Bob Luttman, Robert Luttman & Associates
The Next Generation Quality Model
Balanced Scorecards
Balanced Scorecards
Scorecards, balanced and unbalanced, have become a hot topic in healthcare. Publicly available scorecards of physician and hospital performance are becoming more common. The Joint Commission's ORYX initiative has brought the concept of scorecards to the forefront of the accreditation process.
Balanced scorecards, if they are properly constructed, provide a comprehensive picture of organizational performance. Balanced scorecards must recognize that multiple levels of the organization own different parts of a problem, different solutions, and have different data needs:
In the Next Generation model the patient specific feedback is provided by the patient documentation and a great graphical tool developed by Tidwell (Sandra Tidwell. Virginia Mason Medical Center, Seattle, WA):
The Tidwell Graph is a picture of the patients stay. Outcomes are shown in the margin. The vertical axis is the day outcomes are planned, the horizontal axis when outcomes are actually achieved. The dotted 45 degree line is the expected progression. The solid line is the patients actual progression.
The patients progress, and the cause of any delays, are clearly and concisely shown.
Pathway level information is conveyed using the Gateway Report presented in Week 3:
At the population or clinical service the reports begin to broaden and take on the look of traditional management reports. The different dimensions of performance are incorporated: financial, LOS, quality, pathways, outcomes, health status, and patient satisfaction. The reports allow users to analyze performance of individual indicators and the interaction between indicators.
At the organization level the indicators remain the but are enhanced by comparisons across services or populations. This is one graphic that shows the general hospital LOS trend and the trends for several services:
The indicator is Percent Change in LOS from a base year. This solves the apples/oranges problem for organization-wide indicators. The graphic also compares variation amongst the services and between the services and the organization-wide data. This helps illuminate the Halo Effect and establish the general variability in the data.
Summary
Overall, balanced scorecards provide a powerful tool for monitoring and managing organizational performance. Trends within and across organizational units are illuminated, as are the relationships between indicators.
This helps the organization answer important questions:
- Has reducing LOS hurt patient satisfaction?
- Has reducing LOS actually reduced costs?
- Are the trends in quality across the board, or are some services performing better than others?
The organization can then focus on important problems and opportunities. A comprehensive balanced scorecard system can provide this power at all levels of the organization and more rationally allocate process improvement responsibilities, integrating "Quality" into the daily work life of all levels of the organization.
