How Balanced Scorecards Help Hospitals Put IHI Recommendations Into Action

What’s the one weak area for all hospitals implementing IHI’s “Boards on Board” guide?  Execution.

The IHI white paper, Execution of Strategic Improvement Initiatives to Produce System-Level Results (by Thomas W. Nolan,  Institute for Healthcare Improvement; 2007; available on www.IHI.org) makes this case and offers a plan for overcoming the execution hurdle.

The fact is the very heart of the solution this white paper proposes already exists within your organization if you have a Balanced Scorecard (BSC) framework. A healthy BSC framework and IHI’s proposal are both based upon two key factors: FOCUS and REVIEWS. 

FOCUS
The struggle within large health care organizations is that everybody wants to see everything and it’s hard to keep executives focused on the “critical few.”  Lack of focus leads to under-resourced projects that don’t achieve improvement. The BSC is all about focus (narrowing a strategic plan down to a max of 10-12 objectives).

REVIEWS
Here is my high-level summary of what IHI suggests are best practices for conducting reviews:

1)       Insist that all teams follow a consistent review structure

2)       Start by reviewing action items from the last review

3)       Discuss alignment (your team’s objectives to system level objectives, measures to the objectives, initiatives to the measures)

4)       Discuss progress on the aligned initiatives that will move results (IHI recommends following the SBAR technique: Situation, Background, Assessment, Recommendation)

5)       Agree on barriers or emerging issues

6)       Capture your action plan

7)       Document and spread knowledge you’ve learned

These best practices resonate closely with guidelines for reviewing a BSC that Jack Steele covers in his two posts: Building Accountability Into a Balanced Scorecard Framework and Balanced Scorecard-Based Business Reviews: What to Look For

IHI recommends a performance management framework with four components. Here is how the BSC fits with and complements these recommendations:

1)       Setting breakthrough performance goals – in the BSC goals = objectives.  The pitfall IHI wants to help you avoid is simply “rewording” the objective to a lower level audience.  Hospitals that do this stay within their silos and align measures horizontally.

2)       Developing a portfolio of projects to support the goals – in the BSC, projects are ideally aligned to leading measures.  IHI asks executives to concede that one project is not sufficient to accomplish a top level objective.  They ask executives to make sure they have leading measures aligned to the outcome measures on their scorecards and to align projects to those leading measures that are under-performing.

3)       Deploying resources to the projects that are appropriate for the aim – sustained improvement is a cornerstone of the BSC.  Try thinking of project resources as executive sponsorship and dedicated time.  Have an executive team member sponsor the objective and executive sponsors for each project that will influence it.  Then allow project leaders to dedicate at least 40% of their time to getting the project done on time.

4)       Establishing an oversight and learning system to increase the chance of producing the intended results – this is what your organization gains from holding consistent reviews of your scorecards. Here is an overview of what the IHI "learning system" entails:

- Provide encouragement

- Review scorecards to see if key projects are on track

- Get late projects back on track

- Decide if projects need to be modified or stopped

- Set expectations

- Develop leaders' skills

- Role model behavior

Summing up, if you have even a preliminary BSC framework, you've already taken at least one big step toward achieving the IHI recommendations (by articulating your focus areas). And, just as I preach that a BSC must fit into a broader performance framework, which we call Strategy Execution, IHI recognizes that taking a systematic approach to execution is critical.