2022

Copansburg 

Regional Health 

System Case Study

health care

www.nist.gov/baldrige
Baldrige Performance Excellence Program

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

July 2022

To download copies of this or other publications of the Baldrige Performance Excellence Program, visit 

www.nist.gov/baldrige/publications.

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 Copansburg Regional Health System Case Study is a fictitious Baldrige Award application prepared for use in the 2022 Malcolm 

Baldrige National Quality Award Examiner Preparation Course. The fictitious case study organization is a large, not-for-profit, integrated 

delivery health care provider that is headquartered in the greater Lexington, KY region and offers service lines for cardiology, oncology, 

orthopedics, women’s and children’s, behavioral health/substance abuse, and neurology (with programming varying depending on 

hospital size, complexity, and local population needs). The case study illustrates the format and general content of an award application. 

However, since the case study serves primarily as a tool for training examiners to evaluate organizations against the 2021–2022 

Baldrige Excellence Framework (Health Care) and its Criteria for Performance Excellence, it may not address all Criteria questions or 

demonstrate role-model responses in all Criteria areas. Please refer to the Copansburg Regional Health System Feedback Report to 

learn how the organization was scored by one team of examiners and to see its strengths and opportunities for improvement.

This case study is a work of fiction, created and produced for the sole purpose of training regarding the use of the Baldrige Excellence 

Framework. There is no connection between the fictitious Copansburg Regional Health System and any other organization, named 

either Copansburg Regional Health System 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 any data and content about them may have been fictionalized, as appropriate; 

all other organizations cited in the case study are fictitious or have been fictionalized. 

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

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

BALDRIGE EXECUTIVE FELLOWS PROGRAM®, (IM)PROVE YOUR PERFORMANCE®, PERFORMANCE EXCELLENCE®, THE QUEST 

FOR EXCELLENCE®, MALCOLM BALDRIGE NATIONAL QUALITY AWARD®, BALDRIGE PERFORMANCE EXCELLENCE PROGRAM®, 

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, conducting 

research that advances the nation’s technology infrastructure and is needed by U.S. industry to continually improve products and 

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business assistance to small manufacturers.

Suggested citation: Baldrige Performance Excellence Program. 2022. 2022 Baldrige Case Study: Copansburg Regional Health System. 

Gaithersburg, MD: U.S. Department of Commerce, National Institute of Standards and Technology. https://www.nist.gov/baldrige.
CONTENTS

2022 Eligibility Certification Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E1

Organization Charts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O1

2022 Award Application Form, Page A-1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A1

Glossary of Terms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G1

Preface: Organizational Profile

P.1 Organizational Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i

P.2 Organizational Situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv

Category 1: Leadership

1.1 Senior Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

1.2 Governance and Societal Contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

Category 2: Strategy

2.1 Strategy Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

2.2 Strategy Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  

Category 3: Customers

3.1 Customer Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

3.2 Customer Engagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Category 4 : Measurement, Analysis, and Knowledge Management

4.1 Measurement, Analysis, and Improvement of Organizational Performance . . . . . . . . . . . . . . . . . . . . . . . . . 1

4.2 Information and Knowledge Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Category 5: Workforce

5.1 Workforce Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

5.2 Workforce Engagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Category 6: Operations

6.1 Work Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

6.2. Operational Effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Category 7: Results

7.1 Health Care and Process Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

7.2 Customer Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

7.3 Workforce Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

7.4 Leadership and Governance Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

7.5 Financial, Market, and Strategy Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2022 ELIGIBILITY 

CERTIFICATION 

FORM
2022 Eligibility Certification Form

Malcolm Baldrige National Quality Award®

OMB Control No. 0693-0006

Expiration Date: 07/31/2023

Page E-1 of 12

1. Your Organization

Official name Copansburg Regional Health System Headquarters 

address

1000 Copansburg Boulevard

Other name Lexington, KY 40517 

Prior name (if changed within the past 5 years)

2. Highest-Ranking Official

 Mr.  Mrs.  Ms.  Dr.

Name Keith Turley Address   Same as above

Job title President and CEO

Email Keith.Turley@crhs.org

Telephone 502-555-1234

Fax 502-555-5678

3. Eligibility Contact Point

Designate a person who can answer inquiries about your organization. Questions from your organization and requests from the 

Baldrige Program will be limited to this person and the alternate identified below.

 Mr.  Mrs.  Ms.  Dr.

Name Cody St. Ours Address   Same as above

Job title VP, Performance Improvement

Email Cody.StOurs@crhs.org

Telephone 

(office and cell, 

if possible)

Office: 502-555-1357

Cell: 502-555-2468

Overnight 

mailing 

address

  Same as above (Do not use a 

P.O. box number.)

Fax 502-555-5678

4. Alternate Eligibility Contact Point

 Mr.  Mrs.  Ms.  Dr.

Name Devon Koonce Telephone 502-555-9753

E-mail Devon.Koonce@crhs.org Fax 502-555-5678

5. Application History

a. Has your organization previously submitted an eligibility certification package?

 Yes. Indicate the year(s). Also indicate the organization’s name at that time, if different.

Year(s) 2020, 2021

Name(s)

 No

 Don’t know 

2022 Eligibility Certification Form

Eligibility package due February 16, 2022 

Award package due April 26, 2022
2022 Eligibility Certification Form

Malcolm Baldrige National Quality Award®

OMB Control No. 0693-0006

Expiration Date: 07/31/2023

Page E-2 of 12

Eligibility package due February 16, 2022 

Award package due April 26, 2022

b. Has your organization ever received the Malcolm Baldrige National Quality Award

 Yes. 

Did your organization receive the award in 2015 (the year you submitted award-winning application) or earlier?

 Yes. Your organization is eligible to apply for the award.

 No. If your organization received an award between 2016 and 2020, it is eligible to apply for feedback only. Contact 

the Baldrige Program at (877) 237-9064, option 3, if you have questions.

 No

c. Has your organization participated in a regional/state/local or sector-specific Baldrige-based award process?

 Yes. Years: 2016, 2017, 2018, 2019

 No

d. Is your organization submitting additional materials (i.e., a completed Organizational Profile and two results measures for each 

of the five Criteria results items [option 8 in section 6k]) as a means of establishing eligibility?

 No. Proceed to question 6.

 Yes. In the box below, briefly explain the reason your organization chose this eligibility option. (This information will be 

shared with the Alliance leadership, without revealing your organization’s identity.)

6. Eligibility Determination 

See also Is Your Organization Eligible? (https://www.nist.gov/baldrige/baldrige-award/your-organization-eligible/).

a. Is your organization a distinct organization or business unit headquartered in the United States?

 Yes  No. Briefly explain.

b. Has your organization officially or legally existed for at least one year, or since April 1, 202

 Yes  No

c. Can your organization respond to all seven Baldrige Criteria categories? Specifically, does your organization have processes 

and related results for its unique operations, products, and/or services? For example, does it have an independent leadership 

system to set and deploy its vision, values, strategy, and action plans? Does it have approaches for engaging customers and 

the workforce, as well as for tracking and using data on the effectiveness of these approaches? 

 Yes  No 

d. If some of your organization’s activities are performed outside the United States or its territories and your organization 

receives a site visit, will you make available sufficient personnel, documentation, and facilities in the United States or its 

territories to allow a full examination of your worldwide organization? 

 Yes  No  Not applicable

e. If your organization receives an award, can it make sufficient personnel and documentation available to share its practices a

the Quest for Excellence® Conference and at your organization’s U.S. facilities?

 Yes  No 

If you checked “No” for 6a, 6b, 6c, 6d, or 6e, call the Baldrige Program at (877) 237-9064, option 3.
2022 Eligibility Certification Form

Malcolm Baldrige National Quality Award®

OMB Control No. 0693-0006

Expiration Date: 07/31/2023

Page E-3 of 12

Eligibility package due February 16, 2022 

Award package due April 26, 2022

Questions for Subunits Only

f. If your organization is a subunit in education or health care, does your subunit provide direct teaching and instructional 

service to students or direct health care services to people?

 Yes. (https://www.nist.gov/baldrige/baldrige-award/your-organization-eligible). Then proceed to item 6k.

 No. Continue with 6g.

g. Does your subunit function independently and as a discrete entity, with substantial authority to make key administrativ

and operational decisions? (It may receive policy direction and oversight from the parent organization.)

 Yes. Continue with 6h.

 No. Your subunit probably is not eligible to apply for the award. Call the Baldrige Program at (877) 237-9064, option 3.

h. Does your subunit have a clear definition of “organization” reflected in its literature? Does it function as a business or 

operational entity, not as activities assembled to write an award application?

 Yes. Continue with 6i.

 No. Your subunit probably is not eligible to apply for the award. Call the Baldrige Program at (877) 237-9064, option 3.

i. Is your subunit in manufacturing or servic

 Yes. Does it have 500 or fewer employees? Is it separately incorporated and distinct from the parent organization’s 

other subunits? Or was it independent before being acquired by the parent, and does it continue to operate independently 

under its own identity? 

 Yes. Your subunit is eligible in the small business category. Attach relevant portions of a supporting official document 

(e.g., articles of incorporation) to this form. 

*If your subunit has 500 or less employees, you may apply under Manufacturing or Service if it is more appropriate than 

Small Business. Proceed to item 6k.

 No. Continue with 6j.

j. Is your subunit self-sufficient enough to be examined in all seven categories of the Criteri

• Does it have its own senior leaders?

• Does it plan and implement its own strategy?

• Does it serve identifiable customers either inside or outside the organization?

• Is it responsible for measuring its performance and managing knowledge and information?

• Does it manage its own workforce?

• Does it manage its own work processes and other aspects of its operations?

• Can it report results related to these areas?

 Yes. Proceed to 6k (table on next page).

 No. Your organization probably is not eligible to apply for the award. Call the Baldrige Program at (877) 237-9064, 

option 3.
2022 Eligibility Certification Form

Malcolm Baldrige National Quality Award®

OMB Control No. 0693-0006

Expiration Date: 07/31/2023

Page E-4 of 12

Eligibility package due February 16, 2022 

Award package due April 26, 2022

k. Does your organization meet one of the following conditions?

1. My organization has won the Baldrige Award 

(prior to 2017).

Yes



Your organization 

is eligible.

No Continue with 

statement 2.

2. Between 2017 and 2021, my organizatio

applied for the national Baldrige Award, and the 

total of the process and results band numbers 

assigned in the feedback report was 8 or higher.

Yes



Your organization 

is eligible. 

Year: 2020

Total of band 

scores: 9

No Continue with 

statement 3.

3. Between 2017 and 2021, my organizatio

applied for the national Baldrige Award and 

received a site visit.

Yes



Your organization 

is eligible. 

Year of site visit: 

2021

No Continue with 

statement 4.

4. Between 2016 and 2021, my organizatio

received the top award from an award program 

that is a member of the Alliance for Performance 

Excellence.

Yes



Your organization 

is eligible. 

Award program: 

State Center for 

Performance 

Excellence (SCPE)

Year of top 

award: 2019

No Continue with 

statement 5.

5. More than 25% of my organization’s workforc

is located outside the organization’s home state.

Yes



Your organization 

is eligible. 

No Continue with 

statement 6.

6. There is no Alliance for Performance Excellenc

award program available for my organization.

Yes



Your organization 

is eligible. 

No Continue with 

statement 7.

7. Between 2017 and 2021, my organizatio

applied for the national Baldrige Award through 

the alternate method (option 8 below) and the 

total of the process and results bands assigned in 

the feedback report was 6 or higher. 

Yes



Your organization 

is eligible.

Year: 

No, my 

organization did 

not apply using 

this method.

 My organization 

applied using this 

method, but did 

NOT receive a 

total of 6 or higher.

Continue with 

statement 8.

Your organization 

is not eligible. Call 

877-237-9064, 

option 3, if you 

have questions. 

8. My organization will submit additional 

eligibility screening materials (i.e., a complete 

Organizational Profile and two results measures 

for each of the five Criteria results items). The 

Baldrige Program will use the materials to 

determine if my organization is eligible to apply 

for the award this year (as described in the fact 

sheet at Eligibility FAQs). 

Yes



The Baldrige 

Program will 

review the 

materials and 

contact your ECP 

after determining 

your eligibility.

No Call 877-237-9064, 

option 3, if you 

have questions.
2022 Eligibility Certification Form

Malcolm Baldrige National Quality Award®

OMB Control No. 0693-0006

Expiration Date: 07/31/2023

Page E-5 of 12

Eligibility package due February 16, 2022 

Award package due April 26, 2022

7. Award Category 

a. Award category (Check one.) 

Your education or health care organization may use the Business/Nonprofit Criteria and apply in the service, small business, 

or nonprofit category. However, you probably will find the sector-specific (Education or Health Care) Criteria more 

appropriate. 

For-Profit	 Nonprofit

 Manufacturing  Nonprofit

 Service  Education

 Small business (≤ 500 employees)  Health Care

 Education

 Health Care 

b. Industrial classifications. In table below, list up to three of the most descriptive NAICS codes for your organization (se

NAICS list included at the end of this document). These are used to identify your organizational functions and to assign 

applications to examiners.

622 6214 6211

8. Organizational Structure

a. For the preceding fiscal year, the organization had

 up to $1 million  $1.1 million–$10 million  sales

 $10.1 million–$100 million  $100.1 million–$500 million  revenue

 $500.1 million–$1 billion  more than $1 billion  budget

b.  Attach a line-and-box organization chart that includes divisions or unit levels. In each box, include the name of the unit o

division and the name of its leader. Do not use shading or color in the boxes.

 The chart is attached.
Eligibility package due February 16, 2022 

Award package due April 26, 2022

2022 Eligibility Certification Form

Malcolm Baldrige National Quality Award®

OMB Control No. 0693-0006

Expiration Date: 07/31/2023

Page E-6 of 12

c. The organization is _____ a larger parent or system. (Check all that apply.)

 not a subunit of (See item 6 above.)

 a subsidiary of  controlled by  administered by  owned by

 a division of  a unit of  a school of  other _____________________ 

Parent organization Address

Total number of 

paid employees*

Highest-ranking 

official

Job title

Telephone

*Paid employees include permanent, part-time, temporary, and telecommuting employees, as well as contract employees 

supervised by the organization. Include employees of subunits but not of joint ventures.

Attach a line-and-box organization chart(s) showing your organization’s relationship to the parent’s highest management 

level, including all intervening levels. In each box, include the name of the unit or division and its leader. Do not use 

shading or color in the boxes.

 The chart is attached.

d. Considering the organization chart, briefly describe below how your organization relates to the parent and its other subunits 

in terms of products, services, and management structure.

e. Provide the title and date of an official document (e.g., an annual report, organizational literature, a press release) tha

clearly defines your organization as a discrete entity. 

Title Date

Attach a copy of relevant portions of the document. If you name a website as documentation, print and attach the relevant 

pages, providing the name only (not the URL) of the website.

 Relevant portions of the document are attached.

f. Briefly describe the major functions your parent or its other subunits provide to your organization, if appropriate. Examples 

are strategic planning, business acquisition, research and development, facilities management, data gathering and analysis, 

human resource services, legal services, finance or accounting, sales/marketing, supply chain management, global 

expansion, information and knowledge management, education/training programs, information systems and technology 

services, curriculum and instruction, and academic program coordination/development.
2022 Eligibility Certification Form

Malcolm Baldrige National Quality Award®

OMB Control No. 0693-0006

Expiration Date: 07/31/2023

Page E-7 of 12

Eligibility package due February 16, 2022 

Award package due April 26, 2022

9. Site Listing

You may attach or continue your site listing on a separate page as long as you include all the information requested here. You may 

group sites by function or location (city, state), as appropriate. Please include the total for each column (sites, employees/faculty/

staff, volunteers, and products/services). If different sites are located on the same campus (e.g., medical building and acute care 

hospital), please indicate that in the “Sites” column. See the ABC HealthCare example below. If your organization has any joint 

ventures, please list and describe those in the second table below.

Please include a detailed listing showing all your sites. If your organization receives a site visit, an examiner team will use this 

information for planning and conducting its visit. Although site visits are not conducted at facilities outside the United States or its 

territories, these facilities may be contacted by teleconference or videoconference.

Example (ABC HealthCare)

Sites (U.S. and Foreign)

List the city and the state or country.

Workforce*

List the numbers at 

each site.

List the % at 

each site, or 

use “N/A” 

(not applicable).

Check one 

or more.

 Employees

 Faculty

 Staff

Volunteers

(no. or

N/A)

Check one.

% of 

 Sales 

 Revenue

 Budget

Relevant Products, Services,

and/or Technologies

ABC Medical Center, Anytown, NY 1,232 147 77% Admin. offices, inpatient care, 

ED, imaging services, lab

ABC Hospital West, West Anytown, NY 255 78 14% Inpatient services, ED, lab

ABC Medical Group, Anytown, NY

Located on same campus as ABC Medical 

Center

236 N/A 6% Primary & specialty physician 

care

ABC Imaging Center, West Anytown, NY 11 N/A 1% Imaging services

ABC Hospice Services, West Anytown, NY

Different location than ABC Hospital West 

and ABC Imaging Center

94 89 1% On- and off-site hospice 

services

ABC Urgent Care, West Anytown, NY 8 N/A 1% Outpatient emergency and 

urgent care services

Total 6 1,836 314 100%
Eligibility package due February 16, 2022 

Award package due April 26, 2022

2022 Eligibility Certification Form

Malcolm Baldrige National Quality Award®

OMB Control No. 0693-0006

Expiration Date: 07/31/2023

Page E-8 of 12

Your Organization

Sites (U.S. and Foreign)

List the city and the state or country.

Workforce*

List the numbers at 

each site.

List the % at 

each site, 

or use “N/A” 

(not applicable).

Check one 

or more.

 Employees

 Faculty

 Staff

Volunteers

(no. or

N/A)

Check one.

% of 

 Sales 

 Revenue

 Budget

Relevant Products, Services,

and/or Technologies

Copansburg Medical Center—Lexington; 

Lexington, KY

4,500 315 44.5% 600-bed academic medical 

center, inpatient care, ED, 

imaging services, lab

Copansburg Hospital—Berea;

Barea, KY

1,500 85 15.3% 150-bed community hospital, 

inpatient care, ED, imaging 

services, lab

Copansburg Hospital—Frankfort;

Frankfort, KY

1,000 65 9.8% 50-bed community hospital, 

inpatient care, ED, imaging 

services, lab

Copansburg Rehab Hospital, 

Richmond, KY

500 25 6.7% 50-bed rehabilitation hospital, 

post-acute care, therapy 

services

Copansburg Hospital—Stanton;

Stanton, KY

300 10 3.3% 25-bed critical-access hospital, 

inpatient care, imaging 

services, lab (no surgery or 

OB services)

Copansburg Medical Offices—Lexington 200 0 1.7% Primary and specialty 

physician care, imaging, lab, 

home health/DME

Copansburg Medical Offices—Berea 150 0 .6% Primary and specialty 

physician care, lab

Copansburg Medical Offices—Frankfort 150 0 .5% Primary and specialty 

physician care, lab

Copansburg Medical Offices—Richmond 150 0 .5% Primary and specialty 

physician care, imaging, lab

Copansburg Surgery Center—Lexington 60 0 .9%

Copansburg Surgery Center—Georgetown 60 0 .9%

Copansburg Surgery Center—Richmond 60 0 1.5%

Copansburg Advanced Imaging Centers—

Lexington, Georgetown, Richmond, 

Winchester, Frankfort, Paris

120 0 3.3%

Copansburg Urgent Care—Lexington 20 0 .05% Urgent care services
2022 Eligibility Certification Form

Malcolm Baldrige National Quality Award®

OMB Control No. 0693-0006

Expiration Date: 07/31/2023

Page E-9 of 12

Eligibility package due February 16, 2022 

Award package due April 26, 2022

Copansburg Urgent Care—Nicholasville 20 0 .03% Urgent care services

Copansburg Urgent Care—Winchester 20 0 .03% Urgent care services

Copansburg Urgent Care—Shelbyville 20 0 .03% Urgent care services

Copansburg Urgent Care—Mount Sterling 20 0 .02% Urgent care services

Copansburg Physical Therapy and 

Rehabilitation Services—Lexington

20 0 .03% Physical therapy, occupational 

therapy, speech pathology

Copansburg Physical Therapy and 

Rehabilitation Services—Georgetown

20 0 .02% Physical therapy, occupational 

therapy, speech pathology

Copansburg Physical Therapy and 

Rehabilitation Services—Winchester

50 0 .02% Physical therapy, occupational 

therapy, speech pathology

Copansburg Corporate Service Center 890 0 10.27% Corporate services supporting 

health care, ACO and health 

plan operations

Total 26 9,830 500 100%

*The term workforce refers to all people actively involved in accomplishing the work of an organization. The workforce includes 

paid employees (e.g., permanent, part-time, temporary, telecommuting, and contract employees supervised by the organization) 

and volunteers, as appropriate; it also includes team leaders, supervisors, and managers at all levels.

Joint Ventures

Partner Organization

# of applicant

employees

included in

joint venture

% Owned

by the

Applicant

Describe extent/level of operational and

managerial responsibility your organization

has for the joint venture.

Copansburg Surgery Center—Lexington 60 51% CRHS has 100% operational and managerial 

responsibility for joint venture

Copansburg Surgery Center—

Georgetown

60 51% CRHS has 100% operational and managerial 

responsibility for joint venture

Copansburg Surgery Center—Richmond 60 51% CRHS has 100% operational and managerial 

responsibility for joint venture

Copansburg Advanced Imaging Centers—

Lexington, Georgetown, Richmond, 

Winchester, Frankfort, Paris

120 60% CRHS has 100% operational and managerial 

responsibility for joint venture

Total 4 300
2022 Eligibility Certification Form

Malcolm Baldrige National Quality Award®

OMB Control No. 0693-0006

Expiration Date: 07/31/2023

Page E-10 of 12

Eligibility package due February 16, 2022 

Award package due April 26, 2022

10. Key Business/Organization Factors

List or briefly describe where necessary the following key business/organization factors (we recommend using bullets). Please be 

concise, but be as specific as possible. Provide full names of organizations (i.e., do not use acronyms). The Baldrige Program uses 

this information to avoid conflicts of interest when assigning examiners to your application. Examiners also use this information in 

their evaluations. 

a. Main products and/or services and major markets served (local, regional, national, and international)

Copansburg Regional Health System is a not-for-profit integrated delivery health care provider serving the 

greater Lexington, KY region of more than 1 million residents, encompassing both urban communities in 

Lexington and rural areas of Kentucky. Services across the continuum of care include inpatient care, emergency 

care, physical medicine and rehabilitation care, and outpatient services, including physician office care, imaging 

services, and rehabilitation therapy.

b. Key competitors (those that constitute 5 percent or more of your competitor

Hospital competitors (with bed sizes) include academic medical centers at University of Churchill Downs (400) 

and Rivertown University (450); a National Hospital Corporation hospital (250); and independent hospitals such 

as St. Paul’s Hospital (200) and Edwardia Hospital (150). Competition in the outpatient setting includes those 

same hospitals and some for-profit entities, such as Mount Washington, LaGrange, Rivers Imaging Centers, 

Trulent Surgery Centers, Movement Physical Therapy, and PatientNow Urgent Care. Competition in the health 

insurance space comes from national health insurers, such as Ryland, Xyrus, Norwood, Haferty, and Briars.

c. Key customers/users (those that constitute 5 percent or more of your customers/users)

Patients and people they define as family within the CRHS service area

d. Key suppliers/partners (those that constitute 5 percent or more of your suppliers/partners)

Suppliers include Bluebird and Hilltop (medical supplies, equipment, and pharmaceuticals); Sarmac (imaging 

equipment); Ingleton, Marcus, J & M (surgical supplies and equipment); Apex (electronic medical record); 

Wellmed (emergency and anesthesia physician services), and Amwell GPO.

Partners include independent surgeons in surgery center joint venture; Radiology Physicians of Kentucky in 

imaging centers joint venture; University of Lexington School of Medicine (medical students and residents); 

Excel Ambulance (ambulance and transport services); University of Churchill Downs (nursing, mid-level 

providers [MLPs], technologists, and pharmacy personnel); Nicholasville Community College (nursing 

personnel); and Communities of Excellence partners.

e. Financial auditorFiscal year (e.g., O

Pinnacle Audit Services January 1–December 31

f. Parent organization (if your organization is a subunit).
2022 Eligibility Certification Form

Malcolm Baldrige National Quality Award®

OMB Control No. 0693-0006

Expiration Date: 07/31/2023

Page E-11 of 12

Eligibility package due February 16, 2022 

Award package due April 26, 2022

11. Nomination to the Board of Examiners

If your organization is eligible to apply for the Baldrige Award in 2022, you may nominate one senior member from your 

organization to the 2022 Board of Examiners.

Nominees are appointed for one year only. Nominees

■ must not have served previously on the Board of Examiners and

■ must be citizens of the United States, be located in the United States or its territories, and be employees of the 

applicant organization.

The program limits the number of examiners from any one organization. If your organization already has representatives on the 

board, nominating an additional person may affect their reappointment.

Board appointments provide a significant opportunity for your organization to learn about the Criteria and the evaluation 

process. The time commitment is also substantial: examiners commit to a minimum of 200 hours from April to August, including 

approximately 40–60 hours in April/May to complete self-study, four days in May to attend Examiner Preparation, and 95–130 

hours from June through August to complete an Independent and Consensus Review. If requested by the program, examiners also 

participate in a Site Visit Review of approximately nine days. The nominee or the organization must cover travel and housing 

expenses incurred for Examiner Preparation. 

 Mr.  Mrs.  Ms.  Dr.

Devon Koonce from our organization will serve on the 2022 Board of Examiners.

Devon.Koonce@crhs.org Email address

 I understand that the nominee or the organization will cover travel and hotel costs associated with participation in Examiner 

Preparation. I also understand that if my organization is determined to be ineligible to apply for the Baldrige Award in 2022, this 

examiner nomination will not be considered for the 2022 Board of Examiners.

