2006 National Institute of Standards and Technology Technology Administration Department of Commerce Baldrige National Quality Program Arroyo Fresco Community Health Center Case Study 2006 National Institute of Standards and Technology Technology Administration Department of Commerce Baldrige National Quality Program Arroyo Fresco Community Health Center Case Study The Arroyo Fresco Community Health Center Case Study was prepared for use in the 2006 Malcolm Baldrige National Quality Award Examiner Preparation Course. The Arroyo Fresco Community Health Center Case Study describes a fictitious nonprofit organization in the health care sector. There is no connection between the fictitious Arroyo Fresco Community Health Center and any other organization, either named Arroyo Fresco Community Health Center or otherwise. Other organizations cited in the case study also are fictitious, except for several national and government organizations. Because the case study is developed to train Baldrige Examiners and others and to provide an example of the possible content of a Baldrige application, there are areas in the case study where Criteria requirements are not addressed. CONTENTS 2006 Eligibility Certification Form ........................................................................... i Organization Chart ............................................................................................. xi 2006 Application Form ....................................................................................... xii Glossary of Terms and Abbreviations ........................................................................ xiv Preface: Organizational Profile P.1 P.2 Organizational Description ............................................................... xviii Organizational Challenges ............................................................... xxi Category 1Leadership 1.1 1.2 Senior Leadership ........................................................................ Governance and Social Responsibilities................................................ 1 3 Category 2Strategic Planning 2.1 2.2 Strategy Development .................................................................. Strategy Deployment ..................................................................... 5 8 Category 3Focus on Patients, Other Customers, and Markets 3.1 3.2 Patient, Other Customer, and Health Care Market Knowledge ..................... Patient and Other Customer Relationships and Satisfaction ........................ 11 13 Category 4Measurement, Analysis, and Knowledge Management 4.1 4.2 Measurement, Analysis, and Review of Organizational Performance ............ Information and Knowledge Management ............................................. 16 17 Category 5Human Resource Focus 5.1 5.2 5.3 Work Systems.............................................................................. Staff Learning and Motivation ......................................................... Staff Well-Being and Satisfaction ...................................................... 19 21 24 Category 6Process Management 6.1 6.2 Health Care Processes .................................................................. Support Processes and Operational Planning .......................................... 25 29 Category 7Results 7.1 7.2 7.3 7.4 7.5 7.6 Health Care and Service Delivery Outcomes .......................................... Patient- and Other Customer-Focused Outcomes .................................... Financial and Market Outcomes......................................................... Human Resource Outcomes ............................................................ Organizational Effectiveness Outcomes ................................................ Leadership and Social Responsibility Outcomes .................................... 32 38 41 43 46 48 2006 Eligibility Certification Form Page 1of 7 Malcolm Baldrige National Quality Award OMB Clearance #0693-0006 Expiration Date: January 31, 2007 1. Applicant Official Name Arroyo Fresco Community _______________________________________________ Headquarters Address 1345 Desert Bloom Ave. _________________________________________________ Health Center _______________________________________________ Yuma, AZ 85364 _________________________________________________ Other Name n/a _______________________________________________ _________________________________________________ Prior Name n/a _______________________________________________ _________________________________________________ Has the applicant self-certified for eligibility in a prior year(s)? X No \u0001 Do Not Know \u0001 Yes \u0001 If \"yes,\" indicate the year(s) in which the applicant submitted the Eligibility Certification Package and the name(s) of the applicant at that time, if different. Year(s) __________________________________________________________________________________________________________ Name(s) of Applicant __________________________________________________________________________________________________________ 2. Highest-Ranking Official X Mr. \u0001 Mrs. \u0001 Ms. \u0001 Dr. \u0001 Name Ramon Gonzalez _______________________________________________ 1345 Desert Bloom Ave. Address _________________________________________________ CEO Title _______________________________________________ Yuma, AZ 85364 _________________________________________________ Telephone No. (555) ARROYOF (277-6963), ext. 12 _______________________________________________ _________________________________________________ r_gonzalez@af.net E-Mail _______________________________________________ Fax No. (555) 277-6967 _________________________________________________ 3. Eligibility Contact Point X Mr. \u0001 Mrs. \u0001 Ms. \u0001 Dr. \u0001 Name Roger Sinclair _______________________________________________ 2219 Lakeview Blvd. Address _________________________________________________ Director of Performance Excellence Title _______________________________________________ San Luis, AZ 85349 _________________________________________________ Telephone No. (555) 487-6235 _______________________________________________ Overnight Mailing Address (Do not use a P.O. Box number.) (555) 487-6277 Fax No. _______________________________________________ same as above _________________________________________________ E-Mail r_sinclair@af.net _______________________________________________ _________________________________________________ 4. Alternate Eligibility Contact Point X Ms. \u0001 Dr. \u0001 Mr. \u0001 Mrs. \u0001 Name Judy Jackson-Gomez __________________________________________________________________________________________________________ Telephone No.(555) ARROYOF (277-6963), ext. 18 __________________________________________________________________________________________________________ Fax No. (555) 277-6967 __________________________________________________________________________________________________________ 5. Applicant Status a. Has the applicant officially or legally existed for at least one year, or prior to April 11, 2005? (Check one.) X Yes \u0001 No \u0001 If you are unable to respond to any item, please contact the Baldrige National Quality Program Office at (800) 898-4506 before submitting your form. i 2006 Eligibility Certification Form Page 2 of 7 Malcolm Baldrige National Quality Award 5. Applicant Statuscontinued b. Has your organization ever been a Malcolm Baldrige National Quality Award recipient? (Check one.) X No \u0001 Yes \u0001 If you checked \"No,\" proceed to item 6. c. If yes, was your organization an Award recipient in 2000 or earlier? (Check one.) \u0001 Yes \u0001 No If you checked \"No,\" your organization is not eligible to reapply this year for the Award or for feedback (please contact the Baldrige National Quality Program Office at 800-898-4506 if you have any questions). If you checked \"Yes,\" please choose one of the following options: \u0001 Applying for feedback only \u0001 Applying for the Malcolm Baldrige National Quality Award 6. Award Category and For-Profit/Nonprofit Designation (Check as appropriate.) \u0001 Manufacturing (For-Profit Only) \u0001 Education (For-Profit) \u0001 Service (For-Profit Only) \u0001 Education (Nonprofit) \u0001 Small Business (For-Profit Only) \u0001 Health Care (For-Profit) X Health Care (Nonprofit) \u0001 Criteria being used: (Check one.) \u0001 Criteria for Performance Excellence \u0001 Education Criteria for Performance Excellence X Health Care Criteria for Performance Excellence \u0001 Note: For-profit education and health care organizations may choose to use the Criteria for Performance Excellence and apply in the service or small business categories. However, they probably will find their sector-specific Criteria (Education Criteria for Performance Excellence or Health Care Criteria for Performance Excellence) more appropriate. 