Journal of the Academy of Hospital Administration

Title: Benchmarking of Operation Theatre Processes - A Study in a Corporate Hospital

Author(s): B. Krishna Reddy*, G.V.R.K. Acharyulu**

Vol. 17, No. 2 (2005-01 - 2005-12)

Key WordsHealthcare, Benchmarking, Operation Theatre, Process, Quality Improvement, Performance Measurement, and Supply Chain

Key Messages

Cost of surgery varies from discipline to discipline with Oncosurgery being most expensive

Medical equipments contribute to significant capital costs in OT

Abstract

Healthcare, by its nature, is an industry composed of numerous and complex processes. Benchmarking is the continual and collaborative discipline of measuring and comparing the results of key work processes with those of the best performers. Benchmarking ushers in a new direction to the way activities are performed in hospitals, as there is no other tool by which supply chain performance is measured in a reliable and comparable level. It is learning how to adapt the best practices to achieve breakthrough in process improvements and build healthier communities. With significant changes in the field of medical science and technology, hospitals are competing neck- to- neck to attract patients not only from the local areas but also from the Afro- Asian countries. Benchmarking is an endeavor to push performance and capability to enormous levels and discover better methods and quality standards. Those involved in continues improvement efforts rely on benchmarking to formulate goals and targets for performance. This paper studies the procedure times in operation theatres of a corporate hospital and their variability which can help in setting benchmark for consistency in internal processes.

INTRODUCTION

In a competitive business environment, it is not enough for an organization to be doing well. The performance has to be seen in comparison with its best competitors. It is necessary to have a point of reference to know how well one is doing. Need for keeping a constant watch on the competition is necessary for achieving and maintaining leadership position. Benchmarking is an approach to identifying "quality" by comparing a service or organization with another similar service or organization. In industry, this approach can

be highly competitive where companies attempt to emulate the performance of identified high performers.(1)

Conceptually, the form of "benchmarking" is to the extent that an Organization or service meets or exceeds all known standards of performance in all aspects. International best practice is often adopted by managers as a term to signify organizational policy. Continuous improvement is clearly an integral part of benchmarking, and is a vital component in permitting flexibility for rapid response to opportunity. The philosophy of benchmarking is to create a change - oriented workplace culture within which 'participative, people-driven approaches to benchmarking create outward looking, cooperative, and responsive organisation'.(2) Companies use benchmarking to understand better how outstanding companies do things so that they can improve their own operations. Typical measures used in benchmarking include cost per unit, service upsets (breakdowns) per customer, processing time per unit, customer retention rates, revenue per unit, return on investment, and customer satisfaction levels.

Benchmarking firms must assess the strengths and weaknesses of their current work processes, analyze critical cost components, consider customer complaints, spot areas for improvement and cycle time reduction and find ways to reduce errors and defects or to increase asset turns. Benchmarking firms must find out who is the best of the best. To identify the best of the best, benchmarking firms must learn from leaders, uncover where they are going, learn from the leader's superior practices and why they work, and emulate the best practices. It is the process of measuring against best practice, similar products & processing industry leaders and world class buisness.(3)

BENCHMARKING IN HEALTHCARE

In India, Hospitals gained the status of corporate sector in the year 1984. This has led to a spurt, which is evident by the growing number of hospitals in the country. The opening up of the General Insurance to Private companies has come up as a turning point and an effort to make healthcare accessible to even a common man.

Benchmarking is one of the tools of Total Quality Management. The concept of seeking best practices and implementing those practices within individual organizations can be applied to any type of organization, including health care. The move towards Benchmarking in health care is a relatively new concept.(1)

Benchmarking in health care is conceptually the same as benchmarking in other industries. The difference is in the key processes selected for benchmarking in the health care industry. Health care, by its nature, is an industry composed of numerous and complex processes. Processes in health care typically are defined broadly as input, processing and output, which are the same broad categories of production in industry. Examples of these processes in a hospital setting are input activities of parking, registration and admission; processing activities of taking a patient's history, serving meals, answering call lights, administering medications, performing procedures and providing education; and output activities of discharging or transferring patients. The

result of input, processing and output activities is the outcome of patient care. Examples of outcome measurements are patient satisfaction, functional status, health status, mortality rates, and complication rates. Input, processing and output activities and outcomes can be measured and benchmarked.

