Names are important, they tell us who we are, they tell us where we come from, they tell us who you are. Have you ever given your name at a coffee shop and they write on a cup, then your cappuccino arrives and suddenly that name you’ve had all your life is shouted out, but it isn’t at all what you said and you wonder whether that coffee really is yours? I know I have and it can be quite frustrating, can’t it.
The same is true in medicine, what if you went to the doctor and he said you had hypertension (high Blood Pressure), but you heard hypotension (Low blood pressure) and you started looking up things to put your blood pressure up, it could be catastrophic.
Sometimes though we use words thinking it means one thing and it really doesn’t but it gets used so much that it actually takes on a different meaning think about the word Mouse, Prior to 1984 a Mouse was a squeaking animal, after 1984 it became a tool you used with a computer.
But worse we say one thing and someone who all their life has known it as something else is confused about what you’re talking about. As a Global company this is a challenge we all face daily. What do you call the place you go following an accident? In many countries, it is the ED, Emergency Department, but in the UK it is A&E, Accident and Emergency, but in the UAE A&E is the place you go to by alcohol, African and Eastern.
See the problem, language matters, it matters to those to whom we are trying to communicate. We can appear to the receiver that sometimes we don’t know what we’re talking about even though we think we know what we are saying.
There is the famous story quoted by Stephen King about the great author James Joyce
“A friend came to visit James Joyce one day and found the great man sprawled across his writing desk in a posture of utter despair.
James, what’s wrong?' the friend asked. 'Is it the work?'
Joyce indicated assent without even raising his head to look at his friend. Of course, it was the work; isn’t it always?
How many words did you get today?' the friend pursued.
Joyce (still in despair, still sprawled facedown on his desk): 'Seven.'
Seven? But James… that’s good, at least for you.'
Yes,' Joyce said, finally looking up. 'I suppose it is… but I don’t know what order they go in!”
This amusing tale brings us to the crux of the problem. In Cerner, the choice of words has appeared to become a problem in the Value space, I hear daily words such as “Value”, “KPI”, “Metric”, “Quality Measure” used often interchangeably but they are different, they mean different things and if you are trying to communicate with people who understand the area you may come across as not really understanding what you’re saying, or at least frustrate them like the cappuccino.
If we really want to communicate with our colleagues and clients effectively , We should use the right names for the right things. Let’s try and help to define the words and concepts for a common understanding across the globe.
Yes, you can put a screw in with a hammer but the correct tool is a screwdriver, so if you want to put a screw in the wall correctly you don’t as for a wrench (or should that be a spanner).
So let’s begin:
In a data context, measures are the numbers or values that can be summed and/or averaged, such as sales, heights, durations, temperatures, and weight. Basically, it is a number, it may or not be related to performance, quality or value, all it is a quantity of things at a point in time.
“3,234 patients were referred to our hospital today”, “We saw 136 cases of Breast Cancer last year” – they’re measures.
These are derived from measures and unlike measures are not always unit specific, so an example may be the average number of referrals per day last month was 3,100. Metrics are much more common than measures, which are very specific snapshots in time, and frequently get confused with performance indicators the main difference is that not all metrics are influenced by how we as an organization are performing.
They are still important and there may even be recognised standards, e.g. the number of referrals in a certain sized population area, so they are useful to track but not all Metrics are a performance indicator.
The number of cases of flu in a given population each week may be an important metric to track, but it is not a performance indicator.
“A variable by which the success or productivity of a venture, policy, or product can be gauged.”
They focus on the business processes and functions that are seen as important for measuring progress toward meeting strategic goals and performance targets. Here’s the challenge, that performance indicators should measure performance of those business processes of functions, it should be able to be influenced by the actions of the organization. Performance indicators do not measure luck or randomness. e.g. you can do something about it. You can measure the performance.
Let me give an example: The percentage of patients whose catheter is replaced or removed within 5 days is a great Performance Indicator. This is SMART - Specific purpose for the business, it is Measurable to really get a value of the Performance Indicator, the defined norms have to be Achievable, the improvement of a Performance Indicator has to be Relevant to the success of the organization, and finally it must be Time phased.
