The seven healthcare outcome measures are meant to understand the quality of health systems and how they could be measured and how quality care could be provided to clients.

1. The Top Seven Healthcare Outcome
Measures and Three Measurement
Essentials
Ann Tinker,MSN,RN
, Professional Services,SVP
October30,2018
Posted in OutcomesImprovement.
The healthcare industry is riddled with
administrative and regulatory complexities that make it difficult for health systems to achieve
the Triple–or better yet, the Quadruple–Aim of healthcare. The complexities found in outcomes
improvement are particularly challenging, as health systems measure and report on hundreds
of these outcomes annually. Health systems can manage these complexities by taking a closer
look at outcome measures—understanding their definitions and nuances, reviewing real-world
examples, and integrating three essentials for successful outcomes measurement.
Why Measuring Healthcare Outcomes Is Important
The goal of measuring, reporting, and comparing healthcare outcomes is to achieve the
Quadruple Aim of healthcare:
1. Improve the patient experience of care.
2. Improve the health of populations.
3. Reduce the per capita cost of healthcare.

2. 4. Reduce clinician and staff burnout.
The organization behind the Triple Aim—the Institute for Healthcare Improvement (IHI)—is
dedicated to outcomes improvement. IHI describes measurement as “a critical part of testing
and implementing changes. Measures tell a team whether the changes they are making actually
lead to improvement.” The fourth aim may vary depending on the organization.
Healthcare organizations–motivated by the Quadruple Aim–measure outcomes for several
reasons:
 Reveal areas in which interventions could improve care.
 Identify variations of care.
 Provide evidence about interventions that work best for certain types of patients under
certain circumstances.
 Compare the effectiveness of various treatments and procedures.
Outcome Measures Defined
The World Health Organization defines an outcome measure as a “change in the health of an
individual, group of people, or population that is attributable to an intervention or series of
interventions.” Outcome measures (mortality, readmission, patient experience, etc.) are the
quality and cost targets healthcare organizations are trying to improve.
Outcome measures are frequently reported to the government, commercial payers, and
organizations that report on quality, such as The LeapFrog Group—a national nonprofit that
evaluates and reports U.S. hospital safety and quality performance. LeapFrog’s work centers on
“increasing transparency among health care providers in order to reduce the estimated 440,000
annual deaths from hospital errors, accidents, and injuries.” While initial measures focused on
inpatient care, they have since expanded to include most aspects of care delivery.
Outcome Measures Are Driven by National Standards and
Financial Incentives
Outcome measures are primarily defined and prioritized by national organizations, including
CMS, The Joint Commission, and the National Association for Healthcare Quality (NAHQ).
Health systems target outcome measures based on state and federal government mandates,
accreditation requirements, and financial incentives.
Although healthcare outcomes and targets are defined at the national level, health systems
might set more aggressive targets. Meeting and exceeding these national targets, benefits not
only quality of care, but also healthcare organizations’ marketing and contracting efforts.

3. Reporting and accreditation entities have processes in place to normalize outcomes data to
account for context, which is key when it comes to reporting. It’s easy to take data out of
context. Using fall rates as an example, if a small, 10-bed hospital sees 10 patients in one month
and one patient falls, then their fall rate is high (10 percent).
The Joint Commission is a regulatory body that accredits health systems and has national
standards for quality measures that are “developed with input from healthcare professionals,
providers, subject matter experts, consumers, government agencies (including CMS) and
employers.” New standards must meet the following strict requirements:
 Relate to patient safety or quality of care.
 Positively impact healthcare outcomes.
 Meet or surpass law and regulation.
 Can be accurately and readily measured.
CMS uses outcome measures to calculate overall hospital quality. In a 2018 report, CMS
explained how it arrived at its 2018 hospital star ratings. CMS grouped outcome measures into
seven categories weighted by importance:
5. Mortality (22 percent)
6. Safety of care (22 percent)
7. Readmissions (22 percent)
8. Patient experience (22 percent)
9. Effectiveness of care (4 percent)
10. Timeliness of care (4 percent)
11. Efficient use of medical imaging (4 percent)
The Top Seven Healthcare Outcome Measures Explained
There are hundreds of outcome measures, ranging from changes in blood pressure in patients
with hypertension to patient-reported outcome measures (PROMs). The seven groupings of
outcome measures CMS uses to calculate hospital quality are some of the most common in
healthcare:
#1: Mortality
Mortality is an essential population health outcome measure. For example, Piedmont
Healthcare’s evidence-based care standardization for pneumonia patients, resulted in a 56.5
percent relative reduction in the pneumonia mortality rate.
#2: Safety of Care
Safety of care outcome measures pertain to medical mistakes. Skin breakdown and hospital-
acquired infections (HAIs) are common safety of care outcome measures:

4.  Skin breakdown—happens when pressure decreases blood flow to the skin. A skin
assessment tool can be used to reduce skin breakdown. Patients with skin breakdown
are at a higher risk of infection. Patients’ risk scores go up if they’re diabetic, for
example, because their circulation is poor.
 HAIs—caused by viral, bacterial, and fungal pathogens. For example, Texas Children’s
Hospital identified evidence-based bundles to reduce HAIs in children through their
partnership with the Solutions for Patient Safety National Children’s Network. Using an
enterprise data warehouse (EDW) and analytics applications to identify vulnerable
patients and monitor clinicians’ compliance with best practice bundles, Texas Children’s
Hospital decreased HAIs by 35 percent.
#3: Readmissions
Readmission following hospitalization is a common outcome measure. Readmission is costly
(and often preventable). In fact, researchers estimate that in one year, $25 to $45 billion is
spent on avoidable complications and unnecessary hospital readmissions. After increasing
efforts to reduce their hospital readmission rate, the University of Texas Medical Branch
(UTMB) saw a 14.5 percent relative reduction in their 30-day all-cause readmission rate,
resulting in $1.9 million in cost avoidance. UTMB reduced their hospital readmission rate by
implementing several care coordination programs and leveraging their analytics platform and
advanced analytics applications to improve the accuracy and timeliness of data for informing
decision making and monitoring performance.
#4: Patient Experience
Patient-reported outcome measures (PROMs) fall within the patient experience outcome
measure category. According to the Agency for Clinical Innovation (ACI), PROMs “assess the
patient’s experience and perception of their healthcare. This information can provide a more
realistic gauge of patient satisfaction as well as real-time information for local service
improvement and to enable a more rapid response to identified issues.” For example, a patient
might be asked to complete a satisfaction survey (on a scale of 1-5) about the care they
received.
Patient experience may also be used as a balance metric for improvement work. For example, a
care delivery process may decrease the LOS, which can be a positive outcome, but result in a
decreased patient satisfaction score if patients instead feel they are being pushed out.
#5: Effectiveness of Care
Effectiveness of care outcome measures evaluate two things:
12. Compliance with best practice care guidelines.
13. Achieved outcomes (e.g., lower readmission rates for heart failure patients).
Given the rapid changes that occur within healthcare, making sure best practice care guidelines
are current is critical for achieving the best care outcomes. It’s important to track clinician

