Creating the Results That Matter: Dashboards, Portfolio Management and Execution SPSP Networking Event Leadership Workstream 27 August, 2008 Dashboards are a tool for improving quality, not measurement! Combining Indicators into a Dashboard Instrument Panel or Dashboard Image Decision making . . . Dynamic . . . Empowered • Who uses them? Cockpit crew (pilot, copilot, navigator) • Who interprets? Cockpit crew • Focus? Present and future • Utility? Real-time monitoring, predicting the future and taking action Adapted from “Report Cards or Instrument Panels: Who Needs What?” By Eugene Nelson, et al, Journal of Quality Improvement volume 21, number 4, April, 1995. The Instrument Panel or Dashboard Metaphor • Entirely different than report card • Connotes vitality, timeliness, and clear-cut utility • Key feature is providing critical, real-time information to the user • Prompts wise decisions and, if needs be, rapid midcourse corrections What Are the Benefits of Developing and Using a Dashboard of Indicators? • It brings together, in a single management report, many of the seemingly disparate elements of an organisation’s strategic agenda. • It helps to reduce information overload, by focusing on the “vital few” indicators. • It helps to guard against sub-optimisation by forcing senior managers to consider all the important measures together. How Many Measures Do You Need on Your Dashboard? Focus on the Vital Few! There are many things in life that are interesting to know. It is far more important, however, to work on those things that are essential to quality than to spend time working on what is merely interesting! The challenge, therefore, is to be disciplined enough to focus on the essential (or vital few) things and set aside those things that might be interesting but trivial! Building a Cascading System of Measurement Driving to System Level Changes: The Portfolio A Very Large System Problem Medication Safety PROBLEM Harm from medications alone occurs in over 25% of all hospitalised patients. Harm to outpatients appears to be much higher. Example: Board Medication Safety Tier 1: Board Medication Safety Big Dot Hospitals Rehab Offices Tier 2: Portfolio Med. Patient Self med Capability reconciliation Family Tier 3: Capacity Projects Standardised Correct list dosing Availability Example: Hospital Medication Safety Tier 1: Hospital Medication Safety Big Dot Med Surg ITU Pharm. Tier 2: Portfolio Med. Admix Anti coag. reconciliation Glycemic Tier 3: control Projects IV pumps Standardised dosing Availability Example: Service Line Medication Safety Tier 1: Hospital Medication Safety Big Dot Gen Ward 1 Gen Ward Gen Ward 2 3 Tier 2: Portfolio Med. reconciliation Tier 3: Projects IV pumps A “Project”… Source: J. Reinertsen, 2005 Moving a Big Dot! 6 June, 1944 Source: J. Reinertsen, 2005 What is the Difference? A Project Moving a Big Dot! Source: J. Reinertsen, 2005 The Differences Are…. • Level of ambition • Commitment: hearts pounding • Core strategy: staying alive • Clear measure of daily success: territory • Clear overarching goal: Berlin • People are shooting live ammo! • “Will, Ideas and Execution”! Leading the Whole System to Provide Highly Efficient and Effective Results The Ground Level View (Staff) The Big Picture View (Management) Tier 3: Projects Issues • Team organisation and capacity matter • Front-line leadership is critical • Measures tracked over time and visible • Senior leaders remove obstacles • Clear changes important • Ability to run PDSA cycles Tier 2: Portfolio Issues • Middle Management key • What are the “drivers” of the outcomes we want? • Outcomes tracked over time • “Connecting the Dots” – Putting the learning together • Continual readjustment of portfolio • Strong linkage to finance Tier 1: Big Dot Issues • Aims of strategic importance to the system as a whole • “Big Dot” measure of progress • Executive, Board and Senior Leader engagement • Vision and the associated structural changes • Strong linkage to finance • Managing the learning, the politics, and the risks How Will You Know if … You are Winning or Losing the War or the Battle? How Will You Know if … All of Your Efforts to Improve Quality and Value are Working? What Are We Measuring? IOM Dimension Whole System Measures Safe • Adverse events • Work days lost Effective • Hospital standardised mortality ratio (HSMR) • Unadjusted (raw) mortality • Functional outcomes • Readmission percentage Patient-Centered • Patient satisfaction Timely • 3rd next appointment available Efficient • Patient days during the last 6 months of life • Costs per capita Equitable Start to Think About Moving Beyond Process Measures Process Measures Whole System Outcome – AMI care Measures Time to stent – Hospital mortality rate Beta Blockers on – Adverse event rate arrival – Days lost to work – Pneumonia care Antibiotic timing – Immunisation rates Influenza vaccination – Medication reconciliation Portfolio What would a portfolio of projects look like for safety? 