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Performance management is a process for setting goals and regularly checking progress toward achieving those goals. It includes activities that ...
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This module describes in detail why performance measurement is important and provides a step- by-step guide for the performance management process.
Performance measurement is a process by which an organization monitors important aspects of its programs, systems, and care processes. Data is collected to reflect how its processes are working, and that information is used to drive an organization’s decisions over time. Typically, performance is measured and compared to organizational goals and objectives. Results of performance measurement provide information on how an organization’s current programs are working and how its resources can be allocated to optimize the programs’ efficiencies and effectiveness.
Performance measurement is well established throughout health care in the core areas of finance, operations, and clinical care services. For example:
There are other examples of performance measurement in health care organizations today. As information technology is widely integrated into health care settings, support for performance measurement will also expand throughout the organization.
There are a number of reasons why an organization may choose to measure its performance. Performance measurement provides a reliable process to determine if an organization’s current system is working well. Also in today’s economy, there is a demand for transparency and increasing scrutiny of an organization’s business practices. These reasons promote an organization’s use of process and outcome data as a means to demonstrate its performance. There are other typical circumstances of why an organization may choose to measure its performance, such as:
Distinguish what appears to be happening from what is really happening Establish a baseline; i.e., measure before improvements are made Make decisions based on solid evidence Demonstrate that changes lead to improvements Allow performance comparisons across sites Monitor process changes to ensure improvements are sustained over time Recognize improved performance
There are additional motives for a health care organization to measure its performance:
It is useful to categorize performance measures to better understand what systems or processes are measured. An organization may combine different types of measures to provide a complete picture of its underlying systems. There are four types of performance measures:
Performance management is a process for setting goals and regularly checking progress toward achieving those goals. It includes activities that ensure organizational goals are consistently met in an effective and efficient manner. The overall goal of performance management is to ensure that an organization and its subsystems (processes, departments, teams, etc.), are optimally working together to achieve the results desired by the organization. Performance management has a wide variety of applications, such as, staff performance, business performance, or in health care, health outcome performance measures.
Because performance management strives to align all the subsystems to achieve results, the focus of performance management should also affect the management of an organization’s performance overall. Figure 1.1 provides an example of a performance measure (cycle time), the process that the organization is measuring, and the benefit the organization might gain in evaluating its performance. While the example is reflective of the patient flow process, an organization often achieves the same benefit when evaluating its staff, business performance, and targets for clinical outcomes.
Adapted from Kaplan & Norton
Figure 1.2: Balanced Scorecard
IMPORTANT NOTE: The basic steps for managing an organization’s performance are the same for any performance measure targeted for improvement. In keeping with the focus of this toolkit on HRSA Clinical Core Measures, the remainder of this module concentrates on performance management within clinical areas. Clinical examples are provided to illustrate these basic concepts.
Successful performance management relies on understanding the foundational concepts that are covered in other modules of this toolkit. It is assumed that readers have an overall understanding of quality principles, understand the basics of performance measurement, and are ready to embrace a quality improvement project within their organization. Performance management concepts presented here allow an organization to systematically manage the performance data required to support QI projects. Links to key concepts are embedded so that readers new to this content can link to the basic concepts before moving forward.
Performance management encompasses a series of steps with some embedded decision points. This part of the module illustrates each step in the performance management process based on the practices of effective health care organizations. The schematic in Figure 2.1: Process Map
of Performance Management Pathway provides an overview of the critical steps and flow, which is followed by a detailed description for each step.
