QUALITY IN PRACTICE
H. BENJAMIM HARVEY, MD, JD
Key Performance Indicators and the
Balanced Scorecard
H. Benjamin Harvey, MD, JD, Susan T. Sotardi, MD
INTRODUCTION
How do you judge the quality of a
restaurant? If you are like the average
person, your opinion probably
hinges on factors beyond simply
whether or not your meal was deli-
cious. It is about “the experience.”
You may consider the ease of getting
the reservation, friendliness of the
wait staff, innovativeness of the
menu, ambiance of the dining room,
and price of the experience, just to
name a few. Therefore, even a
restaurant that uses the best in-
gredients to serve the best food can
fail if these other important aspects
of quality are ignored.
The same holds true for diag-
nostic imaging. Simply adhering to
an image-centric approach to quality
may not be enough. To be success-
ful, we need to expand our definition
of quality to encompass all of the
expectations of our patients and
referring clinicians. But how do we
measure and improve the quality of
our care given the complexity of
these needs and expectations?
QUALITY CONCEPT: KEY
PERFORMANCE INDICATORS
Key performance indicators (KPIs)
are the “vital signs” of a company,
which signal its health in real time.
They enable us to examine the inner
workings of an imaging practice and
monitor the quality of clinical and
support functions, as well as the
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strength of governance and man-
agement. To be effective, a set of
KPIs must account for the major
aspects of organizational perfor-
mance and distill down all the
components critical for success.
Hundreds of potential KPIs
could be monitored within an im-
aging enterprise [1]. However, it is
not necessary or prudent to
consider each and every one. Too
many KPIs can result in
distraction, and too few may result
in unacceptable blind spots. Thus,
selecting a feasible yet
representative set of KPIs that
reflect different aspects of
organizational health is vital.
KPIs fall under several over-
arching headings: clinical perfor-
mance, service-level performance,
productivity, and financial perfor-
mance. Examples of clinical perfor-
mance KPIs include peer review
results, false-positive rates, or
complication rates. Service-level
performance KPIs include missed
appointment rates, patient wait time,
recall rates, report turnaround time,
and patient or referrer satisfaction.
KPIs focused on utilization and
productivity may examine equip-
ment idle time, repeat sequence
rates, radiologist or technologist
productivity, and PACS down-
time. And finally, basic financial
KPIs include net income, variance
from budget, preauthorization
effectiveness, and claims rejection
rates.
With the myriad KPIs to choose
from, identifying and organizing
those to actively monitor in your
organization can be a challenge. The
balanced scorecard can help.
QUALITY IN PRACTICE: THE
BALANCED SCORECARD
The balanced scorecard is a perfor-
mance measurement and strategic
planning methodology that turns a
group of chosen KPIs into a mosaic
of organizational performance
health. The approach arose in
response to conventional, financially
focused performance measurement,
which often was found to hinder,
rather than facilitate, organizational
growth and success. The balanced
scorecard merges financial KPIs—
largely lag indicators—with KPIs
that represent lead indicators of
organizational health, thereby
allowing an organization to better
adjust to problems and plan for the
future.
Many radiology enterprises
across the country (including ours)
have translated the balanced score-
card idea into radiology-specific KPI
dashboards. However, very few have
achieved the impressive depth
and thoroughness of Cincinnati
Children’s Hospital Medical
Center. The Cincinnati Children’s
radiology scorecard organizes KPIs
1
into six areas: clinical services, edu-
cation, research, professionalism,
staffing, communication and user
satisfaction, finances and adminis-
tration. For each metric, the target
goal, current value, prior value,
measurement interval, and date of
last update are clearly displayed. The
measurement interval, quarterly,
semiannual, or annual, varies by the
metric. Donnelly et al detail which
KPIs were followed for each cate-
gory, as well as the goals set for each
KPI [2].
Of the 33 KPIs followed in the
Cincinnati Children’s radiology
scorecard, 94% showed improved
or stable performance after
introduction of the scorecard,
with only 6% demonstrating
decreased performance [2]. The
results of the scorecard can then
be used to focus ongoing quality
improvement efforts.
DISCUSSION
Rightly or wrongly, in today’s
world, measurements are required
to justify your time and
effort. KPIs and the balanced
scorecard provide a multifactorial
means for assessing and maintain-
ing the quality and health of your
practice. Armed with these tools, a
practice can go beyond just quality
imaging to achieve a sustainable
and comprehensive quality
experience.
REFERENCES
1. Karami M. A design protocol to develop
radiology dashboards. Acta Inform Med
2014;22:341-6.
2. Donnelly LF, Gessner KE, Dickerson JM,
et al. Quality initiatives: department score-
card: a tool to help drive imaging care de-
livery performance. Radiographics 2010;30:
2029-38.

H. Benjamin Harvey, MD, JD, and Susan T. Sotardi, MD, are from the Harvard Medical School, Boston, Massachusetts, and the
Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts. H. Benjamin Harvey, MD, JD, is also from the
Massachusetts General Hospital Institute for Technology Assessment, Boston, Massachusetts.

The authors have no conflicts of interest related to the material discussed in this article.
H. Benjamin Harvey, MD, JD: Institute for Technology Assessment, 175 Cambridge Street, Suite 200, Boston, MA 02114;
e-mail: hbharvey@partners.org.

2 Journal of the American College of Radiology

Volume - n Number - n - 2018