Baldrige Health Care:
Sample Organizational Self-assessment

All Rights Reserved

By Mark L. Blazey, Ed.D.

Copyright 1998-2007, Quantum Performance Group, Inc.

Version05.03.02 Bald-short-0-6

No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval systems, without permission in writing from Quantum Performance Group, Inc. Inquires should be addressed to:

Quantum Performance Group, Inc.
3336 Fallbrook Park
Canandaigua, New York 14424

Published by Quantum Performance Group, Inc. in the United States of America

ISBN: 0-9657708-4-2

This organizational assessment instrument/workbook is based on the Malcolm Baldrige National Quality Award Criteria for Performance Excellence. The author wishes to recognize the hard work and dedication of the entire Award Office staff led by Dr. Harry Hertz. Their efforts are making a significant difference in the quality of life and business competitiveness in the United States.

Customized Demographic Profile

Please circle one selection from EACH column below to indicate your position within the organization.

Position

Location

Function

Org

Years of Service

Nurse
Doctor
Other Medical Staff
Administrator

North
South
East
West

Medical Support
Clinician
Administration
Human Resources
Finance
Marketing/Public Relations
Supply Management
Info Technology
Long Term Care

1
2
3
4
5

Other

0 < 1
1 < 3
3 < 5
5 < 10
10+

 

The Performance Improvement Assessment is a confidential assessment. Do not write your own name or other personally identifiable information on this questionnaire. We will compile performance information feedback results. This assessment will be used to help evaluate the progress of your organization toward developing high performance systems.

Please return the completed survey to:

tableNational Council for Performance Excellence
480 Hercules Drive
Colchester, Vermont 05446

If you have any questions please call Laurie Emerson at (802) 655-1922.

Do not proceed until you have CIRCLED THE APPROPRIATE SELECTIONS ABOVE.

 

 

Instructions:

The full length Baldrige organizational self assessment survey consists of 49 themes or questions that relate to the 2005 Baldrige Criteria for Performance Excellence. It is organized into seven ?sectionss? one for each of the seven Baldrige Categories.

 

  1. To the best of your knowledge, select a rating (1 to 6) that describes the level of development in your organization. Note that all of the elements of a statement must be true before you can select that level. If one or more is not true, you must go to a lower level. After you have selected the rating level, please enter the value in the empty box to the right of the row of statements.
    1. Accuracy Tip: The rating scale involves your assessment about the extent of use of the required management processes. The following definitions should help you rate this consistently:
      1. Few                      less than 15%
      2. Some                    15% to less than 30%
      3. Many                    30% to less than 50%
      4. Most                     50% to less than 80%
      5. Nearly All             80% to less than 99%
      6. All                        100%

F¸   Time Saving Tip: Start reading at level 3. If all parts of the statement are true, go to level 4, if not, drop back to read level 2. After a few answers, save even more time by starting at the number you select most often. Don?t waste time by reading from row 1 each time (unless most of your answers are 1).

  1. If you do not know an answer, enter NA (Not Applicable/Does Not Apply) or ? (Don?t Know). If you are unsure of the meaning of a word or phrase, please check the glossary at the end of this booklet.
  2. After all statements in each category have been rated, you will be directed to identify two areas you believe are the most important to improve in your organization now. Then, go back to the space below each row of statements you identified as vital to improve and describe briefly the activities your organization conducts that relate to the topic. Also, please suggest steps that your organization or its leaders could take to improve the processes. Your thoughtful comments are as helpful as the rating itself. If you want to comment on more themes, please do so.
  3. Continue in the same way to complete all seven categories.

 


Summary of Category 1: Leadership

This category contains 8 themes.

The first part (four questions ? 1A through 1D) looks at how senior leaders guide and sustain the organization by setting organizational vision and values and deploying these through the organization to all staff, and key suppliers and partners. Senior leaders need to communicate openly with staff and set high performance expectations. Their personal actions must reflect the values they communicate. In addition, they must promote an environment that fosters legal and ethical behavior as well as one where accomplishment of strategic objectives, innovation, and organizational agility will lead to performance improvement. Senior leaders must empower staff to achieve high performance through customer and health care focus.