Figure 2.1: Process Map of Performance Management Pathway
After an organization discusses what is important to measure, the next step is to choose specific performance measures. Understanding that the delivery of care is a number of systems and processes, performance measures serve as indicators for the effectiveness of those systems and processes. Consider the following in selecting performance measures:
These first two considerations often overlap. Agencies supporting or funding a health care organization may require specific performance measures. If an organization is currently funded by HRSA, it should review the program’s Web site or guidelines for specific requirements when choosing measures of quality performance. Guidelines and program-specific information can be found at the following links:
BPHC MCHB HAB BHPr ORHP OHITQ ORO
Note: If an organization is currently funded by HRSA, some performance measures, including clinical quality measures, may be among those reported to HRSA. An organization should consult its project officer and/or program’s Web site and links to Bureau and Office required guidelines and measures for more information: BPHC MCHB HAB HSB BHPr ORHP OHITQ ORO General information on HRSA grants including searchable guidelines are available and accessible at the HRSA Grants Web site.
o Relevance : Does the performance measure relate to a frequently-occurring condition or has a great impact on patients at an organization’s facility? o Measurability : Can the performance measure realistically and efficiently be quantified given the facility’s finite resources? o Accuracy : Is the performance measure based on accepted guidelines or developed through formal group decision-making methods? o Feasibility : Can the performance rate associated with the performance measure realistically be improved given the limitations of the clinical services and patient population?
A hypothetical case story is provided in sections throughout this module. The story depicts the effort of one (fictional) organization named Harper Clinic to choose a strategy for measuring performance improvement. The full case story can be accessed by clicking here.
The Problem
Harper Clinic is a Federally Qualified Health Center (FQHC) that was established as a new start last year. The construction proved more challenging than anticipated but the clinic leadership was ready to embark on tackling some of the issues uncovered during the Community Needs Assessment. In addition to providing general services for the community, it wants to focus on the sizeable elderly population. Organization-led focus groups determined that geriatric patients have transportation difficulties, which led to challenges in attending clinic appointments and refilling prescriptions.
The organization planned a systematic approach to improve care delivery and outcomes for the geriatric population. “Improve geriatric services” is included as a goal in the strategic plan and the quality improvement plan stated a focus on clinical outcomes for patients over age 65 during the next year. Based on research and feedback from the focus groups, the QI team proposed changes it wants to make but agreed that measurement should be an important part of any improvement. The QI team lead explored the HRSA Web site and suggested possible performance metrics.
Based on organizational goals and the information from focus group members, Harper Clinic chose to research two measures – Older Adult Immunizations and Hypertension Adequate Control. The team reasoned that immunization measures would allow it to experiment with different strategies to deliver care and consider challenges with transportation and access. It selected the Hypertension measure since cardiovascular disease was prevalent in the community and required medication adherence for successful performance. The team looked at the available data in a way that was most helpful. It looked at the Older Adult Immunization measures for those 65 and over and calculated the hypertension measure considering the entire patient population with hypertension.
Once performance measures are chosen, an organization collects the baseline data for each measure. Baseline data is a snapshot of the performance of a process or outcome that is
The Approach
The clinic used its electronic health record and practice management system to calculate a baseline for each measure. The team found that, for patients 65 and older, the influenza vaccine rate for the last season was 52 percent; the pneumococcal vaccine rate was 44 percent, and the hypertension in control rate for patients between 65 and 85 years of age was 34 percent. It then compared the data with available benchmarks. For vaccine rates, the National Immunization Survey of 2007 indicated rates for influenza vaccine were 69 percent while pneumococcal vaccine rates were 66 percent. NCQA State of Health Care Quality (ncqa.org) stated that blood pressure was controlled in 58 percent of Medicare recipients, closely corresponding to the target population.
As Figure 2.2: Evaluate Performance Map shows, once the baseline calculation is complete, an organization decides if performance is satisfactory or improvements are needed. To provide context for evaluating baseline data, an organization may choose to compare and benchmark its data against other health care organizations. Benchmarking is a process that compares organizational performance with health care industry best practices, which may include data from local, regional, or national sources. Benchmarking brings objectivity to the analysis of performance and identifies the strengths and weaknesses of a health care organization.
Figure 2.2: Evaluate Performance Map
If an organization is satisfied with its current level of performance, then it may:
Acknowledge and celebrate its success!
