2022

Copansburg 

Regional Health 

System Case Study Feedback Report

health care

www.nist.gov/baldrige
Baldrige Performance Excellence Program

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

July 2022

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

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

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

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

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

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

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

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

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

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

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

either Copansburg Regional Health System or otherwise. The names of several national and government organizations are included to 

promote the realism of the case study as a training tool, but any data and content about them may have been fictionalized, as appropriate; 

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

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

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

Regional Health System 

Feedback Report 
 

 

 

 

 

 

When we submitted our first application ..., we discovered the richness of receiving and applying 

he feedback report in helping us improve as an organization. ... This is an ongoing improvement 

journey that is helping us achieve our goals and objectives. The Baldrige framework has become 

a way of life for us. 

Carolyn Candiello, Vice President, Quality and Patient Safety 

GBMC HealthCare, Inc. 

2020 Baldrige Award Recipient 

Preparing to read your feedback report . . . 

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

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

strengths and opportunities for improvement relative to the Baldrige Criteria and the Scoring 

Guidelines. Examiners are instructed to give appropriate benefit of the doubt when evaluating 

an application; however, important information that is missing may result in feedback about an 

opportunity for improvement. The feedback is not intended to be comprehensive or 

prescriptive. It will tell you where examiners think you have important strengths to celebrate 

and where they think key improvement opportunities exist. The feedback will not necessarily 

cover every question in the Criteria; nor will it say specifically how you should address these 

opportunities. You will decide what is most important to your organization and how best to 

address the opportunities. 

If your organization has previously applied to the national program, you will notice a change in 

the way feedback is structured in the report. Based on applicant feedback, the Baldrige 

Program now asks examiners to express the main points of their feedback in what we now call 

“Finding Statements.” These are followed by relevant evidence. For key strengths and 

opportunities for improvement, examiners provide the potential impact on your organization 

for your consideration. In addition, the program has included Criteria item references with each 

finding to assist you in understanding the source of the feedback. 

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

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

applicants for you to consider. 

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

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

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

Criteria item references (which are included in the finding); doing this may help you 

understand the basis of the examiners’ evaluation. 

Malcolm Baldrige National Quality Award—2022 Feedback Report 2 
 

 

 

 

• Especially note finding statements in boldface type. These statements indicate observations 

that the examiner team found particularly important—strengths or opportunities for 

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

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

of that particular item. 

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

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

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

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

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

strength findings as a foundation to improve the things you do well. Sharing those things 

you do well with the rest of your organization can speed organizational learning. 

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

what’s most important, impactful, and actionable at this time. 

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

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

We are able to prove that you can serve a poor community like ours and still be the best at 

what you do. ... All of this is a result of the journey that we’ve been on with Baldrige. ... 

Delivering quality care can be very rewarding financially to you, and you can build your 

financial strength as a result of that. 

John Raffoul, President 

Adventist Health White Memorial 

2019 Baldrige Award Recipient 

Malcolm Baldrige National Quality Award—2022 Feedback Report 3 
 

 

 

 

 

Key Themes—Process Items 

Copansburg Regional Health System (CRHS) scored in band 5 for process items (1.1–6.2). 

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

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

learning, including some innovation, that result in improving the effectiveness and efficiency of 

key processes. 

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

organizations) identified in CRHS’s response to process items are as follows: 

Demonstrating a systems perspective in its interdependent operations, CRHS has multiple 

step-wise and improved approaches that are fully deployed and aligned to support key 

organizational strategic objectives and goals. 

• Senior leaders demonstrate a commitment to legal and ethical behavior and 

promote an organizational environment that requires it. (1.1a[2]) 

• CRHS’s systematic approach to societal well-being is integrated with its strategic 

planning process (SPP) and has undergone evaluation and improvement. (1.2c[1]) 

• CRHS has a systematic, well-deployed complaint management system that is 

integrated with organizational values and has experienced cycles of learning and 

improvement. (3.2a[3]) 

• Data and information are systematically selected, collected, aligned, and integrated 

to track daily operations and monitor progress toward achieving strategic objectives. 

(4.1a[1]) 

• CRHS determines which strategic opportunities to pursue in the SPP using return on 

investment (ROI) and alignment with its mission, vision, and values (MVV) as key 

considerations. (6.1d) 

Using systematic processes for strategic planning, measurement and analysis, and process 

improvement, CRHS selects and uses measures that best reflect performance levels for 

improving its health care outcomes, as well as for achieving overall organizational 

effectiveness and efficiency. 

• CRHS has a systematic approach to collect and analyze data and to develop 

information for use in its SPP, with cycles of refinement evident. (2.1a[3]) 

• The systematic approaches to action plan measurement reinforce 

organizational alignment. (2.2a[5]) 

• CRHS uses a systematic approach to review organizational performance and 

key comparative data in order to assess organizational success. (4.1b) 

Malcolm Baldrige National Quality Award—2022 Feedback Report 4 
 

 

• Findings from performance reviews drive the development of priorities for 

continuous improvement. (4.1c[2]) 

• Processes for building and managing organizational knowledge benefit from 

systematic evaluation and improvement cycles. (4.2b[1]) 

• CRHS assesses its workforce for changing capacity and capability needs through 

predictive analytics, knowledge and certification assessments, and evaluation of 

the performance of measures such as workforce retention, average time to fill 

vacancies, percentage of employees cross-trained, and registered nurse (RN) 

education levels. (5.1a[1]) 

• CRHS uses Lean methodology to eliminate waste, prevent work process errors, 

and minimize the cost of rework. (6.2a) 

CRHS’s systematic approaches to patient-focused excellence address today’s customer 

needs/expectations and anticipate future needs/expectations. 

• CRHS has clearly defined strategic objectives, goals, and key performance 

indicators (KPIs); and these are aligned with the strategic advantages, challenges, 

and opportunities (SA/SC/SO). (2.1b[1]) 

• CRHS uses multiple methods to listen to patients and other customers to obtain 

actionable information across the stages of the customer relationship. (3.1a[1]) 

• CRHS has a systematic approach to listening to potential customers for 

actionable information, with evidence of learning. (3.1a[2]) 

• CRHS uses a variety of data inputs to determine health care service offerings, 

including consideration of customer needs, preferences, and expectations. 

(3.1b[2]) 

• CRHS utilizes multiple methods to determine patient satisfaction and 

engagement that vary by customer groups and market segments, and it obtains 

information relative to other organizations (competitors and those offering 

similar services). (3.2b) 

• CRHS uses patient input gathered from all stages of the patient relationship to 

set realistic patient expectations. (6.1b[2]) 

• CRHS uses multiple approaches to improve work processes, health care services, 

and performance. (6.1b[4]) 

CRHS demonstrates a commitment to and valuing of the workforce through its leadership 

system and approaches to strategy development, workforce engagement, and a safe working 

environment. 

• Senior leaders communicate with and engage the entire workforce, key partners, 

patients, and other key customers to motivate high performance and a patient 

focus. (1.1b) 

Malcolm Baldrige National Quality Award—2022 Feedback Report 5 
 

• CRHS has clearly defined strategic objectives, goals, and KPIs; and these are aligned 

with the SA/SC/SO. (2.1b[1]) 

• CRHS utilizes multiple methods to prepare its workforce for changing capability and 

capacity needs and to prevent workforce reductions and minimize the impact of any 

necessary staffing reductions. (5.1a[3]) 

• CRHS utilizes multiple approaches to ensure workplace health and security. (5.1b[1]) 

• CRHS systematically supports high performance through its Integrated Talent 

Management Process. (5.2c[1]) 

• CRHS has deployed multiple processes to manage the career development of its 

workforce and its future leaders, including succession planning. (5.2c[4]) 

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

response to results items are as follows: 

In areas across categories, CRHS has not made evident systematic approaches related to work 

processes and effectiveness. 

• It is not clear how the organization recognizes when internal or external 

circumstances require a shift in action plans. (2.2b) 

• It is unclear if CRHS has a systematic process to determine its customer segments. 

(3.1b[1]) 

• It is not clear how CRHS uses knowledge and resources to embed learning in the way 

it operates. (4.2b[3]) 

• It is unclear how CRHS systematically ensures that the workplace is technologically 

and attitudinally accessible without bias for all members of its workforce. (5.1b[1]) 

CRHS appears to lack systematic approaches to creating an environment for success now and in 

the future with regard to its support of innovation and intelligent risk taking, balancing of 

resource needs, and equity and diversity. 

• It is not apparent that CRHS has a systematic approach to create and reinforce a 

culture that fosters patient and other customer engagement, equity, and inclusion. 

(1.1c[1]) 

• It is not evident that CRHS has a systematic approach to create and balance value for 

all stakeholders. (1.1c[2]) 

• It is unclear how CRHS’s strategy development process stimulates innovation. 

(2.1a[2]) 

• It is not clear how CRHS systematically considers and balances the needs of all key 

stakeholders in relation to its strategic objectives. (2.1b[2]) 

Malcolm Baldrige National Quality Award—2022 Feedback Report 6 
 

 

 

 

• Beyond the approach to access, it is unclear if CRHS has processes for ensuring fair 

treatment for different patients and patient and other customer groups/market 

segments. (3.2a[4]) 

• It is not evident how CRHS’s performance management and learning and 

development systems support intelligent risk taking, ethical health care, and ethical 

business practices. (5.2c[1,2]) 

• It is not clear how the organization ensures that its performance and career 

development approaches promote equity and inclusion for a diverse workforce and 

different workforce groups and segments. (5.2c[5]) 

Key Themes—Results Items 

Copansburg Regional Health System (CRHS) scored in band 5 for results items (7.1–7.5). 

For an organization in band 5, typically results address most key customer/stakeholder, market, 

and process requirements, and they demonstrate areas of strength against relevant comparisons 

and/or benchmarks. Beneficial trends and/or good performance are reported for most areas of 

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

mission. 

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

found in its response to results items are as follows: 

CRHS demonstrates beneficial trends and favorable comparisons for some results of health care 

outcomes, customer satisfaction, and workforce climate measures. 

• Many results for health care outcomes and performance of services demonstrate 

beneficial trends and are favorable in comparison to relevant benchmarks. (7.1a) 

• Some results for measures of customer satisfaction have achieved top-decile levels 

and demonstrate beneficial trends. (7.2a[1]) 

• CRHS reports some workplace climate results for health, security, and diversity 

measures that demonstrate favorable trends and performance levels relative to 

competitors or CRHS’s goal. (7.3a[2]) 

Many of CRHS’s results for process efficiency and effectiveness, leadership and governance, and 

financial and marketplace performance measures show beneficial trends and favorable 

comparisons. 

Malcolm Baldrige National Quality Award—2022 Feedback Report 7 
 

 

 

 

• Some results for process efficiency and effectiveness compare favorably to relevant 

benchmarks by hospital location. (7.1b[1]) 

• CRHS’s results for legal and ethical behavior approaches demonstrate beneficial 

performance trends and favorable levels in comparison to others. (7.4a[3,4]) 

• Most results for key financial performance measures demonstrate beneficial trends 

and show areas of leadership when evaluated against relevant benchmarks and 

comparisons. (7.5a[1]) 

• Results for marketplace performance demonstrate beneficial trends and show very 

good performance in comparison to others. (7.5a[2]) 

Beneficial trends across segments are evident for many patient, customer, and workforce results. 

• Results for measures of patient satisfaction across multiple patient groups and 

service lines demonstrate beneficial trends. (7.2a[1]) 

• CRHS reports multiple results for measures of workforce satisfaction and 

engagement for its various workforce groups and segments that demonstrate 

favorable trends. (7.3a[3]) 

• CRHS’s leadership and governance results demonstrate favorable levels and 

comparisons as well as beneficial trends in many areas of importance. (7.4a[1,2,4]) 

d. Considering CRHS’s key business/organization factors, the most significant 

opportunities, vulnerabilities, and/or gaps (related to data, comparisons, linkages) 

found in its response to results items are as follows: 

Key results and/or segmentation of results are missing across categories for measures of process 

effectiveness, work processes, customer dissatisfaction, and workforce. 

• Some results for process efficiency and supply-network management measures are 

missing. (7.1b,c) 

• CRHS has provided limited results for measures related to patient dissatisfaction. 

(7.2a[1]) 

• CRHS is missing patient satisfaction results for some key outpatient (OP) and postacute care service offerings. (7.2a[1]) 

• CRHS is missing some results to demonstrate its senior leadership and governance 

performance. (7.4a[1,2,4,5]) 

• Some results are missing, and some measures presented are missing results for key 

segments. (7.5a,b) 

Malcolm Baldrige National Quality Award—2022 Feedback Report 8 
 

 

 

Some of CRHS’s results for its customers, workforce, leadership, and strategy implementation 

approaches demonstrate unfavorable performance relative to comparisons. 

• Results for many measures of patient satisfaction and engagement compare 

unfavorably to top-decile benchmarks. (7.2a) 

• CRHS reports multiple results for measures of workforce satisfaction and 

engagement for its various workforce groups and segments that do not achieve topquartile or top-decile performance levels of comparisons. (7.3a[3]) 

• CRHS’s societal well-being results show unfavorable trends in some areas and 

perform unfavorably compared to others. (7.4a[5]) 

• Only one of 17 key performance measures (Figure 2.2-2) for strategic goals/action 

plans demonstrates achievement of top-decile performance (that is, Operating 

Margin, Figure 7.5-2). (7.5b) 

• Results for some key measures of marketplace performance do not compare 

favorably to competitors’ results. (7.5a[2]) 

Malcolm Baldrige National Quality Award—2022 Feedback Report 9 
 

Category 1 Leadership 

Item 1.1 Senior Leadership 

Strengths 

Finding: Senior leaders communicate with and engage the entire workforce, key partners, 

patients, and other key customers to motivate high performance and a patient focus. 

Item Reference: 1.1b 

Evidence: 

● Communication System (Figure 1.1-2 identifies what, who, how, when, and 

messenger matters) 

● Two-way communication methods (listed in Figure 1.1-3) 

● Evaluates communication system using surveys/evaluations or other data (e.g., 

open rates/clicks/attendance/watch rates) 

● Examples of learning: communicate through desktops rather than emails, 

change-of-shift huddles, use of stakeholder personas in 2019 

● Round-the-Clock forums scheduled for each shift and live-streamed to reach all 

locations; base location rotates, forums recorded, and recordings placed on 

intranet 

Finding: Senior leaders demonstrate a commitment to legal and ethical behavior and promote 

an organizational environment that requires it. 

