Module Three: Produc.ve Management Methodology for Health Services (PMMHS) Indicators Part 1

Module Three: Produc.ve Management Methodology for Health Services (PMMHS) Indicators Part 1

Developed by: Dr. Edgar Hernán Gallo Montoya. Consultant Produc.ve Management Methodology for Health Services Adapted for English- speaking audiences by: A faculty team of St. George s University, Grenada, coordinated by Dr. Omowale Amuleru- Marshall General Coordina.on: Dr. Reynaldo Holder, Regional Advisor - Health on Hospitals and Integrated Healthcare Delivery Networks Area of Health Systems based on PHC PAHO/WHO April 2011. Washington, DC The Pan American Health Organiza.on will give favourable considera.on to requests for permission to reproduce or translate many of its publica.ons in whole or in part. Inquiries and requests for informa.on should be addressed to the Publica.ons Program, Pan American Health Organiza.on, Washington, D.C., USA. This office will be pleased to provide current informa.on regarding changes in any work, plans for new edi.ons, reprints and transla.ons available. Pan American Health Organiza.on, 2011 The publica.ons of the Pan American Health Organiza.on are protected by the provisions regarding reproduc.on of original works contained in Protocol 2 annexed to the Universal Copyright Conven.on. All rights reserved. Terminology employed in this publica.on and the manner in which data are presented in this volume do not imply any judgement on the part of the Pan American Health Organiza.on as to any legal status of countries, ci.es or zones, or their authori.es, or regarding the way in which their borders or demarca.ons are drawn. The men.on of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the Pan American Health Organiza.on in preference to others of similar nature that are not men.oned. Errors and omissions excepted, the names of proprietary products are dis.nguished by ini.al capital le\ers.

Indicators are data that reflect a specific situa.on or par.cular condi.on in a given.me or period and are o^en expressed as sta.s.cal data, i.e., percentages, rates, etc. h\p://www.oect.es/portal/site/ Observatorio/menuitem.

Management Indicators These are a group of indicators that evaluate the organiza.on s structure, processes and results They are defined by management for the purpose of developing and evaluadng their insdtudon Good management is reflected in the achievement of the objec.ves, goals and proposed standards MALAGON LONDOÑO GUSTAVO. Garanba de la Calidad en Salud. Segunda Edición. Editorial Médica Internacional. Bogotá, Colombia. 2006

What indicators should be used? In PMMHS indicators are classified as Structural Indicators These measure the physical and ins.tu.onal condi.ons in which services are provided Process Indicators These measure ac.ons that result in good service delivery. They reflect the steps, events or ac.ons at play in service delivery and represent any contact between clients (demand) and service providers (supply) Results Indicators These monitor what happens to clients following the service delivery process and measure the effects of the service delivery in the development of clients and the popula.on at large

Example of standardiza.on of Indicators Structure Indicators NAME MEASURING UNIT OPERATIONAL UNIT GOAL FREQUENCY SOURCE OF INFORMATION RESPONSIBLE FOR DATA COLLECTION RESPONSIBLE FOR DATA PROCESSING RESPONSIBLE FOR DATA ANALYSIS VISUALIZATION Days bed availability Days Number of beds days in the period By service Monthly Medical Records or Sta.s.cs Department Head/Supervisor of Nursing Services Head of Medical Records or Sta.s.cs Department Management Team Table of absolute numbers

Example of standardiza.on of Indicators Process Indicators NAME MEASURING UNIT OPERATIONAL UNIT GOAL 95% FREQUENCY SOURCE OF INFORMATION RESPONSIBLE FOR DATA COLLECTION RESPONSIBLE FOR DATA PROCESSING RESPONSIBLE FOR DATA ANALYSIS VISUALIZATION Occupancy Rate Percentage (Number of occupied bed days/number of available bed days) 100 Monthly Daily Census Head/Supervisor of Nursing Services Head of Medical Records or Sta.s.cs Department Management Team Line graph