5. compliance with care guidelines; It’s equally important to monitor treatment outcomes and
alert clinicians when care guidelines need to be reviewed.
Failing to adhere to evidence-based care guidelines can have negative consequences for
patients. For example, according to The Dartmouth Atlas of Healthcare, “even though it is well
established that beta-blockers can reduce the risk of heart attack in patients who have already
had one heart attack, many heart attack patients are never prescribed beta-blockers.”
#6: Timeliness of Care
Timeliness of care outcome measures assess patient access to care. Overcrowding in the
emergency department has been associated with increased inpatient mortality, increased
length of stay, and increased costs for admitted patients.
A community hospital system implemented an improvement process to address overcrowding
in its ED after determining that approximately 4,000 patients were leaving its ED each year
without being seen. They leveraged their analytics platform to develop an ED analytics
application that provided actionable, timely ED performance data to focus improvement efforts
on four areas: staffing patterns, registration, triage assessment by the registered nurse, and
early access to a qualified medical provider. They achieved significant performance
improvements, including an 89 percent relative reduction in the rate of patients that left
without being seen, with current performance at 0.4 percent.
#7: Efficient Use of Medical Imaging
The efficient use of medical imaging is an increasingly important outcome measure. According
to the European Science Foundation, “Medical imaging plays a central role in the global
healthcare system as it contributes to improved patient outcome and more cost-efficient
healthcare in all major disease entities.”
For example, during Texas Children’s Hospital’s efforts to improve asthma care it discovered a
high volume of chest X-rays being administered to asthma patients. Using its EDW to examine
real-time X-ray data, it realized clinicians were ordering chest X-rays for 65 percent of their
asthma patients—evidence-based practice calls for X-rays in only five percent of cases. Texas
Children’s Hospital’s IT team traced the problem to a faulty order set within the hospital’s EHR,
and rewrote the order set to reflect the evidence-based best practice.
Process Measures Are Equally Important
Achieving outcomes is important, but the process by which health systems achieve outcomes is
equally important. Process measures capture provider productivity and adherence to standards
of recommended care. For example, if a health system wants to reduce the incidence of skin
breakdown, then it might implement the process measure of performing a risk assessment

6. using the Barden Scale for reducing pressure ulcer risk in all the appropriate units in the
hospital. If health systems are too focused on an outcome, then they lose sight of the process.
The following outcome and process measures illustrate how systems can improve healthcare
outcomes by improving processes:
 Conducting a medication reconciliation systemcheck with heart failure patients at the
time of discharge (process measure) can reduce heart failure readmission rates
(outcome measure).
 Performing a fall risk assessment on a patient at the time of admission (process
measure) can reduce fall rates (outcome measure).
 Using a skin assessment tool (process measure) can prevent skin breakdown (outcome
measure).
Three Essentials for Successful Healthcare Outcomes
Measurement
Among every health system’s goals is to improve patient outcomes. But outcomes
improvement can’t happen without effective outcomes measurement. As health systems work
diligently to achieve the Quadruple Aim, they need to prioritize three outcomes measurement
essentials: transparency, integrated care, and interoperability.
Used in tandem, these essentials improve and sustain outcomes measurement efforts by
creating a data-driven culture that embraces data transparency, an integrated care
environment that treats the whole patient and improves critical care transitions, and
interoperable systems that enable the seamless exchange of outcomes measurement data
between clinicians, departments, and hospitals.
#1: Data Transparency
Healthcare is on a journey to outcomes transparency. Patients rely on outcomes data to make
educated decisions about their healthcare. Quality reporting organizations, such as The
LeapFrog Group, evaluate and report on U.S. hospital safety and quality performance. Patients
want reassurance that they’re receiving the best care for the lowest cost. Publicly reported
healthcare outcomes help do just that.
#2: Integrated Care and Transitions of Care
The industry is also shifting toward integrated care—hospitals aren’t just treating a hip
anymore; they’re treating the whole person. A key component of integrated care is helping
patients with transitions: easing patient transitions from the ER, to surgery, to inpatient care, to
rehab, and, ultimately, back to a steady, normal state. Transitional points of care are critical for
managing consistency of care and providing the right care in the right setting at the lowest cost.

7. #3: Data Interoperability
Sharing data between departments within an integrated systemis another important
component. Outcomes measurement and improvement depends on the system’s ability to
share data across clinicians, labs, hospitals, clinics, pharmacies, and other staff, departments,
and settings. EDWs improve interoperability by integrating data and providing a single source of
truth.
Improving critical care transitions through integrated care and seamlessly exchanging data
through interoperability are essential ingredients for better outcomes measurement. For
example, as heart failure patients are discharged (depending on the risk stratification), it’s
critical for them to see a cardiologist or primary care physician as quickly as possible.
Otherwise, they have a higher risk of being readmitted.
The Quadruple Aim: The Goal of Outcomes Measurement
Outcomes measurement should always tie back to the Quadruple Aim, so healthcare
organizations aren’t just reporting numbers. Health systems shouldn’t become so obsessed
with numbers that they forget their Quadruple Aim goal. Instead, they should focus on quality
and improving the care experience at the most efficient cost.
Health systems measure outcomes to ensure they are delivering the best care for patients and
providing a transparent, efficient, and accessible environment for all healthcare providers. That
is outcomes nirvana.
Additional Reading
14. Improving Outcomes That Matter Most to Patients
15. The Top Six Early Detection and Action Must-Haves for Improving Outcomes
16. The Top Success Factors for Making the Switch to Outcomes-Based Healthcare
17. 7 Features of Highly Effective Outcomes Improvement Projects
18. 6 Steps for Implementing Successful Performance Improvement Initiatives in Healthcare
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8. Improving Patient-Reported Outcomes
March 31,2016
Patient-reported outcomes (PROs) and patient-
reported outcome measures (PROMs) aren’t new to the healthcare industry. What is new is the
pioneering work the International Consortium for Health Outcomes Measurement (ICHOM) is
doing to help healthcare organizations worldwide understand and use PROs and PROMs to
improve patient outcomes.
ICHOMis a research–based, nonprofit organization with a mission to unlock the potential of
value-based healthcare. The core of its work is to define and drive adoption of international
standards on the outcomes—by condition—that really matter to patients. According to
ICHOM’s Vice President of Standardization and Business Development, Dr. Caleb Stowell,
“Everyone’s talking about value-based health care, but what defines value? ICHOMwas
founded to answer that question.” ICHOMhas already identified standard sets for 13 conditions
(covering 35 percent of the global disease burden) and is currently working with innovative
providers and health systems globally to support the adoption of these standard sets.
The philosophy behind using PROs and PROMs is to understand patients’ health from their
perspective. Traditionally, health systems and clinicians have focused on measuring concrete
clinical outcomes because they are much easier to measure—survival is a simple, dichotomous
event. “But for most of medicine, the question is no longer whether someone will survive, but
how their life will be after treatment,” says Dr. Stowell.
In an industry that ranks health systems according to clinical and process indicators (e.g.,
mortality and infection rates), ICHOMis proving that healthcare organizations that collect and
measure PROs can learn and improve, demonstrate superior outcomes, attract patients, earn
respect, and become leaders among their peers.

9. What Are PROs and PROMs? In Search of Useful,
Meaningful Definitions
Patient-Reported Outcome (PRO)
The acronym “PRO” has been an umbrella term for decades; it’s included patient satisfaction,
productivity assessments, and anything else patient reported. The resulting definition was
broad—too broad to be useful. ICHOM’s PRO definition is based on Wilson and Cleary’s work,
which divides PROs into three main categories:
19. Symptom burden
20. Functional impact
21. Health-related quality of life
ICHOMreaffirmed this definition because it is clear and specific and distinguishes between
measures of patients’ health versus the experience of their care (increasingly documented
using Patient-Reported Experience Measures or PREMs).
ICHOMProject Leader, Dr. Sara Sprinkhuizen, has conducted extensive PROs and PROMs
research and is helping to develop a framework for global healthcare data collection and
analysis. When it comes to PROs she says, “An outcome is a result or end state; anything
measuring an intermediate state isn’t an outcome.”
Patient-Reported Outcome Measure (PROM)
A patient-reported outcome measure (PROM) is any instrument, scale, or single-itemmeasure
used to assess the PRO concept as perceived by the patient, obtained by directly asking the
patient to self-report. PROMs include any method used to collect patient input, from diaries
and event logs, to one-item or multi-item multi-domain scales.
PROs and PROMs have been used in healthcare for decades, but primarily in research settings.
The Medical Outcome Study in the 1970s measured the impact of care patterns on outcomes
for patients with chronic medical conditions and depression. The study used a 116-item survey
to assess quality of life including physical, mental, and general health. It was a landmark study;
adapted forms of the study’s survey have become gold standards in the field.
Since the 1970s, hundreds of PROMs have been developed across nearly the full breadth of
medicine, but for the most part, their use has remained narrow. However, as healthcare
consumers become more interested in understanding and acting on their own health data, and
clinicians demand analytics to understand the health of their patient populations, the demand
for PROMs has surged.
Improving Outcomes with PROs and PROMs
PROs and PROMs help healthcare organizations answer several important questions, including:

