By Julie Yonek, Stephen Hines, and Maulik Joshi
Our research shows that high-performing multihospital systems use dashboards-for example, a balanced scorecard-to measure and manage system performance. Setting system-level targets within each strategic priority area is a strategy used by top performing systems to improve performance across hospitals. Sharing system dashboards regularly with hospital leaders, clinicians, and other staff helps promote quality improvement and accountability.
Below are several approaches that systems can use to set performance targets:
Use an "all or none" or "perfect care" approach to set targets for all performance measures. High-performing health systems are more likely to use composite measures or bundled measures for driving performance improvement. This may include an "all or none" approach where you only receive credit for meeting all the measurement or care standards for a specific condition set. Alternatively, organizations can bundle different measures into a composite metric. Here are several examples:
At John Muir Health, the goal for Centers for Medicare & Medicaid Services (CMS) core measures is that 95 percent of all patients will receive all measures (e.g., heart attack patients receive aspirin on arrival). For harm measures, the goal is set at zero.
At Novant, the top decile of performance is the goal for every indicator on their scorecard. As a system, they score themselves based on the percentage of indicators that are >/= 90th percentile. The system's target is to have at least 75 percent of all indicators on the scorecard at or above the top decile.
At Alegent Health, when they reached 98 percent compliance on core measures, they took system performance to the next level and created an evidence-based care composite score. This score combines all clinical processes of core measures and clinical outcomes targets.
Covenant Health (Tennessee) created a new "safety bundle" performance target, which encompasses medication errors, falls, and hospital-acquired infections.
Aurora Health System uses a care management impact score to assess systemwide performance, a composite score that combines performance on 33 quality and safety indicators.
Consider setting targets based upon event counts (numerator) as well as rates. In addition to tracking rates, which are often useful for benchmarking and performing risk adjustment, systems may use actual event counts (e.g., the number of patient deaths) to assess performance. Using event counts to report performance may reveal additional areas for improvement and help systems drive toward achieving perfect care scores.
For example, once Mayo Clinic surpassed the top decile of performance, leaders changed the way they set targets. For instance, the target for reducing hospital-acquired infections is now based on the patient count rather than the rate.
Similarly, Covenant Health (Tennessee) uses the number of patient events (numerator) rather than the rate for their harm reduction target.
Sharing dashboards with hospital leaders and staff frequently. At Covenant Health (Tennessee), quality scores for each facility are reported monthly. If they see that one is going off course, they have a chance to devise an action plan and get back on course much more quickly than would otherwise be possible.
At Partners Health Care, internal reporting of performance has proven to be an effective incentive for improvement-such transparency promotes healthy competition among its hospitals to strive to do better as compared to their colleagues.
At North Mississippi Health Services and IASIS, sharing results with staff on core measure performance is a major contributor to the system's performance improvement within the past two years.
Post dashboard information on the system's intranet. This is a commonly used approach for systems to provide all employees access to up-to-date information on system and hospital-specific performance.
Engage in national benchmarking initiatives to achieve transparency and foster competition. Compared to other systems, high-performing systems participated in national improvement initiatives 7 percent more frequently. The transparency and public commitment required by these activities has played a significant role in performance improvement for all healthcare organizations.
Publicly reporting their information and participating in national or regional benchmarking or quality collaborative activities has shined the light on opportunities for improvement and spurred pressure to improve. Examples include participation with Institute for Healthcare Improvement, state hospital association activities, and other collaboratives.
For example, at Baystate Health in Massachusetts, participation in a variety of collaboratives, such as CMS Hospital Quality Improvement Demonstration Project, has improved transparency and served as a strong incentive for improvement.
Through its engagement in benchmarking programs and databases, Health Quest has promoted greater standardization of performance measurement across the system and transparency-"wanting to look better, not worse than the next person" has been a major motivator to improve.
Use corporate support through data mining of existing information systems, frequent analyses, and reporting of measures for hospital level performance improvement. Health system corporate quality and patient safety departments may provide the enterprise significant support through data mining, analysis, and reporting to support individual hospital-level improvement.
For example, Catholic Health Initiatives uses its corporate business intelligence teams to support the quality functions.
At Catholic Healthcare Partners, the corporate department provides support for standardization and reporting of quality measures across the system, as well as ad hoc information as needed.
Julie Yonek, is senior researcher at Health Research & Educational Trust (HRET), Chicago. Stephen C. Hines, PhD, is vice president of research, HRET. Maulik S. Joshi, DrPH, is president, HRET, and senior vice president of research, American Hospital Association (firstname.lastname@example.org).
This article is excerpted with permission from the following resource: Yonek, J., Hines S., and Joshi, M., A Guide to Achieving High Performance in Multi-Hospital Health Systems, HRET, Chicago, Ill., March 2010.
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