2020 www.nist.gov/baldrige

nonprofit

LifeBridge Organ 

and Tissue Sharing, 

Year 2 Case Study 

Feedback Report
Baldrige Performance Excellence Program

National Institute of Standards and Technology (NIST) • United States Department of Commerce

July 2020

To order copies of this publication or obtain other Baldrige Program products and services, contact 

Baldrige Performance Excellence Program

Administration Building, Room A600, 100 Bureau Drive, Stop 1020, Gaithersburg, MD 20899-1020

www.nist.gov/baldrige | 301.975.2036 | baldrige@nist.gov

The Baldrige Program welcomes your comments on the case study and other Baldrige products and services. 

Please direct your comments to the address above.

The Baldrige Program is very grateful to an actual organ procurement organization that allowed its own Baldrige-based award application 

to be the basis for this case study. From that real application, names and data have been fictionalized, and elements have been intentionally 

edited to be less mature, less beneficial, and missing. 

The LifeBridge Organ and Tissue Sharing Case Study, Year 2, Feedback Report is a fictional Baldrige Award feedback report developed 

by a team of experienced Baldrige examiners who evaluated the corresponding case study against the 2019–2020 Baldrige Criteria for 

Performance Excellence. The fictitious case study organization is intended to be a regional organ and tissue procurement organization 

for people living in a federally assigned territory within made-up states. There is no connection between the fictitious LifeBridge Organ 

and Tissue Sharing and any other organization, named either LifeBridge Organ and Tissue Sharing or otherwise. The names of several 

national and government organizations are included to promote the realism of the case study as a training tool, but all data and content 

about them have been fictionalized, as appropriate; all other organizations cited in the case study are fictitious or have been fictionalized.

LifeBridge Organ and Tissue Sharing scored in band 5 for process items and band 4 for results items. An organization in band 5 for 

process items demonstrates effective, systematic, well-deployed approaches responsive to most overall Criteria questions. It demonstrates 

fact-based, systematic evaluation and improvement and organizational learning, including some innovation, that result in improving 

the effectiveness and efficiency of key processes. For an organization that scores in band 4 for results items, results address some key 

customer/stakeholder, market, and process requirements, and they demonstrate good relative performance against relevant comparisons. 

There are no patterns of adverse trends or poor performance in areas of importance to the overall Criteria questions and the accomplishment 

of the organization’s mission. 

BALDRIGE EXCELLENCE FRAMEWORK®, BALDRIGE CRITERIA FOR PERFORMANCE EXCELLENCE®, BALDRIGE PERFORMANCE 

EXCELLENCE PROGRAM®, BALDRIGE COLLABORATIVE ASSESSMENT®, BALDRIGE EXAMINER®, BALDRIGE EXCELLENCE BUILDER®, 

PERFORMANCE EXCELLENCE®, THE QUEST FOR EXCELLENCE®, and the MALCOLM BALDRIGE NATIONAL QUALITY AWARD® medal 

and depictions or representations thereof are federally registered trademarks and service marks of the U.S. Department of Commerce, 

National Institute of Standards and Technology. The unauthorized use of these trademarks and service marks is prohibited.

NIST, an agency of the U.S. Department of Commerce, manages the Baldrige Program. NIST has a 100-plus-year track record of 

serving U.S. industry, science, and the public with the mission to promote U.S. innovation and industrial competitiveness by advancing 

measurement science, standards, and technology in ways that enhance economic security and improve our quality of life. NIST carries 

out its mission in three cooperative programs, including the Baldrige Program. The other two are the NIST laboratories and the 

Hollings Manufacturing Extension Partnership.

Suggested citation: Baldrige Performance Excellence Program. 2020. 2020 Baldrige Case Study Feedback Report: LifeBridge 

Organ and Tissue Sharing. Gaithersburg, MD: U.S. Department of Commerce, National Institute of Standards and Technology. 

https://www.nist.gov/baldrige.

Baldrige Performance Excellence Program

National Institute of Standards and Technology (NIST) • United States Department of Commerce

July 2020

To order copies of this publication or obtain other Baldrige Program products and services, contact 

Baldrige Performance Excellence Program

Administration Building, Room A600, 100 Bureau Drive, Stop 1020, Gaithersburg, MD 20899-1020

www.nist.gov/baldrige | 301.975.2036 | baldrige@nist.gov

The Baldrige Program welcomes your comments on the case study and other Baldrige products and services. 

Please direct your comments to the address above.

The Baldrige Program is very grateful to an actual organ procurement organization that allowed its own Baldrige-based award application 

to be the basis for this case study. From that real application, names and data have been fictionalized, and elements have been intentionally 

edited to be less mature, less beneficial, and missing. 

The LifeBridge Organ and Tissue Sharing Case Study, Year 2, Feedback Report is a fictional Baldrige Award feedback report developed 

by a team of experienced Baldrige examiners who evaluated the corresponding case study against the 2019–2020 Baldrige Criteria for 

Performance Excellence. The fictitious case study organization is intended to be a regional organ and tissue procurement organization 

for people living in a federally assigned territory within made-up states. There is no connection between the fictitious LifeBridge Organ 

and Tissue Sharing and any other organization, named either LifeBridge Organ and Tissue Sharing or otherwise. The names of several 

national and government organizations are included to promote the realism of the case study as a training tool, but all data and content 

about them have been fictionalized, as appropriate; all other organizations cited in the case study are fictitious or have been fictionalized.

LifeBridge Organ and Tissue Sharing scored in band 5 for process items and band 4 for results items. An organization in band 5 for 

process items demonstrates effective, systematic, well-deployed approaches responsive to most overall Criteria questions. It demonstrates 

fact-based, systematic evaluation and improvement and organizational learning, including some innovation, that result in improving 

the effectiveness and efficiency of key processes. For an organization that scores in band 4 for results items, results address some key 

customer/stakeholder, market, and process requirements, and they demonstrate good relative performance against relevant comparisons. 

There are no patterns of adverse trends or poor performance in areas of importance to the overall Criteria questions and the accomplishment 

of the organization’s mission. 

BALDRIGE EXCELLENCE FRAMEWORK®, BALDRIGE CRITERIA FOR PERFORMANCE EXCELLENCE®, BALDRIGE PERFORMANCE 

EXCELLENCE PROGRAM®, BALDRIGE COLLABORATIVE ASSESSMENT®, BALDRIGE EXAMINER®, BALDRIGE EXCELLENCE BUILDER®, 

PERFORMANCE EXCELLENCE®, THE QUEST FOR EXCELLENCE®, and the MALCOLM BALDRIGE NATIONAL QUALITY AWARD® medal 

and depictions or representations thereof are federally registered trademarks and service marks of the U.S. Department of Commerce, 

National Institute of Standards and Technology. The unauthorized use of these trademarks and service marks is prohibited.

NIST, an agency of the U.S. Department of Commerce, manages the Baldrige Program. NIST has a 100-plus-year track record of 

serving U.S. industry, science, and the public with the mission to promote U.S. innovation and industrial competitiveness by advancing 

measurement science, standards, and technology in ways that enhance economic security and improve our quality of life. NIST carries 

out its mission in three cooperative programs, including the Baldrige Program. The other two are the NIST laboratories and the 

Hollings Manufacturing Extension Partnership.

Suggested citation: Baldrige Performance Excellence Program. 2020. 2020 Baldrige Case Study Feedback Report: LifeBridge 

Organ and Tissue Sharing. Gaithersburg, MD: U.S. Department of Commerce, National Institute of Standards and Technology. 

https://www.nist.gov/baldrige.
October 1, 2020

Marie Jamerson

Chief Executive Officer

LifeBridge Organ and Tissue Sharing

444000 Georgie Blvd., Suite 100 

Columbia, NT 01011

Dear Ms. Jamerson:

Congratulations for taking the Baldrige challenge this year! We commend you for your commitment to 

performance excellence as demonstrated by your applying for the Malcolm Baldrige National Quality 

Award (MBNQA), the nation’s highest award for organizational excellence.

The enclosed feedback report, which was prepared for your organization by members of the allvolunteer Board of Examiners in response to your application, describes areas identified as strengths 

and opportunities for possible improvement and shows your organization’s scoring. The report contains 

the examiners’ observations about your organization, but it is not intended to prescribe a specific course 

of action. In some cases, the comments do not cover all areas to address within a Criteria item; instead, 

the examiner team collectively identifies your most significant strengths and your most important 

opportunities for improvement. Please refer to the “Preparing to Read Your Feedback Report” 

introductory section for suggestions about how to use the information in your feedback report.

We are eager to ensure that the comments in the report are clear to you so that you can incorporate the 

feedback into your planning process to continue to improve your organization. As direct communication 

between examiners and applicants is not permitted, please contact me at (301) 975-2361 if you wish to 

clarify the meaning of any comment in your report. We will contact the examiners for clarification and 

convey their intentions to you.

The feedback report is not your only source of ideas about organizational improvement and excellence. 

Current and previous Baldrige Award recipients can be potential resources for your organization’s 

efforts in any performance dimension addressed by the Criteria. Information on contacting Baldrige 

Award recipients is located at the end of your feedback report. The 2019 and 2020 award recipients and 

any organizations recognized for category best practices, as well as previous recipients, will share their 

best practices at our annual Quest for Excellence® Conference, April 11–14, 2021. Current and previous 

award recipients also participate in the Baldrige Fall Conference held each year. 

In addition to the Baldrige Award and our annual conference, we offer several other products and 

services to assist your organization’s improvement efforts. The Baldrige Collaborative Assessment can 

give you detailed insight into what examiners look for and evidence found during assessments, through

a tailored, collaborative approach to help you identify and prioritize opportunities. More information 

can be found on our website at www.nist.gov/baldrige or by contacting us at baldrige@nist.gov or (301) 

975-2036.
In approximately 60 days, you will receive a survey from the Judges Panel of the MBNQA. As an 

applicant, you are uniquely qualified to provide an effective evaluation of the materials and processes 

that we use in administering the Baldrige Program. 

Thank you for participating in the Malcolm Baldrige National Quality Award process this year. Best 

wishes for continued progress in your organization’s quest for excellence.

Sincerely,

Robert G. Fangmeyer, Director 

Baldrige Performance Excellence Program

Enclosures

LifeBridge Organ and

Tissue Sharing
Malcolm Baldrige National Quality Award—2020 Feedback Report 3

Preparing to read your feedback report . . .

Your feedback report contains Baldrige examiners’ observations based on their understanding 

of your organization. The examiner team has provided comments on your organization’s 

strengths and opportunities for improvement relative to the Baldrige Criteria. The feedback is 

not intended to be comprehensive or prescriptive. It will tell you where examiners think you 

have important strengths to celebrate and where they think key improvement opportunities 

exist. The feedback will not necessarily cover every question in the Criteria, nor will it say 

specifically how you should address these opportunities. You will decide what is most 

important to your organization and how best to address the opportunities.