Item Reference: 1.1a(2) 

Evidence: 

Executive and senior leaders 

● established Code of Ethical Standards of Behavior (CESB) for all members of the 

workforce, including leaders; 

● incorporated CESB into contractual agreements with suppliers, partners, and 

collaborators; 

● conduct open discussions of close calls to promote learning; 

● call out behaviors that cross the line and ensure investigation and follow-up; 

● developed Guiding Principles and the Community Excellence Group (CEG) 

demonstration of these principles in 2020; 

● developed Medical Staff Code of Professional Behavior Policy, providing for the 

raising and investigation of complaints; and 

● established the Bioethics Committee. 

Malcolm Baldrige National Quality Award—2022 Feedback Report 10 
 

 

Finding: Senior leaders create a focus on action to achieve the organization's mission, and they 

set expectations for organizational performance. 

Item Reference: 1.1c(2) 

Evidence: 

● Focus on action: the leadership system includes cascading goals, with 

accountability at multiple levels 

● Leadership system: cascading goals; deployed action plans; and measurements, 

evaluations, learning, and actions based on results 

● Organizational goals are established during the SPP. 

● Core competencies (CCs) of safe, high-quality clinical care and efficiency in 

operations give priority to processes and systems supporting the delivery of 

patient care. 

● 2019 cycle of learning ensured that supplier, partner, and collaborator 

agreements reflect alignment with CRHS’s strategic goals. 

Opportunities for Improvement 

Finding: It is not apparent that the organization has a systematic approach to create and 

reinforce a culture that fosters patient and other customer engagement, equity, and inclusion. 

Item Reference: 1.1c(1) 

Evidence: 

● In reference to care model of inclusion, a systematic approach is not evident; for 

example, no steps of a process were described. 

● In regard to health care team’s seeking to engage and partner with family to 

make decisions, such as through rounding and in-person discussions, a stepwise 

process is not apparent. 

● Despite leadership’s creation of new position of vice president of diversity and 

inclusion, no systematic approach related to that position were described. 

● A process is not evident in reference to the Performance Improvement Council 

(PIC) & Teams Realizing Awesome Care (TRAC) approach that the leadership 

encourages for proposing ideas that reflect intelligent risks. 

● Despite the innovation process in category 6 (Figure 6.1-5), it is not evident how 

the leadership creates an environment for intelligent risk taking. 

Potential Impact of Addressing: 

• Without a systematic approach to a culture that fosters the engagement of 

patients and other customers, as well as fostering equity and inclusion, the 

Malcolm Baldrige National Quality Award—2022 Feedback Report 11 
 

 

 

 

 

 

 

organization may hinder its ability to meet a customer requirement related to 

participation in care and may not align with its WE CARE value of Respect. 

Finding: It is not evident that CRHS has a systematic approach to create and balance value for 

all stakeholders. 

Item Reference: 1.1c(2) 

Evidence: 

● A process for systematically balancing value for patients, families, and 

stakeholders during step 2 of the SPP was not described. 

● Beyond the selection of metrics and requirements that support each group, it is 

unclear how the leadership balances competing needs/priorities. 

● In reference to communication that leads to information for the strategic 

planning process, how balancing is systematically achieved was not described. 

Potential Impact of Addressing: 

● A process for creating and balancing value for all stakeholders may enhance the 

organization’s ability to address its strategic challenge related to the difficulty in 

reducing health disparities. 

Finding: A systematic approach to set the vision and values is not clear. 

Item Reference: 1.1a(1) 

Evidence: 

● CRHS’s vision and values were initially established in 2000 by the leadership and 

boards of the two original hospitals; process used is not apparent. 

● In regard to the vision and values being reviewed and affirmed annually during 

the SPP retreat, the process for updating or setting a new vision and values was 

not described. 

Potential Impact of Addressing: 

● Without a process to establish or reaffirm its vision and values, CRHS may inhibit 

its ability to achieve its strategic objectives of top-decile performance in 

customer, workforce, financial, and process excellence. 

Malcolm Baldrige National Quality Award—2022 Feedback Report 12 
 

 

Scoring Range 

50–65% 

Rationale: Score should not be in 70-85 range in part because approaches are not evident in 

response to some Criteria questions at the multiple level. Score should not be in 30-45 range in 

part because the organization is responsive to overall Criteria questions and demonstrates good 

deployment of approaches in many areas. 

Malcolm Baldrige National Quality Award—2022 Feedback Report 13 
 

 

 

Item 1.2 Governance and Societal Contributions 

Strengths 

Finding: CRHS systematically anticipates public concerns with its future health care services and 

prepares for those impacts proactively. 

Item Reference: 1.2b(1) 

Evidence: 

● Includes key stakeholders in the planning and designs of new/expanded services. 

● Uses Failure Mode and Effects Analysis (FMEA) to anticipate what could go 

wrong and to identify failure points, the likelihood of occurrence, and the 

significance of each. 

● Incorporates inputs from customer, stakeholder, and objective outsiders during 

the FMEA process and allows them to help determine what design changes are 

needed to avert or mitigate potential risks. 

● Leaders/senior leaders (L/SL) are actively involved in hospital associations, 

accountable care collaboratives, health plan associations, and advisory groups to 

anticipate future legal, regulatory, and community concerns with the 

organization’s operations. 

● Other information from the community comes through voice-of-the-customer 

(VOC) channels (Figures 3.1-1 and 3.1-2). 

Finding: The organization has a process to evaluate its senior leaders and governance board. 

Item Reference: 1.2a(2) 

Evidence: 

● BOT conducts an annual self-assessment of the board as a whole and of 

individual BOT member effectiveness. 

● BOT Executive Committee evaluates CEO, CEO evaluates executive leaders (ELs), 

and ELs evaluate senior leaders (SLs). 

● Incentive performance-based model rewards EL and SL performance. 

● Cascading goals from SPP to Performance and Professional Development Plan 

(PPDP) 

● The leadership system is evaluated annually for effectiveness. 

● BOT reviews assessment results to identify OFIs leading to cycles of 

improvement, such as the creation of the Board Quality Committee in 2009 and 

a move to a consent agenda in 2018. 

Malcolm Baldrige National Quality Award—2022 Feedback Report 14 
 

 

 

Finding: The organization’s systematic approach to societal well-being is integrated with its SPP 

and has undergone evaluation and improvement. 

Item Reference: 1.2c(1) 

Evidence: 

● CRHS has a systematic approach to select new services (listed in Figure 1.2-3), 

which is based on Plan, Do, Check, Act (PDCA). 

● Cycle of learning: incorporated community priority of “Live Green Lexington” 

into next planning cycle 

● Collaborates with city and community organizations to support and strengthen 

social and economic systems 

● Community leaders serve on the CEG. 

● Members of the community participate in the SPP, and information is used to 

select strategic goals and design services. 

● In 2019, the organization expanded partner opportunities around education, 

economy, and quality of life. 

Finding: CRHS utilizes multiple methods to ensure responsible governance. 

Item Reference: 1.2a(1) 

Evidence: 

● Identifies approaches and frequencies for approaches (Figure 1.2-1), supporting 

responsible governance, including 

o accountability for senior leaders’ actions, 

o accountability for strategy, 

o fiscal accountability, 

o accountability for patient safety and health care quality, 

o transparency of operations, 

o governance BOT, 

o community-based advisory board, 

o independence and effectiveness of internal and external audits, 

o protection of stakeholder interests, and 

o succession planning. 

Malcolm Baldrige National Quality Award—2022 Feedback Report 15 
 

 

 

 

Opportunities for Improvement 

Finding: It is unclear how the organization’s activities related to determining areas for 

organizational involvement in supporting and strengthening its communities form a wellordered, repeatable approach. 

Item Reference: 1.2c(2) 

Evidence: 

● Despite key community examples provided by CRHS, a process for identifying key 

communities is not apparent. 

● For key communities that CRHS describes as being 40 miles east to west and 50 

miles north to south of Lexington, the organization does not make evident a 

process for determining these key communities within that geographic space. 

● Not clear how CRHS’s approach for selecting unmet health needs of relying on 

triage and community health needs assessment (CHNA) findings and executive 

leaders’/senior leaders’ service on community groups is integrated into the 

organization’s determinations. 

Potential Impact of Addressing: 

● Lack of a systematic approach to identify key communities and determine areas 

for organizational involvement may limit the organization’s ability to maintain its 

strategic advantage of market share leadership. 

Finding: It is not clear that approaches to promote and ensure ethical behavior in the governance 

system are deployed beyond the workforce, such as in interactions with patients, other customers, 

and the community. 

Item Reference: 1.2b(2) 

Evidence: 

● CESB only applies to the workforce. 

● Medical staff president and medical executive committee address only physicianrelated breaches. 

● No deployment is evident to governance, patient/customer interactions, 

partners/suppliers, and community stakeholders. 

● Deployment is unclear for CRHS’s formal mechanisms for ensuring ethical 

behavior through specifications, criteria, and a scoring system that relates to 

suppliers and partners. 

Malcolm Baldrige National Quality Award—2022 Feedback Report 16 
 

 

Potential Impact of Addressing: 

● Full deployment of ethical behavior approaches may enhance the organization’s 

ability to ensure that it meets expectations of patients, other customers, and the 

community, such as the expectation for high-quality and safe care. 

Scoring Range 

50–65% 

Rationale: Score should not be in 70-85 range in part because the organization has OFIs related 

to some overall and multiple-level Criteria questions, as well as an important OFI for deployment. 

The score should not be in 30-45 range because the organization has approaches responsive to 

overall questions (beyond basic level), and there is evidence of deployment in some areas. 

Additionally, there is some evidence of learning and integration in the organization’s evaluation 

of senior leaders and the BOD and in the approaches to societal well-being. 

Malcolm Baldrige National Quality Award—2022 Feedback Report 17 
 

 

 

Category 2 Strategy 

Item 2.1 Strategy Development 

Strengths 

Finding: CRHS’s well-deployed and systematic approach to strategic planning benefits from 

cycles of learning and improvement. 

Item Reference: 2.1a(1) 

Evidence: 

● CRHS has four-stage PDCA approach (illustrated in Figure 2.1-1). 

● 16-step SPP: Planning involves the ELT, business-unit SLTs, and board members. 

● Planning horizons are set for short term, long term, and ultra-long term. 

● Cycle of learning and improvement caused move from three-year planning 

process to annual planning process. 

● Capital budget process was integrated with the same three-year time frame of 

the SPP, with annual refresh. 

● In steps 7 through 8, draft goals and objectives are provided to business-unit 

leaders, who have their own retreats and develop and refine plans that are 

aligned to the system plan. 

● SPP is integrated with budgeting process, PDCA, communication 

methods/modes, and the CHNA. 

Finding: CRHS has a systematic approach to collect and analyze data and to develop 

information for use in its SPP, with cycles of refinement evident. 

Item Reference: 2.1a(3) 

Evidence: 

● First three steps of the SPP (Figure 2.1-1) involve data collection and analysis as 

well as an environmental scan. 

● Since improvement in 2019, BOT and leaders reach out to area organizations to 

gain additional community data. 

● Improvement in 2020 provided new segmentation methods to segment 

information and reduce bias. 

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Finding: CRHS has clearly defined strategic objectives, goals, and KPIs; and these are aligned 

with the SA/SC/SO. 

Item Reference: 2.1b(1) 

Evidence: 

● CRHS presents strategic objectives, goals, and results that are aligned with 

SA/SC/SO (Figure 2.2-2). 

● Objectives of top-decile performance in customer excellence, workforce 

excellence, process excellence, and financial excellence 

Opportunities for Improvement 

Finding: It is unclear how the organization’s strategy development process stimulates 

innovation. 

Item Reference: 2.1a(2) 

Evidence: 

● Unclear how Baldrige Award recipient (BAR) process that provides input to 

identify strategic opportunities stimulates innovation (unclear how discussion of 

processes of BARs and attendance at Quest for Excellence Conference stimulates 

innovation). 

● Not clear how the Shark Tank program (in which people can present ideas vetted 

for cost/benefit) that the organization incorporated into the Action Planning 

Process (APP) is used in SPP to support intelligent risk taking and stimulate 

innovation. 

● Not evident how strategic opportunities are identified or how CRHS 

systematically determines that strategic opportunities are intelligent risks to 

pursue. 

Potential Impact of Addressing: 

● A systematic approach to stimulate innovation as part of the strategy 

development process may facilitate CRHS’s identification of strategies to address 

some strategic challenges and ways to capitalize on strategic advantages. 

Finding: It is not clear how the organization systematically considers and balances the needs of 

all key stakeholders in relation to its strategic objectives. 

Item Reference: 2.1b(2) 

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Evidence: 

● Not clear how balancing occurs when key stakeholder needs are considered 

through the budgeting process inherent in the APP (Figure 2.2-1). 

● Not clear how CRHS ensures balancing of needs through discussions by the BOT 

and the leadership. 

Potential Impact of Addressing: 

● An approach to ensure that the organization considers and balances the needs of 

all key stakeholders as part of determining strategic objectives may help the 

organization enhance the future engagement of some key stakeholders and thus 

may help it execute its strategies and action plans. 

Scoring Range 

70–85% 

Rationale: Score should not be in 90-100 range because the organization is missing approaches 

in response to some multiple-level Criteria questions, and there is an OFI around innovation. 

Score should not be in 50-65 range because the organization addresses most multiple-level 

questions (beyond overall level); and systematic approaches, deployment, and learning are 

evident. 

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Item 2.2 Strategy Implementation 

Strengths 

Finding: CRHS has a systematic approach to developing action plans, with evidence of learning. 

Item Reference: 2.2a(1) 

Evidence: 

● CRHS has 11-step, PDCA-based Action Planning Process (APP; Figure 2.2-1). 

● Action plans (APs) are developed using an APP template. 

● In 2018, SMART goals were converted into SMARTER (Specific, Measurable, 

Aligned, Realistic, Time-bound, Evaluated, Reviewed) goals, adding “evaluated” 

and “reviewed.” 

Finding: CRHS has deployed a systematic approach to ensure that financial and other resources 

are available to support the achievement of action plans, and this includes the allocation of 

resources to support action plans. 

Item Reference: 2.2a(3) 

Evidence: 

● Ensures that financial and other resources are available to support the 

achievement of action plans through integration of the plans with the budgeting 

process. 

● Action plan template includes requirements for all types of resources, including 

funds, staff time, space, and equipment. Action plan template includes analysis 

of the costs and benefits to calculate the overall financial impact. 

● If insufficient resources are available, plans are negotiated. Plan of Actions and 

Milestones (POAM) also states when support department resources will be 

required to optimize and allocate those resources. 

