When we think of measurement and reporting on health care quality or performance, our minds often go to the kinds of reports we see reported in newspapers or on websites that show a slew (or maybe it’s a slough!) of tables and graphs with careful footnotes on methodology and limitations and summary interpretive notes on the side. This view of health care quality/performance measurement has become predominant in our minds because it has been the form that we’ve most often seen from national agencies, quality councils, governments, health regions, etc – the kind of organizations that produce such reports that ultimately get picked up in the news.
This kind of reporting has an important place in the overall approach to health care performance measurement and transparency. I’ve done a good bit of it myself. What’s often forgotten, however, is that there are a whole host of other much more immediate forms of measurement and reporting that never make it to the newspapers, but arguably have much more impact on improvements to the daily work of health care.
Our friends from John Black and Associates (JBA) often tell the story of the “poker chip exit poll” used to gauge patient satisfaction in the spine clinic at Virginia Mason Medical Center. Five clear plastic tubes were set out in the public space of the clinic and a supply of coloured poker chips were placed beside them. Patients were asked to respond to the question “Based on your experience today, would you recommend our spine clinic to a friend or relative?” by putting a chip in the tube corresponding to the response they wanted to give (from “No, definitely not” to “Yes, definitely”).
As the day proceeds and the chips fall where they may (sorry, I couldn’t resist) the care staff and physicians get instant visual feedback from the patients they are serving as they see the chips pile up in the tubes. If the chips are down (sorry…) in the “Yes, definitely” response tube, the clinic can add in use of a small (5-10 item) supplemental pencil-and-paper questionnaire for the rest of the day to get more information on what aspect of service they may need to improve.
The idea of visual cues and feedback is central to how Lean works. As part of Lean Certification Training, I visited Autoliv, a manufacturer of vehicle airbags. One of keys to their success has been ensuring that the daily work is balanced across workers/teams and across work days, to avoid the development of bottlenecks and backlogs. This principle applies to both the work happening on the shop floor and in the office. The plant financial controller showed us the system his team developed (pictured here) to ensure their work was balanced and likely to flow well.
One of these little desktop magnetic boards sits on each office worker’s desk. It has row spaces for 30-minute time increments during the work day starting from the bottom and working to the top of each column. Each day in Autoliv’s 4-day work week is represented by a column. As the worker plans their day and week, they apply magnetic pads (like a fridge magnet) to the daily work columns, labelled with the specific work they will do. The size of the magnet pads represent the amount of time the work is predicted to take. Some pads are for 30-minute block, others are for longer durations.
When the planned work for a day begins to add up to more than 7 hours the magnets start to creep into the yellow area of the board. This is a warning level: Showing one day with work stretching into the yellow zone is okay. But multiple days in a week means that the worker is more likely to become backlogged – and is a signal to them and to their manager their workload needs to be adjusted for that day or week. If the work for planned for any day starts to add up to 9 hours or more the magnets will extend into the red zone. This is a signal to “stop and rebalance,” because work flow or quality is likely to suffer.
The beauty of this little “measurement and reporting” tool is that it is highly visible and enables the workers and their manager to instantly see who is looking overloaded with work and who might have a bit of spare capacity to share in a given day. It helps teams actively manage the workload.
We saw many of these simple, visual management tools being used in health care settings too. (I’ll share more of them in future posts) It reinforced for me that there various ways to measure and report on the quality of health care; each has its place. When it comes to helping teams actively monitor and improve their work in the moment, it’s tough to beat the KISS and tell approach.