Healthcare Performance Management Using the Balanced ...

Toronto, November 20, 2003

© SSPA 2003. Todos los derechos reservados

Healthcare Performance Management using the Balanced Scorecard in Andalusia

Víctor Reyes. MD, PhD

Agencia de Evaluación de Tecnologías Sanitarias de Andalucía

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Organisational structure of the PHSA

Functional Organization

Strategic Framework of the Information Systems

Current state of the Information Systems

BudgetContents

Public Healthcare Service in Andalusia

Balanced Scorecard

Starting Point: Strategic Approaches

Conceptual Model Perspectives

Project Stages

PHSA-Balanced Scorecard

Conclusion

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Organisational structure of the PHSA

Functional Organization

Strategic framework of the Information Systems

Current state of the Information Systems

BudgetContents

Public Healthcare Service in Andalusia

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Andalusian Public Healthcare Service organisational chartLegal framework PUBLIC HEALTHCARE Law (14/1986, 25 April)

PUBLIC HEALTHCARE Law FOR ANDALUSIA (2/1998, 15 June)

Principles

Public financing

Universal protection

Integral provision

Equitable distribution of resources

Healthcare Technologies Assessment Agency

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The PHSA´s functional Organization

33 areas of primary assistance.

It provides healthcare services to 7.4 million citizens

33 public hospitals

150 specialized assistance centres

7 blood transfusion centres

Healthcare and non-healthcare Personnel

Board of Healthcare – Provincial Delegations - SAS central services

SAS provision of healthcare services centres

Emergency healthcare, state company

Source: Andalusian hospitals, directory 2000 . Situation in 31/12/00

Beds: 25,000

Source: Andalusian Autonomous Community budget. Personnel AnnexDrafted by: Insuring, financing and planning General Management

People: 91,817

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Strategic framework of the PHSA´s information systems

The PHSA-Board of Healthcare has made a great effort over the last five years to improve the way that information technology is managed.

Improving the way that information technologies are managed has become a strategic target for the PHSA-Board of Healthcare, and this is reflected in the Quality and Efficiency Framework Plan, which includes a specific approach for strategic performance from the outset of the legislature.

Numerous projects linked to ICT have been developed over the latter period, which lay the groundwork for integration in the future, the development of systems that generate information for decision-taking and the concept of a single digital strategy for the PHSA as a whole.

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Position: In the information age, information and communication technologies are the driving force required to modernise the PHSA.

The digital strategy of the Public Healthcare Service of Andalusia is studying current information and communication technologies with a view to using them as tools that generate new growth strategies and lines of action.

The Public Healthcare Administration of Andalusia considers the modernisation of the Healthcare service as a core strategic element, which is fully expressed in a new concept called Digital Healthcare in Andalusia.

The framework for the new strategic orientation of the Public Healthcare Service of Andalusia takes a new approach, with regard to information and communication systems and technologies, and seeks to generate value, both in terms of quality and efficiency.

Digital Healthcare in Andalusia (Digital strategy): defined as an organisational process whereby the Public Healthcare Service of Andalusia incorporates digital information and communication systems and technologies into its corporate functions, not only as the scenario and driving force for change and but also as a model of technological integration geared to the individual member of the public (ISTGC Paradigm, integration of systems and technologies geared to the individual).

ISTGC

Strategic framework of the information systems

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This shows the elements that have been analysed, those developed and those under development; the existing information gap is also shown:

StrategicHealthcare Directives

Technological projects plan

Application projects plan

Change management

Current state of the PHSA´s

ISs

PHSA´s IS functional framework

STRATEGIC MAP

TACTICAL MAP

OPERATIONAL PLAN DIGITAL STRATEGY

GAP

High level functional

implications

DIGITAL STRATEGY

An analysis of the framework for the information systems consists of the following elements:

Definition of the

architectural model

Digital Paradigm

SS.II.´sfunctional strategy

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The functional architectural model must reflect the PHSA´s determination to place the individual at the centre of the Service, converting the professionals, who work in the Healthcare Service, into its linchpin, guaranteeing the attainment of these objectives and use knowledge management as one of the key elements in reaching this target.

Objective

The elements of change that underpin this model can be summarised as:

Services provided solely in person

Separate management areas

Difficulty in integrating the provision of healthcare services process Personnel administrative management

Orientated to the individual

Process management / Single provision of healthcare services process Use of digital clinical records

CHANGE

Integral people management

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Analysis of the current state of the PHSA´s information systems

The principal conclusions that can be drawn from the study carried out on the Public Healthcare Service of Andalusia's (PHSA) informational resources and applications, which analysed their current state, show that there are 871 IT systems operating at the present time.

