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.

Category 2: Strategic Planning

This category deals with how the ICU establishes its strategic objectives and action plans and how they are deployed throughout the unit. The ICU leadership system incorporates a number of internal and external inputs to create a yearly plan, with both short- and long-term goals for the unit. These goals must align with the MVV of the unit and hospital to communicate a constancy of purpose. When the leadership team meets to discuss the strategic plan, it must consider how the strategic plan is developed, communicated, prioritized, benchmarked, and measured. In addition, it should consider how the ICU’s strategic planning process incorporates the following:

To illustrate this concept, the following example is offered: ICU leaders organize a plan that answers the basic question, “What do we want to accomplish this year and in the future, and how do we get there?” Together with the hospital’s strategy, the ICU’s MVV drive the entire decision-making and strategic planning process. While aligning with the MVV and other data such as an environmental assessment (data on the external and internal environment), a strengths, weaknesses, opportunities, and threats (SWOT) analysis, and past ICU performance, the leadership group uses the yearly strategic planning process to identify the unit’s key objectives and goals, key customer groups and segments, measurement strategies, workforce-related issues, opportunities to innovate, and action plans needed to achieve the strategic objectives. The strategic plan is not static; it is organic and constantly evolves and remains agile as new opportunities and challenges emerge on the unit. The leadership group is always doing strategic planning, and the annual plan document serves as a foundation for beginning to accomplish excellence. The strategic plan creates clarity, purpose, and a vision of where the ICU is headed and how they plan to arrive at that destination.

Once the plan has been completed, it is cascaded down to all ICU staff with clear linkages to their role and contributions to the work. It gives meaning to their job—purpose. Each year, the overall planning process is updated according to key customer feedback, ICU performance analysis, organizational positioning, competitive data, and industry standards and trends. Integral to this process is the implementation of actionable measures of the strategic objectives. For example, part of this ICU’s mission is “to first eliminate all preventable harm to the patient, followed by exceptional care.” Bloodstream infections were identified by data analysis as one area of preventable risk for cardiac patients. After the multidisciplinary leadership group discovered that bloodstream infection was an area of concern (and benchmarked their results against local competitors, national averages, and best in class), its prevention became a key strategic objective for the following year, and action plans were designed to create systems that would lower and move to eliminate these infections. The plans included education and training on an infection bundle, staff empowerment tools to monitor conformance to standards, transparently monitoring and reporting infection rates, and further teamwork training, particularly around the use of an infection checklist.

Crucial to this process is how the ICU communicates the strategic plan to the entire unit. This plan should not only be known by the leadership group; in high performing organizations, every employee knows what’s going on and how they fit in to the overall work. In our example, the ICU provided every person with a laminated color card listing the unit’s strategic objectives and key measures for performance. In addition, each employee was issued a cascade plan to guide work processes, goal setting, and professional development. These cascade plans list and strategically link and align the objectives of the hospital, the ICU, and the individual. The cascade plan is used quarterly as a performance assessment tool (Table 221-1).

All together, strategic planning is an important part of an organization’s approach to excellence and sustaining excellence. A plan is just that—a set of steps to achieve an end. The real challenge is in effectively executing the plan every month, week, day, and minute.

Category 3: Customer Focus

These criteria address how the ICU engages patients and stakeholders to better serve their needs through specific listening posts, build relationships, and improve services based on the expectations of the various customer groups. Customer engagement refers to patient/customer commitment to an organization’s services. It is a much higher determination of relationship compared to mere satisfaction. At the ICU level, no patient or family member really wants to be loyal to an ICU, since it means their health is at serious risk, yet as leaders and managers, there is an obligation to organization and deliver care at such amazing levels of distinction that if a patient or family member had to be admitted to the ICU, they would only want your unit. A key element in this section of the framework is segmentation. Most ICUs can predict with some relative confidence the types of patients who occupy their beds, and through segmentation of this population, it is possible to customize all aspects of care delivery to improve outcomes and service and eliminate inefficiencies. The following description details how a Baldrige ICU might operate using a few of the principles in Category 3.

The ICU is a complex place dealing with complex patients and processes. The challenge for ICU leadership is to determine how to ensure consistency of practice in the midst of this complexity. Key to this effort is the need for the ICU to identify the types of patients (and their families) for whom they typically provide services, segment them according to needs and expectations, and then tailor healthcare services to meet their particular needs. The concept of “stages of relationship” in the framework is an important consideration for increasing customer engagement. It suggests that leaders think about the various phases of a patient’s interaction with the ICU—from admission, to their stay, to transferring to another unit, for example. During these stages, the needs of the patient and family members might change, signaling the need to alter certain systems and processes. In doing so, the ICU is better positioned to secure and/or increase their engagement at each stage of their relationship with the ICU.

