Q

People with health care needs

People with health care needs met

Feedback

People with health care needs met

National

Spine Network survey

Functional health status

Biological status

Functional health status

Biological status

Expectations

Costs

Expectations

Costs

National

Spine Network survey

Biological status

Functional health status

Satisfaction against

Functional health status

Biological status

Need

Costs

Need

Costs

Each of these three clinical microsystems uses feed-forward data concepts to engineer timely data collection and interpretation into the microsystem and thus to enable staff to do the right thing at the right time. In addition, all three microsystems use a variety of data feedback methods (such as graphical data displays; statistical process control charts; data walls; and weekly, monthly, quarterly, and annual reports) to aggregate up performance measures and use the resulting information to manage and improve care. It is possible and desirable to use advanced process flow analysis methods, such as value stream mapping and other lean-thinking methods and tools, to specify the flow of information that should accompany the flow of health care service delivery (Rother & Shook, 1998).

Framework 2: Patient Value Compass—Can We Use Data to Measure and Improve the Quality and Value of Care? Patient value compass (PVC) thinking can be used to determine whether the microsystem is providing care and services that meet patients' needs for high quality and high value (Nelson, Mohr, Batalden, & Plume, 1996; Nelson, Batalden, & Ryer, 1998; Splaine, Batalden, Nelson, Plume, & Wasson, 1998).

The PVC was designed to provide a balanced view of outcomes—health status, patient satisfaction, and patient care costs—for an individual patient or a defined population of patients. Like a conventional magnetic compass used for navigation, the PVC has four cardinal points that can be pursued in exploring answers to critical questions:

• West: What are the biological and clinical outcomes?

• North: What are the functional status and risk status outcomes?

• East: How do patients view the goodness of their care?—What is their level of satisfaction with services and perceived health benefit?

• South: What costs are incurred in the process of delivering care? What direct and indirect costs are incurred by the patient?

The PVC framework can be adapted to virtually any population of patients— such as outpatients, inpatients, home health clients, and community residents (Speroff, Miles, & Mathews, 1998). The model assumes that patient outcomes— health status, satisfaction, and costs—evolve over time and through illness episodes. For example, a person may be in generally good health at thirty-two years of age and then suffer a herniated disc, undergo short-term treatment for the disc problem, and regain full health. Then at age thirty-five he may reinjure his back, suffer from prolonged chronic back pain, lose his job, and become clinically depressed. At each point in the patient's illness journey it is possible, through data collection, to explore that individual patient's PVC for that point in time and compare it to his PVC readings at earlier points in time. PVC data can be collected and analyzed to answer the question, Is this patient improving or declining with respect to health status and satisfaction and in relation to his need for care, and at what cost?

The Spine Center case illustrates the use of the PVC framework to design the information environment. First, feed-forward data are used at each patient visit to create an up-to-date PVC, which is placed on the front of the patient's medical record and which launches the patient—clinician interaction (Figure 9.1). The individualized PVC puts the clinician in an excellent position to rapidly understand the patient's health strengths and health deficits and to codevelop a plan of care with the patient that best matches evidence-based medicine with the patient's own preferences and needs. Second, feedback data are used to evaluate the care for distinct subpopulations seen at the Spine Center, such as patients who underwent surgery for a herniated disk (Figure 9.3).

Many clinical microsystems and health systems in the United States and abroad use the PVC to manage and improve the quality and costs of care. Moreover, the PVC framework can be used to blend strategic thinking with specific objectives and target values for measurable results at the level of the system as a whole (the macrosystem) or at the level of clinical service lines (such as mesosystems for oncology care, cardiac care, and so forth) and frontline operating units within the system (that is, specific clinical microsystems).

Framework 3: Balanced Scorecard—Can We Use Data to Measure and Improve the Performance of the Microsystem? The balanced scorecard approach developed by Kaplan and Norton can be used to answer the question, Is the microsystem making progress in areas that contribute to operating excellence and strategic progress? It is a popular and powerful approach that has gained popularity during the past decade (Griffith, Alexander, & Jelinek, 2002; Kaplan & Norton, 1992, 1993, 2001, 2004; Oliveira, 2001). In contrast to the PVC, which uses the patient as the unit of analysis, the balanced scorecard model examines the organization or a smaller operational unit within the organization. Just as the PVC can work at multiple levels—the individual patient or a discrete subpopulation—the balanced scorecard can work at the level of the clinical microsystem, the mesosystem, or the macrosystem.

The balanced scorecard is designed to provide a well-rounded view, specifying and assessing an organization's strategic progress from four critical perspectives— learning and growth, core processes, customer viewpoint, and financial results. It can be used to answer fundamental questions such as these:

• Are we learning and growing in business-critical areas?

