From the December 2006 Issue

Using Data to Drive Performance Improvement in Hospitals

An Ounce of Prevention for the Healthcare IT Network

On Track to Improved Workflow

Accuracy in Motion: Case History

A Tale of Two Attitudes

Using Data to Drive Performance
Improvement in Hospitals

By Melissa A. Fitzpatrick, R.N., M.S.N., FAAN

Melissa A. Fitzpatrick, R.N., M.S.N., FAAN, is chief healthcare strategist, education and medical practice, at SAS in Cary, N.C. Contact her at melissa.fitzpatrick@sas.com.

Even with the best of intentions, hospital executives and clinicians often make decisions that are far from evidence-based or data-driven. They want to improve quality of care, efficiency and financial performance, but cannot always get to the data that could inform their decisions, much less predict and optimize performance.

What’s the problem? There are many. In hospitals, so much effort is spent chasing after the data that there are few resources left to spend on analyzing the data, looking for trends and correlations, and being more proactive. The data is resident, and in many cases, there is more data than you can imagine, but it is not being used to drive decision-making. In fact, much of the data that is being collected at great labor and expense probably doesn’t matter, and many may not even know why that data is being collected in the first place. The phrase, “That’s the way we’ve always done it,” should immediately serve as an alert to the need to use data, rather than history and anecdote, to drive practice.

Most hospital leaders would say that they need to become more efficient in accessing, organizing and sharing data and that they want to focus on what matters. They don’t have much margin for error, and they want to use their constrained resources to the best effect. Hospital leaders have made substantial investments in departmental and transactional information systems that accomplish specific tasks, but are not integrated. Nor do they deliver an enterprisewide view of performance. These silos of information are often “owned” by different groups and managed by teams that, at face value, are working toward competing goals.

Yet hospital leaders feel the need more than ever to measure, report and sustain improvements in patient care quality and safety as they respond to increased regulation, public scrutiny and demand for quality outcomes and data transparency. Systems are desperately needed to create intelligence from data and to facilitate collaboration across multiple groups. As information is pushed closer to the point of service, these intelligence systems hold the promise of enhancing decision-making at all levels, from the Board of Trustees to the individual care provider.

It’s All About the Data
These systems do exist and are being used to create cultures of evidence-based performance and to achieve improvements in patient care quality, patient and employee satisfaction, physician engagement, and financial and operational performance. There is no magic bullet, but several elements are fundamental to success.

One of the most important is strong leadership to carry the flag for data-driven dialogue and evidence-based decision-making. Having the C-level team “walk the talk” sets the expectation that meetings will be run using data, that trending graphics will be prominently displayed at the unit/department/executive level, and that less anecdote and more fact will be used to allocate resources and to manage improvement efforts. It’s amazing what happens when the CEO becomes evidence-based and when he holds team members accountable for achieving established targets on metrics that have been deemed mission critical. This level of executive sponsorship also is essential to cut through the turf and territorial issues that may surface as data from disparate sources is pulled together into one business intelligence platform to facilitate analysis.

Once executive support is assured, it’s all about the data. Getting to the data, assuring its integrity and quality, and then making the data available to those at the point of service are key steps if data is to be used to optimize performance. Tools to cleanse the data and to enable the extraction, transformation and loading of data from multiple sources into a data warehouse or repository can greatly reduce the labor and time required to report outcomes. Automating these processes and running these jobs as frequently as reporting is necessary enables the performance management team to focus on analyzing results, looking for cause-and-effect relationships between the metrics and optimizing future performance.

Data mining and online analytical processing tools can further enhance the use of the data, once it is aggregated, to understand the relationships between measures related to staffing, quality, patient satisfaction, employee turnover and costs among others. These tools give hospital leaders permission to stop measuring everything under the sun and instead focus on a set of core measures or key drivers of performance. Doing so puts limited resources to more efficient use and achieves better outcomes from a variety of perspectives.

