Critical Decision-Making and Organizational Performance

View the scenario called “Critical Decision Making for Providers” found in the Allied Health Community media.
In a 1,000-1,250-word paper, examine the scenario involving Mike, the lab technician, and discuss the following:

Discuss the consequences of a failure to report.
Explain the impact his decision had on patient safety and organizational performance (risk for litigation, organization’s quality metrics, workload of other hospital departments, etc.).
As Mike’s manager, describe how you would address the issue with him and steps you would take to ensure other staff members do not repeat the same kind of mistake.
Reflect on the scenario and describe what underlying aspects or issues may be contributing to workplace dilemmas such as this.
Consider the manner in which most health care organizations function (structure, people, technology, environment). As a leader, discuss what principles of organizational behavior and development can be applied to effectively contribute to the success of a health care organization. How could these principles be applied to this scenario?

A minimum of three academic references from credible sources are required for this assignment.

Leadership Approaches and Models in Healthcare
XXXXX- NAME
Grand Canyon University: Leadership and Vocation
Name of the Instructor
DATE

Running head: ASSIGNMENT TITLE HERE

Healthcare organizations are business with unique needs and goals. Leadership in healthcare can make a different in the company’s level of success. Effective leadership from regulatory professionals guides healthcare organization quality. Servant leadership and good stewardship can improve an organization overall. Not all leaders need to be formal however, informal leaders can impact companies too. Collaborative leadership models can also benefit healthcare by enhancing communication and organizational efficiency.

Leadership and Organizational Performance

Leadership efficacy has a direct effect on organizational performance. Health care organization performance must be superior to be competitive in today’s dynamic social, economic, political, and financial environments (Chatterjee, Suy, Yen, & Chhay, 2017). Companies in the healthcare sector have unique needs and structures compared to other businesses, and tend to lack cooperation between different areas, therefore strong leadership is needed to change ineffective old ways to improve the coordination and quality of healthcare (Chatterjee et al, 2017). When systemic changes are needed, leaders can use strategies to meet organizational goals to keep the company successful (Chatterjee et al, 2017). Leadership is a source for innovative thinking and seeing the big picture, to adopt changes that will keep the organization on top of current trends and prepared to face the future (Chatterjee et al, 2017).

Regulatory Professionals

Regulatory professionals are involved in regulatory compliance, quality assurance, and ensuring healthcare products are safe and effective (About the Regulatory Profession, 2020). Regulatory professionals can be involved in drugs, medical devices, biotechnology, and many other aspects of healthcare as researchers, part of clinical trials, clinical liaisons, and as part of surveillance and auditing teams (About the Regulatory Profession, 2020). These professionals need leadership skills to lead regulatory departments, work groups, and are part of the corporate leadership teams of healthcare organizations (Brousseau, 2015). In addition, regulatory professionals are experts in developing global strategies for healthcare quality improvement, and will be better at communicating, influencing, and persuading others to make improvements and implement new strategies (Brousseau, 2015). Good communication is an essential strategy for regulatory professionals to use in the many ways that they can interact with others such as by email, professional conversations, managing and participation in meetings, presentations, and document review (Brousseau, 2015). Excellent communication skills are needed to convey regulatory information to be well received from others perspective (Brousseau, 2015). Context should be provided, as well as analysis, the truth about unknowns (Brousseau, 2015). Other communication skills that are helpful are optimism, diplomacy, empathy, learning agility, and an interest in teaching (Brousseau, 2015). Another strategy for regulatory professionals to use is self-awareness by knowing personal strengths and weaknesses and understand how others perceive you to improve listening skill and effectiveness of presentations (Brousseau, 2015).

Servant Leadership and the Christian Worldview

Servant leadership is a style of leadership in which, the leader is a “servant first” (Servant Leadership: Putting Your Team First, and Yourself Second, 2020). Another way to describe is “using leadership as a means to help others” as opposed to seeking power or positions of authority (Nagy, 1994). The servant leader sees themselves as “first among equals” meaning they believe that they see themselves on a peer to peer level with those that they lead and take responsibility for meeting the goals of the company (Nagy, 1994). An ideal of servant leadership is to serve other’s needs (Nagy, 1994). In this sense, servant leaders are stewards of the people that they serve, and the organizations that they are “taking care of” by empowering followers to work to the best of their ability by fostering their self-efficacy. The Christian Worldview beliefs of one all-powerful God who loves humanity enough to sacrifice his son, and offer us grace, forgive our sins, restore us to Christ, heal us, and offer salvation provide a framework of reference for other aspects of life (Dockery, 2020). According to Union University, a Christian worldview gives one confidence, hope for the future, stability, a link to God’s faithfulness and consistency (Dockery, 2020). It also builds a foundation for ethical thinking and the standards for good, love, holiness, grace and truth are set by Jesus Christ (Dockery, 2020).

