Sanigest Internacional White Paper. Benchmarking Hospital Performance in Health

Transcription

1 Sanigest Internacional White Paper Benchmarking Performance in

2 P a g e 2 Objective: Efforts to assess and rank hospital performance should rely on a composite indicator that ranks hospital performance relative to other hospitals and provide insights into hospital performance across key areas. The review of hospital performance indicators in this paper will provide policymakers, hospital managers and clinicians with a range of options for the selection of key performance indicators for hospital benchmarking. Authors: James Cercone and Lisa O Brien Sanigest Internacional 2010 This document is a formal publication by Sanigest International and all rights are reserved by the firm. The views expressed in documents carrying the name of the author/s are the sole responsibility of the author/s and do not represent the views of Sanigest International.

3 P a g e 3 Table of Contents INTRODUCTION... 4 MEASUREMENT OF HOSPITAL PERFORMANCE IN THE UNITED STATES, EUROPE AND LATIN AMERICA... 5 REVIEW OF HOSPITAL BENCHMARKING TOOLS... 7 HOSPITAL COMPARE... 7 Scoring System... 7 HEALTHINSIGHT NATIONAL RANKINGS FOR HOSPITALS... 8 Scoring system... 8 LEAPFROG GROUP... 8 Scoring System... 9 MICHIGAN MANUFACTURING TECHNOLOGY CENTER (MMTC)... 9 Scoring System... 9 US NEWS & WORLD REPORT... 9 Scoring System THOMSON & REUTERS TOP 100 HOSPITALS PROGRAM Scoring System HEALTH CONSUMER POWERHOUSE Scoring System NATIONAL HEALTH SERVICES CHOICES HOSPITAL SCORE CARD Scoring System CHKS TOP HOSPITALS PROGRAM Scoring System IASIST TOP 20 HOSPITALS Scoring System WORLD HEALTH ORGANIZATION - PERFORMANCE ASSESSMENT TOOL FOR QUALITY IMPROVEMENT IN HOSPITALS (PATH) Scoring System INTERNATIONAL QUALITY INDICATOR PROGRAM (IQIP) Scoring System LESSONS LEARNED DATA ANALYSIS AND COMPOSITE INDEX QUALITY ASSURANCE Background Proposed Methodology for Quality Assurance ADDITIONAL CONSIDERATIONS IMPLEMENTATION STRATEGY SANIGEST INTERNATIONAL ANNEX 1: INDICATORS USED BY VARIOUS HOSPITAL BENCHMARKING SYSTEMS Tables TABLE 1: LIST OF HOSPITAL BENCHMARKING INITIATIVES REVIEWED... 5 TABLE 2: PROPOSED INDICATORS FOR PILOT PROJECT BY CATEGORY Figure FIGURE 1: STRUCTURE OF THE LATIN AMERICAN HOSPITAL BENCHMARKING TOOL... 20

4 P a g e 4 Introduction are a vital part of any health care system and account for a large proportion of a government s health care budget. Increased competition between providers, the demand for value from payers, patient safety concerns, and mounting evidence of variation in medical practice has placed the assessment of hospital performance high on the agenda of policy makers, payers, patients and regulators around the world. In low and middle-income income countries, such as those found in many emerging markets, hospitals continue to be the main providers of health care. The ability to measure and compare hospital performance within this context is an important step in beginning to address some of the health care disparities that exist in this region. There are four principal methods of measuring hospital performance: regulatory inspection, public satisfaction surveys, third-party assessment sessment and comparison of statistical indicators. The majority of these methods however, have not been tested rigorously. 1 The use of statistical indicators and third-party assessments (i.e. accreditation) are becoming popular in health care institutions throughout the world. Statistical indicators have been used to develop various hospital benchmarking tools, particularly in the Untied States. Raw or aggregated data from predetermined areas of interest are voluntarily reported and then combined to produce an overall rating; no such systematic tool exists or is routinely used for hospitals in the Latin American context. Furthermore, rmore, many hospitals in the North America and Europe have undergone accreditation processes with national and/or international regulatory bodies and this trend is continuing in regions such as Latin America. Benchmarking performance of any kind has been shown to be a powerful tool and impetus to for change. For example, in the United States, hospital comparison tools and benchmarking initiatives such as Compare (Centers for Medicare and Medicaid Services) have helped to establish and disseminate best practices for treating conditions such as acute myocardial infarction, congestive heart failure and pneumonia. Furthermore, they have provided an avenue for the patient to become more of an active participant and decision maker in their own healthcare. The present paper reviews the top initiatives in the development and comparison of key performance indicators to measure hospital performance. The information provided is intended as a menu of options for policymakers, hospital managers and clinicians ians to choose the most appropriate indicators for their healthcare system or hospital. 1 How can hospital performance be measured and monitored? WHO Regional Office for Europe s Evidence Network. August 2003.

5 P a g e 5 Measurement of Performance in the United States, Europe and Latin America Many governments, non-governmental institutions and members of the private sector have initiated or engaged in projects, some in partnership with each other, to assess hospital performance. The areas in which hospital performance can be assessed and the rationale for doing so are varied, as such a diverse range of instruments have emerged with varying indicator sets. Benchmarking tools that have emerged in the United States and Europe have primarily focused on outcome and process of care measures; a measure e of patient experience/satisfaction is also commonly included in many of these instruments. In creating our proposed indicator set for hospital ranking and benchmarking, we examined benchmarking systems from around the world that used statistical indicators to measure hospital performance (Table 2); a brief overview of 12 of these benchmarking tools are outlined below and a full list of indicators by project can be found in Annex I. Table 1: List of Benchmarking Initiatives Reviewed PROJECT TITLE COUNTRY/REGION YEAR INITIATED CHKS Top Program Consumer Powerhouse United Kingdom 2001 European Union 2005 Insight National Rankings for United States 2004 Compare IASIST Top 20 United States 2003 Spain 2000 International Quality Program International 1997 Leapfrog Group United States 2001

6 P a g e 6 PROJECT TITLE COUNTRY/REGION YEAR INITIATED Michigan Manufacturing Technology United States 2005 Center (MMTC) National Services (NHS) Choices Scorecard Thomson & Reuters Top 100 United Kingdom United States US News & World Report United States 1990 World Organization - Performance Assessment Tool for Quality Improvement in International 2004 (PATH)

