Coming in the Winter Issue of Frontiers

Value-Based Care and Reimbursement

Feature articles by Robert J. Henkel, FACHE, and Patricia A. 

Maryland and by Becky Kuhn, FACHE, and Chuck Lehn
VOLUME 32 • NUMBER 1 • FALL 2015

FRONTIERS

OF HEALTH SERVICES MANAGEMENT

Frontiers of Health Services Management is committed to providing our readers with compelling, in-depth 

features and commentaries that are of current importance to the practice of health services management by 

drawing on the expertise of the best practitioners and scholars.

CONTENTS

ACHE and the editorial staff of ACHE publications reserve full editorial control over the content of ACHE publications.

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For more information, please visit www.coniferhealth.com.

Editorial

1 Trudy Land, FACHE

Features

Improving Ourselves for the Sake of Others: Our Baldrige Journey

3 Jayne E. Pope, FACHE, Emily Padula, FACHE, 

and Debbye Wallace-Dooley

Small-Town Touch, Big-City Innovation, World-Class Aspirations

17 Warren L. Forgey, FACHE, and Tammy Dye, FACHE

Commentaries

Can Baldrige Build Learning Organizations?

30 Kathleen Jennison Goonan

Sharing Leadership Insights on Our Baldrige Journey to Excellence 

40 Janet Wagner

A Framework for Performance Excellence and Success

45 C. David Huffstutler and David Thomsen

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Frontiers of Health Services Management

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editorial board

LT Temitope O. Ayeni, FACHE, Naval Hospital, Twentynine Palms, CA

Gina L. Calder, FACHE, Executive Director, Clinical Services, Bridgeport Hospital, Bridgeport, CT

LaWanda Courtney, Director, Environmental Services, Moffitt Cancer Center, Tampa, FL

Richelle R. Webb Dixon, FACHE, Vice President, Ambulatory Care, CHI St. Luke’s Health, Houston, TX

Jamie L. Haeuser, Haeuser Health Strategies LLC, Robert, LA

Richard W. Haraldson, FACHE, Chief Executive Officer, Sidney Health Center, Sidney, MT

Neil A. Hilton, FACHE, Wyoming Hospital Association, Cheyenne, WY

John C. Laux, Division of Behavioral Health, Anchorage, AK

Betty Mortensen, RN, FACHE, President, Innovative Healthcare Solutions Inc., Crystal Lake, IL

Gwendolyn H. Parker, MD, FACHE, Blue Cross Blue Shield of Michigan, Detroit

Stephen J. Pribyl, FACHE, Chief Executive Officer, District One Hospital, Faribault, MN

José S. Rosado, FACHE, Chief Executive Officer, Manatí Medical Center, Manatí, PR

Cherie Sibley, FACHE, Chief Executive Officer, Clark Regional Medical Center, Winchester, KY

Maj Statwell G. Sinclair Jr., FACHE, Developmental Director, Air Force Medical Support Agency, Travis Air Force Base, CA

Maureen C. Glass, FACHE, CAE, Publisher, Foundation of the American College of Healthcare Executives, Chicago, IL

Trudy Land, FACHE, Editor, Health Administration Press, Chicago, IL

Janice Snider, Managing Editor, Health Administration Press, Chicago, IL

Cepheus Edmondson, Layout Editor, Health Administration Press, Chicago, IL

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Trudy Land, FACHE • 1

EDITORIAL

Editorial

Trudy Land, FACHE, is editor of Frontiers of Health Services Management.

Trudy Land, FACHE

With increasing pressure to transform the healthcare delivery 

system, organizations face enormous challenges and opportunities to improve 

quality and decrease costs. The rapidity of change has been accelerated by 

healthcare reform’s directives that hospitals and health systems develop more 

effective and efficient ways of delivering care. What frameworks or process 

improvement approaches are being used by hospitals and health systems to 

transform their organizations and maximize positive outcomes? 

The Baldrige Performance Excellence Program provides organizations 

with one such framework to identify improvement opportunities, develop best 

practices, and attain and sustain top performance. Hospitals and health systems on the Baldrige journey use “this proven improvement and innovation 

framework” to assess their functioning and operations in the following key 

areas: leadership; strategic planning; customer focus; measurement, analysis, 

and knowledge management; workforce focus; operations focus; and results 

(Baldrige Performance Excellence Program 2015).

Many organizations are achieving significant quality, safety, and financial improvements by applying this framework in daily operations. Some have been recipients of the prestigious Malcolm Baldrige National Quality Award, while others 

have been recognized for best practices or are on the Baldrige journey. According to 

Truven Health Analytics research, a significant correlation exists between Baldrige 

Award recipients and 100 Top Hospitals winners, and adoption of Baldrige practices leads to high performance (Chenoweth 2014; Shook and Chenoweth 2012).

The Baldrige journey is a tremendous undertaking. Leadership must drive 

the process, integrate it into all departments and services, and focus on improvement opportunities in the delivery of patient care. The impact of using the Baldrige Criteria for Performance Excellence can be significant in improving quality, 

reducing costs, and becoming the market leader. Differentiation through demonstration of top performance is essential for survivability and sustainability.

This issue of Frontiers focuses on several organizations that have received 

the prestigious Malcolm Baldrige National Quality Award and their journeys to 

continually improve their performance in achieving desired outcomes. 

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2 • frontiers of health services management 32:1

Jayne E. Pope, RN, FACHE, Emily R. Padula, RN, FACHE, and Debbye 

Wallace-Dooley share the Baldrige story of Hill Country Memorial Hospital in 

Fredericksburg, Texas. Their inspirational journey “in pursuit of remarkable” 

is based on the core competencies of relationship building, a values-driven culture, and execution. These key factors differentiate their organization; as the 

authors note, they are the “footholds in our climb. 

Feature authors Warren L. Forgey, CPA, FACHE, and Tammy Dye, RN, 

FACHE, discuss how Baldrige began as a project at Schneck Medical Center 

in Seymour, Indiana, but became their business model. They write, “Today, 

Schneck thinks and operates differently. We have transitioned into a fact-based, 

results-oriented organization.”

In her commentary, Kathleen Jennison Goonan, MD, describes how recipients of the Baldrige Award achieve transformational change through the 

use of an effective and systematic approach. She provides a model of key processes and capabilities and a road map to successful organizational change.

In her commentary, Janet Wagner suggests that an engaged leader and 

team with strategic direction and a willingness to focus and learn can achieve 

and sustain results and continue to evolve.

St. David’s HealthCare, a regional multihospital system in Austin, Texas, 

is a 2014 recipient of the Baldrige Award. In their commentary, C. David Huffstutler and David Thomsen note how adopting the Baldrige Framework and 

using it to achieve the organization’s goals of exceptional care, customer loyalty, 

and financial strength have resulted in significant positive outcomes.

These recipients of the Baldrige Award exemplify the sterling achievements in 

quality and cost-effectiveness that can occur in today’s challenging healthcare environment. We congratulate these organizations for their dedication and commitment 

to improving processes and care for their patients and the communities they serve.

References

Baldrige Performance Excellence Program. 2015. “Why Baldrige?” Accessed June 15. www.

nist.gov/baldrige/enter/.

Chenoweth, J. 2014. “Correlation Between Baldrige Award Recipients and 100 Top Hospitals 

Winners.” Published November 18. http://truvenhealth.com/blog/

correlation-between-baldrige-award-recipients-and-100-top-hospitals-winners.

Shook, J., and J. Chenoweth. 2012. “100 Top Hospitals CEO Insights: Adoption Rates of 

Select Baldrige Award Practices and Processes.” Published October. www.nist.gov/

baldrige/upload/100-Top-Hosp-CEO-Insights-RB-final.pdf.

The editor of Frontiers would like to hear from you! If you have comments or thoughts 

about this or any issue of Frontiers, please share them by e-mailing hapbooks@ache.org.

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Jayne E. Pope, RN, FACHE, Emily Padula, RN, FACHE, and Debbye Wallace-Dooley • 3

F EATUR E

Jayne E. Pope, RN, FACHE, is CEO of Hill Country Memorial (HCM) Hospital in Fredericksburg, Texas. Emily Padula, RN, FACHE, is chief strategy officer at HCM. Debbye 

Wallace-Dooley is executive director of business intelligence at HCM.

Improving Ourselves for the Sake 

of Others: Our Baldrige Journey

Jayne E. Pope, RN, FACHE, Emily Padula, RN, 

FACHE, and Debbye Wallace-Dooley

Summary

In today’s healthcare environment, healthcare organizations are trying to balance 

one foot in each of two boats: one for traditional fee-for-service reimbursement and 

one for population health and pay-for-quality reimbursement. The Baldrige Performance Excellence Program and its associated Criteria will help healthcare leaders navigate this changing environment and improve healthcare outcomes for patients while improving financial performance, enhancing the patient experience, 

and creating a positive work environment. This balanced approach, grounded in 

behaviors identified in high-performing organizations, provides leaders and their 

teams with the key to realizing strategic goals and long-term sustainability. The 

Baldrige Criteria alone will not improve an organization; rather, it is the unique 

and disciplined application of the Criteria to each organization that makes the 

difference. A Baldrige journey is not a sprint, but rather a marathon; it requires a 

long-term commitment to improvement at all levels of the organization. 

At Hill Country Memorial (HCM) Hospital in Fredericksburg, Texas, we 

selected the Baldrige Framework to guide our team as we embarked on a performance excellence climb that would take us from merely average to the national 

top 10 percent of performance as evaluated on important organizational metrics. 

HCM did not achieve overnight success; instead, we achieved year-overyear improvement in finance and growth, patient experience, quality of care, 

and workforce environment and engagement. The story of our climb is one 

of perseverance, willingness to learn from our mistakes, pursuit of innovative 

best practices both inside and outside of healthcare, and a team committed to 

providing the highest-quality service to our customers—our patients and our 

community. 

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4 • frontiers of health services management 32:1

The decision to embark 

on a journey requires 

a significant level of 

commitment, perseverance, 

and willingness to learn 

from mistakes, as well as 

the ability to motivate a 

team toward a vision.

Our climb started when our community worked together, making 

sacrifices to bring this healthcare system 

into being more than 30 years ago, and 

it continues to this day. Critical to our 

success has been the identification of 

our strengths and those we still need to 

develop to be successful for years to come. 

These strengths became our core competencies, our footholds for the climb: relationship building, values-driven culture, 

and execution.

Being named a Malcolm Baldrige National Quality Award recipient is not the 

work of the CEO alone or 

the CEO along with just 

the executive team. Achieving the levels of performance and results required 

to be named a recipient is 

attainable only when the 

entire team is engaged and 

actively pursuing worldclass performance. At 

HCM, employees, physicians, and volunteers developed into a high-performing team and 

continually improved themselves for the 

sake of others. Realization of this goal is 

not the end but rather a milestone on our 

performance excellence journey. 

The decision to embark on a journey, 

whether it be climbing Mount Everest or 

moving an organization’s performance 

from mediocre to remarkable, requires 

a significant level of commitment, perseverance, and willingness to learn from 

mistakes, as well as the ability to motivate 

a team toward a vision. Such was the 

mindset of HCM’s board of trustees and 

executives in 2008 as we began our performance excellence climb. Like leaders 

in many other hospitals and health systems across the nation striving to improve 

the quality and safety of care, the patient 

experience, and financial performance, 

HCM’s leaders looked to organizations 

that were consistently outperforming others and found a common element. That 

element was the adoption of the Baldrige 

Framework to achieve long-term sustainability. The foresight of those leaders led 

to our ability to provide world-class healthcare and service to our customers, grow 

our market base, and maintain financial 

viability in an ever-changing and increasingly challenging healthcare environment. 

The journey to achieving our current level 

of performance and receiving recognition 

as a Baldrige Award recipient was not easy. 

The climb was steep, but once we committed to it, we strove to find the best and 

most efficient path to the summit. Along 

the way, we learned new skills, innovative 

approaches, and other lessons to aid us. 

History

The history of how HCM got its start is 

the beginning of our climb, the bedrock 

of our values, and a legacy of the trust 

our community placed in us to provide a 

healthcare system designed to serve them 

for generations to come. It is our stewardship of this legacy that led us to pursue 

the Baldrige Framework for Performance 

Excellence. Hospitals are havens for healing and hope, centers for compassion and 

care. In rural communities like ours, a 

hospital often provides the town’s sturdiest 

economic and civic foundations. Our interests, successes, and concerns are woven 

into the fabric of our community because 

the community’s residents created us to 

take care of their families, friends, and 

neighbors. People reached into their pockets and filled mason jars with nickels and 

dimes to fund the hospital at its inception. 

Ninety-three percent of Gillespie County 

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Jayne E. Pope, RN, FACHE, Emily Padula, RN, FACHE, and Debbye Wallace-Dooley • 5

F EATUR E

households contributed to the building of 

the hospital, and when the doors of HCM 

were opened on Valentine’s Day 1971, 

it was the realization of a community’s 

dream.

In Pursuit of Remarkable

By 2008, HCM leaders were confident in 

the quality of care and service provided to 

our patients and the community. In fact, 

everyone believed it to be outstanding—

that is, until we started benchmarking. 

When we began to compare ourselves with 

others, we found that, in many areas, we 

were performing at or below the national 

median. This reality was difficult to face, 

and we had to overcome our initial excuses 

for the performance gaps. You might recognize some of them:

• We are smaller. 

• Our patients are sicker.

• We are rural. 

• We are in Texas. 

• We are just different. 

We overcame these excuses by engaging physicians, employees, volunteers, and 

the community in the discussion. We were 

transparent with our results and created 

an open dialogue. Yes, we had pockets of 

excellence, but nothing as extensive as 

we thought we had. We all agreed that 

our mediocre performance was not acceptable. We decided that we had to strive 

to move from being an average hospital 

to one that provided world-class quality, 

safety, and service, as well as a world-class 

work environment. Our vision was to be 

the best community hospital anywhere. 

With this vision in mind, HCM’s board of 

trustees and executives committed to the 

performance excellence climb. We set our 

sights on providing remarkable care and 

service. At first, remarkable was a loosely 

defined word for us; it meant we wanted 

to be better. A critical turning point in our 

journey came when we challenged ourselves to take that word, which we used 

so commonly, and make it measurable. 

We defined remarkable as performance in 

the top 10 percent, according to national 

databases—not just among small rural 

and community hospitals, but among all 

hospitals in the nation. 

We were at base camp looking up at the 

summit: national top 10 percent performance. Although we were committed to 

improvement, we were not sure how to 

get there. We began to research successful organizations, both inside and outside 

healthcare, to gain an understanding of 

how they achieved such levels of performance. We read On Becoming Exceptional: 

SSM Health Care’s Journey to Baldrige and 

Beyond (Ryan 2007) and The Baptist Health 

Care Journey to Excellence: Creating a Culture That WOWs! (Stubblefield 2005). 

The lessons we learned inspired us 

to research the Baldrige Program. What 

we found excited our leadership team. 

The Baldrige Framework is based on core 

values and concepts that represent beliefs 

and behaviors found in high-performing 

organizations:

• Systems perspective

• Visionary leadership

• Patient-focused excellence

• Valuing people

• Organizational learning and agility

• Focus on success

• Managing for innovation

• Management by fact

• Societal responsibility and community 

health

• Ethics and transparency

• Delivering value and results

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6 • frontiers of health services management 32:1

Baldrige ensures a balanced or systematic approach to organizational improvement, with a focus on leadership, strategy, 

customers, measurement and knowledge 

management, workforce, operations, and 

results. The comprehensive approach 

reassured us; we wanted to be certain that 

we improved in all areas and were not 

distracted by chasing trends. We now had a 

guidebook to aid us on our climb. 

