This is Part 4 in a periodic series of articles linking the Centers for Medicare & Medicaid Services (CMS) impending Quality Assurance and Performance Improvement (QAPI) procedures with the requirements of the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) National Quality Award Program.
The focus of this month’s QAPI feature is bringing meaningful resident and family voices into setting goals and evaluating progress. In the Baldrige Criteria, the core value of Patient-Focused Excellence says that because customers are the ultimate judges of performance and quality, the organization should take into account all features and characteristics of patient care delivery and all modes of customer access and support that contribute value to customers.

A truly patient-focused organization addresses the health care service characteristics that meet basic patient and other customer requirements as well as characteristics that differentiate the organization from its competitors. Patient-focused excellence promotes patient and other customer retention and loyalty, referral of new patients, customer engagement, and market share gain.

Relationship To Bronze Criteria

At the Bronze award level, applicants are required to identify their key customer groups, the requirements these customer groups have of the organization, and the methods they used to determine these requirements.

■ Key customer groups always include residents, and an accurate understanding of their requirements is at the heart of the Baldrige Health Care criteria.

■ Requirements of different patient and customer groups might include accessibility, continuity of care, safety, security, accurate and timely billing, socially responsible behavior, cultural preferences, and multilingual services.

■ Applicants must think systematically about the methods used to understand customer requirements. For example, if informal listening is a key feedback source, the center should ensure it is being done systematically and all voices receive appropriate attention. If a few vocal residents dominate the feedback, how does the center ensure that it understands the needs of more quiet/reserved residents?
At the Bronze level, applicants are simply asked to describe their key market segments, including patient and other customer groups, and list the key requirements and expectations of each. However, at the Silver and Gold levels, organizations should also focus on engaging and building relationships with patients and other customers.

Relationship To Silver Criteria

At the Silver award level, applicants are asked to respond to the “basic” and “overall” questions in the Baldrige Health Care Criteria, which can be considered an outline of the full criteria.
In the first section of Category 3, Customer Focus, applicants are asked how they systematically and effectively obtain information from their patients and other customers. Applicants must clearly explain the steps they take to gain accurate information on their customers’ satisfaction, dissatisfaction, and engagement. Examiners are looking for a clear, systematic approach to obtaining these data in order to establish its accuracy.

The second section builds on the first, asking applicants to explain how they use this information to serve their patients’ and other customers’ needs and build better relationships with them.

In the first part of Category 4, Measurement, Analysis, and Improvement of Organizational Performance, applicants are asked to describe their methods for using customer data to support decision making.
In Category 6, Operations Focus, providers begin to see the relationship between customer feedback and improving their community’s key health care services. Category 6 asks how the organization designs its health care processes to deliver value for residents and other customers to achieve success and sustainability.

Relationship To Gold Criteria

The Gold criteria delves more deeply into the concepts discussed at the Silver level and fully embodies the fourth feature of QAPI. Gold applicants respond fully to the Baldrige Health Care Criteria, including addressing the basic- and overall-level questions that are required of Silver applicants, with the addition of more detailed multiple-level questions.

■ In Category 1, senior leaders are expected to create a workforce culture that delivers a consistently positive experience for patients and other customers and foster customer engagement, create and promote a culture of patient safety, and focus on creating and balancing value for patients and other customers.

■ In Category 3, Gold applicants describe in great detail how they listen to residents and other stakeholders, both current and future.

In the first part, they are asked how listening methods may vary among patient and other customer groups, how social media might be used, and how those interactions may vary with different groups of residents and other customers. Satisfaction, dissatisfaction, and engagement even are further explored in this category.

In the second part of Category 3, applicants should have in place effective systems to manage complaints of patients and other customers and ensure that they are resolved promptly and effectively in order to recover customer confidence.

■ In the first part of Category 4, applicants are expected to use customer and market data (including aggregated data on complaints and data gathered through social media, as appropriate) to build a more patient-focused culture.

■ In the second part of Category 5, applicants should ensure their process for managing workforce performance reinforces a focus on patients and other customers.

■  In Category 6, Gold applicants are asked how they build patient expectations and preferences into the delivery of health care service processes. Applicants should also have effective processes in place to set realistic patient expectations and factor patient decision making and patient preferences into the delivery of health care services.

Again, the criteria are looking for applicants to describe how they fully incorporate resident needs and expectations into key processes for the organization, as well as determining opportunities for improvement.

Following Criteria Gets Results

Lori Cooper, administrator of 2014 Gold recipient Stonebrook Healthcare Center, talks about the value the Baldrige criteria had in their organization.

“As an independent facility, taking the Quality Award journey is one of the best decisions we ever made. We utilized the criteria and feedback at every stage to identify, develop, and implement systems to make us a high-performing organization and a leader in our marketplace,” she says.

As Stonebrook incorporated the Baldrige criteria into its daily routines, staff learned about their organization: the good, the bad, and the ugly, Cooper says. “With that information, we are able to identify what we do best and identify areas where we need to improve our processes,” she says. “We understand the importance and value of being a data-driven organization. By being willing to address the areas where we were not as good as our competitors, our results have improved over time.”

Barbara Baylis, RN MSN, vice president of clinical services at Sava Senior Care Consulting, is a nurse executive accomplished in clinical and quality improvement systems. She serves as a Quality Award Examiner and is a past member of the Quality Award Board of Overseers. Mark Blazey, EdD, is a leading expert in the application of the Baldrige criteria for performance excellence. Blazey serves as a member of the Quality Award Panel of Judges as well as a current member of the Quality Award Board of Overseers.