2017 2018 baldrige excellence framework pdf

2017 www.nist.gov/baldrige#Baldrige

health care

Arroyo Fresco Community Health Center Case Study

Baldrige Performance Excellence Program National Institute of Standards and Technology (NIST) • United States Department of Commerce

July 2017

To obtain Baldrige Program products and services, contact Baldrige Performance Excellence Program Administration Building, Room A600 100 Bureau Drive, Stop 1020 Gaithersburg, MD 20899-1020

Telephone: (301) 975-2036 Fax: (301) 948-3716 E-mail: baldrige@nist.gov Web: https://www.nist.gov/baldrige

The Arroyo Fresco Community Health Center Case Study is a fictitious Baldrige Award application prepared for use in the 2017 Malcolm Baldrige National Quality Award Examiner Preparation Course. The fictitious case study organization is a nonprofit, community health center serving western Arizona from 11 clinics and 4 mobile service vans. The case study illustrates the format and general content of an award application. However, since the case study serves primarily as a tool for training examiners to evaluate organizations against the 2017–2018 Baldrige Excellence Framework and its Criteria for Performance Excellence, it may not address all Criteria requirements or demonstrate role-model responses in all Criteria areas. Please refer to the Arroyo Fresco Community Health Center Feedback Report to learn how the organization scored and to see its strengths and opportunities for improvement.

This case study is a work of fiction, created and produced for the sole purpose of training regarding the use of the Baldrige Excellence Framework. There is no connection between the fictitious Arroyo Fresco Community Health Center and any other organization, named either Arroyo Fresco Community Health Center or otherwise. Any resemblance to any specific organization is purely coincidental. The names of several national and government organizations are included to promote the realism of the case study as a training tool, but all data and content about them have been fictionalized, as appropriate; all other organizations cited in the case study are fictitious or have been fictionalized.

The Baldrige Program welcomes your comments on this case study and other Baldrige products and services. Please direct your com-ments to the address above.

BALDRIGE CRITERIA FOR PERFORMANCE EXCELLENCE®, BALDRIGE PERFORMANCE EXCELLENCE PROGRAM®, CRITERIA FOR PERFORMANCE EXCELLENCE®, MALCOLM BALDRIGE NATIONAL QUALITY AWARD®, and PERFORMANCE EXCELLENCE® are federally registered trademarks and service marks of the U.S. Department of Commerce, National Institute of Standards and Technology. The unauthorized use of these trademarks and service marks is prohibited.

NIST, an agency of the U.S. Department of Commerce, manages the Baldrige Program. NIST has a 100-plus-year track record of serving U.S. industry, science, and the public with the mission to promote U.S. innovation and industrial competitiveness by advancing measurement science, standards, and technology in ways that enhance economic security and improve our quality of life. NIST carries out its mission in three cooperative programs, including the Baldrige Program. The other two are the NIST laboratories, conducting research that advances the nation’s technology infrastructure and is needed by U.S. industry to continually improve products and services; and the Hollings Manufacturing Extension Partnership, a nationwide network of local centers offering technical and business assistance to small manufacturers.

Suggested citation: Baldrige Performance Excellence Program. 2017. 2017 Baldrige Case Study: Arroyo Fresco Community Health Center. Gaithersburg, MD: U.S. Department of Commerce, National Institute of Standards and Technology. https://www.nist.gov/baldrige.

CONTENTS 2017 Eligibility Certification Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . E1 Organization Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O1 2017 Award Application Form, page A-1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A1 Glossary of Terms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G1

Preface: Organizational Profile P.1 Organizational Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i P.2 Organizational Situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv

Category 1: Leadership 1.1 Senior Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 1.2 Governance and Societal Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Category 2: Strategy 2.1 Strategy Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 2.2 Strategy Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Category 3: Customers 3.1 Voice of the Customer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 3.2 Customer Engagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Category 4: Measurement, Analysis, and Knowledge Management 4.1 Measurement, Analysis, and Improvement of

Organizational Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 4.2 Information and Knowledge Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Category 5: Workforce 5.1 Workforce Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 5.2 Workforce Engagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Category 6: Operations 6.1 Work Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 6.2 Operational Effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Category 7: Results 7.1 Health Care and Process Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 7.2 Customer-Focused Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 7.3 Workforce-Focused Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 7.4 Leadership and Governance Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 7.5 Financial and Market Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

2017 ELIGIBILITY CERTIFICATION

FORM

Eligibility package due February 22, 2017 Award package due May 2, 2017

1. Your Organization

Official name Arroyo Fresco Community Health Center

Headquarters address

1345 Desert Bloom Ave. Yuma, AZ 85364

Other name n/a

Prior name (if changed within the past 5 years) n/a

2. Highest-Ranking Official  Mr.  Mrs.  Ms.  Dr.

Name Ramon Gonzalez Address   Same as above

Job title CEO

E-mail r_gonzalez@af.net

Telephone (555) ARROYOF (277-6963), ext. 12

Fax (555) 277-6967

3. Eligibility Contact Point Designate a person who can answer inquiries about your organization. Questions from your organization and requests from the Baldrige Program will be limited to this person and the alternate identified below.

 Mr.  Mrs.  Ms.  Dr.

Name Roger Sinclair Address  Same as above

Job title Director of Performance Excellence 2219 Lakeview Blvd San Luis, AZ 85349

E-mail r_sinclair@af.net

Telephone (555) 487-6235 Overnight mailing address

  Same as above (Do not use a P.O. Box number.)