  1. You are asked to comment on the extent to which senior leaders guide and sustain the organization through clear values, vision, and setting of high performance expectations. This includes how leaders create an environment for innovation, learning, knowledge sharing, and organizational agility. You are asked how senior leaders create an environment that fosters legal and ethical behavior. You are also asked how senior leaders personally participate in succession planning and develop future leaders.
  2. You are asked how senior leaders communicate with, empower, and motivate staff while encouraging frank, two-way communication.  This includes taking an active role in reward and recognition to encourage high performance. You are asked how they focus on creating and balancing value for patients and other customers.

The second part (four ? questions 1E through 1H) looks at how well the organization?s governance system works to address its responsibilities to the public and contributes to the health of the community.

  1. You are asked to comment on management accountability and governance system effectiveness in protecting interests of stakeholders and stockholders, and how senior leaders and members of the governance board are evaluated and how the system has improved.
  2. You are asked to comment on how well the organization ensures its behavior addresses impacts on the public and complies with legal and other regulatory requirements, as well as acts ethically in health care interactions.
  3. Finally, you are asked to comment on the organization?s support for its communities and community health.

 


1A

Vision and Values: Set and Deploy Vision and Values [Baldrige ref: 1.1a(1)]

How well do senior leaders set and deploy vision and values throughout the organization and to appropriate key suppliers, partners, and patients and other customers? Do their personal actions show they are committed to these values?

1
Not Evident

2

Beginning

3
Basically Effective

4
Mature

5
Advanced

6
Role Model

Level

Top leaders do not effectively guide the organization or establish and convey the organization?s values and directions. Leaders usually wait and react to problems  after they become serious. 

A few top leaders have started to guide the organization by establishing and conveying directions to some staff. The process is not very effective since it is not consistently or widely used.

Some top leaders effectively guide the organization by establishing and conveying directions to many staff. Leaders are starting to gather data to evaluate the effectiveness of some of these processes.

Many top leaders effectively guide the organization and convey the organization?s vision and values to many staff. Leaders sometimes evaluate the effectiveness of these processes and check to see if the vision and values are understood. They may have made some changes as a result.

Most top leaders effectively establish and convey the organization?s vision and values to most staff and key suppliers. Their personal actions usually follow these values. Leaders regularly evaluate the effectiveness of these processes and check to see if the vision and values are understood. They sometimes make process improvements as a result.

Nearly all top leaders effectively establish and convey the organization?s vision and values to nearly all staff, and appropriate suppliers, partners, patients, and other customers. Their personal actions nearly always follow these values. Leaders regularly evaluate the effectiveness of these processes and check to see if the vision and values are understood. They consistently make process improvements as a result. They have developed innovative approaches in these areas and share best practices with leaders across the organization.

 

Comments: Describe how senior leaders set and deploy vision and values across the organization. To what extent do their personal actions and words reflect the vision and values? How widely are they understood? Describe improvements and/or innovations to these processes, if any.

 

 

Suggest ways to improve these processes.

 

 


 

1B

Vision and Values: Promoting a Climate for Legal and Ethical Behavior [Baldrige ref: 1.1a(2)]
How well do senior leaders promote a work environment that requires ethical and legal behavior?

1
Not Evident

2
Beginning

3
Basically Effective

4
Mature

5
Advanced

6
Role Model

Level

Top leaders have not created an environment to guide the organization effectively or encourage legal or ethical behavior. Leaders usually wait and react to problems  after they become serious. 

Legal and ethical behavior is  discussed by top leaders but not systematically addressed.

Legal and ethical behavior is addressed by some top leaders as part of the organization?s required values but no special emphasis is provided unless a problem occurs in this area.

Legal and ethical behavior is addressed by many top leaders as part of the organization?s required values but no special emphasis is provided unless a problem occurs in this area. When a problem arises, they usually check compliance and may have made some changes as a result.

