Intervention Title:
Sharing Information on Hospital Performance through Development and Dissemination of a Balanced Scorecard; Duke University Hospital; Durham, N.C.

Goal:
Improve information tracking on key institutional performance measures, including Centers for Medicare & Medicaid Services (CMS) metrics, and manage quality performance.

Innovation:
Staff developed a standardized scorecard to track key institutionwide performance metrics. It is updated monthly and communicated to hospital leaders and staff through hospital publications, meetings, storyboards, online communication, etc.

Result:
The scorecard clearly shows performance metrics at all levels of the hospital, allowing it to direct specific quality improvement efforts, showcase positive achievements and communicate Duke's status as a top performing hospital.

Institution:
Duke University Hospital
2301 Erwin Road
Durham, NC  27710

From the experts:
“The balanced scorecard provides a simple yet comprehensive view of performance metrics at all levels of our hospital. This helps us to maximize measurement of hospital operations and direct quality improvement efforts. It also allows staff and the public to see the high level of patient satisfaction and quality cardiac care that we achieve, supporting our reputation as a top-performing hospital in the community.”

Catherine McCarver, M.B.A., M.H.A.
Director, Center of Excellence

Profile:
Duke University Hospital is a 946-bed not-for-profit, academic medical center.

Clinical areas affected:
The scorecard was deployed throughout the health system, hospitals, clinics, labs and other direct clinical care areas.

Staff involved:

• Senior leadership
• Performance and quality improvement personnel
• Information Technology (IT)

Timeline:
Development and full implementation of the balanced scorecard took a significant amount of time and remains an ongoing process. Each year the senior leadership reviews and updates the priorities, which then drive the measures and targets within the system to improve its effectiveness. Designing the custom software and technology infrastructure took several months, as did subsequent staff education.

Contact:
Catherine McCarver, M.B.A., M.H.A.
Director, Center of Excellence
P: (919) 668-0652
Catherine.mccarver@duke.edu

Innovation implementation:
The complex nature of collecting, processing and acting on performance metrics is a common difficulty for hospitals everywhere. For those interested in meeting the growing demand to publicly report this information, the challenge is even greater: How can the data be effectively communicated so that they are useful to audiences both inside and outside the institution?

For Duke University Hospital, the solution has been the development of a balanced institutional scorecard. Key performance metrics are thoroughly tracked at all levels of the hospital and presented in an easy to understand, standardized scorecard format. These include measures such as patient satisfaction and compliance with CMS cardiac care scores for cardiac patients, accompanied by target goals for the reporting period and year-to-date.

The scorecard serves multiple purposes beyond helping Duke maximize measurement of hospital operations and direct quality improvement efforts. Because the information is presented in a simple manner and broken down to all levels of the institution, it allows every staff member to understand his/her role and be involved in the quality improvement process. This outcome has also made it an effective tool in creating accountability and rewarding achievements, resulting in measurable increases in job performance and satisfaction. For external audiences, the balanced scorecard supports transparency to the health care system and supports Duke's image as a top-performing hospital in the community.

Advice and lessons learned:

1. Present the scorecard information in a simple, easy-to-understand manner. This makes the data accessible to a variety of audiences—hospital senior leaders, clinicians, staff and the public.
2. Begin any effort to track this information on a smaller scale. Choose the critical few factors that will determine your organization's success and build from there. Doing so will help you focus on what is most important and direct resources and efforts to achieving those goals.
3. Start by setting reasonable improvement goals that can be achieved in that year. Use benchmarks as a reference to set annual targets, and stretch for multi-year goals. Setting expectations for unachievable results can be demoralizing to staff and improvement efforts.
4. Ensure the effort is driven by senior leadership. Without the full participation of senior hospital leadership, effective target setting, data collection and reporting efforts are very difficult. The scorecard should be an extension of the organizational priorities and goals, thus directly aligned with customer needs. The involvement of senior leadership is critical to setting the direction, aligning resources for improvement and overcoming any staff concerns.
5. Centralize resources for creation and management. Consolidate the production of the scorecards within a central department or group to ensure measure alignment across the hospital and service lines, maximization of warehouse and technical resources, wider access to all department information. This process naturally creates a hub for systematic review of the measures and evaluation against benchmarks.

Cost/benefit estimate:
The costs and staff time needed to implement the scorecard can be significant. However, the proven quality improvement resources and public relations benefits of the scorecard are much more valuable to institutions.

Most of the expense is in the initial system implementation. Some of the factors that drive cost:

• Data collection method or availability (e.g., do you have a data warehouse or electronic medical record to pull from?);
• Number of measures;
• Ongoing administration/support of the system;
• Priority and target setting (the scorecard tool is not as useful without processes to review priorities and measures annually, create targets and traffic lighting thresholds);
• Server(s)/software used.