Fax (555) 487-6277

4. Alternate Eligibility Contact Point  Mr.  Mrs.  Ms.  Dr.

Name Judy Jackson-Gomez Telephone (555) ARROYOF (277-6963), ext. 18

E-mail j_gomez@af.net Fax (555) 277-6967

2017 Eligibility Certification Form Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006 Expiration Date: 06/30/2019

Page E-1 of 12

Eligibility package due February 22, 2017 Award package due May 2, 2017

2017 Eligibility Certification Form Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006 Expiration Date: 06/30/2019

Page E-2 of 12

5. Application History a. Has your organization previously submitted an eligibility certification package?

 Yes. Indicate the year(s). Also indicate the organization’s name at that time, if different.

Year(s) 2007, 2009, 2015, 2016

Name(s)

 No  Don’t know

b. Has your organization ever received the Malcolm Baldrige National Quality Award®?

 Yes. Did your organization receive the award in 2011 or earlier?

 Yes. Your organization is eligible to apply for the award.

 No. If your organization received an award during 2011 and 2015, it is eligible to apply for feedback only. Contact the Baldrige Program at (877) 237-9064, option 3, if you have questions.

 No c. Has your organization participated in a regional/state/local or sector-specific Baldrige-based award process?

 Yes. Years: 1997, 1998, 1999, 2000, 2002, 2004  No

d. Is your organization submitting additional materials (i.e., a completed Organizational Profile and two results measures for each of the five Criteria results items) as a means of establishing eligibility?

 No. Proceed to question 6.

 Yes. In the box below, briefly explain the reason your organization chose this eligibility option. (This information will be shared with the Alliance leadership, without revealing your organization’s identity.)

6. Eligibility Determination See also Is Your Organization Eligible? (http://www.nist.gov/baldrige/enter/eligible.cfm).

a. Is your organization a distinct organization or business unit headquartered in the United States?

 Yes  No. Briefly explain.

b. Has your organization officially or legally existed for at least one year, or since April 1, 2016?

 Yes  No

Eligibility package due February 22, 2017 Award package due May 2, 2017

2017 Eligibility Certification Form Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006 Expiration Date: 06/30/2019

Page E-3 of 12

c. Can your organization respond to all seven Baldrige Criteria categories? Specifically, does your organization have processes and related results for its unique operations, products, and/or services? For example, does it have an independent leadership system to set and deploy its vision, values, strategy, and action plans? Does it have approaches for engaging customers and the work- force, as well as for tracking and using data on the effectiveness of these approaches?

 Yes  No

d. If some of your organization’s activities are performed outside the United States or its territories and your organization receives a site visit, will you make available sufficient personnel, documentation, and facilities in the United States or its territories to allow a full examination of your worldwide organization?

 Yes  No  Not applicable e. If your organization receives an award, can it make sufficient personnel and documentation available to share its practices at the

Quest for Excellence® Conference and at your organization’s U.S. facilities?

 Yes  No

If you checked “No” for 6a, 6b, 6c, 6d, or 6e, call the Baldrige Program at (877) 237-9064, option 3.

Questions for Subunits Only f. Is your organization a subunit in education or health care?

 Yes. Check your eligibility by reading Is Your Organization Eligible? (http://www.nist.gov/baldrige/enter/eligible.cfm). Then proceed to item 6k.

 No. Continue with 6g. g. Does your subunit function independently and as a discrete entity, with substantial authority to make key administrative and

operational decisions? (It may receive policy direction and oversight from the parent organization.)

 Yes. Continue with 6h.  No. Your subunit probably is not eligible to apply for the award. Call the Baldrige Program at (877) 237-9064, option 3.

h. Does your subunit have a clear definition of “organization” reflected in its literature? Does it function as a business or operational entity, not as activities assembled to write an award application?

 Yes. Continue with 6i.  No. Your subunit probably is not eligible to apply for the award. Call the Baldrige Program at (877) 237-9064, option 3.

i. Is your subunit in manufacturing or service?

 Yes. Does it have 500 or fewer employees? Is it separately incorporated and distinct from the parent organization’s other subunits? Or was it independent before being acquired by the parent, and does it continue to operate independently under its own identity?

 Yes. Your subunit is eligible in the small business category. Attach relevant portions of a supporting official document (e.g., articles of incorporation) to this form. Proceed to item 6k.

 No. Continue with 6j.

Eligibility package due February 22, 2017 Award package due May 2, 2017

2017 Eligibility Certification Form Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006 Expiration Date: 06/30/2019

Page E-4 of 12

j. Is your subunit self-sufficient enough to be examined in all seven categories of the Criteria?

• Does it have its own senior leaders?

• Does it plan and implement its own strategy?

• Does it serve identifiable customers either inside or outside the organization?

• Is it responsible for measuring its performance and managing knowledge and information?

• Does it manage its own workforce?

• Does it manage its own work processes and other aspects of its operations?

• Can it report results related to these areas?

 Yes. Proceed to 6k (table below).  No. Your organization probably is not eligible to apply for the award. Call the Baldrige Program at (877) 237-9064, option 3.

k. Does your organization meet one of the following conditions?

1. My organization has won the Baldrige Award (prior to 2012).

Yes 

Your organization is eligible.

No Continue with statement 2.

2. Between 2012 and 2016, my organization applied for the national Baldrige Award, and the total of the process and results band numbers assigned in the feedback report was 8 or higher.

Yes 

Your organization is eligible.

Year:

Total of band scores:

No Continue with statement 4.

3. Between 2012 and 2016, my organization applied for the national Baldrige Award and received a site visit.

Yes 

Your organization is eligible.

Year of site visit:

No Continue with statement 5.