Core Competencies

We plan to serve our community for 

generations and knew we needed to map 

our path for long-term sustainability. In 

doing so, we asked ourselves, “What are 

our greatest strengths as an organization?” 

and more important, “Can 

those strengths carry us 

into the future?” In Baldrige vocabulary, these are 

core competencies. A defining moment for HCM 

was determining what our 

core competencies were 

and confirming that they 

were the right ones to sustain our vision 

in the long term. We ascertained that our 

initial core competencies were relationship building and a values-driven culture; 

furthermore, we identified the need to 

develop a core competency of execution 

(Exhibit 1). Today, these three competencies differentiate us in healthcare, and we 

leverage them to provide our customers 

with a remarkable experience. The way 

we live them is uniquely ours and sets us 

apart both in our market and in our industry. These competencies are the footholds 

in our climb. They make us who we are, 

provide a path to long-term sustainability, 

and ensure that our community receives 

outstanding healthcare. 

Rather than focusing on execution, the 

largest core competency gap, we elected to 

deepen our core competencies of relationship building and values-driven culture. 

We recognized that strengthening our 

culture would engage all stakeholders and 

enable us to build a high level of trust and 

make a case for change. We worked to create an environment of transparency and 

listening, one in which it is safe to take 

intelligent risks that are aligned with our 

vision. We empowered our employees and 

physicians because we believe that together we are greater than the sum of our 

parts. We know that the ideas and work of 

HCM’s executive team and board of trustees cannot lead us to where we need to go; 

alone, we are not enough. We leveraged 

our core competencies to build a culture 

in which we could benefit from the diverse 

inputs of all our stakeholders by building 

meaningful relationships with them.

Relationship Building

Our core competency of relationship 

building is central to the unique ways we 

connect and communicate our vision. It is 

our longest-standing core competency, one 

that goes back to the day we first opened 

our doors. The community’s commitment 

to its hospital has remained unwavering. 

Often, families that sacrificed their time, 

money, and talent to see our hospital created come in to check on their investment. 

Our relationships with these and other 

stakeholders are strong because we intentionally work to sustain them. Relationship 

building is the first foothold in our climb. 

It is key to providing remarkable patient 

care. The term relationship building may 

sound like a soft skill, not a strategy, but 

we have honed it over the years so that it is 

deployed through systematic approaches. 

We have learned that informal listening 

and gathering a few data points are not 

enough to educate us. To build effective 

relationships, we have to systematically 

We leveraged our core 

competencies to build 

a culture in which we 

could benefit from the 

diverse inputs of all our 

stakeholders.

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Jayne E. Pope, RN, FACHE, Emily Padula, RN, FACHE, and Debbye Wallace-Dooley • 7

F EATUR E

listen to our employees, physicians, volunteers, customers, and the community. 

We have put in place intentional processes 

for listening to our stakeholders. We select 

and evaluate these listening methods to 

ensure they are useful and relevant, and 

the data collected can be aggregated into 

meaningful and actionable information. 

Listening to Patients to Build 

Relationships

We received our first Baldrige feedback report in 2010. It indicated that we were not 

really listening; we were deciding what we 

thought were the expectations of our patients and the community and implementing action plans we thought would address 

the perceived issues. On the basis of that 

feedback, we formed a customer-focused 

improvement team that still functions 

today. This team found that our listening 

methods were informal, varied little by 

customer group, failed to provide actionable information, and were applied inconsistently. Over the past five years, this team 

has refined our listening methods to meet 

the needs of our customers and of HCM. 

The team researches listening methods 

from all industries and pilot tests them to 

determine if they fit our culture. One especially helpful tool developed by this team 

is a single-page aggregation of data across 

all listening methods (e.g., patient satisfaction surveys, focus groups, social media 

feedback) to identify trends and themes. 

Through the team’s leadership and the 

work of our remarkable workforce, HCM 

has achieved and sustained the following:

• Top 10 percent performance on all 

Hospital Consumer Assessment of 

Healthcare Providers and Systems 

(HCAHPS) categories for the past three 

years (i.e., 2012–2014) (Exhibit 2) 

• Top 10 percent performance on overall 

patient satisfaction—as measured 

by Press Ganey—for inpatient care, 

ambulatory surgery, and emergency 

department experience for the past four 

years (i.e., 2011–2014)

Exhibit 1 Hill Country Memorial Hospital Structure

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8 • frontiers of health services management 32:1

• Top 2 percent of customer experience 

scoring in the Centers for Medicare 

& Medicaid Value-Based Purchasing 

program

One innovative listening method is the 

ratings and reviews page on our website 

(www.hillcountrymemorial.org). Customers can share their comments and rate 

their hospital experience with one to five 

stars. The ratings and online comments 

stay on our website regardless of whether 

they are positive or negative. All reviewers 

receive a personal response from our customer experience team, and all postings 

are e-mailed immediately to the executive 

team to identify opportunities for reward 

and recognition or areas needing improvement. We review trends arising from all 

of our voice-of-the-customer listening 

methods at our weekly executive and department huddles; at our monthly board, 

department, and division meetings; and at 

our quarterly workforce forums and business review meetings and councils. 

Listening to Our Workforce to Build 

Relationships

As described earlier, we hardwired our processes for listening to our patients before 

we did so for our workforce. As a leadership 

team, we continue to refine these listening 

methods on the basis of formal and informal feedback. We implemented daily department huddles during which employees 

share issues, and solutions are developed 

according to a best practice learned from a 

visit to Baldrige Award recipient K&N Management in Austin, Texas. In 2014, a team 

of employees at HCM refined the process 

by which employees can submit ideas for 

improvement. This process, developed on 

the basis of feedback from peers, includes 

real-time e-mail notifications of the status 

of their ideas. Our employee engagement 

scores have improved year over year for 

the past five years and currently are at the 

ninetieth percentile, as measured by Press 

Ganey. We also implemented a “just culture,” one in which people are not judged 

by the outcome of their behavior but by the 

Exhibit 2 Hill Country Memorial HCAHPS National Percentile Rankings 

Nursing Physician Responsiveness 

Pain Medication Environment 

Discharge Quality 

Percentage

30 

40 

50 

60 

70 

80 

90 

100 

2007 2008 2009 2010 2011 2012 2013 2014 

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Jayne E. Pope, RN, FACHE, Emily Padula, RN, FACHE, and Debbye Wallace-Dooley • 9

F EATUR E

quality of their decisions. Our goal was to 

encourage the team to share their mistakes 

and the lessons learned so we could all 

improve together. We developed a council 

structure across the entire organization, 

empowering frontline employees, volunteers, and physicians with tools to find, 

develop, and implement best practices. 

Physicians occupy a unique space as 

stakeholders at HCM. They are part of our 

workforce but also are customers of our 

hospital services. They are partners and 

suppliers and, in some cases, our competitors. Maintaining good relationships with 

this group of stakeholders is essential to 

our long-term sustainability. When looking at our communication approaches with 

providers during our Baldrige process, we 

found that we did not really have systematic processes for two-way communication. 

Of course, we had physician engagement 

surveys, a physician liaison, and informal 

meetings in the hallways, but no systematic 

mechanisms for senior leaders to engage in 

ongoing two-way communication with providers. We began to ask, “Where and how 

can we connect with providers in ways that 

work for them?” We found that traditional 

approaches weren’t the answer. So we started 

going to them—not to speak, just to listen 

and make ourselves available. Doing so led 

to more opportunities for connecting with 

providers, which we made a requirement for 

leadership. Each leader comes back to the 

executive huddle with new insights. We are 

working continuously to create an inclusive 

environment that encourages dialogue with 

providers, one that welcomes their diverse 

perspectives and opinions.

Listening to Our Community to Build 

Relationships

Listening to our community is vital to 

our long-term sustainability as a hospital. Without effective listening methods, 

we risk losing relationships with our key 

stakeholder. We need the input of members of the community to provide the right 

services in the right way, and we need 

their loyalty and the philanthropic support 

they give so generously to our foundation. 

Each week in huddle, executives review a 

list of upcoming community events and 

ensure that an HCM representative will 

be in attendance at most of them to connect with the community. Executives then 

report to the team on what they heard at 

the previous week’s community events. 

Before entering a new market, we spent a 

full year engaging in this type of systematic listening to gain a sense of how we 

could best serve that community. Because 

of these relationships, our market share 

continues to be strong and HCM is outperforming our nearest competitor in the 

region. In addition, philanthropic support 

is increasing year over year; in 2014, the 

foundation raised more than $3 million 

to attain a cumulative 20-year total of $36 

million. 

Engaging Stakeholders

Listening alone is not enough. We are 

committed to building empowering relationships with our workforce, our community, and our patients, and an empowering 

relationship means acting on what we 

hear. At HCM, we engage patients, employees, physicians, volunteers, and community members on improvement teams 

to help us ensure that our action plans are 

responsive to their expectations. We have 

engaged patients on teams to improve the 

discharge process, implement quiet time 

on the inpatient units, improve the family 

waiting experience, and define our values, 

and we have formed a patient and family 

advisory council. We also have welldefined organizational and departmentlevel processes to develop action plans 

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10 • frontiers of health services management 32:1

We worked with our team 

to develop a set of core 

values that were deeply 

meaningful to us.

that are responsive to the feedback given 

on the annual employee, provider, and 

volunteer partnership surveys. We analyze 

our approaches at least annually to determine if we have been effective at hearing 

and responding to stakeholder inputs, and 

many improvements and innovations have 

resulted from this systematic review.

Values-Driven Culture

Our second foothold on our performance 

excellence climb is our values-driven culture. The Baldrige Program recognized the 

strength of this core competency in 2013 

by awarding HCM a Best Practice Award 

in leadership related to the broad deployment and deep integration 

of our mission, vision, 

and values. Although our 

organization is replete with 

people who want to do the 

right thing, we found several years ago that our values had simply 

become words on the wall. They were not 

core to our culture, and we strongly believe 

that our success depends on having an 

organizational culture that our community can trust. We worked with our team, 

which included physicians, employees, 

volunteers, and patients, to develop a set 

of core values that were deeply meaningful 

to us. We developed the following definitions of each value and expected behaviors, 

along with icons (Exhibit 1) to help us 

remember their true meaning:

• Others First: Commit to remarkable 

care with each life we touch.

• Compassion: Care for others with a 

kind heart.

• Innovation: Integrate new ideas with 

courage.

• Accountability: Responsibility for our 

actions.

• Stewardship: Uphold our responsibility 

for lives and resources.

However, developing a list of values is 

only the first step. Ingraining our values 

into who we are as an organization and 

what we choose to do every day is the 

greater challenge. We have built a focus on 

doing the right thing into organizational 

processes. For example, using a values– 

behaviors interview tool, we systematically 

screen every team member, volunteer, 

and physician candidate as a first step 

in our selection process. As CEO, Jayne 

Pope uses this tool to “values screen” every 

potential physician partner. Every quarter, 

team members’ behaviors are rated for 

alignment with our values, and we develop 

action plans for improvement as necessary. Physicians and volunteers are evaluated similarly. We integrated our values 

into reward and recognition programs, 

such as daily “Living Our Values” cards 

(Exhibit 3) that offer peer-to-peer or patient 

recognition, quarterly awards for exemplary demonstration of values, and annual 

True North Values Awards for employees, 

volunteers, and providers. For business 

decisions—whether it be entering a new 

market, developing a new partnership, 

or selecting a vendor—we have built a 

values check into our decision matrices. 

Our values-driven culture is pervasive in 

presentations, conversations, and recognition program and is even reflected in icons 

posted around the facilities. Few days go 

by when the question “How does this 

align with our values?” does not come up 

in conversation. This steadfast and systematic focus on “doing the right thing” is the 

foundation of our culture of Remarkable 

Always. Our employee satisfaction scores 

on the question pertaining to “values are 

evident” have improved every year, and 

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Jayne E. Pope, RN, FACHE, Emily Padula, RN, FACHE, and Debbye Wallace-Dooley • 11

F EATUR E

in 2014, we achieved the national ninetysixth percentile. 

Execution: The More Complex 

It Gets, the Simpler We 

Should Get

In 2012, we looked back at how far we had 

come on our climb. We had experienced 

significant progress on many of our initial 

goals. We celebrated with our team and 

were in a position to give our employees 

their first-ever performance bonus as recognition for their accomplishments. However, we knew we could not linger at this 

outcropping on the mountain and turned 

our sights higher. What we saw was daunting, to say the least: The higher you get, 

the steeper the climb, and we knew we 

needed additional skills to navigate the 

next leg of our ascent. 

During the past four years, as we honed 

our cultural core competencies of relationship building and values-driven culture, 

our leadership team also was building the 

framework for a culture of execution. We 

took to heart a statement made by one of 

our board members: “The more complex 

it gets, the simpler we should get.” We 

realized that integration of all we do was 

key to our ability to execute. The concept 

of an “always culture” emerged: a culture 

that integrates our vision, mission, strategy, and values into our daily work. We 

divided our strategy map into four “always 

goals”—strategic objectives that serve as 

broad definitions of our planned future. 

Two of these objectives are “Reshape 

Healthcare for Remarkable Outcomes” 

and “Be a Team of Champions.” Our 

department goals follow the same pattern, 

and individual goals on each employee’s 

quarterly coaching plan are mapped to the 

four always goals, as well as to that year’s 

specific, strategic measurable goals in the 

always goal. This helps us stay focused on 

what is most important and understand 

how we each contribute to achieving the 

organization’s strategic goals. Our values 

are also part of our always culture; we hold 

ourselves and each other accountable for 

our behavior, which will always align with 

our shared values. Finally, and perhaps 

Exhibit 3 HCM “Living Our Values“ Card

Team Member: 

 First & Last Name

From: Chaplain

You are Remarkable because: Night or day – distance no matter! Thank you for sitting on the floor alongside our patient and his mom so that you could connect with them in the way they needed it the 

most! You are one who is called to do and be exactly what God has gifted you for.

Please circle the Value that this team member has demonstrated:

OTHERS FIRST COMPASSION INNOVATION ACCOUNTABILITY STEWARDSHIP

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12 • frontiers of health services management 32:1

Our vision means building 

Hill Country Memorial into 

a network of health services 

that always empowers 

patients, families, and 

workforce members to live 

holistically healthy lives 

with optimal community 

health outcomes.

most important, our always culture represents how we live our mission and vision. 

Mission and Vision

Our neighbors deserve nothing but the best 

from us. To convey this conviction, we redefined our mission in two words: Remarkable 

Always. This short statement is a clear demonstration of our core competency of execution. Rather than adopt an increasingly 

complex mission in these increasingly complex times, we chose a clear and powerful 

message. Our core competency of execution 

denotes a process. We first 

choose a high standard; 

then ask ourselves, “What 

will we monitor to know 

that we are on the path to 

achieving our standard?” 

We develop goals and measures to serve as milestones 

on our journey, and then we 

stay the course by continually evaluating whether we 

are meeting our milestones 

and making course corrections as necessary. Our simple but powerful 

mission—Remarkable Always—enables 

us to focus our attention on achieving what 

matters to us, and we have met our mission 

in almost every measure. 

Our vision also is aspirational and concise: Empower Others. Create Healthy. This 

vision grew alongside our performance excellence journey. When we started, we had 

a vision of being a great community hospital. Implementing the Baldrige Framework 

allowed us to dream bigger: being one of 

the best hospitals in the nation. When we 

engaged our stakeholders in envisioning 

the future, the innovative and proactive attitude of our founders and our community 

shaped our vision into something colossal: 

Empower Others. Create Healthy.

Our vision means building HCM into a 

network of health services that always empowers patients, families, and workforce 

members to live holistically healthy lives 

with optimal community health outcomes. 