10. 22. How is our patient doing today?
23. How can we predict how our patients will respond to treatments?
24. What has the impact been of our team’s intervention on our patient’s health over time?
In their simplest form, PROMs are a mechanism for communicating how patients are actually
doing. As Dr. Stowell explains, “It’s not that clinicians don’t care about patients’ quality of life.
They do. They simply don’t ask them about these things in a structured, reliable way.”
Dr. Stowell cites the work being done at Stanford Health Care, which participated in developing,
and is measuring outcomes consistent with, the ICHOMStandard Set for Low Back Pain: “We
did a great film about their care delivery process with this kind of data in place, including a
patient interview. I loved the quote from one of their neurosurgeons, Dr. John Ratliff: ‘As a
clinician, when you come in to see the patient you have the [PROMs] information immediately
available. This benefits the patient by engaging them prior to the consultation. They are already
thinking about the outcomes that matter to them, and this cue is being provided at exactly the
right time.’ Dr. Ratliff’s patient follows with, ‘I like that when the doctor enters the room, he is
already familiar with my condition. It makes me feel more connected to my healthcare.’”
But PROMs can do more than just communicate; they can also predict a patient’s health status.
Boston-based Partners HealthCare uses PROMs data for patients with suspected coronary
artery disease to predict their likely benefit from coronary intervention. Such predictive models
have helped Partners avoid costly interventions when patients don’t stand to benefit.
And in a study of HIV patients in Alabama, data collected via PROMs regarding substance use
and depression was found to better predict antiretroviral therapy adherence compared to
clinician’s own judgment of patients.
Most importantly, PROMs can complement clinical indicators in understanding the quality of
healthcare a team is delivering. Take prostate cancer for example, in which the most common
treatment—prostatectomy—can cause high rates of incontinence and erectile dysfunction after
the surgery. An improvement program that only focuses on improving blood loss or length of
stay in the hospital completely misses a patient’s biggest fears (second only to survival): will
they need to wear pads for the rest of their life? Will their relationship with their partner be the
same as it was?
Dr. Stowell references the work of the Martini Klinik (a high volume prostate cancer center in
Germany) featured in the documentary Measured Outcomes: A Future View of Value-Based
Healthcare, “This is a care team that defines its outcomes around the patient and works every
day to improve their technique to deliver a better result. Their rates of incontinence and
erectile dysfunction are now far below anything previously thought possible.”
With the continued shift toward fee-for-value and increasing healthcare cost transparency,
patients are demanding more meaningful information on which to base their decisions. PROs
and PROMs are validated methods to provide that information.

11. Overcoming Barriers to PROs and PROMs Adoption
PROMs are getting industry-wide attention for their ability to contribute to a more holistic
picture of a patient’s health, but there are still barriers to adoption – barriers ICHOMis intent
on helping healthcare organizations overcome.
Overcoming Content Concerns
At a first pass, clinicians can have a hard time trusting PROMs. Says Dr. Stowell, “Doctors like
measurements that are physiological: blood pressure, lung function, and blood counts. PROMs
are psychological; they are inherently subjective. But they have to be that way—how else can
we assess how the patient perceives his or her illness?” According to Dr. Sprinkhuizen, the
healthcare industry tends to underestimate how precise PROMs tools are, unaware of the
science and methodology that goes into their development. She says, “PROMs should be taken
as seriously as any other medical instrument. They are scientifically and linguistically validated
instruments.”
Deciding what PROMs to use is also a big barrier adoption. When faced with a choice between
dozens of tools, health systems’ lack of understanding about the most appropriate tools for
their targeted outcomes and improvement goals can stifle their efforts; but selecting the right
tool is essential for PROMs to be clinically interpretable and actionable. As Dr. Stowell explains,
“This is the core of what we are trying to do in the field: give guidance and support
harmonization in what is, today, a very fragmented approach to outcomes measurement.”
ICHOMdevelops its recommendations, including PROM tools, through deep engagement with
international expert groups over a nearly year-long process. “Choosing the best PROM in a
given field is always the single biggest discussion point in any Working Group,” says Dr.
Sprinkhuizen. “We conduct a detailed evaluation of the tools in order to provide guidance,
including a review their validity, reliability, and clinical interpretability, but it’s not always clear
which tool is best. At times, we simply need to recommend the best currently available option
to get started and move the field forward.” ICHOM recommendations are available to the
public on its website and published in academic journals.
Overcoming Operational Concerns
In a field that still utilizes paper questionnaires, technology gives healthcare organizations a
much better channel for collecting PROs. Instead of administering a hard copy survey, clinicians
can reach out to patients by sending a quick email or message.
Dr. Sprinkhuizen believes technological advancements mean better access—for patients and
providers. “For example,” she says, “ophthalmology patients don’t have to see an optometrist
to have their visual acuity tested; there’s an app for that now. Patients with macular
degeneration can use the app to test their visual acuity wherever they want, whenever they
want. The app alerts their optometrist if their visual acuity drops. But technology enabled

12. access to patients introduces a new challenge: collecting patient data in private, secure, non-
invasive ways.”
Getting Started with PROs and PROMs: Five Strategies
Despite the many barriers to PROs and PROMs adoption, most health systems agree PROs and
PROMs are important. But getting started can feel like a high hurdle. Based on ICHOM’s
experience working alongside many healthcare leaders to measure and improve outcomes,
they’ve identified five strategies for organizations eager to get started:
#1: Find the Believers (Identify Clinician Champions)
Identify clinician champions who want to know their outcomes and value transparency. Many
of these champions are already collecting outcomes data and understand the value in using
PROs and PROMs. These champions can help organizations generate momentum and overcome
challenges.
#2: Organize a Cross-Functional Team (with Appropriate
Governance)
Sustainable outcomes measurement depends on the engagement of a broad range of
organizational functions. Appoint a team leader, define deadlines for key milestones, and hold
the team accountable for delivering on them.
#3: Invest Time and Resources
Although outcomes measurement is critical to long-term success, it’s a long-term investment
that won’t pay off immediately. Engage senior leadership to unite organizational functions and
commit resources in pursuit of the long-term benefits.
#4: Celebrate Progress Along the Way
Outcomes measurement programs take time; make sure to celebrate progress along the way to
keep stakeholders engaged and maintain momentum.
#5: Use Early Successes to Scale and Spread
Clinicians and frontline staff respond to inspiration from their colleagues, so share success
stories to spur interest throughout the organization.
ICHOM’s Harvard Business Review article, What Health Care Leaders Need to Do to Improve
Value for Patients provides additional information about these five strategies, including specific
examples of each strategy in action.

