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Alignment from Top to Bottom

Alignment, as defined in the Baldrige framework (Baldrige National Quality Program, 2005), refers to consistency of plans, processes, information, resource decisions, actions, results, and analysis to support key organization-wide goals.  Effective alignment requires not only shared understanding of purposes and goals, but also deployment of resources to reinforce the behaviors, operations and processes that supported organizational goals.  Alignment is represented as a vertical line to signify its role in moving work at all levels of the organization in a consistent direction.

Organizations use different methods to convey their messages to ensure consistent visions and purposes across the organization.  Organizations/systems vary in how they accomplished this deployment, with some actively employing the Baldrige framework to create highly aligned priorities.  In most systems, though, organizational priorities are translated into department goals for which managers were held accountable.  Some systems carry alignment down to the front line of the organization.  Aligning goals down to the level of individual employees is challenging for most organizations but it is a key part of transformation.

Accountability is a key aspect of alignment, ensuring that behaviors, operations and processes were, in fact, aligned to support organization-wide goals.  Performance measures are one mechanism to encourage alignment.  Managers' performance evaluations and bonuses can be tied to their performance on strategic quality measures. These measures can also be included as a component of physician compensation.

Effective alignment and accountability are difficult to achieve.


The leadership at Site D identified 18 corporate strategies that defined the organization's direction and priorities.  Staff members throughout the organization became familiar with these strategies and their meaning.


Site I cascaded its organizational objectives to the front line through individual employee goals, with each employee expected to maintain a document containing position-specific goals that were measurable, time-dependent, and aligned with department and organizational goals.  To illustrate, a nurse on a patient unit might have an individual goal of responding to patient call requests within y minutes to support the unit goal of improving patient satisfaction scores by x percent to support the organization’s overall patient satisfaction goal.