Create Healthy inspires us for our future 

and as something we live every day. We 

are creating a healthy work environment, 

creating healthy balance sheets, creating healthy experiences for our patients, 

and creating healthier community members. Create Healthy also is the summit 

we strive to reach: a thriving healthcare 

system, partnering to create a community 

of people enjoying their highest level of 

health.

Alignment

We have always had a strategic plan, but 

through our journey we learned it was 

not necessarily responsive to the needs 

of our stakeholders, and our workforce 

did not understand their role in achieving 

the goals. Today, our strategy map, posted 

throughout our organization and on our 

website, is simple, clear, and aligned 

directly with our vision, mission, and 

values. The always goals support longterm sustainability and are responsive to 

the healthcare needs of the communities 

we serve. Our performance targets are all 

benchmarked and support the mission of 

Remarkable Always, meaning they are in 

the top 10 percent of performance nationally. We frequently reference our strategy 

map during workforce forums and other 

meetings to ensure that we are all focusing on the most important goals of our 

organization. 

We have worked to build systematic 

ways to empower others. We have councils across the entire organization, made 

up of frontline staff members from every 

department, who are empowered to make 

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Jayne E. Pope, RN, FACHE, Emily Padula, RN, FACHE, and Debbye Wallace-Dooley • 13

F EATUR E

key decisions about how we do our work. 

In addition, each department leader meets 

annually with his or her executive to review the organization’s strategic goals and 

determine how the department can help 

move us toward those goals. These goals 

are then shared with the team and patients 

via the departmental alignment boards, 

which are posted publicly in every department. The boards display the department’s 

goals and how they align with the always 

goals. The boards also show how well the 

department is currently performing on 

a specific goal. The department leader 

then repeats this process with employees, 

helping them set measurable personal 

goals that are aligned with the department and organizational goals. These 

quarterly coaching conversations help to 

maintain our alignment across the entire 

organization. 

Accountability Systems

These methods of alignment are incomplete without accountability, and we are 

accountable through transparency. We 

analyze our key data and benchmark them 

against data from the best-performing 

organizations in the nation. We then publicly share our results and how we measure up in comparison with others. We 

post our strategic targets and our performance in the lobby of the hospital and on 

our intranet, and we review them in detail 

at our quarterly workforce forums. Several 

pages of our public website are devoted to 

presentation of our benchmarked performance data, and our ratings and reviews 

page shows the public on a daily basis how 

we are doing with regard to customer experience. Department goals, action plans, 

and results are displayed on alignment 

boards in each department. Our value of 

accountability drives us to transparency. 

We believe our patients and community 

members deserve to know where we are 

strong and where we have opportunity to 

grow. 

Although we were committed to transparency before the Baldrige journey, we 

found some logistical hurdles to overcome. An effective accountability system 

requires data that are accessible, user 

friendly, and relevant. Over time, we have 

increased our investment in data management to meet the needs of our organization. While we value the informal insights 

of our team, we also do our best to support 

key assumptions with data. We have been 

surprised often enough that we began to 

seek out more and more data. Eventually, we found ourselves in data overload. 

Going back to our always goals, we honed 

our information management system to 

make readily available and user friendly 

those key data points that were critical 

to achieving our strategy. Those who are 

interested in diving more deeply into the 

data have the opportunity to do so, but we 

were able to define for our team the specific data points that were most important 

to us and the frequency with which each 

should be monitored. 

This process, which we call our performance review cycle, ensures that all key 

metrics, including performance, target, 

and benchmark comparisons, are aligned 

with our always goals and reviewed at 

appropriate intervals, and action plans 

are implemented when indicated. All 

measures affecting our always goals are 

reviewed at prescribed intervals and in 

predetermined settings, including quarterly business reviews, monthly leadership 

meetings, and weekly huddles. This cycle 

also supports agility. Such was the case in 

the first quarter of 2014 when we experienced a negative trend in key HCAHPS 

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14 • frontiers of health services management 32:1

Moving from a culture 

of informal knowledge 

and data overload to a 

standard performance 

review cycle process 

promotes fact-based 

decision making.

categories. We had fallen below the ninetieth percentile (our definition of Remarkable Always) in nursing communication 

and responsiveness of staff. We quickly 

formed a performance improvement team, 

prioritized potential action plans, and 

implemented a specific cascading goal 

and action plan in all inpatient departments around responsiveness of staff. By 

the third quarter, our performance had 

improved to the ninety-ninth percentile 

and we ended the year above the ninetieth 

percentile in all HCAHPS 

categories. Moving from a 

culture of informal knowledge and data overload to 

a standard performance 

review cycle process promotes fact-based decision 

making, drives a culture 

that supports achievement 

of remarkable, encourages 

organizational and individual learning, 

and is inclusive of all stakeholders. 

Alignment and transparency allowed us 

to make huge strides in our performance, 

but we found that we needed a complementary strategy to achieve our interdepartmental goals.

Strategic Breakthrough Initiatives

Late in 2011, we recognized that, though 

achieving our strategic goals was crucial 

to our continued success as an organization, we regularly saw fewer than half of 

our strategic goals realized. An analysis 

of the problem made it clear that, while 

we were achieving goals that centered 

on specific departments or work groups, 

we were not achieving our cross-silo 

strategic goals as frequently. With this 

in mind, we researched best practices. 

Inspired by the 2010 American Hospital 

Association—McKesson Quest for Quality 

Prize winner McLeod Regional Medical 

Center in Florence, South Carolina, we 

chose to implement a process that would 

help us take small steps each quarter to 

“move the big dots” of our three-year strategic objectives. We call this our Strategic 

Breakthrough Initiative (SBI) process. 

Each year, we look at our strategic goals 

and determine the action plans necessary 

to reach those goals. We then evaluate 

whether those goals can best be achieved 

via the cascading department goals or the 

SBI process. We review the list of potential SBIs each quarter to determine if they 

remain the right action plans, the SBIs are 

still the right format for achieving goals, 

and the timing of the SBIs is still accurate. Often, we have had to add a different SBI as a result of unexpected issues 

arising. This agility helps us to respond 

strategically and quickly each quarter. One 

example of an SBI is our work toward 

eliminating preventable harm caused by 

catheter-acquired urinary tract infections. 

The SBI process starts with the assignment of initiative leaders, who lead a 

small team of staff who focus intensively 

for one quarter on implementation of the 

initiative. The teams meet weekly and 

use a standardized set of documents to 

guide them through the process, including charts, timelines, and tools for process 

mapping; stakeholder analysis; and identification of best practices. Each week, team 

members present project status reports 

to each other and the executive team and 

post their documents on a bulletin board. 

They discuss any barriers or other issues 

they face in weekly huddle-type sessions 

with the executive team. This process has 

become a key way to identify and develop 

future leaders of the organization, as well 

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Jayne E. Pope, RN, FACHE, Emily Padula, RN, FACHE, and Debbye Wallace-Dooley • 15

F EATUR E

for Medicare & Medicaid Value-Based 

Purchasing Program for the past three 

years, achieved top 2 percent performance 

on 30-day readmission, and attained top 1 

percent performance on hospital-acquired 

conditions. 

Simple Tools Support Execution

Our process management and process 

improvement tools include Plan-DoCheck-Act, Six Sigma, Lean, and other 

advanced performance improvement 

methodologies. We found that only a few 

team members were truly proficient in 

use of these tools; consequently, at times, 

process management and improvement 

were bottlenecked while we waited for 

a subject matter expert to facilitate the 

process. Like many other organizations, 

HCM had invested in classroom training for most of our staff, but we found 

that people often forgot what they learned 

because they were not applying the knowledge daily. To overcome this challenge, we 

developed simple process management 

and improvement tools that guide team 

members through the process, similar to 

the way a facilitator might. Team members 

use everyday language to discuss process 

management issues. For example, rather 

than asking for “customer requirements,” 

the tool states, “Write down who will benefit from this process.” It asks, “What do 

they want from the process?” and “How 

do you know that’s what they want?” The 

process management and improvement 

tools also include hypothetical examples 

of how to answer each question. This 

hands-on approach to learning process 

management has been far more educational and effective for our team than have 

classroom courses, and it has engaged 

people at all levels in process leadership. 

as to ensure a highly focused method of 

reaching our objectives. To date, we have 

implemented 50 SBIs, and almost one-half 

of our 650-person workforce has been on 

an SBI team. 

Process Management 

Although SBIs and strategic alignment 

have resulted in systematic process improvement and accountability methodology, they do not focus specifically on 

the day-to-day work of documenting and 

managing processes. In 2012, senior leaders identified ongoing process management as a strategic challenge, and they set 

out to develop organizational competency 

in this skill. We recognized that our ability 

to execute remarkable quality and service 

must be sustained through a focus on 

designing, managing, improving, and innovating work processes at multiple levels 

of the organization. In doing so, we create 

value for the customer by providing highquality care and service at a reasonable 

cost. Benchmarking the best practice of 

2011 Baldrige recipient Schneck Medical 

Center in Seymour, Indiana, we developed 

and deployed the HCM Enterprise Process Model as the framework to take the 

organization to the next level of performance on our journey. We use this model 

to organize our processes within our 

always goals, to identify key processes, and 

to identify process owners. Process owners document customer requirements for 

the process, track in-process and outcome 

measures, report results by means of the 

performance review cycle, and initiate 

improvements. 

Our ability to effectively execute our 

processes is evident in our results. We 

have performed in the top 5 percent of 

hospitals across the nation in the Centers 

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16 • frontiers of health services management 32:1

Organizationally, we have seen substantial 

improvement in our ability to manage and 

improve processes, with correspondingly 

higher results in outcome measures. 

Conclusion

Today’s healthcare environment is one of 

constant change. As healthcare leaders, we 

are still finding our footing in the quest 

to achieve long-term sustainability in this 

new environment. We must constantly 

ask ourselves, “How can we achieve the 

level of performance that we will need to 

be successful into the future?” At HCM, 

we found the Baldrige Framework to be 

the field guide we needed to navigate the 

steep and often-obscured ascent to worldclass performance. We found our core 

competencies—relationship building, 

values-based culture, and execution—to be 

the footholds we need to support us in our 

climb. Being named a 2014 Malcolm Baldrige National Quality Award recipient is an 

honor and a milestone on our journey. We 

celebrate reaching this particular summit; 

however, we know that we cannot linger. 

New challenges await and our vision still 

lies ahead, so even as we celebrate our success, we turn our sights to the next summit on our climb. 

References

Ryan, M. J. 2007. On Becoming Exceptional: 

SSM Health Care’s Journey to Baldrige and 

Beyond. Milwaukee, WI: American 

Society for Quality Control.

Stubblefield, A. 2005. The Baptist Health 

Care Journey to Excellence: Creating a 

Culture that WOWs! Hoboken, NJ: John 

Wiley & Sons.

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Warren L. Forgey, FACHE, and Tammy Dye, FACHE • 17

F EATUR E

Warren L. Forgey, CPA, FACHE, is president and CEO of Schneck Medical Center in 

Seymour, Indiana. Tammy Dye, RN, FACHE, is vice president of clinical services and 

chief quality officer at Schneck Medical Center.

Small-Town Touch, Big-City Innovation, 

World-Class Aspirations

Warren L. Forgey, FACHE, 

and Tammy Dye, FACHE

Summary 

The healthcare system in the United States is at a critical crossroads. Costs 

are rising, measures of healthcare quality are well below those of other industrialized nations, and public and regulatory scrutiny is increasing. Healthcare 

leaders are searching for more effective, efficient, and sustainable operational 

models to address the mounting challenges they face.

We at Schneck Medical Center in Seymour, Indiana, chose the Baldrige 

Excellence Framework to guide our organization, to accelerate our performance 

improvement journey, and to create sustainable results in our core services. 

The Baldrige Framework uses a systematic approach to innovation and improvement in seven key management areas. These seven areas were leadership; strategic planning; customer focus; measurement, analysis, and knowledge management; workforce focus; operations focus; and results (Baldrige 

Performance Excellence Program 2015). 

In this article, we describe our Baldrige journey. We address why we chose 

to use the Framework, how we engaged our key stakeholders, and what challenges we faced and lessons we learned along the way. In addition, we detail 

how Schneck’s focus on performance improvement has resulted in significant 

returns to the organization.

Throughout the article, we refer to our pursuit of performance excellence 

as a “journey,” and it is indeed just that. Quality improvement takes time, because it is a transformation with many steps. World-class performance is attainable only with years of work and constant refinement.

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18 • frontiers of health services management 32:1

Baldrige offers an overall 

system framework, focusing 

on results in all areas of an 

organization.

Hospitals are facing a whole new set 

of challenges and will need different 

tools and competencies to remain viable 

into the future. How do we balance lower 

census and higher acuity with decreasing 

reimbursement? How do we ensure that 

the supply of nurses and physicians will 

meet the demand for services? How do we 

address the demand for 

transparency from both 

regulatory agencies and the 

general public? How can 

we remain independent 

in an age of mergers and 

acquisitions? And what impact will the move from a pay-for-service 

model to a pay-for-performance model 

have on hospitals?

These were the questions Schneck 

Medical Center faced when deciding to 

embark on the Baldrige journey.

The Baldrige Tool Belt

The challenges we faced were numerous—from ensuring that excellent quality 

of care was not compromised, to providing 

access to care for all the patients we served 

in the manner they deserved, to maintaining a competent and engaged workforce 

and medical staff, to remaining financially 

viable. We soon determined that a systematic process to address the ever-increasing 

challenges in healthcare was essential. 

There was little room for error as we 

planned for the future, and maintaining 

the status quo was not an option.

As Jack Welch, former chairman and 

CEO of General Electric, has been quoted 

as saying, “If the rate of change on the 

outside of a company exceeds the rate of 

change on the inside, the end is near.” 

Schneck was experiencing a significant 

rate of change outside our organization. 

We needed to develop processes that 

would allow us to change the business 

while continuing to run the business. 

As we explored alternative models 

for sustaining the organization’s longterm viability, we found that the Baldrige 

Criteria provided a structure conducive to 

our culture. In general terms, the Baldrige 

Criteria are not prescriptive; in fact, they 

are nearly the opposite. They are focused 

on results, and they encouraged us to take 

steps to make our results exceptional. 

The Criteria challenged us to identify and 

document our processes, demonstrate 

how those processes advanced our mission, validate data from all stakeholders, 

and ensure we were making logical and 

data-driven decisions. They drove us to 

develop processes that were often unique 

and always tailored to our own organization’s needs. 

Baldrige offers an overall system framework, focusing on results in all areas of 

an organization. The approach is strategic 

and includes organizational and personal 

learning, knowledge sharing, corporate 

governance, ethics, societal responsibility, 

and sustainability. 

Accomplishing organizational excellence requires a variety of tools depending 

on the situation and circumstances. We say 

that Baldrige is the “tool belt” that holds all 

the tools we may need. The Baldrige Award 

was not the end of our journey, but only a 

milestone on the path we are taking. We 

continue to use these tools for excellence 

every day, with every patient we serve.

Driving Organizational 

Excellence

Building engagement and alignment 

among key stakeholders is a critical step on 

the performance excellence journey. It is 

not something that happens by chance; it 

involves a great deal of effort and thought. 

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Warren L. Forgey, FACHE, and Tammy Dye, FACHE • 19

F EATUR E

Leadership Sets the Tone

Schneck’s pursuit of organizational excellence has been driven from the top. Our 

commitment to the Baldrige journey 

began with our former president and CEO 

Gary A. Meyer. His leadership was essential in establishing that our performance 

excellence journey is to be owned by the 

entire management team.

Meyer’s strategy actively involved key 

stakeholders, including the board of trustees, medical staff, and hospital personnel. 

This inclusion has been critical in achieving Schneck’s high performance and 

progressing toward our vision of being a 

healthcare organization of excellence—

every person, every time. 

