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HOSPITAL PERFORMANCE INDICATORSOVERVIEW AND INTRODUCTION

1. Summary

Hospitals are large and complex organisations comprising many different services. It is not an easy task to manage such an organisation, so relevant, timely and accurate information is required. Performance indicators summarise important data that a hospital produces and act as a management tool. They are invaluable to managers in the process of decision making and optimising performance.South African hospitals, in the majority of cases, do not adequately use information to inform the decision making processes. Hospitals often collect masses of statistics but rarely do they manipulate them into meaningful information. A limited number of indicators have been identified and combined into a system which can provide an overview of the hospital, and can be used as a management tool. In the future, a user friendly software package will be developed to assist hospital managers to implement the system. This package will enable all indicators to be graphically represented which will make the interpretation of such indicators very easy. In the interim, it can be used on a manual basis or using a basic spreadsheet.

2. Performance Indicators

2.1 Performance indicators are measures that provide an overview of a hospital’s performance. They summarise essential data in the form of relevant information which is represented in an indicator.

2.2 Indicators are selected to provide a global picture of a hospital’s performance, and chosen from several of the core management functions. Data is collected from financial management systems, personnel systems, clinical records and ward records. It is essential that only relevant information is collected and all indicators have a clear purpose.

2.3 Indicators should be used as a management tool to improve decision making and to ensure that a hospital is managed effectively and efficiently. Senior managers may use the indicators to help in the allocation of, and effective use of resources, the identification of deficiencies and prioritisation of needs. In addition, they can be used to help set and monitor targets for the hospital.

2.4 Performance indicators essentially provide a summary of hospital performance which is used primarily as an internal management tool to assess performance against set objectives. However, an additional

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feature is the ability to compare performance between similar hospitals. Such a benchmarking process highlights hospitals that need to improve performance and facilitates the sharing of ‘best practice’ in hospitals.

3. Use of Performance Indicators in South African Hospitals

The Current Situation3.1 Data currently collected and indicators used in most hospitals are as

follows:

· Many hospitals use a national financial management system (FMS), and a personnel and administration management system (PERSAL). However, large numbers of hospitals in the country currently use neither of these systems.

· Data to assess activity and efficiency is collected and reported in different ways in hospitals, for example, business status reports are used in some hospitals in the Western Cape but not others

3.2 There is no uniform approach to data collection in South Africa. Some Provinces collect vast amounts of data, whilst others collect little data on a regular basis. In addition, there are differences in the calculations used. This has meant that reliable comparisons between hospitals is difficult.

3.3 Hospital managers generally do not use information to its full potential for many reasons, some of which are detailed below:

· Data is not manipulated into meaningful information

· If relevant data is produced, it is often presented statistically in a cumbersome format, which complicates interpretation

· Even when information is available, it does not lead to management decisions and is not routinely reviewed

· Hospital managers have not been trained to use such information

3.4 Hospital managers in South Africa do not have adequate authority to manage hospitals, as many of the key management functions are controlled at provincial level. This has resulted in the lack of a driving force to develop management information systems in hospitals. If in

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the future, hospital managers have more authority to manage their organisations, it is essential that they have timely management information on which to base their decisions.

4. A New System of Hospital Performance Indicators

4.1 In response to the situation described above, the Hospital Strategy Project has developed a proposed system of hospital performance indicators. These have been developed in consultation with hospital managers, provincial representatives and representatives of NHIS/SA. The system was approved in principle by a representative workshop of the provinces and Department of Health, held on 10 April 1996. At the workshop, it was decided that the system should be piloted in the Northern Province before implementation on a national level. Further details on implementation are given in section 6. In the following sections, the basic structure, parameters and operation of the system are outlined.

Standard Set of IndicatorsA standard set of a limited number of indicators should be introduced into all public hospitals in South Africa. These indicators have been chosen as a minimum requirement to monitor critical areas of a hospital performance. They should provide a comprehensive overview of the hospital whilst at the same time limiting the volume of information.

Below is a list of the suggested performance indicators that have been identified to provide a summary of hospital activity for a month or quarter, separated into the following categories:

(i) ActivityInpatient daysInpatient admissionsOutpatients - headcounts and attendance’sEmergency attendance’sInpatients in hospital for more than 8 daysWaiting lists for outpatient appointments

(ii) EfficiencyAverage length of stay

Bed occupancy rateSickness and absence rateTheatre utilisation Staff turnoverAdmission rates per staff

(iii) QualityComplaintsPost operative infection ratePercentage of patients that fail to attend clinicsPercentage of deaths that are clinically audited

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(iv) FinanceMonthly expenditure

Cost per patient dayHospital Income

As can be seen from the list of indicators, a new information system is not being suggested, only that the important elements from systems currently in place are incorporated into global indicators to provide a summary of hospital performance.

4.2 Categories of indicators

Indicators have been categorised into different groups as detailed below:

(i) Basic Indicators Indicators that all hospitals should be able to produce, are essential to manage a hospital, and must be reviewed regularly.

(ii) Additional IndicatorsIndicators that provide a more detailed analysis of the hospital, using the data collected for basic indicators. For example, a manager monitoring bed occupancy rate may also be interested in bed turnover rate, this indicator does not require additional data, but can be calculated by manipulating the current data.

Additional information can be obtained by dis-aggregating the data in an indicator, for example, average length of stay for the hospital can be broken down into average length of stay per speciality. These indicators will be produced only on request by a manager, to avoid overloading the manager with information.

