Benchmark report: Woon-, Zorg- en Dienstencentrum 't Dijkhuis (Stichting) Woon-, Zorg- en Dienstencentrum 't Dijkhuis (Stichting)

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1 Benchmark report: 1

2 Name 1. General information General information Town/City Number of locations Number of organisational units Number of members of Board of Directors Number of members of Supervisory Board Information for institutions for nursing and residential care BATHMEN Number of clients at the institution on the basis of a care intensity package Number of (ZZP) residential clients on the basis of a full package (VPT) Number of extramural clients Number of available beds/places with residential care Number of days of residential care Number of days of care on the basis of a full package (VPT) Number of permanent employees Number of FTEs of permanent staff Number of half-day sessions of daytime activities 0 22, Number of hours of extramural production Aggregate operating income 3,402,316 3,880,819 3,986,109 Operating income from nursing and residential care 3,397,280 3,880,819 3,986,109 Statutory budget for care under the ZVW Statutory budget for care under the AWBZ 3,233,524 3,707,265 3,815,513 Statutory budget for care under the AWBZ/ZVW Statutory budget for care under the PGB Municipal budget for care 163, Other operating income 168, ,596 Other non-sector income , ,706 1,376 2

3 2. Key financial figures benchmark The table below shows the values for some commonly used key financial figures. Annex 1 contains an overview of the meaning and interpretation of each figure. The table also shows the relative scores vis-à-vis all institutions that provide intramural care ( Z scores). The average score for the sector has been set at 0, so a positive value means the institution scores above average for the aspect concerned, and a negative value means it scores below average. The values do not indicate actual performance, only whether an institution performs above or below par. A Z score of -2 means the institution scores two standard deviations below the average value. The colour scale slides from dark pink (<-3) to dark yellow (>3). A strong yellow score for increase in turnover for example indicates the institution has shown strong growth compared to the average. A positive score is not necessarily better (see the explanation in Annex 1). 3

4 Key financial figures value z-score value z score value z score Increase in turnover -0.5% % % -0.1 Operating income 1.2% % % 2.9 Solvency 23.4% % % -0.2 Buffer capital 35.8% % % 1.6 Capital intensity Liquidity 226% % % 0.2 Return on Assets 4.3% % % 0.9 Return on Equity 18% % % 0.1 EBITDA 14.4% % % 2.8 DSCR DSCR Budget per client 51, , , Number of FTEs per client Absenteeism 2.3% % % -0.4 Average wage (corrected) 48, , Rate of labour costs for hired staff 5.4% % % -0.2 Part-time ratio

5 3. Spending categories The table and graph below show the spending of the institution per category. Institutions are free to divide the budget between the different spending categories, in part depending on the type of patients. No appraisal can be made on the relative values, as a high value on one category is not necessarily better than a low value. Again, the Z-scores represent the deviations from the average. Relative spending waarde z-score waarde z score waarde z score Loonkosten 41.0% % % -2.0 Premies 11.9% % % -1.9 Inhuur externen 3.0% % % -0.3 Voedingskosten 8.6% % % 0.8 Algemene kosten 5.7% % % 0.2 Cliëntgebonden kosten 1.6% % % -0.3 Onderhoud 5.9% % % -0.8 Afschrijvingen 7.9% % % 0.2 Dotaties 7.8% % % 0.3 Brutoresultaat 6.5% % % 3.1 5

6 Budget spending % 7% 5% 22% 38% Labour costs Social security premiums Percentage of hired staff Food costs General costs Client-related costs Accommodation costs Depreciation costs Build-up of capital reserves Gross revenu 2% 6% 8% 2% 9% 6

7 4. Quality The benchmark for quality is based on the score for the quality indicators at the level of the institution. This is not the same as the quality of care, which is much harder to measure. See Annex 2 for an explanation of the method used. Also in this respect, the average quality score has been set at 0, so a positive value means the institution scores above average for the quality indicator concerned. In addition to overall quality, a distinction is made between the process indicators ( ZI measurements) and the quality experienced by clients ( CQ measurements). It is quite possible an institution has a 0 score for quality in a certain year (see Annex 2). Institution: quality Quality Number of indicators Client experienced quality Number of indicators Care related quality Number of indicators z-score z score z score The tables below give a breakdown for each indicator per year, including the Z scores. In the CQ Index, a higher Z score indicates a relatively higher level of satisfaction. In the ZI measurements, a higher Z score for most indicators indicates a lower value, such as less fall incidents. 7

