““The Power of Outcome Thinking in The Power of Outcome Thinking in Transforming the State of Health”

The Annual Institute forGovernors’ Health Policy Advisors

Septembe10, 2004

William J. Phillips William J. Phillips

Center for Outcomes Center for Outcomes

The Think Tank with Muddy Boots

OverviewOverview

• Outcome Thinking versus Other KindsOutcome Thinking versus Other Kinds

• Terms, Models and the likeTerms, Models and the like

• Applications to Transformation Applications to Transformation

Hypothetical Scenario:Hypothetical Scenario:

• Health program staff are largely in an activity mode. They focus on the Health program staff are largely in an activity mode. They focus on the process, services provided and numbers served. process, services provided and numbers served.

• Two years ago THE Governor issued an executive order demanding that all Two years ago THE Governor issued an executive order demanding that all Health programs become outcome focused. Health programs become outcome focused.

• Progress has been slow, staff have not been able to make the shift. It’s been Progress has been slow, staff have not been able to make the shift. It’s been “Business as Usual”.“Business as Usual”.

• You have been asked to make this your top priority. You have been asked to make this your top priority.

• How do you start?How do you start?

  

  

A.A.            

2.2.        

Three OptionsThree Options

• Problem ApproachProblem Approach

• Activity MindsetActivity Mindset

• Outcome ThinkingOutcome Thinking

The Problem Approach…The Problem Approach…

1.1. Why do we have this problem?Why do we have this problem?

2.2. What or who caused it?What or who caused it?

3.3. What obstacles exist to solving it?What obstacles exist to solving it?

The Activity Mindset…The Activity Mindset…

1.1. What should we do?What should we do?

2.2. When can we start?When can we start?

3.3. Who can do it?Who can do it?

• Close your eyes; take a deep breathClose your eyes; take a deep breath

• You are now in a future place at a future timeYou are now in a future place at a future time

• Imagine that the situation we described earlier is goneImagine that the situation we described earlier is gone

• Now open your eyes and answer these questionsNow open your eyes and answer these questions

1.1. What are you hearing, seeing, feeling, What are you hearing, seeing, feeling, experiencing?experiencing?

2.2. What is in place that wasn’t before?What is in place that wasn’t before?

3.3. What has been gained ?What has been gained ?

Outcome Thinking

What’s the Difference?What’s the Difference?

The DifferenceThe Difference

• Creates possibilities; generates ideasCreates possibilities; generates ideas

• Increases hope and energyIncreases hope and energy

• Mobilizes resourcesMobilizes resources

• Increases control; reduces stressIncreases control; reduces stress

• Attracts the best and brightestAttracts the best and brightest

““Beginning with Beginning with success in success in mind and mind and keeping it there.”keeping it there.”

What is Outcome Thinking?

4 Outcome Shifts4 Outcome Shifts

• PROCESS TO RESULTSPROCESS TO RESULTS

• EVALUATION TO LEARNINGEVALUATION TO LEARNING

• FUNDER TO INVESTORFUNDER TO INVESTOR

• SUPPLICANT TO RESULTS MANAGERSUPPLICANT TO RESULTS MANAGER

FUNDERS ASK:FUNDERS ASK:

• Has all the money been spent?Has all the money been spent?

• Have all the rules been followed?Have all the rules been followed?

• Can we justify an increase?Can we justify an increase?

INVESTORS ASKINVESTORS ASK::

• What results are we buying?What results are we buying?

• What are the chances for success?What are the chances for success?

• Are we paying the lowest possible Are we paying the lowest possible costs for the best possible results?costs for the best possible results?

Supplicants Ask:Supplicants Ask:

• Have I carried out the plan?Have I carried out the plan?

• Have I followed the rules?Have I followed the rules?

• Have I spent all the money?Have I spent all the money?

RESULTS MANAGERS ASK:RESULTS MANAGERS ASK:

• What results did I commit to achieve?What results did I commit to achieve?