12. Self-Certification and Signature 

I state and attest the following:

(1) I have reviewed the information provided in this eligibility certification package.

(2) To the best of my knowledge, 

■ this package includes no untrue statement of a material fact, and

■ no material fact has been omitted.

(3) Based on the information herein and the current eligibility requirements for the Malcolm Baldrige National Quality 

Award®, organization is eligible to apply.

(4) I understand that if the information is found not to support eligibility at any time during the 2022 award process, my 

organization will no longer receive consideration for the award and will receive only a feedback report.

Keith Turley Keith Turley 2/12/2022

Signature of highest-ranking official Printed name Date
2022 Eligibility Certification Form

Malcolm Baldrige National Quality Award®

OMB Control No. 0693-0006

Expiration Date: 07/31/2023

Page E-12 of 12

Eligibility package due February 16, 2022 

Award package due April 26, 2022

13. Submission 

To be considered for the 2022 award, your complete eligibility certification package must be submitted electronically 

no later than February 16, 2022. 

To submit your Eligibility Certification package, request a link to NIST’s secure file transfer system by emailing

asqbaldrige@asq.org. Do not email your eligibility package directly to ASQ. 

Do you authorize ASQ to return copies of your date-stamped eligibility forms (required to be included in your application 

package) via email? If you check “no” below, the copies will be returned to you via the secure file transfer system. 

 Yes  No 

14. Fee 

Indicate your method of payment for the $400 eligibility certification fee.

 Check  Money order

Official Name of Organization: 

Copansburg Regional Health System

Mailing Address: 

1000 Copansburg Boulevard

Lexington, KY 40517

To pay by check or money order, please make payable to the Malcolm Baldrige National Quality Award® and include the name 

of the organization applying on the memo line. Include one printed copy of this page with your payment. 

 ACH payment  Wire transfer

Checking ABA routing number: 041000124 Checking account number: 4245714835

Before sending an ACH payment or wire transfer, please notify the American Society for Quality (ASQ; [414] 765-7205, or 

asqbaldrige@asq.org). Reference the Baldrige Award with your payment.

 Visa  MasterCard  American Express

Card number Authorized signature

Expiration date Printed name

Card billing address Today’s date

W-9 Request: If you require an IRS Form W-9 (Request for Taxpayer Identification Number and Certification), contact ASQ 

at (414) 765-7205.
2022 Eligibility Certification Form

Malcolm Baldrige National Quality Award®

OMB Control No. 0693-0006

Expiration Date: 07/31/2023

Eligibility package due February 16, 2022 

Award package due April 26, 2022

1. Eligibility Certification Form* 

 I have answered all questions completely.

 I have included a line-and-box organization chart showing all components of the organization and the name of each unit 

or division and its leader.

 The highest-ranking official has signed the form.

For Organizations Submitting Additional Eligibility Screening Materials (to meet the alternative eligibility 

condition no. 8 for question 6k; see the table on page E-4)

 I have enclosed a complete Organizational Profile.

 I have enclosed data for two results measures for each of the five Criteria results items.

For Subunits Only

 I have included a line-and-box organization chart(s) showing the subunit’s relationship to the parent’s highest 

management level, including all intervening levels.

 I have enclosed copies of relevant portions of an official document clearly defining the subunit as a discrete entity.

*Please do not staple the pages of this form.

2. Fee

 I have indicated my method of payment for the nonrefundable $400 eligibility certification fee.

 If paying by check or money order, I have made it payable to the Malcolm Baldrige National Quality Award® and 

included it in the eligibility certification package. 

3. Submission and Baldrige Examiner Nomination

 I am nominating a senior member of my organization to the 2022 Board of Examiners.

 I am not nominating a senior member of my organization to the 2022 Board of Examiners.

 I am emailing asqbaldrige@asq.org to request a link to NIST’s secure file transfer system to upload my eligibility 

certification package. 
ORGANIZATION 

CHARTS
Organization Charts

O1

Copansburg Regional Health System Corporate Organization Chart

Copansburg Regional Health System 

5/1/2020

KY Corporation

Tax Exempt

501 (c) (3) Organization 

54-7777777

Copansburg 

Hospitals

KY Corporation

Tax Exempt

501c3 

Copansburg 

Foundation

KY Corporation

Tax Exempt

501c3

54-7777772 

Copansburg 

Clinical Services

KY Corporation

Tax Exempt

501c3

54-7777773

Copansburg 

Accountable Care 

Organization

KY Corporation

Tax Exempt

501c3

54-888888

Copansburg 

Healthcare 

Services Inc.

KY Corporation

Taxable

54-123456

Copansburg 

Properties Inc.

KY Corporation

Tax Exempt

501c3

54-999999

Lexington 

Professional Risk 

Exchange

VT Corporation

Tax Exempt

33-111111

Copansburg 

Health Plans Inc.

KY Corporation

Tax Exempt

501c3

Copansburg 

Medical Group

54-777776

Joint Venture—

Surgery Center 

of Georgetown

54-777775

Joint Venture—

Medical Imaging 

of Kentucky

54-777774

Joint Venture—

Surgery Centers 

of Richmond

54-777775

Joint Venture—

Surgery Center 

of Lexington

54-777775

Copansburg 

Corporate Health 

Insurance Plan, 

Inc.

54-222221

Copansburg 

Medicare 

Advantage Plan, 

Inc.

54-222224

Copansburg 

Rehab Hospital

54-067777

Copansburg—

Stanton

54-047777

Copansburg—

Frankfort

54-037777

Copansburg 

Medical Center—

Lexington

54-0177777

Copansburg— 

Berea

54-027777

LazySmith 

Medical Office 

Partnership

54-123444

Physician Help 

Management 

15% ownership

Services

54-123457

Cardiac Imaging 

 of Kentucky

54-123458

20% ownership

Trent Medical 

Office 

Partnership

54-123459

10% ownership
O2

Copansburg Regional Health System Organization Chart

Copansburg Regional 

Health System 

Board of Trustees

Chief Medical Officer 

Beverly Tai, MD

Chief Information Officer 

Tom Wick

Chief Nursing Officer 

Eileen Kay, DNP

Chief Operating Officer

Tejas Lopez

Chief Financial Officer

Sean O’Casey

Chief Strategy Officer

Marcus Wright

Chief 

Human Resources Officer

Jerome Thomas

Foundation President

Xavier Mulkie

VP, Inpatient 

Nursing Practice

Jen Freed, RN

VP, Ambulatory 

Nursing Practice

Eric Thomas, RN

VP, Clinical 

Education

Sara Mikel, DNP

VP, Major Gifts

Alexandria 

Wolinski

VP, Fundraising 

Events

Chris Wall

VP, 

Graduate Medical 

Education

John Jett, MD

VP, Medical 

Informatics

Carl Szlyk, MD

VP, 

Medical Group

John Moss, MD

VP, Practice 

Operations

Mike Johnson

VP, Physician 

Services

Carla Robinson

VP, Cybersecurity

Geoff Wylie

VP, Technology

Maria 

Thomasino

VP, Nursing 

Informatics

Monica Lee, RN

VP, Analytics

Johnathan 

Leslie

VP, Ambulatory 

Operations

Marie Anafere

Hospital Leaders

Becky Anders,

Michelle 

Pastorius,

Jackie Santonio,

Michael Watson,

Nancy Yablonski

VP, Performance 

Improvement

Cody St. Ours

Service Line VPs

Cardiac —

Marie Hager

Oncology—

Mike Brown

Women’s—

Missy Reese

Orthopedics—

Tammy Matthis

Neurology—

Vacant

VP, Facility 

Management

Curt Brody

VP, Supply Chain

Alan Tillon

VP, Revenue 

Cycle

Sarah Barden

VP, 

Managed Care

Luis Bandera

VP, Biomed & 

Engineering

Joe Tracy

VP, ACO and 

Population Health

Vy Turner

VP, Corporate 

Strategy

Phillip Dermott

VP, Business 

Development

Tina Brooks

VP, Marketing & 

Communications

Lisa Flaherty

VP, Government 

Relations

Chris Ryan

VP, Health Plans

Lavert MagrinoSmith

VP, Patient 

Experience

Takiya Rey

VP, Learning & 

Development

Devon Koonce

VP, Associate 

Relations

Kathy Cruz

VP, Recruitment 

Alwad 

Chaudhari

VP, Benefits & 

Compensation

Anna Chijka

VP, Volunteer 

Services

Annie Riddick

VP, Diversity and 

Inclusion

Sandy Gomez

Risk Management 

& Compliance 

Officer 

Tom Blalock

Medical Staff 

President

Blain Joe, MD President and CEO Keith Turley

Designates 

Executive Leadership 

Team Member

Copansburg Hospital Advisory Boards

Copansburg Foundation 

Board of Trustees
O3

Copansburg Medical Center—Lexington Organization Chart

Designates 

Executive Leadership 

Team Member

Positions with blue 

backgrounds are matrixed 

positions, with reporting 

relationships to aligned 

functions on Copansburg 

Regional Health System

Organization Chart

Director, Lab

Keneisha 

Thompson

Director, 

Operating Room

Lisa Matusz, RN

Director, 

Emergency 

Room

Ken Stills, RN

Director, 

 Pharmacy

John McElroy, 

PharmD

Director, 

Radiology

Tim Koonce

Director, 

Medical Care 

Frans Lars, RN

Director, 

Critical Care 

Nursing

Jen Freed, RN

Director, 

Women’s Care

Cindy Yu, RN

Director, 

Surgical Nursing

Naomi Watt, RN

Director, 

Case 

Management 

Marie Jones

Copansburg Regional 

Health System COO

Tejas Lopez

Vice President, 

Med Staff Relations

Mike Ryan, MD

Vice President, 

Support Services

Rebecca Morgan

Vice President, 

Nursing 

Tammi Oz, RN

Vice President, 

Operations

Cheri Brown

Vice President, 

Finance

Sandra O’Dell

Director, Patient 

Experience

Pam Bryant

Director, PR & 

Marketing

Emily Watts

Director, Human 

Resources

Sherry DeLaCruz

Director, 

Graduate Medical 

Education

John Tim, MD

Director, 

Med Staff Support 

Mona Kelly

Director, 

Plant 

Operations

Kenny Shelton

Director, 

Housekeeping

Mike Johnson

Director, 

Food & Nutrition

Natalie Young

Medical Staff 

President

Nancy Trementozi, MD

Copansburg Medical Center—

Lexington CEO

Becky Anders

Copansburg Medical 

Center— 

Advisory Board

Director, Health 

Information 

Management

Janet Tyson

Director, 

Accounting

Keith Tilson

Director, 

Registration

Elisha Deneal

Director, 

Budgeting

Reggie Alippe

Director, IT Services

Wendy Pitts

Director, Risk 

Management

Tom Bradley
O4

Copansburg—Berea Organization Chart

Designates 

Executive Leadership 

Team Member

Positions with blue 

backgrounds are matrixed 

positions, with reporting 

relationships to aligned 

functions on Copansburg 

Regional Health System

Organization Chart

Manager, 

Medical Care 

Ren Hu, RN

Manager, 

Critical Care

Val Lime, RN

Manager, 

Women’s Care

Vy Davis, RN

Manager, 

Surgical Nursing

Tom Mix, RN

Copansburg Regional 

Health System COO

Tejas Lopez

Director, Nursing 

Chassidy 

O’Connor, RN

Director, Operations

Max Campbell

Director, Finance

Mike Jones

Manager, 

Patient Experience

Mena Lucy

Manager, 

PR & Marketing

Erin Supko

Manager, 

Human Resources

Kim Brooks

Manager, 

Med Staff 

Support 

Mina Thomas

Medical Staff President

Steve McCoy, MD

Copansburg—Berea

Administrator 

 Michael Watson

Copansburg— 

Berea Hospital 

Advisory Board

Manager, 

Plant Operations

Mike Ervin

Manager, 

Accounting

Karen Thomas

Manager, 

Registration

Sybil Jones

Manager, 

Budgeting

Kambia Gordon

Manager, 

IT Services

Steve Darcy

Manager, 

Risk Management

Wanda Kite

Manager, 

Radiology

Carole Welford

Manager, Lab

Christinna 

Hossenpfeffer

Manager, 

Operating Room

Rhett Lu, RN

Manager, 

Emergency 

Room

Louise Tims, RN

Manager, 

Pharmacy

Tammy Vrabel, 

PharmD

Manager, 

Food & Nutrition,

Tim Johnson

Manager, 

Housekeeping

Vacant
O5

Copansburg Medical Center—Frankfort Organization Chart

Designates 

Executive Leadership 

Team Member

Positions with blue 

backgrounds are matrixed 

positions, with reporting 

relationships to aligned 

corporate functions on 

the Copansburg Regional 

Health System

Organization Chart

Manager, 

Food Services & 

Housekeeping

Harriett Johnson

Manager, 

Operating Room

Stan Bryant

Manager, 

Emergency 

Room

Brian Wexler, RN

Manager, 

Ancillary Services

Sue Ellen 

Jaworksi

Copansburg Regional 

Health System COO

Tejas Lopez

Director, 

Nursing 

Fionna Wells, RN

Director, 

Operations

Lou Miller

Manager, 

Human Resources

Tom Casey

Manager, 

IT Services

Gidget Michelle

Manager, 

Plant Operations

Mike Brown

Manager, 

Surgical Care

Shaniqua 

Forrest, RN

Manager, 

Medical Care 

Valencia 

Santos, RN

Medical Staff 

President

Winona Masterson, MD

Copansburg—Frankfort

Nancy Yablonski

Administrator

Copansburg— 

Frankfort Hospital 

Advisory Board

Manager, 

Finance

Jacquiz Ronald

Manager, 

Med Staff Support 

Lucy Sills
O6

Copansburg Rehab Hospital Organization Chart

Designates 

Executive Leadership 

Team Member

Positions with blue 

backgrounds are matrixed 

positions, with reporting 

relationships to aligned 

corporate functions on 

the Copansburg Regional 

Health System

Organization Chart

Manager, 

Support Services

Copansburg Regional 

Vacant

Health System COO

Tejas Lopez

Director, 

Nursing 

Vonda Sheller, RN

Director, 

Operations

Valarie Smith

Manager, 

Human Resources

Melanie Betts

Manager, 

Plant Operations

Vacant

Manager, 

Finance

Samantha Yelin

Nursing Manager

Jonie Johnston, 

RN

Therapy Manager

Melissa Tobias

Medical Director

Tom Begovich, MD

Copansburg Rehab Hospital

Jackie Santonio

Administrator

Copansburg— 

Rehab Hospital 

Advisory Board

Manager, 

Med Staff Support 

Tina Blues
O7

Copansburg—Stanton Organization Chart

Designates 

Executive Leadership 

Team Member

Positions with blue 

backgrounds are 

matrixed positions, with 

reporting relationships to 

aligned functions on the 

Copansburg Regional 

Health System

Organization Chart

Copansburg Regional 

Health System COO

Tejas Lopez

Nursing Manager

Sam Hunter, RN

Operations Manager

Peerless Mikel

Human Resources 

Coordinator

Heaven Amos

Finance Coordinator 

Vacant

Facility Coordinator

Sal Valencia

Medical Director

Pam Blegoyavic, MD

Copansburg—Stanton

Michelle Pastorius

Administrator

Copansburg— 

Stanton Hospital 

Advisory Board
PAGE A-1 OF THE 

2022 AWARD 

APPLICATION FORM
2022 Award Application Form 

Malcolm Baldrige National Quality Award®

OMB Clearance #0693-0006

Expiration Date: 07/31/2023

Page A-1

2022 Award Application Form, Page A-1

1. Your Organization 

Official name Copansburg Regional Health System

Mailing address 1000 Copansburg Boulevard

Lexington, KY 40517

2. Award Category and Criteria Used 

a. Award category (Check one.)

 Manufacturing

 Service

 Small business. The larger percentage of sales is in

(check one)  Manufacturing  Service

 Education

 Health care

 Nonprofit

b. Criteria used (Check one

 Business/Nonprofit

 Education

 Health Care

3. Official Contact Point 

Designate a person with in-depth knowledge of the 

organization, a good understanding of the application, and 

the authority to answer inquiries and arrange a site visit, if 

necessary. Contact between the Baldrige Program and your 

organization is limited to this individual and the alternate 

official contact point. If the official contact point changes 

during the application process, please inform the program.

 Mr.  Mrs.  Ms.  Dr.

Name Cody St. Ours

Title VP, Performance Improvement

Mailing address  Same as above

Overnight 

mailing address

 Same as above

 (Do not use a P.O. box number.)

Telephone Office: 502-555-1357

Cell: 502-555-2468

Fax 502-555-5678

E-mail Cody.StOurs@crhs.orgs

4. Alternate Official Contact Point

 Mr.  Mrs.  Ms.  Dr.

Name Devon Koonce

Telephone 502-555-9753

Fax 502-555-5678

E-mail Devon.Koonce@crhs.org

5. Release and Ethics Statements

Release Statement

I understand that this application will be reviewed by members 

of the Board of Examiners. If my organization is selected for a 

site visit, I agree that the organization will

■ host the site visit, 

■ facilitate an open and unbiased examination, and

■ pay reasonable costs associated with the site 

visit (see Baldrige Award Process Fees on our 

website [https://www.nist.gov/baldrige/baldrige-award/

award-process-fees]).

If selected to receive an award, my organization will share 

nonproprietary information on its successful performance 

excellence strategies with other U.S. organizations.

Ethics Statement and Signature of 

Highest-Ranking Official

I state and attest that

(1) I have reviewed the information provided by my

organization in this award application package. 

(2) To the best of my knowledge, this package contains no 

untrue statement of a material fact and omits no material 

fact that I am legally permitted to disclose and that 

affects my organization’s ethical and legal practices. 

This includes but is not limited to sanctions and ethical 

breaches.

Keith Turley 02/12/2022

Signature Date

 Mr.  Mrs.  Ms.  Dr.

Printed name Keith Turley

Job title President and CEO

Applicant name Copansburg Regional Health System

Mailing address  Same as above

Telephone 502-555-1234

Email Keith.Turley@crhs.org

Fax 502-555-5678
GLOSSARY OF 

TERMS AND 

ABBREVIATIONS
G1

Glossary of Terms and Abbreviations

A

A: Annual

A3: A3 quality improvement process

A3E2: Ability, Agility, Aspiration, Engagement, Exposure

A3E3: Ability, Agility, Aspiration, Engagement, Exposure, 

Emotional Intelligence

AB: Advisory Board

ACO: Accountable Care Organization

ACR: American Collect of Radiology

AMD: Advance Medical Directive

AOS: Available On-site

APP: Action Planning Process

ASC: Ambulatory Surgery Center

ASG: American Surgeons Group

ASQ: American Society for Quality

B

BAR: Baldrige Award Recipient

BM: Benchmark

BOT: Board of Trustees

BSC: Balanced Scorecard

BSN: Bachelor of Science in Nursing

C

C: Collaborators

CAH: Critical Access Hospital

CAHPS: Consumer Assessment of Healthcare Providers 

and Systems 

CAPA: Corrective and Preventive Actions

CB: Copansburg Hospital—Berea

CC: Core Competency

C&C: Capability and capacity

CCC: Corporate Compliance Committee

CCM: Capability and Capacity Model

CCP: Corporate Compliance Program

CDC: Centers for Disease Control and Prevention

CDI: Clinical Documentation Improvement

CDL: Commercial Driver’s License

CEG: Community Excellence Group

CEO: Chief Executive Officer

CESB: Code of Ethical Standards of Behavior 

CF: Copansburg Hospital—Frankfort

CGCAHPS: Clinician and Groups Consumer Assessment 

of Healthcare Providers and Systems

CHDMG: College of Healthcare Data Management Group

CHNA: Community Health Needs Assessment

CHRO: Chief Human Resources Officer

CI: Continuous Improvement

CIO: Chief Information Officer

CMCL: Copansburg Medical Center—Lexington

CMI: Case-Mix Index

CMS: Centers for Medicare and Medicaid Services

CNA: Certified Nurse Assistant

COE: Communities of Excellence 2026

COPs: Communities of Practice

COS: Culture of Safety

COVID: Coronavirus

CPT: COVID Process Team

CRH: Copansburg Rehab Hospital

CRHS: Copansburg Regional Health System

CS: Copansburg Hospital—Stanton

CT: Computerized Tomography

D

DDI: Data Drive Improvement

DEI: Diversity, Equity and Inclusion

DEIC: Diversity, Equity and Inclusion Committee

DME: Durable Medical Equipment

DOE: U.S. Department of Education

E

E: Employees

EBIDA: Earnings Before Interest, Depreciation, and 

Amortization

ED: Emergency Department

EDCAHPS: Emergency Department Consumer Assessment 

of Healthcare Providers and Systems

EEOC: Equal Employment Opportunity Commission 

EL: Executive Leader

EL/SL: Executive and Senior Leader

ELT: Executive Leadership Team

EMR: electronic medical record

EOC: Environment of Care

EPA: Environmental Protection Agency

EPOP: Emergency Preparedness and Operations Plan 
G2

F

F: Family

FAQ: Frequently Asked Questions

FDA: Food and Drug Administration

FM: Facilities Management

FMEA: Failure Mode and Effects Analysis

FQHC: Federally Qualified Health Center

FT: Full Time

FTE: Full Time Equivalent

G

GPO: group purchasing organization

GSF: Gross Square Feet

GYN: Gynecology

H

H: Hospital

HAC: Hospital-Acquired Conditions

HAI: Healthcare-Associated Infection

HAPU: Hospital-Acquired Pressure Ulcer

HCAHPS: Hospital Consumer Assessment of Healthcare 

Providers and Systems

HDR: High Dynamic Range

HEDIS: Healthcare Effectiveness Data and Information Set

HH: Home Health

HHCAHPS: Home Health Consumer Assessment of 

Healthcare Providers and Systems 

HIPAA: Health Insurance Portability and Accountability Act

HP: Health Plan

HPCAHPS: Hospice Consumer Assessment of Healthcare 

Providers and Systems

HR: Human Resources

HS: High School

I

ICU: Intensive Care Unit

IDT: Interdisciplinary Team

IM: Information Management

IP/Inpt: Inpatient

IRB: Institutional Review Board

IRS: Internal Revenue Service

IT: Information Technology

ITM: Integrated Talent Management

J

JV: Joint Venture

K

KPI: Key Performance Indicator

KSA: Knowledge, Skills and Abilities

KWH: Kilowatt-hour

KY: Kentucky

KY HA: Kentucky Hospital Association

L

L&D: Learning and Development

LDP: Leadership Development Program

LDS: Learning and Development System

LED: Light-Emitting Diode

LEED: Leadership in Energy and Environmental Design

LERC: Legal, Ethics, Regulatory and Compliance

LGBTQ: Lesbian, Gay, Bisexual, Transgender, Queer or 

Questioning

LOS: Length of Stay

LS: Leadership System

LWBS: Left Without Being Seen

M

M: Monthly

MA: Medicare Advantage

MADS: Maximum Annual Debt Service

MAP: Medicare Advantage Program

MCP: Multidisciplinary Care Plan

MD: Medical Doctor/physicians

MLP: Mid-Level Provider

MM: Middle Managers

MO: Medical Office

MRI: Magnetic Resonance Imaging

MS: Medical Staff

MVV: mission, vision, values

MYPHI: Patient electronic medical record

N

NDCQF: National Database of Care Quality Factors

NEO: New Employee Orientation

NHC: National Hospital Corporation

NHSN: National Healthcare Safety Network

NICU: Neonatal Intensive Care Unit
G3

NIST: National Institute of Standards and Technology

NSQIP: National Surgical Quality Improvement Program

O

O: Other

OB: Obstetrics

OC: Organizational Change

OCR: Office for Civil Rights

OIG: Office of Inspector General

OP/Outpt: Outpatient

OPPE: Ongoing Professional Practice Evaluation

OR: Operating Room

OSBC: Office of Safety and Business Continuity

OSHA: Occupational Safety & Health Administration 

P

P: Partners or Projection

PA: Post Acute

Pandemic: COVID-19

PCP: Primary Care Physician/Provider

PCR: Polymerase Chain Reaction

PDCA: Plan, Do, Check, Act

PEO: Patient Experience Office

PESTLE+W: Political, Economic, Social, Technological, 

Legal, Environmental, Workforce

PET: Positron Emission Tomography

PFAC: Patient Family Advisory Council

PHI: Protected Health Information

PHQ-9: Patient health questionnaire for depression screening

PI: Process Improvement

PIC: Performance Improvement Council

PIP: Performance Improvement Plan

PIT: Process Improvement Teams

POAM: Plan of actions and milestones

PPDP: Performance and Professional Development Plan

PPE: Personal Protective Equipment

PSI: Patient Safety Indicators

PT: Part Time

Pt: Patient

Q

Q: Quarterly

QI: Quality Improvement

R

RCA: Root Cause Analysis

RN: Registered Nurse

ROI: Return on Investment

S

S: Semi-annual

SA: Strategic Advantage

SC: Strategic Challenge

SCM: Supply Chain Management

SCPE: State Center for Performance Excellence

SEEGs: Strategic Employee Engagement Groups

SHRM: Society for Human Resource Management

S/I: Strategy/Innovation

SL: Senior Leader

SLA: Service Level Agreement

SLT: Senior Leadership Team

SMARTER: Specific, Measurable, Aligned, Realistic, 

Time-bound, Evaluated, Reviewed

SNAC: Staff Nurse Advisory Council

SO: Strategic Opportunities

SObj: Strategic Objectives

SP: Strategic Plan

SPC: Statistical Process Control

SPP: Strategic Planning Process

St: Students

Su: Suppliers

SWOT: Strengths, Weaknesses, Opportunities, and Threats

SWPD: Service and Work Process Design

T

TAT: Turnaround Time

TB: Tuberculosis

tPA: Tissue Plasminogen Activator

TRAC: Teams Realizing Awesome Care

TUP: The United Practice

TV: Television

U

US: United States
G4

V

V: Volunteers

VBP: Value-Based Purchasing

VOC: Voice of the Customer

VP: Vice President

VPP: Voluntary Protection Program

W

WE CARE values: World-class medicine, Efficiency, 

Compassion, Accountability, Respect, Excellence

WF: Workforce

WHO: World Health Organization

Y

YTD: Year-to-Date
ORGANIZATIONAL 

PROFILE
i

Preface: Organizational Profile

P.1 Organizational Description

Copansburg Regional Health System (CRHS) is a large, not-forprofit, integrated delivery health care provider headquartered 

in the greater Lexington, KY region. The area and citizenry 

it serves is diverse. The urban hustle of Lexington gives way 

to the gently rolling fields of Kentucky. The service area is 

centered around Lexington (stretching roughly 40 miles from 

east to west and about 50 miles from north to south) and has a 

population of more than 1 million residents, encompassing both 

urban communities and rural areas of Kentucky. 

