4 2021–2022 Health Care Criteria for Performance Excellence

(Continued on the next page)

Health Care Criteria for 

Performance Excellence

Begin with the Organizational Profile

The Organizational Profile is the most appropriate starting point for self-assessment and for writing an application. It is critically important for the following reasons: 

• You can use it as an initial self-assessment. If you identify topics for which conflicting, little, or no information is available, use these topics for action planning.

• It sets the context for understanding your organization and how it operates, and allows you to address unique aspects of

your organization in your responses to the Health Care Criteria questions in categories 1–7. Your responses to all other

questions in the Criteria should relate to the organizational context you describe in this profile.

• It helps you identify gaps in key information about your organization and focus on key performance requirements and

results.

P Organizational Profile

The Organizational Profile is a snapshot of your organization and its strategic environment.

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

a. Organizational Environment

(1) HealtH Care ServiCe Offerings What are your main health care service offerings (see the note on the next

page)? What is the relative importance of each to your success? What mechanisms do you use to deliver your

health care services?

(2) MiSSion, viSion, valueS, and Culture What are your mission, vision, and values? Other than values, what

are the characteristics of your organizational culture? What are your organization’s core competencies, and what

is their relationship to your mission?

(3) WorkforCe Profile What is your workforce profile? What recent changes have you experienced in

workforce composition or in your needs with regard to your workforce? What are

• your workforce or employee groups and segments;

• the educational requirements for different employee groups and segments;

• the key drivers that engage them;

• your organized bargaining units (union representation), if any; and

• your special health and safety requirements, if any?

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

(5) Regulatory Environment What are your key applicable occupational health and safety regulations; accreditation,

certification, or registration requirements; industry standards; and environmental, financial, and health care

service delivery regulations?

b. Organizational Relationships

(1) Organizational Structure What are your organizational leadership structure and governance structure? What

structures and mechanisms make up your organization’s leadership system? What are the reporting relationships

among your governance board, senior leaders, and parent organization, as appropriate?

(2) Patients, Other CuStoMerS, and StakeHolderS What are your key market segments, patient and other

customer groups, and stakeholder groups, as appropriate? What are their key requirements and expectations

for your health care services, patient and other customer support services, and operations, including any differences among the groups?

From Baldrige Performance Excellence Program. 2021. 2021–2022 Baldrige Excellence Framework (Health Care): Leadership and 

Management Practices for High Performance. Gaithersburg, MD: U.S. Department of Commerce, National Institute of Standards 

and Technology. https://www.nist.gov/ baldrige.
Organizational Profile 5

(3) Suppliers, PartnerS, and CollaboratorS What are your key types of suppliers, partners, and collaborators? What role do they play in producing and delivering your key health care services and patient and other

customer support services, and in enhancing your competitiveness? What role do they play in contributing and

implementing innovations in your organization? What are your key supply-network requirements?

Terms in small caps are defined in the Glossary of Key Terms (pages 46–53).

Notes

P.1a(1). Health care service offerings are the services you

offer in the marketplace. Mechanisms for delivering services

to your patients or other customers might be direct or might

be indirect, through contractors, collaborators, or partners.

P.1a(2). If your organization has a stated purpose as well

as a mission, you should include it in your response. Some

organizations define a mission and a purpose, and some use

the terms interchangeably. Purpose refers to the fundamental reason that the organization exists. Its role is to inspire

the organization and guide its setting of values.

P.1a(2). Your values are part of your organization’s culture.

Other characteristics of your culture might include shared

beliefs and norms that contribute to the uniqueness of the

environment within your organization.

P.1a(3). Workforce or employee groups and segments

(including organized bargaining units) might be based on

type of employment or contract-reporting relationship,

location (including remote work), tour of duty, work

environment, use of flexible work policies, or other factors.

Organizations that also rely on volunteers and interns to

accomplish their work should include these groups as part

of their workforce.

P.1a(5). Industry standards might include industrywide

codes of conduct and policy guidance. Depending on the

regions and context in which you operate, special financial

covenants, standards regarding relationships with physicians

or other referral sources, and environmental regulations

may apply.

P.1b(1). The Organizational Profile asks for the “what” of

your leadership system (its structures and mechanisms).

Questions in categories 1 and 5 ask how the system is used.

P.1b(2). Customers include the direct users and potential

users of your health care services (patients), as well as

referring health care providers and those who pay for your

services, such as patients’ families, insurers, and other thirdparty payors. Your organization may use another term for

patient, such as client, resident, consumer, or member.

P.1b(2). Patient and other customer groups might be based

on common expectations, behaviors, preferences, or profiles.

Within a group, there may be segments based on differences, commonalities, or both. You might subdivide your

market into segments based on health care service lines or

features, service delivery modes, payors, volume, geography,

or other defining factors.

P.1b(2). Patient, other customer, stakeholder, and

operational requirements and expectations will drive your

organization’s sensitivity to the risk of service, support, and

supply-network interruptions, including those due to natural

disasters and other emergencies.

P.1b(3). Your supply network consists of the entities that

contribute to producing your health care services and delivering them to your patients and other customers. For some

organizations, these entities form a chain, in which one

entity directly supplies another. Increasingly, however, these

entities are interlinked and exist in interdependent rather

than linear relationships. The Health Care Criteria use the

term supply network to emphasize the interdependencies

among organizations and their suppliers.

For additional guidance on this item, see the Health Care 

Criteria Commentary (https://www.nist.gov/baldrige

/baldrige-criteria-commentary-health-care). 
6 2021–2022 Health Care Criteria for Performance Excellence

P.2 Organizational Situation: What is your organization’s strategic situation?

a. Competitive Environment

(1) Competitive Position What are your relative size and growth in the health care industry or the markets you

serve? How many and what types of competitors do you have?

(2) Competitiveness Changes What key changes, if any, are affecting your competitive situation, including changes

that create opportunities for innovation and collaboration, as appropriate?

(3) Comparative Data What key sources of comparative and competitive data are available from within the health

care industry? What key sources of comparative data are available from outside the health care industry? What

limitations, if any, affect your ability to obtain or use these data?

b. Strategic Context

What are your key strategic challenges and advantages?

c. PerforManCe Improvement System

What is your performance improvement system, including your processes for evaluation and improvement of key

organizational projects and processes?

Terms in small caps are defined in the Glossary of Key Terms (pages 46–53).

Notes

P.2b. Strategic challenges and advantages might be in the

areas of business, operations, societal contributions, and 

workforce. They might relate to health care services or 

service features, quality and outcomes, finances, organizational structure and culture, emerging technology, digital 

integration, data and information security and cybersecurity, 

emerging competitors, changing stakeholder requirements, 

workforce capability or capacity, brand recognition and 

reputation, your supply network, and the health care 

industry. 

P.2c. The Baldrige Scoring System (pages 29–34) uses

performance improvement through learning and integration as a factor in assessing the maturity of organizational

approaches and their deployment. This question is intended

to set an overall context for your approach to performance 

improvement. The approach you use should be related to 

your organization’s needs. Approaches that are compatible 

with the overarching systems approach provided by the 

Baldrige framework might include implementing a Lean 

Enterprise System, applying Six Sigma methodology, using 

PDCA methodology, using standards from ISO (e.g., the 

9000 or 14000 series, or sector-specific standards), using 

decision or implementation science, or employing other 

improvement tools. 

For additional guidance on this item, see the Health Care 

Criteria Commentary (https://www.nist.gov/baldrige

/baldrige-criteria-commentary-health-care).