The AHCA Quality Award (PowerPoint) by yaofenji


									  2008 AHCA/NCAL
National Quality Award
  - Step III Overview -
           Jon Frantsvog
         Ira Schoenberger
              Tim Case
    The 2008 Step III Criteria

      Strategic Planning
      Focus on Patients, Other Customers and Markets
      Measurement, Analysis, and Knowledge Management
      Workforce Focus
      Process Management
    4. Measurement, Analysis, and
       Knowledge Management (90 pts.)

    Addresses Analysis, Review, and Improvement of
    Organizational Performance and Management of
    Data, Knowledge, and Information

       4.1 Measurement, Analysis, and Improvement of
             Organizational Performance (45 pts.)

       4.2 Management of Information, Information
             Technology, and Knowledge (45 pts.)

    5. Workforce Focus (85 pts.)

    Addresses How an Organization Engages,
    Develops, and Manages Its Workforce and Builds
    an Effective Workforce Environment

         5.1    Workforce Engagement (45 pts.)

         5.2    Workforce Environment (40 pts.)

    6. Process Management (85 pts.)

    Addresses How an Organization Designs Its
    Work Systems, Prepares for Emergencies, and
    Manages and Improves Its Work Processes

         6.1 Work Systems Design (35 pts.)

         6.2 Work Process Management and
         Improvement (50 pts.)

     7. Results (450 pts.)

    Addresses Progress on Results—Including Current
      Performance Levels, Trends, and Comparative Data

      7.1 Health Care Outcomes (100 pts.)
      7.2 Patient- and Other Customer-Focused Outcomes (70 pts.)
      7.3 Financial and Market Outcomes (70 pts.)
      7.4 Workforce-Focused Outcomes (70 pts.)
      7.5 Process Effectiveness Outcomes (70 pts.)
      7.6 Leadership Outcomes (70 pts.)

    7.1 Health Care Outcomes

     N1. Health care results reported in this Item should
     relate to the key health care features identified as
     patient and other customer requirements or
     expectations in P.1b(2), based on information
     gathered in Items 3.1 and 3.2. The measures or
     indicators should address factors that affect patient
     and other customer preference, such as those
     included in Item P.1, Note 7, and Item 3.1, Note 4.

     See other notes (N2 and N3) in this section.

    7.2 Patient- and Other Customer-
    Focused Outcomes

     N1. Patient and other customer satisfaction and
     dissatisfaction results reported in this Item should
     relate to the patient and other customer groups and
     market segments discussed in P.1(b)2 and Item 3.1
     and to the determination methods and data described
     in Item 3.2. Other customers might include patients’
     families, the community, insurers and other third-party
     payers, employers, health care providers, patient
     advocacy groups, Department of Health, and students.

    7.2 Patient- and Other Customer-
    Focused Outcomes

    N2. There may be several different dimensions of
    patient satisfaction, such as satisfaction with the quality
    of care, satisfaction with provider interactions,
    satisfaction with long-term health outcomes, and
    satisfaction with ancillary services. All of these areas
    are appropriate satisfaction indicators.
    N3. Measures and indicators of patients’ and other
    customers’ satisfaction with your services relative to
    their satisfaction with competitors or other
    organizations providing similar health care services
    (7.2a[1]) might include information and data from your
    customers and from independent organizations.

     7.3 Financial and Market Outcomes

      Responses to 7.3a(1) might include aggregate
      measures of financial return, such as return on
      investment (ROI), operating margins, profitability, or
      profitability by health care market or patient and
      other customer segment. Responses also might
      include measures of financial viability, such as
      liquidity, debt-to-equity ratio, days cash on hand,
      asset utilization, cash flow, and bond ratings (if
      appropriate). Measures should relate to the financial
      measures reported in 4.1a(1) and the financial
      management approaches described in Item 2.2.

     7.4 Workforce-Focused Outcomes

      N1. Results reported in this Item should relate to processes
      described in Category 5. Your results should be responsive to
      key work process needs described in Category 6 and to your
      organization’s action plans and human resource plans
      described in Item 2.2.

      N2. Responses to 7.4a(1) should include measures and
      indicators identified in response to 5.1c(1).

      N3. Results for paid staff, independent practitioners, volunteers,
      and health profession students should be included, as

     7.5 Process Effectiveness Outcomes
      N1. Results reported in Item 7.5 should address your key
      operational requirements as presented in the Organizational
      Profile and in Items 6.1 and 6.2. Include results not reported in
      Items 7.1–7.4.

      N2. Results reported in Item 7.5 should provide key information for
      analysis and review of your organizational performance (Item 4.1)
      and should provide the operational basis for health care outcomes
      (Item 7.1), patient- and other customer-focused outcomes (Item
      7.2), and financial and market outcomes (Item 7.3).

      N3. Appropriate measures and indicators of work system
      performance (7.5a[1]) might include audit, just in- time delivery,
      and acceptance results for externally provided products, services,
      and processes; supplier

     7.6 Leadership Outcomes

      N1. Measures or indicators of strategy and action plan
      accomplishment (7.6a[1]) should address your strategic
      objectives and goals identified in 2.1b(1) and your action plan
      performance measures and projected performance identified in
      2.2a(6) and 2.2b, respectively.

      N2. For examples of measures of ethical behavior and
      stakeholder trust (7.6a[2]), see Item 1.2, Note 7.

      N3. Responses to 7.6a(3) might include financial statement
      issues and risks, important internal and external auditor
      recommendations, and management’s responses to these
      matters. For some nonprofit health care organizations, results of
      IRS 990 audits also might be included.

