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2010 AHCA/NCAL National Quality Award Program - Silver Award Overview - Session Two

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Title: 2009 AHCA/NCAL National Quality Award Program - Step II Overview - Session Two Last modified by: twilliams Created Date: 12/29/2009 3:09:03 PM – PowerPoint PPT presentation

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Title: 2010 AHCA/NCAL National Quality Award Program - Silver Award Overview - Session Two


1
2010 AHCA/NCAL National Quality Award Program-
Silver Award Overview -Session Two
Lance Reynolds Kevin Warren Tim Case
2
Silver Award Criteria
  • 2.0 Organizational Profile
  • 2.1 Visionary Leadership and Social
    Responsibility and Community Health
  • 2.2 Focus on the Future
  • 2.3 Resident-Focused Excellence
  • 2.4 Management by Fact
  • 2.5 Organizational and Personal Learning
  • 2.6 Valuing Staff and Partners
  • 2.7 Systems Perspective, Agility, Managing for
    Innovation
  • 2.8 Focus on Results and Creating Value

3
  • The first step towards getting somewhere is to
    decide that you are not going to stay where you
    are.
  • J. Pierpont Morgan

4
2.0 Organizational Profile
  • This was formerly referred to as Step I, and
    remains largely based on, the Bronze Award
    criteria.
  • Make sure you update any information you copy
    from a former Bronze Award application.
  • You are not bound by your previous Bronze Award
    application.
  • 2.0 establishes the foundation for the entire
    application.

5
The Writing Process Linkages
  • Organizational Profile (Key Factors)
  • Category Response

  • Results

6
Linkages
  • Example 1
  • Organizational Profile
  • Vision Best Nursing Home in the State as
    measured by Resident, Family and Staff
    Satisfaction.
  • Category 2.3 Response No Resident, Family and
    Staff Satisfaction processes described.
  • Results No results

7
Linkages (continued)
  • Example 2
  • Organizational Profile
  • Vision Best Nursing Home in the Nation as
    measured by Resident, Family and Staff
    Satisfaction.
  • Category 2.3 Response Two years of conducting
    surveys
  • Results Results are compared to local nursing
    homes only.

8
Organizational Profile
  • Examiners use the Organizational Profile to
    determine what is important to you, the
    applicant, throughout their entire review
    process. It is a required part of their work.
  • FOCUS

9
Silver Award Criteria
  • 2.0 Organizational Profile
  • 2.1 Visionary Leadership and Social
    Responsibility and Community Health
  • 2.2 Focus on the Future
  • 2.3 Resident-Focused Excellence
  • 2.4 Management by Fact
  • 2.5 Organizational and Personal Learning
  • 2.6 Valuing Staff and Partners
  • 2.7 Systems Perspective, Agility, Managing for
    Innovation
  • 2.8 Focus on Results and Creating Value

10
2.7 Systems Perspective, Agility, Managing for
Innovation
  • How does the organization effectively
    interconnect the individual components of its
    performance management system to view the
    organization as a whole and to ensure consistency
    of plans, processes, measures, and actions in
    order to maximize agility, encourage innovation,
    and achieve performance excellence?

11
2.7 Systems Perspective, Agility, Managing for
Innovation
  • How does your organization systematically
  • a. Ensure alignment of processes, measures, and
    action plans across departments and throughout
    various organizational levels to improve
    performance and customer satisfaction.
  • Describe key work processes.
  • Describe how the organization manages these
    processes to ensure that they are consistent with
    your strategic objectives and action plans
    described in 2.2.
  • Describe how action plans are integrated across
    departments and organizational levels to improve
    performance and customer satisfaction.

12
2.7 Systems Perspective, Agility, Managing for
Innovation
  • How does your organization systematically
  • b. Make meaningful change to improve your
    services, programs, processes, operations, care
    delivery model, and business model to create new
    value for your stakeholders.
  • Give examples of innovative changes made in the
    last year to improve resident care and quality of
    life, organization of work, and business results.

13
2.7 Systems Perspective, Agility, Managing for
Innovation
  • How does your organization systematically
  • c. Build agilitya capacity for rapid change and
    flexibility.
  • Describe how the workforce is cross-trained and
    empowered to be flexible.
  • Describe how work systems and processes are
    simplified to reduce response times to changes in
    customer needs and expectations. Give one or two
    examples.