(iii) Advanced IndicatorsIndicators that provide a comprehensive overview of the hospital. These require additional data to be collected and it is the choice of the individual hospital whether or not they wish to collect such data. Hospitals should aim to collect the data as the indicators provide a detailed view of the hospital service. However, it is recognised that systems are not yet in place in all hospitals to capture such data.

4.3 Format of the indicatorsThe format for all of the indicators is as follows:

4.3.1 DefinitionA clear definition of each indicator is included. This should overcome any ambiguities.

4.3.2 Calculation

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The method to calculate the indicator has been defined and all hospitals should use this calculation, thus allowing comparisons to be made between hospitals. It is noted that some provinces use different calculations and the most used calculation has been included. However, once national definitions are in place, then these must be adopted by the hospitals.

A suggested reporting time, either monthly or quarterly is also stated. Hospitals can review all indicators on a monthly basis if they wish, however, certain indicators they may only need to be reviewed on a quarterly basis and suggestions are made for review frequencies. This aims to reduce the amount of information a manager needs to monitor on a monthly basis, but also implies that every quarter an in depth analysis of the hospital should take place.

4.3.3 RationaleThe reason why the indicator should be monitored is explained, to ensure that all indicators have a definite purpose.

4.3.4 Data SourceIdentifies where the data should be collected, for example PERSAL system, FMS or from ward level.

4.3.5 Actions to ConsiderIf an indicator highlights a problem, some basic actions are suggested to guide the thinking of a manager as to what to do next. It must be noted that these are basic suggestions, and that the list is not exhaustive. The actions listed also highlight the other indicators that should be monitored to provide a more comprehensive analysis of the problem.

4.3.6 Possible Additional IndicatorsSuggestions of additional indicators that may be produced to support the basic indicator are made. In addition, dis -aggregation of the indicators are suggested to allow further breakdown of the data which may help answer queries raised.

4.4 Graphical RepresentationRepresenting the indicators in a graph will allow easy interpretation of the information, as comparisons can be made over time highlighting trends. It is proposed that a simple software package be developed, to present the indicators in this user friendly format. A draft specification for such a package has been included in Appendix 3. The package will print indicators in a summary form, as well as produce graphs of the basic indicators highlighting trends. Some example graphs have been produced and are attached in Appendix 2.

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4.5 Use at provincial levelIndicators can be used at a Provincial level in the following ways:

· To monitor performance of hospitals within the Province

· To assess equity of services offered both within the Province and nationally

· To aid the strategic planning process

· To assist in resource allocation

4.6 Future IndicatorsIt is recognised that the proposed standard set of indicators is not exhaustive. A list of additional indicators that may be used at a future date have been provided in Appendix 1. It is also recognised that Provinces and hospitals may develop other indicators relevant to their specific situation.

5. Compatibility of the proposed set of indicators with other systems and projects

5.1 There are a number of initiatives currently being undertaken regarding hospital information. The proposed hospital performance indicators are compatible with all these systems, and are not meant to replace or supersede them.

5.2 The National Health Information Systems/ South Africa (NHIS/SA), is currently being developed. This system will be introduced in the next few years and will provide a comprehensive information system. Although the proposed system of performance indicators utilise information generated from systems currently in use, the indicators can be modified to accommodate new sources of data and be incorporated into NHIS/SA. However, during this transitional period, the use of performance indicators as set out in this document will produce a simple and easy to use management tool which will help to develop a culture that uses information to take decisions. All relevant elements of the proposed new indicators will be included into the data dictionary currently being produced by the Department of Health.

5.3 A Standards Committee has been developed by NHIS/SA. This aims to develop national standards. As part of its work it will try to obtain consensus on certain definitions, for instance, inpatient day. The Standards Committee has agreed to give priority to finalise definitions for the indicators in the system. When the Committee produces national definitions, these will be introduced as the required definitions for the package.

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5.4 The Council for Health Service Accreditation of South Africa (COHSASA) is currently introducing a quality improvement programme into 10 public hospitals in the North West Province. COHSASA has indicated that it is willing to develop an additional management module which will audit the data input into the system to ensure that it is accurate, and to evaluate the use of performance indicators to make decisions in the hospitals.

5.5 Information systems currently in place in hospitals will not be compromised, as the indicators developed will use the data that they produce and will purely be an additional tool.

6. Implementation of the system

6.1 A national workshop took place on 10 April 1996 to discuss the proposed indicators. Relevant comments and suggestions have been incorporated in this revised version of the document that was discussed. The participants at the workshop suggested that the system be introduced as soon as possible. A strategy for implementation was proposed in the workshop and is summarised below:

· The revised document be sent to Provinces for further consultation.

· The Northern Province will pilot the system which should be introduced by August 1996.

· Following a brief implementation time period the Northern Province will then present the system to the NHIS/SA. A comprehensive implementation program led by individual provinces may then take place.

· Introduction and training in the use of performance indicators should take place in each Province. It is the responsibility of each Province to train and support managers in the use of the system.

· Definitions will be addressed by the NHIS/SA National Standards Committee. Once national consensus is reached, the definitions will be altered within this system.

