Purpose
This assignment is intended to help you learn to do the following:
- Evaluate the structural design of healthcare organizations. (III.A.2.i)
- Analyze operational assessment and improvement strategies in a healthcare organization. (III.A.2.ii)
- Critique quality assessment for patient care improvement in a healthcare organization. (III.A.2.iii)
- Summarize the impact and influence of management and leadership in a healthcare organization. (III.A.5.i)
Overview
This assignment represents Part 1 of a two-part project that you will complete for your ePortfolio. As you work on this assignment, you will be developing the following Commission on Accreditation of Healthcare Management Education (CAHME) competencies:
III.A.2 Healthcare System and Healthcare Management
- Structural Design of Healthcare Organizations
- Operations Assessment & Improvement
- Quality Assessment for Patient Care Improvement
III.A.5 Management & Leadership
- Impact & Influence
Action Items
- Complete Exercise 6: Organizational Self-Assessment (p. 295) in your textbook.
- Prepare your assignment for submission:
Follow all applicable APA Guidelines Links to an external site.regarding in-text citations, list of cited references, and document formatting for this paper. Failure to properly cite and reference sources constitutes plagiarism.
Write 3-4 pages answer. The title page and reference list are not included in the page count for this paper.
Proofread your assignment carefully. Improper English grammar, sentence structure, punctuation, or spelling will result in significant point deductions. - Submit your assignment. Your work will automatically be checked by Turnitin.
295295
PRACTICE EXERCISE 6: ORGANIZATIONAL
SELF-ASSESSMENT
Objectives
• To practice using an organizational assessment as a means of
documenting current reality and identifying performance gaps
.
• To practice using the Baldrige Performance Excellence Program Health
Care Criteria for Performance Excellence as a guide for completing an
organizational assessment.
• To conduct a miniassessment of an organization using questions from
the Baldrige Excellence Builder self-assessment tool.
Note: Working managers may complete this exercise by basing it on the
practices of their own organizations. Students may complete this exercise by
basing it on the practices of a current or previous employer.
Instructions
1. Select and describe the boundaries of the system of interest; the term
“organization” will be used to refer to this system. You may select a
team, a department, a small organization (e.g., an office practice), or an
entire organization.
2. To familiarize yourself with the criteria, review the section called
“Health Care Criteria Category and Item Commentary” in the Baldrige
Health Care Criteria for Performance Excellence, available at www.nist
.gov/baldrige/enter/health_care.cfm.
3. The Baldrige Excellence Builder self-assessment provides a general
description of the criteria category followed by questions from the self-
assessment (pp. 5–13) from the 2017–2018 Health Care Criteria for
Performance Excellence.
4. Based on the system selected in question 1, write brief replies to the
Baldrige questions.
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017.
ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.
Created from franklin-ebooks on 2023-01-30 02:21:03.
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.
Applying Qual i ty Management in Healthcare: A Systems Approach296296
Organizational Assessment Worksheet
Organizational Profile
This category of the self-assessment is a snapshot of your organization, including
the key influences on how it operates, and of your competitive environment.
• Briefly describe your organization, including its services; size;
geographic community; key patient or customer groups; and current
facilities, equipment, and technology, as well as the number of patients
or clients it serves.
• Briefly describe your organization’s key challenges and current
performance improvement system.
Leadership
This category examines how the personal actions of your organization’s senior
leaders guide and sustain your organization. It also examines your organization’s
governance system and how your organization fulfills its legal, ethical, and
societal responsibilities and supports its key communities.
• How do senior leaders deploy your organization’s vision and values
through your leadership system, to the workforce, to key suppliers and
partners, and to patients and stakeholders, as appropriate?
• How do senior leaders encourage frank, two-way communication
throughout the organization?
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017.
ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.
Created from franklin-ebooks on 2023-01-30 02:21:03.
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.
297Pract ice Lab 297
Strategy
This category examines how your organization develops strategic objectives
and action plans. It also examines how your chosen strategic objectives and
action plans are deployed and changed, if circumstances require, and how
progress is measured.
• How does your organization conduct strategic planning?