Theirs is a region where people can enjoy the benefits of 

urbanity and the serenity of a breeze in the bluegrass. Quality of 

life is a driving factor in people’s decision to live in their region. 

And CRHS believes the health care it provides enhances the 

attractiveness of the region. 

It is against this backdrop that CRHS was formed in 2000, after 

the merger of two regional health care providers, Downton 

Health and Bluegrass Healthcare. Since 2000, CRHS has 

seen significant growth, both organically driven and through 

acquisition of additional hospitals in the region. In 2012, CRHS 

began using the Baldrige Excellence Framework® as a method 

to help it achieve a more systematic approach across its large 

network of facilities and services, which led to achieving the 

2019 Excellence Award from the State Center for Performance 

Excellence. CRHS has learned much over the past decade and 

achieved tremendous improvement in operations and results to 

the benefit of those served.

P.1a. Organizational Environment

P.1a(1). CRHS includes five hospitals. They range in size from 

the system’s largest hospital, Copansburg Medical Center—

Lexington (CMCL), which is a teaching facility with an active 

residency program featuring 120 physician residents, to a 

25-bed critical access hospital (CAH), Copansburg Hospital— 

Stanton (CS). 

CRHS has service lines for cardiology, oncology, orthopedics, 

women’s and children’s, behavioral health/substance abuse, 

and neurology, with programming varying depending on 

hospital size, complexity, and local population needs. CRHS’s 

hospitals and their related outpatient and post-acute services 

(home health, hospice, and durable medical equipment [DME]) 

generate more than 70% of the system’s revenue and house 

most of the workforce, so they are of primary importance.

CRHS also has numerous outpatient diagnostic and treatment 

facilities, including:

■ joint-ventured (JV) surgery centers, 

■ JV imaging centers, 

■ rehabilitation services, 

■ urgent care, and

■ four medical office buildings. 

CRHS boasts a 750-member employed, multispecialty medical 

group; 120 physician residents; and a broader medical staff 

that includes another 420 independent physician members. The 

employed medical group directly supports the operation of both 

hospitals and outpatient services.

CRHS also has numerous outpatient diagnostic and treatment 

facilities, including joint-ventured (JV) surgery centers, JV 

imaging centers, rehabilitation services, urgent care, and 

four medical office buildings. CRHS boasts a 750-member 

employed, multispecialty medical group; 120 physician 

residents; and a broader medical staff that includes another 

420 independent physician members. The employed medical 

group directly supports the operation of both hospitals and 

outpatient services. 

CRHS also operates health insurance plans with products in 

the commercial market for local employers and products in 

the Medicare Advantage market. Today, these insurance plans 

represent its fourth area of focus, although they may well take 

on additional importance as CRHS grows in the future.

Finally, the 1,290 physicians on the medical staff and CRHS 

facilities form the region’s largest accountable care organization 

(ACO), participating in Medicare’s NextGen ACO program as 

well as multiple value-based contracts with private insurers. The 

ACO continues to be an entity that focuses on Medicare’s triple 

aim of providing high-quality care, with high levels of patient 

satisfaction, in the most efficient way possible.

CRHS is proud to be a heavily decorated health system with an 

impressive list of accolades, accreditations, and certifications, 

including CMCL and Copansburg Hospital—Berea (CB) attaining Magnet status, CHDMG Most-Wired Hospital, Kentucky 

“Best Place to Work” designation, LeapCore A ratings, LEED/

Practice Bluefit Excellence Award, The United Practice Stroke 

and Orthopedic certifications, trauma center designations, 

specialties with Wooland Health top 100 designations, and 

Voluntary Protection Program (VPP) star status (from OSHA) 

for workplace safety.

P.1a(2). During the merger proceedings between Downton 

Health and Bluegrass Healthcare, the leadership teams and 

boards of the two hospitals began discussions about the desired 

mission and vision of the potential new combined regional 

health care system. From those discussions, the ultimate mission 

and vision of CRHS was born. And, although the new leadership team and board reviews the mission and vision annually, 

they have remained remarkably unchanged since 2000.

In 2002, new CRHS leadership team members embarked on a 

process to clearly define the values they use each day in pursuit 

of the mission and vision. From this effort came CRHS’s WE 

CARE values. 

In terms of culture, CRHS is a reflection of its region and the 

people it serves. CRHS is inclusive and diverse, and it understands how important a great quality of life is to both patients 

and the workforce. 

It is because of the mission, vision, values (MVV) and culture 

that CRHS has developed its core competencies (CCs). The 

combination of safe, efficient, and high-quality care is the most 

effective differentiator for CRHS.
ii

P.1a(3). CRHS’s key workforce members and their requirements 

are in Figure P.1-2. The recent pandemic did not change the 

make-up of the workforce significantly, but it did result in more 

nonclinical employees working remotely. The pandemic also 

caused CRHS to redouble its efforts around safety and wellness 

for the entire workforce. There are organized bargaining units 

for nurses at CMCL and for environmental and facility services 

employees at all hospitals. Health and safety requirements for 

all segments include safe environment, appropriate protective 

equipment, and appropriate safety education.

P.1a(4). CRHS’s key assets include its five hospitals (with 

bed size): 

■ CMCL (600), 

■ CB (150),

■ Copansburg Hospital—Frankfort (CF) (50), 

■ Copansburg Rehab Hospital (CRH) (50), and 

■ CS (25).

Other key facility assets are a corporate office building, substantial outpatient facilities including four medical office buildings, 

three six-suite JV surgery centers, six JV outpatient advanced 

imaging centers, and five urgent care and three rehabilitation 

therapy facilities. 

Equipment assets include a full spectrum of imaging equipment, 

including 10 MRI machines, 3 PET scanners, 35 CT machines, 

and 5 3D mammography units. Advanced radiation oncology 

equipment includes a photon center, gamma knife, rapid arc, 

HDR, and stereotactic radiosurgery capabilities. 

CRHS has e-ICU capabilities to support its rural hospitals. It 

also has state-of-the-art cardiology and neurosurgery equipment, 

including hybrid ORs for open heart and valve procedures, 

interventional radiology and neurology suites, and robotic 

assisted surgical capabilities at three hospitals. It also operates a 

mobile clinic to provide access to rural populations.

Nonphysical key assets are CRHS’s Apex EMR (electronic 

medical records system) and its corporate health insurance plan 

and Medicare Advantage plan. Its telehealth platform through 

Apex is a key asset as well—it supports televisits with health 

care providers in the medical offices and facilitates specialty 

consultation at the smaller hospitals. Finally, both the residency 

curriculum and programming and the accountable care analytics 

platform are CRHS’s most significant pieces of intellectual 

property.
iii

P.1a(5). U.S. health care is one of the most highly regulated 

environments in the world. The most significant federal 

regulators include the Centers for Medicare & Medicaid 

Services (CMS), Occupational Safety & Health Administration 

(OSHA), Office of Inspector General (OIG), Office for Civil 

Rights (OCR), Equal Employment Opportunity Commission 

(EEOC), Food and Drug Administration (FDA), Environmental 

Protection Agency (EPA), Internal Revenue Service (IRS), and 

U.S. Department of Education (DOE). 

In addition, the Commonwealth of Kentucky has state-level 

agencies with regulatory authority such as the Department of 

Health, Department of Insurance, Department of Medicaid 

Services, and Department of Emergency Medical Services. 

A third layer of regulation exists at the industry level. Relevant 

regulators include The United Practice, American Surgeons 

Group (ASG), American Pathologists Group, Accreditation 

Council for Graduate Healthcare Education, Radiologists Group 

of America, and the Commission of Education Advancement.

P.1b. Organizational Relationships 

P.1b(1). CRHS’s highest-level leadership structure is a volunteer, 16-member Board of Trustees (BOT). Further, there are 

local Advisory Boards at each CRHS hospital that report to the 

BOT. BOT and Advisory Board members serve three-year terms 

and can be re-elected to the board to serve up to three terms. 

The BOT officers include the chair, vice chair, secretary, and 

treasurer. BOT committees are Quality, Finance, Governance, 

Risk Management, and Executive. CRHS’s president and CEO, 

Keith Turley, reports to the BOT. 

The Executive Leadership Team (ELT) includes the president 

and CEO and his direct reports. Each business unit has a Senior 

Leadership Team (SLT) composed of the senior leader of the 

business unit and her or his direct reports. The corporate office 

provides key services for the organization, including strategic 

planning, marketing, finance, legal, risk management, accreditation, information technology, performance excellence, medical 

staff credentialing, materials management, security, facilities, 

biomedical services, and human resources. The Copansburg 

Foundation supports the efforts of the organization and has a 

separate, 12-member community-based advisory board.

P.1b(2). CRHS considers the patient its primary key customer. 

In a cycle of refinement driven by a board retreat in 2017, the 

organization added family members as a second key customer. 

And, it considers the broader community served as the ultimate 

stakeholder.

P.1b(3). CRHS’s suppliers are those organizations from whom 

CRHS purchases the supplies, equipment, pharmaceuticals, and 

services needed for core operations. CRHS key requirements 

of its suppliers are quality of products/services, availability of 

products/services, and cost. 

CRHS has four key equity partnerships and maintains at least 

51% equity in each of these partnerships. It partners with more 

than 50 independent surgeons in three distinct JV surgery 

centers. It partners with a 40-member radiology group on six 

outpatient imaging centers. The JV structure provides a competitive advantage to CRHS, as physicians with an equity stake in 

these ventures are tightly aligned with CRHS and help CRHS 

drive performance and innovation in these services.

Recognizing the tremendous improvement in operations that 

CRHS has achieved as a result of implementing the Baldrige 

framework, CRHS has partnered with several local organizations to improve the performance of the community using 

the Communities of Excellence 2026 (COE) Baldrige-based 

framework. CRHS serves as a backbone organization for this 

community improvement effort, currently in its second year.

CRHS also has several key collaborators. These collaborators 

help the organization with workforce recruitment and training, 

and also with community health and safety initiatives. Collaborating with its local college and university has enhanced 

CRHS’s ability to recruit and retain personnel in key areas. It 

has also worked with higher education and the health department on several innovative initiatives focused on community 

health. CRHS’s key suppliers, partners, and collaborators are 

listed in Figure P.1-4.
iv

P.2 Organizational Situation

P.2a. Competitive Environment

P.2a(1). CRHS is the market share leader for almost all clinical 

services in its region. That market leadership position has been 

cultivated over time. Its market position and sheer scope of 

services have become a significant advantage. 

However, it does have some robust competitors in the service 

area. Hospital competitors (with bed sizes) include academic 

medical centers at University of Churchill Downs (400) and 

Rivertown University (450), a National Hospital Corporation 

(NHC) hospital (250), and independent hospitals such as 

St. Paul’s Hospital (200) and Edwardia Hospital (150). Competition in the outpatient setting includes those same hospitals and 

some for-profit entities such as Rivers Imaging Centers, Trulent 

Surgery Centers, Movement Physical Therapy, and PatientNow 

Urgent Care. Competition in the health insurance space comes 

from national health insurers such as Ryland, Xyrus, Norwood, 

Haferty, and Briars.

P.2a(2). Since the merger that formed CRHS in 2000, the 

regional market has slowly been consolidating, and rumors swirl 

consistently about the remaining independent hospitals joining 

other large health care systems. In addition, two unaffiliated 

rural hospitals have announced they are closing. 

This consolidation and uncertain future for some hospitals 

present an opportunity for collaboration, and CRHS is investigating an innovative rural health collaborative with the two 

unaffiliated rural hospitals to try to maintain access in those 

communities. Finally, a for-profit competitor in an ambulatory 

surgery center (ASC) has been approved to build a four-suite 

surgery center in Lexington. Competition in the surgery center 

space serves as a catalyst for innovation and collaboration 

within CRHS’s JV surgery centers.

P.2a(3). Health care is blessed with significant amounts of 

comparative data both within and external to the industry, with 

the only real limitations being the timeliness of some data, and 

in-depth competitor data can be difficult to obtain. CRHS also 

experienced a disruption in comparative data related to the 

COVID pandemic. Its most substantial sources of comparative 

data include CMS, Consumer Assessment of Healthcare 

Providers and Systems (CAHPS), Centers for Disease Control 

and Prevention (CDC), National Healthcare Safety Network 

(NHSN), Healthcare Effectiveness Data and Information Set 

(HEDIS), ASG, National Database of Care Quality Factors 

(NDCQF), Medical Agency Research and Quality, Bureau 

of Labor Statistics, Kentucky Health Group, Kress Daney, 

the Upwood Organization, National Data Sort Corporation, 

Carerank, Voorlan, LeapCore, Zandi’s Rating Agency, and 

Craigly Rating Agency. 

P.2b. Strategic Context

Each year, CRHS reviews and assesses its competitive position 

and context as part of the strategic planning process (SPP). As 

its market is relatively dynamic, as is the industry itself, CRHS 

has needed to change its lists of the most important strategic 

advantages, challenges, and opportunities for the system. See 

Figure P.2-1 for results from the most recently completed 

strategic planning retreat.
v

P.2c. Performance Improvement System

CRHS uses the Baldrige framework as its overarching system to 

inspire performance excellence. All CRHS employees receive 

basic training on the Baldrige framework, and more than 

50 leaders at all levels across the organization have received 

advanced Baldrige training, with more than a dozen serving as 

Baldrige examiners at the state or national levels. CRHS uses 

its Baldrige feedback reports as one input in generating performance improvement projects.

In addition, all employees receive training in the Plan, Do, 

Check, Act (PDCA) methodology; and they use this knowledge 

for day-to-day improvement work at the department/unit 

level. Each department/unit has a performance improvement 

board and is required to always be working on one rapid cycle 

improvement project. Departments/units meet with leaders 

weekly at the performance improvement board to review 

progress on these projects. These projects are specific to the 

department/unit and last 4 to 12 weeks.

At a system level, the CRHS’s Performance Improvement 

Council (PIC) selects and sanctions performance improvement 

projects. Each selected project is assigned to a TRAC (Teams 

Realizing Awesome Care). The TRAC teams report monthly to 

the PIC on project progress. Within TRAC team projects, some 

Lean improvement tools are used.

There is a research department with an Institutional Review 

Board (IRB) that supports innovation in medical care, and the 

performance excellence and strategy teams at the corporate 

level help identify strategic opportunities to determine those that 

are intelligent risks to pursue. 
RESPONSES 

ADDRESSING ALL 

CRITERIA ITEMS
1

Category 1: Leadership

1.1 Senior Leadership

1.1a. Vision and Values

1.1a(1). When Downton Health and Bluegrass Healthcare 

merged to form CRHS in 2000, the mission and vision of the 

new regional health system were established by the leadership 

teams and boards of the two original hospitals. The CRHS Mission, Vision, and Values (MVV; Figure P.1-1) are reviewed and 

affirmed annually to determine if any modification is needed.

The ELT and SLT systematically deploy the MVV to all stakeholders throughout the organization via the Leadership System 

(Figure 1.1-1) and via multiple communication methods (Figure 

1.1-3) to the WF, suppliers, partners, collaborators, patients, 

families, and key communities (other stakeholders). Since 2018, 

executive and senior leaders (EL/SLs) have incorporated reallife examples of the MVV in Action to the WF during each key 

gathering/meeting and to patients, families, and the community 

during community forums, focus groups, and via the website 

and bulletins. MVV in Action are stories describing how the WF 

have emulated the MVV in caring for patients, their colleagues, 

and/or their communities. The MVV and Code of Ethical 

Standards of Behavior (CESB) are incorporated into CRHS 

contractual purchase and service agreements with suppliers, 

partners, and collaborators to ensure their commitment in 

upholding these credos.

EL/SLs personally demonstrate their commitment to WE CARE 

in leading by example and emulating the values in all their 

interactions. EL/SLs highlight specific values that resonate with 

them at the beginning of their own division meetings and in 

business meetings with suppliers, partners, and collaborators. 

EL/SLs further demonstrate their commitment to WE CARE 

by ensuring that decisions made align with the MVV. During 

leader rounding, SLs specifically focus on conveying the values 

of compassion and respect in their interactions with the WF, 

physicians, volunteers, students, patients, and families. On a 

rotational basis, the SLs address the orientation sessions for new 

employees, volunteers, students, and medical staff members 

to discuss and share examples of the MVV in Action and to 

convey the personal and profound impact of the MVV on the 

key communities served. 

1.1a(2). To promote a legal and ethical environment and ingrain 

these characteristics throughout CRHS’s organizational culture, 

the ELT established a CESB that applies to the entire WF and 

all business operations. EL/SLs demonstrate their personal 

commitment to legal and ethical behavior using multiple 

approaches, beginning with modeling the CESB and leading 

by example in their interactions with the WF, patients, families, 

partners, suppliers, and other stakeholders. EL/SLs uphold 

ethical and legal standards in their individual communications and ensure they are maintained in business 

meetings and decision making. In their commitment to 

these standards as well as to transparency and accountability, EL/SLs openly discuss close calls to help raise 

awareness and provide an opportunity for learning. 

They also call out comments, behaviors, or actions 

that appear to cross the line and ensure the appropriate 

investigation and follow-up occurs. As a cycle of learning through COE, the Community Excellence Group 

(CEG) has identified how its members, inclusive of 

CRHS leadership, will demonstrate commitment to 

legal and ethical behavior through its Guiding Principles adopted in early 2020.

To further promote an organizational environment 

requiring legal and ethical behavior, the Medical Staff 

Code of Professional Behavior Policy was established 

by the Medical Executive Committee and applies to all 

medical staff members. Complaints of inappropriate or 

disruptive behavior are reviewed by the Chief of Staff 

and investigated and addressed within the Medical 

Staff governance. Issues such as bioethical medical 

care considerations are referred to the Bioethics 

Committee (a standing committee of the medical staff 

with multidisciplinary and SL representation). The 

Bioethics Committee provides a forum for discussion 

of clinical ethical considerations associated with 

CRHS’s clinical, educational, and research activities.

1.1b. Communication 

CRHS’s Communication System (Figure 1.1-2) 

provides the framework to communicate information 

across the various business unit locations, service lines, 
2

and stakeholders. It is structured around a system of Plan, Do, 

Check, Act (PDCA) for continuous evaluation, learning, and 

improvement (Figure 1.1-3). CRHS launches the communication and uses feedback (meeting evaluations/surveys or other 

data) to evaluate and determine the effectiveness and “reach” of 

its messaging, which allows it to quickly modify the method, if 

necessary. For example, when releasing news and information 

to the WF, CRHS learned from past experience that email and 

electronic newsletters are among the least effective modes of 

delivery for time-sensitive information. In this instance, during 

the C (check) step of the Communication System, it identified 

both a low frequency and delayed “open” and “read” rates 

using those modes of communication. These data informed the 

process under A (act on results), and CRHS pivoted to push 

news and information to the WF via desktops and workstations. 

EL/SLs use multiple approaches to transparently communicate 

and engage the entire CRHS WF, patients, families, stakeholders, suppliers, partners, and collaborators, with an emphasis 

on providing forums and mechanisms to support two-way 

communication (Figure 1.1-3). To reach as many staff members 

as possible, the Round-the-Clock forums are scheduled each 

shift and are simultaneously livestreamed for viewing from 

any location. The base location is rotated to different care 

sites, to increase visibility and engagement across the entire 

health system. The sessions are recorded and made available 

on the intranet. CRHS has intentionally created redundancy in 

its communication methods to reach as many stakeholders as 

possible, across multiple locations, work shifts, and levels of 

access. Combined, these approaches serve as the primary means 

for communicating key decisions, needs for organizational 

change, news, and information impacting the organization. 

Engaging the entire WF across multiple campuses is a high 

priority. CRHS continuously evaluates communication channels 

by analyzing data and information such as attendance/hits/readwatch rates and meeting effectiveness using evaluations and 

surveys. The communications team will recommend changes 

based upon what the data reveals. 

In a 2017 cycle of learning, a section of the CRHS intranet 

was set up to provide informational updates with summaries 

of meeting topics and follow-up, to ensure the entire WF has 

access and is informed. Key decisions impacting the organization are further disseminated with the distribution of summaries 

and FAQs that are specifically geared to the stakeholder audience and used by leaders during department and business unit 

meetings. In 2019, CRHS incorporated stakeholder personas to 

better understand stakeholder groups and how they access information. The personas create reliable and realistic representations 

of stakeholders to support effective communication with each 

specific audience. This led to the use of short, monthly video 

messages from SLs to provide an easily accessed update. These 

proved especially effective during the pandemic, while people 

were not able to gather in person. As a result, CRHS continues 

to use video as a key communication method.
3

1.1c. Mission and Organizational Performance 

1.1c(1). Using the CRHS Leadership System framework 

(Figure 1.1-1), EL/SLs create an environment for success now 

and in the future, with the Mission and Values as the foundation 

and patients and families at the center of care. EL/SLs set the 

direction through the selection of objectives and goals as part of 

the SPP (Figure 2.1-1, step 6). Goals are cascaded throughout 

the organization via the development and deployment of action 

plans, measurement, assessment of performance to goal and 

acting on the results, through the performance improvement 

system of PDCA (Figure 2.2-1). A single action plan owner is 

designated and may be supported by a SL champion and/or a 

clinical champion, as appropriate, to facilitate engagement and 

to help break down barriers to improvement. The cascading 

of action plans, performance metrics, and goals extends to 

departments and service units (with accountable leaders 

identified) and are captured in the employees’ Performance and 

Professional Development Plan (PPDP), so there is a clear line 

of sight from the SPP to employee.

EL/SLs create and reinforce a culture that fosters the engagement of patients, families, and the entire WF, supported by 

the framework of the Leadership System (Figure 1.1-1). The 

care model of inclusion places the patient and family at the 

center, with the health care team seeking to engage and partner 

with the patient and family in care decisions from admission 

through discharge (ambulatory and inpatient settings). During 

inpatient rounds, the health care team will meet at the patient’s 

bedside whenever possible, to understand his/her preferences 

and to discuss his/her progress and plan of care. In ambulatory 

encounters, patient preferences are collected as part of the intake 

process and incorporated into the patient’s health record. Leader 

rounding in all settings is focused on engaging the WF and 

listening to their ideas, needs, concerns, and challenges. 

With the value of respect and a deep commitment to patients, 

families, and communities, SLs strive to ingrain equity and 

inclusion throughout all patient care and WF approaches. This 

includes understanding the diversity of communities and fostering diversity, equity, and inclusion (DEI) in the WF. In 2021, 

CRHS created a new position: Vice President, Diversity and 

Inclusion, responsible for the ongoing development, implementation, and oversight of the DEI strategy to ensure integration 

into the organizational culture, care delivery systems, and all 

program offerings.

SL commitment to a culture of safety (COS) and high-reliability 

principles are critical components of creating an environment 

for success. CRHS’s CC of safe, high-quality care is supported 

by the organization’s Just Culture, which emphasizes a systems 

approach, teamwork, transparency in operations, and a focus on 

learning with a nonpunitive approach to errors. Daily Patient 

Safety Huddles and leadership rounds are integral to promoting 

the COS as well as the ability to cultivate agility and resilience. 

These approaches provide leaders with real-time information to 

anticipate, understand, and prioritize issues requiring action. It 

is not uncommon for changes in patient volume, acuity, staffing, 

or supplies to result in changes to process or staff assignments 

throughout the day. During the pandemic, CRHS recognized 

the need to hold huddles more often due to the rapidly changing 

situation. 

The CRHS Performance Improvement Council (PIC) and 

TRAC model and cultivate intelligent risk-taking behavior, 

creating a safe environment for risk-taking across the organization. TRAC teams are encouraged to propose ideas and potential 

solutions that reflect intelligent risks. TRAC team members test 

the ideas, learn from them, and are encouraged to modify and 

try again. All attempts (failures and successes) are rewarded to 

motivate intelligent risk-taking and foster innovation. 

EL/SLs participate in succession planning and the development 

of future organizational leaders through the CRHS’s Leadership 

Development Program (LDP; AOS). Within the LDP, EL/SLs 

and their direct reports identify individuals who exhibit high 

leadership potential and exemplify WE CARE as likely successors. EL/SLs and their direct reports will meet with the potential 

leaders directly to ascertain their interest in participating in the 

LDP (5.2c[4]) and serve as mentors and advisors.

1.1c(2). EL/SLs create a focus on action to achieve the CRHS 

mission through the Leadership System and cascading goals 

through all levels of the organization. Each organizational goal 

is cascaded to applicable divisions, departments, service lines, 

and individual members of the WF via their individual PPDP. 

Action plans are developed with WF input. Plans are deployed, 

and data are collected to measure the impact of the actions 

taken. Modifications are made, as warranted. Division and 

department/service line leaders track results, posting and sharing 

the information with their staff members. This approach creates 

a focus on action across the organization with accountability at 

multiple levels: EL/SLs, department, service line leaders, and 

individual WF members. 