7 P a g e 7 Review of Benchmarking Tools Various methodologies have been employed to rank and benchmark hospital performance. A literature review was undertaken to learn from the diverse experiences of hospitals and organizations that have already undertaken ranking and benchmarking processes. An internet search was performed using search terms including hospital performance; benchmarking tools; hospital comparison; and ranking hospitals. Publically available data from benchmarking and healthcare organizations were reviewed including but not limited to WHO reports on measuring hospital performance, discussion papers regarding the creation of the WHO Performance Assessment Tool for Quality Improvement in and sample benchmarking reports from the Michigan Manufacturing Technology Center. The results of the literature review are presented below. Compare Compare is a large public database that uses nationally standardized performance measures to compare over 4000 US hospitals that submitted data relating to the quality of care provided in their institutions and allowed it to be made public. The four areas in which hospital performance is measured and reported are: Process of care Outcome of care Patients hospital experience Medicare payment and volume This database is the result of collaboration between both public and private stakeholders. Scoring System Compare doesn t rank hospitals, rather it reports the percentage of patients for which a given indicator was performed/completed (i.e. 98% of the time patient received prophylactic antibiotics prior to surgery). Comparative graphs are also available in which the nationwide and state averages for all hospitals reporting that indicator are displayed alongside the score for the specific hospital(s) chosen. Website:

8 P a g e 8 Insight National Rankings for Insight is a private not-for-profit organization that conducts various health performance rakings including national rankings for hospitals, home health agencies and nursing homes in an effort to improve healthcare systems in Nevada and Utah. It uses publicly reported data from the Centers for Medicare & Medicaid Services (CMS) Compare website to conduct the hospital rankings. insight measures hospital performance by examining the process of care measures for acute myocardial infarction, heart failure, pneumonia and surgical infection prevention as set out by CMS. Scoring system are ranked based on their overall success rate for performing the process of care measures for the above mentioned conditions; rankings are converted and reported as percentiles. Website: Leapfrog Group This initiative is comprised of private and public purchasers of health care that seek to leverage their purchasing power to improve the quality of services provided by health care institutions. Unlike Compare, here hospital performance is measured by using structural indicators instead of clinical ones to produce a composite index of hospital performance. The Leapfrog Group uses the following structural indicators to measure hospital performance: Computerized physician order entry (CPOE) system ICU staffing High risk treatments (evidence based hospital referral) Leapfrog safe practice scores (27 procedures in place to reduce preventable medical mistakes) Leapfrog invites hospitals from 39 regions of the US to participate in their survey (although any hospital is welcome to participate); they target hospitals predominantly in areas where their members have a large presence. voluntarily submit data if they agree to participate in the program. Leapfrog has a comprehensive incentive and rewards program to encourage and reward hospitals for participating in their program and implementing their quality/safety standards.

9 P a g e 9 Scoring System Leapfrog uses a scoring algorithm to come up with their ratings which fall into five categories. The rating system is based on how far the health care institution has come with regards to meeting the criteria/standards set out by Leapfrog. The five categories are: Declined to respond Willing to report Some Progress Substantial Progress Fully Meets Standards Website: Michigan Manufacturing Technology Center (MMTC) This benchmarking system uses 23 metrics to measure a hospital s performance. These metrics fall into the following five categories: Business (3) Productivity (5) Asset utilization (5) Throughput (6) Clinical outcomes (4) Data on hospital practices are also collected in the areas of clinical practices, cost profile and patient safety policies. Scoring System MMTC reports a hospital s relative performance on each measure within a comparison group of similar hospitals; hospital percentile rankings range from 0 (worst in the group) to 100 (best in the group). Website: US News & World Report Every year the US News & World Report releases a list of the best hospitals in the United States. It ranks hospitals based on 16 specialty areas (e.g., oncology, cardiology),, 12 of which are based on hard data while the remaining four are based on nominations by specialists that were surveyed.

10 P a g e 10 To be considered for one of the 12 data-driven driven specialties hospitals had to meet one of the following criteria: Be a member of the Council of Teaching and Systems Be affiliated with a medical school Have at least a certain number of key technologies (e.g., image-guided guided radiation therapy, full-field digital mammography) In addition to the above mentioned criteria, hospitals also had to perform a minimum number of specified procedures (specialty dependent) on Medicare patients to qualify for ranking. that meet all these criteria were then ranked. Scoring System A score from is assigned based on three factors that are given equal weight: 1. Reputation (random sample of 200 physicians from ABMS database) 2. Death rate (mortality index) 3. Care-related related factors (nursing staff, technology, volume, patient services) with the 50 highest scores are subsequently ranked. Website: Thomson & Reuters Top 100 Program The primary goal of this program is to objectively identify US hospitals that have the best organization- wide performance and make this data publically available. The performance of all members of the hospital is measured including that of the Board, executives and health care professionals. The organization-wide performance is then compared against national benchmarks. are classified into 5 comparison peer groups based on bed size and teaching status: Major teaching hospitals Teaching hospitals Large community hospitals Medium community hospitals Small community hospitals

11 P a g e 11 Scoring System Statistical analyses of publically available data sources is carried out to rank hospitals. are scored based on a set of weighted performance measures spanning the following 4 areas: Clinical excellence Operating efficiency Financial health Responsiveness to the community are subsequently ently ranked relative to their comparison group; median and quartile values are reported. Website: Consumer Powerhouse Consumer Powerhouse produces an annual index comparing performance of health care systems of the European Union in various areas in an attempt to strengthen the position of the healthcare consumer. It examines indicators in the following 5 sub-disciplines: Patients rights and information (9) Waiting times (5) Outcomes (5) Generosity of public healthcare systems (4) Pharmaceuticals (4) Scoring System Each sub-discipline is weighted as follows: Sub discipline Patient rights and information Waiting time for treatment Outcomes Generosity Pharmaceuticals Relative weight

12 P a g e 12 Furthermore, each indicator has a maximum possible score of 3; scores are color coded as follows: green = 3 pts amber = 2 pts red/not available = 1 pt Scores for each sub-discipline are calculated as a percentage of the maximum possible score and subsequently multiplied by the weight coefficients and added up to make the final country score. These percentages are then multiplied by 133, and rounded to a three digit integer; the maximum total score is 1000 indicating the perfect healthcare system. National Services Choices Score Card The NHS has developed a scorecard in which hospitals are assessed and compared in a variety of areas depending on the treatment/condition a patient is interested in. The following are the areas in which hospitals are assessed. Wait time from referral to treatment Length of stay in hospital Risk of readmission (rated lower than expected, expected, higher than expected) Experience of surgical department with specific procedure Patient rating of care received Patient experience during treatment (respect, dignity, feeling involved ) Survival rate for elective procedure (rated better than, worse than or as expected) Survival rate for emergency procedure MRSA control for elective patients Cleanliness of hospital Scoring System The overall quality of service for the trust that runs the hospital is colour coded and given a rating of excellent (green), good (blue), fair (yellow) or weak (red). are not ranked against each other, information is only compared. Website:

13 P a g e 13 CHKS Top Program CHKS is a healthcare benchmarking company that annually prepares a benchmarking report on UK hospitals using data from the National Care service. Performance is based on 20 indicators in the following five areas: Clinical effectiveness outcomes Efficiency Patient experience Quality of care Scoring System Each indicator has an actual value (reported by hospital) and expected value (derived using overall performance level of the hospital s peers); from these two values an index is derived and hospitals are subsequently ranked. Website: IASIST Top 20 Top 20 is a hospital assessment program that benchmarks public and private hospitals in Spain. Top 20 hospitals use six indicators in the following three areas to carry out its benchmarking: Quality Functioning Clinical practice Scoring System It is not clear how the scoring and ranking system for IASIST works, however, all indicators are equally weighted and summed once normalized. Website:

14 P a g e 14 World Organization - (PATH ) Performance Assessment Tool for Quality Improvement in In 2003, the World Organization (WHO) Regional Office for Europe initiated a project to develop a tool to measure hospital performance. This tool was named Performance Assessment Tool for quality improvement in (PATH). It defines five key areas for assessment: Clinical effectiveness and safety (7) Patient centeredness (1) Production efficiency (2) Staff orientation (5) Responsive governance (2) Within these five dimensions are 17 core quality indicators for PATH; additional tailored indicators exists that can also be used. This tool allows for the collection and analysis of data on a set of indicators for comprehensive performance assessment in hospitals in regions and countries with different cultures and resource availability. in Europe, Canada and Africa have participated in a pilot project using this assessment tool. Scoring System The PATH tool does not rank hospitals, rather it reports the following comparative data: The number of hospitals reporting the particular/specific indicator Number of cases Minimum/maximum values Mean (standard deviation) Value for that hospital on that particular indicator International Quality Program (IQIP) The International Quality Program is a branch of the Quality Program (QIP) that was first developed in the US over 20 years ago. The QIP collects data on quality of patient care and seeks to identify opportunities for improvement. It has a variety of performance metrics depending on the type of health care institution as does the IQIP. IQIP is the only other international hospital assessment program aside from the WHO s PATH program. For acute care institutions, the IQIP examines acute care process and outcome measures in the following areas:

15 P a g e 15 Acute Myocardial Infarction Cardiac Surgery Colorectal Surgery Appendectomy Hysterectomies Maternity and Childbirth Patient Safety Infection Control Ambulatory Care Heart Failure Pneumonia Vascular Surgery Liver, Biliary Tract, Pancreatic, or Gallbladder Surgery Hernia Surgery Orthopedic Surgery Emergency Care Intensive Care Units Internal Medicine Methyllin Resistant Staphylococcus Aureus (MRSA) Over 180 health care organizations in 12 countries use IQIP and its indicators to collect, analyze and compare their data. Several countries in Latin America are participating in IQIP (# of institutions): Mexico (7) Brazil (8) Argentina (5) Chile (5) Colombia (7) Uruguay (2) Scoring System IQIP does not rank institutions, rather it produces an institution-specific specific report for participants every quarter, providing both historical and comparative data for each measure that data was submitted for; more narrowly user-defined peer group reports can also be obtained. Depending on the nature of the data, outcomes reported include numerators, denominators, minimum and maximum rates, median, means (weighted and unweighted), standard deviation and quartiles. Website:

16 P a g e 16 Lessons Learned In developing the proposed ranking and benchmarking tool we reviewed and summarized 12 benchmarking systems, focusing particularly on indicators that may be relevant in the Latin American context, challenges to implementation of such a tool and any other relevant lessons that surfaced. The key lessons that emerged from the review of the various hospital benchmarking systems and that were taken into consideration when developing the proposed tool are as follows: The burden of data collection appears to be one of the greatest impediments to the implementation of a successful performance assessment program. It is important to choose indicators that are relevant but do not require extensive data collection or greatly increased resources to collect them. The PATH project found that the burden of data collection was too high for four of their indicators in particular antibiotic use, surgical theatre use, expenditure and absenteeism. The PATH project also stated that a lack of personnel, resources, expertise and time for participating hospitals to collect data was an issue. 2 It is essential that clear and very specific definitions of what the indicators mean are established to ensure that all participants collect the same data and are able to interpret it and ultimately make the data comparable. The ease and cost of collecting data from structural indicators is considerably better than with process and outcomes of care data; however, the relevance of data is greater with process and outcome of care measures in regards to quality and performance measurement. The institutional embedding of the performance measurement project at the regional/national level, consideration of various stakeholder interests and technical support during data collection have all been sited as essential parts of a successful quality indicator program. 3 Patient experience appears to be a good indicator to include as it is measurable, it can be improved and collection of this type of data is inexpensive and most hospitals already gather this type of information. 4 It is important to ensure that the selected indicators reflect measurement areas that are relevant to a broad range of institutions. Different stages of development and organizational structures in institutions, resource availability and cultural differences between regions and countries may be hurdles that have to be overcome when implementing a benchmarking tool. 2 The World Organization Performance Assessment Tool for Quality Improvement in (PATH): An analysis of the pilot implementation in 37 hospitals. Groene O, et al. Intl J. Quality Care. 20(3) An international review of projects on hospital performance assessment. Groene O, Skau JK, Frolich A. Intl J. Quality Care. 20(3) performance evaluation: What data do we want, how do we get it, and how should we use it? Mehrotra A, Lee S, RA Dudley. Institute for Policy Studies University of California, San Francisco

17 P a g e 17 On the basis of the above review and subsequent lessons learned, it was decided that indicators for the proposed osed ranking and benchmarking tool would be selected based on the following criteria: Measurability of indicator Availability of data Relevance to Latin American health care setting Consistency across other hospital benchmarking tools (see Annex IV for matrix) Four thematic indicator areas emerged that fit these criteria and which we considered essential for assessing hospital performance in Latin America: hospital infrastructure and resources; hospital volumes and wait times; hospital clinical effectiveness and efficiency; hospital policies and patient experience. A description of the reasoning behind each choice follows: The Infrastructure and Resources component was selected to capture information outlining both the technical and human resources available to hospitals. cannot function without adequate and appropriate staffing and therefore it is important to take these into account when assessing hospital performance thus hospital staffing and training is the first sub-component of this category. Furthermore, it is essential to ascertain the technological resources available to staff to carry out their duties, facilities and technologies available are therefore the second and last sub-dimension of this category. Overall this component consists of the two sub-components that attempt to gauge the readiness and ability of a hospital to serve its community. The Volumes and Wait Times component seeks to gather information regarding the volume of patients attended to as well as the volume of selected procedures performed in the hospital. These two sub-components will allow for the calculation of staff: patient ratios and provide a sense of whether hospitals are operating under optimal staffing conditions. Finally, wait times in areas such as surgery, diagnostics and the emergency department are considered to determine if services are being received in a timely manner. The Clinical Effectiveness and Best Practices component seeks to capture and quantify the quality of hospital services provided as clinical care is the defining hallmark of a hospital. Not only are outcomes such as mortality, infection and readmission assessed, process of care measures are also included to determine if hospitals are employing current best practices in their clinical service provision; thus outcomes of care and process of care are the two sub-components of this category. The Policies and Patient Experience component attempts to evaluate two important but often neglected areas of health care provision: systematic policies reflecting the value a hospital places on patient and staff safety and patient experience and satisfaction with care received. These two areas thus form the sub-components of this category.