14
SECTION 2.1 2.7
  • Scoring Guidelines

15
Factor 0-5 10-25 30-45
Approach No systematic approach to Item requirements is evident information is anecdotal The beginning of a systematic approach to the basic requirements of the Item, is evident An effective, systematic approach, responsive to the basic requirements of the Item, is evident
Deployment Little or no deployment of any systematic approach is evident The approach is in the early stages of deployment in most areas or work units, inhibiting progress in achieving the basic requirements of the Item The approach is deployed, although some areas or work units are in the early stages of deployment
Learning An improvement orientation is not evident improvement is achieved through reacting to problems Early stages of a transition from reacting to problems to a general improvement orientation are evident The beginning of a systematic approach to evaluation and improvement of key processes is evident
Integration No organizational alignment is evident individual areas or work units operate independently The approach is aligned with other areas or work units largely through joint problem solving The approach is in early stages of alignment with your basic organizational needs identified in response to the Organizational Profile and other Process Items
16
50-65 70-85 90-100
An effective, systematic approach , responsive to the overall requirements of the Item, is evident An effective, systematic approach, responsive to the multiple requirements of the Item, is evident An effective, systematic approach, fully responsive to the multiple requirements of the Item, is evident
The approach is well deployed, although deployment may vary in some areas or work units The approach is well deployed with no significant gaps The approach is fully deployed without significant weaknesses or gaps in any areas or work units
A fact-based, systematic evaluation and improvement process and some organizational learning are in place for improving the efficiency and effectiveness of key processes Fact-based, systematic evaluation and improvement and organizational learning are key management tools there is clear evidence of refinement and innovation as a result of organizational-level analysis and sharing Fact-based, systematic evaluation and improvement and organizational learning are key organization-wide tools refinement and innovation, backed by analysis and sharing, are evident throughout the organization
The approach is aligned with your organizational needs identified in response to the Organizational Profile and other Process Items The approach is integrated with your organizational needs identified in response to the Organizational Profile and other Process Items The approach is well integrated with your organizational needs identified in response to the Organizational Profile and other Process Items
Factor
Approach
Deployment
Learning
Integration
17
Comparisons and Scoring
  • 50 to 65 (This is a strong organization)
  • Some current performance levels have been
    evaluated against relevant comparisons and/or
    benchmarks and show good relative performance
  • 70 to 85 (This is a National Award Winner)
  • Many to most trends and current performance
    levels have been evaluated against relevant
    comparisons and/or benchmarks and show areas of
    leadership and very good relative performance

18
Criteria Scoring Points and Weighted Percentages
Criteria Points
2.0 25 2.5
2.1 180 18
2.2 50 5
2.3 110 11
2.4 90 9
2.5 75 7.5
2.6 75 7.5
2.7 175 17.5
2.8 220 22
1000 100
18
57.5
39.5
19
2.8 Focus on Results and Creating Value
  • What are your organizations key results that
    create value for your key stakeholders?
  • Explain how you use these key measures to drive
    performance improvement, or cross reference to
    relevant examples in other sections of the
    application.

20
2.8 Focus on Results and Creating Value a.
Health care outcomes
  • Give at least three (3) key clinical outcome
    results over appropriate time frames. At least
    one of the outcomes should clearly show
    improvement over time across at least three data
    points. Identify the strategies and specific
    changes used to improve this outcome. Assisted
    Living Facilities (ALFs) and Developmental
    Disability Residential Services providers (DD)
    may choose to substitute non-clinical process
    outcome results. If available, show your outcomes
    in comparison to competitors or to state or
    national averages, whichever seems most
    appropriate.

21
2.8 Focus on Results and Creating Value b.
Government survey performance outcomes
  • Provide government/state survey (deficiency)
    results over time (minimum of the last 3 surveys,
    but preferably 4 or 5 surveys). This requirement
    applies only to skilled nursing, ICF/MR, and
    others for which compliance with routine
    government compliance inspections is required. If
    available, show your outcomes in comparison to
    competitors or to state or national averages,
    whichever seems most appropriate.

22
2.8 Focus on Results and Creating Value c.
Other outcomes
  • In addition to the results reported above,
    provide a minimum of five (5) additional results
    drawn from the areas on the next slides. The
    results chosen and reported should cover the most
    important requirements for your organizations
    success, highlighted in your organizational
    profile (section 2.0) and responses to the core
    values and concepts (sections 2.1 to 2.7). If
    possible, choose results to report for which you
    can provide comparative data from competitors and
    other long term care facilities.
  • Whenever possible, show your outcomes in
    comparison to competitors or other long term care
    organizations. You must at least show early
    stages of efforts to gather and use comparative
    data. You are encouraged to identify performance
    benchmarks or targets within your results
    reporting.

