Performance Excellence: Proceedings from the Quality Colloquium Using the Baldrige Criteria to Achieve Performance Excellence


May / June 2005

Performance Excellence

Proceedings from the Quality Colloquium Using the Baldrige Criteria to Achieve Performance Excellence

The Baldrige Criteria for Performance Excellence have proven in healthcare as well as other industries to be an effective roadmap through complex and challenging conditions. The Baldrige criteria provide a structured approach to performance excellence. They move organizations from providing good quality care for one patient one time to all patients all of the time. This article provides a brief history of the Baldrige program, discusses how Malcolm Baldrige National Quality Award recipients are selected, gives a general overview of the criteria, and tells how organizations use the Baldrige criteria.

Each year the president of the United States gives the Baldrige Award to the best performing organizations in the country. In a nutshell, a Baldrige Award recipient is an organization that demonstrates performance excellence. They are well-led organizations that provide high-quality services and products. They have satisfied patients and other customers as well as satisfied employees and staff. The organization obtains excellent results in multiple areas — healthcare and operational performance outcomes, patient and employee/staff satisfaction, financial and organizational viability, information use and knowledge transfer, process management — and they are good citizens in their community. Who would not want to work for an organization that has these qualities?

Beyond identifying these excellent performing organizations, the primary purpose of the Baldrige program is education. In exchange for the prestige associated with receiving the Baldrige Award from the president, recipients are obligated to share with others “how they did it.” They conduct this sharing through conferences that showcase best practices, supporting state and local award programs, and hosting visits to their sites. The Baldrige program experience has been that recipients are very generous in this sharing.

What is the history of the program? In the early and mid 1980s, many industry and government leaders saw that an emphasis on quality was necessary for survival in the U.S. marketplace and for doing business in an ever-expanding, more demanding, highly competitive global market. Congress responded by passing the Malcolm Baldrige National Quality Improvement Act of 1987. The goal of the act was to enhance the competitiveness of U.S. business. In 1998, the original legislation was expanded to go beyond businesses to include making healthcare and education organizations eligible to receive the Baldrige Award. The Commerce Department’s National Institute of Standards and Technology manages the Baldrige Award program in conjunction with the private sector.

To date, three healthcare organizations have received the Baldrige Award. In 2003 there were two recipients: Baptist Hospital Inc., a healthcare system located in Pensacola, Florida, consisting of two hospitals and an ambulatory care complex; and Saint Luke’s Hospital, the largest hospital in Kansas City, Missouri. [An article about Saint Luke’s Hospital immediately follow this introduction. —Ed.] In 2001, SSM Healthcare was our first healthcare recipient. SSM, headquartered in St. Louis, Missouri, is a healthcare system consisting of 21 acute care hospitals and three nursing homes in four states: Missouri, Illinois, Oklahoma, and Wisconsin. SSM also has physician practices, home care, and hospice services.

How are Baldrige Award recipients selected? Applicants for the Baldrige Award identify themselves and submit to the Baldrige program a 50-page description of their organization written against the Baldrige criteria. Applicants go through a three-stage review process. All applicants go through Stage 1, about half of the applicants advance to Stage 2, and about one-quarter of the applicants progress to Stage 3.

At Stage 1, Independent Review, 7 to 10 Baldrige examiners complete a written review of their assigned application. Each examiner conducts his/her work individually with no discussion or sharing of his/her work with other examiners. The examiner’s written evaluation and numerical scoring of the application is returned to the Baldrige program. The scores of all applicants are reviewed by the Baldrige panel of judges, which selects the applicants that will advance to Stage 2. All of the remaining applicants go into the feedback report writing process. Every applicant receives a written report detailing their strengths and opportunities for improvement against the Baldrige criteria.

At Stage 2, Consensus Review, a team of six Baldrige examiners review and jointly agree on their evaluation and scoring of each application. Again the panel of judges meet and use the scoring data to select which applicants will advance to the next stage, Stage 3, and which will go into the feedback report process.

At Stage 3, Site Visit Review, teams of six to eight examiners visit the applicant organizations to interview the leadership team and employees, to observe processes, and to review applicant materials. A comprehensive site visit report is written. These reports are reviewed and discussed by the panel of judges that decides which organizations to recommend to the secretary of Commerce to become Baldrige Award recipients. The secretary makes the final decision.

What are the Baldrige Criteria for Performance Excellence? In addition to their use in identifying Baldrige Award recipients to serve as role models of performance excellence, the criteria are used to help organizations assess their improvement efforts, to diagnose their overall performance management system, and to identify their strengths and opportunities for improvement. Three versions of the criteria represent each of the main organizational sectors: business, education, and healthcare. The primary differences among the criteria are the use of language appropriate for each sector and the integration of sector-specific themes. For healthcare, the themes include a focus on patient care and patient health outcomes.