• Can I do it, both financially and Can I do it, both financially and programmatically?programmatically?

• What did we learn and how can we What did we learn and how can we use it to improveuse it to improve??

Outcomes, schmoutcomes…Outcomes, schmoutcomes…

Terms, Models, Systems, Terms, Models, Systems, Graphics, etc, etc,…..Graphics, etc, etc,…..

Key Outcome TermsKey Outcome Terms

• Inputs:Inputs: what goes in what goes in

• ProgramProgram: the products and services created from : the products and services created from inputs and which add value (hopefully)inputs and which add value (hopefully)

• OutputsOutputs: what comes out; what programs produce : what comes out; what programs produce

• Outcomes: Outcomes: the direct intended beneficial effect on the direct intended beneficial effect on those being served those being served

• Impacts: Impacts: long term or indirect effects of long term or indirect effects of outcomes outcomes on on communities or individualscommunities or individuals

A Health Example:A Health Example:

• Program: Program: smoking cessation workshopssmoking cessation workshops

• OutputsOutputs: curricula; horror films, people who attend : curricula; horror films, people who attend one or more sessions; stop smoking plans one or more sessions; stop smoking plans

• Outcomes: Outcomes: the number/percent completing who stop the number/percent completing who stop smoking for at least one year smoking for at least one year

• Impacts: Impacts: reduced health care costs; improved air reduced health care costs; improved air quality, reduced effects of second hand smoke.quality, reduced effects of second hand smoke.

Major Outcome ModelsMajor Outcome Models

Logic Model/Theory of ChangeLogic Model/Theory of Change Balanced ScorecardBalanced Scorecard

Outcome Funding Framework Outcome Funding Framework

Toward Outcomes for ProgramsToward Outcomes for Programs

Managing for ResultsManaging for Results

Getting to OutcomesGetting to Outcomes

Scales and LaddersScales and Ladders

Results MappingResults Mapping

Results Based AccountabilityResults Based Accountability

A Logic ModelA Logic Model

Providing Leadership for Program Evaluation

Logical Linkages: Series of If-Then Relationships

IF THEN IF THEN IF THEN IF THEN

INPUTS OUTPUTS OUTCOMES

Programinvests time

&money

Resourceinventorycan be

developed

Familieswill knowwhat is

available

Familieswill accessservices

Familieswill have

needs met

Theory of ChangeTheory of Change

Getting to Outcomes Getting to Outcomes

Community Equity ScaleCommunity Equity Scale

RBA CrosswalkRBA Crosswalk

Balanced ScorecardBalanced Scorecard

Clarifying and translating 1the vision and strategy, andgaining consensus.

Communicating and 2Linking:-communicating and education-setting goals-linking rew ards to performance measures

Strategic feedback and 4Learning:-articulate the shared vision-supply strategic feedback-facilitate strategic review and learning

Planning and target 3setting:-setting targets-aligning strategic initiatives-allocating resources-establishing milestones

BALANCEDSCORECARD

T.O.P. PyramidT.O.P. Pyramid

Targeting Outcomes of Programs (TOP) Model

KASA:K = KnowledgeA = AttitudeS = SkillA = Aspiration

Program Development(Goals/Objectives)

SEEC:S = SocialE = EconomicE = EnvironmentalC = Conditions

SEEC

PracticesKASA

Reactions

ParticipationActivities

Resources

Program Performance(Evaluation Measures)

ResourcesActivities

Participation

ReactionsKASA

PracticesSEEC

Source: Claude Bennett & Kay Rockwell, 1994

RI Outcome Framework Funnel

MILESTONES NUMBER NEEDED

CONVERSION FACTOR

1. Inquire about program

2. Decide to enroll

3. Attend first session

4. Retain information/skills

5. Attend all remaining

6. Retains information/ skills from all sessions

7. Start at job site

8. Performs

9. Stay at job for at least 6 months

2,000

400

300

200

100

100

80

60

50

5.0

1.3

1.5

2.0

1.0

1.2

1.3

1.2

MILESTONES NUMBER NEEDED

CONVERSION FACTOR

3.

