The old adage, “form follows function” describes considering the importance of what you are trying to accomplish before you decide how to get there. It is important to remember that you have to have the will to improve, ideas about alternatives to the status quo, and make it real—execute (Nolan, 2007).
In this Discussion, you will describe strategic health care quality initiatives in two organizations attempting to accomplish their goals and objectives in quality improvement. You will also examine the purpose of the initiatives(s) and share the issues and opportunities for improvement, as well as address any elements crucial to improving quality in your health care organization or one you are familiar with.
To prepare:
Read and review the resources in the Learning
section as they relate to initiatives in strategic health care organizations.
SelectONE organization from each of the TWO groups listed:
Group I:
- Agency for Healthcare Research and Quality (AHRQ)
- Institute for Healthcare Improvement (IHI)
- Institute for Safe Medication Practices (ISMP)
Group II:
- ANCC Magnet Recognition Program
- Baldrige Performance Excellence Program
- The Leapfrog Group
The Assignment:
In a 3- to 4-page paper (excluding title page and references):
- Describe strategic health care quality initiatives in two of the organizations. Compare and contrast the purposes of the initiatives.
- Analyze strategic quality issues and opportunities for improvement within the two organizations.
- Evaluate which elements of the initiatives are crucial to the quality-improvement opportunities of your health care organization or an organization with which you are familiar
- https://www.nursingworld.org/organizational-progra…
- https://www.nist.gov/baldrige
- http://www.ihi.org/resources/pages/ihiwhitepapers/highimpactleadership.aspx
- https://www.leapfroggroup.org/
Resources
Understanding High-Reliability
Organizations: Are Baldrige
Recipients Models?
John R. Griffith, LFACHE, professor emeritus, Health Management & Polity University
of Michigan, Ann Arbor
E X E C U T I V E
S U M M A R Y
Chassin and Loeb argue persuasively that healthcare organizations (HCOs) can and
should be “high-reliability organizations” (HROs) seeking zero defects in outcomes
quality. They suggest that the Baldrige model is a sound platform for achieving high
reliability. This article analyzes the similarity of the HRO concept to the Baldrige
model using a recent Malcolm Baldrige National Quality Award recipient’s applica
tion. The analysis suggests that neither high reliability nor Baldrige criteria are easily
achieved, but the two have strong similarities. The principal difference is in Baldrige’s
emphasis on strategic independence versus the HRO commitment to “zero patient
harm” and quality as “the organization’s highest-priority strategic goal.”
Based on this analysis, the article reviews data on the actual performance of
Baldrige recipients as recorded at WhyNotTheBest.org. The data show that the
Baldrige approach is an effective method of generating above-average performance.
Award recipients have made substantial strides in safety, reductions of infections,
immunizations, and patient satisfaction, but receipt of the award has not translated
as effectively to reduced readmissions, mortality, and costs.
The pattern of results suggests that Baldrige recipients have exploited the right to
establish their own strategic goals and are likely to respond to strengthened financial
rewards for quality. The Baldrige model has documented successes in quality
improvement and should be the standard of excellence in managing all HCOs.
For more information about the concepts in this article, contact Mr. Griffith at
jrg@umich.edu.
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U nderstanding H igh -R eliability O rganizations: A re Baldrige R ecipients M odels?
INTRODUCTION
Only award recipients’ applications
are made public; the names and all
other information about other appli
cants are held in strict confidence. The
award selection process is based on
scoring by multiple reviewers and
heavily weighted to quantified results,
including measures of patient care
outcomes and processes, patient satisfac
tion, workforce satisfaction, and finan
cial and market performance (NIST,
2014d; Evans & Mai, 2014). Award
recipients typically report top-quartile
and often top-decile performance.
Recipient organizations are exten
sively audited by the Baldrige Board of
Overseers (NIST, 2014b). Thus, there is
no comparable source of documented
best practice descriptions for healthcare
organizations.
