Posted: May 1st, 2025

DDHA-8203-1/Ddha

In the case study provided, you are asked to examine the operations of an ambulatory, non-emergent care clinic which treats private and occupational health patients and provides services which do not include continuing or specialized medical care. Cooperstown Medical Associates is currently facing a few challenges and opportunities which will impact their profitability.

To prepare for this Assignment:

• Review the issues that surround provider productivity, to evaluate whether the organization can be successful in the new era of healthcare reform.
• Consider the information that would need to be known by a president and/or medical director before making any financial and organizational decisions.
• In your paper, address the following based on the Cooperstown Medical Associates case study:Describe at least three metrics you will use to evaluate the organization’s productivity.Explain how you will use these metrics in evaluating productivity.Explain how the metrics will help measure the potential of the organization’s success in the new era of healthcare reform.Analyze opportunities for improvement using Lean Management and Six Sigma principles.Develop five measurable stretch goals and how they will help the organization in the future.

health care
BALDRIGE
EXCELLENCE
FRAMEWORK
Proven leadership and management
practices for high performance
LEADERSHIP
STRATEGY
CUSTOMERS
MEASUREMENT, ANALYSIS, AND
KNOWLEDGE MANAGEMENT
WORKFORCE
2021
2022
OPERATIONS
RESULTS
www.nist.gov/baldrige
Baldrige Performance Excellence Program
National Institute of Standards and Technology (NIST) • United States Department of Commerce
January 2021
To order copies of this publication or obtain other Baldrige Program products and services, contact
Baldrige Performance Excellence Program
Administration Building, Room A600, 100 Bureau Drive, Stop 1020, Gaithersburg, MD 20899-1020
www.nist.gov/baldrige | 301.975.2036 | baldrige@nist.gov
The Baldrige Program welcomes your comments on the Baldrige Excellence Framework and other Baldrige products and
services. Please direct your comments to the address above.
The Baldrige Excellence Framework® (Health Care) is an official publication of NIST under the authority of the Malcolm Baldrige National
Quality Improvement Act of 1987 (Public Law 100-107; codified at 15 U.S.C. § 3711a). This publication is a work of the U.S. Government
and is not subject to copyright protection in the United States under Section 105 of Title 17 of the United States Code. The U.S. Department
of Commerce, as represented by NIST, holds copyright to the publication in all countries outside of the United States.
BALDRIGE EXCELLENCE FRAMEWORK®, BALDRIGE CRITERIA FOR PERFORMANCE EXCELLENCE®, BALDRIGE PERFORMANCE
EXCELLENCE PROGRAM®, BALDRIGE COLLABORATIVE ASSESSMENT®, BALDRIGE EXAMINER®, BALDRIGE EXCELLENCE BUILDER®,
PERFORMANCE EXCELLENCE®, THE QUEST FOR EXCELLENCE®, and the MALCOLM BALDRIGE NATIONAL QUALITY AWARD® medal
and depictions or representations thereof are federally registered trademarks and service marks of the U.S. Department of Commerce,
National Institute of Standards and Technology. The unauthorized use of these trademarks and service marks is prohibited.
NIST, an agency of the U.S. Department of Commerce, manages the Baldrige Program. NIST has a 100-plus-year track record of
serving U.S. industry, science, and the public with the mission to promote U.S. innovation and industrial competitiveness by advancing
measurement science, standards, and technology in ways that enhance economic security and improve our quality of life. NIST carries
out its mission in three cooperative programs, including the Baldrige Program. The other two are the NIST laboratories, conducting
research that advances the nation’s technology infrastructure and is needed by U.S. industry to continually improve products and
services; and the Hollings Manufacturing Extension Partnership, a nationwide network of local centers offering technical and
business assistance to small manufacturers.
Suggested citation: Baldrige Performance Excellence Program. 2021. 2021–2022 Baldrige Excellence Framework (Health Care): Proven
Leadership and Management Practices for High Performance. Gaithersburg, MD: U.S. Department of Commerce, National Institute of
Standards and Technology. https://www.nist.gov/baldrige.
The Baldrige Program thanks the Baldrige Foundation for supporting the program’s mission and
the following Mac Baldrige Society organizations for supporting the publication of this booklet.
We also thank these health care organizations
for their support.
Contents
ii
About the Baldrige Excellence Framework
The Baldrige framework empowers your organization to reach its goals, improve results, and become more
competitive. The framework consists of the Criteria, the core values and concepts, and the scoring guidelines.
v
How to Use the Baldrige Excellence Framework
You can use this booklet as a reference, for self-assessment, or as the basis of an external assessment.
1
Health Care Criteria for Performance Excellence Overview and Structure
The Health Care Criteria include the Organizational Profile and seven interconnected categories.
3
Health Care Criteria for Performance Excellence Items and Point Values
4
Health Care Criteria for Performance Excellence
4
Organizational Profile
7
1
Leadership
10
2
Strategy
13
3
Customers
16
4
Measurement, Analysis, and Knowledge Management
19
5 Workforce
22
6
Operations
25
7
Results
29
Scoring System
Performance against Health Care Criteria items is scored on two evaluation dimensions: process and results.
32
Process Scoring Guidelines
33
Results Scoring Guidelines
35
How to Respond to the Health Care Criteria
This section explains how to respond most effectively to the Health Care Criteria item questions.
38
Core Values and Concepts
These embedded beliefs and behaviors form the foundation of the Health Care Criteria.
44
Changes from the 2019–2020 Baldrige Excellence Framework
46
Glossary of Key Terms
The glossary includes definitions of terms in small caps in the Health Care Criteria and scoring guidelines.
54
Index of Key Terms
58
List of Contributors
On the Web
Health Care Criteria Commentary (https://www.nist.gov/baldrige/baldrige-criteria-commentary-health-care)
• This commentary provides the “why” behind the Health Care Criteria, as well as additional examples and guidance.
i
About the Baldrige Excellence Framework
The Baldrige framework helps you answer three questions: Is your organization doing as well as it
needs to? How do you know? What and how should your organization improve or change?
What can Baldrige do for my organization?
Whether your organization is new, is growing, or has existed for many years, it faces daily and long-term challenges. It also
has strengths that have served you well so far. The Baldrige Excellence Framework and its Criteria for Performance Excellence
(pages 4–28) incorporate proven practices on current health care leadership and management issues into a set of questions
that help you rise to challenges, leverage strengths, and manage all the components of your organization as a unified whole
to achieve your mission, ongoing success, and performance excellence. This view of an organization is called a systems
perspective.
You may find some of the questions difficult to answer. You may also decide that some questions are not as relevant to your
organization as others are. Even so, all the questions will help you identify areas of strength and opportunities to improve your
performance and sustainability.
How does Baldrige work?
Baldrige is a nonprescriptive framework that empowers your organization to reach its goals, improve results, and
become more competitive. The Core Values and Concepts (see pages 38–43), a set of beliefs and behaviors found in
high-performing organizations, are the foundation of the Baldrige framework:
•
Systems perspective
•
Visionary leadership
•
Patient-focused excellence
•
Valuing people
•
Agility and resilience
•
Organizational learning
•
Focus on success and innovation
•
Management by fact
•
Societal contributions and community health
•
Ethics and transparency
•
Delivering value and results
The Baldrige Criteria are organized into seven categories representing key areas of your organization: (1) Leadership;
(2) Strategy; (3) Customers; (4) Measurement, Analysis, and Knowledge Management; (5) Workforce; (6) Operations;
and (7) Results. The critical issues facing today’s organizations are woven throughout these categories.
I see the Baldrige process as a powerful set of mechanisms for disciplined people engaged
in disciplined thought and taking disciplined action to create great organizations that
produce exceptional results.
—Jim Collins, author of Good to Great: Why Some Companies Make the Leap . . .
and Others Don’t
ii
2021–2022 Baldrige Excellence Framework (Health Care)
Here are some examples of those critical issues.
Resilience and safety. Organizational resilience is the ability to anticipate, prepare for, and recover from disruptions,
and to protect and enhance all aspects of your operations when disruptions occur. The Criteria’s systems approach
prepares you for resilience, and for patient and workforce safety, by helping you understand your organization as a
whole, including the changing needs of your organization, staff, physicians, patients, other customers, and stakeholders. Specific questions ask how you reduce and prevent patient harm and how you ensure a safe workplace. The
Criteria also ask how leaders intentionally cultivate resilience; how your strategic planning addresses the need for
resilience, and how you reinforce resilience in organizing and managing your staff, physicians, and volunteers. Also
covered is how you ensure supply-network resilience and organizational continuity and resilience in the event of
disasters, emergencies, and other disruptions, taking into account risk, prevention, protection, response, and recovery.
Digitization and technology. Digitization and the use of data analytics, the Internet of Things, artificial intelligence,
cloud operations, large dataset-enabled analytics, enhanced automation (including robotics), and other “smart” technologies are accelerating rapidly in health care. The Criteria ask how your leaders consider the need for technological
innovation, how your strategic planning considers emerging technologies, how you prepare your staff for changes in
technology, and how you incorporate new technology into your health care and business processes. The Criteria also
emphasize the use of digital and web-based technologies in patient processes, the need for agility when disruptive
technologies arise, and the use of digital data analytics and artificial intelligence in performance analysis and knowledge management.
Innovation. The Criteria lead you to maximize innovation throughout your organization by asking how leaders
cultivate intelligent risk taking and innovation; how you incorporate innovation into strategic planning; how you
develop priorities for innovation and share information to use in innovation; how you support your workforce in
taking intelligent risks; and how you manage, resource, and ultimately decide whether or not to pursue opportunities
for innovation.
