Research Brief

100 Top Hospitals CEO Insights:

Adoption Rates of Select Baldrige Award 

Practices and Processes

Julie Shook, FACHE

Jean Chenoweth

October 2012

100 TOP HOSPITALS

RESEARCH 

Truven Health AnalyticsSM undertakes annual survey-based research to expand our 

knowledge about the practices and strategic focus of the 100 Top Hospitals®

 awardwinning CEOs. This year’s research focused on adoption rates of the Malcolm 

T. Baldrige leadership practices in three areas — organizational environment, 

processes, and results — and was a continuation of our research into the links 

between the Baldrige National Quality Award for performance excellence and the 

100 Top Hospitals award. 

The results demonstrated that:

§ Overall, 100 Top Hospitals winners have extensively adopted the prescribed 

Baldrige practices, even though 63 percent reported they did not intentionally 

use Baldrige criteria to develop organizational goals and/or process improvement 

initiatives. 

§ Teaching hospitals reported the highest formal use of the Baldrige criteria. Nearly 

70 percent of these hospitals noted that their teams have used the award criteria to 

develop organizational goals and process improvement initiatives. 

§ It appears that for 100 Top Hospitals CEOs, organization-wide alignment remains 

a very challenging issue as they prepare their organizations for healthcare reform. 

Only 44 percent of respondents strongly agreed they had good alignment of results 

across the whole organization.

Background

Truven Health’s formal research into Baldrige practices began in October 2011, when 

we published a study,1

 commissioned by the Foundation for the Malcolm Baldrige 

National Quality Award. That study found that Baldrige hospitals were six times 

more likely to be counted among the 100 Top Hospitals award winners, which 

represent the top 3 percent of hospitals in the United States. The study also found 

that Baldrige hospitals outperformed non-Baldrige hospitals on nearly all of the 

individual measures of performance used in the 100 Top Hospitals composite score.
2

The goal of this year’s 100 Top Hospitals survey was to understand more specifically 

whether there is a relationship between the 100 Top Hospitals award and the 

Baldrige program, beyond high performance. We wanted to understand the degree 

to which 100 Top Hospitals leadership teams have adopted Baldrige practices — 

regardless of whether they have applied for a Baldrige award. 

Methodology

We conducted a brief survey with the 2012 100 Top Hospitals award winners 

between April and May 2012. The survey contained 26 questions organized into 

four areas: organizational environment, processes, results, and basic demographic 

information. The questions were written by a Truven Health researcher with an 

extensive background in hospital performance management and an analyst with 

expertise in survey design.

Respondents were offered a choice of a paper or online survey; hard-copy surveys 

were mailed and a link to the online survey was sent to all CEOs of hospitals that 

won a 2012 100 Top Hospitals award. To boost response, follow-up calls were made 

to all CEOs who had not responded after two weeks, and again after three weeks. 

The survey was closed in late May 2012, with 63 percent of hospitals responding. 

Considering the percentage of winners the 100 Top Hospitals study selects from 

each comparison group, the responses were well distributed across the five groups. 

(Compare “surveys received” and “percent of winners” columns in Figure 1.)

Figure 1: Survey Responses

Hospital Comparison Group Surveys 

Received

Percent of 

Winners

Percent of 

Group Received

Major Teaching Hospital 10 15 67%

Teaching Hospital 15 25 60%

Large Community Hospital 10 20 50%

Medium Community Hospital 10 20 50%

Small Community Hospital 16 20 80%

Unknown 2 — — 

TOTAL 63 100% 63%

Findings

Top Hospitals Are Following Recommended Practices

The fact that top-performing hospitals have an ingrained organization-wide culture 

of performance improvement was not news to our 100 Top Hospitals research team; 

this was a theme that ran through our interviews with 100 Top Hospitals CEOs 

during our 2011 survey research,2

 and one that has shown itself anecdotally again 

and again in our work with these top leaders. 