8 Institution: quality indicators 2013 Recommendation question - Net Promotor Score (NPS) Living in freedom: use of antipsychotics Symptoms of depression Respect: the way personal contact is experienced The way the availability of staff is experienced The way information provision is experienced The way clients are involved The way the quality of staff is experienced The way security is experienced The way (physical) care is experienced The way food and drink are experienced The way meals are experienced: ambiance The way meals are experienced: taste The way privacy is experienced The way cleaning is experienced Medication incidents Contact with other clients Occurrence of problematic behaviour Fall incidents Freedom-restricting measures: prevalence Sense of meaningfulness value mean z-score

9 Institution: quality indicators 2012 Symptoms of depression Respect: the way personal contact is experienced The way the availability of staff is experienced The way information provision is experienced The way clients are involved The way the quality of staff is experienced The way security is experienced The way (physical) care is experienced The way food and drink are experienced The way meals are experienced: ambiance The way meals are experienced: taste The way privacy is experienced The way the living quarters are experienced The way cleaning is experienced Living in freedom: use of antipsychotics Freedom-restricting measures: prevalence Medication incidents Contact with other clients Occurrence of problematic behaviour Fall incidents Sense of meaningfulness value mean z-score

10 Institution: quality indicators 2011 Use of antipsychotics Symptoms of depression The way personal contact is experienced The way the availability of staff is experienced The way the reliability of the care providers is experienced The way information provision is experienced Experiences with the way clients are involved and consulted The way the living quarters and privacy are experienced The way the professionalism and security of care are experienced Experiences with the way rights are respected when freedomrestricting measures are instigated The way coherence of care is experienced The way the ambiance is experienced The way telephone accessibility is experienced The way the security of the living environment is experienced The way independence/autonomy is experienced The way daytime activities and participation are experienced The way physical care is experienced The way meals are experienced The way cleaning is experienced The way the care/support plan and its evaluation are experienced The way mental well-being is experienced Occurrence of skin lesions Incontinence diagnosis Incontinence prevalence Medication incidents Occurrence of problematic behaviour Fall incidents Nutritional status unwanted weight loss Freedom-restricting measures prevalence value mean z-score

11 Annex 1: Key financial figures description - Increase in turnover indicates the degree turnover has increased compared to the previous year. - Operating income indicates the percentage of receipts not used for expenditures. It may be considered an institution's profit and may be used in the future. Operating income supplements an institution's equity position. - Solvency is the part of an institution's total assets that is its equity capital. A healthy institution will have a 15-20% solvency rate. - Buffer capital indicates the extent an institution can accommodate losses with its own equity capital, usually 15%. - Capital intensity indicates the capital required to generate 1 euro in earnings. The average ratio for the sector is approx Liquidity measures whether the institution has sufficient disposable equity to meet its current liabilities. A liquidity rate of 150% is generally recommended. If the liquidity rate is too high, money is left in the bank unused. - EBITDA is an institution's earnings before interests, taxes, depreciation and amortisation. This indicator is less useful for the sector concerned (intramural care for the elderly) as it is strongly dependent on whether an institution owns or rents its buildings. As rent is considered regular expenditure and depreciation of real estate is not, an institution renting its buildings has a much lower EBITDA. Apart from that, depreciation of assets outside of real estate is usually quite small, and care institutions generally do not pay taxes. - Debt Service Coverage Ratio (DSCR) can be measured in two ways: in the narrow sense (DSCR1: [operating income + interest income] / interest expenditure) and in the broad sense (DSCR2: EBITDA / interest expenditure). DSCR measures the extent to which an institution's earnings suffice to meet its financial liabilities. If the DSCR is smaller than 1, an institution cannot meet its financial liabilities, and if it exceeds 1, the institution can theoretically take out new loans. The figure for DSCR shows a large variation and may differ from year to year. For that reason, the median rather than the average value was used for calculating the Z score. - Fixed assets ratio indicates the relation between fixed assets and turnover. Institutions owning a large share of fixed assets such as real estate compared to their turnover are potentially less flexible in their strategy. - Rent ratio indicates what proportion of capital expenses consists of rent. A large value indicates the institution rents a large part of its buildings, for example from housing corporations. As this often concerns long-term lease contracts, it decreases an institution's flexibility. - Budget per client indicates the amount of receipts available for each client. This figure reflects an institution's possibilities to provide care, and is closely interrelated with an institution's average level of care intensity. - Number of FTEs per client is the average number of hours staff can spend on clients, and strongly depends on the balance between intramural and extramural clients. As extramural clients require significantly less contact hours, the number of FTEs per client for extramural institutions is much 11

