Beyond Data: How Analytics and Culture Change Management Combine to Drive Performance Improvement
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Beyond Data: How Analytics and Culture Change Management Combine to Drive Performance Improvement
Healthcare organizations are virtually swimming in data. From compulsory reporting for CMS and other regulatory bodies to self-directed performance improvement initiatives, most hospitals and healthcare delivery organizations capture data for hundreds of metrics and measures. The quantity and complexity of these measures continues to grow. New mandates in healthcare delivery and payment reform models rely heavily on reported performance data to gauge the efficiency and quality of care being delivered.
With so much emphasis on data collection and reporting, it’s fair to wonder what the impact has been on the quality of care. How well do we actually apply this data to our daily activities? How well do we connect the insight that data can provide to the actions that create better health outcomes?
As our healthcare industry struggles to move the dual levers of cost and quality, hospitals and healthcare providers need to harness the right data at the right time to drive improved performance. Of course, data alone achieves nothing. To successfully contain costs and improve outcomes in this climate, hospitals must blend effective change management with highly targeted data analytics.
Below, we discuss three strategies your healthcare organization can take now to effectively bridge the chasm between performance measurement and sustained performance excellence.
1. Identify the right data sources and analytics tools.
Hospitals today capture data to support hundreds of formally defined metrics and clinically endorsed measure sets. However, not all data are created equal—particularly if your goal is to drive sustainable culture change across your organization. From a performance improvement standpoint, the cost of capturing certain data is not worth its value. In other words, choose the wrong metric, and your efforts could be doomed before you begin.
A pertinent example of this “data disconnect” with front-line delivery of services involves lagging data. We recently worked to improve HCAHPS[1] scores by focusing on nurse-physician communication. The challenge was that performance data was not available until nine months after the intervention. By this time, many new projects and initiatives had been launched across the region, and the focus had shifted to “hand-offs” and nurse-to-nurse communication. Initial results were disappointing. To overcome the disconnect created by data lag, we used proxy measures that were collected ahead of time at the team level, then presented during the training session, and finally re-tested 90 days after the intervention. Having a more tightly connected data stream throughout the project ensured data was relevant and timely to front-line clinicians. What resulted was a 6 to 9% increase in outcome scores.
In the same way, data sources and analytics tools should be prioritized by, and optimized for, the following factors:
- Accurate
- Real time
- Outcomes-focused
- Clinically engaging
- Financially relevant
By now, the value of accurate, real-time and outcomes-focused metrics and measures should be self-evident to those of us with plenty of experience capturing and measuring healthcare data. But the concepts of “clinically engaging” and “financially relevant” data are important to the success of any performance improvement initiative.
Every day, nurses, physicians, and other clinicians capture data for mandatory regulatory measures. Over time, these obligations can seem onerous, creating a “data collection fatigue” that can quickly undermine worthwhile efforts. In some cases, the process of care measures have “topped out” with consistent performance in more than 90% of targeted patients. Furthermore, the clinical interest in well-established but dated clinical processes wanes. On the other hand, more clinically engaging performance data might focus on locally relevant performance gaps, locally prevalent clinical conditions, or emerging evidence-based care standards.
Recent and renewed efforts to tie financial incentives to quality improvement efforts certainly hit home to front-line clinicians. It’s no longer taboo to discuss the financial impact of specific reporting initiatives. In fact, clearly articulating the financial impact to those who are shouldering the data capture and reporting burden goes a long way toward achieving the culture changes necessary to reach performance improvement goals.
2. Balance rapid improvement expectations with sustainable culture change.
Hospitals and healthcare providers are under significant pressure to demonstrate rapid improvement. For a well-publicized example, we need to look no further than the industry-wide initiative to reduce preventable hospital readmissions.
In October 2012, more than 2,000 hospitals were identified publically for CMS reimbursement penalties they received for readmissions rates deemed too high. The financial impact of these penalties is significant: up to 1% of total Medicare and Medicaid reimbursement for fiscal year 2013, rising to 2% in fiscal year 2014, and 3% in 2015 (U.S. Dept of Health and Human Services, 2013).
Additionally, a report from the U.S. Department of Health and Human Services (2010) showed that the rate of preventable deaths due to medical errors in Medicare beneficiaries has not changed since the IOM report in 2000.
For nationally mandated initiatives like decreasing readmissions, the intense pressure for hospital leaders to produce positive results can lead to poor decision-making with hasty problem identification and misapplied solutions. The result can feel like an organization careening from one crisis to the next, with little action taken to understand and address root causes.
To create a culture committed to quality and safety, change must often begin at the leadership suite. Hospitals and other healthcare organizations must make time to:
- Identify quality or safety issues connected to overt behaviors, such as outbursts in the operating room or in front of patients.
- Articulate and build consensus around accelerated (less than 90-day) improvement strategies.
- Implement effective measurement protocols that provide real-time feedback.
- Apply sufficient resources to achieve improvement goals. Given the rampant “initiative overload” in healthcare delivery, resource allocation in the form of measurement support or personnel support for improvement is critical to success.
Only then can hospital leaders begin to balance rapid improvement demands with sustained levels of high performance.
In one case, we were stymied with a lack of progress in an aggressive project to improve diabetes population care while working with a multispecialty group practice in the Northwest. As part of the work, we completed a culture survey and realized that across 15 metrics, many of the responses indicated a front-line stress level of “orange/red” instead of “green.” They were unable to summon the effort and focus to succeed with the diabetes project and additional resources were not available. However, we were able to use this information to modify the project by sharpening focus to the most critical elements, sequencing the work, and extending the timeline for an additional three months. This made it possible for front-line clinicians to succeed with the project without creating burnout. Furthermore, at the end of the project, several of the indicators of stress turned “green”—an additional, unexpected benefit.
