The business and clinical intelligence that are necessary for healthcare leaders to better manage their organizations are changing rapidly. Returns may be greatest for organizations that are able to measure outcomes and show value.

This article first appeared in the July/August 2017 issue of HealthLeaders magazine.

An old saying from Six Sigma and other process improvement regimes is that "what gets measured gets done." That’s important for senior healthcare executives to remember. But that truth leaves out the critical question of what should be measured.

The options are literally endless, but determining the most important metrics to measure in an era in which healthcare is transforming is no trivial decision.

The move toward reimbursement based on the value the healthcare organization provides to the patient and the payer, which is happening at vastly different rates in some geographical areas compared to others, means that asking and answering that question at regular intervals is crucial.

If that’s the case, what are the metrics that leaders need to watch to ensure clinical, financial, and strategic success?

This special issue of HealthLeaders examines how high-performing organizations are instilling and adapting to new performance measures that healthcare leaders need to track to "get value done."

Our editorial team talked with more than a dozen organizations in a variety of sectors, from leaders of hospital inpatient organizations to payer leaders, from leaders of postacute care organizations to information technology, nursing, and finance leaders; all have measurements they find useful to achieve value in a rapidly transforming healthcare business environment.

Some metrics may be familiar, such as admissions or readmissions per thousand patients. Other metrics may be unfamiliar, such as a "user resource metric," part of which incorporates the speed with which patient calls are answered at a call center.

Many more important metrics are clinical in nature, but are often monitored and reported by the financial arms of the organization, as they provide a proxy for customer satisfaction, a growing component of the value equation.

Also critical is the latency of such measurements. For example, it’s less valuable to learn about line infection rates and sepsis diagnoses after the patient has been discharged, because little can be done to influence the statistics by that time.

Still other metrics are based upon the area of the organization that is seeking to improve. The nursing department is held accountable for catheter-associated blood infections, for example.

The IT department may be charged with synthesizing and developing measurement dashboards that allow chief medical officers to keep track of patient statistics in as close to real time as possible. Different dashboards are needed for senior executives, who might need to keep track of staffing efficiency or patient census trends.

Regardless, the measures that matter are changing, and for hospitals and health systems to thrive, they need IT departments and patient analytics partners not only to keep up with the changes, but to help develop new metrics that span the continuum of care.

Metrics: A Third Pair of Eyes for CEOs

For President and CEO Nancy Howell Agee, more information is better in helping her synthesize a daily snapshot of how Carilion Clinic is performing.

She likes to drill deeply into a statistics page for the Roanoke, Virginia–based nonprofit, 1,026-licensed-bed, seven-hospital system. The page is updated as information is entered, and it shows how busy the emergency departments or the inpatient facilities are.

It shows med-surg scheduling statistics, census information in the ICU, pediatrics, and whether there are any "holes" in the OR schedule, she says. Dozens of other related metrics are available.

"I look at that twice a day, and most of our senior management team routinely looks at that," she says.

The same daily stats provide information compared to plan (budget), or compared to previous time frames.

Howell Agee says the dashboard she favors allows her to look at admissions, obstetrics volume, volume at the cancer center, high-level imaging stats, and both inpatient and outpatient ED and OR volumes.

She can drill down further into all these metrics, but high-level intelligence about the operations of the facility are also available at a glance.

On the outpatient side, she looks daily at visits to the health system’s 240 practice locations. She pays special attention to a workforce report that measures whether the health system is staffing appropriately based on volume.

Howell Agee views financial metrics less frequently—monthly and quarterly—with her leadership team. They discuss whether the system is meeting its budget, how the payer mix is changing, or how clinician RVUs are trending.

They also spend time reviewing home health visits, urgent care health visits, and what kinds of cases are trending higher or lower in the OR.

They also analyze whether the health system is meeting, ahead of, or behind plan, by entity.

"That’s about a half-day meeting with senior execs to go through the monthly stats," she says.

