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Management Healthcare organizations have generally been ran by physicians. Physicians are not trained as professional managers. Enough said. InHCc InHCc works on the principles of Management by Exception where there is continuous monitoring of ALL events through rules and, yes, indicators on EVERY EVENT. When any rule or indicator is wrong....we act immediately make corrections to that process...We do not wait until the stop light of the KPI is red. We do NOT rely on a "few" KPIs displayed on a computer screen with a "stop light" to tell the "Executive" if his organization was running correctly! Management Indicators While indicators are important to determine how well you are doing against that "indicator", it does nothing to tell you how to manipulate that indicator for change. In order to manipulate an indicator it is required that you first know ALL the variables that affect that indicator. The problem with healthcare is that there are so many variables that are both known and unknown that it is hard to set up a monitoring system based on these variable and the KPIs are a disaster. The idea of the "Executive" setting behind his desk watching a "few key performance indicators (KPI)" where the "stop sign" would either show a red light or green light...would be a joke except for the fact that it is being used in many organizations...and some of the Certification/Quality of Care organizations are actually promoting them. The KPI is designed to help an organization "define" and "evaluate" important organization "goals" such as the number of patients, the revenue of the organization, or the employee turnover. And many of these KPIs are a composite of all of the above into what is called a "Balanced Scorecard." It is quite obvious that the individuals that have designed these KPIs are NOT Managers but rather "Executives." Balanced Scorecard The Balanced Scorecard comes out of our desire to "Classify" and to "rate" events. A manager cannot use this system to manage...if the Scorecard only looks at what has happened in the past...the history. Summarizing and Averaging always produces less information and cannot be used by management. The good manager needs to see the "whole picture." Problems with KPIs An example of where a KPI is a real problem is when "poor performances" or averaged out with the "good performances." In the case of "Completed Documentation" where a measure is calculated to indicate the "Performance" of Physicians in completing their documentation we may have one really bad physician that doesn't complete any of his documentation....but since everyone else does a "good" job....this one physician is complete missed...the "Average is OK". Not a good thing. It is NOT the average that counts...but rather it is EVERY transaction that is important. The the time that a KPIs shows that there is a problem...it may be too late! Another problem with KPIs are that they usually focus on a "few key indicators." Even when there is a "Balanced Scorecard" in place, concentrating on a limited number of indicators causes employees to "concentrate on a few indicators" at the expense of the rest of the organization. If the even is not measured...then who cares what happens to it! All the resources of the organization go to ensure that these Indicators are always "Green"..."we must get a good score for certification!" Another example...common...is calculating the number of times that a certain drug was given for a symptom at either admit or discharge....A KPI will only indicate the percentages of times that it was performed. It is better to have a rule to indicate immediately to the Healthcare Professional through a protocol that it MUST be done. Then the KPI would always be 100% Evaluation The organization must have first have goals, a vision, or a "directive." After the goals are set, strategies to obtain these goals are developed. It is this difference between Goals and Strategies that causes problems in using KPIs. KPIs are goals, where you want to be, and "may" be useful in the improvement of the organization...It is only when Management understands "WHY' these KPIs are what they are and how to change them that real improvement takes place. Redefining KPIs to more closely evaluate the variables that affect improvement does produce better healthcare, however, what are these variables? The example given above, "Employee Turnover", is a nice KPI (what we at InHCc calls an "oh wow" indicator)....but think about it, what can you do with it...? First the Manager needs to know if a high turnover is good or bad. What is the advantages and disadvantages of having a high turnover. The answer to this question is not automatic. There are organizations that believe having a high turnover is cheaper because they do not have to pay these employee benefits (Example: the California Community Colleges system) and "new employees" usually "work harder" if for no other reason then they are afraid that they are going to lose their jobs. The "fear" of the stick may be a better motivator than that of the gift of the "carrot"... And once you have decided that having a low employee turnover is good, for whatever your individual reasons, you must decide what variables and how you need to change that complex single "oh wow" value...This is Management...(The KPI is the executive sitting behind his desk) You may need to know all of the following: What salary arrangement satisfies each employee: Once the salary arrangement is determined (and many organizations make the mistake of assuming that all the employees are of the same type. IBM use to have a salary arrangement where the employee could chose between three different plans...however the fourth one above was not one of the options), then the type of working environment that the employees require has to be worked out. Lots of opportunities for advancement, education, self motivation, etc. Believe it or not...there are many people that are "afraid" of these concepts. ...and so on. Incentives Incentives work well when things are going up but work negative when things are going down.
A recent article in HDM from a study in England stated that incentives have not been proved to work and there are indications that they drive up costs.... Of course, the AMA doesn't support these conclusions! |
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