18 P a g e 18 Table 2: Proposed s for Pilot Project by Category INDICATOR CATEGORY Infrastructure and Resources Volumes and Wait Times Clinical Effectiveness and Best Practices Policies and Patient Experience PROPOSED INDICATORS 1. Staff (volumes) 2. Staff (training) 3. Medical Equipment (availability) 4. Medical Facilities (availability) 1. Patient (volumes) 2. Selected Procedures (volumes) 3. Surgery (wait times) 4. Emergency Department (wait times to see physician) 5. Diagnostic Tests (i.e. CT scan, MRI) (wait times from time requested to performance of test) 6. Cancer Treatment Wait Times (wait time from time requested to time of treatment) 1. Outcome of care measures - hospital wide survival/mortality rates - infection rates - length of stay (risk-adjusted all discharges) - readmission rates ( i.e. AMI, CHF, elective and emergency surgery) 2. Process of care measures - Acute myocardial infarction (AMI) - Congestive heart failure (CHF) - Pneumonia 1. Patient s rights law (present or absent) 2. Patient access to own medical records 3. Latex-free policy (present or absent) 4. No-lift policy (present or absent) 5. Needleless policy (whenever possible) (present or absent) 6. Patient satisfaction survey (overall satisfaction rating)

19 P a g e 19 Data Analysis and Composite Index Once data collection is complete and verified, data will be normalized to ensure comparability using the following procedure: individual hospital scores for a particular indicator will be divided by the average indicator score from all hospitals and subsequently sequently multiplied by five. This will create results that are normalized to fall within a range of zero to ten and have a mean of five, thus allowing for easier interpretation and comparison of results. For example a hospital that receives a score of 7.5 will be 2.5 points or 50% above the index average whereas a hospital that receives a score of 4 will be 1 point or 20% below the average of the index. The normalization process is represented by Equation (1) where NV i,j represents the normalized score of indicator i for hospital j, OV i,j the observed value for indicator i for hospital j and AVG i the average score for the indicator across hospitals: Equation (1): NV i,j = OV i,j * 5 AVG i For the sub-components of the index, simple averages will be calculated for all indicators; for example the average for all Volume related indicators in the Volumes and Wait Times component will be calculated and then weighted according to the corresponding weight of each sub-component. Consequently, this will create a sub-index for each of the four components as outlined below that will then make up the overall benchmarking index (Figure 2).

20 P a g e 20 Figure 1: Structure of the Latin American Benchmarking Tool Infrastructure & Resources Component Volumes & Wait Times Component Clinical Effectiveness & Best Practices Component Policies & Patient Experience Component A. Staffing & Training B. Facilities & Technology Available C. Volumes D. Wait Times E. Outcome of Care Measures F. Process of Care Measures G. Policies H. Patient Experience s s s s s s s s A1- A5 B1- B8 C1- C4 D1- D5 E1- E10 F1- F10 G1- G5 H1 Infrastructure & Resources Index Volumes & Wait Times Index Clinical Effectiveness & Best Practices Index Policies & Patient Experience Index Latin American Performance Composite Index The scale for each indicator will range from zero, indicating no data or no action to 10, indicating optimal performance in regards to achieving the highest standard for that indicator. Reporting no data for an indicator will result in a score of zero to encourage hospitals to systematically collect and report the missing information; penalizing hospitals for not reporting data will also ensure fairness in the final standings. The majority of the selected indicators represent continuous data (83%) such that their values will either be percentages or absolute values, while a small percentage of the indicators produce binary data (17%). Binary data will be rescaled to continuous variables using a scale from The four main components that comprise the composite index will be weighted equally (one-quarter each) to reflect the importance, value and interdependence of all components in contributing to hospital performance; the eight sub-components however, will not necessarily be of equal weight. The overall composite index is therefore represented by the following equation:

21 P a g e 21 Equation (2): Composite Index = 1 * HIRI + 1 * HVWI + 1 * HCEBPI + 1 * HPPEI will be separated into peer groups to make for fair comparisons. For example hospitals may be divided into categories of public or private institutions and then further sub-divided by number of beds or teaching status. Once the ranking is carried out, data will be transformed into a visual representation, for easy interpretation of the overall performance index. specific comparisons and data on the number of hospitals that participated and the number of cases involved will also be made available. Various methodologies were consulted in developing this composite index including the OECD Handbook for Constructing Composite Indexes 5 and the World Bank Composite HIV/AIDS Response Index. 6 Quality Assurance Background Assuring the quality of the data submitted by hospitals is very important as the integrity of the results and the conclusions that can be drawn from them are based on this. It is therefore important to ensure that when the data is being collected, processed and warehoused the following five errors are guarded against; Design or conformation errors (i.e. incompatible units) Collection errors ( i.e. incorrectly recorded values, untimely data collection practices) Staging errors (i.e. improper translation processes) Data integration (i.e. improper data alignment) Query errors (i.e. improper query formation) A quality assurance strategy for healthcare data must assess, monitor, and ultimately prevent these five types of data errors. It has also been shown that the inclusion ion of fact, aggregate and dimensions filters can improve the quality of data collected to perform ranking and benchmarking. 7 5 Organisation for Economic Co-operation operation and Development. Handbook on Constructing Composite s: Methodology and User Guide World Bank. Composite HIV/AIDS Response Index: Benchmarking Eastern Europe and Central Asia Country Performance in Response to HIV/AIDS 7 Berndt DJ, Fisher JW, Hevner AR and Studnicki J. care e data warehousing and quality assurance.