"We also have a close to real-time view of everything happening in all seven of our EDs, and we look at volume, work hours, holds, wait times, and left-without-being-seen.

"Finally, we’ve pioneered with a service to look at our reputation radar, a sort of seven-day view of what our patients are telling us based on social media," she says.

"Everything boils down to metrics, but I’m always cautious that they tell you a story but not the whole story," she says. "You also have to tune into what’s really happening to your patients and staff."

In other words, metrics are important but not sufficient.

"Taking the information and pressing back is important," she says. "Data is not the intelligence. What else do you need to know?"

For example, she says, recently, observation days jumped 20% across the organization. She followed up and asked why. The explanation was that it was a holiday and effects of the two-midnight rule for inpatient status.

"Why would that suddenly change? We’d planned on that," she says. "I went with it, but as I was thinking more about it, they reran the statistics, found a mathematical error, and observation days weren’t up at all. That’s important because our workdays and PTO are affected by this statistic."

Marc Harrison, MD, president and CEO of 22-hospital nonprofit integrated delivery system Intermountain Healthcare based in Salt Lake City, says he pays more attention to certain metrics that are closely associated with customer service than clinical outcomes, at least on a daily basis.

"I’m more interested in access than just about anything, because we can’t make people better if they can’t get in to see us," he says.

He looks at waiting lists for outpatient clinics, outpatient wait times, call abandonment rates at the health system’s call centers, and the time taken and ease of getting a hospital transfer into the system’s tertiary and quaternary facilities.

"I try to know as much as I can about this on a daily basis."

He also finds himself drawn to paying special attention to conversations happening among clinicians about best practices, for example.

While that type of monitoring isn’t a metric exactly, he sees such diligence as essential to the health system’s attempt to drive value.

For example, the orthopedic program runs a weekly meeting in which surgeons from around the system make presentations to each other on best practices—based on their recent experience with patient cases.

"It’s kind of a group consult, but as a system leader, I’m less interested in the outcome of those conversations than whether the conversations are actually occurring," he says.

Harrison sees these meetings as a way both he and the relevant clinicians can learn about physician preference items, for example, or adequate volumes to justify offering sophisticated procedures in certain facilities, he says.

"This is a surrogate for population health and value," he says.

He also pays close daily attention to hospital transfers because he says they speak to accessibility on the inpatient side, but he wants to understand the ROI behind the things the health system does.

Sometimes that’s easier said than done, but one area of innovation at Intermountain is its work on integration of behavioral health and clinical programs, which embeds mental health services in some of the system’s primary care clinics.

"We’re able to do that as a payer and provider," he says. "We spend $22 per patient per year and return $120 per patient per year in the form of better overall health and less ER visits."

Those kinds of metrics, in which it takes time and trial-and-error to make the connections to come up with an ROI, are important in a world where there is a race on to make use of predictive analytics, he says.

"Predictive analytics is trying to understand which patient needs an intensive approach and who needs a less intensive one to maintain their good health," he says. "That suite of metrics will be important in providing ultra-segmentation of a market."

Initially, that work will be algorithm-driven, but in the near future, Harrison says with machine learning and automation, healthcare can take advantage of what he calls a fourth industrial revolution.

"Each of us represents a couple thousand data points, and a supercomputer can compile our risks compared to a large population based on our characteristics," he says. "Then we can actually provide precision medicine—not for cancer or heart disease—but to keep people well."

In the interim, taking more risk is a way to force reliance on data and metrics, says Harrison, who estimates between 35% and 40% of the system’s reimbursement is at risk.

"Because we have a health plan [Select Health], we’re ahead of some other organizations. We’re learning, but eventually all healthcare systems have to get in the water and swim."

Metrics That Matter to Medical Groups

"We always thought we were doing a great job," says Meryl Moss, MPA, EMHL, chief operating officer of Coastal Medical, a primary care group practice in Rhode Island, with 19 locations throughout the state.