If your organization has not applied in the recent past, you may notice a change in the way 

feedback comments are now structured in the report. In response to applicant feedback, the 

Baldrige Program now asks examiners to express the main point of the comment in the first 

sentence, followed by relevant examples, in many cases resulting in more concise, focused 

comments. In addition, the program has included Criteria item references with each comment 

to assist you in understanding the source of the feedback. Each 2020 feedback report also 

includes a graph in Appendix A that shows your organization’s scoring profile compared to the 

median scores for all 2020 applicants at Consensus Review.

Applicant organizations understand and respond to feedback comments in different ways. To 

make the feedback most useful to you, we’ve gathered the following tips and practices from 

previous applicants for you to consider.

• Take a deep breath and approach your Baldrige feedback with an open mind. You applied to 

get the feedback. Read it, take time to digest it, and read it again. 

• Before reading each comment, review the Criteria questions that correspond to each of the 

Criteria item references (which now precede each comment); doing this may help you 

understand the basis of the examiners’ evaluation. The 2019–2020 Baldrige Excellence 

Framework containing the Business/Nonprofit Criteria for Performance Excellence can be 

purchased at http://www.nist.gov/baldrige/publications/business_nonprofit_criteria.cfm.

Baldrige ... clearly impacted our ability to achieve better strategies. We’re a company that 

helps create and execute strategies for others. Yet [the Baldrige framework] helped us to 

take our own strategy to a new and impactful level.

C. Richard Panico, President and CEO

Integrated Project Management Company, Inc.

2018 Baldrige Award Recipient
Malcolm Baldrige National Quality Award—2020 Feedback Report 4

• Especially note comments in boldface type. These comments indicate observations that the 

examiner team found particularly important—strengths or opportunities for improvement 

that the team felt had substantial impact on your organization’s performance practices, 

capabilities, or results and, therefore, had more influence on the team’s scoring of that 

particular item. 

• You know your organization better than the examiners know it. If the examiners have 

misread your application or misunderstood information contained in it, don’t discount the 

whole feedback report. Consider the other comments, and focus on the most important 

ones.

• Celebrate your strengths and build on them to achieve world-class performance and a 

competitive advantage. You’ve worked hard and should congratulate yourselves.

• Use your strength comments as a foundation to improve the things you do well. Sharing 

those things you do well with the rest of your organization can speed organizational 

learning. 

• Prioritize your opportunities for improvement. You can’t do everything at once. Think about 

what’s most important for your organization at this time, and decide which things to work 

on first. 

• Use the feedback as input to your strategic planning process. Focus on the strengths and 

opportunities for improvement that have an impact on your strategic goals and objectives.

One of the beauties of the Baldrige framework is how it saved us from ourselves by 

forcing the really hard questions about organizational systems and what is most 

essential. . . . Everything flows of course [from] our leadership system.

Sue Dunn, President and CEO

Donor Alliance

2018 Baldrige Award Recipient
Malcolm Baldrige National Quality Award—2020 Feedback Report 5

KEY THEMES

Key Themes–Process Items

LifeBridge Organ and Tissue Sharing (LOTS) scored in band 5 for process items (1.1–6.2) in the 

Consensus Review for the Malcolm Baldrige National Quality Award. For an explanation of the 

process scoring bands, please refer to Figure 6a, Process Scoring Band Descriptors.

An organization in band 5 for process items typically demonstrates effective, systematic, welldeployed approaches responsive to the overall questions in most Criteria items. The 

organization demonstrates a fact-based, systematic evaluation and improvement process and 

organizational learning, including some innovation, that result in improving the effectiveness 

and efficiency of key processes.

a. The most important strengths or outstanding practices (of potential value to other 

organizations) identified in LOTS's response to process items are as follows:

• LOTS has integrated processes for hiring, workforce development, performance 

evaluation, planning, and leadership communication that support its core competency 

of a mission-driven workforce. These include the Hiring Process (Figure 5.1-3), which 

fosters a strong cultural fit for new employees; the Learning and Development System 

(LDS, Figure 5.2-2), which promotes both personal career development and 

organizational learning; and the Performance Evaluation Process (PEP, Figure 5.1-2), 

which ensures individual accountability for organizational goals and expectations 

through the alignment of systemwide scorecards. In addition, the Workforce 

Performance Management System (WPMS) is integrated with the LDS and the PEP, as 

well as with the Performance Measurement System (PMS, Figure 4.1-1) and Strategic 

Planning Process (SPP, Figure 2.1-1). The Workforce Planning Process (Figure 5.1-1), 

which addresses capability and capacity needs, also connects employees in LOTS’s two 

work systems with the SPP and with other organizational processes through cascading 

goals and cross-training. Further supporting LOTS’s mission-driven workforce culture, 

the Leadership Team analyzes current and future workforce needs annually. In a recent 

cycle of learning, senior leaders added a new method for rounding to help them better 

connect with workforce members. 

• Senior leaders have created an integrated system of key processes to promote LOTS’s 

success, ultimately to achieve the vision to ensure that organs and tissues are always 

available. These key processes include the SPP, the PMS, the Operational Management 

Process (OMP, Figure 6.1-1), and the LDS. The Leadership System ( Figure 1.1-1), which 

integrates and deploys these key processes, creates a focus on action to establish an 

environment for success, operationalize the strategy, set expectations for organizational 

performance, and monitor progress toward objectives. For example, through the SPP, 

leaders and a broad group of participants define LOTS’s key strategic objectives and 

organizational goals. Leaders then track and monitor progress on these through the 

PMS. The SPP is also effectively used to evaluate internal and external capabilities to 
Malcolm Baldrige National Quality Award—2020 Feedback Report 6

determine which key processes should be accomplished internally versus through 

outsourcing, helping LOTS address business and operational strategic challenges such as 

industry changes. In addition, senior leaders’ systematic communications (Figure 1.1-3), 

including two-way mechanisms, reach customers and stakeholders as well as workforce 

members.

• LOTS has systematic approaches for gathering and disseminating data, particularly in the 

areas of strategy development, customer listening, performance measurement, 

knowledge management, and workforce engagement. For example, the SPP (Figure 

2.1-1) encompasses the selection and collection of data from industry and nonindustry 

sources for strategy development; the SPP also integrates data for use in daily tracking 

of operational performance. Through the PMS (Figure 4.1-1), LOTS systematically 

collects and disseminates data and information for use in organizational performance 

review and improvement. The organization also systematically gathers information to 

meet customers’ expectations through its methods of listening to current customers 

(Figure 3.1-1) throughout the customer life cycle. In addition, LOTS gathers a variety of 

data from customers and stakeholders in order to build organizational knowledge. 

Further, LOTS systematically collects data and information via workforce surveys to 

determine key drivers of its employees’ engagement. Together, these processes support 

management by fact, providing many types of data and information to enable LOTS to 

effectively manage its performance.

b. The most significant opportunities, concerns, or vulnerabilities identified in LOTS's 

response to process items are as follows:

• Systematic approaches to ensure the evaluation and improvement of some 

organizational approaches are not evident. For example, it is not clear that LOTS

routinely evaluates for improvement its processes for data and information quality or 

for organizational knowledge management. In addition, cycles of learning and 

improvement are not evident for some approaches to the workforce environment, such 

as those for determining capability and capacity needs, promoting work 

accomplishment, and determining workforce benefits and policies. It is also unclear if 

LOTS systematically evaluates some workforce performance management and 

development processes for potential improvements. A systematic approach to process 

evaluation and improvement may help LOTS be better prepared to address its strategic 

challenge related to industry changes by ensuring the efficiency and effectiveness of its 

work processes.

• It is not clear if senior leaders have systematic approaches in place to address 

organizational agility and create an environment that promotes intelligent risk taking. 

For example, it is not apparent how LOTS stimulates and incorporates innovation in its 

strategy development process or uses findings from performance reviews to develop 

priorities for improvement. Further, it is not evident that LOTS has a systematic 

approach to rapidly add to, replace, or eliminate measures in the PMS (Figure 4.1-1), 
Malcolm Baldrige National Quality Award—2020 Feedback Report 7

even though changes in regulatory requirements may make such a process critical to the 

ability to respond rapidly to changes in LOTS’s operating environment. It is also not clear 

how the WPMS supports intelligent risk taking. Leveraging systematic approaches to 

support agility and intelligent risk taking may support LOTS in achieving its strategic 

objectives to maximize donations, stakeholder relations, and organizational excellence 

while being responsive to its strategic challenge of industry changes.

Key Themes–Results Items

LOTS scored in band 4 for results items (7.1–7.5). For an explanation of the results scoring

bands, please refer to Figure 6b, Results Scoring Band Descriptors.

For an organization in band 4 for results items, results address some key customer/stakeholder, 

market, and process requirements, and they demonstrate good relative performance against 

relevant comparisons. There are no patterns of adverse trends or poor performance in areas of 

importance to the overall Criteria questions and the accomplishment of the organization’s 

mission. 

c. Considering LOTS's key business/organization factors, the most significant strengths 

found in response to results items are as follows:

• Good performance levels and beneficial trends for several measures of customerfocused service results of importance to stakeholders—as well as for measures of the 

satisfaction of the two key customer groups—reflect LOTS’s commitment to delivering 

value and results. For example, among outcomes important to LOTS’s key stakeholders, 

results for organ and tissue transplantation by population (Figures 7.1-4, 7.1-6, and 7.1-

7) and for local transplantation (Figures 7.1-10 through 7.1-14), as well as for tissue 

referrals, organ authorization, and age-targeted bone donors released (Figures 7.1-3, 

7.1-5, and 7.1-8) show good levels and beneficial trends. In addition, satisfaction and 

engagement measures for organ transplant centers show high levels overall and for 

meeting this customer group’s key requirements of competence and information. For 

the customer group of tissue processors, satisfaction results show sustained 

improvement to a current level near 100%.

• Results for many measures of work process effectiveness, safety and emergency 

preparedness, workforce engagement and development, and financial and marketplace 

performance demonstrate good levels, with several comparing favorably to top-quartile 

benchmarks or other relevant comparators. Work process effectiveness results showing 

good-to-excellent levels that approach or exceed top-quartile comparisons include a 

rate of zero for missed organ referrals, tissue authorization levels that are consistently 

above the top-quartile benchmark, and levels of organ donor cases in-house that have 

outperformed the top quartile for three consecutive years (Figures 7.1-16, 7.1-18, and 

7.1-21). Among safety and emergency preparedness results, LOTS has achieved 100% 

completion of safe workplace training, has consistently met population and time 

requirements for safety drills, and reports 100% compliance with a number of measures 
Malcolm Baldrige National Quality Award—2020 Feedback Report 8

(Figures 7.1-28, 7.1-30, and 7.1-31). For workforce engagement and workforce 

development, such results include those for employees’ connection to the mission 

(Figure 7.3-11), as well as for training expenditures and leadership development 

satisfaction (Figures 7.3-19 and 7.3-20), which both exceed the top-quartile benchmark. 

For financial results, consolidated results of operations, total gross revenue, net margin, 

and total assets (Figures 7.5-1, 7.5-2, 7.5-4, and 7.5-10) are better than the top-quartile 

benchmark, and operating reserves (Figure 7.5-9) shows good relative performance. 

