LeanHealthcare_leadingindicatorsHCAHPS. Employee Satisfaction. FTE numbers. Readmissions. Overtime. Press Ganey. Length of Stay. Market Share. Infection Rates. And on and on and on.  Data.  We are inundated with data in healthcare.

Data is a good thing.  No, actually, that is great thing.  There have been many blogs written about the power of data:  how to use it to make good decisions, how to use it for prioritization in problem solving, and how to use it as the fundamental driving force for our organizations’ strategies and plans.  As we progress down the pathway of Lean Healthcare, data has indeed taken the role envisioned by the early advocates of every process improvement strategy from Total Quality Management to Lean Management Systems.

But there is one important aspect of data understanding and usage that is largely misunderstood by many organizations at all levels from the senior leadership to the front-line staff.

All of the indicators mentioned above—HCAHPS, readmissions, all of these numbers that we seem to live and die with every week and every month—are outcomes.  They are the outcomes of our processes for quality.  Outcomes of our processes for control.  Outcomes of our processes for really everything we do every day.  They are, by definition, lagging indicators.  This data, these outcome measures, are the result of the actions and things we do every day.  We focus on these outcomes and we measure as often as we can to try to understand what that the final metric at the end of the month on our scorecard will be.  Why?  So we can solve problems, adjust, then measure and measure again.

That is where the key point is missed.  Our HCAHPS scores, for instance, are not improved by the multiple questions we ask our patients and our customers every day as we go to the gemba.  Our length of stay is not improved by examining in detail the discharges every day.  We can and do chart those results. Then, we rejoice or agonize over those daily results, cross our fingers and hope that the end of the month will reflect our daily outcomes.

The key point is that these interim outcome measures are not important.  It is the behaviors that drive these interim outcomes and final outcomes that are important.  That is what we must measure daily and as often as possible in the course of our work to drive the improvement that we are seeking.  The behaviors!

All of the A3’s that we worked so hard on to define our countermeasures; all of the kaizen events that gave us action plans and new processes; we didn’t do this great work to come up with more interim measures of outcome.  We did this great work to define where and how to change our behavior.  By changing our behavior, we drive process improvement.  That behavior change is what we need to measure every day.  Because if we are correct in defining the basic behavior change, guess what?  The metrics and measures that we live and die with, will follow!

This is the misunderstood application of data.  Defining and measuring a true “leading indicator.”

Leading and lagging indicators are difficult to understand.  Profit is a lagging indicator and an outcome.  It is driven by two leading indicators: revenue and expenses.  But those two “leading indicators” are also lagging indicators and outcomes.  Expenses are the lagging indicator of leading indicators like supply cost, FTE cost, overtime cost, etc.  But again, these are also lagging indicators and outcomes as well.  We can measure these indicators every day and not show improvement.  But if we define the behavior that drives overtime and change that behavior, then improvement will follow.  And by holding accountable and measuring that behavior every day, we are now able to be confident about what the lagging indicator or outcome will be at the end of the month.  Here is the real kicker – it is much easier to monitor and measure behavior than it is to measure those interim outcomes we agonize over.

Let me give you a non-healthcare example that has helped others to understand these phenomena that are leading indicators:

I want to lose weight.  I have charted my weight for the past year and have an average weight of 200 pounds at the end of each month.  I have a range between 195 and 210 pounds (holidays and vacation).  My weight at the end of each month is a lagging indicator and an outcome measure.  So I decide I am going to draft an A3 on my weight loss.  It is a good A3 and it clearly defines the root cause and subsequently countermeasures of a 2,000-calorie diet and daily exercise.

I now decide that I am going to weigh myself not monthly but every single day.  So I do that and I chart the results.  202, 201, 199 (Hurrah!  A cause for celebration), 204 (dang, two much celebration apparently) and on and on.  I weigh myself every day and I chart it religiously.  I have meetings to discuss the results and I agonize over what the metric will be at the end of the month.

These daily measures are a “leading indicator,” just like expenses, revenue or daily overtime.  But they are not behavioral based leading indicators; they are still outcome measures.