Chassin and Loeb (2013) argue persua
sively that healthcare organizations
(HCOs) can and should be “highreliability organizations” (HROs). They
outline a series of 14 steps, which they
call Robust Process Improvement (RPI;
discussed in more depth later), that
form “a practical framework that indi
vidual healthcare organizations can use
to evaluate their readiness for and
progress toward the goal of high reliabil
ity” (Chassin & Loeb, 2013, p. 461). This
article compares the practices of one
group of high-performing HCOs—
recipients of the Malcolm Baldrige
National Quality Award—to Chassin
and Loeb’s 14 steps and reviews their
performance using data assembled by
WhyNotTheBest.org, an online resource
operated by The Commonwealth Fund.
H ig h -R e lia b ility O rg a n iza tio n s
Chassin and Loeb (2013, p. 461) define
high-reliability organizations as having
an environment of “collective mindful
ness” in which all workers look for, and
report, small problems or unsafe condi
tions before those issues pose a substan
tial risk to the organization and when
they are easy to fix (Weick & Sutcliffe,
2007, paraphrased in Chassin & Loeb,
2013, p. 461).
Working from the Weick and
Sutcliffe research, Chassin and Loeb
(2013, p. 461)
BACKGROUND
The B a ld rig e A w ard in H e a lth c a re
The Baldrige National Quality Program
(now known as the Baldrige Performance
Excellence Program) began as a congressionally sponsored effort “to identify and
recognize role-model businesses, estab
lish criteria for evaluating improvement
efforts, and disseminate and share best
practices” (NIST, 2010). With the begin
ning of the Baldrige Awards in Health
Care in 2002, the applications of award
recipients have become a unique
resource from which to understand the
operation of successful HCOs. The
applications are densely written, 50-page
documents following rigorous seven-part
criteria addressing leadership, strategy,
customer relations, human resources,
knowledge management, operations, and
results (NIST, 2014c).
developed a conceptual and practical
framework for assessing hospitals’
readiness for and progress toward high
reliability. By iterative testing with
hospital leaders, we refined the
framework and, for each of its fourteen
components, defined stages of maturity
through which we believe hospitals
must pass to reach high reliability.
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J ournal of H ealthcare M anagement 60:1 January/ F ebruary 2015
They note that seeking high reliabil
ity, as through the Baldrige criteria, is a
journey and that “we know of no
hospitals that have achieved high
reliability across all their activities”
(Chassin & Loeb, 2013, p. 472). The
highest stage of maturity of the 14
components in the Chassin-Loeb
model, Approaching, is described in
Table 1, with an assessment of whether
North Mississippi Health Systems
(NMHS), a recent Baldrige award
recipient, meets the standard. Our
judgment is based on specific wording
in the NMHS application, cited by
application section number. Other
recent applications are generally consis
tent as to both practice and the section
references.
Chassin (2013, p. 1761) argues:
Perspectives has also compared perfor
mance at NMHS, the 2012 Baldrige
healthcare award recipient, to outcomes
desired in the high reliability concept
(“Together, Joint Commission,” 2013).
In short, the Baldrige Health Care
Criteria and recipients’ practices are fully
congruent with 11 of the 14 ChassinLoeb standards. The major difference
lies in strategic emphasis. Baldrige
explicitly leaves strategic priorities to the
corporate governance; Chassin and Loeb
(2013) ask for a commitment to “zero
patient harm” and quality as “the
organization’s highest-priority strategic
goal.”
The financing of HRO and RPI is a
critical matter. Noting that virtually
every transition in Table 1 implies extra
expenditures, one key issue is the
dynamic by which best practice becomes
a sustainable business model. Baldrige
recipients’ data suggest that they are
performing quite well in a wide variety
of situations. Their success appears to be
attained through the power of service
excellence.