For example, cardiac ICUs see a variety of patient types, yet most can be broken into two large segments: short-term and long-term patients. Within these segments are subgroups of patients ranging from those recovering from coronary artery bypass grafts to those requiring ventricular assist devices. Care plans can be implemented that are customized to deliver the best outcomes for each of these groups and are consistent with the unit’s goals and directions. Patients requiring ventricular assist devices tend to require prolonged ICU stays. Therefore, the ICU team develops a plan to coordinate resources efficiently to meet the needs and expectations of this long-term patient cohort, such as how a room is set up to accommodate family members. Similarly, the short-term patient cohort can be segmented according to needs and expectations to better use the unit’s resources. For example, medications most frequently used by the short-term patient group can be trended over time for predictability, and the evidence shows that just six medications actually account for over 85% of all medications given to these patients. These medications can then be located in a locked cart at the patient’s bedside, reducing the need for the nurse to use the highly complex medication dispensing and delivery process, which at times is frustrating to patients awaiting their medications. Numerous studies have identified substantial inefficiencies in the medication system. Use of data to track and predict trends in medication usage can allow unit staff to work more effectively and better serve the needs of patients.

Medically, the talented professionals working in the ICU know what is best for the patient; however, the question remains: What do the patient and family need and expect in order to have a positive experience which includes the family, whose needs are too often unmet? To some, this might seem of limited significance, considering the condition of most ICU patients. Yet there should be a way to determine these additional customer/patient requirements, and ICUs should incorporate systems for gathering this information and apply it to the delivery of care in real time. For instance, one approach might be to follow up on the ICU experience by having a nurse from the ICU speak with the patient or family after transfer to the step-down unit. The information gained could be analyzed for trends and fed into a prioritization system for planning and implementation. It could also become part of the transfer documentation so the incoming staff knows the patient’s needs without having to query the family another time. For example, by talking to families, it was identified that they desired wireless Internet connection in the waiting room. The ICU can also proactively use quarterly focus groups, information sessions, and information gleaned from medical associations to elicit key knowledge to design care that is both medically optimal and patient driven.

In 2002, the Institute of Medicine recommended six tenets of the 21st century healthcare system. One of these is a focus on patient-centered care and involvement of the patient and family in the care plan. This concept, though intuitively right, is difficult in practice, especially in the ICU setting. Notwithstanding, it is vital to the success of the ICU to make concerted efforts to identify the key requirements of their patients by segment and then build care plans around those requirements. Without this input, it is unlikely a given ICU will reach levels of world-class performance and excellence. In addition, if we are to consider sustainability, the ICU must always identify, incorporate, and amend services with the changing needs of all their customers. Through leadership, role-model behavior, and appropriate and effective communication, the workforce will feel empowered to incorporate the information gathered from the different patient segments and deliver care that is deemed appropriate based on the medical evidence and the wants and needs of the patient.

Category 4: Measurement, Analysis, and Knowledge Management

Now that the ICU has refined its leadership system, created its strategic goals and objectives, and gathered and used key patient data to set action plans and work processes, a robust and clear structure of measurement and analysis is needed to evaluate the effectiveness of the strategy and key healthcare systems and processes.

How does one measure performance, analyze performance, and use benchmarking information to support fact-based decision making, drive innovation, and ensure sustainability? How does one make certain everyone in the chain of delivery of ICU care has all the necessary information when they need it, and that it is in the correct form and accurate so the next clinical decision, diagnostic test, or treatment can be carried out in a timely manner? How does one make certain that clinical information is available rapidly on request, given the life-and-death reality of intensive care? And, in the interest of achieving high ICU performance, how does one make certain the sharing of knowledge (the great ideas, experiences, and talents of the workforce) is a cherished part of the culture and is actively (versus passively) managed?

This section describes how the ICU measures key indicators to track performance and identifies opportunities for improvement and innovation. In addition to measurement, this section addresses how the ICU manages knowledge, transfers information to staff and patients, and shares best practices within and outside the unit. The ICU leadership needs to be sure its measurement system is tracking the indicators that have been identified as key to the success of the organization and the unit. The criteria ask us to think innovatively about how we measure performance, the importance of relationship between all outcomes (e.g., issues with the workforce could impact clinical outcomes), process and outcome measures, and what is the true measure of mission and vision achievement. Further, the criteria challenge us to create a structure for ensuring the measures are valid, ensuring the data are accurate and of high quality, reviewing performance, identifying opportunities for improvement/innovation, and translating them into priorities. Some of these important criteria are demonstrated through the following examples.