1. Patient experience 2. Mortality 3. Safety/Harm 4. Timeliness An Example: Reduce Mortality Tier 1: Mortality Reduction Big Dot Tier 2: Portfolio Tier 3: Projects Depicting Data to Drive Action FY 2007 CCHMC QUARTERLY SCORECARD (Next Update Due 1/31/2006) HEALTH CARE DELIVERY Goals FY 2007 Q1 FY 2007 Q2 FY 2007 Q3 Long FY 07 Term Good Indicator Goal Goal Access Wait for 3rd next available appointment for new visits: % divisions <= 10 days (31 divisions currently measured) 60% 100% 52% Flow Percent of Patients Delayed (Includes the ED, PICU and PACU) 34% 20% 71% Patient Safety Adverse drug events (ADE) per 1000 doses - Overall 2 1 3.6 Adverse drug events (ADE) per 1000 doses - Preventable 0.50 0 0.3 Ventilator Acquired Pneumonia per 1000 ventilator days 0.25 0 0.8 Bloodstream infections per 1000 catheter days 0.80 0 1.4 Surgical Site infections per 100 procedure days (Inpatients only. Includes Class I and Class II infections) 0.50 0 0.5 Clinical Excellence Codes outside the ICU: Rate per 1000 patient days - Overall 0.10 0.10 0.10 Codes outside the ICU: Rate per 1000 patient days - MRT Preventable 0 0 0.05 Standardized PICU Mortality Ratio (# actual patient deaths / # of expected deaths.) 0.80 0.80 0.57 Percent of Eligible Patients Receiving Evidence Based Care (Includes Inpatient and Emergency Department) 95% 100% 92% Family Centered Care Overall Satisfaction Rating: Percent Giving CCHMC a Rating of 10 to a Single Overall Question (Includes Inpatient, Outpatient, ED, Urgent Care and Home Health Care) 60% 80% 59% Overall Satisfaction Rating: Percent Giving CCHMC a Rating of 0 - 6 to a Single Overall Question (Includes Inpatient, Outpatient, ED, Urgent Care and Home Health 3% 0% 3.5% Care) Well Being Team Turnover Rate (Nursing Only) TBD TBD 14.6% Accident Rate with Lost Workdays per 100 Employees 0.25 0.15 0.05 Staff Satisfaction--TBD TBD TBD TBD Reduce Hassles Touch Time (% time nurse in patient or procedure rooms) TBD TBD 26.7% Cost Risk Adjusted Cost per Discharge 1% (Inflation adjusted to current quarter dollars. Data are lagged by one quarter) Decrease $86,195 TBD $ 103,479 Last Updated 11/2/2006 by J. LaBare, Division of Health Policy & Clinical Effectiveness Learn from Other Industries Technical and Ambulatory Nursing and Trade Schools Health Services Manufacturing Hospitals Construction Residential Care Alcoa 0.1 0.2 1.9 2.9 0 0.4 0.8 1.2 1.6 2.0 2.4 2.6 3.0 Cases with Days Away from Work per 100 Full-time Employees per Year The incidence rate represents the number of injuries and illnesses per 100 full-time workers and is calculated as: (N/EH) x 200,000 where: • N = number of injuries and illnesses • EH = total hours worked by all employees during the calendar year • 200,000 = base for 100 equivalent workers (working 40 hours per week, 50 weeks per year) Source: Bureau of Labor Statistics Top Leaders Need to be Able to Answer Big Questions • Is access to care getting better? – How fast can patients see a doctor? • Is quality getting better? – How does our quality compare to best? • Is safety getting better? Some – How do we compare to best? “Big Dot” • Is the value of care getting better? questions – How do our costs compare to best? • For chronic care patients, are we providing better care at lower costs? Resources & References 1. Kaplan, Norton. “The balanced scorecard: translating strategy into action.” Harvard Business School Press, 1996. 2. Lloyd, Quality Health Care: A Guide to Developing and Using Indicators. Jones and Bartlett Publishers, 2004. 3. Lloyd, Martin, Nelson. IHI Whole System Measures Toolkit, Version 2.0, IHI Boston, 2006. 4. Nelson, Batalden, Ryer. The clinical improvement action guide. JCAHO Press, 1998. 5. Nelson, Mohr, Batalden, Plume: “Improving Health Care, Part 1: The Clinical Value Compass.” The Joint Commission Journal on Quality Improvement, 22(4):243-258, April 1996. 6. Few, Stephen: Information Dashboard Design, the Effective Visual Communication of Data. O’Reilly Media Inc. Publishers, 2006.