7. Industrial Classification List up to three of the most descriptive three- or four-digit NAICS codes. (See page 24 of the PDF version of the Baldrige Award Application Forms at www.baldrige.nist.gov/Award_ Application.htm.) 6214 a. _____________ 6211 b. _____________ c. _____________ 8. Size and Location of Applicant a. Total number of employees (business) ________ faculty/staff (education) ________ 379 staff (health care) ________ b. For the preceding fiscal year, check one financial descriptor: \u0001 Sales X Budgets \u0001 Revenues \u0001 X $10M-$100M \u0001 $100M-$500M check the range: \u0001 0-$1M \u0001 $1M-$10M \u0001 \u0001 $500M-$1B \u0001 More than $1B If you are unable to respond to any item, please contact the Baldrige National Quality Program Office at (800) 898-4506 before submitting your form. ii 2006 Eligibility Certification Form Page 3 of 7 Malcolm Baldrige National Quality Award 8. Size and Location of Applicantcontinued c. Number of sites: U.S./Territories _____ 11 Outside U.S./Territories _______ d. Percentage of employees: 100% U.S./Territories _____ Outside U.S./Territories _______ e. Percentage of physical assets: 100% U.S./Territories _____ Outside U.S./Territories _______ f. Operational practices associated with all major organizational functions must be accessible for examination in the United States. If some activities are performed outside the applicant's organization (e.g., by a component of the applicant that is outside the United States or its territories, the parent organization, or its other subunits), will the applicant, if selected for a site visit, make available in the United States sufficient personnel, documentation, and facilities to allow full examination of its operational practices for all major functions of its worldwide operations? X Not Applicable \u0001 Yes \u0001 No \u0001 g. In the event the applicant receives an Award, can the applicant make available sufficient personnel and documentation to share its practices at The Quest for Excellence Conference and at its U.S. facilities? X Yes \u0001 No \u0001 h. Attach a line and box organization chart for the applicant. In each box, include the name of the unit or division and its head. 9. Subunits (If the applicant is not a subunit as defined on pages 7-8, please proceed to question 10.) a. Is the applicant _____ a larger parent or system? (Check all that apply.) \u0001 a subsidiary of \u0001 a division of \u0001 controlled by \u0001 a unit of \u0001 administered by \u0001 a school of \u0001 owned by b. Parent organization (\"Parent\" means the highest organizational level eligible to apply for the Award.) Name _______________________________________________________________ Highest-Ranking Official Address _______________________________________________________________ Name ________________________________________________________ __________________________________________________ Title ________________________________________________________ Number of worldwide employees of the parent ______ c. Is the applicant the only subunit of the parent organization intending to apply? (Check one.) \u0001 Yes \u0001 No (Briefly explain) \u0001 Do Not Know d. Briefly describe the major functions provided to the applicant by the parent or by other subunits of the parent. Examples of such functions include but are not limited to strategic planning, business acquisition, research and development, data gathering and analysis, human resources, legal services, finance or accounting, sales/marketing, supply chain management, global expansion, information and knowledge management, education/training programs, information systems and technology services, curriculum and instruction, and academic program coordination/development. If you are unable to respond to any item, please contact the Baldrige National Quality Program Office at (800) 898-4506 before submitting your form. iii 2006 Eligibility Certification Form Page 4 of 7 Malcolm Baldrige National Quality Award 9. Subunitscontinued e. Is the applicant self-sufficient enough to respond to all seven Baldrige Criteria Categories? \u0001 Yes f. \u0001 No (Briefly explain.) Provide the name and date of the official document (e.g., annual report, organization literature, press release) supporting the subunit designation. Attach relevant portions of the document showing clear definition of the applicant as a discrete entity. Note: Applicants supplying a Web site as documentation must print the relevant pages and include these with the application. Name of the Document Date g. Briefly describe the organizational structure and relationship to the parent. Attach a line and box organization chart(s) showing the relationship of the applicant to the highest management level of the parent, including all intervening levels. Each box within the chart should include the name of the head of the unit or division. h. Is the applicant's product or service unique within the parent organization? (Check one.) \u0001 Yes \u0001 No If \"No,\" do other units within the parent provide the same products or services to a different customer base? (Check one.) \u0001 Yes \u0001 No If neither of the \"Yes\" boxes in \"h\" is checked, complete 1, 2, and 3 below. (1) Provide a brief description of how the market and product(s) or service(s) are similar. (2) Indicate the organizational relationships of all units that provide similar or identical products or services, including the approximate sales, revenues, or budgets for each. (3) Describe how the applicant is different from its parent and the other subunits of the organization (e.g., differences in market, location, or name). If you are unable to respond to any item, please contact the Baldrige National Quality Program Office at (800) 898-4506 before submitting your form. iv 2006 Eligibility Certification Form Page 5 of 7 Malcolm Baldrige National Quality Award 9. Subunitscontinued i. Manufacturing and service subunits of parents with >500 employees, only. Are more than 50 percent of the applicant's products or services sold or provided directly to customers outside the applicant's organization, the parent organization, and organizations controlled by the applicant or the parent? (Check one.) \u0001 Yes Does the applicant have more than 500 employees? (Check one.) \u0001 Yes \u0001 No \u0001 No Do the applicant's employees make up more than 25 percent of the worldwide employees of the parent? (Check one.) \u0001 Yes \u0001 No j. All business subunits, regardless of parent size. Was the applicant independent prior to being acquired, and does it continue to operate independently under its own identity? (Check one.) \u0001 Yes \u0001 No \u0001 Not Applicable Note: If self-certification is based on the subunit being independent prior to being acquired and continuing to operate independently under its own identity, attach relevant portions of an official document to support this response. Is the applicant separately incorporated and distinct from other subunits of the parent? (Check one.) \u0001 Yes \u0001 No Note: If self-certification is based on the subunit being separately incorporated and distinct from other subunits of the parent, attach relevant portions of an official document (e.g., articles of incorporation) to support this response. Note: If all answers to \"i\" and \"j\" are \"No,\" contact the Baldrige Office at (800) 898-4506 before