As programs such as meaningful use and the National Committee for Quality Assurance’s certification process called for the group practice to track various metrics more deliberately in recent years, leaders recognized that elderly patients weren’t receiving flu shots as consistently across all clinics as they could be, for example, or that more patients were using the
ED unnecessarily.

Through increasingly standardizing and systematizing operations and care over time, however, Coastal Medical can now empirically say that it received an MSSP quality score of 100% in 2015.

"The idea of working toward quality for our patients fit in with Coastal’s culture," Moss says.

"Physicians here didn’t want to just jump through hoops to chase an incentive. They absolutely wanted anything we did to be connected to higher-quality care and better patient outcomes."

Thus quality represents the first of four major areas of measurement, she says, followed by patient satisfaction, utilization, and cost.

The growing prevalence of value-based reimbursement is driving medical groups’ emphasis on quality, says Scott Hayworth, MD, FACOG, president and CEO of CareMount Medical, PC, an independent multispecialty medical group in New York State, with 43 locations, including seven urgent care centers.

"We’re focused on quality and cost. And if we can provide patients with quality healthcare in a cost-effective way, that’s the key. That’s where many organizations are being driven, and that’s where we have been focused and will continue over the next five to 10 years," he says.

Quality is also the first of five strategic pillars for Oregon Medical Group, a physician-owned multispecialty clinic of 140 providers in Eugene. The other four are patient experience, healthy workforce, growth, and total cost of care, says Karen Weiner, MD, MMM, CPE, the group’s CEO.

But defining success in those pillars is about more than scores on an annual report card or completing one-off projects, Weiner says.

In the spring of 2016, the group began implementing a daily management system (DMS) that has taken the high-level goals of the organization and translated them into the daily work of clinicians and staff.

The DMS, an element of Lean business methodology, is especially interesting because it allows workers to choose their department’s metrics.

For example, while the group tracks CGCAHPS (Clinician and Group Consumer Assessment of Healthcare Providers and Systems) scores to monitor patient satisfaction, the DMS has helped improve results around particular questions related to accessibility by telephone.

"We had low scores in that area, so the clinics decided we’d make a goal of fewer than 5% dropped calls," says Weiner.

The clinics then measure themselves against that goal daily, and report their results as part of an organizationwide huddle every morning that includes the central business office looking on via smartboard.

"Well, we did get more than 5%," Weiner says. But the group noted that the spike occurred between 10 a.m. and 11 a.m., so they shifted staff around so that there were no outbound calls during that hour, freeing everyone up to take inbound calls.

"They problem-solve on the front end," she notes. "It’s not the administration that has to come in and show them their stats and tell them they’ve got to fix it. They’re right on it, and they celebrate their daily successes."

So far, seven of the group’s 14 clinics have adopted the DMS and give a report during the daily huddle. The clinics that haven’t been part of the deliberately slow, methodical rollout yet are eager to implement.

"It honestly takes 90 seconds to hear it all," Weiner says. "And the whole organization gets to hear what’s happening across all clinics. And if there are problems that need to be kicked up, that’s where they’re kicked up, and everybody hears about it at the same time. It’s changed everything," she says.

Another example of a goal set by Oregon Medical Group clinics is to have support staff all receive a 60-minute lunch break every day, which falls under the pillar of healthy workforce.

"It’s a way to put your money where your mouth is and let the staff know this is something we prioritize," Weiner says.

A healthy workforce is of prime importance for CareMount as well, says Hayworth, noting the symbiotic nature of many of the key areas medical groups track.

"We’re centered around our 550,000 patients; they are the primary responsibility of the organization," he says. "On top of that, CareMount is focused on our employees and our physicians. In addition to patient satisfaction and quality, we are very interested in staff and physician morale—because if you don’t have engaged staff members, you’re not going to provide excellent care."

