate your continuity‐of-operations efforts
with your efforts to ensure the availability of data and information (item 4.2).
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You should carefully plan how you will continue to provide an information technology infrastructure, data, and
information in the event of either a natural or man‐made disaster. These plans should consider the needs of all your
stakeholders, including the workforce, patients, other customers, suppliers, partners, and collaborators. The plans also
should be coordinated with your overall plan for operational continuity and cybersecurity.
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Results (Category 7)
This category provides a systems focus that encompasses all results necessary to sustaining an enterprise: your key process
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and health care results, your patient- and other customer‐focused results, your workforce results, your leadership and
governance system results, and your overall financial and market performance.
This systems focus maintains the purposes of the Baldrige Excellence Framework—superior health care quality and value
of offerings as viewed by your patients, your other customers, and the marketplace; superior organizational performance
as reflected in your clinical and operational indicators; and organizational learning and learning by workforce members.
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Category 7 thus provides “real‐time” information (measures of progress) for evaluating, improving, and innovating health
care services and processes, in alignment with your overall organizational strategy. While category 7 asks about results
broadly, you should place a premium on monitoring outcomes that are the consequence of your operational performance
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and serve as predictors of future performance.
7.1 Health Care and Process Results

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Purpose
This item asks about your key health care and operational performance results, which demonstrate health care outcomes,
service quality, and value that lead to patient and other customer satisfaction and engagement.
Commentary
Measures of health care outcomes. This item addresses those measures that best reflect your organization’s success in
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delivering on its mission as a health care provider. It calls for the use of key data and information to demonstrate your
organization’s performance on health care outcomes and processes and in delivering health care. Overall, this is the most
important item in the Health Care Criteria, as it focuses on demonstrating improving health care results over time.
Examples of patient outcome measures. Patient outcome measures might include improvement in perceived pain,
resumption of activities of daily living, return to work, decreased severity of decubitus ulcer, decreased mortality and
morbidity, and long-term survival rates.
Measures of service performance. This item also emphasizes measures of health care service performance that serve as
indicators of patients’ and other customers’ views and decisions relative to future interactions and relationships. These
measures of service performance are derived from patient- and other customer-related information gathered in category 3.

Examples of health care process measures. Health care process measures appropriate for inclusion might be based on the
following: adherence to patient safety practices, treatment protocols, care plans, critical pathways, care bundles,
medication administration, patient involvement in decisions, timeliness of care, information transfers and communication
of treatment plans and orders, and coordination of care across practitioners and settings.
Service performance and patient and other customer indicators. The correlation between health care service performance
and patient and other customer indicators is a critical management tool with multiple uses: (1) defining and focusing on
key quality and patient and other customer requirements, (2) identifying service differentiators in the health care
marketplace, and (3) determining cause-effect relationships between your health care service attributes and evidence of
patients’ and other customers’ satisfaction and engagement. The correlation might reveal emerging or changing market
segments, the changing importance of requirements, or even the potential obsolescence of offerings.
Process effectiveness and efficiency measures. Measures and indicators of process effectiveness and efficiency might
include the following:
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 Work system performance that demonstrates improved cost savings or higher productivity by using internal
and/or external resources
 Internal responsiveness indicators, such as cycle times and turnaround times
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 Improved performance of administrative and other support functions
 Indicators of the effectiveness of security and cybersecurity approaches
 Utilization rates
 Waste reduction, such as reductions in repeat diagnostic tests
 Reduced emission levels, carbon footprint, or energy consumption
 Waste stream reductions, by-product use, and recycling
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 Strategic indicators, such as innovation rates, time to introduce new health care services, and increased use of e-
technology
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Supply-chain indicators, such as reductions in inventory, increases in quality and productivity, Six Sigma initiative
results, improvements in electronic data exchange, and reductions in supply-chain management costs
Measures of organizational and operational performance. This item encourages you to develop and include unique and
innovative measures to track key processes and operational improvement. Unique measures should consider cause‐effect
relationships between operational performance and health care service quality or performance. All key areas of
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organizational and operational performance, including your organization’s readiness for emergencies, should be evaluated
by measures that are relevant and important to your organization.
7.2 Customer-Focused Results