Finding: The systematic approaches to action plan measurement reinforce organizational 

alignment. 

Item Reference: 2.2a(5) 

Evidence: 

● Action plan measurement system reinforces organizational alignment with two 

approaches. 

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● Each action plan includes determination of the key intended outcome prior to 

identification of the measures and metrics that will be tracked. 

● Action plan numbering system underscores the alignment of the plan(s) that 

support strategic objectives and meeting of goals. 

● If action plan timing goals and performance targets are being met but the 

progress toward accomplishing the strategic objective is not on a glide slope, this 

is regarded as a trigger to evaluate the need for analysis and adjustment or 

possibly the creation of new action plans. 

● Subplans are considered leading indicators of plan performance and lack of 

progress may trigger changes in the plan. 

Opportunities for Improvement 

Finding: It is not clear how the organization recognizes when internal or external circumstances 

require a shift in action plans. 

Item Reference: 2.2b 

Evidence: 

● Despite new plan development via a mid-cycle action plan using the same 

process, approval, and signature (difference is that it is “mid cycle”) and despite 

contingency fund budgeting if resources exceed the approved budget, it is not 

clear how the organization might recognize the need for a shift in action plans 

other than through missing an existing target. 

● Despite CRHS’s monitoring of plan performance, it is not clear how the 

organization distinguishes between the need to modify a plan as opposed to the 

rapid execution of new plans. 

● It is not apparent that CRHS monitors external changes. 

● During virtual interview, CRHS provided example of responding to a target not 

being met as a need for modified action plans but did not describe a systematic 

approach to recognizing when action plan modifications and rapid execution was 

needed. 

Potential Impact of Addressing: 

● Beyond use of missed targets as an indicator, a systematic approach to enable 

the organization to recognize when circumstances require a shift in action plans 

and rapid execution of new plans could help it embed resiliency in its operations 

(a strategic objective) and could enhance its ability to respond to challenges and 

blind spots as well as take advantage of some unexpected opportunities. 

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Finding: In the organization’s use of Communication Methods/Modes (Figure 1.1-3) to deploy 

action plans, it is not clear that action plans are communicated to suppliers, partners, and 

volunteers. 

Item Reference: 2.2a(2) 

Evidence: 

● Action plan deployment occurs in step 10 of the SPP and is usually accomplished 

by groups. 

● CRHS describes how action plans are implemented/deployed as “usually,” 

“occasionally,” and “more commonly,” indicating irregular deployment. 

● During virtual interviews, when CRHS referenced communication methods 

(Figure 1.1-3) as the deployment method for all action plans, it did not provide 

specific examples of communication to the segments of suppliers, partners, and 

volunteers. 

Potential Impact of Addressing: 

● Systematic deployment of action plans to suppliers, partners, and volunteers 

may enhance the organization’s ability to execute some action plans. 

Scoring Range 

50–65% 

Rationale: Score should not be in 70-85 range because only some approaches address Criteria 

questions at the multiple level (beyond the overall questions); and evidence is missing for how 

the organization manages for innovation. Score should not be in 30-45 range in part because the 

organization has demonstrated deployed approaches that address Criteria questions beyond the 

basic level. 

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Category 3 Customers 

Item 3.1 Customer Expectations 

Strengths 

Finding: CRHS uses multiple methods to listen to patients and other customers to obtain 

actionable information across the stages of the customer relationship. 

Item Reference: 3.1a(1) 

Evidence: 

● Develops customer listening posts based on PDCA by researching the 

characteristics of each group, followed by focus group interviews to understand 

communication and service preferences, testing the draft method, gathering 

feedback, refining the design, and checking to assess effectiveness (Figure 3.1-2). 

● Sample of Key Patient, Family Member, and Other Customer Listening Methods 

(Figure 3.1-1) 

● Immediate and actionable feedback varies by service area and benefits from 

automation, which enables moving from responding to needs to systemic 

improvements and comparisons across multiple facilities. 

Potential Impact of Addressing: 

● This enables the organization to learn from patients and meet key requirements 

as it is striving to perform at the top-decile level. 

Finding: CRHS has a systematic approach to listening to potential customers for actionable 

information, with evidence of learning. 

Item Reference: 3.1a(2) 

Evidence: 

● Multiple listening posts, partnerships (Figure P.1-4), and public data sources are 

used to gather actionable information from competitors and potential 

customers. 

● Data are aggregated monthly and annually to detect trends and assess 

performance. 

● Learning example: targeted advertising on social media increased unique visitors 

by 12%. 

● Data are turned into actionable information through the Voice of the Customer 

System (Figure 3.1-2). 

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Potential Impact of Addressing: 

● This enables CRHS to learn from potential customers and attract new patients, 

maintaining/improving its market leader position. 

Finding: CRHS uses a variety of data inputs to determine health care service offerings, including 

consideration of customer needs, preferences, and expectations. 

Item Reference: 3.1b(2) 

Evidence: 

● Use of preference data and dissatisfiers 

● Assessment includes “gap versus enhance” and examines if opportunity aligns 

with CRHS’s vision, values, and CCs. 

● Sources of data: Press Ganey, CHNAs, and CAHPS 

● Emerging preferences for technology and home services have been identified. 

● New preferences are analyzed as either an enhancement to current offerings or 

as entirely new services. New services are further analyzed to determine if they 

can be offered in-house or through third parties. 

● Employees travel to communities in service areas to help identify customer 

needs. 

Opportunities for Improvement 

Finding: It is unclear if the organization has a systematic process to determine its customer 

segments. 

Item Reference: 3.1b(1) 

Evidence: 

● CRHS’s explanation that customer satisfaction and Consumer Preference Survey 

data are evaluated to detect shifts in preferences, types of service, and service 

delivery methods seems to address service offerings rather than customer 

segments. 

● Unclear if customer segmentation is based on service, preference, delivery, use 

of technology, etc. 

● Figure P1.3 information does not align with segment/group narrative in item 3.1. 

● Despite examples provided of new customer segment (or special population) 

based on preferences, no process is described/evident. 

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Potential Impact of Addressing: 

● A systematic process to determine customer segmentation may enable more 

actionable information for planning and may increase CRHS’s ability to mitigate 

its strategic challenge (competitive change) of increasing competition. 

Finding: It is unclear if the organization has a systematic process to listen to former patients. 

Item Reference: 3.1a(2) 

Evidence: 

● In regard to after-service surveys and telephone follow-ups, CRHS does not 

appear to address former patients (rather than current patients who have 

finished encounter). 

● CRHS’s examples of former customers were limited to members who leave 

health plan and patients who change physician group (join competitor). 

Potential Impact of Addressing: 

● Establishing a process to listen to former patients may enable the organization to 

identify sources of dissatisfaction and thus better meet customer/patient 

expectations. 

Scoring Range 

50–65% 

Rationale: Score should not be in 70-85 range because of OFI finding for a Criteria question at 

the overall level, as well as limited evidence of learning. Score should not be in 30-45 range 

because the organization demonstrates systematic, well-deployed approaches for most overall 

and some multiple-level Criteria questions. 

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Item 3.2 Customer Engagement 

Strengths 

Finding: CRHS has a systematic, well-deployed complaint management system that is 

integrated with organizational values and has experienced cycles of learning and improvement. 

Item Reference: 3.2a(3) 

Evidence: 

● Complaint/Grievance Management System (shown in Figure 3.2-2) follows PDCA 

methodology and is composed of 14 steps. 

● Evidence of learning: Each year, the Complaint Management System is reviewed 

for potential improvements. Example of improvement (2018): tracked 

complaints resolved in real time. 

● Frontline staff members are equipped to provide compliant resolution. 

● Patient Experience Office (PEO) handles referrals from frontline staff members. 

● Complaints are aggregated and analyzed monthly. 

● Analyses are evaluated by the PIC and given to TRAC teams, as appropriate, to go 

through the PDCA process. 

Potential Impact of Addressing: 

● This demonstrates CRHS’s values of accountability, respect, and excellence. 

Finding: CRHS utilizes multiple methods to determine patient satisfaction and engagement that 

vary by customer groups and market segments, and it obtains information relative to other 

organizations (competitors and those offering similar services). 

Item Reference: 3.2b 

Evidence: 

● Focus group interviews (face to face and virtual), COE partnership 

● Focus groups identify unique quality features for senior leaders; surveys assess 

satisfaction with those features. 

● Net Promoter Scores and event counts (website visits/hits) are used to assess 

engagement. 

● Electronic surveys began in 2018 (for cost savings). 

● Health plan data and satisfaction and complaint data are analyzed together. 

● Surveys are tracked and aggregated for analysis by business units. 

● Survey are administered on a continuous basis and updated annually. 

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● Responses are aggregated monthly for actionable process improvements and 

annually for more complex systemic improvements through PIC. 

● Results are compared against competitor groups’ performance using database of 

survey vendor. 

● Seekers program allows CRHS to capture regional data through in-person 

interactions. 

● Data exchange program allows sharing of certain types of data, such as wait 

times and data for overall satisfaction measures. 

● Community Health Needs Assessments (CHNAs) 

Finding: The organization uses a systematic, three-phase approach to acquire, manage, and 

retain customers, which helps it maintain its strategic advantage related to its market share 

position. 

Item Reference: 3.2a(1) 

Evidence: 

● Three-phase approach to build CRHS’s brand and to acquire and retain patients 

and other customers (create awareness, experience services, become a repeat 

customer/promoter) 

● These phases also appear to align with the three stages of the patient/customer 

lifecycle. 

● Approaches for creating awareness include mobile clinics, participation in 

community fairs, tour offerings, and senior center outreach. 

● Relationship management software and patient portal affect the customer 

experience. 

● Patient portal addresses post-service needs. 

● Proactive approach to brand image and awareness via social media marketing 

Finding: CRHS systematically uses VOC data to create a patient-focused culture, with evidence 

of learning. 

Item Reference: 3.2c 

Evidence: 

● Data are categorized, aggregated, and used at multiple levels: front line for quick 

adjustments, middle management for functional changes, and senior leadership 

for new services/investments; data are aggregated quarterly. 

● Listening posts and customer segments are evaluated annually. 

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● Customer access, satisfaction, and dissatisfaction are corporate measures, 

facility measures, and functional measures, which are aligned often with key 

drivers of satisfaction and loyalty. Senior leaders have performance targets (for 

the number of complaints and the percentage of satisfaction scores, by customer 

segments) embedded in their performance plans and included in individual 

performance standards. 

● Staff members are incentivized to document and resolve complaints. 

● Educating, measuring, recognizing, and rewarding individuals and groups at 

every level of the organization—in alignment with meeting or exceeding 

customer expectations—enable CRHS to foster and maintain a customer-focused 

culture. 

Opportunities for Improvement 

Finding: A systematic process to determine customers’ key support requirements is not evident. 

Item Reference: 3.2a(2) 

Evidence: 

● Beyond information provided about access (Seeker program) and information 

(Figure 3.2-1), CRHS does not make evident how it provides support services. 

● For example, it is not clear how patients might get support for making 

appointments, billing, etc. (or if the services are available in other languages). 

● CRHS “feels” that the basic driver is access. 

Potential Impact of Addressing: 

● Without a process, CRHS may miss an opportunity to identify a customer key 

requirement, may limit its ability to meet customer expectations, and may 

adversely impact its strategic advantage related to its market position. 

Finding: Beyond the approach to access, it is unclear if CRHS has processes for ensuring fair 

treatment for different patients and patient and other customer groups/market segments. 

Item Reference: 3.2a(4) 

Evidence: 

● Various examples are provided to illustrate CRHS’s sensitivity to this issue, to 

include research, studies, and the identification of underserved people and 

communities, but a systematic approach to ensure fair treatment is not 

described. 

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● CRHS does not address fair treatment in managing patient and customer 

relationships, enabling patient and other customers to seek information and 

support, and managing complaints to promote equity and inclusion. There is no 

evidence of processes to ensure that the organization does not inadvertently 

discriminate unfairly or inappropriately against specific patients or patient 

groups. 

Potential Impact of Addressing: 

● With systematic approaches in place to fully ensure fair treatment of different 

patients and other customers and groups, CRHS may ensure that it does not 

inadvertently discriminate against any patient/customer or groups, may better 

meet patient expectations, and may enhance its ability to achieve its mission to 

provide outstanding health care services to improve the health of all citizens in 

the service area. 

Scoring Range 

50–65% 

Rationale: Score should not be in 70-85 range because the organization has an OFI for a Criteria 

question at the overall level and is not yet managing for innovation and sharing refinements. 

Score should not be in 30-45 range because the organization is responsive not only to overalllevel questions, but also has some approaches responsive to multiple-level questions, with good 

deployment and some learning evident. 

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Category 4 Measurement, Analysis, and Knowledge Management 

Item 4.1 Measurement, Analysis, and Improvement of Organizational 

Performance 

Strengths 

Finding: Data and information are systematically selected, collected, aligned, and integrated to 

track daily operations and monitor progress toward achieving strategic objectives. 

Item Reference: 4.1a(1) 

Evidence: 

● Selects, collects, aligns, and integrates data and information using eight-step 

Performance Management System (Figure 4.1-1) 

● Tracks data and information on daily operations using an automated health 

informatics system (DDI). 

● Alignment and integration are reinforced through a set of dashboards that are 

cascaded through system's strategic scorecard. 

● Dashboards and SPC provide for visual management of results and operational 

measures. 

● A 2019 cycle of evaluation and improvement resulted in the use of a statistical 

process control format. 

Potential Impact of Addressing: 

● Systematically gathering appropriate data and information supports daily 

operations and fact-based decision making and sets the conditions to establish 

priorities for continuous improvement and innovation. 

Finding: A systematic approach is used to review organizational performance and key 

comparative data in order to assess organizational success. 

Item Reference: 4.1b 

Evidence: 

● CRHS uses forums to review organizational performance and capabilities (Figure 

4.1-2). 

● Specified performance data are reviewed daily, weekly, monthly, quarterly, biannually, and annually. 

● Comparative data are presented with metrics in a balanced scorecard. 

● Analysis and decisions are also approaches used during scheduled reviews to 

ensure that strategic goals are achieved and that daily operations are monitored. 

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Potential Impact of Addressing: 

● Reviewing organizational performance enables CRHS to assess success, 

determine its progress relative to objectives and goals, and address changing 

needs and requirements. 

Finding: Findings from performance reviews drive the development of priorities for continuous 

improvement. 

Item Reference: 4.1c(2) 

Evidence: 

● When the rate of change is not sufficient to achieve a strategic objective in the 

timetable identified, CRHS looks for innovation to provide a breakthrough 

change. 

