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2012 AHCA/NCAL National Quality Award Program

2012 AHCA/NCAL National Quality Award Program. The Bronze Quality Award “How To” Session Tim Case, Program Administrator. Program History . Launched in 1996 Board of Overseers established in 2006 Over 5,000 member organizations have applied for the award

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2012 AHCA/NCAL National Quality Award Program

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  1. 2012 AHCA/NCAL National Quality Award Program The Bronze Quality Award “How To” Session Tim Case, Program Administrator

  2. Program History • Launched in 1996 • Board of Overseers established in 2006 • Over 5,000 member organizations have applied for the award • Mission: To support the application of continuous quality improvement in member organizations by promoting quality awareness and education and by recognizing significant achievements in quality improvement

  3. Three Levels of Distinction • A progressive three-step program • Organizations must achieve the award at each level to continue to the next level • Bronze – Commitment to Quality • Organizational Profile (5 pages) • Silver – Achievement in Quality Baldrige Criteria Outline (18 pages) • Gold – Excellence in Quality • Full Baldrige Criteria (55 pages)

  4. Program Criteria • Based on the criteria of the Baldrige Performance Excellence Program • Framework for Performance Excellence • Leadership • Strategic Planning • Customer Focus • Workforce Focus • Operations Focus • Measurement, Analysis and Knowledge Management • Results

  5. Asking the Right Questions • The power of the criteria as a mechanism to drive a facility-based QI system lies in asking the right questions. • Realization that you do not have a solid response to a question posed by the criteria is progress, not failure! • View the criteria as the course syllabus, not the final exam.

  6. Bronze Application Requirements • Responses to 2.0 criteria in two areas: • Organizational Description • Organizational Environment • Organizational Relationships • Organizational Situations • Competitive Environment • Strategic Context • Performance Improvement System

  7. P.1: Organizational Description • What are your key organizational characteristics? Describe your organization’s operating environments and your key relationships with residents, stakeholders, suppliers and partners.

  8. P.1:Organizational Description a. Organizational Environment b. Organizational Relationships

  9. a. Organizational Environment (1) What is the organization’s environment: urban, suburban, rural, etc.? (2) What are your organization’s main HEALTH CARE SERVICE offerings? What is the relative importance of each to your organizational SUCCESS?

  10. a. Organizational Environment (3) What is the organization’s mission/vision statement (verbatim) and the specific methods used to communicate it across the organization? What are your organization’s CORE COMPETENCIES and their relationship to your MISSION? (4) What is the organization’s workforce profile? Identify your key workforce groups by position (e.g., professional nurse, nursing assistant, cook, dietary aide, housekeeper), the desired number in each position, and a general description of the education level and/or professional requirements for each position. Consider using a table to provide your response.

  11. a. Organizational Environment (5) What are the organization’s major equipment and technologies (e.g. computers, transfer equipment, automated dispensers, alarm devices, etc.)? (6) What is the regulatory environment under which the organization operates? What are the applicable health care delivery, occupational health and safety, physical plant, payment and reimbursement regulations?

  12. b. Organizational Relationships (1) What are the organization’s principal stakeholders groups? Include customers and other groups most affected by the organization's services, actions, and success. What are the differences in requirements and expectations among stakeholder groups? In addition to residents, identify up to three other principal stakeholders in the first column of the table below. In the second column, identify the important requirements that each of these principal stakeholder groups has of the organization. In the third column, identify the processes that your organization uses to learn of these important stakeholder requirements. Your responses should be complete and clear.

  13. b. Organizational Relationships (2) What are the key types of suppliers of goods and services, including other health care providers? What are your key mechanisms for communicating with suppliers? (3) From the above, what are the most important types of suppliers of goods and services?

  14. b. Organizational Relationships (4) What are the limitations, special business relationships, or special requirements that may exist with some or all suppliers and partners? (5) What are the organizational structure and key management links to the parent company if the applicant organization is owned by a parent organization? Respond “NA” if the applicant is not owned by a parent organization.

  15. P.2 Organizational Situation What is your organization’s strategic situation? Describe your organization’s competitive environment, key strategic challenges and advantages, and your system for performance improvement.

  16. P.2 Organizational Situation a. Competitive Environment b. Strategic Context c. Performance Improvement System

  17. a. Competitive Environment (1) What is the organization’s position (relative size) within the local market environment? Include numbers and types of competitors. (2) What are the principal factors that determine competitive success in the local market?

  18. a. Competitive Environment (3) What are your key available sources of comparative and competitive data from within the long term care profession? What limitations, if any, are there in your ability to obtain this data?

  19. b. Strategic Context (1) What are at least two major strategic challenges or advantages for the organization (e.g., entry into new markets or segments, human resource recruitment and retention, new alliances with suppliers, physicians, or other partners, introduction of new technologies, changes in the health care environment that impact the organization’s delivery of services, changes in strategy, or other challenges or advantages)?

  20. b. Strategic Context (2) What is the reason(s) why it is important that the organization address these challenges or advantages?

  21. c. Performance Improvement System (1) What are the key elements of your performance improvement system? In your response, describe the key steps and/or tools that you typically use for process improvement or innovation. To qualify for the Bronze award level, you must be able to articulate the approach you generally use to improve a performance outcome. This may be a methodology such as FOCUS-PDSA, Six Sigma's DMAIC, or another approach that has been developed or adopted by the organization from other resources such as Advancing Excellence.

  22. PIS Plug-Ins • In your response, describe the key steps and/or tools that you typically use for process improvement or innovation. • Data Collection • SWOT Analysis • Plan-Do-Check-Act • Root Cause Analysis • Histogram • Scattergram

  23. c. Performance Improvement System (2) What one clinical quality indicator did the organization improve by applying the key elements of your performance improvement system? The indicator should be clearly clinical in nature, not merely a process measure that impacts a clinical indicator. Using the key steps and/or tools of your performance improvement system, describe the process by which this indicator was improved, including what specific changes were made. Include data illustrating the improvement. Assisted Living, Developmental Disability (DD) Providers and IFC/MR facilities: Given the largely non-clinical nature of services provided, these type facilities may choose to report on improvement of a non-clinical resident-related indicator in response to this criteria.

  24. c. Performance Improvement System (3) Assisted Living Facilities (ALFs) and Developmental Disability (DD) residential services providers only: Because you are unable to report survey data, please report briefly on a second quality improvement effort. This effort need not necessarily be clinical in nature. Describe the process by which improvement was attained, including what specific changes were made. Include data illustrating the improvement.

  25. c. Performance Improvement System (4) What are the organization’s key organizational performance measures?

  26. Bronze Keys to Success • There are no trick questions • The Bronze Award is judged based on consistence. The applicant who addresses all areas according to the specific demands of the criteria is likely to be successful • Labelingsections as directed is required • Address all areas of each criteria • Adhere to the technical requirements

  27. For more information... For more information about the AHCA/NCAL Quality Award Program, please contact: Tim Case at tcase3362@charter.net or Courtney Krier at ckrier@ahca.org

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