Diversity, equity, and inclusion. Successful organizations capitalize on the diverse backgrounds and characteristics,
knowledge, skills, creativity, and motivation of people, and foster equity and inclusion for all people. The outcome
can be improved patient, staff, physician, and stakeholder engagement, as well as improved loyalty and brand image.
Questions in the Criteria ask how you ensure fair treatment for your patients and workforce, how you ensure that
your workforce represents the diversity in your hiring and patient communities, how you tailor benefits and policies
to the diverse needs of your workforce, and how your leaders and your workforce performance management and
development foster equity and inclusion.
Cybersecurity. For health care organizations of all kinds, ensuring the security of patient information, as well as managing and reducing cyber risks to other data, information, and operational and other systems, has become a necessity. The
Criteria incorporate principles from NIST’s Framework for Improving Critical Infrastructure Cybersecurity, which focuses
on using business drivers to guide cybersecurity activities and considering cybersecurity risks in risk management
processes. The Criteria emphasize awareness of emerging security and cybersecurity threats; the role of your workforce,
customers, partners, and suppliers in cybersecurity; the importance of identifying and prioritizing information technology
and operational systems to secure; and the imperatives of protection, detection, response, and recovery.
Societal responsibility and global sustainability. As the concept of social responsibility has become accepted,
high-performing health care organizations see contributing to their community and society as more than something
they must do: it can be a driver of customer and workforce engagement and a market differentiator. The Criteria
promote societal responsibility and global sustainability through a focus on incorporating societal benefit into strategy
and operations, including contributions to supporting and strengthening key communities, protecting the environment, and aiding the social and economic systems around your organization. The Criteria also stress the need to go
beyond compliance with relevant laws and regulations.
Other critical issues similarly woven through the Baldrige framework include hiring and retaining a high-performing
workforce, capitalizing on your organizational ecosystem, managing enterprise risk, managing for success in a time of
rapid change, and many more.
How do I know if Baldrige is right for my organization?
Baldrige is adaptable to any organization’s needs. It does not prescribe how you should structure your organization or
its operations. In the Organizational Profile (pages 4–6), you describe what is important to your organization. Baldrige
encourages you to use creative, adaptive, innovative, and flexible approaches and to choose the tools (e.g., Lean,
Six Sigma, International Organization for Standardization [ISO] series, a balanced scorecard, Plan-Do-Check-Act
[PDCA]) that are best suited to your organization and are the most effective in driving improvements and sustainable
high performance.
About the Baldrige Excellence Framework
iii
How do I know how I’m doing?
With Baldrige, you assess the maturity of your responses based on four evaluation dimensions for the process categories and four for the results category (see the scoring guidelines on pages 32–33).
With the Baldrige framework, you assess and improve your processes along these dimensions:
1.
Approach: How do you accomplish your organization’s work? How systematic and effective are your key
approaches?
2.
Deployment: How consistently are your key approaches used in relevant parts of your organization?
3.
Learning: How well have you evaluated and improved your key approaches? How well have improvements been
shared within your organization? Has new knowledge led to innovation?
4.
Integration: How well do your approaches reflect your current and future organizational needs? How well are
processes and operations harmonized across your organization to achieve key organization-wide goals?
With Baldrige, you assess your results along these dimensions:
1.
Levels: What is your current performance on a meaningful measurement scale?
2.
Trends: Are the results improving, staying the same, or getting worse?
3.
Comparisons: How does your performance compare with that of competitors, or with benchmarks or industry
leaders?
4.
Integration: Are you tracking results that are important to your organization? Are you using the results in
decision making?
As you respond to the Criteria questions and assess your responses, you will begin to identify strengths and gaps—
first within the Criteria categories and then among them. The coordination of key processes, and feedback between
your processes and your results, will lead to cycles of improvement. As you continue to use the framework, you will
learn more and more about your organization and begin to define the best ways to build on your strengths, close gaps,
and innovate.
What is the impact of Baldrige nationally and globally?
The Baldrige framework and Criteria play three roles in strengthening U.S. competitiveness:
•
They help improve organizational processes, capabilities, and results.
•
They facilitate the communication and sharing of best practices among U.S. organizations through the
Baldrige Award, the Quest for Excellence® Conference, the Baldrige Executive Fellows Program, and other
educational offerings.
•
They serve as a working tool for understanding and managing organizational performance, guiding your
strategic thinking, and providing opportunities to learn.
Baldrige works with public- and private-sector partners to address critical national needs related to long-term success
and sustainability, including cybersecurity risk management (see https://www.nist.gov/baldrige/products-services/
baldrige-cybersecurity-initiative) and excellence in U.S. communities (see Communities of Excellence 2026, http://
www.communitiesofexcellence2026.org).
Within the United States, state, regional, sector, and organizational performance excellence programs use the Baldrige
framework to help organizations improve their competitiveness and results. Globally, many performance or business
excellence programs use the Baldrige framework or a derivative as their organizational excellence model.
How do I get started?
However you plan to use the Baldrige framework, the Baldrige community is there to help your organization learn,
grow, and improve. See the following pages and visit https://www.nist.gov/baldrige to see the possibilities.
iv
2021–2022 Baldrige Excellence Framework (Health Care)
How to Use the Baldrige Excellence Framework
Whether your health care organization is large or small, you can use the Baldrige Excellence
Framework for improvement. Your experience with Baldrige will help you decide where to begin.
If your organization is in the business/nonprofit or education sector, you should use the business/nonprofit or
education version of this booklet, respectively. See https://www.nist.gov/baldrige/publications to obtain a copy.
If you are just learning about the Baldrige framework . . .
Here are some ways to begin using the Baldrige framework to improve your organization.
Scan the questions in the Organizational Profile (pages 4–6). Discussing the answers to these questions with your
senior leadership team might be your first Baldrige self-assessment.
Study the 11 Baldrige core values and concepts (pages 38–43). Consider how your organization measures up in
relation to the core values. Are there any improvements you should be making?
Answer the questions in the titles of the 17 Health Care Criteria for Performance Excellence items to reach a
basic understanding of the Criteria and your organization’s performance.
See a simple outline of a holistic performance management system by reading the headings in purple in the
Health Care Criteria section of this booklet (pages 4–28). Are you considering all of these dimensions in establishing
your leadership system and measuring performance?
Use the Baldrige framework and its supporting material as a general resource on organizational performance
improvement. This booklet and the materials online (https://www.nist.gov/baldrige/publications) may help you think
in a different way or give you a fresh frame of reference.
Attend the Quest for Excellence® Conference, the Baldrige Fall Conference, or a state or regional Baldrigebased conference. These events highlight the role-model approaches of recipients of the Baldrige Award or Baldrigebased awards. These organizations have used the Baldrige framework to improve performance, innovate, and achieve
world-class results. Workshops on Baldrige self-assessment are often offered in conjunction with these conferences.
Become an examiner or attend the Baldrige Examiner Training Experience (https://www.nist.gov/baldrige
/products-services). Examiners receive valuable training, evaluate award applications, and learn to apply the Criteria to
their organizations.
Become a Baldrige Executive Fellow. Baldrige Fellows (C-suite and rising executives) participate in an executive
development program (see https://www.nist.gov/baldrige/products-services), learning from each other and from
Baldrige Award recipients.
If you are ready to assess your organization using Baldrige . . .
To assess your organization with the Baldrige framework, follow one or more of the suggestions below.
Check your progress on achieving organizational excellence and improve communication among your workforce members and leadership team with two simple questionnaires: Are We Making Progress? and Are We Making
Progress as Leaders? (https://www.nist.gov/baldrige/self-assessing/improvement-tools).
Identify gaps in your understanding of your organization and compare your organization with others with
easyInsight: Take a First Step toward a Baldrige Self-Assessment (https://www.nist.gov/baldrige/self-assessing
/improvement-tools). This assessment is based on the Organizational Profile.
Complete the Organizational Profile (pages 4–6). Have your leadership team answer the questions. If you identify
topics for which you have conflicting, little, or no information, use these topics for action planning. For many organizations, this approach serves as a first Baldrige self-assessment.
Answer the questions in the Baldrige Excellence Builder (https://www.nist.gov/baldrige/publications). This assessment tool includes key questions for improving your organization’s performance. They are the questions in black
boldface in the Health Care Criteria section of this booklet.
How to Use the Baldrige Excellence Framework
v
Use the full set of Health Care Criteria questions as a personal guide to everything that is important in
leading your organization. You may discover blind spots or areas where you should place additional emphasis.
Review the scoring guidelines (pages 32–33). They help you assess your organizational maturity, especially when
used in conjunction with “Steps toward Mature Processes” (page 31) and “From Fighting Fires to Innovation:
An Analogy for Learning” (page 34).
Answer the questions in one Health Care Criteria category in which you know you need improvement, either
yourself or with leadership team colleagues. Then assess your strengths and opportunities for improvement, and
develop action plans. Be aware, though, that this kind of assessment limits the benefits of the systems perspective
embodied in the Baldrige framework.
Have your leadership team assess your organization. At a retreat, have your leadership team develop responses
to the Organizational Profile and the seven Health Care Criteria categories using the Baldrige Excellence Builder
(https://www.nist.gov/baldrige/publications), and record the responses. Then assess your strengths and opportunities
for improvement, and develop action plans.
Conduct a full Baldrige self-assessment. Set up teams within your organization to develop responses to the
Organizational Profile and Criteria categories. For details, see https://www.nist.gov/baldrige/self-assessing and the
slide presentation “Self-Assessing Your Organization with the Baldrige Excellence Framework” (https://www.nist.gov
/baldrige/community/baldrige-ambassadors).
Contact your state, local, or sector-specific Baldrige-based program (see the Alliance for Performance Excellence,
https://www.baldrigealliance.org). Many programs provide networking opportunities, training, coaching, and selfassessment services in addition to an award program.
