Growing a culture for quality improvement- whose quality interests does the manager promote?

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Growing a culture for quality improvement- whose
quality interests does the manager promote?

• Rod Perkins
• Senior Lecturer in Health Management, School of
  Population Health, University of Auckland
• and
• Business Leader, Mental Health Addiction
  Services, Bay of Plenty DHB

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My objective

• To offer managers and those with an interest in
  organisational life some pointers to engaging
  with clinicians around performance management
• Managers are interested in organisations and
  their welfare
• Clinicians working at the coalface generally
  arent

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People view organisations differently

• Some see them-
• being like machines
• as complex systems
• Communities of work etc
• Where every one is pulling in the same direction
• I see them as
• Places of contest where those at the top have
  different interests from those at the coalface-
  acknowledging that those at the coalface,
  sometimes cohabit the top

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Values
Strategic direction
Different Leadership Roles
Ideologically driven
Strategic development
Professionally driven
Best practice
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• Well return to this later

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(No Transcript)
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Summative and formative indicators

• The literature considers performance indicators
  as broadly relating to either internal or
  external control and accountability.
• There are two axes
• The source of control
• Internal or external
• The nature of resultant action
• Positive, supportive and formative or
• Negative, punitive or summative

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Formative Summative
Emphasis Continual improvement Verification
Rationale Promote change and quality improvement Provide external accountability
Culture Learn from differences, promote discussion Compare in order to make judgements
Precision Lower High- use of statistics
Adapted from Tim Freemans Using performance
indicators to improve health care quality in the
public sector a review of the literature, Health
Services Management Research 15, 126-137, (2002)
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Types of indicators
Strategic direction
Different Leadership Roles
Summative
Strategic development
Formative
Best practice
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What do we mean by good performance?

• The points of emphasis change over time
• Sometimes the emphasis is on-
• Economy
• Efficiency
• Effectiveness
• Outputs
• quality outcomes
• Social results

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Griffith et al
Use several hundred measures benchmarks to
provide each responsibility centre with
multidimensional measures of performance
Baptist Hospital Inc aggregates more than 75
measures to 14 for governance reporting. Report
promptly and often publicly important
performance measures are reported daily,
biweekly and monthly so that managers and most
employees know exactly where they stand
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Indicators Hospital Health Services in the
late 90s
Operational Case-mix weighted average length of stay for inpatients only DRG-Based Case-Mix Weighted Average Length of Stay for both inpatients and day-cases
Resourced beds inpatient occupancy rate Physical capacity beds inpatient occupancy rate
Year to Date (YTD) Overhead Expenses as a Percentage of Total Costs
Direct Personnel Salaries per Inpatient Day Equivalent
Case-Mix Weighted Elective Day Stay Surgery Percentage
Staff Turnover per Full Time Equivalents
Quality Customer Satisfaction Survey - Percentage Very Good Customer Satisfaction- Quarterly Rate of Change Hospital Acquired Blood Stream Infections
Financial YTD Net Income Ratio YTD Return on Equity
Debt/ (Debt Equity) Ratio Acid Test (Quick) Ratio YTD Debt Service Coverage Ratio
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Indicators Examples indicators used to monitor
DHB performance in 2007
Dimension Indicators
Financial performance DHBs monitored through monthly financial reporting with actual results measured against the District Annual Plan. Parliament receives audited reports- both financial and service performance
- Governance DHBs report separately on performance in these three areas. The funding arms of district health boards have contracts with private and non-Government Agencies in addition to contracts with the DHB provider arms
- Funder DHBs report separately on performance in these three areas. The funding arms of district health boards have contracts with private and non-Government Agencies in addition to contracts with the DHB provider arms
- Provider DHBs report separately on performance in these three areas. The funding arms of district health boards have contracts with private and non-Government Agencies in addition to contracts with the DHB provider arms
Health Status of people with severe mental illness The average number of people domiciled in the DHB region, seen per year rolling every three months being reported. These access rates are reported according to age group and ethnicity
Immunisation of children The number of 2 year olds fully immunised. (The MOH target is 95)
Oncology treatment and waiting times The time interval between referral to an Oncology service and the beginning of radiation/chemotherapy treatment
Incorporating health inequality concepts into policy planning DHBs are required to undertake health needs assessments and actions or steps to address inequalities
Service coverage DHBs report progress towards resolving gaps in service coverage
Accessibility to Primary Health Care Age-standardised rate of general practitioner consultations per high need person, and ditto for non high need people
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Seen one of these?
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Maybe this?
Maybe this?
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maybe?
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What place do these have in performance
management?

• I think theyre fine for school children- younger
  ones
• But they have the potential to damage credibility
• e.g. a hospital in the UK with a hospice adjacent
  was reported to have a higher death rate than
  like size hospitals and got a in a league
  table
• But expect to see more public disclosure of
  performance and the challenge to us is to make
  sure that performance tables are meaningful and
  compare like with like

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We must be critical

• We should never get a smiley face for an average
  length of stay that is lowest in the league
  unless other factors are also taken into account
  e.g. readmission rates
• Epidemiologists use meta-analysis in their search
  to understand cause and effect relationships
• Managers need to critically appraise their use of
  indicators to determine whether they are pointing
  to the performance domains they are wanting to
  identify

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Quality in Healthcare 101

• Good structure leads to good process and good
  process leads to a good outcome
• Structure Process Outcome
• When we understand the relationship between
  process and outcome, well often favour measuring
  process, remembering of course that it is always
  outcome that were interested in

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Returning to the different interests of those in
the system
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Health of the Nation Outcome Scale (HONOS)

• Is a set of 12 scales, each one measuring a type
  of problem commonly presented by patients/clients
  in mental health care settings. A completed HoNOS
  score sheet provides a profile of 12 items
  measuring behaviour, impairment, symptoms and
  social functioning
• It is a numerical record of a clinical assessment
  but does not replace clinical notes or any other
  records. It is intended that it becomes an
  integral part of a minimum data set

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The use potential for misuse of HONOS

• Clinicians or case managers complete a HONOS
  after a client visit
• Advocates of HONOS say that it informs clinicians
  about how well their clients are doing. Some
  clinicians say that they dont need HONOS- they
  can figure it out for themselves
• Advocates of HONOS also say that it can be a
  powerful tool to assist managers and in resource
  allocation decisions..
• And when you aggregate the results, HONOS can
  inform the Minister about whether the mental
  health of the Nation is improving

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Values
Strategic direction
Different Leadership Roles
Ideologically driven
Strategic development
Professionally driven
Best practice
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Lessons for managers

• Dont use information generated at the grass
  roots against the interests of those at the grass
  roots
• Talk up the goals and ambitions of the
  organisation you work for to achieve clinician
  buy-in, but dont bull shit
• Promote the use of performance indicators when
  you are confident that they are valid and can be
  collected reliably
• Take care in the use of smiley faces and sad
  faces- remember they are part of managerial (
  political) discourse, not professional discourse
• Remember data collection relies on the goodwill
  of clinicians and is thus susceptible to
  manipulation, particularly when reward and
  censure depend on results (Audit Commission,
  Aiming to improve the principles of performance
  measurement, London, 2000)

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The Revolution in Hospital Management John R
Griffith, Kenneth White and David Bernd. Jnl of
Healthcare Management May/Jun 05