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Vital Signs
What does Richard D’Aquila mean when he states, leaders need to “have a method of
monitoring vital signs and deciding where to channel problem solving efforts.”? What
are ‘vital signs’ and how should leaders assess the quality if evidence used to make
evidence-based decisions?
Include at least two APA-formatted citation (in-text, as well as the full reference). The
citation may be from course textbooks, assigned readings, or an outside source. Your
initial post must be a minimum of 300 words in length.
CHAPTER 2: APPLICATION OF EVIDENCE-BASED
MANAGEMENT AT AN ACADEMIC MEDICAL CENTER: THE
YALE-NEW HAVEN HOSPITAL EXPERIENCE
Richard D’Aquila
Introduction
This chapter describes a comprehensive and contemporary movement toward evidence-based management
(EB management) at a large academic medical center. It profiles a model for incorporating evidence-based
analysis and decision making in all major dimensions of organizational performance, including strategic
planning, resource allocation, quality and safety surveillance, performance management, and operational
dashboard systems designed to provide real-time assessments.
This chapter demonstrates that an EB management approach enables managers in healthcare
organizations to elevate the performance of their institutions—and their own effectiveness as leaders—by
improving the quality of their decisions. It illustrates how EB management can be at the core of a set of
principles and behaviors guiding efforts to continuously improve hospital performance.
For EB management to work, organizations must:
•Make comprehensive performance information systems visible and available to the entire staff;
•Strategize planning and decision making regarding major resource investments;
•Perform evaluations of, and offer rewards for, leaders’ performance; and
•Have a method of monitoring their “vital signs” and deciding where to channel problem-solving
efforts.
In short, EB management is the underpinning of a culture that demands discipline, rewards performance,
and encourages a climate that has little tolerance for the status quo. The next section describes our
experience at Yale-New Haven Hospital in New Haven, Connecticut, which has incorporated EB
management principles in every facet of organizational performance.
About Yale-New Haven Hospital
The nation’s fourth hospital—originally chartered in 1826—Yale-New Haven Hospital (YNHH) is the largest
and most comprehensive hospital in Connecticut. It is a 944-licensed-bed tertiary referral center that
includes 270 beds designated as the Yale-New Haven Children’s Hospital and 72 beds in the nearby YaleNew Haven Psychiatric Hospital.
YNHH is the primary teaching hospital for the Yale University School of Medicine (YSM) and is one of 50
teaching hospitals nationwide that together train nearly 40 percent of all U.S. medical residents.
Evidence-Based Management: Application of Principles at YaleNew Haven Hospital
The following applications of EB management illustrate YNHH’s comprehensive approach, which integrates
strategic planning, performance monitoring, management objectives, and operating dashboards.
Service Line Planning
One of the major challenges facing executives in an academic medical center is making informed decisions
about growth management, service expansion, and investments. With hospital beds, staff, and available
capital in short supply, administrators must make intelligent, data-driven decisions about the allocation of
these resources. Academic medical centers have additional pressures to develop and maintain clinical and
research programs that attract top national talent and build clinical excellence on a regional and national
basis.
YNHH has adopted service line planning as its model for making these critical resource allocation decisions
and achieving consensus on strategic direction. YSM also has adopted this process to ensure that the
hospital and university are jointly planning for clinical program development that reflects sound investment
decisions.
Service line planning, patterned on product lines in manufacturing, is not a new model in healthcare. Since
the 1980s, hospitals across the country have recognized the value of developing strategic plans according to
discrete clinical business categories. YNHH studied the attempts of others to adopt service line planning and
modified the model to accommodate the particular attributes of the hospital and university. The structure of
YNHH is a matrix. Some managers (called clinical service coordinators) have specific service responsibilities
(for oncology or pediatrics, for example), and some managers have traditional line-management
responsibilities. YNHH created the matrix largely to support the service line model.