Stewardship

Stewardship is an important element of the Christian life which proposes that one should make their best effort to make the best of use of one’s time, talents, abilities, resources, and finances as they are all blessings from God (The Role of Stewardship in The Life of a Christian, 2019). Being a good steward of God’s gifts is the way that mankind can show appreciation, faithfulness, and devotion to God (The Role of Stewardship in The Life of a Christian, 2019). Stewardship also correlates with professional responsibility in the fact that professionals work to see good results in their company, and then stewardship takes it a step further, by moving professionals from just making rules to actively being involved in taking care of the organization and being personally invested in achieving moral principles and meeting goals.
Stewardship should be used by leadership and management in healthcare settings to cultivate a high quality, ethical healthcare environment and optimize functions to ensure success. An analogy could be made to simplify the concept, consider a wild, unhealthy, vicious dog as compared to a well-groomed, quiet, obedient, well trained one. The owners of the dogs are both responsible for their resulting conditions, however one used good stewardship and had a vision for how others would perceive their pet. The other didn’t put effort into training or caring for their animal and the results are dangerous, problematic, and a menace to others. In the same way, leaders must use good stewardship to take care of their organizations so that they develop into smoothly operating, efficient, ethical and reputable companies. The benefits for the organization overall are a good reputation, stable or even increased revenue, well defined mission, values, policies, standards of care and high-quality outcomes. The benefits of stakeholders are numerous, leadership can enjoy personal and professional success, company growth and expansion, and higher salary or bonuses. Staff are able to work in a safe, well organized environment, and patients can receive high quality medical care with newer equipment, a wider variety of services available, a staff better able to focus on quality, efficiency, and safety.

Formal and Informal Leadership

Formal leaders are those that are officially in leadership positions within their organization (Vercillo, 2020). Their designated leadership roles are either assigned or they are hired into them (Vercillo, 2020). A manager is an example of a formal leader (Vercillo, 2020). The formal leader responsibility is to organize and direct subordinates to meet company goals (Vercillo, 2020). Informal leaders do not hold an organizationally recognized leadership role but are looked to by their peers to make decisions, approve or disapprove of changes and form opinions (Vercillo, 2020). An informal leader may be popular because of charisma, social skills, or knowledge, creativity or intelligence (Vercillo, 2020). An informal leader can purposefully attempt to influence others, or just naturally be a person that others gravitate to (Vercillo, 2020). Sometimes informal leaders can have more influence over a group because they have earned the groups respect by their behavior, as opposed to someone who is seen as a rule maker (Vercillo, 2020). Formal leaders impact healthcare organizations by listening to concerns, making decisions, enforcing rules, and setting standards. Informal leaders influence healthcare by leading their peers to accept or resistant changes, setting the mood, level of moral, and attitude of the unit. Formal leaders and issues punishments and rewards, so the group does have motivation to follow their requests and orders, but often the group’s loyalty is to the informal leader because they know that their goals are the same (Vercillo, 2020).

Collaborative Leadership Model

The collaborative leadership model provides a method that would be effective in a healthcare environment. Collaborative leadership requires continual communication between separate areas of (Chatterjee, 2017). Channels of communication should stay open to ensure shared knowledge (Chatterjee, 2017). Managers makes changes in all areas frequently as needed to best meet the needs of entire organization, not just their own department (Chatterjee, 2017). Leaders also make the most use of assists, even unconventional ones to reduce waste, and fully utilize all resources (Chatterjee, 2017). This model maximizes organizational efficiency (Chatterjee, 2017). In healthcare, communication is essential, and many improvements could be made if all departments in healthcare are working together, and not competing for the most money, the best equipment and other resources against each other. When the different areas of the organization collaborate together, time, money and resources are saved. The more efficient the organization is, the more finances will be available to provide staff and resources for higher quality patient care.
Healthcare companies must compete in the ever-changing climate of scientific research, politics, and economics, as well as keep patient safety a priority and improve patient outcomes. In order to manage all of these arenas, healthcare needs effective leadership to be successful. Regulatory professionals foster quality improvement by conveying standards and creating strategies. Good stewardship of resources is an element of the Christian Worldview that can improve an organizations ethics, efficiency, and quality. Servant leadership and the collaborative leadership model are both methods that can be applied in the healthcare sector. Servant Leadership can improve the quality of an organization by improving staff self-efficacy, job performance, and role ownership. Collaborative leadership requires increased communication, and results in increased efficiency. Every role in health is important, but good leadership can set all other roles up for success.