22 P a g e 22 There are several examples of quality assurance measures that are employed by other hospital benchmarking systems that attempt to address some of these problem areas. The WHO s PATH program has a two step system in which hospitals submit their data online where it then goes through a preliminary validation after which the data is reported back to each hospital for verification. Only once these processes are complete are data included into the PATH database for further analysis. The Centers for Medicare and Medicaid abstraction and reporting tool (CART) is used as a part of a quality assurance program for The Centers for Medicare and Medicaid, as it is a comprehensive tool that enables them to collect data, conduct retrospective analyses and do real time reporting. The application is available at no charge to hospitals or other organizations that seek to improve the quality of care in the following clinical areas: Acute Myocardial Infarction (AMI) Heart Failure (HF) Pneumonia (PN) Surgical Care Improvement Project (SCIP) The US Department of and Human Services has a Data Integrity Verification Strategy that may prove useful. The health care institution reporting the data is responsible for the quality of the data being submitted, while the US Department of and Human Services tests data at the following levels to ensuring data integrity: Source to Target Counts (10% of data) Source to Target Data Verification Column to Column Verification (for columns undergoing transformations) Transformation Verification Exception Processing Summary and Detailed Results Reporting of Integrity Data Proposed Methodology for Quality Assurance To ensure the accuracy and quality of the data received, measures need to be embedded throughout various steps of the benchmarking process. First, it is important that the standard measures and definitions that will be provided are understood by the participating institutions; as such training will be provided in regards to the indicator set and the standardized data collection procedures that will be employed. Once data has been received from institutions and before it is processed, a random sampling of records (1-5 %) will be verified with original sources for all participating hospitals. An accuracy score will be assigned to each institution based on the following equation: Computer. December (12);

23 P a g e 23 Equation (3): Accuracy Score = Total # of variables verified - Number of inaccurate variables * 100 Total # of variables verified The minimally acceptable accuracy score is 80%; values below this cutoff will not be included in the database for processing. Upon passing the data quality assessment, data will be processed into the central database. Automated data edits will be built into the processing system such that missing or out of range data will be identified. Furthermore, post-processing processing measures such as source to target counts, source to target verification and transformation verification will be employed. The feasibility of conducting independent audits of the participating institutions will be considered for future versions of the benchmarking tool.

24 P a g e 24 Additional Considerations Implementation Strategy The implementation of the Latin American hospital ranking and benchmarking tool is a dynamic and multi-phase process that will invariably undergo modifications as the project unfolds. The following strategy seeks to establish a preliminary framework in which the ranking and benchmarking project will be carried out. Seek out funders for initial ranking project, potentially health insurers or drug companies, until the project becomes self-sustainingsustaining Assign project manager to be the contact person for hospitals that show interest and want further information or want to become involved. This person will also serve as the liaison between funders and other stakeholders and provide support for implementation of performance measurement within hospitals Obtain technical advisor to design data collection templates and test benchmarking tool with simulated data. Web demonstrations and sample reports will be created to show potential participants Identify interested hospitals to participate in a pilot test to determine feasibility of collecting proposed indicators Review indicator set with pilot hospitals to ensure that they are able to collect/already collect data; adjustments to indicator set will be made based on feedback from hospitals Identify steps required to develop required information infrastructure, identify technology and cost implications involved in data collection Develop rules and standards for data collection and aggregation Establish protocol for data collection (how and by whom), define documentation procedure Establish time frame for data collection

25 P a g e 25 Sanigest International Sanigest International is a healthcare consulting and management firm based out of San Jose, Costa Rica with additional offices in the United States and Europe. For over a decade, Sanigest has worked extensively in the hospital sector providing high quality service and innovative solutions to its clients in the public and private sector as evidenced ed by its ISO 9001:2008 certification. Some of Sanigest s most recent success stories include successfully defining a National Insurance basic package of services, a health purchasing plan and implementing a management information system in Belize. In Slovakia, Sanigest created a hospital restructuring plan and defined provider payment mechanisms and a health insurance regulatory frame work. Sanigest s experience spans the globe with extensive experience in the developing nations of Latin America such as Costa Rica, Belize, Colombia, Ecuador, El Salvador and Nicaragua. Sanigest is optimally suited and equipped to design, implement and deliver a high impact hospital ranking and benchmarking tool for Latin America.

26 P a g e 26 ANNEX 1: s Used by Various Benchmarking Systems BENCHMARKING SYSTEM INDICATORS INCLUDED Acute Myocardial Infarction Aspirin at arrival Aspirin at discharge ACE Inhibitor or Angiotensin Receptor Blocker for Left Ventricular Systolic Dysfunction Beta Blocker at discharge Fibrinolytic Medication within 30 min of arrival Percutaneous Coronary Intervention (PCI) received within 90 mins of hospital arrival Smoking cessation advice/counseling Compare Heart Failure Evaluation of left ventricular systolic (LVS) function ACE Inhibitor or Angiotensin Receptor Blocker for Left Ventricular Systolic Dysfunction Discharge instructions Smoking cessation advice/counseling Pneumonia Oxygenation assessment Initial antibiotic timing (within 4hrs) Pneumococcal vaccination Influenza vaccination Blood culture performed in Emergency Dept prior to initial antibiotic received in hospital Appropriate initial antibiotic selection Smoking cessation advice/counseling Surgical Care Improvement Project Prophylactic antibiotic received within 1 hr prior to surgical incision Prophylactic antibiotic discontinued within 24 hrs after surgery end time Prophylactic antibiotic selection Surgery patients with recommended venous thromboembolism prophylaxis ordered Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hrs prior to surgery to 24 hrs after surgery Cardiac surgery patients with controlled 6 AM postoperative blood glucose Surgery patients with appropriate hair removal Children's Asthma Care Use of reliever medication for inpatient asthma Use of systemic corticosteroid medication for inpatient asthma 30 day risk-adjusted mortality rate Acute Myocardial Infarction Heart Failure Pneumonia Patient Satisfaction Patient survey of Experience Insight Acute Myocardial Infarction Aspirin at arrival Aspirin at discharge

27 P a g e 27 BENCHMARKING SYSTEM INDICATORS INCLUDED ACE Inhibitor or Angiotensin Receptor Blocker for Left Ventricular Systolic Dysfunction Beta Blocker at arrival Beta Blocker at discharge Fibrinolytic Medication within 30 min of arrival Percutaneous Coronary Intervention (PCI) received within 90 mins of hospital arrival Smoking cessation advice/counseling Heart Failure Evaluation of left ventricular systolic (LVS) function ACE Inhibitor or Angiotensin Receptor Blocker for Left Ventricular Systolic Dysfunction Discharge instructions Smoking cessation advice/counseling Pneumonia Oxygenation assessment Initial antibiotic timing (within 4hrs) Pneumococcal vaccination Influenza vaccination Blood culture performed in Emergency Dept prior to initial antibiotic received in hospital Appropriate initial antibiotic selection Smoking cessation advice/counseling Surgical Care Improvement Project Prophylactic antibiotic received within 1 hr prior to surgical incision Prophylactic antibiotic discontinued within 24 hrs after surgery end time Prophylactic antibiotic selection Surgery patients with recommended venous thromboembolism prophylaxis ordered Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hrs prior to surgery to 24 hrs after surgery Cardiac surgery patients with controlled 6 AM postoperative blood glucose Surgery patients with appropriate hair removal Leapfrog Group Structural indicators Computerized physician order entry (CPOE) system ICU staffing High risk treatments (evidence based hospital referral) Safe practice scores Policies No lift policy (use lifts to raise patients to avoid staff and patient injury) Latex-free policy Needleless policy (administer medications without needles whenever possible) Michigan Manufacturing Technology Centre (MMTC) Acute Myocardial Infarction Aspirin at arrival Aspirin at discharge ACE Inhibitor or Angiotensin Receptor Blocker for Left Ventricular Systolic Dysfunction Beta Blocker at arrival Beta Blocker at discharge Heart Failure Evaluation of left ventricular systolic (LVS) function ACE Inhibitor or Angiotensin Receptor Blocker for Left Ventricular Systolic Dysfunction

