The dashboard is a quick, comprehensive way to keep trustees informed on hospital performance. But don’t neglect to update it as care and payment models change.
Board members who stick with the status quo and allow their dashboards to ossify risk missing the sorts of metrics that will help their hospitals to thrive amid the rapidly changing U.S. health system, according to hospital leaders and governance experts.
Some trustees have already begun to tinker, adding such measurements as reported health status or the cost of a specific treatment episode as they prepare for value-based care, says John Combes, M.D., president and chief operating officer of the American Hospital Association’s Center for Healthcare Governance. “I think that they are getting better at picking up very high-level metrics that give them a sense of where the organization is headed,” he says. “These need to be very high-level so that we don’t drag the boards into the weeds of the operation.”
Rather than reporting a bevy of patient safety indicators, for example, trustees can select one or two metrics that tell a larger story, such as the hospital’s overall infection rate. Then, Combes says, “if it starts to go up, you can dig in further to [see] if you’re having problems in other areas around patient safety.”
Early this year, the board of Texas Health Resources added a measure to assess the effect of safety training at the Arlington, Texas-based nonprofit system. In Green Bay, Wis., Bellin Health has adopted several new metrics, including looking at annual health cost per capita for the 12-county region that the nonprofit system serves.
At this point, there’s no such thing as a definitive list of top dashboard measures, says David Nash, M.D., dean of the Jefferson College of Population Health in Philadelphia. Every system’s dashboard, sometimes dubbed a scorecard, should be tailored to its own needs and circumstances, says Nash, who also implores trustees not to overload themselves with too many metrics.
In general, however, most dashboard or scorecard metrics fall into one of three or four categories: quality and patient safety, finance, population health and culture or workforce. Pamela Thompson, R.N., CEO of the American Organization of Nurse Executives, a subsidiary of the American Hospital Association, advises having someone behind the scenes to monitor quality and other indicators so a new measure can be added swiftly if it warrants dashboard-level scrutiny. “The dashboard has to have some kind of flexibility to be able to pick up those things that suddenly emerge,” she says. “Maybe it’s something as simple as having a spot on the dashboard for unexpected measures,” she says. “I think that would make dashboards much more dynamic.”
First Priority? Quality
While Nash acknowledges the truth behind the old “no money, no mission” maxim, he believes that board dashboards should lead with a clinical focus. “You can tell a good board — they’re the ones that put quality and safety before finance on every report,” he says. In recent years, some boards have stopped incorporating traditional Medicare core measures — such as the percentage of patients’ getting prompt antibiotics — to make room for broader quality measurements, Nash says.
A good start would be to monitor deaths from sepsis, he says. “First of all, it’s preventable mortality. You can’t think of a priority higher than that. And we have recent solid clinical evidence about what to do, so it’s a prime opportunity for boards.”
Moreover, patients with sepsis are costly in terms of 30-day readmissions, according to a study published earlier this year in Critical Care Medicine, which analyzed sepsis data at California hospitals from 2009 to 2011. Researchers found that 30-day readmissions for the life-threatening infection cost $500 million annually, more than the price tag of heart failure and heart attack readmissions combined.
Including a specific treatment indicator also enables board members to assess whether certain interventions make a difference, Combes says. For example, if a hospital is struggling with a high rate of Clostridium difficile infections, trustees could follow the data to see if an antibiotic stewardship program or aggressive handwashing campaign made a dent.
At Texas Health Resources, trustees review a metric for effective blood sugar control for its patients treated through an accountable care organization. It’s a statistic THR board member Jimmy Wynne watches closely because of how prevalent diabetes is in Texas and because, he says, “there are so many complications that come from diabetes.” When one of the system’s hospitals achieves significant headway in that metric, the result and how it was achieved are promoted to other hospitals as a learning tool, Wynne says.
At Community Hospital Corp., a Plano, Texas-based system that also manages and consults with hospitals, the board closely monitors the metrics of the five acute care hospitals that it owns. Of the 20 measures on the dashboard, which trustees call a scorecard, a dozen of them involve quality, including 30-day readmission for pneumonia and the rate of central line-associated blood stream infections, says Kenneth Gordon, the board chair.
During the meetings, board members spend relatively little time on finances, focusing more on these quality metrics, Gordon says. “We certainly enjoy the good stories,” he says, “but we’re far more interested in what went wrong, what happened and what’s being done about it.”
When the board noticed an uptick in the number of falls a few years ago, trustees started asking questions. “We did really drill into that,” Gordon says. “Why is that happening? Why are we having any?” Hospital leaders heightened their focus and falls subsequently declined, he says.
Combes encourages board members to consider creating a single “harm across the board” metric, as “a way to engage the board in looking at harm.” The indicator is an outgrowth from the work that AHA’s Health Research & Educational Trust did with its Hospital Engagement Network to reduce inpatient harm and readmissions. [Access an improvement calculator and other tools at www.hret.org.]
Board members also should consult with their own quality staff to make sure that their system’s single harm metric encapsulates all of the elements they want to track moving forward, Combes says. “The board has to decide what’s meaningful to them in understanding where the organization is in its quality area,” he explains.