4. Between 2012 and 2016, my organization received the top award from an award program that is a member of the Alliance for Performance Excellence.

Yes 

Your organization is eligible.

Award program:

Year of top award:

No Continue with statement 3.

5. More than 25% of my organization’s workforce is located outside the organization’s home state.

Yes 

Your organization is eligible.

No Continue with statement 6.

6. There is no Alliance for Performance Excellence award program available for my organization.

Yes 

Your organization is eligible.

No Continue with statement 7.

7. My organization will submit additional eli- gibility screening materials (i.e., a complete Organizational Profile and two results measures for each of the five Criteria results items). The Baldrige Program will use the materials to determine if my organization is eligible to apply for the award this year (as described in the fact sheet at www.nist.gov/baldrige/publications /upload/2015-Baldrige-Eligibility-FAQs.docx).

Yes 

The Baldrige Program will review the materials and contact your ECP after determining your eligibility.

No Call 877-237-9064, option 3, if you have questions.

Eligibility package due February 22, 2017 Award package due May 2, 2017

2017 Eligibility Certification Form Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006 Expiration Date: 06/30/2019

Page E-5 of 12

7. Award Category a. Award category (Check one.)

Your education or health care organization may use the Business/Nonprofit Criteria and apply in the service, small business, or nonprofit category. However, you probably will find the sector-specific (Education or Health Care) Criteria more appropriate.

For-Profit Nonprofit

 Manufacturing  Service  Small business (# 500 employees)  Education  Health Care

 Nonprofit  Education  Health Care

b. Industrial classifications. List up to three of the most descriptive NAICS codes for your organization (see NAICS list included at the end of this document). These are used to identify your organizational functions and to assign applications to examiners.

6214 6211

8. Organizational Structure a. For the preceding fiscal year, the organization had in

 up to $1 million  $1.1 million–$10 million  $10.1 million–$100 million  $100.1 million–$500 million  $500.1 million–$1 billion  more than $1 billion

 sales  revenue

 budget

b. Attach a line-and-box organization chart that includes divisions or unit levels. In each box, include the name of the unit or division and the name of its leader. Do not use shading or color in the boxes.

 The chart is attached.

c. The organization is _____ a larger parent or system. (Check all that apply.)

 not a subunit of (See item 6 above.)

 a subsidiary of  controlled by  administered by  owned by  a division of  a unit of  a school of  other _____________________

Parent organization

Address

Total number of paid employees*

Highest-ranking official

Job title

Telephone

*Paid employees include permanent, part-time, temporary, and telecommuting employees, as well as contract employees supervised by the organization. Include employees of subunits but not those of joint ventures.

Eligibility package due February 22, 2017 Award package due May 2, 2017

2017 Eligibility Certification Form Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006 Expiration Date: 06/30/2019

Page E-6 of 12

Attach a line-and-box organization chart(s) showing your organization’s relationship to the parent’s highest management level, including all intervening levels. In each box, include the name of the unit or division and its leader. Do not use shading or color in the boxes.

 The chart is attached.

d. Considering the organization chart, briefly describe below how your organization relates to the parent and its other subunits in terms of products, services, and management structure.

e. Provide the title and date of an official document (e.g., an annual report, organizational literature, a press release) that clearly defines your organization as a discrete entity.

Title Date

Attach a copy of relevant portions of the document. If you name a website as documentation, print and attach the relevant pages, providing the name only (not the URL) of the website.

 Relevant portions of the document are attached.

f. Briefly describe the major functions your parent or its other subunits provide to your organization, if appropriate. Examples are strategic planning, business acquisition, research and development, facilities management, data gathering and analysis, human resource services, legal services, finance or accounting, sales/marketing, supply chain management, global expansion, information and knowledge management, education/training programs, information systems and technology services, curriculum and instruction, and academic program coordination/development.

9. Supplemental Sections The organization has (a) a single performance system that supports all of its product and/or service lines and (b) products or services that are essentially similar in terms of customers/users, technology, workforce or employee types, and planning.

 Yes. Proceed to item 10.

 No. Your organization may need to submit one or more supplemental sections with its application. Call the Baldrige Program at (877) 237-9064, option 3.

Eligibility package due February 22, 2017 Award package due May 2, 2017

2017 Eligibility Certification Form Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006 Expiration Date: 06/30/2019

Page E-7 of 12

10. Use of Cell Phones, Cordless Phones, and Voice-over-Internet Protocol (VoIP) Do you authorize Baldrige examiners to use cell phones, cordless phones, and VoIP to discuss your application? Your answer will not affect your organization’s eligibility. Examiners will hold all your information in strict confidence and will discuss your application only with other assigned examiners and with Baldrige Program representatives as needed.

 Yes  No

11. Site Listing You may attach or continue your site listing on a separate page as long as you include all the information requested here. You may group sites by function or location (city, state), as appropriate. Please include the total for each column (sites, employees/faculty/ staff, volunteers, and products/services). See the ABC HealthCare example below.

Please include a detailed listing showing all your sites. If your organization receives a site visit, an examiner team will use this information for planning and conducting its visit. Although site visits are not conducted at facilities outside the United States or its territories, these facilities may be contacted by teleconference or videoconference.

Example

Sites (U.S. and Foreign) List the city and the state or country.

Workforce* List the numbers at each site.

List the % at each site, or

use “N/A” (not applicable).

Check one or more.

 Employees  Faculty  Staff

Volunteers (no. or N/A)

Check one.