Whereas the number of Catheter Acquired Urinary Tract Infections (CAUTI) is not a performance indicator, you could do absolutely everything right and have superb performance and still a pesky bug gets in and causes an infection. An action beyond the control of the organization, it is not measuring performance. (See also ADEs and HgBA1c later)
There are various definitions but the Agency for Healthcare Research and Quality (AHRQ) defines it as “standardized, evidence-based measures of health care quality that can be used … to measure and track clinical performance and outcomes.”
Note the words Quality and Outcomes here.
I particularly like the Institute of Medicine’s definition of Quality
“Quality is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”
In this case the number of CAUTI is a Quality Indicator, it has a recognized standard, it is evidence based and tracks, in this case, outcomes.
So what about an outcome that has no defined standard, although as Cerner there is nothing stopping us defining an evidence based standard, and in the Middle East we are defining some areas for the region, but if we don’t then they are Clinical Indicators.
The seminal work on this was done by Jan Mainz in 2003, He stated:
“Clinical indicators assess particular health structures, processes, and outcomes. They can be rate- or mean-based, providing a quantitative basis for quality improvement, or sentinel, identifying incidents of care that trigger further investigation. They can assess aspects of the structure, process, or outcome of health care. Furthermore, indicators can be generic measures that are relevant for most patients or disease-specific, expressing the quality of care for patients with specific diagnoses.”
So as an example, the number of Adverse Drug Events (ADEs) is a Clinical indicator (Note: The number of Adverse Drug Events recorded in a system is a Performance Indicator). ADEs may be due to errors but they can equally be due to an idiosyncratic reaction the first time a patient takes a drug. If the only time you have ADEs is when it happens the first time for patients there is nothing you as an organization can do to modify your performance as you didn’t do anything wrong.
Another example is the percentage of patients with diabetes who have an HgBA1c less than 7.0 this is a Clinical Indicator, even if you as an organization did everything right, the patient may still like their McDonalds and Cola, (Note the number of patients invited for, or potentially having their HgBA1c taken in 6 months is a Performance Indicator).
So, in Summary ask the following questions.
- Are we measuring something that we have control over and can modify? Then that’s a Performance Indicator.
- Is there a clinical outcome that may occur regardless of how well we perform? Then that’s either a Quality or a Clinical Indicator.
- Is there a standard method and evidence based value for the indicator? then that’s a Quality indicator, if not you have a Clinical indicator. Or
- Is it just a number I am recording, it’s a measure or metric.
Key Performance Indicators (KPIs) or KQIs or KCIs
What about KPIs, I hear you ask, a Professor friend used to say to me “I hate KPIs, when an organisation achieves them do they stop progressing or say they were key but not now, these new ones are? In which case, what are the ones that have gone before? They are all performance indicators let’s not confuse them by calling some Key”
To an extent, I have sympathy with him, but also a KPI is what we need to focus on today, what is the most important. So, to this end you can have numerous Performance Indicators but those that are fundamental to delivering the organisations strategic goals are the Key ones. In this context, a KPI is just a special group of performance indicators. You can’t therefore ask a client to pick from a list of KPIs, that makes no logical sense. The Performance Indicators they select from the list are their KPIs. The same is true from a list of Quality Indicators or Clinical Indicators, the most important ones are the Key ones.
So where does Value sit.
The Oxford English Dictionary defines Value as
- The regard that something is held to deserve; the importance, worth, or usefulness of something:
- The material or monetary worth of something:
- The worth of something compared to the price paid or asked for it:
Its Origin is Middle English: from Old French, feminine past participle of valoir 'be worth', from Latin valere.
So Performance, Clinical and Quality indicators that improve should deliver value, but that value will be different for every organisation and even the different actors in the organisation. Be that the Patient, The Clinician or the Administrator.
Metrics in themselves may or may not deliver Value, for instance an increase in the number of referrals may well bring in more income, but that is not necessarily true for all Metrics.
Words are important, we all want to get the right coffee, and we all want to be perceived as understanding that we are here to improve Healthcare so it is beholden on us all to use the right language at the right time.
 Defining and classifying clinical indicators for quality improvement, International Journal for Quality in Health Care, Volume 15, Issue 6, 1 December 2003, Pages 523–530, https://doi.org/10.1093/intqhc/mzg081