References

About the Regulatory Profession. (2020). Retrieved July 27, 2020,
from https://www.raps.org/careers/about-the-regulatory-profession
Brousseau, Z. (2015). How to be a Regulatory Leader. Retrieved July 27, 2020,
from https://www.raps.org/news-articles/news-articles/2015/5/how-to-be-a-regulatory-leader
Chatterjee, R., Suy, R., Yen, Y., & Chhay, L. (2017). Literature Review on Leadership
In Healthcare Management. Journal of Social Science Studies,
5.doi:10.5296/jsss.v5i1.11460
Dockery. (2020). Shaping a Christian Worldview: An Introduction (Part I) | Article | Teaching |

Center for Faculty Development | Union University, a Christian College in Tennessee. Union

University. https://www.uu.edu/centers/faculty/teaching/article.cfm?ID=364

(Remember on five spaces for the indentation)

Rubic_Print_Format

Course Code Class Code Assignment Title Total Points

AMP-450V AMP-450V-O500 Benchmark – Critical Decision-Making and Organizational Performance 140.0

Criteria Percentage Unsatisfactory (0.00%) Less Than Satisfactory (65.00%) Satisfactory (75.00%) Good (85.00%) Excellent (100.00%) Comments Points Earned

Content 70.0%

Consequences of Failure to Report 15.0% The consequences of a failure to report are not discussed. The consequences of a failure to report are partially outlined. The consequences of a failure to report are summarized. The consequences of a failure to report are discussed. Some detail is needed for clarity or accuracy. The consequences of a failure to report are thoroughly discussed.

Impact of Employee Decision 15.0% The impact the employee decision has on patient safety, risk for litigation, organizational quality metrics, and the workload of other hospital departments is not discussed. A discussion on the impact the employee decision has on patient safety, risk for litigation, organizational quality metrics, and the workload of other hospital departments is incomplete. The impact the employee decision has on patient safety, on the risk for litigation, organizational quality metrics, and on the workload of other hospital departments is summarized. There are minor omissions or inaccuracies. The impact the employee decision has on patient safety, risk for litigation, organizational quality metrics, and the workload of other hospital departments is discussed. Some detail is needed for accuracy. The impact of the employee decision has on patient safety, risk for litigation, organizational quality metrics, and the workload of other hospital departments is thoroughly discussed.

Addressing Employee Issue and Proposing Preventative Steps as a Manager 12.0% How to address the issue with the employee, and proposed steps to take that ensure other staff members do not repeat the same mistakes, are omitted. How to address the issue with the employee, and proposed steps to take that ensure other staff members do not repeat the same mistakes, are only partially discussed. How to address the issue with the employee, and proposed steps to take to ensure other staff members do not repeat the same mistakes, are summarized. More information or rationale is needed. How to address the issue with the employee, and proposed steps to take to ensure other staff members do not repeat the same mistakes, are discussed. How to address the issue with the employee, and proposed steps to take to ensure other staff members do not repeat the same mistakes, are discussed. The discussion is well-developed and demonstrates an understanding of decision making as a leader when resolving employee dilemmas.

Underlying Issues Contributing to Dilemma Similar to Scenario 13.0% Underlying aspects or issues that may contribute to similar dilemmas are not described. Some underlying aspects or issues that may contribute to similar dilemmas are partially presented. Underlying aspects or issues that may contribute to similar dilemmas are outlined. More information or rationale is needed. Underlying aspects or issues that may contribute to similar dilemmas are described. Underlying aspects or issues that may contribute to similar dilemmas are well-considered and thoroughly described.

Principles of Organizational Behavior and Development Contributing to Success of Health Care Organizations (4.1) 15.0% Principles of organizational behavior and development that contribute to the success of a health care organization are not discussed. Principles of organizational behavior and development that contribute to the success of a health care organization are only partially discussed. Principles of organizational behavior and development that contribute to the success of a health care organization are summarized. A general application of the principles to the scenario is presented. More information or rationale is needed. Principles of organizational behavior and development that contribute to the success of a health care organization are discussed. Application of principles to the scenario are discussed. Principles of organizational behavior and development that contribute to the success of a health care organization are thoroughly discussed. Application of principles to the scenario are detailed.

Organization, Effectiveness, and Format 30.0%

Thesis Development and Purpose 7.0% Paper lacks any discernible overall purpose or organizing claim. Thesis is insufficiently developed or vague. Purpose is not clear. Thesis is apparent and appropriate to purpose. Thesis is clear and forecasts the development of the paper. Thesis is descriptive and reflective of the arguments and appropriate to the purpose. Thesis is comprehensive and contains the essence of the paper. Thesis statement makes the purpose of the paper clear.