Gauging the Financial Impact of Population Health and Value-Based Care

Yale New Haven Health is developing new strategies to track and measure metrics related to population health and value-based care models, says Stephen Allegretto, YNHH’s vice president of strategic analytics and value innovation.

"To be able to succeed in this new world where quality and cost are important at the patient level, we need to come up with real-time metrics that will give us an understanding of the impact of a procedure on a patient prior to surgery. We are just on the cusp of achieving that for selected patient populations."

In fiscal year 2014, New Haven, Connecticut–based YNHH posted total revenue at $3.4 billion. With last year’s acquisition of Lawrence + Memorial Hospital in New London, Connecticut, the health system became a $4 billion organization.

All healthcare providers face a dual challenge measuring population health and
value-based care metrics that affect an organization’s finances, he says.

"If we are responsible for a Medicaid patient, or we are responsible for a Medicare patient in a lower-joint bundle, we need to understand what portion of the total cost is inside and outside the walls."

At YNHH, which features a medical center that draws tertiary-care patients from across the Constitution State, measuring internal versus external metrics pose contrasting challenges, Allegretto says.

"We have tried to identify populations that we are at risk for to manage. For example, we take a look at the readmission rates for clinical populations within our walls. We are in a market where 90% to 95% of our readmissions happen within our organization. So we look at the quality outcomes for the patients we are responsible for inside our walls."

Participating in risk-based contracts such as Medicare’s bundled payment programs for hip and knee replacements has helped YNHH boost its "new metrics" measurement capability.

"We have a lot of data for patients who fall into bundles. That’s why you need a patient-level data model to be able to include patients in multiple ‘definitions.’ Then you can measure your internal profit-and-loss by patient, then you can understand the variation of patients compared to others. Once you know your portion of total cost of care and utilization, you know what your baseline readmissions are, you know what your baseline physician costs are; so you can manage that closer rather than relying on the timeliness of claims data."

Beyond the walls, data is more scarce and difficult to collect.

"Outside of your walls is a different story. There is the delay in SNF utilization and home health agencies in billing. We try to employ strategies that help us understand the baseline costs outside our walls," Allegretto says.

Since it was founded in 2007, Arlington, Virginia–based Privia Health has shown strong growth and financial performance. In the first quarter of this year, Privia had 1,600 providers in the multistate physician organization, with average annual collections per physician at about $500,000.

"We were built for a purpose. We are not retrofitting as a service group to understand population health and performance and risk arrangement. That has been in our DNA from the get-go," says David Rothenberg, president at Privia Health.

Privia participates in Track 1 of the Medicare Shared Savings Program as Privia Quality Network LLC. Privia’s accountable care organization serves Medicare beneficiaries in the District of Columbia, Maryland, and Virginia.

In MSSP performance year 2014, Privia’s ACO served 13,805 assigned Medicare beneficiaries, with a $110.9 million expenditure benchmark. The ACO generated total shared savings of $5.7 million, earning a $2.8 million shared savings payment.

In MSSP performance year 2015, Privia’s ACO served 28,242 assigned Medicare beneficiaries, with a $229.2 million expenditure benchmark. The ACO generated total shared savings of $12.9 million, earning a $6.2 million shared savings payment.

At Privia, monitoring population health and value-based care metrics are keys to success, Rothenberg says.

"On the population health side, we think a lot about process—the things we need to do day-to-day. … One example is access. We are asking ourselves, ‘Are our providers available for patient needs?’ This is especially true for immediate care. Most practices are open nine-to-five, then they close. What happens after they close is patients go to the emergency room and the ER sometimes runs unnecessary tests—it leads to a bad patient experience and it is expensive.

"So the metric we measure for access is ER visits per thousand patients."

Some new metrics are a blend of population-health and financial measures, he says.

"In population health, one metric that crosses over into finance is accurate documentation: Do we make it easy for our providers to document and code appropriately in the EMR? We track that. We track encounter-to-close lag, documentation time, and risk-adjustment coding gaps closed. With our technology, we are able to track these. If some providers are taking longer than others, we are able to track that in real time."

