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TRANSCRIPT
2019
LifeBridge Organ and Tissue Sharing Case Study
www.nist.gov/baldrige
2019–2020 Bald
rige Excellence Framew
ork
T1550
The ratio of the Baldrige Program’s benefits
for the U.S. economy to its costs is estimated
at 820 to 1.
110 Baldrige Award winners serve as national
role models.
2010 –2018 award applicants represent
641,693 jobs,
3,072 work sites, over $166 billion in
revenue/budgets, and about 451 million
customers served.
352 Baldrige examiners volunteered
roughly $7.9 million in
services in 2018.
State Baldrige-based examiners
volunteered around $29 million in
services in 2017.
What People Are Saying
I have always envisioned Stellar to be a company that is built to last. . . . And if you ask how we can ensure that we are built to last, I would say the answer is Baldrige.
Celeste Ford CEO and FounderStellar Solutions Palo Alto, CA Baldrige Award recipient
We believe that government can be great. We believe that local government can be great. And we believe that the Baldrige framework is ideally suited to help local government go from here to here[low to high].
Darin AtteberryCity ManagerCity of Fort Collins Fort Collins, CO Baldrige Award recipient
CONNECT WITH BALDRIGE@BaldrigeProgram #Baldrige
NIST Training Draft
Baldrige Performance Excellence Program Created by Congress in 1987, the Baldrige Program is managed by the National Institute of Standards andTechnology (NIST), an agency of the U.S. Departmentof Commerce. This unique public-private partnershipis dedicated to helping organizations improve their performance and succeed in the global marketplace. The program administers the Presidential Malcolm Baldrige National Quality Award. In collaboration with the greater Baldrige community, we addresscritical national needs through
• a systems approach to achieving organizational excellence;
• organizational self-assessment tools and analysis of organizational strengths and opportunities for improvement by a team of trained experts;
• training, executive education, conferences, and workshops on proven best management practices and on using the Baldrige Excellence Framework to improve; and
• Baldrige-based approaches to cybersecurity risk management and community excellence.
Foundation for the Malcolm Baldrige National Quality AwardThe mission of the Baldrige Foundation is to ensure the long-term financial growth and viability of the Baldrige Performance Excellence Program and to support organizational performance excellence in the United States and throughout the world. To learn more about the Baldrige Foundation, see www.baldrigefoundation.org.
Alliance for Performance ExcellenceThe Alliance (www.baldrigealliance.org) is a national network of Baldrige-based organizations and supporting members with a mission to grow performance excellence in support of a thriving Baldrige community. Members contribute nearly 300,000 volunteer hours and more than $30 million per year in tools, resources, and expertise to assist organizations on their journeys to excellence. This includes annually evaluating and recognizing over 1,000 organizations that use the Baldrige Excellence Framework and serving as the feeder system for the national Baldrige Award.
American Society for QualityThe American Society for Quality (ASQ; https://asq.org) assists in administering the award program under contract to NIST. ASQ’s vision is to make quality a global priority, an organizational imperative, and a personal ethic and, in the process, to become the community for all who seek quality concepts, technology, or tools to improve themselves and their world.
For more information:www.nist.gov/baldrige | 301.975.2036 | [email protected]
Baldrige Performance Excellence ProgramNational Institute of Standards and Technology (NIST) • United States Department of Commerce
July 2019
To order copies of this publication or obtain other Baldrige Program products and services, contact
Baldrige Performance Excellence ProgramAdministration Building, Room A600, 100 Bureau Drive, Stop 1020, Gaithersburg, MD 20899-1020 www.nist.gov/baldrige | 301.975.2036 | [email protected]
The Baldrige Program welcomes your comments on Baldrige products and services. Please direct your comments to the address above.
The Baldrige Program is very grateful to an actual organ procurement organization that allowed its own Baldrige-based award application to be the basis for this case study. From that real application, names and data have been fictionalized, and elements have been intentionally edited to be less mature, less beneficial, and missing in order for this case study to score lower than the real application. Such editing was done so that Baldrige examiners being trained using the case study can more easily identify opportunities for improvement and general feedback.
The LifeBridge Organ and Tissue Sharing Case Study is a fictitious Baldrige Award application prepared for use in the 2019 Malcolm Baldrige National Quality Award Examiner Preparation Course. The fictitious case study organization is intended to be a regional organ and tissue procurement organization for people living in a federally assigned territory within the made-up states of North and South Takoma. 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 2019–2020 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 LifeBridge Organ and Tissue Sharing 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 LifeBridge Organ and Tissue Sharing and any other organization, named either LifeBridge Organ and Tissue Sharing or otherwise. The names of several national and government organizations are included to promote the realism of the case study as a training tool, but any data and content about them may have been fictionalized, as appropriate; all other organizations cited in the case study are fictitious or have been fictionalized.
BALDRIGE EXCELLENCE FRAMEWORK®, BALDRIGE CRITERIA FOR PERFORMANCE EXCELLENCE®, BALDRIGE PERFORMANCE EXCELLENCE PROGRAM®, BALDRIGE COLLABORATIVE ASSESSMENT®, BALDRIGE EXAMINER®, BALDRIGE EXCELLENCE BUILDER®, PERFORMANCE EXCELLENCE®, THE QUEST FOR EXCELLENCE®, and the MALCOLM BALDRIGE NATIONAL QUALITY AWARD® medal and depictions or representations thereof 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. 2019. 2019 Baldrige Case Study: LifeBridge Organ and Tissue Sharing. Gaithersburg, MD: U.S. Department of Commerce, National Institute of Standards and Technology. https://www.nist.gov/baldrige.
knockout for glue .4375 for .1875 spine
The Annual Quest for Excellence® ConferenceOfficial conference of the Malcolm Baldrige National Quality Award
www.nist.gov/baldrige/qe
Gaylord National HarborNational Harbor, Maryland (near Washington, D.C.)
April 7–10, 2019March 24–27, 2020April 11–14, 2021
Each year at The Quest for Excellence Conference, Baldrige Award recipients share their exceptional performance practices with leaders of business, education, health care, and nonprofit organizations and inspire attendees to apply the insights they gain within their own organizations.
Plan to attend and learn about the recipients’ best management practices, participate in educational presentations on the Baldrige Excellence Framework, and network with Baldrige Award recipients and other attendees.
The Malcolm Baldrige National Quality Award www.nist.gov/baldrige/baldrige-award
The Malcolm Baldrige National Quality Award, created by Public Law 100-107 in 1987, is the highest level of national recognition for performance excellence that a U.S. organization can receive. The award promotes
• awareness of performance excellence as an increasingly important element in U.S.competitiveness and
• the sharing of successful performance strategies and information on the benefits of using these strategies.
The President of the United States traditionally presents the award. A 22-karat, gold-plated medallion that bears the name of the award and “The Quest for Excellence” on one side and the Presidential Seal on the other.
Organizations apply for the award in one of six eligibility categories: manufacturing, service, small business, education, health care, and nonprofit.Up to 18 awards may be given annually across the six categories.
NIST Training Draft
CONTENTS
O1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A1
2019Intent to ApplyForm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I1OrganizationChart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2019AwardApplicationForm.GlossaryofTermsandAbbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G1
Preface: Organizational ProfileP.1 OrganizationalDescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iP.2 OrganizationalSituation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv
Category 1: Leadership1.1 SeniorLeadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.2 GovernanceandSocietalContributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Category 2: Strategy2.1 StrategyDevelopment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62.2 StrategyImplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Category 3: Customers3.1 CustomerExpectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103.2 CustomerEngagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Category 4: Measurement, Analysis, and Knowledge Management4.1 Measurement,Analysis,andImprovementofOrganizationalPerformance . . . . . . . .144.2 InformationandKnowledgeManagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
Category 5: Workforce5.1 WorkforceEnvironment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .195.2 WorkforceEngagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Category 6: Operations6.1 WorkProcesses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .256.2 OperationalEffectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
Category 7: Results7.1 ProductandProcessResults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .307.2 CustomerResults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .377.3 WorkforceResults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .407.4 LeadershipandGovernanceResults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .447.5 Financial,Market,andStrategyResults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46
NIST Training Draft
2019
INTENT TO APPLY FORM
Intent to Apply/Eligibility Form Tennessee Center for Performance Excellence Award Program
You may download this form from the TNCPE website: www.TNCPE.org/awards/apply.
Before you apply for a Level 2, 3, or 4 Award, TNCPE must determine your organization’s eligibility. Please send the $250 Intent to Apply Fee and one copy of the Intent to Apply/Eligibil-ity Form, electronically or postmarked by the date noted above.
Please type or print 1. Applicant
____________________________________________________________ Applicant organization’s official name
____________________________________________________________ Address
____________________________________________________________ City State Zip
2. Size and Locations
Total # of employees (full-time equivalent) _______
Total # of sites _______
3. Industry SectorPlease check the sector that best describes your organizationo Manufacturing o Education o Serviceo Government o Health Care o Nonprofit
4. IndustrialClassificationList up to three NAICS codes that best describe yourorganization.
______________ ______________ ______________
5. How did you hear about TNCPE?
____________________________________________________________
6. OfficialContact
____________________________________________________________ Name
____________________________________________________________ Title
____________________________________________________________ Mailing address
____________________________________________________________ Street address (no PO Box)
____________________________________________________________ City State Zip
____________________________________________________________ Telephone
____________________________________________________________ Email
SUBMITTED By 2019 cycle: APRIL 152020 cycle: aPril 15
Intent to Apply/Eligibilty Form
7. AlternateOfficialContact
____________________________________________________________ Name
____________________________________________________________ Telephone
____________________________________________________________ Email
8. Return Applicant? Yes _____ No _____
Application year(s): ______________________________________
9. Application Level(See award level descriptions on pages vi-vii)Check One: o 2 o 3 o 4
10. Assurance and AuthorizationWe understand this Intent to Apply/Eligibility Form andsubsequent application to TNCPE will be reviewed bymembers of the TNCPE Board of Examiners. We furtherunderstand that all examiners are required to follow theTNCPE Code of Ethics and Standards of Conduct to ensureconfidentiality and avoid possible conflict of interest.
____________________________________________________________ Authorized signature - Highest ranking official of applicant organization
____________________________________________________________ Name (please type or print) Date
____________________________________________________________ Title
____________________________________________________________ Address
____________________________________________________________ City State Zip
____________________________________________________________ Telephone
____________________________________________________________ Email
Intent to Apply/Eligibility Form is continued on next page
I1
I2
11. Participation on the Board of Examiners_____ Our organization wishes to send one employee toTNCPE examiner training free of charge. We understandthat if the examiner attends training but is unableto complete the entire training and review cycle, ourorganization will be invoiced for $595, the value ofexaminer training.
____________________________________________________________ Name of examiner
____________________________________________________________ Title
____________________________________________________________ Telephone
____________________________________________________________ Email
_____ We prefer not to participate on the Board of Examiners this calendar year.
12. Business FactorsIn addition to determining eligibility, this information isused by TNCPE to screen and assign examiner teams toavoid conflict of interest in application reviews.
Please attach a line and box organizational chart or charts for your organization along with the following information:
Business/Organization Description: Provide a briefdescription of the nature of your business or organization (products and services, programs, or technologies). Conclude with a list of key competitors or indicate if no direct competitors exist.
Market and Customers: Provide a brief description ofthe nature of major markets (local, regional, national, international). Conclude with a list of key customers.
Suppliers, Partners and Collaborators: Provide a briefdescription of the importance of suppliers, partners, and collaborators. Conclude with a list of key suppliers/partners and the type of products or services each provides.
13. SubunitsComplete only if the applicant organization is a unit ordivision of a larger (or parent) company. If this is the case,attach a line and box organizational chart showing yourorganization’s relationship to the highest managementlevel of the parent organization.
A. Is the applicant ________ a larger parent or system?(Check all that apply.)
o a subsidiary of o a like organization ofo a division of o administered byo controlled by o a school ofo a unit of o owned by
B. Parent organization
____________________________________________________________ Name
____________________________________________________________ Street address (no PO Box)
____________________________________________________________ City State Zip
Highest ranking official of parent organization
____________________________________________________________ Name
____________________________________________________________ Title
C. Is the applicant the only subunit of the parentorganization intending to apply?
_____ Yes _____ No _____ Do not know
D. Briefly describe the major functions provided to theapplicant by the parent or by other subunits of theparent. Examples of such functions include but are notlimited to strategic planning, research and development,data gathering and analysis, human resources, legalservices, finance or accounting, sales and marketing,supply chain management, global expansion,information and knowledge management, educationand training programs, information systems andtechnology support, curriculum and instruction, andacademic program coordination/development.
E. Is the applicant self-sufficient enough to respond to allseven Baldrige Excellence Framework categories?
_____ Yes _____ No (if no, briefly explain)
14. Intent to Apply FeeSubmit the $250 Intent Fee (non-refundable) made payable to TNCPE to cover initial processing and eligibility determination. A check may be mailed to the address below or call to make a credit card payment. In addition to your Intent to Apply Fee, submit one copy of your Intent to Apply/Eligibility Form and supplementary attachments electronically [email protected].
Tennessee Center for Performance Excellence 2525 Perimeter Place Drive, Suite 122 Nashville, TN 37214-3773(800) 453-6474
ORGANIZATIONCHART
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O1O1
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NIST Training Draft
2019 APPLICATION
FORM
Level 2, 3, and 4 Application Form Tennessee Center for Performance Excellence Award Program
You may download this form from the TNCPE website: www.TNCPE.org/awards/apply.
Please submit TNCPE this Application Form accompanied byone electronic copy of your Organizational Profile and Criteria response, and the appropriate Application Fee. These items should be submitted to the TNCPE office by the date notedabove.
Please type or print.
1. Applicant
____________________________________________________________ Organization name as it will appear on award
____________________________________________________________ Address
____________________________________________________________ City State Zip
2. Size and Locations
Total # of employees (full-time equivalent) _______
Total # of sites _______
3. OfficialContact
____________________________________________________________ Name
____________________________________________________________ Title
____________________________________________________________ Mailing address
____________________________________________________________ Street address (no PO Box)
____________________________________________________________ City State Zip
____________________________________________________________ Telephone
____________________________________________________________ Email
4. AlternateOfficialContact
____________________________________________________________ Name
____________________________________________________________ Telephone
____________________________________________________________ Email
SUBMITTED By 2019 cycle: july 152020 cycle: july 15
Level 2, 3, and 4 Application Form
5. Application Level and Criteria Response
A. Identify the application level for which you are applying.Check One: o 2 o 3 o 4(See Award level descriptions on pages vi - vii)
B. Attach Organizational Profile and Criteria response toApplication Form
C. Check the Criteria you have used to write your responseo Business/Nonprofit o Health Care o Education
D. Application FeeAn Application Fee is required for all award levels basedon workforce size and TNCPE Membership status.
Please refer to the table on page 5 to determine your application fee. Go to TNCPE.org/members for TNCPE membership information.
Total Application Fee
7. One-Sentence Organization DescriptionPlease provide a brief description of your organization to beused for publicity and recognition.
8. Release Statement and SignatureofHighestRankingOfficial
My signature states and attests that: I have reviewed the information provided in this application packet. To the best of my knowledge, no untrue statement or omission of a material fact that is legally disclosable and affects organizational ethical and legal practices has been made in this application packet. I understand that if information is found that could be embarrassing to TNCPE or its Award Program my organization will no longer receive consideration for an award and will only receive a Feedback Report.
____________________________________________________________ Signature Date
____________________________________________________________Name/Title
Submit the appropriate Application Fee to the address below or call to make a credit card payment. In addition to your application fee, submit one copy of your Application Form and one copy of your Organizational Profile and Criteria response saved in one PDF file to [email protected].
Tennessee Center for Performance Excellence 2525 Perimeter Place Drive, Suite 122 Nashville, TN 37214-3773 (800) 453-6474
TNCPECriteriaBook-pages1-74.indd 65 1/26/17 4:14 PM
A1
GLOSSARYOFTERMSAND
ABBREVIATIONS
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G1
Glossary of Terms and Abbreviations
24/7 CMO 24HoursaDay/7DaysaWeek ChiefMedicalOfficer
CMSA CentersforMedicareandMedicaidServicesAATB COIAmericanAssociationofTissueBanks ConflictofinterestADA Conversion RateAmericanswithDisabilitiesAct PercentageofactualdonorsdividedbypotentialdonorsAED COOAutomatedExternalDefibrillators ChiefOperatingOfficerAOPOAssociationofOrganProcurementOrganizations DAOS DART RateAvailableOn-Site Daysaway,restricted,ortransferred(OSHAForm300a)
AP(s) Data MallActionPlan(s) Repositoryofpredefinedreportsthatallowtheusertoaccess
valuableorganizationaldatafordecisionmakingAuthorizationPermissionorpowergrantedbyanauthority(firstperson DCDornext-of-kin)fororganand/ortissuedonation DonationafterCardiacDeath-typeofdonationfororgan
procurementthatoccursaftercardiaccessation
B DHSSBOD U.S.DepartmentofHealthandHumanServicesBoardofDirectors DMV
DepartmentofMotorVehiclesC DoLCAPA DepartmentofLaborCorrectiveActionPreventiveAction DonorNetC&C FacilitatesorganplacementandacceptancebyrapidlyandCapabilityandCapacity efficientlyprovidingkeyinformationtoorgantransplant
centersCCCoreCompetency:Mission-drivenworkforce DOR
DepartmentofRevenue(forstateofNT)CCPCorporateComplianceProgram DSA
DesignatedServiceAreaCDCCentersforDiseaseControlandPrevention
ECEOChiefExecutiveOfficer EBAA
EyeBankAssociationofAmericaCFO ChiefFinancialOfficer EEOC
EqualEmploymentOpportunityCommissionCHROChiefHumanResourcesOfficer EKR
EmployeeKeyRequirementCLIAClinicalLaboratoryImprovementAmendments
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G2
ELT LExecutiveLeadershipTeamconsistingoftheCEO,CMO, LDSCHRO,CFO,andCOO LearningandDevelopmentSystemEMB LOTSExtendedMedicalBank-employeebenefittocoverextended LifeBridgeOrganandTissueSharingillnesses
LSEMR LeadershipSystemElectronicMedicalRecord
LTERP LeadershipTeamEmergencyResponsePlan
MF
MEFDA MedicalExaminerFoodandDrugAdministration
FLSA OFairLaborStandardsAct
OAC(s)Four As OrganAcquisitionCharge(s),thecostthatisbilledtotheComplaintResolutionProcess:Acknowledge,Apologize, transplantcentersfortheprocurementoforgans;includesallAsk,Act directandindirectcosts
FSS OD(s)FamilySupportServices OperationalDiscussions
FTE OMPFull-TimeEmployee OperationalManagementProcess
OPCG OrganProcurementCoordinatorGift of Life OPOOrgansandtissuesdonatedbydonorfamilies OrganProcurementOrganizationGPR OPTNNationalorganizationprovidingcomparativesatisfaction OrganProcurementandTransplantationNetworkandengagementdata.
OROperatingRoom
HOrganHLAReferstokidneys,lungs,liver,heart,intestines,andpancreasHumanLeukocyteAntigenOrgan ConversionHRPercentageofactualorgandonorsdividedbypotentialorganHumanResourcesdonors
HRSAOrgan YieldHealthResourcesandServicesAdministrationOrganstransplantedperdonor
OSHAIOccupationalSafetyandHealthAdministration
ICUIntensiveCareUnit OWS
OrganWorkSystemIndividual ScorecardsMeasurementsystemtooltrackedattheindividuallevel
IT/IS InformationTechnology/InformationSystems
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P SPPStrategicPlanningProcessPDSA
Plan-Do-Study-Actproblem-solvingperformance SQAimprovementtool/methodology StateQualityAward
PEP SRTR PerformanceEvaluationProcess ScientificRegistryofTransplantRecipients
PHI SWOTPersonalHealthInformation Strengths,Weaknesses,Opportunities,Threatsanalysis,partof
environmentalscanningPHSPublicHealthServices
TPIPerformanceImprovement Tissue
Referstomusculoskeletal,skin,cardiovascular,andeyePIIPersonallyIdentifiableInformation Tissue Yield
TissueprocuredperdonorPMSPerformanceMeasurementSystem TOPC
TissueOcularProcurementCoordinatorsPTOPaid/PersonalTimeOff Topline Scorecard
PerformancemeasurementtoolreflectingstatusofkeyorganizationalmetricsQTTQAPITitanTechnologyQualityAssessmentandPerformanceImprovementTWSQSTissueWorkSystemQualitySystems
URUAGARFOUniformAnatomicalGiftActRoundingforOutcomesUNOSROIUnitedNetworkforOrganSharingReturnonInvestment
VSV/MSA(s)Vision/MissionStrategicAdvantage(s)V/M/VSaaS Vision/Mission/ValuesSoftwareasaServiceVOCSC(s)VoiceoftheCustomerStrategicChallenge(s)VOSSD(s)VoiceoftheStakeholderStrategicDiscussion(s)YieldSO(s)OutcomesofdonationactivitiesStrategicObjective(s)YTDSOP(s)YeartoDateStandardOperatingProcedure(s)
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Organizational Profile
Picture Sally, who is only 16 years old, a typical teenager who loves her friends, family, and dog, Spot, and is a beloved daughter, sister, and friend. Following a critical injury during a car accident, she is now in the intensive care unit. After evaluating Sally’s injuries and performing life-saving measures, doctors have diagnosed conclusively that Sally is brain-dead. Machines keep her organs functioning, while a team from LifeBridge Organ and Tissue Sharing (LOTS) talks compassionately to Sally’s family about donating her organs and tissues. On the most agonizing day of this family’s life, family members find the courage to say “yes.” Sally saved multiple lives that day, including a three-year-old boy from North Takoma who received Sally’s left kidney and was then excited to go home with his family after being in the hospital since birth; a 56-year-old father, a factory worker from South Takoma, who had been waiting for a liver for four years; and a nine-year-old fire victim who was airlifted to a state hospital with burns on over 50 percent of her body who received Sally’s skin tissue that helped keep out infection while the victim’s skin regenerated. The ability to impact countless lives motivated Sally’s family to provide the literal “Gift of Life” to waiting recipients. The ability to provide the connection between life and death is the reason LOTS staff members come to work every day—to achieve the organization’s mission to save and improve lives.
P.1 Organizational DescriptionP.1a Organizational EnvironmentP.1a(1) Formorethan25years,LOTShasservedastheregionalorganandtissueprocurementorganization(OPO)for3.2millionpeoplelivingwithinafederallyassignedterritoryinclusiveof62countieslocatedwithinthestatesofNorthTakoma(NT)andSouthTakoma(ST).Fromitsfoundinggoaltoassistinthecoordinationoforgandonations,LOTShasgrowntobecomeamultifaceted,nonprofitorgani-zationdedicatedtosavingandimprovinglives(Figure P.1-1).LocatedinColumbia,NT,LOTSisoneofthe58federallydesignatedorganizationsofitskindintheUnitedStates.
LOTS’smainserviceofferingisthefacilitationoforganandtissuedonation,accomplishedthroughtheorganization’stwoworksystems:OrganandTissue.Thedeliveryofservicesforbothworksystemsrequiresthecarefulcoordinationofpartners,collaborators,andkeysupplierstoensurethatorgansandtissuesareavailableforusebytheorganization’skeycustomergroups(Figure P.1-6).Bothservicelines(organandtissue)arecriticaltoLOTS’ssuccess,whichismeasuredbythenumberoflivessavedandimproved.ThePartnershipModel(Figure P.1-2)highlightstheorganization’scoordina-tionofpartners,collaborators,andsupplierstoensurethatorgansandtissuesarealwaysavailablefortheorganization’skeycustomers.
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Organizational Profile
DonorfamiliescomefromthecommunityatlargeandareidentifiedaspotentialcollaboratorsonceapartnernotifiesLOTSofapatient’sdeath.Atthispoint,assumingthepatientismedicallysuitablefordonation,thefamilyispresentedwiththeopportunityfordonationbyamemberoftheLOTS’sworkforce.Duetothelimitingcriteriagoverningorganandtissuedonation,eachdonationopportunitymustbemaximizedtoitsfullestpotential.Oftheapproximately15,000deathsoccurringannuallywithinLOTS’sdesignatedservicearea(DSA),approximately100patientshavetheopportunitytobecomeorgandonorsduetothespecialcircumstancesofbraindeathunderwhichanorgandonormustdie.Tissuedonationopportunitiesoccurapproximately2,000timesannually(Figure P.1-3).
LOTSpartnerswiththe80hospitalsandseveralnonhospitalreferralorganizations(medicalexaminer[ME]andhospiceoffices)locatedwithinitsDSAtogainaccesstopotentialdonorfamilycollaborators,acriticalcontrolpointofthe
Picture Sally, who is only 16 years old, a typical teenager who loves her friends, family, and dog, Spot, and is a beloved daughter, sister, and friend. Following a critical injury during a car accident, she is now in the intensive care unit. After evaluating Sally’s injuries and performing life-saving measures, doctors have diagnosed conclusively that Sally is brain-dead. Machines keep her organs functioning, while a team from LifeBridge Organ and Tissue Sharing (LOTS) talks compassionately to Sally’s family about donating her organs and tissues. On the most agonizing day of this family’s life, family members find the courage to say “yes.” Sally saved multiple lives that day, including a three-year-old boy from North Takoma who received Sally’s left kidney and was then excited to go home with his family after being in the hospital since birth; a 56-year-old father, a factory worker from South Takoma, who had been waiting for a liver for four years; and a nine-year-old fire victim who was airlifted to a state hospital with burns on over 50 percent of her body who received Sally’s skin tissue that helped keep out infection while the victim’s skin regenerated. The ability to impact countless lives motivated Sally’s family to provide the literal “Gift of Life” to waiting recipients. The ability to provide the connection between life and death is the reason LOTS staff members come to work every day—to achieve the organiza-tion’s mission to save and improve lives.
P.1 Organizational DescriptionP.1a Organizational EnvironmentP.1a(1) Formorethan25years,LOTShasservedastheregionalorganandtissueprocurementorganization(OPO)for3.2millionpeoplelivingwithinafederallyassignedterritoryinclusiveof62countieslocatedwithinthestatesofNorthTakoma(NT)andSouthTakoma(ST).Fromitsfoundinggoaltoassistinthecoordinationoforgandonations,LOTShasgrowntobecomeamultifaceted,nonprofitorgani-zationdedicatedtosavingandimprovinglives(Figure P.1-1).LocatedinColumbia,NT,LOTSisoneofthe58federallydesignatedorganizationsofitskindintheUnitedStates.
LOTS’smainserviceofferingisthefacilitationoforganandtissuedonation,accomplishedthroughtheorganization’stwoworksystems:OrganandTissue.Thedeliveryofservicesforbothworksystemsrequiresthecarefulcoordinationofpartners,collaborators,andkeysupplierstoensurethatorgansandtissuesareavailableforusebytheorganization’skeycustomergroups(Figure P.1-6).Bothservicelines(organandtissue)arecriticaltoLOTS’ssuccess,whichismeasuredbythenumberoflivessavedandimproved.ThePartnershipModel(Figure P.1-2)highlightstheorganization’scoordina-tionofpartners,collaborators,andsupplierstoensurethatorgansandtissuesarealwaysavailablefortheorganization’skeycustomers.
Figure P.1-1: Vision, Mission, Values
VISION Organs and tissues are always available
MISSION We save and improve lives
VALUES Compassion Teamwork Honesty Quality Improvement
LifeBridgeOrgan and
Tissue Sharing
Partners CustomersC
olla
bora
tors Key SuppliersLIVES
SAVED
Figure P.1-2: Partnership Model
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Organizational Profile
DonorfamiliescomefromthecommunityatlargeandareidentifiedaspotentialcollaboratorsonceapartnernotifiesLOTSofapatient’sdeath.Atthispoint,assumingthepatientismedicallysuitablefordonation,thefamilyispresentedwiththeopportunityfordonationbyamemberoftheLOTS’sworkforce.Duetothelimitingcriteriagoverningorganandtissuedonation,eachdonationopportunitymustbemaximizedtoitsfullestpotential.Oftheapproximately15,000deathsoccurringannuallywithinLOTS’sdesignatedservicearea(DSA),approximately100patientshavetheopportunitytobecomeorgandonorsduetothespecialcircumstancesofbraindeathunderwhichanorgandonormustdie.Tissuedonationopportunitiesoccurapproximately2,000timesannually(Figure P.1-3).
LOTSpartnerswiththe80hospitalsandseveralnonhospitalreferralorganizations(medicalexaminer[ME]andhospiceoffices)locatedwithinitsDSAtogainaccesstopotentialdonorfamilycollaborators,acriticalcontrolpointofthe
Picture Sally, who is only 16 years old, a typical teenager who loves her friends, family, and dog, Spot, and is a beloved daughter, sister, and friend. Following a critical injury during a car accident, she is now in the intensive care unit. After evaluating Sally’s injuries and performing life-saving measures, doctors have diagnosed conclusively that Sally is brain-dead. Machines keep her organs functioning, while a team from LifeBridge Organ and Tissue Sharing (LOTS) talks compassionately to Sally’s family about donating her organs and tissues. On the most agonizing day of this family’s life, family members find the courage to say “yes.” Sally saved multiple lives that day, including a three-year-old boy from North Takoma who received Sally’s left kidney and was then excited to go home with his family after being in the hospital since birth; a 56-year-old father, a factory worker from South Takoma, who had been waiting for a liver for four years; and a nine-year-old fire victim who was airlifted to a state hospital with burns on over 50 percent of her body who received Sally’s skin tissue that helped keep out infection while the victim’s skin regenerated. The ability to impact countless lives motivated Sally’s family to provide the literal “Gift of Life” to waiting recipients. The ability to provide the connection between life and death is the reason LOTS staff members come to work every day—to achieve the organiza-tion’s mission to save and improve lives.
P.1 Organizational DescriptionP.1a Organizational EnvironmentP.1a(1) Formorethan25years,LOTShasservedastheregionalorganandtissueprocurementorganization(OPO)for3.2millionpeoplelivingwithinafederallyassignedterritoryinclusiveof62countieslocatedwithinthestatesofNorthTakoma(NT)andSouthTakoma(ST).Fromitsfoundinggoaltoassistinthecoordinationoforgandonations,LOTShasgrowntobecomeamultifaceted,nonprofitorgani-zationdedicatedtosavingandimprovinglives(Figure P.1-1).LocatedinColumbia,NT,LOTSisoneofthe58federallydesignatedorganizationsofitskindintheUnitedStates.
LOTS’smainserviceofferingisthefacilitationoforganandtissuedonation,accomplishedthroughtheorganization’stwoworksystems:OrganandTissue.Thedeliveryofservicesforbothworksystemsrequiresthecarefulcoordinationofpartners,collaborators,andkeysupplierstoensurethatorgansandtissuesareavailableforusebytheorganization’skeycustomergroups(Figure P.1-6).Bothservicelines(organandtissue)arecriticaltoLOTS’ssuccess,whichismeasuredbythenumberoflivessavedandimproved.ThePartnershipModel(Figure P.1-2)highlightstheorganization’scoordina-tionofpartners,collaborators,andsupplierstoensurethatorgansandtissuesarealwaysavailablefortheorganization’skeycustomers.
Figure P.1-1: Vision, Mission, Values
VISION Organs and tissues are always available
MISSION We save and improve lives
VALUES Compassion Teamwork Honesty Quality Improvement
LifeBridgeOrgan and
Tissue Sharing
Partners CustomersC
olla
bora
tors Key SuppliersLIVES
SAVED
Figure P.1-2: Partnership Model
DonorfamiliescomefromthecommunityatlargeandareidentifiedaspotentialcollaboratorsonceapartnernotifiesLOTSofapatient’sdeath.Atthispoint,assumingthepatientismedicallysuitablefordonation,thefamilyispresentedwiththeopportunityfordonationbyamemberoftheLOTS’sworkforce.Duetothelimitingcriteriagoverningorganandtissuedonation,eachdonationopportunitymustbemaximizedtoitsfullestpotential.Oftheapproximately15,000deathsoccurringannuallywithinLOTS’sdesignatedservicearea(DSA),approximately100patientshavetheopportunitytobecomeorgandonorsduetothespecialcircumstancesofbraindeathunderwhichanorgandonormustdie.Tissuedonationopportunitiesoccurapproximately2,000timesannually(Figure P.1-3).
LOTSpartnerswiththe80hospitalsandseveralnonhospitalreferralorganizations(medicalexaminer[ME]andhospiceoffices)locatedwithinitsDSAtogainaccesstopotentialdonorfamilycollaborators,acriticalcontrolpointofthe
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drivetomeetthemission: We save and improve lives. Bydefinition,themissionaffirmsthatLOTSplaysaroleinthelife-savinggiftofdonation.Whetheritisthe“literallifesave”ofanorganrecipientora“qualityoflifeimprovementtoatissuerecipient,”atitscore,LOTSisallabouttransplantationandsavingandimprovinglives.Valuesofcompassion,improve-ment,honesty,teamwork,andqualityserveasaguid-ingforceforhowtheworkforcelivesthecultureonadailybasis.Thevision,mission,andvalues(V/M/V)ofLOTS,validatedduringtheStrategicPlanningProcess(SPP;Figure 2.1-1),serveasthefounda-tionforthecultureandformthebasisforhowtheorganizationismanaged.ThemissionofLOTScouldnotbeaccomplishedwithouttheorganization’scorecompetency(CC)ofamission-drivenworkforce.
Mission-Driven Workforce: TheworkofLOTS,byitsverynature,requiresalevelofcareandcompas-sionthatcanonlybedeliveredbythe“humantouch.”Therefore,theactionsandbehaviorsdemonstratedbythestaffaredirectlylinkedtocreatingapositivedonationexperienceforthedonorfamily(collabora-tors),whichisessentialtotheaccomplishmentofthemissionandthesuccessoftheorganization.ThisCCwasidentifiedusingseveralcyclesofLOTS’s
workforcesurveyresults,whichnotedthatoverallengagementandoveralljobsatisfactioncontinuetoshowstrongresults(Figures 7.3-12, 7.3-12A, and 7.3-14).
P.1a(3) LOTSisa24/7businessinwhichmanyoftheemployeesaredecentralized.TheWorkforceProfile (Figure P.1-4)reflectstheemployeeprofileandincludesjobtype,tenure,gender,andethnicity.Todate,theorganizationhasnotexperiencedanyreductionsinworkforce.Conversely,astheneedfordonationshasincreased,sohastheneedforexpansionofbothclinicalandnonclinicalstafftosupportoperationalefficiencies.Forthepurposeofreportingand
ProcurementProcess(Figure 2.1-2).LOTSprovidesongoingeducationalofferingstothesepartnerstoensurethatthisintro-ductionoccursinatimelymanner.Onceareferralismade,LOTSprescreensthepotentialdonorformedicaleligibilityfordonation.PatientfamiliesarecompassionatelyapproachedbyFamilySupportServices(FSS)staffintheOrganWorkSystem(OWS)andbytheCommunicationCenterstaffintheTissueWorkSystem(TWS).Duringtheapproach,familiesarepresentedwiththeopportunityfordonationortohonortheirlovedone’spreviousdecisiontobecomeadonor(Figure 3.2-1,Pre-DonationPhase).ClinicalstaffmembersassistthedonorhospitalpartnerswiththemedicalmanagementofthedonoruntiltransportationtotheLOTSfacilityoccursandthedonatedgiftsarerecovered(Figure 3.2-1,DonationPhase).IntheOWS,recoveryisperformedbythetransplantsurgeonassistedbyOrganProcurementCoordinators(OPCs);intheTWS,recoveryisperformedbyTissueProcurementCoordina-tors(TPCs).LOTSactsasaresponsiblestewardofthe“GiftofLife”bycoordinatingtheplacementofdonatedorgansandtissuestoitskeycustomergroups:localorgantransplantcentersandtissueprocessors.Thedonatedorgansandtissuesareusedforthebettermentofthecommunitiesserved,whichincludedonorfamiliesandtransplantrecipientpatientsandtheirfamilies(Figure P.1-6).
P.1a(2) ThemissionofLOTSistosaveandimprovelives(Figure P.1-1).LOTS’svisionisOrgans and tissues are always available. Thevisionwasdevelopedinlightofthebeliefthattheorganization’sultimategoalwillonlybereal-izedwhenorgansandtissuearereadilyavailabletopatientswhentheyneedthem.CentraltotheLOTScultureisastrong
Figure P.1-4: Workforce Profile (Employees)
Leadership Team 10%
Staff 90%
Male 35%
Female 65%
1 Year 20%
2–5 Years 41%
6–10 Years 21%
11+ Years 18%
African American 20% (DSA 25%*)
White 70% (DSA 70%*)
Other 10% (DSA 5%*)
*Based on 2010 Census
Job TypeTenure
GenderEthnicity
Figure P.1-3: Finding the Heroes
Deaths Reported
Referrals
Eligible
Authorization
Donors
ORGAN TISSU
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ProcurementProcess(Figure 2.1-2).LOTSprovidesongoingeducationalofferingstothesepartnerstoensurethatthisintro-ductionoccursinatimelymanner.Onceareferralismade,LOTSprescreensthepotentialdonorformedicaleligibilityfordonation.PatientfamiliesarecompassionatelyapproachedbyFamilySupportServices(FSS)staffintheOrganWorkSystem(OWS)andbytheCommunicationCenterstaffintheTissueWorkSystem(TWS).Duringtheapproach,familiesarepresentedwiththeopportunityfordonationortohonortheirlovedone’spreviousdecisiontobecomeadonor(Figure 3.2-1,Pre-DonationPhase).ClinicalstaffmembersassistthedonorhospitalpartnerswiththemedicalmanagementofthedonoruntiltransportationtotheLOTSfacilityoccursandthedonatedgiftsarerecovered(Figure 3.2-1,DonationPhase).IntheOWS,recoveryisperformedbythetransplantsurgeonassistedbyOrganProcurementCoordinators(OPCs);intheTWS,recoveryisperformedbyTissueProcurementCoordina-tors(TPCs).LOTSactsasaresponsiblestewardofthe“GiftofLife”bycoordinatingtheplacementofdonatedorgansandtissuestoitskeycustomergroups:localorgantransplantcentersandtissueprocessors.Thedonatedorgansandtissuesareusedforthebettermentofthecommunitiesserved,whichincludedonorfamiliesandtransplantrecipientpatientsandtheirfamilies(Figure P.1-6).
P.1a(2) ThemissionofLOTSistosaveandimprovelives(Figure P.1-1).LOTS’svisionisOrgans and tissues are always available. Thevisionwasdevelopedinlightofthebeliefthattheorganization’sultimategoalwillonlybereal-izedwhenorgansandtissuearereadilyavailabletopatientswhentheyneedthem.CentraltotheLOTScultureisastrong
drivetomeetthemission: We save and improve lives. Bydefinition,themissionaffirmsthatLOTSplaysaroleinthelife-savinggiftofdonation.Whetheritisthe“literallifesave”ofanorganrecipientora“qualityoflifeimprovementtoatissuerecipient,”atitscore,LOTSisallabouttransplantationandsavingandimprovinglives.Valuesofcompassion,improve-ment,honesty,teamwork,andqualityserveasaguid-ingforceforhowtheworkforcelivesthecultureonadailybasis.Thevision,mission,andvalues(V/M/V)ofLOTS,validatedduringtheStrategicPlanningProcess(SPP;Figure 2.1-1),serveasthefounda-tionforthecultureandformthebasisforhowtheorganizationismanaged.ThemissionofLOTScouldnotbeaccomplishedwithouttheorganization’scorecompetency(CC)ofamission-drivenworkforce.
Mission-Driven Workforce: TheworkofLOTS,byitsverynature,requiresalevelofcareandcompas-sionthatcanonlybedeliveredbythe“humantouch.”Therefore,theactionsandbehaviorsdemonstratedbythestaffaredirectlylinkedtocreatingapositivedonationexperienceforthedonorfamily(collabora-tors),whichisessentialtotheaccomplishmentofthemissionandthesuccessoftheorganization.ThisCCwasidentifiedusingseveralcyclesofLOTS’s
workforcesurveyresults,whichnotedthatoverallengagementandoveralljobsatisfactioncontinuetoshowstrongresults(Figures 7.3-12, 7.3-12A, and 7.3-14).
P.1a(3) LOTSisa24/7businessinwhichmanyoftheemployeesaredecentralized.TheWorkforceProfile (Figure P.1-4)reflectstheemployeeprofileandincludesjobtype,tenure,gender,andethnicity.Todate,theorganizationhasnotexperiencedanyreductionsinworkforce.Conversely,astheneedfordonationshasincreased,sohastheneedforexpansionofbothclinicalandnonclinicalstafftosupportoperationalefficiencies.Forthepurposeofreportingand
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drivetomeetthemission: We save and improve lives. Bydefinition,themissionaffirmsthatLOTSplaysaroleinthelife-savinggiftofdonation.Whetheritisthe“literallifesave”ofanorganrecipientora“qualityoflifeimprovementtoatissuerecipient,”atitscore,LOTSisallabouttransplantationandsavingandimprovinglives.Valuesofcompassion,improve-ment,honesty,teamwork,andqualityserveasaguid-ingforceforhowtheworkforcelivesthecultureonadailybasis.Thevision,mission,andvalues(V/M/V)ofLOTS,validatedduringtheStrategicPlanningProcess(SPP;Figure 2.1-1),serveasthefounda-tionforthecultureandformthebasisforhowtheorganizationismanaged.ThemissionofLOTScouldnotbeaccomplishedwithouttheorganization’scorecompetency(CC)ofamission-drivenworkforce.
