1 Leadership (120 points) The Leadership Category examines HOW your organization’s SENIOR LEADERS personal actions guide and sustain your organization. Also examined are your organization’s governance system and HOW your organization fulfills its legal, ethical, and societal responsibilities and supports its key communities.

Item 1.1 - Senior Leadership

HOW do your SENIOR LEADERS lead?  (70 pts.)                                                                                                                                                   Process

Describe HOW SENIOR LEADERS actions guide and SUSTAIN your organization. Describe HOW SENIOR LEADERS communicate with your WORKFORCE and encourage HIGH PERFORMANCE. Within your response, include answers to the following questions: 1.1a. VISION, VALUES, and MISSION a(1)   HOW do SENIOR LEADERS set organizational VISION and VALUES? HOW do SENIOR LEADERS DEPLOY your organization’s VISION and VALUES through your LEADERSHIP SYSTEM, to the WORKFORCE, to KEY suppliers and PARTNERS, and to PATIENTS and STAKEHOLDERS, as appropriate? HOW do SENIOR LEADERS’ personal actions reflect a commitment to the organization’s VALUES? a(2)   HOW do SENIOR LEADERS personally promote an organizational environment that fosters, requires, and results in legal and ETHICAL BEHAVIOR? a(3)   HOW do SENIOR LEADERS create a SUSTAINABLE organization? HOW do they create an environment for organizational PERFORMANCE improvement, the accomplishment of your MISSION and STRATEGIC OBJECTIVES, INNOVATION, competitive or role model PERFORMANCE leadership, and organizational agility? HOW do they create an environment for organizational and WORKFORCE LEARNING? HOW do they develop and enhance their personal leadership skills? HOW do they participate in organizational LEARNING, in succession planning, and in the development of future organizational leaders? a(4)   HOW do your SENIOR LEADERS create and promote a culture of PATIENT safety? 1.1b. Communication and Organizational PERFORMANCE b(1)   HOW do SENIOR LEADERS communicate with and engage the entire WORKFORCE? HOW do SENIOR LEADERS encourage frank, two-way communication throughout the organization? HOW do SENIOR LEADERS communicate KEY decisions? HOW do they take an active role in reward and recognition programs to reinforce HIGH PERFORMANCE and a focus on the organization, as well as on PATIENTS and STAKEHOLDERS? b(2)   HOW do SENIOR LEADERS create a focus on action to accomplish the organization’s objectives, improve PERFORMANCE, and attain its VISION? What PERFORMANCE MEASURES do SENIOR LEADERS regularly review to identify needed actions? HOW do SENIOR LEADERS include a focus on creating and balancing VALUE for PATIENTS and STAKEHOLDERS in their organizational PERFORMANCE expectations?

Notes: N1. SENIOR LEADERS include the head of the organization and his or her direct reports. In health care organizations with separate administrative/operational and health care provider leadership, “SENIOR LEADERS” refers to both sets of leaders and the relationships between those leaders. N2. Organizational vision (1.1a[1]) should set the context for STRATEGIC OBJECTIVES and ACTION PLANS, which are described in Item 2.1 and Item 2.2. N3. A SUSTAINABLE organization (1.1a[3]) is capable of addressing current organizational needs and possesses the agility and strategic management to prepare successfully for its future organizational and market environment. In this context, the concept of INNOVATION includes both technological and organizational INNOVATION to succeed in the future. A SUSTAINABLE organization also ensures a safe and secure environment for the WORKFORCE and other KEY STAKEHOLDERS. An organization’s contributions to environmental, social, and economic systems beyond those of its WORKFORCE and immediate STAKEHOLDERS are considered in its societal responsibilities (Item 1.2). N4. A focus on action (1.1b[2]) considers the strategy, the WORKFORCE, the WORK SYSTEMS, and the hard assets of your organization. It includes both INNOVATION and ongoing improvements in productivity that may be achieved through eliminating waste or reducing CYCLE TIME, and it might use techniques such as Six Sigma and Lean. It also includes the actions to accomplish your organization’s STRATEGIC OBJECTIVES. N5. Your organizational PERFORMANCE results should be reported in Items 7.1, 7.2, 7.3, 7.4, 7.5, and 7.6.

For additional description of this Item, see 1.1 Senior Leadership Description.

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