% of

 Sales  Revenue  Budget

Relevant Products, Services, and/or Technologies

ABC Medical Center, Anytown, NY 1,232 147 77% Admin. offices, inpatient care, ED, imaging services, lab

ABC Hospital West, West Anytown, NY 255 78 14% Inpatient services, ED, lab ABC Medical Group, Anytown, NY 236 N/A 6% Primary & specialty

physician care ABC Imaging Center, West Anytown, NY 11 N/A 1% Imaging services ABC Hospice Services, West Anytown, NY 94 89 1% On- and off-site hospice

services ABC Urgent Care, West Anytown, NY 8 N/A 1% Outpatient emergency and

urgent care services Total 6 1,836 314 100%

*“Workforce” refers to all people actively involved in accomplishing the work of your organization, including paid employees (e.g., permanent, part-time, temporary, and telecommuting employees, as well as contract employees supervised by the organization) and volunteers, as appropri- ate. The workforce includes team leaders, supervisors, and managers at all levels.

Eligibility package due February 22, 2017 Award package due May 2, 2017

2017 Eligibility Certification Form Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006 Expiration Date: 06/30/2019

Page E-8 of 12

Your Organization

Sites (U.S. and Foreign) List the city and the state or country.

Workforce* List the numbers at each site.

List the % at each site, or use

“N/A” (not applicable).

Check one or more.

 Employees  Faculty  Staff

Volunteers (no. or N/A)

Check one. % of

 Sales  Revenue  Budget

Relevant Products, Services, and/or Technologies

Arroyo Fresco Family Clinic—Somerton, 672 Calle Viejo, Somerton, AZ 85350 (Yuma County)

35 36 9 Medical services (and dental services by mobile van)

Arroyo Fresco Family Clinic—San Luis, 2219 Plaza Del Oro, Yuma, AZ 85349 (Yuma County)

50 42 20 Medical and dental services

Arroyo Fresco Community Health Center 1347 Desert Bloom Ave, Yuma, AZ 85364 (Yuma County)

40 0 0 Corporate services such a HR, Accounting, IT, etc.

Arroyo Fresco Family Clinic—North Yuma, 1345 Desert Bloom Ave, Yuma, AZ 85364 (Yuma County)

32 30 8 Medical and dental services

Arroyo Fresco Family Clinic—Parker, 4010 Colorado St., Parker, AZ 85344 (La Paz County)

31 26 5 Medical services (and dental services by mobile van)

Arroyo Fresco Family Clinic—East Yuma, 18137 Fourth Ave, Yuma, AZ 85367 (Yuma County)

38 28 9 Medical services (and dental services by mobile van)

Arroyo Fresco Family Clinic—Lake Havasu City, 2219 Lakeview Blvd., Lake Havasu City, AZ 85349 (Mohave County)

47 30 11 Medical and dental services

Arroyo Fresco Family Clinic—Bullhead City, 39675 Fisherman’s Way, Bullhead City, AZ 86429 (Mohave County)

41 22 10 Medical and dental services Mobile medical services through Medical Service Van 1, serving towns along Route 8 Mobile dental services through Dental Service Van 1, serving towns along Route 8 and school-based clinics

Arroyo Fresco Family Clinic—Kingman, 6527 Old Mine Rd., Kingman, AZ 86401 (Mohave County)

36 15 9 Medical and dental services Mobile medical services through Medical Service Van 2, and mobile dental services through Dental Service Van 2— both serving the Parker and Kingman areas on alternate weeks

Arroyo Fresco Women’s Health Center— North Yuma, 3529 El Centro Ave, Yuma, AZ 85365

30 8 9 Obstetrics and gynecology

Eligibility package due February 22, 2017 Award package due May 2, 2017

2017 Eligibility Certification Form Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006 Expiration Date: 06/30/2019

Page E-9 of 12

San Juan Elementary School, 2058 Plaza del San Juan, Yuma, AZ 85364

19 5 5 Medical services (and dental services by mobile van)

El Centro High School, 2590 El Centro Ave., Yuma, AZ 85364

20 8 5 Medical services (and dental services by mobile van)

Total 419 250 100%

*The term workforce refers to all people actively involved in accomplishing the work of an organization. The workforce includes paid employees (e.g., permanent, part-time, temporary, telecommuting, and contract employees supervised by the organization) and volunteers, as appropriate; it also includes team leaders, supervisors, and managers at all levels.

12. Key Business/Organization Factors List or briefly describe where necessary the following key business/organization factors (we recommend using bullets). Please be concise, but be as specific as possible. Provide full names of organizations (i.e., do not use acronyms). The Baldrige Program uses this information to avoid conflicts of interest when assigning examiners to your application. Examiners also use this infor- mation in their evaluations.

a. Main products and/or services and major markets served (local, regional, national, and international)

Ambulatory medical (i.e., obstetric/gynecologic, family medicine, pediatric) and dental services, supported by routine laboratory and X-ray services, vision and hearing screening, behavioral health and substance abuse screening, and pharmacy services. Segments include maternal, infant, and child health; chronic disease; senior care; and dental services. High-quality primary care and preventive services are offered regardless of patients’ ability to pay. To increase access to care, Arroyo Fresco also provides “enabling services,” such as transportation, translation, case management, health education, and home visitation. Markets consist of a three-county service area in the state of Arizona: Yuma, La Paz, and Mohave. Services sites are 8 medical/dental clinics, 1 women’s health center, 2 school-based clinics, 2 medical service vans, and 2 dental service vans.

b. Key competitors (those that constitute 5 percent or more of your competitors)

