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In all fairness this is something that I put together a while ago. But I’m passionate about getting metrics right. If done well metrics can link the organization together across all levels (tactical, organizational, and strategic) and can ensure that everyone is working towards a common goal. If done not well they can manifest poor work behavior, misalignment of organizational culture, and create organizational distrust. I’ve come to recognize that no single value can effectively capture the needs of an organization and the best approach is one that creates a balances scorecard that highlights each of the organizational needs.
The Balanced Scorecard:
Although the original “balance” (financial, customer, internal business process, learning and growing) requires a little finesse for translation into healthcare, the basic requirements are the same. The scorecard goal is to translate vision into operational goals, communicating the vision through linkages to individual performances, use for business indexing, and providing feedback/learning/strategic adjustment – and these are perfect for our environment. These scorecards also for the backbone of behavioral modification for teams (or individuals).
The other thing that I think is important is that they MUST be linked to the strategic goals of the organization. (1) Better Health (BH) which may include encouraging healthy behaviors, preventive medicine, increased resilience. (2) Better Care (BC) such as Patient Engagement (PE), compassionate, convenient, equitable, safe, high quality care. (3) Cost ($) which also may include quality metrics, waste reduction, standardization, and total cost of care. (3) Medical Readiness (MR) which includes both a medically ready force (MRF) and a ready medical force (RMF).
Also, we should keep in mind that clinicians are highly motivated by the desire to deliver the best care. The highest levels of burnout seem to be when they perceive barriers to delivering that care and every effort should be made to align the strategic goals with that effort.
So with that out of the way…
1. Leakage. ($) Both ER and UC utilization represent the highest cost for a capitated system such as the Military Health System. Unfortunately, poor access and behavioral encouragement drives our use of healthcare to about 2.4x that of the civilian population. A combined UC/ER calculation (with ER utilization yielding higher rates) is the total desired measure, however it must also include time of day leakage and high utilizers to become actionable data.
2. Access. (BC, PE) Several potential measurements exist. 3rd available. Appointments in the next 7 days. Appointments in the next day. % of appointments available. Studies may indicate that semi-immediate access (number of appointments available in the next 72 business hours) may be the best indicator of patient engagement and care quality by reducing delays in care. Any access measure has the potential for being “gamed” so a combination of % open appointment in the next 7 days and number of appointments in the next 72 hours should give a reasonable measurement of access and be actionable.
3. Continuity. (BH, BC, $, RMF) There appears to be a disconnect between the desire for care continuity at the DHA level and the clinician level. Both seem to want it, but it isn’t getting done. Most likely it is a direct result of not being measured or accounted for. It is unfortunate because continuity does seem to be a drive for both physician and patient engagement and will drive down costs, provide better health, and better care. I also include this a ready medical force measure. Many clinical staff are not engaged (joy in work and attrition would seem to support this assertation). If they are not engaged, they are not a ready medical force. Continuity measures should be at the forefront of PCMH care and measurements on any command scorecard.
4. HEDIS measures (BH, BC, $, MRF). This is a big section, but it is important. Some calculation with a drill-down to individual measures should be available at the individual empanelment and team level. These are often shown at C-suite MTF (or maybe clinic) level, but only some aspects are actionable at that level creating an environment of failure fatigue and frustration by both the command and the clinical staff. As a testament to the “balanced” requirements of the scorecard, without proper continuity this measure becomes somewhat meaningless.
5. Patient Engagement (BC, $). Several measures may indicate the level of engagement. JOES scores. Number of patient messages in the portal. No show rates. Patient contacts, (both face to face and virtual and messages), as interactions with patients at any level that directed them to receiving the right care at the right time by the right person in the right way. These can be reported on a balanced scorecard as a conglomerate but would also need to be individually determined so that they can become actionable items. Use of SSP, nurse-led clinics, group appointments may all appropriately belong in this area as well.
6. Patient Safety Reporting (BC, $). Number of patient safety reports (PSR) submitted. That said, the PSR system is overly cumbersome to be utilized in a functional way. The current system is a deterrent to completing appropriate patient safety and is the antithesis of what should be required if we really want to encourage a culture of safety.
7. Mission specific Measurements (MRF). Some clinics have a mission which is not fully encapsulated by this primarily patient focused list. This may require another scorecard or some significant augmentation. Flight medicine, soldier-based clinics, etc. will have additional requirements (which may be locally driven) that should be available as part of the balanced scorecard. Shop visits, Narrative Summary completion time, ongoing MEB patients, etc. may be examples.
The following may not be directly “actionable” but rather represent functions to which the clinical staff may want action or barriers to properly executing the mission.
8. Staffing (BH, BC, $, RMF). Staffing shortages need to be accounted for within the scorecard to demonstrate the impact that it may have on the clinic staff. This would include “additional duties”, TDY, Deployments, and vacancies (but not leave). Demonstrating over empanelment from long-term vacancies would provide richer context.
9. Staff Satisfaction (RMF). Current burnout rates for physicians across the US is close to 60%. More than 80% demonstrate some evidence of burnout. Burnout has been shown to impact every level of care including cost, but for the DoD the stakes are even higher with the requirements to maintain a Ready Medical Force… one that is not burnt out. Until this starts to be measured and accessible it cannot be addressed much less improved.
I realize this isn’t “GENESIS RELATED” – but WHAT we can measure isn’t nearly as important as WHY we are measuring it. If we want to create an environment that improves care and outcomes for our patients we have to start with the “why”. So as we get into GENESIS reporting in the next couple of weeks, keep in mind that the reports you can get are only as good as your “why” you are getting them to begin with.
GENESIS 101: Medication auto-calculations. Although not as intuitive as I would like, it is great to no longer have to calculate how many pills or how many bottles to dispense. As long as you follow the proper ordering sequence the number of pills and amounts will autogenerate. Because…math is hard.
Next Week: What can GENESIS do for metrics |
