The Quality Cost Connection: Use Baldrige criteria to advance excellence

Criteria can be valuable self-assessment tool

By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

One of the best ways to gain hospitalwide commitment to performance excellence is through participation in a self-assessment using the criteria of the Malcolm Baldrige Quality award. The U.S. Congress established the award in 1987 to recognize organizations for their achievements in quality and business performance and to raise awareness about the importance of quality and performance excellence as a competitive edge. In 1999, an award category for health care organizations was added to the Baldrige program. The most current 2004 health care criteria can be found on the web site of the Baldrige National Quality Program at:

Increasingly, all business sectors view the Baldrige criteria as a quality blueprint for evaluating and improving the effectiveness of their management practices. The Baldrige criteria do not represent a particular management model or business strategy. The criteria provide a flexible umbrella whose core principles allow individual health care organizations the option of applying any of the various, and highly effective, process management philosophies and tools in the manner that best support the needs of the organization. For example, the Baldrige criteria ask, "How do you select, collect, align, and integrate data and information for tracking overall organizational performance?" The organization may choose to use Kaplan & Norton’s Balanced Scorecard Model for tracking organizational performance or another approach. Six Sigma projects can assist health care organizations in meeting the Baldrige criteria related to process management, but the Six Sigma methodology is not specifically recommended over other process improvement models. The Baldrige criteria are grounded in three assumptions:

  1. Based on your years of observation, you are an expert on your organization.
  2. A framework to structure and amplify your knowledge of performance excellence enablers will help you use what you know to effect change.
  3. You want to be part of the change process driving your organization toward becoming a high-performing organization.

Baldrige criteria are a valuable self-assessment tool for health care organizations. When people work in an organization for any length of time, it is easy to develop blind spots. "Business as usual" prohibits the kind of ongoing and fresh analysis needed to continuously improve. Using the Baldrige criteria as a self-assessment tool forces the organization to study its entire management system and the assumptions used to judge performance. The assessment provides an opportunity for senior leaders and managers to reflect on the systems that support quality, think about things that need changing, and focus improvement efforts on the areas most relevant and important to the organization’s goals. The assessment can help managers and staff members understand how they contribute to the principles of continuous improvement in a meaningful way.

Baldrige criteria are applicable to organizations in all stages of excellence. Health care organizations just embarking on the performance excellence journey can use the criteria to broaden understanding of internal management systems and prioritize improvement activities.

Organizations further along on the journey can use the criteria to pinpoint trouble spots and instill a process of continuous improvement. The potential for positive, long-term improvement is limitless. Positive changes in the organization, attitudes, services, processes, measurement, planning, leadership, and patient satisfaction all can be inspired by the Baldrige criteria.

Steps of the initial self-assessment can vary, but the process generally involves six phases:

1. Engage the Leaders

A. Identify a performance excellence champion, usually the CEO.

B. Garner support from senior team; they must be accountable for actions designed to achieve performance excellence.

C. Help everyone in leadership positions understand and appreciate how their roles and responsibilities contribute to performance excellence.

2. Prepare an Assessment Team

A. Select a broad range of individuals, a cross section of the organization.

B. Select individuals who demonstrate fairness and openness.

C. Support education and development of the team to achieve optimal results.

3. Gather the Data

A. Collect information that can be used to understand the current reality about how the organization operates.

B. The assessment team interviews a cross-section of individuals in the organization.

C. The assessment team reviews key documents — plans, policies, and reports.

4. Analyze Data and Prepare Report

A. Conduct a structured evaluation process with specific consideration to the following three dimensions:

  • Soundness and appropriateness of approach.
  • Completeness of deployment.
  • Results obtained.

5. Develop Improvement Plans

A. Identify highest-leverage opportunities for improving performance in the organization.

B. Develop a project plan for each of the identified areas.

C. Agree on the next steps:

  • Specific tasks with time lines.
  • Roles and responsibilities of team members.
  • Communication.
  • Monitoring and follow-through.

6. Implementation and Follow-Through

A. Make the process sustainable.

  • Build improvement goals into performance systems for those accountable.
  • Integrate plan into business plan.
  • Establish measurements of success.
  • Conduct reviews of progress.
  • Communicate key findings and learned lessons to other staff.
  • Celebrate success.
  • Publicly acknowledge the contributions of individuals and work teams.

Once completed, the self-assessment results provide a basis for developing consensus on what needs to be done so activities can be focused in a consistent direction. By using the Baldrige criteria for periodic reassessments, ideally done as part of the annual planning cycle, a health care organization can measure progress in its performance excellence journey.

The assessment process needs to be as inclusive as possible if it is to have a significant impact. It is important to have the full commitment of the CEO and senior executive team. A project team of leaders should coordinate and oversee the evidence-gathering part of the assessment and subgroups formed to gather information for each section of the criteria. One person should not be answering the Baldrige questions; otherwise, individual perceptions may sway the results. For most organizations, valid results are possible only if a team approach is used. If the goal is to actually improve the organization rather than merely obtain a high score, many people should participate in the assessment process. Moreover, those who participate gain a better understanding of what needs to be done to advance performance excellence and are more willing to support the improvement recommendations that come out of the assessment process.

Regular meetings (at least biweekly) should be held by the leadership team to ensure information gathering is going smoothly and the assessment teams remain on target. Don’t hurry the process. The Baldrige criteria present penetrating questions that take time to think about and answer. Often teams must research the organization’s practices to formulate intelligent answers. Much of the benefit of a Baldrige self-assessment lies in discovering gaps that were not evident until people tried to respond to a particular item. Time spent thinking deeply about the Baldrige criteria and how they apply to your organization is time well spent.

When all the questions have been answered, the leadership team evaluates the results. A thorough Baldrige assessment typically highlights dozens of areas for improvement as well as organizational strengths. To advance performance excellence, the organization must concentrate on its weakest areas. Often, it is useful to research how other organizations have solved similar problems. It also may be important to poll experts within the organization to collect their thoughts on how best to solve specific problems.

The Baldrige assessment provides a reproducible yardstick for tracking the performance excellence journey in a health care organization. Often, improvements in periodic Baldrige assessment scores will show up before performance measures indicate substantial improvement.

Periodic reassessments provide an opportunity to celebrate successes as well as discover continued areas of weakness.