Baldrige Site Visit
What is Baldrige?
Baldrige is the Top Performance Excellence Award in the nation.
It is given by the President of the United States
Identifies high-performing organizations across the nation and asks them to share their
best practices with others.
When is the site visit?
September 19-23
There will be 8-10 Baldridge examiners conducting the workarounds.
Their goal is to validate what we do well in our organization and identifying
opportunities for improvement.
Walk arounds will be in daytime (9-5) and Tuesday evening (830pm) visit.
How do you live out the Mission of Duke Hospital?
To put the person who needs our care at the center of everything we do.
Your 3D badge backer has the answers on it.
Key point: you don’t have to memorize the answer, think about a team or a personal
example of how you put the person who needs your care at the center of everything you
do.
What are the values of Duke Hospital and what do they mean to you?
Core Value: Caring for our patients, their loved ones and each other.
Demonstrates by TIDES: Teamwork, Integrity, Diversity, Excellence, Safety
50% of your annual evaluation is TIDES
Unit Based questions:
How do you know what your area is working on? How do you know you are performing well as
a unit?
Balanced Score card
Blue = exceeding expectations, Red = Not meeting expectations
Our 3D Story boards have performance data
Be proud of the great work you have done and step forward to tell your 3D story
of how you Discover, Develop, and Deliver a healthier tomorrow
for our patients and the community.
Can you tell me about a performance improvement effort that you were involved in?
Tell your 3D Story!! Take them to your storyboard if you have one.
RSI – new MICU initiative – outside Dan’s office
EKOS catheter –
MICU website - Collaboration MICU physicians and RN
Quiet Time Practice implemented to decrease ICU delirium
PAD protocol – Revisions made to protocol from staff feedback
Decrease in restraint use secondary to decrease sedation, increase sitter use
Orientee onboarding – Minimize preceptors to 3 consistent RNs, Orientee Toolbox
Rounding Tool – Multiple revisions from staff input to develop a tool
MOVES rollout – Education rollout on BMAT assessment and use of lift equipment
How do you find out about what is going on in the organization?
From my manager
The Intranet
Town Hall Meetings
Storyboards
The All Staff Event!!!
What is the Duke Blueprint? Have you ever seen it? What can you tell me about it?
It is a way that we communicate our Mission, Vision, and Values throughout our
organization.
It also talks about how we measure our performance through the Balanced Scorecard
quadrants.
It is discussed during the All Staff Event and during staff meetings and is also included
on our storyboards.
Be proud of the great work you have done and step forward to tell your 3D story
of how you Discover, Develop, and Deliver a healthier tomorrow
for our patients and the community.
Walk Around Questions:
How does your job/work team impact Duke Hospital’s success? How is your job duties linked to
your organization’s action plans or key strategies?
 Our unit measures (hand hygiene, CLABSI, CAUTI, FALLS)
 The hospital sets targets for all sections of the balanced score card annually and make
efforts to meet these goals.
How often do you see and use the overall performance measures (or the Balanced Scorecard)?
 Posted outside of Manager’s office
 Manager discussed BSC during staff meeting, midyear and annual evaluations,
 Quadrants: Clinical Quality, Customer service, work culture, and fiance
Be proud of the great work you have done and step forward to tell your 3D story
of how you Discover, Develop, and Deliver a healthier tomorrow
for our patients and the community.
Are your leaders approachable, and do they listen to and act on your concerns?
 Hopefully the answer is yes. VP- Brian Wofford, ACNO- Yvonne Spurney, CODStephanie Neimchak, Nurse Manager- Miranda Mathis-Harris
Are your doctors and volunteers recognized by the organization in a similar fashion to other
employees?
 Recognized with Stars for being a “Service Champion”, “Strength, Hope and Caring
Award”
Describe how the organization supports other organizations in the community.
 Duke is a strong supporter of American Heart Association. MICU has a team walking to
raise awareness about heart and stroke disease. For staff, it is also a way to celebrate the
life of a dear coworker.
