Introduction – Why Measure

There is an old adage, “What gets measured is what gets done.” While there are exceptions to this it is a good starting point for thinking about measurement and its benefits. Certainly without measurement one has to rely on perceptions and these are often characterized by:

• blind spots (we can’t see the measure at all), e.g. Patient Satisfaction is something we cannot know unless we ask the patients
• inaccuracy (what we sense is not correct), e.g. One might think our reimbursement rate is excellent, without knowing that 30% are rejected due to errors
• bias (we alter the measure based on our experiences and desires), e.g. someone might consider the healing rate to be good compared with the palliative care facility they came from.

Objective measurement seeks to give us the bald facts, uncomfortable though that may be, and so allow us to confront the issue the measure illuminates.

Furthermore measurements provide a common and visible point of reference on which all may agree, thereby dispensing with discussion of whose perception of the situation is most accurate. Not that they do away with all debate, however the debate may begin at a point closer to the real issue.

Finally measurements remain objective and visible over time, thus showing trends and highlighting effective or ineffective actions that may have been taken towards some goal. Such trends are often hidden from our daily perception either by virtue of their subtlety or complexity.

Good measurement, therefore, forms the basis for establishing what may need changing, informs the decisions on prioritising conflicting demands for action and allows the effect of such actions to be monitored for their quantitative impact. It is likely that any program of work that fails to monitor its progress will be fortunate if it delivers the magnitude of beneficial change that all involved hope for, hence measurement should form both the starting point and the end point of any project to effect change.

Measure to establish current situation → Plan activities → Implement Plan → Measure Effect

What makes a good measure

Regrettably not everything that is necessary to be measured is possible to be measured and vice versus. It is quite common for teams and individuals to have difficulty balancing between importance and practicability. Some measures seem too simple to reflect the complexity of the task while other measures are simply too complex or challenging to obtain. If there are multiple measures that provide an indication of the change being monitored it can become difficult to choose among them.

One way to think about what makes a good measure is to think about the analogy of the motor car, where the driver is presented with a wide range of vital information, but where many things are also not measured.

What isn’t measured?

• Piston wear – this changes slowly over time and the effect is rarely dangerous or immediately detrimental
• Drive shaft radius – this does not change over time.
• Accident status – when an accident does occur it is immediately obvious without a measurement device to inform the driver.
• Vehicle age – although this is important in terms of value and performance, there is nothing you can do about it as a result of the measure.
• Driver tiredness – which is an ideal candidate for measurement since it has the potential for very negative outcomes and so is important, does change over time, can be immediate in its effect and can be acted on if identified. The only reason it is not measured is that it is currently very hard to obtain the objective data (though companies are working on it).

What is measured?

The key criteria considered in the table above are Importance, Variability, Immediacy and Simplicity:

• The Importance of that factor to your business, your customers, your costs etc. There is little point in measuring things that are of no consequence, but it might be worth spending considerable resources to measure those things which are critical to your business success.
• Variability is how often this factor is likely to change. This impacts the frequency of measurement, since there is little point in performing daily measurement of factors that show little change even on a monthly basis. However factors that might become suddenly unacceptable need monitoring often enough to pick up the change.
• Immediacy is how quickly the impact of the change is likely to be felt in your business, by your customers etc. This is also related to frequency of measurement (you need time to react after identifying an issue) and your organization’s responsiveness. A low frequency of measurement may be sufficient for an effect with very low immediacy since you would still have time to correct it (hopefully) before its effects are felt.
• Simplicity is related to the ease by which that factor might be measured. Even the simplest measurement will consume some resources: money, staff time, computing resources etc. However it might be better to monitor 2 or 3 easily measured factors than one difficult one (where the simple ones combined give you insight into the issue).

So, what does make a good measure?

In general one should decide what the priorities in your business are – this is generally driven by your organization’s objectives and strategy. E.g. If the objective is to be considered in the top 10 for clinical performance by achieving superior healing rates then clearly emphasis should be placed on measures that track clinical performance. This is not to say that other measures should be completely excluded – for instance the financial picture should not be overlooked since that might result in the organization being in the list of top 10 facilities for clinical performance that overspent their budget this year! However more measures would be selected relating to clinical performance and patient satisfaction than, say, financial or learning and growth.

The actual measures selected should strike a realistic compromise between providing insightful and actionable information and being reasonably easy to obtain. Try to avoid those measures that consume large amounts of staff time to obtain since this prevents them doing their primary jobs (and probably negatively impacts the measure as a result), unless knowing the measure is vital to the business. If so consider investing in tools or external resources to gather the information.

Seek alternative measurements where the preferred one is too difficult to do. For instance, it would be hard to measure the level of practical, up-to-date clinical knowledge of each member of the clinical team, but you might look at the number of training courses and conferences they have each attended, coupled with a short questionnaire about how they keep themselves up to date.

Focus only on those things where you have a realistic possibility of creating change.

Set the frequency of measurement to be consistent with the likelihood of change – Bed fill might be measured daily, however average staff salary need not be measured so often.

Do not track things that only confirm what you know or where you won’t effect change.

Keep the number of measurements relatively low. If you seek to measure more than a handful of areas you will find you are stretched too thin, overburdened with data and may suffer analysis paralysis. It is better to act on one key area and make it a success than to try to change everything and fail.

Set targets for your measures, so that you and your team know what they are aiming for.

What next

Review your selection of measures and targets periodically to see whether you are achieving what you intend. Once you consistently reach your target for a particular measure you may choose to work on a different area as an alternative to raising the target further. It is entirely reasonable to say that you are happy with your performance in one measure and divert resources to weaker areas. Also remember the Pareto principle, which suggests that there is a law of diminishing returns in striving for perfection.

Conclusion

Above all, keep your measurements as simple as they can be, ensure you and your team understand why they are measuring these things- what you hope to achieve and how – and don’t hesitate to share both the shortfalls and the successes; you will be amazed at how well people respond to the challenge, especially where they can see how their actions are linked to the successes your facility or organization is having.