Organizational goals are established during the SPP with 

consideration of the value created for customer groups and/or 

stakeholders (Figure 2.1-1, steps 1 and 6). With the vision to 

be among America’s best health systems, CRHS’s CCs of Safe, 

High-Quality Clinical Care and Efficiency in Operations give 

priority to the processes and systems supporting the delivery of 

patient care, thus providing value to the patients, families, and 

stakeholder communities served. CRHS balances value for all 

patients, families, and stakeholders during the SPP, selecting 

goals and metrics that support each group and its key requirements (Figure 2.2-1, step 2).

SLs are personally accountable for business operations and 

results, participating in the monthly review of performance metrics. SLs demonstrate personal accountability for specific action 

plans as executive owners, setting expectations, leading regular 

reviews of action plan progress, and assisting in breaking down 

barriers that may impede improvement.

Additionally, cross-functional alignment and accountability 

are achieved by working closely with medical staff members, 

suppliers, partners, and collaborators. Recognizing the role 

of medical staff members in achieving the key performance 

indicators (KPIs) for patient safety and clinical excellence, the 

SLs and medical staff leaders incorporated evidence-based 

practice standards as part of the peer review process in 2018 

and the ongoing professional practice evaluation (OPPE) 

process. In a 2019 cycle of learning, CRHS identified the 

opportunity to ensure that supplier, partner, and collaborator 

agreements reflect alignment with CRHS’s strategic goals, 
4

and CRHS began incorporating performance and service 

expectations. These are reviewed annually after the SPP to 

determine the need for revision. 

1.2 Governance and Societal Contributions

1.2a. Organizational Governance 

1.2a(1). The BOT is the governing body of the CRHS, responsible for oversight of the health system’s quality of care and 

financial health. Responsible governance of CRHS is ensured 

through multiple systematic approaches summarized in Figure

1.2-1. Further detail of each approach is available on-site (AOS).

The CRHS organized medical staff, a self-governing entity that 

is accountable to the BOT, with its own medical staff bylaws, 

rules, standards, and policies to manage medical staff activities. 

The CRHS BOT Governance Committee is charged with 

determining the membership of the boards and measuring the 

quality of performance of the BOT, the Advisory Boards, and 

individual board members.

The CEO Succession Plan is developed by the Executive 

Committee of the BOT and approved by the BOT. The 

Executive Committee is charged with tracking the successor’s 

continued performance and progress throughout the year and 

provides recommendations regarding additional development, if 

needed, to the BOT. Annually, the CHRO provides a report on 

the CRHS LDP to the BOT.

1.2a(2). The Executive Committee of the BOT evaluates the 

performance of the CRHS president and CEO, assessing his 

progress in meeting the assigned strategic plan goals. The 

president and CEO evaluates the ELT, and the ELT evaluates the 

SLT based upon established goals, cascaded from the strategic 

plan as well as individual PPDP goals. The integration with 

the PPDP supports each leader’s professional development 

while advancing his/her effectiveness. The president and CEO, 

EL, and SL base compensation is reviewed annually against 

similar positions in the industry to ensure competitiveness. This 

is augmented by an incentive performance-based model that 
5

rewards EL/SLs, teams, and individuals for progress toward or 

attainment of goals, including those cascaded and linked to the 

strategic goals. The ELT and SLT evaluate the effectiveness of 

the Leadership System annually. 

At the direction of the BOT Governance Committee, BOT 

and Advisory Board members complete a self-assessment of 

board and individual effectiveness on an annual basis. A set of 

standardized assessment tools support benchmarking the results 

to other organizations’ boards. The BOT reviews the results 

to identify opportunities for improvement leading to cycles 

of improvement. This process led to creating a Board Quality 

Committee in 2009 in order to ensure that quality and patient 

safety efforts were prioritized, and in 2012, the BOT recognized 

the need to receive training in quality and requested an annual 

update on national quality and patient safety trends. In 2018, to 

improve meeting efficiency and effectiveness, the BOT moved 

to a consent agenda, placing trust in its committees and allowing 

it to focus on the most important issues.

1.2b. Legal and Ethical Behavior 

1.2b(1). CRHS addresses current and anticipates future legal, 

regulatory, and community concerns with its health care 

services and operations through multiple methods. The CRHS 

corporate office provides direction and support for legal, regulatory, and accreditation compliance. The president and CEO and 

EL/SLs are actively involved at the regional, state, and national 

level as members of hospital association committees, accountable care collaboratives, health plan associations, and physician 

practice and advisory groups, along with their involvement in 

local community groups. These activities, combined with input 

received through voice of the customer (VOC)/listening posts, 

ensure that CRHS is well informed and aware of current and 

future legal, regulatory issues and community concerns with 

health care services and operations. In anticipation of potential 

concerns and/or in response to issues and concerns raised, 

CRHS forms a taskforce with WF representatives, customers, 

and stakeholders to gather information, evaluate current issues 

and risks, and identify a set of solutions. 

CRHS includes key stakeholders in the planning and designs 

a new and/or expanded service. Consistent with the COS and 

a high-reliability preoccupation with failure, CRHS seeks to 

anticipate potential risks related to the service. As described in 

6.1a(3), CRHS uses failure mode effects and analysis (FMEA) 

to anticipate what could go wrong and to identify the failure 

points, the likelihood of occurrence, and the significance of each. 

It benefits from the valuable input from customer, stakeholder, 

and objective outsider representatives in the FMEA process. This 

proactive approach allows CRHS to the determine what design 

changes are needed to avert or mitigate potential risks. 

Key compliance processes include CRHS’s Corporate Compliance Program (CCP), annual WF regulatory compliance training 

and education, an annual risk assessment, compliance plan, 

auditing and monitoring, and a compliance complaint hotline 

managed by the corporate Risk Management and Compliance 

Officer. The scope of the CCP includes all CRHS business 

units (hospitals, health plan, home health/hospice, JV surgery 

centers, JV imaging centers, and physician practices). Legal, 

ethics, regulatory, and compliance (LERC) audit data, as well 

as validated HIPAA complaints and compliance complaints, 

are reported to the Corporate Compliance Committee (CCC). 

An action plan is required for areas performing below target, 

followed by progress reports to the CCC until satisfactorily 

resolved. An Annual Report of LERC activities and results is 

provided to the CCC and Finance and Audit Committee of the 

BOT. CRHS maintains a Special Investigations Unit as required 

for health plan compliance.

CRHS tracks multiple measures that reflect performance within 

legal, ethics, regulatory, and accreditation processes with 

cross-functional stakeholders and impacts. See Figure 1.2-2 for 

a summary of key measures and goals.

1.2b(2). Through multiple systematic approaches, CRHS 

promotes and ensures ethical behavior in all interactions. 

These include the CESB that applies to the entire WF, business 

operations, and the CCP with clear roles, responsibilities, and 

processes to prevent fraud and abuse. CRHS investigates and 

identifies validated breaches of standards of behavior and/or 

practice through auditing, monitoring, event reporting, complaints, and hotline reporting, which may be used by anyone, 

including the WF, patients, families, partners, suppliers, and 

other stakeholders. WF and business operations violations are 

addressed by the accountable EL. The medical staff president 

and Medical Executive Committee address any physicianrelated breaches in alignment with the medical staff rules and 

approach(es). All breaches are reported to the CCC, where 

events are analyzed and aggregated to determine the need for 

process change.

1.2c Societal Contributions

1.2c(1). CRHS’s Societal Contributions System revolves around 

key stakeholders, communities served, and the approach to meet 

their key requirements. 

CRHS’s commitment to its key communities served includes 

ensuring their representation and participation in the SPP, 

community focus groups, and new/modified service-planning 

groups. This representation ensures that CRHS considers the 

interests and key requirements of communities in the selection 

of strategic goals, design of services, and implementation of 

action plans, all of which are integrated into daily operations. 

Through measures of effectiveness, feedback received through 

VOC/listening posts, and application of PDCA, CRHS 

evaluates and determines the need for modification or course 

correction.

In addition, CRHS collaborates with local and regional community organizations, such as local schools, municipalities, and 

service organizations, in its efforts to support and strengthen 

social and economic systems (see approaches described in 

1.2c[2]). It also partners with the City of Lexington to protect 

and improve the environment through “Live Green Lexington.” 

Part of the Green commitment is to implement or improve an 

environmentally conscious practice each year. CRHS facilities 

have adopted energy efficiency methods since 2016, converting 

to LED lighting. In 2017, CRHS replaced drinking fountains 

with filtered water bottle refilling stations and eliminated plastic 

bottles from cafeteria and catering services. In 2018, it began 

purchasing products made from recycled materials, whenever 

possible. In 2019, it began composting kitchen and food waste 
6

in the cafeteria. In 2020–2021, it paused new methods due to 

the pandemic, and it plans to increase use of recyclables in 2022 

by 15%.

CRHS recognized a greater opportunity to contribute to the 

well-being of not only the health but also education, economy, 

and quality of life for its community by partnering with others 

in the community (Figure P.1-4) to address these issues through 

COE, which is based on the Baldrige framework. Serving as a 

backbone organization, the president and CEO named the VP of 

the ACO and Population Health to lead this effort for CRHS in 

2019. Other key leaders in the community were invited to serve 

as part of the CEG. To date, the CEG has developed its Community Strategy and Strategic Objectives and is establishing work 

groups to address the identified community priorities of “Live 

Green Lexington,” health disparities in socioeconomically 

disadvantaged areas, and community revitalization. As a cycle 

of learning, these priorities will be incorporated into a Societal 

Contributions System (AOS).

1.2c(2). Community Health Needs Assessment (CHNA) 

findings are used to identify unmet health and social needs 

within the community to actively support and strengthen key 

communities. Past CHNA results led to the launch of trauma 

services, the expansion of urgent care centers, and the mobile 

health clinic. CRHS has continued to provide behavioral health 

services and substance abuse treatment, while other hospitals 

have closed these services due to the regulatory burden and 

poor ROI. In addition to ongoing collaboration with community 

stakeholders as CRHS improves and grows its health care 

services, EL/SLs actively serve community groups and organizations in varying capacities—whether as volunteers or on 

advisory committees or boards. Participating not only serves 

as a visible CRHS presence but also fosters an enhanced level 

of engagement by EL/SLs who often advocate on behalf of the 

communities served.

Key communities are those in which services are based, roughly 

40 miles east to west and 50 miles north to south of Lexington. 

To promote and build community health, CRHS offers a 

quarterly community health fair, the location of which is rotated 

and staffed by the hospitals, urgent care centers, and ambulatory 

sites within the immediate community. The mobile clinic 
7

supports the health fairs, providing free health screening (blood 

pressure and diabetic screening), and CRHS partners with the 

local department of public health to provide free childhood 

immunizations, influenza immunizations during flu season and 

COVID vaccinations during the coronavirus pandemic. CRHS 

promotes healthy lifestyle choices and nutrition via the website 

and newsletters, which are available in waiting areas. 

In recent years, CRHS has embarked on several initiatives to 

support its communities in new ways, which also further benefit 

the economic and social systems. In 2018, it began offering 

grants to encourage the WF to live near Copansburg Medical 

Center-Lexington (CMCL) to assist employees and support 

community revitalization. In 2019, CRHS and other organizations and businesses within the key communities came together 

to join the COE, which is helping CRHS and other members 

to recognize that its community is a complex ecosystem that 

requires a network of partnerships and new models to address 

community needs. CRHS is committed to leading and supporting these efforts.

Category 2: Strategy

2.1 Strategy Development 

In 2012, when CRHS made the strategic decision to adopt the 

Baldrige framework, leadership assigned an administrative 

“champion” for each of the seven categories. Each champion 

systematically reviews applications of Baldrige Award 

Recipients (BARs) to evaluate processes and identify potential 

opportunities for improvement. Champions and leaders also 

attend the Baldrige Quest for Excellence® Conference to get 

ideas on how to evaluate and refine processes, approaches, and 

systems at the outset of each strategic planning cycle. 

One key improvement that has resulted from this evaluation is 

that champions are no longer assigned to category 7, because a 

determination was made 

that it was better to keep 

the “ownership” of the 

results associated closely 

with the process that 

yields the results. 

2.1a. Strategy 

Development 

Process

2.1a(1). The CRHS SPP 

(Figure 2.1-1) begins 

in August of each year. 

The key participants 

include the corporate ELT, 

business unit SLTs, and 

board members. Prior to 

2017, strategic planning 

was a triennial event. 

During the evaluation 

of the SPP, the ELT and 

SLTs decided to change 

the planning horizons and 

“refresh” the strategic 

plan annually (bold, green font activities in Figure 2.1-1), with 

short-term goals and then conduct full long-term planning (all 

activities) every three years. Since 2019, CRHS also projects 

ultra-long-term (five- to ten-year) horizons specific to the IT and 

master facilities plans during the three-year cycle. Analysis of 

the success of those plans informed the need to begin planning 

for the highly resource-intensive aspects of CRHS further in 

advance, to ensure that sufficient funds and other resources 

are available. The one-year plan refresh enhances CRHS’s 

agility, affords greater resilience, and makes resource allocation 

decisions aligned to the annual personnel and operations 

budgets. Like the strategic plan, the capital budget is a threeyear projection that is refreshed annually. 

The process engages senior leaders and the board in the actual 

formulation of the plan, while systematically gathering inputs to 

hear the “voice” of a much larger group of stakeholders, including customers, payors, suppliers, competitors, the community, 

and the workforce.

The SPP addresses the potential needs for change through the 

environmental scan and review of data during steps 1–3 (plan 

phase) of the SPP, with a focus on understanding key stakeholder requirements and expectations, the external environment, 

and current relative performance. 

Step 1 includes analysis of qualitative and quantitative information from key stakeholders Step 2 evaluates current performance 

levels and the progress on current action plans. Step 3 looks 

externally at the environment, using a PESTLE+W format 

to evaluate political, economic, social, technological, legal, 

environmental, and workforce considerations. The CHNA, 

required every three years, also provides a robust analysis of 

the current status and needs of the region served. The timing of 

the CHNA was shifted in 2018 to align with, and provide input 

to, the full SPP, rather than being timed with the SPP refresh. 

This drove the strategic decision to focus on the health of the 
8

community, rather than remaining focused only on those who 

use CRHS services. In 2021, the CHNA was integrated with the 

COE assessment to better address health disparities and enhance 

community revitalization.

Steps 4–6 of the SPP are accomplished at a facilitated off-site 

retreat, held each September. Prioritization of change initiatives 

is based on alignment with and support of the MVV, as well as 

projections of resource needs of each initiative and availability 

of resources, including funding, workforce time, space, equipment, etc. The tight integration of plans—from the top-level system plan, down through the plans for each business unit, service 

line, and department, to the development plans for each individual—enables a clear “line of sight” to keep plans integrated 

when a change needs to occur, promoting organizational agility 

and resilience. For example, the change to enable telehealth 

visits during the height of the COVID-19 pandemic has been 

integrated with initiatives to expand outreach into the community, particularly the more rural- and socioeconomic-challenged 

portions of the region. Planning to use telehealth as a permanent 

tool enabled CRHS to “bounce forward” from the pandemic to 

help fulfill the mission to “improve the health of all citizens in 

the service area.” As part of COE participation, CRHS has partnered with the Kentucky DigiRun Initiative to expand Internet 

access and build a stronger digital infrastructure in urban and 

rural communities across the commonwealth.

Following the September retreat, during steps 7–8 of the SPP, 

the draft objectives and goals are provided to the leaders of each 

business unit, who then hold their own retreats, using the same 

facilitator for continuity and communication. At these retreats, 

the business units each develop or refine plans that align with 

and support the system-wide plan. After consensus is achieved 

regarding the integrated draft plans, the action planning phase 

(step 8) begins (Figure 2.2-1). Action plans are highly specific 

regarding timelines, resource needs, and measurable milestones 

and targets for activities as well as performance. 

2.1a(2). The SPP stimulates and incorporates innovation and 

identifies strategic opportunities through its systematic review 

of BARs from all sectors and the environmental scan process 

(step 3). Discussion of processes by the category teams during 

the review of current award recipients and after attending Quest 

stimulates ideas for innovation. Two years ago, benchmarking 

with an award recipient led to the creation of a “Shark Tank” 

program (6.1d). Throughout the year, members of the workforce 

are encouraged to submit poster presentations to the team of 

category champions. Those opportunities that represent the best 

cost-benefit potential are presented in person. The innovative 

ideas and strategic opportunities are prioritized using a matrix, 

including criteria of resource requirements, anticipated benefits, 

and ability to execute. Items decided to be “above the cut” are 

selected for implementation and included in the formal action 

planning process (APP), with the person or team that generated 

the idea receiving a cash prize. Those that fall “below the cut” 

on the matrix are held in the pipeline for future consideration. 

The current strategic opportunities were amplified in the SPP 

cycle held during the COVID pandemic. The environmental 

scan revealed disparities in Internet accessibility, particularly 

in rural areas. This created issues during the pandemic when 

people were expected to participate in work and education activities and receive health care services through remote access.

2.1a(3). As described in 2.1a(1), relevant data are collected and 

analyzed through the SPP steps 1–3. Analysis includes trending 

and comparisons with goals and competitor performance. This 

model helps to ensure that potential changes and disruptions are 

identified, particularly in technology, innovations, regulations, 

and other aspects of the external environment that are likely to 

impact health care services and operations.

The environmental scan previously was based on gathering 

data and brainstorming. In 2019, CRHS began to ask board 

members and senior leaders to systematically reach out to their 

social groups, such as churches, sporting groups, scouting, etc., 

as informal focus groups to better understand the needs of the 

community and position the board members as “ambassadors” 

of CRHS. When the plan is completed, it is shared and discussed with the same social groups.

A key element of CRHS’s process evaluation and improvement 

is achieving the appropriate balance between converting 

collected data into usable information through analysis, without 

introducing bias through the filtering of data and information. 

In 2020, when the planning process was conducted remotely 

due to COVID, all data were presented electronically. This new 

method of data presentation enabled “drill down” to multiple 

levels and layers of data, as well as a more robust segmented 

analysis through embedded hyperlinks, and the process was 

retained as an improvement. 

Key strategic challenges and advantages are determined through 

a consensus process during step 5. Since 2018, the planning 

team has used an expert planning facilitator during the SPP 

retreat to engage participants in “courageous conversations” that 

get below the surface and identify benefits and pressures that 

exert a decisive influence on success. The robust environmental 

scan and use of a facilitator also help to identify potential blind 

spots in the planning process and information.

The ability to execute the strategic plan is managed through 

integration of the APP (Figure 2.2-1) with the budgeting 

process, as described in 2.2a (steps 3–4). The timing of the SPP 

was shifted in 2013 to draft the strategic plan, business unit 

plans, and action plans by mid-October, just prior to the annual 

budget cycle kick-off in November (step 9), with approval at the 

December board meetings. 

2.1a(4). The work systems for CRHS are Caregiving Services, 

Caregiving Allies, and Caregiving Support (Figure 2.1-2). 

Decisions about which key processes will be accomplished 

internally, and which by external suppliers, partners, and collaborators, are made by the SLT and grounded in the MVV, with a 

focus on providing the most efficient and effective care for community members. CRHS leadership firmly believes that “what 

is best for the community will be best for CRHS”—in the long 

term, even if not in the short term. For example, in 2017–2018, 

a major investment was made to enter the insurance market 

by offering a Medicare Advantage Program (MAP) in order to 

provide better health services to the community. In 2019, the 

program was expanded to offer plans to the commercial market. 

C&C—of CRHS, suppliers, partners, and collaborators—are the 
9

key factors used to decide whether to outsource processes. The 

primary focus is to close gaps in high-quality services offered 

to the community. When a gap is identified, a cost-benefit 

analysis is done and presented during the SPP retreat. If the 

team determines that the new initiative represents an intelligent 

risk, further due diligence is conducted, and then a business 

plan and associated action plans are developed. If the new 

initiative requires C&C, additional personnel may be hired and/

or education provided to the current personnel. Should changes 

not fit within the current work systems (e.g., such as the MAP 

insurance), new work systems are developed to coordinate 

internal work processes and external resources.

2.1b. Strategic Objectives

2.1b(1). Key strategic objectives, along with their most 

important related goals, example action plans, and timetables, 

are shown in Figure 2.2-2 (remaining goals, action plans, and 

timetables are 

AOS). Key 

changes planned 

in health care 

services, customers, market, and 

operations include 

further outreach to 

impact community health, 

including telehealth services, 

use of the mobile 

medical unit, 

and screening/

education events. 

There are no key 

changes planned 

for supplier and 

partner networks.

2.1b(2). Strategic objectives balance varying 

and potentially competing organizational 

and stakeholder needs primarily through the 

budgeting process inherent in the APP (Figure 

2.2-1). In 2018, based on advice from the 

SPP facilitator, CRHS adopted a “top-down/

bottom-up” approach to strategic planning and 

action planning (2.2a[2]). 

Prior to finalizing the strategic plan, a discussion is held with the board and each business 

unit to achieve consensus that all strategic 

challenges have been addressed, and that the 

plan sufficiently leverages CRHS CCs and 

strategic advantages and gives due consideration to strategic opportunities. The board and 

leadership team also engage in discussion to 

ensure that the plan balances the needs of all 

key stakeholders.

The balance of short- and long-term planning 

horizons is primarily addressed through the 

three budgets: personnel, operations, and 

capital. The Copansburg Foundation assists in funding many of 

the long-term horizon items, using a capital campaign process 

for major initiatives. Additionally, the capital budget includes 

investment accounts that are grown for many years in anticipation of funding major projects from the long- or ultra-long-term 

plans.

Steps 11–16 begin after the budget is finalized and continue 

until the planning cycle begins for the following year. These 

“Check” and “Act” phases of the SPP integrate with the 

measurement system (category 4) and innovation/improvement 

systems (category 6). Steps 11–13 identify needed changes to 

processes and systems—including the SPP and APP—based on 

the results being achieved.

2.2 Strategy Implementation 

Action plans are drafted in step 8 of the SPP, in September and 

October—immediately prior to the beginning of the budget 
10

cycle. Although a single step in the SPP, the APP is a multistage/multi-step system (Figure 2.2-1) with key short- and longterm action plans related to strategic objectives (Figure 2.2-2).

2.2a. Action Plan Development and Deployment

2.2a(1). Action plans are developed in a series of facilitated 

workshops, with the key intended outcome being an integrated 

set of detailed plans documented on the APP template. This 

template designates the specific owner of the plan, the alignment/support to strategic objective(s) and goal(s), a plan of 

actions and milestones (POAM), resource requirements, and 

measures of success with targets.

Figure 2.2-2: Excerpt of Strategic Objectives, Goals, Action Plans, and Results

Objective Goal/Action Plan Key Performance Measure Business Unit ST/LT Projection SC/SA/SO Figure Achieve top decile in customer excellence

Increase outreach to 

disadvantaged communities

Impact on community health All, except 

Hospice

Multiple 

measures

SC1,2,4/SA1,3,4/

SO2,3

7.4-12 + 

AOS

Enhance culturally competent 

care (DEI)

Reputation score/

Consumer Preference

All 4.2/4.6

44.3%/45.1%

SC1,2,4/SA1,2,3,4/

SO1,2,3

7.2-10

7.5-17

Improve community health % follow-up after screening/

Cancer Stage I at diagnosis

All, except 

Hospice

25%/30%

28%/31%

SC1,2,3,4/

SA1,2,3,4/SO1,2,3

7.4-13

Top-decile satisfaction Willingness to recommend/

Net Promoter score

All 79.3%/82.1%

59/64

SC1,4/SA1,2,3,4/

SO2,3

7.2-8

Top Decile health care 

outcomes

CMS Core Measures

HEDIS measures

All, except 

Hospice

Multiple 

measures

SC2,4/SA1,2,3,4/

SO1,2,3

AOS

Achieve top decile in

workforce excellence

Achieve top-decile workforce 

engagement

Engagement score (segmented) All 84%/86% SC1/SA3/SO1,2,3 7.3-12

Re-establish/grow volunteer 

presence

% of total workforce hours per 

volunteer (weekly average)

1 4.7%/5.2%

10/12

SC1/SA3/SO1,2,3 7.3-6

Recruit physicians Primary care panel size/

Patients per hospitalist

1,2,3,5 2,500/2,200

17/15

SC1/SA3/SO1,2,3 AOS

Build workforce resilience Workforce wellness score/

Physician burnout

All 195/220

31%/29%

SC4/SA1/SO1 7.3-8

Decrease workforce vacancies Workforce Retention/

Regrettable losses/

Time to fill vacancies

All 85-92%/>90%

6.3%/<5%

Varies

SC1/SO3 7.3-4

AOS

7.3-5

Balance workforce profile with 

that of the community (DEI)

Diversity variance All 4-10%/<5% SC1,2,4/SO2,3 7.3-10

Achieve 

top decile

in financial

excellenceAchieve operating margin Operating margin All 4.4%/5.2% SC2,3/SA1,3,4/SO1 7.5-2

Increase community support Total community benefit All $480K/$520K SC4/SA1,4/SO1,2,3 7.4-12

Improve cash position Days cash on hand All 248.9/253.6 SC2,3/SA1,3/SO1 7.5-4

Achieve top

decile in process

excellence

Enhance access (telehealth 

and available appointments)

% within 15 days (primary care)/

% within 30 days (specialist care)

2,3 47%/57%

45%/52%

SC3,4/SA1,2,3/

SO1,2,3

AOS

Implement cybersecurity 

framework

External score All 250/600 SC3,4/SA1,2,4/SO2 AOS

Enhance communication % Very satisfied (workforce)/

% Very satisfied (patients)

All 4.4-4.6/>4.5

89%/91%

SC1,3,4/SA1,2,3,4/

SO1,2,3

7.4-1

7.4-2

KEY

Strategic Advantages, Strategic Challenges, Strategic Opportunities (Figure P.2-1)

Applicable Business Units:

1. Hospitals (including acute care, critical access, and emergency services)

2. Outpatient diagnostics and treatment (including JVs, ambulatory surgery, rehab services, urgent care centers, and mobile clinic)

3. Medical offices (including employed physicians and medical staff)

4. Post-acute care (including Home Health, Hospice, and DME) 

5. Health insurance plans (including ACO)

A 2018 refinement was to convert SMART into SMARTER—

including how the plan will be evaluated for progress and 

success, and in which management venue(s) the progress will 

be reviewed. An additional refinement in 2020 was to require 

action plan owners to identify stakeholders who may be 

impacted by the success of a plan, especially if the impact could 

be negative. For example, the shifting of services from inpatient 

to outpatient and decreasing length of stay may cause some job 

changes for the workforce. This identification step enables the 

action plan owner to engage these key stakeholders early so that 

plans can be embraced, rather than resisted.
11

2.2a(2). Although each action plan has a single owner to 

promote accountability, the creation, implementation, and 

deployment of plans (step 10 in the SPP Do phase) is usually 

accomplished by groups. Occasionally, existing teams or 

committees will implement a plan. More commonly, a specific 

team that includes the workforce and key suppliers, partners, 

and collaborators, as appropriate, will be chartered to create and 

implement a plan. There is an expectation that each department, 

business unit, and service line will be working on at least one 

action plan, but no more than five. This helps engage the entire 

workforce in propelling the CRHS toward its vision, while not 

becoming overextended in change.