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Hospital

Performance

Indicators

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SUMMARY PAGE OF INDICATORS

INDICATOR INDICATOR LEVEL

REPORTING FREQUENCY

SUGGESTED NORM

1. Activity1.1 Inpatient days1.2 Inpatient admissions1.3 Outpatients - attendance’s

and head counts1.4 Emergency attendance’s1.5 Inpatients in hospital for

more than 8 days1.6 Waiting lists for outpatient

appointments

2. Efficiency 2.1 Average length of stay2.2. Bed occupancy rate2.3 Sickness and absence rate2.4 Theatre utilisation2.5 Staff turnover2.6 Admission rates per staff 3. Quality3.1 Complaints Received3.2 Post operative infection rate 3.3 Percentage of patients that

fail to attend clinics 3.4 Clinical Audit

4. Financial4.1 Expenditure 4.2 Cost per patient day4.3 Income

BasicBasicBasic

BasicAdvanced

Advanced

BasicBasicBasicBasicAdvancedAdvanced

BasicBasicAdvanced

Advanced

BasicBasicBasic

MonthlyMonthlyMonthly

MonthlyMonthly

Quarterly

MonthlyMonthlyMonthlyQuarterlyQuarterlyQuarterly

MonthlyQuarterlyQuarterly

Quarterly

MonthlyMonthlyMonthly

N/AN/AN/A

N/AN/AN/A

4-8 days 70 - 80 %5 - 10 %5 - 10 %N/ASee indicator

N/AN/AN/A

N/A

N/AN/AN/A

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1.1 In-patient Days - Monthly Total

Definition: An in-patient day is a unit of measure utilised to indicate the services rendered to one in-patient between the census taking hours on two successive days.

Calculation: Inpatient days (L) = census figure from the previous midnight (C)Plus patients admitted and discharged in the previous 24 hours (E)

L = C + E

Total inpatient days per month = The sum of the midnight census figure for the month plus total deaths and discharges for the month.

Note: A stay of less than one day ( i.e. the patient is admitted and discharged on the same day) is counted as one day and must be included when counting the total number of days

Inpatient:A person admitted to a hospital for the purpose of continuous hospital care and who occupies a standard bed, that is, in respect of whom an in-patient admission procedure has been completed.

Discharge:A discharge is the departure from a ward of any in-patient who has already been through the admission procedure before and for whom a bed is not reserved. This definition includes deaths, but not patients who, for example, have been allowed home temporarily over the weekend and for whom a hospital bed is specifically reserved.

Basic Indicator (monthly review)

Rationale: An overall measurement of workload for the hospital wards

Data Source: Census figure from midnightAdmissions for the period (24 hours)Discharges for the period (24 hours)Total Patient days for the month

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Actions to Consider

If total inpatient days have decreased dramatically:· Look at the relationship with outpatient appointments - have

admissions following outpatients decreased?· Look at referrals to other hospitals - have they increased, if so

why?· Have emergency admissions decreased? If so why?

If total inpatient days increase dramatically· Has the admission rate increased dramatically, if so why?· Look at admissions per speciality - are they appropriate

admissions or could the patient have been treated as an outpatient or referred to another hospital?

· Has the population served altered in any way?· What is happening in surrounding hospitals?· Look at the number of emergency admissions

· Possible Indicators

· Show inpatient days per speciality

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1.2 In-patient Admissions

Definition: The number of patients that have been admitted to hospital over a specified time period.

Calculation: Actual figures for admission separated into the following categories:a) Totalb) Emergency c) Plannedd) Obstetricse) Live births

Total admissions: All activity - sum of emergency, elective, obstetric and other admissions.

Emergency admission: A patient admitted to hospital when admission is unpredictable and at short notice because of clinical need.

Planned/Cold admission: An admission where the decision to admit could be separated in time from the actual admission, usually a patient whose admission date is known in advance thus allowing arrangements to be made beforehand. Excludes patients transferred from another hospital.

Obstetric admission: An admission of a pregnant or recently pregnant woman to a maternity ward except when the intention is to terminate pregnancy. Excludes babies born before or during the maternity episode.

Note: Any other admissions to be included in total admissions, for example patients transferred from another hospital


Rationale: To assess activity levels for a hospital and to separate the categories of activity.

Data Source: Number of admissions: Total Number of admissions: EmergencyNumber of admissions: ElectiveNumber of admissions: ObstetricsNumber of live births: Normal & Caesarean Section

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Actions to Consider

If the number of admissions decrease dramatically:· Establish the reason and determine if the change is temporary or a

long-term trend· Look at average length of stay to see if it has increased and assess

the case mix· Look at the relationship with outpatient attendance’s - have they

increased?· Look at referrals to other hospitals· Have emergencies decreased? If so why?

If admissions increase dramatically:· Establish why admissions have increased and determine the affect

on capacity to provide a quality service? Look at bed occupancy rates (2.2)

· Look at admissions per speciality - are they appropriate?· Have referrals increased? - What are the reasons per speciality?· Are there any seasonal reasons as to why activity levels have

changed?· Have the number of admissions following an outpatient attendance

increased? Is it a refection of pathology?· Have emergencies increased? - If so why?


· Births separated into caesarean sections and normal births· Separate data by speciality e.g. Medical, Surgical, Gynaecology,

Obstetrics, Paediatrics, Chronic Care, Other· Show discharges and deaths on a separate graph if requested

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1.3 Outpatient Head Counts & Outpatient Attendance’s - Totals and Ratio

Definition: An outpatient who attends an outpatient clinic to see a health professional for diagnosis or treatment and for whom an outpatient registration procedure is completed. A head count is the number of individuals registered for treatment.

An outpatient visit/attendance is the number of outpatient treatment events for the time period, it is equal to the number of attendance’s (consultations and encounters) with health care professionals. Therefore, if a patient visits four clinics on one day, the patient is counted as four outpatient visits.

Calculation: a) Actual number of outpatients that attend a clinic, often referred to as a head count, for the month.

b) Actual number of visits/attendance’s for the monthc) Attendance’s per patient, that is, average number of visits per

outpatient, if requested.

Number of attendance’s/visits Head Count


Rationale: Monitors outpatient activity and workload, in addition, shows the ratio of visits to clinics per head count. Acts as a proxy indicator of access and utilisation of services.