submitting your form. 10. Supplemental Sections (Check one.) X The applicant has (a) a single performance system that supports all of its product and/or service lines and (b) \u0001 products or services that are essentially similar in terms of customers/users, technology, types of employees, and planning. \u0001 The applicant has (a) multiple performance systems that support all of its product and/or service lines and/or (b) products or services that are not essentially similar in terms of customers/users, technology, types of employees, and planning. If you checked the second option, please describe briefly the differences among the multiple performance systems of your organization in terms of customers, types of employees, technology, planning, and quality systems. Note: The applicant's Eligibility Contact Point will be contacted if the second option is checked. Applicants may have two or more diverse product and/or service lines (i.e., in different NAICS codes) with customers, types of employees, technology, planning, and quality systems that are so different that the application report alone does not allow sufficient detail for a fair examination. Such applicants may submit one or more supplemental sections in addition to the application report. The use of supplemental sections must be approved during the eligibility certification process and is mandatory once approved. If you are unable to respond to any item, please contact the Baldrige National Quality Program Office at (800) 898-4506 before submitting your form. v 2006 Eligibility Certification Form Page 6 of 7 Malcolm Baldrige National Quality Award 11. Application Format If your organization applies for the 2006 Award, in which format would you submit the Application Package? (Check one.) X 25 paper copies (due date May 25, 2006) \u0001 \u0001 CD (due date May 11, 2006) 12. Confidentiality Considerations Baldrige Examiners are authorized to use cell phones, cordless phones, and VoIP to discuss your application. X Yes \u0001 \u0001 No 13. Self-Certification Statement, Signature of the Highest-Ranking Official I state and attest that (1) I have reviewed the information provided by my organization in this Eligibility Certification Package. (2) to the best of my knowledge, no untrue statement of a material fact is contained in this Eligibility Certification Package, and no omission of a material fact has been made in this package. (3) based on the information herein and the current eligibility requirements for the Malcolm Baldrige National Quality Award, my organization is eligible to apply. (4) I understand that at any time during the 2006 Award Process cycle, if the information is found not to support eligibility, my organization will no longer receive consideration for the Award and will receive only a feedback report. April 6, 2006 Date Signature of Highest-Ranking Official Ramon Gonzalez Printed Name 14. Eligibility Certification Filing Fee Enclose a $150 nonrefundable fee to cover the cost of the eligibility certification filing process. Make the check or money order payable to Malcolm Baldrige National Quality Award. You also may pay by VISA, MasterCard, or American Express. Please indicate the method of payment below: X Check or money order (enclosed) \u0001 VISA \u0001 \u0001 MasterCard \u0001 American Express Credit Card Number _______________________________________________ Authorized Signature _______________________________________________ Expiration Date _______________________________________________ Printed Name _______________________________________________ Billing Address for Credit Card _______________________________________________ Today's Date _______________________________________________ _______________________________________________ If you are unable to respond to any item, please contact the Baldrige National Quality Program Office at (800) 898-4506 before submitting your form. vi 2006 Eligibility Certification Form Page 7 of 7 Malcolm Baldrige National Quality Award 15. Nomination to the Board of Examiners One senior member from each organization whose Eligibility Certification Package is postmarked on or before March 10, 2006, may become a member of the 2006 Board of Examiners. The opportunity to learn and the required commitment of time are substantial. The time commitment is a minimum of 110 hours between April and December (including approximately 40 hours in April/May to complete prework for the Examiner Preparation Course, 4 days in May to attend the Examiner Preparation Course, and another 35-50 hours in June to complete a Stage 1, Independent Review). If requested by the Program, Examiners also are expected to participate in the Stage 2, Consensus Review (approximately 25 hours) and Stage 3, Site Visit Review (approximately 9 days). Nominees must be citizens or permanent residents of the United States and be located in the United States or its territories. Roger Sinclair X __________________________________ \u0001 from our organization will serve on the 2006 Board of Examiners. Name of Senior Member Nominee* *Please, no substitutions after April 11, 2006. Nominee's contact information: X Mr. \u0001 Mrs. \u0001 Ms. \u0001 Dr. \u0001 Nominee's Title Director of Performance _______________________________________________ Excellence _______________________________________________ Name of Nominee's Organization _______________________________________________ Nominee's Home Address ____________________________________________ Arroyo Fresco Community Health Center _______________________________________________ 87902 Willards Way ____________________________________________ Nominee's Work Address _______________________________________________ San Luis, AZ 85349 ____________________________________________ Arroyo Fresco Family Health Center _______________________________________________ ____________________________________________ 2219 Lakeview Blvd. _______________________________________________ ____________________________________________ San Luis, AZ 85349 _______________________________________________ ____________________________________________ Work Phone (555) 487-6235* _______________________________________________ Home Phone (555) 487-2839 ____________________________________________ Work Fax (555) 487-6277* _______________________________________________ (555) 487-8723 Home Fax ____________________________________________ Work E-Mail Address r_sinclair@af.net* _______________________________________________ rsinclair@me.com Home E-Mail Address ____________________________________________ If you are unable to respond to any item, please contact the Baldrige National Quality Program Office at (800) 898-4506 before submitting your form. vii 2006 Additional Information Needed Form Page 1 of 2 Malcolm Baldrige National Quality Award The following information is needed by the Malcolm Baldrige National Quality Program Office to avoid conflicts of interest when assigning Examiners to evaluate your application and by Examiners in performing their evaluations. 