Example of standardiza.on of Indicators Results Indicators NAME MEASURING UNIT OPERATIONAL UNIT WaiDng Time for OutpaDent Visit Appointment Days Sum of appointments assigned by date minus date of request GOAL General medicine less than 2 days Specialty less than 5 days FREQUENCY SOURCE OF INFORMATION RESPONSIBLE FOR DATA COLLECTION RESPONSIBLE FOR DATA PROCESSING RESPONSIBLE FOR DATA ANALYSIS VISUALIZATION Monthly Appointment management system Medical Records/Outpa.ent Services Coordinator of Outpa.ent Services Management Team Trend graph

Other Types of Indicators Other ways of categorizing indicators have been used: Produc.on Indicators Healthcare Impact Indicators (or Outcome Indicators) Supply Indicators Cost Indicators

Produc.on Indicators Produc.on indicators are associated with the ins.tu.on s response capacity to the needs of the popula.on for healthcare service (demand) These are considered trace indicators since they are central to the healthcare ins.tu.ons func.on If the indicator is captured in PERC, its mathema.cal expression, numerator and denominator will be analyzed If not, it should be recorded on the data matrix and then the appropriate formula can be applied

Expert consultants working in the development of the PMMHS defined a group of indicators, viewed as the minimum required for managerial decision- making: Trace indicators Total Discharges Total Visits by General Prac..oners Total Visits by Specialists Total Day Surgeries and Inpa.ent Surgeries Total Emergency Services Average Hospital Days Rate of Laboratory Tests Rate of MRIs Average days in ICU Occupancy Rate Rate of Pa.ents Transfers Rate of Medical Visits per Hour

It is a type of absolute indicator and it is classified as a results indicator Hospital discharge is the release of a pa.ent who was hospitalized It could be the result of: improvement, voluntary discharge, escape, transfer or death It does not include pa.ent transfers to a different service within the hospital, or the healthy new- born babies delivered at the hospital

Produc.on Indicators - Total Discharges (2) It should be analyzed in combina.on with associated indicators: Poten.al Discharges or Planned Produc.on Capacity (PPC) established as goals.. It should be discriminated by services It is directly associated with the number of budgeted and conducted ac.vi.es

Produc.on Indicators - Total Discharges (3) SERVICE QUANTITY % General Hospital Beds 324 15% Specialized Medical Hospital Beds Gyno- Obstetric Hospital Beds 438 20% 500 23% Pediatric Hospital Beds 400 19% Surgery Hospital Beds 253 12% Special Care Hospital Beds 236 11% DISCHARGES 2151 100% PERCENTAGE OF DISCHARGES BY SERVICE 12% 19% 11% 23% 15% 20% Camas hospitalización general Camas hospitalización especialidades médicas Camas de hospitalización gineco obstetricia Camas hospitalización pediatria Camas de hospitalización quirúrgica Discharges are discriminated by each service or group of special.es that can be expressed in percentages. Calcula.on of the an.cipated produc.on capacity is required in order to determine the an.cipated discharge goal.

Produc.on Indicators - Total Discharges (4) FORMULA FOR ANTICIPATED PRODUCTION CAPACITY APC DBA S / ADS S CALCULATION 3,592 The APC is a useful tool to jus.fy and budget the resources needed for a determined period (in rela.on to the planned produc.on). It also serves as an indicator that allows the evalua.on of the service as a parameter for the expected results and to determine idle capacity. AVERAGE DAYS BED STAY SCHEDULED 6 DBA S = DAYS BED AVAILABLE SCHEDULED ADS S = AVERAGE DAYS BED STAY SCHEDULED Based on this calcula.on the goal was to produce 3,592 discharges and 2,151 were achieved. This means that only 59.9% of the goal was achieved. BASELINE GOAL RESULTS ACHIEVEMENT 1850 3592 2151 59.9%

It is a type of absolute indicator and it is classified as a results indicator. Consulta.on is the care provided by a qualified health provider to an outpa.ent client. It is registered once for the.me period being analyzed (first.me consulta.on in the period). It should be analyzed with a group of associated indicators: - An.cipated outpa.ent produc.on capacity that might be designated as the goal. - It should be discriminate by general and specialized outpa.ent consulta.on.

