IHI 2007 Institute for Healthcare Improvement 2007 Balanced Scorecard Scorecards and Performance Measures Funded by the Office of Rural Health and Washington’s

IHI 2007Associates, L.L.C.

Pugh Ettinger McCarthy Institute for Healthcare Improvement 2007

Balanced ScorecardScorecards and Performance Measures

Sample Board Dashboard

PEOPLE Benchmark FY Target FY 06 QTR 1 FY 06 QTR 2 FY 06 QTR 3FY 06 QTR

4

Employee Turnover Rate (Annual) .5%/month 2.50% 2.41% 2.84% 2.79%

RN Vacancy Rate 1.00% 8% 18.00% 10.00% 5.00%

PATIENT SAFETY/RISK MANAGEMENT Benchmark FY Target FY 06 QTR 1 FY 06 QTR 2 FY 06 QTR 3FY 06 QTR

4

Falls with injury (Quarterly) 0 50 111 126 111

Medication Errors (ADEs) Category E-I .025/1000 doses 2/1000 doses 3.5 5.0 4.0

Central Line Infections Rate (Critical Care Units) 0 1.8/100 lines 1.8 3.1 1.3

Ventilator Associated Pneumonia 0 1 case per quarter 0 1 5

Mortality Rate Index 0.4 0.75 0.62 0.56 0.61

Number of Lives Saved / IHI Measure 150/quarter 181 219 181

CLINICAL QUALITY Benchmark FY Target FY 06 QTR 1 FY 06 QTR 2 FY 06 QTR 3FY 06 QTR

4

EVIDENCE-BASED CARE % OF PATIENTS RECEIVING ALL REQUIRED ELEMENTS

Acute MI 100% 90-95 98% 98% 97% 95%

Pneumonia 100% 80-90 89% 88% 82% 79%

Congestive Heart Failure 100% 90-95 98% 93% 94% 97%

Surgical Infection Prevention Protocol 100% 100 96% 98% 98% 98%

Below Target Meeting TargetExceedsTarget

Clinical Excellence Customer & Service Excellence

Corporate Effectiveness

Overall Mortality Rate

Overall Morbidity

Overall Patient Satisfaction

Patient Satisfaction "Delighted"

Physician Satisfaction "Delighted"

Physical Surroundings Dissatisfaction

EOS Leadership Scores

Growth

Efficiency

Net Operating Margin

Community Perception

At or better than target

Within 5% of reaching target

Patient Safety

Evidence Based Medicine

Outside of 5% of target

Funded by the Office of Rural Health and Washington’s Department of Health

2

Associates, L.L.C.

Pugh Ettinger McCarthy

IHI 2007

On the phone…

20 Years CEO experience in hospitals, health systems and managed care

CEO of United General Hospital, Sedro Woolley, WA 1979-1984

Senior Faculty Member IHI

Consulting work focuses on improving quality and performance

Michael Pugh

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IHI 2007

How Does Your Board Answer the Questions…

How good is our hospital?

Are we achieving what we need to achieve?

How do we know?

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IHI 2007

Another Way to Think About How Good…

What are you willing to promise patients about medication safety at your hospital?

What are you willing to promise patients about the use of evidence-based medicine in your hospital and clinics?

What are you willing to promise patients about the level of care and service that will be provided?

What are you willing to promise the community about access and cost?

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IHI 2007

How Good?

What level of medication error is acceptable if you are the patient?

How do you pick the patient that is not to receive evidence-based treatment?

How do you decide which patient should have a surgical site infection?

How do you explain to your mother that it is perfectly acceptable to wait in the ER for 8 hours and receive a bill for $3500.00?

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IHI 2007

1. Prevent Harm from High-Alert Medications... starting with a focus on anticoagulants, sedatives,

narcotics, and insulin

2. Reduce Surgical Complications by reliably implementing all of the changes in care

recommended by SCIP, the Surgical Care Improvement Project (www.medqic.org/scip)

3. Prevent Pressure Ulcers... by reliably using science-based guidelines for their

prevention

http://www.medqic.org/scip

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IHI 2007

4. Reduce Methicillin-Resistant Staphylococcus Aureus (MRSA) infection by reliably implementing scientifically proven infection control

practices

5. Deliver Reliable, Evidence-Based Care for Congestive Heart Failure to avoid readmissions

6. Get Boards on Board … by defining and spreading the best-known leveraged

processes for hospital Boards of Directors, so that they can become far more effective in accelerating organizational progress toward safe care

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IHI 2007

Building Stronger Health Care Boards

Basic Governance Functions– Keeper of the Mission– Set Direction and Expectations– Monitor Progress – Hire and Evaluate the CEO– Represent the interests of the

community

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IHI 2007

Scorecards are Tools for Monitoring Progress and Setting Expectations Financial

Operating Budgets and Targets

Cash Capital Expenditures Financial Integrity--

Audits Compliance

Legal and Regulatory Board Policy Risk Management

Strategic Progress on

implementation of key strategies

Results Quality

Patient Satisfaction Clinical Care

Performance Indicators Patient and Employee

Safety

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IHI 2007

Why Use Scorecards and Performance Measures? You should be able to look at what the

leadership of an organization measures and determine the organization’s priorities and strategy

In God we Trust, all else bring data….

