The recent study in Health Affairs by Thomas Tsai, MD, MPH, a surgeon and health policy researcher in the Department of Surgery at Brigham and Women’s Hospital and in the Department of Health Policy and Management at Harvard School of Public Health in Boston, did not include examples of how the hospitals were scored on specific factors related to the board of directors and management. Tsai provided these examples of how two of the categories were measured, using a 1 score as the worst and a 5 score as the best:
OPERATIONS
1. Layout of patient flow
Score 1: Layout of hospital and organization of workplace is not conducive to patient flow (e.g. ward is on different level from theatre or consumables are often not available in the right place at the right time).
Score 3: Layout of hospital has been thought-through and optimized as far as possible; work place organization is not regularly challenged/changed (or vice versa).
Score 5: Hospital layout has been configured to optimize patient flow; workplace organization is challenged regularly and changed whenever needed.
2. Rationale for standardization and pathway management
Score 1: Changes were imposed top-down or because other departments were making (similar) changes; rationale was not communicated or understood.
Score 3: Changes were made because of financial pressure and the need to save money or as a (short-term) measure to achieve government and/or external targets.
Score 5: Changes were made to improve overall performance, both clinical and financial, with buy-in from all affected staff groups; the changes were communicated in a coherent ‘change story.’
3. Standardization and protocols
Score 1: Little standardization and few protocols exist (e.g. different clinical staff have different approaches to the same treatments).
Score 3: Protocols have been created, but are not commonly used because they are too complicated or not monitored adequately (e.g. may be on website or in manual only).
Score 5: Protocols are known and used by all clinical staff and regularly followed up on through some form of monitoring or oversight.
4. Good use of human resources
Score 1: Staff often end up undertaking tasks for which they are not qualified or over-qualified when they could be used elsewhere; staff do not move across units, even when they are generally underutilized.
Score 3: Senior staff try to use the right staff for the right job, but do not go to great lengths to ensure this; staff may move but often in an uncoordinated manner.
Score 5: Staff recognize effective human resource deployment as a key issue and will go to some lengths to make it happen; shifting staff from less busy to busy areas is done routinely and in a coordinated manner, based on the documented skills.
MONITORING
1. Continuous improvement
Score 1: Process improvements are made only when problems occur, or only involve one staff group.
Score 3: Improvements are made in irregular meetings involving all staff groups, to improve performance in their area of work (e.g. ward or theatre).
Score 5: Exposing problems in a structured way is integral to an individuals’ responsibilities and resolution involves all staff groups, along the entire patient pathway; exposing and resolving problems is a part of a regular business process rather than being the result of extraordinary efforts.
2. Performance tracking
Score 1: Measures tracked do not indicate directly if overall objectives are being met (only government targets are tracked); tracking is an ad-hoc process (certain processes aren’t tracked at all).
Score 3: Most important performance or quality indicators are tracked formally; tracking is overseen by senior staff.
Score 5: Performance or quality indicators are continuously tracked and communicated against most critical measures, both formally and informally, to all staff using a range of visual management, too.
3. Performance review
Score 1: Performance is reviewed infrequently or in an un-meaningful way (e.g. only success or failure is noted).
Score 3: Performance is reviewed periodically with both successes and failures identified; results are communicated to senior staff; no clear follow-up plan is adopted.
Score 5: Performance is continually reviewed, based on the indicators tracked; all aspects are followed up on to ensure continuous improvement; results are communicated to all staff.
4. Performance dialogue
Score 1: The right information for a constructive discussion is often not present or the quality is too low; conversations focus overly on data that is not meaningful; a clear agenda is not known and purpose is not explicitly stated; next steps are not clearly defined.
Score 3: Review conversations are held with the appropriate data present; objectives of meetings are clear to all participating and a clear agenda is present; conversations do not drive to the root causes of the problems; next steps are not well defined.
Score 5: Regular review/performance conversations focus on problem solving and addressing root causes; purpose, agenda and follow-up steps are clear to all; meetings are an opportunity for constructive feedback and coaching.
5. Consequence management
Score 1: Failure to achieve agreed objectives does not carry any consequences.
Score 3: Failure to achieve agreed results is tolerated for a period before action is taken.
Score 5: A failure to achieve agreed targets drives retraining in identified areas of weakness or moving individuals to where their skills are appropriate.
