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2010 AHCA/NCAL National Quality Award Program- Silver Award Overview -
Session Two
Lance ReynoldsKevin Warren
Tim Case
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Silver Award Criteria
2.0 Organizational Profile
2.1 Visionary Leadership and Social Responsibility and Community Health
2.2 Focus on the Future
2.3 Resident-Focused Excellence
2.4 Management by Fact
2.5 Organizational and Personal Learning
2.6 Valuing Staff and Partners
2.7 Systems Perspective, Agility, & Managing for Innovation
2.8 Focus on Results and Creating Value
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The first step towards getting somewhere is to decide that you are not going to stay where you are.
J. Pierpont Morgan
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2.0 Organizational Profile
This was formerly referred to as Step I, and remains largely based on, the Bronze Award criteria.Make sure you update any information you copy from a former Bronze Award application.You are not bound by your previous Bronze Award application.2.0 establishes the foundation for the entire application.
The Writing Process Linkages:
Organizational Profile (Key Factors)
+
Category Response
= Results
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Linkages
Example #1 Organizational Profile:
– Vision: “Best Nursing Home in the State as measured by Resident, Family and Staff Satisfaction”.
Category 2.3 Response: No Resident, Family and Staff Satisfaction processes described.
Results: No results
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Linkages (continued)
Example #2 Organizational Profile:
– Vision: “Best Nursing Home in the Nation as measured by Resident, Family and Staff Satisfaction”.
Category 2.3 Response: Two years of conducting surveys
Results: Results are compared to local nursing homes only.
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Organizational Profile
Examiners use the Organizational Profile to determine what is important to you, the applicant, throughout their entire review
process. It is a required part of their work.
FOCUS8
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Silver Award Criteria
2.0 Organizational Profile
2.1 Visionary Leadership and Social Responsibility and Community Health
2.2 Focus on the Future
2.3 Resident-Focused Excellence
2.4 Management by Fact
2.5 Organizational and Personal Learning
2.6 Valuing Staff and Partners
2.7 Systems Perspective, Agility, & Managing for Innovation
2.8 Focus on Results and Creating Value
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2.7 Systems Perspective, Agility, & Managing for Innovation
How does the organization effectively interconnect the individual components of its performance management system to view the organization as a whole and to ensure consistency of plans, processes, measures, and actions in order to maximize agility, encourage innovation, and achieve performance excellence?
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2.7 Systems Perspective, Agility, & Managing for Innovation
How does your organization systematically:a. Ensure alignment of processes, measures, and action plans
across departments and throughout various organizational levels to improve performance and customer satisfaction.
• Describe key work processes.
• Describe how the organization manages these processes to ensure that they are consistent with your strategic objectives and action plans described in 2.2.
• Describe how action plans are integrated across departments and organizational levels to improve performance and customer satisfaction.
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2.7 Systems Perspective, Agility, & Managing for Innovation
How does your organization systematically:
b. Make meaningful change to improve your services, programs, processes, operations, care delivery model, and business model to create new value for your stakeholders.
• Give examples of innovative changes made in the last year to improve resident care and quality of life, organization of work, and business results.
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2.7 Systems Perspective, Agility, & Managing for Innovation
How does your organization systematically:
c. Build agility—a capacity for rapid change and flexibility.
• Describe how the workforce is cross-trained and empowered to be flexible.
• Describe how work systems and processes are simplified to reduce response times to changes in customer needs and expectations. Give one or two examples.