● Action plans and new targets are assigned to a responsible leader for further 

evaluation. 

● Performance Review Process (depicted in Figure 4.1-2). Specified performance 

data are presented daily, weekly, monthly, quarterly, bi-annually, and annually 

for analysis and decisions. 

Potential Impact of Addressing: 

● Performance reviews enhance the organization’s ability to set priorities, resolve 

problems, and evaluate and improve work processes. 

Opportunities for Improvement 

Finding: CRHS’s approach to selecting comparative data and information to support fact-based 

decision making is not consistently deployed. 

Item Reference: 4.1a(2) 

Evidence: 

● Beyond the characteristics of comparative data described, the process for 

determining those characteristics or selecting the comparative data is not 

described. 

● Each KPI owner seeks comparative data: this is not a systematic process but, 

rather, an approach subject to variability. 

● Not clear how organization selects comparative data that reveal how it is 

executing its mission and advancing its vision 

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● Not evident that KPI owners’ responsibility for selecting data to support factbased decision making constitutes a systematic process (rather than an approach 

subject to variability). 

Potential Impact of Addressing: 

● Deploying processes consistently across all parts of the organization may enable 

CRHS to effectively set the priorities and direction required to achieve its vision, 

mission, and strategic objectives. 

Finding: CRHS’s approach to ensuring that its performance measurement system can respond to 

rapid or unexpected organizational or external changes is not consistently deployed. 

Item Reference: 4.2a(3) 

Evidence: 

● Unclear how KPI owners (responsible for agility) maintain constant awareness of 

changes in regulatory requirements. 

● Reliance on individual KPI owners to respond to change means KPI owners are 

responsible for ensuring that CRHS’s performance measurement system remains 

agile, which leads to process variability. 

● Limited process evidence 

● No process to ensure measurement agility 

● No evidence of learning 

Potential Impact of Addressing: 

● Consistently applying approaches in relevant work units may allow CRHS to align 

operations, achieve efficiencies, systematically evaluate and improve relevant 

processes, and achieve top-decile performance. 

Scoring Range 

50–65% 

Rationale: Score should not be in 70-85 range because approaches address overall-level 

questions and show gaps in deployment; OFIs (for multiple-level questions) indicate that 

deployment of approaches varies in some areas. Score should not be in 30-45 range because the 

organization’s approaches are generally aligned to overall organizational needs, and there is 

strong evidence of fact-based, systematic evaluation and improvement, with instances of 

innovation. 

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Item 4.2 Information and Knowledge Management 

Strengths 

Finding: Processes for building and managing organizational knowledge benefit from systematic 

evaluation and improvement cycles. 

Item Reference: 4.2b(1) 

Evidence: 

● Builds and manages organizational knowledge (Figure 4.2-1) using a Create, 

Collect, Curate, Disseminate (Transfer), and Implement Model (Figure 4.2-2) 

● Transfers knowledge using Communities of Practice and Strategic Employee 

Engagement Groups 

● PDCA is incorporated into the Knowledge Management System to 

refresh/update information. 

● Blends and correlates data to build new knowledge through the use and analysis 

of health plan data, which enables organization to acquire insights into the 

unique requirements of health plan customers. For example, analyzing claim 

data led to the development of an alternative medicine program within the 

cancer center. 

● Evidence of learning: improvement examples based on 2010, 2015, and 2019 

evaluation cycles 

Potential Impact of Addressing: 

● Knowledge is an organization’s accumulated intellectual resources and 

represents the expertise available to use, invest, and grow; systematic 

evaluation and improvement cycles allow the organization to continuously 

improve and acquire new knowledge. 

Finding: Systematic, tiered approach ensures the availability and user-friendliness of 

organizational data and information. 

Item Reference: 4.2a(2) 

Evidence: 

● Provides access based on staff position: availability of organizational data and 

information is ensured through identification of the data and information 

required for each position and granting of appropriate access 

● Information technology plan includes cloud-based systems. 

● Applies redundant connectivity pathways (fiber optics, microwave, Wi-Fi) 

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● Ensures user-friendliness by conducting focus groups and benchmarking with 

other organizations 

● Ensures the availability of organizational data and information through a robust 

information technology plan that includes hosting the system in the cloud 

Finding: Data quality is ensured and verified using multiple methods, including training, 

prevention of entry error, and use of standardized data dictionaries. 

Item Reference: 4.2a(1) 

Evidence: 

● Ensures the quality of organizational data and information through data input 

and data inspection training 

● DDI and EMR have embedded rules that check data accuracy against 

standardized data dictionaries and patient safety issues such as medication 

allergies. 

● Ensures accuracy and integrity through training and system checks and balances 

● Staff members are trained on how to input and inspect data; system checks 

ensure that taxonomy is followed for standardization. 

● In 2018, CRHS developed standardized data dictionaries, which are managed by 

the Data and Governance Committee. 

Opportunities for Improvement 

Finding: It is not clear how CRHS uses knowledge and resources to embed learning in the way it 

operates. 

Item Reference: 4.2b(3) 

Evidence: 

● Systematic process is not described 

● Not clear how using the Baldrige framework is a systematic approach to embed 

learning 

● Anecdotal: Learning is built into the MVV and Baldrige framework 

Potential Impact of Addressing: 

● Embedded learning may help CRHS enhance problem solving at the source, build 

and share knowledge throughout the organization, and identify improvement 

and innovation opportunities. 

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Finding: Approaches to share best practices are not consistently deployed. 

Item Reference: 4.2b(2) 

Evidence: 

● Not evident: systematic approach to identify and share best practices across 

multiple support areas 

● Beyond CRHS’s identification of best practices internally and externally and 

piloting and implementation of them in some areas, it is unclear if best practices 

are shared if there is no planned implementation in other areas (sharing versus 

spread). 

● Despite contest to submit administrative best practices, no approach is evident 

to share or implement them. 

● Methods to share best practices, including communities of practice and strategic 

employee engagement groups, require employee opt-in, limiting participation. 

● In identifying departments, units, and individual physicians who are achieving 

high-performing results, CRHS does not identify what constitutes high 

performance. 

● Despite using tracking system to identify high performance, CRHS does not 

describe how high performance is determined. 

Potential Impact of Addressing: 

● Fully sharing best practices may help CRHS ensure effective organization-wide 

action planning, continuous improvement, and innovation. 

Scoring Range 

70–85% 

Rationale: Score should not be in 90-100 range because CRHS’s performance is not fully 

responsive to the multiple-level questions, and best practices are not consistently deployed. 

Score should not be in 50-65 range because evidence shows overall responsiveness to the 

multiple questions, as well as showing fact-based and systematic evaluation and improvement, 

adoption of some best practices, management of innovation, and integration of approaches with 

organizational needs, as data and information are used to measure, review, and analyze 

performance. 

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Category 5 Workforce 

Item 5.1 Workforce Environment 

Strengths 

Finding: CRHS assesses its workforce for changing capability and capacity needs through 

predictive analytics, knowledge and certification assessments, and evaluation of the 

performance using measures such as workforce retention, average time to fill vacancies, 

percentage of employees cross-trained, and RN education levels. 

Item Reference: 5.1a(1) 

Evidence: 

● Capability and Capacity Model (CCM; Figure 5.1-1) is used to assess capability 

and capacity needs and follows the PDCA methodology. 

● Deployed to all hospitals and business units and predicts short- and long-term 

needs for the workforce 

● Root cause analysis is conducted if capacity varies by more than 10% of the 

organization’s predicted rate. 

● Capabilities are assessed annually by people leaders during the Performance and 

Professional Development Plan (PPDP) review and when changes are expected in 

service lines. 

● Other capability and capacity (C&C) metrics include physician C&C, employees 

cross-trained, workforce retention, average time to fill, volunteer presence, and 

nurses with bachelor’s degrees in science of nursing (BSNs) or higher degrees. 

● Reconciliation of capabilities between what leaders identify and what SPP has 

determined is needed is completed in the D step of the SPP, and the resulting 

workforce plan is deployed to HR personnel and hiring managers. 

Potential Impact of Addressing: 

● Systematically assessing its workforce capabilities and capacity needs may help 

CRHS achieve its mission to provide outstanding health care services to improve 

the health of all citizens in the service area. 

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Finding: CRHS utilizes multiple methods to prepare its workforce for changing capability and 

capacity needs and to prevent workforce reductions and minimize the impact of any necessary 

staffing reductions. 

Item Reference: 5.1a(3) 

Evidence: 

● CRHS balances the needs of the workforce with its own and minimizes 

reductions through disciplined head-count management. 

● Resulting from cycles of learning, the cross-training program, the Take a Break 

Program, and other processes enhance flexibility while CRHS retains a highperforming workforce. 

● The cross-functional FTE Committee reviews, evaluates, and confirms growth 

requirements, as well as preparing a detailed implementation plan. 

● The Cotter Model for Organizational change is used when major changes are 

anticipated. 

Finding: CRHS utilizes multiple approaches to ensure workplace health and security. 

Item Reference: 5.1b(1) 

Evidence: 

● Employees are automatically enrolled in the Wellness Program (Figure 5.1-3) 

after 90 days, which offers 13 programs to promote employee wellness and 

includes nutrition courses, fitness centers, coaching, subsidized child care, and 

workforce assistance. 

● Through a cycle of improvement due to the covid pandemic, the Wellness 

Program was greatly enhanced to prevent employee burnout via 

meditation/rejuvenation space for caregivers, additional mental health support, 

and a subscription to a calming app. 

● The Wellness Committee identifies, develops, and communicates offerings. 

● Safe Environment-Related Measures and Goals (Figure 5.1-4) 

● Security methods include badge access, volunteer greeters, panic buttons, and 

patrols. 

● Safety and efficiency of operations are core competencies, which are discussed 

at daily huddles. 

● The Wellness Pulse survey is administered quarterly. 

● Survey of physicians resulted in creation of Physician Wellness Council (through a 

cycle of improvement) to address burnout. 

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Finding: CRHS supports its workforce through multiple services and benefits that can be tailored 

to meet the needs of its different workforce groups. 

Item Reference: 5.1b(2) 

Evidence: 

● Benefits (Figure 5.1-6) 

● Employees can take advantage of cafeteria-style benefit plans to choose benefits 

that best fit their needs. 

● Basic plan provides access to health and dental care, health savings account, life 

and disability insurance, and tax-deferred retirement account. 

● Enhanced plan, despite costing more for employees, offers access to more 

benefits that include vision care; legal services; and discounted home, auto, and 

long-term care insurance. 

● Demonstrating cyclical learning and improvement, CRHS compares its benefits 

using a national survey of benefits conducted by the GWA every three years to 

offer benefits above the median. 

● Apartment units near CRHS’s main facility are offered at cost to 

students/residents. 

● A new benefit is the “Home to Work” program, which provides forgivable loans 

to employees to buy homes in the neighborhood around the hospital in order to 

reclaim the area. 

Opportunities for Improvement 

Finding: It is unclear how CRHS systematically organizes and manages its workforce to reinforce 

organizational resilience and agility. 

Item Reference: 5.1a(4) 

Evidence: 

● Beyond anecdotal examples of resilience and agility, CRHS has not made evident 

a systematic process to organize and manage its workforce to reinforce 

organizational resilience and agility. 

● It is not evident how CRHS organizes and manages its workforce to reinforce a 

patient focus and exceed performance expectations. 

● For mechanisms referenced by CRHS such as safety messages, unit improvement 

boards, communications, and participation on standard work teams, it is not 

evident how the organization ensures their systematic use. 

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Potential Impact of Addressing: 

● Systematically organizing its workforce to reinforce organizational resilience and 

agility may help CRHS address its strategic opportunity of embedding resilience 

in its operations. 

Finding: It is unclear how CRHS systematically ensures that its workplace is technologically and 

attitudinally accessible without bias for all members of its workforce. 

Item Reference: 5.1b(1) 

Evidence: 

● Beyond stating that all buildings are handicapped-accessible due to compliance 

with ADA regulations, CRHS provides no evidence of a process for each facility 

and a work environment to ensure accessibility for all members of the workforce 

or evidence of ongoing accessibility evaluation of facilities and work 

environments. 

● No evidence that accessibility is included in environmental risk assessments 

● Regarding CRHS’s indication that it makes reasonable accommodations for 90%-

92% of requests, the organization has provided no evidence of a process for how 

this occurs. 

● CRHS has not made evident that it has a proactive, systematic approach to 

ensure accessibility for staff members, apparently relying instead on compliance 

with regulatory requirements to be accessible. 

● No evidence of how workplace is technologically and attitudinally accessible 

without bias 

Potential Impact of Addressing: 

● Ensuring physical, technological, and attitudinal accessibility in all of its facilities 

may help CRHS address its strategic challenge of staffing shortages by widening 

its pool of potential employees. 

Scoring Range 

70–85% 

Rationale: Score should not be in 90-100 range because performance is not fully responsive to 

the multiple-level Criteria questions, and it is not evident that all approaches receive systematic 

evaluation and improvement. (There is evidence of evaluation and improvement for only 3 of the 

4 strength findings; and there is an OFI for an overall-level question). Score should not be in 50-

Malcolm Baldrige National Quality Award—2022 Feedback Report 40 
 

 

65 range because CRHS is mostly responsive to multiple-level questions (beyond the overall 

level), approaches are well deployed, and there is evidence of cycles of improvement and 

learning. 

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Item 5.2 Workforce Engagement 

Strengths 

Finding: CRHS utilizes multiple systematic processes to determine, assess, and improve 

workforce engagement. 

Item Reference: 5.2a 

Evidence: 

● For the Upwood Survey, administered annually and reassessed every three 

years, CRHS has added a set of questions on satisfaction and engagement. 

● In the Workforce Engagement System (Figure 5.2-1), CRHS evaluates surveys and 

administrative processes during the “Check” phase; during the “Act” phase, it 

updates LDS offerings based on reviews to demonstrate learning and 

improvement. 

● Workforce engagement drivers are re-validated through focus groups every 

three years. 

● Other indicators used by CRHS to assess workforce engagement include 

rounding, survey participation, volunteerism at events, first-year retention rate, 

and grievances. 

● People leaders are expected to develop action plans in response to workforce 

satisfaction and engagement; a coach is assigned if improvements are not seen 

in two years. 

● Key drivers of engagement (Figure P.1-2) have been determined for all major 

workforce classifications, including students and volunteers. 

Finding: CRHS systematically supports high performance through its Integrated Talent 

Management Process (ITM). 