12 lower than for intramural institutions. If the figure is corrected for this, the number of FTEs per client is a good predictor of quality: the more FTEs are available, the better the quality of care. - Absenteeism is also a good predictor of quality, as a high rate of absenteeism (red) is usually indicative of lower quality. The average rate of absenteeism is around 5%. - Average wage is related to the number of FTEs per client: the lower the average wage, the more FTEs are available for each client for the same share of labour costs. Generally, institutions deliver good quality of care if the number of FTEs per client is above average, the average wage below average, and the share of labour costs in the total costs also above average. The average wage is corrected for any other activities an institution might engage in, so the corrected average wage will better reflect its nursing and residential and home care activities. - Ideally, the Rate of labour costs for hired staff should be kept low. Hired staff is more expensive than permanent staff, as VAT is charged on hired services. A high percentage of hired staff might be indicative of lower quality. - Part-time ratio is the number of FTEs divided by the number of employees. If the figure is low, many employees work on a part-time contract. - Expenditure for 2012 is subdivided into a number of categories. Labour costs are usually by far the greatest item of expenditure. On average, an institution will spend 50% on Labour costs, 15% on social security premiums and other costs, 15% on subsistence costs ( Food costs ; General costs ; Client-related costs ), 15% on Accommodation costs, and 5% on General operational costs. A large percentage of labour costs and a small percentage of accommodation costs are related to higher quality. - General operational costs include interest on loans as well as any allocations to be made. Interest received, extraordinary receipts or allocations released are not added to general operational costs. Therefore, the general operational income may differ from the (total) operating income. Finally, the table shows the percentage of turnover used for Build-up of capital reserves (total operating income plus any allocations). 12

13 Annex 2: Description and explanation of aggregation method for quality Description of variables The quality is measured using 35 indicators (Table 1). There are 16 objective performance indicators describing matters such as the percentage of medication incidents, the percentage of incontinence accidents, the occurrence of unwanted weight change, or the presence of an emergency power supply. 19 indicators are derived from a survey filled in by clients describing their experiences. These indicate the score (on a scale from 1 to 5) clients have assigned to various quality aspects, such as the way they experience the availability of staff, the ambiance, or the living space/quarters. These indicators were surveyed at ward level at a location (nursing / residential care, psychogeriatric care, or home care). The reliability of the variable concerned therefore depends on the number of respondents. However, the figures are not expected to contain a bias depending on the number of respondents, so the average value may be considered the actual value. This means that the values for each ward at an institution may be averaged, resulting in a value per indicator for an institution. Method The scores between institutions differ: some institutions score higher than others. The question which score represents good quality and which score signifies bad quality is a normative one. It is difficult to determine the upper and lower limits for the indicators, i.e. the scope for an institution to have a satisfactory score. The method used here measures the extent to which institutions score above or below average. An institution with an average score is assigned the value 0. An institution that scores above average has a positive value, and an institution that scores below average has a negative one. The level of the score depends on how much better (or worse) the institution scores compared to the population. The values are then transformed from a quality score to a benchmark score. Hence, the benchmark score does not say anything about the level of quality at the institution, but only says something about the position of the institution compared to the other institutions. An institution with a low benchmark score therefore does not necessarily deliver poor quality; it is only outperformed by the other institutions. Quality may be fine, but the quality at the other institutions may be better. The benchmark score is the Z score (standard normal score) and is calculated as follows: Whereby i indicates the quality variable per institution, is the average of the population i, and is the standard deviation. This formula results in an average value of 0 for each variable and a standard deviation of 1 ( Z value). 13