Mission-Driven Workforce: TheworkofLOTS,byitsverynature,requiresalevelofcareandcompas-sionthatcanonlybedeliveredbythe“humantouch.”Therefore,theactionsandbehaviorsdemonstratedbythestaffaredirectlylinkedtocreatingapositivedonationexperienceforthedonorfamily(collabora-tors),whichisessentialtotheaccomplishmentofthemissionandthesuccessoftheorganization.ThisCCwasidentifiedusingseveralcyclesofLOTS’s
workforcesurveyresults,whichnotedthatoverallengagementandoveralljobsatisfactioncontinuetoshowstrongresults(Figures 7.3-12, 7.3-12A, and 7.3-14).
P.1a(3) LOTSisa24/7businessinwhichmanyoftheemployeesaredecentralized.TheWorkforceProfile (Figure P.1-4)reflectstheemployeeprofileandincludesjobtype,tenure,gender,andethnicity.Todate,theorganizationhasnotexperiencedanyreductionsinworkforce.Conversely,astheneedfordonationshasincreased,sohastheneedforexpansionofbothclinicalandnonclinicalstafftosupportoperationalefficiencies.Forthepurposeofreportingand
ProcurementProcess(Figure 2.1-2).LOTSprovidesongoingeducationalofferingstothesepartnerstoensurethatthisintro-ductionoccursinatimelymanner.Onceareferralismade,LOTSprescreensthepotentialdonorformedicaleligibilityfordonation.PatientfamiliesarecompassionatelyapproachedbyFamilySupportServices(FSS)staffintheOrganWorkSystem(OWS)andbytheCommunicationCenterstaffintheTissueWorkSystem(TWS).Duringtheapproach,familiesarepresentedwiththeopportunityfordonationortohonortheirlovedone’spreviousdecisiontobecomeadonor(Figure 3.2-1,Pre-DonationPhase).ClinicalstaffmembersassistthedonorhospitalpartnerswiththemedicalmanagementofthedonoruntiltransportationtotheLOTSfacilityoccursandthedonatedgiftsarerecovered(Figure 3.2-1,DonationPhase).IntheOWS,recoveryisperformedbythetransplantsurgeonassistedbyOrganProcurementCoordinators(OPCs);intheTWS,recoveryisperformedbyTissueProcurementCoordina-tors(TPCs).LOTSactsasaresponsiblestewardofthe“GiftofLife”bycoordinatingtheplacementofdonatedorgansandtissuestoitskeycustomergroups:localorgantransplantcentersandtissueprocessors.Thedonatedorgansandtissuesareusedforthebettermentofthecommunitiesserved,whichincludedonorfamiliesandtransplantrecipientpatientsandtheirfamilies(Figure P.1-6).
P.1a(2) ThemissionofLOTSistosaveandimprovelives(Figure P.1-1).LOTS’svisionisOrgans and tissues are always available. Thevisionwasdevelopedinlightofthebeliefthattheorganization’sultimategoalwillonlybereal-izedwhenorgansandtissuearereadilyavailabletopatientswhentheyneedthem.CentraltotheLOTScultureisastrong
Figure P.1-4: Workforce Profile (Employees)
Leadership Team 10%
Staff 90%
Male 35%
Female 65%
1 Year 20%
2–5 Years 41%
6–10 Years 21%
11+ Years 18%
African American 20% (DSA 25%*)
White 70% (DSA 70%*)
Other 10% (DSA 5%*)
*Based on 2010 Census
Job TypeTenure
GenderEthnicity
Figure P.1-3: Finding the Heroes
Deaths Reported
Referrals
Eligible
Authorization
Donors
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comparingdata,theworkforceissegmentedbyworksystemanddepartment.TheOWSmanagestheProcurementProcessfororgans,theTWSmanagestheProcurementProcessfortissues,andthesupportdepartmentsprovidetheinfrastructuretomaximizeorganizationalperformance(Figure 2.1-2).Theorganizationdoesnotutilizetheassistanceofvolunteers.Workforceeducationalrequirements,includingapplicablecertifications,mayvarybyworksystemanddepartmentandareincludedinalljobdescriptions.Inaddition,theLearningandDevelopmentSystem(LDS;Figure 5.2-2)includescomponentsthatallowthetrackingofpersonalgoalsandcertificationsintheonlinePerformanceEvaluationProcess(PEP;Figure 5.1-2).UtilizingtheCommunicationProcess(Figure 1.1-3),LOTSroutinelyunderscoresthateveryroleintheorganizationcontributestothesuccessofthemission.Multiplestaffsurveycycleshavevalidatedthreeofthehighest-scoringsurveyattributes:thestaffconnectiontothemission,followedcloselybyemployeebenefitsandrelation-shipswithcoworkers.
LOTShasnoorganizedbargainingunits.Allemployeesrequireahealthy,safe,andsecureworkenvironment.LOTS’sapproachestoaddresstheserequirementsincludesystem-wideprogramsfocusingonrisksinparticularsettings.Manymem-bersoftheworkforcecarryoutclinicaldutiesinahospital,ratherthanperformworkinanoffice.Healthandsafetyissuesrelatedtostaffworkinginhospitalsalsoapplytononclinicalstaff.Similarly,typicaloffice-relatedsafetyrequirementsapplytononclinicalstaff.AtLOTS,suchissuesareaddressedthroughannualtrainingandstandardoperatingprocedures(SOPs).Duetothe24-hournatureofsomework,for“after-hours”staffmembers,specialsafetyrequirementsexistthatincludereservedofficeparkingspots,securedparking,andsensorlighting(5.1b[1]).
P.1a(4) LOTSownsacustom-builtfacilityinColumbia,NT,whichhousesacriticalcareunitwhereorgandonormanage-mentoccursandwithafullyequippedoperatingroom(OR).Thekeyclinicaltechnologiesandequipmentincludex-ray,ultrasound,andtypicalORequipment.LOTSleasesatwin-engineturbopropplaneequippedwithmedicalequipmenttotransportdonorstotheLOTSfacilityfororganandtissuerecovery.Utilizingtechnology,LOTSprovidesstaffwithcollaborativetools,real-timeaccesstokeydataincludinganelectronicmedicalrecord(EMR)system,andreportingservicesthatprovidecustomizedreports.
P.1a(5) LOTSoperatesunderahighlyregulatedenviron-mentandidentifieskeyregulatoryrequirementsinQualityComplianceManagement(Figure P.1-5).Inaddition,localenvironmentalandregulatoryinitiativesapplyforfireandsanitationmeasures;biohazardtrashdisposalmeetsalllocalandstateregulations.
P.1b Organizational RelationshipsP.1b(1) IncorporatedinthestateofNorthTakoma,LOTSisaprivate,nonprofit501(c)(3)organization.Avoluntary,commu-nity-basedgovernanceBoardofDirectors(BOD)setspolicy
fortheorganizationandiscomposedofhospitalexecutives,physicians,anddonorfamilymembers.RepresentativesfromLOTS’skeydonorhospitals(partners)andtransplantcenters(customers)areappointed,allowingtheseseniorleaderstorepresentcustomerandpartnerrequirements.Reportingtothegovernanceboard,theChiefExecutiveOfficer(CEO)directsanExecutiveLeadershipTeam(ELT)composedoftheChiefMedicalOfficer(CMO),ChiefHumanResourcesOfficer(CHRO),ChiefFinancialOfficer(CFO),andChiefOperatingOfficer(COO).TheLeadershipTeam(LT)consistsoftheELTandthedirectors,managers,andsupervisors.
TheBODevaluatestheperformanceoftheCEOutilizingongoingmonitoringofperformancemeasuresasoutlinedintheScorecardReviewProcessnotedin1.2a(2).TheCEOevaluatestheperformanceofherdirectreports,andthosereportsevaluatetheperformanceofthedirectors,who,inturn,evaluatemanagersandothermembersofthestaff.
P.1b(2) Figure P.1-6 outlinesLOTS’skeycustomers,partners,andstakeholders,aswellastherequirementsandexpectationsfortheorganization’sservicesandoperationsforeachgroup.LOTS’skeymarketsegmentistheorganization’sDSA,whichisassignedbythefederalgovernment.Localorgantransplantcenters(PremierHealth,ColumbiaUniver-sityHospital,PremierChildren’sHospital,andColumbiaChildren’sHospital)andtissueprocessors(TissueTrans-formations,LifeBank,andAdvantageLife)areLOTS’skeycustomergroups.LOTScollaborateswiththedonorfamilies
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comparingdata,theworkforceissegmentedbyworksystemanddepartment.TheOWSmanagestheProcure-mentProcessfororgans,theTWSmanagestheProcure-mentProcessfortissues,andthesupportdepartmentsprovidetheinfrastructuretomaximizeorganizationalperformance(Figure 2.1-2).Theorganizationdoesnotutilizetheassistanceofvolunteers.Workforceeducationalrequirements,includingapplicablecertifications,mayvarybyworksystemanddepartmentandareincludedinalljobdescriptions.Inaddition,theLearningandDevelopmentSystem(LDS;Figure 5.2-2)includescomponentsthatallowthetrackingofpersonalgoalsandcertificationsintheonlinePerformanceEvaluationProcess(PEP;Figure 5.1-2). UtilizingtheCommunicationProcess(Figure 1.1-3),LOTSroutinelyunderscoresthateveryroleintheorganiza-tioncontributestothesuccessofthemission.Multiplestaffsurveycycleshavevalidatedthreeofthehighest-scoringsurveyattributes:thestaffconnectiontothemission,fol-lowedcloselybyemployeebenefitsandrelationshipswithcoworkers.
LOTShasnoorganizedbargainingunits.Allemployeesrequireahealthy,safe,andsecureworkenvironment.LOTS’sapproachestoaddresstheserequirementsincludesystem-wideprogramsfocusingonrisksinparticularsettings.Manymembersoftheworkforcecarryoutclinicaldutiesinahospital,ratherthanperformworkinanoffice.Healthandsafetyissuesrelatedtostaffworkinginhospitalsalsoapplytononclinicalstaff.Similarly,typicaloffice-relatedsafetyrequirementsapplytononclinicalstaff.AtLOTS,suchissuesareaddressedthroughannualtrainingandstandardoperatingprocedures(SOPs).Duetothe24-hournatureofsomework,for“after-hours”staffmembers,specialsafetyrequirementsexistthatincludereservedofficeparkingspots,securedparking,andsensorlighting(5.1b[1]).
P.1a(4) LOTSownsacustom-builtfacilityinColumbia,NT,whichhousesacriticalcareunitwhereorgandonormanage-mentoccursandwithafullyequippedoperatingroom(OR).Thekeyclinicaltechnologiesandequipmentincludex-ray,ultrasound,andtypicalORequipment.LOTSleasesatwin-engineturbopropplaneequippedwithmedicalequipmenttotransportdonorstotheLOTSfacilityfororganandtissuerecovery.Utilizingtechnology,LOTSprovidesstaffwithcollaborativetools,real-timeaccesstokeydataincludinganelectronicmedicalrecord(EMR)system,andreportingservicesthatprovidecustomizedreports.
P.1a(5) LOTSoperatesunderahighlyregulatedenviron-mentandidentifieskeyregulatoryrequirementsinQualityComplianceManagement(Figure P.1-5).Inaddition,localenvironmentalandregulatoryinitiativesapplyforfireandsanitationmeasures;biohazardtrashdisposalmeetsalllocalandstateregulations.
P.1b Organizational RelationshipsP.1b(1) IncorporatedinthestateofNorthTakoma,LOTSisaprivate,nonprofit501(c)(3)organization.Avoluntary,
community-basedgovernanceBoardofDirectors(BOD)setspolicyfortheorganizationandiscomposedofhospitalexecu-tives,physicians,anddonorfamilymembers.RepresentativesfromLOTS’skeydonorhospitals(partners)andtransplantcenters(customers)areappointed,allowingtheseseniorlead-erstorepresentcustomerandpartnerrequirements.Reportingtothegovernanceboard,theChiefExecutiveOfficer(CEO)directsanExecutiveLeadershipTeam(ELT)composedoftheChiefMedicalOfficer(CMO),ChiefHumanResourcesOfficer(CHRO),ChiefFinancialOfficer(CFO),andChiefOperatingOfficer(COO).TheLeadershipTeam(LT)consistsoftheELTandthedirectors,managers,andsupervisors.
TheBODevaluatestheperformanceoftheCEOutilizingongoingmonitoringofperformancemeasuresasoutlinedintheScorecardReviewProcessnotedin1.2a(2).TheCEOevaluatestheperformanceofherdirectreports,andthosereportsevaluatetheperformanceofthedirectors,who,inturn,evaluatemanagersandothermembersofthestaff.
P.1b(2) Figure P.1-6 outlinesLOTS’skeycustomers,partners,andstakeholders,aswellastherequirementsandexpectationsfortheorganization’sservicesandoperationsforeachgroup.LOTS’skeymarketsegmentistheorganization’sDSA,whichisassignedbythefederalgovernment.Localorgantransplantcenters(PremierHealth,ColumbiaUniversityHospital,PremierChildren’sHospital,andColumbiaChildren’sHospital)andtissueprocessors(TissueTrans-formations,LifeBank,andAdvantageLife)areLOTS’skey
Figure P.1-5: Quality Compliance Management
Regulatory AgencyMandatory/ Voluntary
CAP SafeLaboratoryPractices Mandatory
CMS BillingandPerformanceRequirements
Mandatory
EEOC EmploymentPractices Mandatory
FDA CompliancewithRequirements Mandatory
DoL EmploymentPractices Mandatory
IRS NonprofitRequirements Mandatory
UNOS/OPTN
OrganAllocation/OperationalOversight
Voluntary
Occupational Health and Safety
OSHA WorkplaceSafety Mandatory
Accreditation
AATB StandardsforTissueBankingAccreditation
Voluntary
AOPO StandardsforOrganProcurementAccreditation
Voluntary
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tohonortheirlovedones’decisionstobedonorsoronbehalfoftheirlovedones;donorfamilyrequirementsarethesameregardlessofdonationtype.
P.1b(3) LOTSrecognizesthatkeysuppliers,partners,andcollaboratorsplayanimportantroleinsupportingitinachievingitsvision,mission,andstrategicobjectives(SOs).KeysuppliersincludeGuardianAmbulance,WrightBrothersCharter,TitanTechnology(TT),TransplantTechnologies,andColumbiaCremation(Figure P.1-6).Theseorganizationshavemadesignificantbusinessmodelaccommodationstoprovide24/7availabilitytoensurethatthedonationcanproceedsmoothly.GuardianAmbulance,WrightBrothersCharter,andColumbiaCremationprovideairandgroundtransportationservicesforstaff,aswellasorganandtissuedonors,ensuringthatthedonationisexpedited.TTprovidesallroutinemain-tenanceandinfrastructuresupportofinformationtechnology(IT),allowingtheinternalITstaffemployedbyLOTStofocusontechnologiesspecifictotheOPOindustry.TransplantTech-nologiesprovidestheEMRsystem,includingtheplatformthatallowssequelreportingfunctions,whichareacriticalpartofthePerformanceMeasurementSystem(PMS;Figure 4.1-1).TransplantTechnologiesalsoaffordstheorganizationtheabilitytouploadtissuedonorrecordstotheprocessorstoensuretimelyreleaseoftissue.Thesesuppliers,partners,andcollaboratorsprovideLOTSwiththeabilitytoassessprocessperformanceandenhancecompetitivenessbyexceedingcus-tomerrequirements.AsLOTS’skeypartnersandmainreferralsources,donorhospitalsandnonhospitalreferralsourcesareessentialtogainingaccesstopotentialdonorfamilies.Throughongoingtraining,theHospitalServicesstaffassistswiththeestablishmentofsystemsthatinitiatethepre-donationAuthorizationProcess(throughtheReferralManagementProcess)andsupportthedonationdecision.OnceareferraltoLOTSismade,aLOTSstaffmemberpresentstheoptionofdonationtothepotentialdonorfamily.Ascollaborators,donorfamilymembersprovideauthorizationfordonationonbehalfoftheirlovedonesortohonortheirlovedones’documentedauthorizationtobeanorganand/ortissuedonor.Fordonorfamilycollaborators,two-waycommunicationoccursduringthePre-DonationPhaseviaface-to-faceconversations(OWS)andbyphone(TWS).Theprimarymethodsforknowledgesharingandcommunicationwithsuppliers,collaborators,andpartnersarenotedinVoiceoftheStakeholder(VOS;(Figure 4.2-1);primarymethodsforcustomercommunicationarenotedinVoiceoftheCustomer(VOC;Figure 3.1-1).Supplierandpartnercommunicationismainlyconductedviatwo-waycommunicationandface-to-facemeetingswithfollow-upcommunicationviaphoneandemail.Inputsfrompartnersandcollaborators,aswellasotherkeystakeholders,feedintotheSPP(Figure 2.1-1)andhelpdriveorganizationalimprovements.LOTS’skeysupply-networkrequirementsforsuppliersincludetimelycommunication,accurateinformation,andservicequality(Figure P.1-6).
iv
customergroups.LOTScollaborateswiththedonorfamiliestohonortheirlovedones’decisionstobedonorsoronbehalfoftheirlovedones;donorfamilyrequirementsarethesameregardlessofdonationtype.
P.1b(3) LOTSrecognizesthatkeysuppliers,partners,andcollaboratorsplayanimportantroleinsupportingitinachievingitsvision,mission,andstrategicobjectives(SOs).KeysuppliersincludeGuardianAmbulance,WrightBrothersCharter,TitanTechnology(TT),TransplantTechnologies,andColumbiaCremation(Figure P.1-6).Theseorganizationshavemadesignificantbusinessmodelaccommodationstoprovide24/7availabilitytoensurethatthedonationcanproceedsmoothly.GuardianAmbulance,WrightBrothersCharter,andColumbiaCremationprovideairandgroundtransportationservicesforstaff,aswellasorganandtissuedonors,ensuringthatthedonationisexpedited.TTprovidesallroutinemain-tenanceandinfrastructuresupportofinformationtechnology(IT),allowingtheinternalITstaffemployedbyLOTStofocusontechnologiesspecifictotheOPOindustry.TransplantTech-nologiesprovidestheEMRsystem,includingtheplatformthatallowssequelreportingfunctions,whichareacriticalpartofthePerformanceMeasurementSystem(PMS;Figure 4.1-1).TransplantTechnologiesalsoaffordstheorganizationtheabilitytouploadtissuedonorrecordstotheprocessorstoensuretimelyreleaseoftissue.Thesesuppliers,partners,andcollaboratorsprovideLOTSwiththeabilitytoassessprocessperformanceandenhancecompetitivenessbyexceedingcus-tomerrequirements.AsLOTS’skeypartnersandmainreferralsources,donorhospitalsandnonhospitalreferralsourcesareessentialtogainingaccesstopotentialdonorfamilies.Throughongoingtraining,theHospitalServicesstaffassistswiththeestablishmentofsystemsthatinitiatethepre-donationAuthorizationProcess(throughtheReferralManagementProcess)andsupportthedonationdecision.OnceareferraltoLOTSismade,aLOTSstaffmemberpresentstheoptionofdonationtothepotentialdonorfamily.Ascollaborators,donorfamilymembersprovideauthorizationfordonationonbehalfoftheirlovedonesortohonortheirlovedones’documentedauthorizationtobeanorganand/ortissuedonor.Fordonorfamilycollaborators,two-waycommunicationoccursduringthePre-DonationPhaseviaface-to-faceconversations(OWS)andbyphone(TWS).Theprimarymethodsforknowledgesharingandcommunicationwithsuppliers,collaborators,andpartnersarenotedinVoiceoftheStakeholder(VOS;(Figure 4.2-1);primarymethodsforcustomercommunicationarenotedinVoiceoftheCustomer(VOC;Figure 3.1-1).Supplierandpartnercommunicationismainlyconductedviatwo-waycommunicationandface-to-facemeetingswithfollow-upcommunicationviaphoneandemail.Inputsfrompartnersandcollaborators,aswellasotherkeystakeholders,feedintotheSPP(Figure 2.1-1)andhelpdriveorganizationalimprovements.LOTS’skeysupply-networkrequirementsforsuppliersincludetimelycommunication,accurateinformation,andservicequality(Figure P.1-6).
Figure P.1-6: Key Stakeholder Requirements
Customers Requirements
TransplantCenters—Organ • MaximizeDonation• Information• Competence
TissueProcessors • MaximizeDonation• Information• Accountability
Partners
DonorHospitalsMedicalExaminersHospice
• Respect/Sensitivity• Information• ServiceQuality
Collaborators
OrganandTissue DonorFamilies
• Compassion• StewardshipoftheGift• HonortheDonor
FuneralHomes • Communication• Service
Stakeholders
Communitieswithin ServiceArea
• ComplywithLegal,Ethical,andRegulatoryRequirementsWhileProvidingQualityOrgansandTissues
Workforce • ConnectionwithV/M/V• ExcellentBenefits• Coworkers
BoardofDirectors • StrategicPlanning• Administration• FinancialManagement
Suppliers Expectations
GuardianAmbulanceWrightBrothersCharterTTTransplantTechnologiesColumbiaCremation
• AccurateInformation• ServiceQuality• TimelyCommunication
P.2 Organizational SituationP.2a Competitive EnvironmentP.2a(1) AsthefederallydesignatedOPOwithinitsservicearea,LOTSdoesnothavetraditionalorganprocurementcompetitors.Muchlikeautilitycompany,LOTSisaregu-lated“monopoly”thatoperatessolelywithinthebordersofitsDSA;nootherOPOsmayprocureorganswithinthisboundary.Tomaintainthisdesignation,however,OPOsmust
P.2 Organizational SituationP.2a Competitive EnvironmentP.2a(1) AsthefederallydesignatedOPOwithinitsservicearea,LOTSdoesnothavetraditionalorganprocurementcompetitors.Muchlikeautilitycompany,LOTSisaregu-lated“monopoly”thatoperatessolelywithinthebordersofitsDSA;nootherOPOsmayprocureorganswithinthisboundary.Tomaintainthisdesignation,however,OPOsmust
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meetnationalperformancestandardssetbytheCentersforMedicareandMedicaidServices(CMS).Shouldperformanceconsistentlyfallshortofthenationalstandards,CMScouldchoosetoawardtheDSAtoanotherOPO.WhileOPOsdonotcompetefororgans,thereassignmentofpotentialfutureDSAswouldbebasedonperformancetothestandards.FortheTWS,donorhospitalsarerequiredbylawtoreportalldeathstoLOTS;however,theymaycontractwithanothertissuebankattheirowndiscretionfortherecoveryprocess.LOTSmaintainstissuerecoverycontractswith100%ofthe80donorhospitalpartnerswithinitsservicearea.LOTSpartnerswithaneyebank,VisionMax,toensureeyedonationopportunitiesforfamiliesintheDSA.LOTSranks40thamongtheexisting58OPOsintermsofpopulationlivingwithinitsDSA.SinceexpansionoftheDSAisnotallowed,growthindonationmustcomefromincreasesinmedicallyeligiblecandidatesfromwithintheDSA,fromincreasesinthenumberoffamilieswhosay“yes”(authorization)todonation,orfromtheidentifica-tionofnonhospitalreferralsources.Theconstraintsofalimitedserviceareareinforcetheimportanceofmaximizingdonationforeachdonorinordertoachievethemissionofsavinglives(Figure P.1-3).
P.2a(2) BecauseLOTSdoesnothavecompetitorsinthetra-ditionalsense,therearenokeychangestakingplacethataffecttheorganization’scompetitivepositionasanOPO.WhilethechangestotheAffordableCareActwillbeachallengeforthehealthcareindustry,thescopeofitschangestotheOPOindustryisuncertainatthistime.Assuch,theorganizationhasdecidedtofocusonwhatitcancontrol;utilizingLOTS’sdriveandprovenabilitytoimproveandrelyonitsmission-drivenworkforce(CC)toachievecost-effectivenessandefficienciestoplaceitselfinastrongfinancialposition(SA)tomanagefuturechallenges.KeyfactorsinfluencingthesuccessofLOTSinclude
■ Amission-drivenworkforcethatishighlymotivatedandengagedinsaving lives(CC)
■ Strongrelationshipsformedthroughpartneringandcollaboration
Asstatedpreviously,theOWSandTWSdonotcurrentlyhavecompetitors.
P.2a(3) TheComparativeDataProcess(Figure 4.1-4)liststheorganization’skeycomparativedatasources.Theorganindustryhasselectnationalbenchmarksavailablethroughmultiplesources;however,theleadtimebeforesuchresultsbecomeavailablecanbemanymonths.Comparativedataaremorelimitedfortissueoperations,inwhichtissueprocessorsprovidemonthlyfeedbackforselectresultsintheformofscorecards.Tooffsettheselimitations,LOTSreliesonsharingthroughcollaborationwithotherOPOstoobtaincomparativedata.
P.2b Strategic ContextStrategicChallenges(SCs)andAdvantages(SAs;Figure P.2-1)providesasummarythatreflectsthecurrentstrategicstateofLOTS.SCsandSAsarereviewedannuallyduringstep3of
theSPP(Figure 2.1-1);steps5through8ensurethatappropri-ateactionplans(APs)arelinkedtoorganizationalsuccess.
P.2c Performance Improvement SystemTogetherwiththeBOD,theLOTSLTcreatesanenvironmentthatsupportsimprovementthroughthecreationofstrategies,systems,andmethodsforachievingperformanceexcellence.TheLeadershipSystem(LS;Figure 1.1-1)isusedtosetanddeploytheV/M/VandculturetotheworkforceviatheCommunicationProcess(Figure 1.1-3).LOTShasdevelopedanorganizationalstructure,processes,andculturetofocusonactionandachievesustainableperformance,fosterimprove-ment,andseekoutstrategicopportunities.AcontinuousprocessimprovementenvironmentallowsLOTStodeliveradistinctivevaluestreamthatbenefitsboththeperformanceofcustomer-focusedoperationsandthelivesoforganandtissuerecipients.
LOTSusestheBaldrigeCriteriaforPerformanceExcellenceasitsbusinessmodelanditsfoundationforperformanceimprovement(PI).Ultimately,thismodelprovidesongo-ingfeedbackintotheSPP.Additionally,step3oftheLS(Figure 1.1-1)provideskeybusinessprocessmonitoringtoalignbusinessstrategytoorganizationalperformance.OperationalimprovementsareidentifiedandimplementedthroughtheSPPandtheOperationalManagementProcess(OMP;Figure 6.1-1).Bothprocessesbringtotheforefrontkeyinformationtomanagethebusiness,aggregatedata,createactionsthatsynthesizeinformationintoknowledge,andultimatelyfacilitatethesharingofknowledge,bothinternallyandexternally.PerformanceimprovementstaffarepartoftheQuality/Regulatorydepartmentandhelpsupporttheoverarch-ingorganizationalgoalofimprovement.Tomonitorsuccess,thePMS(Figure 4.1-1)isused.Theover-archingapproach,formalandinformal,tosupportprocessimprovementeffortsisthePlan-Do-Study-Act(PDSA)problem-solvingmethodol-ogy.ThismethodologyisembeddedinLOTS’simprovementprocesses.
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meetnationalperformancestandardssetbytheCentersforMedicareandMedicaidServices(CMS).Shouldperformanceconsistentlyfallshortofthenationalstandards,CMScouldchoosetoawardtheDSAtoanotherOPO.WhileOPOsdonotcompetefororgans,thereassignmentofpotentialfutureDSAswouldbebasedonperformancetothestandards.FortheTWS,donorhospitalsarerequiredbylawtoreportalldeathstoLOTS;however,theymaycontractwithanothertissuebankattheirowndiscretionfortherecoveryprocess.LOTSmaintainstissuerecoverycontractswith100%ofthe80donorhospitalpartnerswithinitsservicearea.LOTSpartnerswithaneyebank,VisionMax,toensureeyedonationopportunitiesforfamiliesintheDSA.LOTSranks40thamongtheexisting58OPOsintermsofpopulationlivingwithinitsDSA.SinceexpansionoftheDSAisnotallowed,growthindonationmustcomefromincreasesinmedicallyeligiblecandidatesfromwithintheDSA,fromincreasesinthenumberoffamilieswhosay“yes”(authorization)todonation,orfromtheidentifica-tionofnonhospitalreferralsources.Theconstraintsofalimitedserviceareareinforcetheimportanceofmaximizingdonationforeachdonorinordertoachievethemissionofsavinglives(Figure P.1-3).
P.2a(2) BecauseLOTSdoesnothavecompetitorsinthetra-ditionalsense,therearenokeychangestakingplacethataffecttheorganization’scompetitivepositionasanOPO.WhilethechangestotheAffordableCareActwillbeachallengeforthehealthcareindustry,thescopeofitschangestotheOPOindustryisuncertainatthistime.Assuch,theorganizationhasdecidedtofocusonwhatitcancontrol;utilizingLOTS’sdriveandprovenabilitytoimproveandrelyonitsmission-drivenworkforce(CC)toachievecost-effectivenessandefficienciestoplaceitselfinastrongfinancialposition(SA)tomanagefuturechallenges.KeyfactorsinfluencingthesuccessofLOTSinclude
■ Amission-drivenworkforcethatishighlymotivatedandengagedinsaving lives(CC)
■ Strongrelationshipsformedthroughpartneringandcollaboration
Asstatedpreviously,theOWSandTWSdonotcurrentlyhavecompetitors.
P.2a(3) TheComparativeDataProcess(Figure 4.1-4)liststheorganization’skeycomparativedatasources.Theorganindustryhasselectnationalbenchmarksavailablethroughmultiplesources;however,theleadtimebeforesuchresultsbecomeavailablecanbemanymonths.Comparativedataaremorelimitedfortissueoperations,inwhichtissueprocessorsprovidemonthlyfeedbackforselectresultsintheformofscorecards.Tooffsettheselimitations,LOTSreliesonsharingthroughcollaborationwithotherOPOstoobtaincomparativedata.
P.2b Strategic ContextStrategicChallenges(SCs)andAdvantages(SAs;Figure P.2-1)providesasummarythatreflectsthecurrentstrategicstateofLOTS.SCsandSAsarereviewedannuallyduringstep3of
theSPP(Figure 2.1-1);steps5through8ensurethatappropri-ateactionplans(APs)arelinkedtoorganizationalsuccess.
P.2c Performance Improvement SystemTogetherwiththeBOD,theLOTSLTcreatesanenvironmentthatsupportsimprovementthroughthecreationofstrategies,systems,andmethodsforachievingperformanceexcellence.TheLeadershipSystem(LS;Figure 1.1-1)isusedtosetanddeploytheV/M/VandculturetotheworkforceviatheCommunicationProcess(Figure 1.1-3).LOTShasdevelopedanorganizationalstructure,processes,andculturetofocusonactionandachievesustainableperformance,fosterimprove-ment,andseekoutstrategicopportunities.AcontinuousprocessimprovementenvironmentallowsLOTStodeliveradistinctivevaluestreamthatbenefitsboththeperformanceofcustomer-focusedoperationsandthelivesoforganandtissuerecipients.
LOTSusestheBaldrigeCriteriaforPerformanceExcellenceasitsbusinessmodelanditsfoundationforperformanceimprovement(PI).Ultimately,thismodelprovidesongo-ingfeedbackintotheSPP.Additionally,step3oftheLS(Figure 1.1-1)provideskeybusinessprocessmonitoringtoalignbusinessstrategytoorganizationalperformance.OperationalimprovementsareidentifiedandimplementedthroughtheSPPandtheOperationalManagementProcess(OMP;Figure 6.1-1).Bothprocessesbringtotheforefrontkeyinformationtomanagethebusiness,aggregatedata,createactionsthatsynthesizeinformationintoknowledge,andultimatelyfacilitatethesharingofknowledge,bothinternallyandexternally.PerformanceimprovementstaffarepartoftheQuality/Regulatorydepartmentandhelpsupporttheoverarch-ingorganizationalgoalofimprovement.Tomonitorsuccess,thePMS(Figure 4.1-1)isused.Theover-archingapproach,formalandinformal,tosupportprocessimprovementeffortsisthePlan-Do-Study-Act(PDSA)problem-solvingmethodol-ogy.ThismethodologyisembeddedinLOTS’simprovementprocesses.
Figure P.2-1: Strategic Challenges and Advantages
Challenges
Business • IndustryChanges
Operational • Authorization
SocietalResponsibility • IncreaseRegistry
Workforce • Retention
Advantages
Business • StakeholderSatisfaction
Operational • FacilitiesandEquipment
SocietalResponsibility • BaldrigeBusinessModel
Workforce • SupportiveCulture
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RESPONSESADDRESSINGALLCRITERIAITEMS
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Category 1: Leadership
1.1 Senior Leadership1.1a Vision and Values1.1a(1) LOTSLS(Figure 1.1-1)providesdirectionforanengagedworkforcethatsuccessfullyfacilitatesorganandtissuedonationinalignmentwiththeVisionandValues (V/V;Figure P.1-1).DuringarecentSPPsession,LOTSreviewedtheV/Voftheorganization.Thisrevalidationprocessincorporatedemployeeinputusinganinternalsurvey.TheV/Vwereupdated,vetted,andratifiedbytheBOD.
TheLTdeploystheV/Vandculturetotheworkforce,aswellastocustomers,stakeholders,partners,andsuppliers,viamultiplecommunicationmechanismsasmanagedbytheCommunicationProcess(Figure 1.1-3).Examplesinclude■ ReviewingandemphasizingtheV/M/Vduringboard,staff,
anddepartmentmeetings■ Incorporatingthestoriesofdonorfamilies,recipients,
andpatientswaitingforatransplantintomultiplecommunicationmethods
TheLTmembersserveasrolemodelsanddemonstratetheircommitmenttothecorevaluesbysettingthecultureviatheLS,includingthroughdailypracticeandduringstaffmeetings,duringdepartmentmeetings,andinconversationsinRoundingforOutcomes(RFO).Leadersprovidepersonalacknowledge-menttoemployeesfordemonstratingbehaviorsconsistentwiththeorganization’scorevalues.TheLTusesa360-degreereviewtoprovidesystematicfeedbacktoallLTmembersfrompeersanddirectreportspertainingtotheleader’sindividualeffectiveness,includingexhibitingbehaviorsconsistentwiththeV/V.ThisreviewprocessalsoprovidestheLTwithindividualopportunitiesforimprovementandisusedtoassesstheeffectivenessoftheLS.TheBODevaluatestheCEO’seffectivenesswithoperatingtheorganizationinalignmentwiththeV/V.
1.1a(2) TheLT’sactionspersonallydemonstratethehigheststandardsofethicalbehaviorbypromotingtheprinciplesandideasreflectedintheV/Vatstaff,worksystem,anddepartmentmeetings,aswellasregularlythroughRFOconversations.TheLTadherestoworkplacepoliciesincludingtheCodeofProfessionalConduct,Donor/RecipientConfi-dentiality,andConflictofInterest(COI)withasignedannualdisclosure.
ThroughtheLOTSCorporateComplianceProgram(CCP;Figure 1.1-2),leaderspromoteanatmospherethatencouragesemployeesandstakeholderstoreportanyquestionablebehav-ior.Ananonymoushotlinereportingsystemisinplacetoensureconfidentiality.TheentireLOTSworkforce,includingtheLTandBOD,istrainedannuallyontheCCPpolicy.Inaddition,compliancepoliciesarereviewedbyLOTSQualitystaff.
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Category 1: Leadership
1.1b Communication TheLTcommunicateswithandengagestheworkforceusingtheCommunicationProcess(Figure 1.1-3).AsLOTShasgrown,theCommunicationProcesshasgonethroughmodificationstostaycurrentwithorganizationalneeds.Keydecisionsaredisseminatedtotheentireworkforcethroughvariousmeetingsorelectroniccommunications.Forexample,workforcesurveyfeedbackaboutthemonthlystaffmeetingsresultedinanewformat,anewschedule,andinformation-sharingmechanismsthatwerethensharedviatheCommuni-cationProcess(Figure 1.1-3).CompletionoftheCommunica-tionProcessisaccomplishedthroughknowledgesharingandfeedback,ensuringaclosedcommunicationloop.
Topromotefrank,two-waycommunicationwithemployees,theLTusestheCommunicationProcess,whichsupportsanopen-doorpolicy,andRFO,theconsistentpracticeofaskingspecificquestionstoobtainactionableinformation.LTmem-bers“round”witheachoftheirdirectreportstogainknowl-edge,includingthesupportneededtohelpthestaffmemberachievehis/hergoals,additionalresourceneeds,andpeerrecognition.Thispracticeisalsobeneficialinbuildingrela-tionshipsamongleadersandtheirdirectreportsandensuringthatcommunicationiseffective.Toclosethecommunicationloop,feedbackisprovidedatstaffmeetingsviatheStoplightReport,whichisareportthatcollectsinformationobtainedinroundingandidentifiessuggestions,actionsinprogress,or
1.1 Senior Leadership1.1a Vision and Values1.1a(1) LOTSLS(Figure 1.1-1)providesdirectionforanengagedworkforcethatsuccessfullyfacilitatesorganandtissuedonationinalignmentwiththeVisionandValues (V/V;Figure P.1-1).DuringarecentSPPsession,LOTSreviewedtheV/Voftheorganization.Thisrevalidationprocessincorporatedemployeeinputusinganinternalsurvey.TheV/Vwereupdated,vetted,andratifiedbytheBOD.
TheLTdeploystheV/Vandculturetotheworkforce,aswellastocustomers,stakeholders,partners,andsuppliers,viamultiplecommunicationmechanismsasmanagedbytheCommunicationProcess(Figure 1.1-3).Examplesinclude■ ReviewingandemphasizingtheV/M/Vduringboard,staff,
anddepartmentmeetings■ Incorporatingthestoriesofdonorfamilies,recipients,
andpatientswaitingforatransplantintomultiplecommunicationmethods
TheLTmembersserveasrolemodelsanddemonstratetheircommitmenttothecorevaluesbysettingthecultureviatheLS,includingthroughdailypracticeandduringstaffmeetings,duringdepartmentmeetings,andinconversationsinRoundingforOutcomes(RFO).Leadersprovidepersonalacknowledge-menttoemployeesfordemonstratingbehaviorsconsistentwiththeorganization’scorevalues.TheLTusesa360-degreereviewtoprovidesystematicfeedbacktoallLTmembersfrompeersanddirectreportspertainingtotheleader’sindividualeffectiveness,includingexhibitingbehaviorsconsistentwiththeV/V.ThisreviewprocessalsoprovidestheLTwithindividualopportunitiesforimprovementandisusedtoassesstheeffectivenessoftheLS.TheBODevaluatestheCEO’seffectivenesswithoperatingtheorganizationinalignmentwiththeV/V.
1.1a(2) TheLT’sactionspersonallydemonstratethehigheststandardsofethicalbehaviorbypromotingtheprinciplesandideasreflectedintheV/Vatstaff,worksystem,anddepartmentmeetings,aswellasregularlythroughRFOconversations.TheLTadherestoworkplacepoliciesincludingtheCodeofProfessionalConduct,Donor/RecipientConfi-dentiality,andConflictofInterest(COI)withasignedannualdisclosure.
ThroughtheLOTSCorporateComplianceProgram(CCP;Figure 1.1-2),leaderspromoteanatmospherethatencouragesemployeesandstakeholderstoreportanyquestionablebehav-ior.Ananonymoushotlinereportingsystemisinplacetoensureconfidentiality.TheentireLOTSworkforce,includingtheLTandBOD,istrainedannuallyontheCCPpolicy.Inaddition,compliancepoliciesarereviewedbyLOTSQualitystaff.
Figure 1.1-1: Leadership System (LS)
Enab
led b
y Org
aniza
tiona
l Stru
ctur
e (F
igure
1.2
-2)
Monitor the Performance • Performance Measurement System (Figure 4.1-1)
• Performance Evaluation Process (Figure 5.1-2)
3
Operationalize the Strategy • Communication Process (Figure 1.1-3) • Strategic Planning Process (Figure 2.1-1) • Learning and Development System (Figure 5.2-2) • Operational Management Process (Figure 6.1-1)
2
Create the Environment • V/M/V (Figure P.1-1) • VOC (Figure 3.1-1)
1
1.1b Communication TheLTcommunicateswithandengagestheworkforceusingtheCommunicationProcess(Figure 1.1-3).AsLOTShasgrown,theCommunicationProcesshasgonethroughmodificationstostaycurrentwithorganizationalneeds.Keydecisionsaredisseminatedtotheentireworkforcethroughvariousmeetingsorelectroniccommunications.Forexample,workforcesurveyfeedbackaboutthemonthlystaffmeetingsresultedinanewformat,anewschedule,andinformation-sharingmechanismsthatwerethensharedviatheCommuni-cationProcess(Figure 1.1-3).CompletionoftheCommunica-tionProcessisaccomplishedthroughknowledgesharingandfeedback,ensuringaclosedcommunicationloop.