28 P a g e 28 BENCHMARKING SYSTEM INDICATORS INCLUDED Pneumonia Oxygenation assessment Initial antibiotic timing (within 4hrs) Pneumococcal vaccination Clinical outcomes -wide Mortality Index % of cardiac patients with acute readmission within 31 days % of patients with unscheduled Inpatient returns to OR within same stay % of Inpatient admissions following unscheduled returns to Emergency Dept within 72 hrs Business, Productivity, Asset Utilization and Throughput Operating (profit) margin Dollars of Expenses per Case Mix-Adjusted Equivalent Discharge (and wage-adjusted) adjusted) Bad Debt Expenses as a % of net Patient Service Revenue Value added per FTE Employee/Contractor Value added per Case Mix-Adjusted Equivalent Discharge (CMAED) FTE Employees/Contractors per CMAED Net Patient Service Revenue per FTE Employee/Contractor Operating Room 'Cut & Sew' Time as % of booked time Cost per unit of production (adjusted) Avg length of stay (days), Case-Mix adjusted % of discharges made before noon Mean outpatient door-to-door time (min) Mean Emergency Dept Door-to-Physician time (min) Mean Troponin Lab test turnaround time (min) Mean radiology order-to transcription time (hrs) Clinical Outcomes and Services US News & World Report Risk adjusted mortality Reputation Number of discharges Nurse staffing Nurse Magnet hospital Advanced technologies Patient services Thomson & Reuters Top 100 Program Acute Myocardial Infarction Aspirin at arrival Aspirin at discharge ACE Inhibitor or Angiotensin Receptor Blocker for Left Ventricular Systolic Dysfunction Beta Blocker at arrival Beta Blocker at discharge Fibrinolytic Medication within 30 min of arrival Percutaneous Coronary Intervention (PCI) received within 90 mins of hospital arrival Smoking cessation advice/counseling Heart Failure Evaluation of left ventricular systolic (LVS) function ACE Inhibitor or Angiotensin Receptor Blocker for Left Ventricular Systolic Dysfunction Discharge instructions

29 P a g e 29 BENCHMARKING SYSTEM INDICATORS INCLUDED Smoking cessation advice/counseling Pneumonia Oxygenation assessment Initial antibiotic timing (within 4hrs) Pneumococcal vaccination Influenza vaccination Blood culture performed in Emergency Dept prior to initial antibiotic received in hospital Appropriate initial antibiotic selection Smoking cessation advice/counseling Surgical Care Improvement Project Prophylactic antibiotic received within 1 hr prior to surgical incision Prophylactic antibiotic discontinued within 24 hrs after surgery end time Prophylactic antibiotic selection Clinical Outcomes Risk adjusted mortality Risk adjusted complications index Risk adjusted patient safety index Severity adjusted length of stay Business Operating(profit margin Expenses per Adjusted Discharge (case-mix and wage-adjusted) Cash to total debt ratio Powerhouse Consumer Patients rights & Information Patients rights law Patient organizations involved in decision making No fault malpractice insurance Right to second opinion Access to own medical record Readily accessible register of legit doctors Electronic patient record (EPR) penetration in primary care Provider catalogue with quality ranking Web or 24/7 telephone healthcare info Waiting Times Family doctor same day service Direct access to specialist care Major non-acute operations Cancer, radiation/chemotherapy MRI scan examination Clinical Outcomes Heart infarct mortality < 28 days after getting to hospital Infant deaths/ 1000 live births Cancer 5-yr survival rates

30 P a g e 30 BENCHMARKING SYSTEM INDICATORS INCLUDED Avoidable deaths potential years of life lost (PYLL)/ 100,000 MRSA Generosity of Public care Systems Cataract operation rates per 100,000 citizens (age adjusted) Infant 4-disease vaccination Kidney transplants per million population Is dental care a part of the offering from public healthcare system Pharmaceuticals Prescription subsidy % Layman-adapted adapted pharmacopoeia Speed of deployment of novel cancer drugs Access to new drugs National Services Choices Scorecard Clinical Effectiveness and Safety Readmission Length of Stay Survival rate (elective and emergency surgeries) Rate of MRSA Time from referral to treatment # times surgical department performs operation/yr Standardized admission ratio (SAR) Patient rating of overall care Cleanliness of hospital Clinical effectiveness and safety CHKS Top Program Risk adjusted mortality (or mortality index) Rate of emergency readmission to hospital - 28 days Rate of emergency readmission to hospital following treatment for fractured hip Rate of emergency readmission to hospital following AMI (within 28 dys) Rate of emergency readmissions to hospital within 14 days for COPD Rate of MRSA Rate of C. difficile for patients 65 yrs Throughput Risk adjusted length of stay Day Case rate for target procedures (case mix adjusted) Day Case conversion rate (case mix adjusted) % of elective inpatients admitted on day of surgery Pre-op length of stay for fractured neck of femur Pre-op length of stay for elective surgery % elective in-patient admission with no procedure Missed out-patient appointments (1st attendance) Overall data quality Procedures not carried out (hospital decision) Waiting times for common diagnostic procedures Clinical Effectiveness and Safety

31 P a g e 31 BENCHMARKING INDICATORS INCLUDED SYSTEM IASIST Top 20 Risk adjusted mortality Risk adjusted complications index Risk adjusted length of stay Readmissions index (risk-adjusted) Surgery index (without adjusted incomes) Cost per unit of production Clinical Effectiveness and Safety World Organization - Performance Assessment Tool for Quality Improvement in (PATH ) Caesarean Section Prophylactic Antibiotic Use (surgery) Mortality (Acute myocardial infarction, stroke, community acquired pneumonia, hip fracture, coronary artery bypass graft) Readmission Day surgery for 8 tracers Admission after day surgery (same 8 tracers) Return to ICU Efficiency Length of stay Surgical theatre use Staff Orientation & Safety Training expenditure Absenteeism Working excessive hours Needle injuries Staff smoking prevalence Responsive Governance Breastfeeding at discharge care transitions Patient Centeredness Patient expectations Surgical Care Improvement Project International Quality Program (IQIP) Prophylactic antibiotic received within 1 hr prior to surgical incision Prophylactic antibiotic discontinued within 24 hrs after surgery end time Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hrs prior to surgery to 24 hrs after surgery