23
2.8 Focus on Results and Creating Value
  • Resident- and stakeholder-focused results
  • Report your current levels and trends in key
    measures or indicators of resident, family and
    other stakeholder and partner satisfaction and
    dissatisfaction. Show how these results compare
    with the performance of your competitors and
    other nursing homes or long term care facilities.

24
2.8 Focus on Results and Creating Value
  • Financial and marketplace results
  • Report current levels and trends in key measures
    or indicators of financial performance, including
    financial return, financial viability, or
    budgetary performance as appropriate.
  • Report current levels and trends in key measures
    or indicators of marketplace performance,
    including market share or position, market and
    market share growth, and new markets entered, as
    appropriate.

25
2.8 Focus on Results and Creating Value
Workforce-focused results
  • Report staff turnover and/or retention rates
    (minimum of 3, but preferably 4-5 years). Show
    how these results compare with the performance of
    your competitors and other nursing homes or long
    term care facilities.
  • Report current levels and trends in key
    measures of employee satisfaction for the past
    four to five years. Show how these results
    compare with the performance of your competitors
    and other nursing homes or long term care
    facilities.
  • Report current levels and trends in key
    measures of workforce and leadership development.
  • Report current levels and trends in key
    measures of workforce health, safety and
    security, and workforce services and benefits, as
    appropriate. Include workers compensation claims
    and grievances over a four to five year period.

26
2.8 Focus on Results and Creating Value Process
effectiveness results
  • Report current levels and trends in key
    measures of occupancy.
  • Report current levels and trends in key
    measures of work system performance such as
    supplier and partner performance, job
    simplification, changing supervisory ratios,
    med-pass, and cycle time reduction.
  • Report current levels and trends in key
    measures of preparedness for disasters or
    emergencies.

27
2.8 Focus on Results and Creating Value
Leadership results
  • Report results for your key measures of
    accomplishment for your strategic and action
    plans outlined in 2.2.
  • Report results for key measures of ethical
    behavior.
  • Report results for key measures of promoting or
    supporting community health and services.
  • And, Other results
  • As deemed appropriate for the applicants
    individual organization.

28
Guidelines for Responding to the Results Items
  1. Focus on the most critical organizational
    performance results.

29
Guidelines for Responding to the Results Items
  • Focus on the most critical organizational
    performance results.
  • Note the meaning of four key requirements for
    effective reporting of results data
  • Performance Levels
  • Trends
  • Comparisons
  • Integration To show that all important results
    are included, segmented (e.g. by important
    resident or stakeholder, workforce, process and
    healthcare service groups), and as appropriate,
    related to key performance projections.

30
Guidelines for Responding to the Results Items
  • Focus on the most critical organizational
    performance results.
  • Note the meaning of four key requirements for
    effective reporting of results data.
  • Performance Levels
  • Trends
  • Comparisons
  • Integration
  • Include trend data covering actual periods for
    tracking trends.

31
Guidelines for Responding to the Results Items
  • Focus on the most critical organizational
    performance results.
  • Note the meaning of four key requirements for
    effective reporting of results data.
  • Performance Levels
  • Trends
  • Comparisons
  • Integration
  • Include trend data covering actual periods for
    tracking trends.
  • Use a compact format graphs and tables.

32
Graphs and Tables
33
Graphs and Tables
  • Quality of Dining Experience

October 2006 October 2007 October 2008
67 71 82
12/1/2005 2/1/2006 4/1/2006 6/1/2006 8/
1/2006 10/1/2006 12/1/2006 2/1/2007 4/1/
2007 6/1/2007 8/1/2007 10/1/2007 12/1/
2007 2/1/2008
34
Graphs and Tables
35
Graphs and Tables
14 13 12 11 10 9 8 6 5 4 3 2 1
2008 J F M A M J J A S O N D
36
Graphs and Tables
Year 2003 2004 2005 2006 2007 2008 Year 2001 2002 2003 2004 2005 2006
YTD Census () 68 60 72 89 89 86 YTD Census () 6 8 10 13 13 10
Table 2.8a Year to Date Census Table 2.8a Year to Date Census Table 2.8a Year to Date Census Table 2.8a Year to Date Census Table 2.8a Year to Date Census Table 2.8a Year to Date Census Table 2.8a Year to Date Census Table 2.8b Year to Date Medicare Census Table 2.8b Year to Date Medicare Census Table 2.8b Year to Date Medicare Census Table 2.8b Year to Date Medicare Census Table 2.8b Year to Date Medicare Census Table 2.8b Year to Date Medicare Census Table 2.8b Year to Date Medicare Census
37
Graphs and Tables
2004
2005
2006
2007
2008
38
Guidelines for Responding to the Results Items
  • Focus on the most critical organizational
    performance results.
  • Note the meaning of four key requirements for
    effective reporting of results data.
  • Performance Levels
  • Trends
  • Comparisons
  • Integration
  • Include trend data covering actual periods for
    tracking trends.
  • Use a compact format graphs and tables
  • Integrate results into the body of the text and
    interpret where appropriate.