CONSULTATION ACTIVITIES % General medical consulta.on 1200 52,2% Internal medicine consulta.on 400 17,4% Pediatric consulta.on 300 13,0% Gyno- obstetric consulta.on 250 10,9% 7% 13% 17% Percentage distribudon of outpadent consultadon 11% 52% Consulta médica general Consulta medicina interna Consulta de pediatria General surgery consulta.on 150 6,5% TOTAL CONSULTATIONS 2300 100% Consulta.ons are discriminated at least by general medicine and special.es. Doing so for these two basic groups would show: 52.2% for general medicine and 47.8% for special.es.

Consulta.ons/visits are discriminated at least by general medicine and special.es. Doing so for these two basic groups would show 52.2% for general medicine and 47.8% for special.es. FORMULA CONTRACTED HOURS X PUSA X TCH CALCULATION 2957 The APC is a useful tool to jus.fy and budget the resources needed for a determined period (in rela.on to the planned produc.on). It also serves as an indicator that allows the evalua.on of the service as a parameter for the expected results and to determine idle capacity. CONTRACTED HOURS 1056 NORMAL VISITS PER HOUR 4 PERCENTAGE OF UTILIZATION IN SUBSTANTIVE ACTIVITY 70% DOCTOR DAY 6 HOURS DAY 8 CONTRACTED HOURS 1056 CONSULTATION DAYS 22 BASELINE GOAL RESULTS ACHIEVEMENT 2000 2957 2300 77.7% In this case 77.75% of the an.cipated goal is achieved. It is determined that the number of visits is growing.

It is a type of absolute indicator and it is classified as a results indicator It considers the ins.tu.on s surgical care: it is classified by outpa.ent and inpa.ent surgeries. It should be noted that data are not obtained from the hospital intake, but from the surgery rooms registry. SURGERY ACTIVITIES % OutpaDent surgeries 180 33.6% General outpa.ent surgery 100 18.7% Orthopedic outpa.ent surgery 50 9.3% Obstetric outpa.ent surgery 30 5.6% InpaDent surgeries 355 66.4% General inpa.ent surgery 200 37.4% Orthopedic inpa.ent surgery 95 17.8% Obstetric inpa.ent surgery 60 11.2% TOTAL PROCEDURES 535 100.0% Note how the procedures are dis.nguished by type of interven.on and specialty

Produc.on Indicators - Total Surgeries (2) FORMULA HOURS CONTRACTED X PUSA X AVERAGE PROCEDURES PER HOUR CALCULATION 729 The APC is a useful tool to jus.fy and budget the resources needed for a determined period (in rela.on to the planned produc.on). It also serves as an indicator that allows the evalua.on of the service as a parameter for the expected results and to determine idle capacity. ACTUAL SURGERY ROOM HOURS 1620 AVERAGE PROCEDURES PER HOUR 0,5 PERCENTAGE OF UTILIZATION IN SUBSTANTIVE ACTIVITY 90% SURGERY ROOMS 3 HOURS DAY 18 CARE DAYS 30 ACTUAL SURGERY ROOM HOURS For the calcula.on of the an.cipated produc.on capacity the actual hours of service, which depend of the exis.ng surgery rooms and human surgery teams capacity, must be iden.fied. 1620 BASELINE GOAL RESULTS ACHIEVEMENT 450 729 535 73%

It considers services provided in the emergency room: Observa.on rooms used for periods of less than 24 hours should be considered Greater.me periods are considered hospitaliza.ons