Similarly, for marketplace results, organ donor costs (Figures 7.5-11 and 

7.5-12) show good performance against relevant comparators. These results support 

LOTS’s long-term success by demonstrating that it is maintaining a safe work 

environment, emergency preparedness, and an engaged and skilled workforce, while 

reinforcing its strategic advantage of a strong financial position.

d. Considering LOTS's key business/organization factors, the most significant opportunities, 

vulnerabilities, and/or gaps (related to data, comparisons, linkages) found in response to 

results items are as follows:

• Results are missing in some areas that LOTS identifies as important. For example, results 

are not reported for measures of the supply-network requirements of accurate 

information, timely communication, and service quality, which LOTS identifies as 

significant for accomplishing its mission. Missing work process effectiveness results 

include those for cybersecurity and innovation, and missing customer-focused service 

results include rates or numbers of organ rejection, lab requisition errors, donor chart 

errors, sterilizer accuracy, and radiation exposure. Among leadership and governance 

measures, results are not reported for environmental impact, senior leaders’ and staff 

members’ support of key communities, internal or external audits, other measures of 

fiscal responsibility, or LOTS’s impact on societal well-being. In addition, missing results 

for several key strategy implementation measures include those for registry 

enrollment—a key strategic opportunity in LOTS’s 2019 planning cycle—and for 

achievement of individual action plans as well as action plans modified based on 

performance projection gaps and potential partnerships. Ensuring that it has results for 

key performance measures reflecting all areas of importance may help LOTS advance in 

its mission to save and improve lives. 
Malcolm Baldrige National Quality Award—2020 Feedback Report 9

DETAILS OF STRENGTHS AND OPPORTUNITIES FOR IMPROVEMENT

The numbers and letters preceding each comment indicate the Criteria item questions to which 

the comment refers. Not every Criteria question will have a corresponding comment; rather, 

these comments were deemed the most significant by a team of examiners.

Category 1 Leadership

1.1 Senior Leadership

Your score in this Criteria item for the Consensus Review is in the 50–65 percentage range. 

(Please refer to Figure 5a, Process Scoring Guidelines.) 

STRENGTHS 

• b To support work systems that require careful coordination, senior leaders 

communicate with key customers and stakeholders through a systematic process, with 

regular evaluation and improvement (Figure 1.1-3). Multiple approaches are used to 

ensure frank, two-way communication. Improvements include monthly rounding and a 

new format and schedule for monthly staff meetings.

• c(1) To create an environment for mission achievement and reinforce customer and 

workforce engagement, senior leaders integrate the SPP (Figure 2.1-1) with the 

Leadership System (Figure 1.1-1), with multiple enhancements resulting from routine 

evaluation and improvement. Leaders’ approaches include the PMS (Figure 4.1-1), OMP 

(Figure 6.1-1), and LDS (Figure 5.2-1), as well as participation in succession planning.

• a(1) The Leadership Team (LT) systematically defines and refines LOTS’s vision, 

mission, and values during the annual SPP and deploys these to the workforce through 

the Communication Process (Figure 1.1-3). The LT models the values through 

approaches such as rounding with staff, recognition, and the CEO Café. This approach 

may enable LOTS to create and nurture a culture supportive of delivering its mission.

• c(2) Senior leaders create a focus on action, identify actions, and demonstrate 

personal accountability by integrating and deploying essential elements of the 

Leadership System (Figure 1.1-1), which includes creating the environment, 

operationalizing the strategy, and monitoring performance. LOTS cascades work system 

scorecards to the individual level and evaluates performance during the PEP and via 

annual goal plans.

OPPORTUNITIES FOR IMPROVEMENT 

• a(1) It is unclear how LOTS deploys its vision and values to all customers, partners, 

and suppliers. For example, deployment to the Eye Bank, a key customer, is not evident. 

In addition, it is not evident how LOTS uses the voice-of-the-stakeholder (VOS)

methodology (Figure 4.2-1) to share the vision and values with partners and suppliers 
Malcolm Baldrige National Quality Award—2020 Feedback Report 10

and ensure key stakeholders’ commitment. Systematic deployment to key customers 

and stakeholders may help LOTS ensure their alignment to the mission.

• a(2) In the context of LOTS’s approaches to ensure ethical behavior (the Corporate 

Compliance program, Anonymous Call Line, and Code of Personal Conduct), it is unclear 

how senior leaders’ personal actions demonstrate a commitment to such behavior. 

Personally demonstrating this commitment may help reinforce legal and ethical 

behavior as a high priority.

• c(1) It is not clear how senior leaders systematically cultivate agility, organizational 

innovation, and intelligent risk taking; LOTS’s process for leveraging the Baldrige 

Excellence Framework, relationships with suppliers and partners, and changes in the 

organ procurement organization (OPO) environment for this purpose is not evident. A 

systematic approach may help LOTS reinforce its innovation value, which serves as a 

guiding force for how the workforce lives the culture on a daily basis.

• c(2) It is not clear how the LT uses step 1 of the Leadership System to balance value 

among various stakeholder groups—in particular, how leaders recognize and resolve 

potential conflicts among stakeholder groups regarding LOTS’s planned actions and 

priorities. An approach in this area may help LOTS achieve the strategic objective of 

maximizing stakeholder relationships.
Malcolm Baldrige National Quality Award—2020 Feedback Report 11

1.2 Governance and Societal Contributions

Your score in this Criteria item for the Consensus Review is in the 70–85 percentage range. 

(Please refer to Figure 5a, Process Scoring Guidelines.) 

STRENGTHS 

• a(1) A variety of systematic approaches are in place to ensure and improve many 

aspects of responsible governance, which meets key stakeholder expectations. For 

example, the Board of Directors (BOD) evaluates monthly Status Reports/Topline 

Scorecards to ensure accountability for senior leaders’ actions and achieves fiscal 

accountability through reviews of financial reports. Transparency is achieved through 

the availability of minutes, presentations, and reports. In addition, an annual external 

audit maintains independence and effectiveness in audits. These approaches are 

systematically evaluated and improved through Plan-Do-Check-Act (PDSA).

• b The BOD and senior leaders ensure legal and ethical behavior through multiple 

approaches, including the Corporate Compliance Program, which includes annual 

training and an anonymous hotline. BOD members come from the greater stakeholder 

community, and the Crisis Communication Plan addresses public concerns if needed. 

Senior leaders strictly adhere to policies and procedures for organ allocation and 

regularly review all audit report findings. These approaches reinforce LOTS’s value of 

honesty and may help leverage its strategic advantage of a supportive, mission-driven 

culture.

• c(2) Through the Community Support Determination Process (Figure 1.2-3), LOTS

systematically identifies key communities and activities to support, with a review and 

assessment step to evaluate results and determine future participation. Identification is 

based on feedback from donor families, transplant recipients, workforce members, and 

community partners. This approach aligns with the mission, vision, and values in 

determining allocation of time, treasure, and talent.

OPPORTUNITIES FOR IMPROVEMENT 

• a(2) It is unclear how the CEO evaluates senior leaders, how evaluations are used to 

advance leadership development and improve effectiveness, or how evaluations of the 

LT and BOD are used to improve the Leadership System. A systematic approach in this 

area may help LOTS address its strategic challenge of workforce retention.

• a(2) It is unclear how senior leaders personally contribute to improving key 

communities in concert with the workforce. With an approach in this area, senior 

leaders may be better able to model LOTS’s value of teamwork.
Malcolm Baldrige National Quality Award—2020 Feedback Report 12

Category 2 Strategy

2.1 Strategy Development

Your score in this Criteria item for the Consensus Review is in the 50–65 percentage range. 

(Please refer to Figure 5a, Process Scoring Guidelines.) 

STRENGTHS 

• a(1) LOTS’s nine-step SPP benefits from broad participation and an annual cycle of 

evaluation and improvement, providing the context for ongoing decision making, 

resource allocation, and overall management. Participants consist of the LT, BOD, 

customers, frontline staff, key partners, and key suppliers, with additional input from 

the Organ Procurement and Transplantation Network. The strategic time frame includes 

short-term and long-term targets and objectives.

• a(4) LOTS’s systematic, well-deployed approach to deciding which key processes will 

be accomplished by internal or external resources supports its efforts to determine 

measures that drive cost-effectiveness and efficiency. During step 5 of the SPP (Assess & 

Review), LOTS considers suppliers and partners that could provide capabilities that it 

does not possess, thereby making outsourcing an option. Each outsourcing opportunity 

is evaluated, and the ultimate decision made, through a defined make/buy process. 

• a(3) LOTS’s comprehensive approach to collecting and analyzing data for use in the 

SPP enhances its ability to effectively address strategic challenges, such as industry 

changes and authorizations. LOTS collects data from industry and nonindustry sources. 

Feedback is obtained from various stakeholder groups, and ongoing strategic 

discussions include a review of changes impacting LOTS’s ability to execute its strategic 

plan. 

• b(1) LOTS’s key strategic objectives and organizational goals are aligned with strategic 

challenges, strategic advantages, measures, results, and short-term and long-term goals

(Strategic Linkages, Figure 2.1-3). Key upcoming changes include the development of 

new marketing partnerships, with a “check-the-box” campaign with the Department of 

Motor Vehicles (DMV) and a new “Workplace for Life” campaign. Such alignment, and 

accompanying timetables, enhance LOTS’s ability to ensure that organs and tissue are 

readily available to patients when they need them.

OPPORTUNITIES FOR IMPROVEMENT 

• a(2) It is not clear how LOTS stimulates and incorporates innovation in its strategy 

development process; there is no description of how the Innovation Risk Board explores 

the enterprise for scalable innovations or how strategic discussions promote “out-ofthe-box” thinking to stimulate innovation. A systematic approach may help LOTS ingrain 

its new innovation value.
Malcolm Baldrige National Quality Award—2020 Feedback Report 13

• b(2) It is not clear how LOTS’s strategic objectives achieve an appropriate balance 

among all aspects of varying and potentially competing organizational needs. For 

example, LOTS does not describe how it balances short- and longer-term planning 

horizons in its strategic objectives or how those objectives address LOTS’s core 

competency. A systematic approach may help place LOTS in a strong financial position 

to address its strategic objective of maximizing organizational excellence.
Malcolm Baldrige National Quality Award—2020 Feedback Report 14

2.2 Strategy Implementation

Your score in this Criteria item for the Consensus Review is in the 50–65 percentage range. 

(Please refer to Figure 5a, Process Scoring Guidelines.) 

STRENGTHS 

• a(1) LOTS systematically develops the action plans required to carry out strategic 

objectives and achieve organizational goals, with clear linkages to strategic objectives 

(Figure 2.1-3). Development begins in strategic discussions through the SPP and is a 

cooperative effort between the LT and employees. Strategic objectives, organizational 

goals, and key action plans are cascaded to the workforce.

• a(3) LOTS’s systematic resource allocation process facilitates the achievement of 

action plans while it meets current obligations to maximize organizational excellence. A 

detailed review of action plans during strategic planning ensures alignment with 

strategic objectives, resource availability, and a summary discussion of workforce 

capabilities and capacities to identify adequacy and development resources. The 

comprehensive budgeting process enables simultaneous support of ongoing operations 

and action plans.