The addition of the evaluated and reviewed elements for action 

planning ensures that key outcomes of those action plans are 

sustained. Action plans are integrated with the scorecard and 

dashboard systems (category 4) and improvement system 

(category 6). Typically, once action plans are fully implemented 

and “completed,” tracking of measures is gradually tapered in 

frequency and/or sample size until the activities associated with 

the plan become a habit—and part of “the Copansburg Way.” 

As long as tracking demonstrates sustainability, investment in 

ongoing monitoring is gradually shifted to other priorities.

2.2a(3). CRHS ensures that financial and other resources 

support the achievement of action plans through integration of 

the plans with the budgeting process. The action plan template 

includes requirements for all types of resources, including 

funds, staff time, space, and equipment. The budget process 

allocates these resources to support the plans. The action 

plan template includes analysis of the costs and benefits to 

calculate the overall financial impact of each plan. If insufficient 

resources are available, plans are negotiated—and occasionally 

may be scaled back or tabled for future consideration. Each 

business unit administrator and board have the overarching 

perspective of all plans within their business unit to allocate 

resources to provide appropriate balance, with the corporate 

ELT and board having oversight of all plans. 

The structure of the action plan template clearly identifies costs 

and risks associated with the plans, including any potential 

negative impact of the plan being successfully achieved. 

Progress on the plan and the associated performance measures 

are evaluated in the specified venue, no less than quarterly, to 

ensure viability and progress—from both financial and operational perspectives.

The POAM also includes when support department resources 

will be required, so that those engaged in the Caregiving 

Support work system can optimize and allocate their resources. 

This avoids instances where multiple action plans would 

simultaneously require support from IT, HR, facilities, etc., 

and exceed their capacity.

2.2a(4). Workforce plans to support short- and long-term 

strategic objectives and action plans typically revolve around 

capacity and/or capability. These needs are managed through 

the “resources needed” section of the action plan template. For 

example, the requirement for commercial driver’s licensed 

(CDL) personnel was identified as a capability need in the 

action plan to purchase the mobile medical unit. The initial plan 

was to hire “drivers,” but CRHS discovered that it had nursing 

personnel who had maintained CDL from prior careers and 

were interested in transitioning to a role to provide care in the 

mobile unit. Over time, CRHS has achieved the status where 

everyone who staffs the mobile unit is CDL licensed, providing 

maximum flexibility in scheduling and enabling the mobile unit 

to operate full time. 

2.2a(5). Key performance measures used to track the achievement and effectiveness of action plans are shown in Figure 

2.2-2, with the associated results figures. The action plan 

measurement system reinforces organizational alignment in two 

primary approaches: First, based on a nonhealth care BAR, each 

action plan includes determining the “key intended outcome” 

prior to identifying the measures and metrics that will be 

tracked. Second, the action plan numbering system underscores 

the alignment of the plan(s) that support strategic objectives 

and goals. The supporting action plans are regarded as “leading 

indicators” of accomplishing the strategic objectives and 

meeting the goals. If action plan timing goals and performance 

targets are being met, but the progress toward accomplishing 

the strategic objective is not on glide slope, this is regarded as 

a trigger to evaluate the need for analysis and adjustment, or 

possibly the creation of new action plans.

2.2a(6) Performance projections are included in the POAM 

on the action plan template, and across the long-term planning 

horizon for strategic objectives and goals. Short- and longterm projections are included in Figure 2.2-2. Projections 

are calculated based on the trajectory of the historic trend 

for both CRHS and comparison/competitor organizations. If 

projections uncover gaps where CRHS performance is lagging, 

a cost-benefit analysis is conducted to prioritize closing the gap. 

If closing the gap is an intelligent risk and wise use of resources, 

a strategic action plan may be created (2.2a[2]); the PIC may 

charter an improvement TRAC, or PDCA projects may be 

launched to improve performance. The vision always compels 

CRHS to seek top-decile performance, which typically places 

CRHS above local competitors. When CRHS supports staff 

participation in conferences, participants are required to identify 

the “top-three” learnings to share upon their return. This has 

helped close many gaps.

2.2b. Action Plan Modification 

Once approved, the action plan owner and the head of the 

system or business unit sign the plan. Signed plans are considered covenantal agreements—the key intended outcomes will 

be accomplished in exchange for the identified resources being 

provided, and resources are provided in exchange for accomplishing the key intended outcomes. When the POAM or targets 

are not achieved, the plan must be evaluated and modified as 

appropriate. Tracking performance (2.2a[5]) enables CRHS to 

recognize and respond when plan modification is needed.

When circumstances change, either externally or internally, that 

require rapid execution of new plans, a mid-cycle action plan is 

created using the same processes, approved, and signed rather 

than waiting until the next planning cycle. A contingency fund 

is included in the budget process, should resource requirements 

exceed the approved budget.
12

Category 3: Customers

3.1 Customer Expectations

3.1a. Listening to Patients and Other Customers

Customers’ needs and expectations—and how well CRHS supports and satisfies them—are critical to the system’s near- and 

long-term success. Through its Voice of the Customer (VOC) 

System (Figure 3.1-2), knowledge learned from CRHS’s various 

listening methods (Figure 3.1-1) provide the actionable information for corrective actions (service recovery through Complaint 

Management System) and systemic improvements (quarterly 

and annual analyses of VOC data providing improvement 

opportunities to business units and system-wide). System-wide 

opportunities are referred to the PIC for review and decision to 

assign or not assign a project to the TRAC. All types of change 

go through the PDCA improvement process. PDCA is also used 

to drive change within the VOC System. 

3.1a(1). The general approach to developing custom listening 

posts is based on PDCA. CRHS “Plans” by researching the 

characteristics of each customer group. This is followed by 

focus group interviews to understand communication and 

service preferences. This leads to the initial design of a listening 

method. Then CRHS moves to the “do” phase where it tests the 

draft method, gathers feedback, refines the design, and prepares 

for a broader pilot of the method. Once the method is piloted, it 

“Checks” to assess effectiveness and make final revisions prior 

to implementation. Once the product/method is ready, the “act” 

phase is to implement the new method. 

CRHS’s approach to listening, interacting with, and observing 

patients and other customers across the patient phases of 

pre-service, service, and post-service is shown in Figure 3.1-1. 

These listening methods gather data from patients, families, and 

other customers prior to service (e.g., setting up appointments, 

completing paperwork at arrival, waiting for service), during 

service (e.g., in-patient, emergency room, outpatient), and 

post-service (e.g., follow-up, future care). It is important for 

CRHS to understand and respond to the needs of family, as well 

as direct customers. 

Methods of listening vary depending on the type of customer 

and the service phase. For example, waiting areas (such as 

where families wait while a loved one is in surgery or where a 

patient waits to see the physician) have electronic “sounding 

boards.” These laptop-sized sounding boards enable family and 

patients to write compliments and concerns anonymously. Each 

day, these comments are reviewed and stored in a database. 

At the end of each week, data are evaluated and categorized. 

The results feed into potential waiting-room improvement 

efforts. An example of a recent improvement is the addition 

of a customer wait-time board. Customers are given a number 

when they check in. A display board tells the customer the 

number being serviced and the expected wait times for other 

customers. This helps set expectations for patients and family 

members. Electronic boards also indicate patient status time in 

pre-operation, operating room, and post-operation.

For inpatients, CRHS listens with an electronic pain board 

(tablet-like device) where a patient can indicate their level of 

discomfort. CRHS also uses data from rounding and provides 

a quick daily four-question survey about meals (i.e., timeliness, 

quality, temperature, and taste). Automation of these methods 

two years ago enabled CRHS to move from responding to 

individual needs (reactive) to systemic improvements and 

comparisons across multiple facilities. 

Telehealth is a service that is expanding. As a result, it is a key 

area of consideration when developing listening methods and 

improving CRHS’s understanding of needs and expectations. 

With video meeting applications, CRHS physicians and nurses 

conduct virtual face-to-face in-home meetings. During these 

sessions, CRHS gathers data about ease of understanding, clarity of instructions, and other unique patient and family needs. 
13

CRHS also works closely with physician groups that refer 

patients to its facilities for service. Outreach efforts increase 

awareness of services. Understanding needs and expectations is 

how CRHS obtains and maintains business. It gathers data on 

the types and numbers of patients being serviced and then works 

with operations to ensure it possesses the capacity to meet 

current and future demands. To meet customers’ needs, CHRS 

recognizes that mental health, substance abuse, and obesity 

are three areas where service must prove to be responsive and 

capable (skills and capacity). 

3.1a(2). CRHS uses its multiple listening posts, partnerships 

(Figure P.1-4), and public data sources to gather actionable 

information from competitors and potential customers. CRHS 

gathers various types of data throughout the year, while 

analyzing some quarterly and all annually. Annual analyses are 

considered with other customer data and evaluated as part of the 

VOC System (Figure 3.1-2). 

CRHS reaches former customers through after-service surveys 

and telephone follow-ups. Potential customers are often reached 

through outreach activities such as the website, Lookbook, 

consumer surveys, focus groups, community events (fairs and 

farmer markets), and other venues. While these methods are 

ongoing, data are aggregated monthly and annually to detect 

trends and assess performance. In 2019, CRHS contracted with 

a marketing company to provide targeted advertising within 

Lookbook and various websites. This process improvement 

increased website unique visitors by 12% (Figure 7.2-9) over 

the previous year and showed significant promise based on the 

2020 customer survey where 10% of first-time customers said 

they heard about CHRS). 

Competitor data are difficult to acquire directly. As a result, 

much of these data are acquired through reviews of research 

studies, national health care data, and COE. CAHPS Surveys 

provide not only satisfaction data on customers and customers 

of competitors, but also comparison data so CRHS can identify 

relative strengths and opportunities. Areas of strength are used 

in “planning” outreach efforts. 

3.1b. Patient and Other Customer Segmentation 

and Service Offerings

3.1b(1). Customer (satisfaction and dissatisfaction) and market 

data are the main drivers in determining customer groups 

and market segments. Each year, customer satisfaction and 

Consumer Preference Survey data are evaluated to detect shifts 

in preferences, types of service, and service delivery methods. 

CRHS’s success in identifying new segments and markets is 

based on its willingness to use data to detect differences in 

customers and help identify segments and special populations. 

Data that have been collected and evaluated are used in the 

PDCA method to make fact-based decisions. For example, over 

the past four years, there has been a significant shift within 

established customer groups based on technology use. Heavy 

Wi-Fi users, a special population within each existing group, 

prefer electronic communications over face-to-face. This 

technology shift has helped CRHS to identify an entirely new 

segment of customers. Similar to the shift from stores to online 

shopping, a growing number of customers expect services from 

the comfort of their home. Understanding this new segment and 

the special populations within it (elderly, home-bound, and busy 

technology-dependent users) has helped CRHS develop a robust 

telehealth program that meets key patient, family, and community needs for value, access, and high-quality care. 

3.1b(2). Determining service offerings begins with an internal 

analysis of CRHS’s customers’ needs and preferences, as well 

as current opportunities (dissatisfiers). Products and services 

meeting or exceeding current needs and expectations are kept 

and enhanced. Emerging preferences (such as home services 

through increased use of technology) and dissatisfiers (current 

preferences that are not being met) also provide opportunities 

for new products and services. All potential opportunities go 

through two types of basic assessments as part of the planning 

phase: (1) Is it a service enhancement or a gap (requiring a new 

service); and (2) does it align with CRHS’s mission, vision, and 

CCs? This initial step in the planning phase of PDCA enables 

leadership to determine how the opportunity fits within the 

current product/service mix and if it could be delivered internally or through a third party. If the results of the initial planning 

phase are favorable, the information is forwarded to senior 

leadership with a recommendation on if and how to pursue this 

new service or product. 

Data from the past three years have shown a definite shift 

in patients’ preferences, becoming more accepting of the 

advantages associated with the use of robotics in surgical cases. 

CRHS used these data (increased acceptance of robotics) to 

launch robotic surgical programs in orthopedics and GYN 

surgeries, and is evaluating additional robotic-assisted surgical 
14

methods. CRHS also identified potential customers through a 

detailed PDCA analysis of external information. This includes 

information gathered through the Seekers Program, study of 

local competitor services, and use of national data sources. 

As part of the Seekers Program, staff members research various 

demographics and travel into the communities to better understand customer preferences and why they exist. For example, 

do people not go to the hospital because they prefer telehealth 

options or are they unable to travel to the doctor? CRHS 

Seekers determined that many of the underserved people in the 

service area don’t have access to transportation or the Internet. 

As a result, CRHS recently increased the number of mobile clinics to better serve these individuals (former potential customers 

that are now its customers). Through these mobile clinics, 

CRHS now has a new market with little to no competition. 

Market research (services offered by competitors and national 

comparison data) also provides objective data as CRHS plans 

to identify potential new services or customer segments to 

pursue. For example, seeing services provided by competitors 

led CRHS to place time estimators in emergency departments 

(EDs). Patients are given a randomly selected number when 

signing in at one of its emergency rooms. A display board shows 

each number and the estimated wait time. The board is refreshed 

every 3 minutes. This provides patients and family members 

with an estimated wait time, reducing stress. 

3.2 Customer Engagement

3.2a. Patient and Other Customer Experience

3.2a(1). Since 2013, CRHS has had multiple processes in 

place to acquire, manage, and retain new customers. Initially, 

these processes were based on traditional outreach activities: 

advertising on local stations and being active with community organizations. In 2017, CRHS took a more systematic 

approach to developing a brand image and acquiring customers. 

This three-phase approach includes (1) creating awareness, 

(2) experiencing services, and (3) becoming a repeat customer 

and promoter. To enhance phase I activities, CRHS began 

adding more proactive approaches to increase awareness. These 

included mobile clinics; participation in community fairs; and 

offering tours to local associations, educational group presentations/tours, and senior center briefings and outreach. These 

proactive enhancements have resulted in increased awareness 

and more first-time customers. In 2020, prompted by COVID19, CRHS launched a virtual tour option, which has also been 

used by current customers wanting more detail of the facility 

prior to surgery or by family members wishing to learn more. 

More recently, CRHS initiated two programs to address 

opportunity gaps (groups or segments of potential customers 

that are not touched by phase I efforts) identified during cycles 

of review and improvement. These opportunities resulted in the 

Seekers Program and a new Marketing Relationship Management System. The Seekers Program is used to target areas that 

are under-served, evaluate the root causes, and then develop 

programs to eliminate or reduce barriers, thus enabling CRHS to 

acquire new patient customers (3.1b[2]). 

The transition to computers in society has also impacted health 

care. CRHS’s efforts in phase I also recognize the growing 

segment of the population that uses technology (smart phones 

and computers). This segment is often not interested or able to 

travel to one of CRHS’s facilities. These are often educated, 

busy people, who want service delivered to their home or 

business. Through online, proactive marketing (email and 

google searches), CRHS reaches these individuals and initiates 

a relationship that has translated into steady market growth. 

Once CRHS acquires new customers and new markets 

(phase II), it quickly develops or adapts products and services 

to meet unique needs. The relationship management software 

provides the flexibility for potential customers to be introduced 

to products and services; then receive updates on CRHS 

initiatives; and once engaged, evolve into a personalized “My 

Health” Patient Portal account (phase III), where a patient’s 

health information, provider information and communication, 

prescription information, scheduling, and bill-pay capabilities 

are housed. The goal is to provide each person with the care he/

she needs in the way he/she wants it delivered. CRHS covers a 

large area, but services are usually delivered locally. As a result, 

great local service leads to customer loyalty. Loyal customers 

tell their stories through community interactions that further 

CRHS’s brand marketing efforts. 

CRHS’s goal is to retain customers by exceeding expectations 

the first time and every time. It achieves this with a Life-Cycle 

Feedback and Adjustment System (Figure 3.1-2). From the 

first time CRHS communicates with a potential customer, until 

the last time it ever sees the customer, CRHS is interacting, 

understanding, and responding to his/her needs. Relationships 

are built over time through multiple positive interactions and 

customer awareness. Patient Experience Office (PEO) staff 

members work closely with operations to ensure that systems 

and people are customer focused, providing access, education/

information, and high-quality care. 

3.2a(2). Access is a basic driver of satisfaction and engagement. 

Drivers of customer satisfaction have been determined through 

multiple regression analyses of survey results. Various survey 

questions are correlated with overall satisfaction questions to 

identify those areas with the highest correlation. This analysis 

is repeated every second year to identify possible shifts in 

drivers or shifts in the level of priority among drivers. For 

the “access” driver, the options available to enable access are 

identified through focus group interviews and two questions on 

most of the surveys, asking, “How did you hear about us?” and 

“How did you obtain the information you needed throughout 

your interactions with us? Check all that apply.” CRHS uses 

these data (annual analysis) to develop, strengthen, or eliminate 

access methods throughout the organization. The result has been 

to add access options/methods to maximize options and provide 

patients, families, and others with the ability to choose the mode 

that best suits their needs. Figure 3.2-1 shows various access 

options for customer groups. 

The Seekers Program has been instrumental in identifying and 

refining unique access needs of specific customer segments. For 

example, potential insurance customers want to know costs, 

key services, and if the physicians and facilities they want are 

covered. CRHS leverages these types of information as key 

inputs to the “plan” step in the PDCA methodology, which it 
15

uses to translate needs into access options and outreach materials. When working with customer information, PEO often leads 

cross-functional teams (operations, facilities, care-providers, 

etc.) through the analysis to ensure that recommendations and 

solutions are feasible, measured, and effective. The two main 

types of access CRHS focuses on are entry and support. Entry 

provides a means for entering the system to identify and decide 

to use the services. Support provides a means for re-entry and 

ongoing support/service. 

3.2a(3). CRHS has a mature Complaint/Grievance Management System (Figure 3.2-2) with multiple sources of input, 

a high-level process flow, quick response (actionable), and 

periodic analyses (aggregated/evaluated) to identify systemic 

issues that could be addressed through process improvement or 

redesign. The process begins when a customer (patient, family 

member, insurance member, other) has a complaint and makes it 

known (step 1). If the complaint cannot be resolved in real-time, 

it is understood, assigned to an appropriate person or team 

(depending on the issue), and logged into the Complaint Management System to be tracked (steps 3 and 4). In steps 5 and 6, 

the issue is addressed by the person/team and the customer is 

informed on the solution. In steps 7/13 and 8, individual complaints are aggregated 

and analyzed monthly 

to identify potential 

systematic opportunities. These may result in 

process improvements 

and identification of 

new risks, and/or they 

may be forwarded 

to strategic planning 

if they highlight a 

potential resourceintensive solution. If the 

incoming complaint can 

be handled in real-time, 

it follows a different 

path. Steps 9, 10, and 

11 are to understand, 

resolve, and then verify 

by closing the loop with 

the customer. Once 

this is done, step 12 is 

to log the complaint 

and resolution into the 

system. All complaints 

are aggregated and 
16

evaluated in steps 7/13. PEO analysts periodically (monthly) 

aggregate and evaluate all complaint data to identify potential 

systemic improvements. These are then evaluated by the PIC 

and given to TRAC teams, as appropriate, to go through the 

PDCA process (step 8) where systematic opportunities are 

worked, larger items reported to strategic planning, and risks 

reported to risk management. Each year, the Complaint Management System is reviewed for potential improvements. 

The Complaint Management System is used throughout CRHS 

and is integrated through a corporate database. CRHS meets 

or exceeds requirements set by CMS for handling grievances. 

A single Complaint/Grievance Management System enables it 

to slice and dice data by location, complaint category, etc., for 

analysis and for assessing the impact of improvements.

A key improvement to this system occurred in 2018 when 

CRHS added the step of documenting complaints that are 

resolved in real-time. Documentation of these real-time 

corrective actions has had multiple benefits. CRHS can now 

aggregate and analyze quick corrective actions. Often, these 

types of actions can lead to relatively simple, low-cost process 

changes/improvements. Improvements are then shared across 

the organization, resulting in fewer complaints, improved 

performance, and higher survey scores. An example of a simple 

improvement identified through this process: Patients have 

access to more people to respond to their needs. In the past, a 

patient would wait for a nurse to ask a question. Often these 

questions did not require a nurse. Now, when employees enter 

a room to clean, restock, etc., they check with the patient to see 

if they need something or have a question. The result is better 

service, more engaged employees, and patients receiving more 

responsive service. To encourage employees to input these 

types of complaints, CRHS has issued a monthly lottery. It pulls 

names from the list of quick-response complaints submitted the 

previous month and gives the person a $25 gift card.

The more complex, time-consuming corrective actions are also 

aggregated and evaluated. These issues and proposed recommendations are forwarded to SLTs for consideration. 

3.2a(4). Variances in the accessibility of health care services 

mean that certain groups and locations are less likely to receive 

health care and are more likely to have unfavorable health care 

outcomes. CRHS leadership is sensitive to these variances 

and has implemented multiple processes to quickly identify, 

understand, and then address these opportunities. Traditional 

approaches included survey and patient demographics. This 

provided some information but gave an incomplete picture of 

the service area. In 2018, senior leadership charged the PEO 

with going beyond simply identifying underserved areas to 

identifying underserved people. PEO led a 12-month study 

to assess and quantify the extent of this opportunity. Reasons 

special populations within customer groups were underserved 

varied, including religion, culture, distrust, language, location, 

and work schedules. In 2019, senior leadership expanded 

educational outreach activities, which helped to educate some 

in health care opportunities and benefits; however, it did not 

significantly close the gap. In 2020, senior leadership approved 

the creation of the Seekers Program to research, study, and 

identify underserviced populations, and to engage, understand, 

and reduce barriers to minimize the risk of unequal treatment. 

3.2b. Determination of Patient and Other Customer 

Satisfaction and Engagement

3.2b(1). Most satisfaction and engagement metrics for CRHS’s 

customers are determined through surveys. The number of 

questions, types of questions, and timing of survey administration depends on the customer group. CRHS uses Net Promoter 

Scores to assess engagement and loyalty. 

Patient surveys are tracked and periodically aggregated for 

analysis by business units. Surveys are administered on a continuous basis and updated annually. A follow-up survey is sent 

to inpatients and their families approximately two weeks after 

discharge from any service. Responses are aggregated monthly 

(for actionable process improvements) and annually (for larger, 

more complex systemic improvements) through the PIC. In 

2017, CRHS began offering patients who provided their email 

addresses with electronic surveys (more convenient for them 

and less costly for CRHS). This improvement was implemented 

across all business units in 2018.

Family member engagement is almost as important as patient 

engagement. Key family requirements are high-quality care, 

safe care, and service excellence. Surveys are designed to assess 

these requirements for each of the main service lines. While the 

basic requirements are constant across different services, such 

as inpatient or home health, each has unique quality features. 

Focus group information enables CRHS to identify unique 

features and then assess those features through surveys. It can 

then aggregate data by basic requirement and still be able to 

analyze by location, service, or unique feature. (Data showing 

the overall satisfaction scores for these requirements are AOS.) 

Health plan members and partner medical offices are also 

surveyed to ensure that their needs are being met. These two 

groups are often correlated. A favorable relationship with 

independent medical offices often translates into more health 

plan members and more customers when the need arises. Taken 

together, these surveys and the Complaint Management System 

capture critical satisfaction, dissatisfaction, and loyalty data. 

Engagement is assessed through event counts. Prior to 2015, 

CRHS measured engagement through the number of hits on 

social media, the website, patient portals, and other access 

points; however, hits on a website or posts to social media are 

not a strong indicator of engagement. As a result, CRHS began 

tracking events, which are considered meaningful interactions 

where the customer is actively engaged (e.g., ask a question, 

set up an appointment, comment on a service). As a result, the 

counts decreased (approximately 30%), but CRHS’s ability 

to assess effectiveness and the types of issues customers have 

has improved significantly. For example, by using this new 

methodology, CRHS is better able to target times for system 

updates, providing customers with access when they want it, not 

when it is convenient for CRHS. This has reduced the number 

of complaints regarding online systems and improved CRHS’s 

ability to respond to inquiries. 

3.2b(2). CHNAs provide a snapshot of local demographics 

and health issues. Data on age, gender, race, language, and 
17

education are available. This information enables CRHS 

to develop targeted listening methods to understand how it 

stands locally and nationally in these areas of importance to its 

customers. The third-party vendor that administers many of its 

surveys has certain core questions that are used across multiple 

customers and stored in their systems. These core questions 

enable comparisons to other organizations using the same 

vendor. As a result, CRHS can compare to the top quartile in the 

vendor database. 

Traditionally, local information was the key to success. Now, 

technology (new ways of researching options and new ways of 

treating people over distances) has moved CRHS to compare 

and compete on a regional and national level. This shift in 

comparisons has driven it to higher levels of performance. 