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Purpose
This item asks about your patient- and other customer‐focused performance results, which demonstrate how well you have
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been satisfying your patients and other customers and engaging them in loyalty‐building relationships.
Commentary
Your performance as viewed by your customers. This item focuses on all relevant data to determine and help predict your
performance as viewed by your patients and other customers. Relevant data and information include the following:
 Patient and other customer satisfaction and dissatisfaction
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 Retention, gains, and losses of patients, other customers, and their accounts
 Patient and other customer complaints, complaint management, and effective complaint resolution
 Patient- and other customer-perceived value based on health care quality, outcomes, and cost
 Patients’ and other customers’ assessment of access and ease of use (including courtesy in service interactions)
 Patients’ and other customers’ advocacy for your brand and health care service offerings
 Awards, ratings, and recognition from patients, other customers, and independent rating organizations
Results that go beyond satisfaction. This item places an emphasis on patient- and other customer‐focused results that go
beyond satisfaction measurements, because customer engagement and relationships are better indicators and measures of
future success in the marketplace and of organizational sustainability.

7.3 Workforce-Focused Results
Purpose
This item asks about your workforce‐focused performance results, which demonstrate how well you have been creating
and maintaining a productive, caring, engaging, and learning environment for all members of your workforce.
Commentary
Workforce results factors. Results reported might include generic or organization‐specific factors. Generic factors might
include safety, absenteeism, turnover, satisfaction, and complaints (grievances). For some measures, such as absenteeism
and turnover, local or regional comparisons might be appropriate. Organization‐specific factors are those you assess to
determine workforce climate and engagement. These factors might include the extent of training, retraining, or cross‐
training to meet capability and capacity needs; the extent and success of workforce empowerment; the extent of union-
management partnering; or the extent of volunteer and independent practitioner involvement in process and program
activities.
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Workforce capacity and capability. Results reported for indicators of workforce capacity and capability might include
staffing levels across organizational units and certifications to meet skill needs. Additional factors may include
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organizational restructuring, as well as job rotations designed to meet strategic directions or patients’ and other customers’
requirements.
Workforce engagement. Results measures reported for indicators of workforce engagement and satisfaction might include
improvement in local decision making, commitment to organizational change initiatives (such as implementation of
evidence-based care processes), organizational culture, and workforce knowledge sharing. Input data, such as the number
of cash awards, might be included, but the main emphasis should be on data that show effectiveness or outcomes. For
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example, an outcome measure might be increased workforce retention resulting from establishing a peer recognition
program or the number of promotions into leadership positions that have resulted from the organization’s leadership
development program.
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7.4 Leadership and Governance Results
Purpose
This item asks about your key results in the areas of senior leadership and governance, which demonstrate the extent to
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which your organization is fiscally sound, ethical, and socially responsible.
Commentary
Importance of high ethical standards. Independent of an increased national focus on issues of governance and fiscal
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accountability, ethics, and leadership accountability, it is important for organizations to practice and demonstrate high
standards of overall conduct. Governance bodies and senior leaders should track relevant performance measures regularly
and emphasize this performance in stakeholder communications.
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Results to report. Your results should include key accreditation and regulatory review findings, patient safety data, staff
licensure and recredentialing determinations, external audit findings, proficiency testing results, and utilization review
results, as appropriate. Other results should include environmental, legal, and regulatory compliance; results of oversight
audits by government or funding agencies; noteworthy achievements in these areas, as appropriate; and organizational
contributions to societal well‐being, support for key communities, and contributions to improving community health.
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Sanctions or adverse actions. If your organization has received sanctions or adverse actions under law (including
malpractice), regulation, accreditation, or contract during the past five years, you should summarize the incidents, their
current status, and actions to prevent reoccurrence.
Measures of strategy implementation. Because many organizations have difficulty determining appropriate measures,
measuring progress in accomplishing their strategy is a key challenge. Frequently, organizations can discern these progress
measures by first defining the results that would indicate end‐goal success in achieving a strategic objective and then using
that end‐goal to define intermediate measures.

