Measure What Matters
Clinical Value Compass
Balanced Scorecards
Microsystem Dashboards
Unit Name
Date:
Organization Name:
Aim: Provide a clear path forward to identify key measures to track unit performance in real time and over time:
 Patient Outcomes (Clinical Value Compass)
 Microsystem Performance (Balanced Scorecard)
 Microsystem Dashboard/Instrument Panel ( and )
 Linkage to Organization Strategy (Cascading Measures)
Background:
Organized data displays provide feedback on system performance. Key measures which reflect the purpose and
goals of the microsystem include measures regarding population and/or subpopulation outcomes (e.g. clinical
value compass), and system performance measures (e.g. balanced scorecard) both of which reflect microsystem
results toward desired outcomes. The unit dashboard/instrument panel provides a method to monitor a blend of
current indicators (clinical value compass and balanced scorecard) of a microsystem to provide real time
indications over time on how the unit is performing. It is important to remember that the microsystem level
dashboard/instrument panel variables can change as improvements, priorities and process measures change.
Path Forward:
 Create Clinical Value Compass
 Create Balanced Scorecard
 Determine Organization’s Strategic Measures
 Create Microsystem Dashboard/Instrument Panel
 Cascading Measures
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© 2007 Trustees of Dartmouth College, Godfrey, Nelson, Batalden Adapted July 2007 Vermont Oxford Network
Page 1

Create clinical value compass (unit of analysis if patients)
 Whole population
Functional
 Subpopulation

 Disease specific subpopulation

 Individual patient


Biological/Clinical




Patient/Family Satisfaction




Cost




 Your microsystem dashboard/instrument panel
Use Key Value
Compass and
Key Balanced
Scorecard
Measures to
create your
dashboard
* Recommend to track data over time (run charts, control charts, p-charts)
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© 2007 Trustees of Dartmouth College, Godfrey, Nelson, Batalden/ Adapted July 2007 Vermont Oxford Network
Page 2

Create your balanced scorecard (unit of analysis is microsystem)
Core Processes
Determine where the
7 NIC/Q Themes Fit:
Safe
Timely
Effective
Efficient
Equitable
Patient Centered
Socially Responsible

Innovation and Learning
Customer Satisfaction


Financial

 Determine macrosystem and mesosystem strategic goals
Use Key Value
Compass and
Key Balanced
Scorecard
Measures to
create your
dashboard
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© 2007 Trustees of Dartmouth College, Godfrey, Nelson, Batalden/ Adapted July 2007 Vermont Oxford Network
Page 3
Key Processes
NICU Scorecard
Learning and Growth
Aim: Implement/Continue Best Practices
Measure:
1. Establish Kangaroo Mother Care
Program
2. Transition Feeding Protocol
3. O2 Sat monitoring feedback to staff
4. Staffing
 Nurses from System partner in
Oregon
 Tracking Chg RN w/o assignment
 Tracking surgery days/off unit
procedures
 Participation in LIC
Aim: Culture of Safety: Safe/Timely/Effective/Efficient/Equitable/Patient and Family
Centered
1. Establish Quality & Safety
1. Established January 2007; meeting
Measure:
Council w/regular meetings
weekly
2. Culture of Safety Survey –share
2. In process
results and develop action plan
3. Monthly reviews; forwarding
3. Review UOR’s monthly; followissues and concerns to appropriate
up with actions
persons or groups to follow-up
4. Reviewing “Suggestion Box”
4. Create a template for feedback to
concerns .
those who submit
5. Review JCAHO preparedness
suggestions/concerns
6. Review Emergency Preparedness
5. Establish report for JCAHO
plans
readiness
6. Review/revise and update current
plan
Action See #4,5,6
plan:
Customer Satisfaction
Aim: Patient/Employee/Physician
Satisfaction: Likelihood of
Recommending Providence to Others;
Measure: HYB.com for NICU specific results
Kenexa Employee Opinion Survey
W ould you recommend this hospital to other parents - % answering "Yes"
100
97
94
90
98 98
98
93
98
98
98
97
97
99
95
96
94
80
70
5. Nurse Extern/Intern /Fellowship
Programs
6. Developed Foundation /Funding for
staff to attend
Education/conferences
Action plan:
60
50
Qtr 1 '03 Qtr 2 '03 Qtr 3 '03 Qtr 4 '03 Qtr 1 '04 Qtr 2 '04 Qtr 3 '04 Qtr 4 '04 Qtr 1 '05 Qtr 2 '05 Qtr 3 '05 Qtr 4 '05
calls
Aim: Acheivement of NICU Net Operating Income as budgeted for 2007 —roll up to PAMC
Action plan:
July '06
Action plan: Improve scores/ develop follow-up D/C phone
Financial Performance
Measure:
Qtr 1 '06 Qtr 2 '06
1.
2.
3.
1.
Patient days/volumes
4. Labor costs
Revenue
5. Transfers
Costs/stat (UOS)
6. LOS
Review of Financial performance monthly with NICU Finance Management
meeting (4th Wed) . Includes supervisors, lead RT, educator, and ACNE for the
Children’s Hospital.
2. Inventory and accounting review (supervisors/manager)
3. Labor cost /productivity review bi-weekly with ACNE (Monthly with supervisors)
4