With COVID-19 in 2020, this technology-driven transition 

was accelerated. Potential patients search the Internet and 

view more public information to identify the best health care 

options for their needs. That means, even though services are 

often delivered locally, the competition is often national. As a 

result, CRHS needs to be better than the local competition and 

nationally competitive to remain relevant.

CRHS uses multiple processes for gathering data relative 

to potential/future customers (AOS), including the Seekers 

Program, focus group interviews, research—national indicators 

such as CMS and health care studies, and COE. In addition, 

surveys include comparison questions to better understand how 

current customers view CRHS and why. All these sources of 

data go through its VOC System (Figure 3.1-2) to provide a 

better understanding of CRHS’s relative strengths and opportunities (locally and nationally). 

CRHS has entered into a data exchange agreement to share 

some selected, similar types of customer data (wait times, 

in-service overall satisfaction, and satisfaction with follow-up 

activities). Specifics about the type and way the supporting 

services are delivered are not shared; however, this information 

provides CRHS with general areas of strength and opportunity. 

The Seekers Program looks at customers of others and of 

underserved groups. Through the work of the Seekers Program, 

CRHS is identifying and bringing in special populations and 

expanding its service delivery methods, thereby increasing 

market share and providing new opportunities. 

3.2c. Use of Voice-of-the-Customer and Market Data

CRHS gathers customer needs, expectations, and complaints 

through multiple systems. These data are aggregated, 

categorized, and evaluated to support recommendations and

decision-making at multiple levels of the organization (e.g., 

front-line managers for quick process adjustments, midmanagement for functional or single-facility changes, and senior 

leadership for new products/services and major investments). 

The PEO is responsible for bringing customer-focused metrics 

and supporting culture to the organization. The PEO aggregates 

and analyzes VOC data on a quarterly basis to identify the needs 

and preferences of different customer groups and segments 

(“Do”). Then, depending on the initial results of the analysis, 

the process may involve performance measurement for monitoring and driving a customer-centric culture, a PEO improvement 

analyst for team analysis and improvement, or development of 

new recommendations for SLTs and the ELT. Each type of listening post and each customer segment is reviewed annually to 

ensure that segmentation is correct, preferences are understood, 

and assessment/listening methods are effective and efficient. 

Metrics are the basis for building a customer-focused culture 

within CRHS. Customer access, satisfaction, dissatisfaction, 

etc., are corporate measures, facility measures, and functional 

measures; and they are included in individual performance 

standards. In addition, many of CRHS’s operational metrics 

align with key drivers of satisfaction and loyalty. For example, 

through focus group interviews, CRHS determined that 

physician medical offices expected real-time access to a live 

person. Annual analysis determined through multiple regression 

analysis that for patients listening is a key driver of satisfaction. 

Category 4 : Measurement, Analysis, 

and Knowledge Management

4.1 Measurement, Analysis, and Improvement 

of Organizational Performance

4.1a. Performance Measurement

4.1a(1). CRHS tracks data and information on daily operations 

through its sophisticated, automated health informatics system 

known as Data Drive Improvement (DDI), which provides realtime results for key performance indicators such as length of 

stay (LOS), patient satisfaction, employee engagement, as well 

as dashboards posted in all departments in all hospitals. Other 

units, such as Urgent Care, Ambulatory Sites, etc., develop their 

own dashboards specific to their operations. SLs track overall 

organizational performance through the reviews described in 

4.1b using scorecards.

CRHS selects, collects, aligns, and integrates data and information (Figure 4.1-1). Alignment and integration are reinforced 

through a set of dashboards that are cascaded from its system’s 

strategic scorecard. CRHS tracks progress on achieving its 

strategic objectives and associated action plans through the 

applicable reviews described in 4.1b and a following colorcoding system (AOS).

In 2019, in a cycle of evaluation and improvement, CRHS 

upgraded DDI to present most KPIs in statistical process control 

(SPC) format and strengthen its ability to analyze and respond 

to trends.

4.1a(2). CRHS selects comparative data that reveal how it 

is executing its mission and advancing its vision. This is not 

restricted to health care outcomes, but also customer satisfaction, employee engagement, leadership and governance, and 

financial and marketplace outcomes. To assess its progress, 

it selects comparative data that is top decile, top quartile, and 

verified benchmarks of world-class performance. Every KPI has 

an owner, and each owner is required to seek relevant comparisons that are the highest performance available. The sources of 

the comparisons are shown with the reports generated by DDI.

4.1a(3). CRHS ensures that its performance measurement 

system remains agile, and it assigns a standing agenda item 
18

to each review forum to discuss whether additional KPIs are 

needed and if any should be eliminated (Figure 4.1-2). This 

agility was demonstrated during the COVID-19 pandemic when 

CRHS implemented a COVID-19 dashboard that tracked new, 

key measures such as PPE inventory. 

4.1b. Performance Analysis and Review 

SLs use forums to review the organization’s performance and 

capabilities (Figure 4.1-2). KPI owners report their results 

along with relevant comparative data, and the analyses are used 

to ensure conclusions are valid. These reviews contribute to 

CRHS’s measurement agility (4.1a[3]). Results of financial and 

other key measures are presented quarterly to the board. 

4.1c. Performance 

Improvement

4.1c(1). CRHS projects future 

performance by extrapolating trend 

data presented in the review forums 

(Figure 4.1-2) at a continuing rate 

of change. However, if it knows that 

there is an expected disruption to 

the process, such as an impending 

change in a regulation, CRHS will 

adjust the projection to account for 

that. In the case of the COVID-19 

pandemic with comparative data 

changing on a moment-by-moment

basis, CRHS adjusted its projections 

for some KPIs on a daily basis.

4.1c(2). CRHS uses the findings 

from the performance reviews 

(Figure 4.1-2) to develop priorities 

for continuous improvement (CI). When the rate of change is 

not sufficient for CRHS to achieve its strategic objective in 

the timetable identified, it looks for innovation to provide a 

breakthrough change. Action plans and new targets are assigned 

to a responsible leader for further evaluation. This person is 

responsible for engaging staff members, physicians, suppliers, 

partners, and/or collaborators as appropriate. This effort is 

supported by its Innovation Management System (6.1d). 

4.2 Information and Knowledge Management

4.2a. Data and Information

4.2a(1). CRHS ensures the quality of organizational data and 

information through training on how to input and inspect data. 
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In addition, both its DDI and EMR have embedded “rules” that 

prevent the entry of data that would be impossible to be correct 

(for instance, prescription for an antibiotic for a patient with 

a known, documented allergy to it). CRHS ensures accuracy 

and integrity through training and system checks and balances. 

This is done through the limiting of text box fields in its EMR. 

In 2018, in a cycle of evaluation and improvement, CRHS 

developed standardized data dictionaries managed by the Data 

and Governance Committee. The data flow from the EMR and 

DDI is real time to all integrated systems, which ensures data 

currency. CRHS also reviews and edits social media posts about 

the organization as needed.

4.2a(2). CRHS ensures the availability of organizational data 

and information first by identifying the data and information 

required for each position and granting appropriate access. 

However, it also ensures the availability of organizational data 

and information through a robust information technology plan 

that includes hosting the system in the cloud. All missioncritical apps have also been moved from servers to be cloudbased. CRHS also uses redundant systems to systematically 

remove single points of failure (details AOS). 

In 2015, CRHS implemented an electronic, visual bed management system that allows family members to track their patients 

(with a secure patient identification number) through the various 

stages of pre-op, in surgery, post-op recovery, and transfer to 

their in-patient rooms. This has been deployed to each hospital. 

In 2019, CRHS implemented an innovative online scheduling 

program that allows patients to book their own appointments 

at the date and time most convenient for them. It is currently 

piloting expansion of that program for outpatient services such 

as diagnostic tests and pre-surgery testing as well.

4.2b. Organizational Knowledge

4.2b(1). CRHS builds and manages organizational knowledge 

(Figure 4.2-1) utilizing a Create, Collect, Curate, Disseminate 

(Transfer), and Implement Model (Figure 4.2-2). Its Knowledge 

Management System has been fully deployed across CRHS.

Starting with its knowledge officer and implemented through its 

Knowledge Management Team, CRHS coaches each function 

through the process of identifying what knowledge is critical 

to its team, developing processes for capturing/creating that 

knowledge, and working with IT to curate the knowledge that is 

easily accessible to appropriate personnel across the organization. In 2010, CRHS had a homemade database when it started 

the Knowledge Management System, but it quickly became 

cumbersome. In 2015, in a cycle of evaluation and improvement, it implemented a TalkPoint site that has its hierarchy 

based on the Performance Management Institute’s taxonomy of 

processes. In 2019, CRHS added step 6 and a PDCA loop (see 

Figure 4.2-1) to keep its knowledge assets refreshed with new 

information. 

CRHS blends and correlates data to build new knowledge 

through the use of health plan data to gain insights into its 

health plan customers. For example, by analyzing claims data, 
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it identified that pain management among its oncology patients 

is a concern and that many patients were seeking alternative 

medicine approaches such as acupuncture, aroma therapy, and 

homeopathic remedies. CRHS subsequently developed an 

alternative medicine program within the cancer center.

In 2021, CRHS adopted two approaches used by a 2020 BAR 

to collect, transfer, and use its knowledge assets. The first 

approach is Communities of Practice (COPs), which connects 

employees with a common interest in the health care setting to 

come together in a virtual forum to exchange ideas, literature 

searches, active research, and more to further the understanding 

of the focus. CRHS currently has 12 COPs with areas of focus 

including patient-centered care, palliative care, diabetes management, post-partum depression, attention-deficit/hyperactivity 

disorder, and administrative functions (HR, finance, IT, etc.). 

The second approach CRHS adopted was the establishment of 

Strategic Employee Engagement Groups (SEEGs). Employees 

may request the establishment of a SEEG, which must receive 

approval by the SLT. A SEEG must also have an executive 

champion. SEEGs generally are formed around workforce 

segments and are a key effort to approach DEI and a sense of 

belonging in a more proactive manner. CRHS currently has six 

SEEGs that include African Americans, LGBTQ, Hispanics 

and Latinos, People with Disabilities, Asian Americans, and 

Mothers with Young Children. 

4.2b(2). As part of CRHS’s review of organizational performance (4.1b), it identifies departments, units, or individual 

physicians who are achieving high-performing results. Then it 

identifies the processes, practices, equipment, and/or technology 

that contributes to those results. It proceeds to document, 

conduct training, and deploy them, as appropriate, across its 

system. Best practices also come from obtaining certifications, 

attendance at continuing educational conferences, reference 

materials such as online Cottervoy procedures and the Staff 

Nurse Advisory Council (SNAC). With its teaching hospital, 

CRHS also has projects being conducted by a wide variety of 

students, family medicine residents, and nurse residents.

In 2020, in a cycle of evaluation and improvement, SLs added 

a contest for the submission of administrative best practices 

since the majority had been directed toward clinical practices. 

“Traffic” to each submitted best practice was monitored for 

three months, and the submitters of the most sought-after best 

practices were recognized in the next town hall meeting and 

given a gift card to a local bookstore.

CRHS actively seeks evidence-based practices for a wide range 

of processes across multiple industries and sectors. For more 

than eight years, SLs have attended Quest to learn from BARs 

about their best practices. Upon return, they identify those most 

promising to be adopted or adapted and charter a team to first 

conduct a small pilot to test the change.

4.2b(3). Organizational learning is built upon CRHS’s MVV, 

as well as the Baldrige Excellence Framework®. CRHS ensures 

organizational learning by having a systematic process that 

routinely measures performance and evaluates results to drive 

improvement. Submitting applications to CRHS’s state program 

and following the Framework ensures that it receives valuable 

feedback on process effectiveness to help drive improvement.

Category 5: Workforce

5.1 Workforce Environment

5.1a. Workforce Capability and Capacity

5.1a(1). SLs attend Quest (4.2b[2]) to identify best practices, 

often with specific issues in mind. After struggling for several 

years with optimizing capacity, leaders found that several BARs 

seemed to have better ways to assess capability and capacity 

(C&C). These ideas were brought back and augmented with 

research into other industries to develop the Capability and 

Capacity Model (CCM; Figure 5.1-1) in 2012, and it has been 

subsequently refined over several years. The model predicts 

short- and long-term variable needs for physicians, nurses, 

CNAs, and caregiving support staff such as transporters and 

environmental staff members. Other support staff members are 

more fixed in nature over normal volumes, such as accounting, 

finance, HR, IT, etc. The model determines capacity based on 

the surgery schedule and past and projected census/service 

volumes one year out, one quarter out, one month out, and one 

week out. A weekly meeting confirms needs for the following 

week so the workforce schedule can be finalized and part-time 

and contingent staff members can be deployed as necessary. The 

CCM was deployed first to the medical center and then over the 

next three years to the other hospitals, then to other business 

units. It is effective at predicting capacity needs in units that 

have fluctuating census. The capability part of the model is used 

in all business units, including those that have more stable and/

or fixed capacity, such as hospice, home health care, the health 

plan, and DME. Capacity is evaluated annually by comparing 

predicted and budgeted labor to actual. Root cause analysis 

(RCA) is conducted when the capacity variance is greater than 

10% and findings are used to improve the model. 

Capabilities (knowledge, skills, abilities, specialties, and 

certifications) are assessed annually by people leaders during 

the Performance and Professional Development Plan (PPDP) 

review. In addition to considering the capabilities of their direct 

reports, people leaders also evaluate changes expected in their 
21

functional and service lines, such as purchase of new equipment, planned expansion of a service line, etc. This information 

is rolled up and used as an input to the P step of the SPP—

collect and analyze data and information. The reconciliation of 

future capabilities between what people leaders have identified 

and the SPP has determined is needed is completed in the D step 

of the SPP—develop and deploy strategic and business plans, 

and the resulting workforce plan is deployed to HR and hiring 

managers, as appropriate. Since both C&C are integrated with 

the SPP, CRHS has rarely been faced with a talent shortage. 

During COVID-19, CRHS found that some caregivers were 

“poached” for higher salaries, and it faced temporary shortages 

in physicians, respiratory therapists, and critical care-certified 

nurses due to the quarantine. It added critical care nurses in late 

2020, while the number of physicians and respiratory therapists 

stabilized in 2021. Some capabilities may be short-term, within 

the year, to develop and/or hire, while some specialty capabilities may take longer than a year. 

In addition to the CCM variance, other C&C metrics include 

physician C&C, employees cross-trained, workforce retention, 

average time to fill, volunteer presence, and nurses with BSNs 

or higher. The CCM and other efforts have been instrumental in 

helping CRHS achieve the action plans to recruit physicians and 

re-engage/increase the presence of volunteers. 

5.1a(2). HR and the hiring manager share responsibility for 

hiring the best-qualified candidates while keeping the diversity 

of the patient and hiring community in mind—not only in physical attributes, but also in educational background, experience, 

thinking, and ideas (details AOS).

HR is responsible for tracking current workforce profile 

demographic statistics, comparing them with the patient and 

hiring profile in the areas served, and annually updating a 

diversity report showing how aligned the system is with patient 

and hiring communities. A plan is developed annually to attract 

and recruit needed members of the workforce. The diversity 

report was developed at the system level initially and then 

expanded and deployed to each business unit. In another cycle 

of improvement in 2018, the report was expanded to the work 

unit level to increase the accountability of people leaders. The 

goal is to have work units within +/- 5% of the diversity of the 

patient and hiring community. This is more difficult to achieve 

for smaller and specialized work units. 

CRHS also seeks candidates who hold values that complement 

its own. HR recruits from CRHS’s own student trainees, interns, 

and residents for the professions and skills needed. CRHS also 

recruits from universities and medical schools that train in the 

skills needed and that themselves serve a diverse student population. For caregiving support and allied staff, it also recruits 

from state and local employment offices, which helps ensure 

that staff members reflect the hiring community. Recruiting ads 

are run in both English- and Spanish-speaking media. Positions 

are also posted internally. 

Potential hires are usually interviewed by the hiring leader, 

another leader, and two coworkers. The hiring team comes to 

consensus on each applicant. In a cycle of improvement after 

reviewing an adverse trend in first-year retention, behaviorbased interviews were researched and added in 2018. The 

interview focuses not on behaviors candidates might exhibit, 

but on behaviors that they have exhibited in past situations. The 

behavior-based questions align with CRHS’s values. A shorter 

and modified behavior-based interview is used for volunteers.

First-year retention has improved as a result of incorporating 

behavior-based interviews. To help address the challenge of 

shortages in nursing, technologists, and some physician specialties, CRHS has stepped up recruiting efforts for these positions 

and focused on closely monitoring the average time to fill these 

positions. In the short-term, CRHS has partnered with some 

specialty groups for tele-neurology, tele-dermatology, and other 

difficult-to-recruit specialties that can be supported remotely. 

CRHS is also working with nearby nursing programs to identify 

ways to remove barriers for potential nursing students. Being 

the backbone organization for the COE, which has a goal of 

making the community a great place to live, will also enhance 

CRHS’s ability to recruit in the long-term (Figure 5.1-2). 

Onboarding is a three-day program consisting of two days of 

introduction to the organization led by HR and SLs. Two SLs 

lead a half-day session on the MVV, CCs of safe care and efficiency, ethical behavior, and DEI. This is followed by a one-day 

structured orientation to the hiring department, led by a people 

leader. Thirty days after hire, new employees attend a session 

on valuing diversity and are encouraged to take the one-day 

class on Lean and CI tools. Onboarding is the same for all new 

employees—those based in hospitals as well as those based in 

other business units. Nonemployed physicians, volunteers, and 

students have a similar orientation (although shorter), and they 

receive diversity training after 30 days. New nursing graduates 

are partnered with an experienced nurse during the first 60 days. 

Nurses in specialty areas such as the OR and NICU require a 

longer orientation. Most new hires have a 90-day probationary 

period, after which the people leader conducts their first PPDP. 

5.1a(3). CRHS balances the needs of the workforce with its 

own and minimizes reductions through disciplined headcount 

management, cross-training, the Take a Break Program, 

and other processes to enhance flexibility while retaining its 

high-performing workforce. 
22

The CCM is used to predict capacity one year in advance. HR 

partners with people leaders annually about the positions that 

are planned for the upcoming year. When the CCM predicts 

growth in the need for C&C, the cross-functional FTE Committee reviews these requests to ensure they are justified and to 

determine whether these capabilities already exist somewhere 

else in the organization rather than hire externally. The committee also determines if anticipated reductions in other areas may 

provide an opportunity for training staff members for reassignment. Once the need is confirmed, the committee considers all 

needed aspects, from physical space, IT needs, parking capacity, 

and additional training and development. A detailed plan is 

prepared and actions taken to prepare the organization up to six 

months in advance of new hires or reductions. 

People leaders are expected to proactively manage the transitions of their direct reports, with support from HR, and seek out 

fellow leaders to discuss cross-training and opportunities for 

employees when one is no longer needed in a particular department, but may have skills suited for another department. People 

leaders also routinely evaluate whether a FT position may be 

shifted to a PT position or the reverse; CRHS also has a number 

of job-sharing situations, in which two employees would prefer 

to not be FT, but agree to share one position instead. 

To increase flexibility, in 2018, CRHS began cross-training the 

nonphysician workforce to support and temporarily work in two 

different departments with a goal to have 100% cross-trained by 

2023. These other departments are selected based on employee 

preference and functional needs. Nurses and CNAs work on at 

least two different units during the year to become familiar with 

those employees and unique circumstances. Volunteers participate in this as well; most volunteers have a favorite role, but 

CRHS has them serve in two other roles sometimes throughout 

each year. Working in different departments is already part 

of the student curriculum. CRHS actually cross-trained more 

volunteers than expected in 2020, particularly in caregiver 

support and caregiver allies, because they helped out in so many 

nontraditional roles during the pandemic. 

To meet the diverse needs of the workforce as well as the organization, the Take a Break Program allows nonunion employees 

to go on furloughed or contingency status when the census or 

other circumstances dictate that they are temporarily not needed, 

either PT or FT. These opportunities are communicated to the 

classification of employees impacted, for example, a temporary 

over-staffing of medical coders. If more employees want to 

take advantage than needs dictate, the longer-tenured employee 

is offered it first, provided the employee is a good performer. 

When they are on a “break,” they may be called in to cover for 

others as needed. As more permanent needs are identified, they 

may revert back to PT or FT status. There are no guarantees 

made, but there have been no involuntary reductions in force 

since the program started and no furloughs during the pandemic. 

These are unpaid leaves of short duration from a few weeks 

to a few months, which about 10% of the workforce has taken 

advantage of over the years since they became available. CRHS 

is working with union leaders to develop a similar program for 

its unionized members in the future. Results for this program 

are AOS. 

5.1a(4). Caregiving workforce members are organized functionally under people leaders and assigned to Interdisciplinary 

Teams (IDT) to focus on the delivery of high-quality care. 

Caregiving support and allied employees are organized under 

people leaders in functional departments to further develop their 

functional skills and focus on efficiency of operations. Workforce members may also nominate themselves to join a COP. 

To reinforce CRHS’s CCs, people leaders are expected to 

deliver a safety message and the importance of reducing waste 

and rework at least once a week; most deliver these messages in 

daily huddles by the unit’s performance improvement boards; 

many include them daily. All SL communications reinforce the 

CCs in their communications as well. Efficiency in Operations 

is reinforced through the expectation that employees routinely 

participate in PDCAs at their worksites. Since the introduction 

of Lean tools in 2018, employees are asked to work together 

to develop standard work in their units. Most of this has been 

completed. They also map processes that are experiencing 

issues. Some workforce members may also participate in 

cross-functional TRAC teams. 

The cross-training discussed in 5.1a(3) proved invaluable during 

the pandemic when the caregiving workforce worked nearly 

nonstop, and caregiving support and allied workforce members 

filled in where possible, such as by administering COVID-19 

tests and developing a process to sterilize and re-use PPE until 

more could be acquired, as well as many other tasks to relieve 

clinical staff. Agility and resilience were demonstrated from 

each individual as well as the organization itself. 

Another impact of the pandemic occurred when all caregivingallied employees and some support staff members who did not 

support patient care were transitioned to work remotely from 

home. While there were initially concerns about potentially 

lower productivity, effectiveness, and engagement, these concerns were not born out. A Pandemic Task Force was quickly 

established to address all aspects of the pandemic, starting first 

with the safety of caregiving employees, and then it moved 

on to ensure remote employees had what they needed to work 

safely at home with encrypted hospital-issued laptops. Employees were authorized to take home their ergonomic desk chairs 

and other supplies necessary to support their remote work. 

Many IT systems already provided for connecting remotely, and 

access was updated to ensure that employees working remotely 

were not hampered in their ability to be effective outside of 

CRHS’s facilities. People leaders were trained in how to keep 

employees engaged and continued to hold daily huddles, even 

if at times these were video conferences or simple chats. A 

number of people leaders reported that employees seemed to 

be more productive, not less, likely due to the elimination of 

commute time.

As pandemic restrictions eased in 2021 and vaccines were 

widely available, it was determined that some employees could 

continue to work remotely, while others would adopt a hybrid 

solution. As a system, CRHS determined that maintaining the 

most flexibility as possible would be the default to better meet 

the diverse needs of the workforce. People leaders share their 

plans with their leader and HR generalist to assess risks and 
23

identify any obstacles. Today, about a quarter of the noncaregiving workforce are 100% remote, about a quarter are 

working in a hybrid mode, and the rest continue to work onsite. 

CRHS is evaluating space needs now and in the future as these 

modes of remote working become more permanent. It expects 

to have more space available in 2022 and beyond to expand 

patient care. 

5.1b. Workplace Climate

5.1b(1). Workplace health is incorporated in CRHS’s CCs 

and its focus on safety for patients and staff members. All 

members of the workforce are enrolled in Copansburg Wellness 

after 90 days. Once enrolled, they may take advantage of free 

offerings. A discount on health insurance premiums is available 

to employees who meet biometric objectives. Nonemployed 

physicians, residents, volunteers, and students are not enrolled 

in Copansburg Wellness, but they have full access to fitness 

centers and other free clubs and courses. The Wellness Committee identifies, develops, and communicates offerings. 

Because burnout was already a concern for physicians and some 

nursing staff members prior to the pandemic, CRHS added 

considerably to the wellness program (Figure 5.1-3). These 

additions were kept in place in 2021, and CRHS is considering 

whether it will continue them into 2022 and beyond. For 

example, at each hospital, it converted a room into a meditation/

rejuvenation space for caregivers and added additional mental 

health support, mindfulness, and weekly guided practice, along 

with a subscription to a calming app for those who requested it. 

To address physician burnout, CRHS administered a short 

survey in 2019 and found that 34% of physicians were experiencing symptoms of burnout—5% greater than the national 

average of 29%. In response, physician leaders established a 

Physician Wellness Council that systematically takes actions to 

address burnout based on the Clairgrade Professional Fulfillment continuum, which addresses personal resiliency, efficiency 

of practice, and a culture of wellness. The 2020 and 2021 survey 

results show improvement. 

CRHS administered a short survey to learn what would be most 

helpful to them to reduce their own stress. It learned that meals 

were valued, but so were other things, such as the relaxation 

rooms it put in place, massages, gift certificates, hotel rooms, 

and more. CRHS partnered with the community to find ways 

to deliver on these, with many businesses and residents making 

contributions to ease the stress of the workforce during this 

period. CRHS believes these efforts contributed to its ability to 

maintain high engagement despite the pandemic.

CRHS is focused on helping employees pursue work/life 

balance, with people leaders encouraging their direct reports to 

take appropriate time off. In January 2021, in recognition of the 

extraordinary resilience demonstrated by employees during the 

pandemic, CRHS made a special award of 16 additional hours 

of vacation time and encouraged employees to use them as early 

in the year as work allowed. 

CRHS also implemented a short Wellness Pulse Survey that it 

administered quarterly during the pandemic and into 2021 to 

monitor progress on this issue. 