Accurately gauging and monitoring financial metrics is critical in risk-based contracting, Rothenberg says.

"Everyone is tracking revenue. We look at 12-month trailing revenue. For our medical group, a lot of that is physician practices tracking how well they are doing compared to how they were doing before joining the group. Part of our model is ensuring practices are better off financially net of our fees. We want to document that, track that, and make that clear to the practices."

Metrics—The Buck Stops With Nursing

Nurse leaders are responsible for a vast array of metrics related to processes, clinical outcomes, and everything in between.

"Our CNOs are held accountable for readmissions, mortality rates, [and] hospital-acquired conditions, and for the financial bottom line in their particular hospital," says Maggie Hansen, RN, BSN, MHSc, senior vice president and chief nurse executive at the South Florida–based Memorial Healthcare System, which had net income of $189.7 million in 2016.

"Nurses have to worry about almost every touch point on the continuum of care. We’re counted on to produce great and enviable metrics. We’re the ones that can make it happen, because healthcare is about the patient care that nurses provide."

The National Database of Nursing Quality Indicators, HCAHPS surveys, and Joint Commission standards are common means of measuring outcomes such as catheter-associated bloodstream infections, falls with injury, length of stay, staff engagement, and patient satisfaction scores.

To help CNOs get their arms around the myriad metrics they need to collect, Sean Lynch, RN, MSN, SCRN, assistant administrator for patient services and nurse executive at the 136-staffed-bed Baptist Medical Center Beaches in Jacksonville Beach, Florida—part of Northeast Florida’s five-hospital Baptist Health system—suggests looking at data through the four "pillars" of finance, quality, patient experience, and team engagement.

Throughout the Baptist system, all meetings in every department begin with a review of quality metrics. And while quality is important, Lynch says the pillar of team engagement should not be overlooked.

"Your team is what makes the other three pillars happen," he says.

To measure employee engagement, Baptist Medical Center Beaches administers a Willis Towers Watson team engagement survey every two years.

"Each department identifies their strengths and their weakness, and they build action plans based on their opportunities," he says.

Hospitals and health systems may also want to consider ways to collect metrics in real-time, Lynch says.

"Press Ganey is wonderful, although the delayed results make it challenging to look at retrospectively," he says.

Baptist Medical Center Beaches is piloting a program called Rounding and Driving Awesome Results (RADAR), which one of the organization’s administrators created to help leaders respond to patient issues as they occur.

During a RADAR survey, nurse managers ask patients five questions, including "Are we meeting all your expectations?" and "Are the staff responsive to you?" The patients’ answers are entered into a tablet, and each day at 7 a.m., a report is printed.

Depending on the patients’ responses, the program issues a red light (dissatisfied) or a green light (satisfied or very satisfied).

The organization’s leadership can also review patient comments entered into the survey. The color-coded system makes it easy to identify opportunities for service recovery before a patient leaves the hospital.

"If there are opportunities, we want to intervene as a leadership team," Lynch says. For example, if there is a dietary issue, the dietary manager can go directly to the patient’s room to assist in his or her concerns.

At Mission Health, a nonprofit, independent community health system in Asheville, North Carolina, the organization is improving care by collecting metrics across the board related to harm.

"Webenchmark that," says Jill Hoggard Green, PhD, RN, Mission Health System’s chief operating officer and president of Mission Hospital, the system’s 763-bed flagship hospital.

"Over the last three years, we have had a substantial reduction in harm across the board. For us, that’s everyone’s goal. We do it at the system level and then we look at it on individual units, usually with specific measures, where we can see we have opportunities."

At Mission Hospital, the organization is creating team-based care units where a physician provider, care manager, and nurse leader colead a unit that focuses on a specific patient population.

"We work on having standard work with outcomes, and we have huddle boards where we assess our metrics and how well we’re moving forward," says Karen Olsen, MBA, BSN, RN, NE-BC, vice president and chief nurse executive at Mission Hospital.