32 P a g e 32 BENCHMARKING SYSTEM INDICATORS INCLUDED Use of Devices in ICU Central line use Ventilator use Indwelling urinary catheter use Management of Labour Primary C-sections Repeat C-sections Total C-sections Vaginal births after C-sections Process of Care Measures Active surveillance cultures for MRSA Clinical Effectiveness and Safety Device-associated infections in ICU Device-associated infections in ICU due to MRSA Surgical site infections Inpatient mortality Neonatal mortality Perioperative mortality Total unscheduled readmissions within 15 and 31 days Unscheduled admissions following ambulatory procedures Unscheduled returns to ICU Unscheduled returns to OR Unscheduled returns to ER Physical restraint events Documented falls Documented falls in ambulatory care Complications following sedation and analgesia in ICU Complications following sedation and analgesia in Emergency Dept Complications following sedation and analgesia in Cardiac Catherization lab Complications following sedation and analgesia in Radiology Suites Pressure ulcers in acute inpatient care Deep vein thrombosis and pulmonary thromboembolism following surgery Multi-drug resistant organisms

33 P a g e 33 HOSPITAL PERFORMANCE DIMENSION Clinical Effectiveness & Safety APPENDIX IV: MATRIX OF INDICATORS FROM REVIEWD HOSPITAL BENHCMAKRING SYSTEMS BENCHMARKING SYSTEMS WHO PATH Caesarean Section Prophylactic Antibiotic Use (surgery) Mortality (Acute myocardial infarction, stroke, community acquired pneumonia, hip fracture, coronary artery bypass graft) Readmission Day surgery for 8 tracers Admission after day surgery (same 8 tracers) Return to ICU Consumer Powerhouse Leapfrog Group Compare MMTC Community Benchmarking Survey International Quality Project Insight National Service ScoreCard CHKS 40 Top US News & World Report Thomson & Reuters Top 100 IASIST Top 20 (Spain) Total Counts for % of systems with indicator Efficiency Length of stay Surgical theatre use Staff Orientation & Safety Training expenditure Absenteeism Working excessive hours

34 P a g e 34 HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS WHO PATH Consumer Powerhouse Leapfrog Group Compare MMTC Community Benchmarking Survey International Quality Project Insight National Service ScoreCard CHKS 40 Top US News & World Report Thomson & Reuters Top 100 IASIST Top 20 (Spain) Total Counts for % of systems with indicator Needle injuries Staff smoking prevalence No lift policy (use lifts to raise patients to avoid staff and patient injury) Latex-free policy Needleless policy (administer medications without needles whenever possible) Responsive Governance Breastfeeding at discharge care transitions Patient Centeredness Patient expectations Patient rights & information

35 P a g e 35 HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS WHO PATH Consumer Powerhous e Direct access to specialist care Major non-acute operations Cancer, radiation/chemotherapy Leapfrog Group Compare MMTC Community Benchmarkin g Survey Internationa l Quality Project Insigh t National Service ScoreCard CHKS 40 Top US News & World Report Thomson & Reuters Top 100 IASIST Top 20 (Spain) Total Counts for % of systems with indicator MRI scan examination Outcomes Heart infarct mortality < 28 days after getting to hospital Infant deaths/ 1000 live births Cancer 5-yr survival rates Avoidable deaths - potential years of life lost (PYLL)/ 100,000 MRSA Generosity of public healthcare systems Cataract operation rates per 100,000 citizens (age adjusted)

36 P a g e 36 HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS WHO PATH Cataract operation rates per 100,000 citizens (age adjusted) Infant vaccination 4-disease Consumer Powerhouse Leapfrog Group Compare MMTC Community Benchmarking Survey International Quality Project Insight National Service ScoreCard CHKS 40 Top US News & World Report Thomson & Reuters Top 100 IASIST Top 20 (Spain) Total Counts for % of systems with indicator Kidney transplants per million population Is dental care a part of the offering from public healthcare system Pharmaceuticals Prescription subsidy % Layman-adapted pharmacopoeia Speed of deployment of novel cancer drugs Access to new drugs Structural s Computerized physician order entry (CPOE) system ICU staffing High risk treatments (evidence based hospital referral)

37 P a g e 37 HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS WHO PATH Consumer Powerhouse Leapfrog Group Compare MMTC Community Benchmarking Survey International Quality Project Insight National Service ScoreCard CHKS 40 Top US News & World Report Thomson & Reuters Top 100 IASIST Top 20 (Spain) Total Counts for % of systems with indicator Safe practice scores Process of Care Measures Acute Infarction Myocardial Aspirin at arrival Aspirin at discharge ACE Inhibitor or Angiotensin Receptor Blocker for Left Ventricular Systolic Dysfunction Beta Blocker at discharge Fibrinolytic Medication within 30 min of arrival Percutaneous Coronary Intervention (PCI) received within 90 mins of hospital arrival Smoking cessation advice/counseling Beta Blocker at arrival

38 P a g e 38 HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS WHO PATH Consumer Powerhouse Leapfrog Group Compare MMTC Community Benchmarking Survey International Quality Project Insight National Service ScoreCard CHKS 40 Top US News & World Report Thomson & Reuters Top 100 IASIST Top 20 (Spain) Total Counts for % of systems with indicator Heart Failure Evaluation of left ventricular systolic (LVS) function ACE Inhibitor or Angiotensin Receptor Blocker for Left Ventricular Systolic Dysfunction Discharge instructions Smoking cessation advice/counseling Pneumonia Oxygenation assessment Initial antibiotic timing (within 4hrs) Pneumococcal vaccination Influenza vaccination Blood culture performed in Emergency Dept prior to initial antibiotic received in hospital

39 P a g e 39 HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS WHO PATH Consumer Powerhouse Leapfrog Group Compare MMTC Community Benchmarking Survey International Quality Project Insight National Service ScoreCard CHKS 40 Top US News & World Report Thomson & Reuters Top 100 IASIST Top 20 (Spain) Total Counts for % of systems with indicator Appropriate initial antibiotic selection Smoking cessation advice/counseling Surgical Care Improvement Project Prophylactic antibiotic received within 1 hr prior to surgical incision Prophylactic antibiotic discontinued within 24 hrs after surgery end time Prophylactic antibiotic selection Surgery patients with recommended venous thromboembolism prophylaxis ordered Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hrs prior to surgery to 24 hrs after surgery Cardiac surgery patients with controlled 6 AM postoperative blood glucose Surgery patients with appropriate hair removal