1. Site Listing and Descriptors Please refer to the instructions on page 19 of the PDF version of the Baldrige Award Application Forms at www.baldrige.nist.gov/Award_ Application.htm to complete this Site Listing and Descriptors form. It is important that the totals for the number of employees, faculty, and/or staff; percentage of sales, revenues, or budgets; and sites on this form match the totals provided in response to 8a, 8b, and 8c on pages 2 and 3 of the 2006 Eligibility Certification Form. For example, if you report 600 employees in response to question 8a, the total number of employees provided in the Site Listing and Descriptors form should be 600 (see example below). Duplicate the Site Listing and Descriptors page if all sites cannot be listed on a single page. Address of Site(s) Number \u0001 Employees x Faculty \u0001 x Staff \u0001 EXAMPLE Percentage For each site, describe the relevant products, services, and/or technologies. \u0001 Sales \u0001 Revenues x Budgets \u0001 Coyote Hall 85 Campus Way 381 Faculty 200 Staff 95% Administrative headquarters, instructional and educational services Cactus Hall 85 IT Parkway 17 Faculty 2 Staff 5% Satellite campus for information technology instruction, including a technology lab Address of Site(s) Number \u0001 Employees \u0001 Faculty X Staff \u0001 Percentage \u0001 Sales \u0001 Revenues X Budgets \u0001 For each site, describe the relevant products, services, and/or technologies. (Check one or more (Check one above, above, and list below the and list below the % number at each site.) at each site.) Arroyo Fresco Family Health CenterNorth Yuma 1345 Desert Bloom Ave Yuma, AZ 85364 59 15 Medical and dental services Administrative and information services Arroyo Fresco Family Health CenterEast Yuma 18137 Fourth Ave Yuma, AZ 85367 42 10 Medical and dental services Arroyo Fresco Women's Health CenterNorth Yuma 3529 El Centro Ave Yuma, AZ 85365 39 11 Obstetrics and gynecology If you are unable to respond to any item, please contact the Baldrige National Quality Program Office at (800) 898-4506 before submitting your form. viii 2006 Additional Information Needed Form Page 1 of 2 (continued) Malcolm Baldrige National Quality Award Address of Site(s) Number \u0001 Employees \u0001 Faculty X Staff \u0001 Percentage \u0001 Sales \u0001 Revenues X Budgets \u0001 For each site, describe the relevant products, services, and/or technologies. (Check one or more (Check one above, above, and list below the and list below the % number at each site.) at each site.) Arroyo Fresco Family Health CenterSan Luis 2219 Plaza Del Oro Yuma, AZ 85349 40 10 Medical and dental services Arroyo Fresco Family Health CenterSomerton 672 Calle Viejo Somerton, AZ 85350 25 9 Medical services (and dental services by mobile van) Arroyo Fresco Family Health CenterParker 4010 Colorado St. Parker, AZ 85344 21 5 Medical services (and dental services by mobile van) Arroyo Fresco Family Health CenterKingman 6527 Old Mine Rd. Kingman, AZ 86401 36 9 Medical and dental services Mobile medical services through Medical Service Van 2, and mobile dental services through Dental Service Van 2 both serving the Parker and Kingman areas on alternate weeks Arroyo Fresco Family Health CenterBullhead City 39675 Fisherman's Way Bullhead City, AZ 86429 41 10 Medical and dental services Mobile medical services through Medical Service Van 1, serving towns along Route 8 Mobile dental services through Dental Service Van 1, serving towns along Route 8 and school-based clinics Arroyo Fresco CenterLake 2219 Lakeview San Luis, AZ 47 11 Medical and dental services San Juan Elementary School 2058 Plaza del San Juan Yuma, AZ 85364 14 5 Medical services (and dental services by mobile van) El Centro High School 2590 El Centro Ave. Yuma, AZ 85364 15 5 Medical services (and dental services by mobile van) Family Health Havasu City Blvd. 85349 Provide all the information for each site, except where multiple sites produce similar products or services. For multiple site cases, refer to 8c on page 3 of the Eligibility Certification Form. Also, see the 2006 Eligibility Certification FormInstructions on page 9 of the PDF version of the Baldrige Award Application Forms at www.baldrige.nist.gov/Award_ Application.htm. Use as many additional copies of this form as needed to include all sites. ix 2006 Additional Information Needed Form Page 2 of 2 Malcolm Baldrige National Quality Award 2. Key Business/Organization Factors List, briefly describe, or identify the following key organization factors. Be as specific as possible to help us avoid real or perceived conflicts of interest when assigning Examiners to evaluate your application. \"Key\" means those organizations that constitute 5 percent or more of the applicant's competitors, customers/users, or suppliers. A. List of key competitors Other community health centers in adjacent counties and agencies offering access to health care services regardless of patients' ability to pay; community-based private medical and dental health care providers; Indian Health Services facilities; Veterans Health Administration facilities; health care providers in Mexico (for border residents) B. List of key customers/users Patients and their families in the three western counties of ArizonaYuma, La Paz, and Mohaveregardless of their ability to pay Hospitals and specialists in the above counties C. List of key suppliers/partners Desert Data Solutions (DDS) for information technology management and support; HR Leaders, Inc., for qualified contract staff; Gil's Garage for repair and maintenance of vans; Shiny Clean for indoor and outdoor custodial services; and MedProducts, Inc., for medical and dental supplies and pharmacy and lab services. Partners include CactusCom (a large telecommunications company), Winding River Casinos, Saguaro State University, a regional pharmaceutical company, several local community colleges, and community hospitals. D. Description of the applicant's major markets (local, regional, national, and international) The three western counties of Arizona: Yuma, La Paz, and Mohave E. The name of the organization's financial auditor Johansen, Simon, and Clark F. The applicant's fiscal year (e.g., October 1-September 30) January 1-December 31 If you are unable to respond to any item, please contact the Baldrige National Quality Program Office at (800) 898-4506 before submitting your form. x xi Healing Partners Team (HPT) physicians allied health (medical) contract providers health care partnerships George Hughes, DO Medical Director Medical Services Service With Spirit Team (SWST) Robert Yellowhawk, PA-C County Director La Paz Info Interns Emily Anderson, MSW County Director Mohave finance billing information systems Tony Joachin Director Human Resources People Potential Team (PPT) work systems and environment performance management, compensation, and benefits education and training educational partnerships community relations board development fundraising grant writing legislative advocacy Jay Nguyen CFO Information Officer Judy Jackson-Gomez Director Development Teresa Aguilar, RN, MBA Director Clinical Operations clinic operations facilities supplies/equipment lab services pharmacy services Teresa Torres County Director Yuma dentists allied health (dental) Ross Figueroa, DDS Dental Director Dental Services CFO Ramon Frank Gonzalez Fendly Fin., Acctg., CEO IT, Warehouse Committees: QualityEthicsCommunity Partner RelationsDevelopmentAudit Board of Directors Arroyo Fresco Community Health Center Organization Chart Data Docs Roger Sinclair Director Performance Excellence performance improvement and quality assurance corporate compliance risk management 2006 Application Form Page 1 of 2 Malcolm Baldrige National Quality Award 5. Release and Ethics Statements Provide all information requested. A copy of page 1 of this 2006 Application Form must be included in each of the 25 paper copies of the application report (or, alternatively, in the PDF version on a CD). a. Release Statement We understand that this application will be reviewed by members of the Board of Examiners. Should our organization be selected for a site visit, we agree to host the site visit and to facilitate an open and unbiased examination. We understand that our organization must pay reasonable costs associated with a site visit. The site visit fees range from $1,500 to $35,000, depending on the type of applicant. (The fees are shown on page 4 of the PDF version of the Baldrige Award Application Forms at www.baldrige.nist.gov/Award_ Application.htm.) 1. Applicant Applicant Name Arroyo Fresco Community _________________________________________ Health Center _________________________________________ Mailing Address 1345 Desert Bloom Ave. _________________________________________ Yuma, AZ 85364 _________________________________________ 2. Award Category (Check one.) \u0001 Manufacturing \u0001 Service \u0001 Small Business X Health Care \u0001 Education \u0001 If our organization is selected to receive an Award, we agree to share nonproprietary information on our successful performance excellence strategies with other U.S. organizations. For small businesses, indicate whether the larger percentage of sales is in service or