Topromotefrank,two-waycommunicationwithemployees,theLTusestheCommunicationProcess,whichsupportsanopen-doorpolicy,andRFO,theconsistentpracticeofaskingspecificquestionstoobtainactionableinformation.LTmem-bers“round”witheachoftheirdirectreportstogainknowl-edge,includingthesupportneededtohelpthestaffmemberachievehis/hergoals,additionalresourceneeds,andpeerrecognition.Thispracticeisalsobeneficialinbuildingrela-tionshipsamongleadersandtheirdirectreportsandensuringthatcommunicationiseffective.Toclosethecommunicationloop,feedbackisprovidedatstaffmeetingsviatheStoplightReport,whichisareportthatcollectsinformationobtainedinroundingandidentifiessuggestions,actionsinprogress,or
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suggestionsnottaken.MembersoftheLTreinforcehighperformanceandacustomerandbusinessfocusinmultipleways(Figure 5.2-1, Rewards and Recognition).PersonalnotesofrecognitioncanbewrittenbyanymemberoftheLT,includingtheCEO,toacknowledgespecialachieve-ment.AcustomerandbusinessfocusandmotivationforhighperformancearealsoaccomplishedusingtheCom-municationProcess(Figure 1.1-3).
LocalorgantransplantcentersandtissueprocessorsareLOTS’skeycustomers.TheLTcommunicatesandengageswithitscustomerspertheVOC(Figure 3.1-1).Commu-nicationwithkeycustomersisbasedonone-andtwo-waycommunicationandoccursinallphasesofthecustomerlifecycle.Duetotheconfidentialnatureofdonation,socialmediaarenotusedforoperationalcommunication.Socialmediaareusedforinternalandexternalcommunicationforbroadernonconfidentialmessagingthatdoesnotincorpo-ratedonorinformation.Inaddition,socialmediaareusedtocommunicateandhighlightdonorfamilyandrecipientstoriesviaFacebook,Instagram,andTwitter,reinforcingthemissionofsaving and improving lives .
1.1c Mission and Organizational Performance 1.1c(1) TheLTcreatesasuccessfulorganizationnowandinthefuturethroughtheSPP(Figure 2.1-1)andtheLS (Figure 1.1-1),whichallowafocusontheorganization’splanningandkeyprocessestocreateintegratedworksys-tems.Toensuresustainability,processesaremappedanddocumented,andsuccessionplansaredeveloped;therebyensuringtheenvironmenttoaccomplishLOTS’slife-sav-ingmission.Step1oftheLS(Figure 1.1-1)ensuresthat
Figure 1.1-2: Corporate Compliance Program (CCP)An
nual
Revie
w/Fe
edba
ck R
epor
t
Legend:“1” 5 Proactive; “2” 5 Reactive
CommunitiesWithin DSA
2 Website
Key Suppliers 1 Contracts 2 Anonymous Hotline
Donor Families VOS (Figure 4.2-1)2 Anonymous Hotline
Hospital/Non-Hospital Partners 1 Contract Expectation 2 Anonymous Hotline 2 Website
Transplant Center, Tissue Processor
1 Contract Expectation 1 Physician Code of Professional Conduct 2 Anonymous Hotline 2 Website
BOD, WFAnnual Review & Acknowledgement: 1 Code of Professional Conduct (WF Only) 1 Conflict of Interest 1 Corporate Compliance Training 2 Anonymous Email & 24-Hour Hotline
Core Value: Honesty
Communication Process (1.1-3)
Communication Process (1.1-3)
Figure 1.1-3: Communication Process
Staff Meetings Electronic Means
PublicationsOne-Way Communication
2Work System Meetings Operations Meetings Department Meetings
Two-Way Communication
3
Strategic Operational Discussions Discussions SPP (Figure 2.1-1) OMP (Figure 6.1-1)
Key Decisions
Knowledge Sharing & FeedbackRounding for Outcomes
Electronic Means Relationship Management
VOC (Figure 3.1-1)VOS (Figure 4.2-1)
Two-Way Communications
4
1
2
suggestionsnottaken.MembersoftheLTreinforcehighperformanceandacustomerandbusinessfocusinmultipleways(Figure 5.2-1, Rewards and Recognition).PersonalnotesofrecognitioncanbewrittenbyanymemberoftheLT,includingtheCEO,toacknowledgespecialachieve-ment.AcustomerandbusinessfocusandmotivationforhighperformancearealsoaccomplishedusingtheCom-municationProcess(Figure 1.1-3).
LocalorgantransplantcentersandtissueprocessorsareLOTS’skeycustomers.TheLTcommunicatesandengageswithitscustomerspertheVOC(Figure 3.1-1).Commu-nicationwithkeycustomersisbasedonone-andtwo-waycommunicationandoccursinallphasesofthecustomerlifecycle.Duetotheconfidentialnatureofdonation,socialmediaarenotusedforoperationalcommunication.Socialmediaareusedforinternalandexternalcommunicationforbroadernonconfidentialmessagingthatdoesnotincorpo-ratedonorinformation.Inaddition,socialmediaareusedtocommunicateandhighlightdonorfamilyandrecipientstoriesviaFacebook,Instagram,andTwitter,reinforcingthemissionofsaving and improving lives .
1.1c Mission and Organizational Performance 1.1c(1) TheLTcreatesasuccessfulorganizationnowandinthefuturethroughtheSPP(Figure 2.1-1)andtheLS (Figure 1.1-1),whichallowafocusontheorganization’splanningandkeyprocessestocreateintegratedworksys-tems.Toensuresustainability,processesaremappedanddocumented,andsuccessionplansaredeveloped;therebyensuringtheenvironmenttoaccomplishLOTS’slife-sav-ingmission.Step1oftheLS(Figure 1.1-1)ensuresthat
Figure 1.1-2: Corporate Compliance Program (CCP)An
nual
Revie
w/Fe
edba
ck R
epor
t
Legend:“1” 5 Proactive; “2” 5 Reactive
CommunitiesWithin DSA
2 Website
Key Suppliers 1 Contracts 2 Anonymous Hotline
Donor Families VOS (Figure 4.2-1)2 Anonymous Hotline
Hospital/Non-Hospital Partners 1 Contract Expectation 2 Anonymous Hotline 2 Website
Transplant Center, Tissue Processor
1 Contract Expectation 1 Physician Code of Professional Conduct 2 Anonymous Hotline 2 Website
BOD, WFAnnual Review & Acknowledgement: 1 Code of Professional Conduct (WF Only) 1 Conflict of Interest 1 Corporate Compliance Training 2 Anonymous Email & 24-Hour Hotline
Core Value: Honesty
Communication Process (1.1-3)
Communication Process (1.1-3)
Figure 1.1-3: Communication Process
Staff Meetings Electronic Means
PublicationsOne-Way Communication
2Work System Meetings Operations Meetings Department Meetings
Two-Way Communication
3
Strategic Operational Discussions Discussions SPP (Figure 2.1-1) OMP (Figure 6.1-1)
Key Decisions
Knowledge Sharing & FeedbackRounding for Outcomes
Electronic Means Relationship Management
VOC (Figure 3.1-1)VOS (Figure 4.2-1)
Two-Way Communications
4
1
suggestionsnottaken.MembersoftheLTreinforcehighperformanceandacustomerandbusinessfocusinmultipleways(Figure 5.2-1, Rewards and Recognition).PersonalnotesofrecognitioncanbewrittenbyanymemberoftheLT,includingtheCEO,toacknowledgespecialachieve-ment.AcustomerandbusinessfocusandmotivationforhighperformancearealsoaccomplishedusingtheCom-municationProcess(Figure 1.1-3).
LocalorgantransplantcentersandtissueprocessorsareLOTS’skeycustomers.TheLTcommunicatesandengageswithitscustomerspertheVOC(Figure 3.1-1).Commu-nicationwithkeycustomersisbasedonone-andtwo-waycommunicationandoccursinallphasesofthecustomerlifecycle.Duetotheconfidentialnatureofdonation,socialmediaarenotusedforoperationalcommunication.Socialmediaareusedforinternalandexternalcommunicationforbroadernonconfidentialmessagingthatdoesnotincorpo-ratedonorinformation.Inaddition,socialmediaareusedtocommunicateandhighlightdonorfamilyandrecipientstoriesviaFacebook,Instagram,andTwitter,reinforcingthemissionofsaving and improving lives .
1.1c Mission and Organizational Performance 1.1c(1) TheLTcreatesasuccessfulorganizationnowandinthefuturethroughtheSPP(Figure 2.1-1)andtheLS (Figure 1.1-1),whichallowafocusontheorganization’splanningandkeyprocessestocreateintegratedworksys-tems.Toensuresustainability,processesaremappedanddocumented,andsuccessionplansaredeveloped;therebyensuringtheenvironmenttoaccomplishLOTS’slife-sav-ingmission.Step1oftheLS(Figure 1.1-1)ensuresthat
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LOTSisabletocreateandreinforceanorganizationalculture andincorporatedintotheweb-basedPMS,areakeypiecethatfostersworkforceandcustomerengagement,utilizingthe ofthePMSandarereviewedateachworksystemmeetingCommunicationProcess(Figure 1.1-3)andtheVOCProcess (Figures 4.1-1 and 4.1-2).Seniorleaderaccountabilityforthe(Figure 3.1-1). organization’sactionsisaccomplishedthroughannualgoal
plansreflectedinthePEP(Figure 5.1-2).ReviewoftheworkLOTS’sstrategyisoperationalizedviatheSPP(Figure 2.1-1),systemscorecardsoccursattheworksystemmeetingsandOMP(Figure 6.1-1),andCommunicationProcessensurestheabilitytorecognizetheneedtomodifyorimple-(Figure 1.1-3).TheSPPestablishesstrategicorganizationalmentAPsasprioritieschange.APprogressforalldepartmentsdirection,fromwhichAPsaredeveloped,implemented,andisreviewedatLTmeetings.SystematicreviewsoftheAPs,viamodifiedasneeded.TheOMPisutilizedtoreview,analyze,one-on-onemeetingswithmanagers,providestaffaccount-improve,andprioritizetheorganization’sinternalandabilityandopportunitiestoensurethatorganizationalper-externalprocesses;keystrategicandoperationaldecisionsformanceisprogressingtoplanandthatLOTSisultimatelyarecommunicatedtotheworkforceandkeypartnersviatheattainingitsvision.Forexample,theTissueProcurementCommunicationProcess.Theorganization’sperformanceisDepartmentandthePIstaffworkedcollaborativelyin2018tomonitoredbytheLTusingthePMS(Figure 4.1-1);leader-address“redboxes”fordocumentationcompliance.SeveralshipandemployeeperformanceismonitoredviathePEPinitiativeswerecreatedandimplemented,resultinginprocess(Figure 5.1-2).TheLOTSculture,theV/M/V,andtheLDSandprocedureimprovementsthatresultedinimproved(Figure 5.2-2)createanenvironmentamenabletoemployeedocumentationmetricsthatdidachievetarget.andorganizationallearning.Thecommitmenttothemissionof
saving and improving lives,alongwiththevalueofimprove- Step1oftheannualSPPhelpstheorganizationfocusonment,drivesLOTStostayawareofindustryknowledgeand balancingtheneedsofcustomers,partners,andstakeholders.bestpractices.Individualtraininganddevelopmentgoals ExpectationsarevalidatedbyperiodicsurveysandfocusareaddressedthroughtheongoingPEP.Asdescribedin groups.PerformancemetricsinthePMSrepresentkeyP.1a(2),theLOTScultureencouragesanenvironmentwhere performancemeasuresoftheorganizationandensurebalanceemployeescontinuouslyseekimprovementinordertosave forkeycustomersandstakeholders.andimprovemorelives.
1.2 Governance and Societal ContributionsTheLTcreatesanenvironmentthatencouragesandsupportsimprovement,andthisimprovementismeasuredovertime 1.2a Organizational GovernancewiththekeymetricsontheToplineScorecard(Figure 4.1-2). 1.2a(1) GovernanceoftheorganizationisprovidedbyaIfametricis“inthered”forthreemonths,theresponsible 15-memberBODthatstrategicallyreviewsorganizationalleadermustanalyzeandunderstandwhy,andifthemetric resultstoachievefiscalandmanagementaccountability.continuesbelowthetarget,anewormodifiedAPmustbe TransparencyinoperationsensuresthatLOTSaddressesitsdevelopedtoaddresstheshortfall. responsibilitytothecommunity,exhibitsethicalbehavior,
practicesgoodcitizenship,andprotectsstakeholderinterests.LTmembers,includingtheCEO,developsuccessionplansforLOTS’sdiverseboardreflectskeycustomers,stakeholders,theirpositionstoensurethatappropriateinterimleadershipisandpartnersandisbalancedtopromoteadiversityofinsightsavailableshouldavacancyoccur,aswellasplansforfutureandperspectives.PracticesoftheLOTS’sBODtoreviewandleaderstogrowwithintheorganization.Successionplansareachievekeyaspectsandaccountabilityofgovernanceincludealignedwiththeannualperformanceevaluationstoensurethat
currentandfutureleadersarereceivingtheneededleadership ■ Holdingmanagementaccountableforoperationalresultstrainingtosupporttheirindividualgrowthanddevelopment. throughevaluationofthemonthlyStatusReport,whichA360-degreefeedbackreviewisusedtoidentifyspecific showsSOtargetprogressimprovementopportunitiesforallcurrentleaders.LT ■ Reviewingandapprovingthestrategicplan,budget,Qual-developmenthasincludedtrainingthroughLearningDevel- ityAssessmentandPerformanceImprovement(QAPI),andopmentInstitutes,attendanceatstateandnationalindustry toplinemetricsannuallyconferences,andattendanceatnation-widenon-industry ■ Achievingfiscalaccountabilitybyreviewoffinancialconferences. reports,whicharereviewedindetailatboardmeetings
■ Ensuringtransparencyoftheboardandcommitteeopera-1.1c(2) ThroughtheLS(Figure 1.1-1),theLTcreatesationsthroughtheavailabilityofminutes,presentations,focusonaccomplishingtheorganization’sobjectives,improv-andreportsthatincludequality/regulatoryoutcomes.ingperformance,andachievingtheV/M/V.Step1oftheLSTransparentselectionofgovernanceboardmembersisiscreatingtheenvironment,akeypartoftheorganization’saccomplishedbyactivelysolicitingnominationsfromsuccess.Thisincludesusingthecustomer-focusedandsourcesincludingkeymembersofthecommunityandmission-drivenculturetoseekcontinuousimprovement.membersoftheMedicalAdvisoryBoard,inadditiontoStep2oftheLS(OperationalizetheStrategy)establishesanominationsfromexistingBODmembersandseniorfocusonactions,whicharemonitoredinstep3(Monitortheleaders.COI,corporatecompliancetraining,anddisclosurePerformance).Cascadingscorecards,integratedintoworkstatementsaresignedannuallybyallboardmembers.systems,departments,andmanyindividualmetriclevels
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■ Maintainingindependenceandeffectivenessinaudits ACrisisCommunicationPlanhasbeendevelopedtoensureanthroughanannualexternalaudit.Theauditfirmisengaged appropriateresponsetopublicconcerns,ifneeded.bytheboardAuditCommittee,whichcomprisesinde- Conservationofnaturalresourcesisconsideredthroughpendentboardmembers.Auditresultsarereportedtothe greenbuildingpractices,temperatureandlightconservation,committeealongwithanyrecommendations. recyclingprograms,andassurancethattheenvironmentis
■ Developingandapprovingaformalsuccessionplanfor protectedthrougheffectivebiohazardouswastedisposal.AstheCEO.AuthorityhasbeendelegatedbytheBODtothe anexample,multipleeffortsaremadeacrosstheorganizationCEOtooverseesuccessionplandevelopmentforotherELT toreducepaperusage,includingtheuseofaboardportalmembers. andscreenprojectionofallmeetingdataandthetransitionof
1.2a(2) AsystematicreviewprocessisutilizedbytheBOD’s severalsupportdepartmentstousepaperlesssystems.LOTSCompensationCommitteetoconductanannualreviewofthe preparesforimpactsandconcernsproactivelythrougheffec-CEO’sperformance.Theprocessinputsincludeaself-eval- tivesupply-networkmanagementprocesses,whichincludeauationbytheCEO,areviewoforganizationalperformance secureelectronicdatabaseandestablishedparlevels.metrics,andanonlineevaluationoftheCEObytheBOD.
DuetoLOTS’slife-savingmission,allvoluntaryindustryTheseinputsareusedbytheCompensationCommitteetoaccreditationsaresoughttohelpensureregulatoryandlegaldeveloptheCEO’sperformancereviewand,incollaborationcompliance(Figure P.1-5),aswellasethicalbehavior.ThesewiththeCEO,tosetnewgoalsfortheupcomingyear.ThevoluntaryaccreditationshelpLOTSensurethatprocessesCompensationCommitteeengagesanexternalconsultingfirmmeetorexceedcurrentstandardsandassisttheorganizationtoconductasalarysurvey.Inconjunctionwiththesalarysur-withproactivelyidentifyinganypotentialopportunitiesforveyinformation,acompensationphilosophyandsalaryrangeimprovingprocesses.FeedbackfromtheseaccreditationsisfortheCEOareestablishedbytheCompensationCommittee.incorporatedintotheorganization’sPIprocesses.LOTShasFeedbackfromtheBODandassessmentofthecommitteearereceivedfullaccreditationfromAOPOandAATB.Inaddition,utilizedtoadjustsalarybasedonperformance.LOTShasinternalandexternalauditsscheduledacrossthe
TheCEOconductsannualperformanceevaluationsforthe organizationtoaddressregulatoryrequirementsandtoidentifyELTusingthesamePEPasisusedforevaluationsofthe potentialrisksassociatedwithitsoperations,ensuringthattheLTandtheworkforce.AspartofthePEPprocess,theCEO organizationremainsinastateofreadiness.providestheseleaderswithongoingfeedback,including
Aseriesofinternalandexternalauditsensurecomplianceleadershipeffectivenessandprogresstowardsgoalcompletionwithkeyregulatoryandlegalrequirements,asshownininordertodriveimprovementsinperformance.TheBODFigure 1.2-1.Certainauditfindingsincludeadeviationcompletesself-evaluationsurveysbienniallytodeterminetheformaspartofaformalfeedbackloopandassistLOTSlevelofperformanceofboardmembers,aswellastoidentifywithproactivelyaddressingissuesrelatedtokeycomplianceopportunitiesforimprovement.Thesurveyincludesaself-processes,measures,andgoals.Additionally,theauditspushassessmentoftheirknowledgeandcomfortlevelswithkeytheorganizationtoexceedregulatoryandlegalrequirementsareasofLOTS’soperations;thisfeedbackisusedtodevelopbyservingasmethodsusedforaddressingrisksassociatedaneducationalagendatargetingtheiridentifieddevelopmentwithkeyservicesandoperations(Figures 7.4-4 and 7.4-6).needs(Figure 7.4-2).BoardsurveyresultshelpguideBODAuditfeedbackreportsarereviewedbytheappropriateworkmeetingsandcommunication.groupandsummarizedfortheLTandBOD.Shouldimprove-
1.2b Legal and Ethical Behavior mentsbeidentified,aresponseplanisdevelopedanddeployedviatheOMP(Figure 6.1-1).1.2b(1) Todate,LOTShasnotbeeninvolvedwithany
adverseeventthathadsocietalimpactontheorganization’s 1.2b(2) TheBODandLTpromoteanenvironmentthatservicesandoperations.Historically,nationalindustry fostersandrequireslegalandethicalbehaviorsthroughtheconcernshavefocusedonthesafetyoftheorgansandtissues, CCP (Figure 1.1-2).Furthermore,theorganization’sethicalcoupledwithfairnessintheallocationoforganstorecipients. behaviorstandardsarereflectedinitscorevalueofhonesty.ToLOTSproactivelyapproachesthesepotentialthreatsthrough promoteandensureethicalbehavioracrosstheorganization,strictadherencetopoliciesandprocedures.LOTSleverages allemployeesadheretoaCodeofProfessionalConduct.theOrganizationalStructure(Figure 1.2-2)andutilizesthe LOTS’sCCPisconsistentwithindustrystandards,whichpro-SPP(Figure 2.1-1,Step2)togatherinformationfromavari- videeducation,monitoring,andinvestigationofbreaches.Theetyofsourcestoanticipatelegal,regulatory,andcommunity programprovidesananonymousmechanismfortheworkforceconcerns.Asanexample,theorganizationengagesthegreater andothercustomers,partners,suppliers,andstakeholderstocommunitythroughboardrepresentationofstakeholder reportanynoncomplianceeventsoroccurrences.TheCCPcommunitiesonboththegoverningandadvisoryboards. Officerisresponsibleforinvestigatingcomplaintsandreport-Mediaalertsandpositionstatementscreatedbyindustry ingtotheCEOorBOD’sExecutiveCommittee,ifappropri-organizationsareusedinresponsetonationalnewsstories ate.AlltheelementsoftheCCParereviewedannuallybytheandaredistributedtotheworkforceandBODasappropriate. CorporateGovernance/NominatingCommittee
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society.Thiscanbemeasuredbytheincreaseinthenumberoforganstransplantedandthereductionofdeathsonthelocaltransplantwaitinglist,aswellastheincreasingnumberoftis-suetransplants(Figures 7.1-3 through 7.1-14).Step1oftheannualSPPsessionincludesadiscussionofkeycommunitiestoensurethattheorganizationisresponsivetotheirneedsandrequirements(Figure 2.1-1).
Throughthedesignofitsfacility,whichincludesanenergymanagementsystem,LOTScontributestoenvironmentalwell-being.Theorganizationcontinuestoexplore“green”opportunitiessuggestedbytheworkforce;previousstaffsug-gestionsresultedinaformalizedrecyclingprogramforpaper,plastic,andaluminum,aswellasareductioninhand-outsforstakeholdersbyprovidingdataelectronically.
1.2c(2) TheBODidentifiesLOTS’skeycommunities,andtheLTreviewsandvalidatesthemannuallyaspartoftheSPP(Figure 2.1-1).LOTS’skeycommunitiesincludedonorfami-lies,transplantrecipients,andtheirfamilieswithintheDSA.LOTSsupportsandstrengthenskeycommunitiesinmultipleways.Tosupportdonorfamilies,LOTSconstructedaDonorMemorialMonumentandparkfordonorandrecipientfamiliestogather,remember,andhonortheirlovedones.Inaddition,moreformalwaystohonoradonorfamily’slovedonearememorialeventsinwhichstaffmembersactivelyparticipateateventshostedacrosstheorganization’sDSA.
Figure 1.2-2: Organizational StructureLevel Roles Outcomes
BOD
• ValidateV/M/V• Establishaccountability
• Long-termstrategicdirection
• Organizationalsustainability
Leadership Team
(ELT and LT)
• Createtheenvironment
• Operationalize thestrategy
• Monitortheperformance
• Organizationalculture
• Strategicplandeployment
• People&performancemanagement
Workforce• Supportandfacilitateorgan&tissuedonation
• Maximizedonation
1
2
3
Feed
back
Feed
back
Figure 1.2-1: Key Regulatory and Legal Requirements
Key Regulatory and Legal Requirements
Key Risk Reduction Processes
Measures and Indicators Goals Figures
Compliancewithorganallocation UNOS/OPTNauditsInternalaudits
UNOSorganplacementpolicies
Memberingoodstanding
7.4-5
CompliancewithFDArequirements FDAaudits FDAapproval No adverse findings 7.4-5
Voluntarycompliancetomeetorgandonationindustrystandards
InternalauditsQA/Training
AOPOaccreditation Fullaccreditation 7.4-5
Voluntarycompliancetomeettissuedonationindustrystandards
InternalauditsQA/Training
AATB Fullaccreditation 7.4-5
CompliancewithCMSregulations impactingreimbursement
CMSauditInternalaudit
CMS certification Full certification 7.4-5
CompliancewithIRSregulations impacting not-for-profit organizations
ExternalFinancialaudits Minimalauditadjustments
Unqualified opinion 7.4-4
AOSCorporateComplianceProcess(CCP)
AnnualtrainingacknowledgementReportedhotlineissues
100%CompletionNoEvents
CompliancewithregulationsimpactingHumanResources
EEOCguidelines PolicyCompliance Noeventsoroccurrences
7.4-6
FLSAposted Posting
Safeworkplace Safety officerSafetycommitteeEmployeetraining
OSHAsiteauditsReportableevents
FullcomplianceNoreportableevents
7.4-57.3-7
CompliancewithDORrequirements DORaudit DORapproval No adverse findings 7.4-5
1.2c Societal Contributions1.2c(1) Theaccomplishmentofthemission—we save and improve lives—isLOTS’sgreatestgiftandcontributionto
5
society.Thiscanbemeasuredbytheincreaseinthenumberoforganstransplantedandthereductionofdeathsonthelocaltransplantwaitinglist,aswellastheincreasingnumberoftis-suetransplants(Figures 7.1-3 through 7.1-14).Step1oftheannualSPPsessionincludesadiscussionofkeycommunitiestoensurethattheorganizationisresponsivetotheirneedsandrequirements(Figure 2.1-1).
Throughthedesignofitsfacility,whichincludesanenergymanagementsystem,LOTScontributestoenvironmentalwell-being.Theorganizationcontinuestoexplore“green”opportunitiessuggestedbytheworkforce;previousstaffsug-gestionsresultedinaformalizedrecyclingprogramforpaper,plastic,andaluminum,aswellasareductioninhand-outsforstakeholdersbyprovidingdataelectronically.
1.2c(2) TheBODidentifiesLOTS’skeycommunities,andtheLTreviewsandvalidatesthemannuallyaspartoftheSPP(Figure 2.1-1).LOTS’skeycommunitiesincludedonorfami-lies,transplantrecipients,andtheirfamilieswithintheDSA.LOTSsupportsandstrengthenskeycommunitiesinmultipleways.Tosupportdonorfamilies,LOTSconstructedaDonorMemorialMonumentandparkfordonorandrecipientfamiliestogather,remember,andhonortheirlovedones.Inaddition,moreformalwaystohonoradonorfamily’slovedonearememorialeventsinwhichstaffmembersactivelyparticipateateventshostedacrosstheorganization’sDSA.
Figure 1.2-2: Organizational StructureLevel Roles Outcomes
BOD
• ValidateV/M/V• Establishaccountability
• Long-termstrategicdirection
• Organizationalsustainability
Leadership Team
(ELT and LT)
• Createtheenvironment
• Operationalize thestrategy
• Monitortheperformance
• Organizationalculture
• Strategicplandeployment
• People&performancemanagement
Workforce• Supportandfacilitateorgan&tissuedonation
• Maximizedonation
1
2
3
Feed
back
Feed
back
Figure 1.2-1: Key Regulatory and Legal Requirements
Key Regulatory and Legal Requirements
Key Risk Reduction Processes
Measures and Indicators Goals Figures
Compliancewithorganallocation UNOS/OPTNauditsInternalaudits
UNOSorganplacementpolicies
Memberingoodstanding
7.4-5
CompliancewithFDArequirements FDAaudits FDAapproval No adverse findings 7.4-5
Voluntarycompliancetomeetorgandonationindustrystandards
InternalauditsQA/Training
AOPOaccreditation Fullaccreditation 7.4-5
Voluntarycompliancetomeettissuedonationindustrystandards
InternalauditsQA/Training
AATB Fullaccreditation 7.4-5
CompliancewithCMSregulations impactingreimbursement
CMSauditInternalaudit
CMS certification Full certification 7.4-5
CompliancewithIRSregulations impacting not-for-profit organizations
ExternalFinancialaudits Minimalauditadjustments
Unqualified opinion 7.4-4
AOSCorporateComplianceProcess(CCP)
AnnualtrainingacknowledgementReportedhotlineissues
100%CompletionNoEvents
CompliancewithregulationsimpactingHumanResources
EEOCguidelines PolicyCompliance Noeventsoroccurrences
7.4-6
FLSAposted Posting
Safeworkplace Safety officerSafetycommitteeEmployeetraining
OSHAsiteauditsReportableevents
FullcomplianceNoreportableevents
7.4-57.3-7
CompliancewithDORrequirements DORaudit DORapproval No adverse findings 7.4-5
1.2c Societal Contributions1.2c(1) Theaccomplishmentofthemission—we save and improve lives—isLOTS’sgreatestgiftandcontributionto
1.2c Societal Contributions1.2c(1) Theaccomplishmentofthemission—we save and improve lives—isLOTS’sgreatestgiftandcontributionto
society.Thiscanbemeasuredbytheincreaseinthenumberoforganstransplantedandthereductionofdeathsonthelocaltransplantwaitinglist,aswellastheincreasingnumberoftis-suetransplants(Figures 7.1-3 through 7.1-14).Step1oftheannualSPPsessionincludesadiscussionofkeycommunitiestoensurethattheorganizationisresponsivetotheirneedsandrequirements(Figure 2.1-1).
Throughthedesignofitsfacility,whichincludesanenergymanagementsystem,LOTScontributestoenvironmentalwell-being.Theorganizationcontinuestoexplore“green”opportunitiessuggestedbytheworkforce;previousstaffsug-gestionsresultedinaformalizedrecyclingprogramforpaper,plastic,andaluminum,aswellasareductioninhand-outsforstakeholdersbyprovidingdataelectronically.
1.2c(2) TheBODidentifiesLOTS’skeycommunities,andtheLTreviewsandvalidatesthemannuallyaspartoftheSPP(Figure 2.1-1).LOTS’skeycommunitiesincludedonorfami-lies,transplantrecipients,andtheirfamilieswithintheDSA.LOTSsupportsandstrengthenskeycommunitiesinmultipleways.Tosupportdonorfamilies,LOTSconstructedaDonorMemorialMonumentandparkfordonorandrecipientfamiliestogather,remember,andhonortheirlovedones.Inaddition,moreformalwaystohonoradonorfamily’slovedonearememorialeventsinwhichstaffmembersactivelyparticipateateventshostedacrosstheorganization’sDSA.
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Category 2: Strategy
2.1 Strategy Development BoththeBODandLTfocusonastrategictimeframe;short- termtargetsandobjectivesaretobemetinoneyear,and2.1a Strategy Development Processlong-termtargetsandobjectivesaresetfortwoyears.Instep4
2.1a(1) Throughcyclesoflearning,thefocusofstrategic oftheSPP,focusedstrategicdiscussionsaddresstheperfor-planningevolvedfromaprocessbasedondefiningand manceprojectionsfortheone-andtwo-yeartimehorizonsapprovingactionstosupportthebudget,tothesystematicSPP establishedforkeymetrics.occurringthroughouttheyear,supportedbyAPsandgoal
Anychangesand/orprioritizationofchangeorimprove-achievement.TheOPObusinessecosystemisonethatrequiresmentinitiativesareidentifiedandevaluatedwithintheSPPLOTStobeagiletoensureitsabilitytomeetcustomer(Figure 2.1-1).LOTScapitalizesonitsagilityachievedand,ultimately,recipientneeds.TheSPPinvolvesstrategicthroughtheOrganizationalStructure(Figure 1.2-2)toutilizedevelopment,implementation,anddiscussions,eachofwhichacontinuousSPP (Figure 2.1-1),whichhasseenlearningandconsistsofmultiplesteps(Figure 2.1-1).Currently,partici-improvements.TheLTparticipatesinstrategicdiscussionspantsintheSPPincludetheLT,BODmembers,customers,(SDs)thattakeplaceduringleadershipandworksystemmeet-front-linestaff,keypartners,andkeysuppliers.ings,creatingconsistencyacrosstheSPP.DuringtheseSDs,
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Category 2: Strategy
2.1 Strategy Development2.1a Strategy Development Process2.1a(1) Throughcyclesoflearning,thefocusofstrategicplanningevolvedfromaprocessbasedondefiningandapprovingactionstosupportthebudget,tothesystematicSPPoccurringthroughouttheyear,supportedbyAPsandgoalachievement.TheOPObusinessecosystemisonethatrequiresLOTStobeagiletoensureitsabilitytomeetcustomerand,ultimately,recipientneeds.TheSPPinvolvesstrategicdevelopment,implementation,anddiscussions,eachofwhichconsistsofmultiplesteps(Figure 2.1-1).Currently,partici-pantsintheSPPincludetheLT,BODmembers,customers,front-linestaff,keypartners,andkeysuppliers.
BoththeBODandLTfocusonastrategictimeframe;short- termtargetsandobjectivesaretobemetinoneyear,andlong-termtargetsandobjectivesaresetfortwoyears.Instep4oftheSPP,focusedstrategicdiscussionsaddresstheperfor-manceprojectionsfortheone-andtwo-yeartimehorizonsestablishedforkeymetrics.
Anychangesand/orprioritizationofchangeorimprove-mentinitiativesareidentifiedandevaluatedwithintheSPP(Figure 2.1-1).LOTScapitalizesonitsagilityachievedthroughtheOrganizationalStructure(Figure 1.2-2)toutilizeacontinuousSPP (Figure 2.1-1),whichhasseenlearningandimprovements.TheLTparticipatesinstrategicdiscussions(SDs)thattakeplaceduringleadershipandworksystemmeet-ings,creatingconsistencyacrosstheSPP.DuringtheseSDs,
Figure 2.1-1: Strategic Planning Process (SPP)
Strategic Discussions(Occurs annually at SPP and ongoing)
1. DEFINE
Idea Generation
Key Work Process Design Resource Utilization
2. DEP
LOY
Create, Mod
ify, Im
plem
ent,
and3. M
ONITOR
Organizational Performance
(PMS, PEP)
Commun
icate
Actio
ns
Meetings:
• Leadership • Work System
• Other
Strategy Implementation
Assess & ReviewWorkforce/Succession Planning
Financial Impact AP Selection
DevelopPrioritize and Cascade
Organizational Goals into APs, Ensuring Balance for Partners and
Key Stakeholders
Deploy Strategic PlanCommunicate Strategic Direction
(Fig. 1.1-3)
6 75
8
Meetings:
• Leadership• Work System
• Other
Strategic PlanningStrategy Development
Validate/Revalidate1
Analyze2
IdentifyStrategic Challenges, Advantages, & Opportunities
Current/Future Core CompetenciesStrategic Objectives and Organizational Goals
3
ProjectPerformance for 1–3 years
4
Re-validate Performance Projections
Board of Directors Input
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APsmaybecreated,modified,anddeployedasneeded,and customers.Anexampleoflearningandimprovementisthattheprogress-to-planismonitoredandevaluated,ensuringagil- LOTSaddedtheexpansionofformalinputfromkeypartnersityandoperationalflexibility.Thisongoingcycleofstrategy toincludeadditionalrelevantindustrydatagatheredfromdevelopmentanddeploymenthascreatedastrategicLTthat customerandpartnerorganizationsandprovidedinpresenta-fostersanenvironmentforactionandcontinuousimprovement tionstotheLT.ThesedatamaybecollectedfromindustryortosupportLOTS’slife-savingmission.TheSPPundergoesan nonindustryorganizationalconferences(AATB,AOPO,etc.).annualreviewtoensurethatallelementsareaddressedand Duringstep6(Develop),LOTScascadesorganizationalgoalsthatthemethodsutilizedremainagile,flexible,andeffective intoAPstoaccomplishtheSOs,addresstheSCs,andmakeainrespondingtochangesinthedonationenvironment. finaldeterminationaboutthefeasibilityofaccomplishingthe2.1a(2) Thecommitmenttothemissionof saving and SOsduringthedesiredtimeframe.Throughouttheyear,SDsimproving lives,alongwiththevalueofimprovement,drives includeareviewofrelevantchangesimpactingtheorganiza-LOTStostayonthetopofindustryknowledgeandbest tion’sabilitytoexecutethestrategicplan.TheLOTS’spractices.Operationalimprovementsareidentifiedandimple- strategicplanisfluidandprovidesreviewatmanylevels,mentedthroughtheSPPandtheOMP(Figure 6.1-1). Aspart therebyprovidingtheorganizationtheagilitynecessarytobeoftheimprovementapproach,improvementsuggestionsand abletomodifypreviousstrategiesasneeded.Thisconstantideasareidentifiedthroughmultipleinputsandthenvetted evaluation,monitoredbythePMS(Figure 4.1-1)andfacili-throughtheLTandaPDSAcycle.Thismightincludetheuti- tatedbytheCommunicationProcess(Figure 1.1-3),keepslizationofimprovementteams,comprisingmultidisciplinary theorganizationfocusedonexecutingthestrategicplanwithanddiversedepartmentsandstaff.Theteamsperformdata suitableflexibility.OrganizationalresultsarelinkedtotheSPPreview,and,usingPItoolsincludingPDSA,theycomplete (Figure 2.1-1,Step2),andifAPresultsarenotontargetperbrainstormingandprioritizationsessions.Theimprovement thePMS,actionistakentoaddressthegap.systemhasundergoneseveralcyclesoflearningtoensurethat 2.1a(4) ThedecisiontooutsourceaprocessortomanageitallpartsofthePDSAsystemareidentifiedandactedon. internallyisinitiatedthroughtheSPPandincludesassessmentTheSWOT(Strengths,Weaknesses,Opportunities,and ofmanyfactorsincludingcorecompetencies,businesseco-Threats)listisreviewedduringtheSPP(Step2)andvalidated systemchanges,andchangesinregulation.OngoinganalysisthroughongoingSDs (Step8).Strategicopportunitiesare ofkeysupplierandpartnerexpertiseand/orskillsetsviatheidentifiedinstep3oftheSPPandduringongoingSDsthat OMPprovideskeyinformationtoaidinthedeterminationofpromote“out-of-the-box”thinking.Forthe2018planning whichkeyprocesseswillbeaccomplishedinternallyorexter-cycle,thekeystrategicopportunitiesidentifiedareregistry nally.Forexample,LOTStestedabusinesscasestudytobringenrollmentandcustomersatisfaction. laboratorytestingwithintheorganization.Afterreviewingthe
internalskillsetandfinancialcommitmentrequired,LOTS2.1a(3) Duringstep2(Analyze)oftheSPP,LOTSevaluatesdecidedtocontinuetopartnerwiththeColumbiaUniversityitsstrategicposition.Thisstepalsoincludesreviewofkeyper-Hospital’slaboratorytoperformallinfectiousdiseasetestingformancemeasurementresultsandanenvironmentalscanofandHumanLeukocyteAntigen(HLA)typing.Thisallowsthedonationandtransplantationindustry,aswellastheoverallLOTStofocusonsavingandimprovinglives.healthcareclimateofthecommunity.ThereviewincludesThekeyworksystemsaretheOWSandtheTWS(Figure 2.1-2).■ Keyperformancemeasurementresults(Figure 4.1-1)Worksystemdecisionsaremadeviastep8oftheSPP.■ SWOT;SCsandSAs(Figure P.2-1)Incorporationoforganizationalknowledge,newtechnology,■ BODinput(Figure 1.2-2)productexcellence,andagilityarealsoaccomplishedthrough■ Customer,donorfamily(collaborator),andotherkeytheOMP(Figure 6.1-1).Withinstep3oftheSPP,LOTSstakeholderfeedbackandpreferences(Figure 4.2-1)definesandvalidatesitsSAs,SCs,SOs,currentandfuture■ CurrentandproposedchangestoregulatoryrequirementsCCs,andorganizationalgoalsbasedoncurrentperformance(Figure 1.2-1)andtheenvironmentalscanninganalysiscompletedinstep2.
Followinganalysisofthepresentsituation,whichincludesa AllCCsareassessedtoensurethattheyarebasedonareviewofhistoricaldata,step4involvesthecompletionofa strategicassessmentofmeasurableattributes(7.4b).performanceprojectionexercisetoeffectivelyforecastactivitylevelsforkeyorganizationalmetricsforthenexttwoyears. 2.1b Strategic Objectives
Duringstep3(Identify)oftheannualSPP,LOTScollects 2.1b(1) CriticaltoLOTS’ssustainabilityarethetwostrategicandanalyzesrelevantdatatoassistintheidentificationor objectivesthataremostcriticaltosavinglives:maximizevalidationoftheSCsandSAs,usinginformationgleaned donorsandmaximizestakeholderrelationships.Performancefromstep2.ThisprocessvalidatestheSOsandestablishes projectionsreflectingeffortstoaccomplishtheSOsareestab-theappropriategoalscriticaltothefuturesuccessofthe lishedinstep4oftheSPPandarehighlightedinFigure 2.1-3 .organization.Potentialblindspotsthatlimitgoalachievement LOTShasminimalplannedchangeswithcustomers,markets,ortheaccomplishmentoftheorganization’sSOsareidentified suppliers,andpartners.instep2oftheSPPduringtheenvironmentalscanwithkey
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2.1b(2) TheSOsarecomplementarybynaturetoensureappropriatebalancefororganizationalneeds.TheSOofmaximizingstakeholderrelationshipshelpscreateafocusondrivingcustomerandstakeholdersatisfaction.Theculturealsoempowersthemission-drivenworkforce(CC)tomaximizedonationtoachievetheSOofincreasingorganandtissuedonors.LOTSsupportsitsSOswithorganizationalgoalsandresultingAPsthatleverageitsSAsandCCwhiletacklingitsSCs(Figure 2.1-1,Steps4and5)andstrategicopportunities.
AspartoftheSPP,ongoingSDsbasedoninformationfromthePMS(Figure 4.1-1)provideLOTSwithanopportunitytobalanceshort-andlong-termchallengeswithinanevolvingindustrytoensureadaptabilitytosuddenshifts.Theorganiza-tion’sSOsconsiderandbalancetheneedsofstakeholdersbyleveragingtheorganizationalstructure,worksystemdesign,andgoalprioritizationinstep6oftheSPP(Figure 2.1-1).