• b A standardized review process allows LOTS to modify action plans and proactively 

address its strategic challenge of industry change. Reviews occur during work system 

meetings, LT meetings, and ongoing strategic discussions (Figure 2.1-1). Lagging 

performance measures are identified, and new action plans are created or existing 

action plans modified to address the measures. New and modified action plans are 

deployed through activities that flow from the work system or department level to the 

individual level. Modified action plans are tracked and discussed during LT meetings and 

anchored to strategic objectives.

OPPORTUNITIES FOR IMPROVEMENT 

• a(5) The measures presented in Strategic Linkages (Figure 2.1-3) do not appear to 

track the achievement and effectiveness of action plans. For example, the measures for 

SO1, Maximize Donations, are tied to goals: increase organ donors, increase organs 

transplanted, and increase bone donors; the sample action plans include “identify and 

pursue potential partnerships with nonhospital referral sources,” yet there are no 

corresponding measures. Such measures may help employees at all levels understand 

the work they must do to help LOTS be successful.

• a(4) It is not clear how LOTS’s “Right Size Workforce Plan” (Figure 2.1-3) addresses 

potential impacts on retention and short-term versus longer-term needs for 

accomplishing goals and action plans, as key workforce plans are not evident. Specific 

plans relating to LOTS’s strategic challenge of workforce retention may help the 

organization capitalize on its core competency of a mission-driven workforce.
Malcolm Baldrige National Quality Award—2020 Feedback Report 15

• a(2) It is not clear how the deployment of action plans to key suppliers and partners 

ensures the successful accomplishment of those plans; whether the plans are deployed 

to key suppliers and partners for information only, or whether they contribute to the 

accomplishment of plans, is not clear. Leveraging the contributions of all stakeholders to 

accomplish action plans may provide a broader perspective on LOTS’s value of 

teamwork.
Malcolm Baldrige National Quality Award—2020 Feedback Report 16

Category 3 Customers

3.1 Customer Expectations

Your score in this Criteria item for the Consensus Review is in the 70–85 percentage range. 

(Please refer to Figure 5a, Process Scoring Guidelines.) 

STRENGTHS 

• a(1) LOTS’s multiple listening methods span the customer life cycle (Figure 3.1-1) and 

benefit from evaluation and improvement. Through a cycle of learning, LOTS now uses 

social media to share information, answer questions, and encourage donor registration. 

These methods support LOTS in meeting its strategic objective of optimizing stakeholder 

relationships.

• a(2) LOTS’s methods of listening to potential tissue processor customers help identify 

key opportunities by incorporating knowledge, data, and other OPO resources. This 

process resulted in the addition of two additional tissue processors in 2017. 

• b(1) The LT and work system leaders review learning, information on customers, and 

markets and service offerings in order to systematically determine customer groups to 

emphasize for business growth and to anticipate future customer groups and 

requirements within the Designated Service Area. Strategic discussions are held during 

step 9 of the SPP, with the information gathered through a variety of approaches, 

including the PMS, voice-of-the-customer (VOC) methods, and the OMP. 

• b(2) LOTS uses its VOC approaches (Figure 3.1-1) to identify customer needs and 

requirements, with the information then used in the SPP and to design work processes. 

For example, ongoing two-way interactions with customers enable collection of the VOC 

during phases of the life cycle; best-practice sharing allows broad transfer of the VOC to 

both work systems. In addition, the Corrective Action Preventive Action (CAPA) system

uses VOC information to improve the work systems. This approach may enable LOTS to 

leverage the strategic opportunity related to customer satisfaction.

OPPORTUNITIES FOR IMPROVEMENT 

• a(1) It is not clear how LOTS uses its various VOC mechanisms (Figure 3.1-1) as a 

systematic approach for listening to, interacting with, and observing key customers, and 

then integrates the input to create actionable information. Without such an approach, 

LOTS may not ensure that it can mitigate the strategic challenge of increasing registry.

• a(2) It is not clear how LOTS systematically uses its relationship management methods 

(i.e., interactions at industry conferences and webinars) to listen to former and 

competitors’ customers to obtain actionable information on its services, customer 
Malcolm Baldrige National Quality Award—2020 Feedback Report 17

support, and transactions. A systematic approach may help create improvement and 

innovation opportunities.

• b(2) LOTS does not appear to systematically identify and adapt product offerings to 

attract new customers based on the multiple inputs it collects and evaluates. This 

includes adapting offerings for the tissue work system (TWS) and identifying new 

services for the organ work system (OWS). A systematic approach may help LOTS

address the strategic opportunity of registry enrollment.
Malcolm Baldrige National Quality Award—2020 Feedback Report 18

3.2 Customer Engagement

Your score in this Criteria item for the Consensus Review is in the 50–65 percentage range. 

(Please refer to Figure 5a, Process Scoring Guidelines.) 

STRENGTHS 

• a(1) LOTS uses multiple systematic methods (Figure 3.1-1) to build a public awareness 

program intended to increase the number of donor registrations in the region, with 

improvements evident. Approaches include print materials, web materials, social media, 

and partnerships with the DMVs in NT and ST. Private, closed Facebook groups were 

created in response to donor family requests. These approaches may help LOTS build 

relationships with patients and other customers.

• a(2) The systematic, well-deployed VOC Process for organ and tissue products (Figure 

3.1-1) and the Communication Process (Figure 1.1-3) enable customers to seek 

information and support. Additionally, transplant centers and tissue processors receive 

support and conduct business with 24/7 phone and website access and daily 

interactions at customer meetings. This approach may help LOTS maximize organ and 

tissue donations.

• a(3) In support of its strategic objective and organizational goals related to maximizing 

stakeholder relationships, the systematic, well-deployed, and integrated Customer 

Complaint Process (Figure 3.2-2) helps LOTS create a positive experience in all of its 

interactions. All staff are trained in service recovery, and frontline staff are empowered 

to implement immediate corrective action at the point of service. Customer complaint 

trend data are incorporated into the SPP for process improvement.

• b LOTS has systematic, well-deployed, and integrated processes to determine 

customer satisfaction, dissatisfaction, and engagement through its survey processes and 

the Deviation and Complaint Process, which is part of the CAPA system. Through 

collaboration with other OPOs, LOTS obtains information on satisfaction relative to 

other organizations that provide similar products and services. These approaches 

support LOTS’s ability to meet the customer requirements of maximizing donation and 

transplant organs.

OPPORTUNITIES FOR IMPROVEMENT 

• b(2) It is not evident that LOTS systematically obtains information on TWS customer 

satisfaction relative to the satisfaction of customers of other organizations providing 

similar services; in-process actions, such as seeking information about customer 

satisfaction with other OPOs and sharing best practices with other OPOs, do not appear 

to constitute a systematic approach. Systematic comparisons to other OPOs may

uncover ways to increase customer satisfaction.
Malcolm Baldrige National Quality Award—2020 Feedback Report 19

• b(1) It is not clear that the survey methods and measures LOTS uses to capture 

customer satisfaction and engagement provide actionable information. For example, it 

is not evident how root-cause analysis of recent survey results and Baldrige feedback, 

which identified a need to improve relationships with tissue processors, drives

actionable information for improvement efforts. A systematic approach may help LOTS

improve relationships with tissue processors.

• c A systematic approach to use VOC and market data and information to build a more 

customer focused culture and support operational decision making is not evident; it is 

not evident how LOTS uses the data that it collects, analyzes, and shares. This may limit 

efforts to improve customer satisfaction and engagement.
Malcolm Baldrige National Quality Award—2020 Feedback Report 20

Category 4 Measurement, Analysis, and Knowledge Management

4.1 Measurement, Analysis, and Improvement of Organizational Performance

Your score in this Criteria item for the Consensus Review is in the 50–65 percentage range. 

(Please refer to Figure 5a, Process Scoring Guidelines.) 

STRENGTHS 

• a(1) LOTS systematically selects, collects, aligns, and integrates data and information 

for tracking daily operations and overall performance through the SPP, with good 

deployment and integration with other approaches. The PMS (Figure 4.1-1) defines the 

process for defining measures, collecting, transferring, and using data and information 

for review and improvement. The Topline Scorecard (Figure 4.1-2) shows actual 

measures vs. targets in a green-yellow-red approach. These measures drill down to 

department-level scorecards. This approach may assist LOTS in achieving its strategic 

objective to maximize organizational excellence.

• a(2) LOTS’s systematic approach to selecting comparative data and information drives 

operational excellence by supporting performance measurement, analysis, review, and 

organizational planning and improvement. The Comparative Data Process (Figure 4.1-4) 

is used to select key comparative data and information. LOTS also relies on data-sharing 

collaborations with other OPOs, tissue processors, and eye banks. Once collected, the 

comparative data are evaluated, prioritized, selected, and incorporated into the PMS

(Figure 4.1-1), and identified gaps drive improvement.

• b Systematic review of LOTS’s performance helps ensure that the organization makes 

fact-based decisions on changes that may require modification of action plans to meet 

goals. Senior leaders review key performance measures during monthly Operational 

Discussions and quarterly Capability and Capacity meetings. The BOD reviews Topline 

Scorecard metrics (Figure 4.1-2), monthly financial statements, and progress reports on 

strategic objectives and action plans. The LT reviews department scorecards available in 

the Data Mall. 

• c(1) In a systematic approach, LOTS analyzes historical organizational trends for three 

years, as well as industry trends, to set projections for future performance. When

comparisons are available, LOTS prepares a course of action for improvement or action 

plans to close any gaps.

OPPORTUNITIES FOR IMPROVEMENT 

• a(3) It is not clear how LOTS systematically adds, replaces, or eliminates measures 

rapidly in its PMS. A systematic approach may increase LOTS’s ability to respond rapidly 

to changes in its operating environment, especially given the importance of regulatory 

compliance to LOTS.
Malcolm Baldrige National Quality Award—2020 Feedback Report 21

• c(2) It is not clear how LOTS uses findings from performance reviews to develop 

priorities for improvement and opportunities for innovation. Systematic use may enable 

the organization to effectively use its resources for improvement.

• a(2) LOTS’s use of the Comparative Data Process (Figure 4.1-4) does not appear to 

align with its long-term goal of national top-decile performance. The process does not 

appear to have a step to reset the evaluation criteria when appropriate, and in multiple 

instances where LOTS’s performance is better than the top-quartile benchmark, the topquartile comparative benchmarks are still used. Resetting comparative targets to reflect 

top-decile performance when the interim top-quartile goal has been achieved may 

enable LOTS to drive its performance toward that long-term goal.
Malcolm Baldrige National Quality Award—2020 Feedback Report 22

4.2 Information and Knowledge Management

Your score in this Criteria item for the Consensus Review is in the 50–65 percentage range. 

(Please refer to Figure 5a, Process Scoring Guidelines.) 

STRENGTHS 

• b(1) To systematically build organizational knowledge, LOTS collects a variety of data 

from customers and stakeholders, combined with clinical information captured through 

electronic medical records. For example, a correlation analysis of the Scientific Registry 

of Transplant Recipients with data from recent internal organ yield cases provided 

information to validate future performance projections. The OMP includes a variety of 

mechanisms for transfer of relevant knowledge to the organization and to customers, 

suppliers, partners, and collaborators. This approach reinforces LOTS’s values of quality 

and innovation.