The ICU’s key measures cascade down from the hospital’s overall goals, which in this example fall into five areas of focus: clinical performance, customer engagement, workforce engagement, operational performance, and financial performance (Table 221-2). During the strategic planning process, the leadership group, using input from the workforce, identified three or four leading indicators within each area that directly predicted the achievement of the key objectives and goals of the unit. These were then validated through a set of criteria asking certain questions:

Once validated, the measures become part of the unit’s balanced scorecard, a tool often using a traffic-light color format, to indicate performance across various areas of importance. Measures then are “drilled down” for each employee to create a line of site from the big goals to their specific work. For instance, one of the unit’s measures was zero infections, and subsequently the environmental staff that serviced the unit had a goal linked to cleanliness of the rooms. Their job, and the communication of the leadership, is not just cleaning—rather it is helping reduce infections and improve patient safety.

As another example, the leadership group set a goal of zero catheter-related infections. Data reviewed at the monthly leadership meeting revealed the incidence of bloodstream infections to be increasing and the rate of infection to be well above that of best-in-class, not to mention previous performance levels. The leadership group identified this as an opportunity for improvement and elected to convene a multidisciplinary team to reduce the number of bloodstream infections. This group replicated the approach used in the Michigan Keystone ICU study that virtually eliminated these infections throughout the state.¹ As part of this process, the leadership group communicated to the entire unit that reducing the number of bloodstream infections was a key strategic objective and would be reviewed each month. The bloodstream infection reduction team used the weekly infection control data collected and implemented interventions such as a catheter checklist on line carts, empowering the nurses to stop catheter placement if physicians did not comply with the checklist items, investigating every infection as a defect, and training on teamwork and communication for the nurses and physicians. Continuous cycles of improvement were implemented, and the bloodstream infection trend data demonstrated a progressive reduction. Work systems and processes related to catheter insertions became standardized in the unit and were ultimately communicated through the organization via a new policy and monitored for adherence.

It is also important for ICU leaders to consider how they manage the knowledge assets contained within the ICU. Baldrige defines knowledge assets as “the accumulated intellectual resources … it’s the knowledge possessed by your organization and employees in the form of information, ideas, learning, understanding, memory, insights, cognitive and technical skills, and capabilities.” ICU leaders who are committed not only to high performance but also to distinctive performance should learn how to manage the unique knowledge of their units. For example, in an academic setting, fellows and residents move in and out of different ICUs, bringing new knowledge, skills, and insights; however, there is also the potential for the erosion of existing best practices through lack of knowledge in some key areas. This is particularly important in today’s healthcare industry, where nurse turnover is high and hospitals are losing valuable staff. A mechanism to maintain this knowledge, communicate it, and share it across the organization is vital to an ICU moving toward high performance.

In health care, all stakeholders—physicians, nurses, administration—often have legitimate concerns about the validity of performance measures. Category 4 attempts to mitigate these concerns by developing a system of aligned measures, relevant comparisons to gauge results, a structure for reviewing these metrics, prioritizing them into opportunities for improvement and innovation, and establishing a robust framework for liberalizing data and information to all key stakeholders in the care process.

Category 5: Workforce Focus

In health care, the term workforce traditionally means all paid individuals, yet Baldrige takes a different view—a more holistic approach—defining the workforce through the eyes of the patient. The traditional view presents physicians as customers of the hospital, yet in high-performing healthcare settings, doctors (paid or volunteer staff) are considered part of the workforce (sans certain benefits), engaged in planning, work system design, and budgetary authority. Specifically, Baldrige states workforce “refers to the people actively involved in accomplishing the work … it includes your permanent, temporary, part-time personnel, independent practitioners, volunteers, and health profession students.”

Similar to Category 3 (customer engagement), this section brings to the forefront the importance of an engaged workforce, meaning the extent to which all members demonstrate a “commitment, both emotional and intellectual, to accomplishing the work, the Mission, and Vision of the organization” (or ICU). Here, leaders and staff are asked to determine the key factors that drive the engagement of a segmented ICU workforce, how to create a culture of high performance on the unit, learning and development opportunities, career progression, and hiring and organizing a workforce dedicated to achieving excellence.

