Defining your KPI’s – What is your Hospital Measuring ?

KPIs what are you measuring

Ill start with a  Cliche  – “What is not measured is not done”, but  i truly believe  in the power of measurement  and that’s why measuring all that you have envisioned for your hospital becomes critical.  But then how good are our hospitals at measuring?

Before we can really answer that question we need to identify what it is exactly that we our measuring.  I have come across a few discussions which were based entirely around what hospitals should measure and honestly every individual seems to have his / her own response.  Yes there are some basic KPIs such  as  ALOS , Occupancy, Revenue etc that keep cropping up from time to time however  I haven’t really come across a  really well defined KPI directory that you can choose from .  And sadly enough some  rare  managers and administrators that I have come across  are not  even aware of  the  entire  implication that a  particular KPI has  on the  functioning  of the  hospital.

My attempt here is not to define a directory for you but rather to set a direction to our way of thinking about KPIs

So what do hospitals measure?

Our entire KPI classification is based around

 Clinical Quality  – e.g. Medication errors, outcomes, mortality, hospital acquired infection , repeated surgeries, readmissions etc

Operational Quality – e.g. waiting times,  Going  above  estimates, Consultation quality, Discharge times, Admission times etc

Operational efficiency – e.g. ALOS, Volume growth, Cost per bed, Material cost  %, utilization rates, Your basic time motion studies regarding process efficiency etc

Financial health – eg. EBITA, Debtors outstanding, Case mix, Revenue source mix, Cash to debtor’s ratio, Cash flow etc.

This is definitely not all inclusive in terms of KPIs or categories but basically top of the head stuff. I have  also seen people merge Operational quality and efficiency but id rather keep them separated.

Wow that’s quite a lot of things to measure  if you think about it and  we haven’t even quite scratched the surface yet.  How will I keep an eye on the ball when I’m being bombarded with balls? The answer my friend is simple identify what’s important for you

So what is important for you? Prioritise

The KPI dashboard that you are most concerned about is directly related to the level / nature of involvement that you have with the organization.

If you are a C level executive your KPI dashboard might be entirely different from let’s say someone related solely to Operations which might be different from the individual heading Quality. When i say different it doesn’t mean there is no overlap there will be overlaps but functionalities are different.

So a CEO would have some of these things on his / her  mind  –  EBITA , Material Expenditure, Volumes for critical procedures , Case Mix , ALOS, Debtors , Utilization etc.

And then this further would percolate down to departmental levels.  Eg OPD would have different Performance indicators such as waiting times, doctor punctuality, material consumption, Staff attendance, Overtimes, Complains, average consultation times, volumes,  etc .Marketing would have measures  like – call volunmes, sector wise revenue, cost per  customer  acquisition ,  doctor wise  performance, activity vs conversion etc

I would say define your parameters well at the departmental levels to drive true quality and efficiency.

Ideally a C level manager should look at about 30 – 50 selected indicators on a daily basis and then selectively look at indicators from departmental levels which show huge discrepancy from the expected values or unusual results. Focus can also be shifted while working on specific projects. Please note it’s difficult to keep an eye  on 170 parameters so prioritise and reorganize your dashboard  on regular intervals

At the departmental level each department should be encouraged to develop their own KPI bout 20 – 30 against which they measure themselves. Please remember while defining your KPI it’s important to understand why you are measuring it and whether you need to include it, be specific and be selective.  Also VOC (voice of customer) must  be imbibed into your Dashboard structure. Lastly  identify the correct method to measure the KPI you are defining a lot of times time is wasted on goose  chases with either  the  wrong  data or  erroneous  data  collection.

Implementation 

This is the tough part here is where you record, review and correct and this is not only for a particular phenomenon that you  are  measuring  but also your dashboard structure add omit and refine the  dashboard as  you go along. But before  that  i can not stress on the  importance of getting the  message across to your entire hospital team. The  grass root level must understand the  importance of  an entry they make or the data they capture to ensure the quality of data and the  success of the system.

What would be the benefit?

The answer is simple consistent quality service provided with efficiency and accuracy.

HIS / BI Tools

I am certain there are quite a few HIS systems as well as Business Intelligence tools which integrate with your HIS systems to raise alarm and to bring things to your notice. However treat them as tools but don’t be over dependent on them. Because solutions which come in a tin are not necessarily the solutions we need.

Authors note:

My overall experience with KPI mapping in hospitals in India is that we are inept at measurement.  Most hospitals basically follow a basic set of indicators that are commonly predefined and taught in Hospital Management courses, however creative development of newer indicators seems rare.  A problem that is causing this is that management professionals are not necessarily keen at sharing their knowledge,  and the knowledge share which happens is mostly of data which is already out there in the  public domain.  Also as an industry there is a lot to learn from the Manufacturing sector and we must keep our minds open to newer possibilities through cross industrial / sector learning. In the end Collective Cognition is the need of the hour.

Disclaimer: The views expressed in this  post are my own and  are  not meant to be derogatory  to any institution or organisation. These are just my thoughts and  these are open for further  discussion and  development. Please do comment and  share and  let’s get some universal cognition into this. Thank you for your patience and  tolerance.