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IHI 2007

Balanced Scorecards Drive Operating Strategies

Strategic Feedback/Learning

•articulating vision•strategic feedback

•review and learning

Balanced Scorecard

Adapted fromThe Balanced ScorecardKaplan & Norton

Adapted fromThe Balanced ScorecardKaplan & Norton

Clarify/TranslateVision and Strategy

•consensus

Communicating andLinking

•goals•performance measures

Planning and TargetSetting

•align w/ strategy•allocate resources

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IHI 2007

Seven Leadership Leverage Points for Driving Great Performance*

1. Set measured system-level aims and oversee their achievement at the Board level

2. Align aims, measures and strategies in a leadership learning system

3. Channel leadership attention to aims4. Engage an effective and committed executive

team5. Engage the CFO in this work6. Engage with physicians7. Build deep improvement capability

*www.ihi.orgReinertsen, Pugh, Bisognano 2006

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IHI 2007

Leverage Point 1: Establish system level measures

Set measured system-level aims and oversee their achievement at the Board level Owned by the governing board Collectively, the measures answer the

question: How good are we? Transparent—everyone in the organization

should know the Key Measures

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IHI 2007

What Should Be On the Hospital Board’s Performance Scorecard?

Mortality Readmission Rates Patient Experience % of Patients

Receiving Care According to the Evidence

Employee Satisfaction or Engagement

Cost per Discharge Days Cash on Hand Patient Safety Access

Board performance measures should at minimum include expected aims and results for:

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IHI 2007

IHI Proposed System Level Measures

IOM Dimension System MetricSafe ADEs/1000 doses

Effective & Equitable HSMRFunctional Outcomes (SF-6 for Chronic disease)

Patient-Centered Inpatient Satisfaction% patients dying in hospital

Timely Days to 3rd next available appointment

Efficient Health care costs per capitaHospital costs per discharge

Other Staff voluntary turnoverInvestment per capita

Critical Questions For Creating Alignment Between Desired Results and Quality Projects

Organizational Performance

Measures

Drivers(Core Strategies and

Theories)

Quality Projects(Operating Plan)

1. What are your system level aims and aspirations?

2. What are the system-level measures of those aims? (Big Dots)

3. How good must you be, and by when?

1. What are your key organizational strategies for moving your dots?

2. What really has to be changed, or put in place, in order to achieve each of these goals?

1. What set of projects will move the Drivers far enough, fast enough, to achieve your aims?

IHI 2007

Aligned Operating Strategies and Quality Projects Drive Desired Results

Organizational

AimsWhat by When

Drivers(Core Operating Strategies

and Theories)

Quality Projects(Operating Plan)

Cost per Discharge decrease by 2% in 2007

HSMR Mortality Rate less than 70 in 2007

Patient Satisfaction 75% rate top box in 2007

Decrease Nosocomial Infections

Improve Flow

Remove Waste

Surgical Site Infection Project

Ventilator Project Evidence-based Care

Project Clean Hands Project ER to Bed Project

IHI 2007

An Organization’s Measurement System Should Be Linked to Drive Desired Results

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Strategic Measures/Drivers

Process & OperationalMeasures

IHI 2007

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IHI 2007

Simple Rules for Board Level Scorecards and Dashboards Measure what is

important Review every meeting Use topic specific

scorecards to drill down at committee level (finance, strategy & planning, quality, safety, etc.)

Use Simple Formats

Set all-or-none target levels for clinical care and safety measures (100% or 0%)

Avoid using averages; use percentiles measured against standards

Avoid color coding to low expectations

Data graphed over time is the most powerful format

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IHI 2007

Color Coded DashboardsOnly As Good As Your Targets

Simple, and sometimes too simple

Color coding without numbers can mislead

Tendency is to assume that only the “red” blocks need attention

If used, boards need to frequently ask how the targets are set

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IHI 2007

The Case For All-or-None Measurement

Report to the Board Quality Committee

“Our MI Core Indicators were greatly improved last quarter. Only one EBC requires corrective action.”

Evidence-Based Care

Measure

EBC Compliance

%EBC 1 80% At or Above Target

EBC 2 100% Needs Work

EBC 3 100% Corrective Action

EBC 4 60%EBC 5 80%EBC 6 90%

Governance Question: “What % of Patients Got the Right Care?”