List of corporate IS projects currently under development in the PHSA:

PHSA balanced scorecard

Geographic information system

Digital Healthcare record of the individual.

Virtual work environment (Corporate Intranet)

Citizen information and services Centre (CEIS).

Healthcare Portal (Inters@s).

Purchases and logistics complete cycle model .

Computerisation of GPs´surgeries.

Economic-financial management information systems.

Decision support system (DSS).

Personnel management information system.

Healthcare virtual environments.

States Nº %

Exploitation 747 86%

Development 16 2%

Implementation 49 6%

Short-medium term 47 5%

Obsolete 1 0%

Others 11 1%

Total 871 100%

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The investment in information and communication systems and technologies in the Public Healthcare Service of Andalusia:

The percentage of the budget allocated to information and communication technologies currently stands at 0.91%, and the goal is to reach 2% over the next four years.

% in systemsand technology

Systemsand technology budget (€) SAS Budget (€)

0.68%39,053,8415,731,426,5252002

0.91%52,429,5355,762,651,0002003

Budget

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Objective

Proposal for recommended action

Benefits

Project stages

Crucial aspects for success

ContentsBalanced Scorecard

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DataReports

Ad-hoc & OLAP

reports

Descriptive Model

Predictive & Optimization

model

Wisdom

Data Information Knowledge Intelligence

The analytical systems´ evolutionary levels

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PAST

Transactional systems

TODAY

FUTURE

Analytical applications

The information system should look to the future

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What is it?

A BSC is a management tool

Definition

What does it do?

that helps organisations translate strategy into operational objectives

Why?

that in turn act as guidelines to achieve business results and to strategically align the behaviour of the people in the Organization.

Source: Robert Kaplan: The 2nd Annual Balanced Scorecard Summit, Oct 1999 .

“Anything that can't be measured can't be improved ””

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Initiative 1Initiative 1

Initiative NInitiative N

Strategic objective

IndicatorsIndicators Period 1Period 1 ...... Period nPeriod n ManagerManager

Indicator 1 Target 1 ... Target n Manager 1



Strategic map

The strategic map defines the strategic management context at each level of the entire structure's strategic architecture. It consists of strategic objectives drawn up according to the cause-effect relationship.

This defines the key indicators used to measure each strategic objective, the goals that mark the plan's benchmarks and the managers responsible for assessing whether they have been reached.

The strategic initiatives enable the proposed objectives and targets to be reached.

Strategic initiatives

The Balanced Scorecard's basic elements

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Perspectives ANDALUSIAN PUBLIC HEALTHCARE SERVICE Perspectives ANDALUSIAN PUBLIC HEALTHCARE SERVICE

Kaplan and Norton's BSC uses 4 perspectives to analyse the Organization

Financial

Customers-Citizens

Internal processes

Learning and growth

What financial objectives do we have to reach in order to fulfil the Andalusian Parliament's budgetary restrictions?

What healthcare do we have to provide the individual with to ensure that resources are being used efficiently?

What processes must we excel at to satisfy the individual?

What infrastructure do we need in order to achieve excellence?

Vision

Mission

Values

ObjectivesStrategic approaches Indicators

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Contents Starting point: Strategic Approaches

Conceptual model perspectives

Project stages

Balanced scorecard - PHSA

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The PHSA´s principal strategic lines

The Board of Healthcare establishes that the citizen is at the centre of the Public Healthcare Service of Andalusia and that their satisfaction is an intrinsic part of quality.

The PHSA´s strategic framework is embodied in the following strategic lines:

Citizen

People development

Quality

Assessment

Information systems and

technology

Financing

Communication

Research

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• Healthcare based on the definition of the provision of healthcare services processes, from the perspective of continuity of provision of healthcare services.

• Introduction of accreditation mechanisms for processes, centres, services and people.

• Introduction of quality criteria for the provision of healthcare services processes for contracts with suppliers.

• Consolidation of a quality culture in centres that provide healthcare services.

• Development of people policy both in the present and the future.

• Efficient management of human resources.

• Incentive measures-motivation model.

• Making the system more flexible, from the judicial-legal point of view.

• Development of a Research Line, allocating finance to the Research Programme in order to improve the PHSA´s healthcare services.