Setting up Hospital Quality System-six simple steps

When I was new to the healthcare management, I used to wonder how to initiate and setup quality system in a new hospital? What to do first and what to do next. As I suggested in my previous article, the setting up quality system should be initiate from the stage of civil planning. While looking for information, I came across an article on ‘Ford Assembly line’ and that gave me an idea to develop my own approach, assuming services as product and various execution stages as assembly docks which will refine and bring services in shape. The first and the most important step is to identify the services provided by the hospital and its focus areas.

For the selected services, organization should identify various processes & activities their flow with interdependent activities. Eg. If a high end trauma unit is the in the scope of services then one has to define process of delivering services, which will leads to resource planning (including neuro, ortho, reconstructive surgery as support services which will be requiring man, machine and material) and in turn will impact the civil drawings to accommodate them. This should be done by a cross functional team including quality champions, administrators, architect & doctors. The flow should be patient friendly and should address universal guidelines provided by national or international regulatory bodies. When the activities & detailed workflows are defined, the next step is to define procedures to perform these processes; rules to follow these procedures; how to follow procedures as work instruction. These are collected as documents known as SOPs, Policies and collectively called as manuals. eg. Process of trauma patient care include one procedure as triaging defined stepwise details in SOP; rules to follow during triaging including zoning, colour codes, responsibility matrix etc. will be covered in policy.

Who will execute these processes & policies? Before implementation Staff Awareness is required.  A detailed plan has to be made for training the staff as soon as they join the organization. While training, the points should be clear that how to do it, rules to follow, what if things went wrong & overall expectation. The comprehensive training programme can be divided in Universal Induction, department induction and continuous refresher training. The training content should be customized according to different categories of staff eg. Nursing, doctors etc. for better results. It should not be just dump of information but in small pieces so that the employee can absorb it. This would be time consuming process. Never forget to check the staff understanding towards these processes.

While the staff getting prepared for implementation, a parallel plan to be prepared on how to communicate and make our patients/visitors aware about our system. Patient’s awareness should be aligned to vision & mission of the top management. Eg if hospital is talking about ethical & transparent clinical practices in the mission statement, it should provide information regarding clinician’s protocols; doctor to patient communication, regular counselling during treatment/surgeries, how we take consent and why it’s important; what are the patient rights; how our feedback system works; what are our codes of conduct for patient care etc. Medium of communication is also very important aspect.

It’s very important to follow the process but it is more important to track whether these have been followed correctly with desirable outcome. That’s why key performance indicators and quality indicators come into picture which quantifies the procedures. These can be defined by identifying processes important to the management. For better understanding & for impact analysis, these can be collected in logical fashion under various dashboards with the aim of creating a decision support system. Identification of these QI & KPI can be during the first step but implementation and tracking would be done while hospital is operational.

Tracking & analysis of QI & KPI is a continuous process. Shortcomings or deviation from the assigned benchmark should be evaluated thoroughly. Root Cause Analysis, internal audits are the tools helping us to identify defects in the process or how the things went wrong. These audits must focus on processes not on an individual. Corrective action can be taken by the front team after consent from superiors but the preventive actions must be executed after through discussion amongst multi-disciplinary team. Preventive action will lead to change in the design of the complete system including SOPs & Policies. This will not only impact the hospital operations but also the finances. eg. If hospital identify the cause of decreasing hand hygiene rates as non-availability of disinfectants & training process, preventive measure may include adding-up more locations for keeping disinfectants which will leads to increase in inventory & cost, training staff repeatedly on usage thus impact on working shifts, changing the training process to increase its impact or policy of inclusion of bedside disinfectant bottle charges in bills etc.

This is a cycle and gets repeated during hospital operations for existing services & processes. Even new processes go through same sequence of synthesis.

Hospital Quality System setup

Disclaimer: The views expressed in this post are purely the thought of the author and are not meant to be derogatory to any institution or organisation. The author is open to further discussions. Thank you for your patience and tolerance.

Value Based Healthcare Delivery

I recently came across this talk by Michael Porter about healthcare that he had delivered at Harvard  Business  School though the  talk was  generally about the healthcare system in the US  however  i felt that  it was quite  relevant  to healthcare  systems in general across the globe.

One  of the  most  important things that he talked about was  Value Creation and  improving the  Value delivery system. But then the question which arises is what is the  true value.  How do we  define Value becomes  critical , is it just patient outcomes , is it cost of delivery , could it be a  generalised figure and  he defines  it quite comprehensively  he says that it the patient health outcomes achieved  relative to the money spent to achieve those outcomes.  Which becomes a  simplified outcomes as numerator and cost as denominator.

This is  quite  a shift  in our existing way of  measuring success  which are either  based around profit maximisation, or Volume  delivered, or  access to healthcare in general. Quality as  it stands currently is  based entirely around the  process definition and  improvement. Be it any guideline we  follow NABH or JCI its  mostly process based. Process improvement  is very important  however outcomes  are  even more important.  And  are we really measuring the  clinical outcomes. If the  system is to improve  then the competition has to move from being profit or  process based to becoming outcome based and then to value creation and thats the  only way we can get a  handle on the spiralling costs of healthcare delivery.