So a revelation occurs:  I now begin to chart two things every day.  I chart whether I met my calorie goal and I chart whether I met my exercise goal.  Diet and exercise are two key behaviors that I defined as countermeasures on my A3.  My assumption is that if I can change my behavior by eating right and exercising, I will lose weight.  Weighing myself everyday will not drive weight loss, it is only an outcome of the diet and exercise.  I measure whether I exercise and diet every day and if the chart shows 0/2, 0/2, 0/2, etc. my weight is not going to change, but I will not be surprised at the end of the month.  If the chart shows 2/2, 2/2, 2/2, etc., I have confidence that at the end of the month my outcome will improve.  By measuring behaviors, it is much easier to course correct and problem solve immediately if the behavior is not being followed:  I may need to change my schedule to allow time to exercise or stop the bedtime snack.  I can be proactive in making a change to allow me to be accountable to complete the behaviors.

The key is to define the behavior based leading indicators, hold them accountable, measure them daily and problem solve and adjust if the behaviors are not being adhered to.

I was working with two units that were focused on eliminating patient falls.  Both did excellent A3’s on the subject.  Both identified multiple countermeasures like fall risk assessment, fall risk patient identifiers at the room, regularly scheduled toileting of fall risk patients, and so on.  Both had excellent visual management boards that they huddled on every shift.  Both charted the monthly fall rate and also the “leading indicators” on the board and discussed it in the daily huddle.

But here was the difference.  Unit A, for a leading indicator charted and discussed in the huddle whether they had any falls the previous day.  If they did, they did the appropriate follow-up and problem solved with the use of their A3 what had “gone wrong.”  All are good processes, but very reactive.  The leading indicator was clearly an outcome measure.

Unit B charted and discussed whether three behaviors were followed the previous day.  Were all new patients assessed for fall risk?  Did all fall risk patients have their rooms identified as such?  Were all fall risk patients toileted on a regular schedule?   Their chart showed 3/3, 2/3, 3/3, etc. by shift every day.  When there was a behavior that was not adhered to, that drove real time specific problem solving in the huddle.  “Why was the fall risk assessment not done?  What will we do today if that situation occurs?”  Why were there patients that were not toileted on the schedule?  What can we do differently to drive the completion of this behavior?”

Guess which unit showed the greater success?

These measures didn’t need to be a 100 percent audit of these behaviors, but they needed to be a sample of the behaviors that was gathered in the course of the daily work and part of the leadership standard work.

The message was clear on the visual management boards and in the huddles.  Our problem solving has defined the behaviors we feel will be effective in reducing and eliminating patient falls.  If we follow these behaviors every day, we feel that we will reach the outcome measures we desire (lagging indicator – monthly fall rate improvement).  We are charting these behaviors every day to drive accountability into our processes and ensure the behaviors are followed.

These behavior based leading indicators often seem hard to define, however they are very simple. Look at the right side of the A3:  The countermeasures and action plans are full of behaviors that need to be changed or developed.  Changing or developing these are the leading indicators that will drive the improvement.

Drilling down to a behavioral based leading indicator and then driving accountability by measuring it every day is a part of a very proactive process improvement methodology.  As part of a Lean Management System approach it is integral with A3 deployment (defining the root cause and the behavioral countermeasures), standard work (defining how to complete the behavior), leadership standard work (verifying the behavior occurs) and visual management (visually showing the link between the behavior and the outcome measure for the staff to understand and discuss).

Define your leading indicators and let them truly lead your process improvement!

Steve Taninecz, Director for Lean Healthcare and Process Improvement at HPP

Today’s blog was written by Steve Taninecz, director at HPP.

Steve has 40 years of experience in manufacturing and healthcare organizations.  Steve’s work in the healthcare field began as an educator, trainer and coach for the Pittsburgh Regional Health Initiative, then as part of a New England for-profit health system overseeing, counseling and coaching culture change to the hospital system’s leadership for the successful implementation of lean.  Steve holds a Bachelor’s Degree from Youngstown State University in Industrial Management and a Master’s Degree in Organization Leadership from Geneva College.


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