Prepared by
Aysha Al-Quda RN
Supervised by
Ali Saleh, PhD, RN
Outline
Introduction
Quality Measures & Metrics
Quality Assurance, Quality Control, and
Quality Improvement
Leadership, Measurement, and Improvement
Keys to Success
Conclusion
Objectives
After the end of this presentation each student will be
able to:
Discuss the importance of quality measures & metrics.
Differentiate between dashboards & scorecards.
List the key characteristics of quality assurance, quality
control, and quality improvement.
Mention the essential high impact leadership behaviors.
Understand measures aligned to function.
Discuss the keys to success of healthcare organization.
Introduction
Creating alignment is a critical leadership function.
Poorly articulated, non-measurable quality aims
generally lead to poor execution.
Improving quality, patient safety, patient experience,
and clinical care begin with clearly articulated and
measurable quality aims.
Quality Measures & Metrics
Used to support internal quality improvement efforts, meet
the demands of external accreditation agencies, health
insurance companies, and government payment programs.
Example of accreditation agencies is The Joint Commission.
Example of payment programs is the Centers for Medicare &
Medicaid Services (CMS)
Quality Measures & Metrics
Types of payment systems incorporate traditional fee-for-
service models & value-based payment models.
Value-based payment is depend on the achievement of
measure-based quality goals.
Both government programs and private health insurance
payment systems are moving toward value-based payment
programs.
Quality Measures & Metrics
Transparency about quality and performance is important to
pay closer attention to important indicators and to provide
consumers with the information they need to make better
healthcare purchasing decisions.
Many people in the healthcare field consider the public
reporting of performance data as a questionable regulatory
process hat does not necessarily provide a meaningful
reflection of an organization’s performance
Commonly Used Quality-
Measurement Sets
Healthcare Effectiveness Data and Information Set (HEDIS).
Sponsored by The National Committee for Quality Assurance
(NCQA).
Used by more than 90 percent of US health plans and managed care
organizations.
Collect information on whether members receive appropriate
treatment for diabetes, breast cancer, cholesterol management in heart
disease, and upper respiratory infections in children.
Dashboards
It is similar to the instrument panel on an automobile, which, when
the car is moving, enables the driver to monitor key performance
metrics such as speed, fuel level, and direction.
In the business world, dashboards are tools that report on the
ongoing performance of the critical processes that lead to
organizational success rather than on the success itself.
Scorecards
Used to record and report on periods of past performance, rather
than on real-time performance.
Reflect outcome measures rather than process measures.
They are analogous to school report cards, which are issued after
all work has been completed and use a specific grading standard.
Many organizational scorecards and dashboards contain a mix of
outcome-, strategy-, and process-related measures.
Quality Assurance, Quality
Control, and Quality Improvement
Leadership, Measurement, and
Improvement
Leadership, Measurement, and
Improvement
Leadership, Measurement, and
Improvement
Dashboards and Scorecards in a
Strategic Leadership System
Leadership in a healthcare organization is a complex system that
incorporates beliefs, values, and behaviors, as well as a series of
complex processes.
Leadership is commonly defined or associated with individual
behaviors or characteristics
Organization has a system of leadership that is defined by the values,
behaviors, and actions of leaders—in particular, where and how they
spend their time, energy, and attention.
Dashboards and Scorecards in a
Strategic Leadership System
One of the key elements of the leadership system is the measurement
process, which includes dashboards and scorecards.
Scorecards and dashboards are useful for organizing important
metrics.
Scorecards and dashboards should drive leadership behavior and be
used to create alignment in organizations.
Financial and volume measures have traditionally driven
management behavior in healthcare.
Organizing Measures by Category
The availability of electronic medical record and billing systems in the United
States is making it easier for healthcare delivery organizations to collect some
quality and performance measures.
Healthcare organizations traditionally sort the measures they collect into
categories such as financial, volume, satisfaction, patient safety, clinical quality,
and population health.
Some healthcare organizations have developed summary dashboards of key
indicators, organized by category, to sharpen focus and to facilitate reporting
and day-to-day management of various functions.
Organizing Measures by Category
Dashboards and scorecards may be organized in formats ranging
from simple tables to web-based graphical reports.
Data report formats include tables, radar charts, bar graphs, run or
control charts, and color-coded indicators designed to highlight
metrics that do not meet targets or expectations.
Measures for Governance and
Leadership
Dimensions of Performance in
Healthcare
Creating an Organizational
Scorecard
The development of an organizational scorecard should involve more than
a simple transfer of existing measures into a new format or framework.
The first step is to decide on an appropriate framework.
Next, senior leadership and the governing body should define the
dimensions of performance that are relevant to the organization’s mission
and the results they wish to achieve.
Then, they should select appropriate outcome measures for each of the
chosen dimensions.
Creating an Organizational
Scorecard
The ideal cycle time for performance measurement is quarterly.
Organizations should compare their performance results to the best
levels of performance, or benchmarks, reported by similar types of
organizations.
Keys to Success
Develop a Clear Understanding of the Intended Use of scorecard or
dashboard
Engage the Governing Board in Development of Organizational
Performance Measures.
Use the Scorecard to Evaluate Organizational and Leadership
Performance.
Be Prepared to Change the Measures
Keys to Success
Make the Data Useful, Not Pretty.
Integrate the Measures to Achieve a Balanced View.
Develop Clear and Measurable Strategies.
Use Organizational Performance Dimensions to Align Efforts.
Avoid Using Indicators Based on Averages.
Develop Composite Clinical Indicators for Processes and Outcome
Indicators for Results
Keys to Success
Use Comparative Data and External Benchmarks.
Change Your Leadership System.
Focus on Results, Not on Activities.
Cultivate Transparency
Conclusion
Healthcare organizations are dependent on quality and performance
measures for regulatory and payment purposes.
Performance is measured across multiple dimensions, including
financial performance, patient experience, clinical outcomes,
employee engagement, and patient safety
Scorecards and dashboards are useful leadership and governance
tools for creating focus and alignment within the organization