So how do we really shift the  focus to value.

Lets Look at Outcomes outcomes need to defined per  patient and  his / her medical condition. We need to look at survival,  functional status, independence, residual defect / illness. Yes it is an intensive  exercise  but the  results would truly be  enlightening and  a true move towards the  goal  of quality. Define the  Outcome parameters for any surgery / medical treatment that is meted out including survival rates, extension of survival period, dependence of medication etc etc.

Secondly identify your costs. For some strange reason healthcare seems to shy away from a  practice which is so commonly followed in the manufacturing  sector and this is ABC (Activity based Costing ) .For Healthcare i would suggest a  time related Activity based  costing. Whats even more  specific is that it will  be a  patient based time related activity based costing.  We tend to see ourselves as distinct departments and subunits and we tend to do our costings similarly too(that  is if we do our costings). However a  true costing exercise must capture the entire cost related to the  patients  journey through  care  pathways. And through this way we should be able to define  the true value of a  patient outcome. The focus needs to be on the  Outcome , and  existing technology in terms of HIS  systems must integrate these costing parameters  but  the  end result could truly be transformational .

I personally look  forward to a  day where  we will focus on the right performance indicators though that  is a  different post in itself. But  i think this could very well be a move  in the right direction be it for a private hospital, a charitable trust or a  public trust.  Efficiency , effectiveness  both would be  effectively measured and  documented and  true value would lead to better profits / access/ volumes so this is a  win win no matter  which way you take  it.

Here is the  Video if you are  interested , apologies for the poor sound quality.

Disclaimer: The views expressed in this  post are my own and  are  not meant to be derogatory  to any institution or organisation. These are just my thoughts and  these are open for further  discussion and  development. Please do comment and  share and  let’s get some universal cognition into this. Thank you for your patience and  tolerance.

Quality for Hospitals, are we there yet?

Quality in hospitals seems to be one of the  most talked about issues  of today. I can understand why it is so important with consumers being more  aware, with competition being as high as  it is  and  expected to increase  further  in the  future and  with legislation being the  way it is for hospitals. Process  improvement  , documentation and  SOP creation seem to be a bare essential for hospitals in the world of today . Honestly speaking i don’t quite know how the  past was in  an era before 2003 , however  the  impetus that  is laid on quality  ever since  that era  has  only  grown manyfold over the  years.

No ifs and buts about the importance of quality, However what bothers  me the  most is that quality seems to be the means  to an end for most administrators. Historically if we are to look at quality in hospitals , Initially it was the  selected few going in for JCI accreditation who sought the  ghost of quality, in the  lucrative  pursuit of medical tourism. Then there  were the  local champions seeking ISO and Crasyl  ratings, remember   those  times, when we had  representatives of accreditation firms shooting quality down our  gullets, and  of course the  most  recent  turn is NABH. This now  seems to be our  gold measure  for quality and  standardisation at least nationally .

But think about it if these are the reasons we seek quality then isn’t  the quality itself limited by these  reasons. What are  we  checking for  what  comes under the  purview  of quality is it just those 638 parameters  defined by NABH 2011 (which might be  revised to 736 unofficial sources)that an organisation is assessed against. Is that  all there is to quality then aren’t we  constraining quality in stray jackets of limited vision.

Quality when taken up  as  an end  in itself is more beneficial to an organisation. Yes i would be wrong in saying  go against the  norms  forget  NABH its not quality, because it is and  is very important . All I,m saying is that just don’t  limit yourself to these parameters. Quality is  about  consistency, its about clinical outcomes , is  about processes , but in the  end its about (includes but  is not limited to)Patient experience, Consultant  relation, Employee  experience, and  well about anything and anyone  that comes in contact with our organisation.

I think  a newer approach is required to quality  where quality supersedes everything and is  not subservient to accreditation. And that  is where  creativity, innovation, progress and  differentiation will come  in.  I think quality departments  need to evolve , they need to expand their visions and  grow. Quality parameters must be developed reassessed and  re-envisioned intrinsically. Newer methodology other  than the existing  reaccreditation inspections must  be  used to assess quality. Innovative cross industrial methods  like the  Mystery patient a  once  talked  about concept could be re looked at. Seeking VOC (Voice  of customer) to define these parameters could be  experimented with. Opening  channels of communication are  essential. Newer technologies  such  as  social media could  be experimented with not just  for Branding but also  to define quality. Its high time we as administrators redefined our quality rather  than just measuring it.

In the end Creating  freely communicating open organisations that seek quality  for the sake of quality is the  step forward  not just for your Organization but for the industry as a  whole. And yes  we might not quite be there  but surely it would be a move in that direction.

Disclaimer:

The views expressed in this  post are my own and  are  not meant to be derogatory  to any institution or organisation. These are just my thoughts and  these are open for further  discussion and  development. Please do comment and  share and  lets get some universal cognition into this. Thank you for your patience and  tolerance.