The Baldrige criteria address seven major areas, called categories. In the Healthcare Criteria for Performance Excellence, these categories are: Leadership; Strategic Planning; Focus on Patients, Other Customers, and Markets; Measurement, Analysis, and Knowledge Management; Staff Focus; Process Management; and Organizational Performance Results. The Baldrige criteria and process start with leadership and end with results.

The criteria are designed to work as an integrated framework to achieve a system of performance excellence. Leadership; Strategic Planning; and Focus on Patients, Other Customers, and Markets link together to emphasize the importance of leaderships’ focus on strategy and patients and other customers. Staff Focus, Process Management, and Organizational Performance Results create a focus upon the staff and key processes that accomplish the work of the organization that yields performance results. The Measurement, Analysis, and Knowledge Management category acts as the foundation for this performance management system. A fact-based system is critical to improving an organization’s healthcare and operational performance. All of the categories link together to support a systems perspective of the organization and the importance of feedback in an effective performance management system.

“Know thyself” — Plato. The criteria are written as a series of questions. Answering these questions helps organizations to gain knowledge of themselves. These questions can be compared to the questions that Socrates used as his teaching method with his students.

There are two types of criteria questions: questions about the organization’s processes and questions about the organization’s results. Under the seven criteria categories, these questions are grouped into topic areas that in the criteria are called “items.” The questions under process items seek information on how an organization does its work. How are processes designed? How are data and information used in the processes? How does the organization spread or deploy its processes, data, and information to appropriate units throughout the organization, and how does the organization evaluate and improve its processes?

A sampling of these process questions can be taken from criteria item 3.1, titled Patient, Other Customer, and Healthcare Market Knowledge. The questions include “How do you listen and learn to determine key patient/customer requirements and expectations … and their relative importance?” The questions explore further into how the listening and learning methods vary for different patient/customer groups, and how the organization uses information from current and former patients and customers.

In criteria item 6.1, Healthcare Processes, a primary question asked is “How does your organization determine its key healthcare processes,… process requirements,… and design these processes to meet all key requirements?” This is followed by “How do these processes contribute to improved healthcare service outcomes?” and “How are healthcare delivery processes and likely outcomes explained to set realistic patient expectations?”

You can see from these examples that the criteria are written to be non-prescriptive. The criteria do not prescribe that an organization should or should not have specific structures such as departments for quality, planning, or other functions. They also do not prescribe the use of specific procedures, tools, or measures. Each organization identifies what is best for itself based upon the key influences on how it operates and the key challenges it faces.

The criteria also ask questions about results. The questions for results are linked to the important processes and action plans that the organization identified in its answers to the process questions. This supports the systems approach to performance excellence. In the results items, the organization is asked to provide its current level, past trends, and comparative data or benchmarks for its results.

As an example, item 7.1 addresses the organization’s healthcare results. The questions asked in this item are “What are the current levels and trends in key measures or indicators of healthcare outcomes, healthcare service delivery results, patient safety, and patients’ functional status important to your patients and other customers?” and “How do these results compare to the performance of competitors and other organizations providing similar healthcare services?”

Using the Baldrige Criteria. It is never too early to begin using the Baldrige Criteria for Performance Excellence. Many organizations begin using the criteria in the early stages of their journeys toward performance excellence. They do not wait until they are ready to apply for the Baldrige Award. Benefits can be received from using the criteria for self-assessment or for applying for the award.

For More Information. There are a number of ways that you can learn more about the Baldrige program and award. The Baldrige National Quality Program Web site,, has several tools to assist organizations in learning about the Criteria for Performance Excellence. These include tools for organizations that are just beginning with Baldrige and those that are more mature with Baldrige. Abbreviated copies of the award recipients’ applications, tools used for training Baldrige examiners, and, of course, the criteria also are available. All of these products are copyright free so organizations can be comfortable in downloading and copying these documents.

Organizations can contact their state or local Baldrige-based award program. These programs can provide assistance with self-assessment, networking opportunities, training, and consultation in addition to their award programs. Anyone interested in Baldrige also can attend a conference. The Baldrige National Quality Program sponsors the Quest for ExcellenceÆ conference and regional conferences annually to showcase the award recipients and give attendees an opportunity to learn about recipients’ best practices. Anyone can apply to become a Baldrige examiner. Examiners at both the state and national level receive valuable training and experience in understanding and applying the criteria, and they strengthen their ability to use the criteria within their own organizations. You also may contact the Baldrige program by phone (301/975-2036) or by email (

Jane Poulter is a senior staff member with the Baldrige National Quality Program at the National Institute of Standards and Technology. She led the development of three healthcare case studies, the writing of the healthcare criteria, and has managed the feedback report process for the Baldrige program. Prior to joining the Baldrige program, Poulter served as the manager of quality assurance for Group Health Association in Washington, D.C. She also has been a case manager, the director of quality assurance and utilization review for the Northern Virginia PSRO, and has performed direct patient care for medicine, surgery, and neurosurgery patients. Poulter holds a master’s degree in health services administration from Central Michigan University and a bachelor’s degree in nursing from the University of Virginia. She may be contacted at