Originally posted on Blogrige by Christine Schaefer

Following is an interview with Baldrige alumnus examiner Christopher E. Laxton, executive director of AMDA–The Society for Post-Acute and Long-Term Care Medicine (formerly the American Medical Directors Association). Laxton compares the Baldrige Excellence Framework (which includes the Health Care Criteria for Performance Excellence) to two other approaches used in his sector today to improve the performance of post-acute and long-term care organizations: Quality Assurance and Performance Improvement (QAPI) and Advancing Excellence in America’s Nursing Homes Campaign (AE).

Christopher Laxton, CAE

Christopher Laxton, CAE

Tell us about recent developments in your industry and how those impact the focus on improving the performance of care-providing organizations.

I work in post-acute and long-term care. This sub-sector of the health care field has gained a great deal of visibility and importance lately as many Baby Boomers move into retirement—by some estimates (Pew, AARP) at the rate of some 10,000 a day for the next 18 years.

It is not surprising, therefore, that those who work in this sector and its federal and state regulators are looking for ways to improve the performance of post-acute and long-term care (PA/LTC) provider organizations.

The Baldrige Excellence Framework is a helpful guide for organizations that are pursuing performance improvement. At the same time, there are other performance-improvement approaches in use across the multiple sectors of the U.S. economy. For PA/LTC organizations, two programs that have become more prominent because of their systems approach (like that of the Baldrige framework) to performance improvement are (1) AE, which comes from the provider side of this industry; and QAPI, which comes from the main federal payer and regulatory agency: the Centers for Medicare and Medicare Services (CMS).

Would you please explain first how QAPI is similar to the Baldrige framework and approach?

Yes. I think it is useful to look at how the QAPI and AE programs align to the Baldrige framework, both to understand their many points of connection to Baldrige Criteria categories, as well as to discern what may not be explicit in them.

The CMS’s QAPI program was introduced in 2013 for nursing homes to voluntarily adopt a systems approach to improvement (http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/nhqapi.html). The program describes QAPI as “the merger of two complementary approaches to quality management, Quality Assurance (QA) and Performance Improvement (PI). QA and PI combine to form QAPI, a comprehensive approach to ensuring high quality care.”

QAPI is defined as having five elements (see Figure 1): Design and Scope; Governance and Leadership; Feedback, Data Systems and Monitoring; Performance Improvement Projects; and Systematic Analysis and Systemic Action. These will be familiar to those organizations using the Baldrige approach to improve, since they align relatively well with 2015–2016 Baldrige Criteria categories: QAPI’s “Design and Scope” element relates to Baldrige Criteria category 2, “Strategy”; QAPI’s “Governance and Leadership” relates to Baldrige Criteria category 1, “ Leadership”; QAPI’s “Feedback, Data Systems and Monitoring” relates to Baldrige Criteria category 4, “Measurement, Analysis, and Knowledge Management”; and QAPI’s “Systematic Analysis and Systemic Action, and Performance Improvement Projects” relates to Baldrige Criteria category 6, “Operations.”


The five QAPI elements have open, non-prescriptive definitions and guidance for applying them. This is comparable to the Baldrige framework’s approach of asking questions rather than dictating particular solutions, based on the understanding that there is no “one-size-fits-all” solution to organizational excellence. This is especially true in the PA/LTC sector, where—despite years of organizational improvement efforts and extensive regulatory oversight—there is wide variability in provider size, scope, capacity, and quality.

Next, would you please tell us about the AE program and how it compares to the Baldrige framework?

Of course. Advancing Excellence (AE) was founded in 2006 by a coalition of 28 organizations that included nursing home providers, quality improvement experts, and government agencies (https://www.nhqualitycampaign.org/). The Campaign now includes more than 62 percent of the nation’s nursing homes and has a local presence in every state and the District of Columbia through a network of participants called Local Area Networks for Excellence (LANEs).

AE has identified nine quality goals (see Figure 2) that describe areas of key importance to good nursing home care that are often challenging for providers. Those areas are where it is likely that nursing homes will find opportunities for improvement, to use a Baldrige term. The AE goals are organized into two groups that will sound very familiar to Baldrige framework users: four organizational goals, which are process-focused; and five clinical outcome goals, which are results-focused.

The nine AE goals align the Baldrige Criteria in the following ways: AE’s Consistent Assignment goal is a Baldrige Criteria category 5 (“Workforce”) goal, as is AE’s Staff Stability goal. AE’s Hospitalizations goal aligns with Baldrige Criteria category 6 (“Operations”), since it principally relates to item 6.1 (on work processes). AE’s Person-Centered Care goal is clearly a Baldrige Criteria category 3 (“Customers”) goal. And AE’s five Clinical Outcomes goals (Infections, Medications, Mobility, Pain, and Pressure Ulcers) are all Baldrige Criteria category 7 (“Results”) goals, though they each have process elements that are relevant to Baldrige Criteria categories 4 and 6.


The AE program also identifies a seven-step process that organizations can adopt to systematically address each goal in their organization (see Figure 3). These seven steps have some alignment with the Baldrige process-evaluation factors (approach, deployment, learning, integration [ADLI]) and, to a lesser extent, the Baldrige results evaluation factors (levels, trends, comparisons, integration [LeTCI]).


With all these similarities, do you see these approaches as competing or complementary with each other?

While the CMS QAPI program may resonate with those familiar with the Baldrige framework, I believe it would be a mistake to “choose” one over the other. One reason is that the Baldrige framework is very inclusive—accommodating all varieties of performance improvement tools, such as Plan-Do-Study-Act, Lean, Six Sigma, and so forth. Furthermore, when you line up both the QAPI and AE programs against the Baldrige Criteria (see crosswalk of 2013-2014 Baldrige Criteria to QAPI and AE), a comprehensive performance excellence framework for the PA/LTC sector is revealed. It is well aligned with the Baldrige Criteria categories, and it is specifically focused on the highly complex and challenging organizational and customer/patient/resident environment found in this sector’s care settings.

These are not simply academic considerations for how quality might be improved in this important and previously neglected sector of U.S. health care. The demographic shift to an older population in this country and around the world—sometimes referred to as the “Silver Tsunami”—is producing major changes in public policy and rapid and massive shifts in market forces that will have a direct impact on the care and support available to our nation’s elders.

What do you believe needs to happen in relation to the Baldrige, QAPI, and AE improvement tools to address the current and coming challenge of caring for more senior citizens?

It is a basic principle of organizational excellence that systems produce exactly the results that they are designed to produce—intentional and unintentional. Having worked in the long-term care field for 30 years and having served as a Baldrige examiner for seven, I am inspired by the existence of such powerful frameworks for improvement.

Now our long-term care leaders must take up these tools and apply them. Who better to do so than those who know intimately the complexity and challenges facing this sector? If they do not, others—with less commitment and connection to preserving and enhancing the health and well-being of our seniors—are sure to impose changes on us that will be neither of our design nor of our choosing.

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