YNHH selects operational improvement initiatives according to priorities it establishes annually in its
business plan. It closely monitors operational performance through a set of indicators and identifies
improvement opportunities when these indicators begin to lag. An operations group, comprising the vice
presidents, senior vice presidents, and executive vice presidents, meets weekly to review the indicators and
determine whether action is required. This model of regular, high-level performance monitoring is replicated
throughout the organization—down to the unit level.
Prior to adopting the service line model, YNHH had a more traditional planning process that did not directly
engage the school of medicine. The process was largely opportunistic and not helpful in establishing
priorities for growth. Using service line planning, YNHH has been able to:
•Conduct realistic assessments of its current position;
•Set a clear vision and road map;
•Create a sense of discomfort with the status quo;
•Communicate vision and priorities in multiple forums, led by a vocal and visible leadership group;
•Align the organizational structure with strategic priorities (i.e., the service lines); and
•Constantly reinforce key messages through initiatives and funding decisions.
The cost of service line planning is difficult to quantify. However, for the initial five service lines, over the first
six months of fiscal year 2007, the Planning Department spent approximately 2,700 hours on all aspects of
the service line initiative, including data formulation, data runs, analysis, review, and meetings. As YNHH is
still in the recommendation phases for several of these service lines, management cannot yet estimate the
full cost associated with the implementation.
Principles and Organization
Service line planning at YNHH enables management to develop comprehensive strategic plans for
delivering a continuum of services for each major clinical service group. The process enables maximum
physician input. Select committees lead the overall effort and planning for the five initial service lines (Figure
2.1).
FIGURE 2.1: Service Line Planning Structure
The five initial service lines are:
•Transplant Service Line: kidney, pancreas, liver, small bowel
•Neuroscience Service Line: neurology, neurosurgery, stroke, spine, interventional
neuroradiology, brain and spine trauma, brain cancer
•Cardiovascular Service Line: cardiac surgery, cardiology, vascular surgery imaging, cardiac and
lung transplant, endovascular, electrophysiology
•Cancer Service Line: all screening, diagnostic, and treatment services for patients with known or
suspected neoplasms
•Children’s Service Line: Inpatient services and ambulatory services for patients (1) registered
with a children’s hospital for care; (2) whose physician is from the Department of Pediatrics, the
pediatric section of another department (e.g., Pediatric Surgery), or a known pediatric provider in a
non-pediatric area (e.g., pediatric trauma surgeon, neurosurgeon); and (3) under age 18, regardless of
location or physician.
Also, management tentatively identified seven additional service lines for subsequent planning efforts:
•Behavioral Health
•Women’s Services
•Gastrointestinal Disease
•Vascular Disease
•Geriatrics
•Emergency/Ambulatory Care
•Orthopedics
The Executive Committee, which has joint and equal representation by YSM and YNHH senior leadership
teams, governs the overall process. It meets monthly, appoints and sets the charge for each service line
committee, and reviews all interim findings. More important, the Executive Committee reviews all strategic
and programmatic recommendations and gives final approval of all resource recommendations, priorities,
and commitments.
Use of the Evidence-Based Management Approach
Step 1. Framing the Question. The planning team identified 12 to 13 potential service lines from observation
of how patients cluster around
various clinical services. From this list, it selected the first group of service lines by determining which of the
services have the greatest impact—especially financial—on the hospital, and which face possible increase
or decrease due to various internal and external forces.
Step 2. Finding Information. The team conducted extensive research, following a standardized format for
data collection. Project teams focused on identifying best practices, collecting and reviewing relevant
industry and market-specific data, and employing other forms of data collection and analysis.
Step 3. Evaluating the Information. The team drew on the standard data set for each service line and
conducted SWOT (strengths/weaknesses/opportunities/threats) and other types of analyses. A committee
with broad representation from key clinical and administrative leadership evaluated this information.