The results of this year’s survey make it clear that 100 Top Hospitals winners have 

indeed adopted Baldrige practices through much of their organizations — but they 

just might not know it. More than 80 percent of the respondents agreed or strongly 

agreed that they have implemented the practices listed on the survey (which 

were Baldrige practices, but not identified as such, Figure 5), with the exception 

of alignment of results across all areas (68 percent, Figure 5). But many appeared 
3

unaware that their practices and Baldrige practices are the same — only 37 percent 

said they used the criteria to develop organizational goals, and of those, most 

(69 percent) have never applied for a Baldrige-based award (Figure 2). Note: Baldrigebased awards include the Baldrige Award itself and state quality awards patterned 

after Baldrige. 

Figure 2. Few Respondents Report Direct Baldrige Involvement

Given that Baldrige practices are published on the Internet and the criteria are 

available to all who are interested, this presents a chicken-and-egg question: Were 

these best practices enacted before Baldrige or because of Baldrige? We believe that it 

doesn’t matter. The practices are important regardless and can become a foundation 

for evidence-based management after further research.

Teaching Hospitals Report Highest Baldrige Use for Goal-Setting

Looking at Baldrige criteria practices and award application rates by comparison 

group, we found that teaching hospitals reported the highest formal use of the 

Baldrige criteria. When asked, “Has your team ever used the National Baldrige Award 

criteria to develop organizational goals and/or process improvement initiatives?” 

nearly 70 percent of teaching hospitals said yes (Figure 3). This group also had the 

highest rate of applications for Baldrige-based awards (56 percent), with 44 percent 

of teaching hospital respondents winning an award (Figure 4). 

Large community hospitals were a distant second in reporting the use of Baldrige 

criteria (40 percent). Of these hospitals, 30 percent reported applying for Baldrigebased awards and winning them (Figures 3 and 4).

Although small community hospitals had relatively low percentages for all listed 

Baldrige practices, they were close to large community hospitals in applying for 

Baldrige-based awards (29 percent), and 24 percent reported winning an award 

(Figures 3 and 4).

Has your leadership team ever used 

the National Baldrige Award criteria to 

develop organizational goals and/or 

process improvement initiatives?

Have you applied for the National 

Baldrige Award or a state Baldrigebased award?

63%

37% 69%

31%

n Yes

n No
4

Figure 3: Teaching Hospitals Report Highest Use of Baldrige Criteria

Figure 4: Teaching Hospitals Report Highest Award Application and Win Rates

*No hospitals in this group reported winning an award.

Assessing Organizational Environment

Of the Baldrige practices detailed in our survey, it appears that as a group, the 

100 Top Hospitals winners are performing best in assessing their environment 

(Figure 5), specifically: 

§ Identifying key stakeholders, suppliers, and partners (76 percent strongly agree)

§ Addressing early indications of shifts in technology, markets, healthcare services, 

patient and stakeholder preferences, competition, the economy, and the regulatory 

environment (67 percent strongly agree)

More than half (58 percent) said they have a detailed profile of their workforce 

(i.e., by employment segment, detailing education levels, longevity, age mix, 

diversity, and other factors important to achieving organizational goals), but less 

than half of the CEOs surveyed strongly agreed that they have:

§ A written assessment of the organization’s core competencies and their 

relationship to the mission or a written market profile that includes key market 

segment requirements (for both, 49 percent strongly agreed)

§ Routinely addressed key stakeholder, supplier, and partner relationships in 

planning, performance improvement, and communications processes (46 percent 

strongly agreed)

Percent Responding

Yes

Major 

Teaching

Teaching Large 

Community

Medium 

Community

Small 

Community

80%

60%

40%

20%

0%

60%

50%

40%

30%

20%

10%

0%

Major 

Teaching*

Teaching Large 

Community

Medium 

Community*

Small 

Community

n Applied for Award

n Won Award
5

Figure 5: Practice Adoption Rates, All Hospitals Surveyed

Survey 

Question

Baldrige Practice Question Summary Respondents that 

Strongly Agreed (%)

Respondents that Agreed 

or Strongly Agreed (%)

3 Identify key stakeholders 76 95

8a Plan for shifts in tech, markets, competition 67 92

11 Workforce engagement assessed and used 62 92

7 Workforce understands goals and acts on them 60 95

15 Outcomes by service line and patient segment 60 92

9 Formal workforce learning programs 59 92

10 Two-way internal communications 59 97

8b Projections of future performance 59 87

6 Detailed workforce profile 58 86

12 Patient and stakeholder feedback obtained 57 97

1 Written core competencies 49 81

2 Market profiles by segment 49 81

4 Define key stakeholders 48 87

5 Plans and communications address stakeholder groups 46 89

16 Good results alignment across organization 44 68

13 Structured to deliver integrated services 43 97

14 Key work process evaluation cycles 27 94

Note: See appendix for complete question text.