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IHI 2007

The Case For All-or-None MeasuresOnly 30% of Patients Received the Right Care*

Patient 1

Patient 2

Patient 3

Patient 4

Patient 5

Patient 6

Patient 7

Patient 8

Patient 9

Patient 10 Total

EBC Compliance

%EBC 1 1 1 0 1 1 1 1 0 1 1 8 80%EBC 2 1 1 1 1 1 1 1 1 1 1 10 100%EBC 3 1 1 1 1 1 1 1 1 1 1 10 100%EBC 4 0 1 0 1 1 1 1 0 1 0 6 60%EBC 5 1 1 1 0 1 0 1 1 1 1 8 80%EBC 6 1 1 1 1 0 1 1 1 1 1 9 90%

Per Patient Totals

5 6 4 5 5 5 6 4 6 5

% of Care Elements

Received by Patient

83% 100% 67% 83% 83% 83% 100% 67% 100% 83%

% of Patients Receiving Perfect

Care

30%

*Right Care defined as receiving all of the required EBC elements that the patient was eligible for

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IHI 2007

The Case for Measuring Against Standards/Expectations

Door to Intervention time proven to be critical to Heart Attack outcomes

Standard=30 minutes from presentation to (Thrombolytics or 90 minutes to Angioplasty)

Quality Committee Report “Our data indicates that

we are exceeding the national standard. Our average time for thrombolytics is 29.5 minutes.”

Great Report or Not?

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IHI 2007

Not. What about the 25% of patients with delayed care?

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%

0 10 20 30 40 50 60 70 80 90

Minutes

Door to Therapy-MI

25% of All PatientsBeyond the Standard

Average = 29.5 Minutes

30 Minute Standard

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IHI 2007

Anywhere HospitalHeart Surgery Program Board Report

5.9%

1.1%

Jan 05

Jan 06

Monthly Mortality

Should this be a cause for celebration?

“Compared to January of last year, our heart surgery mortality has decreased from 5.9% to 1.1%

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IHI 2007

When do you want to have your Heart Surgery?

0

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2

3

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6

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-05

Feb

Mar

Ap

r

May

Ju

n

Ju

l

Au

g

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Oct

Nov

Dec

Jan

-06

St. Elsewhere Monthly Heart SurgeryMortality

AVG = 3.5%

5.9%

1.1%

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IHI 2007

An Oregon Hospital’s Proposed Governance Scorecard (example)

Quality Dimension Measure Dashboard Metric

Access to Care ER Waiting Time% of Patients treated and discharged in less than 2 hours

Effectiveness30 Day Hospital Readmissions

% of Total Discharges Readmitted within 30 days

Effectiveness Mortality% of in hospital deaths/total monthly discharges

SafetyNumber of Adverse

EventsTotal Number of Patient Injuries During the Month (Falls, ADEs, Infections)

SafetyNosocomial Infections

% of Patients with hospital acquired infection as percentage of monthly discharges

Financial Effectiveness Cost/Discharge

Total Monthly Inpatient Operating Cost/Total Number of Discharges

28 In Partnership with the

American Hospital Association

Clinical Excellence Customer & Service Excellence

Corporate Effectiveness

Overall Mortality Rate

Overall Morbidity

Overall Patient Satisfaction

Patient Satisfaction "Delighted"

Physician Satisfaction "Delighted"