2.2 Strategy Implementation2.2a Action Plan Development and Deployment2.2a(1) APdevelopmentbeginsinSDsthroughtheSPPandisacooperativeeffortbetweentheLTandemployees.Throughlearningandimprovement,theorganizationhasmovedfromareactivenaturewheretheLTpushedAPstothestafffollowingtheSPP,toaproactivenaturewheretheLTsolicitsstaffparticipationinSDstoprovideinputintoestab-lishingAPs,thusensuringworkforceownership.Figure 2.1-3 outlinesseveralofthekeyshort-andlong-termorganizationalgoalsthatarecascadedtotheworkforce.SomegoalsarecomplexenoughtowarrantmultipleAPs,whileothersaremaintainedthroughcurrentbusinesspracticesandthereforedonotrequireadditionalAPs.
2.2a(2) StrategyandAPdeploymenttotheworkforce,sup-pliers,andpartnersoccurinstep7oftheSPPandthroughtheCommunicationProcess(Figure 1.1-3).LOTSsustainskey
Figure 2.1-3: Strategic Linkages
SO Organizational Goals2018
(Actual)
2019* 1-year
(short-term)
2020* 2-year
(long-term)
Strategic Challenges/ Advantages
(SC/SA) Results
Max
imiz
e D
onor
s O
WS
AchieveOrganDonorsat110 102 110 120 SC 7.1-3
AchieveOrgansTransplantedat360 352 375 400 SC 7.1-5
AchieveTotalBoneDonorsReleasedat750 755 800 850 SC 7.1-6
Opt
imiz
e St
akeh
olde
r R
elat
ions
hips
T
WS
SustainTransplantCenterSatisfaction 4.81 4 .5 4 .5 SA 7.2-1
SustainTissueProcessorSatisfaction 4.8 4 .5 4 .5 SA 7.2-2
StaffRetentionRate 70% 75% 80% SC 7.3-13*Complete list of APs AOS
Figure 2.1-2: Work System AlignmentRelationship Management
Support DepartmentsORGAN WORK SYSTEM
TISSUE WORK SYSTEMSupport Departments
Relationship Management
Authorization Procurement Allocation Post Donation
2.1b(2) TheSOsarecomplementarybynaturetoensureappropriatebalancefororganizationalneeds.TheSOofmaximizingstakeholderrelationshipshelpscreateafocusondrivingcustomerandstakeholdersatisfaction.Theculturealsoempowersthemission-drivenworkforce(CC)tomaximizedonationtoachievetheSOofincreasingorganandtissuedonors.LOTSsupportsitsSOswithorganizationalgoalsandresultingAPsthatleverageitsSAsandCCwhiletacklingitsSCs(Figure 2.1-1,Steps4and5)andstrategicopportunities.
AspartoftheSPP,ongoingSDsbasedoninformationfromthePMS(Figure 4.1-1)provideLOTSwithanopportunitytobalanceshort-andlong-termchallengeswithinanevolvingindustrytoensureadaptabilitytosuddenshifts.Theorganiza-tion’sSOsconsiderandbalancetheneedsofstakeholdersbyleveragingtheorganizationalstructure,worksystemdesign,andgoalprioritizationinstep6oftheSPP(Figure 2.1-1).
2.2 Strategy Implementation2.2a Action Plan Development and Deployment2.2a(1) APdevelopmentbeginsinSDsthroughtheSPPandisacooperativeeffortbetweentheLTandemployees.Throughlearningandimprovement,theorganizationhasmovedfromareactivenaturewheretheLTpushedAPstothestafffollowingtheSPP,toaproactivenaturewheretheLTsolicitsstaffparticipationinSDstoprovideinputintoestab-lishingAPs,thusensuringworkforceownership.Figure 2.1-3 outlinesseveralofthekeyshort-andlong-termorganizationalgoalsthatarecascadedtotheworkforce.SomegoalsarecomplexenoughtowarrantmultipleAPs,whileothersaremaintainedthroughcurrentbusinesspracticesandthereforedonotrequireadditionalAPs.
2.2a(2) StrategyandAPdeploymenttotheworkforce,sup-pliers,andpartnersoccurinstep7oftheSPPandthroughtheCommunicationProcess(Figure 1.1-3).LOTSsustainskey
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2.1b(2) TheSOsarecomplementarybynaturetoensureappropriatebalancefororganizationalneeds.TheSOofmaximizingstakeholderrelationshipshelpscreateafocusondrivingcustomerandstakeholdersatisfaction.Theculturealsoempowersthemission-drivenworkforce(CC)tomaximizedonationtoachievetheSOofincreasingorganandtissuedonors.LOTSsupportsitsSOswithorganizationalgoalsandresultingAPsthatleverageitsSAsandCCwhiletacklingitsSCs(Figure 2.1-1,Steps4and5)andstrategicopportunities.
AspartoftheSPP,ongoingSDsbasedoninformationfromthePMS(Figure 4.1-1)provideLOTSwithanopportunitytobalanceshort-andlong-termchallengeswithinanevolvingindustrytoensureadaptabilitytosuddenshifts.Theorganiza-tion’sSOsconsiderandbalancetheneedsofstakeholdersbyleveragingtheorganizationalstructure,worksystemdesign,andgoalprioritizationinstep6oftheSPP(Figure 2.1-1).
2.2 Strategy Implementation2.2a Action Plan Development and Deployment2.2a(1) APdevelopmentbeginsinSDsthroughtheSPPandisacooperativeeffortbetweentheLTandemployees.Throughlearningandimprovement,theorganizationhasmovedfromareactivenaturewheretheLTpushedAPstothestafffollowingtheSPP,toaproactivenaturewheretheLTsolicitsstaffparticipationinSDstoprovideinputintoestab-lishingAPs,thusensuringworkforceownership.Figure 2.1-3 outlinesseveralofthekeyshort-andlong-termorganizationalgoalsthatarecascadedtotheworkforce.SomegoalsarecomplexenoughtowarrantmultipleAPs,whileothersaremaintainedthroughcurrentbusinesspracticesandthereforedonotrequireadditionalAPs.
2.2a(2) StrategyandAPdeploymenttotheworkforce,sup-pliers,andpartnersoccurinstep7oftheSPPandthroughtheCommunicationProcess(Figure 1.1-3).LOTSsustainskey
Figure 2.1-3: Strategic Linkages
SO Organizational Goals2018
(Actual)
2019* 1-year
(short-term)
2020* 2-year
(long-term)
Strategic Challenges/ Advantages
(SC/SA) Results
Max
imiz
e D
onor
s O
WS
AchieveOrganDonorsat110 102 110 120 SC 7.1-3
AchieveOrgansTransplantedat360 352 375 400 SC 7.1-5
AchieveTotalBoneDonorsReleasedat750 755 800 850 SC 7.1-6
Opt
imiz
e St
akeh
olde
r R
elat
ions
hips
T
WS
SustainTransplantCenterSatisfaction 4.81 4 .5 4 .5 SA 7.2-1
SustainTissueProcessorSatisfaction 4.8 4 .5 4 .5 SA 7.2-2
StaffRetentionRate 70% 75% 80% SC 7.3-13*Complete list of APs AOS
Figure 2.1-2: Work System AlignmentRelationship Management
Support DepartmentsORGAN WORK SYSTEM
TISSUE WORK SYSTEMSupport Departments
Relationship Management
Authorization Procurement Allocation Post Donation
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outcomesofAPsthroughtrackingandmonitoringviaaweb- 2.2a(5) Keyperformancemeasuresfortrackingtheachieve-basedprogramthatalignsgoalswithindividualperformance mentofAPsandassociatedorganizationalgoalsthatsupportforallmembersoftheworkforcetowardstheaccomplishment theSOsareincludedinthePMSoutputs(Figure 4.1-1).oforganizationalgoals,APs,andalignedSOs.Thestatus TrackingtheeffectivenessofAPsisfurtheraccomplishedofAPsisreviewedbymembersoftheLTandstaffduring throughAPstatusreviewsatLTmeetings.APstatusisalsoroutineone-to-onemeetingsandin-depthattheLTmeetings. reviewedbymanagersintheirrespectiveone-to-onemeetingsThisallowsforstrategyshiftsandresourcere-allocationand withtheirdirectmanagersandwiththeirstaffmembersduringensuresthattheoutcomesofAPscanbesustained.Keyout- RFO.TopromotetransparencyoftheongoingassessmentcomesoftheAPsaremonitoredthroughreviewofthePMS. oforganizationalperformance,APsareupdatedregularlyInaddition,modelingindustrybestpracticesinboththeOWS andarehousedonaweb-basedprogramaccessibletoallandTWS,benchmarkingorganizationalresultstoindustry membersoftheworkforce.Theprioryear’sAPsareassessedhighperformers,andhavingamission-drivenworkforce(CC) forcompletionandeffectivenessandaresummarizedinafurtherdefinetheroadmapforLOTStoaccomplishitsSOs. Q1LTmeeting.ThroughongoingSDs,theLTensuresthat
themeasurementsystem(Figure 4.1-1)coversallkeyareas2.2a(3) Duringstep5oftheSPP,APsarereviewedinofdeploymentandstakeholderrequirements.TheAPsaredetailtoensurealignmentwiththeorganization’sSOsandultimatelymeasuredbytoplineorganizationalperformance.resourceavailability.Workforceplanning(Step5)includesaToplinemeasurescascadethroughoutdepartmentstoansummaryofthecapabilityandcapacity(C&C)discussions,individual’sPEPviaAPstoreinforcealignmentandthewhichprompttheidentificationofadequatecapacityandaccountabilitynecessarytoaccomplishthemissionofLOTSthekeylearninganddevelopmentresourcesneededtodrive(Figure 4.1-2).theaccomplishmentofAPs.Throughadetailedbudgeting
process,amonthlydepartmentalfinancialtrendanalysis,and 2.2a(6) Initialprojectionsareestablishedduringstep4oftheaforecastoffinancialrisk(includinganassessmentofthe SPP,modifiedthroughthebudgetingprocess,andre-validatedfinancialimpactoftheAPsandorganizationalgoals),LOTS withend-of-the-yearoutcomes.Past,present,andprojectedensuresthatadequatefinancialresourcesareavailabletosup- performanceoutcomesandbenchmarksarereviewedthroughportongoingoperationsandnewlydevelopedAPs.Members thePMS.Afterthereview,theLTestablishesone-,two-,andoftheLTparticipateintheprocessofbudgetcreationand three-yearprojectionsthroughtraditionaltrendinganalysis.review;thebudgetisinitiallyapprovedbytheCEO,withfinal Thisassistsintheidentificationofperformancegaps,aidsapprovalbytheBOD. ingoal-setting,andiscriticalgiventhelimitednumberof
publicdatasources.Ifgapsinperformanceareidentified,SDsInstep8(SDs—ongoing)oftheSPP,financialriskandoccur,PItoolsareutilized,APsarecreatedormodified,andviabilityareassessedforcurrentoperationsandobligations.resourcesareallocatedtoaddresstheopportunities.Financialresultsareaffectedbyallocationofcoststhroughthe
CMScostreport.Afinancialstatementispreparedmonthlyfor 2.2b Action Plan ModificationtheLTandBOD.Year-to-datefinancialsarealsopresentedat Systematicreviewsoccurringduringworksystemmeetings,BODmeetings.Riskassessmentincludescostmodelingthe LTmeetings,andongoingSDs(Figure 2.1-1,Step8)providepotentialeffectsofactionsviafinancialstatements,cashflow theopportunitytoidentifyperformancemeasuresthatarelag-projections,andreturnoninvestment(ROI)calculations. gingandtomodifyexistingAPsorcreatenewonesasneeded.2.2a(4) Workforceplansarecapturedwithinstep5(Assess) Scorecardmeasureslaggingoverathree-monthperiodinitiateoftheannualSPPandintheWorkforcePlanningProcess a“red-box”discussionwiththeassociatedLTmembersanda(Figure 5.1-1).Asapartoftheseprocesses,theLTperforms memberfromPI.AdataanalysisandsubsequentAPdeploy-ananalysisofcurrentandfutureneedsandreviewscapacity ment,orAPmodificationforimprovement,maybeperformed,andcapabilityinformationalongwithonboardingandstayand dependingontheoutcomeoftheanalysis.Deploymentofexitinterviewdata.Thesediscussionsdeterminethepotential APsandmodifiedAPsareaccomplishedthroughactionsthatimpactontheworkforce,aswellasworkforceneedsforthe cascadefromtheworksystemordepartmentlevelandmayaccomplishmentoftheshort-andlong-termAPs.Manage- cascadedowntotheindividuallevel.Ongoingmonitoringandmentone-to-onemeetings,RFO,andC&Cdiscussionswith discussionoftheAPsoccurthroughLTmeetings,thePEP,managementrepresentationfromeverydepartmentprovide staffRFO,andworksystemmeetings.ModificationstoAPsLOTSwiththeabilitytoreviewincreasingC&Cneeds,as aretrackedanddiscussedduringLTmeetingstoensurethatwellasanypotentialchangesthatcouldimpacttheworkforce. thedecision-makingprocessiscommunicated.TheabilityTheseongoingSDsandoperationaldiscussions(ODs)aid toeffectivelytrackAPsandtheirmodificationsenablestheinaddressingtraininganddevelopmentneedsrelatedto organizationtoallocateresourceseffectively.workforcecapability,whileassessingthepotentialneedformodificationintheworkforceshoulddemandschange.
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Category 3: Customers
3.1 Customer Expectations asmethodsforlisteningforeachphaseinthecustomerlifecycle,arenotedintheVOCProcess;listeningandlearning3.1a Customer Listeningmethodsarethesameforbothcustomergroups.Learning
3.1a(1) LOTSusesmultipleformalandinformalmechanisms andstrategicimprovementshaveledtoaCustomerSurveytocollect,transfer,andusecustomerinformationtoidentify Process(AOS)thatincorporatesfeedbackreportsandprovidesopportunitiesforimprovementandinnovation.ThisVOC resultstothesurveyparticipantsandthedevelopmentofanyProcess(Figure 3.1-1)incorporatesmethodsforlistening, associatedAPs.LOTSisabletorespondtofeedbackfrominteracting,andobservinglocalorgantransplantcentersand theCustomerSurveyProcessthroughimmediateactionsviatissueprocessorstoobtainactionableinformationthroughout SDsandtheSPP,asillustratedintheCommunicationProcesstheCustomerLifeCycle(Figure 3.2-1).Thevariouslistening (Figure 1.1-3).TheprimarymethodologyusedbyLOTStoandlearningmethodsusedforeachcustomergroup,aswell
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3.1 Customer Expectations3.1a Customer Listening3.1a(1) LOTSusesmultipleformalandinformalmechanismstocollect,transfer,andusecustomerinformationtoidentifyopportunitiesforimprovementandinnovation.ThisVOCProcess(Figure 3.1-1)incorporatesmethodsforlistening,interacting,andobservinglocalorgantransplantcentersandtissueprocessorstoobtainactionableinformationthroughouttheCustomerLifeCycle(Figure 3.2-1).Thevariouslisteningandlearningmethodsusedforeachcustomergroup,aswell
Category 3: Customers
asmethodsforlisteningforeachphaseinthecustomerlifecycle,arenotedintheVOCProcess;listeningandlearningmethodsarethesameforbothcustomergroups.LearningandstrategicimprovementshaveledtoaCustomerSurveyProcess(AOS)thatincorporatesfeedbackreportsandprovidesresultstothesurveyparticipantsandthedevelopmentofanyassociatedAPs.LOTSisabletorespondtofeedbackfromtheCustomerSurveyProcessthroughimmediateactionsviaSDsandtheSPP,asillustratedintheCommunicationProcess(Figure 1.1-3).TheprimarymethodologyusedbyLOTSto
Figure 3.1-1: Voice of the Customer (VOC)
Method
Frequency Life Cycle Phase Customers
M
Mon
thly
O
O
ngoi
ngA
A
nnua
l Q
Q
uart
erly
SA =
Sem
i-Ann
ual
Pre-
Don
atio
n
Donation
Post
-Don
atio
n
Loc
al O
rgan
Tr
ansp
lant
Cen
ters
Tiss
ue P
roce
ssor
s
Proc
urem
ent
Allo
catio
n
Col
lect
(F
igur
e 4.
1-1)
OperationalDiscussions O • • • •Day-to-DayWork/Interactions/DepartmentMeetings O • • • •ParticipationinSPP(Figure 2.1-1) O • • • •BoardofDirectors Q • • • •MedicalAdvisoryBoard SA • •TransplantCenterMeetings SA • • •Surveys O • • • •Audits,Internal/External O • • • •SocialandElectronicMedia O • • • •Figure 1.1-2 Corporate Compliance Program O • • • •Events/CandlelightMemorial/OpenHouse/Receptions O • • • •CAPA/Deviations O • • • •
Tran
sfer
(F
igur
e 1.
1-3)
Best-PracticeSharing O • • • •Scorecards/StatusReports/MetricsOn-Demand O • • • •Meetings,ScheduledandAdHoc O • • • •Survey/ProcessorFeedback O • • • •SocialandElectronicMedia(e.g.,EMR,Facebook,Website,DonorNet)
O • • • •
Util
ize
Figure 2.1-1 SPP O • • • •SurveyFeedback/BaldrigeFeedback/AnnualReport A • • • •CAPA/Deviations Figure 1.1-2 Corporate Compliance Program
O • • • •
AuditFindings O • • • •Best-PracticeSharing O • • • •
Legend: 5 2-way communication; and 1-way communication, in and out, respectively
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obtaincustomerfeedbackistheonlinesurvey.LOTShasan systems.InformationcollectedintheVOC,alongwiththeestablishedwebsiteandsocialmediapresenceonFacebook, analysiscompletedinthePMS,isusedtoassesspotentialVimeo,Twitter,andInstagram.Giventhehighlyregulated businessgrowthopportunities.TheOMPisusedtodeterminenatureofthedonationandtransplantindustry,thereisno whichcustomergroupstoemphasizeforbusinessgrowth.sharingofconfidentialinformationacrosssocialmedia 3.1b(2) LOTSreliesuponitsVOC(Figure 3.1-1)tosites.LOTSfocusessocialmediaeffortsoncommunication determinecustomerneedsandrequirementsfororganandstrategiesthatstrengthentheorganization’sbrand,reinforce tissuedonationservices(Figure P.1-6).Customerrequire-companyculture,andcelebratestakeholdersuccesses. mentsaresolicitedthroughLOTS’sformalCustomerSurveyLOTSseeksactionablefeedbackonthequalityofservicesand Process(AOS),andresultsarevalidatedduringtheSPPcustomersupportviaVOClisteningandlearningmethods, (Figure 2.1-1).Theserequirementsserveascriticalinputsforincludingsurveys,formalandinformalinteractions,and thedesignofworkprocessesandidentificationofopportuni-meetings(Figure 3.1-1).Learningistransferredviamultiple tiesforimprovement.LOTSfocusesonprocessimprovementcommunicationmechanismsthroughtheCommunication effortstoconsistentlymeetandexceedcustomerneedsandProcess(Figure 1.1-3). expectations.
3.1a(2) AsthefederallydesignatedOPOwithinitsservice LOTSfocusesonFindingtheHeroes(Figure P.1-3)andarea,LOTSdoesnothavetraditionalorganprocurement maximizingeachdonationopportunitytoitsfullestpotentialcompetitorsorpotentialcustomers.Transplantcentersexist tomeettheneedsofitscustomers.FormalandinformalVOCwithintheOPO’sDSA,andorgansareallocatedaccordingto mechanismsensurethatrevisedregulationsandopportunitiesUNOS/OPTNthroughtwo-waycommunication.LOTSkeeps arecapturedinODsandSDs,providingorganizationalagilityabreastofpotentialchangesinorgantransplantcenterstatus toincorporateapplicablechangesinmeetingandexceedingutilizingtheCommunicationProcess(Figure 1.1-3)andVOC customerneedsandexpectations.(Figure 3.1-1).Therestrictionofoperatingwithinafederally LeveragingtherobustCommunicationProcess(Figure 1.1-3)designatedterritoryeliminatescompetitionandencourages andworkingwithitscustomerstoidentifyserviceimprove-collaborativeeffortsamongOPOs. mentsandrefinements,LOTSusestheVOC,PMS,andSPPasRelationshipmanagementwithinthesmall,established inputsintotheOMP(Figure 6.1-1).tissueindustryallowsforcontactwithpotential,future, FortheOWS,serviceofferingsinnewmarketsarenotpos-andcompetitorcustomers.Listeningandinteractionsoccur sibleduetotheassignedDSA.TWSnew-customeropportuni-regularlywithpotentialandformercustomersviaindustry ties,expansionofrelationshipswithcurrentcustomers,orconferencesandwebinars,aswellasthroughsurveydata,as newserviceofferingsareidentifiedviatheSPPortheVOCapplicable(Figure 3.1-1).ThesemechanismsallowLOTS Process.LOTS’scommitmenttoimprovementdifferentiatestoobtainactionableinformationonitsservices,customer itsservicesandcreatesopportunitiestoexpandanddeepensupport,andtransactions.Forexample,twoadditionaltissue relationshipswithcurrentcustomers.processorcustomerswereaddedin2017asaresultofprioreffectiverelationshipmanagementandchangesinthetissue 3.2 Customer Engagementmarketplace.
3.2a Customer Relationships and SupportKnowledgesharingandbenchmarkingwithotherOPOsfor 3.2a(1) LOTS’smission-drivenworkforce(CC)developsbothservicelinesallowfortheidentificationofgapsamong andmanagescustomerrelationshipsasoutlinedintheVOCLOTSandhigh-performingpeers.Usingfeedbackonthe (Figure 3.1-1).InformationiscollectedfromcustomersandservicesprovidedbyotherOPOsservesasindirectfeedback transferredintotheSPPandongoingSDs,wheretrending,onthelevelofservicesprovidedbyLOTS.Thisinforma- analysis,andvalidationtakeplace.Validatedinformationistionsupportsoperationalandstrategicdecisionmakingand utilizedtoimprovethelevelofserviceprovidedtocurrentinnovation(4.1a[2]). customers.LOTSleveragesitsbrand,reputation,andperfor-3.1b Customer Segmentation and Product Offerings mancetoacquiretissueprocessorcustomersandbuildmarket
share.Surveysassessingcustomersatisfactionshowthat3.1b(1) TheSPP(Figure 2.1-1)coordinatesinformationLOTSisworkingtoperformatlevelstoensurethatprocessorleveragedthroughmultipleprocessinputstovalidatecurrentsatisfactionismetorexceeded.Forexample,AdvantageLife,customerandanticipatefuturecustomergroupsandmarketaformertissueprocessor,contactedLOTSin2018toresumesegments.InformationgatheredfromtheVOC(Figure 3.1-1)providingtissuedonorsbasedonLOTS’spriorperformanceisalsousedtoidentifyandanticipatemarketsegments.andeffectiverelationshipmanagement.
InformationgatheredthroughthePMS,includingtheVOCTheprovisionofexceptionalserviceallowsLOTStoretaindata,isintegratedwithintheSPP.Knowledgesharingandcustomerswhilemeetingtheirrequirements,exceedingtheirbenchmarkingforbothservicelinesaidintheidentificationexpectations,andincreasingtheirengagementineverystageofgaps(Figure 4.1-4).Thisactionableinformationsupportsofthecustomerlifecycle.TheCustomerSurveyProcessoperationalandstrategicdecisionmakingforbothwork
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includesassessmentstodriveimprovementsinbothsatisfac-tionandengagement.
LOTSusesdataandinformationgatheredthroughsocialmediatohelpenhancetheorganization’sbrandbyraisingawarenessofdonationandtransplantationand,ultimately,drivingitsvisionoforgans and tissues are always available . Asasupplementtotheenvironmentalscanninganalysisperformedduringstep2oftheSPP(Figure 2.1-1),LOTSfollowsthesocialmediapostingsofitscustomersandkeystakeholderstoensureaccesstothelatestdevelopmentsandtocelebratecustomerandpartnersuccesses.Moreover,theorganizationfollowsappropriateindustrynewssourcestoidentifytrendingstoriesoronesgaininginmediaexposure,togeneratetalkingpoints,andtocreatepreparedresponses,asnecessary.Thisincludessocialmediaalertsforseveralkeywordssuchasorganand/ortissuedonationandtrans-plant.Thisadditionalinsightmayassistintheidentificationofnewservicelinesandmarketsegments,including3Dorganprintingandnewprocessingpartners.Inadditiontoenvironmentalscanningandcrisiscommunication,LOTSsupplementsorganizationalstrategiestoincreaseshareratesandfollowerstoitsownsocialmediaoutletsthroughtheidentificationandsharingofvalue-addedcontent.
3.2a(2) LocalorgantransplantcentersandtissueprocessorsareempoweredtoseekinformationandsupportthroughouttheCustomerLifeCycle(Figure 3.2-1),asillustratedintheVOCProcess(Figure 3.1-1).CustomersareabletoconductbusinesswithLOTSviainputsaslistedintheVOCandbyleveragingtheCommunicationProcess(Figure 1.1-3).
Thekeymeansofcustomersupportinbothworksystemsisthefulfillmentofcustomerrequirements(Figure P.1-6).Keycommunicationmechanisms,includingemail,24/7phonecontact,andwebsiteaccessibility,enablecustomerstoseekinformation,receivesupport,andconductbusiness.Methodsofcustomersupportdonotvarybetweencustomers,customergroups,ormarketsegments.
KeycustomersupportrequirementsaredeterminedthroughtheVOC,validatedthroughtheCustomerSurveyProcess(AOS),anddeployedtoallpeopleandprocessesinvolvedincustomersupportviatheCommunicationProcess.TheCustomerSurveyProcesshasundergonelearningandcyclesofimprovement.
3.2a(3) TheLOTSmission-drivenworkforce(CC)isdedicatedtocomplaintresolution,resultinginhighlevelsofcustomersatisfaction(Figures 7.2-1 A–C; 7.2-2; and 7.2-2A–D).AstheinitialstepintheCustomerComplaintProcess(Figure 3.2-2),allstaffmembersaretrainedinservicerecovery.Front-linestaffmembersareempoweredtoimple-mentimmediatecorrectiveactionatthepointofserviceanduseadditionalresourcesifneededtoquicklyresolvecustomer
complaints.ThisprocessallowstheLOTSworkforcetofol-lowupandprovidereal-timefeedbacktosuccessfullyresolvethecomplaint.Complainttrendscontinuetobelow(Figures 7.2-3 and 7.2-3A–B).Iffront-linestaffmembersormanagersarenotabletoresolvethecomplainttosatisfythecustomer,thecomplaintiselevatedtotheELTforresolution.
Localorgantransplantcenterortissueprocessorcomplaintsorpolicy/proceduredeviationsareroutedthroughthecorrec-tiveactionpreventiveaction(CAPA)systemfortrackingandidentifyingrootcausesofthedeviations.TrendanalysisofcustomercomplaintsispresentedatOWS/TWSmeetingsandquarterlyatLTmeetings,anditisincorporatedintotheSPPforprocessimprovements.Thisallowstheorganizationtoavoidsimilarcomplaintsinthefuture.
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complaints.ThisprocessallowstheLOTSworkforcetofol-lowupandprovidereal-timefeedbacktosuccessfullyresolvethecomplaint.Complainttrendscontinuetobelow(Figures 7.2-3 and 7.2-3A–B).Iffront-linestaffmembersormanagersarenotabletoresolvethecomplainttosatisfythecustomer,thecomplaintiselevatedtotheELTforresolution.
Localorgantransplantcenterortissueprocessorcomplaintsorpolicy/proceduredeviationsareroutedthroughthecorrec-tiveactionpreventiveaction(CAPA)systemfortrackingandidentifyingrootcausesofthedeviations.TrendanalysisofcustomercomplaintsispresentedatOWS/TWSmeetingsandquarterlyatLTmeetings,anditisincorporatedintotheSPPforprocessimprovements.Thisallowstheorganizationtoavoidsimilarcomplaintsinthefuture.
includesassessmentstodriveimprovementsinbothsatisfac-tionandengagement.
LOTSusesdataandinformationgatheredthroughsocialmediatohelpenhancetheorganization’sbrandbyraisingawarenessofdonationandtransplantationand,ultimately,drivingitsvisionoforgans and tissues are always available . Asasupplementtotheenvironmentalscanninganalysisperformedduringstep2oftheSPP(Figure 2.1-1),LOTSfollowsthesocialmediapostingsofitscustomersandkeystakeholderstoensureaccesstothelatestdevelopmentsandtocelebratecustomerandpartnersuccesses.Moreover,theorganizationfollowsappropriateindustrynewssourcestoidentifytrendingstoriesoronesgaininginmediaexposure,togeneratetalkingpoints,andtocreatepreparedresponses,asnecessary.Thisincludessocialmediaalertsforseveralkeywordssuchasorganand/ortissuedonationandtrans-plant.Thisadditionalinsightmayassistintheidentificationofnewservicelinesandmarketsegments,including3Dorganprintingandnewprocessingpartners.Inadditiontoenvironmentalscanningandcrisiscommunication,LOTSsupplementsorganizationalstrategiestoincreaseshareratesandfollowerstoitsownsocialmediaoutletsthroughtheidentificationandsharingofvalue-addedcontent.
3.2a(2) LocalorgantransplantcentersandtissueprocessorsareempoweredtoseekinformationandsupportthroughouttheCustomerLifeCycle(Figure 3.2-1),asillustratedintheVOCProcess(Figure 3.1-1).CustomersareabletoconductbusinesswithLOTSviainputsaslistedintheVOCandbyleveragingtheCommunicationProcess(Figure 1.1-3).
Thekeymeansofcustomersupportinbothworksystemsisthefulfillmentofcustomerrequirements(Figure P.1-6).Keycommunicationmechanisms,includingemail,24/7phonecontact,andwebsiteaccessibility,enablecustomerstoseekinformation,receivesupport,andconductbusiness.Methodsofcustomersupportdonotvarybetweencustomers,customergroups,ormarketsegments.
KeycustomersupportrequirementsaredeterminedthroughtheVOC,validatedthroughtheCustomerSurveyProcess(AOS),anddeployedtoallpeopleandprocessesinvolvedincustomersupportviatheCommunicationProcess.TheCustomerSurveyProcesshasundergonelearningandcyclesofimprovement.
3.2a(3) TheLOTSmission-drivenworkforce(CC)isdedicatedtocomplaintresolution,resultinginhighlevelsofcustomersatisfaction(Figures 7.2-1 A–C; 7.2-2; and 7.2-2A–D).AstheinitialstepintheCustomerComplaintProcess(Figure 3.2-2),allstaffmembersaretrainedinservicerecovery.Front-linestaffmembersareempoweredtoimple-mentimmediatecorrectiveactionatthepointofserviceanduseadditionalresourcesifneededtoquicklyresolvecustomer
Figure 3.2-2: Customer Complaint Process
Receive Customer Complaint
Resolve and Provide Feedback to Customer
Track and Trend Complaints
Identify and Implement Improvement
Log Customer Complaint in CAPA System
Referral
Figure 3.2-1: Customer Life Cycle (Phases)
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complaints.ThisprocessallowstheLOTSworkforcetofol-lowupandprovidereal-timefeedbacktosuccessfullyresolvethecomplaint.Complainttrendscontinuetobelow(Figures 7.2-3 and 7.2-3A–B).Iffront-linestaffmembersormanagersarenotabletoresolvethecomplainttosatisfythecustomer,thecomplaintiselevatedtotheELTforresolution.
Localorgantransplantcenterortissueprocessorcomplaintsorpolicy/proceduredeviationsareroutedthroughthecorrec-tiveactionpreventiveaction(CAPA)systemfortrackingandidentifyingrootcausesofthedeviations.TrendanalysisofcustomercomplaintsispresentedatOWS/TWSmeetingsandquarterlyatLTmeetings,anditisincorporatedintotheSPPforprocessimprovements.Thisallowstheorganizationtoavoidsimilarcomplaintsinthefuture.
includesassessmentstodriveimprovementsinbothsatisfac-tionandengagement.
LOTSusesdataandinformationgatheredthroughsocialmediatohelpenhancetheorganization’sbrandbyraisingawarenessofdonationandtransplantationand,ultimately,drivingitsvisionoforgans and tissues are always available . Asasupplementtotheenvironmentalscanninganalysisperformedduringstep2oftheSPP(Figure 2.1-1),LOTSfollowsthesocialmediapostingsofitscustomersandkeystakeholderstoensureaccesstothelatestdevelopmentsandtocelebratecustomerandpartnersuccesses.Moreover,theorganizationfollowsappropriateindustrynewssourcestoidentifytrendingstoriesoronesgaininginmediaexposure,togeneratetalkingpoints,andtocreatepreparedresponses,asnecessary.Thisincludessocialmediaalertsforseveralkeywordssuchasorganand/ortissuedonationandtrans-plant.Thisadditionalinsightmayassistintheidentificationofnewservicelinesandmarketsegments,including3Dorganprintingandnewprocessingpartners.Inadditiontoenvironmentalscanningandcrisiscommunication,LOTSsupplementsorganizationalstrategiestoincreaseshareratesandfollowerstoitsownsocialmediaoutletsthroughtheidentificationandsharingofvalue-addedcontent.
3.2a(2) LocalorgantransplantcentersandtissueprocessorsareempoweredtoseekinformationandsupportthroughouttheCustomerLifeCycle(Figure 3.2-1),asillustratedintheVOCProcess(Figure 3.1-1).CustomersareabletoconductbusinesswithLOTSviainputsaslistedintheVOCandbyleveragingtheCommunicationProcess(Figure 1.1-3).
Thekeymeansofcustomersupportinbothworksystemsisthefulfillmentofcustomerrequirements(Figure P.1-6).Keycommunicationmechanisms,includingemail,24/7phonecontact,andwebsiteaccessibility,enablecustomerstoseekinformation,receivesupport,andconductbusiness.Methodsofcustomersupportdonotvarybetweencustomers,customergroups,ormarketsegments.
KeycustomersupportrequirementsaredeterminedthroughtheVOC,validatedthroughtheCustomerSurveyProcess(AOS),anddeployedtoallpeopleandprocessesinvolvedincustomersupportviatheCommunicationProcess.TheCustomerSurveyProcesshasundergonelearningandcyclesofimprovement.
3.2a(3) TheLOTSmission-drivenworkforce(CC)isdedicatedtocomplaintresolution,resultinginhighlevelsofcustomersatisfaction(Figures 7.2-1 A–C; 7.2-2; and 7.2-2A–D).AstheinitialstepintheCustomerComplaintProcess(Figure 3.2-2),allstaffmembersaretrainedinservicerecovery.Front-linestaffmembersareempoweredtoimple-mentimmediatecorrectiveactionatthepointofserviceanduseadditionalresourcesifneededtoquicklyresolvecustomer
Figure 3.2-2: Customer Complaint Process
Receive Customer Complaint
Resolve and Provide Feedback to Customer
Track and Trend Complaints
Identify and Implement Improvement
Log Customer Complaint in CAPA System
Referral
Figure 3.2-1: Customer Life Cycle (Phases)
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3.2b Determination of Customer Satisfaction and Engagement3.2b(1) Localorgantransplantcenterandtissueprocessorsatisfactionisdeterminedthroughformalsurveyresults(Figures 7.2-1A–C; 7.2-2; and 7.2-2A–D)andpersonalcommunicationandinteractionwithmembersoftheLOTSworkforce(Figure 3.1-1).Themethodstodeterminecus-tomersatisfactionarethesameforallservicelines.Surveydataaresegmentedbymultipledimensions,includingbycustomergroupormarketsegment,thelevelofservicequalityreceived,andcustomerrequirements.CustomersatisfactiondataareanalyzedandsharedviatheCommunicationProcess(Figure 1.1-3)throughSDsatTWS/OWSmeetings,andthefindingsareincorporatedintotheSPP(Figure 2.1-1,Steps2and8).
LOTSusesmultiplemethods,includingsurveys,tocapturecustomerdissatisfactionasshownintheVOC(Figure 3.1-1).LocalorgantransplantcenterandtissueprocessorfeedbackissharedviatheCommunicationProcesswithLOTSstaffandotherstakeholdersandcustomers.ItisalsoreviewedaspartoftheSPP(Figure 2.1-1)andSDsoccurringatworksystemmeetingstoensureactionablefeedbackandprocessimprove-ments.ADeviationandComplaintProcessispartoftheCAPAsystem.DissatisfactiondataaretrendedthroughtheCAPAsystemusingcollecteddeviationand/orcomplaintreports.Thisresultsintheidentificationofrootcausesandactionableitems.TheimplementationoftheFeedbackProcesscreatestheframeworkforanalysisbasedontheservicesprovidedatcertainintervalsintheCustomerLifeCycle(Figure 3.2-1)asitrelatestocustomerrequirements.
LOTSmeasurescustomerengagementbasedonthetheorythatrelationshipstrengthiscorrelatedwithcustomerloyalty,andthatloyaltyisobtainedviathosecustomersthatarehighlysatisfied.Customersatisfaction—or“engagement”—atthehighestlevelisdeterminedvia“top-box”scores—orscoresof5onasurveymeasuringsatisfactiononascalefrom1to5.
ThePMS(Figure 4.1-1)isusedtodefineandcollectkeyper-formanceindicatorsfrombothworksystems.Thesedataare
transferredbackintotheseprocessesintheformofactionableinformationviatheCommunicationProcess,wherethedatacanbeusedtodeliverimprovementstomeetandexceedcus-tomers’expectations,therebysecuringcustomerengagementforthelongterm.Forexample,processorsatisfactionwiththeDonorScreeningProcesswasidentifiedasalow-scoringmetricona2016survey.DiscussionsintheOMPledtothedevelopmentandimplementationofAPsin2017and2018toaddressthegap,resultinginchangesinthewayinforma-tionwasprovidedatscreening.Scoresforprocessoroverallsatisfactionwithdonorscreening,andwiththeinformationprovidedatscreening,werehigherin2017and2018.
3.2b(2) DuetodesignationofitsserviceareabyCMS,LOTSdoesnothavecustomercompetitorsintheOWS.IntheTWS,LOTScollaboratestoobtainindustrybenchmarksoncustomersatisfactionfromotherOPOs(Figure 4.1-4).Processorsprovidemetricsusingindustrycomparisons,whichprovideinformationonkeytissuemetrics.
3.2c Use of Voice-of-the-Customer and Market DataLOTSselectsandcollectsVOCdatathroughmultiplelisten-ing,interaction,andobservationmethodsasindicatedinVOC(Figure 3.1-1).VOCdataareintegratedintothePMS,whichdrivesoperationalandstrategicdecisionmakingthroughtheOMPandSPP,ensuringthatacustomer-focusedcultureexistsintheorganization.Dataaresegmentedbymultipledimensions,includingcustomergroupormarketsegment,thelevelofservicequalityreceived,customerrequirements,andthephaseofthecustomerlifecycle.VOCdataareanalyzedandsharedviatheCommunicationProcess(Figure 1.1-3)throughSDsandatworksystemmeetings.APstobridgegapsinperformanceandminimizecomplaintsaredeployedtoappropriatemembersoftheworkforce(3.1b[1])asanoutputoftheCustomerSurveyProcess(AOS).LOTSusesdataandinformationgatheredthroughsocialmediatohelpenhancetheorganization’sbrandbyraisingawarenessofdonationandtransplantationand,ultimately,drivingitsvisionof organs and tissues are always available.
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Category 4: Measurement, Analysis, and Knowledge Management
4.1 Measurement, Analysis, and Improvement cascadingscorecardsystemandthePEP(Figure 5.1-2).APof Organizational Performance progressistrackedusingaweb-basedperformancemeasure-
mentsystem,andAPsarereviewedatLTmeetingsand4.1a Performance Measurement individuallyduringRFO.Scorecardsuseaseriesoftargets
4.1a(1) LOTSusesthePMS(Figure 4.1-1),whichhas (definedasgoals)tomeasureorganizationalperformanceundergoneacycleoflearning,tomonitorallkeybusiness andprojections,whicharedefinedasannualizedcalculationsanddailyoperationalprocesses.Keyperformancemeasures basedonyear-to-dateand/oractualperformanceinachievingareselected,collected,aligned,andintegratedintheSPP theSOs.Targetsfacilitatethedeterminationoftheappropriate(Figure 2.1-1).TheSPPisthemechanismthattheorganiza- color-codingforallmetrics,allowingreal-timeevaluationtionusestoselectitsSOsandtodevelopgoalssupportedby andtrackingofprogressoftheorganization’sperformance.alignedAPs.Toaccomplishitsmission,LOTSusesthedata TheCommunicationProcess(Figure 1.1-3)deploysandandinformationcollectedfromthePMSasinputsintothe integratesthisinformationacrosstheorganization.TheLTandkeydecision-makingprocesses,SPP,andOMP(Figure 6.1-1). workforceareabletonavigatethecolor-codedscorecardtoCentraltothePMSisanelectronicsystemofcascading enhancedecision-makingeffectivenessandsupportcontinuousscorecards(Figure 5.1-4)startingwiththeToplineScorecard improvement.OncePIstaffmemberspopulateandvalidate(Figure 4.1-2),whichhasthecapabilitytodrilldownthrough theorganization’sscorecards,theymaynotifytheappropriateworksystem-anddepartment-levelscorecards.Informationis managertosetupameetingtoanalyzethedataanddevelopreadilyavailabletoassistintrackingdailyoperationsthrough anAPormodifiedAPifmetricsfallingshortofthetargethavetheDataMall,acentralrepositoryforthePMSthatisavail- beenidentified.Thekeyorganizationalperformancemeasuresabletotheworkforce24/7throughtheLOTSintranet. aretrackedmonthlyandfoundintheToplineScorecardPerformancemeasuresareusedtosupportorganizationaldeci- (Figure 4.1-2).KeyFinancialMeasures(Figure 4.1-3)aresionmakingthroughtheiraggregationandintegrationintothe bothshort-andlong-term.