While a single indicator can be useful, Nash says, lumping too many variables into a single measure means “you lose specificity. What exactly caused this?” For example, he says, if a dashboard includes the overall inpatient mortality rate and it increases over several quarters, trustees might be left to wonder, “Well, now what?”
Finance: Keep It Simple
Nash is a minimalist when it comes to financial metrics. Most systems don’t need more than two or three on their executive dashboard, with the system’s operating margin likely the most common one.
Depending on its particular situation, a health system might also consider metrics to monitor a debt issue or an ongoing construction project, Nash says. Other potential indicators include days of cash on hand, as well as the system’s bond rating. “That’s somebody else’s assessment of your ability to handle additional financial risk,” Combes says.
Combes also recommends that the dashboard incorporate one or two data points with more of a strategic or mission focus, some of which may overlap with the system’s future financial goals. One measure might track how much money the system has accrued through its participation in the Medicare Shared Savings Program, he says. Or, if the system is just starting to build an accountable care organization, it can track the number of covered lives.
Given the ongoing transition away from fee-for-service reimbursement, it’s become increasingly important for trustees to keep an eye on the health system’s mix of payment arrangements, and that should be reflected on the dashboard, says Jim Bohnsack, vice president of solution and corporate development for Conifer Health Solutions in Frisco, Texas. “If I’m 100 percent fee for service today, what percentage do I have in a risk-based arrangement tomorrow?”
Once a health system develops some value-based business, trustees who want to dig further can look beyond that figure to see how that slice of the reimbursement pie divvies up into upside risk, mixed risk, bundled payments and other approaches, says Bohnsack, whose health services company provides revenue management among other services.
They also could look at which of their payers are involved, Bohnsack says. Such as, he says, “of my commercial population, who are my top five payers, and of those top five payers, which ones have some kind of shift to value?”
In addition, Bohnsack suggests scrutinizing patient satisfaction, a measure that he acknowledges may not seem to be a financial driver. But it’s becoming more important with the proliferation of high-deductible plans, which are encouraging patients to become more proactive about shopping around for care that they are paying for out of pocket themselves. Add to that mix, he says, the influx of millennials who have grown accustomed to a more online interactive, text-driven environment that health leaders will have to learn to accommodate to retain their business, he says.
For that patient satisfaction metric to be helpful on the dashboard, it will have to be based on nuanced survey data, Bohnsack says, “as granular as you can get around measuring areas of satisfaction and dissatisfaction.”
Beyond the Basics
George Kerwin, Bellin Health’s president and CEO, already knows that 14 percent of the roughly 600,000 people in his market report their health as fair or poor, based on their feedback in a broad-based survey called the Behavioral Risk Factor Surveillance System. Other data reveal that the average annual cost of health care per resident in that region is nearly $4,300 as of 2014. Those two metrics remind the board that its responsibilities extend beyond the patients being treated by the system today, says Kerwin, who also serves on the Institute for Healthcare Improvement Leadership Alliance, Cambridge, Mass. “We feel very strongly that we are responsible for the physical and mental health of the 600,000 people who live in the counties that we serve.”
Kerwin ticks off numerous initiatives that Bellin has undertaken with local employers, substance abuse and homeless organizations, and others, to cut the “fair or poor” health numbers. “Having this measure on the system scorecard drives our initiatives outside of acute care and really even outside of primary care into the community to actively impact this number,” he says.
When Texas Health Resources embraced the patient safety concept of high reliability earlier this year, it implemented training to teach managers and staffers some of the safety principles already being applied in the airline and nuclear power industries, says spokesman Wendell Watson. It also added a high-reliability metric to assess the effectiveness of that training.
“Because that’s how we’re going to improve quality, Number 1,” Watson says. “And that’s how we’re going to reduce costs and things like readmissions.”
Charlotte Huff is a contributing writer to Trustee.
Watching the Workforce
As health systems evaluate their dashboards, they need to make sure that they are not overlooking the long-term staffing needs upon which patient care relies, says Pamela Thompson, R.N., CEO of the American Organization of Nurse Executives, a subsidiary of the American Hospital Association. “The one thing that I don’t see enough attention being paid to is, ‘What is the plan over the next five years to meet workforce needs?’ ”
Worries about an adequate supply of nurses have been well-documented, with one federal report projecting that one-third of registered nurses are older than 50. Thompson also notes that the roles of some hospital clinicians are being expanded or they are being redeployed, such as from inpatient to outpatient care.
The challenge for boards, she says, is identifying the best metric to gain early insight into workforce staffing trouble. Following the vacancy rate might indicate if it has become more difficult to fill positions, but doesn’t provide any sense of why, Thompson says.
The voluntary attrition rate might be more insightful, she says. “It is sort of a proxy for how satisfied the staff are.
“If you see your attrition rate change and you see people start to leave voluntarily, is that because they don’t want to work there?” Thompson asks. “And that makes it difficult for you to recruit anyway because your working conditions are not good.” — C.H.