Security is ensured through a comprehensive system. CRHS’s 

goal is to ensure a safe environment (Figures 5.1-4 and 5.1-5), 

and when issues are encountered, to handle them internally and 

not have to rely on community emergency responders. Examples of safety tools are AOS.
24

5.1b(2). Employees can take advantage of cafeteria-style benefit 

plans to choose those that best fit their needs (Figure 5.1-6). A 

basic plan provides access to health and dental care, a health 

savings account, life and disability insurance, and 403(b) 

tax-deferred retirement account. The enhanced plan costs more 

to employees, but offers access to these benefits and more, 

including vision care; legal services; and discounted home, auto, 

and long-term care insurance. 

An innovative benefit CRHS offers is subsidies to purchase a 

home in the twelve blocks surrounding the medical center to 

enhance the stability of the community and offer employees 

an opportunity to live close to work. The center is located in a 

community that was beginning to experience blight; however, 

given rising economic conditions in the area, it is starting to 

improve. With the Home to Work Program, employees receive 

an amortized annual benefit equal to 5% of the purchase price, 

which is not to exceed $60,000. If they stay in the home for 

twenty years, the home could be effectively paid off. The cost 

to the medical center averages $2,200 for every employee who 

takes advantage of the program (average cost of a home in the 

neighborhood is $44,000). Currently, this program impacts 

relatively few members of the workforce; results are AOS. 

To provide a similar benefit to residents and students, who 

need housing support more than many, the medical center 

purchased a small apartment building nearby; the area has many 

single-family houses, but few apartments. Units are offered to 

residents and students at cost, and there has been a waiting list 

since this Home to Work Program was launched. 

5.2 Workforce Engagement

5.2a. Assessment of Workforce Engagement

5.2a(1). The Upwood Survey is administered annually, and 

CRHS has added a set of questions on satisfaction and a set 

on engagement. It also asks the workforce about the extent 

of agreement with statements, as well as how important that 

statement is. The most important statements, key workforce 

engagement drivers, are re-validated through focus groups every 

three years. Only minor tweaking to descriptions of a couple 

of drivers was identified in the re-validations in 2015, 2018, 

and 2021. Key drivers of engagement (Figure P.1-2) have been 

determined for all major workforce classifications, including 

students and volunteers. 

5.2a(2). The Upwood Survey, which is part of CRHS’s Workforce Engagement System (Figure 5.2-1), is sent to the entire 

workforce. All people leaders are expected to work with their 
25

teams to develop an annual action plan to address both Engagement and Satisfaction Survey results. If work unit survey results 

do not improve for a people leader over a two-year period, HR 

will assign a coach. 

5.2b. Organizational Culture

The most important way CRHS fosters the organizational 

culture it values is to ensure that every leader, from executive 

leaders down to supervisors, role model the culture. It makes 

clear that this same behavior is expected of every member of the 

workforce. 

In addition to regularly scheduled staff meetings and town halls, 

daily huddles (of 5 to 15 minutes) by people leaders on each 

shift reinforce the message of the day linked to culture (e.g., the 

vision, WE CARE, improvement ideas, weekly safety message). 

Everyone’s ideas are welcome, and employees are expected to 

work together to solve problems in their work units and develop 

standard work.

In 2020, CRHS formed a system-wide Diversity, Equity, and 

Inclusion Committee (DEIC) to identify issues, programs, 

and initiatives to promote DEI and ensure that it benefits from 

the ideas of its diverse workforce. The SEEGs (4.2b[1]) also 

promote DEI. CRHS transformed its culture since its Baldrige 

journey began in 2012 to one that is empowered and relies on 

the engagement and ideas of the entire workforce. 

5.2c. Performance Management and Development

5.2c(1). CRHS adopted Integrated Talent Management (ITM; 

Figure 5.2-2) in 2017 after being frustrated with the length and 

complexity of the existing performance management process, 

as well as the disconnect from and lack of focus on professional 

development. It researched best practices and found successful 

organizations outside of health care that had adopted this model. 

As part of adopting ITM, CRHS developed the PPDP to not 

only align performance and development, but also to integrate 

these two elements. In the performance evaluation section of the 

PPDP, goals are set at each level with organizational goals cascaded down, departmental goals linked to these, and individual 

goals linked to departments. In this way, every employee has 

a clear line of sight to strategic objectives and action plans. If 

goals are met, employees are eligible for the incentive plan. If 

they are exceeded, the incentive is increased commensurately. 

These linkages ensure that everyone is contributing to goals 

important to the organization and aligned to the CCs. Leaders 

are evaluated on how they developed or contributed to intelligent risks. Employees are evaluated on how many PDCA/Lean 

activities and safety initiatives they contributed to, and how they 

contribute ideas in the daily huddles. They are also evaluated on 

behaving in accordance with the WE CARE values to reinforce 

that while results are important, how results are achieved must 

also be in balance. 

The evaluation process requires that employees self-evaluate 

and then have a discussion with their people leader. The PPDP 

is deployed to all employees, including employed physicians. 

Volunteers receive feedback and recognition with an annual 

lunch and gift cards.

CRHS periodically benchmarks total rewards best practices 

through the Human Resource Society (HRS) and GWA. 

Compensation is targeted at 5% above median compensation 

in CRHS’s service area for each classification. A compensation 

study is completed every three years. 

5.2c(2). Annually after the SPP, HR analyzes the workforce 

plan, identifies the necessary KSAs, and plans for how they 

may be obtained. For those that are best suited to a training 

experience, courses are developed and made available to 

employees, and online courses are also available to volunteers 

and students. The workforce is highly encouraged to take the 

one-day course on PDCA, as well as Lean and CI tools. Annual 

courses are required in ethical behavior, HIPAA, safety, WE 

CARE, and current-year strategic objectives. A short refresher 

called Valuing Diversity is also required. 

In a cycle of CI, course descriptions now note the learning 

objectives and ideal background and experiences of learners 

who want to register for the course. Course evaluations are 

reviewed after each class and also annually across multiple 

classes delivered that year. As a result, courses have been 

revised, added, and dropped. Courses have also changed 

modality (in-person to online and vice versa). 

During the PPDP process, after evaluating their current year 

performance, the employee and people leader discuss future 

development. CRHS adapted the Ability, Agility, Aspiration, 

Engagement, and Exposure (A3E2, with Emotional Intelligence) approach developed by the University of Michigan. It 

then added a third E, Emotional Intelligence (A3E3), because 

of its importance to CRHS’s leadership style. It uses A3E3 in 

PPDP discussions. The system quickly learned that aspiration 

was a key gap; almost no people leader was aware of his/her 

direct reports’ aspirations for the future. Since CRHS adopted 

it in 2017 and trained leaders to use it, as well as coaches, 

employees are more satisfied with the development they receive 

and their relationships with their leaders. Development not 

achieved or mastered in one year is rolled over to the next and 

the PPDP refined/updated. The PPDP is not intended to necessarily be completed in one year. 

Deficits in performing the current role are the first priority. From 

there the employee and leader can develop the plan for the next 

year and beyond to make progress on development priorities. 

The plan uses the 70-20-10 formula (AOS).
26

5.2c(3). Courses are evaluated based on Kirkpatrick’s model, 

with the attendees’ people leaders required to submit a short 

evaluation 90 days after the course to report whether they are 

seeing their direct reports exhibit changes to their behavior 

as a result of the course. This survey was adopted in 2020, 

and results are AOS. As a result of the pandemic, CRHS also 

improved the registration process so that participants may 

register for courses from anywhere. The overall Aspire Learning 

and Development System (LDS; AOS) is evaluated by HR 

with input from people leaders on a scale from 1–10 annually 

based on participation and outcomes achieved; it is then also 

correlated to workforce and patient engagement results. 

5.2c(4). Career ladders have been developed for all positions, 

including for nurses who want to eventually go on to become 

certified registered nurse anesthetists or attend nurse practitioner 

schools. These are competency-based and allow employees to 

enhance current competencies and develop new ones. They do 

not automatically lead to promotion; CRHS’s philosophy is that 

some employees do not want to lead people and/or may not 

excel at it, but they still want to grow in capability, competencies, and compensation. CRHS values individual contributors 

just as much as people leaders. People leaders are expected 

to encourage all employees to follow the career ladder and 

seek opportunities and development. This is part of the PPDP 

professional development discussion. 

Managers and above are required to identify three potential 

successors; if three are not identified within the department, or 

the department is so small that this is not practical, HR assists 

with identifying persons outside the department. The Leadership 

Development Program (LDP) was developed in 2016 and is 

targeted to high-performing potential leaders and those identified as potential successors. The Physician Leadership Academy 

is a similar development program for physicians, launched 

in 2018. The LDP was developed after 

benchmarking top workplaces for leader 

development and GWA and HRS organizations, and it is enhanced every year. LDP 

focuses on leadership behaviors to support 

the culture and on emotional and social 

intelligence. Potential successors develop 

a plan with their leaders to enroll in the 

LDP and gain the necessary experiences 

(e.g., assignments in other areas, serving 

on TRAC teams, leading action plans, 

serving as interim leaders, participating 

in external courses and conferences, and 

others). Participants may also request a 

mentor other than their people leader. 

These high-potential development plans 

are usually three years in duration, with 

increasingly visible and challenging 

assignments in year three. About a third 

of current SLs are graduates of the LDP. 

Directors and above have the opportunity 

to also request executive coaching that is 

external to the organization and focuses on 

emotional and social intelligence.

5.2c(5). HR reviews performance results and investigates 

unusual patterns. Performance evaluations must be signed off 

on by their next-level leaders. Data are tracked on the demographics of the workforce identified as potential successors and 

participating in career ladders and the LDP, as well as those 

taking courses in the Aspire LDS. These data are compared to 

the diversity report. If adverse patterns are identified, HR first 

coaches the leader and determines underlying causes. The workforce is expected to reflect +/- 5% of the diversity report for the 

area over time, which is easier to achieve in larger departments 

and challenging in small and specialty units. The DEIC and 

SEEGs also promote DEI and receive summary information 

about the diversity levels in business units, upon which the 

committee (DEIC) may make recommendations. 

Category 6: Operations

6.1 Work Processes

6.1a. Service and Process Design

6.1a(1). CRHS has a defined Service and Work Process Design 

(SWPD; Figure 6.1-1). Service and process requirements are 

determined during the planning phase of the SWPD. Inputs 

include VOC (e.g., Kress Daney), stakeholder input, strategic 

objectives, regulatory requirements, regulatory changes, audit 

findings, technology changes, benchmarks, research, supplier/

partner input, and best practices. 

6.1a(2). CRHS’s key work systems are Caregiving Services, 

Caregiving Allies, and Caregiving Support (Figure 6.1-2). 

Key health care work processes within each work system are 

focused on delivery of care. Key work processes for Caregiving 

Services are Inpatient Care, Outpatient Care, Emergency Care, 

and Post-Acute Care/DME. Key Caregiving Support processes 

include Finance, Supply Chain Management (SCM), Facilities 
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Management (FM), Workforce Services, and Information Management (IM). Key Caregiving Allies support processes include 

Corporate Services, ACO, Insurance Plans, and Partnership. 

6.1a(3). CRHS’s SWPD is used to design service and work processes to meet the requirements of its customers. This process 

is evaluated each year for effectiveness and has been updated 

and improved multiple times based on leader and process owner 

feedback. It was aligned to the PDCA process in 2017 to ensure 

a systematic approach that is considerate of learnings from past 

service process implementations. 

Inputs for the need for a new process can come from any source 

or at any time (step 1). SLs authorize a feasibility analysis and 

further process development (steps 2, 3) and approve implementation (step 4). Process outputs are 

monitored and must undergo improvement if they are not meeting targets. 

Retrospectively, all current key service 

and work processes must have a process 

map created and reviewed for opportunities for improvement periodically 

even when meeting performance targets. 

In 2018, the SWPD was updated to 

require a Failure Mode and Effects 

Analysis (FMEA) for design (or 

redesign) of complex processes to 

proactively identify process risks and 

failures. The most recent change to the 

SWPD came in 2020 to further define 

the societal impact by including a 

reflection on DEI into process development (step 3).

6.1b. Process Management and Improvement

6.1b(1). The consideration and definition of performance and 

in-process measures takes place in step 3 of the SWPD. All 

measures (Figure 6.1-2) are developed to the quality of outcomes and aligned with customer requirements. Process maps 

have been defined for all key processes and are evaluated for 

opportunities for improvement using the PDCA process (Figure 

6.1-3). Any processes not meeting targets are also reviewed by 

the process owner and champion for further action using PDCA.

6.1b(2). Patient input is sought during each stage of the patient 

relationship. Care plans include setting expectations that include 

patient/family, rounding, and informed consent to enhance 

engagement in care decisions and ensure consistency with 

providing safe, quality care. Understanding patient expectations 
28

and preferences begins with admissions (inpatient), scheduling 

(outpatient), intake (emergency/urgent care), and referral (postacute care). A multidisciplinary care plan (MCP) is created, 

resides in the patient EMR, and is available and viewable 

(including updates by all members of the caregiver team). The 

MCP is created with input from the patient and includes patient 

preferences and the patient’s desired outcomes and goals. 

As a result of caregiver feedback about not being able to find 

Advance Medical Directive (AMD) information in a standard 

place and format, a TRAC team was assigned to work with a 

group of hospitalists and palliative physicians. Previously this 

information could be anywhere in the EMR or in paper forms, 

making it difficult to find when needed. Their work resulted in 

changes to the AMD process with EMR to be the designated 

place for AMD information and forms. 

Reassessments are done throughout the delivery of care with 

input from the patient and the patient’s family and documented 

in the MCP. Communication of the MCP is facilitated and 

reinforced through the use of white boards in patient rooms, 

patient electronic medical records (MYPHI), and rounding 

by caregivers. White board content is standardized to include 

information about the patient, the care providers, medication, 

and the treatment timeline to promote standard care and 

enhance communication. Translation services are available 24/7 

through CRHS’s contracted on-demand vendor. Inpatients are 

able to use the features of the interactive room TV monitors to 

order meals for themselves and their families. Normally, CRHS 

has open visiting hours, but when inpatient units were off limits 

to visitors during the pandemic, the TV monitors served to 

promote communication with family and friends through an 

interface with most phones. The interactive monitors also provide care and diagnosis-related educational content for patients 

that enhance their care and contribute to desired outcomes. 

With a focus on understanding and documenting patient 

preferences outside of the hospital setting, a new “preferences” 

component was added to the patient portal in 2020. The portal 

allows patients to indicate their preferences prior to a scheduled 

procedure or visit, which the care team uses to validate care 

planning. This was especially useful to both caregivers and 

patients, providing a standard process for virtual visits that 

became commonplace during the pandemic.

6.1b(3). The SWPD is used to develop and define key support 

processes, as well as health care service processes, and ensure 

that day-to-day operations meet requirements (Figure 6.1-2). 

These day-to-day operational measures are reviewed at an 

appropriate frequency (Figure 4.1-2) to define unstable, out-ofcontrol processes and for referral of improvement, correction, 

and CAPA. The use of Statistical Process Control (SPC) was 

adopted in 2019 to apply predetermined criteria and to standardize tracking of performance results. 

6.1b(4). The Baldrige Excellence Framework® is the overall 

system that inspires excellence at CRHS. All employees receive 

basic training on the Baldrige framework. More than fifty 

system leaders have received additional training in the Baldrige 

Criteria. At least a dozen serve as Baldrige Examiners at the 

national level and for the State Center for Performance Excellence. The Baldrige application provides for a systematic review 

of CRHS as an organization, and the feedback report is used as 

an input to initiate performance improvement (PI) projects.

Work and support processes are improved using Model for 

Improvement, PDCA, and Lean tools based on the type of 

improvement (problem solving or process improvement). Lean 

was added to CRHS’s improvement methods toolbox in 2016 to 

support its CC of Efficiency in Operations. Those areas where 

measures do not meet established targets or processes that 

demonstrate nonbeneficial trends and/or unacceptable variation 

require a PIP from the process owner or designee. CI of support 

processes is addressed in 4.1c(2). Process owners contact the 

TRAC Office for support in forming or re-forming Process 

Improvement Teams (PITs), examine the process, and carry out 

corrective actions. All new employees are required to complete 

a one-day class to familiarize themselves with the PDCA 

method, Lean tools (5S, waste reduction, process mapping, standard work), and common PI/QI tools (pareto, run/control charts, 

brainstorming) to prepare for day-to-day improvement work 

within their area/department and as PIT members. Depending 

on the scope of the process, a process owner may form a PIT 

to solve a problem by exploring the root cause, selecting a 

solution, and implementing the solution using PDCA or Lean 

tools to improve a process to reduce variability. 

More complex processes with many stakeholders can be 

referred to the PIC where projects are assigned to a TRAC for 

facilitation of a cross-functional improvement team and expert 

coaching of the improvement project. Each TRAC is staffed by 

experienced PI practitioners who use PDCA as the PI methodology. The system-wide TRAC teams are led by experienced PI 

champions who can coach and manage system-wide projects. 

The focus on using champions rather than exclusive project 

managers enhances the flexibility of TRAC teams to facilitate 

the improvement process, implement solutions that address 

root cause, and enhance sustainability. TRAC teams report 

project progress and results monthly to the PIC. The system PIC 

convenes a semiannual Convergence of Excellence of entity 

PITs where problems, solutions, and successes are shared. An 

outcome of the Convergence of Excellence is to disseminate 

best practices throughout the system. An annual system-wide 

Celebration of Excellence solicits PI project submissions to 

highlight and promote a focus on improvement and includes 

awards for teams that demonstrate successful projects meeting 

the excellence criteria (details AOS).

6.1c. Supply-Network Management

CRHS centralizes management of its supply network at the 

system level through its GPO and through the SCM (Figure 

6.1-4). SCM coordinates the purchase of supplies, equipment, 

contract negotiations for services and supplies, pricing, and contract utilization of the GPO. The GPO can secure competitive 

pricing for more than 80% of supplies and services and adds 

value in handling screening and evaluation for these suppliers. 

When the best value cannot be obtained through GPO, or for 

non-GPO suppliers, SCM uses its internal supplier process. In 

2018, CRHS created a revised supplier evaluation process that 

uses a decision matrix customized to product requirements and 

participation of users. In 2022, the GPO will assist the organization in reducing the chargemaster listings for orthopedic surgery 
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in order to reduce costs. The GPO saved the organization more 

than 80 million dollars in the cost of pharmaceuticals in 2019, a 

strategic challenge. 

Suppliers are selected using a criteria-based evaluation that 

includes requirements, cost, outcomes, and quality. CRHS 

works with the GPO to define criteria that supports the MVV, 

SOs, and customer satisfaction. Vendors are credentialed 

through Bizplus to ensure alignment and qualifications. Key 

supplier requirements are quality of product/service, availability 

of products/services, and cost of acquisition.

Alignment and collaboration within the CRHS supplier network 

is accomplished through supplier credentialing and the monthly 

supply chain reviews. The supply chain review analyzes 

performance measures, results, and opportunities for new 

programs and is attended by representatives from each CRHS 

entity, which helps to recognize issues and determine if they are 

local or organization-wide. During the COVID crisis, weekly 

and often daily meetings were needed to address issues specific 

to the COVID-affected supply chain to be able to quickly move 

supplies from one facility to another based on projected need. 

Supplies from closed clinics were deployed to areas of need. 

SCM collaborated with Marketing and Communication in 

the early stages of COVID to procure donations from various 

groups outside the health care realm for PPE. Because of these 

agile efforts along with GPO support, CRHS never ran out of 

PPE and essential equipment.

Suppliers receive a quarterly scorecard reporting on contractual 

key performance measures. For suppliers who do not meet 

requirements, an action plan is created and reviewed periodically until performance targets are met or a decision is made to 

change suppliers. 

The spirit of regional cooperation was demonstrated in 2020 

when CRHS partnered with two unaffiliated rural hospitals to 

assist them with obtaining supplies during the COVID crisis. 

6.1d. Management of Opportunities for Innovation

CRHS is focused on learning and understands that with innovation comes an element of risk and possible failure. Opportunities for innovation and SOs that are determined to be intelligent 

risks are part of the SPP (steps 1 and 11). The Strategy/

Innovation (S/I) committee evaluates each idea using defined 

assessment factors such as risk, ROI, and alignment to the 

MVV. Those ideas and intelligent risks deemed worth pursuing 

are recommended to the SPP for inclusion in the plan (Figure 

6.1-5). The S/I committee may also meet outside the SPP cycle 

and recommend ideas for SLT consideration for resourcing. This 

process ensures that resources (financial, human) are provided 

to effectively take advantage of the opportunity.

Department and higher-level meetings require innovation to be 

on meeting agendas to have all voices heard. The criteria for 

innovation is simple: The idea solves a problem in a unique 

or new way or takes the organization to the next level. The 

department Lean team evaluates ideas and may seek approval 

to implement (no/low cost) or refer to the next level for review. 

The department stoplight board report displays progress from 

yellow (in process) to green (implementation completed). Those 

suggestions that rise to higher-level meetings for discussion 

at leader and SL meetings are also displayed with the submitter’s name. A review of predetermined measures (financial, 

regulatory, marketing) for all projects provides evidence of 

effectiveness. Objectives not meeting goals or no longer aligned 

with goals, changes in priorities, and cost-benefit are evaluated 

with a possible outcome being to discontinue. 

In 2019, CRHS created its “Shark Tank” program (2.1a.[2]), 

adapted from a benchmarking partner. The entire workforce is 

invited to submit their posters representing improvement project 

or innovative ideas. These are judged against predetermined criteria with the highest scoring selected for implementation. The 

winners are recognized at the annual Celebration of Excellence.

To support our workforce during the COVID crisis, an innovative service was implemented for clinical and other essential 

staff. A commercial service outlet in a facility closed, and the 

space was reconfigured to provide for pick-up of ready-to-go 

meals prepared by food service.
30

The organization’s Research division includes an IRB and 

supports innovation in medical care. Performance Excellence 

and Strategy teams at the system level identify SOs to determine 

those that are intelligent risks to pursue.

6.2. Operational Effectiveness

6.2a. Process Efficiency and Effectiveness 

CRHS’s focus on Lean methods calls attention to waste in 

operational processes resulting in process modification or 

redesign (Figure 6.1-1). Respective measures and reviews for 

processes are used to manage cost, effectiveness, and efficiency 

of operations. FMEAs provide a proactive focus on risk 

management and mitigation in process design and redesign, 

thereby reducing the cost associated with process failures. 

The use of electronic checklists in rounding helps to minimize 

the cost of formal audits. CRHS prevents rework and errors 

and minimizes the cost of inspections, tests and process, and 

performance audits using its Lean PDCA methods that focus on 

error proofing, standard work, reducing variation, 5S, adoption 

of automation, and review of in-process measures (using SPC as 

appropriate). 

When an error occurs, the RCA process includes a review led 

by a PI champion to identify opportunities for improvement 

and implement more robust processes. CRHS’s Lean methods 

emphasize a focus on its customers and the customer perspective. Periodic process reviews require waste analysis from a 

customer perspective. This customer focus played a big part in 

CRHS’s customer and patient satisfaction rating improvements 

going back to 2018 when Lean was adopted. Identification of 

process waste is a goal for all staff members and included in 

most job descriptions. In 2019, CRHS realized 19 million in 

operating room cost reductions because of process redesign and 

process waste removal. Beginning in 2018, all new buildings 

and clinical facilities (hospital and medical offices/ancillary services), refurbishments, and reconfigurations must be reviewed 

for a focus on Lean principles to eliminate or reduce waste.

6.2b. Security and Cybersecurity

CRHS uses the NIST Cybersecurity Framework to manage 

and reduce cybersecurity risk, which is a strategic challenge. 

The cybersecurity VP reports directly to the CIO; serves on the 

Emergency Preparedness and Operations Plan (EPOP) Committee; and oversees the IM Security Committee, which includes 

representatives from each facility. Security policies define 

operational and employee requirements and disciplinary actions 

for noncompliance. Processes to ensure security of sensitive 

data (such as protected health information [PHI]) include 

limiting access to data and information to those authorized to do 

so based on their job responsibilities. All employees, contractors, suppliers, and others with access to sensitive information 

and data must complete security and HIPAA training during 

onboarding and thereafter, annually. This training is updated 

each year to highlight current cyber threats. All workstations 

(including laptops) require anti-virus software and encryption. 

Downloads to nonencrypted storage devices are prohibited and 

monitored. 

Device security is monitored when accessing organization IM 

systems, and devices are denied connections when equipment 

is noncompliant. Periodic vulnerability scans are performed on 

all servers and web-based applications. Systems with vulnerabilities must be mitigated within 30 days with noncompliance 

resulting in disconnection. An annual security audit is conducted 

by a third party and is the basis for the Information Security 

Protection Plan. Break Glass audits are conducted to identify 

unauthorized access to patient records. A new application, 

MYPHI, continuously monitors electronic health records for 

appropriate access to patient PHI.

Additional security measures include forced password changes 

every six months, two-factor authentication, badge entry to 

facilities, security cameras, spam detection, and user reporting. 

Any email correspondence containing protected health is 

encrypted using secure mail. Phishing testing promotes awareness of security and cyber threats with feedback provided to 

those that fail. The weekly online security and safety blotter 

report contains results on phishing testing using a case study 

and current issues to watch out for. Daily server backups to the 

cloud have replaced many redundant servers, resulting in cost 

efficiencies. 

6.2c. Safety, Business Continuity, and Resilience

6.2c(1). CRHS has committed to providing a safe operating 

environment for its workforce and all who set foot in its 

facilities. The Office of Safety and Business Continuity (OSBC) 

at the system level oversees Biological/Chemical/Hazardous 

Waste Safety, Radiation Safety, Fire Safety, Occupational 

Safety, and Environmental Compliance to maintain a healthy, 

safe, and compliant work environment. Systematic processes 

to ensure workforce safety include preemployment screening, 

safety training at NEO aligned with job requirements, and 

policies and procedures. Audits are conducted to assess safety 

and compliance to requirements, and audit findings require 

action plans that include RCA, correction, corrective action, 

and preventive action (using PDCA). Incidents and near misses 

also require RCA and action plans. A significant learning in 

2018 resulted in the formation of an Employee Safety Council 

comprised of safety officers and an employee representative 

from each facility. Council members meet quarterly to provide 

VOC, identify high-risk activities and processes, and provide 

suggestions for improving safety and implementing best 

practices.

