Balanced Scorecard

Every clinic should have some sort of a balanced scorecard. A scorecard is just a way to track the key metrics of you're clinic. In hospitals, they include a variety of metrics ranging from how the hospital is treating it's employees (turnover rates, hours, lost time) to how it's treating it's patients (infection rates, satisfaction, etc..). For an excellent example of a performance measurement scorecard check out Toronto's University Health Network performance measurement and balanced scorecard.

From a clinic's point of view however, there are usually problems creating such an extensive scorecard. Few of us have the staffing or desire to create these kinds of metrics nor the computer integration to make it happen (how many of us can track clinic acquired infection rates). That being said, a methodical approach to building key performance indicators in medical offices is achievable. Our clinic has been slowly building our own balanced scorecard by adding one or two metrics related to the service of patients and employees each year for the past 5 years. We now have a yearly report of 20 pages on which to base decisions.

I'd offer the following suggestions if you'd like to start you're own scorecard:
1. Think big -- carefully research clinic scorecards and decide which metrics you want to include. Create an overall plan of where you'd like it to be in the next 5 years. Aim for the stars.
2. Start small -- you'll be amazed at the road blocks you hit along the way. Start with one metric
3. Find ways to automate -- if it requires more than 5 minutes to retrieve the data it will not be collected 5 years down the road. See if you can automate the collection somehow. Often you can pay you're EMR or accounting software vendor a small fee to program it into a spreadsheet or report.
4. Keep building -- each year/quarter add another metric to you're scorecard. It'll be rich with data before you know it.
5. Use the data at least once a year -- make a concerted effort to collect, analyze and act on the data once or twice a year. Build you're own yearly practice report.
6. Share the data -- it's easy to read into the data you're expectations. Share it with as many stakeholders as reasonable and get their interpretation.

I'd suggest that each practice collect the following basic data to start:
1. Number of Patients (New and returning)
2. Number of Doctor Days (or Provider Days depending on who is providing the service)
3. Number of Referrals (if a referral based practice)
4. Average Wait Time (watch how it changes with number of provider days)
5. Average Daily Revenue (if fee-for-service = revenue/days worked)

I'd also recommend that you list the changes from quarter to quarter (e.g. Q1-2007 compared to Q1-2008). To calculate the percent change use the formula (New-Old)/(Old) x 100%. If for instance a practice had a provider work 58 days in Q1-2007 and 48 days in Q1-2008 then the difference is (48-58)/(58) x 100% = -17%. If you work 17% fewer days you'd expect a 17% rise in wait time. If there is only a 5% rise in wait time is it because you saw fewer patients (look at the patient data) or because you were more efficient (look at the average daily revenue data)?

These are 5 basic metrics that will help you adjust how many days to work and where to spend time each year. Since wait time is a major factor in patient satisfaction it will also give you an objective measure of patient service level. The hospital scorecards are fantastic but difficult to achieve in smaller practices so if you're practice requires other suggestions for key metrics feel free to email me or leave a comment.