manufacturing. (Check one.) \u0001 Manufacturing \u0001 Service b. Ethics Statement and Signature of the Highest-Ranking Official I state and attest that Criteria being used (Check one.) X Health Care \u0001 Business \u0001 Education \u0001 (1) I have reviewed the information provided by my organization in this Application Package. (2) to the best of my knowledge, 3. Official Contact Point X Mr. \u0001 Mrs. \u0001 Ms. \u0001 Dr. \u0001 Roger Sinclair Name _________________________________________ Director of Performance Excellence Title _________________________________________ Mailing Address 2219 Lakeview Blvd. _________________________________________ San Luis, AZ 85349 _________________________________________ Overnight Mailing Address (Do not use P.O. Box number.) _________________________________________ no untrue statement of a material fact is contained in this Application Package, and no omission of a material fact that I am legally permitted to disclose and that affects my organization's ethical and legal practices has been made. This includes but is not limited to sanctions and ethical breaches. Date May 21, 2006 ___________________ Signature _________________________________________ X Mr. \u0001 Mrs. \u0001 Ms. \u0001 Dr. \u0001 same as above _________________________________________ Telephone No. (555) 487-6235 _________________________________________ Printed Name Ramon Gonzalez _________________________________________ (555) 487-6277 Fax No. _________________________________________ CEO Title _________________________________________ Applicant Name Arroyo Fresco _________________________________________ 4. Alternate Official Contact Point X Ms. \u0001 Dr. \u0001 Mr. \u0001 Mrs. \u0001 Mailing Address 1345 Desert Bloom Ave. _________________________________________ Judy Jackson-Gomez Name _________________________________________ Yuma, AZ 85364 _________________________________________ Telephone No. (555) ARROYOF (277-6963), ext. 18 _________________________________________ Telephone No. (555) ARROYOF (277-6963), ext. 12 _________________________________________ (555) 277-6967 Fax No. _________________________________________ (555) 277-6967 Fax No. _________________________________________ xii 2006 Application Form Page 2 of 2 Malcolm Baldrige National Quality Award 6. Confidential Information Make the check or money order payable to Malcolm Baldrige National Quality Award. Please note: To help ensure the confidentiality of the information requested, submission requirements for this page (page 2) of your Application Form differ from those for page 1 of the form and for the application report. Whether you submit 25 paper copies or a CD of your application report, one completed paper copy of page 2 may be submitted with your Award Application Package, or the information may be telephoned to ASQ at (414) 298-8789, extension 7205. Do not include this page (page 2) in the 25 copies of your application report. You also may pay by VISA, MasterCard, or American Express. Please indicate your method of payment below: X Check or money order (enclosed) \u0001 \u0001 VISA \u0001 MasterCard \u0001 American Express Credit Card Number _________________________________________ Expiration Date _________________________________________ Today's Date _________________________________________ Billing Address for Credit Card _________________________________________ _________________________________________ a. Social Security Number and Date of Birth of the Highest-Ranking Official Authorized Signature _________________________________________ If your application is selected for Stage 3 review, this information will be used in the process for determining role model organizations. (See pages 3-4 of the PDF version of the Baldrige Award Application Forms at www.baldrige.nist.gov/Award_ Application.htm.) Printed Name _________________________________________ 7. Submission The complete Award Application Package must be postmarked or consigned to an overnight delivery service no later than May 25, 2006 (May 11, 2006, if submitting on a CD) for delivery to Ramon Gonzalez Name _________________________________________ Malcolm Baldrige National Quality Award c/o ASQBaldrige Award Administration 600 North Plankinton Avenue Milwaukee, WI 53203 (414) 298-8789, extension 7205 Social Security Number XXX-XXX-XXXX _________________________________________ June 3, 1949 Date of Birth _________________________________________ b. Application Fees (see page 30 for instructions) 2,000 to cover one application Enclosed is $________ 0 report and ________ supplemental sections. Note: An additional $1,250 is required if you are submitting the application report on a CD. xiii OMB Clearance #0693-0006 Expiration Date: January 31, 2007 C Community: The community at large served by AF Glossary of Terms and Abbreviations 360-Degree Review Process: A process for performance feedback that includes feedback from superiors, peers, and reports 5S: A Japanese concept for good housekeeping and visual management: (1) Sort (Seiri), (2) Straighten (Seiton), (3) Shine (Seiso), (4) Standardize (Seiketsu), and (5) Sustain (Shitsuke) A AAFP: American Academy of Family Physicians, a national professional membership organization of family physicians from which AF gets clinical guidelines, performance indicators, and comparative data AAP: American Academy of Pediatrics, a national professional membership organization of pediatricians from which AF gets clinical guidelines, performance indicators, and comparative data AAR: After Action Review, a formal method to debrief and evaluate an initiative to identify strengths and opportunities for improvement ACEI: Angiotensin-Converting Enzyme Inhibitors, a group of pharmaceuticals that are used primarily in treatment of hypertension and congestive heart failure Catchball: A form of two-way communication that takes place among multiple levels of the organization during action plan development CCK: Care Connection Kiosk, the multi-use portable electronic information unit used in all facilities and in the community to disseminate health information, gather ideas and feedback, and give patients access to their own PHPs and health information CDC: Centers for Disease Control and Prevention, one of HHS's major operating components, which is responsible for monitoring U.S. health and health behaviors, conducting research, taking part in advocacy and policy development, and promoting health improvement. AF gets clinical guidelines, performance indicators, and comparative data from the CDC. CEO: Chief Executive OfficerRamon Gonzalez CFO: Chief Financial OfficerJay Nguyen CHCs: Community Health Centers, nonprofit, communityowned organizations like AF that provide primary and preventive services to the underserved and strive to improve access and eliminate health disparities regardless of people's ability to pay CHF: Congestive heart failure ACOG: American College of Obstetricians and Gynecologists, the national professional membership organization of obstetricians and gynecologists from which AF gets clinical guidelines, performance indicators, and comparative data AF: Arroyo Fresco, which in Spanish means \"cool, flowing stream\" AQA: Ambulatory Care Quality Alliance, a large body of U.S. health care stakeholdersclinicians, consumers, health insurers, and othersworking collaboratively to develop a strategy for measuring, reporting, and improving performance at the physician level and to promote availability of uniform information for consumer decisions about quality B BRFSS: Behavioral Risk Factor Surveillance System, a database, managed by the Centers for Disease Control and Prevention, on U.S. health risk prevalence and trends BPHC: Bureau of Primary Health Care, the agency within HRSA responsible for oversight of federally funded community health centers CM: Clinical microsystem, a small group of providers, along with their patients, processes, information, and information systems; the elements of a CM are interdependent and share a common purpose. CME: Continuing Medical Education, the requirements physicians (and other clinicians) must fulfill