High Performance Health Care

It is very likely that the health care delivery environment will changes significantly over the next four years as elements of health care reform are implemented. Organizations need effective implementation tools, and the Balanced Scorecard has proven very successful in many organizations as a way to move strategy to action.

The key element of the Balanced Scorecard is, of course, balance. An organization can be viewed from many perspectives, but Kaplan and Norton identified four common perspectives from which an organization must examine its operations:

1. Financial
2. Customer
3. Internal process and innovation
4. Employee learning and growth

As an organization is viewed from each perspective, different measures of performance are important. Every perspective in a complete Balanced Scorecard contains a set of objectives, measures, targets and actions. These measures are displayed graphically in performance dashboards. In addition, each measure in each perspective must be linked to the organization’s overall strategy.

The indicators of performance in each of the four perspectives must be both leading (predicting the future) and lagging (reporting on performance today). Indicators also must be obtained from inside the organization and from the external environment.

Although many think of the balanced scorecard as a reporting technique, its true power comes from its ability to link strategy to action. Balanced Scorecard practitioners develop strategy maps that link projects and actions to outcomes in a series of maps. These maps display the “theory of the company” and can be evaluated and fine tuned. The illustration at the top of this post is a strategy map for implementing a medical home model in a clinic. Each initiative (in a box) is linked to other initiatives that eventually result in better patient care and improved financial performance. Follow this link to a set of videos that shows how to create Balanced Scorecards and strategy maps with PowerPoint and Excel.

Balanced Scorecards and performance dashboards have begun to be used more widely by health care organizations. In an extensive study of 139 hospitals, Kroch found that “greater hospital quality was linked to shorter, more focused use of dashboards for operations management and strong influence of board quality committees in dashboard content and implementation.” Denham undertook a study a health care leaders and found that “If the quality destination determines the performance profile required . . . then leaders really do need to be involved in the design of their performance measures, especially if they are taking a new transformative trajectory to high performance.”

The Balanced Scorecard approach is an effective tool to execute strategy and measure performance. To quote Don Berwick from the 10,000 lives campaign, “Some is not a number . . . soon is not a time.”

References
Denham, C. R. 2006. "Leaders Need Dashboards, Dashboards Need Leaders." Journal of Patient Safety 2(1)

Inamdar, N., and R. S. Kaplan. 2002. “Applying the Balanced Scorecard in Healthcare Provider Organizations.” Journal of Healthcare Management 47 (3): 179–95.

Kaplan, R. S., and D. P. Norton. 2001. The Strategy-Focused Organization: How Balanced Scorecard Companies Thrive in the New Business Environment. Boston: Harvard Business School Press.

Kroch, E., T. Vaughn, M. Koepke, S. Roman, D. Foster, S. Sinha, and S. Levy. 2006. "Hospital Boards and Quality Dashboards." J Patient Saf 2(1): 10.

Mankins, M. C., and R. Steele. 2005. “Turning Great Strategy into Great Performance.” Harvard Business Review 83 (7): 64–72.

Niven, P. R. 2002. Balanced Scorecard Step-by-Step: Maximizing Performance and Maintaining Results. New York: John Wiley & Sons.

Posted by Dan McLaughlin at 01:47 PM | Permalink | Comments (0)

This country has a misplaced over-reliance on litigation, poorly trained lawyers and ambulance chasers (including attorneys general) to remedy errors in products, professional services and public policy.

The quest for value (quality/price) has led to CQI and error-free products delivered by producers around the world. How long does a supplier of defective product survive contracts with Wal-Mart or Target? Zero hours from discovery, not years, as in medicine.

In medicine, we have always relied on the medical professions to police themselves via a combination of education, licensing, credentialing and state medical boards. It doesn't work in an age of sophistication in diagnosis, treatment, technology and the like. The data on medical errors, including deaths, is incontrovertible, and yet the medical professions refuse efforts to change, preferring to blame others for their "defensive medicine."

The professions have ready allies in patients like us who have always relied on our trusting relationships with them to deliver exactly what we need or want. It's a rare doctor who doesn't take his own precious time to excoriate insurance, managed care, Medicare, the government, regulations, lawyers or "the business of health care," whenever patients raise questions about prescriptions or cost.