13. Measure and Deliver Outcomes Patients Actually Care
About
According to Dr. Stowell, “Health systems today face a dizzying array of measures; but how
many of those measures are actually useful? If we aren’t measuring and delivering the
outcomes our patients actually care about, what use is all of our measurement activity?”
It appears that an increasing number of organizations are of this same mindset. For example,
the Core Quality Measures Collaborative—an initiative that bridges public and private payers—
recently stated its ambition to reduce, refine, and relate quality measures to focus on
“measures that matter.”
Dr. Stowell says, “It’s pretty clear that value-based health care is coming. The question is, do
you want to get ahead of it?” He notes that “forward-thinking provider organizations are
already taking active steps to incorporate a more patient-centered view of value into their
strategic priorities.”
Learn More about ICHOM’s Outcomes Work
Healthcare leaders interested in learning more about ICHOM’s work to define standards,
benchmark on outcomes, and establish outcomes transparency, can visit the ICHOM website
and read Standardizing Patient Outcomes Measurement, a recently published perspective in
the New England Journal of Medicine.
For healthcare leaders interested in being a part of the global value-based care and outcomes
improvement conversation, the Annual ICHOMConference brings together healthcare leaders
throughout the world to discuss the “why” and “how” of outcomes measurement.
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The Top Six Early Detection and Action
Must-Haves for Improving Outcomes
May 31,2016

14. DOWNLOAD
Outcomes improvement work in healthcare isn’t about enforcing cookie-cutter medicine—it’s
about standardizing care around best practices, which is a highly customized experience. For
example, everyone knows that a consistent, evidence-based approach to sepsis screening is
critical; but what’s just as critical is implementing a screening process and tool in a customized
way that meets the health system’s needs, culture, workflow, and goals. Continuous,
sustainable improvement demands this sensitivity to context.
Health Catalyst’s outcomes improvement work embraces the standardization-customization
paradox in healthcare by empowering health systems to make it easy to do the right thing
through evidence-based best practices that truly work in their unique environments. In Health
Catalyst’s work with clients on clinical care processes (e.g., sepsis, heart failure, and
pneumonia), early detection is a frequent outcomes improvement focus. Prioritizing
improvements in early detection and action can yield significantly better clinical, financial, and
patient experience outcomes.
This executive report explains the importance of focusing on early detection and action,
identifies the top three barriers to improvements in this area, and describes the six must-haves
(including the most effective tools) for improving early detection and action. It also features an
early detection and action success story—a real-world example of how Health Catalyst applied
its Three-Systems Approach to outcomes improvement to yield measurable, sustainable results.
A Three-Systems Approach to Outcomes Improvement
Health Catalyst tackles the standardization-customization paradox using its Three-Systems
Approach for achieving meaningful, sustainable outcomes improvement. In this approach, best
practice (standardization), healthcare analytics, and adoption (customization) come together to
garner system-wide support for improvement work, engage all stakeholders (administrative,
technical, and clinical), and inspire a system’s best thinking about what works best for their
system.
 System #1—Best Practice: The synthesis of evidence-based content helps systems focus
on best practices. Answers the question, “What should we do?”

15.  System #2—Analytics: Tailored analytics surface and communicate performance in key
areas. Answers the question, “How are we doing?”
 System #3—Adoption: Improvement services help outcomes improvement teams drive
adoption. Answers the question, “How do we transform?”
Prioritize Early Detection and Action to Improve
Outcomes
Healthcare is transitioning away from fee-for-service toward value-based care; a switch that
necessitates outcomes-based healthcare. As healthcare organizations strive to make the switch,
they must balance the reactive and proactive aspects of outcomes-based healthcare. On the
reactive side of the balance, for example, systems must improve how they care for their sick or
injured patients—continually find ways to make care safer, more effective, and less costly.
Outcomes-based healthcare also targets a more proactive approach to healthcare: creating a
healthcare system that can maintain healthy populations and prevent illness. Early detection
embodies a proactive approach to healthcare; and it is often a very promising focus area for
outcomes improvement work. Most conditions have better outcomes (require less intensive
treatment or allow for interventions that prevent complications) the earlier they’re detected.
Taking a look at sepsis, for example, early detection is particularly important when it comes to
improving sepsis outcomes because sepsis progresses rapidly and has a high mortality rate. The
patient frequently presents with multiple non-specific complaints that make it easy to
misdiagnose the problem and fail to recognize the seriousness of the patient’s condition. In
severe sepsis, timing becomes the most important component of the patient’s care. According
to a 2006 study by Anand Kumar, each hour that care is delayed increases mortality by 7.6
percent.
Health systems need to improve early detection and shorten the time to treatment by focusing
their efforts first in the ED, where the majority of sepsis patients present, and make screening
part of triage. Although standardized care, such as a sepsis screening tool, is widely understood
and targeted, it’s the adoption (customization) aspect that tends to stand in the way of
meaningful, sustainable outcomes improvement.
Three Common Barriers to Outcomes Improvement
Health systems understand the importance of early detection and standardized tools, but
struggle to overcome logistical, technical, and cultural barriers to outcomes improvement.
Barrier #1: Logistical
Health systems frequently mention the logistical barrier of not having the right people or
enough people to implement best practices. Logistical barriers related to work flow and clinical
processes (e.g., having IV supplies available at triage), such as scheduling and supplies, can be a

16. barrier to improving early detection. Truly understanding who does what and implementing a
standardized way of doing it are logistical barriers health systems must overcome.
Barrier #2: Technical
The availability of and access to healthcare data is a technical barrier that can be overcome
with an enterprise data warehouse (EDW) that aggregates data and puts the right information
into the right hands at the right time. Analytics is one of three vital systems in Health Catalyst’s
Three-Systems Approach for improving outcomes; without it, systems will struggle to improve
early detection and action efforts.
Barrier #3: Cultural
Cultural barriers tend to present the most nuanced challenges, ranging from clinicians who
resist standardized tools because they “know sepsis when they see it” to problems escalating
concerns without an effective feedback loop, especially in a chaotic ED environment. Many
health systems take the “check box” approach to improvement, in which they accomplish a
goal, check it off the list, and move on. Multidisciplinary teams can help remove this cultural
barrier by integrating change into the workflow and sustaining it. For example, regarding a
sepsis screening tool to be administered at triage, multidisciplinary teams can help redesign the
workflow in a way that increases adoption of this early detection initiative. Multidisciplinary
teams bring diverse roles, expertise, and responsibilities together; a diversity of experience
that’s critical for managing care transitions. Teams united around a patient focus can improve
care transitions, workflows, and outcomes.
According to the Journal of the American Medical Informatics Association article, Managing
Change, “The major challenges to systemsuccess are often more behavioral than technical.
Successfully introducing such systems into complex health care organizations requires an
effective blend of good technical and good organizational skills.” Health systems and clinicians
may have a strong understanding of sepsis best practice, for example, but still aren’t achieving
their outcomes improvement goals. To move beyond understanding to implementation, health
systems need to focus as much on the “how” of adoption and intervention as they do the
“why” of best practice.
Six Must-Haves for Improving Early Detection and Action
Overcoming logistical, technical, and cultural barriers to improvement efforts requires a variety
of tools and strategies, from analytics and multidisciplinary teams to a willingness to shift an
entire culture and get creative about customized ways to implement standard best practices.
Must-Have #1: Multidisciplinary Teams
Multidisciplinary teams have the power to drive adoption by garnering broad support for
standardization and integrating necessary changes into the workflow. Multidisciplinary teams
include the variety of roles, expertise, and responsibilities necessary for safe and seamless
transitions of care and sustainable improvements. These teams are critical for improving care