Physical Surroundings Dissatisfaction

EOS Leadership Scores

Growth

Efficiency

Net Operating Margin

Community Perception

At or better than target

Within 5% of reaching target

Patient Safety

Evidence Based Medicine

Outside of 5% of target

Bronson 2004 Scorecard

2005 Jan-06 Goal Grade Trendf

NQF

MeasuresInitiatives

100KSAVEDLIVES

CAMPAIGN

# of Falls With Injury/1000 Patient Days7

% of Pneumonia Patients With Antibiotic Within 4 Hrs.4

AMI Mortality4

Reduce Falls

% of Patients With Central Line Bundle6

ATB Within 4 Hrs. for Pneumonia

Prevention of Central Line Infections

Prevention of Ventilator-Associated Pneumonia

DVT Screening/ProphylaxisPerioperative Beta Blockade

Prevention of Surgical Site Infections

# of Falls/1000 Patient Days7

% of ICU Vent Patients With Bundle2

# of VAP Cases in ICU/1000 Ventilator Days6

# of Central Line Related Primary BSI6

Rate of Infection in Clean Surgical Patients6

Appropriate Prophylactic Antibiotic Selected4

Prophylactic Antibiotic Discontinued Within 24 Hrs.4

% of Patients With Appropriate DVT Prophylaxis8

% of Patients With Appropriate Prophylactic Beta Blocker8

Prophylactic Antibiotic Started Within 1 Hour4

% of Code Blues Occurring Outside ICU2,2a

Beta-Blocker at Arrival4

Medication Errors5

# of Unreconciled Medications/100 Admissions5

Smoking Cessation Counseling4

Beta-Blocker at Discharge4

ACE1 or ARB at Discharge for Patients with LVSD4

PCI Door to Dilation < 120 Minutes4

% of Unreconciled Medications5

Patient Safety and Quality Scorecard

Prepared by: M.Mullesch and J.Lovrien. Updated: 2/22/06. Sources 1: Preliminary Data, 2: AMH Critical Care PI, 2a: HPF Code Blue Que, 3: TSI, 4: Delta, 5: AMH Pharm., 6: AMH Infection Control, 7: AMH QI Dept., 8: Random Sample AMH IP Records a: Institute of Healthcare Improvement, b: AMH Target, c: Hospital Quality Alliance, d: IHS Target, e: National Quality Forum, f: + Better, - Worse, = No Change

Adverse Drug Events

Deploy RapidResponse Team

Evidence-Based Care for AMI

ASA at Discharge4

# of Calls to the Rapid Response Team2

ASA at Arrival4# of Code Blues/1000 Inpatient Discharges2,2a,3

GRADES: = Worse Than Target = At Target = Better Than Target

AMH Mortality4

1

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2

1

Pe

rce

nta

ge

Actual Expected

Sample Board Dashboard Format

CULTURE Benchmark FY Target FY 06 QTR 1 FY 06 QTR 2 FY 06 QTR 3FY 06 QTR

4

Employee Turnover Rate (Annual) .5%/month 2.50% 2.41% 2.84% 2.79% 3.00%

RN Vacancy Rate 1.00% 8% 18.00% 10.00% 5.00% 7.00%

PREVENTING HARM (Safety) Benchmark FY Target

Falls with injury (Quarterly) 0 5 TO 10 15 18 10 3

Medication Errors (ADEs) Category E-I .025/1000 doses 2/1000 doses 3.5 5.0 4.0 1

Central Line Infections Rate (Critical Care Units) 0 3 TO 5 2 6 0 0

Ventilator Associated Pneumonia 0 1 case per quarter 0 1 5 1

Pressure Ulcers 0 10 to 15 40 30 15 12

CLINICAL QUALITY Benchmark FY Target

EVIDENCE-BASED CARE % OF PATIENTS RECEIVING ALL REQUIRED ELEMENTS

Acute MI 100% 90-95 98% 98% 97% 95%

Pneumonia 100% 80-90 89% 88% 82% 79%

Congestive Heart Failure 100% 90-95 98% 93% 94% 97%

Surgical Infection Prevention Protocol 100% 100 96% 98% 98% 98%

Mortality Rate (HSMR) 40 80 to 85 101 84 84 60

FINANCIAL HEALTH Benchmark FY Target

Cost/discharge $4,200 $5,500 $4,900 $5,100 $7,000 $6,000

Days Cash On Hand 180 days 80-90 91 80 67 82

Sample Board Dashboard Below Target Meeting TargetExceedsTarget

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IHI 2007

Summary Every hospital board should adopt a set of high

level performance measures and targets used to define expectations and track performance

Content and systematic review is more important than format

Use All-or-None Targets for Key Clinical Measures

Asking good questions the key to successful governance

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IHI 2007

For More Information

Michael Pugh

Pugh Ettinger McCarthy Associates, LLC

P.O. Box 8298

Pueblo, Colorado 81008

719 542-2433 Direct

719 542-2564 Fax

[email protected]

Institute for Healthcare Improvement www.ihi.org

Center for Healthcare Governance

www.americangovernance.com

These slides may be used by others only in their existing format with proper attribution/service marks of Pugh Ettinger McCarthy Associates, IHI and the Center for Healthcare Governance



Questions/Comments?

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IHI 2007

Future WSHA & AWPHD Programs

Governing Board Orientation & Education

May 1, 2007

12-1 PM

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IHI 2007


CEO & Trustee Quality Summit

SeaTac Hilton

May 31, 2007

8 AM-5 PM Facilitated by Dr. James Reinertsen

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IHI 2007


Rural Hospital Summer Workshop

Campbell’s Resort

Chelan, WA

June 25-27, 2007 Dennis Stillman: Board Self-Evaluation Brad Berg: Compliance Planning Jan Jennings: Building Better Boards and

Managing a Hospital in the 21st Century

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IHI 2007


WSHA 75th Annual Meeting

Bell Harbor International Conference Center

Seattle, WA

October 11, 2007

1:00-3:00 PM Mock Board Meeting – Relationships,

Learning, Decision-making, and Behavior: Larry Walker, playwright



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Documents

IHI 2007 Institute for Healthcare Improvement 2007 Balanced Scorecard Scorecards and Performance Measures Funded by the Office of Rural Health and Washington’s