Build the Culture

Schneck is a healthcare organization 

with strong workplace practices rooted 

in respect, teamwork, and good communication. Our Patient First culture has 

resulted in numerous advances in clinical 

outcomes, patient safety enhancements, 

and organizational and customer service 

improvements. Whether you are a patient, 

family member, vendor, supplier, partner, 

physician, volunteer, or employee, our 

organizational culture is our sustainable 

point of difference.

Employees thrive when their opinions 

are valued. Their input helps drive decision making regarding the care of our 

patients. Our organization approaches 

issues with open minds and innovative 

thinking. We train and educate to encourage teamwork and communication. We 

have developed a Hiring for Excellence 

program that mirrors our mission, vision, 

and values. 

To align and engage frontline staff in 

the journey, we ensure that our employees understand the Schneck mission—to 

provide quality healthcare to all we serve. 

All our employees can recite our mission, and they see it and live it each day. 

We define our culture so that employees 

know the expectations to which they are 

being held accountable, and we hold them 

accountable.

A Shared Vision

A shared vision, shared knowledge, and 

shared understanding set the stage for 

successful change. It is said that every 

organization is designed to produce the 

results it gets. Schneck’s leadership owns 

this message. If we do not like our customer service or quality scores, we recognize that we designed the system and that 

we need to correct it. Such efforts involve 

thinking differently and innovating to 

solve problems.

Focus

Jim Collins, author of Good to Great 

(2001), stated, “The real path to greatness, it turns out, requires simplicity and 

diligence. It requires clarity, not instant 

illumination. It demands each of us to 

focus on what is vital—and to eliminate all 

of the extraneous distractions.”

Schneck’s management philosophy 

focuses on a few key priorities rather than 

an unmanageable variety of initiatives. Addressing too many projects at once can become overwhelming, and it can result in a 

failure to devote sufficient time to specific 

tasks. Prioritizing efforts in strategic areas 

of performance allows leadership and 

frontline employees to truly engage in the 

initiative and drive better, faster improvement efforts.

Link People and Their Work

Employees at all levels must understand 

that the Baldrige journey is not about 

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20 • frontiers of health services management 32:1

Schneck uses dashboards 

at the department, service 

line, and organizational 

levels to link employees, 

results, plans, and processes 

so people can see the 

results and the impact of 

their efforts.

adding to people’s daily work; instead, it is 

about making daily work easier and providing better care to patients. It is about 

actively incorporating performance excellence into people’s work instead of just 

talking about it. Schneck uses dashboards 

at the department, service line, and organizational levels to link employees, results, 

plans, and processes so people can see the 

results and the impact of their efforts.

Winning Versus Improving

One early challenge we faced in adopting the Baldrige Framework was moving 

away from a focus on trying to win the 

Baldrige Award. Instead, we had to focus 

on improving organizational results in 

our defined pillars of excellence—Quality 

of Care, Fiscal and Operations, Customer 

Service, and Human Resources. 

Our initial approach 

was to document, through 

the Baldrige Criteria, our 

results and level of success. 

We expected our results to 

show that we were worthy 

of the Baldrige Award. 

However, our first feedback reports indicated that 

we were not. The feedback 

forced us to ask ourselves 

some tough questions: 

How did we know the needs of our stakeholders and whether or not we were meeting them? What were our key processes, 

and how did we know if they were delivering “excellent” results? How were we to 

improve our processes? How were we to 

sustain performance excellence? Not only 

did answers vary among the members of 

our leadership team, but in some cases we 

had no answers. 

It was at this point that we realized 

we needed to focus on processes, process 

improvements, and methods to validate 

data and opinions. We needed to make 

data-driven decisions and, ultimately, 

improve results and outcomes until they 

reached the defined level of excellence.

Do not misunderstand: Receiving the 

Baldrige Award is wonderful, but our drive 

did not come from chasing it. Instead, it 

came from improving the value we provide to our patients, their families, and our 

workforce. Our results were getting better, 

our capabilities were expanding, and our 

practices were becoming sustainable and 

repeatable. We were thinking and behaving differently.

The Proof Is in the Results

Every organization has its journey. The 

story of our small-town, not-for-profit, 

independent hospital is not something 

we take for granted. When we received 

the 2011 Baldrige Award, we achieved the 

nation’s highest honor. But, although we 

are proud of our crystal, the real prize has 

been the transformation of our organization. The impact has been pivotal in our 

ability to adapt to the changing dynamics 

in healthcare. 

A number of our key investments garnered huge returns. We benefited greatly 

by obtaining and acting on customer feedback through cross-functional collaborative teams, building world-class employee 

engagement, implementing a strategic 

planning process integrated with key customer requirements and Lean Six Sigma 

process enhancements, and committing to 

best-practice sharing. 

An exact return on investment for 

the time and money devoted to the Baldrige process is difficult to determine. 

But the return on investment can be 

indirectly measured by, and attributed to, 

the improvement in performance across 

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Warren L. Forgey, FACHE, and Tammy Dye, FACHE • 21

F EATUR E

the seven Baldrige categories: leadership; strategic planning; customer focus; 

measurement, analysis, and knowledge 

management; workforce focus; operations 

focus; and results.

Patient First Culture

At the forefront of Schneck’s commitment to excellence is our Patient First 

culture. This culture is woven throughout 

the recruitment, development, evaluation, and retention of all our employees. 

Each employee is a vital link in providing 

outstanding service, and each employee 

must maintain the values set forth by the 

organization. The philosophy of placing 

patients first is evident in our patientsatisfaction surveys, most of which have 

reached the ninetieth percentile nationally. 

Surveys that have not yet reached that level 

have improved significantly and are typically above the seventy-fifth percentile.

Financial Wellness Yields Quality 

Healthcare

Schneck demonstrates excellence in 

measures of its operating margin, cash 

flow, and cash position. Specific financial 

improvements achieved during the Baldrige journey include 

• annual operating margins typically 

exceeding 5 to 6 percent,

• an increase in days of cash on hand to 

more than 400,

• a reduction in the debt-to-capitalization 

ratio to 14 percent,

• an increase in the debt-service coverage 

ratio to 5.7, and

• a reduction in the average age of plant 

to 9 years.

All of these measures meet or exceed 

the benchmarks for Standard & Poor’s and 

Fitch’s “AA”-rated hospitals. In fact, over 

the past seven years, Standard & Poor’s 

increased Schneck’s credit rating from “A−” 

to “A,” while Fitch increased our credit rating from “A−” to “A+.” These results facilitate Schneck’s long-term financial viability.

Schneck further demonstrated growth 

in gross revenue in focus areas tied to strategic objectives. These areas include our 

cancer center, joint replacement services, 

cardiac and vascular services, bariatric surgery, and women’s services. Additionally, 

Schneck’s market share increased in our 

secondary service areas for inpatient and 

outpatient surgeries, addressing one of our 

strategic challenges related to expanding 

services to our outlying markets. These results support Schneck’s principal success 

factor of a strong financial foundation. 

An Empowered and Involved Workforce

Schneck has a strong commitment to its 

employees, volunteers, and physicians. 

This commitment is demonstrated by the 

establishment, operation, and continuous improvement of workforce-focused 

programs, projects, and policies based on 

survey feedback from various groups. In 

the two most recent surveys, employee 

engagement has ranked higher than 90 

percent nationally. Even more compelling 

is that only 1.6 percent of Schneck employees were categorized as disengaged. Key 

drivers of the high level of engagement 

include the following survey findings:

• The actions of executives at Schneck 

reflect our mission and values—82.4 

percent versus a national benchmark of 

63.7 percent.

• Executives at Schneck respect the 

contributions of employees and 

departments—73.3 percent versus a 

national benchmark of 56.3 percent.

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22 • frontiers of health services management 32:1

• Schneck recognizes employees for 

excellent work—70.2 percent versus a 

national benchmark of 55.4 percent.

• Schneck helps employees deal with 

stress and burnout—55.3 percent versus 

a national benchmark of 39.9 percent.

In 2013, Schneck was awarded The 

Advisory Board Company’s Excellence 

in Engagement Award. The award recognized Schneck’s commitment to creating 

a best-in-class work environment for its 

employees.

High Performance in Quality of Care

Schneck’s Patient First culture has resulted 

in numerous advances in clinical outcomes and patient safety enhancements.

In the treatment of a patient who has 

had a heart attack, “door-to-balloon” time 

represents the critical period for assessing and diagnosing a heart attack and 

delivering the needed intervention. The 

gold standard for door-to-balloon time is 

less than 90 minutes. To address limited 

treatment options for myocardial infarctions, Schneck partnered with its largest 

competitor, located 25 miles away, to create 

a collaborative initiative for the coordinated handoff of patients needing emergency cardiac catheterizations. Through 

this effort, door-to-balloon times have been 

reduced from 120 minutes to as low as 

43 minutes (which includes transport of 

more than 25 miles) (Exhibit 1). To date, 

we have had zero lives lost under this 

partnership.

Reducing readmissions is a focus for 

healthcare across the country. Our success 

comes from analyzing data, determining 

the causes of readmissions, and putting 

processes in place to address those challenges (Exhibit 2). Our improvement 

processes have included the following:

Exhibit 1 Door-to-Balloon Times Minutes 

Year

30 

40 

50 

60 

70 

80 

90 

100 

110 

120 

2010 2011 2012 2013 2014 

100% lives saved through 

this process 

Goal without lab 

(120 minutes) 

Goal with 

catheterization lab 

(90 minutes) 

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Warren L. Forgey, FACHE, and Tammy Dye, FACHE • 23

F EATUR E

• Partnering with local long-term care 

facilities to provide a physician and 

nurse practitioner to improve the 

continuum of care

• Providing a complimentary visit 

through our home services department 

when requested by the case manager

• Telemonitoring for appropriate patients

• Providing a medication assistance 

program for patients who are unable to 

fill their prescriptions (and then working 

with drug companies’ patient assistance 

programs to ensure long-term solutions)

• Capturing information—including 

standardized follow-up and root cause 

analysis—to continually tweak processes 

while keeping our patients safe

Schneck’s continuous improvement efforts have resulted in the following quality 

outcomes and processes:

• A 26 percent increase in adverse 

event reporting by employees, which 

supports our Just Culture and High 

Reliability journey

• A mortality index of 0.48, which is well 

below the University HealthSystem 

Consortium (UHC) database top decile 

of 0.64

• A 25 percent reduction in safety index 

score, from 1.10 percent in 2012 to 0.82 

percent in 2014, which is approaching the 

top decile (Truven Health Analytics 2014)

• Immediate distribution of daily safetyhuddle minutes to all leadership, 

registered nurses, safety committee 

members, and key stakeholders

• Participation of a board member and 

hospital executive on our patient and 

family advisory council

• Nine certified Six Sigma Black Belts to 

facilitate and drive improvement

Exhibit 2 Schneck Medical Center Overall Readmissions

B

e

t

t

e

r

0% 

2% 

4% 

6% 

8% 

10% 

12% 

2012 Q1 13 Q2 13 Q3 13 Q4 13 Q1 14 Q2 14 Q3 14 

Schneck Medical Center Top Decile* Top Quartile* 

More than $1,500,000

Healthcare Dollars

Saved

* Based on University HealthSystem Consortium (2014) Clinical Data Base (fourth quarter 2013 to third quarter 2014).

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24 • frontiers of health services management 32:1

The Baldrige Framework 

has helped us integrate our 

processes throughout the 

organization to achieve 

and maintain world-class 

results.

• Systematic variance-reporting process 

for fiscal, customer service, and quality 

metrics

• Tracking and monitoring by process 

owners who provide oversight and 

accountability

Sustaining World-Class 

Results

At Schneck, we believe there is a difference between being an organization 

with a vision statement and being a truly 

visionary organization. The difference 

is in the ability to create 

alignment to maintain an 

organization’s core values, 

to reinforce its purpose, 

and to encourage continued progress toward its 

objectives. When your 

organization is aligned, 

any individual who comes 

into your hospital can articulate what your 

organization stands for without having to 

read it on paper.

A set of core values and a relentless 

drive for progress are keys to organizational success, but the most important 

element is the ability to translate these 

concepts into concrete methods and 

processes. The Baldrige Framework has 

helped us to do just that—to integrate our 

processes throughout the organization to 

achieve and maintain world-class results.

Know Your Strengths, Recognize Your 

Opportunities

Through use of the Baldrige Criteria, we 

have come to know our strengths and are 

better at recognizing our opportunities. 

These benefits apply regardless of your 

industry, the size of your organization, or 

your location. The key to success is understanding your strengths and capitalizing 

on them, while at the same time identifying your weaknesses and doing everything 

possible to minimize their impact on your 

future. 

Change-the-Business Initiatives

Today, Schneck thinks and operates 

differently. We have transitioned into 

a fact-based, results-oriented organization. Before we incorporated the Baldrige 

Criteria, we made some decisions based 

on anecdotal information. Today, data and 

facts drive our outcomes. We ask those 

critical questions that we did not know to 

ask before our journey. 

Our senior executives now operate in a 

strategic environment instead of an operational one. As leaders, we previously spent 

about 80 percent of our time on operational issues, or “running the business,” 

and only 20 percent on strategic initiatives, or “changing the business.” We all 

had agendas to make our areas of responsibility successful. By using the Baldrige 

Framework, we discovered that we needed 

to focus on the success of the organization 

and determine how each of our divisions 

would support the organization’s goals. As 

we progressed on our journey, we began to 

see our outcomes improve. The executive 

team now focuses on moving the entire 

organization forward and positioning Schneck for success in today’s rapidly changing healthcare environment. 

Clear Definition of Excellence

Our leadership team today is aligned and 

focused and has a shared vision. We were 

not that way at first, although we thought 

we were. When we first sat down as a leadership team to complete our organization 

profile, we saw very quickly how mistaken 

we had been. We stated that we wanted to 

be an organization of excellence, yet when 

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Warren L. Forgey, FACHE, and Tammy Dye, FACHE • 25

F EATUR E

our senior executives discussed this topic, 

we each had our own definition of what 

we perceived excellence to be. When the 

senior leaders are not aligned and focused, 

you can imagine how disjointed the improvement efforts become by the time they 

reach the frontline staff. 

Schneck now has a clear definition of 

excellence for each of our four pillars—

Quality of Care, Fiscal and Operations, 

Customer Service, and Human Resources. 

We have aligned the definitions and expectations to our dashboards, divisional goals, 

leadership incentives, and employee evaluations in ways that link daily work to the 

overall success of the organization. This 

integration provides a clear linkage and 

line of sight visible throughout Schneck.

Manage Processes and Lead People

Schneck now manages processes and 

leads people. Before using the Baldrige 

Framework, we had really good people 

doing some really good things, but many 

of our processes were isolated and not 

systematic throughout the organization. 

To improve, we had to become process 

literate. We had to design system-wide 

standards, expectations, and measurements for the areas we identified as key to 

delivering our product of healthcare. 

Once a process is designed, a key 

process owner has the ultimate responsibility for the outcomes, regardless of 

whether the owner performs a role in the 

process. For example, Schneck’s director 

of pharmacy owns the medication safety 

process throughout the organization, yet 

a pharmacist never administers a drug. It 

is the director’s responsibility to measure 

and monitor outcomes, and if a problem 

arises, he pulls the key people together to 

develop an action plan to correct or improve the situation. Having a key process 

owner allows for systematic alignment and 

ensures that the process is completed in 

the same manner every time, regardless of 

the department or the caregiver. 

Invest in Leadership

Simply having performance excellence 

goals does not constitute change. Mentalities and attitudes must be altered for the 

better for beliefs to take hold and thrive 

in an organization. Schneck’s leaders are 

change agents who are not afraid of challenges created by improvements.

