Organizational Profile

The first integrated component, the organizational profile, is a brief description of how the organization (or ICU) operates, its customers and their expectations, its primary services, core competencies, the workforce (which includes all paid staff, medical staff, and volunteers) requirements/needs, critical success factors, and key challenges, to name a few. There are around 20 questions that ask the ICU to identify, with extreme clarity, the important elements that guide the delivery of care.

Eleven Core Values and Concepts

The second integrated component consists of 11 interrelated core values and concepts that have strong cultural enrichment implications. They have been validated to be embedded in the beliefs and behaviors (the culture) of high-performing organizations:

Seven Categories of Criteria for High Performance

The seven categories of healthcare criteria for performance excellence, which constitute the third integrated component, serve as the locus of role-model performance. The criteria are presented as a series of questions that ask how an organization’s (or unit’s) approaches (or methods) to work are designed and managed so that they are systematic (or repeatable), deployed to all locations and internal/external people as appropriate, and are continuously improved, aligned with the key areas of importance to the ICU, and integrated with other processes and systems to effectively deliver care. The criteria present direct actionable guidance by identifying existing strengths and opportunities for improvement. The power lies not in the individual areas but rather the interplay of the seven categories, which are as follows:

Differentiation of High Performance Versus Average Performance or Scoring Guidelines

The scoring guidelines serve as the fourth component of the framework. These four elements are critical to understanding performance, identifying opportunities for improvement and innovation, and achieving sustained excellence. Together, the characteristics differentiate high-performing organizations from average ones in that all work must be:

High-performing organizations differentiate the results of their critical success factors from those of lesser organizations based on (1) whether current results are good, (2) how results trend over time (i.e., show consistently better performance), and (3) how trended results compare with best-in-industry (role-model) performance.

How does all this relate to ICUs? ICUs across the country are struggling with increased complexity, higher costs, more errors, staffing shortages, decreasing morale, and low staff, customer, and patient satisfaction and engagement. The human service purpose of ICUs is far too precious for ICU quality to become increasingly debilitated—a sign of leadership failure. Industry experts must find a road map that can guide the pursuit of sustained excellence. The objective is to move progressively higher in the realm of excellence.

Next, we provide an overview of each of the Baldrige criteria, using a selection of the key ideas in the seven categories, and provide examples of how they can be applied in the ICU to achieve world-class performance and excellence. It is important to remember that the Baldrige program is not an improvement tool like Six Sigma or the Plan-Do-Check-Act (PDCA). Rather, it is a framework that provides guidelines and a structure to establish and sustain culture and processes that go beyond conformance to standards, differing from requirements such as those of The Joint Commission. Baldrige asks fundamental questions that will help lead and guide organizations—and ICUs—toward the highest levels of performance excellence. It is how the work should be organized, managed, improved, and innovated. And, whereas the Baldrige framework asks these important questions, the ICU leaders need to provide the answers.

Category 1: Leadership

The leadership category provides insight on how leaders can guide their organizations to high levels of performance. It analyzes how clinical and nonclinical leaders use values, directions, and performance expectations, as well as a focus on patients, other customers, workforce engagement, innovation, and continuous improvement, as vehicles to secure systematic action and sustained excellence. In the Baldrige framework, leadership is not just an organizational chart of positions. It is also a system—a set of leadership behaviors that move and align the organization toward a common purpose with specific goals and objectives. Leadership systems include the formal and informal method of exercising leadership elements such as decision making, communication, setting expectations, organization of work, reward and recognition for high performance, and planning. Using the unit’s mission, vision, and values (MVV), the ICU leadership system orchestrates a systematic approach to communicating and deploying key organizational requirements and expectations throughout the entire workforce by providing a single, unifying purpose to all actions.

The criteria for leadership are instructive as they relate to ICUs and are likely very different from the current approach. Within the ICU, opportunities exist for the leadership team to become a more instructive leadership system (Figure 221-2) and promote a unit that demonstrates repeatable and fully deployed process across all areas of delivering ICU care. The leadership team ensures consistency of care across boundaries, incorporates and supports continuous cycles of improvement and/or innovation, and strategically aligns with the overall goals and objectives of the hospital.

Figure 221-2 Example of a leadership system (Sharp Healthcare, San Diego, California).

(Adapted from 2007 National Baldrige Application.)

To illustrate this point, the following example is offered: one ICU used a multidisciplinary leadership group to set and deploy the values, short- and long-term directions, and performance expectations throughout the unit. This team consisted of the intensivist physician leader, functional administrator, and nursing supervisor. The multidisciplinary leadership group used a variety of tools and methods to communicate the values and directions of the unit, such as cascading employee development plans that correlated the high-level ICU goals and objectives down to each employee, articulating how they contribute to the achievement of those goals. Prior to this process of cascading accountability, the leadership team held four revolving all-ICU-participant meetings to get input from the workforce on key changes, ideas, and needs such as new equipment and guidelines for improving patient safety as they developed the strategic plan. Involvement of the workforce in planning demonstrates a departure from typical strategy processes, which usually live at the senior leader level, and fostered workforce buy-in and engagement.

Consistent with the Baldrige criterion that asks how leaders review performance and translate their reviews into continuous breakthrough improvement and opportunities for innovation, the multidisciplinary leadership group met every month to review performance—using metrics on a balanced scorecard that specifically correlated with the strategic goals and objectives. For example, the leadership group, through its strategic planning process, identified teamwork and communication as areas for improvement as it related to patient safety and employee engagement (two strategic objectives set by the leadership group). Using a cultural assessment tool to obtain the facts (management by fact is a Baldrige core value), it was discovered that over the past year, the ICU had a decrease in nurse satisfaction and an increase in issues identified via a nurse assessment of patient safety. After drill-down sessions with the doctors, nurses, pharmacists, patients, and others, the leadership group learned that communication between the nurses and the physicians was lacking and that patients were suffering—all impacting job satisfaction. In addition, the ICU was experiencing an unprecedented level of staff turnover. As a result, the leadership group added to each employee’s job description the requirement to participate in quarterly teamwork and communication training sessions and added a key patient safety indicator(s) to the annual individual evaluations. The intention was to drive accountability further down to all workforce members and link to new rewards and recognition initiatives. This process became systematic—repeatable—and the leadership team sought feedback from the workforce on the process’s effectiveness.

In addition to the individual goal requirements, the leadership group set a unit goal to increase employee engagement, learning, and rates of improvement and innovation. Critical to this goal was the creation of improvement teams that were supported by the hospital and ICU leadership in terms of time, finances, and other resources. Through the strategic planning process, the multidisciplinary leadership group learned that the staff felt their efforts to change and improve patient care consumed large amounts of time, and that these efforts were neither supported nor appreciated by senior leadership. The stress level and complexity of the ICU environment contributed to turnover and dissatisfaction. The leadership group realized that the creation of conduits for the staff to change, innovate, and improve processes that decreased complexity and raised satisfaction levels needed to occur rapidly. The leadership group put together a multidisciplinary action team, using a Lean/Six Sigma method of improvement, to design systems that would empower and motivate the staff to change and innovate. Six Sigma is an improvement process developed by Motorola that focuses on error and/or defect reductions; Lean, based on the Toyota Productions system focuses on flow of work and removing waste and unnecessary redundancies from processes. These were then presented to the multidisciplinary leadership group for implementation and tracking of performance.