BY: ROBERT G. GIFT and JULIE M. JONES
Mr. Gift is president, Systems Management Associates, Inc.,
Omaha, NE; Ms. Jones is project administrator, mission services,
Catholic Health Association, St. Louis.
In 1998, after strategy sessions with membership from across
the nation, the Catholic Health Association (CHA) launched its
breakthrough initiative entitled "Living Our Promises, Acting
On Faith: A National Program of Performance Improvement for
the Catholic Health Ministry." The impetus for this initiative
came from a growing desire for accountability in the ministry
and to sustain "who we are."
Grounded in the Ethical and Religious Directives for Catholic
Health Care Services, this effort focuses on helping CHA members
more effectively articulate and realize their Catholic identity.
The overall purpose of this work is performance improvement
for the Catholic health ministry. The approach designed to help
achieve this purpose required gathering facility performance
data and compiling that data into a comparative report. The
first round of acute-care data was collected in February 2000
and published in June 2000; the second round of data collection
occurred in November 2001 and will be distributed to members
in May 2002.*
* Copies of these reports are available to CHA members at
no cost; visit our online Resource Catalog at www.chausa.org/RESOURCES/
or call 314-253-3458.
The Role of Comparative Data
Comparative performance data serve several useful purposes.
First, the data describe the ministry's overall performance
in quantifiable measures, which allows the ministry to discuss
these topics in concrete terms. Second, the data inform the
entire ministry about collective opportunities for improvement.
Analysis reveals potential performance gaps and provides direction
for moving the entire ministry. Third, potential sources of
successful practices that lead to improved performance are revealed.
Comparative data indicate which factors influence performance,
which is vital to the benchmarking process. Fourth, comparative
data offer individual facilities a wealth of information with
which they can stimulate internal performance improvement.
By comparing individual facility performance with ministry-wide
and peer group performance, facility leaders can incorporate
performance improvement of the measures included in this dataset
into the organization's overall performance improvement initiatives.
Comparative data provide powerful motivation for organizational
change by identifying opportunities for improvement and assisting
in setting improvement goals. With the outcomes reported in
the "Living Our Promises, Acting On Faith" comparative dataset,
leaders can establish improvement goals that are motivational,
realistically achievable, and rooted in the demonstrated performance
of others in the ministry.
A Two-Part Approach
The "Living Our Promises, Acting On Faith" report provides
two types of interconnected data.
Performance Measures Data The data collection tool
included 21 different measures of organizational performance.
These ranged from satisfaction measures (the percent of employees
indicating satisfaction with their involvement in decision making)
to volume-related measures (the percent of total pastoral care
visits performed in acute inpatient care settings) to selected
financial measures (long-term debt to capitalization ratios).
The Table below presents a hypothetical facility's comparative
data for a selected performance measure: "The percent of patients
who died in the facility in the last calendar year who received
palliative care." This hypothetical hospital is a 250-bed urban
facility that belongs to a health care system. As such, the
comparative peer groups include all participants, system participants,
urban facility participants, and those participants that have
between 200 and 299 beds.
Characteristics Data Characteristics used in the performance
comparison are factors believed to influence performance, as
gauged by the measure. The characteristics applicable to each
measure were developed from discussions with practitioners active
in each field.
The characteristics are affirmative statements about the presence
of some attribute within the facility, such as "The facility
provides education on supportive services such as palliative
care and/or hospice for all physicians." Each performance measure
in the data collection tool has a group of related characteristics
When data were collected, study participants responded to
the characteristics statements with either a "yes" or "no."
The final report presents the hospital's response alongside
the four peer group comparisons listed. The percent of participants
in each peer group who responded "yes" appears for each characteristic.
When comparative performance measures data are supported by
detailed comparative characteristics data, hospitals can use
the composite information to analyze differences in organizational
policies, processes, and practices that influence performance.
Discerning these differences and acting on them unleashes the
power of comparative data in the hospital's internal improvement
Incorporating Comparative Data in Existing Performance
Once a management team decides to incorporate comparative data
in the organization's improvement efforts, the team needs a
pathway to guide its application. Without such a pathway, the
management team risks missed opportunities or misapplication
of the data. To accomplish this, hospital leadership must treat
improving performance in demonstrating its ministry the same
way it treats improving performance in clinical and operational
The comparative data report now available for acute-care facilities
can assist hospital leadership with setting improvement goals
and can provide direction for better performance. This effort,
however, does not require an entirely new initiative. Today,
virtually all hospitals have some type of performance improvement
structures in place.
In a manner similar to clinical or operational improvement,
leadership can create a performance improvement team. The performance
improvement team, in turn, uses the hospital's designated process
to address the challenge. As it works to accomplish its mission,
the improvement team reports its progress using the existing
An Approach to Using Comparative Data
The Figure below presents an approach for using comparative
data to drive internal improvement. Figure 1 presents the hypothetical
comparative data to use in the algorithm.
