Organizational

Excellence

putting the pieces together

Management for International Public Health Course

Sustainable Management Development Program
Organizational Excellence
John Marsh

Excellence Model (c) EFQM 1

Organizational Excellence

Putting the pieces together

Learning Objectives

• On completion of this module attendees will:

• Understand an operational definition of excellence based on 

the Baldrige National Quality Award.

• Understand similarities with the European Performance 

Excellence Model.

• Be familiar with how it is used in public health care.

• Be able to conduct a simple scoring exercise.

• Be able to use the Baldrige Framework to integrate all the 

learning on MIPH 2005.
John Marsh

Excellence Model (c) EFQM 2

Handouts

• Paper

– PowerPoint Handouts 

– Baldrige 2005 Health Care Criteria

– Scoring Template

• CD-Rom

– Getting Started Baldrige

– Baldrige 2005 Education Criteria

– EFQM Introducing Excellence

– EFQM Fundamentals

– Scoring Tables

What is Excellence?

Generating an Operational 

Definition
John Marsh

Excellence Model (c) EFQM 3

Group Work One

• In teams of five brainstorm all the elements that 

make an organization, a partnership or a program 

truly excellent.

• Discuss results and build an operational definition.

Models of Excellence

International, National and 

Regional
John Marsh

Excellence Model (c) EFQM 4

History

• Deming Prize, Japan

• National Malcolm Baldrige Quality Award, US

• European Excellence Model

• Proliferation of National and Regional derivatives

• ISO 9004:2000 hybrid

Underpinning Concepts

• Visionary leadership

• Patient-focused 

excellence

• Organizational and 

personal learning

• Valuing staff and partners

• Agility

• Focus on the future

• Managing for innovation

• Management by fact

• Social responsibility and 

community health

• Focus on results and 

creating value

• Systems perspective
John Marsh

Excellence Model (c) EFQM 5

European Excellence Model

INNOVATION AND LEARNING

ENABLERS RESULTS

Key

Performance

Results

Partnerships

& Resources

Policy &

Strategy

People

Leadership Processes

People

Results

Customer

Results

Society

Results

Performance Excellence Framework 

Baldrige Quality Award - US

Measurement, Analysis and Knowledge Management

Focus on Patients,

Other Customers &

Markets

Leadership

Strategic

Planning

Process

Management

Organizational

Performance

Results

Staff Focus
John Marsh

Excellence Model (c) EFQM 6

Nations

• Baldrige

– United States

– Brazil

– Mexico

• European Quality Award

– European Union

– Russia

– India

– Botswana (SA)

– Macedonia

– Serbia and Montenegro

• Deming Prize

– Japan

• Don’t Know yet

– Ethiopia

– Haiti

– Lesotho

– Malawi

– Mozambique

– Swaziland

– Thailand

– Uganda

– Vietnam

– Zambia

Italics – educated guess

Performance Excellence Model 

Baldrige National Quality Award 

(BNQA)

Work from 2005 Health Care 

Baldrige Criteria
John Marsh

Excellence Model (c) EFQM 7

Self Assessment

Be careful of scoring!

Self Assessment

• A comprehensive, systematic and regular review 

of an organization’s activities and results, 

referenced against the BNQA Performance 

Excellence Framework, which results in planned 

improvement.

PLAN

DO

STUDY

ACT
John Marsh

Excellence Model (c) EFQM 8

Why do it?

• Identifies progress made

• Identifies improvements

• Defines best practice

• Enables benchmarking

• Facilitates learning

• Provides momentum

• Integrates initiatives

• Don’t worry about Awards!

‘The overall message is clear. 

When Business Excellence is implemented

effectively, financial performance improves 

dramatically.’

1999/2000 by Kevin B Hendricks of the Richard Ivey School of Business at the 

University of Western Ontario and Vinod R Singhal of the DuPree College of 

Management at the Georgia Institute of Technology

Methods of Self Assessment

• Award style reports

• Facilitator led workshops

• Questionnaires

• One-to-one discussions

• Hybrids of above

• Scoring – be careful!
John Marsh

Excellence Model (c) EFQM 9

Scoring - ADLIR

• Process

– Approach

– Deployment

– Learning

– Integration

• Results

Approach

• The methods used to accomplish the process.

• The appropriateness of the methods to the Item

requirements.

• The effectiveness of your use of the methods.

• The degree to which the approach is repeatable

and based on reliable data and information 

(i.e., systematic).
John Marsh

Excellence Model (c) EFQM 10

Deployment

• Your approach is applied in addressing Item 

requirements relevant and important to your 

organization.

• Your approach is applied consistently.

• Your approach is used by all appropriate work 

units.

Learning

• Refining your approach through cycles of 

evaluation and improvement.

• Encouraging breakthrough change to your 

approach through innovation.

• Sharing of refinements and innovation with other

relevant work units and processes in your 

organization.
John Marsh

Excellence Model (c) EFQM 11

Integration

• Your approach is aligned with your organizational 

needs identified in other Criteria Item 

requirements.

• Your measures, information, and improvement 

systems are complementary across processes 

and work units

• Your plans, processes, results, analyses, learning, 

and actions are harmonized across processes and 

work units to support organization-wide goals

Results

• Your current level of performance.

• Rate (i.e., slope of trend data) and breadth (i.e., how

widely deployed and shared) of your performance 

improvements.

• Your performance relative to appropriate comparisons

and/or benchmarks.

• Linkage of your results measures (often through 

segmentation) to important customer, product and service, 

market, process, and action plan performance 

requirements identified in your Organizational Profile and 

in Process Items.
John Marsh

Excellence Model (c) EFQM 12

Group Work Two

• Working on your own consider a single criterion.

• Identify the strengths and areas for improvement 

for an organization you know well.

• Would this ‘score’ well?

• Feedback and discussion.

The fit with other initiatives

Putting pieces of MIPH 2005 

together
John Marsh

Excellence Model (c) EFQM 13

Linkages

Baldrige Criteria

Leadership

Strategic Planning

Focus on Patients, Other 

Customers and Markets

Staff Focus

Process Management

Measurement, Analysis 

and Knowledge 

Management

MIPH 2005 Integration Table

Senior Leadership

Strategy Development

Patient, Other Customer and Health Care 

Market Knowledge

Patient, Other Customer Relationships and 

Satisfaction

Work Systems

Staff Well-Being and Satisfaction

Governance & Social Responsibilities

Strategy Deployment

Measurement and Analysis of 

Organizational Performance

Information and Knowledge Management

Staff Learning and Motivation

Health Care Processes

Sub-criteria

Support Processes and Operational 

Planning

Group Work Three

• Work in teams of five people.

• Complete the table showing how each element of 

MIPH 2005 fits within the Baldrige framework.

• Present and discuss.
John Marsh

Excellence Model (c) EFQM 14

Group Work Four

• Working on your own consider the following.

• How can you exploit the excellence models in your 

public health system in your country?

• Feedback, discussion, questions and answers.

Important Websites

• NIST http://baldrige.nist.gov/

• EFQM http://www.efqm.org

• UNECE National Quality Award Schemes http://www.unece.org/indust/sme/Qnational-award.html

• International Standards Organization http://www.iso.org/iso/en/ISOOnline.frontpage

• Modernizing Public Services Group www.servicefirst.gov.uk

• An Organization for Economic Co-operation and Development 

www.oecd.org/puma/country/index.htm

• International Government Benchmarking AssociationTM http://igba.org

• Public Sector Benchmarking Service www.benchmarking.gov.uk

• ORC International www.orc.co.uk/newsevents/folder.htm

• Organization for Economic Cooperation and Development www.oecd.org

• The European Benchmarking Forum

www.benchmarking-in-europe.com

• Global Benchmarking Network www.globalbenchmarking.org

• South African Quality Institute http://www.saqi.co.za/About.htm
John Marsh

Excellence Model (c) EFQM 15

Free Subscription for MIPH 2005

• A year’s free subscription to the Marsh and 

Barnes, Inc Learning Portal.

• http://tqp.inets.com

• Username & password required.

• Toolkits included on Portal

Review and Close

• Strengths • Areas for Improvement
Healthcare Criteria

for Performance Excellence
Baldrige National Quality Program

Health Care

Criteria for

Performance

Excellence

2005
A Public-Private Partnership

Building active partnerships in the private sector—and

among the private sector and all levels of government—is

fundamental to the success of the Baldrige National Quality

Program in improving national competitiveness. Privatesector support for the Program in the form of funds, volunteer efforts, and participation in information transfer

continues to grow.

To ensure the continued growth and success of these partnerships, each of the following organizations plays an important role.

Foundation for the Malcolm Baldrige

National Quality Award

The Foundation for the Malcolm Baldrige National Quality

Award was created to foster the success of the Program.

The Foundation’s main objective is to raise funds to permanently endow the Award Program.

Prominent leaders from U.S. organizations serve as Foundation Trustees to ensure that the Foundation’s objectives

are accomplished. A broad cross section of organizations

throughout the United States provides financial support to

the Foundation.

National Institute of Standards and

Technology

The U.S. Department of Commerce is responsible for the

Baldrige National Quality Program and the Award. The

National Institute of Standards and Technology (NIST), an

agency of the Department’s Technology Administration,

manages the Baldrige Program. NIST promotes U.S. economic growth by working with industry to develop and deliver the high-quality measurement tools, data, and services

necessary for the nation’s technology infrastructure. NIST

also participates in a unique, government/private sector

partnership to accelerate the development of high-risk

technologies that promise significant commercial and economic benefits. Through a network of technology extension centers and field offices serving all 50 states and

Puerto Rico, NIST helps small- and medium-sized businesses access the information and expertise they need to

improve their competitiveness in the global marketplace.

American Society for Quality 

The American Society for Quality (ASQ) assists in administering the Award Program under contract to NIST. ASQ is

dedicated to the ongoing development, advancement, and

promotion of quality concepts, principles, and techniques.

ASQ strives to be the world’s recognized champion and

leading authority on all issues related to quality. ASQ recognizes that continuous quality improvement will help the

favorable positioning of American goods and services in the

international marketplace.

Board of Overseers

The Board of Overseers advises the Department of Commerce on the Baldrige National Quality Program. The

board is appointed by the Secretary of Commerce and consists of distinguished leaders from all sectors of the U.S.

economy.

The Board of Overseers evaluates all aspects of the Program, including the adequacy of the Criteria and processes

for determining Award recipients. An important part of the

board’s responsibility is to assess how well the Program is

serving the national interest. Accordingly, the board makes

recommendations to the Secretary of Commerce and to the

Director of NIST regarding changes and improvements in

the Program. 

Board of Examiners

The Board of Examiners evaluates Award applications and

prepares feedback reports. The Panel of Judges, part of the

Board of Examiners, makes Award recommendations to the

Director of NIST. The board consists of leading U.S. business, education, and health care experts. NIST selects

members through a competitive application process. For

2005, the board consists of about 540 members. Of these, 

10 (who are appointed by the Secretary of Commerce) serve

as Judges, and approximately 110 serve as Senior Examiners.

The remainder serve as Examiners. All members of the

board must take part in an Examiner preparation course.

In addition to reviewing applications, board members play

a significant role in sharing information about the Baldrige

Program. Their membership in hundreds of professional,

trade, community, and state organizations helps them disseminate this information.

Award Recipients

Award recipients are required to share information on their

successful performance and quality strategies with other

U.S. organizations. However, recipients are not required to

share proprietary information, even if such information was

part of their Award application. The principal mechanism

for sharing information is The Quest for Excellence® Conference, held annually.

Award recipients in the 17 years of the Award have been

extremely generous in their commitment to improving U.S.

competitiveness and furthering the U.S. pursuit of performance excellence. They have shared information with

hundreds of thousands of companies, education organizations,

health care organizations, government agencies, and others.

This sharing far exceeds expectations and Program requirements. Award recipients’ efforts have encouraged many

other organizations in all sectors of the U.S. economy to

undertake their own performance improvement efforts.

THE MALCOLM BALDRIGE NATIONAL QUALITY AWARD PROGRAM
Baldrige National Quality Program

National Institute of Standards and Technology • Technology Administration • Department of Commerce 

To: U.S. Health Care Community 

From: Harry S. Hertz, Director

Baldrige National Quality Program

Subject: Win the Baldrige Challenge

The Baldrige Health Care Criteria for Performance Excellence are about winning! They are about winning organizational success with a high-performing, high integrity, ethical organization. Every Baldrige Criteria user is a

winner.

The Health Care Criteria help organizations respond to current challenges and address all the complexities of

delivering today’s results while preparing effectively for the future. The 2005 Health Care Criteria have been

updated to deal with the specific pressures on senior leaders; the needs for organizational, not just technological,

innovation; and the challenges of long-term viability and sustainability as a high-performing organization. The

Health Care Criteria deal more directly with the topic of execution: being agile and still executing with speed.

How does your organization measure up to these and overall health care challenges? 

Whether your organization is small or large, is involved in ambulance service or health maintenance, or has one

facility or multiple sites across the country, the Health Care Criteria provide a valuable framework that can help

you measure performance and plan in an uncertain environment. The Health Care Criteria can help you align resources with approaches, such as Plan-Do-Study-Act cycles, a Balanced Scorecard, and Six Sigma; improve communication, productivity, and effectiveness; and achieve strategic goals.

How to begin that first Baldrige assessment? Take a few minutes and scan the questions in the Organizational

Profile on pages 12–14. A discussion of the answers to these questions might be your first Baldrige assessment. For

additional guidance, refer to our free booklet Getting Started with the Baldrige Criteria for Performance Excellence.

Do you need to know what your staff and your senior managers think? Do you believe you have been making

progress but want to accelerate or better focus your efforts? Try using our simple Are We Making Progress? and

Are We Making Progress as Leaders? questionnaires. Organized by the seven Baldrige Criteria Categories, they will

help you check your progress toward meeting your organizational goals and can improve communication among

your staff and your leadership team.

Even if you don’t expect to win the Baldrige Award, submitting an Award application has valuable benefits. Every

applicant receives a detailed feedback report based on an independent, external assessment conducted by a panel

of specially trained and recognized experts.

The Health Care Criteria are in your hands . . . so is an incredible opportunity. Why not take advantage of that

opportunity? When you turn these pages, you turn the corner toward performance excellence. If you want more

information, contact me at nqp@nist.gov.

Baldrige National Quality Program • NIST • Administration Building, Room A600 • 100 Bureau Drive, Stop 1020 • Gaithersburg, MD 20899-1020

Telephone: (301) 975-2036 • Fax: (301) 948-3716 • E-mail: nqp@nist.gov • Web site: www.baldrige.nist.gov

Need some useful tools to meet the Baldrige challenge? Try using

• Getting Started with the Baldrige Criteria for Performance Excellence

• E-Baldrige Organizational Profile found on our Web site at

www.baldrige.nist.gov/eBaldrige/Step_One.htm

• Are We Making Progress? and Are We Making Progress as Leaders?

Contact the Baldrige National Quality Program or visit our Web site for these and other educational materials.
ii 2005 Health Care Criteria for Performance Excellence

THE QUEST FOR EXCELLENCE

The Malcolm Baldrige National Quality Award

The Award crystal, composed of two solid crystal prismatic

forms, stands 14 inches tall. The crystal 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 inscriptions “Malcolm Baldrige National Quality

Award” and “The Quest for Excellence” on one side and

the Presidential Seal on the other.

The President of the United States traditionally presents

the Awards at a special ceremony in Washington, DC.

Crystal by Steuben 

The Quest for Excellence® XVII Conference

Each year, The Quest for Excellence, the official conference of the Malcolm Baldrige National Quality Award,

provides a forum for Baldrige Award recipients to share

their exceptional performance practices with worldwide

leaders in business, education, health care, and nonprofit

organizations. The Quest for Excellence XVII will showcase the year 2004 Award recipients.

For the last 16 years, executives, managers, and quality

leaders have come to this conference to learn how these

role model organizations have achieved performance excellence. CEOs and other leaders from the Award recipient organizations give presentations covering all seven

Categories of the Baldrige Criteria, their journey to performance excellence, and their lessons learned. At this

three-day conference, designed to maximize learning 

and networking opportunities, attendees will be able 

to interact with Award recipients.

The Quest for Excellence XVII Conference will be held

April 10–13, 2005, at the Marriott Wardman Park Hotel

in Washington, DC. For further information, contact the

Baldrige Program by mail: Baldrige National Quality

Program, NIST, Administration Building, Room A600,

100 Bureau Drive, Stop 1020, Gaithersburg, MD 20899-

1020; telephone: (301) 975-2036; fax: (301) 948-3716; or

e-mail: nqp@nist.gov. For a general overview of the

Baldrige National Quality Program, visit its Web site:

www.baldrige.nist.gov.

The Malcolm Baldrige National Quality Award logo and the phrases “The Quest for Excellence”

and “Performance Excellence” are trademarks and service marks of the 

National Institute of Standards and Technology.
2005 Health Care Criteria for Performance Excellence iii

CONTENTS 1 2005 Health Care Criteria: Core Values, Concepts, and Framework

7 Key Characteristics of the Health Care Criteria

9 Changes from the 2004 Health Care Criteria 

11 2005 Health Care Criteria for Performance Excellence—Item Listing

12 2005 Health Care Criteria for Performance Excellence

12 Preface: Organizational Profile

15 1 Leadership

18 2 Strategic Planning 

21 3 Focus on Patients, Other Customers, and Markets

23 4 Measurement, Analysis, and Knowledge Management

25 5 Staff Focus 

28 6 Process Management

31 7 Organizational Performance Results 

36 Baldrige Application Self-Analysis Worksheet

38 2005 Health Care Criteria: Category and Item Descriptions

53 Scoring System

54 Scoring Guidelines 

57 2005 Health Care Criteria Response Guidelines

61 Applying for the Malcolm Baldrige National Quality Award

61 Fees for the 2005 Award Cycle

63 Summary of Health Care Eligibility and Restrictions

64 How to Obtain Copies of Baldrige Program Materials

66 Glossary of Key Terms

75 Index of Key Terms

If you plan to apply for the Award in 2005, you also need the Baldrige Award Application Forms,

which can be downloaded at www.baldrige.nist.gov/Award_Application.htm.

The first step in the Award application process is to provide the Eligibility Certification

Package, which is due April 12, 2005. If you would like to recommend a senior member of 

your organization for the Board of Examiners, the package is due March 11, 2005.

Award Application Packages are due May 26, 2005, or May 12, 2005, if submitted on CD.

We are easy to reach. Our Web site is www.baldrige.nist.gov.

Business and education organizations should use the appropriate Criteria 

booklets for their respective sectors. See pages 64–65 for ordering information.
iv 2005 Health Care Criteria for Performance Excellence
2005 Health Care Criteria for Performance Excellence 1

2005 HEALTH CARE CRITERIA: CORE VALUES, CONCEPTS, AND FRAMEWORK

Criteria Purposes 

The Health Care Criteria are the basis for organizational

self-assessments, for making Awards, and for giving feedback

to applicants. In addition, the Health Care Criteria have three

important roles in strengthening U.S. competitiveness:

■ to help improve organizational performance practices,

capabilities, and results 

■ to facilitate communication and sharing of best practices information among health care organizations and

among U.S. organizations of all types

■ to serve as a working tool for understanding and

managing performance and for guiding organizational

planning and opportunities for learning

Health Care Criteria for Performance Excellence Goals 

The Health Care Criteria are designed to help organizations use an integrated approach to organizational

performance management that results in 

■ delivery of ever-improving value to patients and

other customers, contributing to improved health

care quality

■ improvement of overall organizational effectiveness

and capabilities as a health care provider

■ organizational and personal learning

Core Values and Concepts 

The Health Care Criteria are built upon the following set

of interrelated Core Values and Concepts:

■ visionary leadership

■ patient-focused excellence

■ organizational and personal learning

■ valuing staff and partners

■ agility

■ focus on the future

■ managing for innovation

■ management by fact

■ social responsibility and community health

■ focus on results and creating value

■ systems perspective

These values and concepts, described below, are embedded

beliefs and behaviors found in high-performing organizations. They are the foundation for integrating key organizational requirements within a results-oriented framework

that creates a basis for action and feedback. 

Visionary Leadership

Your organization’s senior leaders (administrative/operational

and health care provider leaders) should set directions and

create a patient focus, clear and visible values, and high expectations. The directions, values, and expectations should

balance the needs of all your stakeholders. Your leaders

should ensure the creation of strategies, systems, and methods for achieving performance excellence in health care,

stimulating innovation, building knowledge and capabilities,

and ensuring organizational sustainability. The values and

strategies should help guide all of your organization’s activities and decisions. Senior leaders should inspire and motivate your entire staff and should encourage all staff to contribute, to develop and learn, to be innovative, and to be

creative. Senior leaders should be responsible to your organization’s governance body for their actions and performance.

The governance body should be responsible ultimately to

all your stakeholders for the ethics, actions, and performance

of your organization and its senior leaders.

Senior leaders should serve as role models through their

ethical behavior and their personal involvement in planning,

communications, coaching, development of future leaders,

review of organizational performance, and staff recognition.

As role models, they can reinforce ethics, values, and expectations while building leadership, commitment, and initiative throughout your organization.

Patient-Focused Excellence

The delivery of health care services must be patient focused.

Quality and performance are the key components in determining patient satisfaction, and all attributes of patient care

delivery (including those not directly related to medical/

clinical services) factor into the judgment of satisfaction and

value. Satisfaction and value to patients are key considerations for other customers as well. Patient-focused excellence

has both current and future components: understanding

today’s patient desires and anticipating future patient desires

and health care marketplace offerings.

Value and satisfaction may be influenced by many factors

during a patient’s experience participating in health care.

Primary among these factors is an expectation that patient

safety will be ensured throughout the health care delivery

process. Additional factors include a clear understanding of

likely health and functional status outcomes, as well as the

patient’s relationship with the health care provider and ancillary staff, cost, responsiveness, and continuing care and

attention. For many patients, the ability to participate in

making decisions about their health care is considered an

important factor. This requires patient education for an informed decision. Characteristics that differentiate one

provider from another also contribute to the sense of being

patient focused.

Patient-focused excellence is thus a strategic concept. It is

directed toward obtaining and retaining patient loyalty, referral of new patients, and market share gain in competitive

markets. Patient-focused excellence thus demands rapid and
2 2005 Health Care Criteria for Performance Excellence

flexible response to emerging patient desires and health care

marketplace requirements, and measurement of the factors

that drive patient satisfaction. It demands listening to your

patients and other customers. Patient-focused excellence

also demands awareness of new technology and new modalities for delivery of health care services.

Organizational and Personal Learning

Achieving the highest levels of performance requires a wellexecuted approach to organizational and personal learning.

Organizational learning includes both continuous improvement of existing approaches and significant change, leading

to new goals and approaches. Learning needs to be embedded in the way your organization operates. This means that

learning (1) is a regular part of daily work; (2) is practiced at

personal, department/work unit, and organizational levels;

(3) results in solving problems at their source (“root cause”);

(4) is focused on building and sharing knowledge throughout your organization; and (5) is driven by opportunities to

effect significant, meaningful change. Sources for learning

include staff’s ideas, health care research findings, patients’

and other customers’ input, best practice sharing, and

benchmarking.

Organizational learning can result in (1) enhancing value to

patients through new and improved patient care services;

(2) developing new health care opportunities; (3) reducing

errors, defects, waste, and related costs; (4) improving responsiveness and cycle time performance; (5) increasing

productivity and effectiveness in the use of all your resources; and (6) enhancing your organization’s performance

in building community health and fulfilling its societal

responsibilities.

Staff success depends increasingly on having opportunities

for personal learning and on practicing new skills. Organizations invest in staff’s personal learning through education,

training, and other opportunities for continuing growth and

development. Such opportunities might include job rotation

and increased pay for demonstrated knowledge and skills.

On-the-job training offers a cost-effective way to train and

to better link training to your organizational needs and priorities. For health care providers, personal learning includes

building discipline knowledge, discipline retraining to adjust

to a changing health care environment, and enhancing

knowledge of measurement systems that influence outcome

assessments and clinical guidelines, decision trees, or critical

pathways. Education and training programs may benefit

from advanced technologies, such as computer- and Internetbased learning and satellite broadcasts.

Personal learning can result in (1) more satisfied and versatile staff who stay with your organization, (2) organizational

cross-functional learning, (3) the building of your organization’s knowledge assets, and (4) an improved environment

for innovation.

Thus, learning is directed not only toward better health care

services but also toward being more responsive, adaptive,

innovative, and efficient—giving your organization health

care marketplace sustainability and performance advantages

and giving your staff satisfaction and motivation to excel.

Valuing Staff and Partners

An organization’s success depends increasingly on the diverse

backgrounds, knowledge, skills, creativity, and motivation of

all its staff and partners.

Valuing staff means committing to their satisfaction, development, and well-being. Increasingly, this involves more

flexible, high-performance work practices tailored to staff

with varying workplace and home life needs. Major challenges in the area of valuing staff include (1) demonstrating

your leaders’ commitment to your staff’s success, (2) providing recognition that goes beyond the regular compensation

system, (3) offering development and progression within

your organization, (4) sharing your organization’s knowledge so your staff can better serve your patients and other

customers and contribute to achieving your strategic objectives, (5) creating an environment that encourages appropriate risk taking and innovation, and (6) creating a supportive

environment for a diverse workforce. 

Organizations need to build internal and external partnerships to better accomplish overall goals. Internal partnerships

might include cooperation between health care providers and

other staff, and labor-management cooperation. Partnerships

with staff might entail staff development, cross-training, or

new work organizations, such as high-performance work

teams. Internal partnerships also might involve creating

network relationships among your departments/work units

to improve flexibility, responsiveness, and knowledge sharing and to develop processes that better meet patient care

and needs. 

External partnerships might be with customers, suppliers,

business associations, third-party payors, community and

social service organizations, and other health care providers.

Strategic partnerships or alliances are increasingly important kinds of external partnerships. Such partnerships with

other health care organizations could result in referrals or

in shared facilities that are either capital intensive or require

unique and scarce expertise. Also, partnerships might permit
2005 Health Care Criteria for Performance Excellence 3

the blending of your organization’s core competencies or

leadership capabilities with the complementary strengths

and capabilities of partners.

Successful internal and external partnerships develop

longer-term objectives, thereby creating a basis for mutual

investments and respect. Partners should address the key

requirements for success, means for regular communication, approaches to evaluating progress, and means for

adapting to changing conditions. In some cases, joint education and training could offer a cost-effective method for

staff development. 

Agility

Success in today’s health care environment demands agility—

a capacity for rapid change and flexibility. All aspects of

electronic communication and information transfer require

and enable more rapid, flexible, and customized responses.

Health care providers face ever-shorter cycles for the introduction of new/improved health care services, as well as for

faster and more flexible responses to patients and other customers. Major improvements in response times often require

simplification of work units and processes or the ability for

rapid changeover from one process to another. Crosstrained and empowered staff are vital assets in such a

demanding environment. 

Today’s health care environment places a heavy burden on

the timely design of health care delivery systems, disease

prevention programs, health promotion programs, and

effective and efficient diagnostic and treatment systems.

Overall design must include the opportunity to learn for

continuous organizational improvement and must value the

individual needs of patients. Design also must include effective means for gauging improvement of health status—for

patients and populations/communities. Beneficial changes

must be introduced at the earliest appropriate opportunity. 

All aspects of time performance now are more critical, and

cycle time has become a key process measure. Other important benefits can be derived from this focus on time; time

improvements often drive simultaneous improvements in

organization, quality, cost, patient focus, and productivity. 

Focus on the Future

In today’s health care environment, creating a sustainable

organization requires understanding the short- and longerterm factors that affect your organization and health care

marketplace. Pursuit of health care excellence requires a

strong future orientation and a willingness to make longterm commitments to key stakeholders—your patients and

families, staff, communities, employers, payors, health profession students, and suppliers and partners.

Your organization’s planning should anticipate many factors,

such as changes in health care delivery systems, resource

availability, patient and other stakeholder expectations,

technological developments, new partnering opportunities,

staff development and hiring needs, evolving importance of

electronic communication and information transfer, changes

in customer and market segments, evolving regulatory requirements, community and societal expectations, and new

thrusts by competitors and other organizations providing

similar services. Strategic objectives and resource allocations

need to accommodate these influences. A focus on the future

includes developing staff and suppliers, doing effective succession planning, creating opportunities for innovation, and

anticipating public responsibilities.

A major long-term investment associated with health care

excellence is the investment in creating and sustaining an

assessment system focused on health care outcomes. This

entails becoming familiar with research findings and ongoing application of assessment methods.

Managing for Innovation

Innovation means making meaningful change to improve an

organization’s services, processes, and operations and to create

new value for the organization’s stakeholders. Innovation

should lead your organization to new dimensions of performance. Innovation is no longer strictly the purview of health

care researchers; innovation is important for all aspects of

your organizational performance and all processes. Organizations should be led and managed so that innovation becomes part of the learning culture. Innovation should be

integrated into daily work and should be supported by your

performance improvement system. 

Innovation builds on the accumulated knowledge of your

organization and its staff. Therefore, the ability to rapidly

disseminate and capitalize on this knowledge is critical to

driving organizational innovation.

Management by Fact

An effective health care service and administrative management system depends on the measurement and analysis of

performance. Such measurements should derive from health

care service needs and strategy, and they should provide

critical data and information about key processes, outputs,

and results. Many types of data and information are needed

for performance management. Performance measurement

should include information on health care outcomes; community health; epidemiological data; critical pathways and

practice guidelines; administrative, payor, staff, cost, and

financial performance; competitive comparisons; customer

satisfaction; and corporate governance and compliance.

Data should be segmented by, for example, markets, health

care service lines, and staff groups to facilitate analysis.

Analysis refers to extracting larger meaning from data and

information to support evaluation, decision making, and improvement. Analysis entails using data to determine trends,

projections, and cause and effect that might not otherwise

be evident. Analysis supports a variety of purposes, such as

planning, reviewing your overall performance, improving

operations, change management, and comparing your
4 2005 Health Care Criteria for Performance Excellence

performance with competitors’, with similar health care

organizations’, or with “best practices” benchmarks.

A major consideration in performance improvement and

change management involves the selection and use of performance measures or indicators. The measures or indicators

you select should best represent the factors that lead to improved

health care outcomes; improved customer, operational, financial,

and ethical performance; and healthier communities. A comprehensive set of measures or indicators tied to patient/customer and

organizational performance requirements represents a clear basis

for aligning all processes with your organization’s goals. Through

the analysis of data from your tracking processes, your

measures or indicators themselves may be evaluated and

changed to better support your goals.