• Foment a culture of research excellence.• Use assessment and quality systems for the research projects. • Institutional support for the public dissemination of the results of research into Healthcare.


Citizen

People development

Quality

Assessment


technology

Financing

Communication

Research Quality

People development

Research

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• Assessment system (KPI Indicators) for provision of healthcare services processes.

• BSC management.

• Concept development: Digital activity.• Implementation of digital strategy.• Implementation of the ISTOC paradigm.

• Budgetary forecast analysis.• Definition of the financial models. • Definition of the investment policy and the acquisition of goods and services model. • Creation of a Central Purchases Agency.

• Design and development of the Communication Plan. • Monitoring and assessment of the PHSA´s strategic lines.


Citizen

People development

Quality

Assessment


technology

Financing

Communication

Research

Assessment

Information systems and technologies

Financing

Communication

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The perspectives are wide analytical areas or dimensions that are used to measure the organisation's strategic performance

They will be the base used to identify, communicate and measure the success of a strategy in the Organization. Studying them as a whole will enable us to gain a complete view of the strategy, in which the PHSA´s aims are clearly shown.

All the perspectives are defined using the basic pillars and criteria on which the BSC´s conceptual framework is built. They should comply with the following specifications:

Conceptual model perspectives

Further the attainment of the PHSA´s mission

Follow a strategic line

Identify the person in charge

Not clash with other perspectives

Be measurable

Be limited in number

Be self-explanatory concepts

Focus on interest groups

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Balanced Scorecard

The Balanced Scorecard for Andalusia’s Public Healthcare System is a tool for managing the strategic objectives established by the Healthcare Department, and moreover it is a means of communication, following the premise of transparency of the system.

The conceptual model of the Balanced Scorecard for Andalusia’s Public Healthcare Department is structured around perspectives

The perspectives are those components into which the strategy is divided, representing a point of view for evaluating the Healthcare or performance of the Organization, making it possible to identify, communicate and measure the success of the organisation’s strategies. The BSC differentiates various perspectives:

CommunityCommunity

CitizenCitizen

FinanceFinance

ProcessesProcesses

PeoplePeople

KnowledgeKnowledge

SupportSupport

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Accessibility

Balance

Comunidad

Swiftness

Participation

Efficiency

Horizontal planning

ComunidadCommunity

Perspectives Balanced Scorecard

CommunityCommunity

The general objective of the Community perspective is to guarantee the viability and the sustainability of the PHSA

This perspective refers to the following strategic objectives which we have to achieve in order to fulfil PHSA’s commitment to the community:

Favour accessibility to Favour accessibility to the PHSAthe PHSA

Improve the speed of Improve the speed of the servicethe service

Promote the ways that Promote the ways that the public participates the public participates

in PHSAin PHSA

Promote planning Promote planning between the sectionsbetween the sections

Improve the efficiency Improve the efficiency of the systemof the system

Degree of Degree of Implementation of Implementation of Horizontal PlansHorizontal Plans

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Public guarantees

Ciudadano

Satisfy expectations

Ability to choose

CiudadanoCitizen


CitizenCitizen

The general objective of the Citizen perspective is the person themselves, acknowledges as the core of PSHA

This perspective refers to the following strategic objectives that we have to achieve to fulfil the commitment of the PSHA to the citizens regarding healthcare:

Ensure that these are fulfilled Ensure that these are fulfilled (knowledge of the statements on Rights and Duties)

Improve satisfaction of Improve satisfaction of expectations expectations (perceived quality, average waiting

times,etc.)

Guarantees the person’s Guarantees the person’s ability to choose ability to choose (to

change doctor, to a second opinion, free choice of

healthcare facility)

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Economy

Investments

EconómicaFinancial TaxationEconómicaFinancial


FinancialFinancial

The general objective of the Financial perspective is effective financial management comprising of all those financial, economic and tax- related aspects which affect healthcare provision

This perspective refers to the following strategic objectives which we much accomplish in order to comply with the budgetary restraints of the Parliament of Andalusia:

Improve additional Improve additional Financial Management Financial Management

(Invoicing insurance companies)

Improve Taxation Improve Taxation management management (claim

interest for PSHA, debt levels)

Ensure cost controls Ensure cost controls (carry out the budget, deviation analysis)

Comply with PSHA’s planned investment policyComply with PSHA’s planned investment policy

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ProcessesProcesses

The general objective of the Processes perspective is to guarantee the provision of healthcare to the utmost levels of science and technology available and the location of the resources to be able to provide such a service

