Scorecard helps measure, document ED performance

Standardizing data presentation was key

Using the balanced scorecard concept, the multidisciplinary Emergency Services Performance Improvement Team at WakeMed health system in Raleigh, NC, was able to standardize the way data were collected and presented. This, in turn, allowed stakeholders at the facility to better understand, analyze, and improve specific processes. The balanced scorecard concept was developed for business and industry in 1992 by Robert. S. Kaplan and David P. Norton in their book, Translating Strategy into Action: The Balanced Scorecard (Harvard Business School Press).

Health care has been slow in jumping on the bandwagon, but that has been changing in recent years as consultants and quality experts look at how a commerce-designed vehicle for performance improvement can translate to hospital management. Indeed, during a presentation given at the Institute for Healthcare Improvement’s 14th Annual National Forum in Orlando last December, a team from WakeMed including Janice Frohman, MS, RN, administrative director for emergency services, discovered that fully one-quarter of their audience had used some type of balanced scorecard.

Essentially, the balanced scorecard is a conceptual framework for translating an organization’s vision into a set of performance indicators distributed among four perspectives:

  • financial perspective;
  • customer perspective;
  • internal business processes perspective;
  • learning and growth perspective.

Within each perspective, performance objectives are established that constitute critical success factors in achieving the organization’s mission, vision, and strategy. Each objective, in turn, is supported by at least one measure that indicates how the organization will measure performance against that objective. Selecting and agreeing on indicators in each perspective forces people in the organization to define what is strategically important to them. Most organizations limit the number of indicators to no more than 20.

At WakeMed, the idea of launching an improvement program involving the ED came about because of the issue of patient time in the department. Staff had made an effective effort to reduce wait times, but an increase in the volume of patients visiting the ED "was making those changes look negligible," Frohman says. Rather than address the problem solely within the ED, Frohman and her colleagues decided to view it "from a hospital standpoint, to say, We believe that improvements within the emergency department involve all the departments within the hospital who are impacted by emergency department patients,’" she says.

This decision led to the creation of the Emergency Services Performance Improvement Team, headed by an operational vice president and including the chief operating officer, medical staff representatives, the ED medical director, ED physicians, Frohman, and others. The team’s external facilitator was A. Blanton Godfrey, PhD, dean of the college of textiles at North Carolina State University in Raleigh, an expert in quality improvement who brought the balanced scorecard concept to the team.

The team’s first order of business was to standardize how data were presented. It was a difficult process, Frohman notes. "We have a manual of data that’s probably 4 inches thick. That was where we started. Basically, what we found was that we had way too much data, and the data weren’t necessarily meaningful. That led us to say, OK, wait a second. We’ve got to put this in a meaningful format so that we can begin to look at where the changes need to be, or if changes need to be made.’ You can’t look at that much data."

Frohman says she is convinced that, had the team not come up with some standard to use, "we would have continued to beat each other with data that weren’t meaningful and weren’t helping us move forward in the process."

Godfrey’s initial presentation to the team regarding the balanced scorecard led in part to some significant changes. These included "the understanding of these different indicators and what they meant and the questions that arose from the information presented on the scorecard, which gave us the ability to do a better job to make decisions that ultimately would help show some performance improvement," Frohman says.

Under the four primary quadrants of the balanced scorecard, the team chose indicators specific to WakeMed and began the process of standardizing graphs. "For all of our indicators, we keep a 12-month rolling graph. Some people have difficulty interpreting graphs; therefore, a data sheet is attached to all the graphs, which makes it very clear where the information comes from and what it means. About 20 different parameters have to be attached to each graph." Having graphs standardized, right down to the designated color of trend lines (black) and average lines (red), "certainly makes it a whole lot easier for everybody to understand any graphed information over the course of time.

"When you see trend lines over the course of time, you’re going to see something meaningful," she adds. "What people are really looking at is not the month-to-month changes but certainly the trends over time and progress toward the target or goal."

Frohman says one of the team’s greatest successes has been developing a process that helps people in the organization understand the data presented to them. Without such a process, "everybody pulls out of graphs or data what they want, depending on their perspective," she says. The process also has helped winnow out useless data that serve more to overwhelm than enlighten.

Frohman says the process has been a learning experience for her. "I’m thrilled that we’re standardizing data displays and making it easier for people to understand. Because we have challenges every day, there needs to be an organized approach to address whatever challenge happens to come up. I think this certainly has put us on the road to making some important changes."