Managing and Improving Performance

With the whole population level strategic planning process completed, we then focus on the proposed actions and define these as services or projects, putting in place a process to ensure accountability of the service provider (and/or commissioner) to clients, customers or service users.

The Outcome Based AccountabilityTM (OBA) approach to performance management is characterised by the simple, common sense, minimum paper approach used at the whole population planning stage. Fundamentally, defining good performance revolves around choosing data that answers three questions about the interventions being provided:

1. How much did we do? (the quantity of service)
2. How well did we do it? (the quality of the service)
3. Is anyone better off? (the impact of the service, or customer* outcome)

This can be illustrated graphically as four quadrants juxtaposing the interlocking questions around Quantity and Quality (on the vertical axis) and Effort and Effect (on the horizontal)

Choosing data to populate these four quadrants gives us our performance measures. Data in the top left hand quadrant measures how many people are served by the intervention (usually broken down demographically) and how many individual units of service are provided.

The performance measures in the top right hand quadrant relate to the quality of the services provided and the quality of the providing organisation. How will we know that we are delivering quality interventions?

Data in the lower left quadrant measures the effect or impact of the intervention, i.e. how many customers are better off. The lower right hand quadrant expresses this data as a percentage of the total number of customers to determine the overall quality of the impact or effect.

There is absolutely no point in delivering services if no one is any better off, yet the bottom quadrant performance measures are usually the least defined and are frequently never measured at all. If no one is any better off as a result of the service provided, then we will make little or no impact on the desired whole population outcomes we want for our communities.

There is little or no correlation between the upper left hand quadrant (quantity of service) and the lower right (quality of impact or customer outcome). This is because it doesn’t necessarily follow that for every unit of service delivered, one person will be better off. There is considerable complexity surrounding customer outcomes and each customer starts off in a different place. Whilst it’s possible to measure an outcome from a single service intervention, some customers will require several interventions over an extended period of time depending on the context. Relying on top left quadrant measures therefore as the only means of determining service impact is fundamentally flawed. Determining and measuring the bottom quadrant performance measures is seldom straight forwards, but we cannot abdicate responsibility for these measures if we are serious about wanting to make a positive difference to communities.

When the Performance Measures have been decided, these form the basis for managing and improving the performance of the intervention and/or the basis for the programme/project specification as part of a commissioning process.

The ‘Five point method’ described in Mark Friedman’s book “Trying Hard is Not Good Enough’ is a briefing for a process to consider each of the quadrants for any given intervention and includes tips for finding ‘Better Off’ measures. The script for this process is also available in the resources section as are examples of completed quadrants for a range of interventions.

Monitoring and Improving Service Delivery

Using OBA to improve service delivery is based on the same seven stage thinking as described in ‘Developing Strategy at the Whole Population Level’ but with two important differences. Instead of starting by defining the whole population, because we are looking to performance manage a specific intervention to a defined group of customers or service users, we start by answering the question “Who are our customers?” By customers, we mean those people whose lives are affected (for better or for worse) by the actions of the service. (Instead of customers, you might want to use the terms service users, patients or clients.)

The second important difference is that instead of using population indicators to measure improvement, we are looking to determine performance measures by populating the four quadrants illustrated above to demonstrate the impact of the service with a particular emphasis on the bottom right hand quadrant measures.

Monitoring and improving performance can be facilitated by creating a scorecard based on the seven performance accountability questions which are:

1. Who are our customers?
2. How can we measure if our customers are better off? (bottom right hand quadrant measures)
3. How can we measure if we’re delivering our services well? (upper right quadrant measures)
4. How are we doing on the most important of these measures? (creating a baseline and a curve to turn in exactly the same way as with population accountability. Understanding the story behind the baseline is crucial to understanding how to improve performance )
5. Who are our partners who have a role to play in doing better? (this will inevitably include our customers and suppliers)
6. What works to do better? (What would it take to turn the performance measure curve? What can we do that is no-cost or low-cost in addition to things that cost money?)
7. What do we propose to do? (the action plan)

The thinking process to improve the performance of services follows an almost identical “Turning the Curve” approach to whole population planning, only defining customers instead of whole populations and performance measures (How Much, How Well, Better Off?) instead of population indicators. Historical data on performance is used to create the baseline and extended to forecast the likely trend if nothing is changed. Those accountable for the intervention will then bring together key players in the service delivery including partners and customers to create the richest possible Story behind the Baseline (the factors impacting on the service performance) and this in turn informs the answer to the key question “What would it take to improve our performance?” and the basis for the action plan.

Once completed, there is the basis to create a performance scorecard to monitor actual against historic and forecast data, either as an internal management tool or as the basis for reporting between commissioner and provider.

The Five Point Method has the potential to generate a large number of Performance Measures and with that, the danger of spending more time collecting and managing data than we spend trying to make our service users better off. There is wisdom in the old understanding that weighing a pig doesn’t make it fatter. To avoid a disproportionate amount of time spent on data management, it is necessary to focus on a handful of the bottom quadrant measures as the basis for populating the Scorecard rather than attempting to measure everything. If we focus on three to five measures that say most about the service’s outcome for customers, much of everything else should follow. In this way, less is more.

A step-by-step briefing paper for The Turning the Curve (Performance) process which includes a report card template is included in the Resources pages

*The use of the term “Customer” in this narrative refers to the service users or the people whose lives will be changed (for better or worse) as a result of the intervention.

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