The history of obstetrics is interesting. (Yeah, I know this is a strange opening sentence for a blog about visual business intelligence, but bear with me.) Its history even includes a bit of unexpected intrigue, such as the early history of forceps. Because forceps delivery was so wildly successful for complicated births, the London-based Frenchman who invented the procedure and his family of physicians refused to reveal the technique for three generations, hiding it even from the mothers giving birth through use of a drape, until they passed it on to a physician in Amsterdam who kept it to himself for 60 more years. A particular event in obstetrical history actually has something to teach us about the importance of performance measure, which we can apply to business. It involves something called the Apgar score, which I learned about by reading Atul Gawande’s wonderful book about healthcare, Better: A Surgeon’s Notes of Performance (Metropolitan Books, New York, NY, 2007). You’ll get a flavor of Gawande’s writing in a couple of quotes from the book below.

During the 20 years or so leading up to the 1950s, great progress was made through tighter medical standards and the introduction of antibiotics, especially penicillin, in improving the odds of the mother surviving the delivery. Up until the mid-1930s, childbirth was the single most dangerous event in a woman’s life. By the 1950s, the risk of death decreased from one of every 150 births resulting in the death of the mother, to only one in 2,000. Despite this dramatic improvement, babies still weren’t faring much better than before. One in 30 still died at birth.

Virginia Apgar, the first woman to be admitted into surgical residency at Columbia University College of Physicians and Surgeons, became an anesthesiologist during this period. She developed particular concern for the fate of newborns, which at the time were left to die if they were “malformed or too small or just blue and not breathing,” because doctors assumed that nothing could be done to save them. Apgar wasn’t an obstetrician, but she was so convinced that deliveries could be done better, she took it upon herself to challenge the system. She did so by devising a score, which is still routinely used in hospitals today, and is called the Apgar score.

Nurses use the Apgar score to rate the condition of newborns on a scale of zero to 10.

An infant got two points if it was pink all over; two for crying, two for taking good, vigorous breaths, two for moving all four limbs, and two if its heart rate was over a hundred. Ten points meant a child born in perfect condition. Four points or less meant a blue, limp baby.

Apgar published her procedure in 1953, the year preceding my own birth. It probably saved my life, for I was so anxious to get going, I tried to breathe before emerging from the birth canal into the world of air. The Apgar score was immediately adopted, resulting in a dramatic turnaround.

The score turned an intangible and impressionistic clinical concept—the condition of new babies—into numbers that people could collect and compare. Using it required more careful observation and documentation of the true condition of every baby. Moreover, even if only because doctors are competitive, it drove them to want to produce better scores—and therefore better outcomes—for the newborns they delivered.

Babies were examined and their condition scored immediately upon delivery and then again after five minutes. Because of this process, it soon became apparent that babies with low initial scores could be revived to score in the acceptable range within five minutes, with the right care.

Part of the reason the Apgar score worked so well is because it was easy to calculate and understand. This is true of business performance measures as well. Measures that people can’t understand or are too hard to figure, rarely catch on. The very existence of a measure—a number—makes performance tangible, something people can think about in concrete terms and invent responses to improve. As long as performance remains nebulous and abstract, it won’t change for the better. People need a measure to wrap their heads around. When the Apgar score was first introduced, no one could imagine the difference it would make. I doubt that Apgar herself foresaw the way that her score would incite doctors and nurses to compete with themselves and one another. When people have a way to evaluate their performance, they are naturally inclined to do better and better.

In my work, I help people examine, make sense of, and then present quantitative data to others, including key performance indicators (KPIs), through the use of visual representations. Visualization makes data accessible in a way that brings meaningful patterns, trends, and exceptions to light. Data visualization isn’t helpful, however, unless you have the right numbers—numbers that actually measure what needs to be measured and do so in a way that can be understood.

If you’re struggling to identify the right measures and express them meaningfully, you might consider turning to some of the folks who specialize in this work. Here are two you might want to consider:

• Stacey Barr, the Performance Measure Specialist
• David Parmenter, of Waymark Solutions and author of the book Key Performance Indicators

Take care,