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Category 4: Measurement, Analysis, and Knowledge Management
4.1 Measurement, Analysis, and Improvement of Organizational Performance4.1a Performance Measurement 4.1a(1) LOTSusesthePMS(Figure 4.1-1),whichhasundergoneacycleoflearning,tomonitorallkeybusinessanddailyoperationalprocesses.Keyperformancemeasuresareselected,collected,aligned,andintegratedintheSPP(Figure 2.1-1).TheSPPisthemechanismthattheorganiza-tionusestoselectitsSOsandtodevelopgoalssupportedbyalignedAPs.Toaccomplishitsmission,LOTSusesthedataandinformationcollectedfromthePMSasinputsintothekeydecision-makingprocesses,SPP,andOMP(Figure 6.1-1). CentraltothePMSisanelectronicsystemofcascadingscorecards(Figure 5.1-4)startingwiththeToplineScorecard(Figure 4.1-2),whichhasthecapabilitytodrilldownthroughworksystem-anddepartment-levelscorecards.InformationisreadilyavailabletoassistintrackingdailyoperationsthroughtheDataMall,acentralrepositoryforthePMSthatisavail-abletotheworkforce24/7throughtheLOTSintranet.
Performancemeasuresareusedtosupportorganizationaldeci-sionmakingthroughtheiraggregationandintegrationintothe
cascadingscorecardsystemandthePEP(Figure 5.1-2).APprogressistrackedusingaweb-basedperformancemeasure-mentsystem,andAPsarereviewedatLTmeetingsandindividuallyduringRFO.Scorecardsuseaseriesoftargets(definedasgoals)tomeasureorganizationalperformanceandprojections,whicharedefinedasannualizedcalculationsbasedonyear-to-dateand/oractualperformanceinachievingtheSOs.Targetsfacilitatethedeterminationoftheappropriatecolor-codingforallmetrics,allowingreal-timeevaluationandtrackingofprogressoftheorganization’sperformance.TheCommunicationProcess(Figure 1.1-3)deploysandintegratesthisinformationacrosstheorganization.TheLTandworkforceareabletonavigatethecolor-codedscorecardtoenhancedecision-makingeffectivenessandsupportcontinuousimprovement.OncePIstaffmemberspopulateandvalidatetheorganization’sscorecards,theymaynotifytheappropriatemanagertosetupameetingtoanalyzethedataanddevelopanAPormodifiedAPifmetricsfallingshortofthetargethavebeenidentified.ThekeyorganizationalperformancemeasuresaretrackedmonthlyandfoundintheToplineScorecard(Figure 4.1-2).KeyFinancialMeasures(Figure 4.1-3)arebothshort-andlong-term.
Figure 4.1-2: Topline Scorecard
2019 Year to Date End-of-Year Projection Last Year
Topline Key Metrics Actual Target % Gap Annualized Year-End Target 2018
First-YearTurnoverRate 22.0% 31.5% 30% 22.0% 31.5% 38%
OrganConversion 58% 60% 23% 58% 60% 58%
OrganDonors 120 125 24% 160 110 150
OrgansTransplanted 335 330 2% 440 375 430
DonorServices AuthorizationRate
55% 55% 0% 55% 55% 53%
BoneDonors 500 520 23.8% 667 800 650
Figure 4.1-1: Performance Measurement System (PMS)
Collect • VOC (Figure 3.1-1) • Comparative DataProcess (Figure 4.1-4)
• Deviations
Transfer • Cascading Scorecards • AP Tracking • Financial Performance • Key Customer Reports
Utilize • LS (Figure 1.1-1) • SPP (Figure 2.1-1) • OMP (Figure 6.1-1) • PEP (Figure 5.1-2) • LDS (Figure 5.2-2)
Define Measures • SPP (Figure 2.1-1) • Comparative DataProcess (Figure 4.1-4)
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performanceregularlyonscorecards.ThesedatasupportoperationaldecisionmakingastheyallowLOTStoassessitssuccessinmeetingtissueprocessorrequirementsandpermittheidentificationofbestpractices.Forexample,whileLOTS’sprocurementeffortsmettheTissueTransformationsrequire-mentforaverageusableskinyieldperdonor,anoperationaldecisionwasmadetoexceedtheprocessorrequirementbyincreasingskinyieldresults.LOTScontactedtheTis-sueTransformationsliaison,discussedbestpractices,andimplementedanewprocessforrecoveringskinthathasledtosizeableimprovements(Figure 7.1-23).
4.1a(3) LOTSformallyreviewsthePMS(Figure 4.1-1)andmodifiesitasappropriateduringtheSPP,ensuringthattheorganizationiscurrentwithaccreditation,regulatory,opera-tional,andfinancialneedsandrequirements.TheorganizationaddressesrapidorunexpectedchangesandtheirimpactonthePMSduringODsandSDsandwithintheworksystemmeetings(Figure 6.1-1).TheformalPDSAimprovementmethodology,inconjunctionwiththeorganizationalstructure(Figure 1.2-2)andongoingSDs,ensuresthattheorganizationisagileandabletorespondquicklytoissuesthatarise.
4.1b Performance Analysis and ReviewTheLTreviewsthekeyorganizationalperformancemea-suresandcapabilitiesduringworksystemmeetingsaspartofODsandduringquarterlyC&Cmeetings.IndividualLTmembersarealsoresponsibleforconductingmonthlyreviewsofworksystemanddepartmentscorecardswithintheirscopeofresponsibilities,asappropriate,withintheOMP(Figure 6.1-1).ComparativeandcustomerdataareinputsintothePMSandareusedtoreviewperformancemetrics.Thesereviewsidentifygapstogoalsandcomparisonstoprovideamechanismtogeneratestepstobringperformancebackontrack,asneeded.PIstaffmembersareresponsiblefordatavalidationandanalysisusingavarietyofstatisticaltools,andtheyworkcollaborativelywithLTmemberstoensureLOTS’sabilitytomeetgoalsandobjectives.ScorecardsanddatareportsarestoredinaDataMallontheintranetthatisaccessible24/7.
LOTSreviewsprogressrelativetotheSOs,keyprocessoutcomemeasures,andAPsduringSDsandthroughtheOMPtoensurethattheorganizationisontargettomeetorexceedthedefinedgoalsandisprogressingtowardsbestinclassinallareas.Organizationalperformance,competitivestanding,financialhealth,andcompletionofSOsandAPsbeginwiththeToplineScorecardandcascadetodepartmentscorecards.ScorecardreviewsprovideamechanismtorapidlyrespondtochangesidentifiedthroughtheSPPorOMP,aswellastoensurechangestoAPsasappropriate,whichmightincludearesponsetoatransformationalchangeinstructureorworksystem.TheworkforceisprovidedwithupdatesonkeyorganizationalmetricsandAPsatvariousmeetings,andtheyhavetheopportunitytoasktheLTquestionsregardingorganizationalperformanceanddirection.
4.1a(2) LOTSusestheComparativeDataProcess(Figure 4.1-4) toselectandeffectivelyusekeycomparativedataandinfor-mationtosupportoperationaldecisionmaking.IntheOWS,nationalregulatoryagenciesselectkeyperformanceindicatorsandestablishperformancethresholdlevelsthatmustbemetbyallOPOsinordertomaintaindesignation.Publishedquarterly,thisinformationisusedtoidentifygapsinperfor-mancebetweenLOTSandhigh-performingpeers.TheOPOCalculatorisagageoforganizationalperformance.ProvidedbytheScientificRegistryofTransplantRecipients(SRTR),thistoolallowsforthemonitoringoflocalorgandonoryieldbycomparingobserved(actual)resultsversuswhatwouldbeexpectedbasedonthenationalexperience(Figure 7.1-19A).Thisinformationisusedinpost-casereviews,SDs,andODs,andgapsinperformanceareaddressedaccordingly.
Duetothelackofastandardnationalprocessoravailabilityofcomparativetissuedata,theselectionofkeyperformanceindicatorsandthedeterminationofperformancethresholdsareestablishedbytissueprocessors.ProcessorstrackOPO
Figure 4.1-4: Comparative Data Process
Evaluation Criteria
Monitor Performance
PMS (Figure 4.1-1)
Define Measures & Comparisons
SPP (Figure 2.1-1)PMS (Figure 4.1-1)
Benchmark Scorecard • AOPO • OPTN/SRTR
• AOPO • Tissue Processors
• AOPO • Board info • DHSS • US DoL
Key Support Processes
TWS
OWS
Figure 4.1-3: Key Financial MeasuresKey Financial Measures
Shor
t Te
rmConsolidatedResultsofOperations 7.5-1
DaysCashonHand 7.5-9
DaysinAccountsReceivable 7.5-5
Lon
g Te
rm OperatingReserves 7.5-8
Total Assets 7.5-10
AverageOACComparison 7.5-12
4.1a(2) LOTSusestheComparativeDataProcess(Figure 4.1-4) toselectandeffectivelyusekeycomparativedataandinfor-mationtosupportoperationaldecisionmaking.IntheOWS,nationalregulatoryagenciesselectkeyperformanceindicatorsandestablishperformancethresholdlevelsthatmustbemetbyallOPOsinordertomaintaindesignation.Publishedquarterly,thisinformationisusedtoidentifygapsinperfor-mancebetweenLOTSandhigh-performingpeers.TheOPOCalculatorisagageoforganizationalperformance.ProvidedbytheScientificRegistryofTransplantRecipients(SRTR),thistoolallowsforthemonitoringoflocalorgandonoryieldbycomparingobserved(actual)resultsversuswhatwouldbeexpectedbasedonthenationalexperience(Figure 7.1-19A).Thisinformationisusedinpost-casereviews,SDs,andODs,andgapsinperformanceareaddressedaccordingly.
Duetothelackofastandardnationalprocessoravailabilityofcomparativetissuedata,theselectionofkeyperformanceindicatorsandthedeterminationofperformancethresholdsareestablishedbytissueprocessors.ProcessorstrackOPO
performanceregularlyonscorecards.ThesedatasupportoperationaldecisionmakingastheyallowLOTStoassessitssuccessinmeetingtissueprocessorrequirementsandpermittheidentificationofbestpractices.Forexample,whileLOTS’sprocurementeffortsmettheTissueTransformationsrequire-mentforaverageusableskinyieldperdonor,anoperationaldecisionwasmadetoexceedtheprocessorrequirementbyincreasingskinyieldresults.LOTScontactedtheTis-sueTransformationsliaison,discussedbestpractices,andimplementedanewprocessforrecoveringskinthathasledtosizeableimprovements(Figure 7.1-23).
4.1a(3) LOTSformallyreviewsthePMS(Figure 4.1-1)andmodifiesitasappropriateduringtheSPP,ensuringthattheorganizationiscurrentwithaccreditation,regulatory,opera-tional,andfinancialneedsandrequirements.TheorganizationaddressesrapidorunexpectedchangesandtheirimpactonthePMSduringODsandSDsandwithintheworksystemmeetings(Figure 6.1-1).TheformalPDSAimprovementmethodology,inconjunctionwiththeorganizationalstructure(Figure 1.2-2)andongoingSDs,ensuresthattheorganizationisagileandabletorespondquicklytoissuesthatarise.
4.1b Performance Analysis and ReviewTheLTreviewsthekeyorganizationalperformancemea-suresandcapabilitiesduringworksystemmeetingsaspartofODsandduringquarterlyC&Cmeetings.IndividualLTmembersarealsoresponsibleforconductingmonthlyreviewsofworksystemanddepartmentscorecardswithintheirscopeofresponsibilities,asappropriate,withintheOMP(Figure 6.1-1).ComparativeandcustomerdataareinputsintothePMSandareusedtoreviewperformancemetrics.Thesereviewsidentifygapstogoalsandcomparisonstoprovidea
mechanismtogeneratestepstobringperformancebackontrack,asneeded.PIstaffmembersareresponsiblefordatavalidationandanalysisusingavarietyofstatisticaltools,andtheyworkcollaborativelywithLTmemberstoensureLOTS’sabilitytomeetgoalsandobjectives.ScorecardsanddatareportsarestoredinaDataMallontheintranetthatisaccessible24/7.
LOTSreviewsprogressrelativetotheSOs,keyprocessoutcomemeasures,andAPsduringSDsandthroughtheOMPtoensurethattheorganizationisontargettomeetorexceedthedefinedgoalsandisprogressingtowardsbestinclassinallareas.Organizationalperformance,competitivestanding,financialhealth,andcompletionofSOsandAPsbeginwiththeToplineScorecardandcascadetodepart-mentscorecards.ScorecardreviewsprovideamechanismtorapidlyrespondtochangesidentifiedthroughtheSPPorOMP,aswellastoensurechangestoAPsasappropri-ate,whichmightincludearesponsetoatransformationalchangeinstructureorworksystem.TheworkforceisprovidedwithupdatesonkeyorganizationalmetricsandAPsatvariousmeetings,andtheyhavetheopportunitytoasktheLTquestionsregardingorganizationalperformanceanddirection.
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performanceregularlyonscorecards.ThesedatasupportoperationaldecisionmakingastheyallowLOTStoassessitssuccessinmeetingtissueprocessorrequirementsandpermittheidentificationofbestpractices.Forexample,whileLOTS’sprocurementeffortsmettheTissueTransformationsrequire-mentforaverageusableskinyieldperdonor,anoperationaldecisionwasmadetoexceedtheprocessorrequirementbyincreasingskinyieldresults.LOTScontactedtheTis-sueTransformationsliaison,discussedbestpractices,andimplementedanewprocessforrecoveringskinthathasledtosizeableimprovements(Figure 7.1-23).
4.1a(3) LOTSformallyreviewsthePMS(Figure 4.1-1)andmodifiesitasappropriateduringtheSPP,ensuringthattheorganizationiscurrentwithaccreditation,regulatory,opera-tional,andfinancialneedsandrequirements.TheorganizationaddressesrapidorunexpectedchangesandtheirimpactonthePMSduringODsandSDsandwithintheworksystemmeetings(Figure 6.1-1).TheformalPDSAimprovementmethodology,inconjunctionwiththeorganizationalstructure(Figure 1.2-2)andongoingSDs,ensuresthattheorganizationisagileandabletorespondquicklytoissuesthatarise.
4.1b Performance Analysis and ReviewTheLTreviewsthekeyorganizationalperformancemea-suresandcapabilitiesduringworksystemmeetingsaspartofODsandduringquarterlyC&Cmeetings.IndividualLTmembersarealsoresponsibleforconductingmonthlyreviewsofworksystemanddepartmentscorecardswithintheirscopeofresponsibilities,asappropriate,withintheOMP(Figure 6.1-1).ComparativeandcustomerdataareinputsintothePMSandareusedtoreviewperformancemetrics.Thesereviewsidentifygapstogoalsandcomparisonstoprovideamechanismtogeneratestepstobringperformancebackontrack,asneeded.PIstaffmembersareresponsiblefordatavalidationandanalysisusingavarietyofstatisticaltools,andtheyworkcollaborativelywithLTmemberstoensureLOTS’sabilitytomeetgoalsandobjectives.ScorecardsanddatareportsarestoredinaDataMallontheintranetthatisaccessible24/7.
LOTSreviewsprogressrelativetotheSOs,keyprocessoutcomemeasures,andAPsduringSDsandthroughtheOMPtoensurethattheorganizationisontargettomeetorexceedthedefinedgoalsandisprogressingtowardsbestinclassinallareas.Organizationalperformance,competitivestanding,financialhealth,andcompletionofSOsandAPsbeginwiththeToplineScorecardandcascadetodepartmentscorecards.ScorecardreviewsprovideamechanismtorapidlyrespondtochangesidentifiedthroughtheSPPorOMP,aswellastoensurechangestoAPsasappropriate,whichmightincludearesponsetoatransformationalchangeinstructureorworksystem.TheworkforceisprovidedwithupdatesonkeyorganizationalmetricsandAPsatvariousmeetings,andtheyhavetheopportunitytoasktheLTquestionsregardingorganizationalperformanceanddirection.
4.1a(2) LOTSusestheComparativeDataProcess(Figure 4.1-4) toselectandeffectivelyusekeycomparativedataandinfor-mationtosupportoperationaldecisionmaking.IntheOWS,nationalregulatoryagenciesselectkeyperformanceindicatorsandestablishperformancethresholdlevelsthatmustbemetbyallOPOsinordertomaintaindesignation.Publishedquarterly,thisinformationisusedtoidentifygapsinperfor-mancebetweenLOTSandhigh-performingpeers.TheOPOCalculatorisagageoforganizationalperformance.ProvidedbytheScientificRegistryofTransplantRecipients(SRTR),thistoolallowsforthemonitoringoflocalorgandonoryieldbycomparingobserved(actual)resultsversuswhatwouldbeexpectedbasedonthenationalexperience(Figure 7.1-19A).Thisinformationisusedinpost-casereviews,SDs,andODs,andgapsinperformanceareaddressedaccordingly.
Duetothelackofastandardnationalprocessoravailabilityofcomparativetissuedata,theselectionofkeyperformanceindicatorsandthedeterminationofperformancethresholdsareestablishedbytissueprocessors.ProcessorstrackOPO
Figure 4.1-4: Comparative Data Process
Evaluation Criteria
Monitor Performance
PMS (Figure 4.1-1)
Define Measures & Comparisons
SPP (Figure 2.1-1)PMS (Figure 4.1-1)
Benchmark Scorecard • AOPO • OPTN/SRTR
• AOPO • Tissue Processors
• AOPO • Board info • DHSS • US DoL
Key Support Processes
TWS
OWS
Figure 4.1-3: Key Financial MeasuresKey Financial Measures
Shor
t Te
rmConsolidatedResultsofOperations 7.5-1
DaysCashonHand 7.5-9
DaysinAccountsReceivable 7.5-5
Lon
g Te
rm OperatingReserves 7.5-8
Total Assets 7.5-10
AverageOACComparison 7.5-12
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TheBODreviewstheorganization’sperformancebyreview-ingtheToplineScorecardandmonthlyfinancialstatements.TheCEOreportsongapsinperformance;progressisalsoreportedonachievingstrategicSOsandAPs.
4.1c Performance Improvement4.1c(1) Theorganization’sfutureperformanceisprojectedthroughtheanalysisofthree-year,historical,organizationaltrenddataandindustrytrendstoidentifygapsandareasofopportunity.Thisanalysiscreatesshort-andlong-termprojectionsthatareutilizedinthePMS(Figure 4.1-1)andPEP(Figure 5.1-2).Identifyingtop-decileperformancefromcomparativeorganizationsforkeymeasurescreatesabenchmarkandacourseofactionforimprovementefforts,asapplicable.Ifindicated,APsarecreatedtoreplicatethetop-decileperformanceofcomparativeorganizations.Thecollegialnatureoftheindustrycreatesanenvironmentforopendialogueforsharingthenecessarystepstoreplicatebenchmarkresultsdemonstratedbyotherorganizations.
Reconciliationofdifferencesbetweenprojectionsoffutureperformance(4.1[b])andperformanceprojections(2.2[b])occursthroughthePMS.
4.1c(2) LOTSutilizesthesystematicreviewofperformancedataintheOMP(Figure 6.1-1)toidentifyopportunitiesforimprovementandinnovationinthein-processandoutcomemeasures.Thesefindingsformthefoundationfortheorganiza-tion’scontinuousimprovementapproach.DiscussionintheOMPalsoprovidesopportunitiesforidentifyingpossibleimprovementsorinnovations.Ifindicated,ateammaybeiden-tifiedtolookatpossibleopportunities.TheteamdevelopsideasthatarevettedthroughtheLTforprioritizationanddisposition.ApprovedplansaredeployedviatheCommunicationProcess.Directorsandmanagersdeploytheprioritiesandopportunitiestomembersoftheirrespectivedepartmentsandworkgroups.Incorporationofaprojectreportatstaffmeetings,usingtheCommunicationProcess,reinforcesthedepartmentalandworkgroupdiscussions.Whenappropriate,prioritiesandopportuni-tiesareidentified,andorganizationalAPsaredeployedtoLOTS’ssuppliersandpartnersthroughtheOMP.
4.2 Information and Knowledge Management4.2a Data and Information4.2a(1) LOTS’spoliciesandproceduresaddressaccuracyfromtheinitialreferral,throughtheorganization’sworksystems,totheallocationoforgansandtissues.Clinicalinfor-mationisenteredintoTransplantTechnology,anelectronicsoftwaresystemthatnowhasseveralbuilt-inaccuracyanderror-proofingcheckpoints.Forkeynonelectronicdata,LOTSensuresaccuracyandintegritythroughmanualvalidationofreportsandauditsofcriticalinformation.Forexample,uponcasecompletion,bothelectronicandnonelectronicdataarevalidatedthroughchartreviewbytheQualitySystems(QS)departmenttoensureaccuracy.QSstaffmembersconductmonthlyaudits,ensuringasystematicapproachforexisting
processevaluationandfeedback.Validity,integrity,reliability,currency,andconfidentiality(Figure 1.1-2)ofelectronicdataandinformationareensuredthroughthemethodslistedin6.2b.
4.2a(2) Dataandinformationavailabilityiscriticaltotheabilityoftheworkforcetocarryoutthemissiontosavelives.Becausemanyemployeesworkoff-site,electronicsystemsareusedtoensurethatstaffmembershaveaccesstocriticaldataandinformation.Toensureuser-friendlyaccesswhilekeepingallconfidentialdatasecure,thecorporateintranetmayonlybeaccessedremotelyviaadirectaccesssoftware.Becausethestaffaccessandinputdatafromaremotelocation,theEMRisaccessiblewhereverwebaccessisavailable.Laptopsareissuedwithpassword-protected,encrypted,diskpartitionstoprotectdatafromcompromiseintheeventoftheftand/orloss.Thetimelinessofdataiscrucialtotheprocessesfordonationandtransplantation.TheTransplantTechnologysystemcreatesreal-timeaccesstodonationactivityfortheworkforceandpartners.Togainneededaccess,datanotstoredinTransplantTechnologycanbeobtainedthroughmultiplemethodsinclud-ingtelephone,fax,email,andtheDataMall.
LOTSprovidesinformationtotheworkforce,partners,sup-pliers,customers,andcollaboratorsusingtheCommunicationProcess(Figure 1.1-3).Inaddition,LOTSprovidesinforma-tiontocustomersthroughreal-timeaccesstotheTransplantTechnologysystemforread-onlyinformation.TransplantTechnologyclinicaldataareuploadedintoanationaldatabase,DonorNet.Thesedataareusedbyregulatorybodiesandorganizationswithintheindustryforcollaboration.Accesstosuchcriticaldatahasimprovedturn-aroundanddecision-makingtimeforLOTS’spartners.TissueprocessorscanaccesscriticaldatathroughadedicatedSharePointportalandcanreceivereal-timedataviaXMLtransferfromTransplantTechnology.TherequirementsforkeysuppliersarecapturedannuallythroughtheSPPandongoingSDs.Currently,therearenooperationalrequirementsforsupplierstobelinkedwithLOTS’sdatainformationsystems(IS).Informationanddataaremadeavailabletosuppliersviaelectronicmeans,conferencecalls,andin-personmeetings,asappropriate.Throughcyclesoflearningandstrategicimprovement,beforeimplementationofnewsoftwareand/orhardware,ausercom-mitteeisformedtoensurethatthesoftwareand/orhardwareisuser-friendly,accessible,andfunctional.
4.2b Organizational KnowledgeLOTSreliesonelectronicmeans,aswellaspersonalcom-munication,tomanageinformationandorganizationalknowledge.TheorganizationisabletocapitalizeontheaccessibleOrganizationalStructure(Figure 1.2-2)throughtheSPP(Figure 2.1-1)andtheOMP(Figure 6.1-1).Thesesystemsworktogethertosynthesizeinformationandturnitintoknowledgethatcanbeusedtoinnovateandmanageworksystemsandprocesses.
4.2b(1) LOTScollectsinformationfrompeople,processes,andtheenvironmentthroughelectronicandnonelectronic
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methodsviathePMS(Figure 4.1-1),whichfeedsintotheOMPwhereSDsorODsoccurandinformationisanalyzedandtranslatedintoactions.TheLDS(Figure 5.2-2)andtheCommunicationProcess(Figure 1.1-3)demonstratehowjob-relatedknowledgeisdisseminated.Transferofworkforceknowledgereadilyoccursduetothealignmentofthework-forceintoworksystems.Multidisciplinarymeetingswithintheworksystemsensurethatconsistentmessagesandinformationareshared.One-on-oneRFOconversationsamongstaffmem-bersandtheirdirectmanagersensurethattheorganizationbenefitsfromtheknowledgeassetsoftheworkforce.Ideas
andinformationgatheredthroughthesystematicdeploymentofRFOaresharedwiththeworkforceatstaffmeetingsviaaStoplightReport.Theintranetservesasa24/7vehicletodisseminateinformationtoadecentralizedworkforce.LOTSreportsorganizationalinformationthroughthePMSandanalyzesittocreateknowledgeusingtheSPP,SDs,andtheOMP(Figure 6.1-1).
AsevidencedinthesecondstepofthePMS,avarietyofdatatypesarecollectedfromcustomersviatheVOC(Figure 3.1-1)andremainingstakeholdergroups(Figure 4.2-1),inadditiontoclinicalinformationcapturedthroughtheorganization’s
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methodsviathePMS(Figure 4.1-1),whichfeedsintotheOMPwhereSDsorODsoccurandinformationisanalyzedandtranslatedintoactions.TheLDS(Figure 5.2-2)andtheCommunicationProcess(Figure 1.1-3)demonstratehowjob-relatedknowledgeisdisseminated.Transferofworkforceknowledgereadilyoccursduetothealignmentofthework-forceintoworksystems.Multidisciplinarymeetingswithintheworksystemsensurethatconsistentmessagesandinformationareshared.One-on-oneRFOconversationsamongstaffmem-bersandtheirdirectmanagersensurethattheorganizationbenefitsfromtheknowledgeassetsoftheworkforce.Ideas
andinformationgatheredthroughthesystematicdeploymentofRFOaresharedwiththeworkforceatstaffmeetingsviaaStoplightReport.Theintranetservesasa24/7vehicletodisseminateinformationtoadecentralizedworkforce.LOTSreportsorganizationalinformationthroughthePMSandanalyzesittocreateknowledgeusingtheSPP,SDs,andtheOMP (Figure 6.1-1).
AsevidencedinthesecondstepofthePMS,avarietyofdatatypesarecollectedfromcustomersviatheVOC(Figure 3.1-1)andremainingstakeholdergroups(Figure 4.2-1),inadditiontoclinicalinformationcapturedthroughtheorganization’s
Figure 4.2-1: Voice of the Stakeholder (VOS)
Method
Frequency Collaborators Partners Suppliers InternalA
A
nnua
l M
M
onth
ly
O
Ong
oing
Q
Q
uart
erly
W
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eekl
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Don
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amili
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ral H
omes
Don
or H
ospi
tals
Non
-Hos
pita
l R
efer
ral S
ourc
es
Gua
rdia
n
Wri
ght B
roth
ers
TT
Tran
spla
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ech.
Col
umbi
a C
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atio
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Boa
rd o
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ecto
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Wor
kfor
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Col
lect
(F
igur
e 4.
1-1)
OperationalDiscussions O • • • • • • • • •
SupplierMeetings Q,W • • • • • •
StrategicDiscussions O • • • • • • • •
ParticipationinSPP (Figure 2.1-1) O • • • • • • • •
Rounding/PEP (Figure 5.1-2) / LDS (Figure 5.2-2)
O •
Surveys O • • • • • • •
Audits,Internal/External O • • • • • • • • •
SocialandElectronicMedia O • • • • • • •
CorporateComplianceProcess (Figure 1.1-2)
O • • • • • • • • •
Contracts O • • • • • • • • •
CAPA/Deviations O • • • • • • • • •
Tran
sfer
(F
igur
e 1.
1-3)
BestPracticeSharing O • • • • • •
Scorecards/StatusReports/ MetricsOn-Demand
O • • • • • • • • •
SurveyFeedbackReports A,O • • • • • • • •
SOPs/SharePoint/Intranet/Email O • • •
Util
ize
StrategicPlanningProcess (Figure 2.1-1)
O • • • • • • • • • • •
SurveyFeedback/ BaldrigeFeedback/AnnualReport
A • • • • • • • • • •
CAPA/Deviations/CorporateComplianceProcess (Figure 1.1-2)
O • • • • • • • • • • •
BestPracticeSharing O • • • • • • • • • •
OMP (Figure 6.1-1) O • • • • • • • • • • •
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EMR(TransplantTechnology).Forexample,combiningtheSRTRdatawiththeTransplantTechnologydatatoanalyze2018organyielddataprovidedinformationaboutthequalityof2018donorsthatwasusedtovalidatefutureperformanceprojections.AvarietyofmechanismsfoundintheOMPareusedtotransferrelevantknowledgetocustomers,suppliers,partners,andcollaborators.ThePMSservesasthebasisfortheknowledgeassemblytointegrateintotheOMPandSPP.TheseprocessesinvolvedetaileddataanalysisdevelopedincollaborationwiththePIstaff.ImprovementinitiativesarepresentedatLTmeetingstoensuretransferofknowledgeandhelpdriveimprovementandinnovationthroughouttheorganization.Step3ofthePMSensuresthetransferoforganizationalawarenessandknowledge.
4.2b(2) ThescorecardsandComparativeDataProcesswithinthePMS(Figure 4.1-1)providetheorganization’sworkforcewithtoolstomonitororganizationalperformance,includingidentificationofbestpractices.Performancereviewdata,whichincludeevidenceofhighperformancewithinorganizationalunitsandbestpractices,aresharedacrosstheorganizationinSDsviatheSPP,OMP,andCommunicationProcess.Implementationofbestpracticesisaccomplished
throughthedevelopmentofAPsandongoingmonitoringofthePMSforsuccess.Forexample,theCommunicationCenterdepartment’sorganauthorizationratefor2018(Figure 7.1-17)exceededallpreviousrecords.Best-practiceidentificationincludedmonitoringmonthlygapsinperformanceattheindividuallevelandtheuseofadepartmentmanagertosup-portandretrainstrugglingindividuals,aswellasidentificationofbestpractices.InformationonthebestpracticeswassharedattheOWS/TWSmeetings,whichcontributedtothehiringofacombinedTWS/OWStrainer.
4.2b(3) LOTShasanumberofprocessesinplacetoensurethatlearningisembeddedintheorganization.TheprimarymechanismforthisistheLDS(Figure 5.2-2),whichisalignedandintegratedwithmultipleorganizationalprocesses.Specificprocessesincluderegulartrainingofferingsinresponsetostafffeedbackandorganizationalgaps,andper-sonallearninggoalsforstaffmembers.Knowledgesharingisastandingagendaiteminworksystemmeetings.Forexample,animprovementteamwasusedtoincreasesatisfactionwithstaffmeetings,whichresultedintheadditionofmanagerreport-outsandaQ/AsessionwiththeCEOateachmeeting.
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Category 5: Workforce
5.1 Workforce Environment5.1a Workforce Capability and Capacity5.1a(1) WorkforceC&CisassessedthroughtheWorkforcePlanningProcess(Figure 5.1-1).Theorganizationhasidenti-fiedtheskillsandcompetenciesthatareneededtoperformeachrolewithintheorganizationsuccessfully.Tobetterdefinecapability,LOTSidentifiesnecessaryskillsinjobdescrip-tions,andjobcompetenciesaremonitoredthroughthePEP(Figure 5.1-2).LOTScontinuallyevaluatestheneedfornewcompetenciesthroughmultipleinputmechanisms,includingtheSPP(Figure 2.1-1),RFO,LDS(Figure 5.2-2),andC&Cmeetings.Inaddition,theneedforvariouscertificationsisdiscussedduringtheHiringProcess(Figure 5.1-3)asacondi-tionofemployment,ifapplicable,andisincludedinthejobdescriptionfortherole.Afterhiring,thecertificationrequire-ments,ifapplicable,arediscussedthroughthecommunicationcycleanddocumentedintheemployee’strainingfile.
LOTSsystematicallyassessesstaffinglevelsbysolicitingfeedbackthroughRFO,ongoingSDsatworksystemmeetings,LTmeetings,ELTmeetings,andC&Cdiscussions.UsingthePMS,LOTSforecastsstaffingneedsintheSPP(Figure 2.1-1).TheSPPassistswithprojectingpotentialstaffingneedsoneyearout,ensur-ingaright-sizedworkforcefortheorganization.Asanexample,intheCommunicationCenterdepartment,thecapabilitytoprovideongoingsupportandtrainingforstaffmembersapproachingfamilieswasidentifiedasadepartmentneed.OngoingSDsandC&Cmeetingsledtotheadditionofatrainertothedepartmentin2016.SubsequentC&CmeetingsandSDsledtothetransitionofthetrainertoamanager/trainerinearly2018.TheresultingorganauthorizationratefortheCommunicationCenterfor2018wasthehighestinorganizationalhistory(Figure 7.1-17).
5.1a(2) LOTSusestheHiringProcess(Figure 5.1-3)torecruit,hire,place,andretainnewworkforcemembers.Validatedintheworkforcesurvey(AOS),LOTS’smissionisthehighestscoringkeyfactorforstaffengagementandsatisfaction(Figures 7.3-12 and 7.3-12A).Therefore,hiringright-fittalentbeginspriortoemploymentbyensuringthattheorganizationalcultureiscleartoallapplicants(Figure 5.1-3,Phase1).Toensurethattheworkforcerepresentsthediverseculturesofthecommunity,LOTSusesdiverserecruitingmethods,includinglocalcommunitycollegesanduniversities,aswellassocialmediasites.Donorfamiliesandrecipientsarealsoconsideredforappropriatepositionswithintheorganization.Theseindividualsreflectthethinkingofthe
organization’skeycommunitiesbyalreadypossessingastrongconnectiontothemission.Thefitoforganizationalculturewithnewstaffisensuredthroughseveralhiringandonboard-ingprocessesincludingshadowingandbehavioral-basedinterviewingpractices.
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Category 5: Workforce
5.1 Workforce Environment5.1a Workforce Capability and Capacity5.1a(1) WorkforceC&CisassessedthroughtheWorkforcePlanningProcess(Figure 5.1-1).Theorganizationhasidenti-fiedtheskillsandcompetenciesthatareneededtoperformeachrolewithintheorganizationsuccessfully.Tobetterdefinecapability,LOTSidentifiesnecessaryskillsinjobdescrip-tions,andjobcompetenciesaremonitoredthroughthePEP(Figure 5.1-2).LOTScontinuallyevaluatestheneedfornewcompetenciesthroughmultipleinputmechanisms,includingtheSPP(Figure 2.1-1),RFO,LDS(Figure 5.2-2),andC&Cmeetings.Inaddition,theneedforvariouscertificationsisdiscussedduringtheHiringProcess(Figure 5.1-3)asacondi-tionofemployment,ifapplicable,andisincludedinthejobdescriptionfortherole.Afterhiring,thecertificationrequire-ments,ifapplicable,arediscussedthroughthecommunicationcycleanddocumentedintheemployee’strainingfile.
LOTSsystematicallyassessesstaffinglevelsbysolicitingfeedbackthroughRFO,ongoingSDsatworksystemmeetings,LTmeetings,ELTmeetings,andC&Cdiscussions.UsingthePMS,LOTSforecastsstaffingneedsintheSPP(Figure 2.1-1).TheSPPassistswithprojectingpotentialstaffingneedsoneyearout,ensur-ingaright-sizedworkforcefortheorganization.Asanexample,intheCommunicationCenterdepartment,thecapabilitytoprovideongoingsupportandtrainingforstaffmembersapproachingfamilieswasidentifiedasadepartmentneed.OngoingSDsandC&Cmeetingsledtotheadditionofatrainertothedepartmentin2016.SubsequentC&CmeetingsandSDsledtothetransitionofthetrainertoamanager/trainerinearly2018.TheresultingorganauthorizationratefortheCommunicationCenterfor2018wasthehighestinorganizationalhistory(Figure 7.1-17).
5.1a(2) LOTSusestheHiringProcess(Figure 5.1-3)torecruit,hire,place,andretainnewworkforcemembers.Validatedintheworkforcesurvey(AOS),LOTS’smissionisthehighestscoringkeyfactorforstaffengagementandsatisfaction(Figures 7.3-12 and 7.3-12A).Therefore,hiringright-fittalentbeginspriortoemploymentbyensuringthattheorganizationalcultureiscleartoallapplicants(Figure 5.1-3,Phase1).Toensurethattheworkforcerepresentsthediverseculturesofthecommunity,LOTSusesdiverserecruitingmethods,includinglocalcommunitycollegesanduniversities,aswellassocialmediasites.Donorfamiliesandrecipientsarealsoconsideredforappropriatepositionswithintheorganization.Theseindividualsreflectthethinkingofthe
Figure 5.1-1: Workforce Planning Process
SPP (Figure 2.1-1) │ RFO │ C&C │ LDS (Figure 5.2-2)
Data analysis
Determine appropriate action
Right-size workforce Hire/Reduce/Realign or train
Prioritize & select needs to address
Communicate the action (Figure 1.1-3)
PMS
│ SD
s
organization’skeycommunitiesbyalreadypossessingastrongconnectiontothemission.Thefitoforganizationalculturewithnewstaffisensuredthroughseveralhiringandonboard-ingprocessesincludingshadowingandbehavioral-basedinterviewingpractices.
Figure 5.1-2: Performance Evaluation Process (PEP)
VMV
(1)Goal Setting During SPP Figure 2.1-1
(2)Goal &
AP Updates
(3)Annual
Evaluations with LT & Staff
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Category 5: Workforce
5.1 Workforce Environment5.1a Workforce Capability and Capacity5.1a(1) WorkforceC&CisassessedthroughtheWorkforcePlanningProcess(Figure 5.1-1).Theorganizationhasidenti-fiedtheskillsandcompetenciesthatareneededtoperformeachrolewithintheorganizationsuccessfully.Tobetterdefinecapability,LOTSidentifiesnecessaryskillsinjobdescrip-tions,andjobcompetenciesaremonitoredthroughthePEP(Figure 5.1-2).LOTScontinuallyevaluatestheneedfornewcompetenciesthroughmultipleinputmechanisms,includingtheSPP(Figure 2.1-1),RFO,LDS(Figure 5.2-2),andC&Cmeetings.Inaddition,theneedforvariouscertificationsisdiscussedduringtheHiringProcess(Figure 5.1-3)asacondi-tionofemployment,ifapplicable,andisincludedinthejobdescriptionfortherole.Afterhiring,thecertificationrequire-ments,ifapplicable,arediscussedthroughthecommunicationcycleanddocumentedintheemployee’strainingfile.
LOTSsystematicallyassessesstaffinglevelsbysolicitingfeedbackthroughRFO,ongoingSDsatworksystemmeetings,LTmeetings,ELTmeetings,andC&Cdiscussions.UsingthePMS,LOTSforecastsstaffingneedsintheSPP(Figure 2.1-1).TheSPPassistswithprojectingpotentialstaffingneedsoneyearout,ensur-ingaright-sizedworkforcefortheorganization.Asanexample,intheCommunicationCenterdepartment,thecapabilitytoprovideongoingsupportandtrainingforstaffmembersapproachingfamilieswasidentifiedasadepartmentneed.OngoingSDsandC&Cmeetingsledtotheadditionofatrainertothedepartmentin2016.SubsequentC&CmeetingsandSDsledtothetransitionofthetrainertoamanager/trainerinearly2018.TheresultingorganauthorizationratefortheCommunicationCenterfor2018wasthehighestinorganizationalhistory(Figure 7.1-17).
5.1a(2) LOTSusestheHiringProcess(Figure 5.1-3)torecruit,hire,place,andretainnewworkforcemembers.Validatedintheworkforcesurvey(AOS),LOTS’smissionisthehighestscoringkeyfactorforstaffengagementandsatisfaction(Figures 7.3-12 and 7.3-12A).Therefore,hiringright-fittalentbeginspriortoemploymentbyensuringthattheorganizationalcultureiscleartoallapplicants(Figure 5.1-3,Phase1).Toensurethattheworkforcerepresentsthediverseculturesofthecommunity,LOTSusesdiverserecruitingmethods,includinglocalcommunitycollegesanduniversities,aswellassocialmediasites.Donorfamiliesandrecipientsarealsoconsideredforappropriatepositionswithintheorganization.Theseindividualsreflectthethinkingofthe
Figure 5.1-1: Workforce Planning Process
SPP (Figure 2.1-1) │ RFO │ C&C │ LDS (Figure 5.2-2)
Data analysis
Determine appropriate action
Right-size workforce Hire/Reduce/Realign or train
Prioritize & select needs to address
Communicate the action (Figure 1.1-3)
PMS
│ SD
s
organization’skeycommunitiesbyalreadypossessingastrongconnectiontothemission.Thefitoforganizationalculturewithnewstaffisensuredthroughseveralhiringandonboard-ingprocessesincludingshadowingandbehavioral-basedinterviewingpractices.