17. coordination and communication because they’re united around common, patient-centered
goals. Health Catalyst works with health systemteams at all levels in all departments, and
carefully addresses competing concerns and unite everyone’s focus around the patient.
Must-Have #2: Analytics
Health systems need to prioritize analytics and data-driven decision-making. Analytics should
surface data to improve and support early detection efforts—showing, for example, where
patients enter the systemand where variation in practice and outcomes is greatest. These are
actionable insights that help systems know where to focus improvement efforts. Health
Catalyst’s clinical analytic visualizations, for example, use health systemdata to communicate
current and historical performance in areas that, based on evidence, are most likely to improve
outcomes. Visualizations are outcome-focused, aim-directed, and actionable.
 Outcome-focused: connected to the health system’s clinical, financial, and patient
experience performance indicators and expressed in a way that matches the system’s
quality improvement vision. For example, one client features a sepsis-related
visualization for the number of “Lives Saved.”
 Aim-directed: tailored to specific aims intended to improve systemoutcomes (e.g.,
process aims, such as improved compliance with a care bundles).
 Actionable: enabling drill-down to granular data at the order or patient level, which
helps staff get to the “why” behind the data. This leads to the necessary refinement of
interventions to improve performance. For example, one client has a view that reveals
and guides the antibiotic choices for pneumonia treatment in sepsis patients.
Must-Have #3: Leadership-Driven Culture Change
Health systems can’t improve outcomes without a system-wide culture that embraces change
and the inevitable challenges that come with it. Leadership-driven buy-in for this improvement
culture transformation is vital. It must be clearly articulated, consistently reinforced, and
continually modeled and demonstrated at all levels. Leadership’s role in transforming
organizational culture must be continuous and sustainable. Leadership support extends beyond
the start of outcomes improvement work it should become the persistent, permanent driving
force behind all improvement efforts.
Must-Have #4: Creative Customization
While high-tech interventions, such as EMR alerts, are valuable, don’t underestimate the power
of low-tech interventions. For example, one health system found that simply putting red
blankets on patients who screened positive for sepsis were powerful visual cues that engaged
clinicians better than EMR alerts. In an industry that’s so focused on innovation and technology,
systems should get creative when it comes to creating and customization improvement tools.
Sometimes the most effective interventions are low tech, which ties back to the importance of
customization (what works best for one systemmay not work for another system).

18. Must-Have #5: Proof-of-Concept Pilot Projects
Some health system departments are more resistant to change than others. Overcome this
barrier by assembling a team of motivated early adopters and identifying a champion or small
team willing to experiment. When other departments witness the success of a small, proof-of-
concept pilot project, they’ll naturally want in on the success. For example, a few providers at
one health systemstarted using a new application that had patient navigators call patients who
weren’t compliant with treatment recommendations (e.g., foot exams for diabetes patients).
They quickly realized a substantial increase in revenue as a result of more patients receiving
standardized, recommended care. They also noticed a spike in patient satisfaction; patients
enjoyed getting a call from a human being. By starting small, the systemfigured out a way to
increase revenue, outcomes, and satisfaction.
Must-Have #6: Health Catalyst Tools: Knowledge Briefs,
Outcomes Improvement Packets and Worksheets, and Care
Process Improvement Maps
Health Catalyst works with a variety of diverse health systems faced with similar outcomes
improvement challenges. Based on its extensive knowledge and experience, Health Catalyst
developed and refined several effective tools to help systems improve quality, zero in on the
appropriate improvement focus areas, and provide answers to important questions:
 Within a particular care process, what should we focus on?
 What’s the impact on key outcomes, such as cost, mortality, patient experience, etc.?
 What can we learn from other healthcare systems efforts?
 What metrics should we use to evaluate our progress?
Outcomes Improvement teams armed with Health Catalyst’s tools, best practices, analytics, and
professional expertise learn from their data and drive sustainable change through organization-
wide adoption.
Knowledge Briefs
Health Catalyst’s Knowledge Briefs summarize current evidence and trends in outcomes
improvement related to specific care/workflow processes and include four helpful elements:
 Why the focus area is important.
 Guidelines influencing best practices.
 Trends/promising areas of focus for outcomes improvement.
 Supporting references.
Outcomes Improvement Packets
Health Catalyst’s Outcomes Improvement Packets distill technical, medical, and quality
improvement knowledge to facilitate quality improvement efforts. They include ideas to help
improvement teams create goals and aims, plan interventions, and focus on meaningful

19. measures. When used with Outcomes Improvement Worksheets, they help teams analyze and
prioritize improvement goals based on their own data and culture. Outcomes Improvement
Packets includes several important elements:
 Key outcome improvement opportunities: clinical (e.g., reduce mortality rate), financial
(e.g., decrease variable cost per case), and experience (e.g., improve health-related
quality of life).
 Recommended initial improvement focus areas: identified by yellow “storm clouds”
based on a literature review, input from clinical experts, and experience with health
system clients. Each recommended focus area includes problems addressed, potential
outcome goals, process aims, and interventions, and tools for transformation.
Outcomes Improvement Worksheets
Health Catalyst’s Outcomes Improvement Worksheets are most helpful when used in tandem
with Outcomes Improvement Packets. These worksheets help systems identify their problems
and understand their unique environments. Worksheets lead to the critical customization step
of implementing standardized best practices. Balancing standardization and customization is
where Health Catalyst professional services can help; best practices are standard; adoption is
customized. Everyone uses the same sepsis screening tool, but adopting it in a way that meets
each system’s needs varies significantly.
Care Process Improvement Maps
Health Catalyst’s Care Process Improvement Maps get clinicians, data experts, and system
leaders on the same page—literally—by merging analytics, improvement opportunities, and
best practices into one simple visual map. They provide a visual overview of the care process
across the continuum of care and includes four helpful items:
 Key, evidence-based best practices for each phase of care.
 Storm clouds indicating areas with the greatest improvement opportunity.
 Metrics and data visualizations available in the application.
 Knowledge assets (e.g., order sets and screening tools).
Early Detection and Action Success Story: Thibodaux
Improves Sepsis Outcomes
Sepsis ranks high on Health Catalyst’s key process analysis of opportunity based on financial
and volume metrics from a large, normalized data set. Sepsis is a serious medical condition
caused by an overwhelming immune response to infection that can lead to tissue damage,
organ failure, and death. Between 28 and 50 percent of people who get sepsis die, and it has
the highest mortality rate and cost of any condition treated in U.S. hospitals.
Thibodaux Regional Medical Center achieved sepsis mortality rates below the national average
using Health Catalyst’s Three-Systems Approach to outcomes improvement.

20.  System #1—Best Practice: Thibodaux performed research and gathered data to identify
problems, root causes, and best practice for care of patients with sepsis.
 System #2—Analytics: Thibodaux provided analytic support and applications to give
faster access to valid and actionable data. The team leveraged the electronic health
record (EHR) to provide decision support through order sets, protocols, and alerts.
 System #3—Adoption: Thibodaux adopted an agile methodology for application
development and implementation. The team also employed education, training, and
road shows to ensure a high level of clinician buy-in and adoption.
System #1: Best Practice
To improve early recognition of sepsis in the ED, the team implemented a screening tool that
clinicians could use as patients presented in the ED. If patients met certain of those criteria,
they were placed on sepsis watch or sepsis alert. Patients with a sepsis watch or sepsis alert
would show up in the EHR with a uniquely colored patient header, helping ensure that they
received rapid treatment.
System #2: Analytics
Thibodaux’s analytics revealed several key problems:
 No screening tool was in place in the ED for early identification of sepsis patients.
 Clinicians were not consistently following best practice recommendations for sepsis.
 Treatment was frequently delayed pending an accurate diagnosis.
The team deployed an advanced analytics application for sepsis powered by Health Catalyst to
support process improvement efforts, making it possible to see the impact of interventions and
to correlate those interventions with patient outcomes. The sepsis teamalso included in its
application an early recognition dashboard that is used to see how often the protocol is
applied, how well the screening is done, and how quickly the physicians see the patients.
System #3: Adoption
The sepsis improvement team knew that well-laid plans and sophisticated analytics applications
would not deliver successful outcomes without a deployment plan that engendered high levels
of engagement and adoption. The team provided clear communication with consistent
messaging in multiple venues, including education and training to foster adoption. The team
used multiple methods of communication across the organization to share expectations and
outcomes with the medical staff, the board, and frontline staff. Teammembers clearly
communicated the end result that they were moving toward.
Thibodaux had fun with the education process, starting off with a big kickoff event with a band,
caterer, and T-shirts. They hosted “Sepsis on the Road” seminars where they sat with primary
care physicians, showed them the application, and shared their plan for practice changes to