Argument Logic and Construction 8.0% Statement of purpose is not justified by the conclusion. The conclusion does not support the claim made. Argument is incoherent and uses noncredible sources. Sufficient justification of claims is lacking. Argument lacks consistent unity. There are obvious flaws in the logic. Some sources have questionable credibility. Argument is orderly but may have a few inconsistencies. The argument presents minimal justification of claims. Argument logically, but not thoroughly, supports the purpose. Sources used are credible. Introduction and conclusion bracket the thesis. Argument shows logical progression. Techniques of argumentation are evident. There is a smooth progression of claims from introduction to conclusion. Most sources are authoritative. Clear and convincing argument presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative.

Mechanics of Writing (includes spelling, punctuation, grammar, language use) 5.0% Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is used. Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register) or word choice are present. Sentence structure is correct but not varied. Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct and varied sentence structure and audience-appropriate language are employed. Prose is largely free of mechanical errors, although a few may be present. The writer uses a variety of effective sentence structures and figures of speech. Writer is clearly in command of standard, written, academic English.

Paper Format (use of appropriate style for the major and assignment) 5.0% Template is not used appropriately, or documentation format is rarely followed correctly. Appropriate template is used, but some elements are missing or mistaken. A lack of control with formatting is apparent. Appropriate template is used. Formatting is correct, although some minor errors may be present. Appropriate template is fully used. There are virtually no errors in formatting style. All format elements are correct.

Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style) 5.0% Sources are not documented. Documentation of sources is inconsistent or incorrect, as appropriate to assignment and style, with numerous formatting errors. Sources are documented, as appropriate to assignment and style, although some formatting errors may be present. Sources are documented, as appropriate to assignment and style, and format is mostly correct. Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error.

Total Weightage 100%

SCENARIO:
Mike is running late again. The last time he spoke with his supervisor, he promised he would be on time. Mike even left his home 20 minutes earlier than usual, but there was an accident on his commute. The job is very important to Mike. He is the sole provider for his wife and newborn baby, but his supervisor told him that if he continued to be late he might face termination. Upon arriving, Mike observes a spill on the floor. He must make a decision: stop and make sure the spill is cleaned up or ignore it all together. If he safeguards the spill, surely he will be late clocking in and could face losing his job. Anyway, the spill is in another work area, and perhaps it will be cleaned up while he is clocking in. What decision should he make?
1. REPORT THE PROBLEM
a. Mike stops in at the front desk to have housekeeping paged. Housekeeping routinely takes 3-5 minutes to arrive on site, but he does not have the time to simply wait. Using the telephone at the front desk, he calls to notify his supervisor that he is in the building, but needed to stop to assist with a spill in the main lobby. His supervisor thanked him for calling and asked Mike if the time could be made up at the end of his shift. Appreciatively, Mike agreed.
b. RESULTS ARE THE HOSPITAL IS SAFE
2. IGNORE THE PROBLEM
a. Mike decides to clock in so he does not face losing his job. He is making every effort to keep his job and cannot afford to be terminated. Besides, he has a list of things he needs to accomplish from yesterday in addition to his assignment for the day. Certainly someone else who is responsible for the area will take care of the spill soon. Later, Mike is asked to go to a patient’s room to gather some patient information. He learns the patient was admitted to the hospital after falling in the lobby this morning. The patient is in a lot of pain and appears to have a broken hip from the injury. The patient goes on to describe the incident and asks him why this would happen in the hospital. She states, “I thought the hospital was a safe place. Don’t they have programs to prevent these things?” A wave of guilt floods over Mike. He questions himself, “Could I have prevented this from happening?” Mike is now faced with a new dilemma. Should he admit to his supervisor what occurred upon his arrival to work this morning? What if by his admission, he is terminated anyway?
b. RESULTS ARE THE PATIENT IS HARMED

Links/article information for the essay:

What is Organizational Development? A Complete Guide

https://www.ahrq.gov/cahps/quality-improvement/improvement-guide/4-approach-qi-process/index.html

https://online.usi.edu/degrees/business/mba/human-resources/what-is-organizational-behavior/

Editor’s Note: A version of this article was originally published
in the June 2014 edition of HFM Magazine

Healthcare organizations routinely pursue performance
improvement initiatives to improve clinical outcomes and patient
experiences and reduce organizational costs. If these efforts are
not well executed, however, they can become black holes that
suck up time, money, and resources while yielding little in the
way of real, sustainable improvements.