Most top leaders effectively promote a climate where organizational behavior is in line with most legal and ethical codes of conduct. They work to prevent bad conduct, rather than wait for the problem to occur. They regularly check compliance and sometimes make improvements in processes to promote legal and ethical behavior. Some sharing of effective practices with leaders in the organization is done.

Nearly all top leaders effectively promote a climate where organizational behavior is fully in line with nearly all legal and ethical codes of conduct. They work to prevent bad conduct, rather than wait for the problem to occur. Ethical and legal behavior is a part of the core value of the organization. Leaders regularly check compliance and make ongoing improvements in effectiveness. They have developed innovative approaches in these areas and share best practices across the organization.

 

Comments: Describe how the leaders promote a climate that requires legal and ethical behavior. List the key performance measures they use. How widely is this done? Describe improvements and/or innovations to these processes, if any.

 

 

Suggest ways to improve these processes.

 

 

 

 

1C

Vision and Values: Sustaining the Organization Through Innovation, Learning, Developing Future Leaders, and Organizational Agility [Baldrige ref: 1.1a(3)]
To what extent do senior leaders promote an environment of innovation, learning, and organizational agility? How well do leaders of today prepare future leaders?

1
Not Evident

2
Beginning

3
Basically Effective

4
Mature

5
Advanced

6
Role Model

Level

Top leaders have not created an environment to guide the organization effectively or prepare for future challenges. Leaders usually wait and react to problems  after they become serious. 

Organizational agility and innovation is discussed by top leaders but not systematically addressed.

Organizational agility and innovation are addressed by some top leaders as part of the organization?s required values but no special emphasis is provided unless a problem occurs in this area.

Top leaders have created an environment to sustain health care success and prepare for future challenges in many parts of the organization. Many leaders work to improve organizational agility in their areas of responsibility by reducing bureaucratic ?red tape? and encouraging work-related decision-making for their staff. Many top leaders are involved in future leader development. They sometimes check to see if their efforts in these areas are effective and may have made some changes as a result.

Top leaders have created an environment of learning and innovation to sustain health care success and prepare for future challenges in most parts of the organization. Most leaders have improved organizational agility in their areas of responsibility by reducing bureaucratic ?red tape? and encouraging individual initiative and work-related decision-making for their staff. Most top leaders are involved in future leader development. They regularly check to see if their efforts in the areas above are effective and they sometimes make improvements as a result. There is some sharing of effective practices within the organization.

Top leaders have created an environment of learning and innovation to sustain health care success and prepare for future challenges in nearly all parts of the organization. Nearly all leaders have improved organizational agility in their areas of responsibility by reducing bureaucratic ?red tape? and encouraging individual initiative and work-related decision-making for their staff. Nearly all top leaders are involved in future leader development. They regularly check to see if their efforts in the areas above are effective and they make ongoing improvements as a result. They have developed innovative approaches in these areas and share best practices across the organization.

 

Comments: Describe how the leaders promote an environment of learning and innovation to sustain health care success and prepare for future challenges. Describe their involvement in succession planning and development of future leaders. How widely is this done? Describe improvements and/or innovations to these processes, if any.

 

 

Suggest ways to improve these processes.

 

 

 

 

1D

Communication and Organizational Performance: Empowerment, Motivation, Taking Action to Improve Performance, and Creating Patient and Other Customer Value [Baldrige ref: 1.1b(1&2)]
How well do senior leaders empower and motivate staff? To what extent do they encourage frank, two-way communication and personally take an active role in supporting employee reward and recognition to emphasize the importance of high performance and a customer and health care focus? To what extent do leaders create a focus on action to accomplish objectives, improve performance, and attain the organization?s vision? To what extent do leaders ensure a focus on creating and balancing value for patients, other customers and other stakeholders?

1
Not Evident

2
Beginning

3
Basically Effective

4
Mature

5
Advanced

6
Role Model

Level

Top leaders do not effectively communicate with, empower, and motivate staff. They do not encourage two-way communication or actively participate in reward and recognition. Leaders usually wait and react to problems  after they become serious. 