21. improve the care for sepsis patients. These seminars included a high level of physician
participation and enabled doctors to talk with doctors about the coming changes.
Key Results
By forming a sepsis improvement team that implemented best practice protocols and
developing an advanced analytics system, application targeted at sepsis care, and adoption
approach that engaged clinicians using education and data, Thibodaux’s sepsis improvement
initiative achieved impressive results in just six months:
 Decreased sepsis mortality rate to half of national average
 7.3 percent reduction in average variable cost
 Reduced Length of Stay (LOS) by one day
 7 percent improvement in patient satisfaction
Embracing the Standardization-Customization Paradox to
Improve Early Detection
Reducing variation requires creativity—health systems must understand their uniqueness and
creatively design interventions that address their distinctive problems. Health systems have to
do the hard work of crafting outcomes improvement efforts that will be successful given their
systems’ diverse environments.
Health Catalyst helps systems do this hard work using tools, such as the Outcomes
Improvement Worksheet, to improve outcomes in customized ways that work for each
individual system. The uniqueness of each approach is evidenced by the variety of successful
low-tech and high-tech interventions systems have created and implemented to improve
outcomes, such as Thibodaux’s early detection efforts to improve outcomes for sepsis patients.
Given the volume of barriers to implementing best practices, from cultural to technical, health
systems are faced with the challenge of identifying and creatively overcoming them to achieve
and sustain improvements. Although implementing standardized tools isn’t a quick win, the
acute and chronic care related improvements make it a worthy pursuit. Creating an
improvement culture that prioritizes early detection and implements standardized screening
tools in ways that meet the organization’s needs is key to significantly improving clinical,
financial, and patient experience outcomes.
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The Top Success Factors for Making the
Switch to Outcomes-Based Healthcare
May 17,2016
Outcomes-based healthcare is a popular
topic of conversation in healthcare today. But despite its popularity, there isn’t a standard
outcomes-based healthcare definition. One possible explanation is outcomes-based
healthcare’s scope; it encompasses a vast spectrum of strategies used to transition from fee-
for-service (FFS) to value-based care.
Although the industry lacks a standard, industry-accepted outcomes-based healthcare
definition, there is something healthcare leaders can agree on: health systems need to embrace
outcomes-based healthcare in order to survive the transition to value-based care. But
healthcare organizations are up against seemingly endless challenges as they attempt to make
the switch to this new, value-based approach to care delivery. While many of these
organizations are slowly but surely (and successfully) making the transition, just as many feel
overwhelmed by the inevitable challenges associated with changing the way they do business.
This article takes a closer look at outcomes-based healthcare and what it really entails. It
describes the importance of making the transition, three challenges health systems are up
against, and key success factors when it comes to moving away from an FFS model. A Texas
Children’s Hospital success story shows these success factors in action and proves that making
the transition, although difficult, is not only achievable, but also an absolute necessity.

23. Why Outcomes-Based Healthcare Is The Ultimate Goal
If saving lives is healthcare’s ultimate goal, then it must embrace outcomes-based healthcare.
Without question, outcomes-based healthcare’s primary beneficiaries are the patient
populations it serves. The main benefit to health systems pursuing outcomes-based healthcare
is having a patient-centered vision that motivates everything they do.
Health systems want to provide the best possible care to their communities. But the FFS model
has interfered with that important goal. Rather than striving to save lives and provide the best
care, health systems stuck in an FFS world spend most of their time managing inefficiencies and
solving problems. While the transition to outcomes-based healthcare is the ideal path toward
restoring health systems’ ability to deliver on their promises to communities, they need an
approachable, attainable guide for successfully making the switch. An outcomes-based
framework requires calculated, thoughtful restructuring to meet current and future needs—
and provides an ongoing template for driving continuous improvement.
Outcomes-Based Healthcare Is Reactive and Proactive
Historically, U.S. healthcare has been more reactive than proactive; its primary focus has been
helping sick patients restore their health. Most outcomes-based healthcare definitions center
on a reactive approach to healthcare—curing diseases, for example. Operating in reactive
mode, health systems continuously ask, “Did we cure that sepsis patient?” or “Did we properly
treat that heart failure patient?”
In outcomes-based healthcare, health systems focus on reducing variation in how they treat a
wide variety of diseases and conditions—a process that requires all clinicians to provide
accurate diagnoses and treatment algorithms to improve patient outcomes. Health systems are
constantly striving to overcome inefficiencies and provide high quality care to patients.
Although improving the way health systems care for sick patients is vital, it is not the only goal
of outcomes-based healthcare—solely focusing on improving health system inefficiencies is
myopic.
Outcomes-based healthcare also targets a more proactive approach to healthcare: creating a
healthcare system that strives to maintain healthy populations and prevent illness. Embracing
the proactive aspect of outcomes-based healthcare leads health systems to consistently ask
several questions:
 How do we maintain the health of our patient populations?
 How do we prevent illness and keep individuals out of the hospital?
 How do we operate outside our system walls to optimize community healthcare?
 How do we incorporate population health into our business model?
Embracing these reactive and proactive nuances is critical for health systems transitioning to
outcomes-based healthcare.

24. Top Three Challenges in Making the Switch to Outcomes-
Based Healthcare
If transitioning to outcomes-based healthcare was easy, every health system would have done
it by now. Although many systems are well on their way, no health system has successfully
completed the switch to outcomes-based care. Health systems struggling to make the transition
face three similar challenges:
Challenge #1: Limited Analytics Capabilities
Many health systems are healthcare data rich and analytics poor. To succeed in outcomes-
based healthcare, health systems need data and the analytics capabilities to make data
actionable. At the very least, systems need the ability to measure performance against
outcomes goals, and the effectiveness of their outcomes improvement strategies. The lack of
analytics and the resulting inability to evaluate performance and processes are barriers to
health systems trying to move away from FFS models.
Challenge #2: Limited Access to Information
Health systems need to get data into the hands of frontline staff. Health systems can’t change
how they care for patients across the continuum of care unless they equip frontline staff with
information; the data-driven insights needed to improve outcomes. From pharmacy to claims
data, clinicians need access to the right information to effectively and proactively manage
patient populations. But many health systems struggle to make data accessible and useful; a
problem that’s compounded by the need to aggregate data from other entities across the
continuum. Aggregating and distributing information requires the technology infrastructure and
organizational support most health systems don’t have in place.
Challenge #3: Inappropriate Organizational Structure
Most health systems aren’t organized for change. Without an effective organizational structure
in place, organizations struggle to combat the inertia inherent in systems that have been
delivering care in the same FFS way for decades. Healthcare leaders won’t transition their
systems to outcomes-based healthcare unless they provide their organizations with realistic
strategies and step-by-step guides for making incremental changes in the right direction.
Many systems have Lean and Six Sigma quality improvement programs in place as part of their
efforts to change the status quo. But these improvement programs rarely translate to sustained
outcomes. They may help improve outcomes in the short-term, but once that rigorous
attention is withdrawn from the project, improvements dissipate.