SECTION 2.1 – 2.7
Scoring Guidelines
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Factor 0-5% 10-25% 30-45%
Approach No systematic approach to Item requirements is evident; information is anecdotal
The beginning of a systematic approach to the basic requirements of the Item, is evident
An effective, systematic approach, responsive to the basic requirements of the Item, is evident
Deployment Little or no deployment of any systematic approach is evident
The approach is in the early stages of deployment in most areas or work units, inhibiting progress in achieving the basic requirements of the Item
The approach is deployed, although some areas or work units are in the early stages of deployment
Learning An improvement orientation is not evident; improvement is achieved through reacting to problems
Early stages of a transition from reacting to problems to a general improvement orientation are evident
The beginning of a systematic approach to evaluation and improvement of key processes is evident
Integration No organizational alignment is evident; individual areas or work units operate independently
The approach is aligned with other areas or work units largely through joint problem solving
The approach is in early stages of alignment with your basic organizational needs identified in response to the Organizational Profile and other Process Items15
50-65% 70-85% 90-100%
An effective, systematic approach , responsive to the overall requirements of the Item, is evident
An effective, systematic approach, responsive to the multiple requirements of the Item, is evident
An effective, systematic approach, fully responsive to the multiple requirements of the Item, is evident
The approach is well deployed, although deployment may vary in some areas or work units
The approach is well deployed with no significant gaps
The approach is fully deployed without significant weaknesses or gaps in any areas or work units
A fact-based, systematic evaluation and improvement process and some organizational learning are in place for improving the efficiency and effectiveness of key processes
Fact-based, systematic evaluation and improvement and organizational learning are key management tools; there is clear evidence of refinement and innovation as a result of organizational-level analysis and sharing
Fact-based, systematic evaluation and improvement and organizational learning are key organization-wide tools; refinement and innovation, backed by analysis and sharing, are evident throughout the organization
The approach is aligned with your organizational needs identified in response to the Organizational Profile and other Process Items
The approach is integrated with your organizational needs identified in response to the Organizational Profile and other Process Items
The approach is well integrated with your organizational needs identified in response to the Organizational Profile and other Process Items
Factor
Approach
Deployment
Learning
Integration
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Comparisons and Scoring
50% to 65% (This is a strong organization) Some current performance levels have been
evaluated against relevant comparisons and/or benchmarks and show good relative performance
70 to 85% (This is a National Award Winner) Many to most trends and current performance levels
have been evaluated against relevant comparisons and/or benchmarks and show areas of leadership and very good relative performance
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Criteria Scoring Points and Weighted Percentages
Criteria Points %
2.0 25 2.5%
2.1 180 18%
2.2 50 5%
2.3 110 11%
2.4 90 9%
2.5 75 7.5%
2.6 75 7.5%
2.7 175 17.5%
2.8 220 22%
1000 100%
39.5%
57.5%
18%
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2.8 Focus on Results and Creating Value
What are your organization’s key results that create value for your key stakeholders?
Explain how you use these key measures to drive performance improvement, or cross reference to relevant examples in other sections of the application.
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2.8 Focus on Results and Creating Value
a. Health care outcomes:
Give at least three (3) key clinical outcome results over appropriate time frames. At least one of the outcomes should clearly show improvement over time across at least three data points. Identify the strategies and specific changes used to improve this outcome. Assisted Living Facilities (ALFs) and Developmental Disability Residential Services providers (DD) may choose to substitute non-clinical process outcome results. If available, show your outcomes in comparison to competitors or to state or national averages, whichever seems most appropriate.
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2.8 Focus on Results and Creating Value:
b. Government survey performance outcomes:
Provide government/state survey (deficiency) results over time (minimum of the last 3 surveys, but preferably 4 or 5 surveys). This requirement applies only to skilled nursing, ICF/MR, and others for which compliance with routine government compliance inspections is required. If available, show your outcomes in comparison to competitors or to state or national averages, whichever seems most appropriate.
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2.8 Focus on Results and Creating Value: c. Other outcomes:
In addition to the results reported above, provide a minimum of five (5) additional results drawn from the areas on the next slides. The results chosen and reported should cover the most important requirements for your organization’s success, highlighted in your organizational profile (section 2.0) and responses to the core values and concepts (sections 2.1 to 2.7). If possible, choose results to report for which you can provide comparative data from competitors and other long term care facilities.
Whenever possible, show your outcomes in comparison to competitors or other long term care organizations. You must at least show early stages of efforts to gather and use comparative data. You are encouraged to identify performance benchmarks or targets within your results reporting.
2.8 Focus on Results and Creating Value
Resident- and stakeholder-focused results:
Report your current levels and trends in key measures or indicators of resident, family and other stakeholder and partner satisfaction and dissatisfaction. Show how these results compare with the performance of your competitors and other nursing homes or long term care facilities.
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2.8 Focus on Results and Creating Value
Financial and marketplace results:
Report current levels and trends in key measures or indicators of financial performance, including financial return, financial viability, or budgetary performance as appropriate.
Report 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.