Leaders are not born with the set of 

skills needed to motivate a team, to build 

relationships and partnerships, and to 

transform a vision into reality. Schneck recognizes the importance of investing in our 

leadership and providing leaders with all 

the tools they need. At the forefront of our 

investment in leadership is the Schneck 

Leaders Institute, developed in partnership with Indiana University. The institute 

provides a core foundation of language and 

knowledge and prepares Schneck managers for a future of change and opportunity. 

Participation is a requirement for all leadership, from frontline managers to the CEO.

Lessons Learned on 

the Journey

The Baldrige process can sometimes be 

frustrating, and thus it is not a journey 

embraced by every organization. It forces 

organizations to take an introspective view 

and ask pointed and challenging questions. At Schneck, these questions were at 

times viewed with a degree of indignation, 

given the level of experience and expertise 

in our organization. We felt we knew the 

needs of our stakeholders, perhaps even 

more so than the stakeholders themselves 

did. However, by working through the process, we learned several important lessons. 

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26 • frontiers of health services management 32:1

We ensure that our 

decisions are driven by 

data and that those data 

are validated, timely, and 

accurate.

Identify and Understand Key 

Stakeholders

One of the lessons we learned early on was 

that we had not identified a complete list of 

stakeholders—that is, all of the individuals 

and groups that could significantly affect 

the operations and future sustainability of 

Schneck. And when we forced ourselves to 

validate our stakeholders’ needs and viewpoints, we found we did not completely 

understand those needs 

and viewpoints. Validation 

of data through independent and unbiased sources 

was critical. As a result of 

the Baldrige process, we 

no longer rely so heavily 

on our own opinions and 

points of view. Instead, we ensure that our 

decisions are driven by data and that those 

data are validated, timely, and accurate. 

Get on Board

You must be willing to jump in and get 

started, even though you may not know 

exactly where you are going. Early in the 

journey, we thought we were close to our 

destination; in reality, we did not realize 

the importance of the organization profile. 

Did anyone know what the feedback report 

meant? We wanted a quick process of “just 

tell us what we did wrong and how to fix it,” 

but we were not even far enough along to 

understand the verbiage. Such experiences 

are a normal part of the learning curve, but 

they were challenging at the time. 

Just Do It

Baldrige is a tool to help you get to a destination, and you must commit to submitting an 

application every year. We at Schneck were 

used to looking at evidence-based tools, 

such as Magnet and specialty accreditations, 

that made it clear when you should apply to 

validate your achievements. Baldrige is different. The feedback report and assessments 

take your organization to the next level. In 

the beginning, we faced a lot of questions 

about why we were applying when we knew 

we were not yet at the world-class level. 

It took time for people to understand the 

rhythm of the tool and realize that you are 

never “there.” Baldrige recognition is simply 

a validation of how far you have come on 

your journey to excellence; it does not state 

that you have reached your destination. 

Aim for Excellence

Looking at past data, we found that on 

many occasions we had compared our 

performance to the median performance 

level. But if we were striving for excellence, why were we benchmarking against 

average? Now we set our goals at the top 

decile of performance in the nation. It 

does not matter if we compare ourselves 

to a tertiary care center or a small community hospital. Who is the best of the best? 

What are they achieving? If we are willing 

to put time and resources into improving, 

then we ought to aim for excellence. 

Apply, Apply, Apply

Get involved with local, state, or regional 

quality programs. Our home state of Indiana 

did not have a state program when we started 

our journey. One of the pivotal points in our 

journey was when the Ohio Partnership for 

Excellence allowed us to apply to its state 

program. We were not eligible for an award 

because we were out of state, but Ohio’s 

program did conduct a site visit. The questions asked by the examiner team helped us 

understand what Baldrige is all about.

Become a Baldrige Examiner 

Becoming a Baldrige examiner is an 

outstanding professional development 

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Warren L. Forgey, FACHE, and Tammy Dye, FACHE • 27

F EATUR E

tool. It is the fastest way to understand the 

Criteria questions, and it provides opportunities to meet and learn from some of 

the nation’s best leaders. Understanding 

the Criteria and trying to link concepts together can be difficult at first, but serving 

as an examiner accelerates the learning 

process. You must first learn your numbers before you can progress to addition, 

multiplication, and finally calculus.

Use a Coach

If you are having trouble gaining momentum, consider using a tutor, consultant, or 

coach. We found that outside help enabled 

us to accelerate our organizational improvement. In the beginning, we needed 

help understanding the Criteria and learning the Framework. But along the journey, 

our needs changed. Our coach’s focus 

quickly evolved into pushing us beyond 

our comfort zone. We learned to challenge 

our peers, identify and acknowledge our 

gaps, and then roll up our sleeves and 

work together to close those gaps.

Learn from Outside Your Industry

Look outside your industry for innovation, 

ideas, and breakthrough improvement. 

Early on, we were mentored by PRO-TEC, 

a coated-sheet steel company that received 

the Baldrige Award in 2007. PRO-TEC 

invited our leadership team to observe 

the ways their organization functions, 

the processes they put into place, and the 

outcomes they achieved. They explained 

their systematic processes and the lessons learned along their journey, sharing 

knowledge that we still use today. 

Think as a System

The drive for performance excellence is an 

evolution, not a revolution. The ebb and 

flow of “running the business” priorities 

and “changing the business” initiatives 

creates a constant balancing act that 

changes as the organization moves forward. Baldrige started off as a project, but 

it evolved into our way of doing business. 

Today, we think as a system and break 

down organizational silos. 

Be Patient

Those who are leading the Baldrige 

journey must be patient. Baldrige is not 

a quick fix; it is a systematic process that 

involves changing the organizational 

culture. Situations may arise where you 

need to slow down, wait, or let something 

go and move on. Doing what is right for 

the organization at the wrong time will fail 

just as not doing what is right will. Confusion and discomfort are normal and to be 

expected. Focus first on a few strong leaders to help move you forward. Education 

on the process and the Framework takes 

time, but acceptance and understanding 

will eventually happen. 

Determine Your Journey

Everyone’s journey will be different. Some 

organizations use category teams, some 

use performance improvement teams, and 

some have oversight committees. What 

worked at Schneck might not work for 

everyone. One of our keys to success has 

been taking what others learned and then 

tweaking it for our culture and environment before implementation. 

Find Your Seat

One common theme across Baldrige 

organizations is that senior leaders support the journey and are visibly “on board 

the plane.” Our senior leadership team 

had to establish positions—or seats on 

the plane—for the movement to really 

gain traction and momentum throughout 

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28 • frontiers of health services management 32:1

One common theme across 

Baldrige organizations is 

that senior leaders support 

the journey and are visibly 

“on board the plane.”

the organization. The plane needed to 

have an owner, and Schneck’s was our 

CEO. Ultimately, the exact role of the 

CEO—whether it be a pilot, mechanic, or 

copilot—does not matter as long as the 

CEO owns the plane. At Schneck, when 

it became clear that the plane was loaded 

and all senior leaders had found a seat, 

the message was clear: We were moving 

forward, and if you wanted to be a part of 

the journey, you needed to be on board. 

Excellence Is the 

Differentiator

A specific return on investment for 

the time and money committed to the 

Baldrige process is difficult 

to calculate. Similarly, the 

degree to which winning 

the Baldrige Award has 

been a market differentiator for Schneck cannot be 

stated definitively. However, the Baldrige process 

had meaningful indirect results that led to 

market differentiation. 

Physician recruitment is an ongoing 

strategic initiative at Schneck. Being able 

to fill medical specialty positions, including those in primary care, leads directly 

to an increase in market share and an 

improved ability to serve a large population base. Many physician candidates are 

familiar with the Baldrige Award and its 

recognition of an organization’s performance excellence, and the award draws 

those candidates to Schneck. Some of 

these candidates may have overlooked 

Schneck in the past as just another smalltown hospital, but as a Baldrige Award 

winner, we have their attention. Being a 

Baldrige Award winner has also led to increased credibility among peers. Again, no 

longer just a small-town hospital, Schneck 

is rightfully recognized as an innovator 

and a leader in healthcare. 

Excellence Is the Goal

For the first two years of our Baldrige 

journey, many of our leaders were completely committed to winning the award. 

Schneck had generally demonstrated high 

performance in our identified pillars of 

excellence, and we believed ourselves to be 

a Baldrige-caliber organization. We dedicated a significant amount of our executive 

and leadership time to demonstrating our 

worthiness of the award. We set out to let 

the Baldrige examiners and the rest of 

the world know that we were a highperforming organization. 

This approach was a costly and timeconsuming part of our journey, filled with 

frustrations of trying to sell ourselves as a 

Baldrige Award winner. In reality, we did 

not even complete simple Baldrige-focused 

exercises to identify excellence; we had no 

way of measuring excellence and no way of 

knowing when we had achieved it. We soon 

realized that we had lost sight of why we adopted the Baldrige process in the first place. 

The purpose was not, and never should 

have been, to win the Baldrige Award. 

Rather, the aim was to ensure our sustainability and to accomplish our mission of 

providing quality healthcare to all we serve. 

At this realization, we knew we had to 

refocus and redirect our efforts. If we truly 

achieved excellence in our four pillars, we 

would be a successful organization and 

meet our stated mission. If we were to be 

recognized for our efforts with an award, 

that would be a bonus. But ultimately, our 

Patient First philosophy and our commitment to top-quality healthcare had to be 

first and foremost in our minds. 

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Warren L. Forgey, FACHE, and Tammy Dye, FACHE • 29

F EATUR E

toward our vision of being an organization 

of excellence—every person, every time. 

References

Baldrige Performance Excellence Program. 

2015. “Why Baldrige?” Accessed June 15. 

www.nist.gov/baldrige/enter/.

Collins, J. C. 2001. “Good to Great.” Fast 

Company. Published September 30. www.

fastcompany.com/43811/good-great.

Truven Health Analytics. 2014. “CareDiscovery.” Accessed August 11. http://truven 

health.com/your-healthcare-focus/

hospital-management-decisions/

carediscovery.

University HealthSystem Consortium (UHC). 

2014. “Clinical Data Base.” Accessed 

December 26. www.uhc.edu/about.

Conclusion

No single person, or even department, 

can drive performance excellence. The 

entire organization—from the bottom to 

the top—must be engaged in the Baldrige 

journey. When performance improvement 

becomes a part of your culture, your team 

of employees will propel the organization 

forward.

As we noted at the beginning, the Baldrige Award is not the end of our journey; it 

is only a milestone. We continue our journey every day, with every patient we serve. 

The Baldrige Criteria and our unwavering 

commitment to quality, satisfaction, and 

continuous improvement have helped us 

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30 • frontiers of health services management 32:1

COMM ENTARY

Kathleen Jennison Goonan, MD, is CEO at Goonan Performance Strategies, LLC, 

in Boston, Massachusetts.

Can Baldrige Build Learning 

Organizations?

Kathleen Jennison Goonan

Recognizing the enormous magnitude of change urgently required of American healthcare over the next several years, the Institute of Medicine (IOM) convened the Committee on the Learning Health Care System in 

America to identify potential strategies to accelerate healthcare organizations’ 

capabilities for continuous learning and improvement. In its final report, Best 

Care at Lower Cost: The Path to Continuously Learning Health Care in America the 

committee concluded, “Health care can lag behind many other sectors [of the 

economy] with respect to its ability to . . . adapt, to improve—in short, to learn” 

(IOM 2013, 6). Indeed, the task of fundamentally changing any organization’s 

capacity to learn and adapt to shifting customer needs and requirements, in 

any sector of the economy, has long challenged renowned business leaders and 

thinkers. As Harvard Business School’s Clay Christensen concluded, “It’s not 

that managers in big companies can’t see disruptive changes coming. Usually 

they can. . . . What managers lack is a habit of thinking about their organization’s capabilities as carefully as they think about individual people’s capabilities” (Christensen and Overdorf 2000, 66).

Having spent 30 years as a healthcare and insurance executive starting 

with managed care in the mid-1980s, I share the IOM committee’s conclusion 

about the limitations on capability for learning and change in the healthcare 

sector. Pick any major topic challenging healthcare today—population health, 

disparities, safety, or cost control—and we find a plethora of articles lamenting the lack of progress (Berwick, Nolan, and Whittington 2008; Chassin and 

Loeb 2013; Kindig and Isham 2014; Siegel 2014). Yet transformational change 

based in agility and true organizational learning is possible. As a member of 

the panel of judges for the Malcolm Baldrige National Quality Award (MBNQA) 

from 1999 to 2002, with the responsibility and privilege of evaluating the 

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Kathleen Jennison Goonan • 31

COMM ENTARY

applications and final examination reports 

of approximately 30 superior organizations 

from all industries, I studied organizations that had demonstrated a capacity for 

learning. The MBNQA judges determine 

which of the site-visited finalists deserve to 

be named a role-model organization by the 

president of the United States. Through 

this effort, I came to appreciate that profound change is indeed possible with an 

effective and systematic approach. Many 

of these organizations started out as rather 

mediocre, so understanding exactly what 

they did to lead transformational change is 

beneficial.

Start with the Results

The feature articles in this issue of Frontiers of Health Services Management represent two such organizations that have 

been recognized as national role models in 

learning and improvement. In both cases, 

the evidence is compelling with regard to 

their comprehensive and significant performance improvement, and their capabilities are noteworthy. Both articles refer 

to a systematic process or journey, highlighted by words such as “perseverance,” 

“transparency” regarding their true comparative performance, and “execution,” or 

the capability to move from aspirations 

to measurable results. Pope, Padula, and 

Wallace-Dooley describe how Hill Country Memorial went from average to the 

national top 10 percent in performance on 

a broad set of organizational metrics, such 

as patient experience, quality, and financial performance. Forgey and Dye offer 

an impressive array of financial, workforce engagement, and quality metrics at 

high levels of performance. For readers 

interested in the details of these or any 

MBNQA recipients’ results, their applications are available to the public (http://

patapsco.nist.gov/Award_Recipients/

index.cfm). Although recipients have the 

opportunity to remove proprietary or confidential information, their application summaries generally include 80–100 graphs 

and charts of data with comparisons and 

trends over at least three years. The results 

speak for themselves. Although some 

individual metrics may tend toward being 

merely above average, generally these 

organizations demonstrate wide-ranging 

top-quartile or top-decile performance 

across all key dimensions. The Baldrige 

scoring process is objective, thorough, and 

highly scientific, providing a score in each 

of 12 process and 5 performance items that 

emphasize overall results achieved. This 

evaluation methodology allows leaders to 

track progress in building their capabilities 

to generate improved results. 

The feature authors’ affirmations of the 

Baldrige approach have been externally 

validated. The 100 Top Hospitals methodology of Truven Health Analytics (formerly 

Thomson Reuters) is a recognized statistical approach to assessing key aspects 

of performance in hospitals and health 

systems. Truven researchers have analyzed 

the relationship between organizations 

that have achieved recognition through the 

Baldrige Performance Excellence Program 

(BPEP) and those that have achieved the 

highest performance (top 3 percent of all 

hospitals) on the balanced scorecard of the 

100 Top Hospitals (Foster and Chenoweth 

2011). They defined Baldrige-recognized 

organizations as those that had received 

national site visits or awards. Their analyses showed the following:

• Baldrige hospitals were significantly 

more likely than their peers to 

display faster five-year performance 

improvement. 

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32 • frontiers of health services management 32:1

The Baldrige Framework is 

a blueprint for operations 

performance.

• Baldrige hospitals, as a group, were 83 

percent more likely than non-Baldrige 

hospitals of similar size and teaching 

status to be recognized among the 100 

Top Hospitals in balanced organizationwide performance for quality, patient 

experience, and financial success. 

• Baldrige hospitals outperformed nonBaldrige hospitals on nearly all of the 

individual measures of performance 

used in the 100 Top Hospitals 

composite score. 