Data Source: Actual outpatient head count figuresActual visit/attendance figures

Actions to Consider:

If the number of outpatients increase:d) Are they appropriate - should some patients attend a primary

health care clinic first?e) Is the increase seasonal?f) Assess the affect the increase has on the hospitals capacity to treat

patientsIf the ratio of visits per head count increases greatly:

g) Perform a snapshot study to establish if they are appropriate visitsh) Compare the hospitals ratio with other similar sized unitsi) Look at casemix of patients attending a clinicj) Separate new and follow up attendance for specialities

k) Possible Indicators

l) Specify the number of outpatients that attend for each specialitym)Specify the different visits to the different departments , such as,

Pathology, Physiotherapy, X - ray, Treatment Room

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1.4 Emergency Attendance’s

Definition: Patients treated at an Emergency facility ( Medical Emergency Unit, Casualty/Trauma Unit or speciality designated areas) of a hospital. The attendance should be to receive treatment from the accident and emergency staff for an urgent problem. Usually patients will not have been seen by a clinic beforehand.

Calculation: Actual figures

Note: If a hospital does not have specially designated emergency room facilities and an outpatient facility only, patients who are treated in such a hospital are to be recorded as follows:During normal working hours (8 a.m. - 5 p.m.) they must be recorded as outpatients whilst patients treated outside normal working hours are to be regarded as emergencies.


Rationale: Shows the demand for emergency services in an area.

Data Source: Actual figures emergency attendance’s

Actions to Consider

Keep an emergency department register that highlights the following issues that are relevant.

If the number of emergency attendance’s increase greatly:· Are they appropriate - could the patient be seen in an outpatient

clinic or a Primary Health Care Facility· Are they more complex e.g. a large number of gunshot wounds

requiring more intensive treatment?· Is it affecting the hospitals capacity to provide elective/planned

patient services?· Are facilities adequate if it is a long term trend?

Admissions following a casualty attendance:· Have the numbers increased? Are they appropriate attendance’s or

home after treatment?· Are they affecting theatre schedules and increasing the number of

cancelled operations - (see 2.4)

Possible Indicators

· Show emergency attendance’s as a percentage of outpatient attendance’s

· Show percentage of emergency inpatient admissions as a percentage of admissions

· Show the percentage of admissions following emergency attendance’s

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1.5 Number of inpatients in hospital for more than 8 days

Definition: Number of inpatients in hospital for more than 8 days, categorised into those in hospital for more than 8, 10, 15 and 30 days.


Note: Excludes patients in TB wards and long term psychiatric stay patients

Note: If a patient is allowed home for a weekend but their bed is kept for them then all days including the home stay days must be counted.

Advanced Indicator (monthly review)

Rationale: Indicates if there are a large number of long stay patients, such as, orthopaedic patients in traction, that may affect average length of stay. In addition, indicates if patients are kept in hospital for longer than medically required. Targets for average length of stay are as follows:Community hospital - Urban 4-6 days, Rural 6-8 daysSecondary hospital - 5-7 daysTertiary hospital - 6-8 days

Data Source: Patients in hospital for more than 8 daysPatients in hospital for more than 10 daysPatients in hospital for more than 15 daysPatients in hospital for more than 30 days

Actions to consider

If there is a large number of patients:· Establish the type of conditions· Establish whether it is appropriate to keep them in an acute

hospital?· Identify the discharge problems and implement discharge planning

procedures


· Indicate as a percentage of all inpatients· Show chronic patients - TB patients and long term psychiatric

patients separately

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1.6 Number of Patients Waiting Over 30 Days for an Outpatient Appointment

Definition: Number patients waiting for more than 30 days for an outpatient appointment

Calculation: Actual figure

Will normally refer to patients referred to specialist outpatient clinics such as an Ophthalmology clinic or an Orthopaedic clinic, that have been given an appointment date.

The figures will be taken from a snapshot of the waiting list on the last day of the period under review.

Advanced Indicator (quarterly review)

Rationale: Monitors the management of waiting times and indicates where resources are required, if there are long waits.

Data Source: Patients with booked appointments from all specialities

Actions to consider

If there is a large number of patients waiting over 30 days for an outpatient appointment:· Establish the specialities and types of conditions· Can the number of sessions be increased for the relevant

personnel?· Can other clinics be opened?· Look at the number of patients that fail to attend clinics


· Specify for each speciality

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2.1 Average Length of Stay

Definition: The Average Length of Stay (ALOS) is the average length of time (in days) that a patient spends in the hospital before discharge.

Calculation: Inpatient days in the monthDischarges and deaths in the month

Inpatient days:the midnight count plus admissions less discharges and deaths plus patients admitted and discharged in the same 24 hour period, totalled for the month. (See inpatient days - monthly total 1.1)

Discharges and deaths:discharge is the end of a patient’s continuous stay using the beds in one hospital. If a patient dies this is included in the figure.

Note: Excludes TB Wards and long term stay Psychiatric patients

Basic Indicator (monthly review)Rationale: Indication of the effectiveness of patient management including

social discharge arrangements.Targets for average length of stay are as follows:Community hospital - Urban 4-6 days, Rural 6-8 daysSecondary hospital - 5-7 daysTertiary hospital - 6-8 days

Data Source: Inpatient daysNumber of inpatient deaths and discharges

Actions to consider

If the average length of stay is longer than previous time periods or comparative hospitals, consider the following:· Look at a breakdown of ALOS for each speciality to see if one

speciality is affecting the hospital ALOS· Perform a snapshot study of the case mix of admissions for the

hospital to see if more complex work is being admitted· Look at the number of patients in hospital for more than 30 days

e.g. a large number of Orthopaedic patients in traction· Look at admission and discharge procedures for patients and

benchmark with hospitals with shorter ALOS· Are there a large number of patients that cannot be discharged for

social and not medical reasons?· Is there efficient scheduling of diagnostic and therapeutic care· Are a large percentage of patients reporting hospital acquired

infections?· Possible

Indicators· Average length of stay can be shown per speciality· Chronic care patients shown on a separate graph

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2.2. Bed Occupancy Rate

Definition: The bed occupancy rate is a measure of the average number of beds that are occupied, expressed as a percentage.

