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Performance Management in Healthcare

Dr. Mohammed Alahmedhttp://fac.ksu.edu.sa/alahmedalahmed@ksu.edu.sa

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Introduction

• Performance management (PM) includes activities which ensure that goals are consistently being met in an effective and efficient manner. • Performance management can focus on the

performance of an organization, a department, employee, or even the processes to build a product or service, as well as many other areas.

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Introduction

• The fundamental goal of performance management is to promote and improve employee effectiveness. • It is a continuous process where managers and

employees work together to plan, monitor and review an employee's work objectives or goals and his or her overall contribution to the organization. • Performance management in health care is not only

aiming at the systematic generation and control of an organization’s economic value but also at the optimization of the efficiency and effectiveness of service delivery.

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Introduction

• Performance management supports better patient outcomes, and provides the knowledge to run more effective organizations.

• For example, integrating your overall healthcare strategy through scorecards or strategy maps with the appropriate underlying reports lets clinicians understand what drives better care, and helps administrators see what drives the bottom line..

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The use of performance measurement information to effect positive change in organizational culture, systems and processes, by helping to set agreed-uponperformance goals, allocating and prioritizing resources, informing managers to either confirm or change current policy or program directions to meet those goals, and sharing results of performance in pursuing those goals.

Performance management

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Performance Management System Goals

• Translate organization vision into clear measurable outcomes that define success, and that are shared throughout the organization and with customers and stakeholders;

• Provide a tool for assessing, managing, and improving the overall health and success of business systems;

• Continue to shift from prescriptive, audit- and compliance-based oversight to an ongoing, forward-looking strategic partnership involving agency headquarters and field components;

• Include measures of quality, cost, speed, customer service, and employee alignment, motivation, and skills to provide an in-depth, predictive performance management system; and

• Replace existing assessment models with a consistent approach to performance management.

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Performance Management Tools

• When you are developing a performance measurement system, you should consider a conceptual reference model:1. The Balanced Scorecard in Healthcare

Organizations2. Logic Models in Public Health Program

Management.

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THE BALANCED SCORECARD IN

HEALTHCARE ORGANIZATIONS

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Introduction

• The Balanced Scorecard (BSC) is a strategic planning and management tool that is used extensively in business and industry, government, and nonprofit organizations worldwide to align business activities to the vision and strategy of the organization, improve internal and external communications, and monitor organization performance against strategic goals.

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Introduction• The BSC was developed in the early 1990s by two guys at the

Harvard Business School: Robert Kaplan and David Norton.

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A Measurement System?

A Management System?

A Management Philosophy?

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Balanced Scorecard – Original Definition

“A multi-dimensional framework for describing, implementing and managing strategy at all levels of an enterprise by linking objectives, initiatives, and measures to an organization’s strategy.”

Kaplan & Norton, 1996 10

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Which

dimensions should we measure?

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The Four Perspectives of the Balanced Scorecard

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• Education of personal, growth strategies

• Optimizing internal process and improving performance

• Improving relations with customers, improving organization image

• All indicators related to financial goals

Financial Customer

Learning/Growth

Internal Process

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Why have a Balanced Scorecard?

• Health sector is complex, has many components• Need an efficient way to assess multiple

objectives• Overloaded with different types of reports• Stakeholders demand vigilance• Poor measurement can lead to crisis

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Balanced Scorecard in Healthcare

• In 1999, Wachtel, Hartford, and Hughes (1999) examined whether BSC method is suitable for the management of medical organizations.• Application of BSC method in healthcare organizations is

also described by:• Stevard and Bestor (2000, s. 75 – 82) - Applying a Balanced

Scorecard to Health Care Organizations,• Bisbe a Barrubés (2012, s. 919-927) – The Balanced

Scorecard as a Management Tool for Assessing and Monitoring Strategy Implementation in Health Care Organizations,

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Balanced Scorecard in Healthcare

• Chow, Gaunulin, Haddad a Williamson (1998) - The Balanced Scorecard: A Potent Tool for Energizing and Focusing Healthcare Organization Management,

• Swayne, Duncan a Ginter (2008, s. 378-379) - Strategic management of health care organizations,

• Fortenberry (2010, s. 248-259) in monography Health care marketing: tools and techniques,

• Lin et al. (2013, s. 1917-1924), in article: Integrating hierarchical balanced scorecard with fuzzy linguistic for evaluating operating room performance in hospitals, apply BSC into specific environment such as hospitals are.