Large Community Hospitals Lead on Organizational Environment Criteria

Based on CEO self-ratings of the identified Baldrige organizational environment 

practices, large community hospitals led on every one. Using “strongly agreed” as 

the criterion, nearly all (90 percent) of large community hospital CEOs said they 

have indentified key stakeholders, and 70 percent said they have both a written 

assessment of their organization’s core competencies and their relationship to the 

mission and a written market profile that includes key market segment requirements 

(Figure 6).

Furthermore, 80 percent of these hospitals have a detailed profile of their workforce 

(i.e., by employment segment, detailing education levels, longevity, age mix, 

diversity, and other factors important to achieving organizational goals) for their 

organization (Figure 7).

Finally, 70 percent of large community hospital leaders strongly agreed that their 

plans and communications address stakeholder needs and that their workforce 

understands their goals and acts on them (Figure 7).

Medium and small community hospitals reported the lowest adoption of most of the 

organizational environment practices (Figures 6 and 7).
6

Figure 6: Large Community Hospitals Report Strongest Agreement With Use of 

Organizational Environment Practices, Part 1 

Figure 7: Large Community Hospitals Report Strongest Agreement With Use of 

Organizational Environment Practices, Part 2

Following Recommended Processes

Leaders Report High Degree of Baldrige Process Adoption

CEO respondents reported a high degree of adoption of Baldrige process practices 

overall. More than two-thirds strongly agreed that their organization develops a 

written strategic plan that uses data and other inputs to address early indications 

of major shifts in technology, markets, healthcare services, patient and stakeholder 

preferences, competition, the economy, and the regulatory environment (Figure 5). In 

addition, 59 percent agreed their strategic plan includes projections of performance 

and that of key competitors. 

The second highest process practice reported by top hospital leaders is assessment 

and use of workforce engagement information to achieve high-performance work 

(62 percent). This is also supported by provision of formal programs of workforce 

learning (59 percent) (Figure 5).

Good communications practices are also widely reported. Fifty-nine percent reported 

structured, two-way communication processes between leadership and workforce; 

and 57 percent said they expand that effort to encompass patients and stakeholders 

(Figure 5). 

Process Practices Fall Short of Full Integration

Fewer 100 Top Hospitals leaders reported being structured to deliver integrated 

services to distinct groups of patients, across departmental lines and service provider 

types (43 percent). Only 27 percent strongly agreed that they prioritize and evaluate 

each key work process on a scheduled cycle, using data and user feedback to make 

changes that increase value to patients and stakeholders while reducing cost (Figure 5).

n Major Teaching

n Teaching

n Large Community

n Medium Community

n Small Community

Written Core 

Competencies

Market Profiles by 

Segment

ID Key 

Stakeholders

100%

90%

80%

70%

60%

50%

40%

30%

20%

Respondents Who 

Strongly Agreed

n Major Teaching n Teaching n Large Community n Medium Community n Small Community

Plans and Communication 

Address Stakeholders

Detailed Workforce Profile Workforce Understands 

and Acts on Goals

100%

90%

80%

70%

60%

50%

40%

30%

20%

Respondents Who 

Strongly Agreed
7

Mixed Results on Implementing Processes by Hospital Type

Based on CEO self-ratings of the identified process practices, large community 

hospitals once again lead on (Figures 8 and 9):

§ Planning for major shifts in technology, markets, competition, and other external 

factors in their written plans (90 percent)

§ Two-way internal communications (80 percent)

§ Systematically acquiring patient and stakeholder feedback (80 percent)

Major teaching hospitals, however, lead on implementing some of the more complex 

processes, such as (Figures 8 and 9): 

§ Projecting future performance (themselves, competitors; 78 percent)

§ Integrating service delivery across departments and providers (67 percent)

Teaching hospitals appear to be more focused on workforce practices. They report 

strongest agreement with both provision of formal workforce learning programs (88 

percent) and assessment of workforce engagement and use of the results to achieve 

high-performance work (81 percent).