Assessment The approach begins with the management
team reviewing the data and determining the hospital's comparative
standing. As the sample report shows, in palliative care, the
hospital compares unfavorably with all its peer groups except
for bed size: Only 35 percent of patients who died in the facility
received palliative care. The important point to take away from
that is that 65 percent of dying patients did not receive this
care. The hospital performs below the overall study, system,
and setting participants in this important service to patients.
The management team then asks if performance, as assessed
by this measure, is consistent with the organization's values,
mission, strategy, and operating model. Given the measure and
the organization's mission and values, along with its pledge
of the fidelity to the Ethical and Religious Directives for
Catholic Health Care Services, the management team affirms that
improvement in this measure is consistent with its core values.
The management team takes this information, adds detailed
knowledge of its own operation, and discusses the appropriateness
of setting an improvement goal. In this instance, given the
nature of the measure, 100 percent represents a desirable long-term
goal. However, the team wishes to set some short-term objectives
for incremental improvement over the next three years. For the
purpose of the example, the team chooses to increase this number
to 60 percent by the end of the first year, 85 percent by the
end of the second year, and 100 percent at the end of the third
Performance Improvement Initiatives Once the management
team reaches agreement on an improvement goal, it incorporates
the project into the organization's existing performance improvement
(PI) initiative. The practices of the hospital's PI initiative
call for establishing a PI committee to analyze performance
and develop recommendations for actions that will accomplish
the set improvement target.
The PI committee reviews the improvement goal and comparative
data. It then analyzes the characteristics to determine how
the hospital performs when compared with the peer groups. As
the sample report demonstrates, the hospital performs consistent
with the peer groups in characteristics C100, C104, C105, and
C106. The hospital appears to differ from the majority of peer
group participants in characteristics C98, C99, C101, C102,
and C103. These differences may represent factors that contribute
to the performance measure.
For example, characteristics C98, C99, and C103 relate to
education and training. In each of these characteristics, the
hospital differs from the majority of its peer groups. The hospital
does, however, provide training about the influence of culture
and ethnic background (C106), which is consistent with its peer
groups. The PI committee reviews existing training practices
and discusses the appropriateness of expanding education and
training offerings into more areas and broadening the audiences
for those offerings. The PI committee recommends an objective
for the first year to increase education and training programs
on palliative care.
The hospital also differs from its peer groups in the evaluation
of the effectiveness of supportive services by bereaved families.
Approximately half the participants in each peer group responded
that they conduct such evaluations. The PI committee discusses
these results and researches an appropriate mechanism with which
to conduct evaluations of the effectiveness of supportive services
by bereaved families. It ultimately recommends the use of structured
telephone interviews as the assessment mechanism.
The third difference revealed by the comparative data lies
in the inclusion of pastoral care interventions in clinical
care paths. The PI committee discusses the hospital's ineffective
attempts to develop and deploy clinical care paths and the reluctance
of the clinical staff to engage in that developmental process.
Although the PI committee recognizes this may represent a method
to improve performance in this measure, the current organizational
climate precludes acting effectively on this potential improvement
idea. The PI committee identifies the work required to create
an accepting atmosphere to act on the idea, but defers a specific
Action Plans Once the PI committee reaches agreement
on the actions it will take to improve performance, it develops
detailed action plans. These action plans identify the specific
steps to be taken to transform the action from an idea to reality.
The action plans also identify the time frame within which the
steps will be completed and the individuals responsible for
The PI committee carries these recommendations back to the
management team. Once approved, implementation of the action
plans begins. Once implemented, performance is monitored to
determine the level of improvement achieved.
As depicted in the Figure,
after a reasonable amount of time has elapsed the committee
takes new measurements and determines if performance has reached
the desired level. If it hasn't, the team cycles through the
approach again, seeking new insights into mechanisms for change.
If it has, the team turns its attention to other areas needing
Incorporating the "Living Our Promises, Acting On Faith" comparative
data by using existing resources and methods, takes advantage
of the flexibility and rigor in the current improvement structures
and processes and involves more staff in a broader array of
areas. In addition, incorporation precludes development of a
new structure to address these opportunities for improvement,
thereby promoting organizational alignment and integration.
A Call to Action
One of the recurring lessons from "Living Our Promises, Acting
On Faith" has been that hospitals that have worked to align
their values, mission, strategy, and operating model tend to
perform more effectively. And most importantly, they serve their
patients better. The data resulting from the project provide
a rich, informed description of the current status of the ministry.
This information has begun to drive collaborative benchmarking
studies at the national level through CHA and at regional levels
through individual systems. In turn, these benchmarking studies
are beginning to indicate successful practices that can help
improve performance across the ministry.
Much more can be done, however, to foster breakthrough improvement
within Catholic health care. If each study participant conducted
one improvement project over the next year, the collective improvement
across the ministry could be astounding. If the entire CHA membership
launched one such internal improvement project using the data
to help set an improvement goal, the ministry-wide impact would
When does your improvement project begin?
Copyright © 2002 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.