A major reason performance improvement efforts fail to produce
desired results is that organizations often mistakenly think of
performance improvement as a series of one-off projects, each
with its own beginning, middle, and end. To be effective and
sustainable, an organization’s performance improvement
initiatives should all be conceived and performed in the context of
an ongoing performance program.

The initial goals for such a program should be to prioritize
performance improvement efforts so that the organization can
achieve early successes and build momentum for future
performance improvement efforts. Health Catalyst® recommends
a framework, known as the Three System Approach for
performance improvement:

Improving measurement and analytics (an analytics system)

Creating permanent cross-functional workgroup teams
focused on identifying, deploying and monitoring the
effectiveness of quality improvements (an adoption system)

Deploying a data-driven approach to implementing
evidence-based best practices (a best practice system)

Six Steps to Implementing a Performance Improvement
Program

Insights

6 Steps for Implementing Successful Performance
Improvement Initiatives in Healthcare
By Bobbi Brown and Leslie Hough Falk

A major reason performance
improvement efforts fail to
produce desired results is that
organizations often mistakenly
think of performance
improvement as a series of
one-off projects, each with its
own beginning, middle, and
end. To be effective and
sustainable, an organization’s
performance improvement
initiatives should all be
conceived and performed in
the context of an ongoing
performance program.

http://www.hfma.org/Content.aspx?id=22965

https://www.healthcatalyst.com/knowledge-center/success-stories/

https://www.healthcatalyst.com/ebooks/healthcare-transformation-healthcare-a-better-way-ebook/

Step 1: Integrate Performance Improvement into Your
Strategic Objectives

Healthcare is a complex, adaptive system where interactions and
relationships of different components simultaneously affect and are
shaped by the system. As such, it is important for performance
improvement to be integrated within the healthcareorganization’s
strategic objectives. Strategic objectives such as becoming an
accountable care organization (ACO), focusing on population health
management, or developing a cardiovascular center of excellence, all
require performance improvement in order to be successful.
Integrating performance improvement also helps avoid wasting time,
effort, and money on programs that may yield little overall benefit.

Step 2: Use Analytics to Unlock Data and Identify Areas of
Opportunity

Performance improvement requires an analytics system that
integrates the organization’s data sources (clinical, claims,
financial, operational, etc.), and that facilitates quick and easy
data sharing. Only with appropriate analytics can an organization
identify specific areas of opportunity among strategic areas of
focus.

Healthcare data analytics is required for any sustainable
performance improvement initiative. It forms the foundation of
discussion and informs decisions. Yet while healthcare
organizations have mountains of clinical, claims, financial,
operational, patient experience and other data, most of it is
locked away in point solutions built for a specific purpose.

Performance improvement requires an analytic system that
integrates the organization’s data sources, and quickly and easily
unlocks data, and enables effective sharing of data and the
addition of new data sources. Doing so allows interdisciplinary
teams to analyze the data and discover patterns that lead to
insights. This should be an Agile, interactive process that
produces balanced metrics. Health Catalyst offers a unique
solution with our Late-Binding™ Enterprise Data Warehouse.

The analytic system also needs to be able to scale over time to
enable different levels of healthcare analytics. As an organization
moves up the hierarchy of the Analytics Adoption Model (see
Figure 1), data is used as an advantage and strength, helping the
organization to compete more effectively.

Performance improvement
requires an analytics system
that integrates the
organization’s data sources
(clinical, claims, financial,
operational, etc.), and that
facilitates quick and easy
data sharing. Only with
appropriate analytics can an
organization identify specific
areas of opportunity among
strategic areas of focus.

https://www.healthcatalyst.com/accountable-care-organization-solutions

https://www.healthcatalyst.com/population-health/

https://www.healthcatalyst.com/ebooks/healthcare-transformation-healthcare-a-better-way-ebook/

https://www.healthcatalyst.com/improve-clinical-data-management-healthcare-reduce-waste/

https://www.healthcatalyst.com/late-binding-data-warehouse/

https://www.healthcatalyst.com/healthcare-analytics-adoption-model/

The starting point (Level 1) for sustainable performance
improvement is an enterprise data warehouse (EDW) that can
aggregate and store data from fragmented point solutions in one
place and make it available to interdisciplinary teams.

Level 2 in the model is a standardized vocabulary and patient
registries. Having a master vocabulary is critical for sharing data.
Registries allow the organization to define the cohort of patients
for a specific performance improvement program. The use of
pre-defined patient registries and starter set measures to
evaluate key metrics such as: financials, length of stay and
readmissions provides a basis for initiating improvement projects.

