JCAHO core performance measures

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The changing nature of today's health care organizations, including pressure to reduce costs, improve the quality of care and meet stringent guidelines, has forced health care professionals to re-examine how they evaluate their performance. While many health care organizations have long recognized the need to look beyond financial measures when evaluating their performance, many still struggle with what measures to select and how to use the results of those measures. Because a growing number of health care professionals have readily adopted quality concepts, health care organizations should be able to quickly improve their performance measurement systems by following a few simple rules.

An impetus for health care organizations to adopt quality principles has been the Joint Commission on Accreditation of Healthcare Organizations' standards. While the JCAHO standards have evolved during the past decade, swayed in part by the Baldrige criteria, health care organizations have been slow to use this organizational assessment as a way to drive performance improvement.

The demand from JCAHO for performance improvement drove many health care organizations to learn as much as possible about continuous quality improvement. They began implementing ideas such as: teams and facilitators with training on conflict resolution; problem solving with use of statistical tools and standardized problem-solving procedures; data collection, including patient, physician and employee satisfaction surveys; process management using clinical algorithms and practice guidelines with training on pathway development; and planning using balanced scorecards and performance measurements. With continuous quality improvement often delegated to levels below senior management, organizations struggled to integrate and justify their many initiatives.

Selecting the right measures:

An effective measurement system integrates initiatives, aligns organizational units and resources, and improves performance.

Paradoxically, most people select measures before they decide how to use them. While it makes sense to discuss selection and use of measures in that order, the effective order in practice is the reverse.

Organizations need performance measures in three areas:

To lead the entire organization in a particular direction.

To manage the resources needed to travel in this direction.

To operate the processes that make the organization work.

Most organizations typically don't use leadership measures. However, many health care organizations have struggled to move beyond their heavy emphasis on financial measures to include leadership measures. With continuous quality improvement ...