Item Reference: 5.2c(1) 

Evidence: 

● Integrated Talent Management Process (Figure 5.2-2) 

● Goals are set at each level, with organizational goals cascaded down to every 

employee. Every employee has a clear line of sight to strategic objectives and 

action plans. 

● Process incentivizes goal achievement. 

● Leaders are evaluated on how they develop or contribute to intelligent risks. 

● Employees are evaluated on the number of PDCA/Lean activities and safety 

initiatives to which they have contributed, and how they contribute ideas in daily 

huddles. 

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● CRHS benchmarks practices with the Human Resource Society (HRS); for 

compensation studies, conducted every three years, targets are set at 5% above 

the median in the service area. 

● The PPDP was developed to integrate with the ITM in order to align performance 

and development. 

Finding: CRHS has deployed multiple processes, including for succession planning, to manage 

the career development of its workforce and its future leaders. 

Item Reference: 5.2c(4) 

Evidence: 

● Aspire Leadership Development System (Figure 5.2-4) 

● Competency-based career ladders for all positions 

● Professional development program (PPDP) discussion used by people leaders 

● Managers and above are required to identify three potential successors. 

● Potential successors are enrolled in the Leadership Development Program (LDP). 

● Directors and above may also receive executive coaching. 

● Demonstrating learning, CRHS reviews and enhances the LDP every year. 

● Physician Academy for physicians 

Opportunities for Improvement 

Finding: It is not evident how CRHS’s performance management and learning and development 

systems support intelligent risk taking, ethical health care, and ethical business practices. 

Item Reference: 5.2c(1,2) 

Evidence: 

● No indication of how the performance management and learning and 

development systems support or reinforce intelligent risk taking or ethical health 

care and ethical business practices 

● Required annual courses in ethical behavior do not necessarily address ethical 

health care or ethical business practices. 

● WE CARE values’ emphasis on ethical health care and business practices is not 

specifically related to performance management or learning and development 

system. 

● Incentive programs to inspire the workforce to be motivated to take intelligent 

risks do not appear to be deployed or implemented systematically. 

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● Daily huddles, with discussion of issues that could spark staff members to take 

an intelligent risk, do not appear to be deployed or implemented systematically. 

Potential Impact of Addressing: 

● Systematically ensuring support for intelligent risk taking, ethical health care 

practices, and ethical business practices may help CRHS achieve its vision to be 

among America’s best health systems. 

Finding: It is not clear how the organization ensures that its performance and career 

development approaches promote equity and inclusion for a diverse workforce and different 

workforce groups and segments. 

Item Reference: 5.2c(5) 

Evidence: 

● It is not clear how data from performance reviews (particularly unusual patterns) 

promote equity and inclusion. 

● CRHS’s use of reviews/comparisons to the diversity report to identify adverse 

patterns and coach leaders appears to be a one-off approach and not 

comprehensive for the entire organization. 

● In regard to CRHS’s reference to recommendations of the Diversity, Equity, and 

Inclusion Committee (DEIC), it is unclear what process is used and to whom 

recommendations are made. 

● Tracking of demographics of career ladder and LDP participants to monitor 

alignment with the diversity goal (+/- 5%) is limited to CRHS-defined diversity 

variables. 

● It is not clear how the DEIC and Strategic Employee Engagement Groups (SEEGs) 

systematically promote diversity, equity, and inclusion (DEI); it also is not clear if 

this approach is integrated with CRHS’s performance management and 

development approaches. 

● Beyond having diverse staff members on PDCA teams and using the A3E3 

approach, CRHS has not made evident a process for promoting equity and 

inclusion in its performance development and career development approaches. 

Potential Impact of Addressing: 

● Systematically promoting equity and inclusion for its diverse workforce groups 

and segments may help CRHS demonstrate its values of accountability and 

respect. 

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Finding: It is not evident that CRHS systematically utilizes informal assessment methods and 

measures to determine workforce satisfaction and engagement; nor is it evident how its 

methods differ across workforce groups and segments. 

Item Reference: 5.2a(2) 

Evidence: 

● In CRHS’s use of non-survey indicators (including leader rounding, level of 

participation in surveys, level of volunteerism at community events, first-year 

retention, and number of grievances among collective-bargaining-agreement 

employees), it is not evident how these data are collected, aggregated, or 

analyzed. For example, it is not apparent how data are reviewed or used as 

inputs to determining engagement and satisfaction levels. 

● In regard to the Satisfaction and Engagement Survey being “sent” to the entire 

workforce, it is not apparent that the delivery method varies based on work 

location, service line, or work group segment. 

● It is not clear how employees with no computer access respond to the survey 

● During virtual interviews, CRHS indicated that there is no process to collect, 

measure, or analyze informal assessment methods of workforce satisfaction and 

engagement. 

● Beyond one informal method that could vary by work group, CRHS evidently 

does not use variable methods for different groups or segments. 

Potential Impact of Addressing: 

● Systematically utilizing informal methods to determine workforce satisfaction 

and engagement for the organization’s various workforce groups and segments 

may help it address its strategic challenge of workforce burnout. 

Scoring Range 

70–85% 

Rationale: Score should not be in 90-100 range because there is a strength finding and an OFI 

finding at the overall level, and there is a lack of evidence of consistent learning and improvement 

for most processes in this item. Score should not be in 50-65 range because most findings (2 of 3 

strengths and 2 of 3 OFIs) are at the multiple level (beyond overall level); some learning is 

apparent; and approaches are well deployed, without apparent variation or significant gaps. 

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Category 6 Operations 

Item 6.1 Work Processes 

Strengths 

Finding: CRHS determines which strategic opportunities to pursue in the SPP using ROI and 

alignment with its MVV as key considerations. 

Item Reference: 6.1d 

Evidence: 

● Strategy/Innovation (S/I) Committee evaluates ideas using defined assessment 

factors such as risk, ROI, and alignment with the MVV. 

● Intelligent Risk and Innovation process (illustrated in Figure 6.1-5) 

● CRHS’s criteria for innovation: Does the idea take the organization to the next 

level? 

● Department stoplight report displays progress through implementation of plans. 

● Objectives not meeting goals are reevaluated for discontinuation. 

● CRHS created its “Shark Tank” program in 2019 after benchmarking a partner. 

Potential Impact of Addressing: 

● This may help the organization achieve its strategic opportunity of increasing 

health care access in its service area and may help it meet its strategic objective 

of top-decile performance. 

Finding: CRHS uses patient input gathered from all stages of the patient relationship to set 

realistic patient expectations. 

Item Reference: 6.1b(2) 

Evidence: 

● Patient expectations are gathered during the admissions, scheduling, intake, and 

referral stages. 

● A Multidisciplinary Care Plan (MCP) resides in the EMR to be available to all 

caregivers. 

● Communication happens during rounds, via white board in the patient’s room. 

● Cycle of learning resulted in a “preference” component being added to the 

patient portal in 2020 in order to indicate preferences prior to a scheduled 

appointment. 

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Potential Impact of Addressing: 

● This assists the organization in meeting its patient expectations of high-quality 

and safe care and service excellence. 

Finding: CRHS’s approach to design service and work processes to meet requirements has gone 

through cycles of evaluation and improvement. 

Item Reference: 6.1a(3) 

Evidence: 

● Service and Work Process Design (SWPD; Figure 6.1-1) is built on the PDCA 

framework. 

● The process was updated in 2018 to include FMEA for design of complex 

processes and to identify risks and failures. 

● In 2020, CRHS added impact on society with a reflection on DEI as criteria in step 

3. 

● Figure 6.1-2: CRHS’s three work systems, key work processes, and their 

requirements. 

● Process map of key service and work processes is reviewed for improvement. 

Potential Impact of Addressing: 

● This may help the organization demonstrate its values of efficiency and 

excellence and may help it improve in relation to the customer expectation of 

access to care. 

Finding: CRHS uses multiple approaches to improve work processes, health care services, and 

performance. 

Item Reference: 6.1b(4) 

Evidence: 

● Improvement Model (Figure 6.1-3) is aligned with PDCA. 

● In-process measures are developed during step 3 of the SWPD (Figure 6.1-1), 

then tracked through the performance system. 

● Process maps have been developed for all processes and are evaluated using 

PDCA. 

● Processes not meeting performance targets are reviewed for further action. 

● Complex processes may be referred to the TRAC team. 

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● PIC holds Convergence of Excellence event to disseminate best practices and 

highlight improvement. 

Potential Impact of Addressing: 

● This supports the organization’s commitment to process improvement and PDCA 

and supports its core competency of efficiency of operations. 

Opportunities for Improvement 

Finding: A systematic approach to determining work process requirements is not apparent. 

Item Reference: 6.1a(1) 

Evidence: 

● Figure 6.1-1 shows inputs but not how requirements are determined. 

● It is not evident how requirements are determined in the Service and Work 

Process Design (SWPD). 

● A process is not apparent for how caregiver work system processes have been 

aligned with customer requirements. 

Potential Impact of Addressing: 

● Without a systematic approach to determining work process requirements, the 

organization may not be able to support its customer expectation of value for 

service provided. 

Finding: It is not evident that the organization has a systematic approach to ensuring agility and 

resilience in responding to changes in patient and market needs. 

Item Reference: 6.1c 

Evidence: 

● Despite stating anecdotally how it responded to COVID, CRHS does not make 

evident a systematic approach. 

● In regard to CRHS’s supply-chain management (Figure 6.1-4), it is not clear how 

agility is built into the approach. 

● It is unclear if CRHS has a systematic approach for identifying changing patient 

needs 

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Potential Impact of Addressing: 

● CRHS’s strategic advantage of resilience may be adversely impacted. 

Scoring Range 

70–85% 

Rationale: Score should not be in 90-100 range because approaches are not fully responsive to 

multiple-level questions, and development of best practices is not evident or integrated with 

organization’s future needs. Score should not be in 50-65 range because approaches are 

responsive to the multiple-level questions (beyond overall level); fact-based evaluation (via 

PDCA) and improvement is evident, including in the innovation process; and approaches are 

integrated with the SPP and VOC processes. 

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Item 6.2 Operational Effectiveness 

Strengths 

Finding: The Office of Safety and Business Continuity (OSBC) has defined and tested processes to 

ensure that the organization is prepared for and can recover from emergencies and business 

disruptions. 

Item Reference: 6.2c(3) 

Evidence: 

● Using the Risk Assessment Process (Figure 6.2-1), CRHS identifies potential 

disasters (natural or human) and builds plans to mitigate them. 

● CRHS participates with state and regional agencies in disaster drills and 

simulations that may reveal gaps in actions plans, which are then used to 

improve the approaches. 

● CRHS was able to continue offering quality care throughout the pandemic and 

had a special COVID task force. 

● CRHS takes action to support employees and their families. 

● The system was tested and improved due to tornados in the area. 

Potential Impact of Addressing: 

● This may help the organization maintain uninterrupted access to health care 

services in the area. 

Finding: CRHS systematically provides a safe operating environment for its workforce and others 

in the workplace environment through screening, training, and compliance processes. 

Item Reference: 6.2c(1) 

Evidence: 

● The OSBC conducts audits, root cause analysis (RCA), and PDCA of processes for 

corrective action. 

● The Employee Safety Council meets quarterly. 

● The OSBC oversees biological/chemical/hazardous waste safety, fire safety, 

occupational safety, and environmental compliance. 

● Other safety procedures: badges for access, on-demand escort services, “Save 

Your Back” training, and ergonomics 

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Potential Impact of Addressing: 

● This aligns with the workforce requirement of a safe work environment. 

Finding: CRHS uses Lean methodology to eliminate waste, prevent work process errors, and 

minimize the cost of rework. 

Item Reference: 6.2a 

Evidence: 

● Process measures are tracked and reviewed for performance improvement. 

● Use of FMEA during design helps error-proof the process. 

● Lean methods are incorporated into the SWPD (Figure 6.1-1). 

● RCA is performed if errors occur. 

● Electronic checklists reduce audit costs. 

Potential Impact of Addressing: 

● This may help the organization achieve its strategic objective of top-decile 

performance. 

Finding: CRHS has a systematic approach to ensure security and cybersecurity for sensitive and 

privileged data and key assets. 

Item Reference: 6.2b 

Evidence: 

● CRHS uses the NIST Cybersecurity Framework. 

● Methods for security of data: access to data limited by job description, Health 

Insurance Portability and Accountability Act (HIPAA) training, and workstations 

that require antivirus and encryption as well as two-factor authentication 

● Audits are conducted to identify unauthorized access to patient records. 

● Passwords must be changed every six months. 

● Information Management (IM) Security Committee 

Potential Impact of Addressing: 

● This may help the organization meet and exceed federal regulations. 

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Opportunities for Improvement 

Finding: A systematic approach to reducing medical errors is not apparent. 

Item Reference: 6.2c(2) 

Evidence: 

● CRHS does not identify a systematic process to reduce medical errors. Most 

efforts for error reduction relate to environmental safety efforts and waste. 

● The Good Catch Program does not proactively prevent errors. 

Potential Impact of Addressing: 

● This may adversely impact the organization’s core competency of high-quality 

clinical care. 

Finding: A process is not evident for systematically maintaining an awareness of emerging 

security and cybersecurity threats. 

Item Reference: 6.2b 

Evidence: 

● Beyond describing mitigation strategies to use as threats occur, CRHS does not 

address proactive awareness of emerging threats. 

Potential Impact of Addressing: 

● Lack of a process in this area may negatively impact the organization’s strategic 

advantage of an integrated EMR and limit its ability to offer telehealth services. 

Finding: An approach to balancing the need for cost control and efficiency with the needs of 

patients and other customers is not apparent. 

Item Reference: 6.2a 

Evidence: 

● In regard to CRHS’s use of Lean tools for customer focus, it is not apparent how 

the organization balances patient and other customer needs. 

● For example, extending care to rural areas and providing telehealth service to 

meet patient needs will add costs; how CRHS evaluates cost vs. need for balance 

is not clear. 

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Potential Impact of Addressing: 

● This may limit the organization’s strategic advantage of having a cost advantage 

due to the scale of its operations. 

Scoring Range 

50–65% 

Rationale: Score should not be in 70-85 range because approaches do not appear to address 

future needs of the organization, and sharing of refinements is not evident as a key tool of 

learning. Score should not be in 30-45 range because the organization is responsive to some 

multiple-level (beyond overall-level) questions, and approaches are deployed to other campuses 

and evaluated for improvement. 

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Category 7 Results 

Item 7.1 Patient and Health Care Process Results 

Strengths 

Finding: Many results for health care outcomes and performance of services demonstrate 

beneficial trends and are favorable in comparison to relevant benchmarks. 