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2.8 Focus on Results and Creating Value: Workforce-focused results
• Report staff turnover and/or retention rates (minimum of 3, but preferably 4-5 years). Show how these results compare with the performance of your competitors and other nursing homes or long term care facilities.
• Report current levels and trends in key measures of employee satisfaction for the past four to five years. Show how these results compare with the performance of your competitors and other nursing homes or long term care facilities.
• Report current levels and trends in key measures of workforce and leadership development.
• Report current levels and trends in key measures of workforce health, safety and security, and workforce services and benefits, as appropriate. Include worker’s compensation claims and grievances over a four to five year period.
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2.8 Focus on Results and Creating Value: Process effectiveness results
• Report current levels and trends in key measures of occupancy.
• Report current levels and trends in key measures of work system performance such as supplier and partner performance, job simplification, changing supervisory ratios, med-pass, and cycle time reduction.
• Report current levels and trends in key measures of preparedness for disasters or emergencies.
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2.8 Focus on Results and Creating Value: Leadership results
• Report results for your key measures of accomplishment for your strategic and action plans outlined in 2.2.
• Report results for key measures of ethical behavior.
• Report results for key measures of promoting or supporting community health and services.
And, Other results
• As deemed appropriate for the applicant’s individual organization.
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Guidelines for Responding to the Results Items
1. Focus on the most critical organizational performance results.
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Guidelines for Responding to the Results Items
1. Focus on the most critical organizational performance results.
2. Note the meaning of four key requirements for effective reporting of results data:
1. Performance Levels2. Trends3. Comparisons4. Integration: To show that all important results are
included, segmented (e.g. by important resident or stakeholder, workforce, process and healthcare service groups), and as appropriate, related to key performance projections.
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Guidelines for Responding to the Results Items
1. Focus on the most critical organizational performance results.2. Note the meaning of four key requirements for effective
reporting of results data.a. Performance Levelsb. Trendsc. Comparisonsd. Integration
3. Include trend data covering actual periods for tracking trends.
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Guidelines for Responding to the Results Items
1. Focus on the most critical organizational performance results.2. Note the meaning of four key requirements for effective
reporting of results data.a. Performance Levelsb. Trendsc. Comparisonsd. Integration
3. Include trend data covering actual periods for tracking trends.
4. Use a compact format – graphs and tables.
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Graphs and Tables
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“Quality of Dining Experience”
October 2006 October 2007 October 2008
67% 71% 82%
Incidental Overtime
0
20
40
60
80
100
12/1
/200
4
2/1/
2005
4/1/
2005
6/1/
2005
8/1/
2005
10/1
/200
5
12/1
/200
5
2/1/
2006
4/1/
2006
6/1/
2006
8/1/
2006
10/1
/200
6
12/1
/200
6
2/1/
2007
Graphs and Tables
12/1
/200
5
2/1/
2006
4/1/
2006
6/1/
2006
8/1/
2006
10/1
/200
6
12/1
/200
6
2/1/
2007
4/1/
2007
6/1/
2007
8/1/
2007
10/1
/200
7
12/1
/200
7
2/1/
2008
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Graphs and Tables
Nursing Staff Data
0
10
20
30
40
50
60
70
80
90
100
Jan.
06
Feb.
06
Mar.
06
Apr.
06
May 0
6
June 0
6
July
06
Aug.0
6
Sep.
06
Oct.
06
Nov.
06
Dec.
06
Jan.
07
NAR withoutturnover
NAR stability
NARs withoutAbsenteeism
RN / LPNTurnover
RN /LPNStability
RN / LPNWithouAbsenteeism
0
5
10
15
20
Percent ofFalls
2003
2004
2005
2006
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Graphs and Tables
0%
2%
4%
6%
8%
10%
12%
14%
16%
Jan-06
Mar-06
May-06
Jul-0
6
Sep-06
Nov-06
Facility
State
USA
14%13%12%11%10%9%8%6%5%4%3%2%1%
2008 J F M A M J J A S O N D
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Graphs and Tables
Year 2003 2004 2005 2006 2007 2008 Year 2001 2002 2003 2004 2005 2006
YTD Census
(%)68 60 72 89 89 86 YTD Census
(%)6 8 10 13 13 10
Table 2.8a Year to Date Census Table 2.8b Year to Date Medicare Census
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Graphs and Tables
2004 2005 2006 2007 2008
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Guidelines for Responding to the Results Items