Such was the experience of Texas Children’s Hospital in
Houston. Before deploying an enterprise-wide late binding EDW
and healthcare analytics, the hospital required roughly six
months to develop a clinical improvement initiative. Having a
healthcare EDW in place reduced this time in half because the
data was available and already integrated across the different
clinical, operational and financial systems. Implementing an
analytics application that included patient registries and a starter
set of common metrics further reduced the time required to just
two weeks since the patient population (cohorts) were already
defined (ICD codes, APR DRGs, clinical data, etc.,), and the
teams could easily compare data (admissions, readmissions,
LOS, etc.,) across the different patient cohorts to help identify the
greatest opportunities.

Figure 1: Analytics Adoption Model

https://www.healthcatalyst.com/how-survive-CMS-hospital-readmissions-penalties-increase

https://www.healthcatalyst.com/success_stories/population-registries-kick-start-rapid-cycle-clinical-process-improvement

In addition to speeding the development of performance
improvement programs, an analytics application can help an
organization identify priorities for improvement efforts by uncovering
variation. Variation points to a potential for standardizing processes,
because the existence of variation inherently means that some care
practices are more efficient and produce higher-quality outcomes
than others, while there also is a greater likelihood that some
practices are not achieving optimum outcomes. Hospitals and health
systems will have a significant opportunity for care improvement if
they can identify their highest-performing practices and begin to
make those practices and evidence-based practices the standards
for all caregivers.

The Anatomy of Healthcare Delivery framework, shown in Figure 2,
and developed by David A. Burton, MD demonstrates the potential
pathways patients can go through in their interactions with the
delivery system. It is a conceptual framework that enables one to
organize their thinking about the care delivery process and to focus
their attention on key processes and decision-making points. The
degree to which an organization standardizes their approach in each
of the knowledge asset categories (indicated by the orange and blue
boxes shown in the diagram) will impact the degree of variation in
care delivery.

Figure 2: Anatomy of Healthcare Delivery Framework

Once an organization examines how patients flow through the
care delivery system and its critical decision points, they can use
the information to create a logical framework to organize a
Clinical Integration hierarchy, as illustrated in Figure 3. The
Clinical Integration hierarchy organizes clinical programs based
on physician specialists and other clinicians who share
management of care processes and who are responsible for the
ordering of care for patients —versus traditional service lines that
are mostly used for marketing purposes. The teams either work
on things together or one team’s output is another team’s input
(e.g., OB-GYN sub-specialists and neonatologists).

Figure 3: Clinical Integration Hierarchy

With clinical programs and clinical support services broken into
categories that align with the way care is delivered, an organization
can use a Pareto approach (also known as the 80/20 rule), to identify
their highest opportunities: the clinical programs with the highest
count, highest cost or those that have the highest variation. One can
review the ranking to see which key clinical care processes make up
the majority of the care provided.

Variation in cost can be a good surrogate for quality of care, because

higher cost may result from delivery of inefficient or unnecessary
services. As the prescribers of care, clinicians are one of the
greatest influencers in managing variable cost, which represents
direct cost in departments. By focusing on variable cost —
looking at the volume of procedures and cost per procedure, in
particular — they can identify avoidable cost and begin working
with clinicians, using evidence-based practices, to address
them.

The Health Catalyst Key Process Analysis application is based
on the Pareto principle, and is used to prioritize performance
improvement efforts. Cost is displayed on the x-axis, as shown
in Figure 4; the y-axis shows the variation in resources
consumed. The clinical programs with the highest cost and
highest variation are in box one. Septicemia is one care process
that shows both high cost and high variation.

Figure 4: Sample Health Catalyst Key Process Analysis

Data governance is also a key component of the analytic strategy. A
data governance committee should be responsible for understanding
and implementing local data standards (facility codes, department
codes, etc.); as well as regional and industry standards (CPT, ICD,

https://www.healthcatalyst.com/product/key-process-analysis-kpa/

https://www.healthcatalyst.com/demystifying-healthcare-data-governance

SNOMED, LOINC, etc.). In addition to coded data standards,
the committee is also involved in the standard use of algorithms
to bind data into analytic algorithms that should be consistently
used throughout the organization, such as calculating length of
stay, defining readmission criteria, defining patient cohorts, and
attributing patients to providers in accountable care
arrangements.

Step 3: Prioritize programs using a combination of analytics
and an adoption system

Successfully improving clinical outcomes and streamlining
operations requires a strong organizational commitment and
changes in culture, organizational structure, staff education,
and workflow processes, what Health Catalyst calls an adoption
system. Consequently, any organization that embarks on this
performance improvement journey should first assess its
readiness for change. Examples of criteria that are evaluated in
an organizational readiness assessment include clinical
leadership readiness, data availability, shared vision, and
administrative support (e.g., data manager, outcomes analyst
availability).