• b(3) The coalescing of resources linked to the LDS (Figure 5.2-2) helps LOTS embed 

learning in the way it operates. The LDS begins with the identification of learning needs

and involves various resources, such as training, leadership development, conferences, 

networking, knowledge sharing, sharing forums, and other internal and external 

learning. The LDS is used to align and integrate multiple organizational work processes. 

In addition, organizational learning is linked to expected outcomes in employee goal 

plans.

• b(2) LOTS’s approach to best practices is systematic and deployed across the 

organization’s work systems, with learning evident. When units or operations are 

recognized as high performing, stretch goals or benchmarks are put in place, and best 

practices are shared. For example, LOTS identified a process to address family needs 

prior to donation approval; the process, considered a best practice, was shared across 

work systems and the industry, and resulted in a cycle of learning that produced higher 

levels of satisfaction for families.

• a(2) Systematically ensuring and improving data availability supports LOTS’s core 

competency of a mission-driven workforce, augmented by the efforts of partners, 

collaborators, and suppliers. Access to electronic systems is user-friendly, and the 

intranet can be accessed only via direct access software. There is real-time access for 

staff and partners. A cycle of learning resulted in the formation of a user committee to 

ensure that software and hardware are user-friendly. 
Malcolm Baldrige National Quality Award—2020 Feedback Report 23

OPPORTUNITIES FOR IMPROVEMENT 

• a(1), b(1) It is not clear how quality and knowledge management processes are 

routinely evaluated for potential improvement. Such evaluation and improvement may 

help address the business strategic challenge of industry changes.

• b(1) It is not clear how LOTS systematically transfers workforce knowledge in support 

of its core competency of a mission-driven workforce. In particular, the process for 

transfer of workforce knowledge through alignment of the workforce with the work 

systems is not evident.
Malcolm Baldrige National Quality Award—2020 Feedback Report 24

Category 5 Workforce

5.1 Workforce Environment

Your score in this Criteria item for the Consensus Review is in the 70–85 percentage range. 

(Please refer to Figure 5a, Process Scoring Guidelines.) 

STRENGTHS 

• a(2) The Hiring Process promotes a strong cultural fit for new employees through 

diverse recruiting approaches and a three-step interviewing process, which benefit 

from evaluation and improvement cycles. Recent process improvements include 

shadowing, interview discussions about values, and peer mentors. Promoting a strong 

cultural fit for new employees may help reinforce LOTS’s core competency of a 

mission-driven workforce.

• a(3) Consistent with the value of teamwork, LOTS’s systematic, well-deployed 

Workforce Planning Process (Figure 5.1-1) anticipates and manages changes to 

capability and capacity needs; the approach is integrated with multiple organizational 

approaches. Planned work connects employees and processes to the OWS/TWS and 

the SPP through cascading goals and cross-training. The LT analyzes current and future 

workforce needs annually. These approaches integrate the Hiring Process, LDS, PEP, 

and SPP, among other approaches. One cycle of improvement for the Workforce 

Planning Process is the creation of a resource pool to address staffing needs during 

growth periods.

• a(1) LOTS’s systematic, well-deployed assessment of workforce capability and 

capacity, along with integration with other approaches, ensures the skills, 

competencies, and staffing levels needed and supports a mission-driven culture. 

Assessment, including the potential for new competencies, is addressed by the 

Workforce Planning Process. This enables planning to integrate with the SPP, Rounding 

for Outcomes, LDS, PMS, strategic discussions, and the Communication Plan.

• b(1) LOTS’s integrated approach to workplace health, security, and accessibility 

provide a work environment conducive to supporting the workforce to accomplish the 

mission. Facility security is addressed through actions such as automatic locking doors, 

badge required entry, and 24/7 video surveillance. Performance measures address 

workplace health, security, and accessibility. A recent cycle of learning addressed offsite 

employees and resulted in personal alarms for all employees as well as various securityfocused training programs.

OPPORTUNITIES FOR IMPROVEMENT 

• a(1,4), b(2) It is not clear how some workforce environment processes, such as 

capability and capacity needs, work accomplishment, and workforce benefits and 
Malcolm Baldrige National Quality Award—2020 Feedback Report 25

policies, are evaluated to identify and make improvements. Fact-based, systematic 

evaluation may identify improvements to help address the strategic challenge of 

workforce retention.

• a(4) It is unclear how LOTS’s workforce management capitalizes on its core 

competency of care and compassion delivered by the human touch, especially with 

regard to processes following the hiring process to reinforce the cultural fit. Ongoing 

reinforcement of that core competency may help LOTS sustain its strategic advantage of 

a supportive, mission-driven culture.
Malcolm Baldrige National Quality Award—2020 Feedback Report 26

5.2 Workforce Engagement

Your score in this Criteria item for the Consensus Review is in the 70–85 percentage range. 

(Please refer to Figure 5a, Process Scoring Guidelines.) 

STRENGTHS 

• a(1) In a well-deployed approach resulting from a cycle of learning, drivers of 

workforce engagement are determined through customized workforce surveys 

developed by a new vendor selected to gain a deeper understanding of these drivers. 

This new approach allows direct input from the workforce on the key drivers of 

engagement, as well as providing additional benchmark data from large cohort of health 

care organizations and an OPO/blood donation facility. This approach may contribute to 

creating and sustaining a mission-driven culture.

• b Multiple systematic approaches, with cycles of improvement, enable and reinforce 

the organizational culture of open communication, high performance, and engagement. 

Examples include the LS, PMS, and SPP. Improvements include Stoplight Reports for 

staff meetings, Café CEO lunches in small-group settings, and the inclusion of donor 

families and recipients in meetings to share their personal stories. These approaches 

may help LOTS prepare the workforce for the strategic challenge of industry changes.

• c(2) To support high performance and workforce development, LOTS integrates the 

LDS with multiple systems and processes, including the SPP, PMS, LS, and Innovation 

Management Process, with improvements evident. All employees have taken 

compliance training and a new course on innovation and intelligent risk taking; crosstraining is provided as needed. Process improvements include two-stage new employee 

orientation, the addition of skill days, and a formal exit interview process. This dual 

focus on organizational performance and personal development needs reinforces the 

values of teamwork and innovation.

• c(1) Through integration with multiple systems and processes, including the PEP, PMS, 

SPP, LDS, and Compensation System, the WPMS systematically supports high 

performance across LOTS. The PEP supports setting goals, cascading them to the 

individual contributor level, setting action plans for improvement, and conducting 

annual evaluations. These performance evaluations were combined with triennial 

market-based compensation evaluations by external consultants.

• c(4) The systematic, well-deployed LDS is used to manage career development 

planning, helping LOTS strengthen its core competency of a mission-driven workforce. 

Through the LDS, LOTS identifies and evaluates learning and development needs, builds 

staff knowledge through learning, shares knowledge, and evaluates effectiveness. 

Career development planning supports horizontal transitions to different roles and 

includes formal development and mentoring. Professional and personal development 

opportunities and cross-training for all staff members and leaders are a BOD policy.
Malcolm Baldrige National Quality Award—2020 Feedback Report 27

OPPORTUNITIES FOR IMPROVEMENT 

• a(2) It is not clear what methods LOTS uses to determine workforce satisfaction. A 

systematic approach may provide insights to help LOTS address its strategic challenge of 

workforce retention.

• c(1,4) It is not clear how performance management and career development 

approaches are evaluated for potential improvements. Such evaluation may support 

LOTS’s strategic advantage of a supportive, mission-driven culture.

• c(1) The process within the WPMS to incentivize, support, reinforce, and reward 

intelligent risk taking when considering strategic opportunities for innovation is not 

clear. A systematic approach in this area may help leverage LOTS’s value of innovation.
Malcolm Baldrige National Quality Award—2020 Feedback Report 28

Category 6 Operations

6.1 Work Processes

Your score in this Criteria item for the Consensus Review is in the 50–65 percentage range. 

(Please refer to Figure 5a, Process Scoring Guidelines.) 

STRENGTHS 

• a(2), b(2) In support of its mission to save and improve lives, LOTS determines key 

work and support processes through a systematic, integrated approach that includes 

regular cycles of learning. The approach begins with the OMP (Figure 6.1-1), which uses 

listening and learning methods to identify key processes (Figures 6.1-2A and 6.1-2B). 

The SPP integrates support and work processes to facilitate coordination, operational 

support, and outcomes through the use of surveys, feedback, and informal interactions. 

Process improvements include the introduction of an information card for physicians 

and nurses to use in donation discussions.

• c LOTS systematically selects suppliers and manages its supply network, which 

includes traditional and nontraditional suppliers (e.g., hospitals) and key nonreferral 

suppliers; cycles of learning are evident. Selection is based on organizational alignment, 

and services provided by referral partners consistently meet customer needs. 

Expectation setting and outcome monitoring aid in managing suppliers; poorly 

performing suppliers that do not improve are replaced. Cycles of learning include 

supplier improvement meetings and a report card for tracking suppliers. These 

approaches may help LOTS achieve the strategic objective of maximizing stakeholder 

relationships.

• d LOTS systematically pursues opportunities for innovation (Figure 6.1-3). The 

Innovation Management Team considers the innovation based on its potential value. If 

it is implemented, results are evaluated, and the Innovation and Risk Board may stop 

projects if deemed necessary. An example is the recently outsourced Organ Biopsy 

Process, which decreased costs and increased customer satisfaction. The approach may 

further the vision of organs always being available.

OPPORTUNITIES FOR IMPROVEMENT 

• a(1), b(3) In two areas, LOTS’s approach to designing and improving work processes 

does not appear to be systematic. First, it is not clear how inputs to the selection and 

determination of work processes (e.g., PMS, Rounding for Outcomes, VOC/VOS, and 

information on environment, technology, risk, and agility; Figure 6.1-1) are considered 

in determining key work process requirements. Additionally, LOTS’s method for 

improving processes (e.g., the use of PDSA to reduce variability) does not appear to be 

used for support processes. A systematic approach may reinforce the strategic 

advantage of stakeholder satisfaction. 
Malcolm Baldrige National Quality Award—2020 Feedback Report 29

• b(1) It is not clear how some in-process measures, such as organ donor in-house cases 

and skin yield, relate to end-product quality and performance measures, such as local 

organs transplanted or skin donors released (Figure 6.1-2A). LOTS may achieve greater 

efficiency in process management by identifying in-process measures that consistently 

drive outcome measures.

• a(3) Beyond the identification of key inputs, the OMP (Figure 6.1-1) does not appear 

to constitute a systematic process for the design of products and work processes. For 

example, the actual process to design products and processes is not described; nor is it 

clear how LOTS incorporates new technology, risk, and need for agility into design. A 

fully systematic approach may enable LOTS to address strategic business and 

operational challenges.
Malcolm Baldrige National Quality Award—2020 Feedback Report 30

6.2 Operational Effectiveness

Your score in this Criteria item for the Consensus Review is in the 50–65 percentage range. 

(Please refer to Figure 5a, Process Scoring Guidelines.) 