• Summarize your organization’s action plans, how they are deployed,
and key action plan performance measures or indicators.
Customers
This category examines how your organization engages its customers—the
users of your healthcare services (e.g., patients, families, insurers, other third-
party payers)—for long-term marketplace success. This engagement strategy
includes how your organization listens to the voice of its customers, builds
customer relationships, and uses customer information to improve and identify
opportunities for innovation.
• How do you identify customers and market requirements for service
offerings?
• How do you build and manage relationships with customers to meet
their requirements and exceed their expectations at each stage of their
relationship with you?
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017.
ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.
Created from franklin-ebooks on 2023-01-30 02:21:03.
C
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.
Applying Qual i ty Management in Healthcare: A Systems Approach298298
Measurement, Analysis, and Knowledge Management
This category examines how your organization selects, gathers, analyzes,
manages, and improves its data, information, and knowledge assets and how
it manages its information technology. It also examines how your organization
uses review findings to improve its performance.
• What are your key organizational performance measures?
• How do you use this information to support organizational decision
making and innovation?
Workforce Focus
This category examines your ability to assess workforce capability and capacity
needs and to build a workforce environment conducive to high performance.
This category examines how your organization engages, manages, and develops
your workforce to use its full potential in alignment with your organization’s
overall mission, strategy, and action plans.
• How do you assess your workforce capability and capacity needs,
including skills, competencies, and staffing levels?
• How do you address workplace environmental factors to ensure and
improve workplace health, safety, and security?
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017.
ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.
Created from franklin-ebooks on 2023-01-30 02:21:03.
C
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rv
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.
299Pract ice Lab 299
Operations
This category examines how your organization designs, manages, and improves
its work systems and work processes to deliver patient and stakeholder value
and achieve organizational success and sustainability. It also examines your
readiness for emergency.
• How do you design and innovate your work processes to meet all the
key requirements?
• How do you improve your work processes to improve healthcare
outcomes, to achieve better performance, to reduce variability, and to
improve healthcare services?
Results
This category examines your organization’s performance and improvement in
all key areas: healthcare and process outcomes, customer-focused outcomes,
workforce-focused outcomes, leadership and governance outcomes, and financial
and market outcomes. Performance levels are examined relative to those of
competitors and other organizations with similar healthcare services offerings.
• Provide data for one key measure or indicator of performance and
process effectiveness.
• Provide data for one key measure or indicator of patient or stakeholder
satisfaction.
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017.
ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.
Created from franklin-ebooks on 2023-01-30 02:21:03.
C
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H
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.
Applying Qual i ty Management in Healthcare: A Systems Approach300300
• Provide data for one key measure or indicator of workforce capability.
• Provide data for one key measure or indicator of achievement of
organizational strategy and action.
• Provide data for one key measure or indicator of financial performance.
• Provide data for one key measure or indicator related to operational
performance.
• Provide data for one key measure related to achieving legal, regulatory,
and accreditation requirements.
Prioritizing Improvement Opportunities
1. Review the responses to the organizational assessment questions.
2. Note any questions for which you could not provide a response (i.e.,
the organization does not have a defined process or approach to address
the topic of the question).
3. Review the results data and select one or more measures that
demonstrate less-than-desirable results.
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017.
ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.
Created from franklin-ebooks on 2023-01-30 02:21:03.
C
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H
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.
295295
PRACTICE EXERCISE 6: ORGANIZATIONAL
SELF-ASSESSMENT
Objectives
• To practice using an organizational assessment as a means of
documenting current reality and identifying performance gaps
.
• To practice using the Baldrige Performance Excellence Program Health
Care Criteria for Performance Excellence as a guide for completing an
organizational assessment.
• To conduct a miniassessment of an organization using questions from
the Baldrige Excellence Builder self-assessment tool.
Note: Working managers may complete this exercise by basing it on the
practices of their own organizations. Students may complete this exercise by
basing it on the practices of a current or previous employer.
Instructions
1. Select and describe the boundaries of the system of interest; the term
“organization” will be used to refer to this system. You may select a
team, a department, a small organization (e.g., an office practice), or an
entire organization.