While the scientific 

evidence illuminating 

effective organizational 

management generally is 

sparse (even more so than 

that for evidence-based medical practice), 

the Truven analysis suggests that the Baldrige process has significant potential. But 

what exactly is the Baldrige Framework, 

and how is it used successfully to orchestrate fundamental change in organizational performance?

What Is Baldrige Really?

Although the achievements of the organizations in the feature articles are impressive, 

the relevant questions for readers relate to 

how their leaders accomplished such dramatic improvement and how other leaders 

might leverage the approach to achieve 

needed improvements in their organizations. The authors refer to having chosen 

the Baldrige Framework among options, 

but they do not elaborate on the basis for 

their choice beyond declaring Baldrige a 

systematic approach and process that fit their 

organizations. The most fundamental questions are these: 

• What exactly is the Baldrige approach 

to change and excellence?

• How can leaders and executives use it 

to transform their organizations? 

Most people who have heard of Baldrige know it as a prestigious national quality award that is challenging to receive. 

In fact, it is much more than an award 

program and is relevant to any organization, regardless of performance or aspiration level. The Baldrige Framework is a 

blueprint for operations performance and 

includes a comprehensive body of knowledge that can assist any leader charged 

with significantly improving an organization or fundamentally changing a business model. Congress created BPEP and 

the MBNQA to establish a public-domain 

repository of industry best practices in 

leadership and management. Initially 

focused on the manufacturing and service 

sectors, the MBNQA expanded to include 

healthcare and education in 1999 and notfor-profit organizations (including government and military) in 2006. 

Forgey and Dye describe the Baldrige 

Framework as a tool belt. I disagree with 

this characterization. Baldrige is not a set 

of tools; rather, it is a set of critical questions that every business or organization 

should be able to address. In fact, Baldrige 

is more like a comprehensive diagnostic 

test, providing the questions every executive team must answer within an elegant 

and logical systems framework. Leaders 

choose methods, tools, and tactics to run 

their organizations. Those decisions and 

the effectiveness of their execution constitute the organizations’ answers to the 

Baldrige diagnostic questions. Answers 

can vary widely depending on an organization’s circumstances, history, culture, and 

market. High performers make different 

choices, as evidenced by the feature articles in this issue. Schneck Medical Center 

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Kathleen Jennison Goonan • 33

COMM ENTARY

and Hill Country Memorial, both Baldrige 

Award recipients, selected different tactics 

to achieve their results. What matters is 

that the chosen tactics worked to achieve 

better results over time. 

For example, consider this Baldrige 

question: “What are the key elements of 

your performance improvement system, 

including your processes for evaluation 

and improvement of key organizational 

projects and processes?” (BPEP 2015). 

This is not a simple question for most 

leaders to answer. Having a robust answer 

that works routinely in real and practical terms throughout a hospital or health 

system is not a simple matter. Answers 

also can vary from one organization to 

another and be equally effective. Some organizations might use Lean or Six Sigma 

to improve processes or manage projects, 

while others might use Plan-Do-Study-Act. 

Still others might use a combination of 

the preceding, along with strategic maps, 

balanced scorecards, and other measurement methods, as well as project management tools. Again, Baldrige provides 

the questions; leaders select the tactics to 

achieve intended results. Understanding 

this clarifies where Baldrige fits on the 

spectrum of executive decisions. Baldrige 

is not an alternative to using various tools; 

rather, it is a blueprint for the capabilities 

an organization must build and integrate 

to be successful. More important, it offers 

an objective measure of the effectiveness 

of the myriad tools and mechanisms a 

complex enterprise uses to operate. The 

scoring methodology, which allows for 

in-depth comparison to best practices, 

ensures a brutally honest assessment of an 

organization’s capabilities.

The Baldrige Framework explores 

how an organization ensures that staff 

members provide compassionate service 

and build relationships with patients and 

other customers. Baldrige does not prescribe how one accomplishes this; it only 

requires that the organization have an 

effective method, deploy it to the staff who 

need to use it, and integrate the approach 

with other tools and tactics to train and 

develop staff. A company might choose to 

use a tool such as AIDET (acknowledge, 

introduce, duration, explanation, thank 

you) (Studer Group 2015) or create its own 

tools, training, or other deployment methods. Baldrige is neutral about choices, but 

it delves into whether the company has 

a systematic approach, whether the approach works, and whether the company 

has results to prove it. Similarly, Baldrige 

does not mandate that an organization 

adopt service lines, build an accountable care organization, or deploy cultural 

concepts such as high reliability or servant 

leadership. 

For every key leadership, management, 

and daily work process of the organization 

(Exhibit 1), the Baldrige Criteria ask four 

questions (BPEP 2015):

1. Do you have a systematic approach, 

tools, and tactics?

2. Is your approach deployed to the 

people who need to use it?

3. Do you evaluate and improve the 

approach periodically?

4. Does this particular approach 

integrate and align with other 

organizational approaches in other 

areas?

The correct way to think about the 

Baldrige Framework is that it provides (1) 

a blueprint for the capabilities an organization needs to build and (2) a diagnostic 

test to measure and monitor operational 

capabilities to deliver results. Goonan 

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34 • frontiers of health services management 32:1

Performance Strategies (2015) considers 

Baldrige as a Blueprint® for the comprehensive set of questions that every leader 

needs to be able to answer. In addition 

to providing the blueprint for building 

capabilities, Baldrige sheds light on an 

Baldrige Category High-Level Critical Processes

1. Senior Leadership Direction-setting and culture development

Creation of organizational success

Communication with and engagement of workforce

Focus on action

Organizational accountability

Leadership and governance improvement 

Legal/regulatory compliance, accreditation, and ethics

Societal responsibilities and community health

2. Strategy Strategy development

Innovation

Action plan development and measurement

Action plan implementation and modification

3. Customers Listening to current and potential customers

Customer satisfaction/determination of engagement

Determination of customer service requirements

Customer access and support

Customer relationship management

Complaint management

4. Measurement, 

Analysis, and 

Knowledge 

Management

Measurement (operations and organizational performance)

Performance analysis and review

Performance projections

Knowledge management and organizational learning

Data and information availability, quality, and security

5. Workforce Workforce capability and capacity

Workplace health, safety, and security

Workforce support

Motivation and engagement

Performance management

Determination of workforce engagement

Workforce and leader development

6. Operations Process requirements and design

Process management

Process improvement

Innovation management

Cost control

Supply-chain management

Safety and emergency preparedness

Exhibit 1 Key Organizational Processes

Source: Goonan Performance Strategies, LLC.

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Kathleen Jennison Goonan • 35

COMM ENTARY

organization’s performance. It provides a 

definitive and comprehensive picture of 

how a healthcare organization performs 

today in customer experience, workforce 

experience, leadership, and finances and 

market share.

Process Literacy

Forgey and Dye offer a clear summary of 

how Schneck Medical Center benefited 

from the Baldrige process over time: The 

organization became “process literate,” 

meaning it had to develop systematic approaches for all of the key organizational 

processes listed in Exhibit 1. This concept 

is critical for leaders faced with managing 

and leading fundamental cultural change, 

and it is an essential aspect of the return 

on investment for the work of Baldrige. 

In his New Yorker article exploring process 

management at The Cheesecake Factory, 

Atul Gawande (2012) examined the value 

of standardizing processes to ensure reliable quality, safety, and experience. Forgey 

and Dye describe how leaders at Schneck 

methodically identified key processes and 

used methods historically applied in other 

industries to redesign and take ownership of such processes as medication 

administration. 

In our research on organizations that 

received the Baldrige Award, we found 

that they not only standardized and hardwired daily work processes such as medication administration and postoperative 

surgical care but also applied these tools 

to leadership and management processes 

(Goonan, Muzikowski, and Stoltz 2009).

Pope, Padula, and Wallace-Dooley discuss how Hill Country Memorial applied 

process tools to their relationship-building 

competence to advance this process and 

ensure it provided strategic advantage 

for the organization. In every key area of 

executive capability, Baldrige organizations 

develop systematic approaches. Consider 

other major areas of focus in most healthcare organizations: Measurement systems 

and use of data to drive improvement. 

Exhibit 2 highlights what we have found 

to be the elements of key processes and 

capabilities, which we refer to as the 

Measurement Maturity Model. Over time, 

organizations that use Baldrige develop 

well-designed and efficient processes to 

produce actionable information for use in 

achieving better results after following a 

process of “maturing” their measurement 

capabilities. 

Effective Use of Baldrige 

As Pope, Padula, and Wallace-Dooley describe, Hill Country Memorial experienced 

a rude awakening in 2008 when staff 

members began critically comparing the 

hospital’s performance with that of other 

organizations. This was the beginning of 

a journey that took it to the top 10 percent of US hospitals on most measures. 

The successful transformation included a 

commitment to building a mature capability of measuring results and transparent 

evaluation of how those results compare 

with results of other similar competitor 

and role-model organizations (Exhibit 2). 

This engaged, regular, and transparent 

review of results, as well as the systematic 

evaluation and improvement of key leadership and management processes, played 

a major role in the success of both Hill 

Country Memorial and Schneck.

However, we still do not really know 

how these organizations made the changes 

happen. What were the actions of leaders that led to this successful change? My 

team tackled this question by studying the 

first nine healthcare MBNQA recipients in 

depth from 2003 to 2007 and publishing 

our analysis (Goonan, Muzikowski, and 

Stoltz 2009). Based on our interviews with 

senior executives at MBNQA-recipient 

organizations and after studying their 

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36 • frontiers of health services management 32:1

applications and presentations, we derived 

a model that summarizes the actions 

they took. We have continued to study all 

subsequent recipients since 2009, and the 

model continues to hold true. The senior 

leaders of these organizations lead their 

journeys by following their own version of 

the LASER road map (Exhibit 3), summarized as follows:

• Leadership: Senior leaders commit to 

objective, systematic, and comprehensive evaluation of their leadership 

and management approaches on 

a periodic basis, inviting objective 

scoring of all key leadership and 

management capabilities against the 

Baldrige diagnostic and providing 

the driving force for major change in 

culture and key processes.

• Assessment: Leaders identify a model 

for assessing baseline and periodic 

performance. Of course, in our 

research, leaders all chose Baldrige. 

Dimension of Maturity Examples of Key Capabilities

1. Why do you measure? • Philosophy of “measures drive results”

• Systems view

• Ask questions; ask for data

2. How do you measure? • Selecting meaningful measures

• Defining measures

• Use of meaningful comparison

• Target setting

• Aligning measures

• Measurement Inventory

3. What support is in place? • Measurement oversight group

• Data governance, including data stewardship and 

data quality

• Data owners and analysts

4. What do you measure? • “Right” measures aligned with strategy and operations to 

drive organizational success

• Proactively address requirements/ pay for performance

5. How do you analyze/review? • Appropriate use of scorecards and dashboards

• Effective data presentation in dashboards and scorecards

• Presentation of dashboards and scorecards in the right 

forums

6. What actions do you take? • Making data available to appropriate stakeholders

• Use data to set performance improvement priorities

7. What is the measurement 

environment?

• Becoming data driven

• Educating key data owners and users starting with the 

measurement oversight group

8. What are the results? • Improving performance

Exhibit 2 Measurement Maturity Model

Source: Goonan Performance Strategies, LLC.

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Kathleen Jennison Goonan • 37

COMM ENTARY

We have not discovered an equally 

comprehensive or robust diagnostic 

tool, but partial substitutes, such as 

accreditation models, Magnet, and 

Shingo, can be found.

• “Sensemaking”: Borrowed from the 

safety literature, the concept of sense 

making describes the leadership activity 

of analyzing and making sense of 

an organization’s performance in all 

seven Baldrige categories, interpreting 

the current state of performance, and

defining a set of priority capabilities for 

design or improvement based on those 

capabilities that will bring the greatest 

return on investment with respect to 

current challenges and barriers to success.

• Execution: Senior leaders develop and 

implement effective action plans to 

ensure greater organizational success in 

the market and higher Baldrige scores at 

the next evaluation. They identify highleverage capabilities to build, improve, 

and integrate these action plans 

with their strategic and operational 

performance improvement plans.

• Results: Always tying all learning 

activity to measurable and meaningful 

results, leaders set in motion a cascade 

of organizational performance reviews 

with periodic enterprise-wide reviews 

of comparative performance on a 

wide array of metrics. They make 

this analysis highly visible, and in 

concrete terms, from their boards to the 

frontline work units. 

The LASER road map describes the 

basic pattern that MBNQA recipients follow. The specifics of their journeys vary in 

terms of starting points, business models, 

and market dynamics, but the common activity is the discipline of documenting how 

they lead and manage their enterprises 

against the Baldrige Framework. They 

do so by means of an application for an 

award, which they submit to an independent and systematic evaluation, scoring, 

and feedback process through a Baldrigebased state program or the national BPEP. 

I prefer to think of these applications as 

operating manuals and not as applications 

for an award. The overall LASER pattern 

of activities appears remarkably consistent 

across organizations, regardless of size, 

market type, business model, or baseline performance level. The hundreds of 

organizations that have used this process 

at the state level follow this model in 

their own customized ways. The capability to manage change and organizational 

learning emerges as organizations using 

the Baldrige Framework maintain these 

disciplined activities over several years 

Leadership Commit to humility, truth telling

Assessment Diagnose the current state

Sensemaking Understand your system and gaps

Execution Deploy robust processes and culture

Results Prove it to yourselves and others

Exhibit 3 LASER Road Map to Higher Performance

Source: Goonan Performance Strategies, LLC.

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38 • frontiers of health services management 32:1

System is the largest and most complex, 

and several systems are small, with one 

or two hospitals and other business units. 

Only three of the single-hospital recipients 

are smaller than 150 beds. Settings are not 

only urban and highly competitive, but also 

suburban and rural. This evidence suggests 

that at least among organizations that go 

the distance, there is significant diversity in 

terms of size and geographic location. 

The Bottom Line

Healthcare organizations are operating in an environment that has become 

more competitive and demands accountability. Expectations of healthcare leaders increasingly include explicit goals for 

performance and consequences for nonperformance. Effective use of the Baldrige 

Framework and process for organizational 

performance evaluation and learning offers a robust approach to addressing these 

challenges.

Acknowledgment 

Marsha Kessler, executive director of 

Goonan Performance Strategies, LLC, developed the Measurement Maturity Model 

through a decade of service to leaders 

building their measurement systems.

References

Baldrige Performance Excellence Program. 

2015. “2015–2016 Baldrige Excellence 

Framework (Health Care).” Published 

February 4. www.nist.gov/baldrige/

publications/hc_criteria.cfm.

Chassin, M. R., and J. M. Loeb. 2013. 

“High-Reliability Health Care: Getting 

There from Here.” The Milbank Quarterly 

91 (3): 459–90.

Chenoweth, C. 2014. “Correlation Between 

Baldrige Award Recipients and 100 Top 

Hospitals Winners.” Published November 18. http://truvenhealth.com/blog/ 

correlation-between-baldrige-awardbefore reaching top-quartile and top-decile 

performance levels on key metrics. 

Strategic Fundamentals 

and Core Competencies

Another aspect to the notion of a journey 

is the idea that the Baldrige process causes 

senior leaders to engage in crucial conversations about their organizational strategic 

direction. Pope, Padula, and Wallace-Dooley 

describe their two organizational core competencies (relationship building and a valuesdriven culture) and how, at a particular stage, 

they realized the organization needed to 

develop a third competency: execution. We 

refer to these decisions as an organization’s 

“strategic fundamentals” or the strategic 

fundamental decisions that only senior leaders can make. Leading significant business 

model, cultural, or performance change 

requires a highly cohesive and focused 

leadership team that can set a new course, 

communicate effectively, and execute on 

action plans. But it starts with the strategic 

decisions. If you want to execute real change, 

you have to have a clear destination in mind. 