Metrics That Matter
Once the data is aggregated and analysis ready, it can be sliced in any number of ways to answer specific questions. A hospital executive may want to analyze one particular metric, such as cost per case or infection rates, across all service lines to determine best practices. Analyzing performance by individual surgeon within a certain specialty may uncover practice variations that warrant intervention and standardization to optimize outcomes and costs. Discovering that certain metrics do not drive quality or costs may be just what is needed to stop spending time on them and to focus on metrics that matter.

With metrics defined and outcomes available for reporting, the next step is to make them accessible to those that need them where they need them and when they need them. Making performance data available via the Web and facilitating a view of the data that matters to the individual enhances the user experience and the likelihood that team members will use the system. Incorporating benchmarks to show internal and external comparisons of performance on a given set of metrics also is a powerful way to drive continued improvement and optimization.

It’s essential that a given user can drill into the information that matters most to his practice or department. An ICU nurse manager needs to see the data that reflects her team’s performance and to be accountable for those metrics. Executives will want to see an aggregated view of performance by individual hospital in a system, by service line, by vice president or by metric. In smaller hospitals, the scale may be different, but the requirements for data and collaboration are the same. There may not be as many cuts of the data, but the need to get granular and to focus on drivers is just as important in a 100-bed hospital as it is in a 500-bed hospital.

The goal of any business intelligence or performance measurement initiative is to align teams around a core set of strategies, objectives and metrics to achieve and sustain improvement. Doing so can speed up the time to issue identification and resolution, enhance collaboration across multidisciplinary teams, and improve clinical and organizational efficiency and outcomes. When data is used to drive performance, individuals and teams can be held accountable to higher standards and can use data to set meaningful performance targets and goals that everyone can feel good about.

Choosing a performance management framework that is consistent with an organization’s vision and values and that is easily communicated helps to get all team members singing from the same song sheet and working toward common goals. Some use the balanced scorecard, the Baldrige leadership criteria, the Six Sigma methodology and others as the framework for visualizing or communicating their performance goals and outcomes. Whatever framework a hospital team chooses, creating a single version of the truth provides the foundation for the integration of strategy, technology, and information to create true business intelligence.

This business intelligence framework then serves as the vehicle to pursue the following as it drives performance from various perspectives:

• Provider Profiling. Analyze physician practice patterns by measuring clinical, quality, customer satisfaction and economic indicators. Conduct comparative analysis to identify performance best practices;
• Clinical Decision Support. Measure and view clinical performance across multiple perspectives to optimize resource utilization, cost effectiveness, pathway development and evidence-based decision-making;
• Disease/Condition Management. Use predictive modeling techniques to identify high-risk patients and to proactively intervene and optimize care across populations;
• Benchmarking/Quality Reporting. Perform necessary data management and analysis to support internal and external comparisons and reporting requirements (JCAHO, NCQA, Hedis, etc.);
• Clinical Research Analysis. Support the conduct of clinical research and outcomes analysis to generate new knowledge and to optimize clinical care;
• Patient Safety/Error Reduction. Utilize data mining approaches to uncover trends and patterns in clinical errors; identify and investigate key drivers of variation across care settings.

The Right Timing
These efforts often result in consolidation of reports, enhanced efficiency of reporting, and refinement of the metrics and areas of focus. It is not uncommon to experience greater employee and physician engagement as they become more data minded and as evidence becomes a key element of their crucial conversations. Enhanced organizational alignment is achieved when all team members are using the same tool to discuss performance and outcomes, and when strategic goals and objectives are incorporated into unit/departmental goals as well as individual accountabilities. Creating a “one-stop shop” for information, whether it’s for the Board or for a frontline manager, enhances efficiency and alignment and keeps the organizational eye on the ball. Putting timely and accurate information at the fingertips of the clinical and operational teams enhances readiness for regulatory surveys and strengthens the connection between regulatory standards and clinical practice.