STRENGTHS 

• b LOTS deploys systematic approaches to ensure security and cybersecurity, including 

means for detection, prevention, backup, and recovery. Improvements such as the 

Information Protection Program and a dedicated cybersecurity team enhance 

awareness of emerging threats. The Technology Refresh Process ensures leading-edge 

technology and security. These approaches assist in protecting sensitive customer and 

donor information and may address the strategic challenge of increasing donor registry.

• a Systematic initiatives and methods to manage cost, process efficiency, and 

effectiveness, with fact-based evaluation for potential improvement, help LOTS

continue strengthening its financial position. Examples include reduction of cycle times 

for organ offers (Figure 6.2-1), an in-house operating room, and an annual audit to drive 

operational effectiveness. These methods are integrated with PDSA (for improvement), 

OMP and PMS (for cost of operations), group purchasing agreements, and capability and 

capacity meetings; preventive measures reduce maintenance costs.

• c(2) The systematic, regularly improved Emergency Response Plan provides for 

disaster preparedness, allowing work systems to continue unimpeded to satisfy 

customer and operational requirements. A variety of scenarios are proactively 

anticipated; for example, remote access capability allows work to continue 

uninterrupted, and planning and reciprocal agreements with other OPOs and local 

hospital allow for short-term staffing and facilities support. Longer-term events have 

alternate contingency plans. The plan undergoes regular testing, and results are 

analyzed for improvement. 

OPPORTUNITIES FOR IMPROVEMENT 

• a It is not evident how LOTS balances the need for cost control and efficiency with the 

needs of the customer. For example, it is not clear how such balance was ensured for 

cost savings achieved through an in-house operation room or for TWS efficiencies that 

allow increases in donor volume without adding workforce. Ensuring appropriate 

balance may reinforce the partnership model (Figure P.1-2), in which collaboration with 

customers, partners, suppliers, and stakeholders demonstrates the values of teamwork 

and quality, resulting in lives saved.

• c(1) Approaches used to provide a safe operating environment are in the early stages 

of deployment. For example, it is unclear how LOTS provides a safe working 

environment for decentralized workforce members, how the organization ensures that 

suppliers meet safety needs, how failure analysis and recovery are performed so as to 
Malcolm Baldrige National Quality Award—2020 Feedback Report 31

prevent future safety failures, and how the system uses inspection to enhance the 

safety of the operating environment. More comprehensive deployment may help 

address the customer requirement of a safe working environment.

• b It is not clear how the Information Protection Plan has been deployed to ensure the 

security and cybersecurity of data and information for customers, key stakeholders, and 

employees working in customer locations, or to secure some key assets, such as the new 

facility housing a critical care unit and an operating room. Full deployment may enable 

LOTS to address the challenge of increasing its registry of organ donors.
Malcolm Baldrige National Quality Award—2020 Feedback Report 32

Category 7 Results

7.1 Product and Process Results

Your score in this Criteria item for the Consensus Review is in the 50–65 percentage range. 

(Please refer to Figure 5b, Results Scoring Guidelines.) 

STRENGTHS 

• a Many measures of importance to key stakeholder requirements (Figure P.1-6) 

show beneficial trends, and some are approaching or are slightly better than the 

benchmarks given. These include results for organ and tissue transplantation by 

population (Figures 7.1-4, 7.1-6, and 7.1-7), for local transplantation (Figures 7.1-10 

through 7.1-14), as well as for Tissue Referrals (Figure 7.1-3), Organ Authorization 

(Figure 7.1-5), and Age-Targeted Bone Donors Released (Figure 7.1-8). These results 

support LOTS’s mission of saving and improving lives.

• b(1) Work process effectiveness results demonstrate beneficial trends and good-toexcellent levels that approach or exceed top-quartile comparisons. Examples include 0% 

missed organ referrals (Figure 7.1-16); tissue authorization, which shows improvement 

and is consistently above the Association of Organ Procurement Organizations (AOPO)

top quartile (Figure 7.1-18); and organ donor cases in-house (Figure 7.1-21), which has 

been above the AOPO top quartile for three consecutive years. These results reinforce 

the strategic advantage of a supportive, mission-driven culture and address the 

challenges of authorization and increasing registry.

• b(2) LOTS reports good-to-excellent levels with beneficial and sustained trends for 

safety and emergency preparedness. For example, the percentage of safe workplace 

training completed has been 100% in the past two years (Figure 7.1-30). Safety drills 

(Figure 7.1-31) have met population and time requirements since 2018, and there is 

100% compliance in training, availability testing, data (communication) testing, and 

injury investigation (Figure 7.1-28) since 2016. These results demonstrate ongoing 

concern with safe practices for the benefit of the workforce, customers, and 

collaborators.

• c The supply-network management results presented demonstrate good levels with 

many beneficial trends. For example, supplier cremation cycle times have been reduced 

nearly 50% since 2017 (Figure 7.1-35); in addition, the electronic medical record supplier 

has significantly increased features since 2017 and has reduced defects from 20% to 

nearly zero since 2018 (Figure 7.1-36). These and similar results demonstrate LOTS’s 

success at partnering and close collaboration with its suppliers to reinforce the core 

competency of delivering care and compassion with the human touch.
Malcolm Baldrige National Quality Award—2020 Feedback Report 33

OPPORTUNITIES FOR IMPROVEMENT 

• b, c Some work process effectiveness and supply-network management results stated 

as important to LOTS are not provided. Examples are results for the supply-network 

requirements of accurate information, timely communication, and service quality, which 

are identified as significant for mission accomplishment. In addition, results are not 

provided for cybersecurity and innovation, organ rejection rate, lab requisition error 

rates, donor chart error rates, sterilizer accuracy, or radiation exposure. Monitoring 

these results may enable LOTS to be more responsive to industry changes.

• a Some results reflecting the strategic objective to maximize donations for the OWS 

and TWS demonstrate adverse trends. These include results for local pancreata 

transplanted (Figure 7.1-14), which has fallen below the benchmark, as well as results 

for the number of skin and bone donors (Figure 7.1-15).

• b(1),c LOTS demonstrates adverse trends in some work process effectiveness and 

supply-network management results. Examples include the observed vs. expected ratio 

for liver, heart, and pancreas (Figure 7.1-20) and a short-term mixed trend for the 

percentage of end-users who are phishing prone (Figure 7.1-38). Further emphasis in 

these areas may assist LOTS in addressing business and operational challenges.
Malcolm Baldrige National Quality Award—2020 Feedback Report 34

7.2 Customer Results

Your score in this Criteria item for the Consensus Review is in the 50–65 percentage range. 

(Please refer to Figure 5b, Results Scoring Guidelines.) 

STRENGTHS 

• a(1) Results for the overall satisfaction and engagement with organ transplant centers 

show high levels overall and for the key requirements of competence and information. 

For example, satisfaction with organ transplants improved from 2017 to 2019, with the 

2019 level at the GPR best in class (Figure 7.2-1). Satisfaction with competence and 

satisfaction with information (Figures 7.2-1A and 7.2-1B) are also at the GPR best-inclass level. These performance results support the effectiveness of the OWS.

• a(1) Sustained performance with regard to tissue processors helps ensure the ongoing 

satisfaction needed to achieve the vision of tissues always being available. Tissue 

processor satisfaction has shown sustained improvement to a level near 100% (Figure 

7.2-2); tissue processor results for the key requirements of accountability (Figures 7.2-

2A and 7.2.2B) also reflect sustained gradual improvement, as do results for satisfaction 

with information (Figure 7.2-2C).

• a(1) Customer dissatisfaction, as measured by the percentage of customers rating 

LOTS as poor or very poor in the survey, shows improving levels at or approaching zero 

(Figure 7.2-4A). These results support the strategic advantage of stakeholder 

satisfaction.

• a(2) Results for Facebook Followers (Figure 7.2-6) show a beneficial trend between 

2013 and 2019. This supports LOTS’s social media goal to increase the number of 

registered donors within the designated service area through campaigns and messaging. 

OPPORTUNITIES FOR IMPROVEMENT 

• a Many results relating to the satisfaction and engagement of key customers and 

partners do not include comparisons or benchmarks. Examples include results for tissue 

processor satisfaction and engagement (Figures 7.2-2, 7.2-2C, and 7.2-2D) and Customer 

Complaints (Figure 7.2-4). Lack of comparisons or benchmarks may create a blind spot 

for LOTS in assessing its performance.

• a(1) Results for satisfaction with the OWS are not segmented by organ (e.g., heart, 

liver, and lung) or by location (e.g., local organ transplant center). Segmented results 

may help LOTS identify opportunities for improvement and build the values of quality 

and innovation.

• a(2) Results for customer engagement across the customer life cycle are not reported. 

For example, Customer Complaints (Figure 7.2-4) does not include results for the eye 

bank, and complaint data are not segmented by stages of the customer life cycle. Such 
Malcolm Baldrige National Quality Award—2020 Feedback Report 35

results may help LOTS pursue the strategic opportunity of improving customer 

satisfaction.
Malcolm Baldrige National Quality Award—2020 Feedback Report 36

7.3 Workforce Results

Your score in this Criteria item for the Consensus Review is in the 50–65 percentage range. 

(Please refer to Figure 5b, Results Scoring Guidelines.) 

STRENGTHS 

• a(1,3) Several workforce capacity and workforce engagement results show beneficial 

trends and good performance against benchmarks for 2016–2019. Examples include 

Workforce Growth (Figure 7.3-4), with staffing levels sustained close to or at the AOPO 

top quartile, and Overall Benefits Satisfaction (for staff; Figure 7.3-17), with satisfaction 

increasing from about 87% to higher than 90%, better than the Excel Employee 

Engagement benchmark. These results support LOTS in meeting the workforce 

requirement of connection with the vision, mission, and values.

• a(1) Some capacity results show sustained beneficial trends in areas that support 

LOTS in mitigating its strategic challenge of retention. Examples include Promotions 

from Within (Figure 7.3-5) and Referrals as a Percentage of New Hires (Figure 7.3-6), 

both of which increased by 10 percentage points from 2017 to 2019. These beneficial 

trends may reinforce LOTS’s core competency of a mission-driven workforce. 

• a(3,4) Some workforce engagement and workforce development results show good 

performance against relevant comparators. Examples include Connection to Mission 

(Figure 7.3-11), sustained above the Excel Employee Engagement benchmark over four 

years; Training Expenditures (Figure 7.3-19), sustained above the AOPO top quartile; 

and Leadership Development Satisfaction (Figure 7.3-20), which is at the AOPO top 

quartile. These results may help LOTS address its strategic objective of maximizing 

organizational excellence.

OPPORTUNITIES FOR IMPROVEMENT 

• a(2) Most workforce climate results show mixed or flat trends for the periods shown. 

Examples include Wellness Screening Participation (Figure 7.3-7), Workplace Satisfaction 

with Safety (Figure 7.3-8, for the organization overall, OWS, and TWS), and Benefits 

Expenditures (Figure 7.3-10). Improving these results may address the workforce 

requirement for a healthy, safe, and secure work environment.