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Balanced Scorecard in Healthcare

• BSC application into management of healthcare organizations can be defined as follow:• How patients perceive an organization? (Customer

perspective).• What is financial situations? (Financial Perspectives)• What can we do to improve level of services?

(Perspective of learning and growth)• What do we want to be the best in? (Perspective of

internal business processes)

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Balanced Scorecard in Healthcare

• Duke University Hospital explained these four perspectives in healthcare organizations as follow (Jones and Filip, 2000):• Customer perspective: Deliver high quality innovative

care while respecting needs of the patient.• Financial perspective: Deliver strong and consistent

financial performance in the eyes of payers and the board of trustees.• Learning perspective: To be recognized as a leader in

developing skills and performance of employees.• Business perspective: To be recognized as the premier

provider of health care services in our region/market17

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Balanced Scorecard in Healthcare

• Potential benefits for the successful implementation of the BSC in the healthcare organizations:• It aligns the organization trend a more market oriented,

customer-focused strategy,• It facilitates, monitors, and assesses the implementation of

the strategy,• It provides a communication and collaboration mechanism,• It assigns accountability for performance at all levels of the

organization,• It provides continual feedback on the strategy and promotes

adjustments to marketplace and regulatory changes18

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Implementing a Balanced Scorecard

• Collaborative Efforts - Implementing the BSC agency-wide will provide: 1. a common methodology and coordinated

framework for all agency performance measurement efforts;

2. a common “language” for agency managers; 3. a common basis for understanding

measurement results; and 4. an integrated picture of the agency overall.

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Implementing a Balanced Scorecard

• Pathway to Success1. Make a commitment at all levels — especially at the

top level2. Develop organizational goals3. Offer training in improvement techniques4. Establish a reward and recognition system to foster

performance improvements5. Break down organizational barriers.6. Coordinate Headquarters and Field Office

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Implementation steps of BSC

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Elements of the Balanced Scorecard

• Mission and vision• Perspectives• Financial• Customer• Internal business process• Learning and growing

• Linking measures to strategy• Structure and strategy• Strategic alignment—top to bottom• Targets, resources, initiatives, and budgets• Feedback and the strategic learning process 22

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Example: Brigham and Women’s / Faulkner Hospital Strategy Map (2009)

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Brigham and Women’s / Faulkner Hospitals

• Some key learnings:• Having automated performance reporting software

facilitates monitoring and analysis of results at all levels of the system as well as more rapid rollout of the Balanced Scorecard.

• Real time reporting, particularly for operational measures, is seen as an important goal for more rapid and timely decision-making.

• This is a good example of where a Balanced Scorecard in the health sector has been cascaded to individuals – it shows it can be done for medical staff as well as management, something that some organizations see as too hard

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What is a logic model ?

• Whether your agency’s programs or initiatives are large or small, simple or complex, short-term or long-term, they probably share some common elements.• A logic model simply depicts the relationships

among all these different elements in some logical order—in a way that can be readily understood by someone who was not involved in the program planning or design.

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What is a logic model ?

• A logic model visually links program inputs and activities to program outputs and outcomes, and shows the basic (logic) for these expectations.• A graphic depiction of the relationship between the key

elements of a program or initiative

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How are logic models used?

Logic models can be used in many ways, including:• For program design/planning• For strategic planning• To test initial assumptions• For ongoing monitoring of program implementation• To evaluate long-term results• To communicate with and establish buy-in from

stakeholders• To negotiate with partners, funders, and other

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What are the benefits of using a logic model approach?