Becoming evidence-based and data-driven is really no longer a choice. It is an imperative. It takes investment of capital dollars in technology and the time and energy of key champions to begin the journey. Start with a service line or team that is data-minded already or one that has a particular problem area that requires focused attention. In one hospital, for example, nursing services and surgical services were chosen to pilot the new performance management approach using a balanced scorecard. These two services represented complex operational areas with large budgets, so the opportunity for efficiency and cost enhancements was significant.

Choose a key physician champion to help engage the physician team members and to use data to inform rounds, patient care conferences and team meetings. Post the results being achieved and share improvements and successes with the team. When a change is implemented, use the data to show its effect and to validate the reason for the change. Constantly reinforce evidence-based thinking in all conversations and in making all decisions. Use the data to stop measuring things that don’t matter and to take some workload off team members’ already overflowing plates. As they see efficiencies gained and positive outcomes achieved and rewarded, they will become the newest champions and advocates of this work.

The key is to get started. If we wait for all of the data to be ready and for consensus to be achieved across all of the turfs, it will take too long. The risks are too great to continue to lead hospitals in anything other than a data-driven manner. Set the tone, create the team and get the tools you need to begin. These can be incremental, iterative steps along the path that build on one another and grow one unit/department/physician at a time. Let data and technology be the tools for performance improvement and optimal outcomes.

Learning from the Masters
Brigham and Women’s Hospital in Boston, Mass. is an example of a hospital team that is achieving meaningful improvements in patient care quality and safety, financial performance and patient and employee satisfaction. The team at Brigham has effectively put into practice the principles of business intelligence and evidence-based decision-making, previously described. From frontline care providers to the Board of Trustees, data drives conversation, decision-making and strategic alignment. A balanced scorecard framework serves as the vehicle for reporting and communicating metrics that were carefully and collaboratively agreed upon by the key stakeholders within each service line.

Starting with nursing services and surgical services, clinicians, managers and executives built consensus on the measures that mattered most to their business and began the work of aligning those metrics with the strategic goals and priorities of the organization. From the start, executive champions led the charge and assured consistency and unflagging commitment to the vision and goals of the performance management initiatives and the balanced scorecard automation.

Today, in its fifth year, the system has come to be seen as the “single source of the truth” across the organization and as integral to the overall performance management process. Brigham’s President and CEO Gary Gottlieb, M.D., M.B.A., is a key user of the system and one of its greatest advocates. The Center for Clinical Excellence, under the leadership of Vice President Michael Gustafson, M.D., M.B.A., and in collaboration with the clinical and operational leadership, measures and monitors key performance indicators across all inpatient areas using nearly 200 scorecards. Almost 100 of those scorecards are used to support nursing services, cascading information from the chief nurse executive to the vice presidents, nurse managers and patient care units. A specific quality outcomes scorecard is used to keep the Board of Trustees apprised of clinical improvements and performance against established targets. Several hundred individual surgeons can view their own scorecards and compare their outcomes against benchmarks established within their specialties.

The performance improvement success at Brigham and Women’s Hospital has been iterative, building on a strong foundation of technology, people and processes of care. Data from more than 80 source systems comprise the various scorecards that are populated in an automated fashion and distributed via the Web. Under CIO Sue Schade’s leadership, the process has resulted in consolidation of reporting and more efficient and timely output to the end users. The system is flexible and scalable, and changes in strategy or clinical priorities are readily accommodated. The scorecard system provides a common language and framework that is used by more than 1,200 employees and physicians across departments and service lines and within roles and scopes of practice. It provides a vehicle for communication, collaboration and accountability and has played a key role in further transforming the evidence-based organizational culture. Strategy maps show the alignment between the key goals and objectives and the mission, vision and values of the organization.

The results being achieved at Brigham are significant and reflect tremendous leadership and teamwork that is supported by technology. Brigham and Women’s Hospital was recognized in 2006 with the prestigious National Quality Healthcare Award and was inducted into the Balanced Scorecard Hall of Fame for Executing Strategy in October. The Brigham team is committed to quality patient care every day, and uses an enterprisewide performance management solution to demonstrate and communicate that commitment. You can do the same.

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