Have you ever participated on a performance improvement team? If yes, can you describe what
your team did and how they enhanced organizational performance?
 Central Line utilization and Foley utilization have decreased due to daily needs
assessment during rounds
How do you learn about the hospital’s future plans?
 From my manager
 The Intranet, All Staff Events,
 Town Hall Meetings, Kevin’s Blog
Who are your major competitors? What do they do better than you? Are you aware of any efforts
to improve in these areas?
 UNC/ Wake Med
In your job, how do you learn what the patient’s requirements are?
 Orientation, Clinical Practice Council, Standards and Protocols
 Patient Care Rounds
 Huddles, Bedside Report,
Do you know of any reasons why, in the past, patients were not satisfied with the care they
received here? If yes, what was done to make it better?
 Communication – Process developed to have RN introduce patient’s family to HUC to
start building a trusting relationship.
When was the last time you heard a complaint? How was it resolved?
 When we hear a complaint, we let the charge nurse, nurse manager know. If necessary
we contact Patient Visitor Relations. Many times the situation is resolved by the nurse
and care team using words that work.
Be proud of the great work you have done and step forward to tell your 3D story
of how you Discover, Develop, and Deliver a healthier tomorrow
for our patients and the community.
How do you know you are doing better or worse than your competition?
 Press Gainey. US News & World Report of hospital rankings.
How does the organization invest in your learning and development?
 Multiple classes through hospital education. Free access to CE Direct and LMS modules.
 If you do a presentation or a poster presentation, Friends of Nursing will support financially.
 Employee Development Initiative funds for some employees to attend conferences.
Do you know the results of the last Employee Perspective Survey? Does everyone participate?
 Employees are asked to take a Work Culture Survey
 Became Tier One on Work Culture Survey
What are some examples of how employees have been rewarded and recognized?
 Friends of Nursing Award Recipient Miranda Mathis-Harris NM
 Strength, Hope, Caring Award Recipient Tonya Cabrera NA
 Gold pins, kudos on kudos board
 First 15 min of each staff meeting is spent on recognizing staff kudos
How were you trained to do your job?
 Orientation, Nurse Residency classes
 Annual competencies check off, CPR/ACLS classes
How is adequate staffing determined in your area?
 Charge nurse uses a variable staffing plan for the MICU, taking into account number of
patient’s, acuity and level of nursing expertise.
Tell me about your new hire orientation?
 Length of new hire orientation depends of experience. New graduates have 12 weeks and
experienced RNs have 6 weeks.
If you were unsure how to do something within your job, what would you do or where would
you go?
 Use the charge nurse, clinical team leads, nurse manager, pharmacy, Dietitian, Case
Managers, OT/PT, Policy and procedures on the intranet.
Have you made a suggestion to improve a work process? If so what happened?
 Staff suggested
o Installing pink body soap dispenser in patient’s room to increase compliance with
using pink soap and water for foley care.
o Installing caviwipes holders in rooms.
Be proud of the great work you have done and step forward to tell your 3D story
of how you Discover, Develop, and Deliver a healthier tomorrow
for our patients and the community.
Terms to remember

EJR – Expected Job Results - 4 clinical quadrants on annual evaluation
Use Words that Work
Words that work
o The process is…
o As a result of…
o Partnering with…
o Beginning in
o Linked to our
o The process was made better by…
o We learned……and changed…..
o Replicate
o Continuous Improvement
Words that don’t work
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
We did that once….
Anticipating
It evolved…
We believe…
We just started…
Came up with ….
Sort of…
We recognized…
If possible…
Potentially…
Not official…
Generally…
I think…
Typically…
Probably…
We don’t really have…
Expect
Attempt to meet
I don’t know if I would say that
Hoping
Bring forward
One time
Be proud of the great work you have done and step forward to tell your 3D story
of how you Discover, Develop, and Deliver a healthier tomorrow
for our patients and the community.