The service excellence model
assumes that an HCO operates in a
competitive market and thrives because
it produces a superior product. It
changes the focus of strategic decision
making from inputs to outputs. It moves
managerial conversations and activities
from cost control to process improve
ment. The HCO application of the
concept is shown in Figure 1. The
massive investment in knowledge
management, training, and performance
improvement teams (PITs), coupled
with deliberate empowerment, senior
management rounding, consultative
support, and a focus on measured
Desired progress will not be achieved
unless substantial changes are made to
the way in which quality improvement
is conducted. . . . Newer and much
more effective strategies and tools are
needed to address the complex quality
challenges confronting healthcare.
Tools such as Lean, Six Sigma, and
change management are proving highly
effective in tackling problems as
difficult as hand-off communication
failures and patient falls. Finally, the
organizational culture of most
American hospitals and other
healthcare organizations must change.
Chassin calls the Lean-Six Sigmachange management tool set Robust
Process Improvement.
The Joint Commission (2013) has
published a detailed review of its
criteria, the Baldrige criteria, and Magnet
Recognition Program (ANCC, 2014)
criteria on its website. Joint Commission
46
U nderstanding H igh -R eliability O rganizations: A re Baldrige Recipients M odels ?
T AB L E 1
One Baldrige Recipient’s Practices and High-Reliability Organizations
Chassin-Loeb Component and Approaching Standard3
NMHS Practice11
Leadership
Board
Board commits to the goal of high
reliability (i.e., zero patient harm)
for all clinical services.
Met, except commitment to zero
harm. Balanced scorecards
routinely address outcomes
quality (l.la .3 ), but the board
sets goals based on its strategic
priorities (l.lb ( l) ) .
CEO/management
CEO leads the development and
implementation of a proactive
quality agenda.
Partially met. The agenda is
based on the strategic priorities
set by the governing board
rather than “proactive quality”
( l.lb ( l) , 7.1).
Physicians
Physicians routinely lead clinical
quality improvement activities
and accept the leadership of other
appropriate clinicians; physicians’
participation in these activities is
uniform throughout the
organization.
Met (6.2b). Uniform compliance is emphasized in the
criteria and judging process
(see “Scoring,” NIST, 2013,
pp. 28-33).
Quality strategy
Quality is the organization’s
highest-priority strategic goal.
Not met. The board retains the
right and the obligation to
establish locally relevant goals.
Quality measures
Key quality measures are routinely
displayed internally and reported
publicly; reward systems for staff
prominently reflect the accomplishment of quality goals.
Met. Measures are now reported
by CMS and private organizations such as WhyNotTheBest.
org. Recipients emphasize
internal review (P. la(2),
4.2a(2)).
Information
technology
Safely adopted IT solutions are
integral to sustaining improved
quality.
Met. (Section 4 of the applications details IT strategies.)
Safety Culture and High Reliability
Trust
High levels of (measured) trust
exist in all clinical areas; selfpolicing of codes of behavior is
in place.
Met. Communication, trust, and
associate satisfaction are
routinely measured and studied
for improvement (see Section 5,
especially 5.2a(2)).
Continued.
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J ournal of H ealthcare M anagement 60:1 January/ F ebruary 2015
TABLE
1
c o n tin u e d
Accountability
All staff recognize and act on their
personal accountability for
maintaining a culture of safety;
equitable and transparent disci
plinary procedures are fully
adopted across the organization.
Met. Processes are described in
Section 5 of the application.
Results are reported in Section
7, especially NMHS figures
7.13-7.19.
Identifying unsafe
conditions
Close calls and unsafe conditions
are routinely reported, leading to
early problem resolution before
patients are harmed; results are
routinely communicated.
Met. NMHS reports a patient
safety program promoting “An
environment of trust & fairness
where it is safe to report and
learn from mistakes” (l.la(3),
P.2). It encourages reporting
“any variance that results in
harm or risk of harm to a patient
or visitor” (p. 58) and studies
these reports closely (6.1b(2)).
Strengthening systems System defenses are proactively
assessed, and weaknesses are
proactively repaired.