Controversies

One elephant in the room deserves comment. Both Hill Country Memorial and 

Schneck Medical Center are small and 

independent and function in rural, relatively noncompetitive markets. Some readers might question whether Baldrige can 

help larger, more complex organizations 

become successful. While the total universe of Baldrige users is difficult to define 

because the identities of the applicants are 

confidential, here are the facts. Twelve of 

the 18 recipients of the MBNQA in healthcare are systems, 6 are single hospitals, 

and 1—Southcentral Foundation—is an 

ambulatory delivery and wellness system. 

Of the 12 systems, Henry Ford Health 

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Kathleen Jennison Goonan • 39

COMM ENTARY

recipients-and-100-top-hospitalswinners-2350.

Christensen, C. M., and M. Overdorf. 2000. 

“Meeting the Challenge of Disruptive 

Change.” Harvard Business Review 78 (2): 

66–76.

Foster, D. A., and J. Chenoweth. 2011. “Comparison of Baldrige Award Applications 

and Recipients with Peer Hospitals on a 

National Balanced Scorecard.” Published 

October. www.nist.gov/baldrige/upload/

baldrige-hospital-research-paper.pdf.

Gawande, A. 2012. “Restaurant Chains Have 

Managed to Combine Quality Control, 

Cost Control, and Innovation: Can 

Health Care?” The New Yorker August 13.

Goonan, K., J. Muzikowski, and P. Stoltz. 

2009. The Journey to Excellence: How the 

Baldrige Health Care Leaders Succeed. 

Milwaukee, WI: American Society for 

Quality Press.

Goonan Performance Strategies. 2015. 

“Baldrige as a Blueprint®. Achieve 

Organizational Sustainability and Marketplace Success.” Accessed June 19. www.

goonangps.com/baldrige-as-a-blueprint.

Institute of Medicine (IOM). 2013. Best Care 

at Lower Cost: The Path to Continuously 

Learning Health Care in America. Washington, DC: National Academies Press.

Kindig, D., and G. Isham. 2014. “Population 

Health Improvement: A Community 

Health Business Model that Engages 

Partners in All Sectors.” Frontiers of 

Health Services Management 30 (4): 3–20.

National Institute of Standards and Technology. 2014. “Baldrige by Sector: Healthcare.” Published May 28. www.nist.gov/

baldrige/enter/health_care.cfm. 

Siegel, B. 2014. “A Historical Perspective on 

Disparities as Context for Our Work 

Ahead.” Frontiers of Health Services 

Management 30 (3): 43–46.

Studer Group. 2015. “Our Glossary of Terms.” 

Accessed May 28. www.studergroup.com/

who-we-are/glossary-of-terms.

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40 • frontiers of health services management 32:1

COMM ENTARY

Janet Wagner is CEO at Mills Peninsula Health Services in Burlingame, California, a Sutter 

Health Network affiliate. She was CEO at Sutter Davis Hospital in Davis, California, when 

the organization received the Malcolm Baldrige National Quality Award in 2013.

Sharing Leadership Insights on Our 

Baldrige Journey to Excellence

Janet Wagner

Congratulations to the feature article authors and their teams for 

their pursuit of excellence, the perseverance to achieve it, and the well-earned 

recognition from the Baldrige Performance Excellence Program.

The driving forces for the Baldrige Award recipients on their journey to 

excellence are twofold:

1. Healthcare is a dynamic industry that requires leadership focus.

2. Using a systematic and proven leadership framework to deliver highquality care and remain competitive is a worthwhile pursuit.

Both Hill Country Memorial Hospital and Schneck Medical Center experienced the joys, enlightenments, and professional fulfillment in rising to 

world-class status by providing the best care to the communities they serve. 

In winning the Malcolm Baldrige National Quality Award, both organizations 

earned the highest level of national recognition for performance excellence.

Like athletes, leaders who pursue this level of excellence realize that both 

mental and physical preparation are needed to pursue an organization’s goals, 

improve results, and become more competitive. An athlete depends on his or 

her coaches for training and inspiration. The same is true for management 

teams pursuing excellence. Organizations on the Baldrige journey seek feedback from coaches, high performers, their workforce, and key internal and 

external stakeholders. The leaders at Hill Country Memorial and Schneck 

realized that their journeys would take years to complete. Pope, Padula, and 

Wallace-Dooley wanted to take their organization from average to the national 

top 10 percent of performance. Forgey and Dye knew that maintaining the status quo was not an option for the future of Schneck.

The leaders in these organizations exemplify role modeling that begins 

with commitment to a goal and follow-through on the vital few objectives in an 

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Janet Wagner • 41

COMM ENTARY

industry with many distractions. Perseverance is necessary to stay the course and dare 

to achieve what few have accomplished. To 

date, only 103 organizations in all industries 

have received the Malcolm Baldrige National 

Quality Award. At speaking engagements 

about the Baldrige journey of Sutter Davis 

Hospital in Davis, California, I am frequently 

asked, “How do you sustain the journey, year 

after year?” The answer lies in leadership 

and the strength of the commitment to be 

the best and to earn the recognition.

Leadership

Organizations that receive the Baldrige 

Award are led by seasoned, tenacious, highperforming leaders who have a vision and 

a passion to fulfill that vision. The Baldrige 

journey cannot be delegated. As Jack Welch 

has been quoted as saying, “Excellence is not 

a spectator sport. Everyone’s involved.” The 

CEOs at Hill Country Memorial and 

Schneck had a vision about how they would 

set their care delivery systems apart from 

those of average hospitals. For Hill Country 

Memorial, this meant “providing remarkable 

care and service,” and for Schneck, “being a 

healthcare organization of excellence—every 

person, every time.” My experience at Sutter 

Davis was the same; after years of dialogue 

with the team, we defined our unique position in healthcare as a “culture of caring.”

At both Hill Country Memorial and 

Schneck, the leaders set the strategic direction and the expectation that everyone in 

the workforce execute the vision through 

their behaviors and choices to achieve success. Therein lies a key quality of senior 

leaders—direction. They also must be able 

to communicate that direction to their 

team and follow up by holding everyone 

accountable for the direction they have set. 

This is how the journey begins. Forgey 

and Dye note that “each employee must 

maintain the values set forth by the organization.” Pope, Padula, and Wallace-Dooley 

explain that members of the workforce 

must understand their roles in achieving 

the organization’s goals.

The vision, mission, and values of an 

organization are translated into expectations that lead to sustained results. Achieving sustained results over time is one of 

the more difficult outcomes to achieve and 

probably the key reason most organizations 

do not achieve a high level of success. At 

Sutter Davis Hospital, we defined the culture of caring by “how we all care for all of 

our patients, how we care for each other as 

team members, how we care for our physicians who brought us patients, and how we 

care for our community.” Each of us had 

the opportunity to contribute to the culture 

of caring. A few basic examples are showing up for work on time, giving the right 

medications to the right patients, ensuring 

we registered patients accurately, picking 

up paper from the floor because we cared 

how our organization looked to visitors, and 

always being aware of our professionalism. 

Setting Direction

The authors of both feature articles outline several examples of how they inspired 

their leaders to lead and how they communicated messages to foster engagement 

by the workforce and physicians. Just as 

the Baldrige Award is earned, so too is the 

trust of the workforce. Credible leadership is built on trust, consistency, fairness, 

and equitability, and it is demonstrated 

through role modeling. Pope, Padula, and 

Wallace-Dooley write about listening to key 

stakeholders and providing transparency, 

listening to provide actionable information 

and transparency to move to a shared vision, and continuing to align the workforce.

Pope, Padula, and Wallace-Dooley and 

Forgey and Dye systematically lay out the 

next steps in their journey. Like a great 

book, the beginning and ending of the 

Baldrige journey are critical to creating a 

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42 • frontiers of health services management 32:1

During the journey, the 

leadership team becomes 

proficient at accepting 

feedback on how they are 

managing and leading the 

business.

captivating story; however, the main theme 

of the story is what keeps readers engaged. 

Once the ground rules—beginning with 

standards of behavior—are established, 

the leaders begin building the infrastructure, which includes these components: 

• Workforce and leadership development

• Skills and knowledge 

− Process improvement

− Customer service

− Workforce engagement

− Identification of systems and 

processes

Focusing on Organizational 

Culture

Culture starts with people, the entire 

workforce. First steps after assessing the 

culture often involve questions such as 

those raised by Jim Collins 

(2001, 13, 41) in Good to 

Great. He asks if we have 

the “right people on the 

bus” and the “right people 

in the right seats.” He 

also asks whether we “are 

hiring for our journey to 

excellence.” Senior leaders have become choosy about who gets 

hired to join the team. Peer interviewing 

practices are refined as interviewers gain 

experience with every hire, and potentially 

low performers are identified more readily.

Schneck developed a Hiring for Excellence program that mirrored the organization’s mission, vision, and values. The 

team at Hill Country Memorial embraced 

a core competency of relationship building 

and listening; through workforce engagement, it ensures that every employee 

understands how he or she contributes to 

achieving the organization’s goals.

An organization’s culture is a reflection 

of its leadership. It is one of the hardest 

elements to measure but is palpable to the 

workforce, the patients, the families, the 

visitors, and anyone who interacts with the 

organization. Onboarding to this culture is 

imperative to sustain the journey’s momentum and continued contribution to the 

organization. Baldrige recipients are often 

asked, “How do you know the workforce is 

engaged and the processes are working?” 

One way is when you listen to team members talking and they sound like the organization’s leaders. You hear comments such 

as, “This is how we do things here and nothing less will do.” The workforce behavior 

begins to move the organization to a completely new level. Staff members become 

owners, and they demonstrate individual 

commitment to the strategic direction and 

the organization’s core competencies. This 

personal engagement is the result of effective employee engagement and communication throughout the organization.

Transforming a Culture

Building a culture or transforming a culture is an outcome of the Baldrige journey. The experience of working together 

as a team in a systematic way affects the 

organization’s outcomes and the team’s 

relationships.

Living the Baldrige Criteria, working within the Framework, submitting 

applications, and receiving feedback 

require the team to engage in dialogue 

and work together as never before. In the 

second and third years of the journey at 

Sutter Davis, the team began to realize 

what integration really means. Having 

experienced this journey for seven years, 

I believe the journey develops the team 

better than any other framework, operating system, or leadership model. This 

development is realized when a team 

actually receives the recognition. During 

the journey, the leadership team becomes 

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Janet Wagner • 43

COMM ENTARY

proficient at accepting feedback on how 

they are managing and leading the business, and they actively seek out the best 

performers, develop the desire to benchmark (e.g., using Centers for Medicare & 

Medicaid benchmarks), and look for ways 

to improve performance (e.g., patient, 

physician, and employee satisfaction). This 

process is transformational. Baldrige leaders become self-motivators and develop 

can-do attitudes. They also exhibit humility as they realize this journey requires the 

willingness to face criticism and the need 

to improve. Success exists at a moment in 

time, and sustaining that success requires 

continued focus and a willingness to continue to learn, integrate new knowledge, 

and evolve.

Investing in Leaders

The development along this journey encompasses coaching, education, training, 

and learning to use feedback to improve 

performance. Forgey and Dye note that 

“leaders are not born with the set of skills 

needed to inspire a team, to build relationships and partnerships.” Pope, Padula, and 

Wallace-Dooley explain that they elected to 

deepen the core competency of relationship building. These leaders understood 

the value of investing in leadership development to reach their strategic goals.

The authors of both feature articles 

stress the importance of process improvement, a crucial tactic that Forgey and Dye 

refer to as the tool belt. Measuring progress, benchmarking, and implementing 

improvements are as important as financial 

tools. Engaging in and leading process 

improvement activities in a department, as 

well as across departments, result in refined 

integration. Schneck’s leaders noted that 

simply having performance goals does not 

constitute a change. Hill Country Memorial’s leaders knew that classroom training 

alone did not ensure process improvement; 

to achieve success, process improvement 

had to be incorporated into daily activities.

Both Hill Country Memorial and 

Schneck found value in training their 

leaders to become Baldrige examiners. 

Through this experience, leaders gain two 

perspectives: (1) As employees in an organization, they observe individual departments 

or silos that are not integrated; and (2) as 

examiners viewing an entire organization, 

they observe the overall functioning of the 

organization. Examiners observe how other 

organizations articulate, network, and get 

things done across departments, which assists leaders in learning from each other.

My experience at Sutter Davis Hospital 

resulted in leadership development’s spilling over into identifying high performers 

throughout the organization, which, in turn, 

led to succession planning. By the time 

Sutter Davis received the Baldrige Award 

in 2013, we were developing three levels of 

leaders in the organization. I have not found 

a better framework for developing leaders.

Achieving and Sustaining 

Results

Achieving and sustaining results requires a 

mature team with vision, strategic direction, and well-developed leaders and, as the 

feature authors point out, knowing one’s 

strengths and weaknesses. Forgey and Dye 

note that through use of the Baldrige Criteria, “We have come to know our strengths 

and are better at recognizing our opportunities.” Awareness is the first step to 

knowing where to improve. The feedback 

from the Baldrige Criteria forces teams to 

examine and reexamine how and why they 

are doing things. The feedback addresses 

the mechanics or the deployment of the 

approach. The Baldrige application process offers leaders a multidimensional, 

nonprescriptive framework to think about 

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44 • frontiers of health services management 32:1

how they are managing and leading their 

teams, as well as the business at hand.

“Moving an organization’s performance 

from mediocre to remarkable requires a significant level of commitment, perseverance, 

and willingness to learn from mistakes,” 

note Pope, Padula, and Wallace-Dooley. The 

maturing during a Baldrige journey focuses 

leaders and the team on facts rather than 

perceptions. The teams at Hill Country 

Memorial and Schneck believed they were 

doing well before embarking on the Baldrige journey. Pope, Padula, and WallaceDooley point out that leaders felt “confident 

in the quality of care. . . . In fact, everyone 

believed it to be outstanding—that is, until 

we started benchmarking.”

Mature teams are willing to confront 

the brutal facts, learn to benchmark 

against the best, and realize that the results are about improving performance on 

the basis of quantifiable outcomes. Forgey 

and Dye’s team did just that and transformed Schneck into a fact-based, datadriven organization to achieve their goals.

Systems and Processes

Hospital departments are interdependent, 

linked by how patients travel through the 

system and how care is delivered. Understanding the integration, as outlined in the 

Baldrige Criteria, moves the overall organizational function to a higher level, and feedback 

from the Baldrige process is particularly helpful in this arena. Many operating systems can 

take an organization only so far, and many, if 

not most, focus on the return on investment. 

The Baldrige Criteria offer a much more balanced framework for leadership.

During the journey, key work systems, 

leadership systems, and other systems are 

identified. In fact, one of my key takeaways 

from the Baldrige journey was how important it is to simply stop and take the time to 

define words. At Sutter Davis, we defined our 

systems and processes, which led to speaking 

and understanding more clearly about how 

our processes were integrated and how we 

contributed to the results. Forgey and Dye explain that Schneck has had isolated processes 

throughout the organization. Like them, we 

at Sutter Davis became “process literate.”

Conclusion

The Malcolm Baldrige National Quality 

Award is a significant achievement for a 

CEO and his or her team. The real value 

in the journey is the experience of a team’s 

working together, learning together, and 

achieving success together. It exemplifies living the organization’s mission. Individuals 

on the journey experience a strong sense of 

professional fulfillment, not only for themselves but for those they serve. In healthcare, 

patients and their families are the recipients 

of great care. Residents of the community 

also share in the pride of having a worldclass healthcare system in their community.

Famed nursing theorist Madeleine 

Leininger (1992) said, “Let us always be 

open to acknowledge, respect and learn 

from great leaders in any field or discipline.” Pope, Padula, and Wallace-Dooley 

at Hill Country Memorial Hospital and 

Forgey and Dye at Schneck Medical Center 

are great leaders who have shared insights 

into their journeys to excellence and offered many great lessons on leadership. 