Calculation: Percentage bed occupancy = Inpatient days X 100Available bed days

Available bed daysNumber of available beds multiplied by the time period specified. An available bed is a bed that if unoccupied is available for use almost immediately. For example, a hospital may have been authorised to accommodate 200 inpatient beds but 20 additional beds have been moved into available space and are currently in use, therefore the hospital will have 220 active beds. If another hospital, authorised for 200 beds has closed wards for some reason and has only 150 beds in actual use, this hospital will have 150 active beds.


Rationale: Bed occupancy is a gross measure of bed utilisation for a hospital. The optimum occupancy for a hospital is between 70-80%.

Data Source: Number of occupied bedsNumber of available beds

Actions to Consider

If bed occupancy is high:· Look at occupancy rates above 90%· Look at admission and discharge protocols· Look at average lengths of stay and inpatient deaths and

discharges - is it volume or the amount of time patients are spending in the hospitals (see 2.1)

· Look at the number of times the hospital has closed to admissions· Look at the bed turnover rate · Look at individual wards and specialities

If bed occupancy is low:· Is it a short term drop or a trend?· Can beds be closed or different services offered?


· Look at specialities separately· Look at the number of times that a hospitals bed occupancy

figures have been above 90% or below 60%

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2.3 Sickness and Absence Rates

Definition: Days lost to sickness and absence as a % of total working days available.

Calculation: Total days lost to sickness and absenceTotal working days available

Sickness and absence: to include authorised sickness (uncertified, self certified and medically certified) plus unauthorised absence (including strikes).

Note: All other leave, such as, maternity leave, annual leave, special leave, study leave, statutory leave etc. is excluded.

Note: Days lost are counted from the first day of sickness or absence regardless of the time allowed before certification is required.

Total working days: sum total of days contracted to be worked in the organisation for filled posts


Rationale: A low sickness and absence rate would indicate pro active performance and a good utilisation of the staff resource. A high sickness and absence rate may also be an indication of low staff morale. The target should be between 5 - 10 %.

Data Source: Total days lost to sickness and absence for professional groupsTotal working days available

Actions to Consider

A high sickness and absence rate· Look at different professional groups rate of sickness and absence · Identify if wards or areas have particularly high levels· Look at the number of days lost to strikes and the number of

grievances or tribunals that have taken place· Introduce a back to work interview for employees on their return

from sick leave· Look at staff turnover figures


· Show sickness and absence for separate professional groups on the same graph

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2.4 Percentage of Theatre Utilisation

Definition: The percentage of available working hours that a theatre is used during the normal working day.The percentage of total hours a theatre is used.

Calculation: Theatre hours used 8 a.m. - 5 p.m. X 100 Available theatre hours 8 a.m. - 5 p.m.

Available working hours are based on weekday working of 8 a.m. to 5 p.m.

Total theatre hours used X 100 Total available theatre hours

Available theatre hours are the total hours that a theatre is available for use.

Basic Indicator (quarterly review)

Rationale: A measure of theatre utilisation

Data Source: The number theatre hours used both total and during working hours.The number of theatre hours available in a normal working day and total hours

Actions to consider

If theatre utilisation hours are low· Breakdown theatre utilisation per theatres - do all theatre need to

be running· Check the number of cancelled sessions and operations· Is it due to a lack of staff or an over capacity


· Percentage of theatre hours used for emergency work

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2.5 Staff Turnover

Definition: A projection of the percentage of personnel turnover for the full year given current tendencies.

Calculation: (losses + appointments) /months * 12 X 100Posts (April) + current posts / 2 1

Staff turnover percentage =Total losses for y.t.d (year to date)plus appointments y.t.d.divided by number of months from the beginning of the financial year multiplied by 12Divided by Posts filled at April plus posts filled this month divided by 2times by 100


Rationale: Staff turnover may be an indication of staff satisfaction.A turnover of between 5-10% would be an indication of natural movement

Data Source: PERSAL

Actions to Consider

If staff turnover rates are high:· Break down global figures to staff speciality groups· Look at sickness and absence figures, see if they are also high

(see 2.3)· Find out where staff are moving to e.g. another hospital etc.· Discuss with staff groups exceptionally high turnover rates· Look at the number of posts that are training posts· Look at posts vacant as a percentage of all posts· Compare turnover rates with the same time period as last year· Look at the ratio of posts filled compared to occupied beds


· Show staff turnover by professional group

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2.6 Admission Rates per Staff Group - Medical and Nursing Staff

Definition: The number of admissions per doctor and per nurse.

Calculation: Number of admissions per quarterNumber of doctors

Number of admission per quarterNumber of nurses

Note: The average number of doctors and nurses in filled posts for the quarter will be used.