Length of stay, readmissions, leader rounding, and patient experience are all evaluated and used to improve unit processes.

For example, if the goal is to discharge patients earlier in the day, metrics are assessed to help identify barriers to reaching that goal. If the unit-based leadership team notices there is a delay in the physical therapy department, for example, they work together to find solutions to the hurdle.

"We shift something to optimize that patient experience and the outcomes on that unit," Olsen says.

Unit-based safety issues are also reviewed.

"We do root cause analysis and partner with our safety and quality leaders to [develop] action plans," she says. "We have a strategic committee, and we are very transparent with our metrics. Those units that are excelling and doing well—we want to transfer that knowledge and that experience so we can have gains across all of our units as well."

Gauging Metrics for Quality and Security

Hospitals’ top information executives find themselves on the front lines of developing ways to track—in as close to real time as possible—information that clinicians and senior executives find are important for consistent care, quality improvement, and system security.

At Beth Israel Deaconess Medical Center in Boston, operational metrics are high on Chief Information Officer Manu Tandon’s priority list.

"As the CIO for the hospital, the metrics I deal with focus on operational needs," says Tandon.

These include gauging the reliability and availability of everything from clinical systems, such as the electronic medical record system and networks, to the telephones and pager systems in the 651-licensed-bed teaching hospital of Harvard Medical School.

The BIDMC IT team is also tasked with accommodating clinicians’ requests for additional quality measures and other changes to the medical center’s EMR system.

"We have metrics around our turnaround time for responding to requests and for making the enhancements and so forth."

BIDMC also has a set of metrics for what Tandon calls "soft measures." These include tracking IT staff training, checking for single points of failure, and conducting employee surveys to gauge morale.

Although the metrics must be fluid to accommodate changing clinical and operational needs, the medical center is adding more measures, not subtracting, especially in the area of security.

Tandon’s department has created metrics to monitor the number and type of malware attacks targeting the hospital, to ensure data are encrypted, and to track whether antivirus software systems are up to date.

"Security has really grown as a big concern, as it has with other healthcare organizations. We are constantly trying to stay ahead in the metrics in that area—most of them change just because the attacks keep changing," Tandon says.

Postacute: Ability to Take Risk Hinges on Metrics

In helping to develop and form HM Home and Community Services, a division of Pittsburgh healthcare conglomerate Highmark Health, Brian Holzer, MD, saw his job in simple terms: Close gaps in postacute care.

The former president of the organization (he left in late May to become president of Kindred Healthcare’s Kindred Innovations unit) says the best way to do that is through measurement of key metrics and collaboration with postacute care providers that allow course correction in the patient care journey at the earliest possible point.

Holzer was in charge of integrating postacute healthcare for a Pennsylvania ACO and a health insurer’s Medicare Advantage line of business, both of which chose HMHCS for its strategic and network management capabilities.

HMHCS manages the interactions between those postacute companies and acute care facilities with the aim of holding postacute providers accountable for their performance in quality and cost control.

HMHCS represents a better model of postacute that "sort of sells those services back into the hospital, with the hospital as one of our customers," Holzer says.

HMHCS depends on a variety of information and analytics to prove it is "better than the market," in Holzer’s words, meaning that based on the facts, hospitals choose to work with HMHCS because of the impacts on performance in quality and efficiency.

For postacute care, the HMHCS team closely monitors metrics such as SNF and home health readmission rates and SNF lengths of stay.

"Generically speaking these are examples of the unit measures of quality, so we’re looking at those trends, but as important on a weekly basis is how well the model is working for our ACO and health plan customers," says Holzer.

That said, he says he hungers for more data that is closer to real time.

"Healthcare, particularly postacute healthcare, suffers from lack of actionable data," he says, adding that, nationally, approximately 40% of hospital admissions recover in some sort of postacute care setting.