• A logic model’s visual depiction of how a program is expected to unfold and/or how an organization is expected to reach its goals offers several benefits.• It allows for quick and efficient testing of

assumptions, providing opportunities for feedback.• It yields insights into potential indicators and

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Logic Model Components

Although there are many different logic model templates and formats available, most cover the following components:• Inputs — any resources needed in order to implement the

activities (e.g., funding, staff time, community partnerships, technology, data, etc.)

• Outputs — what you will do, and whom you intend to reach. Our approach further divides outputs into:• Activities — the specific steps, work plans, or program areas you

(and any partners) expect to undertake with the resources listed above; and

• • Participation — the intended audience you are trying to reach with your activities.

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Logic Model Components

• Outcomes — the results you expect to achieve because of your inputs and outputs. Outcomes can be subdivided into time frames, depending on how long they may take to achieve and how long the project is expected to last overall (i.e., the intensity and duration of the project). For example, short-term outcomes are generally those expected to be achieved in the first year; intermediate outcomes may take up to 2 to 5 years; and long-term outcomes may take longer than 5 years.

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Logic Model Components

• Impact — a vision for the ultimate effect that all the inputs, outputs, and outcomes, taken together, could achieve in an ideal future. Generally, impact isn’t as measurable and concrete as the other components; it might include statements such as “Improved health outcomes for Georgians” or “Equitable access to health care for all residents.” Like a vision statement, impact is intended to be aspirational—and inspirational. 32

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Logic Model Components

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Resources

The inputs dedicated to or consumed by the program

Activities

The actions that the program takes to achieve desired outcomes

Outputs

The measurable products of a program’s activities

Outcomes

The benefits to clients, communities, systems, or organizations

How? Why? So what?

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Logic Models in Public Health Program Management

Context for Logic Models:• Quality improvement in public health is the use of a

process, such as Plan-Do-Study-Act, which is focused on activities that are responsive to community needs and improving population health. • Refers to a continuous and ongoing effort to achieve

measureable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality service.

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Example Logic Model

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ResourcesDental Clinic Coordinator

Community Health Director

Staff dentist

Staff pediatrician

Medical providers

Money for supplies

ActivitiesTraining•Develop curriculum•Two one-hour didactic trainings to medical providers in oral health assessment•One-on-one training to medical providers on oral health

Outreach•Order dental supplies for packets•Make up packets•Distribute to parents at end of each visit

Outputs

Training# of two-hour trainings held# of one-on-one trainings held# of medical providers trained

Outreach# of parents/children receiving packets

Outcomes

Medical providers demonstrate accurate oral health assessment, education and prevention activities

More children receive high-quality oral health assessment, education and prevention activities during well-child visits

Parents/children are more knowledgeable about oral health and caring for children’s teeth

Reduced incidence of caries in children at the community health center

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Benefits of Logic Models

1. Integrates planning, implementation, performance measurement and evaluation

2. Prevents mismatches between activities and effects3. Builds program clarity from the process4. Keeps staff, managers, and partners focused on

outcomes5. Helps planners prioritize most effective activities for

directing resources6. Uses evidence-based models and practice wisdom to

design and refine a program7. Reveals data needs and framework for analyzing data 36

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Limitations and Pitfalls of Logic Models

1. Logic models make the program theory clear not true

2. They take time to complete3. Without data collection, their utility is limited4. They strike fear in the hearts of many5. Pursuit of perfection can impede utility6. The notion that “evaluation is being done to

me, rather than with me”

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The Value of Logic Models

What gets measured gets done

If you don’t measure results, you can’t tell success from failure

If you can’t see success, you can’t reward it

If you can’t reward success, you’re probably rewarding failure

If you can’t see success, you can’t learn from it

If you can’t recognize failure, you can’t correct it

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Creating a Logic Model

• How? • No single way, flexible • Forward logic driven by “But Why?” or “If-

Then” thinking • Starting from the condition or problem end

• Reverse logic driven by “But How?” • Starting from the vision end

• Who? • Depends

• When? • Varies 39

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Smoke-free environments

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