Item Reference: 7.1a 

Evidence: 

● Centers for Medicare and Medicaid Services (CMS) 5-Star Rating (Figure 7.1-1), 

● Patient Safety Indicator (PSI) 90 (Figure 7.1-2), 

● Handwashing (Figure 7.1-3), 

● Hospital-Acquired Pressure Ulcer (HAPU; Figure 7.1-6), 

● Heart Failure Mortality (Figure 7.1-8), 

● Documentation of Meds (Figure 7.1-11), 

● Obstetrics (OB) Mortality (Figure 7.1-14), 

● Elective Delivery (Figure 7.1-15), 

● Stroke Mortality (Figure 7.1-16), 

● Pneumonia Vaccine (Figure 7.1-17), 

● Home Health Pain (Figure 7.1-21), 

● Hospice Care (Figure 7.1-22), 

● Primary Care Physician (PCP) Appointment at Discharge (Figure 7.1-23), 

● Med Reconciliation (Figure 7.1-25), and 

● MYPHI (patient EMR) Activation (Figure 7.1-27). 

Potential Impact of Addressing: 

● These results may help the organization maintain its current market share 

position and continue to meet and exceed federal and state regulations. 

Finding: Some results for process efficiency and effectiveness compare favorably to relevant 

benchmarks by hospital location. 

Item Reference: 7.1b(1) 

Evidence: 

● Lab Emergency Department (ED) Turnaround Time (TAT; Figure 7.1-28): results 

since 2018 for all locations 

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● Imaging ED TAT (Figure 7.1-29): results since 2018 (discounting 2020) for all 

locations 

● Bed TAT (Figure 7.1-30) 

Potential Impact of Addressing: 

● These results may help the organization achieve its vision of being among 

America’s best health care systems. 

Finding: Measures of process efficiency and safety show good-to-excellent performance levels. 

Item Reference: 7.1b 

Evidence: 

● Information Management Services (Figure 7.1-32): uptime, antivirus, and contact 

resolution results are near 100%. 

● Work Order Completion (Figure 7.1-33): results are at 94%. 

● Emergency Preparedness (Figure 7.1-34): results for all measures are at 100%. 

Potential Impact of Addressing: 

● These results may help the organization maintain its core competency of 

efficiency in operations. 

Opportunities for Improvement 

Finding: Some results reported for measures of health care outcomes demonstrate adverse 

trends in performance and failure to achieve top decile. 

Item Reference: 7.1a 

Evidence: 

● Preventable Harm Index (Figure 7.1-4): results adversely increased for CMCL 

from 22 to 32, for CF from 19 to 30, for CB from 16 to 28, for CS from 6 to 8, and 

for Rehab from 7 to 15 from 2017 to 2021. 

● Surgical Site Infections (Figure 7.1-5): results adversely increased for CMCL from 

0.92 to 0.96, for CF from 0.94 to 0.97, and for CB from 0.89 to 0.96 from 2017 to 

2021. 

● PHQ-9 (Patient health questionnaire for depression screening) Completion Rate 

(Figure 7.1-26): results adversely decreased from 77% to 65% from 2019 to 2021 

and failed to reach the CMS top-decile level of 100%. 

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Potential Impact of Addressing: 

● Improving adverse trends for these results may help the organization achieve its 

strategic objective of top-decile performance. 

Finding: Some results for process efficiency and supply-network management measures are 

missing. 

Item Reference: 7.1b,c 

Evidence: 

Missing results include those for 

● effectiveness of caregiver support work processes, 

● service recovery related to customer complaints, 

● effectiveness of the communication system, 

● effectiveness of the workforce training system, 

● supplier scoreboard and quality outcome measures, and 

● effectiveness measures for joint venture (JV) locations. 

Potential Impact of Addressing: 

● The organization may be better able to sustain its core competency of efficiency 

in operations by tracking and analyzing results for these measures. 

Scoring Range 

50–65% 

Rationale: Score should not be in 70-85 range because beneficial trends are not sustained in all 

areas of importance, and some results are not reported for key performance areas. Score should 

not be in 30-45 range because performance levels reported are responsive beyond the basic level 

of Criteria questions, and some results measures show good performance relative to 

comparisons. 

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Item 7.2 Customer Results 

Strengths 

Finding: Results for measures of patient satisfaction across multiple patient groups and service 

lines demonstrate beneficial trends. 

Item Reference: 7.2a(1) 

Evidence: 

● Inpatient (IP) Overall (Figure 7.2-1), 

● IP Registered Nurse (RN) Communication (Figure 7.2-2), 

● IP Medical Doctor (MD) Communication (Figure 7.2-3), 

● IP Discharge Information by Service Line (Figure 7.2-4), 

● Emergency Department (ED) Consumer Assessment of Healthcare Providers and 

Systems (EDCAHPS; Figure 7.2-5), 

● Clinician and Groups Consumer Assessment of Healthcare Providers and Systems 

(CGCAHPS) Overall (Figure 7.2-6), 

● IP Rehab (Figure 7.2-7), 

● Behavioral Health (7.2-8), 

● Outpatient (OP) Satisfaction (Figure 7.2-9), and 

● Home Health Consumer Assessment of Healthcare Providers and Systems 

(HHCAHPS; Figure 7.2-10). 

Finding: Some results for measures of customer satisfaction have achieved top-decile levels and 

demonstrate beneficial trends. 

Item Reference: 7.2a(1) 

Evidence: 

● Health Plan (HP) Member Satisfaction (Figure 7.2-12): results are at or above the 

top decile in 2019-2021, with beneficial trends. 

● HP Provider Satisfaction (Figure 7.2-13): results are at or above the top decile in 

2020-2021, with beneficial trends. 

● Net Promoter Score (Figure 7.2-16): results are at or above the top decile from 

2018 to 2021, with beneficial trends. 

Potential Impact of Addressing: 

● These results may help the organization meet its strategic objective of achieving 

top-decile performance in customer excellence. 

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Finding: Results for many measures of patient and customer engagement demonstrate 

favorable trends. 

Item Reference: 7.2a(2) 

Evidence: 

● Social Media Growth Website Unique Visitors (Figure 7.2-17) increased from 

999,762 to 1,287,325; Lookbook Reach increased from 1,798,402 to 2,765,348; 

Silver Followers increased from 1,450 to 5,892 from 2015 to 2021; Chatgram 

followers increased from 690 in 2017 to 1,211 in 2021; and Vidtime subscribers 

increased from 3,214 in 2015 to 4,211 in 2021. 

● Reputation Score (Figure 7.2-18) increased from 3.8 in 2015 to 4.2 in 2021, 

outperforming competitors. 

● Complaints per 1,000 (1K) Patients per Day (Figure 7.2-19) decreased from 1.7 to 

1.5 from 2015 to 2021 for CMCL, from 2.6 to 2.1 for CB, from 2.4 to 1.9 for CF, 

and from 1.7 to 1.2 for CRH. 

● Overall Satisfaction–Family (Figure 7.2-25) increased from 78% to 85% for CRHS 

overall, from 76% to 82% for IP, and from 81% to 87% for OP from 2017 to 2021. 

● Home Health–Patient Satisfaction (Figure 7.2-27) increased from 85% to 91% for 

CRHS overall from 2018 to 2021. 

● Satisfaction of Family with Hospice Care (Figure 7.2-28) increased from 88% to 

93% from 2016 to 2021. 

Opportunities for Improvement 

Finding: Results for many measures of patient satisfaction and engagement compare 

unfavorably to top-decile benchmarks. 

Item Reference: 7.2a 

Evidence: 

● Note: 2020 results included in comparison analysis. 

● IP Overall (Figure 7.2-1): 0 of 4 facilities are at the top decile. 

● IP RN Communication (Figure 7.2-2): 1 of 4 facilities is at the top decile. 

● IP MD Communication (Figure 7.2-3): 0 of 3 facilities are at the top decile. 

● IP Discharge Information by Service Line (Figure 7.2-4): 2 (Cardiology and 

Oncology) of 5 service lines have reached the top decile for 2 years or more. 

● EDCAHPS (Figure 7.2-5): 0 of 3 facilities have reached the top decile. 

● CGCAHPS Overall (Figure 7.2-6): 1 (Oncology) of 8 service lines has reached the 

top decile for 2 years or more. 

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● IP Behavioral Health (Figure 7.2-8) is not at the top decile in any of the 5 years 

measured. 

● OP by Service Line (Figure 7.2-9): only 1 of 7 service lines (Radiation Therapy) is 

at the top decile for 2 years or more. 

● HHCAHPS (Figure 7.2-10): CRHS did not reach the top quartile for all years 

measured. 

HCAHPS Recommendations (Figure 7.2-14): 0 of 3 facilities are at the top decile. 

● EDCAHPS Recommendations (Figure 7.2-15): 0 of 3 facilities are at the top decile. 

● Reputation Score (Figure 7.2-18): CRHS is not at the top decile (performance has 

been at the top quartile for the last 3 years). 

● Complaints per 1K Patient Day (Figure 7.2-19): only 1 of 4 facilities has been at 

the top decile for 2 years or more. 

● Overall Satisfaction–Family Overall and IP results (Figure 7.2-25): CRHS is not at 

the top quartile. 

● Home Health (Figure 7.2-27) and Hospice (Figure 7.2-28): satisfaction results lag 

benchmarks. 

Potential Impact of Addressing: 

● These results highlight areas where CRHS is not meeting its strategic objective of 

top-decile performance and may hinder its ability to achieve its vision to be 

among America’s best health systems. 

Finding: CRHS has provided limited results for measures related to patient dissatisfaction. 

Item Reference: 7.2a(1) 

Evidence: 

● No results or measures of dissatisfaction beyond complaints/grievances 

● Results lack segmentation: not presented for CS, medical offices, surgery 

centers, and urgent care facilities 

● Despite tracking complaints that could be resolved immediately in addition to 

those traditionally tracked under the complaint management system, CRHS did 

not present these segmented data in related results. 

Potential Impact of Addressing: 

● Without these results, the organization may miss opportunities to identify and 

correct dissatisfiers, highlight the success of its complaint management system, 

and accurately evaluate its effectiveness. 

Malcolm Baldrige National Quality Award—2022 Feedback Report 59 
 

 

 

Finding: CRHS is missing patient satisfaction results for some key OP and post-acute care service 

offerings. 

Item Reference: 7.2a(1) 

Evidence: 

Missing results include those for 

● DME; 

● outpatient diagnostic and treatment facilities, including JV surgery centers, JV 

imaging centers, and urgent care; 

● sounding boards in the emergency room; and 

● daily four-question surveys from the meal service. 

Potential Impact of Addressing: 

● Tracking customer satisfaction and engagement data for all services and across 

the continuum of care may enable the organization to identify opportunities to 

better meet customer expectations. 

Scoring Range 

50–65% 

Rationale: Score should not be in 70-85 range because some significant results are missing and 

many compare unfavorably to the top decile. Score should not be in 30-45 range because results 

show good levels, beneficial trends, and some favorable results compared to the top decile (a 

strategic objective). 

Malcolm Baldrige National Quality Award—2022 Feedback Report 60 
 

 

Item 7.3 Workforce Results 

Strengths 

Finding: CRHS reports multiple results for workforce capacity for its various workforce groups 

and segments that demonstrate favorable trends. 

Item Reference: 7.3a(1) 

Evidence: 

● Capability and Capacity Model (CCM) Variance (Figure 7.3-1): CMCL decreased 

from 13% to 11% from 2013 to 2021, CB decreased from 12% to 10% from 2015 

to 2021, CF decreased from 14% to 7% from 2015 to 2021, CS decreased from 

10% to 8% from 2015 to 2021, and CRH decreased from 9% to 6% from 2015 to 

2021. 

● Physician Capability and Capacity (CC; Figure 7.3-2): the number of physicians 

with admitting privileges increased from 874 in 2017 to 1018 in 2021, the 

number of new practitioners increased from 126 to 232, and resident retention 

increased from 49% to 64% in the same time frame. 

● Cross-Trained Workforce (Figure 7.3-3): rates increased for all business units and 

locations from 2018 to 2021. 

● Workforce Retention Overall (Figure 7.3-4): rates increased for all classifications 

and locations from 2015 to 2021. 

● Average Time to Fill (Figure 7.3-5): days decreased for all classifications except 

caregiving support and for all locations from 2015 to 2021. 

● Volunteer Presence (Figure 7.3-6): total number increased from 2017 to 2021. 

● Nurse Managers with BSN (Figure 7.3-7): numbers increased from 2017 to 2021 

for all hospitals reported. 

Finding: CRHS reports some workplace climate results for health, security, and diversity 

measures that demonstrate favorable trends and performance levels relative to competitors or 

the organization’s goal. 

. Item Reference: 7.3a(2) 

Evidence: 

● Workforce Environment (Figure 7.3-8): CDC Wellness Score increased from 188 

to 195 from 2018 to 2021, Physician Burnout rate decreased from 34% to 31% 

from 2019 to 2021, Wellness Program Participation rate increased from 75% to 

91% from 2017 to 2021, Influenza Vaccine rate increased from 90% to 100% 

from 2017 to 2021, Tuberculosis (TB) Test Compliance rate increased from 92% 

to 100% from 2017 to 2021, Emergency Responders Incidents decreased from 31 

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to 14, and Accommodation Requests Met rate increased from 87% to 90% from 

2018 to 2021. 

● Workforce Safety Overall (Figure 7.3-9): incidents decreased from 7 to 3 from 

2017 to 2021. 

● Diversity Report Variances (Figure 7.3-10): CMCL, CB, CF, CS, Rehab, and all other 

business units favorably decreased variances from 2017 to 2021. 

● Nurse Managers with BSN (Figure 7.3-7): results increased for all locations since 

2017 (though not to the level of comparison or goal). 

Finding: CRHS reports multiple results for measurements of workforce satisfaction and 

engagement for its various workforce groups and segments that demonstrate favorable trends. 

Item Reference: 7.3a(3) 

Evidence: 

● Workforce Satisfaction (Figure 7.3-11): results increased for all settings and work 

groups, and overall satisfaction increased from 75% to 82% from 2018 to 2021. 

● Overall Workforce Engagement (Figure 7.3-12): rates for all units and workforce 

groups increased, and overall engagement increased from 79% to 82% from 

2018 to 2021. 

● Student Engagement (Figure 7.3-16): results for all key drivers increased, and the 

overall rate increased from 81% to 85% from 2018 to 2021. 

● Volunteer Engagement (Figure 7.3-17): results for all key drivers increased, and 

the overall rate increased from 82% to 84% from 2018 to 2021. 