FORMULA CONTRACTED HOURS X PUSA X TCH CALCULATION 5,472 The APC is a useful tool to jus.fy and budget the resources needed for a determined period (in rela.on to the planned produc.on). It also serves as an indicator that allows the evalua.on of the service as a parameter for the expected results and to determine idle capacity. CONTRACTED HOURS 5760 NORMAL CONSULTATION PER HOUR 1 PERCENTAGE UTILIZATION IN SUBSTANTIVE ACTIVITY 95% DOCTOR DAY 8 HOURS DAY 24 CONTRACTED HOURS 5760 CONSULTATION DAYS 30 BASELINE GOAL RESULTS ACHIEVEMENT 4800 5760 5350 92.8% The number of consultations is an absolute figure obtained from the service registry. 92.8% of the goal was achieved.

It is a type of ra.o indicator and is classified as a process indicator Average length of stay is the average number of full or par.al days a pa.ent is hospitalized, occupying a bed. It reflects the average.me that a service takes in order to hospitalize, diagnose, treat or rehabilitate pa.ents (average number of days a group of pa.ents, in general or specified by age, service, condi.on, etc., are hospitalized). Typically is a process indicator, par.cularly an indicator of the u.liza.on of beds, and is closely related to the number of discharges produced by a service or hospital in a given period as a result of a health management process.

It should consider hospitaliza.ons at a general level; however, these should be discriminated for each service since there are significant differences in length of stay based on speciali.es For example, For internal medicine or pediatric the average stay is 7-8 days, For general medicine a good ALOS is around 5 days and For normal obstetric hospitaliza.on (deliveries) usually around 48 hours

Produc.on Indicators - AVERAGE LENGTH OF STAY (ALOS) (3) AVERAGE LENGTH OF STAY (ALOS) FORMULA: DCO / DISCHARGES DCO 13500 DISCHARGES 2151 6.3 It is calculated for each service and the value of the general indicator becomes a comparison point for each service. The most significant comparisons are those between groups that share commonali.es, such as medical special.es and surgical special.es.

Produc.on Indicators - AVERAGE LENGTH OF STAY (ALOS) (4) SERVICE DISCHARGES QUANTITY ODB ALOS General hospital beds 324 2400 7.4 Specialized medical hospital beds 438 2600 5.9 Gyno- obstetric hospital beds 500 1800 3.6 Pediatric hospital beds 400 2800 7.0 Surgery hospital beds 253 1100 4.3 Special care hospital beds 236 2800 11.9 GENERAL 2151 13500 6.3

It is a ra.o and classified as a process indicator It is the measurement of the demand exerted by final services (outpa.ent and inpa.ent- medicine, surgery, pediatrics-, etc.) over the support services (laboratory, surgery rooms, diete.cal, etc.) It is also referred to as the concentra.on of procedures by produc.on unit of the supported service It helps to understand how the supply of support/ complementary (to the diagnosis, treatment, and administra.ve services) services was distributed among the final services.

Produc.on Indicators - Rate Of U.liza.on Of Support Services (2) It also provides informa.on about the demand that recipient services exert over complementary/support services to the diagnosis, treatment and administra.ve services Rate of u)liza)on of support services: Volume of Production of support services by recipent service /Volume of Production of Recipent Service

Produc.on Indicators - Rate Of U.liza.on Of Support Services (3) Let s look at an example of the calcula.on of hospital services rates. RUSS RUSS LABORATORY RATE OF UTILIZATION OF SUPPORT SERVICES RUSS FOR HOSPITALIZATION VOLUME OF PRODUCTION OF SUPPORT SERVICES / DISCHARGES LABORATORY TESTS DONE FOR HOSPITALIZATION / DISCHARGES 5.76 RUSS X RAYS X RAYS DONE FOR HOSPITALIZATION / DISCHARGES 1.95 RUSS SURGERY ROOM SURGICAL PROCEDURES DONE FOR HOSPITALIZATION / DISCHARGES 0.28 RUSS PHARMACY PRESCRIPTIONS FILLED FOR HOSPITALIZATION / DISCHARGES 5.86 LABORATORY 12400 SURGICAL PROCEDURES 600 DISCHARGES 2,151 X RAYS 4200 PRESCRIPTIONS 12600 This type of indicator provides a view of pa.ent care; in this case we see that for each discharge there is an average of 5.76 laboratory tests, 1.95 X- Rays and 5.9 prescrip.ons. In addi.on, 3 out of 10 hospitaliza.ons require surgical procedures.

