Darzi review: Annual “quality accounts” will help improve services and increase choice for patients, says Lord Darzi

Clinical Dashboards and Open Kimonos

My admission: In a previous life I was a sultan of spin. I was the
designer of the Emperors new clothes and a placer of a pot of gold at the
foot of the rainbow. In short I know something about dashboards. I worked
in the fields of corporate venturing and management consultancy for 7
years. When I read that Lord Darzi and his boss Alan Johnson were
championing the clinical dashboard I felt moved to write. Dashboards can
provoke profound motivation.

So Lord Darzi wants us to adopt this management information tool and
display it in hospital foyers. There is no doubt that they are an
attractive tool. The claim is that they take the complexity of running a
large organisation and produce simplicity, the equivalent of management
information sound bites. Its root analogy is the bridge of a ship where
the captain can view which direction the ship is going, at what speed, how
much fuel is left and have warning of any problems the engine is having.
Arrays of colourful indicators – traffic lights – Red, Amber and Green -
that at one glance can help you see how things are going.

Search on Google and you will see that clinical dashboards are not a
new idea. There are over a million results. There are companies
producing the software engine that will provide the statistics. There are
“consultants” who will help you decide what to show on your dashboard and
even where to display it. There is no shortage of public and private
organisations that have adopted them. And I have news for Lord Darzi -
the NHS has already met the “dashboard”. Results 1-10 of the above Google
search show that the Barts and London and the Royal College of Obstetrics
and Gynaecology are practiced users. There is no doubt that managers love
dashboards the question is why? And should we be worried?

How is a dashboard constructed?

First decide what you want to measure. What are the key data
determinants that will show you that your organisation is moving in the
right direction and importantly show you where problems may be brewing?
So for a management team in a hospital what might these things be? Budget
against spend, waiting lists, A and E breeches, procedural success rates
and so on.

Two immediate problems show themselves. First of all these are
measurements against targets which are set at a moment in time. The
psychology is important here. When setting these targets managers are one
or both of two things. Extremely conservative – after all they know they
are going to be judged on them. Testosterone fuelled, setting targets
that show they are a thrusting team. They are not just unwilling but are
unable to let anything stand in their way of achieving these targets! In
the first instance is there any point in measuring the speed of the
tortoise and in the second effort will be employed on failing to meet the
expectations of exaggerated capability.

The Natural History of the dashboard.

In summary they arrive to a large fanfare, they work, they work too
well, they are fudged and then withdrawn. Or put another way at first they
are managed in public and then become managed in private.

A Kentuckian management consultant once told me – “once you open your
kimono you better have something worth showing”. So what happens? The
targets are set and displayed and the energy with which they are pursued
means that red turn’s amber and amber green. Of course it’s the easy
stuff that gets done first. The more difficult things move at a slower
rate. The managers then decide that they are going too slowly and start
to introduce a text commentary to explain the dashboard. They then
realise that some of the testosterone targets are unachievable.
Adaptations and omissions are made. Dashboard 2.0 is released. And so it
goes. Eventually the dashboard is withdrawn and like son in prison – is
never mentioned again.

Is there a message?

Underneath the cynicism I hope I have relayed that the dashboard is a
useful tool. I have one now usefully employed telling me how woefully
behind I am with my finals revision. Who is it useful for though? Back
to the root analogy – It’s useful for the Captain not the passengers. By
making a dashboard public you assure its failure. It’s essential for the
person at the helm to have a simple means of assessing how things are
going. However, the complexity of what lies beneath needs a depth of
understanding and the ability to change course and do what needs to be
done to keep the ship moving.

So a message to Lord Darzi - please sir, keep your kimono closed.

Competing interests:
None declared