on an ongoing basis in order to maintain licensure and, as appropriate, board certification CMS: Centers for Medicare and Medicaid Services, the HHS agency responsible for the administration of Medicare and (in partnership with the states) for the administration of Medicaid, the State Children's Health Insurance Program, and health insurance portability. CMS surveys health care facilities nationwide to ensure compliance with quality standards, including HIPAA. Committee on Rural Health Issues: A statewide group responsible for comprehensive planning to improve health care access in rural areas COPD: Chronic obstructive pulmonary disease CTQ: Critical to Quality, a product's or process's key measurable characteristics, including performance standards or specification limits, that must be met to satisfy the customer xiv H HbA1c: Glycosylated hemoglobin, which is measured in a blood test commonly used to assess blood sugar control in diabetes patients Culturally Competent Care: Care designed to address patient differences in language and cultural norms so that the care meets culturally driven needs, expectations, and preferences. Providing culturally competent care is important to promote access, ensure the effectiveness of care, and reduce health disparities associated with language and race or ethnicity. HCDI: Health Care Data and Information, a set of indicators of health care outcomes and service delivery used by a national health care quality organization D Daily Huddle: The practice of CM staff to gather at the beginning of the day to review planned actions for the day and anticipate patient and staff needs HPT: Healing Partners Team, a cross-location team responsible for reviewing health care results; keeping track of changes in legal, regulatory, and accrediting requirements, as well as clinical science and industry best practices; and identifying crossorganizational opportunities for improvement Data Docs: A cross-location team representing CMs and functional groups that helps evaluate and improve AF's performance measurement system HHS: U.S. Department of Health and Human Services DDS: Desert Data Solutions, AF's information technology strategic partner HIPAA: Health Insurance Portability and Accountability Act of 1996, which includes multiple provisions to protect patient privacy and confidentiality DO: Director of Operations HP 2010: Healthy People 2010, a national public health initiative that identifies priority areas for improvement with measurable ten-year goals. States and many communities have developed programs to support goal achievement DOE: Design of Experiments E ED: Emergency Department HR: Human Resource(s) Elders Council: A council in each county composed of patient and family members that provides input on the specific needs, expectations, and preferences of elders HRSA: Health Resources and Services Administration, the HHS agency responsible for improving access to underserved populations and reducing unequal care and outcomes EHR: Electronic health record EPA: Environmental Protection Agency, the federal agency responsible for developing and enforcing regulations pertaining to environmental quality I IDP: Individual Development Plan, the approach that establishes individual employee goals and development plans, a key element in the performance management system EPSDT: Early Periodic Screening, Diagnosis, and Treatment, the health services required to be provided for Medicaid enrollees 0-21 years old IHS: Indian Health Service, the HHS agency responsible for ensuring comprehensive and culturally competent personal and public health services for Alaska Natives and American Indians Info Interns: A cross-location team responsible for reviewing and providing input at least annually on AF's information system capabilities and needs F FMEA: Failure Modes and Effects Analysis, a structured method to identify, prioritize, and address potential failures in high-risk processes IOM: Institute of Medicine, a group of health care experts and key stakeholders within the National Academy of Sciences that is responsible for a recent series of landmark reports on U.S. health care quality, beginning with To Err Is Human (1999), which put the spotlight on patient safety FOCUS: Financial performance, Organizational learning, Clinical excellence, Utilization, and Satisfactionrefers to AF's framework for performance measurement IT: Information Technology xv J JCAHO: Joint Commission on Accreditation of Healthcare Organizations, a national accrediting body for many different types of health care organizations. JCAHO conducts required periodic performance reviews of CHCs on behalf of HRSA. PFAB: Patient-Family Advisory Board, the eight-member board at each location composed of patients and family members that meets quarterly to provide feedback on current services and input on future needs and plans PDCA: Plan-Do-Check-Act L LDL: Low-density lipoprotein, a type of cholesterol People Review: A step in the Strategic Planning Process to address workforce capability and needs and to develop the HR plan Lean: An initiative focused on eliminating all forms of waste and reducing cycle time while becoming more responsive to customer demand PHP: Personal Health Plan, the plan that patients and providers develop based on assessed needs and personal preferences and goals M MA: Medical Assistant Poka-yoke: From the Japanese yokeru (to avoid), and poka (inadvertent errors)a methodology to prevent errors or to make them easily identifiable MAM: Mothers Aiding Mothers, a volunteer program in which mothers and grandmothers mentor teenage mothers PPT: People Potential Team, a cross-location team responsible for reviewing workforce results, identifying cross-organizational improvement opportunities, and providing feedback on development and measurement approaches N NACHC: National Association of Community Health Centers, a membership organization focused on advocacy, policy development, and education and training. It provides a source of leadership and board development Progress Scan: The FOCUS scorecard review performed at least monthly by County Directors and clinic managers to detect adverse trends Promotoras (or -es): The term frequently used for AF's volunteers, who promote health in many different ways NHSC: National Health Service Corps, a program within HRSA's Bureau of Health Professions focused on recruiting and retaining health professionals in underserved areas Pugh Matrix: A method for prioritizing and selecting options using a matrix to score alternatives against a set of evaluation criteria NP: Nurse Practitioner O OASIS: AF's principal process improvement methodology Q QPG: Quality and Productivity Group OSHA: Occupational Safety and Health Administration, the agency in the U.S. Department of Labor responsible for developing and enforcing regulations pertaining to the safety and health of U.S. workers P PA: Physician Assistant Partners Committee: A committee representing all external stakeholders that meets quarterly to provide input and guidance to AF's planning process Payor: In health care, an organization that pays a patient's health care expenses. For example, a third-party payor is any organization, public or private, that pays or insures health or medical expenses on behalf of beneficiaries or recipients. R RN: Registered Nurse S Saguaro State Award for Performance Excellence: The statelevel performance excellence award based on the Baldrige Criteria for Performance Excellence SWST: Service With Spirit Team, a cross-location team responsible for reviewing customer-related results, identifying crossorganizational improvement priorities, and providing feedback on approaches to customer listening and learning and satisfaction measurement xvi U Uniform Data System: The database managed by BPHC that includes aggregate clinical and operational data for CHCs nationwide Six Sigma: A methodology and an associated set of tools to reduce variability and eliminate defects SSU: Saguaro State University, a key education partner Staff and Volunteer Handbook: The online system for knowledge management, which includes, for