All results are lagging indicators of how well the workforce performs. ICUs that do not emphasize maintaining a workforce that is skilled, trained, engaged, motivated, and safe should expect undistinguished performance. We cannot provide examples and mechanisms for each of these items, but the paragraphs that follow offer some insight into a few of the key components of this category.

In an ICU, different members of the workforce funnel in and out of the unit on a daily basis—from lab technicians, to various physicians, to dietary, to nurses, to pharmacists, and so on. Managing the styles, personalities, and roles each of these groups play in the care delivery process in a highly complex area like the ICU is an extraordinary challenge that often gets overlooked and is left to traditional models of healthcare interactions. Each unit has its own culture, and leaders—together with the workforce—need to first identify the desired attributes of the culture and needs of the workforce, and then develop an approach to fostering and reinforcing the desired culture. One way is through an effective workforce performance management system that supports the cultural expectations through evaluations and rewards and recognitions. For instance, in one ICU, one of the cultural expectations was that each employee should innovate at least one process each year, measured via their annual staff evaluations. In addition, the unit created two awards to celebrate the best innovations: “The Super Innovator” and “The Game Changer,” which were shared throughout the organization and published in the quarterly hospital newsletter. By adding this expectation, monitoring it, and creating reward systems, the ICU leadership demonstrated a commitment to aligning the goals of the unit with the actions of the workforce.

In the traditional and hierarchical world of health care, a work design that allows the workforce to achieve the highest levels of performance while promoting collaboration, initiative, empowerment, and innovation has to be the goal if patients are the true customers. So the question remains: How is this accomplished? Using the Baldrige criteria in their entirety is one way of achieving this end. The framework involves a set of characteristics of high-performing organizations inclusive of thematic linkages throughout all process of an ICU. Specifically, how is work performed so that it is systematic (repeatable based on how it is designed to be done), fully deployed, continuously improved, aligned with other care provided to the patient, and also ensures the work is aligned with the MVV and strategic objectives of the ICU?

Taking this a step further and using the example of bloodstream infections, we can examine how teamwork and communication have helped reduce the number of catheter-related infections through alignment of goals and objectives. After the leadership group identified bloodstream infections as a strategic priority and funneled it through a working team, concerns arose regarding the nursing staff’s ability to intervene when physicians broke standard protocol for catheter insertion. A number of nurses reported situations in which they had tried to intervene, only to have the physician ignore their observations and proceed with central catheter placement that did not follow proper protocol, thus exposing the patient to increased risk for a bloodstream infection. It became clear that the work systems and environment within the ICU allowed physician authority to trump the experience and patient-specific knowledge of the nursing staff, resulting in unsafe practices. Using this feedback, the leadership group deployed multidisciplinary training on the tools and methodologies of teamwork and communication, such as situational awareness and safety briefings. In addition, the leadership group wrote a new policy that required physicians to stop and listen to the nursing staff if a potential for a bloodstream infection was observed, or be subject to corrective actions. The result of this endeavor empowered the nursing staff to be supported and feel comfortable intervening when patient safety might be at risk and reinforce the established safe practice.

This category of the Baldrige criteria allows ICU leadership and staff to examine how its work systems contribute to achieving the ICU’s objectives. The vision and goals of the unit may seem unattainable because the processes that have been created through tradition do not align performance and processes. Using the criteria, the ICU can systematically create work processes that support the mission, vision, and overall goals of the unit, leading to an engaged workforce who would only work for this ICU. Focusing on our people is a great way to begin the path toward sustained excellence.

Category 6: Process Management

Up to this point, we have addressed ICU performance related to its leadership, strategic planning, patient relationships and engagement, performance review, access to information and knowledge, and workforce engagement—all in the context of high performance. Now we address the bottom line: How do we “make” excellent ICU care? It is time to think differently about how ICU care creates value. The Baldrige criteria focus on the creation of value in every step of healthcare design and delivery, improvement, and ongoing management. The criteria in category 6 provide ICU leaders with a structure and discipline to think through their delivery processes to ensure that all steps create value, as measured by effective diagnosis and elimination of disease (to the extent possible), exceeding the expectations of all stakeholders, and capitalizing on the ICU core competencies. What care delivery management system can ensure that value is always created, outcomes do not suffer, performance levels do not decline, and safety prevails? Process management is the focal point for ICU high performance. It provides guidance on how the ICU identifies, designs, improves and innovates, and manages its healthcare services to achieve results when trended over time to approach, demonstrate, or sustain world-class performance. It obligates ICU leaders to clarify how these processes are continuously improved to achieve better performance, improve cycle times, reduce waste, reduce variability, and, of course, improve clinical outcomes. Leaders are guided through a series of questions that ask how health care is designed and managed in ways that are systematic and fully deployed, incorporate ongoing cycles of improvement, and are aligned and integrated with other processes and operations involved in the care and support of ICU patients. These criteria for performance excellence are key to avoiding being just average.