Social Responsibility and Community Health

A health care organization’s leaders should stress responsibilities to the public, ethical behavior, and the need to foster

improved community health. Leaders should be role models

for your organization in focusing on ethics and protection

of public health, safety, and the environment. Protection of

health, safety, and the environment includes any impact of

your organization’s operations. Also, organizations should

emphasize resource conservation and waste reduction at the

source. Planning should anticipate adverse impacts that may

arise in facilities management, as well as use and disposal of

radiation, chemicals, and biohazards. Effective planning

should prevent problems, provide for a forthright response

if problems occur, and make available information and

support needed to maintain public awareness, safety, and

confidence.

Organizations should not only meet all local, state, and federal laws and regulatory and accreditation requirements, but

they should treat these and related requirements as opportunities for improvement “beyond mere compliance.”

Organizations should stress ethical behavior in all stakeholder transactions and interactions. Highly ethical conduct

should be a requirement of and should be monitored by the

organization’s governance body. Ethical practices need to

consider nondiscriminatory patient treatment policies and

protection of patients’ rights and privacy. Public health services and the support of the general health of the community are important citizenship responsibilities of health care

organizations.

Practicing good citizenship refers to leadership in carrying

out these responsibilities—within the limits of an organization’s resources—and includes influencing other organizations, private and public, to partner for these purposes. For

example, your organization might lead or participate in

efforts to establish free clinics or affordable care programs,

to increase public health awareness programs, or to foster

neighborhood services for the elderly. A leadership role also

could include helping to define regional or national health

care issues for action by regional or national networks or

associations.

Managing social responsibility requires the use of appropriate measures and leadership responsibility for those

measures.

Focus on Results and Creating Value

An organization’s performance measurements need to focus

on key results. Results should be used to create and balance

value for your key stakeholders—patients, their families,

staff, the community, payors, businesses, health profession

students, suppliers and partners, investors, and the public.

By creating value for your key stakeholders, your organization builds loyalty and contributes to the community. To

meet the sometimes conflicting and changing aims that balancing value implies, organizational strategy explicitly

should include key stakeholder requirements. This will help

ensure that plans and actions meet differing stakeholder

needs and avoid adverse impacts on any stakeholders. The

use of a balanced composite of leading and lagging performance measures offers an effective means to communicate

short- and longer-term priorities, monitor actual performance, and provide a clear basis for improving results.

Systems Perspective

The Baldrige Health Care Criteria provide a systems perspective for managing your organization and its key processes to achieve results—performance excellence. The

seven Baldrige Categories and the Core Values form the

building blocks and the integrating mechanism for the

system. However, successful management of overall performance requires organization-specific synthesis, alignment,

and integration. Synthesis means looking at your organization as a whole and builds upon key organizational requirements, including your strategic objectives and action plans.

Alignment means using the key linkages among requirements given in the Baldrige Categories to ensure consistency of plans, processes, measures, and actions. Integration

builds on alignment so that the individual components of

your performance management system operate in a fully

interconnected manner.

These concepts are depicted in the Baldrige framework on

page 5. A systems perspective includes your senior leaders’

focus on strategic directions and on your patients and other

customers. It means that your senior leaders monitor, respond to, and manage performance based on your organizational results. A systems perspective also includes using your

measures, indicators, and organizational knowledge to build

your key strategies. It means linking these strategies with

your key processes and aligning your resources to improve

overall performance and satisfy patients and other customers.

Thus, a systems perspective means managing your whole

organization, as well as its components, to achieve success.
2005 Health Care Criteria for Performance Excellence 5

Baldrige Health Care Criteria for Performance Excellence Framework: A Systems Perspective

Linkage of the Health Care Criteria to the

Baldrige Business Sector Criteria

The 2005 Health Care Criteria incorporate the Core

Values and Concepts described on the preceding pages

and are built upon the seven-part framework used in

the Business Criteria for Performance Excellence. The

rationale for the use of the same framework is that it is

adaptable to the requirements of all organizations, including health care organizations. However, this adaptation does not assume that these requirements are necessarily addressed in the same way. This adaptation to

health care, then, is largely a translation of the language

and basic concepts of business excellence to similarly

important concepts in health care excellence. A major

practical benefit derived from using a common framework for all sectors of the economy is that it fosters

cross-sector cooperation and sharing of best practices

information.

Health Care Criteria for Performance

Excellence Framework

The Core Values and Concepts are embodied in seven

Categories, as follows:

1 Leadership

2 Strategic Planning

3 Focus on Patients, Other Customers, and Markets

4 Measurement, Analysis, and Knowledge

Management

5 Staff Focus 

6 Process Management

7 Organizational Performance Results

The figure below provides the framework connecting and

integrating the Categories.

From top to bottom, the framework has the following basic

elements.

2 

Strategic

Planning

1 

Leadership

5 

Staff Focus

6 

Process

Management

4 

Measurement, Analysis, and Knowledge Management

Organizational Profile:

Environment, Relationships, and Challenges

3

Focus on Patients,

Other Customers,

and Markets

7 

Organizational

Performance

Results
6 2005 Health Care Criteria for Performance Excellence

Organizational Profile

Your Organizational Profile (top of figure) sets the context

for the way your organization operates. Your environment,

key working relationships, and strategic challenges serve as

an overarching guide for your organizational performance

management system.

System Operations

The system operations are composed of the six Baldrige

Categories in the center of the figure that define your

operations and the results you achieve.

Leadership (Category 1), Strategic Planning (Category 2),

and Focus on Patients, Other Customers, and Markets

(Category 3) represent the leadership triad. These Categories

are placed together to emphasize the importance of a leadership focus on strategy and patients and other customers.

Senior leaders set your organizational direction and seek

future opportunities for your organization.

Staff Focus (Category 5), Process Management (Category

6), and Organizational Performance Results (Category 7)

represent the results triad. Your organization’s staff and key

processes accomplish the work of the organization that

yields your performance results.

All actions point toward Organizational Performance

Results—a composite of health care, patient and other

customer, and market, financial, and internal operational

performance results, including staff and work system results,

governance, and social responsibility results.

The horizontal arrow in the center of the framework links

the leadership triad to the results triad, a linkage critical to

organizational success. Furthermore, the arrow indicates the

central relationship between Leadership (Category 1) and

Organizational Performance Results (Category 7). The twoheaded arrows indicate the importance of feedback in an

effective performance management system.

System Foundation

Measurement, Analysis, and Knowledge Management (Category 4) are critical to the effective management of your

organization and to a fact-based, knowledge-driven system

for improving health care and operational performance.

Measurement, analysis, and knowledge management serve as

a foundation for the performance management system.

Criteria Structure

The seven Criteria Categories shown in the figure are subdivided into Items and Areas to Address.

Items

There are 19 Items, each focusing on a major requirement.

Item titles and point values are given on page 11. The Item

format is shown on page 57.

Areas to Address

Items consist of one or more Areas to Address (Areas).

Organizations should address their responses to the specific

requirements of these Areas.
2005 Health Care Criteria for Performance Excellence 7

KEY CHARACTERISTICS OF THE HEALTH CARE CRITERIA

1. The Criteria focus on organizational performance

results.

The Criteria focus on the key areas of organizational

performance given below.

Organizational performance areas:

(1) health care outcomes and service delivery results

(2) patient- and other customer-focused results

(3) financial and market results

(4) staff and work system results

(5) organizational effectiveness results, including key

internal operational performance measures

(6) leadership and social responsibility results

The use of this composite of measures is intended to

ensure that strategies are balanced—that they do not

inappropriately trade off among important stakeholders,

objectives, or short- and longer-term goals.

2. The Criteria are nonprescriptive and adaptable.

The Criteria are made up of results-oriented requirements. However, the Criteria do not prescribe

■ how your organization should be structured; 

■ that your organization should or should not have

departments for quality, planning, or other functions; or

■ that different units in your organization should be

managed in the same way.

These factors differ among organizations, and they are

likely to change as needs and strategies evolve.

The Criteria are nonprescriptive for the following reasons:

(1) The focus is on results, not on procedures, tools, or

organizational structure. Health care organizations

are encouraged to develop and demonstrate creative,

adaptive, and flexible approaches for meeting requirements. Nonprescriptive requirements are

intended to foster incremental and major (“breakthrough”) improvements, as well as basic change

through innovation.

(2) The selection of tools, techniques, systems, and

organizational structure usually depends on factors

such as organization type and size, organizational

relationships, your organization’s stage of development, and staff capabilities and responsibilities.

(3) A focus on common requirements, rather than on

common procedures, fosters understanding, communication, sharing, alignment, and integration,

while supporting innovation and diversity in

approaches.

3. The Criteria integrate key health care themes.

The Health Care Criteria have been adapted to be sensitive to and tolerant of the specific needs of health care

organizations. These include

■ the different types of organizational missions, e.g.,

HMOs, home health care agencies, hospitals, and/or

teaching and research institutions; 

■ the patient as key customer and multiple other

customers and stakeholders, e.g., the community

and payors; 

■ the complex leadership structure that includes both

administrative/operational and health care providers;

■ the multiple roles that health care providers may

play as staff, supplier, and customer; and 

■ the importance of health care service delivery as the

primary focus of the organization’s processes. 

4. The Criteria support a systems perspective to

maintaining organization-wide goal alignment.

The systems perspective to goal alignment is embedded

in the integrated structure of the Core Values and

Concepts, the Organizational Profile, the Criteria, the

Scoring Guidelines, and the results-oriented, cause-effect

linkages among the Criteria Items.

Alignment in the Criteria is built around connecting and

reinforcing measures derived from your organization’s

processes and strategy. These measures tie directly to

patient/customer value and to overall performance. The

use of measures thus channels different activities in consistent directions with less need for detailed procedures,

centralized decision making, or overly complex process

management. Measures thereby serve both as a communications tool and as a basis for deploying consistent overall performance requirements. Such alignment ensures

consistency of purpose while also supporting agility,

innovation, and decentralized decision making.

A systems perspective to goal alignment, particularly when

strategy and goals change over time, requires dynamic

linkages among Criteria Items. In the Criteria, actionoriented cycles of learning take place via feedback between processes and results.

The learning cycles have four, clearly defined stages:

(1) planning, including design of processes, selection

of measures, and deployment of requirements

(2) executing plans
8 2005 Health Care Criteria for Performance Excellence

(3) assessing progress and capturing new knowledge,

taking into account internal and external results

(4) revising plans based upon assessment findings,

learning, new inputs, new requirements, and

opportunities for innovation

5. The Criteria support goal-based diagnosis.

The Criteria and the Scoring Guidelines make up a twopart diagnostic (assessment) system. The Criteria are a

set of 19 performance-oriented requirements. The Scoring Guidelines spell out the assessment dimensions—

Process and Results—and the key factors used to assess

each dimension. An assessment thus provides a profile of

strengths and opportunities for improvement relative to

the 19 performance-oriented requirements and relative to

process and performance maturity as determined by the

Scoring Guidelines. In this way, assessment leads to actions that contribute to performance improvement in all

areas, as described in the shaded box on page 7. This

diagnostic assessment is a useful management tool that

goes beyond most performance reviews and is applicable

to a wide range of strategies and management systems.
2005 Health Care Criteria for Performance Excellence 9

CHANGES FROM THE 2004 HEALTH CARE CRITERIA

The Health Care Criteria for Performance Excellence continue to evolve, to help organizations address a dynamic

environment. The specific and focused demands on senior

leaders, the need to attend to long-term (as well as shortterm) organizational sustainability, the challenges of organizational innovation to gain and sustain competitive advantages, the difficulty of plan and process execution, and the

clear need for alignment of all aspects of your performance

management system with your results measurements receive

greater attention in the 2005 Criteria. The Health Care

Criteria continue to emphasize the central role that patients

and other customers play in defining and achieving performance excellence and the importance of key partners and

suppliers in your organizational success.

Criteria questions have been better aligned throughout the

seven Categories and with the Organizational Profile. These

changes have been made to improve Baldrige self-assessment

and external assessment; the determination of organizational

strengths, gaps and alignment in approach, deployment,

learning, and integration (Categories 1–6); and the determination of organizational gaps, strengths of performance, and

opportunities in results areas (Category 7).

A primary consideration in the Health Care Criteria revisions

has been the important relationship between the Criteria

Items and the Scoring Guidelines. Together they form the

assessment system used by Baldrige Examiners and the one

recommended to you for self-assessment purposes. Basically,

the Criteria Item requirements ask how you accomplish the

work of your organization and what were the results. The

Scoring Guidelines help you assess how well you accomplish your work and how good are the results. By studying

the Criteria Item requirements and linkages among them,

you can gauge gaps in your performance management system. By studying the Scoring Guidelines, particularly the

descriptors for the scoring ranges above the ranges of your

scores, you can identify opportunities for reaching the next

level of organizational performance.

After determining how, what, how well, and how good for

your organization, you are in an excellent position to accelerate your improvement journey. To facilitate the process of

acceleration, we have included an optional worksheet in this

year’s Health Care Criteria booklet (see pages 36–37). This

worksheet is for your use and is not for inclusion in a formal

application for the Baldrige Award.

The most significant changes in the Health Care Criteria

and the Criteria booklet for 2005 are summarized as follows:

■ The number of Areas to Address has been increased

from 32 to 33.

■ Category 1, Leadership, now has a more defined

focus on leadership’s key responsibilities for guiding

and sustaining your organization and overseeing its

ethical stewardship.

■ Category 2, Strategic Planning, has been given a

clear focus on planning and executing plans for shortand long-term organizational sustainability.

■ Category 4, Measurement, Analysis, and Knowledge

Management, has an enhanced focus on all aspects of

organizational performance review and information

quality.

■ Category 6, Process Management, has an added

focus on operational planning to ensure availability of

financial resources and continuity of operations in an

emergency.

■ Category 7, Organizational Performance Results,

now includes a specific focus on results related to leadership effectiveness of your senior leaders.

■ A new worksheet has been added for your internal

use in action planning, based on your Baldrige selfassessment. This worksheet is optional and not to be

submitted with a formal Baldrige Award application.

■ Three terms have been added to the Glossary of Key

Terms: “diversity,” “partners,” and “sustainability.”

■ Concepts that have been given careful consideration

in the adaptation of the Business Criteria for Performance Excellence to the health care sector (formerly

Integration of Key Health Care Themes) are now

summarized in the Key Characteristics of the Health

Care Criteria. 

There have been some changes in almost all Criteria Items;

the most significant changes are highlighted and discussed

below.

Preface: Organizational Profile

■ Item P.1, Organizational Description, now includes

an increased focus on the role of suppliers and distributors in all your key processes. This addition helps set

the context for your later Criteria Item responses.

■ Item P.2, Organizational Challenges, now includes a

specific request for strategic challenges associated with

long-term organizational stability to help focus thinking in this important area.

Category 1: Leadership

■ Item 1.1, now Senior Leadership, has been rewritten

to highlight your senior leaders’ role in setting and

communicating vision, values, and a focus on patients

and other customers and accomplishing your organization’s objectives. It also focuses on your senior leaders’

key role in developing future leaders. 
10 2005 Health Care Criteria for Performance Excellence

■ Item 1.2, now Governance and Social Responsibilities,

has been modified to include leadership responsibilities

for all aspects of good governance of your organization.

Category 2: Strategic Planning

■ Item 2.1, Strategy Development, has been rewritten to

clearly address the key aspects of strategy development,

including your ability to execute the strategic plan.

Category 3: Focus on Patients, Other Customers,

and Markets 

■ The Items in this Category have an enhanced focus on

your use of patient and other customer complaint data

and your organization’s processes for minimizing

patient and other customer dissatisfaction and loss of

repeat business.

■ Item 3.1, Patient, Other Customer, and Health Care

Market Knowledge, has an enhanced focus on identifying current and potential patients and other customers for both existing and new health care services.

Category 4: Measurement, Analysis, and Knowledge

Management

■ Item 4.1, now Measurement, Analysis, and Review

of Organizational Performance, has an added emphasis on the purpose and use of the results of analyses

and reviews, including strategic decisions for your

organization.

■ Item 4.2, Information and Knowledge Management,

has a new Area to Address on data, information, and

knowledge quality in recognition of the challenges all

organizations face in this area. This Item also now

addresses the availability of data and information in

the event of an emergency.

Category 5: Staff Focus

■ The Items in this Category have an added focus on

how work systems and staff learning reinforce accomplishment of your organization’s action plans and retention of critical organizational knowledge. These are

key issues associated with long-term sustainability.

Category 6: Process Management

■ Item 6.2, now Support Processes and Operational

Planning, has a new Area to Address on operational

planning. This Area focuses on financial planning and

stewardship of resources, as well as your process for

continuity of operations in case of an emergency.

Category 7: Organizational Performance Results

■ Item 7.1, now Health Care Outcomes and Service

Delivery Results, has been given a point value of 100

points to indicate the importance of health care service

delivery performance results to patient and other customer satisfaction, loyalty, and long-term organization

success.

■ Item 7.6, now Leadership and Social Responsibility

Results, addresses all your key governance, senior

leadership, and social responsibility results. The Item

places in one location the evidence of your accomplishment of organizational strategy, ethical behavior,

fiscal accountability, legal compliance, and organizational citizenship.
2005 Health Care Criteria for Performance Excellence 11

P Preface: Organizational Profile

P.1 Organizational Description

P.2 Organizational Challenges

2005 Categories and Items Point Values

1 Leadership 120

1.1 Senior Leadership 70

1.2 Governance and Social Responsibilities 50

2 Strategic Planning 85

2.1 Strategy Development 40

2.2 Strategy Deployment 45

3 Focus on Patients, Other Customers, and Markets 85

3.1 Patient, Other Customer, and Health Care Market Knowledge 40

3.2 Patient and Other Customer Relationships and Satisfaction 45

4 Measurement, Analysis, and Knowledge Management 90

4.1 Measurement, Analysis, and Review of Organizational Performance 45

4.2 Information and Knowledge Management 45

5 Staff Focus 85

5.1 Work Systems 35

5.2 Staff Learning and Motivation 25

5.3 Staff Well-Being and Satisfaction 25

6 Process Management 85

6.1 Health Care Processes 45

6.2 Support Processes and Operational Planning 40

7 Organizational Performance Results 450

7.1 Health Care Outcomes and Service Delivery Results 100

7.2 Patient- and Other Customer-Focused Results 70

7.3 Financial and Market Results 70

7.4 Staff and Work System Results 70

7.5 Organizational Effectiveness Results 70

7.6 Leadership and Social Responsibility Results 70

TOTAL POINTS 1000

2005 HEALTH CARE CRITERIA FOR PERFORMANCE EXCELLENCE—ITEM LISTING

Note: The Scoring System used with the Criteria Items

in a Baldrige assessment can be found on pages 53–56.
12 2005 Health Care Criteria for Performance Excellence

2005 HEALTH CARE CRITERIA FOR PERFORMANCE EXCELLENCE

P Preface: Organizational Profile

Importance of Beginning With Your Organizational Profile

Your Organizational Profile is critically important because

• it is the most appropriate starting point for self-assessment and for writing an application;

• it helps you identify potential gaps in key information and focus on key performance requirements and organizational

performance results;

• it is used by the Examiners and Judges in application review, including the site visit, to understand your organization

and what you consider important; and

• it also may be used by itself for an initial self-assessment. If you identify topics for which conflicting, little, or no

information is available, it is possible that the Organizational Profile can serve as your complete assessment, and you

can use these topics for action planning.

The Organizational Profile is a snapshot of your organization, the KEY influences on HOW you operate, and the KEY challenges you face.

P.1 Organizational Description

Describe your organization’s PERFORMANCE environment and your KEY relationships with PATIENTS and other

CUSTOMERS, suppliers, PARTNERS, and STAKEHOLDERS.

Within your response, include answers to the following questions:

a. Organizational Environment

(1) What are your organization’s main HEALTH CARE SERVICES? What are the delivery mechanisms used to

provide your HEALTH CARE SERVICES to your PATIENTS and other CUSTOMERS?

(2) What is your organizational culture? What are your stated PURPOSE, VISION, MISSION, and VALUES?

(3) What is your STAFF profile? What are your categories and types of STAFF? What are their educational

LEVELS? What are your organization’s workforce and job DIVERSITY, organized bargaining units, use of

contract and privileged STAFF, and special health and safety requirements?

(4) What are your major technologies, equipment, and facilities?

(5) What is the legal and regulatory environment under which your organization operates? What are the

applicable occupational health and safety regulations; accreditation, certification, or registration

requirements; relevant health care industry standards; and environmental and financial regulations

relevant to HEALTH CARE SERVICE delivery?

b. Organizational Relationships

(1) What are your organizational structure and GOVERNANCE system? What are the reporting relationships

among your GOVERNANCE board, SENIOR LEADERS, and parent organization, as appropriate?

(2) What are your KEY PATIENT and other CUSTOMER groups, STAKEHOLDER groups, and health care market

SEGMENTS, as appropriate? What are their KEY requirements and expectations for your HEALTH CARE SERVICES

and operations? What are the differences in these requirements and expectations among PATIENT, other

CUSTOMER, and STAKEHOLDER groups, and health care market SEGMENTS?

(3) What role do suppliers and PARTNERS play in your KEY support PROCESSES? What role, if any, do they play

in your organizational INNOVATION PROCESSES? What are your most important types of suppliers and

PARTNERS? What are your most important supply chain requirements?

(4) What are your KEY supplier and partnering relationships and communication mechanisms?
2005 Health Care Criteria for Performance Excellence 13

Notes:

N1. Health care service delivery mechanisms to your

patients and other customers (P.1a[1]) might be direct

or through contractors or partners.

N2. Examples of the legal and regulatory environment

under which your organization operates (P.1a[5]) might

include the regulations promulgated by the Centers

for Medicare and Medicaid Services (CMS), such as

the Health Insurance Portability and Accountability

Act of 1996 (HIPAA) and the State Children’s Health

Insurance Program (SCHIP). They might also include

the standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

N3. Health care market segments (P.1b[2]) might be

based on health care services or features, geography,

health care service delivery modes, payors, business

volume, population demographics, or other factors

that are important to your organization to define

related market characteristics.

N4. Patient, other customer and stakeholder groups,

and health care market segment requirements (P.1b[2])

might include accessibility, continuity of care, electronic communication, and billing requirements.

N5. Communication mechanisms (P.1b[4]) should be

two-way and might be in person, via regular mail or

e-mail, or by telephone. For many organizations,

these mechanisms may change as marketplace requirements change.

For definitions of key terms presented throughout the Health Care Criteria and Scoring Guidelines text

in SMALL CAPS/SANS SERIF, see the Glossary of Key Terms on pages 66–73.

Frequently, several questions are grouped under one number (e.g., P.1a[3]). These questions are related

and do not require separate responses. These multiple questions serve as a guide in understanding the full

meaning of the information being requested.

Item notes serve three purposes: (1) to clarify terms or requirements presented in an Item, (2) to give

instructions on responding to the Item requirements, and (3) to indicate key linkages to other Items. In

all cases, the intent is to help you respond to the Item requirements.

For additional description of this Item, see page 38.
14 2005 Health Care Criteria for Performance Excellence

Page Limit

For Baldrige Award applicants, the Organizational Profile is limited to five pages. These pages are not counted in

the overall application page limit. Typing and formatting instructions for the Organizational Profile are the same

as for the application. These instructions are given in the Baldrige Award Application Forms, which can be downloaded

at www.baldrige.nist.gov/Award_Application.htm.

N1. Principal factors (P.2a[2]) might include differentiators such as technology leadership, accessibility,

health care and administrative support services offered, cost, and e-services.

N2. Strategic challenges (P.2b) might include rapid

technological change, disruptive technologies that

rapidly revolutionize or make obsolete existing processes or health care services, reduced cycle times for

health care service introduction, health care industry

volatility, declining health care market share, changing health care marketplace, mergers and acquisitions,

patient and customer loyalty and retention, changing

or emerging patient and other customer or regulatory

requirements, staff retention, and an aging workforce. 

N3. Performance improvement (P.2c) is an assessment

dimension used in the Scoring System to evaluate the

maturity of organizational approaches and deployment

(see pages 53–56). This question is intended to help

you and the Baldrige Examiners set an overall context

for your approach to performance improvement.

N4. Overall approaches to process improvement (P.2c)

might include applying Six Sigma methodology, implementing Plan-Do-Study-Act (PDSA) improvement

cycles, or employing other process improvement tools.

P.2 Organizational Challenges

Describe your organization’s competitive environment, your KEY STRATEGIC CHALLENGES, and your system for

PERFORMANCE improvement. 

Within your response, include answers to the following questions:

a. Competitive Environment

(1) What is your competitive position? What is your relative size and growth in the health care industry

or markets served? What are the numbers and types of competitors and KEY collaborators for your

organization?

(2) What are the principal factors that determine your success relative to your competitors and other

organizations delivering similar HEALTH CARE SERVICES? What are any KEY changes taking place that affect

your competitive situation or opportunities for collaborating?

(3) What are your KEY available sources of comparative and competitive data from within the health care

industry? What are your KEY available sources of comparative data for analogous PROCESSES outside the

health care industry? What limitations, if any, are there in your ability to obtain these data?

b. STRATEGIC CHALLENGES

What are your KEY HEALTH CARE SERVICE, operational, and human resource STRATEGIC CHALLENGES? What are your KEY

STRATEGIC CHALLENGES associated with organizational SUSTAINABILITY?

c. PERFORMANCE Improvement System

HOW do you maintain an overall organizational focus on PERFORMANCE improvement, including organizational

LEARNING? How do you achieve SYSTEMATIC evaluation and improvement of KEY PROCESSES?

Notes:

For additional description of this Item, see pages 38–39.
2005 Health Care Criteria for Performance Excellence 15

1 Leadership (120 pts.)

N1. Senior leaders include the head of the organization and his or her direct reports. In health care organizations with separate administrative/operational and

health care provider leadership, “senior leaders” refers

to both sets of leaders and the relationships among

those leaders.

N2. Organizational vision (1.1a[1]) should set the

context for strategic objectives and action plans,

which are described in Items 2.1 and 2.2.

N3. A sustainable organization (1.1a[3]) is capable of

addressing current organizational needs and possesses

the agility and strategic management to prepare successfully for its future organizational and market environment. In this context, the concept of innovation

includes both technological and organizational innovation to succeed in the future.

N4. A focus on action (1.1b[2]) considers both the

people and the hard assets of the organization. It includes ongoing improvements in productivity that may

be achieved through eliminating waste or reducing cycle

time, and it might use techniques such as Six Sigma.

It also includes the actions to accomplish the organization’s strategic objectives.

N5. Your organizational performance results should

be reported in Items 7.1–7.6.

The Leadership Category examines HOW your organization’s SENIOR LEADERS guide and sustain your organization. Also

examined are your organization’s GOVERNANCE and HOW your organization addresses its ethical, legal, and community

responsibilities.

1.1 Senior Leadership (70 pts.) Process

Describe HOW SENIOR LEADERS guide and sustain your organization. Describe HOW SENIOR LEADERS communicate

with STAFF and encourage high PERFORMANCE.

Within your response, include answers to the following questions:

a. VISION and VALUES

(1) HOW do SENIOR LEADERS set organizational VISION and VALUES? HOW do SENIOR LEADERS deploy your organization’s

VISION and VALUES through your LEADERSHIP SYSTEM, to all STAFF, to KEY suppliers and PARTNERS, and to PATIENTS and

other CUSTOMERS, as appropriate? HOW do their personal actions reflect a commitment to the organization’s VALUES?

(2) HOW do SENIOR LEADERS promote an environment that fosters and requires legal and ETHICAL BEHAVIOR?

(3) HOW do SENIOR LEADERS create a SUSTAINABLE organization? HOW do SENIOR LEADERS create an environment for

PERFORMANCE improvement, accomplishment of STRATEGIC OBJECTIVES, INNOVATION, and organizational agility?

HOW do they create an environment for organizational and STAFF LEARNING? HOW do they personally

participate in succession planning and the development of future organizational leaders?

b. Communication and Organizational PERFORMANCE

(1) HOW do SENIOR LEADERS communicate with, empower, and motivate all STAFF throughout the organization?

HOW do SENIOR LEADERS encourage frank, two-way communication throughout the organization? HOW do

SENIOR LEADERS take an active role in STAFF reward and recognition to reinforce high PERFORMANCE and a focus

on the organization, as well as on PATIENTS and other CUSTOMERS?

(2) HOW do SENIOR LEADERS create a focus on action to accomplish the organization’s objectives, improve

PERFORMANCE, and attain your VISION? HOW do SENIOR LEADERS include a focus on creating and balancing VALUE

for PATIENTS, other CUSTOMERS, and other STAKEHOLDERS in their organizational PERFORMANCE expectations?

Notes:

Item responses are assessed by considering the Criteria Item requirements; your key organizational factors presented in your Organizational Profile; and the maturity of your approaches, breadth of their deployment, and

strength of your improvement process and results relative to the Scoring System. Refer to the Scoring System

information on pages 53–56.

For additional description of this Item, see page 38.
16 2005 Health Care Criteria for Performance Excellence

N1. Societal responsibilities in areas critical to your

organization also should be addressed in Strategy

Development (Item 2.1) and in Process Management

(Category 6). Key results, such as results of regulatory

and legal compliance (including malpractice) and accreditation, should be reported as Leadership and

Social Responsibility Results (in Item 7.6).

N2. Transparency in operations (1.2a[1]) should include your internal controls on governance processes.

N3. Leadership performance evaluation (1.2a[2]) might

be supported by peer reviews, formal performance

management reviews (5.1b), and formal or informal

staff and other stakeholder feedback and surveys.

N4. Public concerns (1.2b[1]) might include patient

safety, cost, equitable and timely access to providers,

emergence of new health care threats, and the handling of medical waste.

N5. Ethical behavior (1.2b) includes business, professional, health care practice, and patient rights issues.

It also includes public accountability and disclosure of

information about your organizational health care

performance.

N6. Measures or indicators of ethical behavior

(1.2b[2]) might include the percentage of independent

board members, measures of relationships with stockholder and nonstockholder constituencies, instances

of ethical conduct breaches and responses, survey

results on staff perceptions of organizational ethics,

ethics hotline use, and results of ethics reviews and

audits.

1.2 Governance and Social Responsibilities (50 pts.) Process

Describe your organization’s GOVERNANCE system. Describe HOW your organization addresses its responsibilities to the public, ensures ETHICAL BEHAVIOR, practices good citizenship, and contributes to the health of the

community.