Step 4. Applicability and Actionability of the Information. Determination of applicability involved facilitated
discussion and decision making. Using the children’s service line as an example, the planning group
developed specific recommendations regarding vision and strategic focus, physician recruitment priorities,
geographic deployment, and program growth. It shared these recommendations with the Dean’s Office and
the YNHH President’s Office to obtain their consent.
Step 5. Adequacy of the Information. Management concluded that the information used to discuss the
service lines’ priorities provided sufficient detail and balance to draw reasonable conclusions.
Work Product and Process
Building a service line plan is a disciplined and data-driven process at YNHH. Each service line committee
includes a trained facilitator, supported by finance staff and planning and information specialists from the
hospital and university. Committees range from 16 to 25 members, approximately equally divided between
physicians and hospital managers, and are co-chaired by a representative of management from YNHH and
a clinical chief from YSM. Committees emphasize creating a common and thorough understanding of the
marketplace; emerging trends in technology and treatment; and strengths, weaknesses, and market position
of the service. In some service lines, such as children’s and cancer treatment, national benchmarks exist, as
do data on strategic characteristics of competitive facilities like Boston Children’s Hospital and Memorial
Sloan-Kettering Cancer Center.
Figure 2.2 displays the schedule for a typical committee and the progression from strategic situational
assessment to the development of
implementation plans. As this process is highly structured and involves assimilation of considerable amounts
of data, trained facilitators and polished data presentations are essential to maintaining a project schedule.
FIGURE 2.2: Planning Process: Framework
Key elements of committees’ plans include:
1.A current assessment of the service line (SWOT analysis) supported by:
•market share and volume trend information (inpatient and outpatient, if available)
•current out-migration data from the New Haven area and from YNHH to other hospitals
•national utilization estimates
•payer-mix data
•existing complement of beds and physicians
•upstream/downstream linkages
•service issues (e.g., from Press-Ganey patient satisfaction surveys, employee opinion
surveys, and physician surveys)
2.Development of a 5- to 10-year vision for the service
3.Requirements and factors critical to achieving the vision, including:
•organizational structure requirements (clinical and administrative)
•market strategies to address national and local trends
•physician recruitment strategies with supporting financial plans
•technology and capital requirements with supporting financial plans
•a financial plan for the service line
•fundraising development strategies (as appropriate)
4.Action steps and strategies for achieving the vision
5.Metrics to monitor and assess performance, such as market share growth relative to
competition, percentile rankings for treatment complications and mortality, opportunities to fulfill unmet
community needs within the service line, and patient/physician/employee satisfaction targets
6.Time frames and accountability assignments, such as:
•What steps will we take now versus two years from now?
•Which parties will be responsible?
•What will the process and deadlines be?
The committees’ work sets a vision and strategy for each service line, which ultimately drive specific
implementation recommendations. Once approved by the Executive Committee, these recommendations
find their way into physician recruitment efforts, annual service line plans, and, in some cases, ongoing
performance measures, such as service utilization targets. Figure 2.3 depicts this transition from service line
planning to operational priorities.
FIGURE 2.3: Strategic Template
Conclusions
Service line planning has proved to be a valuable application of EB management at YNHH. As a strategic
planning process, it already has:
•Created a common clinical vision in high-priority service lines;
•Supported decisions around programs, people, facilities, and the allocation of limited resources
in a manner that best supports the common vision;
•Positioned key clinical services to gain and maintain regional, national, and international stature;
•Set the foundation for realignment of the hospital’s leadership, in particular the assignment of
key senior leadership positions to major service lines; and
•Established productive partnerships between the hospital and YSM.
Performance Management Information Technology
YNHH was the driving force behind the development of Yale New Haven Health System (YNHHS) in 1991.
The four-hospital system spans coastal Connecticut and eastern Rhode Island, and includes YNHH,
Greenwich Hospital (Greenwich, Connecticut), Bridgeport Hospital (Bridgeport, Connecticut), and Westerly
Hospital (Westerly, Rhode Island). This system’s founding principles included a commitment to endeavors
that would have system-wide strategic value, such as deployment of information system and performance
management technologies.