Benchmarking reveals key information as to which Practitioners perform most efficiently given certain diagnoses; patterns and best practice for patient flow adjustment; flexible staffing and patient satisfaction. If one can identify the optimal point of inflection - the point at which facilities are operating efficiently and patients are happy with their care - the industry will begin to make serious inroads toward the overall improvement of patient care.

Benchmarking in Hospitals can be made in the following areas:

1. Managerial areas: Pricing, Utilization, Patient and payer mix, Productivity and efficiency, Revenue, expenses, and profitability.

2. Clinical areas: Ambulatory care services, Anesthesia services, home care services, Medical services, Obstetrical and newborn services, Pediatric services, Post-anesthesia recovery services, Psychiatric services, Rehabilitation services, Respiratory care services, Special care unit services, Surgical services, Housekeeping services, Infection control program, and Laundry and linen services.

3. Process areas in an operation theatre. The Process facilities are compared and benchmarked with other participants in the peer group. Peer groups are determined based on facility size, outpatient, inpatient, or combined services; and teaching or non-teaching facilities available.

4. Some of the process areas where benchmarking can be undertaken are: Patient Scheduling, Preoperative Screening, Day of Surgery, Management Information Systems, Procedure Supply Preparation, Intra operative processes, Between Case Processes, Materials Management, Review of Purchasing and Supply Chain Performance and Measurement, Equipment Management, Facility Utilization, Labor Utilization, Physical Facilities, Performance Improvement Monitoring, Instrument Reprocessing, and Day of Surgery Flow Control.

NEED FOR BENCHMARKING IN HEALTHCARE

Healthcare has significantly changed in the last few decades. With rapid strides in the field of medical science and technology, Hospitals are competing neck- to- neck to attract patients not only from the local areas but also from the Afro-Asian countries. Increasing costs and shrinking resources have created an increased focus on patient outcomes. Executives engage in a constant and valiant struggle to master the fine art of juggling. In health care, concurrent goals of high patient satisfaction must be balanced against organizational efficiency and fiscal solvency. It's a fine line pushing hard to reduce costs. The value of health care to the customer is the ratio of quality to cost. To increase the value of health care, quality must increase more than cost or remain stable while cost decreases. Quality is difficult to define. Currently, there are numerous performance

measurement systems that use different definitions for the same quality measure. This has led to inconsistent measure sets across organizations that do not allow for comparison of performance. Benchmarking ushers in a new direction to the way activities are performed in Hospitals, as there is no other tool by which performance is measured in a reliable and comparable level.

BENCHMARKING PROCESS

The benchmarking process is similar to the plan-do-checkact cycle in continuous improvement, but benchmarking focuses on setting quantitative goals for continues improvement. The process consists of four basic steps(4):

1. Planning: Identify the product, service, or process to be benchmarked and the firm(s) to be used for comparision, determine the measures of performance for analysis, and collect the data,

2. Analysis: Determine the gap between the firm's current performance and that of the benchmark firm(s) and identify the causes of significant gaps,

3. Integration: Establish goals and obtain the support of managers who must provide the resources for accomplishing the goals,

4. Action: Develop cross-functional teams of those most affected by the changes, develop action plans and team assignments, implement the plans, monitor progress, and recalibrate benchmarks as improvements are made. Simply, stated Collect the data, analyse the data, set targets toachieve best processes, develop an action plan, communicate, implement the action plan, remeasure benchmark in the light of progress.