Contact a Baldrige Award recipient. Organizations that receive the Baldrige Award advocate for performance
improvement, share their strategies, and serve as role models. Many undertake ongoing self-assessments of their
organizations and can share their experiences with you. See https://www.nist.gov/baldrige/award-recipients for award
recipients and their contact information.
If you are ready for external feedback . . .
Here are some resources for receiving external feedback on your organization’s strengths and opportunities for
improvement.
Apply to your state, local, or sector-specific Baldrige-based award program (see the Alliance for Performance
Excellence, https://www.baldrigealliance.org). A team of experts will examine your organization objectively and
identify your organization’s strengths and its opportunities to improve.
Arrange for a Baldrige Collaborative Assessment (https://www.nist.gov/baldrige/products-services). In this on-site
assessment, a team of Baldrige examiners works with your leaders and staff to give your organization immediate,
actionable feedback.
Apply for the Malcolm Baldrige National Quality Award. Once you meet eligibility requirements, apply for the
highest level of national recognition for performance excellence that a U.S. organization can receive: the Malcolm
Baldrige National Quality Award. All award applicants receive a feedback report created by a team of Baldrige
examiners.
Award applicants say that the Baldrige evaluation process is one of the best, most cost-effective, most comprehensive
performance assessments you can find, whether or not they receive the Baldrige Award. See https://www.nist.gov
/baldrige/baldrige-award for more information. In the Baldrige process, everyone is a learner.
vi
2021–2022 Baldrige Excellence Framework (Health Care)
Health Care Criteria for Performance
Excellence Overview and Structure
Health Care Criteria for Performance Excellence Overview: A Systems Perspective
The performance system consists of the six categories in the center of the figure. These categories define your processes and
the results you achieve.
Performance excellence requires strong Leadership and is demonstrated through outstanding Results.
The word “integration” at the center of the figure shows that all the elements of the system are interrelated.
The center horizontal arrowheads show the critical linkage between the leadership triad (on the left) and the results triad
(on the right) and the central relationship between the Leadership and Results categories.
The center vertical arrowheads point to the Organizational Profile and the system foundation, which provide information on
and feedback to key processes and the organizational environment.
The leadership triad (Leadership, Strategy, and Customers)
emphasizes the importance of
a leadership focus on strategy
and customers.
The system
foundation
(Measurement,
Analysis, and
Knowledge Management)
is critical to effective
management and to a
fact-based, knowledgedriven, agile system for
improving performance
and competitiveness.
The Organizational Profile
sets the context for your
organization. It serves as the
background for all you do.
The results triad (Workforce,
Operations, and Results)
includes your workforce-focused
processes, your key operational
processes, and the performance
results they yield.
     
The basis of the Health Care Criteria is a set of Core Values and Concepts
that are embedded in high-performing organizations (see pages 38–43).
Health Care Criteria for Performance Excellence Overview and Structure
1
Health Care Criteria for Performance Excellence Structure
The seven Baldrige Health Care Criteria for Performance Excellence categories are subdivided into
items and areas to address.
Items
Item Questions
There are 17 Health Care Criteria items (plus 2 in the
Organizational Profile), each with a particular focus. These
items are divided into three groups according to the kinds of
information they ask for:
Item questions are expressed on three levels:
• The Organizational Profile asks you to define your
organizational environment.
• Process items (categories 1–6) ask you to define your
organization’s processes.
• Results items (category 7) ask you to report results for
your organization’s processes.
See page 3 for a list of item titles and point values.
Item Notes
• Basic questions are expressed in the item titles.
• Overall questions are expressed in boldface in the
shaded box. These leading questions are the starting
point for responding.
• Multiple questions are the individual ones under each
area to address, including the one in boldface. That
first question expresses the most important one in
that group.
Key Terms
Terms in small caps are defined in the Glossary of Key
Terms (pages 46–53).
Item notes (1) clarify terms or questions, (2) give instructions and examples for responding, and (3) indicate key
linkages to other items.
Areas to Address
Each item includes one or more areas to address (labeled
a, b, c, and so on).
2
2021–2022 Baldrige Excellence Framework (Health Care)
Health Care Criteria for Performance
Excellence Items and Point Values
See pages 29–34 for the scoring system used with the Health Care Criteria items in a
Baldrige assessment.
P
Organizational Profile
P.1
Organizational Description
P.2
Organizational Situation
Categories and Items
1
2
3
4
5
6
7
Point Values
Leadership
120
1.1
Senior Leadership
70
1.2
Governance and Societal Contributions
50
Strategy
85
2.1
Strategy Development
45
2.2
Strategy Implementation
40
Customers
85
3.1
Customer Expectations
40
3.2
Customer Engagement
45
Measurement, Analysis, and Knowledge Management
90
4.1
Measurement, Analysis, and Improvement of
Organizational Performance
45
4.2
Information and Knowledge Management
45
Workforce
85
5.1
Workforce Environment
40
5.2
Workforce Engagement
45
Operations
85
6.1
Work Processes
45
6.2
Operational Effectiveness
40
Results
450
7.1
Health Care and Process Results
120
7.2
Customer Results
80
7.3
Workforce Results
80
7.4
Leadership and Governance Results
80
7.5
Financial, Market, and Strategy Results
90
TOTAL POINTS
Health Care Criteria for Performance Excellence Items and Point Values
1,000
3
Health Care Criteria for
Performance Excellence
Begin with the Organizational Profile
The Organizational Profile is the most appropriate starting point for self-assessment and for writing an application. It is critically important for the following reasons:
• You can use it as an initial self-assessment. If you identify topics for which conflicting, little, or no information is available, use these topics for action planning.
• It sets the context for understanding your organization and how it operates, and allows you to address unique aspects of
your organization in your responses to the Health Care Criteria questions in categories 1–7. Your responses to all other
questions in the Criteria should relate to the organizational context you describe in this profile.
• It helps you identify gaps in key information about your organization and focus on key performance requirements and
results.
P
Organizational Profile
The Organizational Profile is a snapshot of your organization and its strategic environment.
P.1 Organizational Description: What are your key organizational characteristics?
a. Organizational Environment
(1) HealtH Care ServiCe Offerings What are your main health care service offerings (see the note on the next
page)? What is the relative importance of each to your success? What mechanisms do you use to deliver your
health care services?
(2) MiSSion, viSion, valueS, and Culture What are your mission, vision, and values? Other than values, what
are the characteristics of your organizational culture? What are your organization’s core competencies, and what
is their relationship to your mission?
(3) WorkforCe Profile What is your workforce profile? What recent changes have you experienced in
workforce composition or in your needs with regard to your workforce? What are
• your workforce or employee groups and segments;
• the educational requirements for different employee groups and segments;
• the key drivers that engage them;
• your organized bargaining units (union representation), if any; and
• your special health and safety requirements, if any?
(4) Assets
What are your major facilities, equipment, technologies, and intellectual property?
(5) Regulatory Environment What are your key applicable occupational health and safety regulations; accreditation,
certification, or registration requirements; industry standards; and environmental, financial, and health care
service delivery regulations?
b. Organizational Relationships
(1) Organizational Structure What are your organizational leadership structure and governance structure? What
structures and mechanisms make up your organization’s leadership system? What are the reporting relationships
among your governance board, senior leaders, and parent organization, as appropriate?
(2) Patients, Other CuStoMerS, and StakeHolderS What are your key market segments, patient and other
customer groups, and stakeholder groups, as appropriate? What are their key requirements and expectations
for your health care services, patient and other customer support services, and operations, including any differences among the groups?
(Continued on the next page)
4
2021–2022 Health Care Criteria for Performance Excellence
(3) Suppliers, PartnerS, and CollaboratorS What are your key types of suppliers, partners, and collaborators? What role do they play in producing and delivering your key health care services and patient and other
customer support services, and in enhancing your competitiveness? What role do they play in contributing and
implementing innovations in your organization? What are your key supply-network requirements?
Terms in small caps are defined in the Glossary of Key Terms (pages 46–53).
Notes
P.1a(1). Health care service offerings are the services you
offer in the marketplace. Mechanisms for delivering services
to your patients or other customers might be direct or might
be indirect, through contractors, collaborators, or partners.
P.1a(2). If your organization has a stated purpose as well
as a mission, you should include it in your response. Some
organizations define a mission and a purpose, and some use
the terms interchangeably. Purpose refers to the fundamental reason that the organization exists. Its role is to inspire
the organization and guide its setting of values.
P.1a(2). Your values are part of your organization’s culture.
Other characteristics of your culture might include shared
beliefs and norms that contribute to the uniqueness of the
environment within your organization.
P.1a(3). Workforce or employee groups and segments
(including organized bargaining units) might be based on
type of employment or contract-reporting relationship,
location (including remote work), tour of duty, work
environment, use of flexible work policies, or other factors.
Organizations that also rely on volunteers and interns to
accomplish their work should include these groups as part
of their workforce.
P.1a(5). Industry standards might include industrywide
codes of conduct and policy guidance. Depending on the
regions and context in which you operate, special financial
covenants, standards regarding relationships with physicians
or other referral sources, and environmental regulations
may apply.
P.1b(1). The Organizational Profile asks for the “what” of
your leadership system (its structures and mechanisms).
Questions in categories 1 and 5 ask how the system is used.
Organizational Profile
P.1b(2). Customers include the direct users and potential
users of your health care services (patients), as well as
referring health care providers and those who pay for your
services, such as patients’ families, insurers, and other thirdparty payors. Your organization may use another term for
patient, such as client, resident, consumer, or member.
P.1b(2). Patient and other customer groups might be based
on common expectations, behaviors, preferences, or profiles.