     7.6 Leadership Outcomes

      N4. Accreditation, assessment, and regulatory and legal
      compliance results (7.6a[4]) should address requirements
      described in 1.2b. If your organization has received sanctions or
      adverse actions under law (including malpractice), regulation,
      accreditation, or contract during the past three years, briefly
      describe the incident's) and current status. If settlements have
      been negotiated in lieu of potential sanctions or adverse actions,
      give explanations. Workforce-related occupational health and
      safety results (e.g., Occupational Safety and Health
      Administration [OSHA] reportable incidents) should be reported in

      N5. Organizational citizenship and community health results
      (7.6a[5]) should address support of the key communities
      discussed in 1.2c.

The Step III (Baldrige)
    Tackling the Beast
     The Project Team

      Project leader who ensures that the outline and
      eventual application stays on target, both for timeline
      and content.
      Management team and select floor staff provide
      Strong business writer has to bring together the input
      of the staff.
      A camel is a horse designed by a committee.

     Writing the Application
      Be very thorough in response to the criteria. Address every
      section of each criterion.
      Make sure you are referring to the footnotes after each
      question to ensure you are linking to other sections.
      Provide examples to illustrate your point.
      When addressing questions referred to the scoring grid make
      sure you share with us how your organization approaches,
      deploys, aligns and integrates processes for each section as
      Prioritize what is most important to your organization.
      Remember you only have 44 pages.
      Plan ahead, outline before writing.
      Write in complete narrative sentences. Say enough, say it
17    well, then stop.
     Suggested Work Plan
     Start now
     •   Review application materials (AHCA/NCAL and Baldrige).
         Note that from year to year questions and requirements
         may change.
     •   Identify what each criterion requires.
     October - November - Develop a Plan of Attack
     •   Review Section 7 and refer back to footnote sections as
         applicable link to other sections.
     •   Review all sections and footnotes and link as applicable to
         other sections.
     •   Gather information. Farm out information gathering to
         department heads and other staff.
18   •   Develop a strong outline for each section (watch space
     Suggested Work Plan
      December - March
       • Write the sections and review weekly with team.
       • Develop strong draft before 2/28.
       • Solicit guidance as needed, the sooner the better.
       • Check request, if necessary.
       • Polish.
       • Study requirements and submittal instructions.
       • Submit by March 31, 2008.
     Engage Others in Learning

      Step III will engage staff with leaders in
      growing and learning
      Set up teams and divide work
      Work with employees who embrace it
      Establish meeting times and requirements
      Communicate across teams
      Celebrate achievement

     Step III Keys to Success
      Articulate systematic processes, not just anecdotal
      Systems and processes aligned and deployed with
      mission-driven strategic and operational goals
      Strong evidence of a quality management system
      with focus on the customer
      Demonstrate measurement, analysis, and action on
      performance results of key processes
      Performance results show improvement over time,
      but need not be always best in class

     Step III Keys to Success

      Applicants who address all criteria
      thoroughly and specifically,
      according to the criteria, are likely
      to be successful.

     Step III Award Recipients

     Step III Award recipients:
       Demonstrate an effective, systematic approach to all
       of the requirements in each category that is well
       deployed with evidence of fact-based and
       systematic evaluation, improvement, learning and
       Show how each approach is aligned or integrated
       with the organization’s needs as described in the
       Organizational Profile and other process areas.
       Are able to effectively demonstrate by approach,
       deployment, and level and consistency of results
23     that they are “best-in-class.”
     Receiving the Award…
     Reaping the Benefits
      Press releases
      Family letters
      Pins and plaques
      Marketing and advertising (using the logo)
      Community and Recognition Events
      Laying the groundwork for the next step
     AHCA/NCAL Quality Award
      Member of AHCA/NCAL
      No substandard quality of care or immediate
      jeopardy on standard or (substantiated) complaint
      surveys within the last three years
      Applicants at Step II and Step III levels must have a
      3-year weighted average survey deficiency score
      that is no higher than 3-year weighted average in
      their state
      Step III applicants must have previously received the
      Step I and Step II Awards

     Technical Requirements

      Due electronically March 31, 2008
      44-page limit
      1” Margins
      12-pt Times New Roman font
      $475 application fee

     2008 Quality Award Schedule

     Step I Award Application Deadline            February 28, 2008
     Step II and III Award Application Deadline   March 31, 2008
     Application Assessment/Scoring               April – July 2008
     Step II Award Recipient Notification         June 30, 2008
     Step I Award Recipient Notification          July 31, 2008
     Step III Award Recipient Notification        August 15, 2008
     Feedback Report Distribution Deadline        September 30, 2008
     AHCA/NCAL Convention and Award Ceremony      October 5-8, 2008


     AHCA/NCAL Quality Award program
     requirements and application information
     Baldrige National Quality Program
     To order a free copy of the Baldrige Health Care
     Criteria for Performance Excellence:
     Tel: 301-975-2036
     More Resources
     Books available at
     •   Conducting Satisfaction-Based Customer Surveys: A Guidebook
         for Long Term Care Providers by Vivian Tellis-Nayak, Ph.D.
     •   Continuous Quality Improvement: Using the Regulatory
         Framework by Barbara Baylis
     •   Developing a Quality Management System: The Foundation for
         Performance Excellence in Long Term Care by Bernie Dana
     •   Quality Management Integration in Long-Term Care: Guidelines
         for Excellence by Maryjane Bradley and Nancy Thompson

For more information...

       For more information about the
        AHCA/NCAL Quality Award
      Program, please contact Wendy
      Vernon at or


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