3. Consider the multiple dimensions of culture.
Remember the saying, “Culture eats strategy for lunch?” Achieving performance excellence usually requires culture change, which is a complex challenge, frequently overlooked or underestimated. Many have implemented various forms of process improvement as a workflow and measurement-driven exercise. The road to organizational excellence is littered with both successful and failed Lean, Six Sigma, CQI (continuous quality improvement), and TQM (total quality management) projects. But very few organizations have gone beyond isolated successes with these projects to address the multiple dimensions of culture, and thereby transform their staff and institutions with a sustainable culture change.
Culture establishes itself around shared purpose. When we search for a shared purpose in healthcare, we have to look no further than being patient-focused, as patient satisfaction is one of the key dimensions of culture. Clearly, patient-centricity should dominate culture change, which is dependent on successes involving the retelling of patient stories to remind staff of their purpose and the impact of their improvement efforts. The focus on patient satisfaction—specifically, tying financial incentives to patient satisfaction—is one of the most interesting facets of new patient-centric delivery models and payment reform initiatives. It’s somewhat ironic, too, in that patient satisfaction can be very subjective in a decidedly objective world of data analysis and health outcomes measurement.
As subjective as patient satisfaction may seem, it’s on a par with other organizational performance factors such as trust, respect, empathy, and communication, each of which have been recently studied and measured with high reliability and validity. These factors highlight the value of the patient satisfaction within the science of organizational development, which relies on valid, data-driven approaches to effect culture change management.
Right now, many hospitals and healthcare providers are collecting data and measuring how physicians, nurses, and other staff interact with patients and with each other. Effective teamwork is another important dimension to acknowledge in pursuit of culture change. Incident reports are being used to capture specific cases of poor team function or frankly disruptive behavior. These types of events have a strong negative influence on patient care, contributing to poor clinical outcomes and decreased patient satisfaction.
Case Example
A cross-covering physician was called at midnight because of a patient with a persistent nosebleed. He had been called very frequently that night for other cases, and he reacted angrily, shouting into the phone. The staff was intimidated by the physician and delayed calling him again until the change of shift the next morning. They were quick to deliver his requested blood count results, but didn’t have the presence of mind to mention the dark stool the patient noted nor did they remind the doctor that the patient was on low-dose heparin prophylaxis for thrombus prevention. The doctor, saying to himself, “It’s probably artifact,” ordered a stat repeat CBC with results to be called to the rounding physician. The repeat CBC showed a drop in hemoglobin to 9 g/dl and a platelet count of 7,000/microL.
In this example, the cross covering physician didn’t appreciate the severity of the situation because he wasn’t given important information by the intimidated nursing staff. As a result, there was a delay in care with potential harm to the patient since the repeat hemoglobin and platelet values had reached critically low levels.
The link between care team interaction and health outcomes is direct: as many as 70% of medical errors can be traced back to communication lapses between clinicians (ECRI, 2009). Because clinical care is complex and unpredictable, it is essential to have good communication, constructive interactions, and problem solving within the team. Incident reports, reports of disruptive behavior, and survey data that reflects the quality of team interactions are useful to describe the team culture of the care delivery environment and can point out specific areas to improve.
In some cases, the results can be illuminating for an organization, with wide deviations between high and poor performers. As with data analysis in other areas, data captured on disruptive events, interactions, and other human factors doesn’t provide the solution; instead, it creates the pathway for appropriate interventions.
In the end, culture change management is critical to creating process improvement and communication strategies necessary for tangible improvements in both health outcomes and patient satisfaction. As reimbursement dollars become more directly tied to patient satisfaction scores—in the form of incentive-based payments or penalties and holdbacks—your organization’s ability to create and sustain a culture of trust, respect, and communication will positively impact your bottom line.
With all of the change we’re experiencing in healthcare with technology adoption, insurance, and payment reform, we can safely say we live in interesting times. But with change comes opportunity, and forward leaning organizations will seize upon this. In the end, the winners will be those that thoughtfully select performance data, focus and control their enthusiasm for performance improvement goals, and embrace a multi-faceted approach to culture change.
Gerard Livaudais is chief medical officer (CMO) for Quantros, Inc. He has many years of healthcare industry experience, both in clinical and administrative medicine, as well as applications development. Before joining Quantros, he was an internist, leading primary care redesign and panel support services, and overseeing prevention and population care with the Kaiser Hawaii Permanente Medical Group. During his career, he has overseen the creation, development, testing, and production of a diverse portfolio of healthcare software. As CMO of Quantros, Livaudais applies his clinical, market, and technology background to gauge market trends and guide product strategy and vision. Gerard received his medical degree from Tulane School of Medicine and his master’s degree in public health from Tulane School of Public Health and Tropical Medicine.
Thomas Huber is senior director for Performance Improvement Consulting for Quantros, Inc. Thomas has a 15-year track record of leading significant performance improvement transformation at dozens of healthcare organizations, including California Children’s Hospital Association, the California Healthcare Foundation, Dartmouth Institute of Health Policy and Clinical Practice, the Institute for Healthcare Improvement, the Lewin Group, and CSC Healthcare. He specializes in change management and organizational strategy in the areas of quality, safety, service and efficiency.
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