• Other CHCs in adjacent counties and agencies, such as Pomegranate Health • Community-based, private, medical, dental, and behavioral health providers in all three counties, but

primarily in areas of denser populations • Indian Health Service (IHS) facilities in all three counties • Veterans Affairs hospitals • Providers and facilities in Mexico

c. Key customers/users (those that constitute 5 percent or more of your customers/users)

• Patients needing ambulatory medical and/or dental services, and their families • Community members who use various screening services through mobile vans that stop at churches,

schools, and community centers • Elementary and high school students at two school-based clinics • Payors

Eligibility package due February 22, 2017 Award package due May 2, 2017

2017 Eligibility Certification Form Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006 Expiration Date: 06/30/2019

Page E-10 of 12

d. Key suppliers/partners (those that constitute 5 percent or more of your suppliers/partners)

• CactusCom: Telecommunications • Community hospital in each county: Emergency and inpatient services, as well as some outpatient

specialty care • County governments and community-service organizations (e.g., school boards): Referrals, Services,

and Outreach activities • Desert Data Solutions (DDS): IT, including support for EHR • Gil’s Garage: Vehicle maintenance • HR Leaders, Inc.: Temporary clinical and office staff • La Sangre de Vida: Dialysis services • MedProducts, Inc.: Group purchasing • National Health Service Corps and other education partners: Recruitment of physicians, dentists,

pharmacists, and midlevel providers • Oates Group: Oates Staff Satisfaction Survey • Pharmaceutical company: Prescription assistance program • Saguaro State University (SSU) Schools of Business, Medicine, Dentistry, Nursing, and Public Health:

Training and preceptorships • Service Excellence: Diversity training • Shiny Clean: Custodial services • State Association of CHCs: Advocacy at state and national levels • Talkeetna Medical School and local community colleges: Training • The Joint Commission (TJC): Survey • Winding River Casinos: Initiatives related to substance abuse and obesity

e. Financial auditor Fiscal year (e.g., October 1–September 30)

Johansen, Simon, and Clark January 1–December 31

f. Parent organization (if your organization is a subunit).

N/A

13. Nomination to the Board of Examiners If your organization is eligible to apply for the Baldrige Award in 2017, you may nominate one senior member from your organiza- tion to the 2017 Board of Examiners.

Nominees are appointed for one year only. Nominees

  ■ must not have served previously on the Board of Examiners and

  ■ must be citizens of the United States, be located in the United States or its territories, and be employees of the applicant organization.

The program limits the number of examiners from any one organization. If your organization already has representatives on the board, nominating an additional person may affect their reappointment.

Board appointments provide a significant opportunity for your organization to learn about the Criteria and the evaluation process. The time commitment is also substantial: examiners may need to commit more than 200 hours from April through August, includ- ing 40–60 hours in April/May to complete self-study training prework, 2.5–3.5 business days in May to attend Examiner Prepara- tion, and 95–120 hours from June through August to complete both Independent Review and Consensus Review. If requested by the program, examiners also participate in a Site Visit Review of approximately 9 days. The nominee or the organization must cover travel and housing expenses incurred for Examiner Preparation.

Eligibility package due February 22, 2017 Award package due May 2, 2017

2017 Eligibility Certification Form Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006 Expiration Date: 06/30/2019

Page E-11 of 12

 Mr.  Mrs.  Ms.  Dr.

from our organization will serve on the 2017 Board of Examiners.

E-mail address

 I understand that the nominee or the organization will cover travel and hotel costs associated with participation in Examiner Preparation. I also understand that if my organization is determined to be ineligible to apply for the Baldrige Award in 2017, this examiner nomination will not be considered for the 2017 Board of Examiners.

14. Self-Certification and Signature I state and attest the following:

(1) I have reviewed the information provided in this eligibility certification package.

(2) To the best of my knowledge,

■ this package includes no untrue statement of a material fact, and

■ no material fact has been omitted.

(3) Based on the information herein and the current eligibility requirements for the Malcolm Baldrige National Quality Award, my organization is eligible to apply.

(4) I understand that if the information is found not to support eligibility at any time during the 2017 award process, my organization will no longer receive consideration for the award and will receive only a feedback report.

Ramon Gonzalez 2/21/17

Signature of highest-ranking official Printed name Date

15. Submission To be considered for the 2017 award, your complete eligibility certification package must be received no later than February 22, 2017, to

Malcolm Baldrige National Quality Award c/o ASQ—Baldrige Award Administration 600 North Plankinton Avenue Milwaukee, WI 53203 (414) 298-8789, ext. 7205

Include proof of the mailing date. Send the package via

■ a delivery service (e.g., Airborne Express, Federal Express, United Parcel Service, or the United States Postal Service [USPS] Express Mail) that automatically records the mailing date or

■ the USPS (other than Express Mail), with a dated receipt from the post office.

2017 Eligibility Certification Form Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006 Expiration Date: 06/30/2019

Page E-12 of 12

Eligibility package due February 22, 2017 Award package due May 2, 2017

16. Fee Indicate your method of payment for the $360 eligibility certification fee.

 Check (enclosed)  Money order (enclosed) Make payable to the Malcolm Baldrige National Quality Award.

 ACH payment  Wire transfer Checking ABA routing number: 075-000-022 Checking account number: 182322730397

Before sending an ACH payment or wire transfer, notify the American Society for Quality (ASQ; [414] 298-8789, ext. 7205, or mbnqa@asq.org). Reference the Baldrige Award with your payment.

 Visa  MasterCard  American Express

Card number Authorized signature

Expiration date Printed name

Card billing address Today’s date

W-9 Request: If you require an IRS Form W-9 (Request for Taxpayer Identification Number and Certification), contact ASQ at (414) 298-8789, ext. 7205.