Rationale: Shows the utilisation of staff per patient services and an indicator of staffing levels. Recommended numbers of admissions per doctor and nurse are shown below:

Hospital Level Admission Admission per Doctor per nurse

Academic and Tertiary 73.9 12Secondary and Community 560 29.6

Data Source: Number of admissionsNumber of doctors employedNumber of nurses employed

Actions to consider:

A low number of admissions per staff:· Compare ratios with other similar hospitals· Look at staff rates per bed and admission rates per bed to get an

overall picture· Look at the bed turnover rate · Look at case mix. Do a large number of patients require

intensive nursing?

A high number of admissions per staff:· Are admissions appropriate? Look at average lengths of stay· Look at admissions as a percentage of all outpatients · Look at admission rate per 1000 population and compare with

similar hospitals


· Staff rates per bed· Admission rates per 1000 population served

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3.1 Complaints Received

Definition: Number of complaints received, separated into clinical and non clinical complaints.


Written complaints must be included, separated into clinical and non clinical

Verbal complaints that are referred to senior management must also be included, a written record of the verbal complaint should be kept.


Rationale: An indicator of patient satisfaction with the service received. Complaints can be a very effective mechanism to improve service delivery.

Data Source: Number of clinical complaints receivedNumber of non clinical complaints received

Actions to Consider

If there are few or no complaints:· Introduce a complaints system that is advertised throughout the

hospital, for example, posters showing how to complain and who to complain to

· Introduce a patient satisfaction survey

If there are a large number of complaints:· Investigate them in full and keep written records of the complaint

and outcome· Categorise complaints to see if the same or similar issues are

raised over time· Use complaints to improve the quality of the service


· Complaints split into clinical and non clinical complaints

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3.2 Post Operative Infection Rate

Definition: A post operative wound infection acquired whilst admitted in hospital.

Calculation: Actual figure

wound infection:purulent discharge, whether or not organisms can be cultured from the purulent material.

Basic Indicator (quarterly review)

Rationale: An indication of quality of care

Data Source: Actual figures

Actions to Consider

· A review of post operative procedures and infection control policies and procedures

· Monthly infection control meetings should be established· Monitor the number of bed sores reported to take place in a

hospital


· Show as a percentage of admissions

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3.3 Percentage of patients that Fail to Attend Clinics

Definition: Number of patients that fail to attend outpatient clinics for a planned appointment to see a doctor.

Calculation:Number of patients that failed to attend a clinic X 100

Total number of patients for planned clinics

Note: Only clinics with planned appointments should be included, either referred patients or repeat patients most probably a specialist clinic, such as, an orthopaedic clinic or an ophthalmology clinic.


Rationale: Indicates if there is a large percentage of “ No shows ”, if so resources may be wasted.

Data Source: Actual number of patients failing to attend planned appointmentsActual number of patients with planned appointments

Actions to Consider

· Send reminder letters to patients before clinics· Develop an appointment card with a telephone number to cancel

an appointment· Look at failure to attend rates per clinic· Remind patients of their appointment by telephone

Possible Indicators

· Show per speciality

26

3.4 Clinical Audit

Definition: The percentage of deaths where the case notes are reviewed.

Calculation:Number of deaths that have been audited X 100

Total number of deaths


Rationale: To analyse the quality of care, including the procedures used for diagnosis and treatment and the use of resources. In addition, it indicates if clinical audit is taking place.

Data Source: Actual number of audited death casesActual number of deaths

Actions to Consider

· Introduce multi disciplinary audit· Introduce random audit of cases


· Show the number of cases that have been audited per speciality

27

4.1 Monthly Expenditure

Definition: Expenditure for the hospital compared to the hospital budget shown in percentage figures to highlight over/under spends

Calculation: Expenditure to day of the last month x 100Budget for the same time period


Rationale: Indicates the financial position at this stage in the year

Data Source: Financial management system

Actions to Consider

Overspend:· Look at the breakdown of expenditure to establish where

expenditure has increased e.g. staff, drugs, meal costs· Set targets to reduce expenditure· Look at cost per patient day· Has activity increased greatly· Start to introduce costs per speciality - cost centre accounting· Try and increase income from private patients and user fees· Review financial projections on a quarterly basis· Split out the personnel element of the budget to show over/under

spend, try and distinguish levels of overtime and other expenditure that can be controlled


· Total income as a percentage of expenditure· Look at cost per admission/discharge

28

4.2 Cost per patient day equivalent

Definition: Average cost for a patient day in the specified time period

Calculation: Total monthly costCalculated patient days in the month

Calculated patient day:Equivalent to inpatient days plus one third of outpatient attendance’s.


Rationale: Indication of average patient day costs enabling the monitoring of unit cost over time.

Data Source: FMS costs for the month or commitment registerNumber of patient days

Actions to Consider

If patient day costs are increasing:· Look at the breakdown of costs · Look at the activity figures, have they decreased, therefore

increasing unit cost?· If drug costs have risen dramatically, look at the drugs prescribed· Try to establish cost centres within the hospital

Possible Indicators

· Patient day cost apportioned to drug cost, personnel cost, consumable cost, meal cost, maintenance

· Compare patient day costs to patient day revenue

29

4.3 Hospital Income - Direct Patient Payment, Health Insurance & Other

Definition: Income for the hospital from patients following treatment and other sources.

Calculation: Actual income received by the hospital from users . Split into the following categories:

Direct patient payment - OutpatientsDirect patient payment - InpatientsHealth Insurance


Rationale: Indicates the sources of income and highlights trends

Data Source: Actual figures from FMS

Actions to Consider:

· Set targets for user fees · Create incentives for increased income from patients· Set targets for private patients· Monitor debtor months


· Show them as percentages· Show the amount of outstanding debts · Show debtor months· Show the number of debts written off

30

APPENDIX 1

Future Indicators

Listed below are some suggested indicators which may be introduced into hospitals at a later date when comprehensive data capture methods are in place.