7.5 Financial and Market Results
Purpose
This item asks about your key financial and market results, which demonstrate your financial sustainability and your
marketplace achievements.
Commentary
Senior leaders’ role. Measures reported in this item are those usually tracked by senior leaders on an ongoing basis to
assess your organization’s financial performance and viability.
Appropriate measures to report. In addition to the measures included in the note to 7.5a(1), appropriate financial measures
and indicators might include revenues, budgets, profits or losses, cash position, net assets, debt leverage, cash‐to‐cash cycle
time, earnings per share, financial operations efficiency (collections, billing, receivables), and financial returns. Marketplace
performance measures might include measures of business growth, charitable donations and grants received, new services
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and markets entered, new populations served, or the percentage of income derived from new health care services or
programs.
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The Malcolm Baldrige
National Quality Award
The Malcolm Baldrige National Quality Award, created
by Public Law 100-107 in 1987, is the highest level of
national recognition for performance excellence that a
U.S. organization can receive. The award promotes
• awareness of performance excellence as an

increasingly important element in U.S.
competitiveness and
• the sharing of successful performance strategies and

information on the benefits of using these strategies.

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The President of the United States traditionally presents
the award. The award crystal, composed of two solid
crystal prismatic forms, stands 14 inches tall. The crystal
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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 name of the award
and “The Quest for Excellence” on one side and the
Presidential Seal on the other.
Organizations apply for the award in one of six eligibility
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categories: manufacturing, service, small business,
education, health care, and nonprofit. Up to 18 awards
may be given annually across the six categories.
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For more information on the award and
the application process, see
https://www.nist.gov/baldrige/baldrige-award.
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The Quest for Excellence®

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Official conference of the Malcolm Baldrige National Quality Award
29th Annual Quest for Excellence Conference and

Award Ceremony
April 2–5, 2017
Baltimore Marriott Waterfront, Baltimore, Maryland
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30th Annual Quest for Excellence Conference and

Award Ceremony
April 8–11, 2018
Baltimore Marriott Waterfront, Baltimore, Maryland
Each year at The Quest for Excellence, Baldrige Award

recipients share their exceptional performance practices
with leaders of business, education, health care, and
nonprofit organizations and inspire attendees to apply the
insights they gain within their own organizations. Plan to
attend and learn about the recipients’ best management
practices and Baldrige journeys, participate in educational
presentations on the Baldrige Excellence Framework, and
network with Baldrige Award recipients and other attendees.
For more information on The Quest for Excellence, see

https://www.nist.gov/baldrige/qe.
Created by Congress in 1987, the Baldrige Program is
managed by the National Institute of Standards and
Technology (NIST), an agency of the U.S. Department
of Commerce. This unique public-private partnership
is dedicated to helping organizations improve their
performance and succeed in the global marketplace.
The program administers the Presidential Malcolm
Baldrige National Quality Award. In collaboration
with the greater Baldrige community, we address
critical national needs through
The ratio of the Baldrige Program’s benefits • a systems approach to achieving organizational
excellence;
for the U.S. economy to its costs is estimated
• organizational self-assessment tools and analysis
at 820 to 1. of organizational strengths and opportunities for

improvement by a team of trained experts;
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• training, executive education, conferences, and
workshops on proven best management practices
Baldrige Award
and on using the Baldrige Excellence Framework
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winners serve as national • Baldrige-based approaches to cybersecurity risk
management and community excellence.
role models. Foundation for the Malcolm Baldrige