● First-Year Retention (Figure 7.3-18): rates increased for all business units and 

caregivers, and the overall rate increased from 75% to 89% from 2017 to 2021. 

● Employed Physician and Resident Engagement (Figure 7.3-13) 

● Retention (Figure 7.3-4): results by class show good levels and trends and are 

better than competitor 2’s results. 

● Volunteer Count and Hours (Figure 7.3-6): trend data show consistent 

performance, and results are better than competitor’s. 

Opportunities for Improvement 

Finding: CRHS reports multiple results for measures of workforce satisfaction and engagement 

for its various workforce groups and segments that do not achieve the top-quartile or top-decile 

performance levels of comparisons. 

Item Reference: 7.3a(3) 

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Evidence: 

● Overall Workforce Engagement (Figure 7.3-12): no results meet or exceed topdecile performance levels. 

● Employed Physician and Resident Engagement (Figure 7.3-13): competitive 

compensation and wellness results do not reach the top quartile. 

● Nonemployed Physician and Caregiver Engagement (Figure 7.3-14): results for 

measures of physicians, staff competency, and support for service growth fail to 

reach the top quartile; and results for caregiver engagement in relation to all key 

drivers fail to reach the top decile. 

● Student Engagement (Figure 7.3-16): all key drivers fail to reach top-decile 

performance levels. 

● Volunteer Engagement (Figure 7.3-17): all key drivers fail to reach top-decile 

performance levels. 

● First-Year Retention (Figure 7.3-18): results compare unfavorably to the SHRM 

median across all business units. 

Potential Impact of Addressing: 

● Ensuring that results achieve top-decile performance against comparators may 

help the organization achieve its strategic objective of top-decile performance in 

workforce excellence. 

Finding: CRHS lacks results segmented by workforce type/group for many workforce measures. 

Item Reference: 7.3a 

Evidence: 

● No leadership development results segmented by workforce group 

● Figure 7.3-16 shows nursing programs as the comparator for student 

engagement, and the results are not segmented by nursing vs. other students. 

● Figure 7.3-17 results for volunteer engagement are not segmented by adult vs. 

teen volunteers. 

● Overall Workforce Engagement (Figure 7.3-12): results are not segmented by 

workforce groups in the Workforce Profile (Figure P.1-2). 

Potential Impact of Addressing: 

● Having workforce results for all its workforce groups may help the organization 

ensure that it meets the workforce engagement requirements of all of its 

workforce groups and segments. 

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Finding: CRHS does not report results for measures of workforce capability, satisfaction results 

for the volunteer workforce group, or results related to differences in workforce and leader 

development by diversity-related segments of the workforce. 

Item Reference: 7.3(1,3,4) 

Evidence: 

● Results for knowledge, skills, and abilities identified by position in the SPP are 

not reported. 

● Results related to employees exhibiting new skills after training are not reported. 

● Workforce satisfaction results for the organization’s 500 volunteers are not 

reported (for example, in Figure 7.3-11). 

● Diversity-related results in the context of workforce and leader development are 

not provided. 

Potential Impact of Addressing: 

● Systematic review of results for workforce capability, satisfaction results for all 

work groups, and results related to differences in workforce and leader 

development may help the organization address its strategic challenges of staff 

burnout and staffing shortages. 

Scoring Range 

70–85% 

Rationale: Score should not be in 90-100 range because the organization is not fully responsive 

to the multiple-level questions, and some results to provide evidence of industry and benchmark 

leadership are missing. Score should not be in 50-65 range because most findings (4 of 6) are at 

the multiple level, as opposed to overall level (3 strength findings, plus 1 OFI changed to a 

strength finding), there are many beneficial trends, and relevant comparisons demonstrate good 

relative performance. 

Malcolm Baldrige National Quality Award—2022 Feedback Report 64 
 

 

Item 7.4 Leadership and Governance Results 

Strengths 

Finding: CRHS's leadership and governance results demonstrate favorable levels and 

comparisons as well as beneficial trends in many areas of importance. 

Item Reference: 7.4(1,2,4) 

Evidence: 

● Results for senior leaders’ communication and engagement with the workforce 

show excellent performance levels (Figure 7.4-1). 

● Opinion Counts measure in Figure 7.4-1: 9 of 10 results exceed or meet Upwood 

Top Decile comparison. 

● Mission Makes Me Feel Important measure in Figure 7.4-1: 10 of 10 results 

exceed or meet Upwood Top Decile comparison. 

● Sample of Senior Leader-Workforce Communication and Engagement (Figure 

7.4-1): 10 of 10 results exceed or meet Upwood Top Decile comparison. 

● Cares about Me measure in Figure 7.4-1: 8 of 10 results exceed or meet Upwood 

Top Decile comparison. 

● Knows What Is Expected measure in Figure 7.4-1: 10 of 10 results exceed or 

meet Upwood Top Decline comparison, and results show beneficial trends in all 

measured areas. 

● Governance Effectiveness, Self-Evaluation (Figure 7.4-6): results show favorable 

levels and beneficial trends in most areas. 

● Fiscal Accountability (Figure 7.4-7): areas show favorable levels and beneficial 

performance sustained for all five years presented. 

● Ethics Compliance Training measures in Figure 7.4-10: results show favorable 

levels and beneficial performance sustained for all five years presented. 

Finding: CRHS’s results for legal and ethical behavior approaches demonstrate beneficial 

performance trends and favorable levels in comparison to others. 

Item Reference: 7.4a(3,4) 

Evidence: 

Surpassing Regulatory and Accreditation Results (Figure 7.4-9) Achievements: 

● “A” rating for LeapCore Hospital Safety Grade 

● Designation as “Best Place to Work” in Kentucky 

● LEED/Practice Bluefit Excellence Award 

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● Seven service lines reported results that surpass regulations and achieve 

accreditation. 

● Results for Ethical Behavior (Figure 7.4-10): achievements reported include 

● sustained, excellent performance levels for conflict-of-interest violations, with 0 

since 2017. 

● Code of Ethical Standards of Behavior Training results: 100% completion since 

2017 

● Code of Ethical Standards of Behavior Signed results: 100% since 2017 

● Workforce complaints decreased from 8 to 2, behavioral standards violations by 

medical staff (MS) decreased from 6 to 3, and patient rights complaints 

decreased from 2 to 1. 

Opportunities for Improvement 

Finding: CRHS is missing some results to demonstrate its senior leadership and governance 

performance. 

Item Reference: 7.4a(1,2,4,5) 

Evidence: 

● Despite the fact that the organization has 100% operational and managerial 

responsibility for the surgical centers and imaging centers, fiscal responsibility 

results for these entities are missing. 

● Two-way communication results are missing. 

● Innovation and risk-taking cultivation results are missing. 

● Results for how senior leaders create a focus on action are missing. 

Potential Impact of Addressing: 

● These missing results may adversely affect the organization's ability to achieve 

its strategic objectives related to top-decile performance. 

Finding: CRHS societal well-being results show unfavorable trends in some areas and perform 

unfavorably compared to others. 

Item Reference: 7.4a(5) 

Evidence: 

● Societal Well-Being (Figure 7.4-13): Community Health Fairs and Impact results 

show unfavorable trends for stages II-IV. 

Malcolm Baldrige National Quality Award—2022 Feedback Report 66 
 

 

● Societal Well-Being (Figure 7.4-13): Environmental results for fuel oil 

consumption, solid waste, infectious waste, and chemo waste reductions have 

not reached the ASHE top quartile performance level. 

● Societal Well-Being (Figure 7.4-12): Community Support and Strength results 

show some unfavorable trends for Charity Care, Opioid-Containing Tablets 

Prescribed, and Community Benefit (Total $) measures. 

● Societal Well Being (Figure 7.4-11): Environmental results for Solid Waste 

Infectious Waste and Chemo Waste measures fall short of the top-quartile 

comparison (despite improvement). 

Potential Impact of Addressing: 

● Improving performance related to societal well-being may help the organization 

assure the communities it serves that their expectation of societal responsibility 

is being met. 

Scoring Range 

50–65% 

Rationale: Score should not be in 70-85 range because the organization is missing results in many 

areas, and only some, not most, results have comparisons. Score should not be in 30-45 range 

because results do respond to the Criteria beyond the basic question level, and comparative data 

provided show good relative performance. However, significant results are missing, so score is at 

low end of this range. 

Malcolm Baldrige National Quality Award—2022 Feedback Report 67 
 

 

 

Item 7.5 Financial, Market, and Strategy Results 

Strengths 

Finding: Most results for key financial performance measures demonstrate beneficial trends and 

show areas of leadership when evaluated against relevant benchmarks and comparisons. 

Item Reference: 7.5a(1) 

Evidence: 

● Net Patient Revenue (Figure 7.5-1): results increased from $2,878.20 in 2015 to 

$3,578 in 2021, outperforming all competitors and Zandi’s A1 rating. 

● Operating Margin (Figure 7.5-2): results increased from 2.4% in 2015 to 4.4% in 

2021 and outperformed Zandi’s A1 rating. 

● Operating Earnings Before Interest, Depreciation, and Amortization (EBIDA) 

Margin (Figure 7.5-3): results increased from 8.9% in 2015 to 10.2% in 2021. 

● Days Cash on Hands (Figure 7.5-4): results show a beneficial trend, with levels 

approaching Zandi’s A1 in each year, and comparing favorably to Zandi’s A2 each 

year. 

● Cash to Direct Debt (Figure 7.5-5) 

● Maximal Annual Debt Service (Figure 7.5-6) 

● Debt to Capitalization (Figure 7.5-7): results show beneficial trend, approaching 

Zandi’s A1 in each year, and comparing favorably to Zandi’s A2 each year. 

● Medicare Spend per Beneficiary (Figure 7.5-8): the overall trend since 2015 is 

beneficial, and levels outperform the median and meet the quartile in 2021, with 

performance expected to be at the top decile in 2022. 

Potential Impact of Addressing: 

● Sustaining financial performance results that show areas of leadership supports 

the organization’s vision to be among America’s best health systems; and strong 

financial performance may help the organization address its strategic challenges 

of national and state health care payment changes and increasing drug costs. 

Finding: Results for marketplace performance demonstrate beneficial trends and show very 

good performance in comparison to others. 

Item Reference: 7.5a(2) 

Evidence: 

● Cardiology Market Share (Figure 7.5-11): CRHS’s share increased from 50.5% to 

51.5% from 2015 to 2021 and outperforms all competitors’ results. 

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● Oncology Market Share (Figure 7.5-12): CRHS’s share increased from 48.5% to 

49.1% from 2015 to 2021 and outperforms all competitors’ results. 

● Medicare Advantage (MA) Plan Market Share (Figure 7.5-14): CRHS’s share 

increased from 15.1% in 2018 to 21.6% in 2021 and outperforms 4 of 5 

competitors’ results. 

● Commercial Plan Market Share (Figure 7.5-15): CRS’s share increased from 4.1% 

in 2019 to 9.2% in 2021. 

● Consumer Preference (Figure 7.5-17): CRHS’s rate increased from 42.1% in 2016 

to 44.3% in 2021 and outperforms all competitors’ rates. 

● Inpatient Market Share (Figure 7.5-10): CRHS is the leader. 

● OB Market Share (Figure 7.5-13): CRHS is the leader. 

Opportunities for Improvement 

Finding: Only 1 of 17 key performance measures (Figure 2.2-2) for strategic goals/action plans 

demonstrates achievement of top-decile performance (that is, Operating Margin, Figure 7.5-2). 

Item Reference: 7.5b 

Evidence: 

● CRHS set strategic objectives to achieve top decile in customer excellence, 

workforce excellence, financial excellence, and process excellence and lists 

strategic goals/action plans and key performance measures for each of the four 

objectives (Figure 2.2-2). 

● Enhance Culturally Competent Care—Reputation Score (Figure 7.5-18): CRHS’s 

performance has not achieved goal. 

● Improve Community Health—Follow-Up Rate after Screening (Figure 7.4-13): 

only 23 of 6 measures reach goal, and Cancer Stage I at diagnosis does not meet 

goal. 

● Top-Decile Satisfaction—Willingness to Recommend (Figure 7.2-14): CRHS’s 

performance does not meet goal. 

● Achieve Top Decile Workforce Engagement—Engagement Score (Figure 7.3-12): 

performance does not meet goal. 

● Balance Workforce Profile with that of the Community (Figure 7.3-10): only 1 

hospital has met goal. 

● Increase Community Support (Figure 7.4-14): results do not meet goal. 

Potential Impact of Addressing: 

● Raising performance levels for most key performance measures could facilitate 

the achievement of the organization’s strategic objective to reach top-decile 

performance in customer excellence, workforce excellence, financial excellence, 

and process excellence (Figure 2.2-2). 

Malcolm Baldrige National Quality Award—2022 Feedback Report 69 
 

 

 

 

Finding: Results for some key measures of marketplace performance do not compare favorably 

to competitors’ results. 

Item Reference: 7.5a(2) 

Evidence: 

● Commercial Plan Market Share (Figure 7.5-15): results show performance level 

20% below market share leader between 2019 and 2022 (projected). (CRHS’s 

commercial plan has been steadily gaining market share since its inception but 

remains in the pack with competitors.) 

● ED Visits (Figure 7.5-16): 2019 total ED visits for CRHA were 134,567 compared 

to competitor total of 146,922, a difference of 12,355. 

● MA Plan Market Share (Figure 7.5-14): CRHS performs below Haferty. 

Potential Impact of Addressing: 

● Improving commercial and Medicare Advantage plan market share to reach a 

level better than competitors’ may help the organization support its strategic 

opportunity of increasing access to health care throughout the service area. 

Finding: A few key results for cost measures fall short of benchmark comparisons; and one key 

cost measure, Inpatient Expense per Discharge (Figure 7.5-9), has an adverse trend. 

Item Reference: 7.5a(1) 

Evidence: 

● Results for Inpatient Expense per Discharge (Figure 7.5-9) show an adverse trend 

between 2015 and 2022 (projected) and performance levels consistently lagging 

national top-quartile comparison. 

● Days Cash on Hand (Figure 7.5-4): CRHS’s performance does not meet Zandi’s A1 

comparison. 

● Cash to Direct Debt (Figure 7.5-5): CRHS’s performance does not meet Zandi’s A1 

comparison. 

● Maximum Annual Debt Service (Figure 7.5-6): CRHS’s performance does not 

meet Zandi’s A1 comparison. 

● Debt to Capitalization (Figure 7.5-7): CRHS’s performance does not meet Zandi’s 

A1 comparison. 