2. To familiarize yourself with the criteria, review the section called
“Health Care Criteria Category and Item Commentary” in the Baldrige
Health Care Criteria for Performance Excellence, available at www.nist
.gov/baldrige/enter/health_care.cfm.
3. The Baldrige Excellence Builder self-assessment provides a general
description of the criteria category followed by questions from the self-
assessment (pp. 5–13) from the 2017–2018 Health Care Criteria for
Performance Excellence.
4. Based on the system selected in question 1, write brief replies to the
Baldrige questions.
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017.
ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.
Created from franklin-ebooks on 2023-01-30 02:21:03.
C
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ht
©
2
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H
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. A
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s
re
se
rv
ed
.
Applying Qual i ty Management in Healthcare: A Systems Approach296296
Organizational Assessment Worksheet
Organizational Profile
This category of the self-assessment is a snapshot of your organization, including
the key influences on how it operates, and of your competitive environment.
• Briefly describe your organization, including its services; size;
geographic community; key patient or customer groups; and current
facilities, equipment, and technology, as well as the number of patients
or clients it serves.
• Briefly describe your organization’s key challenges and current
performance improvement system.
Leadership
This category examines how the personal actions of your organization’s senior
leaders guide and sustain your organization. It also examines your organization’s
governance system and how your organization fulfills its legal, ethical, and
societal responsibilities and supports its key communities.
• How do senior leaders deploy your organization’s vision and values
through your leadership system, to the workforce, to key suppliers and
partners, and to patients and stakeholders, as appropriate?
• How do senior leaders encourage frank, two-way communication
throughout the organization?
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017.
ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.
Created from franklin-ebooks on 2023-01-30 02:21:03.
C
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P
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. A
ll
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s
re
se
rv
ed
.
297Pract ice Lab 297
Strategy
This category examines how your organization develops strategic objectives
and action plans. It also examines how your chosen strategic objectives and
action plans are deployed and changed, if circumstances require, and how
progress is measured.
• How does your organization conduct strategic planning?
• Summarize your organization’s action plans, how they are deployed,
and key action plan performance measures or indicators.
Customers
This category examines how your organization engages its customers—the
users of your healthcare services (e.g., patients, families, insurers, other third-
party payers)—for long-term marketplace success. This engagement strategy
includes how your organization listens to the voice of its customers, builds
customer relationships, and uses customer information to improve and identify
opportunities for innovation.
• How do you identify customers and market requirements for service
offerings?
• How do you build and manage relationships with customers to meet
their requirements and exceed their expectations at each stage of their
relationship with you?
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017.
ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.
Created from franklin-ebooks on 2023-01-30 02:21:03.
C
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ht
©
2
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7.
H
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A
dm
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P
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. A
ll
rig
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s
re
se
rv
ed
.
Applying Qual i ty Management in Healthcare: A Systems Approach298298
Measurement, Analysis, and Knowledge Management
This category examines how your organization selects, gathers, analyzes,
manages, and improves its data, information, and knowledge assets and how
it manages its information technology. It also examines how your organization
uses review findings to improve its performance.
• What are your key organizational performance measures?
• How do you use this information to support organizational decision
making and innovation?
Workforce Focus
This category examines your ability to assess workforce capability and capacity
needs and to build a workforce environment conducive to high performance.
This category examines how your organization engages, manages, and develops
your workforce to use its full potential in alignment with your organization’s
overall mission, strategy, and action plans.
• How do you assess your workforce capability and capacity needs,
including skills, competencies, and staffing levels?
• How do you address workplace environmental factors to ensure and
improve workplace health, safety, and security?
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017.
ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.
Created from franklin-ebooks on 2023-01-30 02:21:03.
C
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H
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s
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se
rv
ed
.
299Pract ice Lab 299
Operations
This category examines how your organization designs, manages, and improves
its work systems and work processes to deliver patient and stakeholder value
and achieve organizational success and sustainability. It also examines your
readiness for emergency.
• How do you design and innovate your work processes to meet all the
key requirements?
• How do you improve your work processes to improve healthcare
outcomes, to achieve better performance, to reduce variability, and to
improve healthcare services?
