Applying_Quality_Management_in_Healthcare_A_SystemPg_295-300.pdf

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PRACTICE EXERCISE 6: ORGANIZATIONAL SELF-ASSESSMENT

Objectives

• To practice using an organizational assessment as a means of documenting current reality and identifying performance gaps.

• To practice using the Baldrige Performance Excellence Program Health Care Criteria for Performance Excellence as a guide for completing an organizational assessment.

• To conduct a miniassessment of an organization using questions from the Baldrige Excellence Builder self-assessment tool.

Note: Working managers may complete this exercise by basing it on the practices of their own organizations. Students may complete this exercise by basing it on the practices of a current or previous employer.

Instructions

1. Select and describe the boundaries of the system of interest; the term “organization” will be used to refer to this system. You may select a team, a department, a small organization (e.g., an office practice), or an entire organization.

2. To familiarize yourself with the criteria, review the section called “Health Care Criteria Category and Item Commentary” in the Baldrige Health Care Criteria for Performance Excellence, available at www.nist .gov/baldrige/enter/health_care.cfm.

3. The Baldrige Excellence Builder self-assessment provides a general description of the criteria category followed by questions from the self-assessment (pp. 5–13) from the 2017–2018 Health Care Criteria for Performance Excellence.

4. Based on the system selected in question 1, write brief replies to the Baldrige questions.

Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.Created from franklin-ebooks on 2023-01-30 02:21:03.

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Organizational Assessment Worksheet

Organizational Profile This category of the self-assessment is a snapshot of your organization, including the key influences on how it operates, and of your competitive environment.

• Briefly describe your organization, including its services; size; geographic community; key patient or customer groups; and current facilities, equipment, and technology, as well as the number of patients or clients it serves.

• Briefly describe your organization’s key challenges and current performance improvement system.

LeadershipThis category examines how the personal actions of your organization’s senior leaders guide and sustain your organization. It also examines your organization’s governance system and how your organization fulfills its legal, ethical, and societal responsibilities and supports its key communities.

• How do senior leaders deploy your organization’s vision and values through your leadership system, to the workforce, to key suppliers and partners, and to patients and stakeholders, as appropriate?

• How do senior leaders encourage frank, two-way communication throughout the organization?

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Strategy This category examines how your organization develops strategic objectives and action plans. It also examines how your chosen strategic objectives and action plans are deployed and changed, if circumstances require, and how progress is measured.

• How does your organization conduct strategic planning?

• Summarize your organization’s action plans, how they are deployed, and key action plan performance measures or indicators.

Customers This category examines how your organization engages its customers—the users of your healthcare services (e.g., patients, families, insurers, other third-party payers)—for long-term marketplace success. This engagement strategy includes how your organization listens to the voice of its customers, builds customer relationships, and uses customer information to improve and identify opportunities for innovation.

• How do you identify customers and market requirements for service offerings?

• How do you build and manage relationships with customers to meet their requirements and exceed their expectations at each stage of their relationship with you?

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Measurement, Analysis, and Knowledge Management This category examines how your organization selects, gathers, analyzes, manages, and improves its data, information, and knowledge assets and how it manages its information technology. It also examines how your organization uses review findings to improve its performance.

• What are your key organizational performance measures?

• How do you use this information to support organizational decision making and innovation?

Workforce Focus This category examines your ability to assess workforce capability and capacity needs and to build a workforce environment conducive to high performance. This category examines how your organization engages, manages, and develops your workforce to use its full potential in alignment with your organization’s overall mission, strategy, and action plans.

• How do you assess your workforce capability and capacity needs, including skills, competencies, and staffing levels?

• How do you address workplace environmental factors to ensure and improve workplace health, safety, and security?

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Operations This category examines how your organization designs, manages, and improves its work systems and work processes to deliver patient and stakeholder value and achieve organizational success and sustainability. It also examines your readiness for emergency.

• How do you design and innovate your work processes to meet all the key requirements?

• How do you improve your work processes to improve healthcare outcomes, to achieve better performance, to reduce variability, and to improve healthcare services?

Results This category examines your organization’s performance and improvement in all key areas: healthcare and process outcomes, customer-focused outcomes, workforce-focused outcomes, leadership and governance outcomes, and financial and market outcomes. Performance levels are examined relative to those of competitors and other organizations with similar healthcare services offerings.

• Provide data for one key measure or indicator of performance and process effectiveness.

• Provide data for one key measure or indicator of patient or stakeholder satisfaction.

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• Provide data for one key measure or indicator of workforce capability.

• Provide data for one key measure or indicator of achievement of organizational strategy and action.

• Provide data for one key measure or indicator of financial performance.

• Provide data for one key measure or indicator related to operational performance.

• Provide data for one key measure related to achieving legal, regulatory, and accreditation requirements.

Prioritizing Improvement Opportunities

1. Review the responses to the organizational assessment questions.2. Note any questions for which you could not provide a response (i.e.,

the organization does not have a defined process or approach to address the topic of the question).

3. Review the results data and select one or more measures that demonstrate less-than-desirable results.

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