"The ability to keep tabs on that patient to see whether medical recommendations are taking place, or when patients are picked up by other healthcare pros, would be very helpful in helping the postacute side make commitments to hospitals and insurers on gains in quality and efficiency," he says.

That would mean insights from real-time data that doesn’t really exist yet.

"We need to have insights from data as they flow," he says. "We’re not the only entity touching patients. We need earlier info on who’s going home and will need services, so that hospitals can better educate the patient on options, build detailed care plans, and measure how those plans work out."

On that point, he’ll get no disagreement with Daniel Varga, MD, chief clinical officer at Texas Health Resources based in Arlington, Texas, who’s basically accountable for all clinical operations in the health system, serving in a dyad management model with the chief operating officer.

The first place to attack inefficiency was the inpatient side, Varga says, but now Texas Health Resources seeks to broaden its reach into the postacute experience, which requires different measures to help improve care coordination and efficiency and prevent gaps in care.

"We know we have to take a significant amount of cost out of our system while not sacrificing quality, reliability, safety, and the patient experience," he says. "That requires an obsessive approach to outcomes, an elegant approach to process redesign, and compliance with that process. That gets to how we manage things on the acute care side."

Compliance with process redesign is especially important in both inpatient and outpatient environments, he says.

The system’s hospital operations improvement dashboard measures, in close to real time, hospital operational metrics such as labor requirements based on patient load, productivity, and cost center analysis.

"Those dashboards allow us to drill into process redesign compliance on a daily basis," he says. "Another piece we look at is something brand-new for us: labor cost per adjusted patient day, discharge and productivity metrics, but essential to our daily analytics is reliable care blueprinting, which is our approach to high reliability in bedside operations."

The redesign of bedside care, which features process-level leading outcome indicators that populate in real time, helps evaluate compliance in time to make course corrections, Varga says.

He monitors reliable care blueprinting almost daily to gauge percentage of compliance in, for example, fall risk, documentation, or assessments. There are 20 leading process indicators to make sure the care redesign parameters are being followed, but more important, where there’s compliance and where there isn’t.

Varga and his team can drill deeply into compliance—even by job title.

"We’ve tried to create a metrics stack that’s valuable to the specific user," Varga says. "For example, if we’re looking at the reliable care blueprint for sepsis, observed versus expected mortality is really not valuable to a frontline technician. But we know a key process metric is early identification, and in order to slip the alert, a certain set of vital signs needs to be obtained. Everyone has a stack that applies to them."

This means for the person who’s responsible for taking vital signs, the percentage of time vital signs are completed is essential to identify sepsis more quickly.

"Their job is to get vital signs early and accurately into the EMR," Varga says. "If 100% of that job is done, they’ve done what they’re supposed to do. If not, we work to close the gaps."

Those tools and others like them will be important on the outpatient side as well, as Texas Health Resources takes more revenue risk, such as with the rollout of its NextGen ACO.

With approximately 80,000 beneficiaries, the ACO will be on the hook for plus-or-minus 15% of about $1.1 billion in annual premiums, depending on how it does in improving outcomes for Medicare beneficiaries.

Coupled with its existing Medicare Advantage offerings, the health system will experience about $1.5 billion in premiums either in total risk or partial risk in 2017, says Varga.

With more healthcare services gravitating away from the acute care space, Varga says to unlock the value the health system creates by managing an entire episode of care, it must take more risk.

"The only way we unlock the value we create is to take more risk."

Health Plans: Value, Integration Drive New Measures for Success

Alan Murray is employee No. 1 in a health insurance startup.

That’s the mindset from which he developed the metrics that matter for CareConnect, the 120,000-member, three-year-old insurance arm of Northwell Health, of which he is the president and CEO.

One group of indicators that rises above all others is a daily one he links directly to the mission of his organization.

"We’re trying to be a trusted advisor to our members," he says.