A few top leaders have started to communicate  systematically with a few staff to reinforce organizational direction. The process is not very effective. The process is not evaluated to see how it could be improved.

Top leaders communicate with some staff to reinforce organizational direction. They are starting to check the effectiveness of some of these processes.

Top leaders effectively motivate and communicate with many staff in many parts of the organization to encourage high performance and a patient/ other customer focus by their actions, not just words. They sometimes check to see if their efforts in these areas are effective and may have made some changes as a result.

Top leaders effectively communicate with, empower, and motivate most staff throughout the organization. Most leaders make sure that frank, two-way communication occurs most the time. They actively participate in reward and recognition and reinforce high performance and a patient/other customer and health care focus. They emphasize taking action to achieve objectives and vision, including creating and balancing value for patients and other customers. They regularly check the effectiveness of these processes and sometimes make improvements. Some sharing of effective practices in this area occurs within the organization.

Top leaders effectively communicate with, empower, and motivate nearly all staff throughout the organization. Nearly all leaders make sure that frank, two-way communication occurs nearly all the time. They actively participate in reward and recognition and reinforce high performance and a patient/other customer and health care focus. They consistently emphasize taking action to achieve objectives and vision, including creating and balancing value for patients and other patients and other customers. They regularly check the effectiveness of these processes and make ongoing improvements. They have developed innovative approaches in these areas and share best practices across the organization.

 

Comments: Describe how top leaders effectively communicate with, empower, and motivate staff. Describe how leaders make sure that frank, two-way communication occurs through out the organization. Describe how leaders actively participate in reward and recognition and reinforce high performance and a patient/other customer and health care focus. Describe how leaders create a focus on action to accomplish objectives, improve performance, and attain the organization?s vision. Describe how leaders focus on creating and balancing value for patients, other customers and other stakeholders. How widely is this done? Describe improvements and/or innovations to these processes, if any.

 

Suggest ways to improve these processes.

 

 

 

1E

Organizational Governance: Management Accountability, Protecting Stakeholder Interests, and Improving Leader Effectiveness [Baldrige ref: 1.2a(1&2)]
How well does the governing board ensure managers are accountable for the organization?s actions and stakeholder interests are protected? To what extent is leadership effectiveness evaluated and improved?

1
Not Evident

2
Beginning

3
Basically Effective

4
Mature

5
Advanced

6
Role Model

Level

Effective processes are not in place to ensure management and fiscal accountability in organization operations. The governing board is not well informed or involved in important fiscal and policy matters. They may be a rubber stamp for management and/or may have significant conflicts of interest that prevent effective oversight of management.

The governing board is beginning to set up systems to hold leaders and managers accountable for the organization?s actions. The processes are not very effective since they are not used consistently. The processes are not evaluated to check effectiveness or see how they could be improved.

The governing board is involved in occasional reviews to hold managers accountable for the organization?s actions and protect stakeholder interests against serious problems. They are starting to gather data about the effectiveness of some of these processes.

Effective processes are in place to ensure management and fiscal accountability. Independent audits help ensure stakeholder interests are protected. The board sometimes checks the effectiveness of its governance processes and the board and/or senior leaders may have made some changes as a result.

Effective processes are in place to ensure management and fiscal accountability and transparency in most governing board operations. Independent audits provide information to support effective governance and help ensure stakeholder interests are protected. The performance of most senior leaders (including administrative, health care, and the chief executive) and the governance board is occasionally evaluated based on organizational performance results and/or other feedback (such as peer and subordinate reviews). The governing board, and many senior leaders and managers throughout the leadership system use this information to improve their personal effectiveness and governance/leadership system processes. Some refinements are made to the processes as a result.

Effective processes are in place to ensure management and fiscal accountability and transparency in nearly all governing board and organization operations. Independent audits provide complete and accurate information to support effective governance and help ensure stakeholder interests are protected. The performance of nearly all senior leaders (including administrative, health care, and the chief executive) and the governance board is regularly evaluated based on organizational performance results and other feedback (such as peer and subordinate reviews). The governing board, and most senior leaders and managers and supervisors throughout the leadership system use this information to improve their personal effectiveness and governance and leadership system processes. Ongoing refinements are made to the processes as a result. Innovative processes have been developed and shared as appropriate.