Met. NMHS documents a
sophisticated continuous
improvement program (6.2).
Assessment
Met. NMHS documents 22
quality and safety measures
tracked and benchmarked (7.1
and 7.3).
Safety culture measures are part of
the strategic metrics reported to the
board; systematic improvement
initiatives are under way to achieve
a fully functioning safety culture.
RP1
Methods
Adoption of RPI tools is accepted
fully throughout the organization.
Met (6.2a(l)).
Training
Training in RPI is mandatory for
all staff, as appropriate to their
jobs.
Met. NMHS invests more than
80 hours/FTE-year (l.la(3);
5.2c; figures 7.3-7.23).
Spread
RPI tools are used throughout the
organization for all improvement
work; patients are engaged in
redesigning care processes, and
RPI proficiency is required for
career advancement.
Met. Systematic continuous
improvement is a core concept
of the Baldrige criteria.
aSource. Chassin & Loeb (2013, table 1, p. 471; table 2, pp. 474-475; table 3, pp. 478-479).
bSummary of material describing NMHS performance, identifying the relevant application section(s) and figures. (The
applications are publicly available. See NIST, 2014b).
Note. NMHS = North Mississippi Health System; CMS = Centers for Medicare & Medicaid Services; IT = information technology;
RPI = Robust Performance Improvement; FTE = full-time equivalent.
48
U nderstanding H igh -R eliability O rganizations: A re Baldrige R ecipients M odels ?
outcomes, creates a workforce that is
substantially more effective than the
norm and delivers a product that costs
less and is more attractive in the
marketplace.
congruence of recipient processes and
the Chassin-Loeb high-reliability model,
the profile of recipient performance
should be exceptional.
HYPOTHESIS
Many of the measures used by recipients
have become public through the Centers
for Medicare & Medicaid Services (CMS,
2014) Hospital Compare program and
voluntary efforts such as WhyNotThe
Best.org, a website operated by The
Commonwealth Fund (2014). Using
METHODOLOGY
It is understood that, as Chassin and
Loeb (2013, p. 459) claim, there are no
high-reliability HCOs. Receiving the
Baldrige award is not equal to achieving
perfection; recipients’ scores are usually
around 60%. However, given the
FIGURE 1
The Service Excellence Chain in H ealthcare
Satisfied Associates
Associates who know they can rely
on each other and will have the
resources they need will be loyal to
the organization and effective in
patient care.
———►
Satisfied Patients
Patients and families will be
favorably impressed by caring and
effective associates and will leave
“delighted.”
\
/
Strong Demand
Well-planned services and high patient
satisfaction will keep demand high,
providing a foundation for lower costs
and higher quality.
Operational Support
Day-to-day and strategic needs are
met; a culture of commitment to the
mission and respect for individuals
and evidence prevails.
Financial Support
A strong demand and efficient
production generate profits that
support up-to-date equipment and
supplies and other strategic needs.
Source. White & Griffith (2010, p. 48).
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J ournal of H ealthcare M anagement 60:1 January/ F ebruary 2015
these data allows a comparison of
recipients to the larger population of
healthcare organizations.
We assembled the list of award
recipients from the Baldrige website,
which are as follows (NIST, 2014a)
(asterisk denotes an application from a
multihospital system):
set contained 44 hospitals, but not all
data are reported for each hospital. We
collected the WhyNotTheBest.org
benchmarks—national means and
top-decile measures—posted as of
January 2014. We grouped the measures
to reflect similar characteristics, as
follows (definitions and sources of the
measures may be found at http://www.