25. The Top Outcomes-Based Healthcare Success Factors:
Multidisciplinary Teams and Analytics
Health systems successfully navigating the transition to outcomes-based healthcare have two
common denominators: multidisciplinary teams and analytics. Although the transition requires
more than just the right teams armed with the right information, these are critical first steps
when making the switch.
Analytics
As evidenced by the Texas Children’s success story described in the next section, aggregating
data into an enterprise data warehouse (EDW) and putting that data into the hands of the
multidisciplinary team responsible for spearheading improvements are essential ingredients for
the outcomes-based healthcare transition. Using analytics, health systems can make data-
driven decisions about which outcomes improvement goals to pursue; ideally, those with the
biggest benefit to patients.
Multidisciplinary Teams
The other common success factor is multidisciplinary teams. Successful systems establish and
empower multidisciplinary teams to be agents of change, responsible for continuously
improving targeted care processes. A team-based approach to outcomes-based healthcare
leverages the expertise and influence of key stakeholders throughout the organization.
Outcomes-driven teams typically consist of key members:
 Clinician lead (most commonly a physician or someone with domain expertise)
 Nurse or administrative champion (someone who can make administrative changes)
 Data analyst (someone who can use data to ask and answer questions)
 Representatives from other key stakeholders in the targeted care process
These teams lead the implementation and measurement of improvement efforts across the
system. The critical characteristic of an outcomes-driven team is that it’s permanent—
permanently dedicated to continuous improvement. Once health systems achieve their desired
improvements (for example, a reduction in 30-day heart failure readmissions), outcomes-driven
teams work to sustain the improvements.
An Outcomes-Based Healthcare Success Story: Texas
Children’s Hospital
Making the switch to outcomes-based healthcare comes with inevitable yet surmountable
challenges. Texas Children’s, a not-for-profit health system consistently ranked among the top
children’s hospitals in the nation, has had measurable, sustained success in its transition to
outcomes-based healthcare. By aggregating data into an EDW, running targeted analytics on
that data, and putting multidisciplinary teams in place to spearhead change, Texas Children’s

26. has made significant quality and cost improvements. Texas Children’s has improved physician
productivity and decreased length of stay (LOS) while generating $74 million in operational
improvements.
Analytics in Action
Texas Children’s first significant success came as a result of analyzing data; it discovered
significant cost variation in asthma care. Using the wealth of new data at its disposal, the team
discovered that a high volume of chest X-rays was being administered to asthma patients within
the hospital. Drilling down into the X-ray data, they discovered that physicians were ordering
chest X-rays for 65 percent of their asthma patients—evidence-based practice calls for an X-ray
in only 5 percent of cases. Health systemleaders thought they had a standardized order set in
place to prevent unnecessary X-rays; however, when team members investigated the issue,
they discovered that several order sets were circulating in the EHR.
By consolidating multiple order sets into a single, evidence-based order set, the team achieved
a dramatic 46 percent reduction in unnecessary chest X-rays. This reduction resulted in a
decrease in LOS for these patients—a driver of quality improvement for patients and cost
improvement for Texas Children’s.
Multidisciplinary Teams in Action
As a first step toward improving the asthma care process, Texas Children’s leaders established a
multidisciplinary team consisting of physicians, nurses, and experts in patient safety, quality
improvement, finance, and IT. Leaders tasked this team with assessing and managing acute
asthma from the time of arrival in the ED to discharge. The team was responsible for improving
asthma care across all hospital facilities.
Texas Children’s clinical improvement team’s work didn’t end with its asthma care outcomes
improvement. As a result of owning outcomes improvement for asthma care, the team has
long-term responsibility for sustaining excellence in other care processes. For example, the
team also took on reducing the delay between the time a child walks into the ED and the time
he or she receives the appropriate asthma medications.
Leading Health Systems Prioritize Outcomes-Based
Healthcare and Upstream Health
Truly mature health systems will transition to outcomes-based healthcare and, eventually,
upstream health, in which genomic and epigenetic factors (social, economic, and
environmental) are incorporated into the patient care model. A successful transition to
upstream health requires access to and analysis of new sources of data, and the
implementation of meaningful predictive analytics to care for patients and prevent disease
from occurring in the first place.

27. The challenges of converting from a FFS care delivery systemto outcomes-based healthcare
abound—but they’re manageable when health systems integrate the two common
denominators of success: putting the right analytics infrastructure in place and empowering
multidisciplinary teams to implement and sustain change. By starting small—focusing on one
improvement area and identifying a capable and enthusiastic team, health systems can
transition to outcomes-based healthcare with the same measurable success as Texas Children’s.
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7 Features of Highly Effective Outcomes
Improvement Projects
May 5,2016
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After you’ve worked on a sufficient number of projects, it’s easy to identify differences
between those that deliver sustainable successful outcomes and those that deliver, shall we

28. say, less-than-stellar results. From my experience, I can offer seven tips for quality
improvement projects in healthcare. Here they are and what makes them tick:
1. Outcomes Versus Accountability Focus
Most outcomes improvement project teams operate under one of two precepts: measure for
accountability or measure for improvement.
Projects that measure for accountability primarily focus on rewarding or punishing based on
whether or not individuals adhere to certain processes and procedures. A classic example
would be paying an individual physician a bonus (or charging a penalty) based on his or her
compliance with some clinical initiative at a facility. The focus of those being measured quickly
shifts to whether or not a specific data point is accurate for a particular individual. The project
becomes mired in a slurry of minutia. When this happens, individuals worry about the negative
spotlight and the ensuing punishment. With this approach, there is no rising tide that lifts all
boats. Sure, some of the outliers at the bottom may improve, but personal interest takes
priority instead of examining the process and focusing on interventions that will help move the
overall mean. Outcome improvement is delayed or never reaches its full potential. Don’t get
me wrong, measuring for accountability has its place, however it is important to evaluate if
your project demands it or if it should instead focus on measuring for improvement.
Ok, so what does measuring for improvement really mean? It’s the concept that we focus on
the process and not on individuals. It’s the concept that interventions to improve outcomes
focus on the inliers and not on the bad outliers. It’s the idea that in looking to improve the
process, we don’t waste time getting every data point 100 percent correct, but get the
information and level of accuracy of information needed to move forward and evaluate if
interventions are working or not. Instead of punishing the three individuals who have the worst
outcomes for a particular surgery by denying them privileges to perform that surgery, focus on
what causes the bad outcomes in the process and implement actions to ensure those outcomes
don’t occur for all providers. It should be no surprise that the project that actually measures for
improvement, improves the targeted outcomes much more quickly and more dramatically
because all participants know the focus is on the systemand the process rather than on people.
Fear is removed from the project, which is one of Deming’s 14 Points for Management, “Drive
out fear, so that everyone may work effectively for the company.” Productivity rises when
individuals can assume positive intent during every interaction. The environment becomes
collaborative instead of combative (in most cases) and more creative solutions come forward
when the focus is on the process.
The Joint Commission published a journal on quality improvement article titled “The three faces
of performance measurement: improvement, accountability, research.” In it, the authors make
this statement: “We are increasingly realizing not only how critical measurement is to the
quality improvement we seek but also how counterproductive it can be to mix measurement
for accountability or research with measurement for improvement.” Although this article is