Within a group, there may be segments based on differences, commonalities, or both. You might subdivide your
market into segments based on health care service lines or
features, service delivery modes, payors, volume, geography,
or other defining factors.
P.1b(2). Patient, other customer, stakeholder, and
operational requirements and expectations will drive your
organization’s sensitivity to the risk of service, support, and
supply-network interruptions, including those due to natural
disasters and other emergencies.
P.1b(3). Your supply network consists of the entities that
contribute to producing your health care services and delivering them to your patients and other customers. For some
organizations, these entities form a chain, in which one
entity directly supplies another. Increasingly, however, these
entities are interlinked and exist in interdependent rather
than linear relationships. The Health Care Criteria use the
term supply network to emphasize the interdependencies
among organizations and their suppliers.
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
5
P.2 Organizational Situation: What is your organization’s strategic situation?
a. Competitive Environment
(1) Competitive Position What are your relative size and growth in the health care industry or the markets you
serve? How many and what types of competitors do you have?
(2) Competitiveness Changes What key changes, if any, are affecting your competitive situation, including changes
that create opportunities for innovation and collaboration, as appropriate?
(3) Comparative Data What key sources of comparative and competitive data are available from within the health
care industry? What key sources of comparative data are available from outside the health care industry? What
limitations, if any, affect your ability to obtain or use these data?
b. Strategic Context
What are your key strategic challenges and advantages?
c. PerforManCe Improvement System
What is your performance improvement system, including your processes for evaluation and improvement of key
organizational projects and processes?
Terms in small caps are defined in the Glossary of Key Terms (pages 46–53).
Notes
P.2b. Strategic challenges and advantages might be in the
areas of business, operations, societal contributions, and
workforce. They might relate to health care services or
service features, quality and outcomes, finances, organizational structure and culture, emerging technology, digital
integration, data and information security and cybersecurity,
emerging competitors, changing stakeholder requirements,
workforce capability or capacity, brand recognition and
reputation, your supply network, and the health care
industry.
to set an overall context for your approach to performance
improvement. The approach you use should be related to
your organization’s needs. Approaches that are compatible
with the overarching systems approach provided by the
Baldrige framework might include implementing a Lean
Enterprise System, applying Six Sigma methodology, using
PDCA methodology, using standards from ISO (e.g., the
9000 or 14000 series, or sector-specific standards), using
decision or implementation science, or employing other
improvement tools.
P.2c. The Baldrige Scoring System (pages 29–34) uses
performance improvement through learning and integration as a factor in assessing the maturity of organizational
approaches and their deployment. This question is intended
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
6
2021–2022 Health Care Criteria for Performance Excellence
1
Leadership (120 pts.)
The Leadership category asks how senior leaders’ personal actions guide and sustain your organization. It also asks about
your organization’s governance system; how your organization fulfills its legal and ethical responsibilities; and how it makes
societal contributions.
1.1 Senior Leadership: How do your senior leaders lead the organization? (70 pts.)
a. viSion and valueS
P R O C ESS
(1) Establishing viSion and valueS HoW do Senior leaderS set and dePloy your organization’s viSion and
valueS? how do senior leaders deploy the vision and values through your leadership system; to the
workforce; to key suppliers and partners; and to patients, other customers, and other stakeholders, as
appropriate? how do senior leaders’ personal actions reflect a commitment to those values?
(2) Promoting Legal and etHiCal beHavior HoW do Senior leaderS’ personal actions demonstrate their
commitment to legal and etHiCal beHavior? how do senior leaders promote an organizational environment
that requires it?
b. Communication
HoW do Senior leaderS communicate with and engage the entire WorkforCe, key PartnerS, patients, and other
key CuStoMerS? how do they
• encourage frank, two-way communication;
• communicate key decisions and needs for organizational change; and
• take a direct role in motivating the workforce toward high performance and a patient, other customer,
and business focus?
c. MiSSion and Organizational PerforManCe
(1) Creating an Environment for Success
in the future? how do they
HoW do Senior leaderS create an environment for success now and
• create an environment for the achievement of your mission;
• create and reinforce your organizational culture; a culture that fosters patient, other customer, and workforce
engagement, equity, and inclusion; and a culture of patient safety;
• cultivate organizational agility and resilience, accountability, organizational and individual learning, innovation, and intelligent risk taking; and
• participate in succession planning and the development of future organizational leaders?
(2) Creating a Focus on Action HoW do Senior leaderS create a focus on action that will achieve the
organization’s MiSSion? how do senior leaders
• create a focus on action that will improve the organization’s performance;
• identify needed actions;
• in setting expectations for organizational performance, include a focus on creating and balancing value for
patients, other customers, and other stakeholders; and
• demonstrate personal accountability for the organization’s actions?
Terms in small caps are defined in the Glossary of Key Terms (pages 46–53).
Notes
1.1. In health care organizations with separate administrative/operational and health-care-provider leaders, the
term “senior leaders” refers to both sets of leaders and the
relationship between them.
1.1. Your organizational performance results should be
reported in items 7.1–7.5. Results related to the effectiveness
of leadership and the leadership system should be reported
in item 7.4.
1
Leadership
1.1a(1). Your organization’s vision should set the context
for the strategic objectives and action plans you describe in
items 2.1 and 2.2.
1.1b. Two-way communication may include use of social
media, such as delivering periodic messages through
internal and external websites, tweets, blogging, and patient
and workforce digital forums, as well as monitoring external
social media outlets and responding, when appropriate.
7
1.1b. Senior leaders’ direct role in motivating the workforce
may include participating in reward and recognition
programs.
1.1b. Organizations that rely heavily on volunteers to
accomplish their work should also discuss efforts to communicate with and engage the volunteer workforce.
1.1c(1). A successful organization is capable of addressing
current organizational needs and, by addressing risk, agility,
resilience, and strategic opportunities, of preparing for its
future business, market, and operating environment. In
creating an environment for success, leaders should consider
both external and internal factors. Factors might include
risk appetite and tolerance; the need for technological and
organizational innovation, including risks and opportunities
arising from emerging technology, data integration, and
digitization; readiness for disruptions; organizational culture;
work systems; the potential need for changes in structure
and culture; workforce capability and capacity; resource
availability; societal benefit and social equity; and core
competencies.
1.1c(1). Promoting equity means ensuring that all customers and workforce members are treated fairly and that all
workforce members can reach their full potential. Inclusion
refers to promoting the full participation of all workforce
members and ensuring a sense of belonging for them.
1.1c(2). Senior leaders’ focus on action considers your strategy, workforce, work systems, and assets. It includes taking
intelligent risks, implementing innovations and ongoing
improvements in performance and productivity, taking the
actions needed to achieve your strategic objectives (see
2.2a[1]), and possibly establishing plans for managing
organizational change or responding rapidly to significant
new information.
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
1.2 Governance and Societal Contributions: How do you govern your organization and
make societal contributions? (50 pts.)
a. Organizational GovernanCe
• Accountability for senior leaders’ actions
• Accountability for strategy
• Fiscal accountability
• Accountability for patient safety and health care quality
• Transparency in operations
• Selection of governance board members and disclosure policies for them, as appropriate
• Independence and effectiveness of internal and external audits
• Protection of stakeholder and stockholder interests, as appropriate
• Succession planning for senior leaders
(2) PerforManCe Evaluation HoW do you evaluate the PerforManCe of your Senior leaderS and your
GovernanCe board? how do you use performance evaluations in determining executive compensation?
how do your senior leaders and governance board use these performance evaluations to advance their
development and improve the effectiveness of leaders, the board, and the leadership system, as appropriate?
b. Legal and etHiCal beHavior
(1) Legal, Regulatory, and Accreditation Compliance HoW do you address current and anticipate future legal,
regulatory, and community concerns with your HealtH Care ServiCeS and operations? how do you
• address any adverse societal impacts of your health care services and operations,
• anticipate public concerns with your future health care services and operations, and
• prepare for these impacts and concerns proactively?
What are your key compliance processes, measures, and goals for meeting and surpassing regulatory, legal, and
accreditation requirements, as appropriate? What are your key processes, measures, and goals for addressing
risks associated with your health care services and operations?
(Continued on the next page)
8
2021–2022 Health Care Criteria for Performance Excellence
PROC ESS
(1) GovernanCe System HoW does your organization ensure responsible GovernanCe? how does your
governance system review and achieve the following?
(2) etHiCal beHavior HoW do you promote and ensure etHiCal beHavior in all interactions? What are your
key processes and measures or indicators for promoting and ensuring ethical behavior in your governance
structure; throughout your organization; and in interactions with your workforce, patients, other customers,
partners, suppliers, and other stakeholders? how do you monitor and respond to breaches of ethical
behavior?
c. Societal Contributions
(1) Societal Well-Being HoW do you incorporate societal well-being and benefit into your strategy and daily
operations? how do you contribute to the well-being of your environmental, social, and economic systems?
(2) Community Support HoW do you actively support and strengthen your key communities? What are your
key communities? how do you identify them and determine areas for organizational involvement? how do
your senior leaders, in concert with your workforce, contribute to improving these communities and building
community health?
Terms in small caps are defined in the Glossary of Key Terms (pages 46–53).
Notes
1.2. Societal contributions in areas critical to your ongoing
success should also be addressed in Strategy Development
(item 2.1) and Operations (category 6). Key societal results
should be reported in item 7.4.
1.2a(1). In protecting stakeholder interests, the governance
system should consider and approve appropriate levels of
risk for the organization, recognizing the need to accept risk
as part of running a successful organization.
1.2a(1). The governance board’s review of organizational
performance and progress, if appropriate, is addressed in
4.1(b).