It is a ra.o and classified as a process indicator. It is the average percentage of beds u.lized during a given.me period (e.g., month, year, etc.). It measures the level of bed u.liza.on.

The terms Occupancy Rate and Percentage of Occupancy represent the same concept although their mathema.cal expression could slightly vary. It is condi.oned by two factors: Bed complement and the Average Length of Stay It is a ra.onality measure: of the use of invested resources (actual capacity, represented by the bed complement) and of the ins.tu.onal capacity to meet the demand for hospital services. This indicator is related with the pressure exerted by the demand (popula.on) for hospital beds.

Produc.on Indicators - Occupancy Rate Percentage Of Occupancy (3) PERCENTAGE OF OCCUPANCY (DBO / DBD) X 100 45.11 OCCUPANCY RATE (DBO / DBD) 0.45 DBO 13500 DBD 29930 The difference between the rate and the percentage is the mathema.cal expression. Just as with the average length of stay, a calcula.on should be done for each inpa.ent service

Produc.on Indicators - Occupancy Rate Percentage Of Occupancy (4) SERVICE BEDS QUANTITY DBO DCD PO OR General hospital beds 20 2400 Specialized medical hospital beds 20 2600 Gyno- obstetric hospital beds 15 1800 Pediatric hospital beds 12 2800 Surgical hospital beds 10 1100 Special care hospital beds 5 2800 GENERAL 82 13500 7.300 32.9% 0.33 7.300 35.6% 0.36 5.475 32.9% 0.33 4.380 63.9% 0.64 3.650 30.1% 0.30 1.825 153.4% 1.53 29.930 45.1% 0.45

Produc.on Indicators - Occupancy Rate Percentage Of Occupancy (5) This indicator establishes the use of exis.ng bed capacity; If the indicator falls below 70% there is a significant idle capacity However, it should never go beyond 95% because otherwise the capacity to respond to unpredictable events is lost If there are services with low indicator values and others with high indicator values we could consider redistribu)ng the beds.

It is a ra.o and classified as a process indicator. It measures the contribu.ons of human resources (hours and minutes) to each produc.on unit, or vice versa, the produc.on for each hour invested in human resources. Defines the human resources available for each produc.on unit. PRODUCTIVITY HUMAN RESOURCES PRODUCTIVITY BY UNIT OF PRODUCTION (HOURS HUMAN RESOURCES X PUSA) / PRODUCTION VOLUME SERVICE PUSA 80% 85% 88% 85% PRODUCTS GENERAL PRACTITIONER NURSE NURSE ASSISTANT SPECIALIST ADMISSIONS PRODUCTIVITY 70 200 200 400 100 2.3 2.4 5.0 1.2 OUTPATIENT VISITS TO GENERAL PRACTITIONERS 50 200 100 400 100 PRODUCTIVITY 3.2 1.7 7.0 1.7 OUTPATIENT VISITS BY SPECIALIST 15 50 100 200 100 PRODUCTIVITY SURGERIES PRODUCTIVITY 65 2.7 5.7 11.7 5.7 100 50 400 200 1.2 0.7 5.4 2.6