Figure 5.1-2: Performance Evaluation Process (PEP)
VMV
(1)Goal Setting During SPP Figure 2.1-1
(2)Goal &
AP Updates
(3)Annual
Evaluations with LT & Staff
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5.1a(3) LOTSpreparestheworkforceforchangesinC&CneedsthroughtheWorkforcePlanningProcess(Figure 5.1-1).InformationaboutchangingC&Crequirementsandneeds,includingworkforcegrowth,isgatheredthroughseveralmethodsincludingC&CmeetingsandRFO.ThroughtheWorkforcePlanningProcess,LOTSmanagestheneedsoftheworkforceandtheorganization,ensurescontinuity,preventsworkforcereductions,andconsidersperiodsofgrowth(2.2a[4]).Additionally,theHiringProcess(Figure 5.1-3)supportscontinuitybyencouragingpromotionfromwithin,aswellascross-trainingforapplicableroles,wheneverpossible.Shouldaworkforcereduction,periodofgrowth,orchangeinorganizationalstructureorworksystemberequired,qualita-tiveorquantitativeinformationfromthePMS(Figure 4.1-1)wouldbeusedtoconductaseriesofSDstodetermineappropriateaction.Suchactionmightincluderecruitment,contingencyplanningforremainingstaff,orpotentialreas-signmentorexitstrategyforaffectedstaff.
5.1a(4) LOTSorganizesandmanagesitsworkforceattheindividual,keyprocess,andworksystemlevelsthroughsystematiccascadingofgoals/scorecards(Figure 5.1-4).
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TheLTprovidesworksystemoversightandstrategicdirectionthroughtheLS(Figure 1.1-1),whichservesasthefoundationforkeydecisionmaking.
Systematiccascadingofgoals/scorecardsreinforcesacustomerandbusinessfocus.ThereinforcementofcustomerandbusinessneedsisapriorityandismanagedbytheLS,whichincorporatesapproachesforcreatingtheenvironment,operationalizingthestrategy,andmonitoringtheorganiza-tion’sperformance.ThisapproachbeginswiththeHiringProcess(Figure 5.1-3),whichensuresthatthebestcandidatesarehiredandfitwiththeLOTScultureofamission-drivenworkforce(CC).TheintegrationoftheLDS(Figure 5.2-2)withtheLSreinforcestheV/M/Vandprovidestrainingforperformingdailytasksandmeetingcustomerneeds.Workforcemembersareempoweredtomakedecisionsforthepromptresolutionofcustomerconcerns.Theseeffortsleadtocompetenceinthedeliveryofservice,whichallowstheorganizationtomeetandexceedcustomersatisfactionandtostrengthenloyalty(Figure 7.2-4).
TheSPP(Figure 2.1-1)createsfocus,establishespriori-ties,andsetsexpectationsfortheworkoftheorganization,whileongoingperformanceismonitoredthroughthePMS( Figure 4.1-1)andPEP(Figure 5.1-2).Performanceexpecta-tionsarereinforcedthroughSDs,RFO,andPEP.Organiza-tionalgoalrangesareestablishedtodefinehowemployeescanexceedexpectations.Ongoingdiscussionsaresupportedthroughaweb-basedPEPsystemthatusestargetsforAPstocreateanawarenessofhoweachmemberoftheworkforcecanmeetandexceedexpectationsandsubsequentlyberewardedthroughmultiplemechanisms.Organizationaltransparencyandaccountabilityareensuredthroughtheweb-basedsystem,allowingeachmemberoftheworkforcetomonitorallstaffprogresstowardsgoals.
5.1a(3) LOTSpreparestheworkforceforchangesinC&CneedsthroughtheWorkforcePlanningProcess(Figure 5.1-1).InformationaboutchangingC&Crequirementsandneeds,includingworkforcegrowth,isgatheredthroughseveralmethodsincludingC&CmeetingsandRFO.ThroughtheWorkforcePlanningProcess,LOTSmanagestheneedsoftheworkforceandtheorganization,ensurescontinuity,preventsworkforcereductions,andconsidersperiodsofgrowth(2.2a[4]).Additionally,theHiringProcess(Figure 5.1-3)supportscontinuitybyencouragingpromotionfromwithin,aswellascross-trainingforapplicableroles,wheneverpossible.Shouldaworkforcereduction,periodofgrowth,orchangeinorganizationalstructureorworksystemberequired,qualita-tiveorquantitativeinformationfromthePMS(Figure 4.1-1)wouldbeusedtoconductaseriesofSDstodetermineappropriateaction.Suchactionmightincluderecruitment,contingencyplanningforremainingstaff,orpotentialreas-signmentorexitstrategyforaffectedstaff.
5.1a(4) LOTSorganizesandmanagesitsworkforceattheindividual,keyprocess,andworksystemlevelsthroughsystematiccascadingofgoals/scorecards(Figure 5.1-4).
Figure 5.1-3: Hiring Process
Workforce Needs IdentifiedCapability and capacity meetings
Position/Opportunity Posted
Phase 1Initial interview with HR
Phase 2Interview with hiring manager/point person
Applicants Identified
Selection • Manager & HR decide best-fit candidate
• Reference check completed
• Conditional offer made
Phase 3Peer interview
Candidate Not Selected
• External: Notify • Internal: Provide developmental feedback
Employee Hired
Figure 5.1-4: Examples of Cascading Goals
Goal: Increase Local Organs Transplanted
Front-line Workforce Level • Educate partners
Director Level • Build relationships w/transplant partners • Review cases
SO: Maximize Donation
OPC/Front-line Workforce Level • Donor management protocols • Follow allocation processes
SPP SPP
TheLTprovidesworksystemoversightandstrategicdirectionthroughtheLS(Figure 1.1-1),whichservesasthefoundationforkeydecisionmaking.
Systematiccascadingofgoals/scorecardsreinforcesacustomerandbusinessfocus.ThereinforcementofcustomerandbusinessneedsisapriorityandismanagedbytheLS,whichincorporatesapproachesforcreatingtheenvironment,operationalizingthestrategy,andmonitoringtheorganiza-tion’sperformance.ThisapproachbeginswiththeHiringProcess(Figure 5.1-3),whichensuresthatthebestcandidatesarehiredandfitwiththeLOTScultureofamission-drivenworkforce(CC).TheintegrationoftheLDS(Figure 5.2-2)withtheLSreinforcestheV/M/Vandprovidestrainingforperformingdailytasksandmeetingcustomerneeds.Workforcemembersareempoweredtomakedecisionsforthepromptresolutionofcustomerconcerns.Theseeffortsleadtocompetenceinthedeliveryofservice,whichallowstheorganizationtomeetandexceedcustomersatisfactionandtostrengthenloyalty(Figure 7.2-4).
TheSPP(Figure 2.1-1)createsfocus,establishespriori-ties,andsetsexpectationsfortheworkoftheorganization,whileongoingperformanceismonitoredthroughthePMS(Figure 4.1-1)andPEP(Figure 5.1-2).Performanceexpecta-tionsarereinforcedthroughSDs,RFO,andPEP.Organiza-tionalgoalrangesareestablishedtodefinehowemployeescanexceedexpectations.Ongoingdiscussionsaresupportedthroughaweb-basedPEPsystemthatusestargetsforAPstocreateanawarenessofhoweachmemberoftheworkforcecanmeetandexceedexpectationsandsubsequentlyberewardedthroughmultiplemechanisms.Organizationaltransparencyandaccountabilityareensuredthroughtheweb-basedsystem,allowingeachmemberoftheworkforcetomonitorallstaffprogresstowardsgoals.
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TheLTprovidesworksystemoversightandstrategicdirectionthroughtheLS(Figure 1.1-1),whichservesasthefoundationforkeydecisionmaking.
Systematiccascadingofgoals/scorecardsreinforcesacustomerandbusinessfocus.ThereinforcementofcustomerandbusinessneedsisapriorityandismanagedbytheLS,whichincorporatesapproachesforcreatingtheenvironment,operationalizingthestrategy,andmonitoringtheorganiza-tion’sperformance.ThisapproachbeginswiththeHiringProcess(Figure 5.1-3),whichensuresthatthebestcandidatesarehiredandfitwiththeLOTScultureofamission-drivenworkforce(CC).TheintegrationoftheLDS(Figure 5.2-2)withtheLSreinforcestheV/M/Vandprovidestrainingforperformingdailytasksandmeetingcustomerneeds.Workforcemembersareempoweredtomakedecisionsforthepromptresolutionofcustomerconcerns.Theseeffortsleadtocompetenceinthedeliveryofservice,whichallowstheorganizationtomeetandexceedcustomersatisfactionandtostrengthenloyalty(Figure 7.2-4).
TheSPP(Figure 2.1-1)createsfocus,establishespriori-ties,andsetsexpectationsfortheworkoftheorganization,whileongoingperformanceismonitoredthroughthePMS( Figure 4.1-1)andPEP(Figure 5.1-2).Performanceexpecta-tionsarereinforcedthroughSDs,RFO,andPEP.Organiza-tionalgoalrangesareestablishedtodefinehowemployeescanexceedexpectations.Ongoingdiscussionsaresupportedthroughaweb-basedPEPsystemthatusestargetsforAPstocreateanawarenessofhoweachmemberoftheworkforcecanmeetandexceedexpectationsandsubsequentlyberewardedthroughmultiplemechanisms.Organizationaltransparencyandaccountabilityareensuredthroughtheweb-basedsystem,allowingeachmemberoftheworkforcetomonitorallstaffprogresstowardsgoals.
5.1a(3) LOTSpreparestheworkforceforchangesinC&CneedsthroughtheWorkforcePlanningProcess(Figure 5.1-1).InformationaboutchangingC&Crequirementsandneeds,includingworkforcegrowth,isgatheredthroughseveralmethodsincludingC&CmeetingsandRFO.ThroughtheWorkforcePlanningProcess,LOTSmanagestheneedsoftheworkforceandtheorganization,ensurescontinuity,preventsworkforcereductions,andconsidersperiodsofgrowth(2.2a[4]).Additionally,theHiringProcess(Figure 5.1-3)supportscontinuitybyencouragingpromotionfromwithin,aswellascross-trainingforapplicableroles,wheneverpossible.Shouldaworkforcereduction,periodofgrowth,orchangeinorganizationalstructureorworksystemberequired,qualita-tiveorquantitativeinformationfromthePMS(Figure 4.1-1)wouldbeusedtoconductaseriesofSDstodetermineappropriateaction.Suchactionmightincluderecruitment,contingencyplanningforremainingstaff,orpotentialreas-signmentorexitstrategyforaffectedstaff.
5.1a(4) LOTSorganizesandmanagesitsworkforceattheindividual,keyprocess,andworksystemlevelsthroughsystematiccascadingofgoals/scorecards(Figure 5.1-4).
Figure 5.1-3: Hiring Process
Workforce Needs IdentifiedCapability and capacity meetings
Position/Opportunity Posted
Phase 1Initial interview with HR
Phase 2Interview with hiring manager/point person
Applicants Identified
Selection • Manager & HR decide best-fit candidate
• Reference check completed
• Conditional offer made
Phase 3Peer interview
Candidate Not Selected
• External: Notify • Internal: Provide developmental feedback
Employee Hired
Figure 5.1-4: Examples of Cascading Goals
Goal: Increase Local Organs Transplanted
Front-line Workforce Level • Educate partners
Director Level • Build relationships w/transplant partners • Review cases
SO: Maximize Donation
OPC/Front-line Workforce Level • Donor management protocols • Follow allocation processes
SPP SPP
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5.1b Workforce Climate5.1b(1) LOTSsystematicallyassessesworkplaceenviron-mentalfactorstoensureandimproveworkforcehealthbyusingacomprehensivewellnessprogram.Componentsofthiscomprehensivewellnessprogramincludeexceptionalhealthinsurancepackages,$20/monthreimbursementtowardswellness-relatedexpenses,no-costwellnessscreenings(Figure 7.3-5)andflushots,24/7accesstoanemployeeassistanceprogram,andotherhealthopportunities.Workplaceenvironmentaldifferencesarenotpertinentforthesebenefits;theseprogramsencourageemployeestobecomemoreproac-tiveinimprovingtheiroverallhealth.
Toensureandimproveworkforcesecurity(Figure 7.3-9),LOTSmaintainsasafefacilitycompletewithautomaticlockingdoorsand24/7videosurveillance.Badgesarerequiredforentryintoalltheworkareasofthefacility,withlevelsofrestrictionbasedonjobfunction.Toensureasecureworkplaceenvironment,policyrequiresallvisitorstosigninandbeescortedbyanemployeethroughthebuilding.Toensureworkplacesecurityforemployeeswhoworkindifferentworkplaceenvironments,includingatareahospitals,employeesarerequiredtoadheretothatsite’suniquesecuritymeasures.LOTShastakenadditionalmeasurestoensurethesecurityoftheworkforcebyofferingpersonalalarmstoallstaffmembers.TraininginCPR,workplaceviolenceresponse,anddefensivedrivingclassesarealsoprovided.
LOTSensuresworkplaceaccessibilitybymaintaininganAmericanswithDisabilitiesAct(ADA)-compliantfacilitywithhandicapentranceoptions.Moreover,LOTSisanequalopportunityemployerandmaintainsrealisticandflexibleexpectationsregardingtheimportanceofreasonableaccom-modations.Toguaranteetechnologicalworkplaceaccessibil-ity,LOTSprovidesallemployeeswithITtrainingtoensuretheirunderstandingoftheITsystems.
Asamplelistingofperformancemeasuresforworkforcehealth,security,andworkplaceaccessibilitycanbefoundinWorkplaceEnvironment(Figure 5.1-5)andWorkforcePreparedness(Figure 7.3-6).Theseperformancemeasuresaredesignedtoprovideaworkenvironmentconducivetosupport-ingtheLOTSworkforcetoaccomplishthemission.
5.1b(2) FocusingontheCCofamission-drivenworkforce,LOTSmaintainsaworkforcephilosophyof“We take care of ‘Our People’ so they can take care of others.”Tomeettheneedsofadiverseworkforce,multiplebenefitsplanoptionsareavailablewithdistinctionswithintheservices,benefits,andpoliciesdependentonworkforcedemographics,includingtenureandperformance.
Thesupportiveworkenvironmentincludesmultifacetedhealth,financial,andschedulingoptionsandbenefits.Theworkforceservices,benefits,andpoliciesareassessedintheworkforcesurvey.LOTShasmanyservicesasapartofitswellnessinitiativethatareavailabletoallemployees,includ-inghealthscreenings,flushots,ahealthcoach,voluntary
smokingcessationprograms,optionalflexiblescheduling,andanemployeeassistanceprogram,whichisavailabletostaffmembersaswellastheirfamilymembers.
LOTSsupportsitsworkforcebyprovidingacomprehensiveinsurancebenefitpackagetoallfull-timeemployees;thepackageincludesthreemedicalplanoptions,aswellasdentalandvisionplans,onatiered-costplatform.Employeescanselectthebestplantomeettheirmedical,financial,andfamilyneeds.Theorganizationalpoliciesthatsupporttheworkforceincludeagenerouspaidtime-off(PTO)plan,ExtendedMedi-calBank(EMB)plan,paidholidays,andtuitionassistance.Benefitswithfinancialimpactsmayvarybasedonstafftype,lengthofservice,andperformance.Agenerous401kplan,whichincludesadiscretionarycontribution,isprovidedtoalleligiblestaffmembers.EmployeeswhochoosetheEmployeeKeyRequirement(EKR)ofbenefitsinthe2017staffsurveyscoredtheirsatisfactionat85%,meetingtheindustrycompar-ative(Figure 7.3-15).TheseworkforcebenefitsandpoliciesenableLOTStostrengthenitsCCoffullyengagedworkforcememberswhoaremotivatedtofulfillitsmissiontosaveandimprovemorelives.
5.2 Workforce Engagement5.2a Assessment of Workforce Engagement 5.2a(1) ThekeydriversofworkforceengagementaredeterminedthroughcustomizedworkforcesurveysdevelopedbySurveySystemSuccess.From2008through2014,theengagementelementsincludedintheworkforcesurveyweredeterminedbyastafffocusgroup.Thesurveyincludedopen-endedquestionstoassesseachemployee’sdriversofwork-forceengagementandsatisfaction.AllworkforcesegmentsindicatedthattheoverarchingreasonsforworkingatLOTSwerethemission,relationshipswithcoworkers,andbenefits.Surveyresultsduringthistimeperiodwereexceptional,withtheorganizationscoringinthe90thpercentileinthevendor’sdatabaseforthe2014survey.Adifferentvendorwaschosenforthe2017workforcesurvey.Thegoalforchanging
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5.1b Workforce Climate5.1b(1) LOTSsystematicallyassessesworkplaceenviron-mentalfactorstoensureandimproveworkforcehealthbyusingacomprehensivewellnessprogram.Componentsofthiscomprehensivewellnessprogramincludeexceptionalhealthinsurancepackages,$20/monthreimbursementtowardswellness-relatedexpenses,no-costwellnessscreenings(Figure 7.3-5)andflushots,24/7accesstoanemployeeassistanceprogram,andotherhealthopportunities.Workplaceenvironmentaldifferencesarenotpertinentforthesebenefits;theseprogramsencourageemployeestobecomemoreproac-tiveinimprovingtheiroverallhealth.
Toensureandimproveworkforcesecurity(Figure 7.3-9),LOTSmaintainsasafefacilitycompletewithautomaticlockingdoorsand24/7videosurveillance.Badgesarerequiredforentryintoalltheworkareasofthefacility,withlevelsofrestrictionbasedonjobfunction.Toensureasecureworkplaceenvironment,policyrequiresallvisitorstosigninandbeescortedbyanemployeethroughthebuilding.Toensureworkplacesecurityforemployeeswhoworkindifferentworkplaceenvironments,includingatareahospitals,employeesarerequiredtoadheretothatsite’suniquesecuritymeasures.LOTShastakenadditionalmeasurestoensurethesecurityoftheworkforcebyofferingpersonalalarmstoallstaffmembers.TraininginCPR,workplaceviolenceresponse,anddefensivedrivingclassesarealsoprovided.
LOTSensuresworkplaceaccessibilitybymaintaininganAmericanswithDisabilitiesAct(ADA)-compliantfacilitywithhandicapentranceoptions.Moreover,LOTSisanequalopportunityemployerandmaintainsrealisticandflexibleexpectationsregardingtheimportanceofreasonableaccom-modations.Toguaranteetechnologicalworkplaceaccessibil-ity,LOTSprovidesallemployeeswithITtrainingtoensuretheirunderstandingoftheITsystems.
Asamplelistingofperformancemeasuresforworkforcehealth,security,andworkplaceaccessibilitycanbefoundinWorkplaceEnvironment(Figure 5.1-5)andWorkforcePreparedness(Figure 7.3-6).Theseperformancemeasuresaredesignedtoprovideaworkenvironmentconducivetosupport-ingtheLOTSworkforcetoaccomplishthemission.
5.1b(2) FocusingontheCCofamission-drivenworkforce,LOTSmaintainsaworkforcephilosophyof“We take care of ‘Our People’ so they can take care of others.”Tomeettheneedsofadiverseworkforce,multiplebenefitsplanoptionsareavailablewithdistinctionswithintheservices,benefits,andpoliciesdependentonworkforcedemographics,includingtenureandperformance.
Thesupportiveworkenvironmentincludesmultifacetedhealth,financial,andschedulingoptionsandbenefits.Theworkforceservices,benefits,andpoliciesareassessedintheworkforcesurvey.LOTShasmanyservicesasapartofitswellnessinitiativethatareavailabletoallemployees,includ-inghealthscreenings,flushots,ahealthcoach,voluntary
smokingcessationprograms,optionalflexiblescheduling,andanemployeeassistanceprogram,whichisavailabletostaffmembersaswellastheirfamilymembers.
LOTSsupportsitsworkforcebyprovidingacomprehensiveinsurancebenefitpackagetoallfull-timeemployees;thepackageincludesthreemedicalplanoptions,aswellasdentalandvisionplans,onatiered-costplatform.Employeescanselectthebestplantomeettheirmedical,financial,andfamilyneeds.Theorganizationalpoliciesthatsupporttheworkforceincludeagenerouspaidtime-off(PTO)plan,ExtendedMedi-calBank(EMB)plan,paidholidays,andtuitionassistance.Benefitswithfinancialimpactsmayvarybasedonstafftype,lengthofservice,andperformance.Agenerous401kplan,whichincludesadiscretionarycontribution,isprovidedtoalleligiblestaffmembers.EmployeeswhochoosetheEmployeeKeyRequirement(EKR)ofbenefitsinthe2017staffsurveyscoredtheirsatisfactionat85%,meetingthehealthcaretop-quartilebenchmark(Figure 7.3-15).TheseworkforcebenefitsandpoliciesenableLOTStostrengthenitsCCoffullyengagedworkforcememberswhoaremotivatedtofulfillitsmissiontosaveandimprovemorelives.
5.2 Workforce Engagement5.2a Assessment of Workforce Engagement 5.2a(1) ThekeydriversofworkforceengagementaredeterminedthroughcustomizedworkforcesurveysdevelopedbySurveySystemSuccess.From2008through2014,theengagementelementsincludedintheworkforcesurveyweredeterminedbyastafffocusgroup.Thesurveyincludedopen-endedquestionstoassesseachemployee’sdriversofwork-forceengagementandsatisfaction.AllworkforcesegmentsindicatedthattheoverarchingreasonsforworkingatLOTSwerethemission,relationshipswithcoworkers,andbenefits.Surveyresultsduringthistimeperiodwereexceptional,withtheorganizationscoringinthe90thpercentileinthevendor’sdatabaseforthe2014survey.Adifferentvendorwaschosenforthe2017workforcesurvey.Thegoalforchanging
Figure 5.1-5: Workplace Environment
Factors Measures Results
Health EAPOSHAComplianceWellnessProgramWellnessScreeningParticipation
AOS7.3-7AOS7.3-5
Security LimitedaccessbyjobfunctionERPTraining
AOSAOSAOS
Accessibility ADAcompliantEEOCcompliantITresources
AOSAOSAOS
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providerswastogainadeeperunderstandingofemployeeengagement,validationofthekeydriversofemployeesatis-factionandengagement,andactionablefeedback.Thevendorchosenforthe2017survey,ExcelEmployeeEngagement,allowedthestaffindividualselectionofsatisfierandengage-mentdrivers(EKRs).ExcelEmployeeEngagementalsoprovidesbenchmarkdatafromavarietyofsources,includingabenchmarkfromacohortof400healthcareorganizationsandanOPO/blooddonationfacilitybenchmark.Segmentedsurveyresults,includingseveralbenchmarks,areAOS.
5.2a(2) LOTSassessesworkforceengagementthroughtheWorkforceSurveyProcess(AOS).Throughlearningandstrategicimprovement,thesurveyhasgonefromaninternallytabulatedquestionnaireregardingcultureandbenefits,toanexternallydevelopedprocessthatincludesnationalbench-marksandprovidesinputintotheSPP(Figure 2.1-1).The2017workforcesurveyvalidatedLOTS’sCCofamission-drivenworkforce(Figures 7.3-11, 7.3-12, and 7.3-12A).TheWorkforceSurveyProcessallowsmeasurementofengage-mentacrossworkforcegroupsandsegments,includingworksystem,tenure,anddepartment(AOS).WorkforceretentionismeasuredontheToplineScorecardandhasremainedapriority(Figure 7.3-13).Departmentalretentionisassessed,andAPsmaybedevelopedforareasthatarefallingbelowtarget.Absenteeismisnotmonitoredasanorganizationalmetricbutismonitoredonacase-by-casebasis.ProductivityismonitoredthroughtheaccomplishmentofAPsthroughthePEPandPMSandismeasuredviagrossrevenueperfull-timeemployee(FTE;AOS).ProductivityoftheworkforceisacknowledgedthroughtheRewardsandRecognitionProgram(Figure 5.2-1).
5.2b Organizational CultureTheLS(Figure 1.1-1),PMS(Figure 4.1-1),SPP(Figure 2.1-1), andV/M/Vfosterandreinforceanorganizationalculturecharacterizedbyopencommunication,highperformance,andanengagedworkforcethatprovidesexcellentservicetoitscustomers.AsacomponentoftheCommunicationProcess(Figure 1.1-3),RFOfostersopencommunication.The2017workforcesurveynotedsatisfactionwithclear,effectivecommunicationat75%,exceedingthehealthcaremedianby15%(AOS).TheRFOquestionshavevariedbasedonSDsandstafffeedbackandcurrentlyincludequestionslike“Whatdoyouneedtoaccomplishyourgoals?”and“Isthereanyoneyouwouldliketorecognize?”AStoplightReport(AOS)wasdesignedtocommunicateprogresstotheorganizationaspartofastaffmeeting;thisservesasafeedbackloopandpossibleinputintoorganizationalimprovements.Anengagementtoolwasaddedin2018andofferedthestafftheoptiontoattendagrouplunchhostedbytheCEO.ThissettingallowsemployeestohaveaccessandconversationswiththeCEOinsmall-groupsettings.These“CafeCEO”luncheshaveprovidedanadditionalforumforopencommunication.
TheSPPandPMSprovidethefoundationforacultureofhighperformance.ThePMSengagesbothleadersandemployeesindefininghigh-performancework,whichisdocumentedthroughthePEP.EmployeeperformanceandsuccessareevaluatedbasedoncompletionofAPsandachievementofspecificgoalsthatalignwiththeSOs.TheLTregularlyacknowledgessuccesstodriveahigh-performanceworkforcethroughtheRewardsandRecognitionProgram(Figure 5.2-1).RFOalsoencourageshighperformanceandachievementofgoalsthroughregulargoalreview.
LOTSfostersanengagedworkforcethroughtheV/M/V(Figure P.1-1).ToreinforceLOTS’sculturalmessage,donorfamiliesandrecipientsperiodicallyattendstaffmeetingsandsharetheirheartfeltstories.ThesestoriesallowLOTStoputafacetothemission,whilemotivating,inspiring,andengag-ingthestaff.ThesetouchingtestimoniesarewhytheLOTSworkforceworkssohardtofulfillitsmission.In2017,staffmembersscoredtheirconnectiontothemissionat93.7%,thehighestofall22EKRs,exceedingthehealthcaremedianbenchmark(Figure 7.3-11).Inaddition,valuesarepartofthePEP(Figure 5.1-2)systemandarehighlightedatvariousstaffmeetingstodemonstratehowthatvaluemaybeapplicableinday-to-dayworkforstaff.Forexample,arecentstaffmeetingpresentationwasmadearoundthevalueofhonestyandtheapplicabilityofthatvaluewhendealingwithdonorfamilies.
TheCommunicationProcessengagestheLOTSworkforceinsharingideasandensuresthattheorganizationbenefitsfromthediverseideas,culture,andthinkingoftheworkforcetosupporttheorganizationalculture.Theworkforceisempow-eredtomakedecisionsandactstoachieveindividualandorganizationalsuccessthroughtransparentcommunication,andspecificallythroughthePMSandPEP.Leveragingitsmission-drivenworkforce(CC),LOTSensuresthattherightstaffmemberisplacedintherightjobwiththerighttraining,empoweringtheworkforcetoprovidesuperiorcustomerservice(includingresolutionofcomplaints),resultingincustomerloyaltyandengagement(Figure 7.2-4).
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providerswastogainadeeperunderstandingofemployeeengagement,validationofthekeydriversofemployeesatis-factionandengagement,andactionablefeedback.Thevendorchosenforthe2017survey,ExcelEmployeeEngagement,allowedthestaffindividualselectionofsatisfierandengage-mentdrivers(EKRs).ExcelEmployeeEngagementalsoprovidesbenchmarkdatafromavarietyofsources,includingabenchmarkfromacohortof400healthcareorganizationsandanOPO/blooddonationfacilitybenchmark.Segmentedsurveyresults,includingseveralbenchmarks,areAOS.
5.2a(2) LOTSassessesworkforceengagementthroughtheWorkforceSurveyProcess(AOS).Throughlearningandstrategicimprovement,thesurveyhasgonefromaninternallytabulatedquestionnaireregardingcultureandbenefits,toanexternallydevelopedprocessthatincludesnationalbench-marksandprovidesinputintotheSPP(Figure 2.1-1).The2017workforcesurveyvalidatedLOTS’sCCofamission-drivenworkforce(Figures 7.3-11, 7.3-12, and 7.3-12A).TheWorkforceSurveyProcessallowsmeasurementofengage-mentacrossworkforcegroupsandsegments,includingworksystem,tenure,anddepartment(AOS).WorkforceretentionismeasuredontheToplineScorecardandhasremainedapriority(Figure 7.3-13).Departmentalretentionisassessed,andAPsmaybedevelopedforareasthatarefallingbelowtarget.Absenteeismisnotmonitoredasanorganizationalmetricbutismonitoredonacase-by-casebasis.ProductivityismonitoredthroughtheaccomplishmentofAPsthroughthePEPandPMSandismeasuredviagrossrevenueperfull-timeemployee(FTE;AOS).ProductivityoftheworkforceisacknowledgedthroughtheRewardsandRecognitionProgram(Figure 5.2-1).
5.2b Organizational CultureTheLS(Figure 1.1-1),PMS(Figure 4.1-1),SPP(Figure 2.1-1), andV/M/Vfosterandreinforceanorganizationalculturecharacterizedbyopencommunication,highperformance,andanengagedworkforcethatprovidesexcellentservicetoitscustomers.AsacomponentoftheCommunicationProcess(Figure 1.1-3),RFOfostersopencommunication.The2017workforcesurveynotedsatisfactionwithclear,effectivecommunicationat75%,exceedingthehealthcaremedianby15%(AOS).TheRFOquestionshavevariedbasedonSDsandstafffeedbackandcurrentlyincludequestionslike“Whatdoyouneedtoaccomplishyourgoals?”and“Isthereanyoneyouwouldliketorecognize?”AStoplightReport(AOS)wasdesignedtocommunicateprogresstotheorganizationaspartofastaffmeeting;thisservesasafeedbackloopandpossibleinputintoorganizationalimprovements.Anengagementtoolwasaddedin2018andofferedthestafftheoptiontoattendagrouplunchhostedbytheCEO.ThissettingallowsemployeestohaveaccessandconversationswiththeCEOinsmall-groupsettings.These“CafeCEO”luncheshaveprovidedanadditionalforumforopencommunication.
TheSPPandPMSprovidethefoundationforacultureofhighperformance.ThePMSengagesbothleadersandemployeesindefininghigh-performancework,whichisdocumentedthroughthePEP.EmployeeperformanceandsuccessareevaluatedbasedoncompletionofAPsandachievementofspecificgoalsthatalignwiththeSOs.TheLTregularlyacknowledgessuccesstodriveahigh-performanceworkforcethroughtheRewardsandRecognitionProgram(Figure 5.2-1).RFOalsoencourageshighperformanceandachievementofgoalsthroughregulargoalreview.
LOTSfostersanengagedworkforcethroughtheV/M/V(Figure P.1-1).ToreinforceLOTS’sculturalmessage,donorfamiliesandrecipientsperiodicallyattendstaffmeetingsandsharetheirheartfeltstories.ThesestoriesallowLOTStoputafacetothemission,whilemotivating,inspiring,andengag-ingthestaff.ThesetouchingtestimoniesarewhytheLOTSworkforceworkssohardtofulfillitsmission.In2017,staffmembersscoredtheirconnectiontothemissionat93.7%,thehighestofall22EKRs,exceedingthehealthcaremedianbenchmark(Figure 7.3-11).Inaddition,valuesarepartofthePEP (Figure 5.1-2)systemandarehighlightedatvariousstaffmeetingstodemonstratehowthatvaluemaybeapplicableinday-to-dayworkforstaff.Forexample,arecentstaffmeetingpresentationwasmadearoundthevalueofhonestyandtheapplicabilityofthatvaluewhendealingwithdonorfamilies.
TheCommunicationProcessengagestheLOTSworkforceinsharingideasandensuresthattheorganizationbenefitsfromthediverseideas,culture,andthinkingoftheworkforcetosupporttheorganizationalculture.Theworkforceisempow-eredtomakedecisionsandactstoachieveindividualandorganizationalsuccessthroughtransparentcommunication,andspecificallythroughthePMSandPEP.Leveragingitsmission-drivenworkforce(CC),LOTSensuresthattherightstaffmemberisplacedintherightjobwiththerighttraining,empoweringtheworkforcetoprovidesuperiorcustomerservice(includingresolutionofcomplaints),resultingincustomerloyaltyandengagement(Figure 7.2-4).
Figure 5.2-1: Rewards and Recognition
Giv
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Sharingofrecipientthank-youletters
Personalnotes/emails/cards
Peer-to-peerrecognition
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Thekeydriversofemployeeengagementandsatisfactionhave staffandLT,beginningwithnew-employeeorientation.New-beendeterminedusingtheworkforcesurveyandtheCommu- employeeorientationisnowofferedintwophases:Introduc-nicationProcess(Figure 1.1-3).Inthe2017workforcesurvey, tionandLOTSLearning.DuringtheIntroductionPhase,newtheoverallengagementscorewas75%,exceedingthehealth hiresareintroducedtothecultureandcompleteonboardingcaremedianaswellastheOPObenchmarkgroup.Workforce activitiesduringtheirfirstweekofemploymenttocreatesurveysegmentationbasedondemographics,includingwork anunderstandingoftheorganization’sneeds.TheLOTSsystem,tenure,andlengthofservice,isAOS. LearningPhaseisofferedasanextensionofnew-employee
orientation.Thiscomprehensive,eight-hourprogramhigh-5.2c Performance Management and Development lightskeyorganizationalelements.Staffmembersparticipate5.2c(1) TheWorkforcePerformanceMeasurementSystem inLOTSLearningaftertheyhavecompletedseveralweekssupportshighperformanceandengagementoftheworkforce ofemployment.TheutilizationofatraininganddevelopmentandLTthroughthefullydeployedPEP(Figure 5.1-2).The goalallowsstaffmembersandleaderstoidentifytrainingPEPconsistsofseverallayersthatarestructuredandsystem- anddevelopmentneedscollaboratively,basedonstrengthsatic.UtilizingtheSPPasthefoundation,APsarecreatedusing andopportunitiesfortheindividual.Thisalsoenhancesthestaffinputtosupporthighperformanceintheaccomplishment organization’scapabilityforgoalaccomplishment.oforganizationalgoals,whichultimatelydrivestheachieve- TheprioritiesoftheworkforceLDS(Figure 5.2-2)areevalu-mentofSOs.ThesegoalsarealignedwiththeV/M/Vofthe atedannuallyandalignedwiththeSOs,SCs,APs(short-andorganizationandarecascadedtotheworkforce.Partofthe long-term),andgoalstoensuresupportoforganizationalPEPalsoincludesindividualpersonaldevelopmentgoalsfor needs.Asanexample,anAPwasinitiatedtoimplementaeachstaffmemberthathelpensurepersonaldevelopment web-basedperformancemanagementsystem.Thecomplexityandgrowthand,ultimately,ensurethattheneedsofthe ofthesoftwarerequiredatwo-yearAP,includingimplementa-organizationaremet.Managersanalyzeperformancereview tionandincorporationoffuturemodelsofthesoftwareandscoresandtrackgoalsandAPprogressinreal-time.ThePEP atrainingcomponent.ThesuccessfulcompletionofthisAPisdesignedtoensuretransparencyacrosstheorganization;in resultedintheworkforcehaving24/7accesstomonitortheturn,eachevaluationtoolincludesresultsonorganizational statusoforganizationalandindividualgoals,whilepromotingandindividualgoals,demonstrationofcorevalues,and transparencyacrosstheorganization.personaldevelopmentplans.
Organizationalimprovement,performanceimprovement,Whilestaffmembersnamethemission,coworkers,and organizationalchange,andinnovationaredrivenfromthebenefitsasthehighest-scoringEKRs,LOTSrecognizesthe SPPthroughtheLS(Figure 1.1-1)andtheOrganizationalimportanceofcompensationandrewardsandrecognition Structure(Figure 1.2-2),totheemployeelevelwheretheyare(Figure 5.2-1).Theorganization’scompensationsystem reinforcedbythePMS(Figure 4.1-1).ForallLTmembers,establishescompetitivesalaryrangesandamerit-basedpay LOTSdeploysasystematicleadershipcurriculum,whichincreasesystemtorewardstaffmembersforachievement isreviewedannually.NewLTmembersareprovidedwithoftheirgoalsanddemonstrationofthecorevalues.LOTS internaltrainingtoassistwithculturalintegrationandtosharehasastrongcommitmenttomaintainingmarket-based organizationalknowledge.Additionally,newleaderscompletesalariesandworkstrienniallywithanexternalconsultantto aleadershiptrainingsessionthatincludescoaching,perfor-determinenecessarymarketadjustments.Theorganization’s mancemanagement,behavioralinterviewing,anddevelop-RewardsandRecognitionProgramincludesaprogramthat mentofdecision-makingskills.allowsemployeestorecognizeoneanother,accomplishmentoforganizationalgoals,andotherpersonalizedrecognition Tosupportethicsandethicalbusinesspractices,annualpolicyopportunities(Figure 5.2-1). trainingincludesreviewoftheConflictofInterestPolicy,
CodeofProfessionalConduct,CorporateComplianceTrain-ThePEP,viatheLDS(Figure 5.2-2),isusedtoevaluate ing,andongoingprocedurecompliance.TheLOTSworkforceeffectiveness,identifylearninganddevelopmentneeds, iseducatedontheorganization’slegalandregulatoryrequire-andserveasadirectinputtothePMS(Figure 4.1-1).The mentsthroughmandatorytraining.TheCCP(Figure 1.1-2)informationfromthePEPisusedthroughouttheyearin trainingisconductedduringnew-employeeorientation,andongoingSDs.LOTS’scustomerandbusinessfocus,aswellas theCCPpolicycompetencyisassessedannuallythereafter;theachievementofAPs,isguidedbythePMSandreinforced CCPtrainingencouragesthereportingofsuspectedbreachesbythePEP.Thisallowstheorganizationtoensurethatall ofpolicyviolationsorunethicalpractices.goalsandtargetsarecloselymonitored,andaccountabilityisachieved. Toperpetuateandimprovethecustomerfocusoftheorganiza-
tion,LOTStrainsallnewemployeesduringorientationon5.2c(2) LOTS’sLDS(Figure 5.2-2)beginswiththeorienta- theorganization’scustomercomplaintphilosophytoensuretionofmission-drivenworkforcemembers,alignmentwith superiorcustomerservice.Customerfocusisalsoachievedtheorganizationalculturetosupporttheorganization’sneeds, throughavarietyofAPstargetingcustomersatisfactionandanandthepersonaldevelopmentoftheworkforce.Toachieve extensiveCustomerSurveyProcessthatassessesperformance.theV/M/V,LOTSfocusesonthecontinualdevelopmentofits
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Thelearninganddevelopmentneedsofworkforcemembers arecapturedinRFOandarealsopartoftheLDS(Figure 5.2-2). AsacomponentoftheLDS,LOTSreinforcesnewknowledgeandon-the-jobskillsthroughongoingcompetencytesting,worksystemdialogue,bringinginsubject-matterexpertsfortraining,andtheCommunicationProcess(Figure 1.1-3).KnowledgesharingisalsoacomponentoftheLDS.
5.2c(3) Learninganddevelopmentarecriticalcomponentsofstaffsuccess,whichinturndrivesorganizationalsustainabilityandsupportstheCCofamission-drivenworkforce.TheLDSsystem(Figure 5.2-2)isvalidatedaspartoftheSPP;pastimprovementshaveincludedtheadditionofskillsdaysandaformalexitinterviewprocess(AOS).Inthe2017staffsurvey,theEKRofcontinuouslearning,training,anddevelopmentshowedan80.6%satisfactionlevel,exceedingthehealthcaremean(Figure 7.3-16).TheHumanResourcesstaffevaluatestheeffectivenessoftrainingbyconductingevaluationsofinternalandexternalopportunitiesattheorganization,worksystem,anddepartmentlevels,affordingemployeestheoppor-tunitytoprovidefeedbackaboutthetrainingtheyreceivedandalsotoidentifyanysubsequenttrainingneedsofinterestthatwillsupportthemission(Figure 5.2-2,Step4).Dependingonthenatureofthetraining,learningislinkedtoanoutcomemeasuredinthegoalplanforeachemployee.Staffmemberswhoattendtrainingoff-siteareaskedtosharetheinformationtheylearnedattheirdepartmentmeetings,worksystems,or
LTmeetingstohelpotherteammembersgaininsightfromthetraining.
5.2c(4) AtLOTS,mostjob-andcareer-relateddevelopmentinvolvesjobenhancementopportunitieswithintheorganiza-tion.Duetotheorganization’ssizeandstructure,careerdevelopmentisoftensupportedinhorizontaltransitionstodifferentroles.Overhalfoftheworkforceisinadifferentpositiontodaythanoriginallyhiredfor,andmanyofthosehavetransitionedmultipletimes.ThePEPhelpsidentifyhighperformerswhocanutilizetheirskills,knowledge,andabilitiesinvariousways.