 

Comments: Describe how the governance system ensures leaders and managers are held accountable for the organization?s actions. Describe how independent audits or other processes are used to support effective governance and help ensure stakeholder interests are protected. Describe how the performance of senior leaders (including the chief executive) and the governance board is evaluated. Describe how these evaluations and feedback are used to improve the personal effectiveness of leaders, governance, and leadership system processes. How widely is this done? Describe improvements and/or innovations to these processes, if any.

 

Suggest ways to improve this process.

 

 


1F

Legal and Ethical Behavior: Following Laws and Regulations, and Addressing Public Risks and Concerns [Baldrige ref: 1.2b(1)]
How well does the organization comply with laws and regulations and anticipate and reduce risks to the public that may come from its health care services and operations?

1
Not Evident

2
Beginning

3
Basically Effective

4
Mature

5
Advanced

6
Role Model

Level

The organization does not systematically consider how its health care services, facilities, or operations are likely to affect the public. It does not work consistently to meet legal requirements. It usually waits and reacts to problems  after they become serious.   

The organization is just beginning to consider how its current health care services, facilities, or operations are likely to affect the public. Some efforts are made to meet legal requirements. The process is not very effective since it is not used consistently. The process is not evaluated to see how it could be improved.

The organization effectively considers how some current health care services, facilities, or operations are likely to affect the public. It does little to consistently address public concerns. Some effective processes have been put in place to meet legal requirements. They are starting to gather data about their effectiveness in meeting some of these legal processes.

The organization    effectively considers how many of its current health care services, facilities, and operations are likely to affect the public. It acts to reduce potential problems and sometimes checks how well these actions work. Effective processes have been put in place to meet legal requirements. Sometimes it evaluates the effectiveness of processes to meet legal requirements and may have made some changes as a result.

The organization effectively considers how most of its current and future health care services, facilities, and operations are likely to affect the public. It usually reduces or eliminates potential problems. Fully effective processes have been put in place to meet legal requirements and even exceed some. It regularly checks the effectiveness of these steps and sometimes makes improvements. The approach they use is consistent with organizational needs and legal requirements. Some sharing of effective practices within the organization is done.

The organization effectively considers how nearly all of its current and future health care services, facilities, and operations are likely to affect the public. It effectively reduces or eliminates potential problems. Fully effective processes have been put in place to meet legal requirements and even exceed many. It has developed innovative approaches to addressing public concerns and exceeding legal requirements and shares best practices across the organization.

 

Comments: Describe how the organization consistently follows legal requirements and anticipates and reduces public risks and concerns. How widely is this done? Describe improvements and/or innovations to these processes, if any.

 

 

Suggest ways to improve these processes.

 

 

 


 

 

1G

Legal and Ethical Behavior: Ensuring Ethical Behavior [Baldrige ref: 1.2b(2)]
How well do all parts of the organization, including the board, top leaders, key patients, other customers, and partners make sure ethical practices are followed and breaches are addressed?

1
Not Evident

2
Beginning

3
Basically Effective

4
Mature

5
Advanced

6
Role Model

Level

The organization does not systematically monitor or prevent ethical problems. It usually waits and reacts to ethical problems after they become serious.

Organizational policies and practices reflect a general commitment to ethical practices. Few organized steps are taken to monitor behavior and ensure ethical compliance. The process is not very effective since it is not used consistently. The process is not evaluated to see how it could be improved.

Policies and practices across some parts of the organization reflect a commitment to ethical practices. Organized and effective steps are taken to monitor behavior and ensure compliance in some areas. The organization has started to gather data about the effectiveness of some of it processes to ensure ethical behavior.

Policies and practices across many parts of the organization including top leaders reflect a commitment to ethical practices most of the time. Organized and effective action is taken to monitor behavior and ensure compliance in many areas. The effectiveness of these policies and practices is sometimes checked and may have made some changes as a result.