Results
This category examines your organization’s performance and improvement in
all key areas: healthcare and process outcomes, customer-focused outcomes,
workforce-focused outcomes, leadership and governance outcomes, and financial
and market outcomes. Performance levels are examined relative to those of
competitors and other organizations with similar healthcare services offerings.
• Provide data for one key measure or indicator of performance and
process effectiveness.
• Provide data for one key measure or indicator of patient or stakeholder
satisfaction.
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017.
ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.
Created from franklin-ebooks on 2023-01-30 02:21:03.
C
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ht
©
2
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7.
H
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A
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. A
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s
re
se
rv
ed
.
Applying Qual i ty Management in Healthcare: A Systems Approach300300
• Provide data for one key measure or indicator of workforce capability.
• Provide data for one key measure or indicator of achievement of
organizational strategy and action.
• Provide data for one key measure or indicator of financial performance.
• Provide data for one key measure or indicator related to operational
performance.
• Provide data for one key measure related to achieving legal, regulatory,
and accreditation requirements.
Prioritizing Improvement Opportunities
1. Review the responses to the organizational assessment questions.
2. Note any questions for which you could not provide a response (i.e.,
the organization does not have a defined process or approach to address
the topic of the question).
3. Review the results data and select one or more measures that
demonstrate less-than-desirable results.
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017.
ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.
Created from franklin-ebooks on 2023-01-30 02:21:03.
C
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ig
ht
©
2
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H
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.
295295
PRACTICE EXERCISE 6: ORGANIZATIONAL
SELF-ASSESSMENT
Objectives
• To practice using an organizational assessment as a means of
documenting current reality and identifying performance gaps
.
• To practice using the Baldrige Performance Excellence Program Health
Care Criteria for Performance Excellence as a guide for completing an
organizational assessment.
• To conduct a miniassessment of an organization using questions from
the Baldrige Excellence Builder self-assessment tool.
Note: Working managers may complete this exercise by basing it on the
practices of their own organizations. Students may complete this exercise by
basing it on the practices of a current or previous employer.
Instructions
1. Select and describe the boundaries of the system of interest; the term
“organization” will be used to refer to this system. You may select a
team, a department, a small organization (e.g., an office practice), or an
entire organization.
2. To familiarize yourself with the criteria, review the section called
“Health Care Criteria Category and Item Commentary” in the Baldrige
Health Care Criteria for Performance Excellence, available at www.nist
.gov/baldrige/enter/health_care.cfm.
3. The Baldrige Excellence Builder self-assessment provides a general
description of the criteria category followed by questions from the self-
assessment (pp. 5–13) from the 2017–2018 Health Care Criteria for
Performance Excellence.
4. Based on the system selected in question 1, write brief replies to the
Baldrige questions.
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017.
ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.
Created from franklin-ebooks on 2023-01-30 02:21:03.
C
op
yr
ig
ht
©
2
01
7.
H
ea
lth
A
dm
in
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P
re
ss
. A
ll
rig
ht
s
re
se
rv
ed
.
Applying Qual i ty Management in Healthcare: A Systems Approach296296
Organizational Assessment Worksheet
Organizational Profile
This category of the self-assessment is a snapshot of your organization, including
the key influences on how it operates, and of your competitive environment.
• Briefly describe your organization, including its services; size;
geographic community; key patient or customer groups; and current
facilities, equipment, and technology, as well as the number of patients
or clients it serves.
• Briefly describe your organization’s key challenges and current
performance improvement system.
Leadership
This category examines how the personal actions of your organization’s senior
leaders guide and sustain your organization. It also examines your organization’s
governance system and how your organization fulfills its legal, ethical, and
societal responsibilities and supports its key communities.
• How do senior leaders deploy your organization’s vision and values
through your leadership system, to the workforce, to key suppliers and
partners, and to patients and stakeholders, as appropriate?
• How do senior leaders encourage frank, two-way communication
throughout the organization?
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017.
ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.
Created from franklin-ebooks on 2023-01-30 02:21:03.
C
op
yr
ig
ht
©
2
01
7.