TheLDSisusedtopreparetheworkforceforreplacementandsuccessionplanning.ThesuccessionplanisreviewedannuallythroughtheSPP(Figure 2.1-1,Step5)andmodifiedasneededbytheCHRO,CEO,COO,CMO,andeachLTmember;theplanprovidesstrategyforshort-andlong-termcoverageforeachLTposition.TheLTsuccessionplanfocusesonthedevelopmentofcurrentleaderspositionedtotakeonadditionalresponsibilitiesandemergingleaderswhocouldserveasthenextgenerationofleadership.Developmentneedsofidentifiedemergingleadersarenowincorporatedwithinthetraininganddevelopmentplanaspartoftheemployee’sPEP.Asanexample,targetedtrainingisbeingprovidedquarterlytoteamleadsacrosstheorganizationtoensurefoundationalunderstanding,includingteamdynamics,difficultconversa-tions,andteammotivation.
Figure 5.2-2: Learning and Development System (LDS)
Identification & Evaluation of Learning and Development Needs
1
Evaluate Effectiveness 4 Knowledge Sharing
3
• Orientation • On-the-Job Training • Policies & Procedures
• Intranet
• On-the-Job Training • Leadership Development
• Industry Networking • Leadership Development
• Industry Conferences
• Regulatory Information
Job/T
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Lear
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Internal Learning External Learning
Grow
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Thelearninganddevelopmentneedsofworkforcemembers LTmeetingstohelpotherteammembersgaininsightfromthearecapturedinRFOandarealsopartoftheLDS(Figure 5.2-2). training.AsacomponentoftheLDS,LOTSreinforcesnewknowledge 5.2c(4) AtLOTS,mostjob-andcareer-relateddevelopmentandon-the-jobskillsthroughongoingcompetencytesting, involvesjobenhancementopportunitieswithintheorganiza-worksystemdialogue,bringinginsubject-matterexpertsfor tion.Duetotheorganization’ssizeandstructure,careertraining,andtheCommunicationProcess(Figure 1.1-3). developmentisoftensupportedinhorizontaltransitionstoKnowledgesharingisalsoacomponentoftheLDS. differentroles.Overhalfoftheworkforceisinadifferent5.2c(3) Learninganddevelopmentarecriticalcomponentsof positiontodaythanoriginallyhiredfor,andmanyofthosestaffsuccess,whichinturndrivesorganizationalsustainability havetransitionedmultipletimes.ThePEPhelpsidentifyandsupportstheCCofamission-drivenworkforce.TheLDS highperformerswhocanutilizetheirskills,knowledge,andsystem(Figure 5.2-2)isvalidatedaspartoftheSPP;past abilitiesinvariousways.improvementshaveincludedtheadditionofskillsdaysanda TheLDSisusedtopreparetheworkforceforreplacementformalexitinterviewprocess(AOS).Inthe2017staffsurvey, andsuccessionplanning.ThesuccessionplanisreviewedtheEKRofcontinuouslearning,training,anddevelopment annuallythroughtheSPP(Figure 2.1-1,Step5)andmodifiedshowedan80.6%satisfactionlevel,exceedingthehealthcare asneededbytheCHRO,CEO,COO,CMO,andeachLTmean(Figure 7.3-16).TheHumanResourcesstaffevaluates member;theplanprovidesstrategyforshort-andlong-termtheeffectivenessoftrainingbyconductingevaluationsof coverageforeachLTposition.TheLTsuccessionplanfocusesinternalandexternalopportunitiesattheorganization,work onthedevelopmentofcurrentleaderspositionedtotakeonsystem,anddepartmentlevels,affordingemployeestheoppor- additionalresponsibilitiesandemergingleaderswhocouldtunitytoprovidefeedbackaboutthetrainingtheyreceivedand serveasthenextgenerationofleadership.Developmentneedsalsotoidentifyanysubsequenttrainingneedsofinterestthat ofidentifiedemergingleadersarenowincorporatedwithinthewillsupportthemission(Figure 5.2-2,Step4).Depending traininganddevelopmentplanaspartoftheemployee’sPEP.onthenatureofthetraining,learningislinkedtoanoutcome Asanexample,targetedtrainingisbeingprovidedquarterlymeasuredinthegoalplanforeachemployee.Staffmembers toteamleadsacrosstheorganizationtoensurefoundationalwhoattendtrainingoff-siteareaskedtosharetheinformation understanding,includingteamdynamics,difficultconversa-theylearnedattheirdepartmentmeetings,worksystems,or tions,andteammotivation.
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Category 6: Operations
6.1 Work Processes 6.1a(3) TheOMP(Figure 6.1-1)demonstratesthemethodsusedtodesign,refine,andconstructkeyworkprocessesto6.1a Product and Process Designmeetrequirements.TheOMPensuresthatkeyrequirements
6.1a(1) Keyworkproductandprocessrequirementsare drivingworkprocessesareanalyzed,reviewed,andtranslateddeterminedthroughavarietyoflisteningandlearningmethods intoprioritiesduringtheSPPandcontinuedthroughouttheviatheVOC(Figure 3.1-1),includingformalandinformal yearduringongoingSDsandODs.surveys,feedbackreports,andinformalinteractions.The
Incorporationoforganizationalknowledge,newtechnology,productandprocessrequirementanalysisanddiscussionstartserviceexcellence,customervalue,risk,andagilityisalsointheSPP(Figure 2.1-1,Step8)andcontinueduringtheyearaccomplishedthroughtheOMPandstep4oftheLDS inongoingSDsandthroughouttheOMP(Figure 6.1-1).For(Figure 5.2-2).BoththeOMPandLDSareintegralinputsexample,itwasdeterminedthroughsurveydatafeedbackintotheSPP,whichdrivesODs,dataanalysis,real-timethatreferringphysiciansfromdonorhospitalpartnersdiddecisionmaking,andimprovementtoensurecustomervalue.notfeelpreparedfortheirinvolvementinDonationafterLOTS’sstaffmembersdriveorganizationalimprovementsCardiacDeath(DCD)organdonorcases.ThisrequirementforusingtheSPP,OMP,andthePMS(Figures 2.1-1, 6.1-1, and informationwastakentotheCriticalCareTaskforce,anda4.1-1)toassessperformance,lookforimprovements,andtoolwasdevelopedusingitsinput.Aninformationcardisnowdeployappropriatesolutionstomeetcustomerneeds.distributedtophysiciansandnursescaringforpotentialorgan
donorstohelppreparethemforinvolvement.In2018,there 6.1b Process Management and ImprovementwerearecordnumberofDCDdonors(AOS),andthehospital 6.1b(1) TheOMPdrivesworkprocessesthroughmultiplepartnersatisfactionexceededprioryears(Figure 7.1-1A) .
inputs,includingtheSPP,PMS,staffknowledge,and6.1a(2) LOTS’skeyserviceisthefacilitationoforganand stakeholderandenvironmentalinformationtoensurethattissuedonation(Figure 2.1-2),aserviceprovidedtocustom- theymeetkeyprocessrequirements.WithintheOMP,theersincollaborationwithkeypartners(Figure P.1-6).Key PMS(Figure 4.1-1)ensuresthatkeymetricrequirementsworkprocessesofreferralmanagement,authorization,and aremeasured,analyzed,andbenchmarked.ODsalsoincludeprocurementaredesignedtodriveorganizationalsustainability analysisofmetrics,evaluationofcurrentAPsandprocessbyfulfillingtheneedsandrequirementsofkeycustomers steps,andvalidationthatcurrentperformanceismeetingor(Figure P.1-6).Throughthesekeyprocesses,theworkforce trendingtomeettargets.Asanexample,duringOrganOpera-advancestheorganization’sSOsandultimatelyprovides tionsmeetings,asystematicreviewofselectedorgancasesorgansandtissuesfortransplant. isperformed.Duringthesemultidisciplinaryreviews,staff
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Figure 6.1-1: Operational Management Process (OMP)
Operational Discussions
• Operations Mtgs • Department Mtgs
PMS(Figure 4.1-1)
Staff Knowledge (RFO)
VOC(Figure 3.1-1)
VOS(Figure 4.2-1)
Environmental Information
Knowledge Feedback Loop/Analyze
SPP(Figure 2.1-1) ANALYSIS
DECISION
MAK
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ALIGNMENT WITH V/M/V
6.1 Work Processes6.1a Product and Process Design6.1a(1) KeyworkproductandprocessrequirementsaredeterminedthroughavarietyoflisteningandlearningmethodsviatheVOC(Figure 3.1-1),includingformalandinformalsurveys,feedbackreports,andinformalinteractions.TheproductandprocessrequirementanalysisanddiscussionstartintheSPP(Figure 2.1-1,Step8)andcontinueduringtheyearinongoingSDsandthroughouttheOMP(Figure 6.1-1).Forexample,itwasdeterminedthroughsurveydatafeedbackthatreferringphysiciansfromdonorhospitalpartnersdidnotfeelpreparedfortheirinvolvementinDonationafterCardiacDeath(DCD)organdonorcases.ThisrequirementforinformationwastakentotheCriticalCareTaskforce,andatoolwasdevelopedusingitsinput.Aninformationcardisnowdistributedtophysiciansandnursescaringforpotentialorgandonorstohelppreparethemforinvolvement.In2018,therewerearecordnumberofDCDdonors(AOS),andthehospitalpartnersatisfactionexceededprioryears(Figure 7.1-1A) .
6.1a(2) LOTS’skeyserviceisthefacilitationoforganandtissuedonation(Figure 2.1-2),aserviceprovidedtocustom-ersincollaborationwithkeypartners(Figure P.1-6).Keyworkprocessesofreferralmanagement,authorization,andprocurementaredesignedtodriveorganizationalsustainabilitybyfulfillingtheneedsandrequirementsofkeycustomers(Figure P.1-6).Throughthesekeyprocesses,theworkforceadvancestheorganization’sSOsandultimatelyprovidesorgansandtissuesfortransplant.
6.1a(3) TheOMP(Figure 6.1-1)demonstratesthemethodsusedtodesign,refine,andconstructkeyworkprocessestomeetrequirements.TheOMPensuresthatkeyrequirementsdrivingworkprocessesareanalyzed,reviewed,andtranslatedintoprioritiesduringtheSPPandcontinuedthroughouttheyearduringongoingSDsandODs.
Incorporationoforganizationalknowledge,newtechnology,serviceexcellence,customervalue,risk,andagilityisalsoaccomplishedthroughtheOMPandstep4oftheLDS (Figure 5.2-2).BoththeOMPandLDSareintegralinputsintotheSPP,whichdrivesODs,dataanalysis,real-timedecisionmaking,andimprovementtoensurecustomervalue.LOTS’sstaffmembersdriveorganizationalimprovementsusingtheSPP,OMP,andthePMS(Figures 2.1-1, 6.1-1, and 4.1-1)toassessperformance,lookforimprovements,anddeployappropriatesolutionstomeetcustomerneeds.
6.1b Process Management and Improvement6.1b(1) TheOMPdrivesworkprocessesthroughmultipleinputs,includingtheSPP,PMS,staffknowledge,andstakeholderandenvironmentalinformationtoensurethattheymeetkeyprocessrequirements.WithintheOMP,thePMS(Figure 4.1-1)ensuresthatkeymetricrequirementsaremeasured,analyzed,andbenchmarked.ODsalsoincludeanalysisofmetrics,evaluationofcurrentAPsandprocesssteps,andvalidationthatcurrentperformanceismeetingortrendingtomeettargets.Asanexample,duringOrganOpera-tionsmeetings,asystematicreviewofselectedorgancasesisperformed.Duringthesemultidisciplinaryreviews,staff
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membersassessachievementoftheHospitalReferralProcess,AuthorizationProcess,andtheClinicalProcurementProcesssteps,alongwithstakeholderfeedback.ThissystematicreviewhelpsdetermineifprocesschangesareindicatedandprovidesanopportunitytosharelearningacrosstheworksystemtoimproveOWSprocesses.
Keyperformanceandin-processmeasuresusedforthecontrolandimprovementofworkprocessesareoutlinedinFigure 6.1-2.Thesein-processmeasuresdriveincreasedperformanceandstrictadherencetoprocessestoensuremaxi-mizedoutcomesandservice.Anextensivesetofpoliciesandprocedures,incorporatingkeystakeholderinput,definestheworkrequiredtoaccomplishthekeyworkprocesses.Devia-tionstotheseprocessesarecapturedintheCAPAdeviationsystem,analyzedfortrendidentification,andresolved.APsaredeployedandworkprocessesaremodified,asindicated.CapitalizingonLOTS’sCCiscriticaltotheaccomplishmentofthekeyworkprocesses.OngoingevaluationofthesekeyworkprocessmeasuresoccursthroughthePMS;alignmentandintegrationofperformancemeasuresbeginintheSPPandcontinuethroughtheOMPtoensurethatalldataandinformationneedsaremettoeffectivelymanageperformance
outcomes.Keyin-processandoutcomemeasureselectionisusedtodriveandassessservicequalityandperformance.
6.1b(2) TheOMP(Figure 6.1-1)demonstratestheprocessusedtodeterminethekeyworksystemrequirementstoconstructthekeysupportprocesses:LaboratoryTesting,DonorChartReviewandReleaseProcess,SupplyandEquip-mentManagement,FinancialManagement,HRManagement,ITManagement,PI,andQualityComplianceManagement.Day-to-dayoperationofthesupportprocesses’abilitytomeetkeybusinesssupportrequirementsisensuredbytheOMP.WithintheOMP,thePMS(Figure 4.1-1)isusedtoensurethatkeysupportmetricrequirementsaremeasured,analyzed,andbenchmarkedtodriveassociatedAPs.ODsalsoincludeanaly-sisofmetricsandevaluationofcurrentAPsandprocesssteps.Keysupportmetricsarereviewedatthedepartmentleveltoassessperformanceformeetingkeybusinessrequirementsonanongoingbasis.Forexample,thelaboratoryrequisitionerrorratewastrackedasakeylaboratorymetricandwasoneofthehighestsourcesoferrors.Requisitionerrorswerethesourceofreworkandhadthepotentialtoslowthetestingand/orreleaseofcriticallaboratoryinfectiousdiseasetesting.PI,laboratory,organ,andtissueprocurementdepartmentsmetanddeveloped
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outcomes.Keyin-processandoutcomemeasureselectionisusedtodriveandassessservicequalityandperformance.
6.1b(2) TheOMP(Figure 6.1-1)demonstratestheprocessusedtodeterminethekeyworksystemrequirementstoconstructthekeysupportprocesses:LaboratoryTesting,DonorChartReviewandReleaseProcess,SupplyandEquip-mentManagement,FinancialManagement,HRManagement,ITManagement,PI,andQualityComplianceManagement.Day-to-dayoperationofthesupportprocesses’abilitytomeetkeybusinesssupportrequirementsisensuredbytheOMP.WithintheOMP,thePMS(Figure 4.1-1)isusedtoensurethatkeysupportmetricrequirementsaremeasured,analyzed,andbenchmarkedtodriveassociatedAPs.ODsalsoincludeanaly-sisofmetricsandevaluationofcurrentAPsandprocesssteps.Keysupportmetricsarereviewedatthedepartmentleveltoassessperformanceformeetingkeybusinessrequirementsonanongoingbasis.Forexample,thelaboratoryrequisitionerrorratewastrackedasakeylaboratorymetricandwasoneofthehighestsourcesoferrors.Requisitionerrorswerethesourceofreworkandhadthepotentialtoslowthetestingand/orreleaseofcriticallaboratoryinfectiousdiseasetesting.PI,laboratory,organ,andtissueprocurementdepartmentsmetanddeveloped
membersassessachievementoftheHospitalReferralProcess,AuthorizationProcess,andtheClinicalProcurementProcesssteps,alongwithstakeholderfeedback.ThissystematicreviewhelpsdetermineifprocesschangesareindicatedandprovidesanopportunitytosharelearningacrosstheworksystemtoimproveOWSprocesses.
Keyperformanceandin-processmeasuresusedforthecontrolandimprovementofworkprocessesareoutlinedinFigure 6.1-2.Thesein-processmeasuresdriveincreasedperformanceandstrictadherencetoprocessestoensuremaxi-mizedoutcomesandservice.Anextensivesetofpoliciesandprocedures,incorporatingkeystakeholderinput,definestheworkrequiredtoaccomplishthekeyworkprocesses.Devia-tionstotheseprocessesarecapturedintheCAPAdeviationsystem,analyzedfortrendidentification,andresolved.APsaredeployedandworkprocessesaremodified,asindicated.CapitalizingonLOTS’sCCiscriticaltotheaccomplishmentofthekeyworkprocesses.OngoingevaluationofthesekeyworkprocessmeasuresoccursthroughthePMS;alignmentandintegrationofperformancemeasuresbeginintheSPPandcontinuethroughtheOMPtoensurethatalldataandinformationneedsaremettoeffectivelymanageperformance
Figure 6.1-2: Key Work Processes
PHASE PRE-DONATION DONATION
Key Work Process Referral Management Authorization Procurement/Allocation
Work System Alignment
OWS TWS OWS TWS OWS TWS
Key Requirement Results
HospitalPartner
Satisfaction:OWS
(7.1-1A)
HospitalPartner
Satisfaction:TWS
(7.1-2A)
Referrals (7.1-1)
Referrals (7.1-2)
OrganDonors (7.1-3)
TissueDonors (7.1-4)
In-ProcessMeasures
MissedOrganReferrals(7.1-15)
LOTSTissueApproachRate
(7.1-16)
OrganAuthorization
(7.1-17)
CollaborativeApproach
TissueAuthorization
(7.1-18)
Re-approach Rate
DonorManagementProtocol
Compliance(7.1-20)
OrganDonorCasesIn-house
(7.1-21)
BoneNo GrowthRates
(7.1-22)
SkinYield (7.1-23)
Outcome Measures OrganReferrals(7.1-1)
TissueReferrals(7.1-2)
LocalOrganDonors(7.1-3)
OrganConversion
(7.1-19)
TotalTissueDonors(7.1-4)
LocalOrgansTransplanted
(7.1-5)
SkinDonors Released(7.1-7)
How Determined• Regulatory
CMS CMS UNOS/OPTN
UAGAAOPO
UAGAAATB VOC(3.1-1) UNOS/OPTN
AOPO
VOC(3.1-1) AATB
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anonlinelaboratoryrequisitionmodulethatreducedthenumberoferrorsdramatically(AOS).
6.1b(3) Improvementofworkprocesses,products(services),theCC,andperformanceisinitiatedthroughtheOMP(Figure 6.1-1)byusingthePMS(Figure 4.1-1)andSPP(Figure 2.1-1)toidentifyimprovementopportunities.TheoverarchingapproachtosupportworkprocessandproductimprovementsisthePDSA.Asanexample,theTWSstaffdevelopedaPDSAtotestamodifieddonorprepproceduretominimizethebonecontaminationrate,acriticalmetrictoensuremaximizingdonationandcustomersatisfaction(Figures 7.2-1 through 7.2-2, 7.2-2C, and 7.2-2D).Initialresultsshowedimprovedoutcomes,andtherigorouspreppracticewasincorporatedintoLOTS’spoliciesandproce-dures.LOTShashadthelowestcontaminationrateofallTissueTransformationspartners,andtheprepprocedurewasidentifiedasabestpractice.LOTShastrainedotherOPOsontheprocedure.Improvementsinworkprocessestoenhancethemission-drivenstaff(CC)arealsopartoftheOMP,ensuringamultifacetedandsystematicanalysisanddiscussionofproductandprocessimprovements.
6.1c Supply-Network Management Inanontraditionalsense,supply-networkmanagementincludesthereceiptofthedonorreferralfromLOTS’shospitalpartnersandisthemostcriticalsupply-networkeventfortheorganization(Figure 2.1-2).Theselectionofthesenontradi-tionalsuppliersispredeterminedbytheDSA.The“donor”supply-networkmanagemententailscreatingandcommunicat-ingperformancestandardsandexpectationsduringregularlyscheduledmeetings.Inaddition,thereisaStandardizedIdentificationandReferralProcessatpartnerhospitalsofallpotentialdonors,ensuringthatoperationalneedsaremet(Figures 7.1-1 and 7.1-2).Aftertheinitiationofthereferralprocess,potentialdonorsuitabilityisestablished,andthepotentialdonor’sfamilyisapproachedfordonation.Thedonorreferralsystemisdevelopedcollaborativelywithhospitalandnonhospitalpartners,andtheProcurementProcessbeginswiththedonorenteringtheOWSorTWS.Hospitalpartnersinitiatethereferral;theirsupplierperformanceisregularlytrackedviametricsnotedontheQuarterlyDashboardreportandintheHospitalServicesscorecard.Poorlyperforminghospitalsareidentifiedviathesemetrics,andsubsequentAPsareestab-lishedwithstaffbuy-intoensureimprovementinoutcomes.Forexample,onepartnerhospitalreferralcompliancefor2017was68%.TheHospitalServicesstaffpersonworkedwiththehospitaltoPDSAseveralimprovements,includingtraining,additionalapproachestocommunication(includingdailyemails),newstafforientation,andfollow-upwithhospitaladministration.AsaresultofthisfocusedPDSA,thehospi-tal’s2018complianceimprovedto85%(AOS).
LOTSrecognizesthatcollaborativerelationshipswithmoretraditionalsuppliersplayanimportantroleinenhancingorga-nizationalperformanceandcustomersatisfaction.LOTSman-agesitstraditionalsupply-networkwithanonlineinventory
managementsystem.Thissystemenablestheorganizationtomanageordering,purchaseorders,purchasinghistory,andsupplyexpirationmonitoring,whichallowsLOTStoestablishminimuminventorylevelsthattakeintoaccountleadtimesandexpirationdates.Additionally,aQuarantineandReleaseProcessforcriticalsuppliesensuresthatsterilitycertificatesandinventoryqualificationsmeetorexceedindustryrequire-ments.Suppliers’performanceismeasuredandevaluatedonavarietyoflevels,includingmetricsondamagedandreturnedsuppliesanddeliverytimes.Poorlyperformingsuppliersarecontactedtoresolverecurringissues,andifissuespersist,theyarereplacedbyanotheravailablesupplier/supply.
Keysupplierperformance(GuardianAmbulance,ColumbiaCremation,TransplantTechnologies,andWrightBrothersCharters)ismonitored,tracked,andtrendedandisincludedinregularfeedbackwiththekeysuppliers(Figures 7.1-30, 7.1-31, 7.1-32, 7.1-33, and 7.1-34).ThesekeysuppliersarealsovettedbasedontheirabilitiestoalignandcollaboratewithLOTS.Forinstance,WrightBrothersChartersrecentlyexpandeditsabilitytotransportdonorsbyaddingplanesandpilotstoadditionalsitesintheDSAtoensurethatitcouldmeettimerequirements.
Organizationalalignmentandcollaborationwithsuppliersincludeensuringthattwo-waycommunicationisutilized.
6.1d Innovation Management InnovationandimprovementareembeddedintheculturefromthegovernancelevelwiththeBOD,downthroughthemission-drivenworkforce.ImprovementorinnovationisinitiatedandmanagedthroughtheOMP(Figure 6.1-1),LDS,andSPP.ImprovementdiscussionscanoriginateintheSPP,OMP,and/orLDS,andanimprovementteammaybeformed.Animprovementteamcomprisesstaffmembersfromdepart-mentsacrosstheorganizationandisledbythePIstaff.Duringimprovementteammeetings,theteamusesvariousPItoolsanddataanalysisfromthePMStodevelopnewprocessestotestandimplementnewideasorprocesses.
TheSAoffinancialstabilitypositionstheorganizationtoactivelypursueinnovativeideasandimprovements.Ideaassessmentincludesthescopeofapotentialproject,schedule,andneededresources,includingfinancialresources.ThesearereviewedattheLTmeetings.Financialandotherresourcesaremadeavailablethrougharobustbudgetingprocessandmul-tiplefinancialanalysistools,includingfinancialprojections.
Decisionstodiscontinuepursuingopportunitiesattheappropri-atetimeareevaluatedthroughtheOMP.TheOMPallowsforasystematicreviewofpotentialandcurrentprojects,anditensurestheagilitytoenhancesupportforhigher-priorityoppor-tunities.Asanexample,organbiopsieshadbeenperformedin-houseformanyyears.AdiscussionduringaC&Cmeeting,alongwithcontinueddiscussionintheOWSmeeting,resultedintheevaluationofwhetherbiopsiesshouldbeperformedin-houseoroutsourced.Robustdiscussionsandanalysisaddressedfinancial,capability,andcustomersatisfaction.Ultimately,the
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OrganBiopsyProcesswasoutsourced,resultingindecreasedcostandhighercustomersatisfaction(AOS).
6.2 Operational Effectiveness 6.2a Process Efficiency and Effectiveness Overallcostsoftheoperations,cycletime,productivity,efficiency,andeffectivenessfactorsareassessedthroughtheOMP,whichincludesinputsfromthePMS.LOTScontrolstheoverallcostofoperationsthroughefficiencyandimprovementgainedbyquarterlyC&Cmeetings,grouppurchasingorgani-zations,inventorycontrol,andLeantools,includingprocessmapping.Thesestrategiesincludefinancialanalysis,suchasanevaluationofbudget,costmodeling,andROI,alongwithongoingSDs(Figure 2.1-1,Step8).Efficiencyandeffective-nessfactorsarepartofthein-processmetricsincludedinFigure 6.1-2.AnexampleofcostcontrolisthedevelopmentofLOTS’sin-houseOR,whichincorporatedcustomerfeedbackandhasresultedinprocessefficienciesandsub-stantialcostssavings.Thesecostsavingshaveimpactedthechargestructure,allowingLOTS’sorganacquisitioncharges(OACs)tobebelowthemedianforallOPOs(Figure 7.5-12).TWSefficiencieshaveallowedincreasesindonorvolumethathavenotrequiredadditionalstaffing(Figure 7.3-3).AnotherexamplethatillustratesthereductionandcostofreworkistheutilizationoftheCMOinreal-timetissuedonorsuitabilityassessments,whichhaveledtoreductionsinon-sitedeferrals,whichhaveimpactedoveralltissuedonornumbers(AOS).
OriginatingfromtheannualSPPsession,awell-definedauditcalendarisestablishedeachyear.Auditsareconductedsystematically,andoutcomesdrivefrequencyandsamplesize,ensuringmaximumeffectivenesswithminimalauditcosts.LOTSusesaninternalqualityreporttocommunicateauditfindingsattheLTmeetings.LOTSexceedsindustrystandardsbyproactivelyseekingallvoluntaryaccreditations(Figure P.1-5)andparticipatinginaccreditationcouncils.Accreditationinspectionsassisttheorganizationwithidentify-ingpossiblegapsinpracticesthatresultinminimizingserviceerrors,rework,anddefects.Participationonthecouncilsallowsforsharingofinformationandbestpracticestoproac-tivelyevaluateandimproveoperations.Inputfrommission-drivenworkforcemembers(CC)duringauditpreparationmeetingsensuresthattheorganization’sworkforcecontributestoprocessimprovementopportunitieswhilemeetingregula-toryandcompliancerequirements.Tofurthermaximizeefficiencyandcostcontrol,LOTSusespreventativemeasurestominimizemaintenancecosts,andcontractsareestablishedtoensurethatcapitalequipmentisproperlymaintainedtopre-ventunplanned,costlyrepairs.Grouppurchasingagreementsareutilizedtoleverageeconomiesofscaleinordertonegoti-atereasonablepricesforsuppliesandmaintenancecontracts.Newsupplyrequestsareevaluatedandapproved/deniedatthedirectorlevelviatheSupplyRequisitionProcess.LOTSemployscomprehensivemeasurestomaximizeefficiencyandensurecostcontrol,whicharebalancedwithcustomerneeds.TheworkwithintheOMPdrivestheorganizationtoperform
asefficientlyaspossible.Costsavingsallowforcontinuedandincreasedfundingofprojectstoensurehighlevelsofcustomersatisfaction.
6.2b Security and CybersecurityTheISusedincludessoftware,data,networkinfrastructure,computerhardware,andkeyassets.AnoverviewofISisacomponentoftheannualSPP.LOTSusescloudsoftwareforserverhardwareanddata;thesoftwareprovidesredundancy,reliability,andmonitoringtoolstoensurespeed,security,uptime,andoverallreliability.In-houseserverscontainredundantcomponents,includingdualpowersupplies,net-workinterfacecards,anddisks.Allhardwareisundervendorsupportandmonitored24/7usingvarioustools.Vendorcontractsincluderequirementsforresponsibilitiesandrolesregardingcybersecurity.Inaddition,vendorcontractsincluderequirementstoovernighthardwarecomponentsthatmayfail;thisensuresthatfullinternalredundancyremainsintact,anduptimeandreliabilitymeetorganizationalrequirements(Figure 7.1-30).
LOTSutilizesSoftwareasaService(SaaS)asapplicable.SaaSdecreasesriskandincreasesoverallreliabilitybyusingvariousvendorsthathostfromdifferentserversanddatacenters.LOTSalsousestheLinkingSmartticketingsystemtotrackITneeds,problems,and/orissues.LinkingSmartallowstrendanalysisanddetectionofapplicationsandcomponents’reliability;unreliablecomponentscanthenberepairedorreplacedbeforereliabilitybecomesanissue.Communica-tionCenterdatareliabilityisensuredthroughaprocessthatincludesnightlybackups,withonecopysenttoasecureoff-sitelocationinColumbia,NT,andtheothercopysenttoWashington,DC(ensuringprotectionfromlocal/regionaldisasters;4.2a[1]).
LOTShasestablishedmultiplepoliciesandprocedurestoensurethesecurityandcybersecurityofsensitiveorprivilegeddataandinformation.Thesepoliciesandproceduresoutlinethephysicalandtechnicalsafeguardsforallcomputersthataccesselectronic,protected,healthinformationtorestrictaccesstoauthorizedusers.Theorganization’spasswordpolicyoutlinestheappropriateparametersforselectingandsecuringsystem-anduser-levelpasswords.StaffmemberswithEMRaccessarerequiredtosignconfidentialityagreements,andITauditsperformedbyQSverifyappropriateaccessandcurrentusers.
TTisLOTS’sprimaryinfrastructurecontractor.TTmonitorssecurity,includingreal-timealertsfromthreat-detectionsystems.TTpreparesalldesktopandlaptopcomputerspriortousetoensurethattheyincludethelatestsecuritypatches,antivirusengines,andhard-driveencryption.Allusersaretrained,andpoliciesrequirestaffmemberstolocktheircomputerswhentheyareaway.LOTSusesfullyredundantfirewallstoensurenetworkandInternetsecurity.Thefirewallincludesintrusiondetectionandpreventionfeatures.Securitypatchesareappliedmonthlyforallphysicalservers,virtualmachines,desktops,andlaptops.LOTShasamailencryption
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policy,whichrequiresencryptionofallemailsthatcontain anddriversafety,andmaliciousintrudertraining.Theinjurypersonallyidentifiedinformation(PII)orpersonalhealth reportingprocessensuresthatallinjuriesareinvestigated,rootinformation(PHI). causeisdetermined,andachangein-processorenvironment
istakenifindicatedtoensurerecovery.Forexample,in2018,Cybersecuritythreatandemergingsecurityissueawarenesstherewasa25%decreaseintissueneedlesticks/injuriesinaremaintainedthroughanumberofapproaches.LOTSthetissueprocurementdepartment,whichwasaresultofreceivessecuritybulletinsdirectlyfromathird-partyvendorimprovedtraininginorientationandtherequiringofprotectiveandcanrespondtoeminent,day-zerothreats.Antivirusgloves.SafetyknowledgeissharedviatheCommunicationenginesarerequiredtobecurrent,andtheycontinuouslyscanProcess;regularsafetyupdatesarecommunicatedtothetheLOTSenvironment.workforceatdepartmentandstaffmeetings.Fireandtornado
Identificationandprioritizationoftechnologysystemprotec- drills,alongwithothersafetydrills,areregularlyconducted.tionfromcybersecurityattacksareprovidedthroughthe PersonalsafetyclassesnowincludeprovidingpersonalsafetyutilizationofSaaS,whichprovideshostingofsolutionsfrom alarmstostaffmembers.Badgesarerequiredforentryintocompleteseparateserversanddatacenters.LOTS’spayroll, workareas,withlevelsofrestrictionbasedonnecessityasaccounting,EMR,andBusinessIntelligencesystems,for determinedbyjobdescription.Moreover,alocalsecurityexample,areallhostedbydifferentvendorsatdifferentdata companyisusedtoprovidecontinuousperimeterandcampuscenters.Inaddition,necessaryintegrationoccursbehind securityduringnonbusinesshours,includingweekendsandLOTS’sfirewalls. holidays.SecuritycamerasaremanagedintheCommunica-Detectionofcybersecuritybreachesisprovidedbymonitoring tionCenterareaandallowfor24/7monitoringofperimetertoolsthatareinplacetocontinuouslyscantheenvironmentfor doorandaccesspoints,alongwithafencedparkingareaforsuspiciousactivity.Acybersecuritybreachhasnotoccurredat staffmembers.LOTS.Theresponseandrecoveryfromapotentialcybersecu- 6.2c(2) LOTShasawell-documented,executabledisasterritybreachwouldincludedetectionoftheattack,andcompro- preparednessplanthatallowstheworksystemstocontinuemisedserverswouldberecovered.Recoverywouldtypically toachieveahighlevelofcustomersatisfaction.Emergencyincluderunningantivirussoftwareandothersecuritytoolsto preparednessisensuredthroughregulartestingandanalysisremoveandcleananyviruses,Trojans,ormonitoringagents. oftheEmergencyResponsePlan(ERP;AOS).TheplanisAnycompromiseddatawouldbedeletedandrecoveredfrom aguidelinethatpreparesthestafftorespondtosafetyandbackups. operationaldisruptionsintheeventofanemergency.Multiple
measuresarealsoinplacetoensurecontinuityofoperations.6.2c Safety and Emergency PreparednessThedesignofLOTS’sfacilityensuresthatallcriticalservices,
6.2c(1) LOTShasestablishedaSafetyProgram,managed includingtheCommunicationCenter,ISnetwork,andclinicalbytheSafetyOfficer,thatutilizessystematicprocesses, operations,arecontinuouslyonlineandsupportedbyanemer-includingtheLDS,forensuringasafeoperatingenvironment. gencygenerator.RoutinetestingandpreventativemaintenanceIdentificationofworkforcesafetyconcernsandaTimely ofallcriticalequipmentoptimizetheorganization’sabilitytoInjuryReportingProcessallowforasystematicreviewto respondtoanyevent.Additionally,remoteaccesscapabilitiesidentifyareasforpreventionandimprovement.Injuriesare allowworktocontinueuninterruptedincaseofadisaster,reported,andthesedataaremonitoredtoidentifypotential emergency,orweatherinterruption.Remoteaccesstophonetrendsandopportunitiesfortrainingonaccidentprevention systemsensures24/7remoteaccessforexternalservices.In(Figure 7.3-7).Inaddition,a2018staffsafetysurveynoted theeventofadisaster,anextremevolumeofcases,orcriticaloverallsatisfactionwithsafetyat85%,anincreaseof2%over staffingshortages,LOTShasagreementswithmultipleotherthepriorsurvey(AOS).Accidentprevention,embeddedinthe OPOstoreciprocateemergencystaffingandfacilitiesonacultureoftheorganization,startswithnewhiresinorientation short-termbasis.Intheeventofalong-term,off-siteoption,andcontinueswithannualtraining.Preventionexamples LOTSispreparedtocompleteorganandtissueclinicalincludeOSHAtraining,blood-bornepathogenstraining,the processesatlocalhospitals,andtheCommunicationCenterprovisionofpersonalprotectionequipment,andstaffmembers wouldbeoperationalviaremoteaccess.RecoveryfollowingbeingprovidedthehepatitisBvaccine.Inaddition,workforce aneventwouldbedependentontheincidentorevent,butsafetyconcernsareidentifiedinODs,departmentmeetings, LOTS’sfacilitywouldbere-establishedatanotherlocationifRFO,staffsurveys,regularqualityaudits,andinvestigationof necessary.Theorganizationmaintainsbusinessinterruptioninjuries.TheSafetyProgram,utilizingtheSafetyCommittee, insurancetoensureadequatefinancialresourcestosupportrecommendsneededtrainingsessions,policychangerecom- continuedoperations.IntheeventthatLOTS’scontinuitycon-mendations,and/orotherneededsafetyenhancements.These tingencyplans,includingsuppliersandpartners,aredeemedlearningsmayresultintrainingsessionsforstaffmembersor ineffectiveornotavailableduetocatastrophiccircumstances,changestopolicy,ifrequired. thehighest-rankingleadershipmemberavailablemaymakeTheSafetyCalendar(AOS)includesmonthlysafetyprograms thedecisiontoceaseoperationsuntilalternativeoptionsareencompassingpersonalsafety,CPR,automatedexternaldefi- identifiedbytheELT.brillators(AED),fireextinguishertraining,defensivedriving
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Category 7: Results
7.1 Product and Process Results7.1a Customer-Focused Product and Service Results AtLOTS,mostjob-andcareer-relatedprogressioninvolvesjobenhancementopportunitieswithintheorganization.Duetotheorganization’ssizeandstructure,careerenhancementisoftensupportedinhorizontaltransitionstodifferentroles.Overhalfoftheworkforceisinadifferentpositiontodaythanorigi-nallyhiredfor,andmanyofthosehavetransitionedmultipletimes.ThePEPhelpsidentifyhighperformerswhocanutilizetheirskills,knowledge,andabilitiesinvariousways.
TheLDSisusedtopreparetheworkforceforreplacementandsuccessionplanning.ThesuccessionplanisreviewedannuallythroughtheSPP(Figure 2.1-1,Step5)andmodifiedasneededbytheCHRO,CEO,COO,CMO,andeachLTmember;theplanprovidesstrategyforshort-andlong-termcoverageforeachLTposition.TheLTsuccessionplanfocusesonthedevelopmentofcurrentleaderspositionedtotakeonadditionalresponsibilitiesandemergingleaderswhocouldserveasthenextgenerationofleadership.Developmentneedsofidentifiedemergingleadersarenowincorporatedwithinthetraininganddevelopmentplanaspartoftheemployee’sPEP.Asanexample,targetedtrainingisbeingprovidedquarterlytoteamleadsacrosstheorganizationtoensurefoundationalunderstanding,includingteamdynamics,difficultconversa-tions,andteammotivation.
LOTShasthreekeyworkprocesseswithintheworksystems:ReferralManagement,Authorization,andProcurement/Allocation(Figure 6.1-2).ReferralManagement,thefirstkeyprocessinbothworksystems,ismeasuredbyorganandtissuereferrals.Referralisthestartofcollaboration;hospitalsatisfactionwiththedonationisreflectedinFigures 7.1-1A and 7.1-2A.Organreferrals(Figure 7.1-1)haveexperiencedorganizationalbestlevelsin2018.Tissuereferralshaveincreased,allowingLOTStoachieve“tenthinthenation”statusin2018(Figure 7.1-2).(GPRisanationalorganizationprovidingcomparativesatisfactionandengagementdata.)
0
1,200
2,400
2016 2017 2018 2019 ytd
Refer
rals
Figure 7.1-1: Organ Referrals
LOTS Internal Target
INTERNAL METRIC
Organ Referrals Remain Consistent Goo
d
0
2,500
5,000
2016 2017 2018 2019 ytd
Refer
rals
/ M P
opFigure 7.1-2: Tissue Referrals
LOTS AOPO Top Quartile
Tenth in the Nation in 2018 Goo
d
INTERNAL METRIC
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ThekeyoutcomemeasurementforauthorizationintheOWSisorgandonors(Figure 7.1-3)andorganauthorization(Figure 7.1-17),andtheauthorizationoutcomemeasureintheTWSistissuedonors(Figure 7.1-4).Organdonornumbersremainhigh.Tissuedonornumbershaveremainedsteadyoverthelastthreeyears,meetingtheindustrycomparative.
Thelastkeyprocessofbothworksystemsisprocurement,whichismeasuredbylocalorganstransplantedintheOWS(Figure 7.1-5).IntheTWS,themeasuresareAge-TargetedBoneDonorsReleased(Figure 7.1-6)andSkinDonorsReleased(Figure 7.1-7).Localorganstransplantedareatopline
0
25
50
2016 2017 2018 2019 ytd
Dono
rs / M
Pop
Figure 7.1-3: Local Organ Donors by Population
LOTS OPTN Top Quartile
Goo
d
Increasing Lives Saved
0
250
500
2016 2017 2018 2019 ytdTissu
e Don
ors /
M P
op
Figure 7.1-4: Total Tissue Donors by Population
LOTS AOPO Top Quartile
Goo
d
Tissue Donors Remain Steady
0
75
150
2016 2017 2018 2019 ytd
Orga
ns T
XP/M
Pop
Figure 7.1-5: Local Organs Transplanted by Population
LOTS OPTN Top Quartile
Goo
d
Near Top Quartile in 2018
0
450
900
2016 2017 2018 2019 ytdBone
Don
ors R
eleas
ed
Figure 7.1-6: Age-Targeted Bone Donors Released
LOTS Allograft Resources Best in Class
Goo
d
Increasing Bone Donors Released
0
450
900
2016 2017 2018 2019 ytd
Skin
Dono
rs Re
lease
d
Figure 7.1-7: Skin Donors Released
LOTS Internal Target
Goo
d
Meeting Internal Release Quotas
measuredirectlyresponsibleforincreasinglivessaved.LocalorganstransplantedpositionsLOTSatthenationaltopquartile.Age-targetedbonedonorsreleasedshowafavorabletrend;skindonorsreleased,amorerecentlyaddedmetric,exceedstheinternaltargetfor2018andshowsabeneficialtrend.