Within your response, include answers to the following questions:

a. Organizational GOVERNANCE

(1) HOW does your organization address the following KEY factors in your GOVERNANCE system:

• accountability for management’s actions

• fiscal accountability

• transparency in operations and selection and disclosure policies for GOVERNANCE board members, as

appropriate

• independence in internal and external audits

• protection of STAKEHOLDER and stockholder interests, as appropriate

(2) HOW do you evaluate the PERFORMANCE of your SENIOR LEADERS, including both administrative and health

care leaders? How do you evaluate the PERFORMANCE of members of the GOVERNANCE board, as appropriate?

HOW do SENIOR LEADERS and the GOVERNANCE board use these PERFORMANCE reviews to improve both their

personal leadership effectiveness and that of your board and LEADERSHIP SYSTEM, as appropriate?

b. Legal and ETHICAL BEHAVIOR

(1) HOW do you address any adverse impacts on society of your HEALTH CARE SERVICES and operations? HOW do

you anticipate public concerns with current and future services, and operations? HOW do you prepare

for these concerns in a proactive manner, including using resource-sustaining PROCESSES, as appropriate?

What are your KEY compliance PROCESSES, MEASURES, and GOALS for achieving 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 other organizational operations?

(2) HOW does your organization promote and ensure ETHICAL BEHAVIOR in all your 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 PATIENTS and other CUSTOMERS and

PARTNERS? HOW do you monitor and respond to breaches of ETHICAL BEHAVIOR?

c. Support of KEY Communities and Community Health

HOW does your organization actively support and strengthen your KEY communities? HOW do you identify KEY

communities and determine areas of emphasis for organizational involvement and support? What are your

KEY communities? HOW do your SENIOR LEADERS and your STAFF contribute to improving these communities and

to building community health?

Notes:
2005 Health Care Criteria for Performance Excellence 17

N7. Actions to build community health (1.2c) are

population-based services supporting the general

health of your community. Such services might include health education programs, immunization programs, unique health services provided at a financial

loss, population-screening programs (e.g., hypertension), safety program sponsorship, and indigent care.

You should report the results of community health

services in Item 7.6.

N8. In addition to actions to build community health,

areas of community support appropriate for inclusion

in 1.2c might include your efforts to strengthen local

community services and education; the environment;

and practices of trade, business, or professional

associations.

N9. The health and safety of staff are not addressed in

Item 1.2; you should address these staff factors in

Item 5.3.

For additional description of this Item, see pages 39–40.
18 2005 Health Care Criteria for Performance Excellence

2 Strategic Planning (85 pts.)

N1. “Strategy development” refers to your organization’s approach (formal or informal) to preparing for

the future. Strategy development might utilize various

types of forecasts, projections, options, scenarios, or

other approaches to envisioning the future for purposes

of decision making and resource allocation. Strategy

development might involve key suppliers, partners,

patients, and other customers.

N2. “Strategy” should be interpreted broadly. Strategy

might be built around or lead to any or all of the following: new health care services and/or delivery processes and markets; revenue growth via various approaches, including acquisitions; new partnerships and

alliances; and new staff relationships. Strategy might

be directed toward becoming a center for clinical and

service excellence, a preferred provider, a research

leader, or an integrated service provider.

N3. Your organization’s strengths, weaknesses, opportunities, and threats (2.1a[2]) should address all factors

that are key to your organization’s future success, including the following, as appropriate: your patient and

other customer and health care market needs, expectations, and opportunities; your culture, policies, and

procedures to ensure patient safety and to avoid medical errors; your competitive and collaborative environment and your capabilities relative to competitors

and comparable organizations; the life cycle of your

health care services; technological and other key innovations or changes that might affect your health care

services and how you operate, as well as the rate of

that innovation; your staff and other resource needs;

your opportunities to redirect resources to higher priority health care services or areas; financial, societal,

ethical, regulatory, technological, and other potential

risks; changes in the national or global economy; partner and supply chain needs, strengths, and weaknesses; and other factors unique to your organization.

N4. Your ability to execute the strategic plan (2.1a[2])

also should address your organizational agility based

The Strategic Planning Category examines HOW your organization develops STRATEGIC OBJECTIVES and ACTION PLANS. Also

examined are HOW your chosen STRATEGIC OBJECTIVES and ACTION PLANS are deployed and changed if circumstances require, and

HOW progress is measured.

2.1 Strategy Development (40 pts.) Process

Describe HOW your organization establishes its strategy and STRATEGIC OBJECTIVES, including HOW you address

your STRATEGIC CHALLENGES. Summarize your organization’s KEY STRATEGIC OBJECTIVES and their related GOALS.

Within your response, include answers to the following questions:

a. Strategy Development PROCESS

(1) HOW does your organization conduct its strategic planning? What are the KEY PROCESS steps? Who are

the KEY participants? HOW does your PROCESS identify potential blind spots? What are your short- and

longer-term planning time horizons? HOW are these time horizons set? HOW does your strategic

planning PROCESS address these time horizons?

(2) HOW do you ensure that strategic planning addresses the KEY factors listed below? HOW do you collect and

analyze relevant data and information pertaining to these factors as part of your strategic planning PROCESS:

• your organization’s strengths, weaknesses, opportunities, and threats

• early indications of major shifts in technology, health care markets, your competitive or collaborative

environment, or the regulatory environment

• long-term organizational SUSTAINABILITY and organizational continuity in emergencies

• your ability to execute the strategic plan

b. STRATEGIC OBJECTIVES

(1) What are your KEY STRATEGIC OBJECTIVES and your timetable for accomplishing them? What are your most

important GOALS for these STRATEGIC OBJECTIVES?

(2) HOW do your STRATEGIC OBJECTIVES address the challenges identified in response to P.2 in your Organizational

Profile? HOW do you ensure that your STRATEGIC OBJECTIVES balance short- and longer-term challenges and

opportunities? HOW do you ensure that your STRATEGIC OBJECTIVES balance the needs of all PATIENTS, other KEY

CUSTOMERS, and KEY STAKEHOLDERS?

Notes:
2005 Health Care Criteria for Performance Excellence 19

For additional description of this Item, see page 41.

on contingency plans or if circumstances require a shift

in plans and rapid execution of new or changed plans.

N5. Strategic objectives that address key challenges

(2.1b[2]) might include access and locations; rapid response; customization; specific joint ventures; rapid

innovation; Web-based provider, patient, and other

customer relationship management; and health care

service quality and enhancements. Responses to Item

2.1 should focus on your specific challenges—those

most important to your organizational success and to

strengthening your organization’s overall performance

as a health care provider.

N6. Item 2.1 addresses your overall organizational

strategy, which might include changes in health care

services and programs. However, the Item does not

address service and program design; you should address these factors in Item 6.1, as appropriate.

2.2 Strategy Deployment (45 pts.) Process

Describe HOW your organization converts its STRATEGIC OBJECTIVES into ACTION PLANS. Summarize your organization’s ACTION PLANS and related KEY PERFORMANCE MEASURES or INDICATORS. Project your organization’s future

PERFORMANCE on these KEY PERFORMANCE MEASURES or INDICATORS.

Within your response, include answers to the following questions:

a. ACTION PLAN Development and DEPLOYMENT

(1) HOW do you develop and deploy ACTION PLANS to achieve your KEY STRATEGIC OBJECTIVES? HOW do you allocate

resources to ensure accomplishment of your ACTION PLANS? HOW do you ensure that the KEY changes

resulting from your ACTION PLANS can be sustained?

(2) HOW do you establish and deploy modified ACTION PLANS if circumstances require a shift in plans and

rapid execution of new plans?

(3) What are your KEY short- and longer-term ACTION PLANS? What are the KEY changes, if any, in your HEALTH

CARE SERVICES and programs, your CUSTOMERS and markets (including PATIENT populations), and how you will

operate?

(4) What are your KEY staffing plans that derive from your short- and longer-term STRATEGIC OBJECTIVES and

ACTION PLANS?

(5) What are your KEY PERFORMANCE MEASURES or INDICATORS for tracking progress on your ACTION PLANS? HOW do

you ensure that your overall ACTION PLAN measurement system reinforces organizational ALIGNMENT? HOW

do you ensure that the measurement system covers all KEY DEPLOYMENT areas and STAKEHOLDERS?

b. PERFORMANCE PROJECTION

For the KEY PERFORMANCE MEASURES or INDICATORS identified in 2.2a(5), what are your PERFORMANCE PROJECTIONS for

both your short- and longer-term planning time horizons? How does your projected PERFORMANCE compare

with the projected PERFORMANCE of your competitors or other comparable organizations providing similar

HEALTH CARE SERVICES? How does it compare with KEY BENCHMARKS, GOALS, and past PERFORMANCE, as appropriate? If

there are current or projected gaps in PERFORMANCE against your competitors or comparable organizations,

HOW will you address them?

Notes:

N1. Strategy and action plan development and deployment are closely linked to other Items in the Criteria.

The following are examples of key linkages:

• Item 1.1 for how your senior leaders set and communicate directions;

• Category 3 for gathering patient, other customer,

and health care market knowledge as input to your

strategy and action plans and for deploying action

plans;

• Category 4 for measurement, analysis, and knowledge management to support your key information

needs, to support your development of strategy, to

provide an effective basis for your performance

measurements, and to track progress relative to

your strategic objectives and action plans;

• Category 5 for your work system needs and staff

education, training, and development needs, and

for implementing staff-related changes resulting

from action plans;
20 2005 Health Care Criteria for Performance Excellence

• Category 6 for process requirements resulting

from your action plans; and

• Item 7.6 for specific accomplishments relative to

your organizational strategy and action plans.

N2. Deployment of action plans (2.2a[1]) might include key partners and suppliers.

N3. Measures and indicators of projected performance

(2.2b) might include changes resulting from new

ventures, acquisitions or mergers, health care market

entry and shifts, and significant anticipated innovations in health care service delivery and technology.

For additional description of this Item, see pages 41–42.
2005 Health Care Criteria for Performance Excellence 21

N1. Patients, as a key customer group, are frequently

identified separately in the Criteria. Other customer

groups could include patients’ families, the community, insurers and other third-party payors, employers,

health care providers, patient advocacy groups, Departments of Health, and students. Generic references

to customers include patients.

N2. Your responses to this Item should include the

patients and other customer groups and the market

segments identified in P.1b(2).

N3. “Health care service features” (3.1a[2]) refers to

all the important characteristics of your health care

services that patients and other customers receive.

This includes all customers’ overall interactions with

you and their service experiences. The focus should

be on features that affect customer health care-related

preference and loyalty and the customers’ view of

clinical and service quality—for example, those features that differentiate your organization’s services

from other providers offering similar services. Beyond

specific health care provisions leading to desired

health care outcomes, those features might include

factors such as extended hours, family support services, cost, assistance with billing/paperwork processes, and transportation assistance. Key health care

service features and purchasing decisions (3.1a[2])

might take into account how transactions occur and

factors such as confidentiality and security.

N4. The determination of health care service features

and their relative importance (3.1a[2]) should take

into account the potentially differing expectations of

patients and other customers.

N5. Listening and learning (3.1a[2]) might include

gathering and integrating surveys, focus group findings, Web-based data, and other data and information

that bear upon health care purchasing decisions.

Keeping your listening and learning methods current

with health care service needs and directions (3.1a[3])

also might include use of newer technology, such as

Web-based data gathering.

For additional description of this Item, see pages 42–43.

3 Focus on Patients, Other Customers, and Markets (85 pts.)

The Focus on , Other , and Markets PATIENTS CUSTOMERS Category examines HOW your organization determines the requirements, expectations, and preferences of PATIENTS, other CUSTOMERS, and markets. Also examined is HOW your organization builds relationships with PATIENTS and other CUSTOMERS and determines the KEY factors that lead to the acquisition, satisfaction, loyalty, and retention of patients and other customers and to HEALTH CARE SERVICE expansion and SUSTAINABILITY.

3.1 Patient, Other Customer, and 

Health Care Market Knowledge (40 pts.) Process

Describe HOW your organization determines requirements, expectations, and preferences of PATIENTS, other

CUSTOMERS, and markets to ensure the continuing relevance of your HEALTH CARE SERVICES and to develop new

HEALTH CARE SERVICE opportunities.

Within your response, include answers to the following questions:

a. PATIENT, Other CUSTOMER, and Health Care Market Knowledge

(1) HOW do you identify PATIENTS, other CUSTOMERS, CUSTOMER groups, and health care market SEGMENTS? HOW do

you determine which PATIENTS, other CUSTOMERS, CUSTOMER groups, and market SEGMENTS to pursue for

current and future HEALTH CARE SERVICES? HOW do you include CUSTOMERS of competitors and other potential

CUSTOMERS and markets in this determination?

(2) HOW do you listen and learn to determine KEY PATIENT and other CUSTOMER requirements and changing expectations (including HEALTH CARE SERVICE features) and their relative importance to PATIENTS’ and other CUSTOMERS’

health care purchasing decisions? HOW do your determination methods vary for different PATIENTS, other

CUSTOMERS, or CUSTOMER groups? HOW do you use relevant information and feedback from current and

former PATIENTS and other CUSTOMERS, including marketing information, PATIENT and other CUSTOMER loyalty

and retention data, win/loss ANALYSIS, and complaint data for PURPOSES of HEALTH CARE SERVICE planning, marketing,

PROCESS improvements, and other business development? HOW do you use this information and feedback

to become more PATIENT and other CUSTOMER focused and to better satisfy PATIENT and CUSTOMER needs? 

(3) HOW do you keep your listening and LEARNING methods current with HEALTH CARE SERVICE needs and directions,

including changes in your health care marketplace?

Notes:
22 2005 Health Care Criteria for Performance Excellence

N1. Customer relationship building (3.2a) might include the development of partnerships or alliances

with customers.

N2. Determining patient and other customer satisfaction and dissatisfaction (3.2b) might include use of any

or all of the following: surveys, formal and informal

feedback, customer account histories, complaints, win/

loss analysis, and information on timeliness of service

delivery. Information might be gathered on the Internet,

through personal contact or a third party, or by mail.

N3. Patient and other customer satisfaction measurements (3.2b[1]) might include both a numerical 

rating scale and descriptors for each unit in the scale.

Actionable satisfaction measurements provide useful

information about specific service features, delivery,

relationships, and transactions that bear upon the customers’ future actions—choice of health care provider

and positive referral.

N4. Your patient and other customer satisfaction and

dissatisfaction results should be reported in Item 7.2.

For additional description of this Item, see page 43.

3.2 Customer Relationships and Satisfaction (45 pts.) Process

Describe HOW your organization builds relationships to acquire, satisfy, and retain PATIENTS and other

CUSTOMERS; to increase loyalty; and to develop new HEALTH CARE SERVICE opportunities. Describe also HOW your

organization determines PATIENT and other CUSTOMER satisfaction.

Within your response, include answers to the following questions:

a. PATIENT and Other CUSTOMER Relationship Building

(1) HOW do you build relationships to acquire PATIENTS and other CUSTOMERS, to meet and exceed their

expectations, to increase loyalty and secure their future interactions with your organization, and to

gain positive referrals?

(2) HOW do your KEY access mechanisms enable PATIENTS and other CUSTOMERS to seek information, obtain

services, and make complaints? What are your KEY access mechanisms? HOW do you determine KEY

contact requirements for each mode of PATIENT and other CUSTOMER access? HOW do you ensure that these

contact requirements are deployed to all people and PROCESSES involved in the CUSTOMER response chain?

(3) HOW do you manage PATIENT and other CUSTOMER complaints? HOW do you ensure that complaints are

resolved effectively and promptly? HOW do you minimize PATIENT and other CUSTOMER dissatisfaction to

secure future interactions? HOW are complaints aggregated and analyzed for use in improvement

throughout your organization and by your PARTNERS?

(4) HOW do you keep your APPROACHES to building relationships and providing PATIENT and other CUSTOMER

access current with HEALTH CARE SERVICE needs and directions?

b. PATIENT and Other CUSTOMER Satisfaction Determination

(1) HOW do you determine PATIENT and other CUSTOMER satisfaction and dissatisfaction? HOW do these determination methods differ among PATIENT and other CUSTOMER groups? HOW do you ensure that your

measurements capture actionable information for use in exceeding your PATIENTS’ and other CUSTOMERS’

expectations, securing their future interactions with your organization, and gaining positive referrals?

HOW do you use PATIENT and other CUSTOMER satisfaction and dissatisfaction information for improvement?

(2) HOW do you follow up with PATIENTS and other CUSTOMERS on HEALTH CARE SERVICES and transaction quality to

receive prompt and actionable feedback?

(3) HOW do you obtain and use information on PATIENTS’ and other CUSTOMERS’ satisfaction relative to their

satisfaction with your competitors, other organizations providing similar HEALTH CARE SERVICES, and/or

health care industry BENCHMARKS?

(4) HOW do you keep your APPROACHES to determining satisfaction current with HEALTH CARE SERVICE needs and

directions?

Notes:
2005 Health Care Criteria for Performance Excellence 23

N1. Performance measurement is used in fact-based

decision making for setting and aligning organizational directions and resource use at the work unit,

key process, departmental, and whole organization

levels.

N2. Comparative data and information sources

(4.1a[2]) are obtained by benchmarking and by seeking competitive comparisons. “Benchmarking” refers

to identifying processes and results that represent best

practices and performance for similar activities, inside

or outside the health care industry. Competitive comparisons relate your organization’s performance to

that of competitors and other organizations providing

similar health care services. Comparative data might

include data from similar organizations and health

care industry benchmarks. Such data might be derived

from surveys, published and public studies, participation in indicator programs, or other sources. These

data may be drawn from local or national sources.

N3. Organizational performance reviews (4.1b[1])

should be informed by organizational performance

measurement and guided by the strategic objectives

and action plans described in Items 2.1 and 2.2. The

reviews also might be informed by internal or external

Baldrige assessments.

N4. Analysis includes examining trends; organizational, health care industry, and technology projections; and comparisons, cause-effect relationships, and

correlations intended to support your performance reviews, help determine root causes, and help set priorities for resource use. Accordingly, analysis draws upon

all types of data: patients and other customer-related,

4 Measurement, Analysis, and Knowledge Management (90 pts.)

The Measurement, , and Knowledge Management ANALYSIS Category examines HOW your organization selects, gathers,

analyzes, manages, and improves its data, information, and KNOWLEDGE ASSETS. Also examined is HOW your organization

reviews its PERFORMANCE.

4.1 Measurement, Analysis, and Review of 

Organizational Performance (45 pts.) Process

Describe HOW your organization measures, analyzes, aligns, reviews, and improves its PERFORMANCE as a

health care provider at all LEVELS and in all parts of your organization.

Within your response, include answers to the following questions:

a. PERFORMANCE Measurement

(1) HOW do you select, collect, align, and integrate data and information for tracking daily operations and

for tracking overall organizational PERFORMANCE, including progress relative to STRATEGIC OBJECTIVES and

ACTION PLANS? What are your KEY organizational PERFORMANCE MEASURES? HOW do you use these data and

information to support organizational decision making and INNOVATION as a health care provider?

(2) HOW do you select and ensure the EFFECTIVE use of KEY comparative data and information to support

operational and strategic decision making and INNOVATION?

(3) HOW do you keep your PERFORMANCE measurement system current with HEALTH CARE SERVICE needs and

directions? HOW do you ensure that your PERFORMANCE measurement system is sensitive to rapid or

unexpected organizational or external changes?

b. PERFORMANCE ANALYSIS and Review

(1) HOW do you review organizational PERFORMANCE and capabilities? HOW do your SENIOR LEADERS participate in

these reviews? What ANALYSES do you perform to support these reviews and to ensure that conclusions

are valid? HOW do you use these reviews to assess organizational success, competitive PERFORMANCE, and

progress relative to STRATEGIC OBJECTIVES and ACTION PLANS? HOW do you use these reviews to assess your

organization’s ability to rapidly respond to changing organizational needs and challenges in your

operating environment?

(2) HOW do you translate organizational PERFORMANCE review findings into priorities for continuous and

breakthrough improvement and into opportunities for INNOVATION? HOW are these priorities and opportunities deployed to work group- and functional-level operations throughout your organization to

enable EFFECTIVE support for their decision making? When appropriate, HOW are the priorities and

opportunities deployed to your suppliers and PARTNERS to ensure organizational ALIGNMENT?

Notes:
24 2005 Health Care Criteria for Performance Excellence

health care outcomes, financial and market, operational, and competitive/comparative.

N5. The results of organizational performance analysis should contribute to your organizational strategic

planning in Category 2.

N6. Your organizational performance results should

be reported in Items 7.1–7.6.

For additional description of this Item, see pages 44–45.

N1. Data and information availability (4.2a) are of

growing importance as the Internet, electronic communication and information transfer, and e-business

are used increasingly for provider, provider-topatient/customer, and business-to-business interactions and as intranets become more important as a

major source of organization-wide communications.

N2. Data and information access (4.2a[1]) might be

via electronic or other means.

N3. Given the increase in availability of data and information, your organization’s efforts to ensure the

quality of your data, information, and knowledge are

of growing importance. Of particular concern to

health care organizations is the need to ensure the

confidentiality of patient records.

For additional description of this Item, see page 46.

4.2 Information and Knowledge Management (45 pts.) Process

Describe HOW your organization ensures the quality and availability of needed data and information for

STAFF, suppliers and PARTNERS, and PATIENTS and other CUSTOMERS. Describe HOW your organization builds and

manages its KNOWLEDGE ASSETS.

Within your response, include answers to the following questions:

a. Data and Information Availability

(1) HOW do you make needed data and information available? HOW do you make them accessible to STAFF,

suppliers and PARTNERS, and PATIENTS and other CUSTOMERS, as appropriate?

(2) HOW do you ensure that hardware and software are reliable, secure, and user friendly?

(3) HOW do you ensure the continued availability of data and information, including the availability of

hardware and software systems, in the event of an emergency?

(4) HOW do you keep your data and information availability mechanisms, including your software and

hardware systems, current with HEALTH CARE SERVICE needs and directions and with technological changes

in your operating environment?

b. Organizational Knowledge Management

HOW do you manage organizational knowledge to accomplish the following:

• the collection and transfer of STAFF knowledge

• the transfer of relevant knowledge from and to PATIENTS and other CUSTOMERS, suppliers, and PARTNERS

• the rapid identification, sharing, and implementation of best practices

c. Data, Information, and Knowledge Quality

HOW do you ensure the following properties of your data, information, and organizational knowledge:

• accuracy

• integrity and reliability

• timeliness

• security and confidentiality

Notes:
2005 Health Care Criteria for Performance Excellence 25

N1. “Staff” refers to all people who contribute to the

delivery of your organization’s services, including paid

staff (e.g., permanent, temporary, and part-time personnel, as well as any contract employees supervised

by your organization), independent practitioners (e.g.,

physicians, physician assistants, nurse practitioners,

acupuncturists, and nutritionists not paid by the organization), volunteers, and health profession students

(e.g., medical, nursing, and ancillary). Staff includes

team leaders, supervisors, and managers at all levels.

Contract employees supervised by a contractor should

be addressed in Category 6.

N2. “Your organization’s work” refers to how your

staff are organized or organize themselves in formal

and informal, temporary, or longer-term units. This

might include work teams, process teams, project

teams, patient/customer action teams, problemsolving teams, centers of excellence, functional units,

remote workers (e.g., at home), cross-functional

teams, and departments—self-managed or managed

by supervisors. 

“Jobs” refers to responsibilities, authorities, and tasks

of individuals. In some work systems, jobs might be

shared by a team.

5 Staff Focus (85 pts.)

The Focus Category examines HOW your organization’s WORK SYSTEMS and your STAFF LEARNING and motivation enable all

STAFF to develop and utilize their full potential in ALIGNMENT with your organization’s overall objectives, strategy, and ACTION

PLANS. Also examined are your organization’s efforts to build and maintain a work environment and STAFF support climate

conducive to PERFORMANCE EXCELLENCE and to personal and organizational growth.

5.1 Work Systems (35 pts.) Process

Describe HOW your organization’s work and jobs enable all STAFF and the organization to achieve HIGH

PERFORMANCE. Describe HOW compensation, career progression, and related workforce practices enable STAFF

and the organization to achieve HIGH PERFORMANCE.

Within your response, include answers to the following questions:

a. Organization and Management of Work

(1) HOW do you organize and manage work and jobs, including skills, to promote cooperation, initiative,

EMPOWERMENT, INNOVATION, and your organizational culture? HOW do you organize and manage work and

jobs, including skills, to achieve the agility to keep current with HEALTH CARE SERVICE needs and to achieve

your ACTION PLANS?

(2) HOW do your WORK SYSTEMS capitalize on the diverse ideas, cultures, and thinking of your STAFF and the

communities with which you interact (your STAFF recruitment and your PATIENT and other CUSTOMER

communities)?

(3) HOW do you achieve EFFECTIVE communication and skill sharing across health care professions, departments and work units, jobs, and locations?

b. STAFF PERFORMANCE Management System

HOW does your STAFF PERFORMANCE management system, including feedback to STAFF, support HIGH-PERFORMANCE

WORK and contribute to the achievement of your ACTION PLANS? HOW does your STAFF PERFORMANCE management

system support a PATIENT and other CUSTOMER and HEALTH CARE SERVICE focus? HOW do your compensation, recognition, and related reward and incentive practices reinforce HIGH-PERFORMANCE WORK and a PATIENT and other

CUSTOMER and HEALTH CARE SERVICE focus?

c. Recruitment and Career Progression

(1) HOW do you identify characteristics and skills needed by potential STAFF?

(2) HOW do you recruit, hire, and retain new STAFF? HOW do you ensure STAFF members represent the diverse

ideas, cultures, and thinking of your recruitment community?

(3) HOW do you accomplish EFFECTIVE succession planning for leadership and management positions,

including senior administrative/operational and health care leadership positions, as appropriate? HOW

do you manage EFFECTIVE career progression for all STAFF throughout the organization?

Notes:

STAFF
26 2005 Health Care Criteria for Performance Excellence

Education and training delivery (5.2a[4]) might occur

inside or outside your organization and involve onthe-job, classroom, computer-based, distance learning,or other types of delivery (formal or informal).

For additional description of this Item, see page 47.

5.2 Staff Learning and Motivation (25 pts.) Process

Describe HOW your organization’s STAFF education, training, and career development support the achievement of your overall objectives and contribute to HIGH PERFORMANCE. Describe HOW your organization’s

education, training, and career development build STAFF knowledge, skills, and capabilities.

Within your response, include answers to the following questions:

a. STAFF Education,Training, and Development

(1) HOW do STAFF education and training contribute to the achievement of your ACTION PLANS? HOW do your

STAFF education, training, and development address your KEY needs associated with organizational

PERFORMANCE measurement, PERFORMANCE improvement, and technological change? HOW does your education and training APPROACH balance short- and longer-term organizational objectives with STAFF needs

(including licensure and recredentialing requirements) for development, ongoing LEARNING, and career

progression?

(2) HOW do STAFF education, training, and development address your KEY organizational needs associated

with new STAFF orientation, DIVERSITY, ethical health care and business practices, and management and

leadership development? HOW do STAFF education, training, and development address your KEY organizational needs associated with STAFF, workplace, and environmental safety?

(3) HOW do you seek and use input from STAFF and their supervisors and managers on education, training,

and development needs? HOW do you incorporate your organizational LEARNING and KNOWLEDGE ASSETS into

your education and training?

(4) HOW do you deliver education and training? HOW do you seek and use input from STAFF and their

supervisors and managers in determining your delivery APPROACHES? HOW do you use both formal and

informal delivery APPROACHES, including mentoring and other APPROACHES, as appropriate?

(5) HOW do you reinforce the use of new knowledge and skills on the job and retain this knowledge for

long-term organizational use? HOW do you SYSTEMATICALLY transfer knowledge from departing or retiring

employees? 

(6) HOW do you evaluate the effectiveness of education and training, taking into account individual and

organizational PERFORMANCE?

b. Motivation and Career Development

HOW do you motivate STAFF to develop and utilize their full potential? HOW does your organization use

formal and informal mechanisms to help STAFF attain job- and career-related development and LEARNING

objectives? HOW do managers and supervisors help STAFF attain job- and career-related development and

LEARNING objectives?

Note:

N3. “Recruitment” refers to how potential staff

are hired and brought into the organization. This

includes paid staff, privileged staff, and volunteers.

N4. Compensation, recognition, and related reward

and incentive practices (5.1b) include promotions

and bonuses that might be based on performance,

skills acquired, and other factors. Recognition includes monetary and nonmonetary, formal and

informal, and individual and group mechanisms.

Recognition systems for volunteers and independent practitioners who contribute to the work of

the organization should be included, as appropriate.

For additional description of this Item, see pages 46–47.
2005 Health Care Criteria for Performance Excellence 27

N1. Specific factors that might affect your staff’s wellbeing, satisfaction, and motivation (5.3b[1]) include

effective staff problem or grievance resolution; safety

factors; staff’s views of management; staff training, development, and career opportunities; staff preparation

for changes in technology or the work organization;

the work environment and other work conditions;

management’s empowerment of staff; information

sharing by management; workload; cooperation and

teamwork; recognition; services and benefits; communications; job security; compensation; and equal

opportunity.

N2. Approaches for staff support (5.3b[2]) might include providing counseling, career development and

employability services, recreational or cultural activities, nonwork-related education, day care, job rotation

or sharing, special leave for family responsibilities or

community service, home safety training, flexible

work hours and location, outplacement, and retirement benefits (including extended health care).

N3. Measures and indicators of well-being, satisfaction, and motivation (5.3b[3]) might include data on

safety and absenteeism; the overall turnover rate; the

turnover rate for patient/customer contact staff; staff

members’ charitable contributions; grievances, strikes,

other job actions; insurance costs; workers’ compensation claims; and results of surveys. Survey indicators

of satisfaction might include staff knowledge of job

roles, staff knowledge of organizational direction, and

staff perception of empowerment and information

sharing. Your results relative to such measures and

indicators should be reported in Item 7.4.

N4. Identifying priorities (5.3b[4]) might draw upon

your staff and work system results presented in Item

7.4 and might involve addressing staff problems based

on their impact on your organizational performance

results.

For additional description of this Item, see pages 47–48.

5.3 Staff Well-Being and Satisfaction (25 pts.) Process

Describe HOW your organization maintains a work environment and STAFF support climate that contribute

to the well-being, satisfaction, and motivation of all STAFF.

