i

Contents

iii About the Baldrige Excellence Framework

The Baldrige framework empowers your organization to reach its goals, improve results, and become more 

competitive. The framework consists of the Criteria, the core values and concepts, and the scoring guidelines.

vii How to Use the Baldrige Excellence Framework

You can use this booklet as a reference, for self-assessment, or as the basis of an external assessment. 

1 Health Care Criteria for Performance Excellence Overview and Structure

The Health Care Criteria include the Organizational Profile and seven interconnected categories. 

3 Health Care Criteria for Performance Excellence

3 P Organizational Profile

P.1 Organizational Description

P.2 Organizational Situation

6 1 Leadership

1.1 Senior Leadership

1.2 Governance and Societal Contributions

10 2 Strategy

2.1 Strategy Development

2.2 Strategy Implementation

13 3 Customers

3.1 Customer Expectations

3.2 Customer Engagement

16 4 Measurement, Analysis, and Knowledge Management

4.1 Measurement, Analysis, Review, and Improvement of Organizational Performance

4.2 Information and Knowledge Management

19 5 Workforce

5.1 Workforce Environment

5.2 Workforce Engagement

22 6 Operations

6.1 Work Processes

6.2 Operational Effectiveness
ii 2023–2024 Baldrige Excellence Framework

25 7 Results

7.1 Health Care and Process Results

7.2 Customer Results 

7.3 Workforce Results

7.4 Leadership and Governance Results

7.5 Financial, Marketplace, and Strategy Results

30 Scoring System

Performance against Health Care Criteria items is scored on two evaluation dimensions: process and results.

32 Process Scoring Guidelines

33 Results Scoring Guidelines

35 Health Care Criteria for Performance Excellence Items and Point Values

37 How to Respond to the Health Care Criteria

This section explains how to respond most effectively to the Health Care Criteria item questions.

40 Core Values and Concepts

These embedded beliefs and behaviors form the foundation of the Health Care Criteria.

46 Changes from the 2021–2022 Baldrige Excellence Framework

48 Glossary of Key Terms

The glossary includes definitions of terms in small caps in the Health Care Criteria and scoring guidelines.

57 Index of Key Terms

60 List of Contributors

On the Web

Health Care Criteria Commentary

For each Criteria item, this commentary provides an in-depth explanation and additional examples to build users’ 

understanding.
3 Customers 15

3.2 Customer Engagement: How do you build relationships and enhance the patient and 

other customer experience? 

response to this itemType of information to provide in 

PROCESS

a. Patient and Other Customer Experience 

(1) Relationship Management How do you build and manage relationships with patients and other customers? 

How do you 

• build a more patient- and other customer-focused organizational culture,

• manage and enhance your brand, and

• meet patients’ and other customers’ requirements and exceed their expectations in each stage of their 

relationship with you?

(2) Patient and Other Customer Access and Support How do you enable patients and other customers to seek 

care from you, seek information, and obtain support? How do your processes or mechanisms vary for different 

patient and other customer groups or market segments, as appropriate? How do you

• determine your patients’ and other customers’ key support requirements and expectations, and

• deploy these requirements to all people and processes involved in patient and other customer support?

(3) Complaint Management How do you manage patient and other customer complaints? How do you resolve 

complaints promptly and effectively and recover your patients’ and other customers’ confidence? How do 

you analyze complaints and use this information to make the necessary changes to prevent future complaints?

(4) Fair Treatment How do your patient and other customer experience processes promote and ensure fair treatment for different patients, patient groups, other customer groups, and market segments?

b. Determination of Patient and Other Customer Satisfaction, Dissatisfaction, and Engagement

How do you determine patient and other customer satisfaction, dissatisfaction, and engagement? How do your 

determination methods differ among your patient and other customer groups and market segments, as appropriate? How do you take action on the results of satisfaction, dissatisfaction, and engagement determination methods? 

How do you obtain information on patients and other customers’ satisfaction with your organization relative to 

competitors and other organizations providing similar services?

Terms in small caps are defined in the Glossary of Key Terms (pages 48–56).

Notes

3.2. Results for patient and other customer perceptions and 

actions (outcomes) should be reported in item 7.2.

3.2a. You should ensure that your approaches for managing patient and other customer relationships, enabling 

patients and other customers to seek information and support, and managing complaints promote fairness, equity, 

and inclusion and do not inadvertently discriminate. 

3.2b. Determining patient and other customer dissatisfaction should be seen as more than reviewing low satisfaction 

scores. It should be independently determined to identify 

root causes and enable a systematic remedy to improve the 

experience of care and avoid future dissatisfaction. 

3.2b. Information on relative satisfaction with other 

organizations may include comparisons with competitors; 

comparisons with other organizations that deliver similar 

health care services in a noncompetitive marketplace; or 

comparisons obtained through third-party surveys or surveys endorsed or required by payors, such as the Consumer 

Assessment of Healthcare Providers and Systems (CAHPS). 

Such information may also include information on why 

customers choose your competitors over you.

For additional guidance on this item, see the Health Care 

Criteria Commentary.