National Quality Award
The mission of the Baldrige Foundation is to ensure
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2010–2016 award applicants represent the long-term financial growth and viability of the
Baldrige Performance Excellence Program and to support
589,635 jobs
organizational performance excellence in the United States
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,
and throughout the world. To learn more about the Baldrige
Foundation, see http://www.baldrigefoundation.org.
2,815 work sites, over $147 billion in Alliance for Performance Excellence
revenue/budgets, and nearly 450 million The Alliance (http://www.baldrigepe.org/alliance) is a
national network of Baldrige-based organizations with a
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mission to grow performance excellence in support of a
customers served. thriving Baldrige community. Members contribute nearly
300,000 volunteer hours and more than $30 million per
year in tools, resources, and expertise to assist organizations
on their journey to excellence. This includes annually
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366 Baldrige examiners volunteered evaluating and recognizing over 1,000 organizations that
use the Baldrige Excellence Framework and serving as
roughly $5.6 million in

the feeder system for the national Baldrige Award.
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American Society for Quality

services in 2016. The American Society for Quality (ASQ; http://www.asq.org/)
assists in administering the award program under contract
to NIST. ASQ’s vision is to make quality a global priority, an
organizational imperative, and a personal ethic and, in the
State Baldrige-based examiners process, to become the community for all who seek quality
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concepts, technology, or tools to improve themselves and

volunteered around $29 million in their world.
services in 2015. For more information:

www.nist.gov/baldrige | 301.975.2036 | [email protected]
CONNECT WITH BALDRIGE

@BaldrigeProgram #Baldrige
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What is the purpose of the Baldrige Excellence Framework?

What is the purpose of the Baldrige Excellence Framework?

What organizations support the Baldrige Performance Excellence Program?

What organizations support the Baldrige Performance Excellence Program?

Examiner Version

Baldrige Performance Excellence Program

Telephone: (301) 975-2036

v How to Use the Baldrige Excellence Framework

1 Health Care Criteria for Performance Excellence Overview and Structure

35 Results Scoring Guidelines

37 How to Respond to the Health Care Criteria

40 Core Values and Concepts

45 Changes from the 2015–2016 Baldrige Excellence Framework

47 Glossary of Key Terms

55 Index of Key Terms

Baldrige promotes a systems perspective.

ii 2017–2018 Baldrige Excellence Framework (Health Care)

1. Levels: What is your current performance on a meaningful measurement scale?

About the Baldrige Excellence Framework iii

Baldrige has national and global impact.

Baldrige is here for your organization.

iv 2017–2018 Baldrige Excellence Framework (Health Care)

If you are just learning about the Baldrige framework . . .

/products-services/baldrige-examiner-training-experience). Examiners receive valuable training, evaluate award

development program (see https://www.nist.gov/baldrige/products-services/baldrige-executive-fellows-program),

If you are ready to assess your organization using Baldrige . . .

How to Use the Baldrige Excellence Framework v

If you are ready for external feedback . . .

Arrange for a Baldrige Collaborative Assessment (https://www.nist.gov/baldrige/products-services/baldrige

Baldrige National Quality Award.

vi 2017–2018 Baldrige Excellence Framework (Health Care)

Health Care Criteria for Performance Excellence Overview: A Systems Perspective

Leadership Integration RESULTS

Measurement, Analysis, and Knowledge Management

The system All actions

Health Care Criteria for Performance Excellence Overview and Structure 1

Item Notes Key Terms

Key term in Item point value Type of information

a. Financial and Market Results

2 2017–2018 Baldrige Excellence Framework (Health Care)

Categories and Items Point Values

4 Measurement, Analysis, and Knowledge Management 90

4.2 Information and Knowledge Management 45

5.1 Workforce Environment 40

6.2 Operational Effectiveness 40

TOTAL POINTS 1,000

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

(Continued on the next page)

4 2017–2018 Health Care Criteria for Performance Excellence

or service environment. Core competencies are frequently

standable language, and they might involve in-person

as a dimension in assessing the maturity of organizational

6 2017–2018 Health Care Criteria for Performance Excellence

• identify needed actions;

• Accountability for senior leaders’ actions

• Succession planning for senior leaders

b. Legal and Ethical Behavior

(Continued on the next page)

8 2017–2018 Health Care Criteria for Performance Excellence

1.2a(2). The evaluation of leaders’ performance might be