1.2a(1). Transparency in the operations of your governance
system should include your internal controls on governance
processes. For some privately held businesses and nonprofit
organizations, an external advisory board may provide some
or all governance board functions.
1.2a(2). The evaluation of leaders’ performance might be
supported by peer reviews, formal performance management reviews, reviews by external advisory boards, and formal or informal feedback from and surveys of the workforce
and other stakeholders.
1.2b(1). Proactively preparing for adverse societal impacts
and concerns may include conserving natural resources,
reducing carbon emissions, and using effective supplynetwork management processes, as appropriate.
1.2b(2). Measures or indicators of ethical behavior might
include the percentage of independent board members,
instances of ethical conduct or compliance breaches and
responses to them, survey results showing workforce
perceptions of organizational ethics, ethics hotline use,
and results of ethics reviews and audits. Such measures
1
Leadership
or indicators might also include evidence that policies,
workforce training, and monitoring systems are in place for
conflicts of interest; protection and use of sensitive data,
information, and knowledge generated through synthesizing
and correlating these data; and proper use of funds.
1.2c. Some health care organizations may contribute to
society and support their key communities totally through
the mission-related activities described in response to other
Criteria questions. In such cases, it is appropriate to respond
here with any “extra efforts” through which you support
these communities.
1.2c(1). Areas of societal well-being and benefit to report
are those that go beyond the compliance processes you
describe in 1.2b(1). They might include organizational or
collaborative efforts to improve the environment; strengthen
local community services, education, health, and emergency
preparedness; address social inequities; and improve the
practices of trade, business, or professional associations.
1.2c(2). Areas for organizational involvement in supporting
your key communities might include areas that leverage
your core competencies. Actions to build community health
are population-based services that support the general
health of the communities in which you operate. Such
services will likely draw on your core competencies and
might include the identification of community health needs,
health education programs, immunization programs, health
screenings, wellness and prevention programs, indigent
care, and programs to eliminate health disparities, perhaps
through partnerships with community organizations.
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
9
2
Strategy (85 pts.)
The Strategy category asks how your organization develops strategic objectives and action plans, implements them,
changes them if circumstances require, and measures progress.
2.1 Strategy Development: How do you develop your strategy? (45 pts.)
a. Strategy Development ProCeSS
(2) innovation HoW does your strategy development ProCeSS stimulate and incorporate innovation? how
do you identify strategic opportunities? how do you decide which strategic opportunities are intelligent
risks to pursue? What are your key strategic opportunities?
(3) Strategy Considerations HoW do you collect and analyze relevant data and develop information for use in
your strategic planning ProCeSS? In this collection and analysis, how do you include these key elements of risk?
• Your strategic challenges and strategic advantages
• Potential changes and disruptions in your regulatory and external environment
• Technological changes and innovations affecting your health care services and operations
• Potential blind spots in your strategic planning process and information
• Your ability to execute the strategic plan
(4) Work SySteMS and Core CoMPetenCieS HoW do you decide which key ProCeSSeS will be accomplished by
your WorkforCe and which by external suppliers, PartnerS, and CollaboratorS? how do those decisions
consider your strategic objectives; your core competencies; and the core competencies of potential suppliers, partners, and collaborators? how do you determine what future organizational core competencies and
work systems you will need?
b. StrateGiC objeCtiveS
(1) key StrateGiC objeCtiveS What are your organization’s key StrateGiC objeCtiveS and their most important
related GoalS? What is your timetable for achieving them? What key changes, if any, are planned in your health
care services, customers and markets, suppliers and partners, and operations?
(2) StrateGiC objeCtive Considerations HoW do your StrateGiC objeCtiveS achieve appropriate balance among
varying and potentially competing organizational needs? how do your strategic objectives
• address your strategic challenges and leverage your core competencies, strategic advantages, and
strategic opportunities;
• balance short- and longer-term planning horizons; and
• consider and balance the needs of all key stakeholders?
Terms in small caps are defined in the Glossary of Key Terms (pages 46–53).
Notes
2.1. This item deals with your overall organizational
strategy, which might include changes in patient and other
customer engagement processes and health care service
offerings. However, you should describe the patient and
other customer engagement and service design strategies,
respectively, in items 3.2 and 6.1, as appropriate.
2.1. Strategy development refers to your organization’s
approach to preparing for the future. In developing your
strategy, you should consider your level of acceptable
enterprise risk. To make decisions and allocate resources,
10
you might use various types of forecasts, projections,
options, scenarios, knowledge (see 4.2b), analyses, or other
approaches to envisioning the future. Strategy development
might involve key suppliers, collaborators, partners, patients,
and other customers.
2.1. The term “strategy” should be interpreted broadly.
Strategy might be built around or lead to any or all of the
following: new, changing, or discontinued health care
services, including acquisitions or entry into new services
to improve access, grow revenue, or reduce costs; redefini-
2021–2022 Health Care Criteria for Performance Excellence
P R O C ESS
(1) Strategic Planning ProCeSS HoW do you conduct your strategic planning? What are the key process steps?
Who are the key participants? What are your short- and longer-term planning horizons? how does your strategic
planning process address the potential need for change, prioritization of change initiatives, and organizational
agility and resilience?
tion of key patient and other customer groups or market
segments; definition or redefinition of your role in your
business ecosystem (your network of partners, suppliers,
collaborators, competitors, patients, other customers, communities, and other relevant organizations inside and outside the health care sector that serve as potential resources);
differentiation of your brand; new core competencies; and
new staff or volunteer relationships. It might also be directed
toward becoming a high-reliability organization, a provider
of a high-end or customized service, an integrated service
provider, or an employer of choice, or toward meeting a
community or population health care need.
2.1a(1). Organizational agility refers to the capacity for
rapid change in strategy and the ability to adjust your operations as opportunities or needs arise.
2.1a(3). Integration of data from all sources to generate
strategically relevant information is a key consideration.
Data and information might relate to patient, other customer, and market requirements, expectations, opportunities,
and risks; financial, societal, ethical, regulatory, technological, security and cybersecurity, and other potential opportunities and risks; your core competencies; the competitive
environment and your performance now and in the future
relative to competitors and comparable organizations; your
culture, policies, and processes to ensure patient safety and
avoid medical errors; your clinical outcomes; policies and
procedures for access to and equity of care; workforce and
other resource needs; your ability to capitalize on diversity
and promote equity and inclusion; your ability to prevent
and respond to disasters and emergencies; opportunities to
redirect resources to higher-priority products, services, or
areas; changes in the local or national economy; requirements for and strengths and weaknesses of your partners
2
Strategy
and supply network; changes in your parent organization;
and other factors unique to your organization.
2.1a(3). Your strategic planning should address your ability
to mobilize the necessary resources and knowledge to
execute the strategic plan. It should also address your ability
to execute contingency plans or, if circumstances require, to
shift strategy and rapidly execute new or changed plans.
2.1a(3). Technologies that continue to drive change include
enhanced automation, the adoption of cloud operations,
the use of data analytics, the Internet of Things, artificial
intelligence, and large dataset-enabled business and process
modeling.
2.1a(4). Your work systems are the coordinated combination of internal work processes and external resources you
need to develop and produce health care services, deliver
them to your patients and other customers, and succeed in
your marketplace. External resources might include partners,
suppliers, collaborators, competitors, customers, and other
entities or organizations that are part of your business
ecosystem. Decisions about work systems involve protecting
intellectual property, capitalizing on core competencies, and
mitigating risk.
2.1b(1). Strategic objectives should focus on your specific
challenges, advantages, and opportunities—those most
important to your ongoing success and to strengthening
your overall performance and your success now and in the
future.
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
11
2.2 Strategy Implementation: How do you implement your strategy? (40 pts.)
a. aCtion Plan Development and dePloyMent
(2) aCtion Plan Implementation HoW do you dePloy your aCtion PlanS? how do you deploy your action
plans to your workforce and to key suppliers, partners, and collaborators, as appropriate, to ensure that
you achieve your key strategic objectives? how do you ensure that you can sustain the key outcomes of your
action plans?
(3) Resource Allocation HoW do you ensure that financial and other resources are available to support the
achievement of your aCtion PlanS while you meet current obligations? how do you allocate these resources to
support the plans? how do you manage the risks associated with the plans to ensure your financial viability?
(4) WorkforCe Plans What are your key WorkforCe plans to support your short- and longer-term StrateGiC
objeCtiveS and aCtion PlanS? how do the plans address potential impacts on your workforce members and
any potential changes in workforce capability and capacity needs?
(5) PerforManCe MeaSureS What key PerforManCe MeaSureS or indiCatorS do you use to track the achievement and effeCtiveneSS of your aCtion PlanS? how does your overall action plan measurement system
reinforce organizational alignment?
(6) PerforManCe ProjeCtionS For these key PerforManCe MeaSureS or indiCatorS, what are your PerforManCe
ProjeCtionS for your short- and longer-term planning horizons? If there are gaps between your projected
performance and that of your competitors or organizations offering similar health care services, how do you
address them in your action plans?
b. aCtion Plan Modification
HoW do you recognize and respond when circumstances require a shift in aCtion PlanS and rapid execution of
new plans?
Terms in small caps are defined in the Glossary of Key Terms (pages 46–53).