More than other hospital comparison groups, large community hospitals and major 

teaching hospitals prioritize and evaluate key work process on a scheduled cycle, to 

make changes that increase value to patients and other stakeholders while reducing 

cost. But adoption rate is still quite low (33 percent for both groups) (Figure 9).

Figure 8: Results on Use of Baldrige Process Practices Vary by Size and Teaching 

Status

Figure 9: Results on Use of Baldrige Process Practices Vary by Size and Teaching 

Status, Part 2 Respondents Who Strongly Agreed n Major Teaching n Teaching n Large Community n Medium Community n Small Community

Plan for Shifts in 

Tech, Markets, 

Competition

Project Future 

Performance

Formal Workforce 

Learning Programs

Two-Way Internal 

Communications

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Respondents Who

Strongly Agreed n Major Teaching n Teaching n Large Community n Medium Community n Small Community

Workforce 

Engagement 

Assessed and Used

Systematic Patient 

and Stakeholder 

Feedback

Integrated Service 

Delivery

Key Work Process 

Evaluation Cycles

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%
8

Getting Results

Overall, the hospitals we surveyed appear to be using key outcomes measures in 

both their service lines and patient segments (diagnostic groups and/or demographic 

groups). As noted earlier, approximately 60 percent strongly agreed with that 

statement (Figure 5).

Our research into the U.S. health system performance3,4 tells us that health systems 

show a weak ability to align performance across member hospitals, as measured by 

both overall performance and overall rate of improvement for member hospitals. In 

our survey, the 100 Top Hospitals CEOs reported similar internal alignment issues 

within individual hospitals. Only 44 percent of respondents strongly agreed that 

they had good alignment of results across the whole organization (Figure 5). 

Outcomes Measurement Widely Adopted, But More Focus Needed on 

Organization-Wide Alignment Practices

Teaching and major teaching hospitals appear to be measuring outcomes by service 

line and patient segment much more than other classes. These two groups report the 

highest “strongly agreed” percentages for key measures of healthcare outcomes by 

service line and patient segment — 81 and 78 percent, respectively (Figure 10). This 

could be due to how they are structured; there may be more service line and patient 

segmentation in teaching and major teaching hospitals, leading to more measurement 

at that level.

Although none of the comparison groups show strong alignment of results across 

the whole organization, large community hospitals appear to have made the most 

progress — 60 percent of the CEOs in this group strongly agreed with the good 

alignment of results statement (Figure 10).

Figure 10: Winner Respondents on Alignment 

Further Research Needed

This study has provided a descriptive analysis of certain management practices 

within 100 Top Hospitals winners. Most have adopted Baldrige practices, but not 

as a part of a Baldrige award application. We have validated top performer adoption 

of the specific practices tested. However, because we have not tested adoption by 

nonwinners, we cannot gauge the direct relationship to higher performance. This 

is an area of interest for further research to establish evidence-based management 

practices. Respondents Who Strongly Agreed n Major Teaching n Teaching n Large Community n Medium Community n Small Community

Outcomes by Service and 

Patient Segment

Good Results Alignment 

Across Organization

100%

80%

60%

40%

20%

0%
9

Class differences in adopting these practices may primarily be caused by differences 

in organizational structure among hospitals. Although all classes of winning 

hospitals have high adoption rates for organization environment practices, the 

impact of size and teaching status on process and outcome practice adoption 

requires further research.

In previous research, we established evidence that Baldrige Award winners are 

significantly more likely to be 100 Top Hospitals winners and perform at the top 

3 percent of all hospitals. In future studies, we hope to examine which Baldrige 

practices lead to improved outcomes in both clinical and operational performance, 

beginning the journey to identifying true, evidence-based management “best” 

practices.