example, organizational policies and clinical guidelines URI: Upper respiratory infection V VA: U.S. Department of Veterans Affairs STAR: Superior Teamwork Achieves Results, AF's principal employee recognition program State Association of CHCs: State Association of Community Health Centers, the nonprofit member organization that provides advocacy, education and training, and group purchasing opportunities, as well as statewide collaborative learning and benchmarking SWOT: Strengths, Weaknesses, Opportunities, and Threatsan analysis performed as an input to the Strategic Planning Process T Takt Time: The pace of production or service delivery needed to meet customer demand Veterans Health Administration: An organization under the VA that provides a broad spectrum of medical, surgical, and rehabilitative care VMV: Vision, mission, and values W WIC: Women, Infants, and Children, a national health and nutrition program for low-income mothers and young children that is administered by the Food and Nutrition Service of the U.S. Department of Agriculture TB: Tuberculosis Town Hall Meeting: An open meeting held annually in each county that provides an opportunity for two-way communication between AF leaders and key stakeholders xvii P Preface: Organizational Profile P.1 Organizational Description P.1a Organizational Environment Arroyo Fresco (AF) is a community health center (CHC) serving western Arizona from 11 clinics and 4 mobile service vans. CHCs, established over the past 40 years in underserved areas in all 50 states, are nonprofit, community-owned health care organizations that offer patients high-quality primary care and preventive services regardless of their ability to pay. They also provide \"enabling services,\" such as transportation, translation, case management, health education, and home visitation, which increase access to care. More than 1,000 such centers serve some 15 million Americans annually. The Health Resources and Services Administration (HRSA) administers the program. A snapshot of AF is shown in Figure P.1-1, and service-area demographics are shown in Figure P.1-2. AF serves three countiesYuma, Mohave, and La Pazwith diverse populations and needs. The service area of over 23,000 square miles has fewer than 400,000 peopleabout one-third of the state's overall population. Yuma County borders Mexico. P.1-1 2005 Snapshot of Arroyo Fresco Total revenue $29.7 million Total visits 192,403 medical, 61,734 dental Patients 59,425 Service sites 8 medical/dental clinics, 1 women's health center, 2 school-based clinics, 2 medical service vans, 2 dental service vans Staff 379 (62% direct patient care) Volunteers 250 Figure P.1-2 AF's Service-Area Population Demographics Yuma La Paz Mohave Persons per 29 4.4 11.6 square mile Persons below 19.2% 19.6% 13.9% poverty threshold Under 5 years old 7.9% 4.9% 6.0% Under 18 years old 28.9% 21.1% 23.1% 65 years old and 16.5% 25.8% 20.5% over White 68.3% 74.2% 90.1% African American 2.2% 0.8% 0.5% Native American 1.6% 12.5% 2.4% Asian/Pacific 1.0% 0.5% 0.9% Islander Other (different 26.8% 12.0% 6.1% race or two or more races) Hispanic heritage* 50.5% 22.4% 11.1% Home language 45.5% 21.6% 10.7% other than English *Persons of Hispanic heritage can be of any race. AZ 45 13.9% 7.5% 26.6% 13.0% 75.5% 3.1% 5.0% 1.9% 14.5% 25.3% 25.9% Communities along the border are among the state's fastestgrowing. La Paz, one of the state's most rural counties, is home to the Colorado River Indian tribes, the largest of western Arizona's Native American populations. Mohave County, also sparsely populated, shares with La Paz 400 miles of Lake Havasu coastline and 300 days of sunshine each year, making these counties a destination for vacationers and retirees from across the country. Barriers to carewhether imposed by geography, culture, income, or other factorsare typically associated with (1) lower levels of prevention screening and (2) less efficient and effective detection and management of chronic disease, with the result that many AF patientsyoung and oldhave poorer health than the general population. Diabetes is a major medical problem throughout the service area, with residents of southern Yuma County experiencing diabetes-related mortality at twice the national rate. Other chronic health problems include asthma, cardiovascular disease, depression, obesity, and substance abuse and other addictive behavior. Specific issues for Yuma County border communities include a higher incidence of communicable diseases (e.g., twice the national rates of tuberculosis and hepatitis A) and a higher mortality rate for accidents. Women's health is a priority in Yuma County; AF established a Women's Health Center with obstetrical and gynecological services in North Yuma to address that area's large proportion of younger females in the population and high birth rates, especially among teens. P.1a(1) Main health care services and delivery mechanisms: AF provides ambulatory medical (i.e., obstetric/gynecologic, family medicine, pediatric) and dental services, supported by routine laboratory and X-ray services, vision and hearing screening, behavioral health and substance abuse screening, and pharmacy services. Its service delivery network includes clinics and mobile service vans that make regularly scheduled stops six days a week at churches, schools, and community centers. AF ensures that patients can access all services required across the continuum of care through partnerships or contractual relationships with hospitals, physicians, and agencies throughout the tricounty area, and these arrangements are spelled out in the annual plan required by the Bureau of Primary Health Care (BPHC). AF delivers care through the clinical microsystem (CM)a small interdisciplinary team whose members form ongoing relationships with patients and families and manage the medical and dental care of these various groups, or \"populations,\" of patients. Essential elements of a CM include the patients, clinicians, and support staff; information and information technology; and the care processes. AF has 25 CMs organized according to its key services. For example, each clinic has at least one family medicine CM. P.1a(2) Organizational culture: AF was founded in 1968 by Joe Regam and Martin Rosales, two Yuma activists committed to providing health care to the underserved. With federal funding through the Migrant Worker Project, they opened their first clinic in a converted gas station in Yuma and called their fledgling operation \"Arroyo Fresco,\" or \"cool, flowing stream,\" to represent a place where one can be refreshed in a vast, harsh desert. AF grew under their leadership. Operations expanded to full-time, three more facilities opened, and the first mobile van was launched in 1988 with grant funds from the BPHC. In 1990, AF merged xviii Figure P.1-3 Vision, Mission, and Values Figure P.1-4 Staff Profile Gender Male Female Race/ White Ethnicity African American Native American Asian/Pacific Islander Other (different race or two or more races) Hispanic heritage* Education Postgraduate Two-four years of college High school *Persons of Hispanic heritage can be of any race. Vision Through our leadership in health care design and delivery, education and training, and community involvement, the people of western Arizona will become the healthiest in the state. Mission Provide residents of Yuma, La Paz, and Mohave counties easy and timely access to high-quality and safe health care services, responsive to their diverse cultural and socioeconomic needs, regardless of their ability to pay. Values Through our decisions and actionswith our patients and their families, key communities, partners, and each other we show our commitment to five core values: Respect: We recognize the worth and honor the dignity of every individual. Trust: We build confidence in our integrity by everything we do. Relationship: We believe strong relationships are key to good health and build long-term relationships by honoring patient and family values, preferences, and goals. Performance: We embrace improvement and innovation; we search for and adopt best practices and continually improve our daily work. Accountability: We demonstrate progress toward our vision by sharing our results. 