2010 Baldrige integrated Health Care Criteria
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Item 1.2 - Governance and Social Responsibilities
(50 pts.)
Process
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HOW do you
govern and
fulfill
your social responsibilities? |
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Describe your organization’s
GOVERNANCE
SYSTEM and
APPROACH to leadership
improvement.
HOW your organization
assures
legal and
ETHICAL BEHAVIOR,
fulfills its
societal responsibilities, and supports its
KEY
communities
and contributes to community health.
Within your
response, include answers to the following questions:
1.2a.
Organizational Governance
(1)
HOW
does your organization review and achieve the following
KEY
aspects of
your
GOVERNANCE
SYSTEM?
•
accountability for management’s actions
• fiscal accountability
•
transparency in operations and selection of and disclosure
policies for
GOVERNANCE
board members, as appropriate
•
independence in internal and external audits
•
protection of
STAKEHOLDER
and stockholder interests, as appropriate
(2)
HOW do
you evaluate the
PERFORMANCE
of your
SENIOR LEADERS,
including both administrative and health care leaders?
HOW do
you evaluate the
PERFORMANCE
of members of the
GOVERNANCE
board, as appropriate?
HOW do
SENIOR LEADERS
and your
GOVERNANCE
board use these
PERFORMANCE
reviews to further their
development
and to
improve both their personal leadership
EFFECTIVENESS
and that of your board and
LEADERSHIP SYSTEM,
as appropriate?
1.2b.
Legal and
ETHICAL BEHAVIOR
(1)
HOW do
you address any adverse impacts on society of your
HEALTH CARE SERVICES
and operations?
HOW do
you anticipate public concerns with current and
future services and operations?
HOW do
you prepare for these [public concerns with current and
future services and operations] concerns in a proactive
manner, including
conserving natural resources and using
EFFECTIVE supply chain management
PROCESSES,
as appropriate?
What are
your
KEY
compliance
PROCESSES,
MEASURES,
and
GOALS
for achieving and surpassing regulatory, legal, and accreditation
requirements, as appropriate?
What are
your
KEY
PROCESSES,
MEASURES,
and
GOALS
for addressing risks associated with your
HEALTH CARE SERVICES and other
organizational operations?
(2)
HOW
does your organization promote and assure
ETHICAL BEHAVIOR
in all your interactions?
What are
your
KEY
PROCESSES
and
MEASURES
or
INDICATORS
for enabling and monitoring
ETHICAL BEHAVIOR
in your
GOVERNANCE
structure, throughout your organization, and in interactions with
PATIENTS,
STAKEHOLDERS,
PARTNERS,
and suppliers?
HOW do
you monitor and respond to breaches of
ETHICAL BEHAVIOR?
1.2c.
Societal Responsibilities,
Support of
KEY
Communities and Community Health
(1)
HOW do you
consider societal well-being and benefit as part of your strategy and
daily operations?
HOW do you consider the well-being of environmental, social, and
economic systems to which your organization does or may contribute?
(2)
HOW
does your organization actively support and strengthen your
KEY
communities?
What are
your
KEY
communities?
HOW do
you identify these communities and determine areas for organizational
involvement,
including areas related to your
CORE COMPETENCIES? HOW do your SENIOR LEADERS, in concert with your WORKFORCE, contribute to improving these communities and to building community health? |
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Notes:
N1.
Societal responsibilities in areas critical to
your organization’s ongoing health care
marketplace
success also should be addressed in Strategy Development (Item 2.1)
and in Process Management (CATEGORY 6).
KEY
RESULTS, such as
RESULTS of regulatory and legal compliance (including malpractice);
accreditation; reductions in
environmental
impacts through use of “green”
technology,
resource-conserving activities,
or other means, or improvements in social
impacts, such as the global use of enlightened labor practices,
should be reported as Leadership
Outcomes (Item 7.6).
N2.
Transparency in operations of your
GOVERNANCE board (1.2a[1])
should include your internal controls on
GOVERNANCE
PROCESSES.
For
nonprofit health care organizations that serve as stewards of public
funds, stewardship of those funds and transparency in operations are
areas of emphasis.
N3.
LEADERSHIP
PERFORMANCE evaluation (1.2a[2])
might be supported by peer reviews, formal
PERFORMANCE management reviews, and formal or
informal
WORKFORCE and
STAKEHOLDERS feedback and surveys.
For some nonprofit and
government health care organizations, external advisory boards might
evaluate the
PERFORMANCE
of
SENIOR LEADERS
and the
GOVERNANCE
board.
N4.
Nonprofit health care organizations should report in
1.2b(1), as appropriate,
HOW they address the legal and regulatory requirements and standards that
govern fundraising and lobbying activities.
N5.
MEASURES
or
INDICATORS of
ETHICAL BEHAVIOR (1.2b[2]) might
include the percentage of independent board members, instances of
ETHICAL CONDUCT breaches and responses,
survey
RESULTS on
WORKFORCE
perceptions of organizational
ETHICS,
ETHICS hotline use, and
RESULTS of
ETHICS reviews and
audits. They also might include evidence that policies,
WORKFORCE training, and monitoring
SYSTEMS are in place with respect to
conflicts of interest and proper use of funds.
N6.
Areas of societal contributions and
community support appropriate for inclusion in Item 1.2c might
include your efforts to improve
the environment (e.g., collaboration to
conserve the environment or natural resources);
strengthen local community services, education, and
improve the practices of trade, business,
or professional associations.
N7.
Actions to build community health (1.2c[2]) are population-based
services supporting the general health of the communities
in which you operate. Such services will
likely draw upon your core competencies and might include health
education programs, immunization programs, unique health services
provided at a financial loss, population-screening programs (e.g., for
hypertension), safety program sponsorship, and indigent care and other
community benefits. You should report the results of your community
health services in Item 7.6.
N8.
The health and safety of your
WORKFORCE are not addressed in Item 1.2;
you should address these
WORKFORCE factors in
Item 5.2. |
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For additional description of this Item, see
1.2 Governance and Social Responsibilities Description.
Assessment of Item Responses
Item responses are assessed by considering the Criteria Item
requirements; your key organizational factors presented in your
Organizational Profile; and the maturity of your approaches, breadth of
their deployment, and strength of your improvement process and results
relative to the Scoring System.
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Note:
Blue
words above are hyperlinks;
Red
words above were added for the
2009 - 2010 Baldrige
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Thank you for using the only truly integrated form of the Baldrige Health Care Criteria available anywhere. Paul Steel