39
Guidelines for Responding to the Results Items
  • Focus on the most critical organizational
    performance results.
  • Note the meaning of four key requirements for
    effective reporting of results data.
  • Performance Levels
  • Trends
  • Comparisons
  • Integration
  • Include trend data covering actual periods for
    tracking trends.
  • Use a compact format graphs and tables.
  • Integrate results into the body of the text and
    interpret where appropriate.
  • Interpret the graphed results.

40
Good Performance Levels
  • Performance levels permit evaluation relative to
    past performance, projections, goals and
    appropriate comparisons
  • Goals refer to a future condition or performance
    level that one intends to attain
  • Quantitative goals targets
  • Targets might be projected on comparative or
    competitive data
  • Benchmarks refer to results that represent best
    performance inside or outside an organizations
    industry

41
Relevant Comparisons and Benchmarks
  • Your organization is not unique
  • Review Baldrige Winners
  • Seek advice from AHCA Winners
  • Think outside the box

42
Scoring System
  • Levels meaningful scale
  • Trends appropriate time period
  • Comparisons appropriate, similar, benchmarks
  • Integration measures identified in your
    Organizational Profile and Process Items
    harmonized to support goals

43
Scoring Guidelines Results
44
Results
  • Results are 22 of the possible score so
  • Start Early!!
  • What results support our Key Strategic Objectives
    and Action Plans?
  • Do we clearly understand what each Item calls
    for?
  • Where do we get comparative data?

45
Silver Award Requirements to Recommend
  • 1.Score a minimum of 358 total points.
  • 2.Have no less than 88 (40) points in sections
    2.8.
  • 3.Have no criterion in Band A and no more than
    two criteria in Band B.

46
Technical Requirements
  • Due electronically March 31, 2010
  • 18-page limit
  • 1 Margins
  • 12-pt Times New Roman font
  • 500 application fee

47
Resources
  • AHCA/NCAL National Quality Award program
    requirements and application information
    (www.ahcancal.org).
  • Baldrige National Quality Award Program To order
    a free copy of the Baldrige Health Care Criteria
    for Performance ExcellenceTel
    301-975-2036Website www.baldrige.nist.gov.

48
More Resources
  • Scoring guidelines at www.baldrige21.com
  • Scroll past Baldrige Excellence Tools list to
    More Baldrige Excellence Tools, Services and
    Resources
  • Scroll down to the line Scoring Guidelines 2010
    Integrated Versions and click on Health Care

49
More Resources
  • Books available at www.ahcapublications.org
  • 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

50
Final Review
  • Best done with Walk the Wall (remember the war
    room)
  • Ensure all sections are addressed
  • Remember Examiners cannot assume, the document
    must stand on its own
  • Reconfirm page limits, page numbering and
    formatting instructions
  • E-mail some copies to ensure nothing lost in
    transmission.
  • And remember

51
Writing Dos and DontsDONTS!
  • Do not start until you have full agreement on
    budget, timeline and application team
  • Do not waste space with anecdotal glorification
  • Do not begin writing until the Organizational
    Profile is clear and complete
  • Do not allow anyone who does not understand the
    criteria, no matter how senior, write any part of
    the application
  • Do not stray from the criteria questions
  • Do not stray from ADLI
  • Do not write forward (We will be)
  • Do not get behind schedule
  • Do not rely on a consultant to do it all for you
  • DO NOT GIVE UP!

52
You are an Original!
Applications must be original, not supplied by
external entities, whether it be corporate office
or consultants. Speak to what you know bestyou
know better than ANYONE why the facility should
be a Silver Award Winner Tell the Story! Sell
the Story!
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