Development of a YNHHS performance management system was an early goal. Ultimately called PMIT—
Performance Management Information Technology—this web-based, real-time system centrally supports
three major databases containing more than 100 performance metrics. Prior to PMIT, YNHHS hospitals had
a variety of information storehouses in different locations, which compromised the validity of the data (as
sources and definitions conflicted) and timely access to information.
Design and Function
The performance management initiative was designed to evaluate and improve YNHHS’s ability to provide
the highest level of patient safety, clinical quality, and service, while enhancing productivity and financial
performance. Its objectives were to:
•Translate YNHHS business plans into clear, measurable outcomes;
•Enforce accountability for successful business plan implementation;
•Provide managers and clinical leaders with the training, education, and resources they need to
continuously monitor, communicate, analyze, and enhance performance;
•Drive cross-functional collaboration and sharing of best practices; and
•Provide quantitative evidence of YNHHS accomplishments.
Another performance management goal was to “flatten” the organization by:
•Increasing its limited access to enterprise information to broad access through PMIT and the
information portal;
•Moving from an organization where only some managers have the required training and
improvement tools to one in which all managers have access to these resources; and
•Bridging the disconnect between corporate objectives and improvement initiatives so that
improvement expertise is focused on significant problems.
The performance management initiative is led by the vice president of performance management, who
reports to the executive vice president of strategy and system development, and who is supported by a
performance management director and resource group that includes Six Sigma-trained individuals at each
YNHHS hospital. The System Executive Committee oversaw the development and implementation of the
performance management initiative and recommended which PMIT reports would be created, distributed, or
discontinued.
A key deliverable of the performance management initiative is the PMIT Balanced Scorecard, the value of
which depends on how effectively the information influences decisions that improve performance. The
Balanced Scorecard reflects real-time information systems organized and designed to support the four
broad categories of annual business plans for the system as a whole and for YNHH, as follows:
•Patient safety, quality, and operations improvement
•Provider of choice
•Employer of choice
•Financial performance
Thus, the PMIT system supports the business plans and objectives on which the hospital and system base
their annual performance assessment.
As of December 2006, three PMIT scorecards were live—an executive scorecard that has 30 metrics, an
operating room scorecard that has 18 metrics (with an additional 12 under development), and a clinical
quality scorecard that has 42 metrics. The following reports are regularly updated on the PMIT website:
•Inpatient activity
•Census variance
•Daily census, discharges
•Vacancy rate
•Intensive Care Unit quality
•Surgical infection rates
•Case management
Performance outcomes to date, in areas such as ICU services, indicate significant positive improvements,
several of which were highlighted in the introduction to this chapter.
Challenges and Next Steps
YNHHS was an early adopter of comprehensive, system-wide performance information systems. The
system has a strong analytical capacity, features distinctive graphical presentation, and is available on every
management desktop.
Despite being over a decade old, this initiative is regarded as a work in progress and is subject to
continuous investment and improvement. The system has confronted several ongoing challenges in its
continued evolution, particularly the need to standardize definitions and data structures across hospitals and
to ensure the integrity and timeliness of data, even as primary data sources change. Nevertheless, PMIT is
considered a valuable system-wide management support tool that has enabled leadership to establish
accountability and has given managers the information they need to make better decisions.
YNHH continues to drive performance expectations down to the department and unit levels in an attempt to
enable all managers to lead their business units with the influence and authority of a CEO. Each manager is
held accountable, both generally and specifically, for (in most cases) seven dimensions of performance:
•Volume, flow, and throughput
•Financial performance (profit and loss or expense management)
•Quality of care
•Regulatory and accreditation readiness
•Patient/customer satisfaction
•Employee satisfaction
•Medical staff satisfaction
Achieving the Corporate Objectives
Explicit cor …
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