29. almost 20 years old, you can see how it is still relevant to illustrating the concept that we need
to measure differently for accountability than we do for improvement.
2. Define Your Goal and Aim Statements Early and Stickto Them
Who hasn’t been part of a project where the scope increases dramatically over time? It usually
starts innocently enough. For example, a group comes together initially to improve asthma
outcomes, but then sees that patients are being referred outside of their group practice. The
focus then shifts to this leakage, and so on, and so forth. Before you know it, the original goal of
improving asthma treatment disappears, is severely delayed, or gets lost in a dashboard that
now is the “one dashboard to rule them all.”
To keep the project moving forward, the project team should define the SMART (Specific,
Measureable, Attainable, Relevant, Time-Bound) goal up front. I’ve found that defining this in
the first or second workgroup meeting is usually the best timing. Establishing these parameters
puts everybody to work on efforts that will return the best bang for the buck. It becomes clear
when work is heading down a sidetrack and, therefore, not beneficial.
At Health Catalyst, we encourage a focus on a clear goal that the team expects to make from its
improvement efforts. Then we outline our aim statements, the tactics to achieve this goal. Aim
statements are written, measurable, and time-sensitive descriptions of the goal. They represent
important quality topics that can stimulate enthusiastic team support. Aim statements:
 Are outcomes-focused (directly implies measurement)
 Contain specific achievable goals and stretch goals
 Include a timeline
 Clearly state the target population
 Are succinct
 Provide value (humanistic and/or financial)
Aim statements are a great tool for project managers to rally discussion and get a lot
accomplished. Without them, projects become bloated, are less agile, and end up floundering
instead of delivering value quickly. This isn’t an indictment against project flexibility. Aim
statements, and even goals, can morph as data is excavated, but as a guiding principle, it is best
to focus on one goal and between two and four aim statements for the initial scope of a
project.
3. Assign a Knowledge Manager of the Analytics (Report or Application) Up Front
One of the best experiences I’ve had on an outcomes improvement project was largely due to a
stellar Knowledge Manager being assigned. We implemented our Key Process Analysis (KPA)
tool to help the physicians identify areas of highest variation and resource consumption in their
practice. We then targeted these areas for our improvement efforts with great success. Three
factors made her participation a critical success factor to the project overall. First, she was

30. assigned up front. This way, she knew everything going on with the project from start to finish.
She was able to champion the project as the permanent owner and coordinator of the team
after the initial round of outcomes improvement. All the key stakeholders in the project knew
her and trusted her as a result of her participation throughout the project. Second, she was not
purely technical, but instead had a bit of technical background and was a subject matter expert
in the process and clinical environment. Too often a purely technical resource is assigned,
which risks making the project “another IT project” that gets little adoption. By having someone
who could relate to both the technical and the clinical side, the Knowledge Manager was able
to translate clinical concerns to the technical team and technical challenges to the clinical side.
Third, she was someone they knew, trusted, and was an innovator. Choose the right Knowledge
Manager and you’ll be well on your way to a successful project. If the Knowledge Manager
doesn’t have the three attributes mentioned above, then the probability of long-term success
decreases.
4. Get End Users Involved In the Process
Outcomes improvement projects aren’t science experiments developed in a lab with “eureka!”
moments. End users need to be involved in the process. A successful outcomes improvement
team cannot be just executives or individuals who aren’t on the front line. When choosing the
end users to participate, it is important to think long term. Which end users do the rest of the
staff trust? Which end users will be able to champion the outcomes improvement project?
Often these individuals are quite busy. Successful projects choose these individuals to
participate and make time in their schedules to help iterate through the application and drive
adoption of the outcomes improvement project. Amazing projects get their buy in and support
before even kicking off the project.
Practice iterative development of the visualizations so end users can modify the analytics to suit
their needs, to something that they will actually use. Involving end users creates project buy-in
and develops trust in the data because the champions have been validating it throughout
implementation.
Finally, an inclusive mentality creates adoption in that you’re generating built-in super users
and champions.
5. Design to Make Doing the Right Thing Easy
First of all, the analytics tools must be simple and easy to use.
For example, I work with one healthcare system that used to run reports by pressing a
figurative “start button,” then would return from lunch to see the output. That is, unless the
computer crashed while they were out enjoying their chicken lettuce wraps. The mechanism
wasn’t easy to use and—you guessed it—reports were minimally accessed and adoption
dropped dramatically in the ensuing months. Ensure a basic level of usability. Remove barriers

31. to accessing the information needed to make improvements. Otherwise, it gets costly to create
workarounds to simplify the process.
The second design element in making the right thing easy to do involves interventions that are
built into the workflow. Interventions that require more work (for example, requiring
handwashing documentation every time a caregiver enters the room) are often unsuccessful.
The burden is too great. If physicians are required to place three new orders (e.g., flu shot, a
lab, and a script) that require five extra minutes with a patient, then this is an intervention that
won’t be successful, unless there is serious buy-in.
Contrast this with example projects that focus on ways to make doing the right thing easy:
 Creating an order set that makes it easy to order the right thing vs. the old way of
hunting down four disparate orders.
 Designing the right interventions and taking the time to think them through and testing
them with end users (another plug for involving them throughout the project).
 A recent project to decrease central line associated blood stream infections (CLABSI)
built into a nurse rounding list the prioritized patients who were at the highest risk of
infection so the nurses could visit them first.
6. Don’t Underestimate the Power of One-on-One Training
Outcome improvements only happen when analytics and interventions are adopted. I’ve seen
many projects flounder because key stakeholders didn’t know enough or had forgotten their
training on how to access reports and analytics related to the outcomes improvement project.
It’s so key that I’ll mention it again: these champions and super users need to be the subject
matter experts, those who know the process well, who others trust, and who, optimally, are
early adopters. Where possible, train super users and key champions one-on-one for 20
minutes on the analytics tools. This has proven to be so much more effective in getting
adoption than group sessions. This isn’t to say that group training doesn’t work, but there is
something magical about sitting down one-on-one with key stakeholders. It’s a safer
environment to ask questions, it builds the relationship should questions come up, it often
results in insights absent from the group situation, and it shows the importance of the project,
particularly if the organization doesn’t do a lot of one-on-one training. Adoption improves when
this happens.
7. Get the Champion Involved
I’ve walked into project kickoff meetings and had the group ask wonderful questions as to why
we are working on this project. Nobody knew why we chose this particular project and the
sponsor of the project was not even in attendance. Indeed, the group questioned if there even
was a problem to solve because their current systems were giving them what they needed.
Needless to say, those projects went nowhere.

32. None of the other features of highly successful outcomes improvement projects compensate
for a project missing a leader who is expert in the subject area and who has bought in. The most
successful projects I’ve been part of have a champion who articulates that problem AND its
impact on individuals and organization. The champion needs to convey the “why” of the project
to the group and ensure that these reasons resonate with those involved at all levels. The best
champions intrinsically motivate the workgroup and others to work toward the common goal.
This is what gets everyone onboard to solving the problem and creating improvement. The
champion regularly shares the vision, encourages and celebrates with all participants and
stakeholders, and ensures the outcome improvement project progresses.
Outcomes Improvement: A Continuous Journey
Doctors, nurses, executives, IT professionals, analysts, administrators—anyone reading this—
are all incredibly busy people with full plates. Quality improvement projects are typically
additional responsibilities to all of us who live and breathe healthcare. But let’s face it,
improving and delivering quality, whether it’s clinical care or operations, is why we do what we
do. When everything clicks and you can measurably say that this project saved lives by
decreasing infection rates, or prevented over a dozen amputations for diabetic patients this
year, or improved the patient experience by decreasing wait time – what a great experience to
be a part of that! Those assigned to outcomes improvement teams need the security of positive
intent. They need clearly defined goals and aim statements. The team needs an owner, a
champion, end users, and super users involved every step of the way with one-on-one training
to aid adoption. Finally, the tools and interventions must be designed so it’s easy to do the right
thing. Outcomes improvement works when permanent teams continuously focus on the
improvements and keep them going over time. When all of these elements fall into place, then
you know you’ve gotten into the habit of a highly effective outcomes improvement project
team.
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33. 6 Steps for Implementing Successful
Performance Improvement Initiatives in
Healthcare
June18,2014
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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
Step 1: Integrate Performance Improvement into Your StrategicObjectives
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

34. performance improvement to be integrated within the healthcare organization’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 systemalso 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.

35. Figure 1: 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.
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

36. 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 systemand 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).

37. 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.

38. 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,
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-

39. 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.
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.

40. 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
[widgetkitid=10584]
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.
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

41. 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.
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 bonus for reducing

42. 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?
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