As a narrow network organization that drives volume to Northwell Health, with which it is fully integrated, CareConnect can take advantage of moving more quickly along the risk continuum, he says.

But none of those lofty goals can be accomplished without keeping a constant eye on metrics that come out of the payer’s call center and, taken together, provide a window into whether CareConnect is that trusted adviser.

On a daily basis, those measures are most important to Murray because CareConnect has promised its members explicitly that it has made the hard decisions on which providers in its network are best, so patients and their employers, in many cases, can trust the insurer as a patient advocate.

"If something goes wrong, you only have to place one phone call and we’ll solve the problem, and that involves all the clinical integration and aspects of care," Murray says.

Murray doesn’t like it when a patient’s call is transferred, so he keeps an eye on the percentage of calls that are resolved by the person who answers the phone. Right now, it’s at 88%.

And it’s always a person answering the phone. There are no menus to navigate. The average speed of answer for the nearly 50,000 calls the center receives a month is less than 30 seconds, another important metric. Backup centers in Alabama and Kentucky keep answer time down in periods of high volume, but most calls are handled locally.

Because frontline call center employees are expected to be able to answer a variety of questions themselves, training costs are higher than they are at other call centers, but solving the problem as quickly as possible "provides tremendous value to the customer, who could be a patient, broker, or provider," says Murray. "You shouldn’t have to figure out who to call—we should figure out how to solve the problem. So we’re continuously monitoring call logs, call handle time, abandonment rate, and Web chat email communications. However you want to communicate with us, we will adapt."

Does that translate into market dominance? Not directly, Murray concedes. Most customers do not buy health insurance because of service, but mostly through price and network.

"Our retention, however, will likely be higher than most other payers because once you’re in, it’s hard to go back to those other guys," Murray says.

Many of the statistics related to member interaction are used in compiling what Murray calls a "user resource metric." In essence, interactions over time are divided by total membership, the idea being that needing as few interactions as possible is a key measure of efficiency.

"Low resource utilization and high customer satisfaction rates are key indicators of our success," he says.

He does spend significant time on variables such as adjudication speed, claims lags, and other standard insurance metrics on a weekly basis. Monthly, he keeps a close eye on enrollment, membership retention rate, and length of time to enroll.

"Assuming we’re succeeding on those, we have a unique approach to reimbursement because our narrow network can move further into risk and value," he says.

That means monitoring a raft of clinical metrics, such as utilization data—like how many patients are in the ER or having surgeries.

"Seeing that in real time allows a significant degree of medical management that’s higher than most," he says.

As always, financial metrics are a big deal as well, but the key metric requires synthetization of many revenue-related statistics to determine the incremental impact on the health system’s margins.

"So far, 60% of the volume that we drive to our health system is brand-new volume the health system would not have had before," he says.

Frank Lucia, president and CEO of Madison, Wisconsin–based Dean Health Plan, part of St. Louis–based SSM Health, says many of the metrics he pays attention to are clinical.

Dean Health Plan is Wisconsin-only, but its forays into integration with Dean Medical Group as well as independent healthcare provider organizations in its contracted network make it a venue for further integration, over time, into SSM’s four-state healthcare services network.

A dashboard Lucia monitors daily tracks episodic events from which care plans are built based on programmatic analysis of high-risk patients.

"So daily, we monitor admissions, authorization levels, the high-risk population, and other situations that might lead to high-cost procedures or unnecessary ED visits," he says. "These metrics help us determine strategy for case management to drive efficient outcomes."

On a programmatic basis, leadership from the medical group and the health plan comprise a value subcommittee that convenes regularly to discuss value initiatives dealing with the episodes. That group focuses on readmissions, pharmacy utilization, ED visits, and care management opportunities for the high-risk population.

In the past two years, Dean has moved many unaffiliated physicians and hospitals to value-based contracting arrangements.

The performance of those contracts depends on key metrics in quality patient satisfaction and cost management that help align goals and incentives with the rest of the contracted network, says Lucia.