Percentile rankings can be moving target; focus on PI instead
At first glance, the proliferation of comparative databases for benchmarking activities may be a good thing, and of course, it always helps to have more data, but benchmarking experts warn there can be too much of a good thing — especially if it causes you to lose perspective.
"I’m finding that there’s an obsession with the desire to attain a certain percentile level of performance, without regard to what that might mean for the organization," says Robert G. Gift, vice president for strategic planning and business development at Memorial Health System in Chattanooga, TN.
"With the proliferation of all of the different comparative databases, it seems to me people are pursuing being at a certain percentile without really understanding: a) that we have to change our underlying processes that produce those results; and b) that if you push on one performance metric to the exclusion of all others, it will create some organizational dissonance as well as performance dysfunctions. You must keep things in context," he adds.
"He’s absolutely right on," says Sharon Lau, a consultant with Medical Management Planning in Los Angeles. "The thing I find I need to stress when talking to people about benchmarking is that it can’t be done in vacuum."
Lau describes the benchmarking process as a three-legged stool, incorporating cost/ productivity/financial; quality, which includes outcomes and customer service; and speed of service — how long it takes to get something done.
To Philip A. Newbold, MBA, chief executive officer for Memorial Hospital and Health System in South Bend, IN, it’s a case of "déjà vu all over again," harkening back to the early days of quality improvement, when American industries first sought to duplicate the efficiency of Japanese companies and began adopting the philosophies of W. Edwards Deming, et al.
"As it was then, this is the key point: Are you really serious about change and transformation, or do you just want to play with the toys?" he challenges. "You must confront what it really means to execute and perform and to change culture, and to make sure that happens every day, all the time."
Gift concurs. "It seems that there is a disconnect — or a lack of understanding — that exists between attaining a level of performance and the changes required in the processes that produce that performance," he says.
The consequences of imbalance
Exactly what can happen to your organization if you take your eyes of the QI ball’? "If we push on the productivity performance without focusing on patient satisfaction, it may be that we get the productivity we want — on the two patients we have left," Gift warns.
He offers what he calls his favorite example: Your organization has an operational database that reports worked hours per departmental work load unit — i.e., per procedure, per patient day, per test. Now further suppose that the organization has decided to focus on achieving the top 25th percentile for all of the departments across the board.
"Here’s what happens: There are nuances in the data that people may not fully understand," Gift explains. "If I’m in the materials management department and I am pressured to achieve at least the 75th percentile, it may be that some other facilities [in the comparative group] may in fact exclude from their departmental performance a key performance, such as sterile processing.
"The flip side also may be true: As director of the OR, I am pushed to the top 25th percentile, whereas other facilities may not do sterile processing or central supply," he notes.
"If you look at materials management and just go after that productivity, you are going to skew your balance — and benchmarking is a balance," Lau adds.
"Sure, you want to be more productive, but if it takes you 12 hours to get a g-tube up to a unit, your speed may be shot to hell. Or you can get it up in two seconds and not meet your other goals. If you tweak one piece [of the three-legged stool], it will impact the other two," she adds.
What you should be looking for, Lau continues, is to try to get the best balance for all three.
"You may not be the most productive, but as long as your service levels are in balance for your organization, that’s where you want to target," she says.
"We had a [children’s] hospital with the best ED productivity in our benchmarking group, but the kids were waiting eight hours. Is that good service? Of course not. They ended up adding staff so they could bring things into balance," Lau points out.
A moving target?
Another reason not to focus exclusively on numbers is that your target can change, Newbold notes.
"Take something like Press Ganey [patient satisfaction scores]; that’s a moving target," he adds. "You may hit the 95th percentile one year, then you may do the same exact things the next year and be in the 85th percentile, because everyone else woke up and started paying attention to satisfaction; the bar has now been raised. You must realize that a percentile is a dynamic number, so the question you should be asking is, How do we build a core capacity, resilience, and strength, so we can continue to get better and better?’"
Your No. 1 focus, he continues, should not be a ranking, but change. "It’s kind of like [football] training camp," Newbold explains.
"It’s about what you have to go through to ensure you’ll be there in the playoffs. You begin with the basics, change plays, and strengthen your players, so you’ll be ready farther down the road. You’re seeking to build a certain capacity within your group so you can do more than hit just one number once, because that number will no doubt change," he notes.
"The benchmarking process is more a process of discovery of the hows’ than it is an establishments of the whats,’" Gift adds. "The big question is how we can change the underlying work processes to produce the desired outcome, rather than just pushing the number."
That, he emphasizes, is the key to benchmarking: Keeping in mind the means and the ends.
"Your goal is the end; the benchmarking process is how we establish the means to that end," Gift explains.
How are we doing?
There are some simple exercises to perform to determine whether you’re on the right track in terms of organizational change, Newbold notes.
"With senior leadership, if their job after [PI] implementation is anywhere near what is before, there probably has been no change," he says. "At least half your day should be really, really different — an entirely new setup of behaviors, action steps, metrics, and accountability measures. Their day should look radically different — or there has not been any change," he asserts.
Newbold recommends that you perform a calendar audit. "Note what you spend your day on, what you pay attention to, and ask yourself, What do I really care about?’" he advises. "The answers should be very different — you can’t fake it. You can’t say I stand for quality,’ then only spend 2% of your day on it. If your organization remains trapped in ineffective processes, it will lead to bad outcomes."
To improve those outcomes, you must get back to the fundamentals and basics of benchmarking, says Gift — and that means paying closer attention to Lau’s three-legged stool.
"In some cases, your organization may be at the whim of the collective marketplace," he notes.
"For example, a hypothetical organization may be currently operating, per all their comparative data, at better than the 25th percentile and still be losing their shirt because they lack the operating margin they need to sustain themselves over the long haul. In such a case, the top 25th percentile bar isn’t high enough. In that marketplace, that facility may need to perform at the top 10th percentile," Gift explains.
"Each organization will be different," adds Lau. "One may have a financial urgency and accept a little less on the other two sides [of the stool], whereas another organization many not have that urgency but does have a pressing need for better speed of service because everyone in town is advertising a guaranteed maximum wait of 10 minutes."
Benchmarking, she continues, "is a guide for where you are in terms of the ballpark; then you make your decisions [as to where you should improve]. It depends entirely on where your organization is internally and externally; make your decisions based on what your goals are, what your culture is, and where you want to be."
"The fundamental requirement is to differentiate the availability of comparative data from the process of benchmarking," Gift notes.
"Having data helps you answer the what’ question — our performance vs. those of others. It says nothing about what might be a successful practice, or a really great operating process, or what the core enablers are to allow that process to function properly and let an organization perform at its highest level," he concludes.
Need More Information?
For more information, contact:
• Robert G. Gift, Vice President, Strategic Planning and Business Development, Memorial Health Care System, 2525 de Sales Ave., Chattanooga, TN 37404. Phone: (423) 495-8664. Fax: (423) 495-7226. E-mail: [email protected].
• Philip A. Newbold, MBA, Chief Executive Officer, Memorial Hospital and Health System, 615 N. Michigan St., South Bend, IN 46601. Phone: (574) 284-7115. E-mail: [email protected].
• Sharon Lau, Medical Management Planning, Inc. (MMP), 2049 Balmer Drive, Los Angeles, CA 90039. Phone: (323) 644-0056. FAX: (323) 644-0057. E-mail: [email protected].
At first glance, the proliferation of comparative databases for benchmarking activities may be a good thing, and of course, it always helps to have more data, but benchmarking experts warn there can be too much of a good thing especially if it causes you to lose perspective.
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