The medical industry (professions and products) have come up with an easy rationale for what they conveniently label "defensive medicine." It's called "cap punitive damages." In Minnesota, no cap is necessary because juries of Minnesotans don't like to penalize their doctors. Damage awards are so low as to induce settlement of even egregious cases. In other states (follow the power of the trial bar a la a Grisham novel) legislative caps are necessary.

The trial bar and the Ralph Nader crusaders fight back and the Democrats fall in line behind "consumer protection" and the American Trial Lawyers Association. So we have a stand-off, and the medical errors, the unnecessary deaths and the poor comparative quality of medical care and over-priced products continues unabated. I am a policy veteran of the wars to get past this stand-off with medical liability reform. It doesn't work because "public opinion" refuses to deal with the fact that their doctors and hospitals make mistakes.

This is a policy debate worth having apart from "health insurance reform" or whatever we currently call the legislative effort at policy change. However, it would require physician, hospital and medical technology leadership. If they won't come forward and be honest about what really goes on in the "practice of medicine," we don't stand a chance.

Posted by Dave Durenberger at 03:38 PM | Permalink | Comments (0)

The 2009 William E. Petersen Symposium on Physician Leadership will feature Dr. James Mongan, president and chief executive officer of Partners HealthCare, Boston, MA, an integrated health system founded in 1994 by Brigham and Women’s Hospital and Massachusetts General Hospital.

A professor of health policy and a professor of social medicine at Harvard Medical School, Dr. Mongan also serves on the board of the Commonwealth Fund and chairs its Commission on a High Performance Health System.

Dr. Mongan is a member of the Institute of Medicine of the National Academy of Sciences. He has served on the boards of the American Hospital Association and the Kaiser Family Foundation, and was a member of both the Medicare Prospective Payment Assessment Commission established by Congress and the Institute of Medicine’s Commission on the Consequences of Uninsurance.

He has received numerous awards and was most recently recognized by Modern Healthcare as the Most Powerful Physician Executive in the U.S. in 2008.

The presentation will be held on October 7, 2009, at 6 p.m. in the Schulze Hall Auditorium, with a reception to follow in the Atrium.

Dr. William E. Petersen was chief medical officer for Allina Health System. Prior to that, he served as vice president of medical affairs at Abbott Northwestern Hospital. He was in private practice, specializing in internal medicine, for 32 years. He served as director of the Center for Health and Medical Affairs from 1995 until he retired in 1999. Throughout his career, Dr. Petersen has modeled the most positive aspects of the physician executive and leader.

Register online for this free event.

Posted by Erica Lyons at 03:02 PM | Permalink | Comments (0)

The GOP can't lose what they never had - public confidence that they understand the problems real people experience accessing and affording health care. The current party comes from parts of the country where medical practice culture is oriented around “more is better” and the doctor is always right, individuals need to take more responsibility for their choices, abortion and euthanasia are not cost containment but liberal values, and the problem lies elsewhere than with me or us (people like me).

Democrats believe that access to health care is a right, that private and for-profit institutions are less likely than public and some nonprofit to guarantee access and care quality and contain cost increases. They believe the success of programs such as Medicare or the VA health system prove that health care is not a commodity but a social good, the right to which is a public necessity and a public responsibility. Democrats represent older, more populous parts of the country which are more attractive to immigrants and low-income persons from Republican parts of the country because of a long tradition of health and social services.

Starting with something like this, you can add your own observations of the two sides represented at the health care town hall meetings across America this past August. Then ask yourself, who is representing the millions of families we all know whose behavioral, mental, disability and medical problems are such that they haven't ever had a consistently confident experience with any institutional or professional resources regardless of where they live in America? Their problems are often compounded by family, education, economic situations and bad relationships, threat of crime, addictions, etc.

The rising cost of medical care ($2.9 trillion this year) in a pluralistic system is a greater threat than Obama care today. Ours is a system in which everyone has choices, few have good information, and no one has any notion of what's quality care nor a "health home" they can count on to be there for them.

So a GOP congresswoman from Minnesota can call for "a covenant, slit our wrists, be blood brothers" to stop any Democratic health reform. And an equally naíve (not the word I'd like to use) Catholic Bishop from Sioux City, Iowa, can argue “the Catholic Church does not teach that government should directly provide health care. Preserving patient choice (through a flourishing private sector) is the only way to prevent a health care monopoly from denying care arbitrarily, as we learned from HMOs in the recent past.”

Posted by Dave Durenberger at 10:27 AM | Permalink | Comments (0)