· Number of Patients Waiting for Operations A quarterly indicator that counts the number of patients waiting over 3 months for a specific operation at any one time, for example, the number of patients waiting for a cataract operation.

· Affirmative Action IndicatorA bi annual indicator that assesses the effectiveness of a hospitals affirmative action policy as compared to target. Clearer definition is required of affirmative action targets to enable this indicator to be introduced.

· Hospital VehiclesAn indicator that shows the number of times over 30% of the hospital vehicles are not functioning.

· Hospital Boiler SystemsAn indicator that will highlight the number of times the boiler system in a hospital is not functioning

· Medical Legal IncidentsAn indicator that shows the number of times an incident occurs where there could be the potential of a medico legal investigation, for example, unnatural deaths, death under anaesthesia, drug administration errors

· Patients kept in hospital for social and not medical reasonsAn indicator that highlights the number of patients kept in hospital who are medically fit for discharge but cannot be discharged for social reasons.

· Financial IndicatorsIndicators that show a more detailed breakdown of costs, for instance, cost per outpatient appointment, cost per admission per speciality etc.

· Number of Cancelled OperationsThe number of planned or cold operations that have to be cancelled or re-scheduled.

· Unplanned Re-Admission RatesThe number patients that have to be re admitted for the same medical condition where the re- admission is not planned.

· Patients Waiting over 4 hours to be seen at the Casualty DepartmentThe number of patients waiting over 4 hours before they are seen by a doctor at a casualty unit.

31

· Industrial tribunals and disciplinary hearingsThe number of industrial tribunals, disciplinary hearings and grievance procedures that have taken place over a specified time period.

· StrikesThe number of working days lost to industrial action in the workplace

· Staff Training The percentage of the budget spent on staff training

· Indicators for other areas of healthIndicators could be developed for other areas of health care, such as, Provincial indicators, Mental Health indicators, Ambulance indicators, Primary Health care indicators

· Ineffective ProceduresProcedures that the weight of medical evidence have shown to be ineffective in the majority of cases, such as grommet insertion, indicators should be used to highlight the number of these procedures taking place

32

APPENDIX 2

Appendix 2 contains example summary pages and example graphs. They show possible layouts for the graphical representation of the indicators by a software package.

Please note that the data used is sample data and not actual data.

Contents of Appendix 2

Sample Summary Page LayoutSample Summary Page Layout for the Medical SpecialityGraph 1 - Comparison of average length of stay between hospitalsGraph 2 - Comparison of average length of stay per speciality between hospitalsGraph 3 - Inpatient days per specialityGraph 4 - Number of complaints (Line Graph)Graph 5 - Number of complaints ( Bar Chart)Graph 6 - Number of inpatients in hospital for more than 8, 10, 15 and 30 days (with

a comment section) Graph 7 - As Graph 6 (Bar Chart)Graph 8 - Percentage of patients failing to attend outpatient attendance’sGraph 9 - Outpatient attendance’sGraph 10 - Outpatient head counts and attendance’sGraph 11 - Ratio of attendance’s and headcountsGraph 12 - Patients waiting over 30 days for an outpatient appointment per speciality

33

Sample Summary PageMarch 96

Indicator March

1996Average 1996

March 1995

Average 1995

1. Activity1.1 Inpatient days1.2 Inpatient admissions1.3 Outpatients attendance’s

Outpatient head counts1.4 Emergency attendance’s1.5 Inpatients in hospital for

more than 8 days 10 days 15 days 30 days

1.6 OPD waiting lists

2. Efficiency 2.1 Average length of stay2.2. Bed occupancy rate2.3 Sickness and absence rate2.4 % Theatre utilisation

Working hoursTotal hours

2.5 Staff turnover2.6 Admission rates per staff 3. Quality3.1 Complaints Received3.2 Post operative infection rate 3.3 % “No Shows” 3.4 % Deaths audited