4. Retain information/skills from first session

5. Attend all remaining sessions

6. Retains information/ skills from all sessions

7. Start at job site

8. Performs Satisfactorily on job

9. Stay at job for at least 6 months

2,000

400

300

200

5.0

1.3

1.5

2.0

1.0

1.2

1.3

1.2

The Corporate The Corporate sector; larger sector; larger nonprofit and nonprofit and philanthropic philanthropic

organizations.organizations.

Harvard Business Harvard Business School; The Balanced School; The Balanced Scorecard Scorecard Collaborative; Collaborative;

numerous numerous management management

consultancies in the consultancies in the U.S. , U .K ., Canada, U.S. , U .K ., Canada, and Australiaand Australia

To moni tor ei ther a To moni tor ei ther a single program with single program with several associated several associated initia tives, or mult iple initia tives, or mult iple

programs within a programs within a specific organization; specific organization;

to analyze the to analyze the alignment of alignment of resources and resources and initia tives to strategic initia tives to strategic targets. Mul tivariate targets. Mul tivariate situations needing a situations needing a

single encapsulating single encapsulating portrait o f several portrait o f several

s imultaneous simultaneous processesprocesses

Allows for a graphic Allows for a graphic assessment of the assessment of the degree to which an degree to which an organizations organizations

resources and resources and efforts ac tually efforts ac tually

support its goals .support its goals .

strategy, strategy, alignment , shortalignment , short --and longand long -- term term objectives; objectives;

financial and nonfinancial and non --financial financial

measures; lagging measures; lagging and leading and leading indicators; indicators; performance performance measures and measures and performance performance

drivers; internal drivers; internal and external and external

indices of indices of success.success.

A businessA business -- based based model, designed model, designed to provide to provide integrated integrated

management and management and accounting for accounting for

multiple variables multiple variables impacting impacting organization organization performance, by performance, by connecting them connecting them to a set o f to a set o f

performance performance indicatorsindicators

Balanced ScorecardBalanced Scorecard

Primarily Primarily used byused by

Most Commonly Most Commonly Associated WithAssociated With

Particularly well Particularly well suited forsuited for

Strong PointsStrong PointsKey Terms Key Terms and and ConceptsConcepts

DescriptionDescriptionName of ModelName of Model

The chart below is offered as a basic guide to a sample of outcome models. Models selected are among the mostly widely known, but not all models are currently used to an equal degree. Models are presented in alphabetical order.

A Table of Leading Outcome Models

Outcome Tool ApplicationsOutcome Tool Applications

Communication Communication

Program planning Program planning

Funding Funding

Learning/Evaluation Learning/Evaluation

Result tracking toolsResult tracking tools

Reporting/AccountabilityReporting/Accountability

Resource Management Resource Management

Application to Transformation Application to Transformation

• Be balanced in your “thoughtware”Be balanced in your “thoughtware”

• Start with Success: What would a transformed health Start with Success: What would a transformed health care system look like AND accomplishcare system look like AND accomplish

• Choose an outcome model that fits Choose an outcome model that fits

• Start with early adoptersStart with early adopters

• Engage Rapid PrototypingEngage Rapid Prototyping

• Emphasize LearningEmphasize Learning

• Think management before accountabilityThink management before accountability

For More InformationFor More Information

• Visit our web site: Visit our web site: www.Rinstitute.orgwww.Rinstitute.org

• Call or Email Call or Email

Bill Phillips, 518-797-3783Bill Phillips, 518-797-3783

Bphillips@Rinstitute.orgBphillips@Rinstitute.org

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Outcome FrameworksOutcome Frameworks …an overview for …an overview for practitionerspractitioners