A readiness assessment helps the organization determine how
ready the teams are to accept change, to estimate what, if any,
impact there is on staffing, and the potential impact on front-line
caregivers. Understanding the strategic objectives and
integrating results from a readiness assessment, along with the
analytics, help the organization prioritize which care families
(clinical services) to begin with.

Step 4: Define the Performance Improvement Program’s
Permanent Teams

The organization will require permanent performance
improvement teams to review and analyze data, define
evidence-based and best practices, and monitor ongoing result.
Improvement teams should be created to coincide with an
organization’s internal structure. One way to organize teams is
described below and shown in Figure 5.

https://www.healthcatalyst.com/healthcare-data-governance-practices

https://www.healthcatalyst.com/wp-content/uploads/2014/03/HC-Healthcare-Analytics-Adoption-Model-Assessment.xlsx

Figure 5: Team interactions

Guidance team. A guidance team should be assigned accountability
for clinical quality across the continuum of care in a specific domain
(such as Women and Children). The primary role of such a team
should be to select goals, prioritize work, allocate resources, and
remove barriers. The team should then delegate accountability to
clinical improvement teams to improve care.

Clinical improvement teams. These teams typically are led by a
physician and nurse and consist of front-line staff who understand
the processes targeted for improvement. Their role is to define
workgroup outputs and lead the implementation of process
improvements. Whenever possible, these teams should represent
a broad range of departments, clinics, hospitals, and regions to
help disseminate knowledge across the organization. These teams
generally create work groups to perform the detailed work.

Work groups. Work groups are generally led by a physician and
nurse subject matter expert and include best practices, analytics,
and technical experts. These teams meet frequently to analyze
processes and data and to look for trends and improvements.
Their role is to develop Aim Statements, identify interventions,

draft knowledge assets (e.g., order sets, patient safety protocols,
etc.,), define the analytic system and provide ongoing feedback of
the status of the care process improvement initiatives.

Step 5: Use a best practice system to define program outcomes
and define interventions

Workgroups are responsible for developing Aim Statements, part of
the best practice system, that establish clear clinical improvement
goals and integrate evidence-based practices to standardize care.
For examples of Aim Statements that relate to heart failure, and are
based on evidence-based practice, see Sample Work Group Aim
Statements: Heart Failure.

Sample Work Group Aim Statements: Heart Failure.

By developing Aim Statements for a performance improvement
initiative, an organization can ensure that all stakeholders
understand the initiative’s goals. The following sample Aim
Statements might be developed for a performance improvement
initiative focused on improving performance in treatment of
patients with heart failure.

Aim Statement 1: Data quality. By [date], establish a baseline
for all-cause 30-day readmission rates for patients found in the
heart failure cohort, and reconcile and validate against the
previous year’s baseline heart failure readmission rates by
[date].

Aim Statement 2: Risk stratification. By [date], identify high-risk
patients with heart failure and establish a baseline for 30-day
readmissions for those patients. Develop a risk stratification
model to predict the likelihood of all-cause 30-day readmission
rates for all patients with heart failure.

Aim Statement 3: Intervention. By [date], the heart failure team
will develop one evidence-based process metric (such as
number of medication reconciliation reviews or number of
follow-up appointments) and one balance metric (such as ED
admissions or observation days) that will have an effect (X) on
all-cause 30-day readmission rates for high-risk patients.

AIM Statement 4: Cost. Reduce the value-based penalty by 0.2
percent for heart failure and improve hospital payments by
$75,000 for next fiscal year.

https://www.healthcatalyst.com/5-Deming-Principles-For-Healthcare-Process-Improvement

https://www.healthcatalyst.com/wp-content/uploads/2015/02/HABW-Chapter-6-mini-2014-12-15a.pdf

The focus of performance improvement initiatives for many
organizations tends to be on low-performance outliers—that is,
on identifying instances where costs are much higher and
outcomes substantially poorer than averages among caregivers.
However, a more effective approach is to identify those practices
that consistently lead to the best outcomes and promote them,
with evidence-based guidelines, to improve outcomes across the
board, as illustrated in Figure 6.