42.2% 57.8% 77.7% 1.2% 5.5% 0.8% 15.2% 26.1% 24.7% 38.1% 37.2% screening, as well as obstetrical ultrasound equipment and dental X-ray machines that reduce radiation exposure. Clinic-based laboratories are equipped with microscopes, blood analyzers, and kits for rapid bacteriologic screening for respiratory and genitourinary diseases. Most clinics are open from 8:00 a.m. to 5:00 p.m. Monday through Friday and on Saturday morning. School-based clinics are open daily when school is in session and provide basic medical services and behavioral health screening, as well as health education through individual, classroom, and peer counseling sessions. Laboratory tests and X-rays for students are performed at the closest AF facility. The Women's Health Center in Yuma has examination rooms equipped for outpatient obstetrics and gynecology services, as well as four labor and delivery suites for routine deliveries. High-risk pregnancies and complicated deliveries are referred to the tertiary care hospital in Yuma, which has specialists on call and a neonatal intensive care unit. AF physicians and midwives also manage routine deliveries at the community hospital in La Paz. with the Mohave CHC, extending AF's reach along the western Arizona corridor. Ramon Gonzalez, who became the CEO in 1996, saw the importance of reaffirming the organization's heritage and direction set by its founders and developed a formal statement of vision, mission, and values (VMV). (See Figure P.1-3.) P.1a(3) Staff profile: AF has 379 employees (12% of whom are part-time), and the workforce mirrors the race/ethnicity and culture of the population served (Figure P.1-4). Clinical providers, who make up 62% of the staff, include 29 physicians, 53 medical assistants (who perform outpatient nursing tasks), 12 dentists, 18 dental hygienists/assistants, 4 nurse practitioners, 4 certified nurse midwives, and 15 physician assistants, as well as pharmacists, pharmacy technicians, community educators and social workers, dietitians, podiatrists, and radiology technicians. Administrative, facility, and patient support service staff make up 33% of the workforce, and 5% of staff are senior leaders or managers. Health and safety risks in the ambulatory patient care setting include exposure to communicable diseases, exposure to radiation and chemicals, ergonomic injuries, and accidents. In addition, safe driving is a primary requirement for mobile van drivers. P.1a(4) Major technologies, equipment, and facilities: Clinical facilities include reception areas; examination/treatment rooms equipped for medical or dental services; space for consultation and education; printed materials in English, Spanish, and large print format; and shared provider offices. All facilities are wheelchair-accessible. Medical clinics have machines for audiometric and tympanometric screening and for electronic vision Four mobile service vans provide care to outlying communities and those unable to access care at clinic sites. Equipped with lifts to accommodate patients in wheelchairs, each van has two examination/treatment rooms outfitted for medical or dental services; X-ray, basic lab, and sterilization equipment; and areas for behavioral health screening, health education, and reception. AF's information technology is managed by Desert Data Solutions (DDS). It includes support for an electronic health record (EHR) integrated with the billing and scheduling system. All staff members have access to computers and the wide array of data and information on the AF intranet. The innovative Care Connection Kiosk (CCK) is a portable, multi-use unit developed in collaboration with CactusCom, a telecommunications partner. P.1a(5) Legal and regulatory environment: AF must meet specific federal requirements related to population needs, services provided, fee scale, and governance structure to receive grant funds as a federally qualified health center under section 330 of the Public Health Service Act. To maintain their federal funding, CHCs are required by HRSA to be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). AF sought accreditation for the first time (then voluntary) in 1996 and has been re-accredited regularly since xix then, receiving full accreditation and no recommendations for improvement in 2004. AF is required to comply with multiple legal and regulatory requirements at the federal, state, and local levels (Figure 1.2-2). care in more innovative ways than it could on its own. The most important supply chain requirements are low cost/high value, on-time delivery of supplies or services, and continuity of operations for providing clinical care. P.1b Organizational Relationships P.1b(1) Organizational structure and governance system: AF is governed by a voluntary 15-member Board of Directors chaired by the founder and former CEO, Joe Regam (see 1.2a[1]). Bylaws and federal program regulations require that at least 51% of voting members be recipients of AF services. Gonzalez and his senior leadership team are nonvoting members of the board. The board has six standing committees: Quality, Ethics, Community, Partner Relations, Development, and Audit. Five cross-location teams systematically support senior leaders in planning and decision making (see the Organization Chart). Each has crossorganizational representation from CMs and functional groups. They share and integrate data and information across AF and link the top team and the front line. The State Association of CHCs provides advocacy at state and national levels; group purchasing arrangements for medical and dental supplies and pharmacy and lab services (through MedProducts, Inc.); assistance with grant writing and recruitment/retention initiatives; and educational programs for clinicians, administrators, and board members. Health Care Partners: AF partners with a community hospital in each county to provide emergency and inpatient services, as well as some outpatient specialty care. AF provides hospital staff members continuing education about high-risk populations and offers learning opportunities for hospital trainees through brief rotational assignments in AF clinics and vans. Also, AF partners with community-based private physicians, who provide most inpatient and specialty care. P.1b(2) Key patient and customer groups, stakeholder groups, and health care market segments: AF's key customer and stakeholder groups are patients and their families, the community, physicians, staff, volunteers, partners, and payors, and their key requirements are shown in Figure P.1-5. As appropriate, AF segments its key stakeholder groups by demographics, health status, location, and other relevant factors. AF acknowledges the many contributions made by its volunteers and considers them a key stakeholder group. Many are patients and patients' family members themselves. Volunteers perform a wide variety of tasks that build relationships with patients and their families and increase the efficiency and effectiveness of care delivery (e.g., providing child care during patient visits, assisting providers' education sessions, and supporting routine administrative tasks). Some have assignments that make use of their professional and technical skills (e.g., participating in grant development), enabling AF to manage resource gaps or reallocate resources to other priorities. AF's health care market segments are the patients in the three counties of its service area. Education Partners: AF partners with the Saguaro State University (SSU) Schools of Business, Medicine, Dentistry, Nursing, and Public Health, as well as with local community colleges. Collaborative efforts include training and preceptorships supervised by AF providers. Community Partners: AF partners with a broad array of community groups, including school boards, other leaders, and parents in the two Yuma schools with school-based AF clinics. Other partners include county governments and communityservice organizations that make referrals, promote and participate in services, and contribute to effecti