Key Takeaways for Healthcare Executives

The data show that top performers have not yet identified best practices for fully 

aligning results across patient care, operations, and support systems. However, the 

strong minority of winning hospital executives (44 percent) who have achieved 

this alignment may be in a much better position to move outside the walls of their 

organizations and tackle the changes driven by payment reform. To get started, it 

may be useful to: 

§ Evaluate your own organization’s adoption of the practices implemented by top 

performers (See appendix for survey questions)

§ Start small with bundled payment projects, allowing for small-scale learning with 

regard to integrating all components

§ If you are already farther along the road, consider projects that will provide 

experience integrating across care settings and with your strategic partners

Success may lie in leadership’s ability to encourage greater collaboration among 

providers and to design patient-centered delivery models that focus on the right care, 

in the right setting, at the right time. Carrying out this redesign of the healthcare 

system alongside — but not in advance of — changes in payment incentives is the 

new challenge faced by all hospital leaders.
10

Appendix: Baldrige Practice Survey Questions and 

Response Summary

Cat Q # Baldrige Practice Question

Mean 

Score

Strongly 

Agree

Agree; 

Strongly 

Agree

E 1 We have a written assessment of our organization’s core competencies and their relationship to our 

mission. 

4.2 49% 81%

E 2 We have a written market profile that includes key market segment requirements. 4.2 49% 81%

E 3 We have identified our key stakeholders, suppliers, and partners. 4.7 76% 95%

E 4 We have defined our key stakeholder, supplier, and partner roles in relationship to our organization. 4.3 48% 87%

E 5 We routinely address our key stakeholder, supplier, and partner relationships in our planning, 

performance improvement, and communications processes.

4.3 46% 89%

E 6 We have a detailed profile of our workforce (i.e., by employment segment, detailing education levels, 

longevity, age mix, diversity, and other factors important to achieving organizational goals).

4.3 58% 86%

E 7 Our workforce understands our goals and can be relied upon to take actions that support 

achieving them.

4.5 60% 95%

P 8a Our organization develops a written strategic plan that uses data and other inputs to address early 

indications of major shifts in technology, markets, healthcare services, patient and stakeholder 

preferences, competition, the economy, and the regulatory environment.

4.6 67% 92%

P 8b Our organization develops a written strategic plan that uses data and other inputs to address 

projections of future performance (both ours and our competitors).

4.4 59% 87%

P 9 We provide formal programs for workforce learning that include leadership skills development, 

succession planning, and development of future organizational leaders.

4.5 59% 92%

P 10 We use structured communication processes, in both directions, between leadership and workforce. 4.6 59% 97%

P 11 We have identified and regularly assess key elements of workforce engagement, and we use the 

results to achieve high-performance work.

4.6 62% 92%

P 12 We systematically communicate with patients and stakeholders to obtain feedback on services, 

understand expectations, define market segment needs, identify business opportunities, improve 

marketing efforts, and grow market share.

4.5 57% 97%

P 13 We are structured to deliver integrated services to distinct groups of patients, across departmental 

lines and service provider types.

4.3 43% 97%

P 14 We prioritize and evaluate each key work process on a scheduled cycle, using data and user feedback 

to make changes that increase value to patients and stakeholders while reducing cost.

3.8 27% 94%

R 15 We have key measures of healthcare outcomes by service line and patient segment (diagnostic 

groups and/or demographic groups).

4.5 60% 92%

R 16 There is good alignment of results across all patient care services, operational systems, and 

support systems.

4.4 44% 68%

Category Key: E = Organizational Environment; P = Process; R = Results 
11

References

1

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

Recipients with Peer Hospitals on a National Balanced Scorecard.” Truven Health 

Analytics. October 2011. 

2

 100 Top Hospitals Center for Healthcare Improvement. “100 Top Hospitals CEO 

Insights: Keys to Success and Future Challenges.” Truven Health Analytics. August 

2011.

3

 “15 Top Health Systems, Study Overview and Research Findings.” Truven Health 

Analytics. April 2012

4

 “10 Top Health Systems Abstract.” Truven Health Analytics. March 2009.
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