References

Collins, J. 2001. Good to Great: Why Some 

Companies Make the Leap . . . and Others 

Don’t. New York: HarperCollins.

Leininger, M. 1992. “Reflections on Nightingale with a Focus on Human Care Theory 

and Leadership.” In Notes on Nursing,

edited by F. Nightingale, and B. S. 

Barnum. Philadelphia, PA: Lippincott 

Williams & Wilkins. 

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C. David Huffstutler and David Thomsen • 45

COMM ENTARY

C. David Huffstutler is president and CEO at St. David’s HealthCare in Austin, Texas. 

David Thomsen is vice president of quality at St. David’s HealthCare.

A Framework for Performance Excellence 

and Success

C. David Huffstutler and David Thomsen

For anyone seeking characteristics of high-performing organizations, a 

framework exists that encompasses a set of beliefs and behaviors that consistently 

emerge from such organizations. That framework can be found in the Baldrige 

Criteria for Performance Excellence (Baldrige Performance Excellence Program 

2015). As a 2014 recipient of the Malcolm Baldrige National Quality Award, St. 

David’s HealthCare in Austin, Texas, has embraced this framework over the past 

decade to refine its work toward accomplishing its mission and vision. 

While change has always marked the road to success, the pace of that 

change is escalating, and leaders must have a road map or framework to help 

them ensure that results, based on key stakeholder expectations, are delivered 

consistently. Doing so enables an organization to sustain itself, not only under 

current conditions but over the long term as well.

W. Edwards Deming was a noted American statistician who played a key 

role in the revitalization of Japan after World War II. He went on to engage 

industries throughout the world in improving themselves. As one of his 14 

principles of management, Deming articulated that “the sole purpose of any 

organization is to stay in business and provide jobs.” He referred to this central 

concept as “constancy of purpose” (Latzko and Saunders 1995). That central 

concept, as many organizations can attest, can be elusive, but it is exemplified 

by the role-model organizations that have embraced the Baldrige Criteria for 

Performance Excellence. The authors of the feature articles in this issue share 

the stories of two of these organizations—Hill Country Memorial Hospital (a 

2014 recipient of the Malcolm Baldrige National Quality Award) and Schneck 

Medical Center (a 2011 recipient). Since the inception of the Malcolm Baldrige 

National Quality Award in 1988, 105 organizations have received the award.

Organizations that have been recognized by the Baldrige Award represent 

a rich blend of small and large organizations from several sectors of industry, 

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46 • frontiers of health services management 32:1

A common trait of Hill 

Country Memorial and 

Schneck is the vision and 

passion of leaders who have 

a firm grasp of the current 

challenges in healthcare.

including education, service, manufacturing, healthcare, and small business. 

Winners have been both public and private 

and both nonprofit and for-profit. Organizations that use the Baldrige Framework 

go through a process in which they assess 

themselves against a set of Criteria questions in six main categories: 

1. Leadership 

2. Strategy 

3. Customers 

4. Measurement, analysis, and 

knowledge management

5. Workforce

6. Operations

These organizations 

also assess their performance and improvement 

in several key areas, which 

we address later in this 

commentary. The Criteria questions, as they are 

referred to in the Baldrige 

Framework, are based 

on a set of core values and concepts that 

are often exhibited by high-performing 

organizations.

Core Values and Behaviors 

of High-Performing 

Organizations

The authors of both feature articles have 

embraced these interrelated core values 

and concepts (Baldrige Performance Excellence Program 2013):

• Visionary leadership

• Focus on the future

• Societal responsibility and community 

health 

• Organizational and personal learning

• Valuing workforce members and partners

• Agility

• Managing for innovation

• Management by fact

• Patient-focused excellence

• Focus on results and creating value

• A systems perspective

Setting Direction Through Visionary 

Leadership, Focus on the Future, and 

Societal Responsibility and Community 

Health

A common trait of Hill Country Memorial 

and Schneck is the vision and passion of 

leaders who have a firm grasp of the current challenges in healthcare, as well as a 

good understanding of the many changes 

that are forthcoming. Pope, Padula, and 

Wallace-Dooley and Forgey and Dye describe the changing nature of healthcare 

and its impact on their organizations at 

the national level and in their own local 

environments. Both organizations are 

small community hospitals in which a specific senior leader or a board of directors 

assumed responsibility for earning the 

trust of the community to be a good steward of their investments and to ensure, as 

Pope, Padula, and Wallace-Dooley put it, a 

“healthcare system designed to serve them 

for generations to come.” This speaks to 

the constancy of purpose that Deming 

addressed. Visionary leaders see beyond 

their tenure at an organization and think 

about the legacy that remains for decades 

to come. The Baldrige value of focusing 

on the future is inextricably linked to the 

values of visionary leadership and societal 

responsibility.

As a result of our own assessment 

using the Baldrige Framework, St. David’s HealthCare created a vision to be 

“the finest care and service organization in the world.” While we may never 

know whether we achieve that vision, it is 

the vision statement itself that provides 

the impetus for physicians, nurses, and 

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C. David Huffstutler and David Thomsen • 47

COMM ENTARY

technicians to continue striving to provide 

exceptional care to every patient every day 

with a spirit of warmth, friendliness, and 

personal pride.

Fostering a Culture Based on 

Organizational and Personal Learning 

and Valuing Workforce Members and 

Partners

The next two core values focus on the workplace itself. It is often said that “culture eats 

strategy for lunch,” and the questions asked 

through the Baldrige Criteria help organizations think through the unique strengths 

of their facilities and identify ways in which 

to address opportunities for improvement. When the individuals who make up 

an organization are part of a culture that 

values their ideas and contributions and 

encourages their professional development, 

communication improves and engagement 

rises, and the effect on performance is palpable. Forgey and Dye provide several examples of achieving a “patients-first culture.” 

Pope, Padula, and Wallace-Dooley write of 

their organization’s core competency of a 

“values-driven culture,” which they describe 

as a key foothold on their climb to excellence. Pope, Padula, and Wallace-Dooley 

speak of the need to manage alignment of 

individual values with those of the organization, as demonstrated by the “values screen” 

conducted for every potential team member, 

volunteer, and physician candidate at Hill 

Country Memorial. Schneck developed its 

Hiring for Excellence program by focusing 

on the same principles. 

Both organizations also emphasize the 

importance of transparency and being able 

to look at themselves objectively, which 

is a critical factor for learning, on both 

a personal and an organizational level. 

Baldrige Award recipients have embraced 

transparency in communication—whether 

it pertains to workplace issues, challenges, 

or results—as a foundational component 

of this type of culture.

St. David’s HealthCare, a system of 

hospitals, physician practices, and surgery 

centers across a growing metropolitan 

area, has implemented similar systems to 

ensure that individuals choosing to work 

here fit with our core values of integrity, 

compassion, accountability, respect, and 

excellence (ICARE). Like Hill Country 

Memorial and other Baldrige Award 

recipients, daily and weekly staff huddles 

designed to review values on a routine 

basis enable St. David’s employees to connect to the mission, values, and goals of 

the larger organization. Everyone in the 

organization, from the board of directors 

to the frontline staff caring for patients, is 

reminded continually, by means of structured systems for sharing connection stories, of its values and culture. For example, 

employees gather briefly each day in their 

work areas to focus on one ICARE value. 

Stories, quotes, and challenges related to 

the value are provided to help facilitate discussion. Each “daily roundup” concludes 

with team members sharing what the 

value means to them, how they will apply 

the value that day, and ways they can help 

keep each other accountable.

Execution Built on the Values of Agility, 

Innovation, and Management by Fact

We recognize that the competitive environments in which healthcare organizations 

operate are changing but vary by location 

and the size and complexity of individual 

settings. Leaders face varying challenges, 

and the ability and fortitude to meet those 

challenges is reflected in the Baldrige core 

values of agility, creating systems to harness innovation, and the competency to 

manage by fact.

The authors of both feature articles 

address the need to execute action plans 

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48 • frontiers of health services management 32:1

designed to realize the organization’s strategic objectives. The ability to execute well 

is built on many factors, but it includes 

leadership competency and discipline, a 

clear understanding of how one’s processes 

work, and providing the tools needed for 

teams to accomplish the task. Pope, Padula, 

and Wallace-Dooley describe the development of a strategic map, aligning measures 

to connect department work to a strategy, 

and then implementing a “strategic breakthrough initiative” process in which experts 

focus on improving processes. Forgey and 

Dye relate how Schneck realized the need 

to “become process literate” and assigned 

process owners to improve performance.

Operational discipline is needed to 

be able to routinely set goals and achieve 

them. Companies need to create systems 

to develop leadership competency and 

provide data via metrics that inform the organization about whether it is progressing 

toward those stated goals. Both Schneck 

and Hill Country Memorial identified key 

measures of performance and reviewed 

them to ensure they were relevant and easily understood at all levels of the workforce.

Benchmarking performance against 

relevant comparisons is also a common 

element of Baldrige Award–recipient organizations. An organization can compare 

performance with that of local competitors 

or with benchmarks to which the organization aspires. Hill Country Memorial defined “remarkable” as being in the top 10 

percent of performance for all hospitals in 

the country, regardless of size. St. David’s 

HealthCare and Schneck have similar aspirations and systems in place to regularly 

communicate actual performance against 

desired incremental goals (for St. David’s 

HealthCare, the goal is typically the national ninety-fifth percentile). As we at St. 

David’s HealthCare like to say, “We want 

to be legends in our time and not just 

legends in our own minds.” Comparing 

measureable results against benchmarks 

is critical to ensuring this happens.

Patient-Focused Excellence, Focus on 

Results and Creating Value, and a 

Systems Perspective

The Baldrige Framework is based on six 

process categories and a results category. As 

an organization assesses itself through use 

of the Baldrige Criteria questions, its leaders can ascertain the level of organizational 

maturity in each category. Nearly half of the 

score on an application is related to the results category, with the understanding that 

if an organization has mature processes in 

place for leadership and strategic planning, 

understands its customer requirements, 

uses data, and engages the workforce to 

improve and refine processes, then results 

should logically follow. In essence, organizations should see the results of effective 

systems in each of the process categories.

In healthcare, patients and their families are the ultimate customers, so results 

are focused on excellence as measured 

by the patient experience. These last core 

values of the Baldrige Framework—a focus 

on results and creating value—are reflected in the last category of Criteria, and 

organizations are asked to portray their 

results in five key areas:

1. Healthcare and process results, 

including patient outcomes

2. Customer-focused results, including 

patient satisfaction and engagement

3. Workforce results, including 

workforce capability, engagement, 

and development

4. Leadership and governance results

5. Financial and market results

Hill Country Memorial, Schneck, and 

every other organization that leverages 

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C. David Huffstutler and David Thomsen • 49

COMM ENTARY

the Baldrige Framework have experienced 

improvement across a broad array of 

performance measures in these categories. 

Perhaps not every recipient has achieved 

all of its espoused goals, but generally 

organizations that adopt this Framework 

and use it to assess and improve their 

organizational systems realize sustained 

improvements over many years.

In their feature article, Forgey and 

Dye provide several examples of successful results at Schneck. Similarly, in their 

feature article, Pope, Padula, and WallaceDooley illustrate, through results at Hill 

Country Memorial, that they are achieving 

remarkable outcomes for the community 

they serve. St. David’s HealthCare has 11 

key measures to address the three goals of 

Exceptional Care, Customer Loyalty, and 

Financial Strength:

1. Risk-adjusted mortality index

2. Risk-adjusted complication index

3. Hospital-acquired conditions

4. Inpatients’ overall rating

5. Patients’ overall satisfaction with 

emergency department

6. Patients’ likelihood to recommend 

physician’s office

7. Employee engagement

8. Voluntary turnover rate of employees

9. A place for physicians to practice 

medicine

10. Tier 1 market share

11. Earnings before interest, tax, 

depreciation, and amortization 

(excluding waiver and Health 

Information Technology for Economic 

and Clinical Health [HITECH])

The organization has experienced sustained superior clinical outcomes, patient 

satisfaction, improved employee engagement, and year-over-year growth in earnings and market share. 

An Unwavering Commitment 

to Performance Excellence

Organizations that have chosen to use the 

Baldrige Framework and the Criteria for 

Performance Excellence usually are not 

seeking an accolade but rather are pursuing something of lasting value to their 

communities—that constancy of purpose. 

The decision to start this journey is evidence of an organization’s commitment to 

improve performance every day. As we like 

to say at St. David’s HealthCare, “Performance improvement never ends.”

We were interested to find that both 

Hill Country Memorial and Schneck 

decided to use the Baldrige Framework by 

first becoming exposed to, and then deepening their understanding of, the systematic nature of the Framework and Criteria. 

The typical journey for many organizations begins with involvement in statelevel programs that promote the use of the 

Criteria. For both Hill Country Memorial 

and Schneck, a small group of individuals 

deepened their knowledge of the Criteria 

questions and brought that information 

back to the organization. This is also how 

St. David’s HealthCare began using the 

Criteria to improve systematically. 

Organizations typically spend years 

learning the Criteria, assessing themselves 

via an annual application process, and 

then applying ideas for improvement garnered from formal feedback in a process 

developed by a team of trained examiners. 

Organizations also capitalize on state and 

national Baldrige programs that sponsor 

annual conferences at which current and 

previous recipient organizations share 

their improvements and best practices; 

these concepts can be applied across 

industries, regardless of company size 

or complexity. For example, St. David’s 

HealthCare was inspired by the application of predictive analytics by Montgomery 

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50 • frontiers of health services management 32:1

County Public Schools, measurement systems at Lockheed Martin Missiles and Fire 

Control, benchmarking at K&N Management, and service delivery at the RitzCarlton, all Baldrige-recipient organizations in education, manufacturing, and 

service. Along our journey, we have found 

that recipients of the Baldrige Award are a 

community of high-performing organizations that are willing to share and enable 

cross-sector learning. Schneck and Hill 

Country Memorial have provided tangible examples of the work involved in 

and the benefit of adopting the Baldrige 

Framework.

Conclusion

As we reflect on our organization’s journey 

in the pursuit of excellence, we can identify with many of the lessons learned by 

Schneck Medical Center and Hill Country 

Memorial Hospital in using the Baldrige 

Framework to improve performance. We 

learned similar lessons and have benefited 

from many of the organizations that have 

embarked on this journey.

Congress developed the Baldrige 

Criteria to

• identify and recognize role-model 

organizations,

• establish criteria for evaluating 

improvement efforts, and

• disseminate and share best practices. 

By demonstrating their willingness to 

share their journeys with the national and 

international community, recipient organizations perpetuate the initial purpose of 

and vision for the Framework itself.

St. David’s HealthCare, a unique joint 

venture between Hospital Corporation of 

America (HCA), St. David’s Foundation, 

and Georgetown Health Foundation, is 

honored and humbled to have been recognized as a 2014 recipient of this prestigious award. However, we also recognize 

that more work is needed to accomplish 

our vision. Many recipient organizations 

acknowledge that the award is simply a 

milestone, a marker of a significant event 

in the history of that organization. Our 

patients expect the best—indeed, they 

deserve the absolute best—care we can 

provide, and we remain committed to 

using the Baldrige Framework to help us 

continue to improve. 

As philosopher Will Durant said in his 

summation of Aristotle’s ideas, “We are 

what we repeatedly do. Excellence then, is 

not an act, but a habit.”

References

Baldrige Performance Excellence Program. 

2015. “2015–2016 Baldrige Excellence 

Framework (Health Care).” Published 

February 4. www.nist.gov/baldrige/

publications/hc_criteria.cfm.

———. 2013. “2013–2014 Health Care 

Criteria for Performance Excellence.” 

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