whynotthebest.Org/methodology#rc):
1. *SSM Health Care, 2002
2. Saint Luke’s Hospital of Kansas City,
2003
Outcomes of acute care
Readmission rates
Mortality rates
Healthcare-associated infections
Inpatient quality indicators
Patient safety indicators
3. Baptist Hospital Inc., 2003
4. Robert Wood Johnson University
Hospital Hamilton, 2004
5. Bronson Methodist Hospital, 2005
Prevention and population health
6. North Mississippi Medical Center,
2006 (see also system award, 2012)
Immunization
Prevention quality indicators
Population health/utilization and
costs
County health rankings
7. *Mercy Health System, 2007
8. *Sharp Healthcare, 2007
9. *Poudre Valley Health System, 2008
Customer service
10. *AtlantiCare, 2009
Hospital Consumer Assessment of
Healthcare Providers and
Systems (HCAHPS)
Emergency care
11. Heartland Health, 2009
12. Advocate Good Samaritan Hospital,
2010 (system not included)
Costs
13. *Henry Ford Health System, 2011
Spending per Medicare beneficiary
Healthcare costs
14. *North Mississippi Health Services,
2012
Process of acute care
Recommended care (CMS Core
Measures)
Composite measures of
recommended care
Health information technology
We excluded Southcentral Foundation
(2011) from the above list, as its acute
care hospital was not part of its
application.
Seven of the 15 recipients applied as
systems. In those cases, we collected
data on all hospitals identified with the
system on WhyNotTheBest.org as of
January 2014. In cases where the appli
cation was for a single hospital, we
collected data only on that hospital. The
The measures are taken from data
submitted to The Joint Commission and
CMS, with the exception of some health
information technology measures from
the American Hospital Association
(AHA) Annual Survey and the inpatient
50
U nderstanding H igh -R eliability O rganizations: A re Baldrige R ecipients M odels ?
quality, safety, and prevention measures
from the Agency for Healthcare Research
and Quality.
We were unable to use the following
measures offered byWhyNotTheBest.org:
differences are not significant. Recipients
excel on five of six infection measures,
but only two are significant. Patient
safety results and pneumonia immuni
zation rates are significantly better than
the national average.
The magnitude of some of the
significantly superior performance is of
interest. WhyNotTheBest.org’s compos
ite safety index is 13% better than the
national average, central line infections
are more than 40% better, and colon
surgery infections are almost 50% better.
Baldrige recipient organizations
perform significantly better on most of
the CMS Core Measures than the
national average, while their emergency
service measures are not significantly
different. Response counts are low for
most of the six Joint Commission
Recommended Care measures, and
recipients are significantly better in
only two.
WhyNotTheBest.org’s cost per case
index of Medicare spending does not
indicate a significant advantage for
recipients.
The recipients excel on patient
satisfaction. They are clearly superior on
two important summary measures:
“highly satisfied” and “would recom
mend.” (They also excel on all of the
eight detailed measures WhyNotThe
Best.org reported, but their measures did
not reach significance on physician
communication, nighttime quiet, or
clean bathrooms.)
Recipient performance is consistent.
The median coefficient of variation is
only 0.11, although high variation
occurs in several important measures,
most notably the infection rates and
the composite patient safety score,
Early elective delivery rates: checked
February 2014; no data for set
Surgical care improvement: national
mean of 97.5 compliance; too
compressed to use
Healthcare costs: no national values
Health information technology: process
measure with no national
standard (most recipients had
top score)
County health rankings: no national
values
The available measures cover many
elements important in high reliability.
Compared to the usual balanced scorecard (White & Griffith, 2010, p. 27), one
dimension—worker satisfaction and
retention—is noticeably lacking. There
is no public source for national data on
this dimension.
We compared recipients to national
means. For each measure, we report the
mean, standard deviation, and standard
error of the recipient set, the national
mean, the difference, and significance.
RESULTS
Results are shown in Table 2. Overall,
Baldrige award recipients’ performance
is good and sometimes, but not consistendy, exceptional. On five mortality
measures, recipients are superior to
national averages on all but one, but
only The Joint Commission nonsurgical
composite is statistically significant. On
readmissions, recipients perform better
than the national averages, but the
51
J ournal of H ealthcare M anagement 60:1 January/ F ebruary 2015
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