14 This formula has been used for 35 benchmark scores for each institution. These benchmark scores have the same scale, so they may be accumulated or averaged (i.e. apples are compared with apples). Hence, the average benchmark score indicates the average quality score compared to the other institutions. The advantage of this model is that comparable figures may be accumulated. The quality indicators often measure various factors that are hard to accumulate. A score of 3 for the way the professionalism and security of care are experienced may mean something else entirely than a score of 3 for the way the ambiance is experienced. The Z scores only indicate the relative deviation compared to the other scores; they do not measure how well an institution scores for a certain item, only to what extent it deviates from the average score. A high negative deviation for the way the professionalism and security of care are experienced means the same thing as a high negative deviation for the way the ambiance is experienced, i.e. the institution performs below par for this item. It should be emphasised, however, that a judgement about the relative importance of the variables cannot be avoided, as explained above. In this study, in addition to a single quality variable, two variables are created from a subset of the indicators. The 19 quality indicators that were surveyed ( the way... is experienced ) may be clustered. This results in a so-called subjective quality variable, as it is largely dependent on the client's subjective experience. The 16 quality indicators that were measured are accumulated into a quality variable hereafter called the objective quality variable. It should be noted that, although this variable may be more objective than the surveyed ones, it shall never be entirely so. These measurements are for instance made by a ward nurse, which means a certain degree of subjectivity may arise. The distinction in names ( objective vs subjective ) is therefore made entirely for the sake of dichotomy. The aggregate quality indicator is a weighted average of the objective quality indicator and the subjective quality indicator. Accumulating variance An institution may score well for one quality item and poor for another. When accumulating the Z scores, these items will then cancel each other out. This in itself is not a problem, as it can be argued that one good and one bad score equal average quality for the client. This only becomes problematic when two quality variables are correlated in a negative way. In that case, these items cancel each other out for all institutions, and variance is lost if all quality scores are accumulated. In other words, by accumulating the quality scores, they are averaged, and all institutions score equally well. Table B5.2 shows all correlations between all variables at the institution level. A positive figure shows a positive correlation, and a negative figure a negative correlation. Figures higher than.5 (yellow) or lower than -.5 (orange) are weakly correlated, figures higher than.75 (light green) or lower than -.75 (light red) are correlated, and figures higher than.85 (dark green) and lower than -.85 (dark red) are strongly correlated. The table shows that there are no significant negative correlations between the variables. Only some strong positive correlations stand out, namely between: - The way physical care is experienced and the way mental well-being is experienced - The way physical care is experienced and the way the professionalism and security of care are experienced - The way the professionalism and security of care are experienced and the way personal contact is experienced 14

15 Although these correlations offer interesting possibilities for further research, this is not within the scope of this report. It is important to note that these strong positive correlations may cause these items to eventually weigh more heavily in the aggregate quality indicator. Seeing the effects are not major and emerge clearly in the case studies, the correlations are taken at face value. The lack of significant negative correlations indicates that variables do not consequently even each other out. 5. Disclaimer This report was compiled by Celsus, academy for sustainable healthcare, (which is part of the Radboud University Nijmegen Medical Centre) and commissioned by the Ministry of Health, Welfare and Sport in the context of the Caretool developed by TNO. The report was produced on the basis of publicly available data. Questions about its methodology can be directed towards No rights may be derived from this report. Celsus is not responsible for the way the report is interpreted, nor for any consequences for the parties involved. The report has been compiled using data from 2011 and 2012, which may be out-of-date. The key figures show only a part of the entire picture, and must be interpreted in combination with additional information supplied by the institution concerned. Rather than drawing conclusions on the basis of key figures alone, the figures may serve as a basis for engaging in a dialogue with an institution. 15