Other safety programs that support workforce and operating 

safety include badge access, emergency call boxes at all 

campuses, on-demand escort service to cars and transportation 

locations, and “save your back” training. Ergonomic assessments are available on request to all employees. An online 

weekly security and safety blotter is used to report incidents 

internally and externally. Crime prevention and self-defense 

training are offered to employees, and workplace violence and 

active shooter training are required. Additional COVID safety 

precautions were implemented system-wide by occupational 

health to protect the workforce and include daily temperature 

checks, daily online monitoring (remote workers), free COVID 

testing, quarantine procedures, and no-cost vaccinations. 

6.2c(2). CRHS’s comprehensive safety program ensures the 

highest levels in patient safety. The patient safety officer heads 

the Environment of Care System with EOC coordinators for 

each business line. Monthly EOC patient safety audits are 
31

conducted at each business line with deficiencies requiring RCA 

and Corrective and Preventive Actions (CAPA). Findings are 

shared at department meetings and daily safety huddles. All 

patient safety events and near misses require RCA and FMEA 

with action plans to address CAPA. A dashboard on the system 

and business line websites displays patient safety results. At 

monthly PIC meetings, patient safety results are reviewed, and 

those metrics not meeting target or demonstrating nonbeneficial 

trends are referred to TRAC teams for investigation and action 

planning (PDCA). 

In 2015, an analysis and review of patient safety events pointed 

to a root cause of lack of communication. To improve patient 

safety and promote effective communication and a commitment 

to teamwork, all patient care positions, including providers, 

now require TeamStepps Training. Largely, as a result of this 

training and a focus on CRHS’s CC of Safe, High-Quality 

Care, its periodic Culture of Safety (COS) Survey has shown 

consistent improvement in the percent positive response in the 

areas of Teamwork Across Units and Overall Perception of 

Safety at each entity. The Medical Office COS Survey was to 

have been conducted in 2020, but due to COVID closures, it has 

been rescheduled for Q4 2021 (AOS). The survey will serve as 

a baseline to Medical Office COS improvement efforts. Even 

though patient safety events have decreased at each entity, that 

is not good enough. In 2021, CRHS is embarking on the journey 

to be a High-Reliability Organization building on its culture of 

safety, the use of methods and tools to improve the quality and 

safety of its processes, and a commitment to zero harm.

CRHS’s Good Catch Program highlights employees who 

recognize errors and defects before they cause harm. Employees 

are recognized and rewarded, and the stories are published in 

the monthly newsletter.

6.2c(3). OSBC uses systematic processes (Figure 6.2-1) to 

ensure that CRHS anticipates, prepares, and recovers from 

disasters, emergencies, and disruptions to maximize survival, 

minimize injury, preserve property, provide for restoration 

of support structures and processes, resume operations, and 

promote self-sufficiency and collaboration.

These processes have been tested and improved not only 

because of events (e.g., tornado activity is 88% greater in 

Kentucky than the overall United States), but also through 

collaboration with state, regional, and city emergency entities 

and agencies who provide input from a customer, patient, and 

community perspective. 

CRHS is a member of Lexington Squared Away and the 

Kentucky Crisis Association. Local and regional drills and 

disaster simulations reveal gaps in planning and require action 

plans/CAPA (PDCA) and feedback to the EPOP.

Reliance on CRHS’s workforce, suppliers, and partners 

becomes critical during a crisis or disaster. The employees who 

are designated as critical (primarily patient care, facilities) are 

expected to report for work despite personal issues, especially 

during the pandemic. CRHS seeks to support the employees’ 

families, as well as the employees themselves. Based on 

employee feedback, CRHS expanded support to include child 

care, pet care, transportation, housing, and food for essential 

staff members during the pandemic.

CRHS’s response to COVID demonstrated the effectiveness of 

its EPOP as it transitioned from an expected short-term crisis 

to the indefinite, long-term new way of conducting business. At 

the system level, the COVID Command Center, established in 

March 2020, worked with all organization entities, along with 

community, state, and regional health care organizations, to 

assess and respond to daily changing needs. Designated COVID 

PI champions (recruited from TRAC) became the COVID 

Process Team (CPT) and considered patient, workforce, supply 

chain, and IM needs to support each key service and support 

process. Outcomes included establishment of the COVID 

Units (medical and ICU), safety precautions, and creation of a 

regional bed/ICU status reporting and response team to support 

surges. As the availability of vaccines started to become a reality 

at the end of 2020, the CPT planned logistics and implemented 

a regional vaccination site and partnered with local churches, 

synagogues, and mosques to set up neighborhood sites that 

significantly contributed to the now 100,000 fully vaccinated 

people. 

This effort was greatly enhanced by the relationships established through COE. Other employee support services include 

workforce hoteling, mental health support, and retrofit of 

the COVID-closed on-site pharmacies to provide meals for 

employees to take home to their families. The regional PPE 

status board set up by the supply chain mitigated the scarcity 

of PPE for not only CRHS but also other health care providers 

and COVID testing sites in CRHS’s service area. IM rapidly 

deployed laptops and conducted training on virtual collaboration tools for staff members who began working remotely. 

These tools promoted greater collaboration across all entities to 

enhance work processes made difficult with physical distancing. 

They now serve to increase productivity and efficiency in the 

current work environment.
32

Category 7: Results

7.1 Health Care and Process Results

7.1a. Health Care and Customer-Focused 

Service Results 

Note that all figures in this category contain 2022 data (when 

available) that are updated to March. Otherwise, unknown data 

may be identified as not available (n/a). Additionally, note that 

sources of comparisons in figures are DDI.

CRHS’s quality is demonstrated by better-than- or near-topdecile performance in most measures recognized by national 

benchmarks. Results cover clinical and process outcomes 

throughout the system. Additional results segmented by 

condition, service line, and facility are AOS.

CMCL is the only hospital in the Lexington-Fayette area recognized by Caregrades, an online resource that evaluates hospital 

quality based on clinical outcomes, for achieving top 5% quality 

from 2018 to 2021 (AOS). In addition, CRHS has achieved 

better-than-its-peer CMS star ratings for health experiences 

(Figure 7.1-1) and projects outstanding ratings by 2022.

The CMS PSI-90 score, a composite of eight patient safety indicators, is part of the overall score for value-based purchasing 

(VBP), for which CRHS has achieved benchmark performance 

(Figure 7.1-2). For VBP measures, CMS benchmark performance is the mean of the top decile.

CRHS’s infection control processes focus on hand hygiene, 

infection awareness, and education. COVID-19 has brought 

greater awareness to hand hygiene (Figure 7.1-3).

The preventable harm index includes actual events and near 

misses to assess patient harm accurately (Figure 7.1-4). In 

CRHS’s quest to be a high reliability organization, it strives for 

zero patient safety events. The COS promotes a safe environment for increased reporting, and increased reporting provides 

data to support improvement activities to reduce events.

CRHS participates in the National Surgical Quality Improvement Program (NSQIP) and demonstrates excellent scores for 

surgical-site infections (Figure 7.1-5).

CRHS has made great strides in reducing the occurrence of 

hospital-acquired pressure ulcers (HAPU), exceeding the 

national benchmark and avoiding more than $13,400 in care 

costs (Figure 7.1-6).

CRHS measures its excellent care for all patients (see Figures 

7.1-7 through 7.1-11). This includes monitoring CS, a CAH, 

even though CAHs are exempt from reporting at the national 

level. 

CRHS’s quality-of-care measures for stroke are the best in the 

region (Figure 7.1-12), and it received the Stroke Association 

USA’s Gold Plus award in 2018 and 2021.

Case-mix index (CMI) adjusted, an indicator of reliable care, 

has remained stable even during the pandemic when each 

institution experienced higher acuity patients (Figure 7.1-13).
33

CRHS had no maternal deaths in 2021, outperforming the 

World Health Organization (WHO) national average (Figure 

7.1-14). In addition, it participated in a state-wide initiative 

to prevent early elective deliveries (Figure 7.1-15) and is the 

trauma quality and mortality outcome leader in the region 

(Figure 7.1-16).

CRHS’s focus on the continuum of patient care is intended to 

keep patients safe even after discharge. For example, the rate 

of pneumonia vaccination demonstrates top decile performance 

(Figure 7.1-17). In 2021, the ACO collaborated with the 
34

Kentucky Ophthalmology Group on a grant to improve diabetic 

preventive care (Figure 7.1-18).

Figure 7.1-19 shows the percentage of patients who left without 

being seen (LWBS).

CRHS performance is in the top decile for Home Health 

measures (Figures 7.1-20 and 7.1-21).

Hospice care enhances quality of life and provides services to 

patients’ loved ones in dealing with loss and grief. A higher 

LOS indicates hospice care was initiated at a most appropriate 

time (Figure 7.1-22). Creation of a hospitalist discharge process at CMCL and CB 

has improved the goal for patients to see their primary care 

physician/provider (PCP) after discharge (Figure 7.1-23). 

These patients also benefitted from a lower rate of readmissions 

(AOS). 

Readmission rates increased because of COVID, but they are 

now returning to pre-COVID levels (Figure 7.1-24).

A TRAC team at CMCL implemented multiple medication reconciliation process improvements that boosted documentation 

to benchmark levels. These improvements have been adopted at 

all facilities, which have also realized significant improvement 

(Figure 7.1-25).
35

CRHS’s work with community behavioral health agencies is 

supported by ensuring that patients are accurately assessed; one 

assessment tool is PHQ-9, a patient health questionnaire for 

depression screening (Figure 7.1-26). 

MYPHI, the electronic medical record, provides a convenient 

way for patients to access their medical records and contact 

their providers. The pandemic helped to push use of MYPHI 

higher (Figure 7.1-27).

7.1b. Work Process Effectiveness Results

7.1b(1). Providing the best care is enhanced by CRHS’s rapid 

turnaround times (TAT) for emergency services from the laboratory and imaging, with performance better than the national 

benchmarks (Figures 7.1-28 and 7.1-29).

CRHS’s bed TAT is evidence of success in using Lean methods 

to improve discharge processes (Figure 7.1-30). In addition, 

operating room (OR) on-time starts is used to measure 

efficiency of surgical processes. Significant financial savings 

and surgical throughput (AOS) have been realized through 

cross-functional improvement teams removing waste from 

processes using Lean (Figure 7.1-31).
36

Service excellence is demonstrated by information systems and 

support services (Figure 7.1-32), and an emphasis on delivering 

service excellence to internal customers has resulted in an 

increase in service levels and satisfaction (AOS), including 

work order completion (Figure 7.1-33).

7.1b(2). CRHS meets or exceeds all requirements for 

emergency and disaster preparedness. The pandemic posed 

challenges that were overcome by the organization and provided 

input for enhanced and more comprehensive action planning 

(Figure 7.1-34).

CRHS’s COS Survey is conducted approximately every 

18 months, and action plans to improve the culture continue 

(Figure 7.1-35). The COS survey for clinics and home health 

was initiated in 2022 (results AOS).

7.1c. Supply-Network Management Results

Supplier management and inventory results are evidence of 

excellent relationships and processes (details and segmentation 

AOS).

7.2 Customer Results

7.2a. Patient- and Other Customer-Focused Results

7.2a(1). The national CAHPS Surveys are the primary method 

of collecting comparable, quantitative data on patient satisfaction. Figures 7.2-1 through 7.2-5 show CRHS’s inpatient 

facilities’ satisfaction relative to competitors and to national 

performance in areas of importance to its patients. CRHS is 

proud to be the market leader in patient satisfaction, with some 

facilities ranking in the top decile nationally.

Segmentation on CRHS’s success in achieving patient satisfaction in its EDs; physician practices; outpatient facilities; and 

services such as behavioral health, home health, and hospice is 

AOS. Data supporting the likelihood of hospital and ED patients 

recommending CRHS’s facilities is also AOS for all services.
37

Figures 7.2-6 and 7.2-7 depict CRHS’s strong member and 

provider satisfaction with its health plans.

Family members are also considered to be customers. As such, 

Figure 7.2-8 shows CRHS’s strong and improving performance 

in Net Promoter Score; this is one measure for showing the 

satisfaction of patients’ families. 
38

7.2a(2). CRHS measures engagement in numerous ways. It 

also monitors social media vigorously to learn and improve its 

offerings. As such, its social media engagement and reputation 

scores (Figures 7.2-9 through 7.2-11) have continued to improve 

and are the best in the market. 

In-person and virtual tours (AOS) were initially developed to 

introduce people to CRHS’s products and services but now are 

sought for professional and educational group tours; tours serve 

as an outreach/marketing method to communicate with the 

community. Virtual tours are on-demand and often viewed by 

individuals who have a near-term need.

CRHS’s relatively new Seekers Program (3.1b[2]) is another 

way it is working to engage patients and community members 

(Figure 7.2-12). 

CRHS is receiving ever-increasing interest and satisfaction from 

the community and potential patients (details and segmentation 

AOS). CRHS also monitors and manages complaints at a 

system and entity level. It continues to see an improvement in 

reducing complaints.
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7.3 Workforce Results

7.3a. Workforce-Focused Results

CRHS disaggregates key results by the five business-unit 

groupings at the bottom of Figure 2.2-2. In addition, most 

results reported there are segmented by workforce classification 

and/or location, as appropriate. Many other segment results are 

AOS, down to the work unit level in many cases. 

7.3a(1). Except for the pandemic effects in 2020, the CCM 

variance has improved since 2014. If the variance is less than 

10% between predicted and actual labor costs, CRHS considers 

it effective. CRHS has searched for comparisons and has had 

little success other than from two previous BARs, which may 

measure the capability differently, but do provide a comparison 

(Figure 7.3-1). Data related to emergency services, outpatient 

diagnostics and treatment, medical offices, and post-acute care 

are AOS.

The results in Figure 7.3-2 show the number of physicians with 

admitting privileges, along with how well CRHS has retained 

residents. 

Cross-trained employees were a lifeline during the pandemic. 

CRHS has a goal to have everyone cross-trained, as defined by 

their departments, by 2023 (Figure 7.3-3). It expects to achieve 

this goal. 

Overall workforce retention is important to maintain CC (Figure 

7.3-4; ST represents short term, LT represents long term). 

As shown in Figure 7.3-5, the metric for average time to fill has 

driven improvements in the recruiting process and especially 

helps CRHS monitor how quickly it is filling positions in 

nursing, health care technology, and some physician specialties. 

Segmented results down to specific positions are AOS.

Volunteers play an important role in expanding CRHS’s 

capacity, and they were missed in 2020 when it asked them to 

stay away during the pandemic (Figure 7.3-6). 

The result shown in Figure 7.3-7 is a good indication of nursing 

capability.
40

7.3a(2). Figure 7.3-8 shows the results of the workforce 

environment metrics and goals discussed in 5.1. 

Figure 7.3-9 summarizes CRHS’s success in keeping the 

workforce safe. Additional segmented results are AOS.

Figure 7.3-10 shows the variance between the workforce and 

the diversity of the patient and community profile. The target is 

+/–5% variance, which is much more challenging in small and 

specialized work units. 
41

7.3a(3). This version of the Satisfaction Survey (Figure 7.3-11) 

has been administered since 2018. More segmented data are 

AOS. 

The results in Figures 7.3-12 through 7.3-17 demonstrate 

overall workforce engagement and engagement by employed 

physicians and residents, nonemployed physicians, other caregivers, caregiver support and allies, students, and volunteers. 

First-year retention is an indicator of engagement with CRHS 

and the effectiveness of the recruitment and hiring processes 

(Figure 7.3-18). CRHS has focused on this indicator in recent 

years. Additional segmentation is AOS.
42

CRHS views the workforce’s support of the community and 

participation in community health events to be another indication 

of engagement (Figure 7.3-19). Additional segmentation is AOS.

CRHS has only two collective bargaining units: (1) environmental and facilities employees at all hospitals and (2) CMCL 

nurses. CRHS monitors grievances filed as an indicator of 

engagement; it expects management to work with union leaders 

to resolve issues before they become formal grievances, if 

possible (Figure 7.3-20). 
Continued on next page

43

7.3a(4). CRHS tracks the level of participation in the Aspire 

LDS courses (Figure 7.3-21). Additional segmentation is AOS. 

CRHS is tracking the number of LDP graduates. After a slow 

start when initially introduced, LDP has a lot of interest from 

many members of the workforce, as they see the activities they 

can become involved in and the potential career advances that 

may result (Figure 7.3-22). Additional segmentation is AOS.

The LDS is evaluated annually, and results are correlated with 

patient and workforce engagement (Figure 7.3-23). 

CRHS strongly supports members of the workforce continuing 

their education and obtaining professional certifications (Figure 

7.3-24). Segmentation is AOS.

7.4 Leadership and Governance Results

7.4a. Leadership, Governance, and Societal 

Contribution Results

7.4a(1). Workforce results are depicted in Figure 7.4-1 with 

CRHS meeting or exceeding benchmarks. (SL–WF communication results are captured via the annual WF Kress Daney 

Survey, and engagement is measured using the Upwood Q12 

Survey.) 

Figure 7.4-2 reflects SL communication and engagement with 

patients, families, the community, and partners. Measures of 

SL’s personal actions supporting CRHS’s MVV are reported in 

Figures 7.4-3 through 7.4-5.
44
45

7.4a(2). Governance accountability results (Figure 7.4-6) 

reflect the BOT’s annual self-assessment using the Kentucky 

Hospital Association’s Governance Survey and individual board 

member satisfaction. Fiscal accountability results (Figure 7.4-7) 

include external audits classified as unqualified for CRHS, the 

Foundation, Multispecialty Group, and Joint Ventures. CRHS 

has maintained the highest Zandi bond AAA rating since 2019; 

and as a result of its COS and top patient safety performance, 

CRHS has not received any CMS hospital-acquired conditions 

or readmission penalties.

Finance-legal regulatory compliance audits are conducted internally as part of the Corporate Compliance Program to ensure 

process integrity and reduce compliance risk, while exceeding 

industry targets (Figure 7.4-8). Results of coding, clinical 

documentation improvement (CDI), and billing audits support 

that claims and revenue integrity exceed industry targets (Figure 

7.4-8). Additional results of regulatory and legal compliance 

demonstrate a consistently high performance at 100% in almost 

all instances in support of CRHS’s values (AOS). 

7.4a(3). Figure 7.4-9 provides results for CRHS business units 

and service lines meeting and surpassing legal, accreditation, 

certification, and verification requirements. CRHS consistently 

surpasses requirements in comparison to competitors.

7.4a(4). Results for ethical behavior including breaches and 

complaints, WF training, and stakeholder trust in SLs and 

governance are reported in Figure 7.4-10. Segmentation by 

business unit is AOS.

7.4a(5). Key results for societal well-being and support of 

CRHS’s key communities are reported in Figures 7.4-11 

through 7.4-13 (segmented results by cancer type are AOS). As 

a result of published reports citing the limited impact of health 

fairs on community health, CRHS began collecting data focused 

on the percentage of patients seeking and receiving follow-up 

care based on health fair screening instead of simply reporting 

the volume of patients screened. An increase in patients seeking 

follow-up based on screening recommendations is seen from 

2017 to 2021. The success of this approach is demonstrated in 

the cancer stage at diagnosis, which has gradually shifted to 

reflect a higher percentage of lower-staged cancers at diagnosis, 

reflecting the benefit of CRHS’s early screening on community 

health.
46
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7.5 Financial, Market, and Strategy Results

7.5a. Financial and Market Results

7.5a(1). Improvements and innovations in efficiency of processes of care have resulted in a steady increase in net patient 

revenue since CRHS’s Baldrige journey began in 2012, with 

the exception of the financial impact of the COVID pandemic 

in 2020. During 2020, there was a moratorium on elective 

surgeries for many months, which decreased revenue. Additionally, structural changes to manage the many patients who 

needed to be placed in negative-pressure rooms with high-level 

filtration, as well as increased cost-per-unit and utilization of 

PPE, increased expenses. The net patient revenue recovered the 

beneficial trend in 2021, as the impact of the pandemic subsided 

(Figure 7.5-1).

CRHS’s operating 

margin has also steadily 

improved since 2012, 

when the Baldrige framework was implemented. 

There was a decline in 

operating margin in 2020 

related to the financial 

impacts of COVID, 

which mirrored the 2020 

decrease in all Zandi’s 

ratings (Figure 7.5-2).

As with net patient 

revenue and operating 

margin, the operating 

earnings before interest, 

depreciation, and amortization (EBIDA) declined during 2020, 

but recovered significantly in 2021. CRHS is projected to 

continue the beneficial trend in 2022 (Figure 7.5-3).

Days of cash on hand also declined in 2020 at CRHS, as with 

virtually all hospitals and health care systems. Due to increases 

in efficiency gained during CRHS’s cross-training of staff, as 

well as patients coming back to hospitals to receive services, 

the cash position fully recovered in 2021 and is projected to 

continue the long-term beneficial trend in 2022 (Figure 7.5-4).

The cash-to-direct-debt position declined in 2020, as with the 

other financial indicators. The debt increased in 2020, in part 

due to the CRHS leadership commitment to not have any staff 

layoffs or furloughs. The increase in debt in order to sustain the 
48

payroll throughout the public health emergency was significantly paid down in 2021, and the cash-to-debt ratio is projected 

to be completely recovered and improving by the end of 2022 

(Figure 7.5-5).

The CRHS debt has been commensurate with Zandi’s A1 level 

for many years, until COVID. The commitment of the ELT and 

board to the workforce, despite the decline in revenue, resulted 

in an increased debt load in 2020. The entire workforce was 

“kept whole” and kept working, although in different roles and 

locations. This commitment resulted in the Maximum Annual 

Debt Service (MADS) slipping below Zandi’s A1 rating. The 

ELT and board determined that demonstrating commitment to 

the workforce and the CRHS MVV was more important than 

the rating. CRHS anticipates achieving Zandi’s A1 rating again 

by 2023 (Figure 7.5-6).

The debt-to-capitalization ratio also declined in performance 

compared with Zandi’s A1 in 2020. Performance recovered in 

2021 to nearly the level of 2019 and is projected to fully recover 

by 2022 (Figure 7.5-7).

Gains in efficiency and effectiveness, as well as the integrated 

network of services including insurance, primary care, acute 

care, and home care, were demonstrating a beneficial trend in 

spending per Medicare beneficiary. This integration contributes 

to earlier intervention and the ability to deliver more care on 

an outpatient basis or through home care, resulting in increased 

patient satisfaction and better clinical outcomes at a reduced 

cost. COVID was particularly devastating in the elderly 

(Medicare) population and very expensive to treat—with some 

very long lengths of stay. CRHS made a commitment to patients 

that they would be retained in the hospital until the disease had 

run its course, rather than discharged to a nursing home or to 

home and risk further spread of disease into the community. 

The Medicare spending per beneficiary has declined in 2021 to 

below the 2019 level, and it is projected to decline even more in 

2022 (Figure 7.5-8).

Similar to the Medicare spending per beneficiary, the inpatient 

expense per discharge increased in 2020, although CRHS 

expenses remained below the national average (Figure 7.5-9). 

This is one aspect of performance where the goal is NOT top 

decile. The commitment to the MVV balances outcomes and 

patient satisfaction with expenses, and the boards, ELT, and 

SLTs do not try to “cut expenses to the bare bones” in order to 
49

be top decile. As long as the operating margin is positive, being 

at or near the top quartile in this metric is acceptable. Inpatient 

expenses per discharge, segmented by both service line and 

facility, is AOS-site.

7.5a(2). CRHS is the market leader for its service area, far 

outpacing any of the competitors, and approaching the market 

share of all competitors combined. The communication to and 

care of the community during the pandemic, and restoring 

trust in the safety of seeking hospital care, were key in gaining 

additional market share in late 2021 and early 2022, with a 

significant increase in inpatient market share projected for 2022 

(Figure 7.5-10).

CRHS is the market leader for all service lines, with cardiology 

having a higher market share than all competitors combined 

(Figure 7.5-11). 

CRHS is also the clear market leader for home health and other 

post-acute care services (Figure 7.5-12). 

CRHS has maintained 55–55.5% of the market share for 

outpatients for many years, and it expects the trend to continue 

(Figure 7.5-13). Segmented data for various outpatient services 

are AOS.

CRHS is not “one of the big players” in the insurance market, 

although market share has steadily increased since entry into the 

market. Preference for the CRHS product is generally attributed 

to the ACO aspects being focused on health, not simply 

treatment, and the “personal touch” of a local company (Figure 

7.5-14).

Similar to the MA insurance plan, the commercial plan offered 

by CRHS has been steadily increasing market share since 

inception (Figure 7.5-15).

As with most hospitals across the country, the ED visit count 

decreased in 2020 due to COVID (Figure 7.5-16). Some of the 

ED volume has been appropriately drawn off by the opening 

of the Urgent Care facilities and the extension 

of their hours to better serve the community. 

Segmented data for the Urgent Care centers, 

showing their increase in encounters, are AOS.

Market share dominance is not only related to the 

locations of the CRHS facilities. Even when more 

rural residents are seeking care, they may bypass 

a competitor to come to a CRHS facility. The 

messaging provided by CRHS during the public 

health emergency contributed to the increase 

in preference for CRHS during 2020. As the 

pandemic subsided in 2021, people who needed 

health care were more likely to go to the nearest 

facility, but preference for CRHS is projected 

to recover to its 2019 “all-time high” in 2022 

(Figure 7.5-17).
50

7.5b. Strategy Implementation Results

Please see the results figures referenced in Figures 2.2-2 and 

7.5-18 related to achievement of organizational strategy and 

action plans. Additional detail and segmentation are AOS.