Figure 1: Benchmarking Process - Common Steps

LEVELS OF BENCHMARKING

There are four levels of benchmarking.

i. Internal benchmarking: Comparing similar processes performed in different parts of the same Organization or service. This can be advantageous for firms that have several business units or divisions.

ii. Competitive benchmarking: Comparing the performance (or an aspect) of an Organization with that of a competitor,

iii. Functional benchmarking: Comparison of performance of the same function for all of those in the same sector,

iv. Generic benchmarking: Comparing functions at a generic level. This is often the only approach available to Government organizations.

BENEFITS OF BENCHMARKING i. Fresh thinking on meaningful comparisons by the industry,

ii. Establishment of a process, which the organization can maintain itself in the future,

iii. Confidence building in the organisation, by setting appropriate Operation's strategy performance targets,

iv. Enhanced understanding of the elements of competitiveness in the organization.

The present study provides an insight of Internal Benchmarking being put to a start in the Hospital. A minimum of twenty cases of a procedure performed during the period of study is considered. The Operation Theatre of a Corporate Hospital was selected as the Study Area. The Operation Theatre has the Operation Rooms - OT1 , OT2, OT3, OT4, OT5, OT6, OT7 , OT8 , OT9 , OT10.

METHODOLOGY

The data for the study was collected from the log data at the scheduling station of a corporate hospital for a period of four consecutive months in the year i.e., from October 2004 to January 2005. The data consists of the Procedures performed in the Operation Rooms by the Surgeons and the time taken for each procedure on a daily basis. There are 7 major and 3 minor Operation Rooms and for the sake of confidentiality they have been named as Operation Rooms OT1 to OT10. Like wise the Surgeon's names are also masked. The Surgeons who have performed less than 8 cases all through the period of the study are not taken into consideration.

STATISTICAL DATA ON PROCEDURE TIMINGS

The following table gives the timings (in minutes) of procedures performed by various specilists and Mean, Standard Deviation (SD) of the respective procedure.

Control Charts ( 3- sigma)

Table 1: Analysis of Procedure Timings

Procedure Number

Number of Cases

Mean (Minutes)

S.D. (Minutes)

1 30 81.96 22.96

2 116 159.02 23.25

3 52 145.21 27.64

4 25 72.20 24.47

5 22 20.54 4.55

6 35 119.68 17.65

7 40 107.30 9.35

8 20 69.35 11.77

9 72 113.73 11.35

10 48 77.87 10.72

11 25 48.32 4.51

12 44 116.36 7.30

13 35 30.82 2.33

14 32 108.71 28.69

15 48 50.12 17.47

16 36 10.11 4.09

17 48 185.20 21.58

18 20 53.40 16.67

Procedure 1: Cases 3,5,21,25,26 have taken very low time in contrast 14,17,22,24 has taken very high time. There are cycles present in the control chart. This indication that there is a systematic difference in procedure times. The reasons need to be thoroughly probed in. Some of the plausible reasons can be: experience and skill of the specialist, complexity of the case itself and skill of the supporting staff.

Procedure 2: Too large variation in procedure times is noticed. But procedure timing on the lower side of the central line which are close to lower control limit need to be thoroughly studied with the objective that similar conditions should be created for reducing the average procedure time. On the other side, good number of procedure times is also observed to be high. For achieving managerial efficiency, these high procedure times should be reduced so that better benchmark can be set. This helps in effective scheduling of OT's.

Procedure 3: Cyclic variation is noticed in the procedure timings. Except the case no.3, all other timings are within the control limits. The cyclic variation can be due to shift wise, day wise and weekly wise observations.

Procedure 4: Though the procedure timings are within the three-sigma control limits, lot of variation is observed inherently. This may be change in specialists, severity of the patients and seasonality. Controllable causes can be identified to bring the process under internal consistency.

Procedure 5: The variation in the procedure times is stable but decreasing trend is noticed. This indicates that improvement in the process due to better working conditions, equipment availability, experienced specialists.

Procedure 6: Though the procedure timings are under 3- sigma control, cyclic variation is noticed. Almost equal number of procedures is above the average line and below the average line. The procedure times above the average line need to be probed for possible reduction in times after adopting changes accordingly.