Eligibility package due February 22, 2017 Award package due May 2, 2017

2017 Eligibility Certification Form Checklist Malcolm Baldrige National Quality Award

OMB Control No. 0693-0006 Expiration Date: 06/30/2019

1. Eligibility Certification Form*  I have answered all questions completely.

 I have included a line-and-box organization chart showing all components of the organization and the name of each unit or division and its leader.

 The highest-ranking official has signed the form.

For Companies Submitting Additional Eligibility Screening Materials (to meet the new alternative eligibility condition no. 7 for question 6k; see the table on page E-4)

 I have enclosed a complete Organizational Profile.  I have enclosed data for two results measures for each of the five Criteria results items.

For Subunits Only

 I have included a line-and-box organization chart(s) showing the subunit’s relationship to the parent’s highest management level, including all intervening levels.

 I have enclosed copies of relevant portions of an official document clearly defining the subunit as a discrete entity.

*Please do not staple the pages of this form.

2. Fee  I have indicated my method of payment for the nonrefundable $360 eligibility certification fee.

 If paying by check or money order, I have made it payable to the Malcolm Baldrige National Quality Award and included it in the eligibility certification package.

3. Submission and Examiner Nomination  I am nominating a senior member of my organization to the 2017 Board of Examiners.  I am not nominating a senior member of my organization to the 2017 Board of Examiners.

 I am sending the complete eligibility certification package to

Malcolm Baldrige National Quality Award c/o ASQ—Baldrige Award Administration 600 North Plankinton Avenue Milwaukee, WI 53203 (414) 298-8789, ext. 7205

 I have included proof of the mailing date. (See Application Form and Content instructions at http://www.nist.gov/baldrige/enter/format.cfm/.)

ORGANIZATION CHART

O1

PAGE A-1 OF THE

2017 AWARD APPLICATION FORM

1. Your Organization

Official name Arroyo Fresco Community Health Center

Mailing address 1345 Desert Bloom Ave. Yuma, AZ 85364

2. Award Category and Criteria Used a. Award category (Check one.)

 Manufacturing  Service  Small business. The larger percentage of sales is in

(check one)  Manufacturing  Service  Education  Health care  Nonprofit b. Criteria used (Check one.)  Business/Nonprofit  Education  Health Care

3. Official Contact Point Designate a person with in-depth knowledge of the organization, a good understanding of the application, and the authority to answer inquiries and arrange a site visit, if necessary. Contact between the Baldrige Program and your organization is limited to this indi- vidual and the alternate official contact point. If the official contact point changes during the application process, please inform the program.

 Mr.  Mrs.  Ms.  Dr.

Name Roger Sinclair

Title Director of Performance Excellence

Mailing address  Same as above

2219 Lakeview Blvd San Luis, AZ 85349

Overnight mailing address

 Same as above (Do not use a P.O. box number.)

Telephone (555) 487-6235

Fax (555) 487-6277

E-mail r_sinclair@af.net

2017 Award Application Form Checklist Malcolm Baldrige National Quality Award

OMB Clearance #0693-0006 Expiration Date: 06/30/2019

Page A-1

4. Alternate Official Contact Point  Mr.  Mrs.  Ms.  Dr.

Name Judy Jackson-Gomez

Telephone (555) ARROYOF (277-6963), ext. 18

Fax (555) 277-6967

E-mail j_gomez@af.net

5. Release and Ethics Statements Release Statement I understand that this application will be reviewed by members of the Board of Examiners. If my organization is selected for a site visit, I agree that the organization will

■ host the site visit, ■ facilitate an open and unbiased examination, and ■ pay reasonable costs associated with the site visit (see

Baldrige Award Process Fees on our website [https:/ /www.nist.gov/baldrige/baldrige-award/award-process-fees]).

If selected to receive an award, my organization will share non- proprietary information on its successful performance excellence strategies with other U.S. organizations.

Ethics Statement and Signature of Highest-Ranking Official I state and attest that

(1) I have reviewed the information provided by my organiza- tion in this award application package.

(2) To the best of my knowledge, ■ this package contains no untrue statement of a material

fact and ■ omits no material fact that I am legally permitted to

disclose and that affects my organization’s ethical and legal practices. This includes but is not limited to sanctions and ethical breaches.

5/1/17

Signature Date

 Mr.  Mrs.  Ms.  Dr.

Printed name Ramon Gonzalez Job title CEO Applicant name Arroyo Fresco Community

Health Center Mailing address  Same as above

Telephone (555) ARROYOF (277-6963), ext. 12 Email r_gonzalez@af.net Fax (555) 277-6967

GLOSSARY OF TERMS AND

ABBREVIATIONS

Glossary of Terms and Abbreviations

AAFP ��������������American Academy of Family Physicians AAP ����������������American Academy of Pediatrics AAR ����������������after action review ACA ����������������Affordable Care Act ACOG ������������American Congress of Obstetricians and

