Building block 4: Measurement

Building block 4: Measurement

All the organizations taking part in our discussions share an obsession with measurement, as Mayo Clinic’s Mike Harper succinctly explains: “We aim to religiously and relentlessly measure and re-measure.”

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State-of-the-art internal dashboards are commonplace, along with process- and outcome measures from the ward-level up, covering a wide range of quality outcomes, prevention practices, re-admissions, length-of-stay and throughput time data, and compliance with protocol. Many measures are real-time and automatically fed to professionals and – where relevant – higher management tiers and, ultimately, the board. Data is fed back to the owners of clinical pathways to enable continuous improvement.

The search for new and better measures never ceases, according to Dr. David Rosser, Executive Medical Director of University Hospitals Birmingham, UK. “We are not sure that we are measuring what we should be measuring as best as we can.” 

This outlook is shared by Mary Jo Haddad, President and CEO of SickKids Hospital in Toronto: “Everybody wants to measure everything. That is in the culture of our organization. We measure, create score cards, dive deeper. We are constantly trying to figure out what’s most important to measure. The leadership task is to keep focusing, connect the measurement with the core organizational goals and priorities and ultimately measure what matters.” 

Interestingly, these organizations do not fall into the trap of over-measurement that has jammed the work schedules of many hospitals, causing project overload. “For us,” says David Dalton, CEO of Salford Royal Foundation Trust, UK, “measurement and improvement is not a project: it is an integrated part of everyday work.”

Measurements are only relevant when they relate to patient outcomes, as Mary Jo Haddad of SickKids Hospital observes: “A key example is in pediatric cardiac surgery. We started a database to measure outcomes of this type of surgery almost 20 years ago. That has helped create an improvement in outcomes across the world; it is truly incredible to have been a part of that. It all started with a professional with a drive for excellence; someone who had seen kids die and wanted to change that. From there on he began to build a registry of cardiovascular outcome data, and reach out to colleagues, to get them on board. All this was driven by a professional passion.”

“We’ve started with a few specialties”, concurs Dr. Panigrahi, Head of Medical Operations of Fortis Healthcare. “Three outcomes are being tracked and measured – percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in Cardiac Sciences and total knee replacement (TKR) in Orthopedics. We have also become part of an international registry for acute myocardial infarction (AMI), where we are looking at how they are managed. This is under the aegis of the International Consortium for Health Outcome Measurement (ICOHM).For all AMI cases we measure 30-day outcomes, one-year outcomes, and revascularization outcomes. For cardiac surgery, we have adopted the Euroscore, a standardized outcome measurement methodology. For hip or knee replacement, we look at the outcomes after one year. We pick from available US and European metrics. We start with new measures, learn to work with them, make them robust and then we move further.”

“We constantly face the issue of limited documentation, yet we work around that, and obtain data through different methods. We measure to improve, to be better than the rest.”Dr. Panigrahi, Head of Medical Operations, Fortis Healthcare, India

All those involved in our interviews agree that IT infrastructure is key to the success of dashboards. However, these pioneers do not let technology gaps such as interoperability or incomplete electronic records hold them back, despite some – such as Fortis hospitals in India – possessing older systems: “We constantly face the issue of limited documentation,” says Dr. Panigrahi, “Yet we work around that, and obtain data through different methods. We measure to improve, to be better than the rest. We started measuring everything we could, using paper records where necessary. We constantly build further, picking up meaningful new measures whenever we see them emerging in the literature.”

The Mayo care process model

The Mayo Clinic is developing a bank of care processes, which is their term for care pathways. “These Care Processes should be used 80 percent of the time, and we measure that,” says Mike Harper, Executive Dean of Clinical Practice. “This is key to how we manage and control quality. We now have 75-125 care process models, including frequently asked questions (FAQs) for the experts to review, comment on and accept.”

They then integrate these guidelines into the workflow: “For example, we have experts on prolonged cardiac QT syndrome, and need to spread their knowledge around the organization. You have to detect this condition on the ECG, because outcomes can be disastrous if you don’t spot it, and medications can make things worse if you don’t know the patient has it. Despite creating a rule for the emergency room, people ignored the rule, and non-experts didn’t know what to do with the alarm. So we added more explanation to the rule, a set of FAQs detailing when to refer, and when to do something else – and many people still got the wrong medications and/or were not referred to the cardiologist. Finally, we built the rules into the order system and inserted checks into the medication system, so that technology ensures that you will remember, bringing the number of mistakes down to zero.”

The power of benchmarking

Forward-thinking organizations aim to benchmark themselves internationally, to learn from best practice around the world. In partnership with University Hospitals Birmingham, UK, KPMG International has developed an International Hospital Benchmark (IHB), which helps hospitals compare quality and safety, productivity and efficiency, and financial performance with one another. This tool is part of KPMG’s commitment to the sector to help increase the effectiveness and efficiency of clinical governance. It allows point-of-care benchmarking and data-exploration at both the hospital and the diagnosis level, using sophisticated, web-based technology. For more information on IHB, contact, or your national practice leader.

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