• a Some workforce engagement results lack relevant comparisons. Examples include 

Workplace Satisfaction with Safety (Figure 7.3-8); My Opinion Seems to Count (Figure 

7.3-13); and Overall Retention (Figure 7.3-15), which includes a comparison to the AOPO 

average. Use of relevant comparative data for these results may provide insights into 

opportunities for increasing satisfaction and engagement.
Malcolm Baldrige National Quality Award—2020 Feedback Report 37

• a(1,2,3) Many workforce-related results are not segmented by job type to provide 

more specific insights for addressing the workforce strategic challenge of retention. 

Examples are Promotions from Within (Figure 7.3-5); Referrals as a Percentage of New 

Hires (Figure 7.3-6); Days Away, Restricted, or Transferred (DART) Rate (Figure 7.3-9);

and Overall Retention (Figure 7.3-15). 
Malcolm Baldrige National Quality Award—2020 Feedback Report 38

7.4 Leadership and Governance Results

Your score in this Criteria item for the Consensus Review is in the 30–45 percentage range. 

(Please refer to Figure 5b, Results Scoring Guidelines.) 

STRENGTHS 

• a(3) LOTS demonstrates full regulatory and legal compliance since its inception (Figure 

7.4-4). It has received full accreditation from all voluntary accreditation agencies 

(American Association of Tissue Banks, AOPO) for the past three years and has had no 

adverse findings with the Department of Revenue or Food and Drug Administration.

• a LOTS reports good levels and beneficial trends in several areas of leadership and 

societal well-being. For example, results reflecting leaders’ engagement and 

communication with the workforce (Figures 7.4-1 and 7.4-2) show improving trends and 

levels ranging from 86% to about 97% from 2017 to 2019. In addition, Deaths on Local 

Waiting List (Figure 7.4-7) improved by about 40 from 2017 to 2019. These results 

reflect leaders’ efforts to increase communication and the customer requirement to 

maximize donation and transplant organs.

• a(1,2) Good performance relative to comparisons in two areas of leadership may help 

LOTS achieve its strategic objective to maximize stakeholder relationships: in Monthly 

Leader Rounding with Staff (Figure 7.4-2), LOTS is approaching the OPO Best, and in 

Board Self-Assessment (Figure 7.4-3), performance exceeds the Board Info benchmark. 

OPPORTUNITIES FOR IMPROVEMENT 

• a Results are missing for several areas of societal well-being, support of key 

communities, and fiscal responsibility. For example, results are not provided for 

environmental impact (e.g., recycling and energy conservation), for senior leader and 

staff support of key communities, or for internal or external audits. Tracking these 

results may support LOTS in achieving its strategic objective to maximize organizational 

excellence.

• a(1) Some leadership and governance results lack segmentation that may provide 

additional insights to address the strategic challenge of workforce retention. Examples 

include Perception of Leadership (Figure 7.4-1) and Monthly Rounding with Staff (Figure 

7.4-2), which are not segmented by job type or other workforce groups. 

• a(4) Corporate Compliance Hotline Issues (Figure 7.4-5) increased from 0 or 1 in 

2014–2018 to 4 in 2019 year-to-date. Analyzing and acting on these results may help 

LOTS achieve its strategic objective around regulatory and legal compliance.
Malcolm Baldrige National Quality Award—2020 Feedback Report 39

7.5 Financial, Market, and Strategy Results

Your score in this Criteria item for the Consensus Review is in the 50–65 percentage range. 

(Please refer to Figure 5b, Results Scoring Guidelines.) 

STRENGTHS 

• a(1) LOTS demonstrates beneficial trends in several key areas of financial 

performance, capitalizing on its strategic advantage of a strong financial position. For 

example, Total Gross Revenue (Figure 7.5-2) improved from 2016 to 2019, and Gross 

Revenue—OWS (Figure 7.5-2A) improved from under $25 million in 2016 to nearly $30 

million. In addition, Net Margin (Figure 7.5-4) as a percent of gross revenue increased 

from 10% in 2016 to slightly under 20% in 2019.

• a(1) LOTS reports good relative performance against comparators in most financial 

results, placing the organization in a strong position to manage future challenges. For 

example, consolidated results of operations (Figure 7.5-1), total gross revenue (Figure 

7.5-2), net margin (Figure 7.5-4), and total assets (Figure 7.5-10) show good relative 

performance against the AOPO top quartile; and operating reserves (Figure 7.5-9) shows 

good relative performance against that of Tissues Transformation.

• a(2) Marketplace performance results show beneficial trends and good performance 

against relevant comparators. For Organ Donor Cost Comparison (Figure 7.5-11), LOTS

outperforms the comparator for the past three years, and Average QAC Comparison—

All Organs (Figure 7.5-12) shows results better than those of the lowest-cost OPO for 

two of past three years. These results support cost containment, which is an essential 

area for LOTS’s transplant partners to remain competitive in the health care payer 

market.

OPPORTUNITIES FOR IMPROVEMENT 

• b Results are missing for several key strategy implementation measures. These 

include results for registry enrollment, a key strategic opportunity in LOTS’s 2019 

planning cycle, and for the achievement of individual action plans and modified action 

plans based on performance projection gaps and potential partnerships. Tracking such 

results may help LOTS’s leaders create a focus on action in support of its life-saving 

mission, and assess the potential viability and risks associated with strategic and action 

plan initiatives.

• a(1) Financial results in three areas of importance to LOTS do not meet benchmark 

performance levels. OWS Gross Revenue (Figure 7.5-2A) has been below the top 

quartile for four consecutive years, Days in Accounts Receivable (Figure 7.5-5) is closing 

the gap but has not reached the benchmark for four years, and Days Cash on Hand 

(Figure 7.5-8) fell below the top quartile in 2018 and 2019. Continuing emphasis on 
Malcolm Baldrige National Quality Award—2020 Feedback Report 40

these areas may help LOTS maintain a strong financial position to manage future 

challenges and address its strategic objective to maximize organizational excellence.
Malcolm Baldrige National Quality Award—2020 Feedback Report 41

APPENDIX A

The spider, or radar, chart that follows depicts your organization’s performance as represented 

by scores for each item. This performance is presented in contrast to the median scores for all 

2020 applicants at Consensus Review. You will note that each ring of the chart corresponds to a 

scoring range.

Each point in red represents the scoring range your organization achieved for the 

corresponding item. The points in blue represent the median scoring ranges for all 2020

applicants at Consensus Review. Seeing where your performance is similar or dissimilar to the 

median of all applicants may help you initially determine or prioritize areas for improvement 

efforts and strengths to leverage. 

[Spider chart to come when 2020 comparisons are available.]
Malcolm Baldrige National Quality Award—2020 Feedback Report 42

APPENDIX B

By submitting a Baldrige Award application, you have differentiated yourself from most U.S. 

organizations. The Board of Examiners has evaluated your application for the Malcolm Baldrige 

National Quality Award. Strict confidentiality is observed at all times and in every aspect of the 

application review and feedback. 

This feedback report contains the examiners’ findings, including a summary of the key themes 

of the evaluation, a detailed listing of strengths and opportunities for improvement, and scoring 

information. Background information on the examination process is provided below.

APPLICATION REVIEW

Independent Review

Following receipt of the award applications, the award process evaluation cycle (shown in 

Figure 1) begins with Independent Review, in which members of the Board of Examiners are 

assigned to each of the applications. Examiners are assigned based on their areas of expertise 

and with attention to avoiding potential conflicts of interest. Each application is evaluated 

independently by the examiners, who write observations relating to the scoring system 

described beginning on page 29 of the 2019–2020 Baldrige Excellence Framework. 
 

Malcolm Baldrige National Quality Award—2020 Feedback Report 43

Figure 1—Award Process Evaluation Cycle
 

Malcolm Baldrige National Quality Award—2020 Feedback Report 44

Consensus Review

In Consensus Review (see Figure 2), a team of examiners, led by a senior or master examiner, 

conducts a series of reviews, first managed virtually through a secure database called BOSS and 

eventually concluded through a focused conference call. The purpose of this series of reviews is 

for the team to reach consensus on comments and scores that capture the team’s collective 

view of the applicant’s strengths and opportunities for improvement. The team documents its 

comments and scores in a Consensus Scorebook. 

Step 1

Consensus Planning

Step 2

Consensus Review in 

BOSS

Step 3

Consensus Call

Step 4

Post–Consensus–Call 

Activities

• Clarify the 

timeline for the 

team to complete 

its work.

• Assign 

category/item 

discussion leaders.

• Discuss key 

business/ 

organization 

factors.

• Review all 

Independent 

Review 

evaluations—

draft consensus 

comments and 

propose scores. 

• Develop 

comments and 

scores for the 

team to review.

• Address 

feedback, 

incorporate 

inputs, and 

propose a 

resolution of 

differences on 

each worksheet.

• Review updated 

comments and 

scores.

• Discuss 

comments, 

scores, and all key 

themes.

• Achieve 

consensus on 

comments and 

scores.

• Revise comments 

and scores to 

reflect consensus 

decisions.

• Prepare final 

Consensus 

Scorebook.

• Prepare feedback 

report.

Figure 2—Consensus Review

Site Visit Review

After Consensus Review, the Judges Panel of the Malcolm Baldrige National Quality Award 

selects applicants to receive site visits based on the scoring profiles. If an applicant is not 

selected for Site Visit Review, the final Consensus Scorebook receives a technical review by a

highly experienced examiner and becomes the feedback report.
 

Malcolm Baldrige National Quality Award—2020 Feedback Report 45

Site visits are conducted for the highest-scoring applicants to clarify any uncertainty or 

confusion the examiners may have regarding the written application and to verify that the 

information in the application is correct (see Figure 3 for the Site Visit Review process). After 

the site visit, the team of examiners prepares a final Site Visit Scorebook. 

Step 1

Team Preparation

Step 2

Site Visit

Step 3

Post–Site–Visit Activities

• Review consensus 

findings.

• Develop site visit issues.

• Plan site visit.

• Make/receive 

presentations.

• Conduct interviews.

• Record observations.

• Review documents.

• Resolve issues.

• Summarize findings.

• Finalize comments.

• Prepare final Site Visit 

Scorebook.

• Prepare feedback report.

Figure 3—Site Visit Review

Applications and Site Visit Scorebooks for all applicants receiving site visits are forwarded to the 

Judges Panel for review (see Figure 4). The judges recommend which applicants should receive 

the Baldrige Award and identify any non-award recipient organizations demonstrating one or 

more Category Best Practices. The judges discuss applications in each of the six award sectors 

separately, and then they vote to keep or eliminate each applicant. Next, the judges decide 

whether each of the top applicants should be recommended as an award recipient based on an 

“absolute” standard: the overall excellence of the applicant and the appropriateness of the 

applicant as a national role model. For each organization not recommended to receive the 

Baldrige Award, the judges have further discussion to determine if the organization 

demonstrates any Category Best Practices. The process is repeated for each award sector.
 