• How are our core processes performing?

FIGURE 9.3. PATIENT VALUE COMPASS: SPINE CENTER HERNIATED DISK PATIENTS.

Functional Health Status

Clinical Status

Common Health Problems

Comorbidities besides spine condition

S7%

Depression

18%

Frequent headaches

18%

High blood pressure

14%

Osteoarthritis

11%

Heart disease

S%

SF-36 Norm-Based (Mean 50 SD 10)

Initial

Follow-Up

Improved

Bodily pain

26

40

77%

Role physical

27

37

S0%

Physical component summary

28

38

62%

Mental component summary

43

S1

S8%

General health

Excellent & very good

40%

43%

26%

Improved for SF-36 is a difference of 5 points or greater between Follow-up and Initial. Improved for General Health is a positive change in category from Initial to Follow-up.

Symptoms

Initial

Follow-Up

Improved

Oswestry Disability Index: How pain has affected your ability to perform activities

46

71

70%

MODEMS: Degree of suffering and bothersome

Numbness, tingling, and/or weakness in lower body

41

70

69%

Numbness, tingling, and/or weakness in upper body

77

89

43%

Oswestry Disability Index (ODI): reported as low score is more disability.

Improved for ODI is a difference of 10 points or greater between Follow-up and Initial.

Improved for MODEMS is a difference of 5 points or greater between Follow-up and Initial.

Oswestry Disability Index (ODI): reported as low score is more disability.

Improved for ODI is a difference of 10 points or greater between Follow-up and Initial.

Improved for MODEMS is a difference of 5 points or greater between Follow-up and Initial.

Costs

Pain at Follow-Up

Experience pain in the neck, arms, lower back, and/or legs most or all of the time

Medications at Follow-Up

Taking medication(s)

Costs

Work Lost

Missed work (28 weeks average)

S4%

On leave from work at follow-up

6%

Financial

Receiving Worker's Compensation

17%

Litigation: legal action pending

6%

Patient Case Mix (July '98 to Mar. '02)

Patients (have follow-up survey)

170

Follow-up rate (N = 370)

46%

Average follow-up (SD) days

121 (47)

Average age (SD) years

44 (12)

Female

42%

Chronic greater than 3 years

35%

Prior surgery

14%

Hospital Surgery Indicators

One-day length of stay

69%

Discharged to home

91%

Average charges

$7,721

Satisfaction

Results of Treatment(s) Met Expectations

For ability to sleep

66%

For symptom relief

61%

For ability to do activities

55%

To return to work

54%

Satisfaction

Satisfied with treatment(s)

85%

Would choose same treatment(s)

85%

Charges: One-Year Episode Spine-Specific ICD-9 Codes

Spine Center

Outpatient

Inpatient

Professional

$48,481

Diagnostic radiology

$63,498

Surgical

$1,525,132

Physical therapist

$71,032

Neurosurgery

$158,411

Inpatient

$2,810,156

Orthopaedics

$160,987

Other

$737,737

Pain clinic

$34,769

Office, urgent, other

$32,918

Total

$119,513

$450,583

$5,073,025

Median per patient: $13,330 Average: $15,995 (SD $10,818) Range: $169 to $74,339

$5/643/121

Median per patient: $13,330 Average: $15,995 (SD $10,818) Range: $169 to $74,339

$5/643/121

Note: SD = standard deviation.

• How do we look in the eyes of our customers?

• How are we doing at managing costs and making margins?

The balanced scorecard approach can be adapted to virtually any type of organization—a manufacturing plant, a service enterprise, or a health care system. Balanced scorecards offer a simple yet elegant way to link strategy and vision with

• Objectives for strategic progress

• Measures of objectives

• Target values for measures

• Initiatives to improve and innovate

Other positive features of the balanced scorecard framework are its capacity to (1) align different parts of a system toward common goals, (2) deploy high-level themes to ground-level operating units that directly serve the patient or customer, (3) establish a succinct method for communicating results and for holding operating units accountable for generating essential results.

Figure 9.4 shows a balanced scorecard for the Spine Center. The Spine Center examines its scorecard at its annual retreats in order to review its progress as revealed by measured results and to sharpen its strategic focus for the upcoming year through an analysis of improvement imperatives. Its balanced scorecard emphasizes top-priority objectives in each of the four dimensions. The figure shows, for example, that the Spine Center had yet to meet its goal of having 80 percent of patients participate by using the shared decision-making video. Patients having timely access to a provider are also targeted for improvement, and this is associated with the financial measure of utilization of clinic time for physicians.

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