This perspective refers to the processes in which we need to achieve excellence in order to satisfy the members of the public:

Degree of introduction of the Degree of introduction of the defined Processes Chartsdefined Processes Charts

Incorporation of Incorporation of guidelines and guidelines and

healthcare provision healthcare provision protocolsprotocols

Improve the Improve the accreditation accreditation mechanismsmechanisms

Monitoring alarm Monitoring alarm systems systems (safeguards)

Improve scientific and Improve scientific and technical effectivenesstechnical effectiveness

Improve PSHA’s ability Improve PSHA’s ability to respondto respond

Management of processes

Warningsystems

Procesos

Continualimprovement

Accreditation

Effectiveness

Average response

times

ProcesosProcesses

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Appropriate workforce

Healthcare and Safety

Personas

Management policies

Motivation

Professional Development

Communications

PersonasPeople


PeoplePeople

The general objective of the People perspective is the management of the organisation’s most valuable asset, which is the personnel

This perspective refers to the following strategic objectives which we must achieve in order for our Organization to be able to count on an excellent team of personnel:

Personnel managementPersonnel management

Improve the qualifications Improve the qualifications of management teamsof management teams

Improve the mostivation Improve the mostivation and expectcations of and expectcations of professionals professionals (salaray

policy)

Improve Healthcare and Safety Improve Healthcare and Safety elementselements

Introduce performance Introduce performance management management (selection, training, assessment and

promotion)

Increase internal Increase internal communicationcommunication

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Co-operative apprentiship

Research

Conocimiento

Develop knowledge

Excellence

Easy to access

Development

Knowledge


KnowledgeKnowledge

The general objective of the Knowledge perspective is managing the knowledge that resides in the whole Organization, which is recognised as the most valuable asset

This perspective refers to the following strategic objective which we have to achieve in order for our Organization to achieve effective and efficient knowledge management:

Structure and organise Structure and organise knowledgeknowledge

Improve on the Improve on the development and growth development and growth

of current knowledgeof current knowledge

Improve PSHA’s Improve PSHA’s excellence through excellence through

researchresearch

Boost researchBoost research

Increase the transparency Increase the transparency of the systemof the system

Develop new Develop new knowledgeknowledge

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Organisational function

Soporte

Healthcare technology

Information systems

SoporteSupport


SupportSupport

The general objective of the Support perspective is to adapt the administrative structures, the institutional resources and the technical resources throughout the Organization

This perspective refers to the following strategic objectives which we have to achieve in order to count on an infrastructure that can guarantee that the PSHA functions properly:

Adapt the organisational and functional structures Adapt the organisational and functional structures to the procedural methodologyto the procedural methodology

Focus information and Focus information and communication communication

technology towards technology towards decision making decision making

(Integration, standardisation and orientation)

Improve the rational Improve the rational use of healthcare use of healthcare

technologytechnology

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Project Planning

Project Organization

Consider the “State of the Art” Balanced Scorecard

Consider the Strategic Objectives of the PSHA

Analysis of the current Technology and Information Systems

STRATEGIC VISION

DIAGNÓSTICO SITUACIÓN ACTUAL

Define the Perspectives and Strategic Objectives

CONCEPTUAL DESIGNNEW MODEL

Identify Indicators (KPI) and metrics

Define the information architecture structure

Managing change / Communication Managing change / Communication

LANZAMIENTO DEL PROYECTO

Analysis of procedures

Identify Information Requirements

Action Plan

Project Calender

“Gap“ Analysis“Gap“

Analysis

Stage 1: Analysis of the situationStage 1: Analysis of the situation Stage 2: Conceptual DesignStage 2: Conceptual Design Stage 3: Action Plan Stage 3: Action Plan

Choose and purchase the software

Project Management Project Management

Project Stages

Define the organizational architecture structure

Technological and Organizational Directives

CRITICAL SUCCESS FACTORS

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Stage 1: Analysis of the situation

Tasks Objectives

Launching the project

Organising and planning the project. Initial communication of the project.

• General Organization of the Project.• Preliminary definition of the scope of the project.• Involvement of the Organization in the work schedule.• Define the work Procedures, communication, access and sharing of

documents. Project Timetable Matrix of resources and tasks. Model documents.

Strategic Vision

Consider the Board’s strategic objectives.

Assess the Information and Technology Systems

• Shared vision of strategy and objectives.• Initial assessment of the impact on the Organization.

