ORIGINAL ARTICLE Performance management tools motivate change at the frontlines Christopher Smith, MBA, BComm; Tanya Christiansen; Don Dick, MD, FRCSC; Jane Squire Howden, RN, BScN; Tracy Wasylak, BN, MSc; Jason Werle, MD, FRCSC Abstract—Performance management tools commonly used in business, such as incentives and the balanced scorecard, can be effectively applied in the public healthcare sector to improve quality of care. The province of Alberta applied these tools with the Institute for Health Improvement Learning Collaborative method to accelerate adoption of a clinical care pathway for hip and knee replacements. The results showed measurable improvements in all quality dimensions, including shorter hospital stays and wait times, higher bed utilization, earlier patient ambulation, and better patient outcomes. F or 3 years, Alberta’s battle to reduce stubbornly high variability in adherence to its provincial care path for elective hip and knee replacements played out on the frontlines of public healthcare. Now, the battle is over and frontline health professionals and the province’s public healthcare agency are counting the spoils. Among them are shorter patient stays in hospital, tens of thousands of bed-days saved, millions of tax dollars freed up for reinvestment, declining wait times for surgery, and hap- pier, healthier patients. The improvements can be linked to the inventive use of two common performance management tools—incentives and scorecards 1 —in an area where they are rarely employed: the frontlines of public healthcare in Canada. It is the area where the hour-to-hour actions of clinicians and managers have an immediate and significant effect on the quality of patient care and the consumption of expensive public resources. The work began in 2010 following a pilot to test the effectiveness of non-monetary incentives for encouraging frontline healthcare workers to adhere to the Integrated Care Path (ICP) for hip and knee replacements. 2 BACKGROUND The ICP was designed by Alberta’s orthopaedic surgeons and the Alberta Bone and Joint Health Institute (ABJHI), a non-profit organization dedicated to improving bone and joint healthcare in Alberta. It sets out evidence-based practices and protocols beginning with referral by primary care physician and continuing through specialist assess- ment, optimization of surgical patients, surgery, recovery, and rehabilitation. Care is fully integrated and provided by a multidisciplinary team. The ICP was evaluated in a 12- month randomized controlled trial in 2005-2006. 3 Managed by ABJHI in collaboration with the Alberta Orthopaedic Society and health regions, and with financial support from the government of Alberta, the clinical trial proved the ICP to be superior to conventional care in the 6 dimensions of quality (Fig. 1). Based on these findings, the health regions and ortho- paedic surgeons adopted the ICP in 2007 as the provincial standard. But spreading it across the province proved slow. Periodic audits by ABJHI over the ensuing years found the ICP was not adopted universally and where it was being followed; the degree of adherence varied significantly. At the same time, the mean wait for hip or knee replacement in Alberta, 4 as in most other jurisdictions in Canada, remained higher than the national 26-week benchmark. 5 Alberta Health Services (AHS), the provincial health service delivery agency, decided to test the effectiveness of non-monetary incentives for increasing adherence to the ICP and accelerating its spread. It turned to the people on the frontlines, forming a multidisciplinary team at Calgary’s Rockyview General Hospital to conduct a pilot in 2009, and engaged ABJHI to manage the process. The Rockyview team comprised frontline clinicians and managers working in an integrated setting whose collabo- ration is essential to delivering care as specified in the ICP. 2 The team set performance targets in key areas of the care path. It adapted the balanced scorecard 1 to measure quality of care across 6 dimensions (Fig. 2). Key Perform- ance Indicators (KPI) were selected based on their potential to influence patient outcomes and health system effi- ciency, team members’ ability to influence the outcomes associated with the indicators, and the correlation between the indicators. The latter served to illustrate vividly the extent to which performance in one area of an ICP can From the Alberta Bone and Joint Health Institute, Calgary, Alberta, Canada; Edmonton Musculoskeletal Centre, Edmonton, Alberta, Canada; Alberta Health Services, Calgary, Alberta, Canada; Rockyview General Hospital, Calgary, Alberta, Canada. Corresponding author: Christopher Smith, MBA, BComm, Alberta Bone and Joint Health Institute, 400, 3280 Hospital Dr. N.W., Calgary, Alberta, Canada, T2N 4Z6. (e-mail: csmith@albertaboneandjoint.com) Healthcare Management Forum 2014 27:15–19 0840-4704/$ - see front matter & 2014 Canadian College of Health Leaders. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hcmf.2013.12.003