1. Focus on the most critical organizational performance results.
2. Note the meaning of four key requirements for effective reporting of results data.
a. Performance Levelsb. Trendsc. Comparisonsd. Integration
3. Include trend data covering actual periods for tracking trends.
4. Use a compact format – graphs and tables
5. Integrate results into the body of the text and interpret where appropriate.
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Guidelines for Responding to the Results Items
1. Focus on the most critical organizational performance results.2. Note the meaning of four key requirements for effective
reporting of results data.a. Performance Levelsb. Trendsc. Comparisonsd. Integration
3. Include trend data covering actual periods for tracking trends.
4. Use a compact format – graphs and tables.5. Integrate results into the body of the text and interpret
where appropriate.6. Interpret the graphed results.
Good Performance Levels
Performance levels permit evaluation relative to past performance, projections, goals and appropriate comparisons
Goals refer to a future condition or performance level that one intends to attain
Quantitative goals – “targets” Targets might be projected on comparative or
competitive data Benchmarks refer to results that represent best
performance inside or outside an organization’s industry
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Relevant Comparisons and Benchmarks
Your organization is not unique
Review Baldrige Winners
Seek advice from AHCA Winners
Think outside the box
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Scoring System
Levels – meaningful scale Trends – appropriate time period Comparisons – appropriate, similar,
benchmarks Integration – measures identified in your
Organizational Profile and Process Items; harmonized to support goals
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Scoring Guidelines Results
43
Results
Results are 22% of the possible score so…
Start Early!! What results support our Key Strategic
Objectives and Action Plans?
Do we clearly understand what each Item calls for?
Where do we get comparative data?44
Silver Award Requirements to Recommend
1.Score a minimum of 358 total points.
2.Have no less than 88 (40%) points in sections 2.8.
3.Have no criterion in Band A and no more than two criteria in Band B.
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Technical Requirements
Due electronically March 31, 2010
18-page limit
1” Margins
12-pt Times New Roman font
$500 application fee
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Resources
AHCA/NCAL National Quality Award program requirements and application information (www.ahcancal.org).
Baldrige National Quality Award Program To order a free copy of the Baldrige Health Care Criteria for Performance Excellence:Tel: 301-975-2036Website: www.baldrige.nist.gov.
More Resources
Scoring guidelines at www.baldrige21.com Scroll past Baldrige Excellence Tools list to
More Baldrige Excellence Tools, Services and Resources
Scroll down to the line Scoring Guidelines 2010 Integrated Versions and click on Health Care
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More Resources
Books available at www.ahcapublications.org:
• Conducting Satisfaction-Based Customer Surveys: A Guidebook for Long Term Care Providers by Vivian Tellis-Nayak, Ph.D.
• Continuous Quality Improvement: Using the Regulatory Framework by Barbara Baylis
• Developing a Quality Management System: The Foundation for Performance Excellence in Long Term Care by Bernie Dana
• Quality Management Integration in Long-Term Care: Guidelines for Excellence by Maryjane Bradley and Nancy Thompson
Final Review
Best done with “Walk the Wall” (remember the “war room”)
Ensure all sections are addressed Remember: Examiners cannot assume, the document
must stand on its own Reconfirm page limits, page numbering and formatting
instructions E-mail some copies to ensure nothing lost in
transmission. And remember……
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Writing Do’s and Don’tsDON’TS!
1. Do not start until you have full agreement on budget, timeline and application team
2. Do not waste space with anecdotal glorification
3. Do not begin writing until the Organizational Profile is clear and complete
4. Do not allow anyone who does not understand the criteria, no matter how senior, write any part of the application
5. Do not stray from the criteria questions
6. Do not stray from ADLI
7. Do not “write forward” (We will be…)
8. Do not get behind schedule
9. Do not rely on a consultant to do it all for you
10. DO NOT GIVE UP!
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You are an Original!
Applications must be original, not supplied by external entities, whether it be corporate office or consultants.
Speak to what you know best……you know better than ANYONE why the facility should be a Silver Award Winner
Tell the Story!Sell the Story!52