Malcolm Baldrige National Quality Award—2020 Feedback Report 46

Step 1

Judges Panel Review

Step 2

Evaluation by Category

Step 3

Assessment of Top 

Organizations

• Applications

• Consensus Scorebooks

• Site Visit Scorebooks

• Manufacturing

• Service

• Small business

• Education

• Health care

• Nonprofit

• Overall strengths/ 

opportunities for 

improvement

• Appropriateness as 

national model of 

performance 

excellence

Figure 4—Judges’ Review

Judges do not participate in discussions or vote on applications from organizations in which 

they have a competing or conflicting interest or in which they have a private or special interest, 

such as an employment or a client relationship, a financial interest, or a personal or family 

relationship. All conflicts are reviewed and discussed so that judges are aware of their own and 

others’ limitations on access to information and participation in discussions and voting. 

Following the judges’ review and recommendation of award recipients, the Site Visit Review 

team leader edits the final Site Visit Scorebook, which becomes the feedback report.
 

Malcolm Baldrige National Quality Award—2020 Feedback Report 47

SCORING

The scoring system used to score each item is designed to differentiate the applicant in the 

various stages of review and to facilitate feedback. As seen in the Process Scoring Guidelines 

and Results Scoring Guidelines (Figures 5a and 5b, respectively), the scoring of responses to 

Criteria items is based on two evaluation dimensions: process and results. The four factors used 

to evaluate process (categories 1–6) are approach (A), deployment (D), learning (L), and 

integration (I), and the four factors used to evaluate results (items 7.1–7.5) are levels (Le), 

trends (T), comparisons (C), and integration (I).

In the feedback report, the applicant receives a percentage range score for each item. The 

range is based on the scoring guidelines, which describe the characteristics typically associated 

with specific percentage ranges.

As shown in Figures 6a and 6b, the applicant’s overall scores for process items and results items 

each fall into one of eight scoring bands. Each band score has a corresponding descriptor of 

attributes associated with that band. Figures 6a and 6b show the percentage of applicants 

scoring in each band at Consensus Review.
Malcolm Baldrige National Quality Award—2020 Feedback Report 48

Figure 5a—Process Scoring Guidelines (For Use with Categories 1–6)

SCORE DESCRIPTION

0% or 5%

• No systematic approach to item questions is evident; information is anecdotal. (A)

• Little or no deployment of any systematic approach is evident. (D)

• An improvement orientation is not evident; improvement is achieved by 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 question in 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 question in 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 question in 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 the early stages of alignment with the basic organizational needs identified in 

response to the Organizational Profile and other process items. (I)

50%, 55%, 

60%, or 65%

• An effective, systematic approach, responsive to the overall questions in 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, 

including innovation, are in place for improving the efficiency and effectiveness of key processes. (L)

• The approach is aligned with your overall organizational needs as identified in response to the 

Organizational Profile and other process items. (I)

70%, 75%, 

80%, or 85%

• An effective, systematic approach, responsive to multiple questions in the item, is evident. (A)

• The approach is well deployed, with no significant gaps. (D)

• Fact-based, systematic evaluation and improvement and organizational learning, including 

innovation, are key management tools; there is clear evidence of refinement as a result of 

organizational-level analysis and sharing. (L)

• The approach is integrated with your current and future organizational needs as identified in 

response to the Organizational Profile and other process items. (I)

90%, 95%, or 

100%

• An effective, systematic approach, fully responsive to the multiple questions in 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 through innovation 

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 current and future organizational needs as identified in 

response to the Organizational Profile and other process items. (I)
Malcolm Baldrige National Quality Award—2020 Feedback Report 49

Figure 5b—Results Scoring Guidelines (For Use with Category 7)

SCORE DESCRIPTION

0% or 5%

• There are no organizational performance results, or the results reported are poor. (Le)

• Trend data either are not reported or show mainly adverse trends. (T)

• Comparative information is not reported. (C)

• Results are not reported for any areas of importance to the accomplishment of your 

organization’s mission. (I)

10%, 15%, 

20%, or 25%

• A few organizational performance results are reported, responsive to the basic question in the 

item, and early good performance levels are evident. (Le)

• Some trend data are reported, with some adverse trends evident. (T)

• Little or no comparative information is reported. (C)

• Results are reported for a few areas of importance to the accomplishment of your 

organization’s mission. (I)

30%, 35%, 

40%, or 45%

• Good organizational performance levels are reported, responsive to the basic question in the 

item. (Le)

• Some trend data are reported, and most of the trends presented are beneficial. (T)

• Early stages of obtaining comparative information are evident. (C)

• Results are reported for many areas of importance to the accomplishment of your 

organization’s mission. (I)

50%, 55%, 

60%, or 65%

• Good organizational performance levels are reported, responsive to the overall questions in the 

item. (Le)

• Beneficial trends are evident in areas of importance to the accomplishment of your 

organization’s mission. (T)

• Some current performance levels have been evaluated against relevant comparisons and/or 

benchmarks and show areas of good relative performance. (C)

• Organizational PERFORMANCE RESULTS are reported for most KEY CUSTOMER, market, and PROCESS

requirements. (I)

70%, 75%, 

80%, or 85%

• Good-to-excellent organizational performance levels are reported, responsive to multiple

questions in the item. (Le)

• Beneficial trends have been sustained over time in most areas of importance to the 

accomplishment of your organization’s mission. (T)

• Many to most trends and current performance levels have been evaluated against relevant 

comparisons and/or benchmarks and show areas of leadership and very good relative 

performance. (C)

• Organizational PERFORMANCE RESULTS are reported for most KEY CUSTOMER, market, PROCESS, and 

ACTION PLAN requirements. (I)

90%, 95%, 

or 100%

• Excellent organizational performance levels are reported that are fully responsive to the 

multiple questions in the item. (Le)

• Beneficial trends have been sustained over time in all areas of importance to the 

accomplishment of your organization’s mission. (T)

• Industry and benchmark leadership is demonstrated in many areas. (C)

• Organizational PERFORMANCE RESULTS and PROJECTIONS are reported for most KEY CUSTOMER, market, 

PROCESS, and ACTION PLAN requirements. (I)
Malcolm Baldrige National Quality Award—2020 Feedback Report 50

1 Percentages are based on scores from the Consensus Review. Figures will be added when 

2020 results are available.

Figure 6a–Process Scoring Band Descriptors 

Band

Score

Band

Number

% Applicants 

in Band1

Process Scoring Band Descriptors

0–150 1

The organization demonstrates early stages of developing and 

implementing approaches to the basic Criteria questions, with deployment 

lagging and inhibiting progress. Improvement efforts are a combination of 

problem solving and an early general improvement orientation. 

151–200 2

The organization demonstrates effective, systematic approaches responsive 

to the basic questions in the Criteria, but some areas or work units are in 

the early stages of deployment. The organization has developed a general 

improvement orientation that is forward-looking. 

201–260 3

The organization demonstrates effective, systematic approaches responsive 

to the basic questions in most Criteria items, although there are still some 

areas or work units in the early stages of deployment. Key processes are 

beginning to be systematically evaluated and improved. 

261–320 4

The organization demonstrates effective, systematic approaches responsive 

to the overall questions in the Criteria, but deployment may vary in some 

areas or work units. Key processes benefit from fact-based evaluation and 

improvement, and approaches are being aligned with overall organizational 

needs. 

321–370 5

The organization demonstrates effective, systematic, well-deployed 

approaches responsive to the overall questions in most Criteria items. The 

organization demonstrates a fact-based, systematic evaluation and 

improvement process and organizational learning, including some 

innovation, that result in improving the effectiveness and efficiency of key 

processes. 

371–430 6

The organization demonstrates refined approaches responsive to the 

multiple questions in the Criteria. These approaches are characterized by 

the use of key measures and good deployment in most areas. 

Organizational learning, including innovation and sharing of best practices, 

is a key management tool, and integration of approaches with current and 

future organizational needs is evident. 

431–480 7

The organization demonstrates refined approaches responsive to the 

multiple questions in most Criteria items. It also demonstrates innovation, 

excellent deployment, and good-to-excellent use of measures in most areas. 

Good-to-excellent integration is evident, with organizational analysis, 

learning through innovation, and sharing of best practices as key 

management strategies. 

481–550 8

The organization demonstrates outstanding approaches focused on 

innovation. Approaches are fully deployed and demonstrate excellent, 

sustained use of measures. There is excellent integration of approaches 

with organizational needs. Organizational analysis, learning through 

innovation, and sharing of best practices are pervasive.
Malcolm Baldrige National Quality Award—2020 Feedback Report 51

1 Percentages are based on scores from the Consensus Review. Figures will be added when 

2020 results are available.

2

“Industry” refers to other organizations performing substantially the same functions, thereby 

facilitating direct comparisons.

Figure 6b—Results Scoring Band Descriptors

Band

Score

Band

Number

% Applicants 

in Band1 Results Scoring Band Descriptors

0–125 1

A few results are reported responsive to the basic Criteria questions, but 

they generally lack trend and comparative data. 

126–170 2

Results are reported for several areas responsive to the basic Criteria 

questions and the accomplishment of the organization’s mission. Some of 

these results demonstrate good performance levels. The use of comparative 

and trend data is in the early stages.

171–210 3

Results address areas of importance to the basic Criteria questions and 

accomplishment of the organization’s mission, with good performance being 

achieved. Comparative and trend data are available for some of these 

important results areas, and some beneficial trends are evident. 

211–255 4

Results address some key customer/stakeholder, market, and process 

requirements, and they demonstrate good relative performance against 

relevant comparisons. There are no patterns of adverse trends or poor 

performance in areas of importance to the overall Criteria questions and the 

accomplishment of the organization’s mission. 

256–300 5

Results address most key customer/stakeholder, market, and process 

requirements, and they demonstrate areas of strength against relevant 

comparisons and/or benchmarks. Beneficial trends and/or good 

performance are reported for most areas of importance to the overall 

Criteria questions and the accomplishment of the organization’s mission. 

301–345 6

Results address most key customer/stakeholder, market, and process 

requirements, as well as many action plan requirements. Results 

demonstrate beneficial trends in most areas of importance to the Criteria 

questions and the accomplishment of the organization’s mission, and the 

organization is an industry2leader in some results areas.

346–390 7

Results address most key customer/stakeholder, market, process, and action 

plan requirements. Results demonstrate excellent organizational 

performance levels and some industry2leadership. Results demonstrate 

sustained beneficial trends in most areas of importance to the multiple 

Criteria questions and the accomplishment of the organization’s mission.

391–450 8

Results fully address key customer/stakeholder, market, process, and action 

plan requirements and include projections of future performance. Results 

demonstrate excellent organizational performance levels, as well as national 

and world leadership. Results demonstrate sustained beneficial trends in all 

areas of importance to the multiple Criteria questions and the 

accomplishment of the organization’s mission. 
Malcolm Baldrige National Quality Award—2020 Feedback Report 52

2020 BALDRIGE AWARD APPLICANTS

BALDRIGE AWARD RECIPIENT CONTACT INFORMATION 1988–2019

Baldrige Award winners generously share information with numerous organizations from all 

sectors. 

To contact an award winner, please see https://www.nist.gov/baldrige/award-recipients, 

which includes links to contact information as well as profiles of the winners.

Sector Total Number of Award 

Applications

Number of Award 

Applicants 

Recommended for Site 

Visit

Health Care 11

Nonprofit 6

Education 1

Business–Small Business 2

Business–Service

Business–Manufacturing

Total 20