If an organization’s performance is less than desired, then it may establish an aim for improvement. If new to writing aim statements, read Developing Aim Statements in the Readiness Assessment and Developing Project Aims module. Since there is more than one way to establish goals for a performance measure, an organization typically considers the following three factors to inform that decision:
Note to HRSA Reviewers: This box may be depicted to link with graphic above from text box associated with the "NO" in the graphic
Factor 1: Are there aims already established that should be used? Program requirements or those required by funding agencies may include performance thresholds. It is prudent to choose the aim that requires the highest level of performance if an organization has overlapping requirements with established aims. An organization currently funded by HRSA should review the program’s Web site or program guidance for program-specific requirements. Guidelines and program-specific information can be found at the following links:
BPHC MCHB HAB HSB BCRS BHPr ORHP OHITQ General information on HRSA grants, including searchable guidelines, is available and accessible at the HRSA Grants Web site.
Factor 2: How does the system currently perform? The baseline reflects the current status quo. The larger the desired change, the more the underlying systems have to change. Some organizations choose to set aims that indicate a percentage of improvement expected over their baseline, while others choose aims that reflect their desired performance, regardless of their baseline performance.
Factor 3: Does the aim statement meet the essential criteria of SMART?
Case Story continued...
Performance Evaluation
The clinic staff decided there was room for improvement in all three measures. It considered the current performance, what others were able to achieve, and what improvement could be accomplished during the next year. The staff wrote the following aim statement: Harper Clinic is dedicated to the improved health of elder residents in our community. To that end, we will implement the Care Model to improve care and achieve the following aims by March 30, 2009:
Note: The "Improvement Journey" within this case study provides examples of how a team used various types of performance measures, both process and outcome, to broadly assess its systems of care.
A critical part of QI is to measure when changes occur. In the same way data for the baseline measurement is calculated, periodic calculations of performance measures should be accomplished. For an organization actively engaged in improvement work, this is often monthly. As performance is measured over time, a trend develops. It is important to use the same methodology to collect and calculate the data each time. For general information about data collection and sampling, refer to the Managing Data for Performance Improvement module.
Changes that improve the underlying critical pathway often reflect improved performance on the measure. An organization may choose to continue its improvement efforts as it moves toward its target or goal for the performance measure. An organization that is not experiencing improvement may reflect on the trend data and use the opportunity to re-evaluate its approach. All changes do not result in improvement and reflection on other change opportunities may be required to get improvement back on track. Most organizations continue to test changes and make improvements until their aims have been achieved. Additional information on tracking and analyzing data can be found in the Managing Data for Performance Improvement module.
The case story continued...
Spreading Lessons Learned
The quality improvement teams continued in this way until March 30, 2009. By that time, the goal of immunizing patients over age 65 years for pneumococcal was exceeded—a performance rate of 68 percent was achieved! Progress was made in the other areas although insufficient to reach their aims. Influenza vaccine rates increased to 58 percent and hypertension-in-control increased to 41 percent. Although patients under 65 were not specifically targeted, system improvements helped that group as well, and rates of hypertension control increased 15 percent over the baseline. The organization celebrated improvement in pneumococcal vaccine rates and continues to monitor those on an annual basis to ensure lasting improvement. The good work on the influenza vaccine rate and the hypertension-in-control rate was also acknowledged, but work continued. Harper Clinic also decided to evaluate the current rates of breast cancer and colorectal screening. Once the baseline was calculated and compared to benchmarks, the organization was prepared to adopt another measure as part of its overall quality improvement strategy. Harper Clinic continued to use the systemic approach of performance management to improve care and health outcomes for an important segment of its community. The clinic’s scope was broadened as resources allowed coverage for chronic disease and preventive care for all ages.
To gain insight into how one QI team approached performance measurement, review the hypothetical case story highlighting the fictional organization, Harper Clinic, and its approach to determining and applying QI efforts to improve vaccination rates and hypertension control in its geriatric population.
Note: Keywords for searching each site are shown in italics.