H
ea
lth
A
dm
in
is
tr
at
io
n
P
re
ss
. A
ll
rig
ht
s
re
se
rv
ed
.
297Pract ice Lab 297
Strategy
This category examines how your organization develops strategic objectives
and action plans. It also examines how your chosen strategic objectives and
action plans are deployed and changed, if circumstances require, and how
progress is measured.
• How does your organization conduct strategic planning?
• Summarize your organization’s action plans, how they are deployed,
and key action plan performance measures or indicators.
Customers
This category examines how your organization engages its customers—the
users of your healthcare services (e.g., patients, families, insurers, other third-
party payers)—for long-term marketplace success. This engagement strategy
includes how your organization listens to the voice of its customers, builds
customer relationships, and uses customer information to improve and identify
opportunities for innovation.
• How do you identify customers and market requirements for service
offerings?
• How do you build and manage relationships with customers to meet
their requirements and exceed their expectations at each stage of their
relationship with you?
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017.
ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.
Created from franklin-ebooks on 2023-01-30 02:21:03.
C
op
yr
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ht
©
2
01
7.
H
ea
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A
dm
in
is
tr
at
io
n
P
re
ss
. A
ll
rig
ht
s
re
se
rv
ed
.
Applying Qual i ty Management in Healthcare: A Systems Approach298298
Measurement, Analysis, and Knowledge Management
This category examines how your organization selects, gathers, analyzes,
manages, and improves its data, information, and knowledge assets and how
it manages its information technology. It also examines how your organization
uses review findings to improve its performance.
• What are your key organizational performance measures?
• How do you use this information to support organizational decision
making and innovation?
Workforce Focus
This category examines your ability to assess workforce capability and capacity
needs and to build a workforce environment conducive to high performance.
This category examines how your organization engages, manages, and develops
your workforce to use its full potential in alignment with your organization’s
overall mission, strategy, and action plans.
• How do you assess your workforce capability and capacity needs,
including skills, competencies, and staffing levels?
• How do you address workplace environmental factors to ensure and
improve workplace health, safety, and security?
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017.
ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.
Created from franklin-ebooks on 2023-01-30 02:21:03.
C
op
yr
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ht
©
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H
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P
re
ss
. A
ll
rig
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s
re
se
rv
ed
.
299Pract ice Lab 299
Operations
This category examines how your organization designs, manages, and improves
its work systems and work processes to deliver patient and stakeholder value
and achieve organizational success and sustainability. It also examines your
readiness for emergency.
• How do you design and innovate your work processes to meet all the
key requirements?
• How do you improve your work processes to improve healthcare
outcomes, to achieve better performance, to reduce variability, and to
improve healthcare services?
Results
This category examines your organization’s performance and improvement in
all key areas: healthcare and process outcomes, customer-focused outcomes,
workforce-focused outcomes, leadership and governance outcomes, and financial
and market outcomes. Performance levels are examined relative to those of
competitors and other organizations with similar healthcare services offerings.
• Provide data for one key measure or indicator of performance and
process effectiveness.
• Provide data for one key measure or indicator of patient or stakeholder
satisfaction.
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017.
ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.
Created from franklin-ebooks on 2023-01-30 02:21:03.
C
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©
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Applying Qual i ty Management in Healthcare: A Systems Approach300300
• Provide data for one key measure or indicator of workforce capability.
• Provide data for one key measure or indicator of achievement of
organizational strategy and action.
• Provide data for one key measure or indicator of financial performance.
• Provide data for one key measure or indicator related to operational
performance.
• Provide data for one key measure related to achieving legal, regulatory,
and accreditation requirements.
Prioritizing Improvement Opportunities
1. Review the responses to the organizational assessment questions.
2. Note any questions for which you could not provide a response (i.e.,
the organization does not have a defined process or approach to address
the topic of the question).
3. Review the results data and select one or more measures that
demonstrate less-than-desirable results.
Spath, Patrice, and Diane L. Kelly. Applying Quality Management in Healthcare : A Systems Approach, Fourth Edition, Health Administration Press, 2017.
ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/franklin-ebooks/detail.action?docID=5517324.
Created from franklin-ebooks on 2023-01-30 02:21:03.
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