4. Financial4.1 % budget over/under spend 4.2 Cost per patient day4.3 Income

34

Sample Summary Page Medical SpecialityMarch 1996

Indicator March

1996Average 1996

March 1995

Average 1995

1. Activity1.1 Inpatient days1.2 Inpatient admissions1.3 Outpatients attendance’s

Outpatient head counts1.4 Emergency attendance’s1.5 Inpatients in hospital for

more than 8 days 10 days 15 days 30 days

1.6 OPD waiting lists

2. Efficiency 2.1 Average length of stay2.2. Bed occupancy rate

3. Quality 3.3 % “No Shows”

35

Appendix 2

8.19

11.2

98.31 8.46

4.98

3.663.16 3.04

0

2

4

6

8

10

12

1 2 3 4 5 6 7 8 9

Hospitals

Aver

age

Leng

th o

f Sta

y in

Day

s

Comparison of average length of stay between similar size hospitals

16.1812.28 10.78 10.42 10.39

5.88 6.39 4.14 4.25

8.9811.15

7.8611.22 9.45

4.11 3.23.42 2.76

12.4111.75

8.94

10.6510

4.84 3.753.53 3.17

4.415.57

6.78

5.22

3.13

4.043.82

3.58 3.6

916.12

10.719.4

9.11

6.46

2.71.46 2.25

1 2 3 4 5 6 7 8 9

Aver

age

Leng

th o

f Sta

y

PaediatricsMaternityAdultSurgicalMedical

Comparison of Average Length of Stay per Speciality

Appendix 2

1500

2000

2500

3000

3500

April June August October December February

Patie

nt D

ays

All medical dysAll surgical daysAll paeds days

Patient Days per Specialty

Appendix 2

0

2

4

6

8

10

12

14

April May June July August Sept

Num

ber

of C

ompl

aint

s

Clinical ComplaintsNon Clinical

Number of complaints clinical vs non clinical

Appendix 2

Appendix 2

0

2

4

6

8

10

12

14

16

18

April May June July August Sept

Num

ber

of C

ompl

aint

s

Non ClinicalClinical Complaints

Number of complaints clinical vs non clinical

Appendix 2

0

10

20

30

40

50

60

70

80

90

100

April May June July August Sept October November

Inpa

tient

in H

ospi

tal f

or m

ore

than

8 D

ays

IP > 8 daysIP >10 daysIP > 15 daysIP > 30 days

The number of patients in hospital for more than 8 days dropped in November due torevised discharge procedures.Four orthopedic patients are in hospital for more than 30 days

Inpatients in hospital for more than 8 days

Appendix 2

0

20

40

60

80

100

120

140

160

180

April May June July August Sept October November

Inpa

tient

in H

ospi

tal f

or m

ore

than

8 D

ays

IP > 30 daysIP > 15 daysIP >10 daysIP > 8 days

The number of patients in hospital for more than 8 days dropped in November due torevised discharge procedures.Four orthopaedic patients are in hospital for more than 30 days

Inpatients in hospital for more than 8 days

Appendix 2

0%

5%

10%

15%

20%

25%

30%

35%

40%

April

May

June

July

Augu

st

Sept

embe

r

Oct

ober

Nov

embe

r

Dec

embe

r

Janu

ary

Febr

uary

Mar

ch

Perc

enta

ge o

f pat

ient

s fa

iling

to a

ttend

app

oint

men

ts

Percentage of Patients Failing to attend Outpatient Appointments

Appendix 2

3000

3200

3400

3600

3800

4000

4200

4400

4600

4800

April

May

June

July

Augu

st

Sept

embe

r

Oct

ober

Nov

embe

r

Dec

embe

r

Janu

ary

Febr

uary

Mar

ch

Num

ber o

f out

patie

nt a

ttend

ance

s

Outpatient Attendance's

Appendix 2

1000

1500

2000

2500

3000

3500

4000

4500

5000

April

May

June

July

Augu

st

Sept

embe

r

Oct

ober

Nov

embe

r

Dec

embe

r

Janu

ary

Febr

uary

Mar

ch

Num

ber o

f out

patie

nt a

ttend

ance

s

OPD AttendancesOPD Head Counts

Outpatient Activity

Appendix 2

2.00

2.10

2.20

2.30

2.40

2.50

2.60

2.70

2.80

2.90

3.00

April

May

June

July

Augu

st

Sept

embe

r

Oct

ober

Nov

embe

r

Dec

embe

r

Janu

ary

Febr

uary

Mar

ch

Rat

io o

f hea

dcou

nts

and

atte

ndan

ces

Outpatient Ratio of Headcounts and Attendance's

Appendix 2

0

10

20

30

40

50

60

70

80

90

100

March April May June July August

Patients waiting for an outpatient appointment

Medical

Surgical

Paediatrics

Obstetrics

Gynaecology

Number of Patients Waiting over 30 days for an Outpatient Appointment

APPENDIX 3

SOFTWARE PACKAGE SPECIFICATIONHOSPITAL PERFORMANCE INDICATORS

1. Background

See Introduction and Overview and accompanying documentation.

2. Conceptual Model of the System

ADataCollectionProcedures

BDataCollectionForm

CDataInput

DPresentationSystem

A Data Collection Procedures

Data will be collected by individual hospitals from the following areas:

· Manual systems

· Existing systems, for example PERSAL and Financial Management Systems

· New procedures to collect the required information

The accuracy of the data input will be the responsibility of the hospital that is entering the data.

B Data Collection Form

A data collection form must be designed for the system. The design of the collection form must be approved by the users.

C Computer System

The computer program must have the following facilities:

· All data to be keyed in by the hospital, each hospital’s data must be keyed in under a hospital ID number

· There must be a facility whereby a Province can consolidate data from hospitals to allow a comparison of performance

· Data can be altered if input is incorrect

· Data will be input per speciality

· Historical data can be input, if available for the last year

· There must be a facility whereby definitions for data entry can be called up on screen and may be altered if national definitions change.

D Presentation Style

The indicators will be presented in a summary page format as well as in graphical format (such as those in Appendix 5). There will be the facility to produce summary pages for each speciality. Ad hoc reports must also be produced on request.

The following parameters must be available in order to produce reports:

· Date range

· Indicators to include or exclude (e.g. advanced/basic indicators or omitting speciality categories)

· Temporal resolution on request ( monthly/quarterly/annual reporting)

· Facility/combination

· Values can be shown either as absolute or as % on request

· Users can include/exclude trend lines on request

· Comparisons of performance compared to the last year can be made on request

· A comment space facility is an option for hospitals to write comments next to each graph, if desired

The indicators will be output on both a screen and on a printer (black and white)

3. System Requirements

The program must be able to run on a network or a minimum system of:

· 486

· 8 MB RAM

· 50 MB free Hard disk space

· Colour VGA screen

· Windows 3.1

· Mouse

· Laser printer

3. Security Requirements

The system can only be accessed with a password.

4. Help Functions

There must be an on-line help function, a user manual and a set-up utility.

5. User Interface

There must be a graphical windows based user interface.

6. Design InputsAdditional design inputs will be provided in the form of workshop and consultation reports, in addition to briefings from the hospital strategy project and the commissioning organisation. No investigation at end user sites should be required.

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