Produc.on Indicators - Human Resources Produc.vity By Unit Of Produc.on (2) This indicator provides a clear picture of the use of human resources as an exis.ng produc.on capacity Extreme care must be paid to the data collected for this calcula.on. Health professionals must specifically state the number of hours they spent in each service and the number of ac.vi.es conducted for each service. When Propor)on of Time Spent on Produc)ve Ac)vi)es (PTSPA) are used: We are making a correc.on in the actual use of contracted hours by professionals, because part of their.me is spent in breaks and administra.ve ac.vi.es This percentage can range between 10% and 15% of the contracted.me

Produc.on Indicators - Human Resources Produc.vity By Unit Of Produc.on (3) In the previous example we show a discharge that required: 2.3 medical hours, 2.4 nursing hours and 5 hours of a nursing assistant. In addition, we can determine that a doctor conducts 3.2 medical consultations per hour.

Produc.on Indicators INDICATOR EXPRESSION NUMERATOR CAPTURE DENOMINATOR CAPTURE FORMULA HOSPITAL DISCHARGES ABSOLUTE NUMBER Discharges of all inpa.ent final services PERC Discharge of all in hospital final services ICU DISCHARGES ABSOLUTE NUMBER ICU discharges PERC Discharge of all ICU services GENERAL MEDICAL VISITS ABSOLUTE NUMBER Monthly number of visits per physician PERC General medical visits SPECIALIST MEDICAL VISITS ABSOLUTE NUMBER Specialist visits PERC Specialist medical visits EMERGENCY VISITS ABSOLUTE NUMBER Number of emergency visits PERC Emergency visits INPATIENT SURGERY ABSOLUTE NUMBER Number of surgical discharges with hospitaliza.on MATRIX In hospital surgical discharges of all services AMBULATORY SURGERY (Day Surgery) ABSOLUTE NUMBER Number of ambulatory surgeries MATRIX Outpa.ent surgical discharges of all services AVERAGE LENGTH OF STAY CORRELATION Occupied bed days in hospital PERC Discharges from all in hospital services PERC Numerator / denominator

INDICATOR EXPRESSION NUMERATOR CAPTURE DENOMINATOR CAPTURE FORMULA AVERAGE STAY ICU CORRELATION Bed days occupancy ICU PERC ICU Discharges PERC Numerator / denominator BED TURNOVER RATE CORRELATION Discharge of all in hospital final services PERC HospIitaliza.on beds PERC Numerator / denominator ICU BED TURNOVER RATE HOSPITAL OCCUPANCY RATE ICU OCCUPANCY RATE CORRELATION CORRELATION CORRELATION ICU discharges PERC Beds ICU MATRIX Numerator / denominator BDO hospitaliza.on PERC DBD Hosptaliza.on PERC Numerator / denominator BDO ICU PERC DBD ICU MATRIX Numerator / denominator EMERGENCY REFERRALS CORRELATION Pa.ents referred MATRIX Emergency discharges PERC (Numerator / denominator) x 100 INDEX OF LABORATORY USE IN HOSPITALICATION CORRELATION Laboratory tests for all in hospital services PERC Hospital discharges PERC Numerator / denominator

INDICATOR EXPRESSION NUMERATOR CAPTURE DENOMINATOR CAPTURE FORMULA INDEX OF LABORATORY USE IN OUTPATIENT VISITS INDEX OF LABORATORY USE IN EMERGENCIES INDEX OF MRI USE IN HOSPITALIZATION INDEX OF MRI USE IN OUTPATIENT VISITS INDEX OF MRI USE IN EMERGENCIES CORRELATION CORRELATION CORRELATION CORRELATION CORRELATION Laboratory tests for outpa.ent visits Laboratory tests for emergencies MRI hospitaliza.ons EMRI Outpa.ent visits MRI emergencies PERC PERC PERC PERC PERC Outpa.ent visits Emergency care Hospital discharges PERC PERC PERC Numerator / denominator Numerator / denominator Numerator / denominator Outpa.ent visits PERC Numerator / denominator Emergency care PERC Numerator / denominator