Procedure 7: Seven cases are found to be very high times and only three are lower times. On Overall basis, reasons for higher times need to be carefully studied and attempts are to be made for possible reduction times.

Procedure 8: Except cases 3 and 8, all other procedure times are stable having cyclic in nature and having systematic variation. On an average more number of timings are below the central line compared to above the central line. This indicates the procedure is done efficiently most of the times.

Procedure 9: Although systematic variation noticed in the procedure times, most number of cases observed to be having lower procedure times. This indicates the efficiency in the process. The times above average lines need to be probed in for possible reduction in time.

Procedure 10: The variation in procedure times is higher even though the process is under 3-sigma control. Internal reasons for the cause of variation have to be identified. If proper precautionary steps are adopted to reduce variation, process can be stabilized with minimum variation.

Procedure 11: The procedure timings are under 3-sigma control. But there is a systematic variation noticed for which the causes need to identified to minimize the variation

Procedure 12: 60 percent of the observations fall under the central line and this shows the efficiency of the process. But for the remaining cases which are above the central line need to be analyzed for possible reduction in procedure times.

Procedure 13: The procedure timings are within 3-sigma limits. The procedure is having cyclic variation. The reasons for this variation need to be identified.

Procedure 14: The variation is observed to be systematic and the reasons for the variation need to be further probed in.

Procedure 15: Though the procedure timings fall under 3- sigma limits, erratic variation is notice. Some of the procedure timings are very far from the central line towards lower control limit, which is good indication that the procedure is done efficiently. Procedure timings, which took higher timings, need to be probed in for finding out the reasons.

Procedure 16: Except cases 7 and 30 all other cases are having cyclic variation in timings and within the control limits. The reasons for the higher timings in the two cases need to be identified and rectified.

Procedure 17: In one particular cycle, the variations are noticed high and in other cycle the variations are less. Case 33 is touching upper control limit. The reasons for the higher variations in cycles need to be identified and possible efforts should be put to minimize variations in the procedure timings.

Procedure 18: Erratic variation observed in the procedure timings. On Overall basis the procedure is under control except case 2, 14 have higher procedure timings and very far from central line towards upper control limit.

5.2 ANALYSIS

The basis for benchmarking of procedure timings is the control charts for studying the variation. The reasons for the cause of variation can be attributed as two factors: 1) Controllable - skill of the staff, equipment and material availability, medical attention, coordination and communication, 2) Uncontrollable - sudden failure of equipment, condition and severity of the patient, Age of the patient, technology, scarcity of material. Benchmarking helps in reducing erratic variation in procedure timings and enable internal consistency, which is crucial for organization for improving process performance. Critical success factors can be identified for continuous improvement in process. They include: i) Patient's physical (including complications) and psychological condition, ii) Skill of the Surgeon based on the Qualification, Experience and Exposure, iii) Type of anesthesia used, iv) Availability of state-of-the-art Equipment, v) A proper and good maintenance schedule, vi) Coordinated effort of anesthetist, nursing staff and supportive staff.

CONCLUSION

The intensive competition encountered in most markets has led to a new emphasis on measuring performance not just in absolute terms, but also rather in terms relative to the competition, and beyond that to 'best-practices'. The results of the benchmarking study can be used to overcome and eliminate complacency within the organization. Hospitals set up by the Government and the Corporate Hospitals constitute a large proportion of healthcare providers in the country. In order to enhance performance, Internal Benchmarking must be adopted for identifying the performance indicators of individual hospitals. Some Key Performance Indicators can be: process timings, Length of Stay (LOS), success rates in surgeries, supply chain process, equipment maintenance, Return on Investment, Quality of service. In order to progress in the present competitive environment, healthcare organisations need to adopt benchmarking practices for continuous improvement in their operations and perform better than competitors for improving their market share.

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* Associate Professor Department of Business Management Osmania University, Hyderabad-500007

** Assistant Professor Apollo Institute of Hospital Administration Jubileehills, Hyderabad-500033