Gynecologists ADA ����������������Americans with Disabilities Act AF �������������������Arroyo Fresco AHRQ ������������Agency for Healthcare Research and Quality ANOVA ����������analysis of variance AOS ����������������available on-site AQA ����������������Ambulatory Care Quality Alliance BMI ����������������body mass index BPHC �������������Bureau of Primary Health Care BRFSS ������������Behavioral Risk Factor Surveillance System BSN �����������������bachelor of science in nursing degree CC �������������������core competency CCK ���������������Care Connection Kiosk CDC ����������������Centers for Disease Control and Prevention CEU ����������������continuing education unit CHC ���������������community health center CKD ���������������chronic kidney disease CMS ���������������Centers for Medicare/Medicaid Services CMs ����������������Clinical Microsystems CoPs ���������������communities of practice CTQ ����������������critical to quality DDDI ��������������Data and Information for Health Care International DDS ����������������Desert Data Solutions DEA ����������������Drug Enforcement Administration DMAIC ����������define-measure-analyze-improve-control DOE ����������������Design of Experiments ED �������������������Emergency Department EEOC �������������Equal Employment and Opportunity Commission EHR ����������������electronic health record EOP ����������������Emergency Operations Plan EPA �����������������Environmental Protection Agency EPSDT �����������early and periodic screening, diagnostic,

and treatment FMEA �������������failure modes and effects analysis FOCUS �����������Financial performance, Organizational learning,

Clinical excellence, Utilization, and Satisfaction FQHC �������������federally qualified health center H and P ����������comprehensive history and physical examination HCAHPS �������Hospital Consumer Assessment of Healthcare

Providers and Systems HEDIS ������������Healthcare Effectiveness Data and Information Set HIPAA ������������Health Insurance Portability and Accountability Act HP2020 �����������Healthy People 2020 HPT ����������������Healing Partners Team

HR ������������������human resources HRSA �������������Health Resources and Services Administration IDP ������������������individual development plan IHS �����������������Indian Health Service IOM ����������������Institute of Medicine IT ��������������������information technology KIC �����������������Knowledge and Innovation Center KMP ���������������Knowledge Management Process KPIs ����������������key performance indicators MAM ��������������Mothers Aiding Mothers MSN ���������������master of nursing NACHC ���������National Association of CHCs NCQA �������������National Committee for Quality Assurance NHSC �������������National Health Service Corps NIST ���������������National Institute of Standards and Technology OASIS ������������Opportunity identification, Assess or analyze,

Set targets and time lines, Improve, Share and sustain

OSHA �������������Occupational Safety and Health Administration PCMH ������������patient-centered medical home PCT ����������������Primary Care Team PDCA �������������plan-do-check-adjust PFABs �������������patient-family advisory boards PHP �����������������personal health profile PIF ������������������Performance Improvement Framework PPT �����������������People Potential Team Promotores/ promotoras ����volunteers QPG ����������������Quality and Productivity Group RN �������������������registered nurse ROI �����������������return on investment RVUs ��������������relative value units SAs ������������������key strategic advantages SCs ������������������key strategic challenges SLT �����������������Senior Leadership Team SPC �����������������statistical process control SSU �����������������Saguaro State University STARs ������������Superior Teamwork Achieves Results SWOT ������������strengths, weaknesses, opportunities, threats SWST �������������Service With Spirit Team TB �������������������tuberculosis TJC �����������������The Joint Commission URI �����������������upper respiratory infection VA �������������������Veterans Affairs VMV ���������������vision, mission, and values VOC ���������������voice of the customer VPN ����������������virtual private network YE �������������������year end

G1

ORGANIZATIONAL PROFILE

Organizational Profile

P.1 Organizational Description P.1a Organizational Environment Arroyo Fresco (AF) is a community health center (CHC) serving western Arizona from 11 clinics and 4 mobile service vans. CHCs, established over the past 50 years in underserved areas in all 50 states, are nonprofit, community-owned health care organizations that offer patients high-quality primary care and preventive services regardless of their ability to pay. They also provide “enabling services,” such as transportation, translation, health education, and home visitation, which increase access to care. More than 1,200 such centers serve more than 24 million Americans annually. The Health Resources and Services Administration (HRSA) administers the program. A snapshot of AF is shown in Figure P.1-1, and service-area demographics are shown in Figure P.1-2.

AF serves three counties—Yuma, Mohave, and La Paz—with diverse populations and needs. The service area of over 23,000 square miles has fewer than 430,000 people—about 6 percent of the state’s overall population. Yuma County borders Mexico.

AF was founded in 1968 by Joe Garcia and Martin Rosales, two Yuma activists committed to providing health care to the under- served. With federal funding through the Migrant Worker Project, they opened their first clinic in a converted gas station in Yuma and called their fledgling operation “Arroyo Fresco,” or “cool, flowing stream,” to represent a place to be refreshed in a vast, harsh desert. AF grew under their leadership. Operations expanded to full-time, three more facilities opened, and the first mobile van was launched in 1988 with grant funds from the Bureau of Primary Health Care (BPHC). In 1990, AF merged with the Mohave CHC, extending AF’s reach along the western Arizona corridor. Ramon Gonzalez, who became the CEO in 1996, saw the importance of reaffirming the organization’s heritage and direction set by its founders and developed the vision, mission, and values (VMV). (See Figure P.1-4.)

Communities along the border are among the state’s fastest- growing. La Paz, one of the state’s most rural counties, is home to the Colorado River Indian tribes, the largest of western Arizona’s Native American populations. Mohave County, also sparsely popu- lated, shares with La Paz 400 miles of Lake Havasu coastline and 300 days of sunshine each year, making these counties a destination for “snowbirds” and retirees from across the country.

Barriers to care—whether imposed by geography, culture, income, or other factors—are typically associated with (1) lower levels of prevention screening and (2) less efficient and effective detection and management of chronic disease, with the result that many AF patients—young and old—have poorer health than the general population. Diabetes is a major medical problem throughout the service area, with residents of southern Yuma County experiencing diabetes-related mortality at twice the national rate. Other chronic health problems include asthma, cardiovascular disease, depression, obesity, and substance abuse and other addictive behavior. Specific issues for Yuma County border communities include a higher incidence of communicable diseases (e.g., half of the tuberculosis [TB] cases for all Arizona border counties), including sexually transmitted diseases, and a higher mortality rate for accidents and

suicide. AF established a Women’s Health Center with obstetrical and gynecological services in North Yuma to address that area’s large proportion of younger females in the population and high birth rates, especially among teens.

