HPM REPORT (AGHA KHAN HOSPITAL CASE)

ANAM SHAHID

TABLE OF CONTENTS

1.INTRODUCTION2.PM DEFINITION3.PM IN HEALTHCARE4.PM IN HEALTHCARE SETUP OF PAKISTAN5.HOSPITAL PROFILE:

MISSION\VISION HOSPITAL PHILOSOPHY ABOUT pm PERFORMANCE MODEL

6.PERFORMANCE INDICATORS7.CONCLUSION8. RECOMMENDATIONS

DEFINITIONPerformance management is a forward-looking process used to set goals and regularly check progress toward achieving those goals. In practice, an organization sets goals, looks at the actual data for its performance measures, and acts on results to improve the performance toward its goals.

Why Does an Organization Need to Measure Performance?

Distinguish what appears to be happening from what is really happening

Establish a baseline; i.e., measure before improvements are made

Make decisions based on solid evidence

Demonstrate that changes lead to improvements

Allow performance comparisons across sites

Monitor process changes to ensure improvements are sustained over time

Recognize improved performance

Process Map of Performance Management Pathway

Organizational (internal) prerequisites Adequate pay levels

Staff have the equipment, tools and skills to do their job

Achieving the right balance of incentives for staff to perform well

Local autonomy and decision making

Familiarity with planning methods

Effective communications

Leadership and effective management systems

A culture of accountability and openness

External prerequisites Political pressure and health care reforms

Financial pressures

Decentralization

Pressure from service users and quality assurance

Health care system in Pakistan Public sector hospitals

Private sector hospitals

Fauji foundation hospitals

Charity hospitals

Health care insurance

Performance management methods Regulatory inspection

Surveys of consumers’ experiences

Third-party assessments

Statistical indicators

Internal assessments

Accreditation & Certification Agencies requirements

VISIONAga khan university hospital will be an autonomous, international institution of distinction, primarily serving the developing world and Muslim societies in innovative and enduring ways.

MISSIONAKU is committed to the development of human capacities through the discoveries and dissemination of knowledge and application through service.

HOSPITAL HISTORY:AKU hospital Karachi started operation in 1985 as an integrated healthcare delivery, component of AKU. It is a philanthropic, private teaching institution committed to providing the best possible options for diagnosis of disease and team management of patient care.

PhilosophyAKUH operates on the core principle of

• Quality

• Relevance

• Impact

• Access

PERFORMANCE INDICATORS

DEFINITION:

How quickly the warehouse of Agha khan is refilled.

FINDINGS:

The critical items warehouse fill rate is high as compare to non critical items.

DEFINITION:

Regulatory reporting’s to the regulatory/government authorities on time.

FINDINGS:

They excel in the timely reporting to the regulatory authority.

DEFINITION:Rate of sensitive complains

FINDINGS:In the ending quarter of 2009 they exceed the limit range but in 2010 they controlled it.

DEFINITION:The ratio of testing the compatibility of donor, recipient & the transfusion.

FINDINGS:They have better results but still need to work on this indicator.

DEFINITION:What is the patient satisfaction ratio?

FINDINGS:They set the limit on 90% but still they hasn’t reached that limit. They need to work on this indicator.

DEFINITION:The staff satisfaction ratio.

FINDINGS:The patient satisfaction ratio was higher in 2009 as compare to 2010.

DEFINITION:

Indicator that shows how many users belongs to socio-economic group.

FINDINGS:

They have a major no. of patients from socio-economic group.

DEFINITION:Full time employees required to employ on particular no. of beds.

FINDINGS:They got 4-5 employees per bed.

DEFINITION:Quick & timely response to fire emergency calls.

FINDINGS:They have 100% response to the fire emergency calls.

DEFINITION:Timely response to security emergency calls.

FINDINGS:In the first quarter they responded 98% while in the rest of the quarters they responded 100%

DEFINITION:Accidental puncture of the skin with an unsterilized syringe injuries.

FINDINGS:The rate of injuries were ranging from 39-42.

DEFINITION:Staff awareness related to FMS issues.

FINDINGS:They set the target on 80% but still lesser than what they target.

DEFINITION:Maintaining safe environment in Psychiatry.

FINDINGS:They excel their working in this dept. from the previous months.

DEFINITION:Overall action of not complying in medical record documentation.

FINDINGS:In July 2010 the value cross the limit of 5% while from August to December 2010 it was 5% i.e. the limit.

DEFINITION:Reassessment of patients (follow ups) & the documentation of progress notes.

FINDINGS:They put their limit at 10% but their working is better than the presumed values.

DEFINITION:The urgent laboratory tests report delay.

FINDINGS:They set their limit at 2% but their values are coming below 1%. Which means they are doing good in it.

DEFINITION:Laboratory quality control.

FINDINGS:They set their target at minimum 90% but values r higher than the limit.

DEFINITION:How much time radiology took to generate a report.

FINDINGS:They have almost achieved 100% in this indicator.

DEFINITION:Prolong stay after day care surgery.

FINDINGS:These values vary in four quarters of both years. They need to work on this indicator.

DEFINITION:Rational usage of antibiotics.

FINDINGS:They are more or less at the limit line that is 83%.

DEFINITION:Medication errors per 100 patients.

FINDINGS:They have a value of 2.5% error per 100 patient.

DEFINITION:The compliance in the assessment of the patient before the administration of anesthesia.

FINDINGS:They got an average of 92-98%

DEFINITION:Incidences of blood transfusion reactions.

FINDINGS:

DEFINITION:How much fast HMIS dept. is at the on time delivery of medical record for booked patients?

FINDINGS:Only first quarter was below the limit line. In rest of the quarters the range is 100%.

DEFINITION:Medical record neglecting rate.

FINDINGS:Its 15-15.5%

DEFINITION:Intervention rate of emergency response coordinator on submission of research proposal.

FINDINGS:They excel their target i.e 100%

Internal Review Processes•Departmental Quality Improvement Committees

•Joint Staff and its Sub-committees Reviews

•Patient Satisfaction

•Medical, Nursing and Others Health Professional Credentialing Programs

•Performance Appraisal Systems

Quality Audits•ISO 9001:2008 Internal Audits

•JCIA Mock Surveys

•Closed and Open Medical Record Audits

•Clinical Audits

•Nursing Quality Improvement Audits

•Infection Control Audits

•Environment Safety Audits

•Risk Management

External review ISO 9001:2008 ISO 22000:2005 Joint Commission International Accreditation

CONCLUSION :• Lower patient satisfaction and employee satisfaction

• Although it provides an outstanding work environment

• lack of staff awareness.

• Over rely on their brand image

• Inadequate referral system

• Expensive image

• Construction constraints

• Emerging new competitors for specialized services.

• They are not following the proper performance management model

RECOMMENDATIONS• Quality department should develop a new performance management model.

• Information system is well develop and can help inbuilt a effective performance management model.

• Should track down an integrated departmental system.

• Change management is required on management side of the institution.

• Ensure better use of resources and, therefore, increased efficiency and patient satisfaction

• Quality standards should be known & practiced by all.

• Better compensation plan