Improving Performance-the missing indicators?

Eilish McAuliffeProfessor of Health SystemsSchool of Nursing, Midwifery & Health Systems UCDNational Healthcare Conference28th May 2015

eilish.mcauliffe@ucd.ie

In 20 minutes…

1. Do performance indicators improve performance?2. Do they continuously improve performance?3. What happens when performance isn’t improving? -

flatlining4. What are the underlying contributors to poor

performance? – are we measuring all the right things?

5. What else should we be measuring?

Systematic review (94 studies included)• Quality of care for incentivized conditions during the first year of the framework

improved at a faster rate than the pre-intervention trend and subsequently returned to prior rates of improvement.

• Modest cost-effective reductions in mortality and hospital admissions in some domains. • Achievement for conditions outside the framework was lower initially and has

worsened in relative terms since inception. • Some doctors reported improved data recording and teamwork, and nurses enhanced

specialist skills. • Both groups believed that the person-centeredness of consultations and continuity were

negatively affected. • Patients’ satisfaction with continuity declined, with little change in other domains of

patient experience.

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associations between the size of financial incentives and expected health gain. Health gain was measured in expected lives saved in one year and in QALYS

• Evidence for lives saved or quality adjusted life years gained was found for 28 indicators accounting for 41% of the total incentive payments.

• No statistically significant associations were found between the expected health gain and incentive gained from a marginal 1% increase in performance in either the 2004 or 2006 version of the Framework

• no associations were found between the size of financial payment for achievement of an indicator and the expected health gain at the performance threshold for maximum payment measured in lives saved or quality adjusted life years.

The Role of Performance Measurement

1. it drives improvement by enabling service users to make choices based on quality measures which in turn creates an incentive for providers to improve performance so as to attract more service users.

2. professionals have an intrinsic desire to improve performance when they are made aware, through performance measurement, that there is potential for improvement.

3. performance measurement drives improvement through comparing the performance of individuals, teams or organisations resulting in a desire to improve or maintain performance relative to others and the reliability of the quality and safety of services that they provide. (p9)

Hospital performance data2012 2013 2014 2015

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PETLOSHMR

Nursing Metrics: Test Your Care IT system

HSE National Performance Assurance Report December 2014Staff absence rates

Balanced Score Card (Kaplan & Norton 1992)

service user perspective measures how an organisation meets the assessedneeds and expectations of the service user- internal management perspective measures the key business processes thathave been identified as necessary for a high quality and effective service- continuous improvement perspective measures the ability of theorganisation’s systems and people to learn and improve- financial perspective measures the efficient use of resources to achieve theorganisations objectives.

Chief Medical Officer’s Report into Perinatal Deaths at Portlaoise Hospital

• Establish a developmental programme whereby those aspiring to such leadership positions are provided with a long-term education and training pathway to enable them develop the skills and experiences they need to fulfil such roles. (p 54)

• The effective management of human resources requires an approach to workforce planning and development that includes recruiting and retaining the right mix of staff, training and upskilling the workforce, providing for professional and career development and creating supportive and healthy workplaces (p55)

Healthstat – Hospital Metrics & Targets

Balanced Score Card Acute Services1, Quality & Safety 3,. Access

• Client experience and complaints• Serious reportable event compliance• Pressure ulcer incidence• Stroke services• Acute coronary syndrome service• Re-admission rates• Hospital mortality rates• National early warning score

implementation

Discharges activityInpatient admissionsInpatient waiting timesEmergency care and patient experience timeColonoscopy/gastroscopy waiting timesDelayed discharge reductionsAmbulance turnaround times at EDsAverage length of stay for all inpatients

2. Finance 4. Human Resources

• Variances against budget: income & expenditure

• Service arrangements in place• Annual compliance statements signed

• Absence rates• Staffing level variance from approved

funding level• Level of agency spend and conversion of

agency spend• Compliance with European Working Time

Directive• Workforce Development & training

HSE National Performance Assurance Report December 2014

Staff absence rates

Service Priorities - Supporting Service Delivery• Implement the HSE Accountability Framework• Deliver on the Finance Reform Programme• Deliver the HSE Capital and ICT Capital plans• Deliver on workforce planning and agency conversion• Ensure compliance with service agreements

Job-Demands Resources ModelPhysical workload

Time Pressures

Recipient contact

Physical Environment

Shift work

Feedback

Rewards

Job control

Participation

Job security

Supervisor support

Job Demands

Job Resources

Exhaustion

Disengagement

Value & Recognition

60% dissatisfied with the extent to which HSE values their work

40% do not feel their performance is recognised

30% dissatisfied with support they receive from their line manager

Only 16% feel valued by their employer

Support for development

Just over half of staff feel that work enables them to improve their skills

35% are happy with opportunities for training

21% are happy with opportunities for career progression

16% feel that the HSE is good at developing employees to their full potential

Balanced Scorecard Strategy Map

Underlying theories of change?1. Measurement alone will improve performance2. Measurement and Incentives(Pay-for-performance) will improve performance

But what if ..Demands are too highResources are insufficientCapacity & capability do not match demand

Key Development Indicators (KDIs)

Approaches to Learning

Initiative: Staff need opportunities to demonstrate their initiativePlanning: Staff need to make their own plans and follow through on their intentions.Engagement: Staff should be encouraged to follow their interests in work.Problem solving: Staff need to exercise their problem solving skills in order to learn.Use of resources: Staff gather information and formulate ideas about their workplace and how it might be improved.Reflection: Staff should be encouraged to reflect on their experiences.

Key Development Indicators (KDIs)

Social and Emotional Performance

7. Self-identity: Staff need a positive self-identity.8. Sense of competence: Staff need to feel they are competent.9. Emotions: Staff need to recognize, label, and regulate their feelings.10. Empathy: Staff should demonstrate empathy toward others.11. Community: Staff should participate in the community of the workplace12. Building relationships: Staff need to build relationships with their co-workers.13. Cooperative teamwork: Staff should engage in cooperative teamwork.14. Moral development: The workplace should allow staff to express their internal sense of right and wrong.15. Conflict resolution: Staff need to learn how to resolve workplace conflicts.

Unlocking potential - Achieving balance

Clinical judgementDecision making tools & protocols

Key Performance

Indicators

Key Development

Indicators

Quantity Quality

Than

k you

eilish.mcauliffe@ucd.ie