Value-compass thinking pictures system interplay
April 1, 1999 5 minutes read
Value-compass thinking pictures system interplay
Useful data displays offer spice, function, motion
This month’s guest columnist, Eugene C. Nelson, DSc, MPH, is a recipient of the 1998 Codman Award from the Joint Commission for Accreditation of Health care Organizations in Oakbrook Terrace, IL, for his contributions to the art and science of quality improvement measurement in health care. His innovative, useful displays of data show up on hospital and clinic computer screens from coast to coast. Nelson teaches in the master’s degree program at Dartmouth’s Center for the Clinical and Evaluative Sciences in Lebanon, NH. His primary interests are in outcomes and performance measurement. He has written on those topics in numerous journal articles and consults with such organizations as the National Institutes of Health and RAND Corp.
Q. What are your signature features that mark a data display as useful to an organization?
A. The shorthand term for one of the themes we use is value-compass thinking or clinical value-compass thinking. We try to develop a way for a health care delivery organization, or a clinical team, to picture their work in the system — at the organizational level or at the department level. And we are focusing more on the small, functional teams of people that work on the front line. We often call these "microsystems of care."
We try to picture the process of a patient, with some defined health need, flowing in at a point in time. Then we try to connect that with major health care processes to identify, assess, treat, and follow that individual’s or the subpopulation’s health needs. And we try to show the change, the level of a health need at an early point compared to a later point in time.
Clinical value-compass models show the transition in outcomes and cost. Value-compass thinking looks at changes in clinical status, functioning, or risk data. It includes the degree to which individuals feel that their health needs were met and their satisfaction level with the health care delivery process they experienced. For example, value compasses compare the incremental costs of moving from health outcomes at Time No. 1 to health outcomes at Time No. 2. They enable people to associate the costs of achieving the level of satisfaction observed.
Q. By incremental costs, do you mean dollar costs or staff time costs, or patient effort costs, or others?
A. The most common cost measure is dollars for doctors’ or nurses’ time, hospital stays, emergency department (ED) visits, medical treatments, and medicine.
But oftentimes those costs, or cost proxy charges, are hard to obtain. So you use proxies for cost, such as number of hospital admissions, ED visits, meds a person takes, or number of office visits. Or you use social costs, such as the number of days a person is out of work or unable to perform normal activities, or the number of days a person has had to cut down on work or normal activities. These things are proxies for dollar costs that are real, but sometimes difficult to quantify.
Q. Are your models of value-compass thinking intended for use by intra-organizational quality improvement teams, for example, in an ED or an impatient unit? Or are they more useful for population health management?
A. Yes, and yes. We’ve applied this to organizations as large as the Dartmouth Hitchcock Health Care System in Lebanon, NH; Mayo Clinics, based in Rochester, MN; and to HMOs such as Aetna and Kaiser.
I’ve taught a course for IHI (Boston-based Institute for Health care Improvement) on performance measurement. Many of those who have taken that course applied this thinking to smaller units within big organizations. It’s a way of thinking that allows you to go right down to the individual patient seen here and now, or to aggregate it up and think of a population an organization is concerned with.
The Spine Center at the Lebanon Campus of the Dartmouth Hitchcock Health care System is a clinical service program for people with back and neck problems. At the clinical micro-unit level, they use the value compass for individual patients. On a feed-forward basis, they match patient needs with services.
On a micro-system level, the staff can use the value compass to look back and write a six-month or 12-month report on how they’re doing as an organization providing care for subpopulations with different diagnoses, such as stenosis, low back pain, or herniated disk. In fact, they’ll write their first annual report very soon.
Dartmouth Medical School uses the model in teaching first-year medical students how to do a history and physical. It enables them to explore the health needs of the person as well as the patient’s expectations and worries about health and health care cost.
Q. Will you give us examples of one or two factors that determine whether a clinical data display is going to be useful or if it’s going to sit there in the computer, unused?
A. Three things come to mind:
1. Spice is the sizzle, the graphic interest, the use of color, things that invite a person into the data display. It’s like the cover on the book. It creates a first impression; it puts a halo — negative or positive — around what’s being analyzed.
2. Utilitarian value is whether the data display literally provides an answer to a person’s critical question. It could be for information on treating a particular patient, controlling a disease, or monitoring an intervention.
3. The display should picture a dynamic process that is rolling forward in time: The display suggests an instrument panel with gauges or dials to tell you how different elements of the system or process are working. The instrument panel information shows inputs, processes, outcomes, costs, and interactions occurring in the system. You put yourself in the cockpit of an airplane, for example. The instrument panels are designed to call your attention, either by sight or noise, to something that is running awry.
In health care, a good data display is strongly connected with the issue of value. In other words, what health results or satisfaction are people getting?
[To contact Eugene C. Nelson, DSc, MPH, and for free single copies of "Clinical Improvement Action Guide," explaining the value compass design and its applications, write to Eugene Nelson, Hitchcock Clinic, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756-0001. Telephone: (603) 650-7048.]
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content