4 Measurement, Analysis, and Knowledge Management (90 pts.)

The Measurement, ANALYSIS, and Knowledge Management Category examines HOW your organization selects, gathers, ANALYZES, manages, and improves its data, information, and KNOWLEDGE ASSETS and HOW it manages its information technology.

The Category also examines HOW your organization reviews and uses reviews to improve its PERFORMANCE.

Item 4.1 - Measurement, Analysis, and Improvement of Organizational Performance (45 pts.)                                         Process

HOW do you MEASURE, ANALYZE, and then improve organizational PERFORMANCE?   

Describe HOW your organization MEASURES, ANALYZES, reviews, and improves its PERFORMANCE as a HEALTH CARE SERVICE provider through the use of data and information at all LEVELS and in all parts of your organization.

Within your response, include answers to the following questions:

4.1a. PERFORMANCE MEASUREMENT

(1)     HOW do you select, collect, ALIGN, and INTEGRATE data and information for tracking daily operations and for tracking overall organizational PERFORMANCE, including progress relative to STRATEGIC OBJECTIVES and ACTION PLANS?

What are your KEY organizational PERFORMANCE MEASURES, including KEY short-term and longer-term financial MEASURES?

HOW frequently are these MEASURES determined?

HOW do you use these data and information to support organizational decision making and INNOVATION?

(2)     HOW do you select and ensure the EFFECTIVE use of KEY COMPARATIVE data and information to support operational and strategic decision making and INNOVATION?

(3)     HOW do you keep your PERFORMANCE MEASUREMENT SYSTEM current with HEALTH CARE SERVICE needs and directions?

HOW do you ensure that your PERFORMANCE MEASUREMENT SYSTEM is sensitive to rapid or unexpected organizational or external changes?

4.1b. PERFORMANCE ANALYSIS and Review

(1)     HOW do you review organizational PERFORMANCE and CAPABILITIES?

What ANALYSES do you perform to support these reviews and to ensure that conclusions are valid?

HOW do you use these reviews to assess organizational success, PERFORMANCE relative to competitors and comparable organizations, and progress relative to STRATEGIC OBJECTIVES and ACTION PLANS?

HOW do you use these reviews to assess your organization’s ability to rapidly respond to changing organizational needs and CHALLENGES in your operating environment?

4.1c. PERFORMANCE Improvement

HOW do you translate organizational PERFORMANCE review findings into priorities for continuous and BREAKTHROUGH IMPROVEMENT and into OPPORTUNITIES for INNOVATION?

HOW are these priorities and OPPORTUNITIES DEPLOYED to work group and functional-level operations throughout your organization to enable EFFECTIVE support for their decision making?

When appropriate, HOW are the priorities and OPPORTUNITIES DEPLOYED to your suppliers, PARTNERS, and COLLABORATORS to ensure organizational ALIGNMENT?

Notes:

N1. PERFORMANCE MEASUREMENT (4.1a) is used in fact-based decision making for setting and ALIGNING organizational directions and resource use at the work unit, KEY PROCESS, departmental, and organizational LEVELS.

N2. COMPARATIVE data and information (4.1a[2]) are obtained by BENCHMARKING and by seeking competitive COMPARISONS. “BENCHMARKING” refers to identifying PROCESSES and RESULTS that represent best practices and PERFORMANCE for similar activities, inside or outside of the health care industry. Competitive COMPARISONS relate your organization's PERFORMANCE to that of competitors and other organizations providing similar HEALTH CARE SERVICES.

N2. COMPARATIVE data and information (4.1a[2]) are obtained by BENCHMARKING and by seeking competitive COMPARISONS. “BENCHMARKING” refers to identifying PROCESSES and RESULTS that represent best practices and PERFORMANCE for similar activities, inside or outside the health care industry. Competitive COMPARISONS relate your organization's PERFORMANCE to that of competitors and other organizations providing similar HEALTH CARE SERVICES. COMPARATIVE data might include data from similar organizations and health care industry benchmarks. Such data might be derived from surveys, published and public studies, participation in indicator programs, or other sources. These data may be drawn from local or national sources.

N3. Organizational PERFORMANCE reviews (4.1b) should be informed by organizational PERFORMANCE MEASUREMENT, PERFORMANCE MEASURES reported throughout your CRITERIA Item responses, and PERFORMANCE MEASURES reviewed by SENIOR LEADERS (1.1b[2]), and they should be guided by the STRATEGIC OBJECTIVES and ACTION PLANS described in Item 2.1 and Item 2.2. The reviews also might be informed by internal or external Baldrige assessments.

N4. ANALSIS (4.1b) includes examining PERFORMANCE TRENDS; organizational, health care industry, and technology PROJECTIONS; and COMPARISONS, cause-effect relationships, and correlations. ANALSIS should support your PERFORMANCE reviews, help determine root causes, and help set priorities for resource use. Accordingly, ANALYSIS draws upon all types of data: PATIENT- and STAKEHOLDER-related, health care outcome, financial and market, operational, and competitive/comparative.

N5. The RESULTS of organizational PERFORMANCE ANALSIS and review should contribute to your organizational strategic planning in Category 2.

N6. Your organizational PERFORMANCE RESULTS should be reported in Item 7.1, Item 7.2, Item 7.3, Item 7.4, Item 7.5, and Item 7.6.