Within your response, include answers to the following questions:

a. Work Environment

(1) HOW do you ensure and improve workplace health, safety, security, and ergonomics in a proactive

manner? HOW do STAFF take part in these improvement efforts? What are your PERFORMANCE MEASURES or

improvement targets for each of these KEY workplace factors? What are the significant differences in

these workplace factors and PERFORMANCE MEASURES or targets if different STAFF groups and work units have

different work environments?

(2) HOW do you ensure workplace preparedness for disasters or emergencies? 

b. STAFF Support and Satisfaction

(1) HOW do you determine the KEY factors that affect STAFF well-being, satisfaction, and motivation? HOW are

these factors SEGMENTED for a diverse workforce and for different categories and types of STAFF?

(2) HOW do you support your STAFF via services, benefits, and policies? HOW are these tailored to the needs

of a diverse workforce and different categories and types of STAFF?

(3) What formal and informal assessment methods and MEASURES do you use to determine STAFF well-being,

satisfaction, and motivation? How do these methods and MEASURES differ across a diverse workforce and

different categories and types of STAFF? HOW do you use other INDICATORS, such as STAFF retention, absenteeism, grievances, safety, and PRODUCTIVITY, to assess and improve STAFF well-being, satisfaction, and

motivation?

(4) HOW do you relate assessment findings to KEY organizational PERFORMANCE RESULTS to identify priorities for

improving the work environment and STAFF support climate?

Notes:
28 2005 Health Care Criteria for Performance Excellence

N1. “Health care processes” refers to patient and

community service processes for the purpose of prevention, maintenance, health promotion, screening,

diagnosis, treatment/therapy, rehabilitation, recovery,

palliative care, or supportive care. This includes services delivered to patients through other providers

(e.g., laboratory or radiology studies). Responses to

Item 6.1 should be based upon the most critical requirements for successful delivery of your services.

N2. Key processes for the conduct of health care research and/or a teaching mission should be reported

in either Item 6.1 or 6.2, as appropriate to your organization’s mission.

N3. Process requirements should include all appropriate components of health care service delivery. In a

group practice, this might be the making of appointments, presentation, evaluation of risk factors, health

education, and appointment closures. Depending

upon the health care service, this might include a significant focus on technology and patient-specific considerations.

6 Process Management (85 pts.)

The PROCESS Management Category examines the KEY aspects of your organization’s PROCESS management, including KEY

health care, business, and other support PROCESSES for CREATING VALUE for PATIENTS, other CUSTOMERS, and the organization.

This Category encompasses all KEY PROCESSES and all departments and work units.

6.1 Health Care Processes (45 pts.) Process

Describe HOW your organization identifies and manages its KEY PROCESSES for delivering PATIENT HEALTH CARE

SERVICES.

Within your response, include answers to the following questions:

a. Health Care PROCESSES

(1) HOW does your organization determine its KEY HEALTH CARE SERVICES and service delivery PROCESSES? What are

your organization’s KEY health care PROCESSES? How do these PROCESSES contribute to improved HEALTH CARE

SERVICE outcomes?

(2) HOW do you determine KEY health care PROCESS requirements, incorporating input from PATIENTS and other

CUSTOMERS, suppliers, and PARTNERS, as appropriate? What are the KEY requirements for these PROCESSES?

(3) HOW do you design these PROCESSES to meet all the KEY requirements, including PATIENT safety, regulatory,

accreditation, and payor requirements? HOW do you incorporate new technology, organizational

knowledge, and the potential need for agility into the design of these PROCESSES? HOW do you incorporate health care outcomes, CYCLE TIME, PRODUCTIVITY, cost control, and other efficiency and effectiveness

factors into the design of these PROCESSES? HOW do you implement these PROCESSES to ensure they meet

design requirements?

(4) HOW are PATIENTS’ expectations addressed and considered? HOW are HEALTH CARE SERVICE delivery PROCESSES and

likely outcomes explained to set realistic PATIENT expectations? HOW are PATIENT decision making and

PATIENT preferences factored into the delivery of HEALTH CARE SERVICES?

(5) What are your KEY PERFORMANCE assessments and MEASURES or INDICATORS used for the control and improvement of your health care PROCESSES? HOW does your day-to-day operation of your health care PROCESSES

ensure meeting KEY PROCESS requirements, including PATIENT safety, regulatory, accreditation, and payor

requirements? HOW are in-process MEASURES used in managing these PROCESSES? HOW is PATIENT and other

CUSTOMER, supplier, and PARTNER input used in managing your health care PROCESSES, as appropriate?

(6) HOW do you minimize overall costs associated with inspections, tests, and PROCESS or PERFORMANCE audits,

as appropriate? HOW do you prevent errors and rework? 

(7) HOW do you improve your health care PROCESSES to achieve better PERFORMANCE, to reduce variability, to

improve HEALTH CARE SERVICES and health care outcomes, and to keep them current with HEALTH CARE SERVICE

needs and directions? HOW are improvements and lessons learned shared with other organizational

units and PROCESSES to drive organizational LEARNING and INNOVATION?

Notes:
2005 Health Care Criteria for Performance Excellence 29

N4. To achieve better process performance and reduce variability, you might implement approaches

such as the PDSA process, Six Sigma methodology,

or other process improvement tools.

N5. To provide as complete and concise a response as

possible for your key health care processes, you might

want to use a tabular format identifying the key processes and the attributes of each as called for in questions 6.1a(1)–6.1a(7). Depending on the structure of

your health care staff, your response to Item 6.1

might deal with some aspects of health care provider

services if there is a customer-supplier relationship.

Health care staff should still be addressed in Item 1.1

and Category 5.

N6. Performance measures and indicators (6.1a[5])

should address health care outcomes, patient and

other customer requirements and health care service

features that affect patient and other customer

preferences.

N7. The results of improvements in health care outcomes and health care service performance should be

reported in Item 7.1. All other process performance

results should be reported in Item 7.5.

For additional description of this Item, see pages 48–49.

6.2 Support Processes and Operational Planning (40 pts.) Process

Describe HOW your organization manages its KEY business and other support PROCESSES. Describe your

PROCESSES for financial management and continuity of operations in an emergency.

Within your response, include answers to the following questions:

a. Business and Other Support PROCESSES

(1) HOW does your organization determine its KEY business and other support PROCESSES? What are your KEY

PROCESSES for supporting your health care PROCESSES?

(2) HOW do you determine KEY support PROCESS requirements, incorporating input from internal and external

CUSTOMERS, and suppliers and PARTNERS, as appropriate? What are the KEY requirements for these PROCESSES?

(3) HOW do you design these PROCESSES to meet all the KEY requirements? HOW do you incorporate new technology, organizational knowledge, and the potential need for agility into the design of these PROCESSES?

HOW do you incorporate CYCLE TIME, PRODUCTIVITY, cost control, and other efficiency and effectiveness

factors into the design of the PROCESSES? HOW do you implement these PROCESSES to ensure they meet

design requirements?

(4) What are your KEY PERFORMANCE MEASURES or INDICATORS used for the control and improvement of your

support PROCESSES? HOW does your day-to-day operation of KEY support PROCESSES ensure meeting KEY

PERFORMANCE requirements? HOW are in-process MEASURES used in managing these PROCESSES? HOW is PATIENT

and other CUSTOMER, supplier, and PARTNER input used in managing these PROCESSES, as appropriate?

(5) HOW do you minimize overall costs associated with inspections, tests, and PROCESS or PERFORMANCE audits,

as appropriate? HOW do you prevent errors and rework?

(6) HOW do you improve your KEY business and support PROCESSES to achieve better PERFORMANCE, to reduce

variability, and to keep them current with HEALTH CARE SERVICE needs and directions? HOW are improvements and lessons learned shared with other organizational units and PROCESSES to drive organizational

LEARNING and INNOVATION?

b. Operational Planning

(1) HOW does your organization ensure adequate financial resources are available to support your operations?

HOW do you determine the resources needed to meet current financial obligations? HOW do you ensure

adequate resources are available to support major new business investments? HOW do you assess the

financial risks associated with your current business operations and major new business investments?

(2) HOW do you ensure continuity of operations in the event of an emergency?
30 2005 Health Care Criteria for Performance Excellence

For additional description of this Item, see pages 49–50.

N1. Your key business processes are those non-health

care service processes that are considered most important to business growth and success by your organization’s senior leaders. These might include processes

for innovation, technology acquisition, information

and knowledge management, supply chain management, supplier partnering, outsourcing, mergers and

acquisitions, project management, and sales and marketing. The key business processes to be included in

Item 6.2 are distinctive to your organization and how

you operate.

N2. Your other key support processes are those that

are considered most important for support of your

organization’s health care service design and delivery

processes, staff, and daily operations. These might

include key patient support processes (e.g., housekeeping and medical records) and key administrative

support processes (e.g., facilities management, legal,

human resource, and project management).

N3. An emergency (6.2b[2]) might be weather related,

utility related, or due to a local or national emergency.

N4. Your financial management results should be reported in Item 7.3. Other results related to your key

business and support processes and operational planning should be reported in Item 7.5.

Notes:
2005 Health Care Criteria for Performance Excellence 31

N1. Health care results reported in this Item should

include the key health care service features identified

as patient and other customer requirements or expectations in P.1b(2), based on information gathered in

Items 3.1 and 3.2. The measures or indicators should

address factors that affect patient and other customer

preference, such as those included in P.1, Note 3, and

Item 3.1, Note 3.

N2. Key health care results should be tailored to your

organization and might include both mandated and

nonmandated results.

7 Organizational Performance Results (450 pts.)

7.2 Patient- and Other Customer-Focused Results (70 pts.) Results

Summarize your organization’s KEY PATIENT- and other CUSTOMER-focused RESULTS, including PATIENT/CUSTOMER

satisfaction and PATIENT/CUSTOMER-perceived VALUE. SEGMENT your RESULTS by CUSTOMER groups and market

SEGMENTS, as appropriate. Include appropriate comparative data.

Provide data and information to answer the following questions:

a. PATIENT- and Other CUSTOMER-Focused RESULTS

(1) What are your current LEVELS and TRENDS in KEY MEASURES or INDICATORS of PATIENT and other CUSTOMER satisfaction and dissatisfaction? HOW do these compare with satisfaction relative to competitors and other

organizations providing similar HEALTH CARE SERVICES?

(2) What are your current LEVELS and TRENDS in KEY MEASURES or INDICATORS of PATIENT- and other CUSTOMERperceived VALUE, including PATIENT and other CUSTOMER loyalty and retention, positive referral, and other

aspects of building relationships with PATIENTS and other CUSTOMERS, as appropriate?

Notes:

N1. Patient and other customer satisfaction and

dissatisfaction results reported in this Item should

relate to determination methods and data described in

Item 3.2.

N2. There may be several different dimensions of

patient satisfaction, such as satisfaction with quality of

care, satisfaction with provider interaction, satisfaction

with the long-term health outcome, and satisfaction

with ancillary services. All of these areas are appropriate satisfaction indicators.

N3. Measures and indicators of your patients’ and

other customers’ satisfaction relative to satisfaction

The Organizational Results Category examines your organization’s PERFORMANCE and improvement in KEY

areas—health care outcomes and service delivery, PATIENT and other CUSTOMER satisfaction, financial and marketplace

PERFORMANCE, STAFF and WORK SYSTEM RESULTS, operational PERFORMANCE, and leadership and social responsibility. PERFORMANCE

LEVELS are examined relative to those of competitors and other organizations providing similar HEALTH CARE SERVICES.

7.1 Health Care Outcomes and Service Delivery Results (100 pts.) Results

Summarize your organization’s KEY health care PERFORMANCE RESULTS. SEGMENT your RESULTS by patient and other

CUSTOMER groups and market SEGMENTS, as appropriate. Include appropriate comparative data. Indicate

those MEASURES that are mandated by regulatory, accreditor, or payor requirements.

Provide data and information to answer the following questions:

a. Health Care RESULTS

What are your current LEVELS and TRENDS in KEY MEASURES or INDICATORS of health care outcomes, HEALTH CARE SERVICE

delivery RESULTS, PATIENT safety, and PATIENTS’ functional status that are important to your PATIENTS and other

CUSTOMERS? HOW do these RESULTS compare to the PERFORMANCE of your competitors and other organizations

providing similar HEALTH CARE SERVICES?

Notes:

PERFORMANCE RESULTS

For additional description of this Item, see page 51.
32 2005 Health Care Criteria for Performance Excellence

For additional description of this Item, see pages 51–52.

Responses to 7.3a(1) might include aggregate measures

such as return on investment (ROI), asset utilization,

operating margins, profitability (if relevant), profitability by market or customer segment, liquidity, debtto-equity ratio, value added per staff member, bond

ratings (if appropriate), and financial activity measures.

Measures should relate to the financial management

approaches described in Item 6.2.

7.3 Financial and Market Results (70 pts.) Results

Summarize your organization’s KEY financial and health care marketplace PERFORMANCE RESULTS by patient or

other CUSTOMER or market SEGMENTS, as appropriate. Include appropriate comparative data.

Provide data and information to answer the following questions:

a. Financial and Market RESULTS

(1) What are your current LEVELS and TRENDS in KEY MEASURES or INDICATORS of financial PERFORMANCE, including

aggregate MEASURES of financial return and economic VALUE, as appropriate?

(2) What are your current LEVELS and TRENDS in KEY MEASURES or INDICATORS of health care marketplace PERFORMANCE, including market share or position, business growth, and new markets entered, as appropriate?

Note:

with competitors or other organizations providing

similar health care services might include objective

information and data from your customers and from

independent organizations.

For additional description of this Item, see page 51.
2005 Health Care Criteria for Performance Excellence 33

N1. Results reported in Item 7.5 should address your

key operational requirements as presented in the Organizational Profile and in Items 6.1 and 6.2. Include

results not reported in Items 7.1–7.4.

N2. Results reported in Item 7.5 should provide key

information for analysis and review of your organizational performance (Item 4.1) and should provide the

operational basis for health care outcomes and service

delivery results (Item 7.1), patient- and other customerfocused results (Item 7.2), and financial and market

results (Item 7.3).

For additional description of this Item, see page 52.

7.5 Organizational Effectiveness Results (70 pts.) Results

Summarize your organization’s KEY operational PERFORMANCE RESULTS that contribute to the improvement of

organizational effectiveness. SEGMENT your RESULTS by HEALTH CARE SERVICE types and groups and by market

SEGMENTS, as appropriate. Include appropriate comparative data.

Provide data and information to answer the following questions:

a. Organizational Effectiveness RESULTS

(1) What are your current LEVELS and TRENDS in KEY MEASURES or INDICATORS of the operational PERFORMANCE of

your KEY health care PROCESSES? Include PRODUCTIVITY, CYCLE TIME, supplier and PARTNER PERFORMANCE, and other

appropriate MEASURES of effectiveness and efficiency.

(2) What are your current LEVELS and TRENDS in KEY MEASURES or INDICATORS of the operational PERFORMANCE of

your other KEY PROCESSES? Include PRODUCTIVITY, CYCLE TIME, supplier and PARTNER PERFORMANCE, and other

appropriate MEASURES of effectiveness and efficiency.

Notes:

N1. Results reported in this Item should relate to activities described in Category 5. Your results should

be responsive to key process needs described in Category 6 and to your organization’s action plans and

staffing plans described in Item 2.2.

N2. Appropriate measures and indicators of work system performance and effectiveness (7.4a[1]) might include job and job classification simplification, job

rotation, work layout improvement, staff retention

and internal promotion rates, and changing supervisory ratios.

N3. Appropriate measures and indicators of staff

learning and development (7.4a[2]) might include

innovation and suggestion rates, courses completed,

learning, on-the-job performance improvements,

credentialing, and cross-training rates.

N4. For appropriate measures of staff well-being and

satisfaction (7.4a[3]), see Item 5.3, Notes.

For additional description of this Item, see page 52.

7.4 Staff and Work System Results (70 pts.) Results

Summarize your organization’s KEY STAFF and WORK SYSTEM RESULTS, including WORK SYSTEM PERFORMANCE and STAFF

LEARNING, development, well-being, and satisfaction. SEGMENT your RESULTS to address the DIVERSITY of your workforce and the different types and categories of STAFF, as appropriate. Include appropriate comparative data.

Provide data and information to answer the following questions:

a. STAFF and WORK SYSTEM RESULTS

(1) What are your current LEVELS and TRENDS in KEY MEASURES or INDICATORS of WORK SYSTEM PERFORMANCE and

effectiveness?

(2) What are your current LEVELS and TRENDS in KEY MEASURES of STAFF LEARNING and development?

(3) What are your current LEVELS and TRENDS in KEY MEASURES or INDICATORS of STAFF well-being, satisfaction, and

dissatisfaction?

Notes:
34 2005 Health Care Criteria for Performance Excellence

N1. For examples of measures of ethical behavior and

stakeholder trust (7.6a[2]), see Item 1.2, Note 6.

N2. Responses to 7.6a(3) might include financial

statement issues and risks, important internal and external auditor recommendations, and management’s

responses to these matters.

N3. Accreditation, assessment, and regulatory and

legal compliance results (7.6a[4]) should address requirements described in 1.2b. If your organization has

received sanctions or adverse actions under law (including malpractice), regulation, accreditation, or contract

during the past three years, briefly describe the incident(s) and current status. If settlements have been

negotiated in lieu of potential sanctions or adverse

actions, give explanations. Staff related occupational

health and safety results (e.g., Occupational Safety and

Health Administration [OSHA]-reportable incidents)

should be reported in 7.4a(3).

N4. Organizational citizenship and community health

results (7.6a[5]) should address support of the key

communities discussed in 1.2c.

For additional description of this Item, see page 52.

7.6 Leadership and Social Responsibility Results (70 pts.) Results

Summarize your organization’s KEY GOVERNANCE, SENIOR LEADERSHIP, and social responsibility RESULTS, including

evidence of ETHICAL BEHAVIOR, fiscal accountability, legal compliance, and organizational citizenship. SEGMENT

your RESULTS by organizational units, as appropriate. Include appropriate comparative data.

Provide data and information to answer the following questions:

a. Leadership and Social Responsibility RESULTS

(1) What are your RESULTS for KEY MEASURES or INDICATORS of accomplishment of your organizational strategy

and ACTION PLANS?

(2) What are your RESULTS for KEY MEASURES or INDICATORS of ETHICAL BEHAVIOR and of STAKEHOLDER trust in the SENIOR

LEADERS and GOVERNANCE of your organization? What are your RESULTS for KEY MEASURES or INDICATORS of

breaches of ETHICAL BEHAVIOR?

(3) What are your KEY current findings and TRENDS in KEY MEASURES or INDICATORS of fiscal accountability, both

internal and external, as appropriate?

(4) What are your RESULTS for KEY MEASURES or INDICATORS of organizational accreditation, assessment, and

regulatory and legal compliance?

(5) What are your RESULTS for KEY MEASURES or INDICATORS of organizational citizenship in support of your KEY

communities, including contributions to the health of your community?

Notes:
2005 Health Care Criteria for Performance Excellence 35
36 2005 Health Care Criteria for Performance Excellence

Category 1—Leadership

Strength

1.

2.

OFI

1.

2.

Category 2—Strategic Planning

Strength

1.

2.

OFI

1.

2.

Category 3—Focus on Patients, Other Customers, and Markets

Strength

1.

2.

OFI

1.

2.

Criteria Category Importance

High, Medium, Low

For High-Importance Areas

Stretch (Strength) or Improvement (OFI) Goal What Action Is Planned? By When? Who Is Responsible?

BALDRIGE APPLICATION SELF-ANALYSIS WORKSHEET (OPTIONAL)

(not to be submitted with your Baldrige application)

While insights gained from external Examiners or reviewers are always helpful, you know your organization better than they

will. You are currently in an excellent position to identify your organization’s key strengths and key opportunities for improvement (OFIs). Having just completed your responses to the Baldrige Criteria questions, you can accelerate your improvement

journey by doing a self-analysis.

Use this optional worksheet to list your key strengths and key OFIs. Start by identifying one or two strengths and one or two

OFIs for each Criteria Category. For those of high importance, establish a goal and a plan of action.

An electronic copy of this worksheet is available in Microsoft Word format at www.baldrige.nist.gov/Word_files/

Optional_Worksheet_HC.doc.
2005 Health Care Criteria for Performance Excellence 37

Criteria Category Importance

High, Medium, Low

For High-Importance Areas

Stretch (Strength) or Improvement (OFI) Goal What Action Is Planned? By When? Who Is Responsible?

Category 4—Measurement, Analysis, and Knowledge Management

Strength

1.

2.

OFI

1.

2.

Category 5—Staff Focus

Strength

1.

2.

OFI

1.

2.

Category 6—Process Management

Strength

1.

2.

OFI

1.

2.

Category 7—Organizational Performance Results

Strength

1.

2.

OFI

1.

2.
38 2005 Health Care Criteria for Performance Excellence

2005 HEALTH CARE CRITERIA: CATEGORY AND ITEM DESCRIPTIONS

Preface: Organizational Profile

The Organizational Profile provides an overview of your

organization. The profile addresses your operating environment, your key organizational relationships, your competitive and collaborative environment and strategic challenges,

and your approach to performance improvement. Your Organizational Profile provides a context for understanding

your organization and for guiding and prioritizing the information you present in response to the Criteria Items in

Categories 1–7.

P.1 Organizational Description

Purpose

This Item addresses the key characteristics and relationships

that shape your organizational environment. It also addresses

your organization’s governance system. The aim is to set

the context for your organization and for your responses to

the Criteria requirements in Categories 1–7.

Comments

■ The Organizational Profile provides your organization

with critical insight into the key internal and external

factors that shape your operating environment. These

factors, such as the mission, vision, values, competitive

and collaborative environment, and strategic challenges,

impact the way that your organization is run and the decisions you make. As such, the Organizational Profile

helps your organization better understand the context in

which it operates; the key requirements for current and

future organizational success and sustainability; and the

needs, opportunities, and constraints placed upon your

organization’s performance management system.

■ Use of such terms as “purpose,” “vision,” “mission,” and

“values” varies depending on the organization, and some

organizations may not use one or more of these terms.

Nevertheless, you should have a clear understanding of the

essence of your organization, why it exists, and where your

senior leaders want to take the organization in the future.

This clarity enables you to make and implement strategic

decisions affecting the future of your organization.

■ The legal and regulatory environment in which you operate places requirements on your organization and impacts how you run your organization. Understanding this

environment is key to making effective operational and

strategic decisions. Further, it allows you to identify

whether you are merely complying with the minimum requirements of applicable laws and regulations or exceeding them, a hallmark of leading organizations.

■ Leading organizations have well-defined governance systems with clear reporting relationships. It is important to

clearly identify which functions are performed by senior

leaders and, as applicable, by your governance board and

your parent organization. Board independence and accountability frequently are key considerations in governance structure.

■ In supplier-dependent organizations, suppliers play critical roles in processes that are important to running the

organization and to maintaining or achieving overall

organizational performance success. Supply chain requirements might include accessibility, continuity of care,

on-time or just-in-time delivery, flexibility, variable staffing, research and design capability, and customized manufacturing or services.

P.2 Organizational Challenges

Purpose

This Item addresses the competitive and collaborative environment in which your organization operates and the key

strategic challenges that your organization faces. It also addresses how you approach performance improvement and

organizational learning. The aim is to understand your key

organizational challenges and your system for maintaining a

sustainable advantage.

Comments

■ Knowledge of an organization’s strengths, vulnerabilities,

and opportunities for both improvement and growth is

essential to the success and sustainability of the organization. With this knowledge, you can identify those health

care service offerings, processes, and performance attributes that are unique to your organization; those that set

you apart from your competitors; and those that help you

to sustain your competitive position.

■ Understanding who your competitors and collaborators are,

how many you have, and their key characteristics is essential for determining what your competitive and collaborative

position is in the health care industry and marketplace.

Leading organizations have an in-depth understanding of

their current competitive and collaborative environment,

including the factors that affect day-to-day performance

and factors that could impact future performance.

■ Sources of comparative and competitive data might include

external organizations (e.g., CMS, the National Committee for Quality Assurance [NCQA], JCAHO, and the

Maryland Quality Indicator Project), health care industry

journals and other publications, benchmarking activities

(comparative data can also be obtained from organizations

outside of the health care sector, particularly in areas

related to patient and other customer satisfaction, staff

satisfaction, and organizational effectiveness [e.g., cycle

time]), annual reports for publicly traded companies,

conferences, local networks, and trade associations.

■ Operating your organization in today’s highly competitive marketplace means you are facing many strategic
2005 Health Care Criteria for Performance Excellence 39

challenges that can affect your ability to sustain performance and maintain your competitive position. These

challenges might include your operational costs (e.g.,

pharmaceuticals, labor, or medical technology); expanding or decreasing markets; mergers or acquisitions both

by your organization and by your competitors; economic

conditions, including fluctuating demand and economic

downturns; needs for public health and bioterrorism preparedness; HIPAA compliance; the introduction of new

or substitute health care services, possibly based on a disruptive technology; rapid technological changes; or emergence of e-health care delivery technology. In addition,

your organization may face challenges related to the recruitment, hiring, and retention of qualified staff.

■ 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. Examples of such technologies include

MRIs replacing myelograms and orthoscopic surgery replacing more invasive types of surgery. Today, organizations need to be scanning the environment inside and

outside their immediate industry to detect such challenges at the earliest possible point in time.

■ One of the many issues facing organizations today is how

to manage, use, and share your ever-increasing organizational knowledge. Leading organizations already benefit

from the knowledge assets of their staff, patients and

other customers, suppliers, and partners, who together

drive organizational learning and improve performance.

Leadership (Category 1)

Leadership addresses how your senior leaders guide and

sustain your organization, setting organizational vision,

values, and performance expectations. Attention is given to

how your senior leaders communicate with staff, develop

future leaders, and create an environment that encourages

ethical behavior and high performance. The Category also

includes your organization’s governance system, its legal and

ethical responsibilities to the public, how your organization

supports its community, and how your organization contributes to the health of its community.

1.1 Senior Leadership

Purpose

This Item examines the key aspects of your senior leaders’

responsibilities. It examines how your senior leaders set and

communicate the organization’s vision and values. It focuses

on your senior leaders actions to create and sustain a highperformance organization.

Comments

■ Senior leadership’s central role in setting values and directions, communicating, creating and balancing value for

all stakeholders, and creating an organizational bias for

action are the focus of this Item. Success requires a

strong orientation to the future and a commitment to

both improvement and innovation. Increasingly, this requires creating an environment for empowerment, agility,

and learning.

■ An important aspect of leadership in health care organizations is the relationship and collaboration between administrative and health care provider leadership in organizations with separate administrative and health care

leadership.

■ In highly respected organizations, senior leaders are committed to the development of the organization’s future

leaders and to the reward and recognition of staff performance. They personally participate in the development of

future leaders, in succession planning, and in staff recognition opportunities and events. Development activities

for future leaders might include personal mentoring or

participating in leadership development courses.

1.2 Governance and Social Responsibilities

Purpose

This Item examines key aspects of your organization’s

governance system. It also examines how your organization

fulfills its public responsibilities, how your senior leaders

ensure that you behave legally and ethically, and how your

senior leaders and staff encourage and practice good

citizenship.

Comments

■ The organizational governance requirement is intended

to address the need for a responsible, informed, and accountable governance or advisory body that can protect

the interests of key stakeholders, such as stockholders. It

should have independence in review and audit functions.

It also should have a performance evaluation function that

monitors organizational and senior leader performance.

■ An integral part of health care delivery, performance

management, and improvement is proactively addressing

(1) the need for ethical behavior; (2) legal, regulatory, and

accreditation requirements; and (3) risk factors. Addressing these areas requires establishing appropriate measures
40 2005 Health Care Criteria for Performance Excellence

or indicators that senior leaders track in their performance

reviews. Your organization should be sensitive to issues of

public concern related to your health care services and

operations, whether or not these issues are currently embodied in law or regulations. Role model organizations

look for opportunities to exceed requirements and to

excel in areas of legal and ethical behavior.

■ This Item addresses the use of resource-sustaining processes. These processes might include the use of “green”

technologies, replacement of hazardous chemicals with

water-based chemicals, energy conservation, use of

cleaner energy sources, or recycling of by-products or

wastes.

■ Social responsibility implies going beyond a compliance

orientation. Good citizenship opportunities are available

to organizations of all sizes. These opportunities include

encouraging and supporting your staff’s community

service.

■ Examples of organizational community involvement include partnering with other health care providers, businesses, and professional associations to engage in beneficial cooperative activities, such as providing education

and volunteer services and sharing best practices to improve overall U.S. health status and health care. Levels of

involvement and leadership are dependent upon your

organization’s size and available resources.

■ This Item addresses actions to build and improve community health, including the consideration of partnering

with other local organizations (public and business) and

health care providers. The community health services

offered by your organization will be dependent upon

your mission, including service requirements for taxexempt organizations.

Strategic Planning (Category 2)

Strategic Planning addresses strategic and action planning,

deployment of plans, how plans are changed if circumstances require a change, and how accomplishments are

measured and sustained. The Category stresses that longterm organizational sustainability and your competitive or

collaborative environment are key strategic issues that need

to be integral parts of your organization’s overall planning.

The Baldrige Health Care Criteria emphasize three key

aspects of organizational excellence. These aspects are

important to strategic planning:

■ Patient-focused quality and health care performance

provide a strategic view of quality. The focus is on the

drivers of patient satisfaction, patient loyalty, patient

health status, and health care service improvement.

■ Operational performance improvement contributes to

short- and longer-term productivity growth and cost

containment. Building operational capability—

including speed, responsiveness, and flexibility—

represents an investment in strengthening your

organizational fitness.

■ Organizational and personal learning are necessary

strategic considerations in today’s fast-paced environment. The Criteria emphasize that improvement and

learning need to be embedded in work processes. The

special role of strategic planning is to align work processes and learning initiatives with your organization’s

strategic directions, thereby ensuring that improvement

and learning prepare you for and reinforce organizational priorities, especially health care priorities.

The Strategic Planning Category examines how your

organization

■ determines its key strengths, weaknesses, opportunities,

and threats, and its ability to execute your strategy.

■ optimizes the use of resources, ensures the availability

of trained staff, and bridges short- and longer-term

requirements that may entail capital expenditures,

technology development or acquisition, and supplier

and health care provider alliances.

■ ensures that deployment will be effective—that there

are mechanisms to communicate requirements and

achieve alignment on three levels: (1) the organization

and the senior leader level, (2) the key process level, and

(3) the department/work unit and individual job level.