Notes
2.2. The development and deployment of your strategy and
action plans are closely linked to other Health Care Criteria
items. The following are examples of key linkages:
• Item 1.1: how your senior leaders set and communicate organizational direction
• Category 3: how you gather patient, other customer,
and market knowledge as input to your strategy and
action plans and to use in deploying action plans
• Category 4: how you measure and analyze data and
manage knowledge to support key information needs,
support strategy development, provide an effective
basis for performance measurements, and track
progress on achieving strategic objectives and
action plans
• Category 5: how you meet workforce capability and
capacity needs, determine needs and design your
workforce learning and development system, and
implement workforce-related changes resulting from
action plans
• Category 6: how you address changes to your work
processes resulting from action plans
12
• Item 7.1: specific accomplishments relative to your
organizational strategy and action plans
• Item 7.5: results for overall strategy and action plan
achievement
2.2a(6). Projected performance might consider new
ventures; organizational acquisitions or mergers; new value
creation; market entry and shifts; new legislative mandates,
legal requirements, industry standards, or accreditation
standards; and significant anticipated innovations in health
care services and technology. Your process for projecting
future performance should be reported in 4.1c(1).
2.2b. Circumstances that might require shifts in action plans
and rapid execution of new plans include disruptive internal
or external events, changes in your competitive environment, changing economic conditions, the emergence of
disruptive technologies, and sudden changes in patient and
other customer requirements and expectations.
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
2021–2022 Health Care Criteria for Performance Excellence
PR O C ESS
(1) aCtion PlanS What are your key short- and longer-term aCtion PlanS? What is their relationship to your
strategic objectives? how do you develop your action plans?
3
Customers (85 pts.)
The Customers category asks how your organization engages its patients and other customers for ongoing marketplace
success, including how your organization listens to the voice of the customer, serves and exceeds patients’ and other
customers’ expectations, and builds long-term relationships with patients and other customers.
3.1 Customer Expectations: How do you listen to your patients and other customers and
determine health care services to meet their needs? (40 pts.)
a. Listening to Patients and Other CuStoMerS
(2) Potential Patients and Other CuStoMerS HoW do you listen to potential patients and other CuStoMerS to
obtain actionable information? how do you listen to former, competitors’, and other potential patients and other
customers to obtain actionable information on your health care services, patient and other customer support,
and transactions, as appropriate?
b. Patient and Other CuStoMer Segmentation and Service Offerings
(1) Patient and Other CuStoMer Segmentation
and market SeGMentS? how do you
HoW do you determine your patient and other CuStoMer groups
• use information on patients, other customers, markets, and health care service offerings to identify current
and anticipate future patient and other customer groups and market segments; and
• determine which patient and other customer groups and market segments to emphasize and pursue for business growth?
(2) Service Offerings
HoW do you determine HealtH Care ServiCe offerings? how do you
• determine patient, other customer, and market needs and requirements for health care service offerings;
• identify and adapt health care service offerings to meet the requirements and exceed the expectations of your
patient and other customer groups and market segments; and
• identify and adapt service offerings to enter new markets, to attract new patients and other customers, and to
create opportunities to expand relationships with current patients and other customers, as appropriate?
Terms in small caps are defined in the Glossary of Key Terms (pages 46–53).
Notes
3.1. Your results on performance relative to key service
features should be reported in item 7.1.
3.1a(1). Your patient and other customer listening methods
might include monitoring comments on social media
outlets.
3.1a(1). Your listening methods should include all stages
of your involvement with patients and other customers.
These stages might include relationship building, the active
relationship, and a follow-up strategy, as appropriate.
3.1b(2). In identifying health care service offerings, you
should consider all the important characteristics of services
that patients and other customers receive in each stage of
their relationship with you. The focus should be on features
3
Customers
that affect patients’ and other customers’ preference for
and loyalty to you and your brand—for example, unique or
innovative features that affect their view of clinical and service quality and that differentiate your offerings from those
of competing organizations. Those latter features might
include ease of access to and use of your services, including
telehealth and new locations; a virtual experience; family
support services; timeliness; cost; assistance with billing/
administrative processes and transportation; environmental
or social stewardship; and the privacy and security of patient
and other customer data.
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
13
P R O C ESS
(1) Current Patients and Other CuStoMerS HoW do you listen to, interact with, and observe patients and
other CuStoMerS to obtain actionable information? how do your listening methods vary for different patient
groups, other customer groups, or market segments? how do your listening methods vary across the stages of
patients’ and other customers’ relationships with you? how do you seek immediate and actionable feedback
from patients and other customers on the quality of health care services, patient and other customer support,
and transactions?
3.2 Customer Engagement: How do you build relationships with patients and other
customers and determine satisfaction and engagement? (45 pts.)
a. Patient and Other CuStoMer Experience
HoW do you build and manage relationships with patients and other CuStoMerS?
• acquire patients and other customers and build market share;
• manage and enhance your brand image;
• retain patients and other customers, meet their requirements, and exceed their expectations in each stage of
their relationship with you?
(2) Patient and Other CuStoMer Access and Support HoW do you enable patients and other CuStoMerS to seek
information and support? how do you enable them to access your services? What are your key means of patient
and other customer support and communication? how do they vary for different patient and other customer
groups or market segments, as appropriate? how do you
• determine your patients’ and other customers’ key support requirements, and
• deploy these requirements to all people and processes involved in patient and other customer support?
(3) Complaint Management HoW do you manage patient and other CuStoMer complaints? how do you
resolve complaints promptly and effectively? how does your management of complaints enable you to recover
your patients’ and other customers’ confidence, enhance their satisfaction and engagement, and avoid similar
complaints in the future?
(4) Fair Treatment How do your patient and other CuStoMer experience ProCeSSeS ensure fair treatment for
different patients, patient groups, other CuStoMer groups, and market SeGMentS?
b. Determination of Patient and Other CuStoMer Satisfaction and enGaGeMent
(1) Satisfaction, Dissatisfaction, and enGaGeMent HoW do you determine patient and other CuStoMer satisfaction, dissatisfaction, and enGaGeMent? how do your determination methods differ among your patient and
other customer groups and market segments, as appropriate? how do your measurements capture actionable
information?
(2) Satisfaction Relative to Other Organizations HoW do you obtain information on patients’ and other
CuStoMerS’ satisfaction with your organization relative to other organizations? how do you obtain information on your patients’ and other customers’ satisfaction
• relative to their satisfaction with your competitors; and
• relative to the satisfaction of patients and other customers of other organizations that provide similar health
care services or to health care industry benchmarks, as appropriate?
c. Use of voiCe-of-tHe-CuStoMer and Market Data
HoW do you use voiCe-of-tHe-CuStoMer and market data and information? how do you use voice-of-thecustomer and market data and information to build a more patient-focused culture and support operational
decision making?
Terms in small caps are defined in the Glossary of Key Terms (pages 46–53).
Notes
3.2. Results for patient and other customer perceptions and
actions (outcomes) should be reported in item 7.2.
unfairly or inappropriately against specific patients or
patient groups.
3.2a(4). You should ensure that your approaches for
managing patient and other customer relationships,
enabling patient and other customers to seek information
and support, and managing complaints promote equity and
inclusion, and that they do not inadvertently discriminate
3.2b(1). Determining dissatisfaction should be seen as more
than reviewing low satisfaction scores. It should be independently determined to identify root causes and enable a
systematic remedy to avoid future dissatisfaction.
14
2021–2022 Health Care Criteria for Performance Excellence
PR O C ESS
(1) Relationship Management
how do you
3.2b(2). Information you obtain on relative satisfaction may
include comparisons with competitors; comparisons with
other organizations that deliver similar health care services
in a noncompetitive marketplace; or comparisons obtained
through third-party surveys or surveys endorsed or required
by payors, such as the Consumer Assessment of Healthcare
Providers and Systems (CAHPS). Such information may
also include information on why customers choose your
competitors over you.
3
Customers
3.2c. Patient and other customer data and information
should be used to support the overall performance reviews
addressed in 4.1b. Voice-of-the-customer and market data
and information to use might include aggregated data on
complaints and, as appropriate, data and information from
social media and other web-based or digital sources.
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
15
4
Measurement, Analysis, and Knowledge Management (90 pts.)
The Measurement, AnAlysis, and Knowledge Management category asks how your organization selects, gathers,
analyzes, manages, and improves its data, information, and knowledge assets; how it uses review findings to improve its
performance; and how it learns.
4.1 Measurement, Analysis, and Improvement of Organizational Performance: How do
you measure, analyze, and then improve organizational performance? (45 pts.)
a. PerforManCe Measurement
• select, collect, align, and integrate data and information to use in tracking daily operations and overall
organizational performance; and
• track progress on achieving strategic objectives and action plans?
What are your key organizational performance measures, including key short- and longer-term financial
measures?
(2) Comparative Data
making?
HoW do you select comparative data and information to support fact-based decision
(3) Measurement Agility HoW do you ensure that your PerforManCe measurement system can respond to rapid
or unexpected organizational or external changes, and provide timely data?
b. PerforManCe analySiS and Review
HoW do you review your organization’s PerforManCe and capabilities? how do you use your key organizational
performance measures, as well as comparative data, in these reviews? What analyses do you perform to support
these reviews and ensure that conclusions are valid? how do your organization and its senior leaders use these
reviews to
• assess organizational success, competitive performance, financial health, and progress on achieving your
strategic objectives and action plans; and
• respond rapidly to changing organizational needs and challenges in your operating environment?
how does your governance board review the organization’s performance and its progress on strategic objectives
and action plans, if appropriate?
c. PerforManCe Improvement
(1) Future PerforManCe HoW do you project your organization’s future PerforManCe? how do you use findings from performance reviews and key comparative and competitive data in your projections?
(2) Continuous Improvement and innovation HoW do you use findings from PerforManCe reviews to develop
priorities for continuous improvement and opportunities for innovation? how do you deploy these priorities
and opportunities
• to work group and functional-level operations; and
• when appropriate, to your suppliers, partners, and collaborators to ensure organizational alignment?
Terms in small caps are defined in the Glossary of Key Terms (pages 46–53).