P.1a(1) AF provides ambulatory medical (i.e., obstetric/gyneco- logic, family medicine, pediatric) and dental services, supported by routine laboratory and x-ray services, vision and hearing screening, behavioral health and substance abuse screening, and pharmacy services. Its service delivery network includes clinics and mobile service vans that make regularly scheduled stops six days a week at churches, schools, and community centers. AF ensures that patients can access all services required across the continuum of care through partnerships or contractual relationships with hospitals, physicians, and agencies throughout the tricounty area, and these arrangements are spelled out in the annual plan required by BPHC.

AF delivers care through the patient-centered Primary Care Teams (PCTs)—small interdisciplinary teams whose members form ongoing relationships with patients and families and manage the medical and dental care of these various groups, or “populations,” of patients. Essential elements of a PCT include the patients, clini- cians, and support staff; information technology (IT); and the care processes. AF has 23 PCTs organized according to its key services. For example, each clinic has at least one family medicine PCT.

i

P.1a(2) The VMV are shown in Figure P.1-4. The core competen- cies follow:

■ (CC1) Culturally competent, patient-centered care ■ (CC2) Expertise in the treatment of diseases prevalent within our patient population

■ (CC3) Collaborative relationships that increase access to specialty care and other services

The core competencies enable AF to execute its mission successfully.

P.1a(3) AF has 419 employees (12% of whom are part-time), and the workforce mirrors the race/ethnicity and culture of the popula- tion served (Figure P.1-2). Although AF is applying in the health care sector, because of its size, it could apply in the small business category. Clinical providers, who make up 62 percent of the staff, include 29 physicians, 53 medical assistants (who perform out- patient nursing tasks), 12 dentists, 18 dental hygienists/assistants, 4 nurse practitioners, 4 certified nurse midwives, and 15 physician assistants, as well as pharmacists, pharmacy technicians, com- munity educators and social workers, dietitians, podiatrists, and radiology technicians. Administrative, facility, and patient support service staff make up 33 percent of the workforce, and 5 percent of staff members are senior leaders or managers. AF has no organized bargaining units. The key drivers of workforce engagement are shown in Figure P.1-6. The differences in these drivers for work- force groups relate to generational expectations.

Volunteers include patients and patients’ family members. Volun- teers perform a wide variety of tasks that build relationships with patients and their families and increase the efficiency and effective- ness of care delivery (e.g., providing child care during patient visits, assisting providers’ education sessions, and supporting routine administrative tasks). Some have assignments that make use of their professional and technical skills (e.g., participating in grant development), and enabling AF to manage resource gaps.

Health and safety risks in the ambulatory patient care setting include exposure to communicable diseases, exposure to radiation and chemicals, needle sticks, ergonomic injuries, and accidents. Safe driving is a primary requirement for mobile van drivers.

P.1a(4) Clinical facilities include reception areas; examination/ treatment rooms equipped for medical or dental services; space for consultation and education; printed materials in English, Spanish, and large print format; and shared provider offices. All facilities are wheelchair-accessible. Medical clinics have machines for audiometric and tympanometric screening and for electronic vision screening, as well as obstetrical ultrasound equipment and dental x-ray machines that reduce radiation exposure. Clinic-based labo- ratories are equipped with microscopes, blood analyzers, and kits for rapid bacteriologic screening for respiratory and genitourinary

ii

diseases. Most clinics are open from 8:00 a.m. to 5:00 p.m. Monday through Friday and on Saturday morning.

School-based clinics are open daily when school is in session and provide basic medical services and behavioral health screening, as well as health education. Laboratory tests and x-rays are performed at the closest AF facility. The Women’s Health Center in Yuma has examination rooms equipped for outpatient obstetrics and gynecology services, as well as four labor and delivery suites for routine deliveries. High-risk pregnancies and complicated deliveries are referred to the tertiary care hospital in Yuma, which has specialists on call and a neonatal intensive care unit. AF physicians and midwives also manage routine deliveries at the community hospital in La Paz.

Four mobile service vans provide care to outlying communities and to those unable to access care at clinic sites. Equipped with lifts to accommodate patients in wheelchairs, each van has two examination/treatment rooms outfitted for medical or dental services; x-ray, basic lab, and sterilization equipment; and areas for behavioral health screening, health education, and reception.

AF’s IT is managed by Desert Data Solutions (DDS). It includes support for an electronic health record (EHR) integrated with the billing and scheduling system. All staff members have access to computers and the wide array of data and information on the AF intranet. The innovative Care Connection Kiosk (CCK) is a por- table, multi-use unit developed in collaboration with CactusCom.

P.1a(5) AF must meet specific federal requirements related to population needs, services provided, fee scale, and governance structure to receive grant funds as a federally qualified health center (FQHC) under section 330 of the Public Health Service Act. AF also received National Committee for Quality Assurance (NCQA) recognition as a patient-centered medical home (PCMH) in 2013. To maintain their federal funding, PCMHs are required by HRSA to be accredited by The Joint Commission (TJC). AF sought accreditation for the first time (then voluntary) in 1996 and has been re-accredited regularly since then, receiving full accreditation and no recommendations for improvement in 2016. AF is required to comply with multiple legal and regulatory requirements at the federal, state, and local levels (Figure 1.2-2).