Thetwoworksystemsincludetwoservicelinesthataresegmentedintotwocustomergroups:localorgantransplantcentersandtissueprocessors(Figure P.1-6).Theorganstransplantedcanbesegmentedbyorgantype:heart,lung,liver,kidney,andpancreas,andresultsareshownbyorganstransplantedpermillion(Figures 7.1-8, 7.1-9, 7.1-10, 7.1-11,
0
10
20
2016 2017 2018 2019 ytd
Hear
ts TX
P/M
Pop
Figure 7.1-8: Local Hearts Transplanted
LOTS OPTN Top Quartile
Goo
d
Near Top-Quartile Performance
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0
25
50
2016 2017 2018 2019 ytd
Lung
s TXP
/M P
opFigure 7.1-9: Local Lungs Transplanted
LOTS OPTN Top Quartile
Goo
d
Strong Performance Continues
0
25
50
2016 2017 2018 2019 ytd
Liver
s TXP
/M P
op
Figure 7.1-10: Local Livers Transplanted
LOTS OPTN Top Quartile
Goo
d
Near Top-Quartile Performance
0
45
90
2016 2017 2018 2019 ytd
Kidn
eys T
XP/M
Pop
Figure 7.1-11: Local Kidneys Transplanted
LOTS OPTN Top Quartile
Goo
d
Steady Achievement
and 7.1-12).In2018,therewasanincreaseinHepatitisC+donorsandPublicHealthServices(PHS)-increasedriskdonors,whichlimitedgrowthinresults.Tohelpincreasethenumberofheartstransplanted,LOTSisinvolvedinaheartresearchprojecttoimproveheartfunction.Locallungstrans-plantedpermillionplacesLOTSinthetopquartilein2018.Liverstransplantedpermillionremainssteady,nearingthetopquartile.Kidneystransplantedpermillionremainssteady,
0
7
14
2016 2017 2018 2019 ytd
Panc
reata
TXP
/M P
op
Figure 7.1-12: Local Pancreata Transplanted
LOTS OPTN Top Quartile
Goo
d
Near Top-Quartile Performance
withsteadyimprovementsince2017.Pancreatatransplantedpermillionremainsneartop-quartileperformance.Tissuedonorscanbesegmentedbybonedonors(Figure 7.1-13)andskindonors(Figure 7.1-14).Boneandskindonornumbershavebeenimpactedbytheopioidepidemic,resultingindecreasedsuitability,andprocessorlimitshavealsoresultedindecreases.
0
800
1,600
2016 2017 2018 2019 ytd
Dono
rs
Figure 7.1-13: Total Bone Donors
LOTS AOPO Top Quartile
Good
Suitability Impacts Performance
0
750
1,500
2016 2017 2018 2019 ytd
Dono
rs
Figure 7.1-14: Total Skin Donors
LOTS AOPO Top Quartile
Goo
d
Meeting Processor Needs
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7.1b Work Process Effectiveness Results7.1b(1) LOTS’skeyprocesseffectivenessandefficiencyresultsarenotedinFigure 6.1-2as“in-processmeasures.”TherelationshipmanagementefficiencyandeffectivenessresultsforOWSaremissedorganreferrals(Figure 7.1-15).Missedreferralshaveremainedatorunder2%since2016.ForTWS,therelationshipmanagementin-processmeasureisthepercentageofapproachesbyLOTS(Figure 7.1-16).HospitalServicesstaffhaveworkedcloselywithhospitalpartnerstotransitiontheTissueAuthorizationProcesstotheLOTSCommunicationCenterdepartment.In2018,LOTSperformedtheapproachfortissueauthorizationat99%ofthehospitals,anincreaseofnearly8%inthelastthreeyears.
Theauthorizationin-processmeasureforOWSistheorganauthorizationrate(Figure 7.1-17),whichshowssteadyperformance.TheTWSin-processauthorizationmeasureisthetissueauthorizationrate(Figure 7.1-18).Breakthroughprocesschangesimplemented,combinedwithnewjobrequirements,hiringpractices,andworkforcedevelopmentandtraining,haveresultedintissueauthorizationoutcomesexceedingtheindustrytopquartile.
0%
2%
4%
2016 2017 2018 2019 ytd
Miss
ed R
eferra
ls
Figure 7.1-15: Missed Organ Referrals
LOTS Hospital PartnersAllograft Resources Best in Class
Good
Relationship Management Results
0%
50%
100%
2016 2017 2018 2019 ytd
Figure 7.1-17: Organ Authorization
LOTS OPTN Top Quartile
Goo
d
Top-Quartile Performance
0%
50%
100%
2016 2017 2018 2019 ytd
Figure 7.1-18: Tissue Authorization
LOTS AOPO Top Quartile
Goo
d
Top-Quartile Performance
Thein-processmeasuresforprocurementarelistedinFigure 6.1-2.Optimizingthegift(yield;Figure 7.1-19)isdemonstratedintheOWSbytheabilityoftheclinicalstafftomanagethedonor’sclinicalstatustoensurethehighestnumberoftransplantableorgans.Yieldwasimpactedin2018byanorganizationalrecordofDCDdonorsandanincreaseinHepatitisC+donorsandPHS-increasedriskdonors.Despitethosechallenges,LOTS’sobservedperformanceexceedsexpectedresultswithlungs(Figure 7.1-19A).DonorManage-mentProtocolCompliance(Figure 7.1-20)continuestoshow100%complianceandrepresentstheabilityoftheclinicalorganstafftomanagedonorseffectively.OrganDonorCases
0.00
2.00
4.00
2016 2017 2018 2019 ytd
Orga
ns T
XP/D
onor
Figure 7.1-19: Organ Donor Yield
LOTS OPTN Top Quartile
Goo
d
APs in Place to Drive Yield
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0.00
1.00
2.00
2016 2017 2018 2019 ytd
Obse
rved :
Exp
ected
Figure 7.1-19A: Observed vs Expected by Organ
Kidneys Heart LiverLungs Pancreas Expected
APs in Place to Drive Yield Goo
d
0%
50%
100%
2016 2017 2018 2019 ytd
Rate
Figure 7.1-20: Donor Management Protocol Compliance
LOTS Internal Target
INTERNAL METRIC
Process Compliance Ensures High ResultsG
ood
In-House(Figure 7.1-21)isthepracticeresponsibleforcreat-ingsignificantcostsavingsandcustomersatisfaction.Thisisapartner/customersatisfierforthedonorhospitalsandthetransplantcenters.LOTSoutperformstheexternalbenchmarkcomparisonswithorganizationalhighoutcomesfor2019.TheTWSprocurementin-processmeasuresincludeboneno-growthandskinyield.LOTSmettheAllograftResourcespartnerbenchmarkforBoneNo-GrowthRates(Figure 7.1-22). SkinYield(Figure 7.1-23)showsfavorabletrends;APsweredevelopedtoaddressbenchmarkperformancegaps.
0%
50%
100%
2016 2017 2018 2019 ytd% E
ligibl
e Cas
es In
-Hou
se
Figure 7.1-21: Organ Donor Cases In-House
LOTS AOPO Top Quartile
Goo
d
Growing In-House Cases
0%
50%
100%
2016 2017 2018 2019
Bone
w/N
o Gro
wth
Figure 7.1-22: Bone No-Growth Rates
LOTS Allograft Resources Best in Class
Goo
d
Meeting Customer Requirements
0
3,000
6,000
2016 2017 2018 2019 ytd
Avg.
Skin
Yield
(cm2 )
Figure 7.1-23: Skin Yield
LOTS Allograft Resources Best in Class
Goo
d
APs in Place to Drive Results
ThekeyorganizationalperformanceindicatorsforkeysupportprocessesareshowninFigure 7.1-27 through Figure 7.1-33 . Laboratorytestingturnaroundtime(Figure 7.1-24)hasseensteadyperformance,withLOTSmeetingitsinternalbench-mark.ChartReleaseCycleTime—Organ(Figure 7.1-25)hasseensteadyperformanceinthenumberofdaysneededfororganchartstobereviewedanduploadedtomeetregulatoryrequirements.ChartReleaseCycleTime—Tissue(Figure 7.1-26) reflectsacriticalstepintheTWSProcessduringwhichchartsarecompleted,qualitychecked,andreleasedtotheprocessors,
0:00
4:48
9:36
14:24
19:12
2018 2019 ytd
Time (
hh:m
m)
Figure 7.1-24: Laboratory Turnaround Time by Work System
LOTs Organ LOTs TissueInternal Benchmark Organ Internal Benchmark Tissue
Turnaround time Ensuring Safe Organs and Tissues
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0%
50%
100%
2016 2017 2018 2019 ytd
% C
omple
ted on
Tim
eFigure 7.1-25: Chart Release Cycle Time—
Organ
LOTS UNOS/OPTN
Steady Performance
Goo
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2016 2017 2018 2019 ytd
Days
to C
lear
Figure 7.1-26: Chart Release Cycle Time—Tissue
LOTS Allograft Resources Requirement
Releasing More Charts in Less Time
Good
fulfillingatissueprocessorrequirementandtriggeringreimbursementtoLOTS.Thetissuechartcycletimeismeet-ingorexceedingtheAllograftResourcespartnerrequirement.SterilizerAccuracy(Figure 7.1-27)showsthedocumentationcompliancethatimpactsclinicalequipmentavailability.ITmanagement(Figure 7.1-28)continuouslyshowstheabilityoftheITdepartmenttohaveserveravailability24/7inordertosupportbusinessoperations.AsseeninFigure 7.1-29,processimprovementisanindicatorofPIutilizationacrossthecompanyandshowsconsistentuseoverthelastthreeyears.QualityComplianceManagement(Figure P.1-5)highlightsLOTS’saccreditationresultsinvoluntaryandrequiredcertifications,meetingorexceedingFDA,UNOS,AOPO,andAATBrequirements.
7.1b(2) EmergencypreparednessactionstakentominimizeinterruptionsinthedeliveryofLOTS’sservicesareAOS.
0%
50%
100%
2016 2017 2018 2019 ytd
Accu
racy
Figure 7.1-27: Sterilizer Accuracy
LOTS Internal Target
Goo
d
Consistently High Accuracy
0%
50%
100%
2016 2017 2018 2019 ytd
Uptim
e
Figure 7.1-28: Server Uptime
LOTS Internal Target
Goo
d
Continuous Availability
0
200
2017 2018 2019 ytd
Ticke
t Req
uests
Figure 7.1-29: PI Help Desk Tickets
Scorecard / Report Data Mining
Procedure or Process Enhancement Survey
Committed to Improvement
7.1c Supply-Network Management ResultsSupplyOptimization(Figure 7.1-30)viaanelectronicinven-torysystemhasresultedin97%availabilityforsuppliesforallin-housecases.WrightBrothersCharters,akeysupplier,providesairservicelogisticsfordonationactivityoutsideoftheColumbia,NT,metropolitanarea.WrightBrothersprovides24/7accesstoaircraftwitha90-minutelaunchrequirement,andasdemonstratedinFigure 7.1-31,delaysduetoproviderissuesoccurredinlessthan5%ofthe260-plus
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0%
50%
100%
2016 2017 2018 2019 ytd
Avail
abilit
yFigure 7.1-30: Supply Optimization
LOTS Internal Target
Strong Compliance Goo
d
0%
50%
100%
2013 2016 2017 2018
% of
Tota
l Leg
s Dela
yed
Figure 7.1-31: Wright Brothers Delays
LOTS Wright Brothers
Good
Few Delays Attributed to Vendor
launchesannually.GuardianAmbulanceexceedsrequirements100%ofthetime(Figure 7.1-32).ColumbiaCremation,anotherkeysupplier,hasseenimprovementssince2016,exceedingdeliverytimerequirementsin2018(Figure 7.1-33).TransplantTechnologies,akeysupplier,hasseenincreasing
0:00
1:00
2:00
2016 2017 2018 2019 ytd
Time (
h:mm)
Figure 7.1-32: Guardian Cycle Time
LOTS Requirement Guardian
Good
Meeting Our Requirements
0.00
1.50
3.00
2016 2017 2018 2019 ytd
Time (
Hour
s)
Figure 7.1-33: Columbia Cremation Cycle Time
LOTS Requirement Columbia Cremation
Good
Improvement Efforts Drive Compliance
numbersofmajorreleaseswithcomplexfeaturesin2018thatexposesmoreopportunitiesfordefects.TransplantTechnolo-giescontinuestoworkwithLOTStoresolveopportunitiesinatimelymanner(Figure 7.1-34).TitanTechnologies,arecentlyaddedkeysupplier,hasmanagedtoreducethenumberofopenITHelpDeskTicketsinQueue(Figure 7.1-35).
0%
20%
40%
0
40
80
2016 2017 2018 2019 ytd
Defec
ts
Featu
res P
ublis
hed
Figure 7.1-34: Transplant Technologies Change Requests
Features Published Defects
Major EMR Enhancements Released in 2018
Good
0
50
100
2017 2018 2019 YTD
Avg #
Tick
ets
Figure 7.1-35: IT Help Desk Tickets in Queue
IT Helpdesk Queue
Good
Significant Reduction in Helpdesk Tickets
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7.2 Customer Results7.2a Customer-Focused Results7.2a(1) AsthefederallydesignatedOPOwithinitsservicearea,LOTSdoesnothaveorganprocurementcompetitors.Regardless,maximizingcustomersatisfactionandengage-mentisanorganizationalgoal,andLOTSworkscloselywithitscustomergroupstomeetandexceedtheirrequirements.CustomersatisfactiondataaregatheredthroughtheVOCmethodsaslistedinFigure 3.1-1,includingtheCustomerSurveyProcess(AOS),whichhasundergonemultiplecyclesoflearningandstrategicimprovement.(Keymeasuresincludeoverallsatisfaction,andsegmentationbycustomergroupandservicelineareAOS.)
OverallsatisfactionlevelswithLOTS’sorgantransplantcen-ters(Figure 7.2-1)demonstrateperformancethatisequaltoorexceedsthebenchmarkforthelastthreeyears.Localorgantransplantcentersatisfaction,segmentedbykeyrequirement,showsstrongperformancein“competence”(Figure 7.2-1A)and“information”(Figure 7.2-1B).Customersatisfactioninmeetingthethirdrequirement,“maximizedonation,”isnotmeasuredthroughsurveys.Instead,operationalresultsareutilizedtogaugeeffectivenessinachievingthiskeycustomerrequirementandSO(Figure 7.1-5).Organtransplantcentersatisfactioncanbesegmentedbyposition,whichincludesTransplantPhysician,Coordinator,andAdministrator (Figure 7.2-1C),andshowsstrongresultsfor2018inall threesegments.
0.0
2.5
5.0
2017 2018 2019 ytd
Satis
factio
n
Figure 7.2-1C: Transplant Center Satisfaction—Organ
Administrator Coordinator Physician
Goo
dOverall Satisfaction
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SatisfactionlevelsamongLOTS’stissueprocessors(Figure 7.2-2)arecriticaltoensuringorganizationalsuccess.Overallsatisfactiondemonstratesnearhighperformance.Cus-tomersatisfactionmeetingthefirstkeyrequirement“account-ability,”definedaserrorrateminimization,ismeasuredutilizingoperationalmetricsreportedviatissueprocessorscorecards(Figures 7.2-2A and 7.2-2B).Whensegmentedbythekeycustomerrequirementof“information”(Figure 7.2-2C),resultsareconsistentlyhigh.Thethirdprocessorrequirementis“maximizedonation,”whichistiedtoLOTS’stissuedona-tionrates(Figure 7.1-4).Tissueprocessorsatisfactioncanbesegmentedbyindividualprocessor(Figure 7.2-2D).Satisfac-tionbyprocessorhasremainedstrong;2019year-to-dateresultsshowbeneficialtrendsforallprocessors.APsareinplacefor2019thattargetspecificareasforfocustocontinueexceptionalresults.FullsegmentedresultsbycustomerandservicelineareAOS.
0%
50%
100%
0.0
2.5
5.0
2016 2017 2018 2019
Enga
geme
nt
Over
all S
atisfa
ction
(All T
Ps)
Figure 7.2-2: Tissue Processor Satisfaction
Overall Satisfaction (All TPs)Allograft Resources Partner (Satisfaction)%Top Box (Engagement)
Goo
d
High Levels of Overall Satisfaction
0%
50%
100%
2016 2017 2018 2019 ytd
Accu
racy
Figure 7.2-2A: Vein Accuracy Rates
Saphenous VeinFemoral VeinCardioSolutions Saphenous VeinCardioSolutions Femoral Vein
Goo
d
Key Requirement: Accountability
0%
50%
100%
2016 2017 2018 2019 ytd
Accu
racy
Figure 7.2-2B: Heart Valve Accuracy Rates
LOTS CardioSolutions Top Quartile
Goo
d
Key Requirement: Accountability
0%
50%
100%
0.0
2.5
5.0
2016 2017 2018
Enga
geme
nt
Satis
factio
n
Figure 7.2-2C: Tissue Processor Satisfaction
Satisfaction %Top Box (Engagement)
Goo
d
Key Requirement: Information
0.0
2.5
5.0
2016 2017
Satis
factio
n
Figure 7.2-2D: Tissue Processor Satisfaction
Allograft Resources CardioSolutions Regeneration Associates
Goo
d
Increasing Overall Satisfaction
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Todeterminedissatisfactionlevelswithlocalorgantransplantcentersandtissueprocessors,LOTSanalyzesdataobtainedthroughtheCustomerComplaintProcess(Figure 3.2-2).Despiteanincreaseinthenumberoforganandtissuedonors,thepercentageofcustomercomplaintsforthetwocustomergroupshasdemonstratedfavorabletrends(Figure 7.2-3).TheimplementationofaformalizedCAPAsystemprovidesstan-dardizationandallowsforsystematicevaluationofcomplaintsregardlessofwheretheyoccurwithinthecustomerlifecycle.
Inadditiontocomplaints,LOTSutilizescustomersurveydatatomeasuredissatisfactionbydeterminingthepercentageofpoorandverypoorresponses(scoresof1or2)oncustomersurveys.Resultsfororganandtissueareatornear0%,withbothmaintaininglowtrendssince2016(Figures 7.2-3A and 7.2-3B).
0%
5%
10%
2016 2017 2018 2019 ytd
Comp
laints
/ Cas
es
Figure 7.2-3: Customer Complaints
Organ Tissue
Systematic Process Drives improvements
Good
0%
5%
10%
2016 2017 2018 2019
Diss
atisfa
ction
Figure 7.2-3A: Customer Dissatisfaction—Organ
Dissatisfaction
Good
Scored as "Poor" or "Very Poor"
0%
5%
10%
2016 2017 2018 2019 ytd
Diss
atisfa
ction
Figure 7.2-3B: Customer Dissatisfaction—Tissue
Dissatisfaction
Good
Scored as "Poor" or "Very Poor"
7.2a(2) Toidentifylevelsandtrendsincustomerengage-ment,LOTScalculatesthepercentageofverysatisfiedortop-boxscores(perfect5outof5)onitscustomersatisfactionscores.Thismethodologyisbasedupon The Loyalty Effect (FredReichheld),whichtheorizesthatrelationshipstrengthisdirectlyrelatedtocustomerloyaltyandengagement(3.2).LOTShasmaintainedconsistentlevelsofengagementwithitslocalorgantransplantcenters(Figure 7.2-1).Tissueprocessorengagementresultshavedemonstratedfavorabletrendssince2016(Figures 7.2-2).
Toassessitsperformanceinbuildingcustomerrelationships,LOTSanalyzesitsnumberofactivecustomers(Figure 7.2-4).Theorganservicelineoperatesinanoncompetitiveserviceareadesignatedbythefederalgovernment,sothenumberoflocalorgantransplantcentershasnotchangedin15years.Inthetissueserviceline,LOTSmaintainscontractualagreementswithitstissuecustomersandexpandeditscustomerbaseattheendof2017andinto2018.
0
10
20
2016 2017 2018 2019
Activ
e Cus
tomer
s
Figure 7.2-4: Customer Loyalty
Organ Tissue
Sustaining Customer Relationships Goo
d
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7.3 Workforce Results7.3a Workforce-Focused Results7.3a(1) WorkforceC&CkeymeasuresandresultsareshowninFigures 7.3-1 through 7.3-4.ThePEPratings(Figures 5.1-2 and 7.3-1)illustratetheaverageperformanceevalua-tionscorefortheLOTSworkforce,whichismeasuredonafour-pointscale.Throughtheimplementationofanoutcome-basedperformanceevaluationtool,PEPratingresultsindicatethatthemajorityoftheworkforce“achieveexpectations,”thereforemeetingtheorganization’scapabilityneeds.LOTSmaintainsadequatecapacityfortheOWSthroughevaluationoforgandonorspertheOPC(Figure 7.3-2).WithintheTWS,evaluationofworkforcecapacityisassessedatquarterlyC&CmeetingsbyongoingcomparisonofthenumberoftissuedonorstothenumberofTOPCstaffmembers(Figure 7.3-3).
WorkforceGrowth(Figure 7.3-4)demonstratescontinuedstaffinglevelsandstableNewHireDiversity(Figure 7.3-4A)overthepastthreeyearsasserviceshaveexpanded.NIST Training Draft
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7.3a(2) Workforceclimatemeasuresarekeytoretainingamission-drivenworkforce(CC)anddonotdifferbydiversityoftheworkforceorworkgroup.Workforcehealth,safety,andsecurity,aswellasemployer-providedservicesandbenefits,aremonitoredcontinuouslytoensureeffectiveness.
Inanefforttoexhibitconcernandcarefortheemployeesaswellasengageemployeesinthetopicofpersonalhealth,awellnessprogramwasinitiatedin2009.Thewellnessprogramparticipationremainsstrong(Figure 7.3-5).LOTStakesgreatcareinensuringthatallemployeesaretraineduponhireandannuallythereafteronproperproceduresandsafetyprotocolsineachpositionanddepartment.WorkplacePreparedness(Figure 7.3-6)demonstratesmultipleeffortsdeployedtoensurethesafetyoftheworkforce.Asaresultoftheorganiza-tion’sdedicationtoadherencetosafetyproceduresandproto-cols,LOTSmonitorsitsDARTrate(DaysAway/Restricted/TransferredRate)duetoworkplaceinjuries(Figure 7.3-7).
RadiationExposure(Figure 7.3-8)ratesareusedtoassesstheamountofradiationorganclinicalstaffmembersareexposedtowhenutilizingimagingequipment.LOTSpoliciesandproceduresensurethatemployeesaresafefromradiationexposure.
Multiplesecuritymeasuresareinplacetocreatethemostsecureenvironmentfortheworkforce(Figure 7.3-9).
Theorganizationhasconsistentlyshowncommitmenttothehealthandsatisfactionofitsemployeesbycontinuingtoofferrichbenefitsplansinmedical,dental,vision,andlifecoverage,aswellasadditionalbenefitsasshowninBenefitsExpenditures(Figure 7.3-10).
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Figure 7.3-6: Workplace Preparedness
Preparations Goal 2016 2017 2018 2019 YTD
SafetyTraining AllEmployees 100% 100% 100% 100%
FireAlarmTesting Quarterly 4 4 4 3
AeroCharterSafetyTraining AllAplicableEmployees 100% 100% 100% 100%
GeneratorsandSystemAvailabilityTesting Weekly 100% 100% 100% 100%
InjuryInvestigation AllInjuries 100% 100% 100% 100%
Data/VOIP(Communication)Testing RealTime 100% 100% 100% 100%
7.3a(2) Workforceclimatemeasuresarekeytoretainingamission-drivenworkforce(CC)anddonotdifferbydiversityoftheworkforceorworkgroup.Workforcehealth,safety,andsecurity,aswellasemployer-providedservicesandbenefits,aremonitoredcontinuouslytoensureeffectiveness.
Inanefforttoexhibitconcernandcarefortheemployeesaswellasengageemployeesinthetopicofpersonalhealth,awellnessprogramwasinitiatedin2009.Thewellnessprogramparticipationremainsstrong(Figure 7.3-5).LOTStakesgreatcareinensuringthatallemployeesaretraineduponhireandannuallythereafteronproperproceduresandsafetyprotocolsineachpositionanddepartment.WorkplacePreparedness(Figure 7.3-6)demonstratesmultipleeffortsdeployedtoensurethesafetyoftheworkforce.Asaresultoftheorganiza-tion’sdedicationtoadherencetosafetyproceduresandproto-cols,LOTSmonitorsitsDARTrate(DaysAway/Restricted/TransferredRate)duetoworkplaceinjuries(Figure 7.3-7).
RadiationExposure(Figure 7.3-8)ratesareusedtoassesstheamountofradiationorganclinicalstaffmembersareexposedtowhenutilizingimagingequipment.LOTSpoliciesandproceduresensurethatemployeesaresafefromradiationexposure.
Multiplesecuritymeasuresareinplacetocreatethemostsecureenvironmentfortheworkforce(Figure 7.3-9).
Theorganizationhasconsistentlyshowncommitmenttothehealthandsatisfactionofitsemployeesbycontinuingtoofferrichbenefitsplansinmedical,dental,vision,andlifecoverage,aswellasadditionalbenefitsasshowninBenefitsExpenditures(Figure 7.3-10).
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7.3a(3) Essentialtotheworkforceclimate,andakeycontributortoemployeeengagement,istheconnectiontotheorganization’smission.Onworkforcesurveys,staffmembersrepeatedlyindicateanexceptionallevelofunderstandingofhowtheirindividualpositionscontributetothemission,exceedingtop-quartileperformance(Figure 7.3-11).ResultsintheExcelEmployeeEngagementsurveyassessingtheorganization’soverallengagementexceedthehealthtop-quartilebenchmark.Inaddition,segmentationbyworksystemdemonstratesstrongengagementscoresinboththetissueandorganworksystems(Figure 7.3-12A).
LOTScontinuestohaveconsistentorganizationalretention;departmentalAPsareinplacefor2018toaddressopportuni-ties(Figure 7.3-13).Overthelastseveralyears,LOTShasfocusedonensuringworkforcesatisfaction.Overallworkforcesatisfactionsurveyresultsshowasustainedtrendandfavor-ablecomparisontotheexternalbenchmark(Figure 7.3-14).Overallbenefitssatisfaction(Figure 7.3-15)showsstrongresults,equaltothehealthcareindustrytopquartile.
Figure 7.3-9: Security Measures
Preparations Goal 2016 2017 2018 2019
SecurityAlarmSurveillance 24/7 24/7 24/7 24/7 24/7
Motion-SensoredLighting 24/7 24/7 24/7 24/7 24/7
DVR-MonitoredSecurityCameras 24/7 24/7 24/7 24/7 24/7
MonitoredPanicButtons(Vendor) 24/7 24/7 24/7 24/7 24/7
BadgeAccessRequired
SecureParking 24/7 NA 24/7 24/7 24/7
In Compliance
7.3a(3) Essentialtotheworkforceclimate,andakeycontributortoemployeeengagement,istheconnectiontotheorganization’smission.Onworkforcesurveys,staffmembersrepeatedlyindicateanexceptionallevelofunderstandingofhowtheirindividualpositionscontributetothemission,exceedinghealthcaremedianperformance(Figure 7.3-11).ResultsintheExcelEmployeeEngagementsurveyassessingtheorganization’soverallengagementexceedthehealthtop-quartilebenchmark.Inaddition,segmentationbyworksystemdemonstratesstrongengagementscoresinboththetissueandorganworksystems(Figure 7.3-12A).
LOTScontinuestohaveconsistentorganizationalretention;departmentalAPsareinplacefor2018toaddressopportuni-ties(Figure 7.3-13).Overthelastseveralyears,LOTShasfocusedonensuringworkforcesatisfaction.Overallworkforcesatisfactionsurveyresultsshowasustainedtrendandfavor-ablecomparisontotheexternalbenchmark(Figure 7.3-14).Overallbenefitssatisfaction(Figure 7.3-15)showsstrongresults,equaltothehealthcareindustrytopquartile.
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7.3a(4) LOTSsupportsthetraininganddevelopmentoftheentireworkforce,asseeninOverallTrainingandDevelop-mentSatisfaction(Figure 7.3-16)andLOTS’sfinancialinvestmentintrainingexpendituresperfull-timeequivalent(FTE;Figure 7.3-17).LOTSalsomeasureslevelsandtrendsinleaderdevelopmentthroughtheannualworkforcesurvey.Figure 7.3-18showsleaderresultsindicatingsatisfactionwithemployer-sponsoredtraininganddevelopmentmeetingtheindustrytopquartile.
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7.4 Leadership and Governance Results7.4a Leadership, Governance, and Societal Contribution Results7.4a(1) LeaderCommunication(Figure 7.4-1)reflectsseniorleadercommunicationwiththeworkforce.Communicationhasremainedsteady,andtherearemultipleAPsinplacein2019tocontinuetodriveperformancetoexceedtop-quartilebenchmarks.
7.4a(2) LOTSBoardSelf-Assessment(Figure 7.4-2)comparesfavorablytothebenchmark.FullsurveydataandresultantactionsareAOS.
LOTSengagesinmultipleactivitiestoensurefiscalaccount-ability,aslistedinsection1.2a(1).Asanonprofitorganization,anAuditCommitteeisnotarequirement,butonewasvolun-tarilyestablishedasabestpracticeingovernancetoexpandfiscalaccountability.Externalfinancialauditssanctionedbythiscommitteehavealwaysachievedthehighestratingof“unqualified”opinion(Figure 7.4-4).
7.4a(3) LOTSviewsaccreditationandregulatorycomplianceasabaselineexpectationforperformance.Theorganizationhasreceivedfullaccreditationfromallvoluntaryaccreditingbodieswithinitsindustryandhasmaintainedthistrendforseveralyears.Additionally,LOTSmaintainsfullcompliancewithregulatoryandlegalmandatesthathavebeensustainedsincetheorganization’sinception(Figure 7.4-3).
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Figure 7.4-3: Regulatory & Legal Compliance Key Measures
Measures & Indicators Results
AATBAccreditation(3years) FullAccreditation
AOPOAccreditation(3years) FullAccreditation
CMSCertification(4years) FullCertification
DHSS(3years) FullCompliance
DOR NoAdverseFindings
EEOC 0Issues
FDAApproval NoAdverseFindings
FLSA 0Issues
IRSCompliance 0Issues
OSHA FullCompliance
UNOS/OPTN(3years) MemberinGoodStanding
UnblemishedPerformance
Figure 7.4-4: External Financial Audit
Year External Auditor Determination
2013 Brother,Sister,&Auditor UnqualifiedOpinion
2014 Brother,Sister,&Auditor UnqualifiedOpinion
2015 Brother,Sister,&Auditor UnqualifiedOpinion
2016 Brother,Sister,&Auditor UnqualifiedOpinion
2017 Brother,Sister,&Auditor UnqualifiedOpinion
ExcellentFiscalAccountability
7.4 Leadership and Governance Results7.4a Leadership, Governance, and Societal Contribution Results7.4a(1) LeaderCommunication(Figure 7.4-1)reflectsseniorleadercommunicationwiththeworkforce.Communicationhasremainedsteady,andtherearemultipleAPsinplacein2019tocontinuetodriveperformancetoexceedtop-quartilebenchmarks.
7.4a(2) LOTSBoardSelf-Assessment(Figure 7.4-2)comparesfavorablytothebenchmark.FullsurveydataandresultantactionsareAOS.
LOTSengagesinmultipleactivitiestoensurefiscalaccount-ability,aslistedinsection1.2a(1).Asanonprofitorganization,anAuditCommitteeisnotarequirement,butonewasvolun-tarilyestablishedasabestpracticeingovernancetoexpandfiscalaccountability.Externalfinancialauditssanctionedbythiscommitteehavealwaysachievedthehighestratingof“unqualified”opinion(Figure 7.4-4).
7.4a(3) LOTSviewsaccreditationandregulatorycomplianceasabaselineexpectationforperformance.Theorganizationhasreceivedfullaccreditationfromallvoluntaryaccreditingbodieswithinitsindustryandhasmaintainedthistrendforseveralyears.Additionally,LOTSmaintainsfullcompliancewithregulatoryandlegalmandatesthathavebeensustainedsincetheorganization’sinception(Figure 7.4-3).
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Figure 7.4-3: Regulatory & Legal Compliance Key Measures
Measures & Indicators Results
AATBAccreditation(3years) FullAccreditation
AOPOAccreditation(3years) FullAccreditation
CMSCertification(4years) FullCertification
DHSS(3years) FullCompliance
DOR NoAdverseFindings
EEOC 0Issues
FDAApproval NoAdverseFindings
FLSA 0Issues
IRSCompliance 0Issues
OSHA FullCompliance
UNOS/OPTN(3years) MemberinGoodStanding
UnblemishedPerformance
Figure 7.4-4: External Financial Audit
Year External Auditor Determination
2013 Brother,Sister,&Auditor UnqualifiedOpinion
2014 Brother,Sister,&Auditor UnqualifiedOpinion
2015 Brother,Sister,&Auditor UnqualifiedOpinion
2016 Brother,Sister,&Auditor UnqualifiedOpinion
2017 Brother,Sister,&Auditor UnqualifiedOpinion
ExcellentFiscalAccountability
7.4 Leadership and Governance Results7.4a Leadership, Governance, and Societal Contribution Results7.4a(1) LeaderCommunication(Figure 7.4-1)reflectsseniorleadercommunicationwiththeworkforce.Communicationhasremainedsteady,andtherearemultipleAPsinplacein2019tocontinuetodriveperformancetoexceedtop-quartilebenchmarks.
7.4a(2) LOTSBoardSelf-Assessment(Figure 7.4-2)comparesfavorablytothebenchmark.FullsurveydataandresultantactionsareAOS.
LOTSengagesinmultipleactivitiestoensurefiscalaccount-ability,aslistedinsection1.2a(1).Asanonprofitorganization,anAuditCommitteeisnotarequirement,butonewasvolun-tarilyestablishedasabestpracticeingovernancetoexpandfiscalaccountability.Externalfinancialauditssanctionedbythiscommitteehavealwaysachievedthehighestratingof“unqualified”opinion(Figure 7.4-4).
7.4a(3) LOTSviewsaccreditationandregulatorycomplianceasabaselineexpectationforperformance.Theorganizationhasreceivedfullaccreditationfromallvoluntaryaccreditingbodieswithinitsindustryandhasmaintainedthistrendforseveralyears.Additionally,LOTSmaintainsfullcompliancewithregulatoryandlegalmandatesthathavebeensustainedsincetheorganization’sinception(Figure 7.4-3).
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7.4a(4) ThenatureofLOTS’sbusinessrequiresthattheorganizationlivesitscorevalueofhonestyanddemonstratessocialresponsibilityasindicatedbykeymetricsrelatedtoethicalbehavior.Inaddition,100%oftheBOD,LT,andworkforcecompleteannualconflict-of-interestdocumentation.EthicalbehaviorisensuredbyprovidingannualCCPtrainingtoallemployees.Currently,100%oftheworkforceandboardisCCP-trained.LimitedcorporatecomplianceissuesarenotedinReportofCorporateComplianceHotlineIssues(Figure 7.4-6), whichillustratesprogrameffectiveness.
Stakeholder(BOD)requirementsshowahighlevelofsatisfac-tion(Figure 7.4-5)basedontheBODevaluationoftheCEO’sperformance.Similarly,trustinleadership(CEO)bytheBODconsistentlymeetsorexceedstheorganizationalgoalof2.5ona3-pointscale(Figure 7.4-7).
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7.4a(4) ThenatureofLOTS’sbusinessrequiresthattheorganizationlivesitscorevalueofhonestyanddemonstratessocialresponsibilityasindicatedbykeymetricsrelatedtoethicalbehavior.Inaddition,100%oftheBOD,LT,andworkforcecompleteannualconflict-of-interestdocumentation.EthicalbehaviorisensuredbyprovidingannualCCPtrainingtoallemployees.Currently,100%oftheworkforceandboardisCCP-trained.LimitedcorporatecomplianceissuesarenotedinReportofCorporateComplianceHotlineIssues(Figure 7.4-6), whichillustratesprogrameffectiveness.
Stakeholder(BOD)requirementsshowahighlevelofsatisfac-tion(Figure 7.4-5)basedontheBODevaluationoftheCEO’sperformance.Similarly,trustinleadership(CEO)bytheBODconsistentlymeetsorexceedstheorganizationalgoalof2.5ona3-pointscale(Figure 7.4-7).
Figure 7.4-6: Reported Corporate Compliance Hotline Issues
Year Results
2014 0ComplaintsReported
2015 0ComplaintsReported
2016 1ComplaintReported
2017 1ComplaintReported
2018 1ComplaintReported
2019YTD 4ComplaintsReported
CommitmenttoIntegrity
Good
7.4a(5) AtruemeasureofsocietalbenefitisthereductionofdeathsonthelocalwaitinglistasLOTSincreasestransplantedorgans;thisdynamictrendhasimpactedthecommunitylivingwithintheDSA(Figure 7.4-8).
7.4a(5) AtruemeasureofsocietalbenefitisthereductionofdeathsonthelocalwaitinglistasLOTSincreasestransplantedorgans;thisdynamictrendhasimpactedthecommunitylivingwithintheDSA(Figure 7.4-8).NIST Training Draft
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7.5 Financial, Market, and Strategy Results7.5a Financial and Market Results7.5a(1) LOTS’sfinancialperformanceisbenchmarkedbyevaluatingkeymeasureswithinOPOfinancialsurveysconductedbyAOPO.LOTSutilizesthesurveystoexamineitsoverallfinancialcondition.TheorganizationalgoalistoassesswhetherLOTS’sfinancialandoperatingstatusareimprovingovertimeandagainstbenchmarks.LOTSalsousesbudgetstooptimizeoutcomesandcontinuebeingaleaderintheindustry.
ConsolidatedResultsofOperations(Figure 7.5-1)demon-stratesthatLOTSisinastrongpositionwithgoodperfor-mancelevelscomparedtobudget,with2018organizationalresultsof$3.36million.LOTSdemonstratesfavorablefinan-ciallevelsinseveralfinancialmeasuresutilizingtheAOPOtop-quartilebenchmarkincludinggrossrevenue(Figures 7.5-2, 7.5-2A, and 7.5-2B),OperatingMargin(Figure 7.5-3),
NetMargin(Figure 7.5-4),DaysinAccountsReceivable(Figure 7.5-5),DaysinAccountsPayable(Figure 7.5-6),CurrentRatioofAssetsversusLiabilities(Figure 7.5-7),andDaysCashonHand(Figure 7.5-9).TheseresultsreflectLOTS’sidentifiedstrategicadvantageofpossessingastrongfinancialpositionandsupportorganizationalsustainability.
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OperatingReserves(Figure 7.5-8)includescash,investments,andaccountsreceivable.TheamountofoperatingreservesissetbyBODpolicyandallowsLOTStoensuremissionattain-mentandorganizationalsustainability.LOTSsetsthestandardasTissueTransformationsbest-in-classperformer.
TotalAssets(Figure 7.5-10)indicatesLOTS’ssustainabilityandstrongfinancialposition.Performanceshowsbest-in- classresults.LOTS’sstrongfinancialandoperatingreturnsdemonstrateviabilityandcontinuetoimproveovertime.Overallfinancialperformancemeasurementsaresimilar,exceedingindustrycomparisons,andperformwellagainstthebudgetaryplan.
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7.5a(2) AsanonprofitorganizationwithaDSAthatisdesignatedbyCMS,LOTSdoesnotlooktoincreasemarket“share”inthetypicalwaythatothercompaniesdo,butitlookstoimproveitsownperformancewithinitsDSAandtotrackitsprogressviathemeasuresrepresentedinitem7.1.
OrganDonorCostComparison(Figure 7.5-11)demonstratesthedifferenceindonorcostswhendonorsarerecoveredinthetraditionalhospitalsettingversuswhentransferredtotheLOTSfacilityfordonorcareandsurgicalrecovery.EffortstocontaincostsaremeasuredbybudgetspendingtrendsandOACs.OACfeesthathavebeenchargedtothetransplantcenterpartnershavehistoricallybeen(andcontinuetobe)inthelowerquartileofsimilarOPOsatthestrategicdirectionoftheLOTSBOD(Figure 7.5-12).ThecomparisondataforthesechargesarecompiledfromOPOs,typicallywithgeographicproximity,thataremostfrequentlyinvolvedwithorgan-sharingactivitiesimpactingthelocaltransplantcenters.CostcontainmentisanessentialareaforLOTS’stransplantpartnerstoremaincompetitiveinthehealthcarepayermarket.
LimitedbyitsDSA,LOTSknowsthatincreasesintissuedonationsarestillpossiblewithidentificationofneworexpandedreferralsources.Tissueactivitylevelsremainstrong.MarketShareGrowth(Figure 7.5-13)showsLOTS’scontri-butiontothetotalTissueTransformationstissuevolume.
7.5b Strategy Implementation ResultsResultsforaccomplishingtheorganizationalAPsarefoundinFigure 7.4-9.APsareputinplaceeachyearatLOTS,andsuccessinaccomplishingthoseAPsismission-criticalinachievingtheSOs.
ThekeymetricsforstrategyachievementofthemissionincludeDeathsonLocalWaitingList(Figure 7.4-8)andorganandtissuedonorsbypopulation(Figures 7.1-3 and 7.1-4).ResultsforbuildingandstrengtheningtheCCofmission-drivenworkforcearegiveninOverallWorkforceEngagement(Figures 7.3-12 and 7.3-12A).
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