40 P a g e 40 HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS WHO PATH Consumer Powerhouse Leapfrog Group Compare MMTC Community Benchmarking Survey International Quality Project Insight National Service ScoreCard CHKS 40 Top US News & World Report Thomson & Reuters Top 100 IASIST Top 20 (Spain) Total Counts for % of systems with indicator Children's Asthma Care Use of reliever medication for inpatient asthma Use of systemic corticosteroid medication for inpatient asthma Use of Devices in ICU Central line use Ventilator use Indwelling catheter use urinary Management of Labour Primary C-sections Repeat C-sections Total C-sections Vaginal births after C- sections

41 P a g e 41 HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS WHO PATH Consumer Powerhouse Leapfrog Group Compare MMTC Community Benchmarking Survey International Quality Project Insight National Service ScoreCard CHKS 40 Top US News & World Report Thomson & Reuters Top 100 IASIST Top 20 (Spain) Total Counts for % of systems with indicator Other Process of Care Measures Active surveillance cultures for MRSA Outcome of Care Measures 30 day risk-adjusted mortality rate Acute Myocardial Infarction Heart Failure Pneumonia Patient survey of hospital experience (i.e. Consumer Assessment of care Providers & Systems (CHAPS)) Other clinical outcomes -wide Mortality Index % of cardiac patients with acute readmission within 31 days

42 P a g e 42 HOSPITAL PERFORMANCE DIMENSION % of patients with unscheduled Inpatient returns to OR within same stay % of Inpatient admissions following unscheduled returns to Emergency Dept within 72 hrs BENCHMARKING SYSTEMS WHO PATH Consumer Powerhouse Leapfrog Group Compare MMTC Community Benchmarking Survey International Quality Project Insight National Service ScoreCard CHKS 40 Top US News & World Report Thomson & Reuters Top 100 IASIST Top 20 (Spain) Total Counts for % of systems with indicator Device-associated infections in ICU Device-associated infections in ICU due to MRSA Surgical infections site Inpatient mortality Neonatal mortality Perioperative mortality Total unscheduled readmissions within 15 and 31 days Unscheduled admissions following ambulatory procedures Unscheduled returns to ICU

43 P a g e 43 HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS WHO PATH Consumer Powerhouse Leapfrog Group Compare MMTC Community Benchmarking Survey International Quality Project Insight National Service ScoreCard CHKS 40 Top US News & World Report Thomson & Reuters Top 100 IASIST Top 20 (Spain) Total Counts for % of systems with indicator Unscheduled returns to OR Unscheduled returns to ER Physical restraint events Documented falls Documented falls in ambulatory care Complications following sedation and analgesia in ICU Complications following sedation and analgesia in Emergency Dept Complications following sedation and analgesia in Cardiac Catherization lab Complications following sedation and analgesia in Radiology Suites Pressure ulcers in acute inpatient care Deep vein thrombosis and pulmonary thromboembolism following surgery Multi-drug resistant organisms

44 P a g e 44 HOSPITAL PERFORMANCE DIMENSION Risk adjusted mortality (or mortality index) Rate of emergency readmission to hospital - 28 days Rate of emergency readmission to hospital following treatment for fractured hip Rate of emergency readmission to hospital following AMI (within 28 dys) Rate of emergency readmissions to hospital within 14 days for COPD BENCHMARKING SYSTEMS WHO PATH Consumer Powerhouse Leapfrog Group Compare MMTC Community Benchmarking Survey International Quality Project Insight National Service ScoreCard CHKS 40 Top US News & World Report Thomson & Reuters Top 100 IASIST Top 20 (Spain) Total Counts for % of systems with indicator Survival rate (elective surgery) Survival rate (emergency surgery) Rate of MRSA Reported rate of C-difficile for patients 65 yrs Risk adjusted complications index Risk adjusted patient safety index Readmissions index (risk adjusted)

45 P a g e 45 HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS WHO PATH Consumer Powerhouse Leapfrog Group Compare MMTC Community Benchmarking Survey International Quality Project Insight National Service ScoreCard CHKS 40 Top US News & World Report Thomson & Reuters Top 100 IASIST Top 20 (Spain) Total Counts for % of systems with indicator Surgery index (without adjusted incomes) Business Operating (profit) margin Dollars of Expenses per Case Mix-Adjusted Equivalent Discharge (and wage-adjusted) Bad Debt Expenses as a % of net Patient Service Revenue Cash to total debt ratio Productivity Value added per FTE Employee/Contractor Value added per Case Mix- Adjusted Equivalent Discharge (CMAED) FTE Employees/Contractors per CMAED Net Patient Service Revenue per FTE Employee/Contractor Operating Room 'Cut & Sew' Time as % of booked time

46 P a g e 46 HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS WHO PATH Consumer Powerhouse Leapfrog Group Compare MMTC Community Benchmarking Survey International Quality Project Insight National Service ScoreCard CHKS 40 Top US News & World Report Thomson & Reuters Top 100 IASIST Top 20 (Spain) Total Counts for % of systems with indicator Occupancy rate, staffed beds Avg days of receivables Avg days of on-hand inventory Throughput Avg length of stay (days), Case-Mix adjusted % of discharges made before noon Mean outpatient door-todoor time (min) Mean Emergency Dept Door-to-Physician time (min) Mean Troponin Lab test turnaround time (min) Mean radiology order-to transcription time (hrs) Length of stay in Emergency department (hrs) Cancellation of scheduled ambulatory procedures Patients leaving Emergency room prior to completion of treatment

47 P a g e 47 HOSPITAL PERFORMANCE DIMENSION Patients leaving Emergency room prior to completion of treatment BENCHMARKING SYSTEMS WHO PATH Consumer Powerhouse Leapfrog Group Compare MMTC Community Benchmarking Survey International Quality Project Insight National Service ScoreCard CHKS 40 Top US News & World Report Thomson & Reuters Top 100 IASIST Top 20 (Spain) Total Counts for % of systems with indicator Time from referral to treatment Risk adjusted length of stay Day Case rate for target procedures (case mix adjusted) Day Case conversion rate (case mix adjusted) % of elective inpatients admitted on day of surgery Pre-op length of stay for fractured neck of femur Pre-op length of stay for elective surgery % elective in-patient admission with no procedure Missed out-patient appointments (1st attendance) Severity adjusted average length of stay # times surgical department performs operation/yr

48 P a g e 48 HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS WHO PATH Consumer Powerhouse Leapfrog Group Compare MMTC Community Benchmarking Survey International Quality Project Insight National Service ScoreCard CHKS 40 Top US News & World Report Thomson & Reuters Top 100 IASIST Top 20 (Spain) Total Counts for % of systems with indicator Standardized admission ratio (SAR) Patient rating of overall care Cleanliness of hospital Overall data quality Procedures not carried out - hospital decision Waiting times for common diagnostic procedures Reputation Number of discharges Nurse staffing Nurse Magnet hospital Advanced technologies Patient services