Case Study #1: Healthcare Performance Measures to Improve Accountability to Patients and Healthcare Workers
Healthcare in British Columbia
“If you’re not measuring, you’re not managing" - Peter Drucker
“You manage to what is measured” – Greg Steer
It’s important that we measure performance and that performance measures align with outcomes. Players and fans look to the scoreboard and the standings to assess performance of a professional sports team, not to the box office. Open and transparent reporting of performance measures is key to accountability. In the absence of performance measures, there is a danger that managers simply manage to budget. In our public Health System, we want everyone from the surgical suite to the C-suite to the Provincial Cabinet accountable for improving patient outcomes.
Before we can keep score, we need to understand the game and the field of play. For our Health System, we’ll use a simple, three-box model to describe patient location and type of care (Figure 1), which is the field of play.
A patient can be in the Community (receiving Primary or Emergency Care), in Hospital (receiving Acute Care or Intensive Care), or in Long-Term Care (e.g. Assisted Living, Residential Care, Hospice). Patients receive care depending on need, and are admitted, transferred, and discharged between care types. Primary, Emergency, Acute, Intensive and Long-Term Care are groups of patient-facing services (Prevention, Diagnosis, Treatment, Care). The objectives of our “health system game” are:
Keep people healthy in the Community, where they receive Primary or Emergency Care to help keep them there,
Place people in Long-Term Care if needed, where they receive specialised or a broader scope of care not available in the Community, and
Keep people out of Hospital, where they receive very specialised and limited healthcare services. Hospitals are for care, repair, and discharge back to the Community or to Long-Term Care.
There are several strategies to keep people healthy.
Prevent injury and disease. Injury and disease that are prevented are injury and disease that don’t need healthcare services. Companies know that prevention is better than “break/fix.” Healthcare workers know this. Everyone knows that 28g of prevention is worth 454g of cure (metric version).
Faster, better diagnosis leads to faster, better treatment, which leads to better outcomes. If you don’t know the problem (diagnosis), you probably won’t provide the solution (treatment).
Don’t make the patient worse, i.e. first do no harm.
A performance metric is a measure of performance from a service. They measure results, not inputs. Together with our service model, we can evaluate performance of our Health System. For example, a performance measure for an Emergency Department is Effectiveness of Treatment (a result) not Hours of Operation (a measure of availability). It’s a failure if a patient with a medical condition leaves the Emergency Department without treatment. This is like an abandoned cart in online retail but potentially more serious. Cost enables us to determine efficiency of service options. Performance and value metrics enable us to objectively evaluate service options, which is essential to a unified, results-driven culture.
We need a few Key Performance Indicators (KPIs) to benchmark our Health System and evaluate benefits of transformation. Performance metrics are usually developed with Subject Matter Experts, in our case Healthcare Professionals. Ideally, we’d use pan-Canadian or international standards so we can benchmark our health system against others. For now, we can can break out KPIs by service type:
Diagnosis
Did you receive a Diagnosis?
What Type of Diagnosis did you receive (Unknown, Preliminary, Conclusive)?
Was it Timely?
Was it Correct?
Are you satisfied with the Diagnosis you received?
Treatment
Was Treatment provided?
Was it Timely?
Was it Correct?
Are you Satisfied with Treatment you received?
Prevention
Were you injured by the healthcare service?
Were Preventive Measures taken?
Were they Timely?
Were they Correct?
Are you Satisfied with the Preventive Measures taken?
Care
Was Care provided?
Was it timely?
Was it appropriate (correct, comprehensive)?
Are you Satisfied with the Care provided?
Outcome
Are you better off after receiving healthcare service?
Are you satisfied with the Outcome?
For hospital admissions, is this a Readmission?
We’ll also have a few KPIs to evaluate the Health System and patient health overall.
If you’re in the Community, do you have access to Primary Care?
Are you satisfied with the Primary Care you receive?
How functional are you relative to your expectation, i.e. how healthy are you?
Open and transparent reporting of performance measures improves Health System performance and ensures that it’s accountable to patients and healthcare workers. Most patient-facing healthcare workers already strive to improve patient outcomes. They chose healthcare as a profession, and they experience the emotions of their patients. Decisions informed by performance measures improve patient outcomes and create a results-driven corporate culture that supports healthcare workers.
“Will this be on the test?” – Question from a student for the teacher in a class
Performance measures can extend accountability beyond the front-line. We can put them on the test. First, we can collect and aggregate them by organisational unit (e.g. hospital, Health Authority, Health System), and publish them quarterly. This creates healthy competition among executives to improve service and outcomes. No executive wants their organisation to be the lowest performing. Next, we can tie executive performance pay to actual performance. Executives in the public sector often have “pay at risk,” where a portion of their salary depends on achieving objectives in their annual workplan. We can make health system performance count. Finally, we can put the Minister of Health on the team. They could put at risk 10% of their salary, and donate it to charity if performance standards aren’t met. They are now accountable every year, not every 4 years in an election. In these ways everyone on the healthcare team has “skin in the game,” and the Health System is accountable to patients and staff.
For our Case Study #1: Healthcare in British Columbia, we now have the following elements of our transformation project:
Performance Measures and Improved Accountability to Patients and Healthcare Workers
As an executive at Fisheries and Oceans Canada once observed, this is a rational framework within which we can make progress at a tolerable pace. We can use it to keep what works, add what’s missing, and eliminate unnecessary duplication. Let’s go! First, we’ll use it to improve primary care. Primary care is important. It’s in crisis. We can’t make it best but we can make it better.
greg
Everyone, keep your eye on the prize