For example, it is important for the ICU leadership group to create work systems that deliver care based on the needs of all ICU constituents—patients, physicians, nurses, pharmacists, and so forth—and align with the goals and objectives of the unit. The question needs to be asked: How do our processes create value for those we serve, and how do we know we have been successful? Using this mantra as a guide, the leadership group in our ICU example aligned the work processes with the unit to continuously meet the expectations of each ICU customer segment. This involved a number of approaches; however, the ultimate deliverable was a system of work designed to achieve the key requirements (categories 2 and 3) identified in the ICU strategic plan. Data indicated that the lack of clarity around a given patient care plan was causing increased errors and longer stays. Using the goal of reducing harm and improving teamwork and communication among the unit’s healthcare professionals (as stated in the strategic plan), the leadership group tested and implemented an evidence-based checklist developed by Peter Pronovost, MD, PhD, and colleagues that incorporates a multidisciplinary team approach to making rounds.² During these rounds, a daily goals sheet is used to communicate the care plan for the particular patient to the multidisciplinary team, consisting of physicians, nurses, pharmacists, and others. The use of this checklist over time led to a reduction in length of stay and adverse drug events, and both nurse and physician teamwork and satisfaction scores have improved. This mechanism is guided by several criteria in this Baldrige category dealing with the inclusion of patient expectations, testing to prevent errors, and achieving better performance by reducing variation in care. Unexplained and avoidable variation in care is one of the principal causes of failure in healthcare process and outcomes.

Health care is too full of waste, errors, and inefficient processes that do not add value. Much of these processes fall under “because we’ve always done it this way” mentality and/or a lack of discipline with improvement and process management. Over the past few years, an increasing number of improvement methodologies have made their way to health care, such as Six Sigma, Lean Thinking, the Toyota Production System, and in the 1990s, PDCA to name a few. All of these offer opportunities to improve ICU effectiveness and value and fall within the Baldrige framework, which asks how an ICU reduces variability, improves outcomes, and shares learning to drive innovation. Yet, the Baldrige criteria go further and help an organization hold the gains from these types of improvement tools. One of the major challenges facing hospitals and ICUs is something called “diminishing returns.” This concept, somewhat akin to economics, dictates that after an organization exerts enormous amounts of time, energy, and other resources to improving a process, the gains often eventually erode back to previous levels of performance, primarily due to a culture that is not set up to sustain improvements. This effect is typically a symptom of the complex world of health care, the always changing and competing priorities, and a lack of reliable monitoring systems. One notable exception was the Keystone ICU project in which reductions in bloodstream infections throughout the state of Michigan were sustained for over 3 years, largely thanks to efforts to improve culture, something akin to the cultural implications when successfully adopting the Baldrige framework. Through the seven integrated Baldrige criteria, it is possible to reduce the likelihood of diminishing returns and effectively address an issue and be able to focus on other initiatives while not worrying about losing ground. All of this and more falls under the notion of process management—the need for the ICU to design, implement, manage, improve, and sustain key processes, key improvements, and key innovations over time.

The complexity of ICU care demands that its leaders employ methods of excellence at a greater intensity compared with other healthcare venues. Application of the Baldrige criteria, designed to enable any operating unit to achieve distinctive performance, is greatest in the ICU. Otherwise, we are left largely with less effective methods of management and improvement that have demonstrated, thus far, the inability to fully leverage the extraordinary talent that resides within.

Category 7: Healthcare Results

In the end, the results of a given ICU are the ultimate measure of its performance. Now that the ICU has defined its mission, vision, and values, set strategic objectives, become relentlessly patient-focused, established methods to ensure that all ICU staff have the required information and knowledge, and created work processes that inspire the staff and add value to the patient, it is paramount that the ICU use the data it collects (on its key objectives) as a feedback loop or mechanism to continuously review its performance and achieve the identified goals outlined in the strategic plan. Selecting measures and having a system or process for making the data actionable and understandable (such as a balanced scorecard) allow the ICU to constantly implement corrective strategies when an area for improvement is identified. This category does not deal with the deployment of key processes; rather, and quite simply, it involves the unit’s ability to effectively align its mission, vision, and values and meet its stated goals and objectives as compared with both the competition and best-in-class benchmarks.