The requirements in the Strategic Planning Category encourage strategic thinking and acting—to develop a basis

for an appropriate competitive and collaborative position in
2005 Health Care Criteria for Performance Excellence 41

the marketplace. These requirements do not imply formalized

plans, planning systems, departments, or specific planning cycles.

They also 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, compete for limited resources. In most cases, setting priorities depends heavily on health care market demands and a cost rationale. However, you also might have

critical requirements, such as incorporating new health care

technology or community health and public responsibilities,

that are not driven by cost considerations alone.

2.1 Strategy Development

Purpose

This Item examines how your organization sets strategic

directions and develops your strategic objectives to guide

and strengthen your overall performance as a health care

provider and your performance relative to other organizations providing similar health care services.

Comments

■ This Item calls for basic information on the planning

process and for information on all the 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 and your

industry or marketplace. This approach is intended to

provide a thorough and realistic context for the development of a patient- and other customer- and health care

market-focused strategy to guide ongoing decision making, resource allocation, and overall management.

■ 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 but do

not imply planning departments, specific planning cycles,

or a specified way of visualizing the future. Even if your

organization is seeking to create an entirely new health

care service or business situation, it is still necessary to set

and to test the objectives that define and guide critical

actions and performance.

■ This Item emphasizes health care industry leadership,

which usually depends on health care service delivery and

operational effectiveness. This leadership requires a view

of the future that includes not only the health care markets

or segments in which your organization provides services

but also how it competes and/or collaborates in these

markets. How it competes and/or collaborates presents many

options and requires that you understand your organization’s and your competitors’/collaborators’ strengths and

weaknesses. Although no specific time horizons are included, the thrust of this Item is sustained performance

leadership.

■ An increasingly important part of strategic planning is

projecting the future competitive environment. Such projections help to detect and reduce competitive threats, to

shorten reaction time, and to identify opportunities.

Depending on the size and type of organization, 

maturity of health care markets, pace of change, and

competitive/collaborative parameters (such as cost or

innovation rate), organizations might use a variety of

modeling, scenarios, or other techniques and judgments

to anticipate the future environment.

■ While many organizations are increasingly adept at strategic planning, plan execution is still a significant challenge.

This is especially true given market demands to be agile

and to be prepared for unexpected change, such as disruptive technologies that can upset an otherwise fast-paced

but more predictable marketplace. This Item and Item 2.2

highlight the need to place a focus not only on developing your plans but also on your capability to execute them.

2.2 Strategy Deployment

Purpose

This Item examines how your organization converts your

strategic objectives into action plans to accomplish the

objectives. It also examines how your organization assesses

progress relative to these action plans. The aim is to ensure

that your strategies are successfully deployed for goal

achievement.

Comments

■ This Item asks how your action plans are developed and

deployed. Accomplishment of action plans requires resources and performance measures, as well as the alignment of department/work unit and supplier and partner

plans. Of central importance is how you achieve alignment and consistency—for example, via key processes and

key measurements. Also, alignment and consistency are

intended to provide a basis for setting and communicating priorities for ongoing improvement activities—part of
42 2005 Health Care Criteria for Performance Excellence

the daily work of all departments/work units. In addition,

performance measures are critical for tracking performance.

■ Key changes in your services or patients and other customers and health care markets might include Web-based

or electronic communication/information transfer initiatives integrated within or separate from your current

health care and other services.

■ Action plans should include human resource plans that

are aligned with and support your overall strategy.

■ Examples of possible human resource plan elements are

• a redesign of your work organization and jobs to increase staff empowerment and decision making;

• initiatives to promote better collaboration and cooperation between health care providers and administrative

staff;

• initiatives to promote greater labor-management cooperation, such as union partnerships;

• initiatives to foster knowledge sharing and organizational learning;

• modification of your compensation and recognition

systems to recognize team, organizational, patient and

other customer satisfaction, or other performance

attributes; or

• education and training initiatives, such as developmental programs for future leaders, partnerships with

universities to help ensure the availability of future

staff, and establishment of training programs on new

technologies important to your future organizational

success.

■ Projections and comparisons in this Item are intended to

improve your organization’s ability to understand and

track dynamic, competitive performance factors.

Through this tracking process, your organization should

be better prepared to take into account its rate of improvement and change relative to that of competitors and

other organizations providing similar health care services

and relative to its own targets or stretch goals. Such

tracking serves as a key diagnostic management tool.

■ In addition to improvement relative to past performance

and to other organizations providing similar health care

services and competitors’ projected performance, projected performance might include changes resulting from

new business ventures, entry into new health care markets, introduction of new technologies, innovations, or

other strategic thrusts.

Focus on Patients, Other Customers, and

Markets (Category 3)

Focus on Patients, Other Customers, and Markets addresses

how your organization seeks to understand the voices of

patients, other customers, and the marketplace, with a focus

on meeting patients’ and other customers’ expectations and

requirements, delighting them, and building loyalty and

positive referrals. The Category stresses relationships as an

important part of an overall listening, learning, and performance excellence strategy. Your patient and other customer

satisfaction and dissatisfaction results provide vital information for understanding your customers and the health care

marketplace. In many cases, such results and trends provide

the most meaningful information, not only on your patients’

and other customers’ views but also on their marketplace

behaviors—patient/customer loyalty and positive referrals—

and how these views and behaviors may contribute to the

sustainability of your organization in the marketplace.

Throughout the Criteria, patients frequently are identified

separately from other customer groups. This is done to

stress the importance of this customer group (i.e., patients)

to health care organizations. However, Item requirements

also address other customers (or refer to customers generically) to ensure inclusion of all customer groups in the organization’s customer focus and performance management

system. Other customers could include patients’ families, the

community, insurers and other third-party payors, employers, health care providers, patient advocacy groups, Departments of Health, and students. A key challenge to health

care organizations frequently may include balancing the differing expectations of patients and other customer groups.

3.1 Patient, Other Customer, and Health Care 

Market Knowledge

Purpose

This Item examines your organization’s key processes for

gaining knowledge about your current and future patients,

other customers, and markets, with the aim of offering relevant health care services, understanding longer-term or

emerging patient/customer requirements and expectations,
2005 Health Care Criteria for Performance Excellence 43

and keeping pace with marketplace changes and changing

ways of doing business.

Comments

■ In a rapidly changing competitive health care environment,

many factors may affect patient and other customer preference and loyalty and your interface with 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 organization’s overall strategy.

■ Knowledge of patient and other customer groups and

health care market segments allows your organization to

tailor listening and learning strategies and marketplace

offerings, to support and tailor your marketing strategies,

to develop new health care service opportunities, and to

ensure marketplace sustainability.

■ A relationship strategy may be possible with some customers but not with others. Differing relationships may

require distinctly different listening and learning strategies. The use of electronic communication and the Internet (e.g., Web-based scheduling, support group, and

health care information) is rapidly changing many marketplaces and may affect your listening and learning

strategies, as well as your definition of patient and other

customer groups and health care market segments.

■ Selection of listening and learning strategies depends on

your key organizational factors. Increasingly, organizations interact with customers via multiple modes. Some

frequently used modes include focus groups with key

customers; close integration with patients and other key

customers; interviews with lost and potential customers

about their health care purchase decisions; use of the patient

and other customer complaint process to understand key

service attributes; win/loss analysis relative to competitors;

and survey or feedback information, including information collected on the Internet.

3.2 Patient and Other Customer Relationships 

and Satisfaction

Purpose

This Item examines your organization’s processes for building

patient and other customer relationships and determining patient and other customer satisfaction, with the aim of acquiring new patients and other customers, retaining existing customers, and developing new health care market opportunities.

Comments

■ This Item emphasizes how you obtain actionable information from patients and other customers. Information

that is actionable can be tied to key health care service

and organizational processes and be used to determine

cost implications for setting improvement goals and priorities for change.

■ 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 service improvements. Successful outcomes require

effective deployment of information throughout the

organization.

■ In determining patients’ and other customers’ satisfaction, a key aspect is their comparative satisfaction with

competitors and/or other 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 patient and other customer

preference are of critical importance in understanding

factors that drive health care markets and potentially

affect longer-term success in the health care marketplace.

■ Changing health care service needs and directions might

include changing modes of patient and other customer

access, such as the Internet. In such cases, key contact requirements might include privacy and access to personal

assistance.

Measurement, Analysis, and Knowledge

Management (Category 4)

The Measurement, Analysis, and Knowledge Management

Category is the main point within the Criteria for all key

information about effectively measuring, analyzing, and reviewing performance and managing organizational knowledge to drive improvement and organizational competitiveness, with specific attention to performance as a health care

provider. In the simplest terms, Category 4 is the “brain

center” for the alignment of your organization’s health care

and administrative operations and its strategic objectives.
44 2005 Health Care Criteria for Performance Excellence

Central to such 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 productivity growth,

the Category also includes such strategic considerations.

4.1 Measurement, Analysis, and Review of 

Organizational Performance

Purpose

This Item examines your organization’s selection, management, and use of data and information for performance

measurement, analysis, and review in support of organizational planning and performance improvement as a health

care provider. This performance improvement includes

efforts to improve health care results and outcomes (e.g.,

through the selection of statistically meaningful indicators,

the risk adjustment of data, and the linking of outcomes to

processes and provider decisions). The Item serves as a

central collection and analysis point in an integrated performance measurement and management system that relies on

clinical, financial, and nonfinancial data and information.

The aim of measurement, analysis, and review is to guide

your organization’s process management toward the achievement of key organizational performance results and strategic

objectives, and to anticipate and respond to rapid or unexpected organizational or external changes.

Comments

■ Alignment and integration are key concepts for successful

implementation of your performance measurement system.

They are viewed in terms of extent and effectiveness of

use to meet your performance assessment needs. Alignment and integration include how measures are aligned

throughout your organization and how they are integrated

to yield organization-wide data and information. Alignment

and integration also include how performance measurement requirements are deployed by your senior leaders to

track departmental, work group, and process-level performance on key measures targeted for organization-wide

significance or improvement.

■ The use of comparative data and information is important to all organizations. The major premises for use are

(1) your organization needs to know where it stands relative to competitors, to other providers, and to best practices; (2) comparative information and information obtained from benchmarking often provide the impetus for

significant (“breakthrough”) improvement or change; and

(3) comparing performance information frequently leads

to a better understanding of your processes and their

performance. Comparative information also may support

analysis and decisions relating to core competencies,

alliances, and outsourcing.

■ Your effective selection and use of comparative data and

information require (1) determination of needs and priorities, (2) criteria for seeking appropriate sources for comparisons—from within and outside the health care industry and your organization’s markets, and (3) use of data

and information to set stretch goals and to promote

major, nonincremental (“breakthrough”) improvements

in areas most critical to your organization’s strategy.

■ Sources of comparative data and information might include (1) information obtained from other organizations

through sharing or contributing to external reference

databases (e.g., the Maryland Quality Indicator Project),

(2) information obtained from the open literature (e.g.,

outcomes of research studies and practice guidelines), and

(3) data gathering and evaluation by independent organizations (e.g., CMS, accrediting organizations [NCQA

and JCAHO], and commercial organizations).

■ The organizational review called for in this Item is intended to cover all areas of performance. This includes

not only how well you currently are performing but also

how well you are moving toward the future. It is anticipated that the review findings will provide a reliable

means to guide both improvement and opportunities for

innovation that are tied to your organization’s key objectives, success factors, and measures. Therefore, an

important component of your organizational review is

the translation of the review findings into an action

agenda sufficiently specific for deployment throughout

your organization and to your suppliers, partners, and

key customers.

■ Analyses that your organization conducts to gain an understanding of performance and needed actions may vary

widely depending on your type of organization, size,

competitive environment, and other factors. Examples of

possible analyses include

• how health care service quality improvement correlates

with key patient and other customer indicators such as

satisfaction, loyalty, and market share
2005 Health Care Criteria for Performance Excellence 45

• cost and revenue implications of patient- and other

customer-related problems and effective problem

resolution

• interpretation of market share changes in terms of

patient and other customer gains and losses and

changes in patient and other customer satisfaction

• improvement trends in key operational performance

indicators such as productivity, cycle time (e.g., length

of stay, turnaround times, wait times, and billing delays), waste reduction, utilization rates, error rates, and

cost per case

• relationships between staff and organizational learning

and value added per staff member

• financial benefits derived from improvements in staff

safety, absenteeism, and turnover

• benefits and costs associated with education and

training, including Internet-based or e-learning

opportunities

• 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 staff requirements

correlates with staff retention, motivation, and

productivity

• cost and revenue implications of staff-related problems

and effective problem resolution

• individual or aggregate measures of productivity and

quality relative to competitors’ performance

• cost trends relative to competitors’ trends (e.g., cost/

case for key diagnosis related groups [DRGs])

• compliance with preventive screenings compared to

similar health care providers

• relationships among patient health care 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 community impact

• net earnings derived from quality, operational, and

human resource performance improvements

• comparisons among cost centers showing how quality

and operational performance improvement affect

financial performance (e.g., impacts of HMO preventive care versus diagnostic expenses and treatment of

potentially preventable illnesses)

• contributions of improvement activities to cash flow,

working capital use, and shareholder and community

value

• financial impacts of customer retention (e.g., retention

of third-party payors)

• cost and revenue implications of new health care

market entry

• cost and revenue, patient and other customer, and productivity implications of engaging in or expanding

electronic communication/information transfer and use

of the Internet and intranets

• health care market share versus profits/financial returns

• trends in economic, market, and shareholder indicators

of value and the impact of these trends on organizational sustainability

■ Individual facts and data do not usually provide an effective basis for setting organizational priorities. This Item

emphasizes that close alignment is needed between your

analysis and your organizational performance review and

between your analysis and your organizational planning.

This ensures that analysis is relevant to decision making

and that decision making is based on relevant data and

information.

■ Action depends on understanding cause-effect connections among processes and between processes and organizational performance results or outcomes. 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 improvement are limited and cause-effect connections often

are unclear.
46 2005 Health Care Criteria for Performance Excellence

4.2 Information and Knowledge Management

Purpose

This Item examines how your organization ensures the

availability of high-quality, timely data and information for

all your key users—staff, suppliers and partners, and patients

and other customers. It also examines how your organization

builds and manages its knowledge assets. The aim is to improve organizational efficiency, effectiveness, and innovation.

Comments

■ Managing information can require a significant commitment of resources as the sources of data and information

grow dramatically. The expanding use of electronic information within organizations’ operations, as part of organizational knowledge networks, from the Internet, and in

electronic communication/information transfer, challenges organizational abilities to ensure reliability, confidentiality, and availability in a user-friendly format.

■ Data and information are especially important in alliances

and supply chains. Your responses to this Item should

take into account this use of data and information and

should recognize the need for rapid data validation and

reliability assurance, given the increasing use of electronic

data transfer.

■ Organizations should carefully plan how they will continue to provide data and information in the event of

either a natural or man-made disaster. These plans should

consider the needs of all of the organization’s stakeholders, including staff, patients and other customers, and

suppliers/partners. The plans also should be coordinated

with the organization’s overall plan for business continuity (Item 6.2).

■ The focus of an organization’s knowledge management is

on the knowledge that people need to do their work; improve processes and health care services; keep current

with changing organizational performance needs and directions; and develop innovative solutions that add value

for the patient/customer and the organization.

Staff Focus (Category 5)

Staff Focus addresses key human resource practices—those

directed toward creating and maintaining a high-performance

workplace and toward developing staff to enable them and

your organization to adapt to change. The Category covers

staff development and management requirements in an integrated way, i.e., aligned with your organization’s strategic

objectives and action plans. Your staff focus includes your

work environment and your staff support climate. A particular challenge in some health care organizations is the breadth

of staff relationships—the variety of people contributing to

the delivery of the organization’s services. This might include paid staff, independent practitioners, volunteers, and

students. All appropriate contributions must be considered

in the Staff Focus Category.

To reinforce the basic alignment of staff management with

overall strategy, the Criteria also cover staffing plans as part

of overall planning in the Strategic Planning Category

(Category 2).

5.1 Work Systems

Purpose

This Item examines your organization’s systems for work and

jobs, compensation, career progression, staff performance

management, recognition, communication, and hiring, with

the aim of enabling and encouraging all staff to contribute

effectively and to the best of their ability. These systems are

intended to foster high performance, to result in individual

and organizational learning, and to enable adaptation to

change, contributing to organizational sustainability.

Comments

■ High-performance work is characterized by flexibility, innovation, knowledge and skill sharing, alignment with organizational objectives, patient and other customer focus,

and rapid response to changing health care service needs

and requirements of the health care marketplace. The

focus of this Item is on a workforce capable of achieving

high performance. In addition to enabled staff and proper

work system design, high-performance work requires ongoing education and training, as well as information systems that ensure proper information flow.

■ Work and job factors for your consideration include simplification of job classifications, cross-training, job rotation, use of teams (including self-directed teams), and

changes in work layout and location to facilitate patientfocused processes. Also important is effective communication across functions and work units to ensure a focus

on patient and other customer requirements and to ensure an environment of trust, knowledge sharing, and

mutual respect. Job design should address the organization’s credentialing and privileging of its health care

practitioners, as appropriate.

■ Compensation and recognition systems should be matched

to your work systems. To be effective, compensation and
2005 Health Care Criteria for Performance Excellence 47

recognition might be tied to demonstrated skills, to peer

evaluations, and/or to collaboration among departments

and health care practitioners.

■ Compensation and recognition approaches also might

include bonuses/profit sharing, the rewarding of exemplary

team or unit performance, and linkage to patient and

other customer satisfaction and loyalty measures, achievement of organizational strategic objectives, or other performance objectives.

■ The requirements of high-performance work, coupled

with the challenges of labor markets, necessitate attention

to succession planning and hiring profiles. This should

include and capitalize on diversity factors. Staff recruitment and career progression planning should consider

both internal and external candidates, with a focus on the

future sustainability and growth of the organization.

5.2 Staff Learning and Motivation

Purpose

This Item examines the education, training, and on-the-job

reinforcement of knowledge and skills of your organization’s

workforce. It also examines your organization’s systems for

motivation and staff career development, with the aim of meeting the ongoing needs of staff, licensure and recredentialing

requirements, and a high-performance workplace.

Comments

■ Depending on the nature of your organization’s health

care services, staff responsibilities, and the stage of organizational and personal development, education and

training needs might vary greatly. These needs might include continuing clinical education; gaining skills for

knowledge sharing, communication, teamwork, and problem solving; interpreting and using data; meeting patient

and other customer requirements; accomplishing process

analysis and simplification; reducing waste and cycle time;

applying HIPAA regulations and concepts in daily work;

and setting priorities based on strategic alignment or

cost/benefit analysis. Education needs also might include

advanced skills in new technologies or basic skills, such as

reading, writing, language, arithmetic, and, increasingly,

computer skills.

■ Education and training delivery might occur inside or

outside your organization and could involve on-the-job,

classroom, computer-based, or distance learning, as well

as other types of delivery. Training also might occur

through developmental assignments within or outside

your organization.

■ When you evaluate education and training, you should

seek effectiveness measures as a critical part of the evaluation. Such measures might address the impact on individual, department, unit, and organizational performance;

the impact on customer-related performance; the impact

on health care outcomes; and a cost/benefit analysis of

the training.

■ Although this Item does not specifically ask you about

training for patient and other customer contact staff, such

training is important and common. It frequently includes

learning critical knowledge and skills in the following

areas: health care services and patients and other customers; how to listen to patients and other customers; how

to recover from problems or failures; and how to effectively manage patient and other customer expectations.

■ An organization’s knowledge management system should

provide the mechanism for sharing the knowledge of staff,

privileged physicians, and the organization to ensure

high-performance work is maintained through transitions.

Each organization should determine what knowledge is

critical for its operations and should then implement

systematic processes for sharing this information. This is

particularly important for implicit knowledge (i.e., knowledge personally retained by your staff).

■ To help staff realize its full potential, many organizations use individual development plans prepared with

each staff member that address his or her career and

learning objectives.

■ Factors inhibiting motivation should be understood and

addressed by your organization. Further understanding of

these factors could be developed through employee surveys or exit interviews with departing staff members.

5.3 Staff Well-Being and Satisfaction

Purpose

This Item examines your organization’s work environment,

your staff support climate, and how you determine staff satisfaction, with the aim of fostering the well-being, satisfaction, and motivation of all staff while recognizing their diverse needs. It also examines your organization’s capabilities

for handling emergencies or disasters, with the aim of employee protection and workplace safety.
48 2005 Health Care Criteria for Performance Excellence

Comments

■ Most organizations, regardless of size, have many opportunities to contribute to staff well-being, satisfaction, and

motivation. Some 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; nonwork-related education; day care; special

leave for family responsibilities and community service;

flexible work hours and benefits packages; outplacement

services; and retiree benefits, including extended health

care and access to staff services.

■ All organizations, regardless of size, are required to meet

minimum regulatory standards for workplace safety; however, high-performing organizations have processes in

place to ensure they not only meet these minimum standards but go beyond a compliance orientation. This includes designing proactive processes, with input from

employees directly involved in the work, to ensure a safe

working environment.

■ Although satisfaction with pay and satisfaction with promotion are important to paid staff, these two factors generally are not sufficient to ensure overall staff satisfaction,

motivation, and high performance. Some examples of

other factors to consider are effective staff problem and

grievance resolution; staff development and career opportunities; work environment and management support;

workplace safety and security; workload; effective communication, cooperation, and teamwork; job security; appreciation of the differing needs of diverse staff groups;

and organizational support for serving patients and other

customers.

■ In addition to direct measures of staff satisfaction and

well-being through formal or informal surveys, some

other indicators include safety, absenteeism, turnover,

grievances, strikes, OSHA reportables, and workers’ compensation claims. For health care staff, indicators might

include patient referrals to other organizations or institutions and willingness to serve on committees.

Process Management (Category 6)

Process Management is the focal point within the Criteria

for all key work processes—health care processes and those

processes that support the delivery of health care. As appropriate to an organization’s mission, key processes might

include the conduct of health care research and/or the

teaching of medical/nursing students or allied health care

professionals. Built into the Category are the central requirements for efficient and effective process management: effective design; a prevention orientation; linkage to patients and

other customers, suppliers, and partners and a focus on

creating value for all key stakeholders; operational and

financial performance; cycle time; and evaluation, continuous improvement, and organizational learning.

Agility, cost efficiencies, and cycle time reduction are increasingly important in all aspects of process management

and organizational design. In the simplest terms, “agility”

refers to your ability to adapt quickly, flexibly, and effectively to changing requirements. Depending on the nature

of your organization’s strategy and markets, agility might

mean rapid change to a new technology or treatment protocol, rapid response to changing payor requirements, or

the ability to produce a wide range of patient-focused services. Agility also increasingly involves shared facilities,

decisions to outsource, agreements with key suppliers, and

novel partnering arrangements. Flexibility might demand

special strategies, such as sharing facilities, cross-training,

and providing specialized training. Cost and cycle time reduction often involve agile process management strategies.

It is crucial to utilize key measures for tracking all aspects of

your overall process management.

6.1 Health Care Processes

Purpose

This Item examines your organization’s key health care

service design and delivery processes, with the aim of creating value for your patients and other customers and other

key stakeholders, and improving your marketplace and

operational performance.

Comments

■ This Item calls for information on the management and

improvement of key health care processes. The information required includes a description of the key processes,

their specific requirements, and how performance relative

to these requirements is determined and maintained. Increasingly, these requirements might include the need for

agility—speed and flexibility—to adapt to change.

■ Design processes might address (1) modifications and

variants of existing health care services that might result
2005 Health Care Criteria for Performance Excellence 49

from the shift of a service from an inpatient to an outpatient setting, the introduction of new technology for an

existing service, or the institution of critical pathways;

(2) new health care services resulting from research;

(3) new/modified facilities to meet performance requirements; and (4) significant redesigns of processes to improve patient focus, productivity, or both. You should

consider the key requirements for your health care services. Factors that might need to be considered in design

include desired health care outcomes; safety and risk

management; timeliness, access, coordination, and continuity of care; patient involvement in care decisions; measurement capability; process capability; variability in customer expectations requiring health care service options;

availability or scarcity of staff with critical skills; availability of referral sources; technology; facility capacity or utilization; supplier capability; regulatory requirements; and

documentation. Effective design also must consider cycle

time and productivity of health care service delivery processes. This might involve detailing critical pathways and

redesigning (“re-engineering”) those delivery processes to

achieve efficiency, as well as to meet changing requirements.

■ This Item calls for information on the incorporation of

new technology. This could include e-technology for

sharing information with suppliers and partners, communicating with patients and other customers, and giving

them continuous (24/7) access and automated information transfer.

■ Coordination of design and delivery processes involves

all departments/work units and/or individuals who will

take part in delivery and whose performance materially

affects overall process outcome. This might include researchers, health care providers, facilities engineering,

and administration.

■ Specific reference is made to regulatory and payor requirements, in-process measurements/assessments, and

patient and other customer and supplier interactions.

These measurements and interactions require the identification of critical points in processes for measurement,

observation, or interaction. These activities should occur

at the earliest points possible in processes to minimize

problems and costs that may result from deviations from

expected performance. Achieving expected 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 the process to its design specifications. Depending on the nature of the process, the corrective action

could involve technical and human considerations. Proper

corrective action involves changes at the source (root

cause) of the deviation. Such corrective action should

minimize the likelihood of this type of variation occurring

again or elsewhere in your organization. When patients’

and other customers’ interactions are involved, differences

among patients and other customers must be considered

in evaluating how well the process is performing. This

might entail allowing for specific or general contingencies,

depending on the patient and other customer information

gathered.

■ Critical to health care service delivery are the consideration of patient expectations, the setting of realistic patient

expectations relative to likely health care outcomes, and

the opportunity for patients to participate on an informed

basis in decision making relative to their own health care.

■ This Item also calls for information on how processes are

improved to achieve better performance. Better performance means not only better quality from your patients’

and other customers’ perspectives and better health care

outcomes, but also better financial and operational performance—such as productivity—from your other stakeholders’ perspectives. A variety of process improvement

approaches are commonly used. These approaches include

(1) sharing successful strategies across your organization

to drive learning and innovation, (2) conducting research

and development, (3) benchmarking, (4) using alternative

technology, and (5) using information from patients and

other customers—within and outside your organization.

6.2 Support Processes and Operational Planning

Purpose

This Item examines your organization’s key business and

other support processes and your operational planning with

respect to financial management and planning for the continuity of operations, with the aim of improving your overall

operational performance.

Comments

■ Your key business processes are those nonhealth care service processes that are considered most important to
50 2005 Health Care Criteria for Performance Excellence

growth and success by your senior leaders. These processes

frequently relate to an organization’s strategic objectives

and critical success factors. Key business processes might

include processes for innovation, 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 might vary

significantly for different processes.

■ Your other key support processes are those that support

your daily operations and your health care service delivery but are not usually designed in detail with the health

care services. The support process requirements usually

do not depend significantly on health care service characteristics. Support process design requirements usually

depend significantly on your 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, facilities management, legal services,

human resource services, public relations, community relations, and other administrative services.

■ For many organizations, supply chain management is a

growing factor in achieving productivity and profitability

goals and overall organizational performance success.

Suppliers and partners are receiving increasing strategic

attention as organizations re-evaluate their core functions. Supplier processes should fulfill two purposes: to

help improve the performance of suppliers and partners

and also, on specific actions, to help them contribute to

your organization’s improved performance. Supply chain

management might include processes for supplier selection, with the aim of reducing the total number of suppliers and increasing preferred supplier and partnering

agreements.

■ This Item calls for information on how your organization

evaluates and improves the performance of your key business and other support processes and shares information

with other organizational units to drive learning and innovation. Four approaches frequently used are (1) process

analysis and research, (2) benchmarking, (3) use of alternative technology, and (4) use of information from patients

and other customers of the processes. Together, these

approaches offer a wide range of possibilities, including

minor process modification and complete redesign (“reengineering”) of processes.

■ Many types of analyses can be performed to ensure adequate financial resources are available to support current

operations and new business investments and to assess

their financial risks. For current operations, these efforts

might include the analysis of cash flows, net income

statements, and current liabilities versus current assets.

For business investments, the efforts might include analysis of discounted cash flows, return on investment (ROI),

or return on invested capital (ROIC). The specific types

of analyses will vary from organization to organization.

These analyses should help your organization assess the

financial viability of your current operations and the

potential viability of and risks associated with your new

business initiatives.

■ Efforts to ensure the continuity of operations in an emergency should consider all facets of a business that are

needed to provide health care services to patients and

other customers. You should consider both your health

care delivery and your key business and other support

processes in your planning. The specific level of service

that you will need to provide will be guided by your mission and your patient and other customer needs and requirements. Health care providers will likely have a

higher need for services than businesses that do not provide an essential function. Your continuity of operations

efforts should be coordinated with your efforts to ensure

data and information availability (Item 4.2) and workplace

preparedness (Item 5.3).

Organizational Performance Results

(Category 7)

The Organizational Performance Results Category provides

a results focus for meeting your organization’s mission as a

health care provider. This focus encompasses your objective

evaluation and your patients’ and other customers’ evaluation of your organization’s health care outcomes and service

delivery results, your overall financial and health care market

performance, your leadership system and social responsibility results, your staff and work system results, and the results

of all your key processes and process improvement activities.

Through this focus, the Criteria’s purposes—superior health

care quality and value as viewed by your patients and other

customers and the marketplace; superior organizational performance as reflected in your clinical, operational, legal,

ethical, and financial indicators; and organizational and personal learning—are maintained. Category 7 thus provides
2005 Health Care Criteria for Performance Excellence 51

“real-time” information (measures of progress) for evaluation

and improvement of health care outcomes and all key processes, in alignment with your overall organizational strategy.

Item 4.1 calls for analysis and review of clinical and operational

results data and information to determine your overall organizational performance and set priorities for improvement.

7.1 Health Care Outcomes and Service Delivery Results

Purpose

This Item examines your organization’s key health care outcomes and service delivery results that lead to patient and

other customer satisfaction, loyalty, and positive referral.

Comments

■ This Item addresses those measures that best reflect your

organization’s success in delivering on its mission as a

health care provider. The Item calls for the use of key

data and information to establish your organization’s performance in delivering health care. Overall, this is the

most important Item in the Criteria, as it focuses on

demonstrating improving health care results over time.

■ This Item addresses the use of comparative data. Comparative data from external organizations (e.g., CMS,

NCQA, JCAHO, and the Maryland Quality Indicator

Project) for your patient population are useful in demonstrating superior results relative to other organizations

that provide similar health care services.