● Medicare Spend per Beneficiary (Figure 7.5-8): CRHS’s performance does not 

meet national top decile. 

Malcolm Baldrige National Quality Award—2022 Feedback Report 70 
 

 

 

 

 

● Inpatient Expense per Discharge (Figure 7.5-9): results since 2015 are worse than 

top decile. 

Potential Impact of Addressing: 

● Improving performance for these measures may help the organization reach its 

objective of top-decile financial excellence; improving results for Expense per 

Discharge (Figure 7.5-9) could support the organization’s value of efficiency. 

Finding: Some results are missing, and some measures presented are missing results for key 

segments. 

Item Reference: 7.5a,b 

Evidence: 

● Market share results for Behavioral Health are missing. 

● Results are lacking to show achievement of strategic objective of top-decile 

performance. 

● Results for intelligent risks are missing. 

● Financial performance results for these segments are missing: OP, UC/ED, 

insurance plan, and all locations. 

Potential Impact of Addressing: 

● Monitoring these results may help the organization identify areas of strength or 

opportunities for improvement that could support its achievement of top-decile 

performance. 

Scoring Range 

50–65% 

Rationale: Score should not be in 70-85 range because some results do not compare favorably 

to competitors’ or benchmarks. Score should not be in 30-45 range because beneficial trends are 

evident in key areas of importance to the accomplishment of the organization’s mission, and 

results show many areas of leadership, particularly in financial measures. 

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APPENDIX 

By submitting an application for Baldrige Criteria-based feedback, you have differentiated 

yourself from most U.S. organizations. A team of members of the 2022 Board of Examiners has 

evaluated your application against the 2021-2022 Health Care Criteria for Performance 

Excellence. Strict confidentiality is observed at all times and in every aspect of the application 

review and feedback. 

This feedback report contains the examiners’ findings, including a summary of the key themes 

of the evaluation, a detailed listing of strengths and opportunities for improvement, and scoring 

information. Background information on the examination process is provided below. 

APPLICATION REVIEW 

Independent Analysis 

Following receipt of applications, the evaluation cycle begins with Independent Analysis, in 

which members of the Board of Examiners are assigned to each of the applications. Examiners 

are assigned based on their areas of expertise and with attention to avoiding potential conflicts 

of interest. Each application is evaluated independently by the examiners, who write 

observations relating to the scoring system described beginning on page 29 of the 2021–2022 

Baldrige Excellence Framework (Health Care). 

Virtual Evaluation by Team 

A team of examiners, led by a senior or master examiner, conducts a series of reviews, first 

managed virtually through a secure database called Bridge and eventually concluded through a 

focused conference call. The purpose of this series of reviews is for the team to reach 

consensus on findings and scores that capture the team’s collective view of the applicant’s 

strengths and opportunities for improvement. The team documents its findings and scores in a 

Virtual Evaluation Scorebook, which is eventually converted into the format of a feedback 

report and edited for grammar and style by a Baldrige Program staff member. 

SCORING 

The scoring system used to score each item is designed to differentiate the applicants in the 

various stages of review and to facilitate feedback. As seen in the Process Scoring Guidelines 

and Results Scoring Guidelines (Figures 1a and 1b, respectively), the scoring of responses to 

Criteria items is based on two evaluation dimensions: process and results. The four factors used 

to evaluate process (categories 1–6) are approach (A), deployment (D), learning (L), and 

integration (I), and the four factors used to evaluate results (items 7.1–7.5) are levels (Le), 

Malcolm Baldrige National Quality Award—2022 Feedback Report 72 
 

trends (T), comparisons (C), and integration (I). 

In the feedback report, the applicant receives a percentage range score for each item. The 

range is based on the scoring guidelines, which describe the characteristics typically associated 

with specific percentage ranges. 

As shown in Figures 2a and 2b, the applicant’s overall scores for process items and results items 

each fall into one of eight scoring bands. Each band score has a corresponding descriptor of 

attributes associated with that band. 

Malcolm Baldrige National Quality Award—2022 Feedback Report 73 
 

 

SCORE DESCRIPTION 

0% or 5% 

• No systematic approach to item questions is evident; information is anecdotal. (A) 

• Little or no deployment of any systematic approach is evident. (D) 

• An improvement orientation is not evident; improvement is achieved by reacting 

to problems. (L) 

• No organizational alignment is evident; individual areas or work units operate independently. (I) 

10%, 15%, 

20%, or 25% 

• The beginning of a systematic approach to the basic question in the item is evident. (A) 

• The approach is in the early stages of deployment in most areas or work units, inhibiting 

progress in achieving the basic question in the item. (D) 

• Early stages of a transition from reacting to problems to a general improvement orientation are 

evident. (L) 

• The approach is aligned with other areas or work units largely through joint problem solving. (I) 

30%, 35%, 

40%, or 45% 

• An effective, systematic approach, responsive to the basic question in the item, is 

evident. (A) 

• The approach is deployed, although some areas or work units are in early stages of 

deployment. (D) 

• The beginning of a systematic approach to evaluation and improvement of key processes is 

evident. (L) 

• The approach is in the early stages of alignment with the basic organizational needs identified in 

response to the Organizational Profile and other process items. (I) 

50%, 55%, 

60%, or 65% 

• An effective, systematic approach, responsive to the overall questions in the item, is evident. 

(A) 

• The approach is well deployed, although deployment may vary in some areas or work units. (D) 

• Fact-based, systematic evaluation and improvement, and some examples of use of best 

practices, instances of innovation, or sharing of refinements, are in place for improving the 

efficiency and effectiveness of key processes. (L) 

• The approach is aligned with your overall organizational needs as identified in response to the 

Organizational Profile and other process items. (I) 

70%, 75%, 

80%, or 85% 

• An effective, systematic approach, responsive to multiple questions in the item, is evident. (A) 

• The approach is well deployed, with no significant gaps. (D) 

• Fact-based, systematic evaluation and improvement, adoption of best practices, managing for 

innovation, and sharing of refinements are key tools for improving organizational efficiency and 

effectiveness. (L) 

• The approach is integrated with your current and future organizational needs as identified in 

response to the Organizational Profile and other process items. (I) 

90%, 95%, or 

100% 

• An effective, systematic approach, fully responsive to the multiple questions in the item, is 

evident. (A) 

• The approach is fully deployed without significant weaknesses or gaps in any areas or work 

units. (D) 

• Fact-based, systematic evaluation and improvement, development of best practices, 

achievement of innovation, and sharing of refinements are key organization-wide tools for 

improving efficiency and effectiveness. (L) 

• The approach is well integrated with your current and future organizational needs as identified 

in response to the Organizational Profile and other process items. (I) 

Figure 1a—Process Scoring Guidelines (For Use with Categories 1–6) 

Baldrige Performance Excellence Program—2022 Feedback Report 74 
 

 

 

 

SCORE DESCRIPTION 

0% or 5% 

• There are no organizational performance results, or the results reported are poor. (Le) 

• Trend data either are not reported or show mainly adverse trends. (T) 

• Comparative information is not reported. (C) 

• Results are not reported for any areas of importance to the accomplishment of your 

organization’s mission. (I) 

10%, 15%, 

20%, or 25% 

• A few organizational performance results are reported, responsive to the basic question in the 

item, and early good performance levels are evident. (Le) 

• Some trend data are reported, with some adverse trends evident. (T) 

• Little or no comparative information is reported. (C) 

• Results are reported for a few areas of importance to the accomplishment of your 

organization’s mission. (I) 

30%, 35%, 

40%, or 45% 

• Good organizational performance levels are reported, responsive to the basic question in the 

item. (Le) 

• Some trend data are reported, and most of the trends presented are beneficial. (T) 

• Early stages of obtaining comparative information are evident. (C) 

• Results are reported for many areas of importance to the accomplishment of your 

organization’s mission. (I) 

50%, 55%, 

60%, or 65% 

• Good organizational performance levels are reported, responsive to the overall questions in the 

item. (Le) 

• Beneficial trends are evident in areas of importance to the accomplishment of your 

organization’s mission. (T) 

• Some current performance levels have been evaluated against relevant comparisons and/or 

benchmarks and show areas of good relative performance. (C) 

• Organizational PERFORMANCE RESULTS are reported for most KEY patient and other CUSTOMER, 

market, and PROCESS requirements. (I) 

70%, 75%, 

80%, or 85% 

• Good-to-excellent organizational performance levels are reported, responsive to multiple 

questions in the item. (Le) 

• Beneficial trends have been sustained over time in most areas of importance to the 

accomplishment of your organization’s mission. (T) 

• Many to most trends and current performance levels have been evaluated against relevant 

comparisons and/or benchmarks and show areas of leadership and very good relative 

performance. (C) 

• Organizational PERFORMANCE RESULTS are reported for most KEY patient and other CUSTOMER, 

market, PROCESS, and ACTION PLAN requirements. (I) 

90%, 95%, 

or 100% 

• Excellent organizational performance levels are reported that are fully responsive to the 

multiple questions in the item. (Le) 

• Beneficial trends have been sustained over time in all areas of importance to the 

accomplishment of your organization’s mission. (T) 

• Industry and benchmark leadership is demonstrated in many areas. (C) 

• Organizational PERFORMANCE RESULTS and PROJECTIONS are reported for most KEY patient and other 

CUSTOMER, market, PROCESS, and ACTION PLAN requirements. (I) 

Figure 1b—Results Scoring Guidelines (For Use with Category 7) 

Baldrige Performance Excellence Program—2022 Feedback Report 75 
 

 

 

 

 

 

 

 

Band 

Score 

Band 

Number Process Scoring Band Descriptors 

0–150 1 The organization demonstrates early stages of developing and 

implementing approaches to the basic Criteria questions, with 

deployment lagging and inhibiting progress. Improvement efforts are a 

combination of problem solving and an early general improvement 

orientation. 

151–200 2 The organization demonstrates effective, systematic approaches 

responsive to the basic questions in the Criteria, but some areas or work 

units are in the early stages of deployment. The organization has 

developed a general improvement orientation that is forward-looking. 

201–260 3 The organization demonstrates effective, systematic approaches 

responsive to the basic questions in most Criteria items, although there 

are still some areas or work units in the early stages of deployment. Key 

processes are beginning to be systematically evaluated and improved. 

261–320 4 The organization demonstrates effective, systematic approaches 

responsive to the overall questions in the Criteria, but deployment may 

vary in some areas or work units. Key processes benefit from fact-based 

evaluation and improvement, and approaches are being aligned with 

overall organizational needs. 

321–370 5 The organization demonstrates effective, systematic, well-deployed 

approaches responsive to the overall questions in most Criteria items. 

The organization demonstrates a fact-based, systematic evaluation and 

improvement process and organizational learning, including some 

innovation, that result in improving the effectiveness and efficiency of 

key processes. 

371–430 6 The organization demonstrates refined approaches responsive to the 

multiple questions in the Criteria. These approaches are characterized 

by the use of key measures and good deployment in most areas. 

Organizational learning, including innovation and sharing of best 

practices, is a key management tool, and integration of approaches with 

current and future organizational needs is evident. 

431–480 7 The organization demonstrates refined approaches responsive to the 

multiple questions in most Criteria items. It also demonstrates 

innovation, excellent deployment, and good-to-excellent use of 

measures in most areas. Good-to-excellent integration is evident, with 

organizational analysis, learning through innovation, and sharing of best 

practices as key management strategies. 

481–550 8 The organization demonstrates outstanding approaches focused on 

innovation. Approaches are fully deployed and demonstrate excellent, 

sustained use of measures. There is excellent integration of approaches 

with organizational needs. Organizational analysis, learning through 

innovation, and sharing of best practices are pervasive. 

Figure 2a–Process Scoring Band Descriptors 

Baldrige Performance Excellence Program—2022 Feedback Report 76 
 

 

 

 

 

 

 

 

 

 

 

Band 

Score 

Band 

Number Results Scoring Band Descriptors 

0–125 1 A few results are reported responsive to the basic Criteria questions, but 

they generally lack trend and comparative data. 

126–170 2 Results are reported for several areas responsive to the basic Criteria 

questions and the accomplishment of the organization’s mission. Some of 

these results demonstrate good performance levels. The use of comparative 

and trend data is in the early stages. 

171–210 3 Results address areas of importance to the basic Criteria questions and 

accomplishment of the organization’s mission, with good performance being 

achieved. Comparative and trend data are available for some of these 

important results areas, and some beneficial trends are evident. 

211–255 4 Results address some key customer/stakeholder, market, and process 

requirements, and they demonstrate good relative performance against 

relevant comparisons. Beneficial trends and/or good performance are 

reported for many areas of importance to the overall Criteria questions and 

the accomplishment of the organization’s mission. 

256–300 5 Results address most key customer/stakeholder, market, and process 

requirements, and they demonstrate areas of strength against relevant 

comparisons and/or benchmarks. Beneficial trends and/or good 

performance are reported for most areas of importance to the overall 

Criteria questions and the accomplishment of the organization’s mission. 

301–345 6 Results address most key customer/stakeholder, market, and process 

requirements, as well as many action plan requirements. Results 

demonstrate beneficial trends in most areas of importance to the Criteria 

questions and the accomplishment of the organization’s mission, and the 

organization is an industry* leader in some results areas. 

346–390 7 Results address most key customer/stakeholder, market, process, and action 

plan requirements. Results demonstrate excellent organizational 

performance levels and some industry* leadership. Results demonstrate 

sustained beneficial trends in most areas of importance to the multiple 

Criteria questions and the accomplishment of the organization’s mission. 

391–450 8 Results fully address key customer/stakeholder, market, process, and action 

plan requirements and include projections of future performance. Results 

demonstrate excellent organizational performance levels, as well as national 

and world leadership. Results demonstrate sustained beneficial trends in all 

areas of importance to the multiple Criteria questions and the 

accomplishment of the organization’s mission. 

*“Industry” refers to other organizations performing substantially the same functions, thereby facilitating 

direct comparisons. 

Figure 2b—Results Scoring Band Descriptors 

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2022 BALDRIGE FEEDBACK APPLICANTS 

Sector Total Number of 

Feedback Applications 

Health Care 6 

Nonprofit 4 

Education 

Business–Small Business 

Business–Service 

Business–Manufacturing 

Total 10 

BALDRIGE AWARD RECIPIENT CONTACT INFORMATION 1988–2021 

Baldrige Award winners generously share information with numerous organizations from all sectors. 

To contact an award winner, please see https://www.nist.gov/baldrige/award-recipients, which 

includes links to contact information as well as profiles of the winners. 

Baldrige Performance Excellence Program—2022 Feedback Report 78