NHS Trust boosts performance with prism method

Results prove performance prism can help in public sector. By Chris Adams and Pietro Micheli, Cranfield School of Management.

Cranfield School of Management’s Centre for Business Performance recently completed an advanced performance measurement project with Two Shires Ambulance Trust (TSAT) based across Buckinghamshire and Northamptonshire in the UK. The aim of the project was to identify how performance measurement could be used to help manage the Trust more effectively.

Improving effectiveness

TSAT is one of only a few Ambulance Trusts that has consistently demonstrated a 3-star status over several years. Star ratings tell you how well a Trust is performing against certain indicators, for example, response times.

Although its performance measurement systems were already relatively sophisticated, its then CEO, Paul Martin, wanted to improve them further. Great emphasis was placed on developing an integrated system and recommending new or improved measures that could be implemented easily. TSAT selected Cranfield’s performance prism approach and obtained partial funding for the work from the Improvement Partnership Ambulance Service.

The framework

The performance prism framework consists of five interrelated perspectives on performance that pose important questions:

• stakeholder satisfaction – who are our main stakeholders and what do they need?
• stakeholder contribution – what do we want and need from our stakeholders?
• strategies – what strategies do we need to put in place to satisfy these twin sets of requirements?
• processes – what internal processes are required to enable us to execute our strategies effectively and efficiently?
• capabilities – what capabilities are required to allow us to operate our processes now and in the future?

Together these provide a comprehensive and integrated framework for thinking about organisational performance.

The performance prism works better than other similar frameworks mainly because it takes account of many stakeholders. It enables organisations to think more rigorously about the nature of the relationships they have with their main stakeholders. It also allows organisations to look beyond their strategic intents and consider how to improve their internal processes with their stakeholders’ needs in mind. This method encourages the development of a success map that illustrates and connects these components.

The process

Project organisers Chris Adams and Pietro Micheli first examined the Trust’s existing strategic plans and conducted preliminary interviews with several members of staff. Six short workshops were then held for the board, senior managers, staff and invited external stakeholders. The workshops, attended by around 45 people, focused first on identifying the important stakeholders. As expected, there proved to be considerable divergence of opinion among the stakeholders on this point.

Once agreement had been reached, each session identified the needs of the most important stakeholders. They also identified what the Trust expected of these stakeholders as part of its reciprocal relationship with them.

Altogether more than 30 stakeholders were identified. Six were deemed of greatest importance:

• accident and emergency patients
• Patient Transport Service
• Primary Care Trusts
• TSAT staff
• Acute Trusts, and
• Mental Health Trusts.

The next stage required the team to come up with measures that would address the management issues identified. These were then ranked according to their perceived importance. A provisional shortlist was then circulated to executive directors. There then followed one-to-one meetings with each director to discuss the practicality of introducing measures within their sphere of control. Some adjustments were made as a result of these discussions.

The net result was an executive team that had bought into the concept of improving their performance management system, and knew how each department could contribute.

Practical measures

Around 30 practical measures were agreed. Of these, seven related to key stakeholder relationships, five addressed the Trust’s strategic intents and 10 concerned important aspects of its operating processes. The rest related to vital capability development.

Of the 30 performance measures, one-third already existed at TSAT, although improved reporting formats were recommended for some of these. A further six were major improvements of current methods, while another 14 were new measures, of which 11 could be implemented immediately (subject to board endorsement). Three were deferred for implementation after current initiatives had been completed.

Alongside the recommendations the success map was used to illustrate the following points:

• the inherent complexities of the two-way stakeholder relationships that TSAT must develop
• how it must prioritise the stakeholders in order to adapt the future strategies
• how these strategies must then be translated into process improvements and capabilities development.

Lessons learned

The performance prism framework had not been used in the public sector before but it proved extremely useful. It allowed an already successful Ambulance Trust to develop an advanced performance management system.

Clearly the measures identified at TSAT will not be suitable for all Trusts, some of which are at different stages in their development. But for those that have already achieved a relatively stable reporting system, there is the opportunity to improve.

TSAT’s directors were delighted with the results. Some of the board’s non-executive directors had initially been sceptical about the value of the project, but by the end they were the most enthusiastic supporters. With a bit of guidance, other Trusts could benefit from applying it, too.

To learn more or obtain a full copy of the report, contact p.micheli@cranfield.ac.uk or visit the Centre for Business Performance website.

January 2006