16
2021–2022 Health Care Criteria for Performance Excellence
P R O C ESS
(1) PerforManCe MeaSureS HoW do you track data and information on daily operations and overall organizational PerforManCe? how do you
Notes
4.1. The questions in this item are closely linked to each
other and to other Health Care Criteria items. The following
are examples of key linkages:
•
Your organizational performance measurement
(4.1a)—including the comparative data and information you select, and the performance measures you
report in your Criteria item responses—should
inform your organizational performance reviews
(4.1b).
•
Organizational performance reviews (4.1b) should
reflect your strategic objectives and action plans
(category 2), and the results of organizational
performance analysis and review should inform your
strategy development and implementation, priorities
for improvement, and opportunities for innovation
(4.1c).
•
Your performance projections for your key action
plans should be reported in 2.2a(6).
•
Your organizational performance results should be
reported in items 7.1–7.5.
4.1a. Data and information from performance measurement
should be used to support fact-based decisions that set and
align organizational directions and resource use at the work
unit, key process, department, and organization levels.
4.1a(2). The comparative data and information you select
should be used to support operational and strategic decision
making. Comparative data and information are obtained
by benchmarking and by seeking competitive comparisons.
Benchmarking is identifying processes and results that
represent best practices and performance for similar activities, inside or outside the health care industry. Competitive
4
Measurement, Analysis, and Knowledge Management
comparisons relate your performance to that of competitors
and other organizations providing similar health care
services.
4.1a(3). Agility in your measurement system might be
necessary in response to regulatory changes, other changes
in the political or societal environment, disasters and
emergencies, innovations in organizational processes or
business models, new competitor offerings, or productivity
enhancements. Responses to such changes might involve,
for example, adopting different performance measures or
adjusting the intervals between measurements.
4.1b. Performance analysis includes examining performance
trends; organizational, health care industry, and technology
projections; and comparisons, cause-effect relationships, and
correlations. This analysis should support your performance
reviews, help determine root causes, and help set priorities
for resource use. Accordingly, such analysis draws on all
types of data: health care outcome, patient- and other
customer-related, financial and market, operational, and
competitive/comparative. The analysis should also draw on
publicly mandated measures, when appropriate, and might
also be informed by internal or external Baldrige assessments. Analysis may involve digital data analytics and data
science techniques that detect patterns in large volumes of
data (“big data”) and interpret their meaning.
4.1b. Rapid response to changing organizational needs and
challenges may include responding to the need for change
in your organizational structure and work systems.
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
17
4.2 Information and Knowledge Management: How do you manage your information
and your organizational knowledge assets? (45 pts.)
a. Data and Information
(2) Availability HoW do you ensure the availability of organizational data and information? how do you make
needed data and information available in a user-friendly format and timely manner to your workforce, suppliers, partners, collaborators, patients, and other customers, as appropriate? how do you ensure that your
information technology systems are reliable and user-friendly?
b. Organizational Knowledge
(1) Knowledge Management
HoW do you build and manage organizational knowledge? how do you
• collect and transfer workforce knowledge;
• blend and correlate data from different sources to build new knowledge;
• transfer relevant knowledge from and to patients, other customers, suppliers, partners, and
collaborators; and
• assemble and transfer relevant knowledge for use in your innovation and strategic planning processes?
(2) Best Practices HoW do you share best practices in your organization? how do you identify internal and
external organizational units or operations that are high performing? how do you identify best practices for
sharing and implement them across your organization, as appropriate?
(3) Organizational learninG HoW do you use your knowledge and resources to embed learninG in the way
your organization operates?
Terms in small caps are defined in the Glossary of Key Terms (pages 46–53).
Notes
4.2a(2). Information technology systems include, for
example, physical devices and systems; software platforms
and applications; and externally based or shared information systems, such as those stored in the cloud or outside
your organization’s control. Your response might include
information related to the interoperability and effective use
of electronic health records within your organization.
and text. Blending and correlating data may involve using
artificial intelligence, digital data analytics, and data science
techniques that detect patterns in large volumes of data and
interpret their meaning. Using these techniques to make
decisions with human consequences requires deploying
technology and leveraging data in a way that protects
information about organizations and individuals.
4.2a(2). The security and cybersecurity of your information
technology systems are addressed as part of your overall
security and cybersecurity system in item 6.2. That system
involves managing and reducing risks to operational
systems as well as to data and information.
4.2b(3). Embedding learning in the way your organization
operates means that learning (1) is a part of everyday work;
(2) results in solving problems at their source; (3) is focused
on building and sharing knowledge throughout your organization; and (4) is driven by opportunities to bring about
significant, meaningful change and to innovate.
4.2b(1). Building and managing organizational knowledge
from different sources may involve handling big data sets
and disparate types of structured and unstructured data
and information, such as data tables, video, audio, photos,
18
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
2021–2022 Health Care Criteria for Performance Excellence
PR O C ESS
(1) Quality HoW do you verify and ensure the quality of organizational data and information? how do you
manage digital and other data and information to ensure their accuracy and validity, integrity and reliability, and
currency?
5
Workforce (85 pts.)
The WorkforCe category asks how your organization assesses workforce capability and capacity needs and builds a
workforce environment that is conducive to high performance. The category also asks how your organization engages,
manages, and develops your workforce to utilize its full potential in alignment with your organization’s overall needs.
5.1 Workforce Environment: How do you build an effective and supportive workforce
environment? (40 pts.)
a. WorkforCe CaPability and CaPaCity
(2) New WorkforCe Members HoW do you recruit, hire, and onboard new WorkforCe members? how do you
ensure that your workforce represents the diversity of ideas, cultures, and thinking in your hiring and patient
communities? how do you ensure the fit of new workforce members with your organizational culture?
(3) WorkforCe Change
how do you
HoW do you prepare your WorkforCe for changing CaPability and CaPaCity needs?
• balance the needs of your workforce and your organization to ensure continuity, prevent workforce reductions, and minimize the impact of any necessary reductions;
• prepare for and manage any periods of workforce growth; and
• prepare your workforce for changes in organizational structure, workplaces, work systems, and technology
when needed?
(4) Work Accomplishment HoW do you organize and manage your WorkforCe? how do you organize and
manage your workforce to
• capitalize on your organization’s core competencies;
• reinforce organizational resilience, agility, and a patient/other customer and business focus; and
• exceed performance expectations?
b. Workplace Climate
(1) Workplace Environment HoW do you ensure workplace health, security, and accessibility for the WorkforCe? What are your performance measures and improvement goals for your workplace environmental
factors?
(2) WorkforCe Benefits and Policies HoW do you support your WorkforCe via services, benefits, and policies?
how do you tailor these to the needs of a diverse workforce and different workforce groups and segments?
Terms in small caps are defined in the Glossary of Key Terms (pages 46–53).
Notes
5. Results related to workforce environment and engagement should be reported in item 7.3. People supervised by a
contractor should be addressed in categories 2 and 6 as part
of your larger work system strategy and your internal work
processes. For organizations that also rely on volunteers, the
workforce includes these volunteers. Workforce approaches
should include these volunteers as appropriate to the functions they fulfill for the organization.
5.1a(3). Preparing your workforce for change might include
preparing for alternate workplaces or telework, or for
changes in patient, other customer, or service requirements
that lead to the use of new technology or redesigned work
systems. Such preparation might include training, education, frequent communication, consideration of workforce
employment and employability, career counseling, and
outplacement and other services.
5.1a(1). Your assessment of workforce capability and
capacity needs should consider not only current needs, but
also future requirements based on the strategic objectives
and action plans you identify in category 2 and the future
performance you discuss in 4.1c(1).
5.1a(3), 5.1a(4). The way you organize and manage your
workforce may be influenced by changes in your internal or
external environment, culture, or strategic objectives.
5 Workforce
19
P R O C ESS
(1) CaPability and CaPaCity Needs HoW do you assess your WorkforCe CaPability and CaPaCity needs? how
do you assess the skills, competencies, certifications, and staffing levels you need in the short and long term?
5.1b(1). Workplace accessibility maximizes productivity by
eliminating barriers that can prevent people with disabilities
from working to their potential. A fully inclusive workplace
is physically, technologically, and attitudinally accessible
without bias.
5.1b(1). If workplace environmental factors and their
performance measures or targets differ significantly for your
different workplace environments, you should include these
differences in your response. You should address workplace
safety in item 6.2 as part of your overall safety system, which
also ensures the safety of all other people in your workplace.
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
5.2 Workforce Engagement: How do you engage your workforce for retention and
high performance? (45 pts.)
a. Assessment of WorkforCe enGaGeMent
(2) Assessment of enGaGeMent HoW do you assess WorkforCe enGaGeMent? What formal and informal assessment methods and measures do you use to determine workforce satisfaction and workforce engagement?
how do these methods and measures differ across workforce groups and segments? how do you also use
other indicators to assess and improve workforce engagement?
b. Organizational Culture
HoW do you foster an organizational culture that is characterized by open communication, HiGH PerforManCe,
patient safety, and an engaged WorkforCe? how do you reinforce your organizational culture? how do you ensure
that your organizational culture supports your vision and values; promotes equity and inclusion; and benefits from the
diversity of the ideas, cultures, and thinking in your workforce? how do you empower your workforce?
c. PerforManCe Management and Development
(1) PerforManCe Management HoW does your WorkforCe PerforManCe management system support HiGH
PerforManCe? how does it consider workforce compensation, reward, recognition, and incentive practices?
how does it reinforce intelligent risk taking, a patient/other customer and business focus, and achievement of
your action plans?
(2) PerforManCe Development HoW does your learninG and development system support the personal development of WorkforCe members and your organization’s needs? how does it consider the learning
and development desires of workforce members, support organizational performance improvement and
intelligent risk taking, and support ethical health care and ethical business practices?