Change Management/Communications Change Management/Communications

Stage 1 Stage 2Stage 2

Stage 3Stage 3


Technology/Organizational Directives Analysis of the implications. Hold meetings between the group and

management teams. Communicate with the Organization

• Shared strategy vision. • Analysis of Technology Models.

Draw up technology and organizational guides.

Project Stages

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Tasks Objectives

Diagnosis of the current situation

Check the critical processes. Identify the key information

requirements. Check the current Information Systems. Check the current communications

system.

• List the functional and information requirements.• Identify opportunities for improvement linked to the Information Systems.• Inventory and description of programs.• Inventory of hardware and networking.

Inventory of requirements Program Chart Technology and networking chart List of opportunities for improvements

Stage 1: Analysis of the situation

Project Stages

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Tasks Objectives

Definition of Perspectives and Strategic Objectives

Construction of a model which guarantees the following premises:

Orientated towards the members of the public.

Continuity in the healthcare provision process.

Integration of the model into the strategic approaches defined by the PSHA

• Conceptual design of the BSC-PSHA model.• Description of the functional implications of the various perspectives

and identification of the relationships between them.

Conceptual Model.

Stage 2: Conceptual Design Change Managenet/Communications Change Managenet/Communications

Stage 1Stage 1 Stage 2 Stage 3

Stage 3


Project Stages

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Tasks Objectives

Identify Key Performance Indicators and metrics

The KPI should guarantee:

The strategic objectives of the PSHA are brought into line.

The information requirements of the different user groups are aligned as much as possible.

Ensure that the future development and upgrading of the model (top-down from the corporate level to the required operational level).

• Describe the KPI´s for the various different strategic objectives being considered

• Identify new KPI’s to be considered to improve the conceptual model.• Estimate the possible future upgrade of the model to other areas of the

Organization.

List of indicators (KPI). Metric definitions.

Stage 2: Conceptual Design Change Management/CommunicationsChange Management/Communications


Stage 3

Project ManagementProject Management

Project Stages

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Tasks Objectives

Design of the infrastructure’s architecture

Technological specifications of the new information system (BSC).

• Conceptual design of the technological and communications architecture.• Specifications for servers, teams and lines of communication.• Specifications for the datawarehouse.• Approximate Implementation Costs for the network.

New technology and communications map. Features of the different teams required.

Stage 2: Conceptual Design

Analysis of the technological, functional and supplier requirements and the software solutions that exist on the market

List of software solutions, describing their adaptability to the PSHA’s objectives

Change Management/Communication Change Management/Communication


Stage 3


Project Management

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Tasks Objectives

GAP Analysis Identify the actions and resources

needed to assist introduction Inventory of actions that conform with the Introduction Plan

Stage 3: Action Plan

Action Plan for introducing the BSC

Identify and quantify the actions to be carried out (projects).

Define the timeframe for this. Prioritise the projects.

• Inventory of projects achieved to introduce the Introduction Plan.• Time and financial planning and management of the resources required.• Approval and communication of the Plan.

Planning of the project in stages. Project specifications.

Change Management/ Communication Change Management/ Communication

Stage 1Stage 1

Stage 2Stage 2 Stage 3

Project ManagementProject Management

Project Stages

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Stage 1Stage 1

Stage 2Stage 2

Stage 3Stage 3

Undertaking the introduction of a BSC in any complex organisational structure, as is the case with the PSHA, requires a series of critical factors to be taken into consideration. These critical factors can have a decisive bearing on the success of the project.

All these factors converge into a common idea: the need to carry out appropriate change management to ensure that the project’s objectives are achieved.

The factors to consider in order to achieve appropriate project management are:

Generate positive attitudes towards change.

Build an understanding and shared idea regarding the reasons for the change.

Count on the commitment of Upper Management.

Balance the technical and personnel aspects of the approaches to change implementations.

Involve the people who have to support the change, in the process.

Communicate and train the teams and people affected.

Create and reward achievements.

Managing Change

Critical Success Factors

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Conclusion

The Balanced Scorecard for Andalusia’s Public Healthcare Service is encompassed within the PSHA’s strategic policy, as a tool for communicating between the different organisational levels, with the objective of providing high quality healthcare services to the citizens.

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Agencia de Evaluación de Tecnologías Sanitarias de Andalucíahttp://www.csalud.junta-andalucia.es/orgdep/AETSA/

Víctor Reyes AlcázarAgencia de Evaluación de Tecnologías Sanitarias de AndalucíaAvda. de la Innovación s/n. Edificio Arena 141020 [email protected]

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