Most health care organizations (at least the good ones) have adopted the mindset of continuous improvement, always aiming to get better by doing better. The natural question follows though, what exactly are these organizations trying to get better at? How should we quantify "better" for health care organizations? Better outcomes? Better financial margins? Better patient experience scores? Some of the above? All of the above?
There are a surprising number of research studies in the health management literature that have attempted to address these questions. Apparently, health policy experts don't agree on which metric(s) to use in order to assess performance. So, I go back to my original question, what exactly are we trying to achieve when we talk about continuous improvement towards better performance? Maybe a better question is what should we be measuring to assess our performance?
As it turns out, most health care executives don't really understand how exactly their organizations are performing. A group of researchers at the RAND Corporation recently published a study in the latest issue (September/October 20201) of the Journal of Healthcare Management. The study investigators interviewed 138 C-suite executives of 24 different health systems in California, Minnesota, Washington, and Wisconsin between 2017 and 2019 (these specific states were selected because they all had required public reporting of health system performance data). They selected health systems specifically with a focus on diversity in size (small, medium, and large) and performance (low, medium, and high).
In general, the subjective assessments of these C-suite executives did not match up with the objective assessments of their health systems (determined using the a variety of metrics - a "whole system measures" set if you will). The subjective assessments matched up with the objective measurement of performance in only 10/24 (42%) of the health systems. In twelve of the fourteen cases where they didn't match, the subjective assessments were more positive than the objective measurement, i.e. the C-suite executives felt that their system was performing better than they actually were doing!
The other interesting finding from this study was that in most of the cases where the subjective and objective assessments were different, the executives focused primarily on local market competition, financial performance, and patient experience data to assess their system's performance. In contrast, where the subjective assessments matched closely with the objective measurements, executives cited quality outcome metrics as the basis for their assessment. In other words, if you really want to determine how well your hospital is performing, make sure that you include quality of care measures in your assessment!
I have always liked the concept of using a parsimonious set of metrics to assess performance, which include (importantly, as it turns out) clinical outcomes. The Institute for Healthcare Improvement (IHI) recommends using a system of measures that they refer to as "whole system measures" that health care leaders can use to assess their system's performance. Importantly, these metrics are not disease- or condition-specific, but rather include metrics that assess the overall quality of care, safety, cost, and experience.
Clinical leaders need to understand how their organizations are performing from a financial standpoint, just as non-clinical leaders need to understand how their organizations are performing from a quality of care and safety perspective! Whatever you wish to call them - "whole system measures" or even the commonly used "balanced scorecard", it's important for all health care leaders to know and understand how their organization is performing with respect to quality, safety, finance, and experience. And when that is the case, they can truly drive to better with continuous improvement.
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