■ This Item places an emphasis on measures of health care

service performance that serve as indicators of patients’

and other customers’ views and health care decisions relative to continuing interactions with your organization

and/or positive referral. These measures of service performance are derived from patient- and other customerrelated information gathered in Items 3.1 and 3.2.

■ The correlation among health care service performance

and patient/customer indicators is a critical management

tool with multiple uses: (1) defining and focusing on key

quality and patient/customer requirements; (2) identifying

service differentiators in the health care marketplace; and

(3) determining cause-effect relationships among your

health care services attributes and evidence of customer

satisfaction and loyalty, as well as positive referrals. The

correlation might reveal emerging or changing market

segments, the changing importance of requirements, or

even the potential obsolescence of health care and other

patient/customer services.

7.2 Patient- and Other Customer-Focused Results

Purpose

This Item examines your organization’s patient- and other

customer-focused performance results, with the aim of

demonstrating how well your organization has been satisfying your patients and other customers and has developed

loyalty, repeat business, and positive referral.

Comments

■ This Item focuses on all relevant data used to determine

and help predict your organization’s performance as

viewed by your patients and other customers. Relevant

data and information include patient and other customer

satisfaction and dissatisfaction; retention, gains, and losses

of patients and other customers and patient and other customer accounts; patient and other customer complaints

and complaint management; effective complaint resolution;

patient- and other customer-perceived value based on

health care quality, outcomes, and cost; patient and other

customer assessment of access and ease of use (including

courtesy in-service interactions); and awards, ratings, and

recognition from patients and other customers and independent rating organizations.

■ This Item places an emphasis on patient- and other

customer-focused results that go beyond satisfaction

measurement because loyalty, retention, positive referral,

and longer-term patient and other customer relationships

are better indicators and measures of future success in the

health care marketplace and organizational sustainability.

7.3 Financial and Market Results

Purpose

This Item examines your organization’s key financial and

health care market results, with the aim of understanding

your financial sustainability and your marketplace challenges

and opportunities.

Comments

■ Measures reported in this Item are those usually tracked

by senior leadership on an ongoing basis to assess your

organization’s performance.

■ Appropriate financial measures and indicators might include revenue, profits, market position, cash-to-cash cycle

time, earnings per share, and financial returns. Marketplace performance measures might include market position, market share, measures of growth, new markets
52 2005 Health Care Criteria for Performance Excellence

entered, entry into e-services for patients and other customers, new populations served, and the percentage of

income derived from new health care services.

7.4 Staff and Work System Results

Purpose

This Item examines your organization’s staff and work system results, with the aim of demonstrating how well your

organization has been creating and maintaining a productive, learning, and caring work environment for all staff.

Comments

■ Results measures reported for work system performance

might include improvement in job classification, job rotation, work layout, and working relationships among

health care providers, administrators, and support staff.

Results reported might include input data, such as the extent of training, but the main emphasis should be on data

that show effectiveness or outcomes. An example of such

an outcome measure might be the productivity enhancements or cost savings resulting from the redesign of work

processes by work teams. 

■ Results reported might include generic or organizationspecific 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

for determining your work system performance and your

staff’s well-being and satisfaction. These factors might include the extent of training or cross-training or the extent

and success of self-direction.

7.5 Organizational Effectiveness Results

Purpose

This Item examines your organization’s other key operational performance results not reported in Items 7.1–7.4,

with the aim of achieving organizational effectiveness and

process efficiency.

Comments

■ This Item encourages your organization to develop and

include unique and innovative measures to track key processes and operational improvement. All key areas of

health care service delivery and operational performance

should be evaluated by measures that are relevant and important to your organization.

■ Measures and indicators of operational effectiveness and

efficiency might include internal responsiveness indicators

such as cycle times and turnaround times; utilization rates;

waste reduction such as reducing repeat diagnostic tests;

cost reduction; strategic indicators such as innovation

rates, time to new health care service introduction, and

increased use of e-technology; and supply chain indicators

such as reductions in inventory, increases in quality and

productivity such as Six Sigma initiative results, improvements in electronic data exchange, and reductions in

supply chain management costs.

7.6 Leadership and Social Responsibility Results

Purpose

This Item examines your organization’s key results in the

areas of leadership and societal responsibilities, with the aim

of maintaining a fiscally sound, ethical organization that is a

good citizen in its communities.

Comments

■ Because of a lack of appropriate measures, a key challenge

for many organizations is measuring their progress in

accomplishing their strategic objectives. Frequently, these

progress measures can be discerned by first defining the

results that would indicate end-goal success in achieving

the strategic objective and then using that measure to

define intermediate measures.

■ Independent of an increased national focus on issues of

governance, 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

on a regular basis and emphasize this performance in

stakeholder communications.

■ Results reported should include key accreditation and

regulatory review findings, patient safety data, staff licensure and recredentialing determinations, external audits,

proficiency testing results, and utilization review results,

as appropriate.

■ Measures should include environmental, legal, and regulatory compliance and noteworthy achievements in these

areas, as appropriate. Results also should include indicators of support for key communities and other public purposes, including contributions to improving community

health.

■ If your organization has received sanctions or adverse

actions under law (including malpractice), regulation,

accreditation, or contract during the past three years, the

incidents and their current status should be summarized.
2005 Health Care Criteria for Performance Excellence 53

The scoring of responses to Criteria Items (Items) and Award

applicant feedback are based on two evaluation dimensions:

(1) Process and (2) Results. Criteria users need to furnish

information relating to these dimensions. Specific factors

for these dimensions are described below. Scoring Guidelines are given on pages 54–55.

Process

“Process” refers to the methods your organization uses and

improves to address the Item requirements in Categories

1–6. The four factors used to evaluate process are Approach,

Deployment, Learning, and Integration (A–D–L–I).

“Approach” refers to

■ the methods used to accomplish the process

■ the appropriateness of the methods to the Item

requirements

■ the effectiveness of your use of the methods 

■ the degree to which the approach is repeatable 

and based on reliable data and information (i.e.,

systematic)

“Deployment” refers to the extent to which

■ your approach is applied in addressing Item requirements relevant and important to your organization

■ your approach is applied consistently

■ your approach is used by all appropriate work units

“Learning” refers to

■ refining your approach through cycles of evaluation

and improvement 

■ encouraging breakthrough change to your approach

through innovation

■ sharing of refinements and innovation with other

relevant work units and processes in your organization

“Integration” refers to the extent to which

■ your approach is aligned with your organizational

needs identified in other Criteria Item requirements

■ your measures, information, and improvement systems

are complementary across processes and work units

■ your plans, processes, results, analyses, learning, and

actions are harmonized across processes and work units

to support organization-wide goals

Results

“Results” refers to your organization’s outputs and outcomes

in achieving the requirements in Items 7.1–7.6. The four

factors used to evaluate results are

■ your current level of performance

■ rate (i.e., slope of trend data) and breadth (i.e., how

widely deployed and shared) of your performance

improvements

■ your performance relative to appropriate comparisons

and/or benchmarks

■ linkage of your results measures (often through segmentation) to important customer, product and service,

market, process, and action plan performance requirements identified in your Organizational Profile and in

Process Items

Item Classification and Scoring Dimensions

Items are classified according to the kinds of information

and data you are expected to furnish relative to the two

evaluation dimensions given above.

The two types of Items are designated as

1. Process Process

2. Results Results

In Process Items, approach–deployment–learning–

integration are linked to emphasize that descriptions of approach should always indicate the deployment—consistent

with the specific requirements of the Item. As processes mature,

their description also should indicate how cycles of learning,

as well as integration with other processes and work units,

occur. Although the approach–deployment–learning–

integration factors are linked, feedback to Award applicants

reflects strengths and opportunities for improvement in any

or all of these factors.

Results Items call for data showing performance levels,

improvement rates, and relevant comparative data for key

measures and indicators of organizational performance.

Results Items also call for data on breadth of performance

improvements. This is directly related to deployment and

organizational learning; if improvement processes are

widely shared and deployed, there should be corresponding results. A score for a Results Item is thus a composite

based upon overall performance, taking into account the

rate and breadth of improvements and their importance to

the Item requirements and your organization. (See next

paragraph.)

“Importance” as a Scoring Consideration

The two evaluation dimensions described previously are

critical to evaluation and feedback. However, another

critical consideration in evaluation and feedback is the

importance of your reported process and results to your key

business factors. The areas of greatest importance should be

identified in your Organizational Profile and in Items such

as 2.1, 2.2, 3.1, 5.1, and 6.1. Your key customer requirements, competitive environment, key strategic objectives,

and action plans are particularly important.

SCORING SYSTEM
54 2005 Health Care Criteria for Performance Excellence

Assignment of Scores to Your Responses

The following guidelines should be observed in assigning

scores to Item responses.

■ All Areas to Address should be included in your Item

response. Also, responses should reflect what is important to your organization.

■ In assigning a score to an Item, first decide which

scoring range (e.g., 50 percent to 65 percent) is most

descriptive of the organization’s achievement level as

presented in the Item response. “Most descriptive of

the organization’s achievement level” can include some

gaps in one or more of the A–D–L–I (process) factors

or results factors for the chosen scoring range. An

organization’s achievement level is based on a holistic

view of either the four process or four results factors in

aggregate and not on a tallying or averaging of independent assessments against each of the four factors.

Assigning the actual score within the chosen range

requires evaluating whether the Item response is closer

to the statements in the next higher or next lower

scoring range.

■ A Process Item score of 50 percent represents an

approach that meets the overall requirements of the

Item, that is deployed consistently and to most work

units covered by the Item, that has been through some

cycles of improvement and learning, and that addresses

the key organizational needs. Higher scores reflect

greater achievement, demonstrated by broader deployment, significant organizational learning, and increased

integration.

■ A Results Item score of 50 percent represents a clear

indication of improvement trends and/or good levels of

performance with appropriate comparative data in the

results areas covered in the Item and important to the

organization. Higher scores reflect better improvement

rates and/or levels of performance, better comparative

performance, and broader coverage and integration

with health care requirements.

■ No SYSTEMATIC APPROACH is evident; information is ANECDOTAL. (A)

■ Little or no DEPLOYMENT of an APPROACH is evident. (D)

■ An improvement orientation is not evident; improvement is achieved through 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 achieving the

BASIC REQUIREMENTS of the Item. (D)

■ Early stages of a transition from reacting to problems to a general improvement orientation are evident. (L)

■ 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)

■ The beginning of a SYSTEMATIC APPROACH to evaluation and improvement of KEY PROCESSES is evident. (L)

■ The APPROACH is in early stages of ALIGNMENT with your basic organizational needs identified in response to the

other Criteria Categories. (I)

■ 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)

■ A fact-based, SYSTEMATIC evaluation and improvement PROCESS and some organizational LEARNING are in place for

improving the efficiency and effectiveness of KEY PROCESSES. (L)

■ The APPROACH is ALIGNED with your organizational needs identified in response to the other Criteria Categories. (I)

■ An EFFECTIVE, SYSTEMATIC APPROACH, responsive to the MULTIPLE REQUIREMENTS of the Item, is evident. (A)

■ The APPROACH is well DEPLOYED, with no significant gaps. (D)

■ 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. (L)

■ The APPROACH is INTEGRATED with your organizational needs identified in response to the other Criteria Items. (I)

■ 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)

■ 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. (L)

■ The APPROACH is well INTEGRATED with your organizational needs identified in response to the other Criteria Items. (I)

SCORING GUIDELINES

SCORE PROCESS

10%, 15%,

20%, or 25%

30%, 35%,

40%, or 45%

50%, 55%,

60%, or 65%

70%, 75%,

80%, or 85%

90%, 95%, or 100%

0% or 5%

For Use With Categories 1–6
2005 Health Care Criteria for Performance Excellence 55

SCORING GUIDELINES

10%, 15%,

20%, or 25%

30%, 35%,

40%, or 45%

50%, 55%,

60%, or 65%

70%, 75%,

80%, or 85%

90%, 95%, or 100%

0% or 5%

■ There are no organizational performance RESULTS or poor RESULTS in areas reported. 

■ TREND data are either not reported or show mainly adverse TRENDS.

■ Comparative information is not reported.

■ RESULTS are not reported for any areas of importance to your KEY organizational requirements.

■ A few organizational performance RESULTS are reported; there are some improvements and/or early good PERFORMANCE LEVELS in a few areas.

■ Little or no TREND data are reported.

■ Little or no comparative information is reported.

■ RESULTS are reported for a few areas of importance to your KEY organizational requirements.

■ Improvements and/or good PERFORMANCE LEVELS are reported in many areas addressed in the Item requirements. 

■ Early stages of developing TRENDS are evident.

■ Early stages of obtaining comparative information are evident.

■ RESULTS are reported for many areas of importance to your KEY organizational requirements.

■ Improvement TRENDS and/or good PERFORMANCE LEVELS are reported for most areas addressed in the Item requirements.

■ No pattern of adverse TRENDS and no poor PERFORMANCE LEVELS are evident in areas of importance to your KEY organizational requirements.

■ Some TRENDS and/or current PERFORMANCE LEVELS—evaluated against relevant comparisons and/or BENCHMARKS—

show areas of good to very good relative PERFORMANCE. ■ Organizational performance RESULTS address most KEY PATIENT and other CUSTOMER, market, and PROCESS requirements.

■ Current PERFORMANCE is good to excellent in most areas of importance to the Item requirements. 

■ Most improvement TRENDS and/or current PERFORMANCE LEVELS are sustained.

■ Many to most reported TRENDS and/or current PERFORMANCE LEVELS—evaluated against relevant comparisons and/or

BENCHMARKS—show areas of leadership and very good relative PERFORMANCE. ■ Organizational performance RESULTS address most KEY PATIENT and other CUSTOMER, market, PROCESS, and ACTION PLAN

requirements.

■ Current PERFORMANCE is excellent in most areas of importance to the Item requirements. 

■ Excellent improvement TRENDS and/or sustained excellent PERFORMANCE LEVELS are reported in most areas.

■ Evidence of health care sector and BENCHMARK leadership is demonstrated in many areas.

■ Organizational performance RESULTS fully address KEY PATIENT and other CUSTOMER, market, PROCESS, and ACTION PLAN

requirements.

SCORE RESULTS

For Use With Category 7
56 2005 Health Care Criteria for Performance Excellence

Steps Toward Mature Processes

An Aid for Scoring Process Items

(1) Reacting to Problems

Operations are characterized by activities rather than by

processes, and they are largely responsive to immediate

needs or problems. Goals are poorly defined.

(3) Aligned Approaches

Operations are characterized by processes that are

repeatable and regularly evaluated for improvement,

with learnings shared and with coordination among

organizational units. Processes address key strategies

and goals of the organization.

(2) Early Systematic Approaches

The organization is at the beginning stages of conducting

operations by processes with repeatability, evaluation and

improvement, and some early coordination among

organizational units. Strategy and quantitative goals are

being defined.

(4) Integrated Approaches

Operations are characterized by processes that are

repeatable and regularly evaluated for change and improvement in collaboration with other affected units. Efficiencies across units are sought and achieved through analysis,

innovation, and sharing. Processes and measures track

progress on key strategic and operational goals.

Strategic 

and Operational

Goals

Strategic 

and Operational 

Goals

Strategic and

Operational 

Goals

Strategic 

and Operational

Goals
2005 Health Care Criteria for Performance Excellence 57

The guidelines given in this section are offered to assist

Criteria users in responding most effectively to the requirements of the 19 Criteria Items. Writing an application for

the Baldrige Award involves responding to these requirements in 50 or fewer pages.

The guidelines are presented in three parts:

(1) General Guidelines regarding the Criteria booklet,

including how the Items are formatted

(2) Guidelines for Responding to Process Items

(3) Guidelines for Responding to Results Items

General Guidelines

1. Read the entire Criteria booklet.

The main sections of the booklet provide a full orientation to the Criteria, including how responses are to be

evaluated for self-assessment or by Award Examiners.

You should become thoroughly familiar with the following sections:

■ Health Care Criteria for Performance Excellence

(pages 12–34)

■ Scoring System (pages 53–56)

■ Glossary of Key Terms (pages 66–73)

■ Category and Item Descriptions (pages 38–52)

2. Review the Item format and understand how to

respond to the Item requirements.

The Item format (see figure below) shows the different

parts of Items, the role of each part, and where each part

is placed. It is especially important to understand the

multiple requirements contained in the Areas to Address.

The Item Notes are an aid to help you understand the

Areas to Address. Each Item and Area to Address is

described in greater detail in the Category and Item

Descriptions section (pages 38–52).

Each Item is classified as either Process or Results,

depending on the type of information required. Guidelines for responding to Process Items are given on pages

58–59. Guidelines for responding to Results Items are

given on pages 59–60.

Item requirements are presented in question format.

Some of the requirements in the Areas to Address include multiple questions. Responses to an Item should

contain responses that address all questions; however,

each question need not be answered separately. Responses to multiple questions within a single Area to

Address may be grouped, as appropriate to your organization. These multiple questions serve as a guide in understanding the full meaning of the information being

requested.

2005 HEALTH CARE CRITERIA RESPONSE GUIDELINES

N1. Senior leaders include the head of the organization and his or her direct reports. In health care organizations with separate administrative/operational and

health care provider leadership, “senior leaders” refers

to both sets of leaders and the relationships among

those leaders.

N2. Organizational vision (1.1a[1]) should set the

context for strategic objectives and action plans,

which are described in Items 2.1 and 2.2.

N3. A sustainable organization (1.1a[3]) is capable of

addressing current organizational needs and possesses

the agility and strategic management to prepare successfully for its future organizational and market environment. In this context, the concept of innovation

includes both technological and organizational innovation to succeed in the future.

N4. A focus on action (1.1b[2]) considers both the

people and the hard assets of the organization. It includes ongoing improvements in productivity that may

be achieved through eliminating waste or reducing cycle

time, and it might use techniques such as Six Sigma.

It also includes the actions to accomplish the organization’s strategic objectives.

N5. Your organizational performance results should

be reported in Items 7.1–7.6.

1.1 Senior Leadership (70 pts.) Process

Describe HOW SENIOR LEADERS guide and sustain your organization. Describe HOW SENIOR LEADERS communicate

with STAFF and encourage high PERFORMANCE.

Within your response, include answers to the following questions:

a. VISION and VALUES

(1) HOW do SENIOR LEADERS set organizational VISION and VALUES? HOW do SENIOR LEADERS deploy your organization’s

VISION and VALUES through your LEADERSHIP SYSTEM, to all STAFF, to KEY suppliers and PARTNERS, and to PATIENTS and

other CUSTOMERS, as appropriate? HOW do their personal actions reflect a commitment to the organization’s VALUES?

(2) HOW do SENIOR LEADERS promote an environment that fosters and requires legal and ETHICAL BEHAVIOR?

(3) HOW do SENIOR LEADERS create a SUSTAINABLE organization? HOW do SENIOR LEADERS create an environment for

PERFORMANCE improvement, accomplishment of STRATEGIC OBJECTIVES, INNOVATION, and organizational agility?

HOW do they create an environment for organizational and STAFF LEARNING? HOW do they personally

participate in succession planning and the development of future organizational leaders?

b. Communication and Organizational PERFORMANCE

(1) HOW do SENIOR LEADERS communicate with, empower, and motivate all STAFF throughout the organization?

HOW do SENIOR LEADERS encourage frank, two-way communication throughout the organization? HOW do

SENIOR LEADERS take an active role in STAFF reward and recognition to reinforce high PERFORMANCE and a focus

on the organization, as well as on PATIENTS and other CUSTOMERS?

(2) HOW do SENIOR LEADERS create a focus on action to accomplish the organization’s objectives, improve

PERFORMANCE, and attain your VISION? HOW do SENIOR LEADERS include a focus on creating and balancing VALUE

for PATIENTS, other CUSTOMERS, and other STAKEHOLDERS in their organizational PERFORMANCE expectations?

Notes:

Item responses are assessed by considering the Criteria Item requirements; your key organizational factors presented in your Organizational Profile; and the maturity of your approaches, breadth of their deployment, and

strength of your improvement process and results relative to the Scoring System. Refer to the Scoring System

information on pages 53–56.

For additional description of this Item, see page 38.

Item Format

Item number

Basic Item requirements

expressed in Item title

Overall Item requirements

expressed as specific topics

users need to address

Areas to Address

Notes have the 

following purposes:

– clarify key terms 

and requirements

– give instructions

– indicate/clarify 

important linkages

Location of Item

description

Item title Item point value Types of information users are expected to

provide in response to this Item

Multiple requirements

expressed as individual

Criteria questions
58 2005 Health Care Criteria for Performance Excellence

3. Start by preparing the Organizational Profile.

The Organizational Profile is the most appropriate starting point. The Organizational Profile is intended to help

everyone—including organizations using the Criteria for

self-assessment, application writers, and reviewers—to

understand what is most relevant and important to your

organization’s performance as a health care provider. The

questions to address in responding to the Organizational

Profile are on pages 12–14. The Organizational Profile is

described in greater detail on pages 38–39.

Guidelines for Responding to Process Items

Although the Criteria focus on key performance results,

these results by themselves offer little diagnostic value. For

example, if some results are poor or are improving at rates

slower than your competitors’, it is important to understand why this is so and what might be done to accelerate

improvement.

The purpose of Process Items is to permit diagnosis of your

organization’s most important processes—the ones that yield

fast-paced organizational performance improvement and

contribute to key organizational results. Diagnosis and feedback depend heavily on the content and completeness of your

Item responses. For this reason, it is important to respond

to these Items by providing your key process information.

Guidelines for organizing and reviewing such information

follow.

1. Understand the meaning of “how.”

Process Items include questions that begin with the word

“how.” Responses should outline your key process information

that addresses approach, deployment, learning, and integration

(see page 53). Responses lacking such information, or

merely providing an example, are referred to in the

Scoring Guidelines as “anecdotal information.”

2. Understand the meaning of “what.”

Two types of questions in Process Items begin with the

word “what.” The first type of question requests basic information on key processes and how they work. Although

it is helpful to include who performs the work, merely

stating who does not permit diagnosis or feedback. The

second type of question requests information on what

your key findings, plans, objectives, goals, or measures

are. These latter questions set the context for showing

alignment and integration in your performance management system. For example, when you identify key strategic objectives, your action plans, human resource development plans, some of your performance measures, and

some results reported in Category 7 should be expected

to relate to the stated strategic objectives.

3. Write and review response(s) with the following

guidelines and comments in mind.

■ Show that approaches are systematic. 

Systematic approaches are repeatable and use data and

information to enable learning. In other words, approaches are systematic if they build in the opportunity for evaluation, improvement, innovation, and

sharing, thereby permitting a gain in maturity.

■ Show deployment. 

Deployment information should summarize how your

approaches are implemented in different parts of your

organization. Deployment can be shown compactly by

using tables.

■ Show evidence of learning. 

Processes should include evaluation and improvement

cycles, as well as the potential for breakthrough

change. Process improvements should be shared with

other appropriate units of the organization to enable

organizational learning.

■ Show integration. 

Integration shows alignment and harmonization

among processes, plans, measures, and actions that

generate organizational effectiveness and efficiencies.

■ Show focus and consistency. 

There are four important considerations regarding

focus and consistency: (1) the Organizational Profile

should make clear what is important; (2) the Strategic

Planning Category, including the strategic objectives

and action plans, should highlight areas of greatest

focus and describe how deployment is accomplished;

(3) descriptions of organizational-level analysis and

review (Item 4.1) should show how your organization

analyzes and reviews performance information to set

priorities; and (4) the Process Management Category
2005 Health Care Criteria for Performance Excellence 59

should highlight processes that are key to your overall

performance. Showing focus and consistency in the Process

Items and tracking corresponding measures in the Results

Items should improve organizational performance.

■ Respond fully to Item requirements.

Missing information will be interpreted as a gap in

your process. All Areas to Address should be addressed.

Individual questions within an Area to Address may be

addressed individually or together.

4. Cross-reference when appropriate.

As much as possible, each Item response should be selfcontained. However, responses to different Items might

be mutually reinforcing. It is then appropriate to refer to

the other responses rather than to repeat information. In

such cases, key process information should be given in

the Item requesting this information. For example, staff

education and training should be described in detail in

Item 5.2. Discussions about education and training elsewhere in your application would then reference but not

repeat details given in your Item 5.2 response.

5. Use a compact format.

Applicants should make the best use of the 50 application

pages permitted. Applicants are encouraged to use

flowcharts, tables, and “bullets” to present information

concisely.

6. Refer to the Scoring Guidelines.

Considerations in the evaluation of Process Item responses

include the Criteria Item requirements and the maturity

of your approaches, breadth of deployment, extent of

learning, and integration with other elements of your

performance management system, as described in the

Scoring Guidelines (page 54). Therefore, you need to

consider both the Criteria and the Scoring Guidelines.

Guidelines for Responding to Results Items

The Health Care Criteria place a major emphasis on results. The following information, guidelines, and example

relate to effective and complete reporting of results.

1. Focus on the most critical organizational

performance results.

Results reported should cover the most important requirements for your organizational success, highlighted

in your Organizational Profile and in the Strategic Planning; Focus on Patients, Other Customers, and Markets;

and Process Management Categories.

2. Note the meaning of the four key requirements

from the Scoring Guidelines for effective reporting

of results data:

■ performance levels that are reported on a meaningful

measurement scale

■ trends to show directions of results and rates of change

■ comparisons to show how results compare with those of

other, appropriately selected organizations

■ breadth and importance of results to show that all important results are included and segmented, e.g., by

patient/customer, staff, process, and health care service

3. Include trend data covering actual periods for

tracking trends.

No minimum period of time is specified for trend data.

Trends might span five years or more for some results.

Time intervals between data points should be meaningful

for the specific measure(s) reported. For important results, new data should be included even if trends and

comparisons are not yet well established.

4. Use a compact format—graphs and tables.

Many results can be reported compactly by using graphs

and tables. Graphs and tables should be labeled for easy

interpretation. Results over time or compared with others

should be “normalized,” i.e., presented in a way (such as

use of ratios) that takes into account various size factors.

For example, reporting safety trends in terms of needle

sticks per 100 staff members would be more meaningful

than total needle sticks if the number of staff has varied

over the time period or if you are comparing your results

to organizations differing in size.

5. Integrate results into the body of the text.

Discussion of results and the results themselves should be

close together in an Award application. Trends that show a

significant positive or negative change should be explained.

Use figure numbers that correspond to Items. For example, the third figure for Item 7.1 would be Figure 7.1-3.

(See the example in the figure that follows.)

The graph shown on page 60 illustrates data an organization might present as part of a response to Item 7.1,

Health Care Outcome and Service Delivery Results. In
60 2005 Health Care Criteria for Performance Excellence

the Organizational Profile, the organization has indicated

use of beta blockers with acute myocardial infarction as a

key requirement.

The graph illustrates a number of characteristics of clear

and effective results reporting. 

■ A figure number is provided for reference to the graph

in the text. 

■ Both axes and units of measure are clearly labeled.

■ Trend lines report data for a key patient/customer requirement—use of beta blockers with acute myocardial

infarction.

■ Results are presented for several years for this threehospital system.

■ An arrow indicates that an upward trend is good for

this measure.

■ Appropriate comparisons are clearly shown.

■ The organization shows, using a single graph, that its

three hospitals are separately tracked for beta blocker

use. 

To help interpret the Scoring Guidelines (page 55), the

following comments on the graphed results would be

appropriate:

■ The current overall organizational performance level is

good. This conclusion is supported by the comparison

with competitors and with a benchmark level.

■ The organization shows excellent improvement trends.

■ Hospital A is the current performance leader—showing

sustained high performance and a slightly positive

trend. Hospital B shows rapid improvement. It is near

that of the best competitor but trails the benchmark

level.

■ Hospital C—identified as a new acquisition in the application—is having early problems with ensuring beta

blocker use. (The organization should explain briefly

these early problems.)

6. Refer to the Scoring Guidelines.

Considerations in the evaluation of Results Item responses

include the Criteria Item requirements and the significance of the results trends, actual performance levels,

relevant comparative data, alignment with important

elements of your performance management system, and

strength of the improvement process relative to the Scoring Guidelines. Therefore, you need to consider both the

Criteria and the Scoring Guidelines (page 55).

Figure 7.1-3 Beta Blocker Use

65

70

75

80

85

90

2000 2001 2002 2003 2004

Hospital A

Hospital B

Hospital C

Best Competitor

Overall

Organization

2004 benchmark from

national hospital

association

2004 

Regional

Average

Year

Acute Myocardial Infarction Beta Blocker Use (%)

Good
2005 Health Care Criteria for Performance Excellence 61

The Malcolm Baldrige National Quality Award is an 

annual Award to recognize U.S. organizations for 

performance excellence.

Award Purpose

The Award promotes

■ awareness of performance excellence as an increasingly

important element in competitiveness

■ information sharing of successful performance strategies

and the benefits derived from using these strategies

Award Participation

The Award eligibility categories include

■ manufacturing businesses

■ service businesses

■ small businesses

■ education organizations

■ health care organizations

Copies of the Business and Education Criteria booklets are

available, and ordering information can be found on pages

64–65.

Up to three awards may be given in each category each year.

To participate in the Award process, an organization must

submit an application package that addresses the Health

Care Criteria for Performance Excellence (pages 12–34).

Application Requirements

Applying for the Award is a two-step process. A brief

description of these steps is provided on page 62. Detailed

information on the requirements and contents of the

Eligibility Certification Package and the Application

Package, due dates, and fees is provided in the Baldrige

Award Application Forms, which can be downloaded at

www.baldrige.nist.gov/Award_Application.htm.

APPLYING FOR THE MALCOLM BALDRIGE NATIONAL QUALITY AWARD

Fees for the 2005 Award Cycle

* An additional processing fee of $1,250 is required for applications submitted on CD.

** Supplemental sections are not applicable for applicants with (a) a single performance system that supports all of their

product and service lines and (b) products and services that are essentially similar in terms of customers or users, technology,

types of employees, and planning.

*** Site Visit Review Fee

This fee is paid only by applicants receiving site visits. The fee is set when visits are scheduled and is dependent on a number

of factors, including the number of sites to be visited, the number of Examiners assigned, and the duration of the visit.

Site visit fees for applicants with more than 500 employees in the manufacturing, service, for-profit education, and health

care sectors usually range between $20,000 and $35,000. However, the site visit fee for small businesses, for-profit education organizations with 500 or fewer faculty/staff, and health care organizations with 500 or fewer staff is approximately

one-half that rate. In 2005, the site visit fee for nonprofit education organizations is $1,500. All site visit fees are due to

ASQ two weeks after completion of the site visit.