(3) learninG and Development effeCtiveneSS
development system? how do you
HoW do you evaluate the effeCtiveneSS of your learninG and
• correlate learning and development outcomes with findings from your assessment of workforce engagement and with key organizational results, and
• use these correlations to identify opportunities for improvement both in workforce engagement and in
learning and development offerings?
(4) Career Development HoW do you manage career development for your WorkforCe and your future
leaders? how do you carry out succession planning for management, leadership, and other key positions?
(5) Equity and Inclusion HoW do you ensure that your performance management, performance development,
and career development approaches promote equity and inclusion for a diverse WorkforCe and different
WorkforCe groups and SeGMentS?
Terms in small caps are defined in the Glossary of Key Terms (pages 46–53).
20
2021–2022 Health Care Criteria for Performance Excellence
P R O C ESS
(1) Drivers of enGaGeMent HoW do you determine the key drivers of WorkforCe enGaGeMent? how do you
determine these drivers for different workforce groups and segments?
Notes
5.2a(1). Drivers of workforce engagement (identified in
P.1a[3]) refer to the drivers of workforce members’ commitment, both emotional and intellectual, to accomplishing the
organization’s work, mission, and vision.
5.2a(2). Other indicators to use in assessing and improving
workforce engagement might include workforce retention,
absenteeism, grievances, safety, and productivity.
5.2c(2). Your response should include how you address
any considerations for workforce development, learning,
and career progression that are unique to your organization. These might include development opportunities that
address your organization’s core competencies, strategic
5 Workforce
challenges, and action plans, including those related to high
reliability; organizational change and innovation; improvements in delivering a positive patient and other customer
experience; and the reinforcement of new knowledge and
skills on the job. Your response should also consider the
breadth of development opportunities you might offer,
including education, training, coaching, mentoring, and
work-related experiences.
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
21
6
Operations (85 pts.)
The Operations category asks how your organization designs, manages, improves, and innovates its health care services
and work processes and improves operational effectiveness to deliver value to patients and other customers and to achieve
ongoing organizational success.
6.1 Work Processes: How do you design, manage, and improve your key health care
services and work processes? (45 pts.)
a. Service and ProCeSS Design
HoW do you determine key HealtH Care ServiCe and
(2) key Work ProCeSSeS What are your organization’s key Work ProCeSSeS? What are the key requirements for
these work processes?
(3) Design Concepts HoW do you design your HealtH Care ServiCeS and Work ProCeSSeS to meet requirements?
how do you incorporate new technology, organizational knowledge, evidence-based medicine, health care
service excellence, patient and other customer value, consideration of risk, and the potential need for agility into
these services and processes?
b. ProCeSS Management and Improvement
(1) ProCeSS Implementation HoW does your day-to-day operation of Work ProCeSSeS ensure that they meet
key ProCeSS requirements? What key performance measures or indicators and in-process measures do you
use to control and improve your work processes? how do these measures relate to the quality of outcomes and
measures of the performance of your health care services?
(2) Patient Expectations and Preferences HoW do you address and consider each patient’s expectations? how
do you explain health care service delivery processes and likely outcomes to set realistic patient expectations?
how do you factor patient decision making and patient preferences into the delivery of health care services?
(3) Support ProCeSSeS HoW do you determine your key support ProCeSSeS? What are your key support
processes? how does your day-to-day operation of these processes ensure that they meet key organizational
requirements?
(4) Service and ProCeSS Improvement HoW do you improve your Work ProCeSSeS and support ProCeSSeS to
improve HealtH Care ServiCeS and PerforManCe, enhance your Core CoMPetenCieS, and reduce variability?
c. Supply-Network Management
HoW do you manage your supply network? how do you select suppliers that are qualified and positioned to meet
your operational needs, enhance your performance, support your strategic objectives, and enhance your patients’
and other customers’ satisfaction? how do you
• promote alignment and collaboration within your supply network;
• ensure supply-network agility and resilience in responding to changes in patient, other customer, market,
and organizational requirements; and
• communicate performance expectations, measure and evaluate suppliers’ performance, provide feedback to
help them improve, and deal with poorly performing suppliers?
d. Management of Opportunities for innovation
HoW do you pursue your identified opportunities for innovation? how do you pursue the strategic opportunities that you have determined are intelligent risks? how do you make financial and other resources available to
pursue these opportunities? how do you decide to discontinue pursuing them at the appropriate time?
Terms in small caps are defined in the Glossary of Key Terms (pages 46–53).
22
2021–2022 Health Care Criteria for Performance Excellence
P R O C ESS
(1) Determination of Service and ProCeSS Requirements
Work ProCeSS requirements?
Notes
6.1. The results of improvements in the performance of your
health care services and processes should be reported in
item 7.1.
6.1a(3). Process design also includes the need to extensively
redesign a process due to changes in requirements or technology, or the need to incorporate digital technology, such
as enhanced automation, the Internet of Things, artificial
intelligence, and cloud operations. Agility may be needed
when work processes need to change as a result of overall
work system changes, such as bringing a supply-network
product, service, or process in-house to avoid disruptions in
supply due to unpredictable external events, or outsourcing
a product, service, or process formerly carried out in-house.
6.1b(3). Your key support processes should support your
value-creation processes. They might include processes that
support leaders and other workforce members engaged in,
for example, service design and delivery, patient and other
customer interactions, and business and enterprise management. Examples might include accounting and purchasing.
6.1b(4). Your approaches to improve process performance
and reduce variability should be part of the performance
improvement system you describe in P.2c in the Organizational Profile.
6
Operations
6.1c. To ensure that suppliers are positioned to meet
operational needs and enhance your performance and
your patients’ and other customers’ satisfaction, you might
partner with suppliers or form alliances among multiple
organizations within the supply network for mutual benefit.
Communication of expectations and feedback to suppliers
should be two-way, allowing suppliers to express what
they need from you and other organizations within the
supply network. For many organizations, these mechanisms
may change as marketplace, patient, other customer, or
stakeholder requirements change.
6.1d. Your process for pursuing opportunities for innovation
should capitalize on strategic opportunities identified as
intelligent risks in 2.1a(2). It should also include other intelligent risks, such as those arising from your performance
reviews (4.1c[2]), your knowledge management approaches
(4.2b), and other sources of potential innovations.
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
23
6.2 Operational Effectiveness: How do you ensure effective management of your
operations? (40 pts.)
a. ProCeSS Efficiency and effeCtiveneSS
• incorporate cycle time, productivity, and other efficiency and effectiveness factors into your work
processes;
• prevent rework and errors;
• minimize the costs of inspections, tests, and process or performance audits, as appropriate; and
• balance the need for cost control and efficiency with the needs of your patients and other customers?
b. Security and Cybersecurity
HoW do you ensure the security and cybersecurity of sensitive or privileged data and information and of
key assets? how do you manage physical and digital data, information, and key operational systems to ensure confidentiality and only appropriate physical and digital access? how do you
• maintain your awareness of emerging security and cybersecurity threats;
• ensure that your workforce, patients, other customers, partners, and suppliers understand and fulfill their
security and cybersecurity roles and responsibilities;
• identify and prioritize key information technology and operational systems to secure; and
• protect these systems from potential cybersecurity events, detect cybersecurity events, and respond to and
recover from cybersecurity incidents?
c. Safety, Business Continuity, and reSilienCe
(1) Safety HoW do you provide a safe operating environment for your WorkforCe and other people in your
workplace? how does your safety system address prevention, inspection, root-cause analysis of failures, and
recovery?
(2) Patient Safety HoW do you reduce patient harm and medical errors? how does your patient safety system
address prevention, root-cause analysis of failures, and recovery?
(3) Business Continuity and reSilienCe HoW do you ensure that your organization can anticipate, prepare for,
and recover from disasters, emergencies, and other disruptions? how do you consider risk, prevention, protection, continuity of operations, and recovery in the event of disruptions? how do you take into account patient,
other customer, and business needs, and your reliance on your workforce, supply network, partners, and
information technology systems?
Terms in small caps are defined in the Glossary of Key Terms (pages 46–53).
Notes
6.2b. For examples of what your information technology
systems might include, see the note to 4.2a(2).
6.2b. Managing cybersecurity includes protecting against
the loss of sensitive information about employees, patients,
other customers, and organizations; protecting assets,
including intellectual property; and protecting against the
financial, legal, and reputational aspects of breaches. Many
sources for general and industry-specific cybersecurity
standards and practices are referenced in the Framework
for Improving Critical Infrastructure Cybersecurity (https://
www.nist.gov/cyberframework). The Baldrige Cybersecurity
Excellence Builder (https://www.nist.gov/baldrige/productsservices) is a self-assessment tool incorporating the concepts
of the Cybersecurity Framework and the Baldrige systems
perspective.
24
6.2c(3). Disasters and emergencies might be short- or longer-term and might be related to weather, climate, utilities,
security, or a local or national health or other emergency.
The extent to which you prepare for such events will depend
on your organization’s environment and its sensitivity to
short- or longer-term disruptions of operations. Acceptable
levels of risk will vary depending on the nature of your
health care services, supply network, and stakeholder needs
and expectations.
For additional guidance on this item, see the Health Care
Criteria Commentary (https://www.nist.gov/baldrige
/baldrige-criteria-commentary-health-care).
2021–2022 Health Care Criteria for Performance Excellence
PR O C ESS
HoW do you manage the cost, efficiency, and effeCtiveneSS of your operations? how do you
7
Results (450 pts.)
The results category asks about your organization’s performance and improvement in all key areas—health care and
process results; customer results; workforce results; leadership and governance results; and financial, market, and
strategy results.
7.1 Health Care and Process Results: What are your health care and process
effectiveness results? (120 pt…