Figure 6: Approach to Improvement: Focus on Better Care

The analytics platform described early in this paper also can be
used to identify and eliminate waste that can be an outgrowth
of non-adherence to evidence-based practices. This type of
waste tends to fall in three categories:

Ordering waste. This waste results from providers ordering
tests, care, and supplies that do not add value. An example of
such waste might be the ordering of unnecessary chest X-rays
for patients with asthma because of a faulty order set,
something Texas Children’s Hospital discovered and addressed
in their process improvement programs.

https://www.healthcatalyst.com/webinar/breakthrough-analysis-new-insights-into-reducing-waste

https://www.healthcatalyst.com/success_stories/launching-an-enterprise-data-warehouse-to-rapidly-reduce-waste-in-asthma-care

Workflow waste. This waste results from inefficiencies in delivering
tests, care, and procedures. As an example, some healthcare
organizations are still manually having charge nurses fax a nightly
list of patients with urinary catheters and central lines to their
infection preventionist team, an untenable manual process as
agencies, such as the Centers for Medicare and Medicaid Services
(CMS) expands surveillance activities to an enterprise-wide, versus
critical care, focus.

Several hospitals have been able to reduce their catheter-
associated urinary tract infection (CAUTI) and central-line
associated bloodstream infections (CLABSI) surveillance activities
by as much as 50 to 90 percent through the use of an analytic
platform that automatically identifies the patient population and
integrates of an electronic surveillance algorithm, allowing nurses
to focus more on infection prevention versus manual reporting.

Defect waste. If delivery of tests, care, and procedures is defective,
the resulting waste could lead not only to higher costs but also to
patient harm. Inpatient fall prevention is an example of a defect,
deemed to be avoidable. Falls can cause injury (ies) to the patient
and incur additional costs to treat the injury (ies) and may require
the patient to have an increased LOS.

Step 6: Estimate the ROI

As the guidance team sets priorities for performance improvement,
the team also should take time to estimate the potential ROI for
each initiative based on available information. The team can start
by identifying organizational costs and estimating benefits using
tools such as industry benchmarks for similar projects, vendor case
studies, and internal estimates. Most organizations will need to
educate their clinicians, operations and finance departments on
the value of sharing data and working together on inter-disciplinary
teams, rather than keeping everything in silos.

Next, the team should identify direct benefits and savings (either
from enhanced efficiency and productivity) or from clinical
improvement and waste reduction. Then, the team can identify
indirect benefits, such as a reduction in future infections or an
improvement in patient satisfaction.

The team also should consider revenue opportunities such as
higher market share and patient volume, an increase in contract
compliance, or a reduction of bad debt. A revenue opportunity
example might be a payer who is willing to pay an organization a

https://www.healthcatalyst.com/success_stories/hospital-data-warehouse-supports-efficient-enterprise-level-infection-surveillance

https://www.healthcatalyst.com/success_stories/hospital-aquired-infections-90-percent-reduction-in-surveillance-waste/

https://www.healthcatalyst.com/how-to-drive-roi-in-your-healthcare-improvement-projects-html

bonus for reducing unnecessary pre-term deliveries. Another
revenue opportunity example is reducing the number of referrals
outside of the healthcare network.

Building the Framework

Creating a foundation for sustainable improvement and prioritizing
initiatives does not have to be overwhelming. By following these
steps and establishing a framework for performance improvement
based on analytics, the right teams, and evidence-based practices,
an organization can obtain the right tools to achieve and sustain
performance improvement gains into the future.

What failures and successes have you had in your performance
improvement initiatives?

About the Authors

Bobbi Brown is the Vice President of Financial
Engagement for Health Catalyst. Ms. Brown
started her healthcare career at Intermountain
Healthcare supporting clinical integration efforts
before moving to Sutter Health and, later, Kaiser
Permanente, where she served as Vice President
of Financial Planning and Performance. Ms.

Brown holds an MBA from the Thunderbird School of Global
Management as well as a BA in Spanish and Education from
Misericordia University. She regularly writes and teaches on
finance-related healthcare topics.

Leslie Hough Falk joined Health Catalyst in
September, 2012, as Vice President, Executive
Engagement. She has worked as both an
Executive Engagement Manager and in various
marketing roles. Leslie is a Registered Nurse.
Prior to joining Health Catalyst, Leslie worked for
Hewlett-Packard in sales, support, and marketing

roles. She also worked for Kaiser Permanente as their first Biomedical
Engineer in the Northern Region and helped launch the first Pediatric
ICU in the state of Nevada. Leslie holds a Masters in Business
Administration, Masters in Community Counseling, and a Bachelor of
Science Degree in Engineering. Leslie has also earned certifications
as a Project Management Professional (PMP), Green Belt Lean, and
Information Privacy Professional (CIPP, CIPP/IT).

https://www.healthcatalyst.com/success_stories/reduce-unnecessary-elective-deliveries

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