Supplemental Site Visit Fee

Eligibility Application Section Fee Usual Range

Award Category Fee Fee* (if applicable)** (if applicable)***

Manufacturing $150 $5,000* $2,000 $20,000–$35,000

Service $150 $5,000* $2,000 $20,000–$35,000

Small Business $150 $2,000* $1,000 $10,000–$17,000

Education $150 $ 500* $ 250 $ 1,500

Nonprofit 

Education $150 $5,000* $2,000 $20,000–$35,000

For-profit >500 faculty/staff

Education $150 $2,000* $1,000 $10,000–$17,500

For-profit 500 or fewer faculty/staff

Health Care $150 $5,000* $2,000 $20,000–$35,000

>500 staff

Health Care $150 $2,000* $1,000 $10,000–$17,500

500 or fewer staff
62 2005 Health Care Criteria for Performance Excellence

If your organization is applying in either the business or education category, refer to the

appropriate sector-specific Criteria booklet and the Baldrige Award Application Forms. See

pages 64–65.

Eligibility Certification Packages with a nomination 

to the Board of Examiners due—March 11, 2005

Eligibility Certification Packages without a nomination 

to the Board of Examiners due—April 12, 2005

Award Application Packages submitted on CD due—May 12, 2005

Award Application Packages submitted on paper due—May 26, 2005

Step 1, Eligibility Certification Package

Organizations filing an Eligibility Certification Package may

nominate one senior member of their staff to serve on the

Board of Examiners. Organizations that wish to reserve a

place on the board for a staff member must submit their

Eligibility Certification Packages by March 11, 2005. If an

organization chooses not to nominate someone to the

board, the due date for the Eligibility Certification Package

is April 12, 2005.

Step 2, Application Package 

The Application Package may be submitted in either

CD/PDF format or on paper.

If submitted in CD/PDF format, the Application Package

must be postmarked no later than May 12, 2005. If submitted on paper, 27 copies of the Application Package must be

postmarked no later than May 26, 2005.

Application Review

Applications are reviewed and evaluated by members of the

Board of Examiners, who adhere to strict rules regarding

conflict of interest, using the following process:

Stage 1 - independent review and evaluation by at least

six members of the board

Stage 2 - consensus review and evaluation for applicants

that score well in Stage 1

Stage 3 - site visits to applicants that score well in Stage 2

Judges’ review and recommendations of 

Award recipients

Feedback to Applicants

Each Award applicant receives a feedback report at the

conclusion of the review process. The feedback report

is a written assessment by an evaluation team of leading

U.S. experts.

The feedback report contains an applicant-specific listing of strengths and opportunities for improvement

based on the Criteria. Used by companies, education

organizations, and health care organizations as part of

their strategic planning processes, the feedback report

helps organizations focus on their customers and improve overall performance. Feedback is one of the

most important parts of the Baldrige Award process; it

provides a pathway for improvement. 

Feedback reports are mailed at various times during

the Award cycle, based on the stage of review an application reaches in the evaluation process. Strict confidentiality is observed at all times and in every aspect of

application review and feedback.

Award Recipients

Award recipients may publicize and advertise their 

Awards. Recipients are expected to share information 

about their successful performance strategies with 

other U.S. organizations.
2005 Health Care Criteria for Performance Excellence 63

SUMMARY OF HEALTH CARE ELIGIBILITY AND RESTRICTIONS

Important Facts about Applying for the Award

■ Criteria contained in this booklet should be used only for

the health care eligibility category. Applicants in the

business and education eligibility categories should use the

Criteria for Performance Excellence and the Education Criteria

for Performance Excellence booklets, respectively.

■ The following is a summary of the eligibility rules for the

health care category only. Summaries of the eligibility

rules for the business and education categories are in

their respective Criteria booklets. For-profit health care

organizations may apply under the service or small

business categories, as appropriate, using the Business

Criteria, or under the health care category, using these

Health Care Criteria. If there is a question on eligibility,

check the complete eligibility rules in the Baldrige Award

Application Forms or call the Baldrige National Quality

Program Office at (301) 975-2036.

■ Whatever your Award eligibility category, you will need

the Baldrige Award Application Forms before proceeding.

You can download the document from our Web site at

www.baldrige.nist.gov/Award_Application.htm.

Basic Eligibility

Public Law 100-107 includes provisions to expand or modify the list of Award categories. Beginning with the 1999

Award cycle, two new eligibility categories—education and

health care—were added. Participation is open to for-profit

and not-for-profit public, private, and government organizations and to some subunits—including U.S. subunits of

foreign organizations—located in the United States and its

territories that are primarily engaged in furnishing medical,

surgical, or other health services directly to persons.

Eligibility is intended to be as open as possible. For example, eligible organizations include hospitals, HMOs, longterm care facilities, health care practitioner offices, home

health agencies, and dialysis centers. Organizations that do

not provide health services directly to persons, such as social

service agencies, health insurance companies, or medical/

dental laboratories, are ineligible to apply for the Award under

the health care category. However, such organizations—if

they are for-profit organizations—may be eligible to apply

for the Award under the small business or service categories.

Eligibility of Subunits

A subunit is a unit or division of a larger (parent) organization. Subunits of organizations might be eligible. To be

eligible, the subunit must be self-sufficient enough to be

examined in all seven Criteria Categories, and it must be a

discrete entity that is readily distinguishable from other

parts of the parent organization. It cannot be primarily a

support function (e.g., housekeeping, radiology, member

services, finance and accounting, billing, human resources,

purchasing, legal services, and health care research).

Other Restrictions on Eligibility

Location: Although an applicant may have facilities outside

the United States or its territories, or it may receive support

from its parent, in the event of a site visit, the applicant

must ensure that the appropriate people and information

are available for examination in the United States. This information is needed to document the operational practices

associated with all of its major functions. In the event that

the applicant receives the Award, it must be able to share

information on the seven Criteria Categories at The Quest

for Excellence Conference and at its U.S. facilities. Sharing

beyond The Quest for Excellence Conference is on a voluntary basis.

Multiple-Application Restrictions: A subunit and its parent may not both apply for Awards in the same year. In

some cases, more than one subunit of a parent may apply. If

the parent organization, including all of its subunits, has

■ 0–1,000 employees, one applicant per parent per

eligibility category may apply

■ 1,001–20,000 employees, two applicants per parent per

eligibility category may apply

■ over 20,000 employees, two applicants per parent per

eligibility category for the first 20,000, plus one per

20,000 or fraction thereof above 20,000 per eligibility

category, may apply

Future Eligibility Restrictions: If an organization or a subunit that has over 50 percent of the total employees of the

parent receives an Award, the organization and all its subunits are ineligible to apply for another Award for a period

of five years. If a subunit receives an Award, that subunit

and all its subunits are ineligible to apply for another Award

for a period of five years. After five years, Award recipients

are eligible to reapply for the Award or to reapply “for feedback only.”

Eligibility Forms

Potential applicants must certify their eligibility prior to

applying for the Award. Potential applicants for the 2005

Award are encouraged to submit their Eligibility Certification Packages as soon as possible but no later than 

April 12, 2005. In order to reserve a place on the Board of

Examiners for a member of your organization’s senior staff,

the package must be submitted no later than March 11, 2005.

The forms and necessary information are contained in the

Baldrige Award Application Forms.
64 2005 Health Care Criteria for Performance Excellence

HOW TO OBTAIN COPIES OF BALDRIGE PROGRAM MATERIALS

Note: If you are planning to apply for the Award,

you will need the Baldrige Award Application Forms

in addition to the Criteria booklet.

Individual Copies

Individual copies of the Criteria booklets may be 

obtained free of charge from

Baldrige National Quality Program

National Institute of Standards and Technology

Administration Building, Room A600

100 Bureau Drive, Stop 1020

Gaithersburg, MD 20899-1020

Telephone: (301) 975-2036

Fax: (301) 948-3716

E-mail: nqp@nist.gov

In addition, the Criteria booklets and the Baldrige 

Award Application Forms may be downloaded from our

Web site at www.baldrige.nist.gov/Criteria.htm and

www.baldrige.nist.gov/Award_Application.htm,

respectively.

Bulk Orders

Multiple copies of the 2005 Criteria for Performance Excellence booklets may be ordered in packets of 10 for $39.95

plus shipping and handling from the American Society for

Quality (ASQ).

2005 Business Criteria—Item Number T1502

2005 Education Criteria—Item Number T1501

2005 Health Care Criteria—Item Number T1500

How to Order

ASQ offers four convenient ways to order:

■ For fastest service, call toll free (800) 248-1946 in the

United States and Canada (in Mexico, dial toll free 

95-800-248-1946). Have item numbers, your credit 

card or purchase order number, and (if applicable) 

ASQ member number ready.

■ Or fax your completed order form to ASQ at 

(414) 272-1734.

■ Or mail your order to ASQ Customer Care Center,

P.O. Box 3005, Milwaukee, WI 53201-3066.

■ Or order on-line by accessing ASQ’s Web site at

www.asq.org.

Payment

Your payment options include check, money order, U.S.

purchase order, VISA, MasterCard, or American Express.

Payment must be made in U.S. currency; checks and money

orders must be drawn on a U.S. financial institution. All

international orders must be prepaid. Please make checks

payable to ASQ.

Shipping Fees

The following shipping and processing schedule applies to

all orders within the United States and Canada.

Order Amount U.S. Charges Canadian Charges 

Up to $34.99 $ 4.25 $ 9.25 

$35.00–$99.99 6.50 11.50 

Over $100.00 12.50* 17.50*

■ There is a shipping and processing charge of 25 percent

of the total order amount for shipments outside the

United States and Canada. 

■ Orders shipped within the continental United States and

Canada where UPS service is available will be shipped by

UPS.

■ Please allow one to two weeks for delivery. International

customers, please allow six to eight weeks for delivery. 

■ Your credit card will not be charged until your items are

shipped. Shipping and processing are charged one time,

up front, for the entire order.

* If actual shipping charges exceed $12.50 ($17.50 Canadian),

ASQ will invoice the customer for the additional expense.

Baldrige Educational Materials

Each year, the Baldrige National Quality Program develops

materials for training members of the Board of Examiners

and for sharing information on the successful performance

excellence strategies of the Award recipients. The following

items are samples of the educational materials that are

available.

Case Studies

Case studies are used to prepare Examiners for the interpretation of the Criteria and the Scoring System. The case

studies, when used with the Criteria, illustrate the Award

application and review process. The case study packet contains the case study and five additional documents: an executive summary, the related Criteria for Performance Excellence

booklet, the case study scorebook, the case study feedback

report, and the Scorebook for Business, Education, and Health

Care. These documents provide information related to scoring, Criteria responses, examination processes, and site visit

procedures, as well as illustrate the format for an application. A variety of case study packets are available, including

the following:
2005 Health Care Criteria for Performance Excellence 65

2004 Education Case Study Packet: Sandy Hill

School District (based on the 2004 Education Criteria for

Performance Excellence)

Available in e-format (PDF version) at 

www.baldrige.nist.gov/Sandy_Hill.htm

2003 Business Case Study Packet: GeoOrb

Polymers, North America (based on the 2003 Criteria

for Performance Excellence)

Available in e-format (PDF version) at 

www.baldrige.nist.gov/GeoOrb.htm

2002 Health Care Case Study Packet: CapStar

Health System (based on the 2002 Health Care Criteria

for Performance Excellence)

Available in e-format (PDF version) at 

www.baldrige.nist.gov/CapStar.htm

1998 Business Case Study Packet: Gemini Home

Health Service (based on the 1998 Criteria for

Performance Excellence)

Item Number T1083: $49.95 plus shipping and handling

Award Recipients Videos

The Award recipients videos are a valuable resource for

gaining a better understanding of performance excellence

and quality achievement. The videos provide background

information on the Baldrige National Quality Program,

highlights from the annual Award ceremony, and interviews

with representatives from the Award recipients’ organizations. Information on the 2004 Award recipients video is

provided below. Videos about Award recipients from other

years also are available from ASQ. 

2004—Item Number T1503 $20.00

(Available May 2005)

How to Order Educational Materials

To order a Case Study Packet (Gemini Home Health Service

or others), bulk orders of the 2005 Criteria booklet, or the

Award recipients videos, contact

ASQ Customer Care Center 

P.O. Box 3005 

Milwaukee, WI 53201-3066 

Telephone: (800) 248-1946 

Fax: (414) 272-1734 

E-mail: asq@asq.org 

Web site: www.asq.org

The Baldrige National Quality Program welcomes your comments on the Criteria

or any of the Baldrige Award processes. Please address your comments to

2005 Health Care Criteria for Performance Excellence 

Baldrige National Quality Program 

National Institute of Standards and Technology 

Administration Building, Room A600

100 Bureau Drive, Stop 1020

Gaithersburg, MD 20899-1020

or E-mail: nqp@nist.gov 

or Web site: www.baldrige.nist.gov
66 2005 Health Care Criteria for Performance Excellence

This Glossary of Key Terms defines and briefly describes

terms used throughout the Health Care Criteria booklet

that are important to performance management. As you may

have noted, key terms are presented in SMALL CAPS/SANS SERIF

every time they appear in the Categories and Scoring

Guidelines sections of this Criteria booklet.

Action Plans

The term “action plans” refers to specific actions that respond to short- and longer-term strategic objectives. Action

plans include details of resource commitments and time

horizons for accomplishment. Action plan development

represents the critical stage in planning when strategic objectives and goals are made specific so that effective, organization-wide understanding and deployment are possible. In

the Criteria, deployment of action plans includes creating

aligned measures for all departments and work units. Deployment might also require specialized training for some

staff or recruitment of personnel.

An example of a strategic objective for a health system in an

area with an active business alliance focusing on cost and

quality of health care might be to become the low-cost provider. Action plans could entail designing efficient processes

to minimize length of hospital stays, analysis of resource and

asset use, and analysis of the most commonly encountered

DRGs with a focus on preventive health in those areas.

Deployment requirements might include departmental/work

unit and staff training in setting priorities based upon costs

and benefits. Organizational-level analysis and review likely

would emphasize process efficiency, cost per member, and

health care quality.

See also the definition of “strategic objectives” on page 72.

Alignment

The term “alignment” refers to consistency of plans, processes, information, resource decisions, actions, results, and

analysis to support key organization-wide goals. Effective

alignment requires a common understanding of purposes

and goals. It also requires the use of complementary measures and information for planning, tracking, analysis, and

improvement at three levels: the organizational level, the

key process level, and the department or work unit level.

See also the definition of “integration” on page 69.

Analysis

The term “analysis” refers to an examination of facts and

data to provide a basis for effective decisions. Analysis often

involves the determination of cause-effect relationships.

Overall organizational analysis guides the management of

processes toward achieving key organizational performance

results and toward attaining strategic objectives.

Despite their importance, individual facts and data do not

usually provide an effective basis for actions or setting priorities. Effective actions depend on an understanding of relationships, derived from analysis of facts and data.

Anecdotal

The term “anecdotal” refers to process information that

lacks specific methods, measures, deployment mechanisms,

and evaluation/improvement/learning factors. Anecdotal information frequently uses examples and describes individual

activities rather than systematic processes.

An anecdotal response to how senior leaders deploy performance expectations might describe a specific occasion when

a senior leader visited all facilities. On the other hand, a systematic process might describe the communication methods

used by all senior leaders to deliver performance expectations on a regular basis to all staff locations, the measures

used to assess effectiveness of the methods, and the tools

and techniques used to evaluate and improve the communication methods.

Approach

The term “approach” refers to the methods used by an organization to address the Baldrige Criteria Item requirements.

Approach includes the appropriateness of the methods to

the Item requirements and the effectiveness of their use. 

Approach is one of the dimensions considered in evaluating

Process Items. For further description, see the Scoring

System on pages 53–56.

Basic Requirements

The term “basic requirements” refers to the topic Criteria

users need to address when responding to the most central

concept of an Item. Basic requirements are the fundamental

theme of that Item (e.g., an approach for strategy development for Item 2.1). In the Criteria, the basic requirements

of each Item are presented as the Item title. This presentation is illustrated in the Item format shown on page 57.

Benchmarks

The term “benchmarks” refers to processes and results that

represent best practices and performance for similar activities,

inside or outside an organization’s industry. Organizations

engage in benchmarking to understand the current dimensions of world-class performance and to achieve discontinuous (nonincremental) or breakthrough improvement.

Benchmarks are one form of comparative data. Other comparative data organizations might use include information

obtained from other organizations through sharing or

contributing to external reference databases, information

GLOSSARY OF KEY TERMS
2005 Health Care Criteria for Performance Excellence 67

obtained from the open literature (e.g., outcomes of research studies and practice guidelines), data gathering and

evaluation by independent organizations (e.g., CMS, accrediting organizations, and commercial organizations) regarding industry data (frequently industry averages), data on

competitors’ performance, and comparisons with other organizations providing similar health care services.

Creating Value

The term “creating value” refers to health care processes

that produce benefit for your patients and other customers

and for your organization. They are the processes most important to “running your organization”—those that involve

the majority of your staff and generate your health care services and positive organizational performance results for

your patients, other customers, and key stakeholders.

Customer

The term “customer” refers to actual and potential users of

your organization’s services. Patients are the primary customers of health care organizations. Other customers could

include patients’ families, the community, insurers and other

third-party payors, employers, health care providers, patient

advocacy groups, Departments of Health, and students. The

Criteria address customers broadly, referencing current

customers, future customers, as well as customers of your

competitors and other organizations providing similar

health care services.

Patient-focused excellence is a Baldrige Core Value embedded in the beliefs and behaviors of high-performance organizations. Customer focus impacts and should integrate an

organization’s strategic directions, its health care processes,

and its organizational performance results.

See the definition of “stakeholders” on page 72 for the

relationship between customers and others who might be

affected by your organization’s services.

Cycle Time

The term “cycle time” refers to the time required to fulfill

commitments or to complete tasks. Time measurements play

a major role in the Criteria because of the great importance

of time performance to improving overall performance.

“Cycle time” refers to all aspects of time performance.

Cycle time improvement might include test results reporting time, time to introduce new health care technology,

order fulfillment time, length of hospital stays, billing time,

and other key measures of time.

Deployment

The term “deployment” refers to the extent to which an

approach is applied in addressing the requirements of a

Baldrige Criteria Item. Deployment is evaluated on the basis

of the breadth and depth of application of the approach to

relevant departments and work units throughout the

organization. 

Deployment is one of the dimensions considered in evaluating Process Items. For further description, see the Scoring

System on pages 53–56.

Diversity

The term “diversity” refers to valuing and benefiting from

personal differences. These differences address many variables including race, religion, color, gender, national origin,

disability, sexual orientation, age, education, geographic

origin, and skill characteristics, as well as differences in

ideas, thinking, academic disciplines, and perspectives.

The Baldrige Criteria refer to the diversity of your staff

recruitment, and patient and other customer communities.

Capitalizing on both provides enhanced opportunities for

high performance; patient and other customer, staff, and

community satisfaction; and patient, customer, and staff

loyalty.

Effective

The term “effective” refers to how well a process or a measure addresses its intended purpose. Determining effectiveness requires the evaluation of how well the approach is

aligned with the organization’s needs and the deployment of

the approach, or the outcome of the measure used.

Empowerment

The term “empowerment” refers to giving staff the authority

and responsibility to make decisions and take appropriate

actions. Empowerment results in decisions being made closest to the patient or the business “front line,” where patient

and customer needs and work-related knowledge and understanding reside.

Empowerment is aimed at enabling staff to satisfy patients

and customers on first contact, to improve processes and increase productivity, and to improve the organization’s health

care and other performance results. Empowered staff require information to make appropriate decisions; thus, an

organizational requirement is to provide that information in

a timely and useful way.

Ethical Behavior

The term “ethical behavior” refers to how an organization

ensures that all its decisions, actions, and stakeholder interactions conform to the organization’s moral and professional

principles. These principles should support all applicable

laws and regulations and are the foundation for the organization’s culture and values. They define “right” from

“wrong.”

Senior leaders should act as role models for these principles

of behavior. The principles apply to all individuals involved
68 2005 Health Care Criteria for Performance Excellence

in the organization, from staff to members of the board of

directors, and need to be communicated and reinforced on a

regular basis. Although there is no universal model for ethical behavior, senior leaders should ensure that the organization’s mission and vision are aligned with its ethical principles.

Ethical behavior should be practiced with all stakeholders,

including patients and other customers, staff, partners, suppliers, and the organization’s local community.

While some organizations may view their ethical principles

as boundary conditions restricting behavior, well-designed

and clearly articulated ethical principles should empower

people to make effective decisions with great confidence.

Goals

The term “goals” refers to a future condition or performance level that one intends to attain. Goals can be both

short- and longer-term. Goals are ends that guide actions.

Quantitative goals, frequently referred to as “targets,” include a numerical point or range. Targets might be projections based on comparative or competitive data. The term

“stretch goals” refers to desired major, discontinuous (nonincremental) or breakthrough improvements, usually in

areas most critical to your organization’s future success.

Goals can serve many purposes, including

■ clarifying strategic objectives and action plans to

indicate how success will be measured

■ fostering teamwork by focusing on a common end

■ encouraging “out-of-the-box” thinking to achieve a

stretch goal

■ providing a basis for measuring and accelerating

progress

Governance

The term “governance” refers to the system of management

and controls exercised in the stewardship of your organization. It includes the responsibilities of your organization’s

owners/shareholders, board of directors, and administrative/

operational and health care leaders. Corporate charters, bylaws, and policies document the rights and responsibilities of

each of the parties and describe how your organization will

be directed and controlled to ensure (1) accountability to all

stakeholders, including owners/shareholders, (2) transparency

of operations, and (3) fair treatment of all stakeholders.

Governance processes may include approving strategic

direction, monitoring and evaluating senior leader performance, establishing executive compensation and benefits,

succession planning, financial auditing, managing risk,

disclosure, and shareholder reporting. Ensuring effective

governance is important to stakeholders’ and the larger

society’s trust and to organizational effectiveness.

Health Care Services

The term “health care services” refers to all services delivered by the organization that involve professional clinical/

medical judgment, including those delivered to patients and

those delivered to the community.

High-Performance Work

The term “high-performance work” refers to work processes used to systematically pursue ever-higher levels of

overall organizational and individual performance, including

quality, productivity, innovation rate, and cycle time performance. High-performance work results in improved service

for patients and other customers and other stakeholders.

Approaches to high-performance work vary in form, function,

and incentive systems. High-performance work frequently

includes cooperation between administration/management

and the staff, which may involve workforce bargaining units;

cooperation among department/work units, often involving

teams; self-directed responsibility and staff empowerment;

staff input to planning; individual and organizational skill

building and learning; learning from other organizations;

flexibility in job design and work assignments; a flattened

organizational structure, where decision making is decentralized and decisions are made closest to the patient or the

business “front line”; and effective use of performance measures, including comparisons. Many high-performance work

systems use monetary and nonmonetary incentives based

upon factors such as organizational performance, team and

individual contributions, and skill building. Also, highperformance work processes usually seek to align the

organization’s structure, work, jobs, staff development,

and incentives.

How

The term “how” refers to the processes that an organization

uses to accomplish its mission requirements. In responding

to “how” questions in the Process Item requirements, process descriptions should include information such as approach

(methods and measures), deployment, learning, and integration factors.

Innovation

The term “innovation” refers to making meaningful change

to improve services, processes, or organizational effectiveness and to create new value for stakeholders. Innovation

involves the adoption of an idea, process, technology, or

product that is either new or new to its proposed application.

Successful organizational innovation is a multistep process

that involves development and knowledge sharing, a decision

to implement, implementation, evaluation, and learning.

Although innovation is often associated with health care research and technological innovation, it is applicable to all

key organizational processes that would benefit from change,
2005 Health Care Criteria for Performance Excellence 69

whether through breakthrough improvement or change in

approach or outputs. It could include fundamental changes

in organizational structure to more effectively accomplish

the organization’s work.

Integration

The term “integration” refers to the harmonization of plans,

processes, information, resource decisions, actions, results,

and analyses to support key organization-wide goals. Effective integration goes beyond alignment and is achieved

when the individual components of a performance management system operate as a fully interconnected unit. 

See also the definition of “alignment” on page 66.

Integration is one of the dimensions considered in evaluating Process Items. For further description, see the Scoring

System on pages 53–56.

Key

The term “key” refers to the major or most important elements or factors, those that are critical to achieving your intended outcome. The Baldrige Criteria, for example, refer

to key challenges, key patient/customer groups, key plans,

key processes, and key measures—those that are most important to the organization’s success. They are the essential

elements for pursuing or monitoring a desired outcome.

Knowledge Assets

The term “knowledge assets” refers to the accumulated intellectual resources of your organization. It is the knowledge

possessed by your organization and its staff in the form of

information, ideas, learning, understanding, memory, insights, cognitive and technical skills, and capabilities. Staff,

databases, documents, guides, policies and procedures, and

software and patents are repositories of an organization’s

knowledge assets. Knowledge assets are held not only by an

organization but reside within its patients and other customers, suppliers, and partners as well.

Knowledge assets are the “know how” that your organization has available to use, to invest, and to grow. Building

and managing its knowledge assets are key components for

your organization to create value for its stakeholders and to

help sustain overall organizational performance success.

Leadership System

The term “leadership system” refers to how leadership is

exercised, formally and informally, throughout the

organization—the basis for and the way key decisions are

made, communicated, and carried out. It includes structures

and mechanisms for decision making; selection and development of leaders and managers; and reinforcement of values,

ethical behavior, directions, and performance expectations.

In health care organizations with separate administrative/

operational and health care provider leadership, the leadership system also includes the relationships among those

leaders.

An effective leadership system respects the capabilities and

requirements of staff and other stakeholders, and it sets high

expectations for performance and performance improvement. It builds loyalties and teamwork based on the organization’s vision and values and the pursuit of shared goals. It

encourages and supports initiative and appropriate risk taking, subordinates organization structure to purpose and

function, and avoids chains of command that require long

decision paths. An effective leadership system includes

mechanisms for the leaders to conduct self-examination,

receive feedback, and improve.

Learning

The term “learning” refers to new knowledge or skills acquired through evaluation, study, experience, and innovation.

The Baldrige Criteria include two distinct kinds of learning:

organizational and personal. Organizational learning is

achieved through research and development; evaluation and

improvement cycles; staff, patients, and other customers’

ideas and input; best practice sharing; and benchmarking.

Personal learning is achieved through education, training,

and developmental opportunities that further individual

growth.

To be effective, learning should be embedded in the way an

organization operates. Learning contributes to organizational performance success for the organization and its staff.

For further description of organizational and personal learning, see the related Core Value and Concept on page 2. 

Learning is one of the dimensions considered in evaluating

Process Items. For further description, see the Scoring

System on pages 53–56.

Levels

The term “levels” refers to numerical information that

places or positions an organization’s results and performance

on a meaningful measurement scale. Performance levels

permit evaluation relative to past performance, projections,

goals, and appropriate comparisons.

Measures and Indicators

The term “measures and indicators” refers to numerical information that quantifies input, output, and performance

dimensions of processes, products, services, and the overall

organization (outcomes). The Health Care Criteria place

particular focus on measures of health care outcomes, health

care service delivery, and patients’ functional status. Measures

and indicators might be simple (derived from one measurement) or composite.
70 2005 Health Care Criteria for Performance Excellence

The Criteria do not make a distinction between measures

and indicators. However, some users of these terms prefer

the term “indicator” (1) when the measurement relates to

performance but is not a direct measure of such performance

(e.g., the number of complaints is an indicator of dissatisfaction but not a direct measure of it) and (2) when the measurement is a predictor (“leading indicator”) of some more

significant performance (e.g., increased patient satisfaction

might be a leading indicator of a gain in HMO member

retention).

Mission

The term “mission” refers to the overall function of an organization. The mission answers the question, “What is this

organization attempting to accomplish?” The mission might

define patients, other customers, or markets served; distinctive competencies; or technologies used.

Multiple Requirements

The term “multiple requirements” refers to the individual

questions Criteria users need to answer within each Area to

Address. These questions constitute the details of an Item’s

requirements. They are presented in black text under each

Item’s Area(s) to Address. This presentation is illustrated in

the Item format shown on page 57.

Overall Requirements

The term “overall requirements” refers to the topics

Criteria users need to address when responding to the

central theme of an Item. Overall requirements address the

most significant features of the Item requirements. In the

Criteria, the overall requirements of each Item are presented in one or more introductory sentences printed in

bold. This presentation is illustrated in the Item format

shown on page 57.

Partners

The term “partners” refers to those key organizations or individuals who are working in concert with your organization

to achieve a common goal or to improve performance. Typically, partnerships are formal arrangements for a specific

aim or purpose, such as to achieve a strategic objective or

deliver a specific service. 

Formal partnerships are usually for an extended period of

time and involve a clear understanding of the individual and

mutual roles and benefits for the partners.

Patient

The term “patient” refers to the person receiving health

care, including preventive, promotional, acute, chronic,

rehabilitative, and all other services in the continuum of

care. Other terms organizations use for “patient” include

member, consumer, client, or resident.

Performance

The term “performance” refers to output results and their

outcomes obtained from processes and services that permit

evaluation and comparison relative to goals, standards, past

results, and other organizations. Performance might be expressed in nonfinancial and financial terms.

The Baldrige Health Care Criteria address four types of

performance: (1) health care outcomes and service delivery,

(2) patient- and other customer-focused, (3) financial and

marketplace, and (4) operational.

“Health care outcomes and service delivery performance”

refers to performance relative to measures and indicators of

health care service important to patients and other customers.

Examples of health care performance include reductions in

hospital admission rates, mortality and morbidity rates,

nosocomial infection rates, length of hospital stays, and

patient-experienced error levels. Other examples include

increases in outside-the-hospital treatment of chronic illnesses, and patient compliance and adherence. Health care

performance might be measured at the organizational level

and at the DRG-specific level.

“Patient- and other customer-focused performance” refers

to performance relative to measures and indicators of

patients’ and other customers’ perceptions, reactions, and

behaviors. Examples include patient loyalty, customer retention, complaints, customer survey results, and service response time.

“Financial and marketplace performance” refers to performance using measures of cost, revenue, and market position,

including asset utilization, asset growth, and market share.

Examples include returns on investments, value added per

staff member, bond ratings, debt-to-equity ratio, returns on

assets, operating margins, other profitability and liquidity

measures, and market gains.