Policies and practices across most parts of the organization, including leaders, the governing board, partners, patients, and other customers reflect a commitment to ethical practices nearly all of the time. Organized and effective action is taken to monitor behavior and ensure breaches of conduct are addressed in most areas. The effectiveness of these policies and practices is regularly checked and improvements are sometimes made. Some sharing of effective practices within the organization is done.

Policies and practices across nearly all parts of the organization, including leaders, the governing board, partners, patients, and other customers reflect a commitment to ethical practices in all interactions. Organized and effective action is taken to monitor behavior and ensure breaches of conduct are addressed. The effectiveness of these processes is regularly checked and ongoing improvements are made. It has developed innovative approaches to ensuring ethical behavior and shares best practices across the organization.

 

Comments: Describe how the organization makes sure ethical practices are followed in all interactions. How widely is this done? Describe improvements and/or innovations to this process, if any.

 

 

Suggest ways to improve this process.

 

 


 

1H

Support of Key Communities: Support of Key Communities and Community Health [Baldrige ref: 1.2c]
How committed is the organization, its leaders, and staff to supporting the communities in which it works?

1
Not Evident

2
Beginning

3
Basically Effective

4
Mature

5
Advanced

6
Role Model

Level

Senior leaders and staff do not systematically provide support to community groups. No consistency is evident.

The organization provides minimal support to key community groups. Most of this support is provided by a few staff without the support of the organization. The process is not very effective since it is not used consistently. The process is not evaluated to see how it could be improved.

The organization provides some support to key community groups by involving some staff and leaders. The organization has identified a few areas of emphasis to support. The organization has started to gather data about the effectiveness of some of its community support processes.

The organization provides some support to key community groups by involving many staff and leaders. The organization has identified some areas of emphasis to support. It sometimes checks the effectiveness of its efforts. The organization gathers data to evaluate the effectiveness of its community support and may have made some changes as a result.

The organization provides appropriate support to key community groups and to building community health consistent with organizational needs. It involves most staff and leaders in planned and structured ways. The organization has identified many key areas of emphasis to support. It regularly checks the effectiveness of its community support efforts. It sometimes makes improve­ments. Some sharing of effective practices within the organization is done.

The organization is a community role model and provides extensive support to key community groups and to building community health consistent with organizational needs. It involves nearly all staff and leaders in planned and structured ways. The organization has identified many key areas of emphasis to support. It regularly checks the effectiveness of its community support efforts and makes ongoing improvements. It has developed innovative approaches to community support and shares best practices across the organization.

 

Comments: Describe how the leaders and staff work to support key communities where they work and build community heallth. How widely is this done? Describe improvements and/or innovations to this process, if any.

 

 

Suggest ways to improve this process.

 

 

 


Text Box: Review the Leadership themes below. Each is the title of a survey question you just answered in the Leadership Category. Pick two themes you believe are the most important to improve now. Check the box next to each.     q 1A	Vision and Values: Set and Deploy Vision and Values    q 1B	Vision and Values: Promoting a Climate for Legal and Ethical Behavior    q 1C	Vision and Values: Sustaining the Organization Through Innovation, Learning, Developing Future Leaders, and Organizational Agility    q 1D	Communication and Organizational Performance: Empowerment, Motivation, Taking Action to Improve Performance, and Creating Patient and Other Customer Value    q 1E	Organizational Governance: Management Accountability, Protecting Stakeholder Interests, and Improving Leader Effectiveness    q 1F	Legal and Ethical Behavior: Following Laws and Regulations, and Addressing Public Risks and Concerns    q 1G	Legal and Ethical Behavior: Ensuring Ethical Behavior    q 1H 	Support of Key Communities: Support of Key Communities and Community Health    REMEMBER TO CHECK ONLY TWO BOXES
 

 

 

                                                                                                                                                                                                                                                        
Text Box:Review

 

Do not proceed until you have CHECKED THE TWO THEMES TO IMPROVE ABOVE.