“Operational performance” refers to staff, leadership, organizational, and ethical performance relative to effectiveness,

efficiency, and accountability measures and indicators. Examples include cycle time, productivity, waste reduction,

staff turnover, staff cross-training rates, accreditation results,

legal/regulatory compliance, fiscal accountability, community involvement, and contributions to community health.

Operational performance might be measured at the department and work unit level, key process level, and organizational level.

Performance Excellence

The term “performance excellence” refers to an integrated

approach to organizational performance management that

results in (1) delivery of ever-improving value to patients

and other customers, contributing to improved health care

quality; (2) improvement of overall organizational effectiveness and capabilities as a health care provider; and (3) organizational and personal learning. The Baldrige Health Care
2005 Health Care Criteria for Performance Excellence 71

Criteria for Performance Excellence provide a framework

and an assessment tool for understanding organizational

strengths and opportunities for improvement and thus for

guiding planning efforts.

Performance Projections

The term “performance projections” refers to estimates of

future performance. Projections may be inferred from past

performance, may be based on competitors’ performance or

the performance of other organizations providing similar

health care services that must be met or exceeded, may be

predicted based on changes in a dynamic health care marketplace, or may be goals for future performance. Projections integrate estimates of your organization’s rate of improvement and change, and they may be used to indicate

where breakthrough improvement or change is needed.

Thus, performance projections serve as a key management

planning tool.

Process

The term “process” refers to linked activities with the purpose of producing a product or service for patients and

other customers within or outside the organization. Generally, processes involve combinations of people, machines,

tools, techniques, and materials in a defined series of steps

or actions. In some situations, processes might require adherence to a specific sequence of steps, with documentation

(sometimes formal) of procedures and requirements, including well-defined measurement and control steps. 

In many service situations, such as health care treatment,

particularly when customers are directly involved in the service, process is used in a more general way, i.e., to spell out

what must be done, possibly including a preferred or expected sequence. If a sequence is critical, the service needs

to include information to help customers understand and

follow the sequence. Such service processes also require

guidance to the providers of those services on handling contingencies related to the possible actions or behaviors of

those served.

In knowledge work such as health care assessment and diagnosis, strategic planning, research, development, and analysis, process does not necessarily imply formal sequences of

steps. Rather, process implies general understandings regarding competent performance such as timing, options to

be included, evaluation, and reporting. Sequences might

arise as part of these understandings.

In the Baldrige Scoring System, process achievement level is

assessed. This achievement level is based on four factors

that can be evaluated for each of an organization’s key processes: Approach, Deployment, Learning, and Integration.

For further description, see the Scoring System on pages

53–56.

Productivity

The term “productivity” refers to measures of the efficiency

of resource use. 

Although the term often is applied to single factors such as

staffing (labor productivity), machines, materials, energy,

and capital, the productivity concept applies as well to the

total resources used in producing outputs. The use of an aggregate measure of overall productivity allows a determination of whether the net effect of overall changes in a process—possibly involving resource tradeoffs—is beneficial.

Purpose

The term “purpose” refers to the fundamental reason that

an organization exists. The primary role of purpose is to inspire an organization and guide its setting of values. Purpose

is generally broad and enduring. Two organizations providing different health care services could have similar purposes, and two organizations providing similar health care

services could have different purposes.

Results

The term “results” refers to outputs and outcomes achieved

by an organization in addressing the requirements of a

Baldrige Criteria Item. Results are evaluated on the basis of

current performance; performance relative to appropriate

comparisons; the rate, breadth, and importance of performance improvements; and the relationship of results measures to key organizational performance requirements. For

further description, see the Scoring System on pages 53–56.

Segment

The term “segment” refers to a part of an organization’s

overall patient, other customer, market, health care service,

or staff base. Segments typically have common characteristics that can be logically grouped. In Results Items, the term

refers to disaggregating results data in a way that allows for

meaningful analysis of an organization’s performance. It is

up to each organization to determine the specific factors

that it uses to segment its patients and other customers,

markets, health care services, and staff.

Understanding segments is critical to identifying the distinct

needs and expectations of different patient and other customer, market, and staff groups and to tailoring health care

services and programs to meet their needs and expectations.

As an example, market segmentation might be based on geography, distribution channels, health care service volume,

or technologies employed. Staff segmentation might be

based on geography, specialties, skills, needs, work assignments, or job classifications.
72 2005 Health Care Criteria for Performance Excellence

Senior Leaders

The term “senior leaders” refers to an organization’s senior

management group or team. In many organizations, this

consists of the head of the organization and his or her direct

reports. In health care organizations with separate administrative/operational and health care provider leadership,

“senior leaders” refers to both sets of leaders and the relationships among those leaders.

Staff

The term “staff” refers to all people who contribute to the

delivery of an organization’s services, including paid staff

(e.g., permanent, part-time, temporary, and contract employees supervised by the organization), independent practitioners (e.g., physicians, physician assistants, nurse practitioners, acupuncturists, and nutritionists not paid by the

organization), volunteers, and health profession students

(e.g., medical, nursing, and ancillary). Staff includes team

leaders, supervisors, and managers at all levels.

Stakeholders

The term “stakeholders” refers to all groups that are or

might be affected by an organization’s services, actions, and

success. Examples of key stakeholders include patients and

other customers (e.g., patients’ families, insurers and other

third-party payors, employers, health care providers, patient

advocacy groups, Departments of Health, and students),

staff, partners, governing boards, investors, suppliers, and

local and professional communities.

See also the definition of “customer” on page 67.

Strategic Challenges

The term “strategic challenges” refers to those pressures

that exert a decisive influence on an organization’s likelihood of future success. These challenges frequently are driven by an organization’s future collaborative environment

and/or competitive position relative to other providers of

similar health care services. While not exclusively so, strategic challenges generally are externally driven. However, in

responding to externally driven strategic challenges, an organization may face internal strategic challenges. 

External strategic challenges may relate to patient and other

customer or health care market needs or expectations;

health care service or technological changes; or financial,

societal, and other risks. Internal strategic challenges may

relate to an organization’s capabilities and its human and

other resources.

See the definition of “strategic objectives” that immediately

follows for the relationship between strategic challenges and

the strategic objectives an organization articulates to address

key challenges.

Strategic Objectives

The term “strategic objectives” refers to an organization’s

articulated aims or responses to address major change or

improvement, competitiveness issues, and health care

advantages. Strategic objectives generally are focused both

externally and internally and relate to significant patient and

other customer, market, service, or technological opportunities and challenges (strategic challenges). Broadly stated,

they are what an organization must achieve to remain or

become competitive and ensure the organization’s long-term

sustainability. Strategic objectives set an organization’s

longer-term directions and guide resource allocations and

redistributions.

See the definition of “action plans” on page 66 for the relationship between strategic objectives and action plans and

for an example of each.

Sustainability

The term “sustainability” refers to your organization’s ability to address current business needs and to have the agility

and strategic management to prepare successfully for your

future organizational and market environment. Both external and internal factors need to be considered. The specific

combination of factors might include health care-wide and

organization-specific components.

In addition to responding to changes in the organizational

and market environment, sustainability also has a component related to preparedness for real-time or short-term

emergencies.

Systematic

The term “systematic” refers to approaches that are wellordered, repeatable, and use data and information so learning is possible. In other words, approaches are systematic if

they build in the opportunity for evaluation, improvement,

and sharing, thereby permitting a gain in maturity. For use

of the term, see the Scoring Guidelines on pages 54–55.

Trends

The term “trends” refers to numerical information that

shows the direction and rate of change for an organization’s

results. Trends provide a time sequence of organizational

performance.

A minimum of three data points generally is needed to

begin to ascertain a trend. More data points are needed to

define a statistically valid trend. The time period for a trend

is determined by the cycle time of the process being measured. Shorter cycle times demand more frequent measurement, while longer cycle times might require longer time

periods before meaningful trends can be determined.
2005 Health Care Criteria for Performance Excellence 73

Examples of trends called for by the Criteria include data

related to health care outcomes and other health care service results, patient/customer and staff satisfaction and

dissatisfaction results, financial performance, health care

marketplace performance, and operational performance,

such as cycle time and productivity.

Value

The term “value” refers to the perceived worth of a product,

service, process, asset, or function relative to cost and possible alternatives. 

Organizations frequently use value considerations to determine the benefits of various options relative to their costs,

such as the value of various product and service combinations to customers. Organizations need to understand what

different stakeholder groups value and then deliver value to

each group. This frequently requires balancing value for

customers and other stakeholders, such as patients, thirdparty payors, investors, staff, and the community.

Values

The term “values” refers to the guiding principles and behaviors that embody how your organization and its people

are expected to operate. Values reflect and reinforce the

desired culture of the organization. Values support and

guide the decision making of every staff member, helping

the organization to accomplish its mission and attain its

vision in an appropriate manner. Examples of values might

include: integrity and fairness in all interactions, exceed

patient and other customer expectations, value staff and

diversity, protect the environment, and performance excellence every day.

Vision

The term “vision” refers to the desired future state of your

organization. The vision describes where the organization is

headed, what it intends to be, or how it wishes to be perceived in the future.

Work Systems

The term “work systems” refers to how your staff members

are organized into formal or informal units to accomplish

your mission and your strategic objectives; how job responsibilities are managed; and your processes for compensation,

staff performance management, recognition, communication, hiring, and succession planning. Organizations design

work systems to align their components to enable and encourage all staff to contribute effectively and to the best of

their ability.
74 2005 Health Care Criteria for Performance Excellence
2005 Health Care Criteria for Performance Excellence 75

INDEX OF KEY TERMS

A

access, C2, 16, 19, 22, 24, 43, 48–49, 51

accreditation, 4, 12–13, 16, 28, 34, 39,

52, 70

achievement level, 54, 71

action plans, 4, 10, 15, 18–20, 23, 25–26,

33–34, 41–42, 46, 53, 58, 66, 68, 72

actionable information, 22, 43

agility, 1, 3, 7, 15, 18, 25, 28–29, 39,

48–49, 72

alignment, 4, 7, 9, 19, 23, 25, 40–41,

43–47, 51, 54, 58, 60, 66, 69

American Society for Quality (ASQ),

C2, 64

analysis, iii, 3–6, 9–11, 19, 21–24, 33,

36–37, 43–45, 47, 50–51, 54, 56, 58, 66,

69, 71

anecdotal, 54, 58, 66

“approach,” 1–2, 9, 14, 18, 26, 38, 41,

53–54, 58, 66–71

“Areas to Address” (Areas), 6, 9, 54, 57,

59

assessment, i, 3, 8–9, 11–12, 14, 27, 34,

44, 51, 57–58, 62, 71, C3

Award cycle, iii, 61–63

Award recipients, C2, ii, 62–65, C3

B

basic requirements, 54

benchmarking, 2, 23, 38, 44, 49–50, 66, 69

best practices, 1, 4–5, 23–24, 40, 44, 66

Board of Examiners, C2, iii, 62–64, C3

Board of Overseers, C2

C

Categories, i, ii, 4–6, 9, 11–12, 27, 33, 38,

53–54, 59, 61, 63, 66, C3

change management, 3–4

citizenship, 4, 10, 16, 34, 39–40

community

– service, 17, 27–28, 40, 48

– staff recruitment, 25

comparative data, 14, 23, 31–34, 38, 44,

51, 53–54, 60, 66, 68

compensation and recognition, 42,

46–47

competitors, 3–4, 14, 18–19, 21–23,

31–32, 38–39, 41–45, 58, 60, 67, 71

complaint, 10, 21–22, 43, 51–52, 70

compliance

– legal, 10, 16, 34

– regulatory, 52, 70

confidentiality, 21, 24, 46, 62

continuous improvement, 2, 48

core competencies, 3, 44

Core Values and Concepts, 1, 5, 7

creating value, 4, 28, 48, 67

Criteria for Performance Excellence, i, 5,

9, 63–65, C3

Criteria Response Guidelines, iii, 57

critical success factors, 50

customer

– key contact requirements, 22, 43

– loyalty and retention, 14, 21, 31

– satisfaction, 3, 10, 22, 31, 38, 42–43,

45, 47, 51

cycle time, 2–3, 15, 28–29, 33, 38, 45,

47–49, 52, 67–68, 70, 72–73

D

“deployment,” 7, 9, 11, 14–15, 19–20,

40–41, 43–44, 53–54, 58–59, 66–68, 71

distance learning, 26, 47

diversity, 7, 9, 12, 26, 33, 47, 67, 73

E

e-technology, 49, 52

Education Criteria for Performance

Excellence, 63, 65

eligibility, iii, 61–63

employee, see staff

empowerment, 25, 27, 39, 42, 67–68

ethics (ethical behavior), 1, 4, 10, 15–16,

34, 39–40, 52, 67–69

F

feedback, C2, i, 1, 6–7, 16, 21–22, 25, 43,

53, 58, 62–64, 69

fees, iii, 61, 64

financial performance, 3, 32, 45, 73

fiscal accountability, 10, 16, 34, 70

focus on results and creating value, 1, 4

focus on the future, 1, 3, 47

Foundation for the Malcolm Baldrige

National Quality Award, C2, C3

G

gap, 9, 12, 19, 54, 59

goals, i, 1–2, 4, 7–8, 16, 18–19, 36–37,

41–44, 50, 52–53, 56, 58, 66, 68–71

governance, 1, 3–4, 6, 10–12, 15–16, 34,

38–39, 52, 68

H

health care category, 63

Health Care Criteria, 63

Health Care Criteria for Performance

Excellence, i, iii, 1, 5, 9, 11–12, 57, 61,

65, 70

health care outcomes, 3–4, 7, 10–11, 21,

24, 28–29, 31, 33, 47, 49–51, 69–70, 73

health care services, 1–3, 10, 12–14, 16,

18–19, 21–23, 28, 31–32, 39–43, 46–47,

49–52, 67–68, 71–72

high performance, 15, 25–26, 39, 46, 48,

60, 67

“how,” 58, 68

I

improvement

– breakthrough, 7, 23, 44, 53, 66,

68–69, 71

– discontinuous (nonincremental),

66, 68

individual development plan (IDP), 47

information transfer, C2, 3, 24, 42,

45–46, 49

integration, 4, 7, 9, 43–44, 53–54, 58–59,

66, 68–69, 71

Items, 6–7, 9–11, 13, 15, 19, 23–24, 31,

33, 38, 51–54, 56–59, 64, 66–67, 69, 71

K

key factor, 8, 16, 18, 21, 27

knowledge assets, 2, 23–24, 26, 39, 46,

69

knowledge management, iii, 5–6, 9–11,

19, 23–24, 30, 37, 43–47, 50

L

linkages, 4, 7, 9, 13, 19, 57

listening and learning methods, 21

listening and learning strategies, 43

M

Malcolm Baldrige National Quality

Award, C2, ii–iii, 61, C3

management by fact, 1, 3

managing for innovation, 1, 3

maturity (organizational learning), 2, 8,

14–15, 26, 28–29, 38–39, 41–42, 45–46,

48, 53–54, 58–59, 69, 72

INDEX OF KEY TERMS

Note: Page number references to “C2” and “C3” refer to inside front cover and inside back cover, respectively.
76 2005 Health Care Criteria for Performance Excellence

measurement, C2, iii, 2–3, 5–6, 9–11, 19,

23, 26, 37, 43–44, 49, 51, 59, 69–72

mentoring, 26, 39

mission, 12, 28, 38, 40, 48, 50–51, 68, 70,

73

multiple requirements, 54, 57, 70

N

National Institute of Standards and

Technology, C2, i, ii, 64–65

O

opportunities for improvement (OFIs),

4, 8, 36, 53, 62, 71; see also strengths

organizational

– and personal learning, 1–2, 40, 51,

69–70

– citizenship, 10, 34

– culture, 12, 25

– knowledge, 4, 10, 24, 28–29, 39, 43, 46

Organizational Profile, i, iii, 5–7, 9,

11–15, 18, 33, 38, 53, 58–60

overall requirements, 54, 70

P

partners, C2, 1–4, 9, 12–13, 15–16, 18,

20, 22–24, 28–30, 33, 39–42, 44, 46,

48–50, 68–70, 72

patient

– health care services, 28

– patient-focused excellence, 1–2, 67

– rights, 16

payor, 2–4, 7, 13, 21, 28, 31, 42, 45,

48–49, 67, 72–73

performance, C2, i–iii, 1–12, 14–16,

19–20, 23–29, 31–33, 37–55, 58–62,

64–73, C3

– excellence, C2, i–ii, 1, 4, 9, 25, 42,

61, 64–65, 70, 73, C3

– financial and marketplace, 31, 70

– health care, 16, 31, 40, 70

– key, 12, 19, 28–29, 58

– management, 1, 3–4, 6, 9, 16, 25,

38–39, 42, 46, 58–60, 66, 69–70, 73

– operational, 6–7, 31, 33, 40, 45,

48–49, 52, 70, 73

– patient- and other customerfocused, 51, 70

– projections, 19, 69, 71

process management, iii, 5–7, 9–11, 16,

28, 37, 44, 48, 58–59

processes

– health care delivery, 1, 18, 28, 30,

48–49

– health care service, 30, 49

– support, 10–12, 28–30, 49–50

productivity, i, 2–3, 15, 27–29, 33, 40,

44–45, 49–50, 52, 67–68, 70–71, 73

provider, 1, 15, 18–19, 22–24, 29, 31,

39–41, 43–44, 50–51, 58, 69–70, 72

Public Law 100-107, 63, C3

Q

quantitative goals, 56, 68

The Quest for Excellence Conference,

C2, ii, 63, C3

R

recruitment, 25–26, 39, 47, 66–67

regulatory environment, 12–13, 18, 38

requirements

– basic, 54, 66

– Item, 9, 13, 15, 42, 53, 55, 57,

59–60, 66, 68, 70

– multiple, 54, 57, 70

– overall, 54, 70

resource allocation, 3, 18, 41, 72

resource conservation, 4

results

– health care, 31, 44, 51

– organizational effectiveness, 7, 11,

33, 52

– patient- and other customerfocused, 7, 11, 31, 33, 51

– staff and work system, 6–7, 11, 27,

31, 33, 50, 52

rework, 28–29

risks, 16, 18, 29, 34, 41, 50, 72

role model organization, ii, 40

S

safety

– environmental, 26

– patient, 1, 16, 18, 28, 31, 52

– staff, 45

– workplace, 48

sanctions, 34, 52

Scoring Guidelines, iii, 7–9, 13, 53–55,

58–60, 66, 72

scoring range, 9, 54

Scoring System, iii, 11, 14–15, 53, 57,

64, 67, 69, 71

segment, 3, 12–13, 21, 27, 31–34, 41, 43,

51, 53, 59, 71

self-directed team, 46

senior leaders, i, 1, 4, 6, 9, 12, 15–16, 19,

23, 30, 34, 38–40, 44, 50, 52, 66–68, 72

Six Sigma, i, 14–15, 29, 52

social responsibility and community

health, 1, 4, 6–7, 10–11, 16, 31, 34, 40,

50, 52

staff

– education and training, 26, 59

– performance management, 25, 46,

73

– students, 3–4, 21, 25, 42, 46, 48, 67,

72

– turnover, 27, 45, 48, 52, 70

– volunteers, 25–26, 46, 72

stakeholders, 1, 3–4, 7, 12–13, 15–16,

18–19, 34, 39, 46, 48–49, 52, 67–69,

72–73

strategic challenges, 6, 9, 14, 18, 38, 72

strategic objectives, 2–4, 15, 18–19, 23,

41, 44, 46–47, 50, 52–53, 58, 66, 68, 70,

72–73

strengths, 15, 36–37, 60; see also

opportunities for improvement

(OFIs)

stretch goals, 42, 44, 68

succession planning, 3, 15, 25, 39, 47,

68, 73

suppliers, 2–4, 9, 12, 15, 18, 20, 23–24,

28–29, 38–39, 44, 46, 48–50, 68–69, 72

supply chain management, 30, 50, 52

sustainability, i, 1–2, 9–10, 14, 18, 21, 38,

40, 42–43, 45–47, 51, 72

sustainable, 3, 15, 38

systematic, 14, 26, 47, 53–54, 56, 58, 66,

68, 72

systematic approach, 54, 56, 58

systems perspective, 1, 4–5, 7

T

trend data, 53, 55, 59

V

value, 1–4, 7, 10, 15, 28, 31–32, 39,

45–46, 48, 50–51, 57–58, 67–70, 73

value added, 32, 45, 70

value creation, see creating value

values, iii, 1, 4–5, 6–7, 9, 11–12, 15,

38–39, 67, 69, 71, 73

valuing staff and partners, 1, 2

vision, 9, 12, 15, 38–39, 68–69, 73

visionary leadership, 1

W

waste reduction, 4, 45, 52, 70

“what,” 58, 70

work systems, 10–11, 25, 46–47, 68, 73
THE BALDRIGE NATIONAL QUALITY PROGRAM AND ITS IMPACTS

On August 20, 1987, President Ronald Reagan signed the

“Malcolm Baldrige National Quality Improvement Act of

1987,” establishing a program that many credit with making

quality a national priority and helping to revitalize the U.S.

economy during the 1990s. Today, the Baldrige National

Quality Program and the Baldrige Award recipients are

imitated and admired worldwide. More than 40 states and

many countries, including Japan, have programs modeled

after Baldrige. In particular, the Baldrige Criteria for

Performance Excellence are widely used as an assessment

and improvement tool. Millions of print and electronic

copies of the Criteria have been distributed. In 1999, categories for education and health care were added to the

original three categories: manufacturing, service, and small

business. Impacts of the Program have been far reaching:

• Since the Baldrige Program began until 2004, there have

been 999 applicants for the Malcolm Baldrige National

Quality Award. These applicants have received vigorous

evaluations by the Board of Examiners using the Criteria

for Performance Excellence.

• Through 2003, 58 Award recipients have been selected

across five categories: 24 manufacturing companies, 13

service companies, 14 small businesses, 4 education

organizations, and 3 health care organizations.

• As of June 2004, there were 49 active state and local

quality award programs in 41 states. All 49 programs are 

modeled to some degree after the Baldrige National

Quality Program, and their award criteria are based on the

Criteria for Performance Excellence. 

• From 1996 to 2003, 25 of the 34 Baldrige Award recipients were previous winners in state award programs.

• Since 1991, there have been nearly 8,000 applications for

state and local quality awards.

• Over the past 17 years of its existence, the Baldrige

Program has trained more than 2,000 Examiners. Since

1991, the state and local programs have trained more

than 25,000 Examiners.

• The Award recipients have presented to tens of thousands

of organizations at conferences worldwide. For example,

Operations Management International, Inc. (OMI), an

international service business with 1,400 employees, has

made presentations to more than 17,000 people since

becoming an Award recipient in November 2000.

Branch-Smith Printing Division, a small family-owned

business with 68 employees, has given presentations to

more than 2,000 people since becoming an Award

recipient in November 2002. The Quest for Excellence

conferences have reached more than 16,000 attendees

over the Program’s history.

The Malcolm Baldrige National Quality Award was created by Public Law 100-107 and signed into law on August 20, 1987.

Public Law 100-107 led to the creation of a new public-private partnership. Principal support for the program comes from the

Foundation for the Malcolm Baldrige National Quality Award, established in 1988.

The Award is named for Malcolm Baldrige, who served as Secretary of Commerce from 1981 until his death in 1987. His managerial excellence contributed to long-term improvement in efficiency and effectiveness of government.

The Baldrige National Quality Program thanks the following 2003 Award recipients for the use of the photographs in this booklet:

Baptist Hospital, Inc. (Pensacola, Florida) and Saint Luke’s Hospital of Kansas City.
Baldrige National Quality Program

Baldrige National Quality Program

National Institute of Standards and Technology

Technology Administration

United States Department of Commerce

Administration Building, Room A600

100 Bureau Drive, Stop 1020

Gaithersburg, MD 20899-1020

The National Institute of Standards and Technology (NIST), an agency of the U.S. Commerce Department’s Technology Administration, manages the Baldrige National Quality

Program (BNQP). For more than a century, NIST has helped to lay the foundation for

the innovation, economic growth, and quality of life that Americans have come to expect.

NIST technology, measurements, and standards help U.S. industry invent and manufacture superior products reliably, provide critical services, ensure a fair marketplace for

consumers and businesses, and promote acceptance of U.S. products in foreign markets.

NIST also partners with the private sector to accelerate the development of innovative

technologies that promise significant commercial payoffs and widespread benefits for the

nation. Through a network of nearly 400 assistance centers that serve all 50 states and

Puerto Rico, NIST provides technical and business assistance to help smaller manufacturers overcome barriers to productivity and competitiveness. 

Call BNQP or visit our Web site for

• information on improving the performance of your organization

• information on eligibility requirements for the Baldrige Award

• information on applying for the Baldrige Award

• information on becoming a Baldrige Examiner

• information on the Baldrige Award recipients 

• individual copies of the Criteria for Performance Excellence—Business, Education,

and Health Care (no cost) 

• information on BNQP educational materials 

• case studies

Telephone: (301) 975-2036; Fax: (301) 948-3716; E-mail: nqp@nist.gov

Web site: www.baldrige.nist.gov 

American Society for Quality

600 North Plankinton Avenue

P.O. Box 3005

Milwaukee, WI 53201-3005

By making quality a global priority, an organizational imperative, and a personal ethic, the

American Society for Quality (ASQ) becomes the community for everyone who seeks

quality technology, concepts, or tools to improve themselves and their world. ASQ

administers the Malcolm Baldrige National Quality Award under contract to NIST.

Call ASQ to order

• bulk copies of the Criteria

• Award recipients videos

Telephone: (800) 248-1946; Fax: (414) 272-1734; E-mail: asq@asq.org

Web site: www.asq.org

T1500 printed on recycled paper
Scoring Work Sheets
Baldridge National Quality Award 

Scoring Guidelines 

For Process 

0% or 5% 

• No SYSTEMATIC APPROACH is evident; information is ANECDOTAL. (A) 

• Little or no DEPLOYMENT of an APPROACH is evident. (D) 

• An improvement orientation is not evident; improvement is achieved through reacting to 

problems. (L) 

• No organizational ALIGNMENT is evident; individual areas or work units operate 

independently. (I) 

10%, 

15%, 20% 

or 25% 

• 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 achieving the 

• BASIC REQUIREMENTS of the Item. (D) 

• Early stages of a transition from reacting to problems to a general improvement 

orientation are evident. (L) 

• The APPROACH is ALIGNED with other areas or work units largely through joint problem 

solving. (I) 

30%, 

35%, 40% 

or 45% 

• 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) 

• The beginning of a SYSTEMATIC APPROACH to evaluation and improvement of KEY 

PROCESSES is evident. (L) 

• The APPROACH is in early stages of ALIGNMENT with your basic organizational needs 

identified in response to the other Criteria Categories. (I) 

50%, 

55%, 60% 

or 65% 

• 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) 

• A fact-based, SYSTEMATIC evaluation and improvement PROCESS and some 

organizational LEARNING are in place for improving the efficiency and effectiveness of 

KEY PROCESSES. (L) 

• The APPROACH is ALIGNED with your organizational needs identified in response to the 

other Criteria Categories. (I) 

70%, 

75%, 80% 

or 85% 

• An EFFECTIVE, SYSTEMATIC APPROACH, responsive to the MULTIPLE REQUIREMENTS 

of the Item, is evident. (A) 

• The APPROACH is well DEPLOYED, with no significant gaps. (D) 

• 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. (L) 

• The APPROACH is INTEGRATED with your organizational needs identified in response to 

the other Criteria Items. (I) 

90%, 95% 

or 100% 

• 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) 

• 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. (L) 

• The APPROACH is well INTEGRATED with your organizational needs identified in 

response to the other Criteria Items. (I) 
Baldridge National Quality Award 

Scoring Guidelines 

For Results 

0% or 5% 

• There are no organizational performance RESULTS or poor RESULTS in areas reported. 

• TREND data are either not reported or show mainly adverse TRENDS. 

• Comparative information is not reported. 

• RESULTS are not reported for any areas of importance to your KEY organizational 

requirements. 

10%, 

15%, 20% 

or 25% 

• A few organizational performance RESULTS are reported; there are some improvements 

and/or early good PERFORMANCE LEVELS in a few areas 

• Little or no TREND data are reported. 

• Little or no comparative information is reported. 

• RESULTS are reported for a few areas of importance to your KEY organizational 

requirements. 

30%, 

35%, 40% 

or 45% 

• Improvements and/or good PERFORMANCE LEVELS are reported in many areas 

addressed in the Item requirements. 

• Early stages of developing TRENDS are evident. 

• Early stages of obtaining comparative information are evident. 

• RESULTS are reported for many areas of importance to your KEY organizational 

requirements. 

50%, 

55%, 60% 

or 65% 

• Improvement TRENDS and/or good PERFORMANCE LEVELS are reported for most areas 

addressed in the Item requirements. 

• No pattern of adverse TRENDS and no poor PERFORMANCE LEVELS are evident in areas 

of importance to your KEY organizational requirements. 

• Some TRENDS and/or current PERFORMANCE LEVELS—evaluated against relevant 

comparisons and/or BENCHMARKS—show areas of good to very good relative 

PERFORMANCE. 

• Organizational performance RESULTS address most KEY PATIENT and other CUSTOMER, 

market, and PROCESS requirements. 

70%, 

75%, 80% 

or 85% 

• Current PERFORMANCE is good to excellent in most areas of importance to the Item 

requirements. 

• Most improvement TRENDS and/or current PERFORMANCE LEVELS are sustained. 

• Many to most reported TRENDS and/or current PERFORMANCE LEVELS—evaluated 

against relevant comparisons and/or BENCHMARKS—show areas of leadership and very 

good relative PERFORMANCE. 

• Organizational performance RESULTS address most KEY PATIENT and other CUSTOMER, 

market, PROCESS, and ACTION PLAN requirements. 

90%, 95% 

or 100% 

• Current PERFORMANCE is excellent in most areas of importance to the Item 

requirements. 

• Excellent improvement TRENDS and/or sustained excellent PERFORMANCE LEVELS are 

reported in most areas. 

• Evidence of health care sector and BENCHMARK leadership is demonstrated in many 

areas. 

• Organizational performance RESULTS fully address KEY PATIENT and other CUSTOMER, 

market, PROCESS, and ACTION PLAN requirements. 
Criterion:

Strengths:

Areas for Improvement:

Actions:

Baldrige Self-Assessment Worksheet

Health Care Criteria