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Paper presented at a Workshop on Hospital Management held at the Bangladesh Institute of Advanced Management Dhaka on Saturday 5th April 2008 by Dr Omar Hasan Kasule MB ChB (MUK), MPH (Harvard), DrPH (Harvard) Professor of Epidemiology and Islamic Medicine, Institute of Medicine Universiti Brunei Darussalam
ABSTRACT
Benchmarking for Islamic hospitals employs generally accepted benchmarking criteria such as financial indicators, overall productivity, quality of care, and management. It must in addition have additional criteria that reflect its added-value to healthcare in the form of a holistic approach that takes care of the patient’s spiritual, physical, and fiqhi needs. Success will be achieved in delivering the added-value at a cost comparable to or below that of top performers in the industry. The cost savings cannot be achieved by compromising quality but can be achieved by a motivated health care team that is more productive per hour than comparable hospitals and that has a sense of personal responsibility and accountability not to waste time and material resources. This sense of concern can enable Islamic hospitals deliver cost-efficient holistic care and at the same time have some resources available to fulfill its duties of mutual social support, takaful, in helping those who cannot afford standard fees. The paper discusses practical benchmarking guidelines in view of the concepts and assertions above.
1.0INTRODUCTION TO BENCHMARKING
1.1 Benchmarking in industry
Benchmarking is new to the hospital industry. It however has been standard practice in other industries. The process of benchmarking starts with identification of a process to be benchmarked. This is followed by identification of a company that is considered a leader in the given industry. Sources used in the identification may be business magazines or other published information about companies. There can be no unanimity of opinion on what constitutes an industry leader since different people employ different criteria. Management practices, processes, and products are the compared with the chosen industry leader. The leader may provide details of their operations or they may obtained from industry publications. The purpose of benchmarking is not to copy the industry leader but rather to evaluate practices in view of what the leader does. This process can generate new insights about the company and its management. As a management tool it helps companies improve their performance using a successful leader as a point of reference. Benchmarking also helps a company measure its performance against potential competitors with the industry leader as a common point of reference.
1.2 Hospital benchmarking
Processes benchmarked:
Benchmarks have been used for a very wide range of hospital processes. Reproduced below is a laundry list from recent literature: percentage of cases referred to a higher center[1], diagnostic criteria for specific conditions[2], mortality[3], readmission rate[4], hospital stay[5], patient privacy[6], nursing[7] [8], radiology[9], disease prevention[10], surgical wounds[11], mental health[12], ambulance call-to-needle time in myocardial infarction[13], outcomes for acute myocardial infarction[14], telephone consultations[15], emergency care[16], drug information center operations[17], quality of care after myocardial infarction[18], psychiatric rehabilitation[19], central line infection[20], pharmacy drug expenditure[21] [22], hospital costs[23], diabetic complications[24], reduction of costs of appendicitis treatment[25], digital imaging[26], pathology services[27], day only or ambulatory surgical procedures[28], utilization of the operating theater[29], costs of cholesystectomy[30], mortality and morbidity outcome for surgical procedures[31], planning, purchasing, and scheduling[32], percapita regional physician workforce[33], patient satisfaction[34], cost of antimicrobials[35], and outcomes of tertiary care centers[36].
Because of interdependence, some benchmarks reflect a combination of items for example hospital stay and utilization can be combined into one benchmark[37]. What we learn from this extensive listing is that virtually any process in the hospital can be benchmarked.
Sources of benchmarking data:
Data for bench-marking is obtained from benchmark data-bases, benchmark registries, or online benchmark tools[38]. Benchmark data bases are widely used for benchmarking purposes some are national while others are local or regional. There is however a dearth of such databanks in the hospital industry[39]. These data bases are specific for procedures and processes such as intensive care[40]. For some procedures special benchmark registries are set up by collaborating institutes and are used for bench-marking procedures such as intra-aortic balloon counterpulsion[41]. Special guides on benchmarking may also be consulted[42]. Special programs and software has been developed to assist in benchmarking[43]. Some institutions that have a high volume of a certain procedure may network to share data that is used for benchmarking[44].
Industry leader
Choice of the benchmark data base or the benchmark to use has an effect on the conclusions reached[45] therefore choices must be made carefully. The best performing centers that can be used as industry leaders for purposes of benchmarking. There are ranking agencies that rank hospitals using a wide range of criteria[46]. Hospitals that are ranked high may be used as a benchmark. Assessment tools are available for identifying specific institutions as centers of excellence in specific procedures[47]. An institution cannot be an industry leader overall; it can be a leader in a specific area such as hospital stay[48]. An industry leader or a benchmark is not permanent. It can change for the better or for the worse therefore benchmarks need constant revision. Industry leaders who are the best performers have a culture of constant improvement with consequent rise of the benchmark levels[49].
Methodology of benchmarking
Data for benchmarking must be checked for completeness and consistency. Then the following basic descriptive statistics are computed for continuous variables (mean, median, standard deviation) or discrete variables (proportion, rate). These computed parameters are then compared to the benchmark parameters. Gap analysis is used to study the differences between the internal and the benchmark parameters. Odds ratios are an additional parameter that can be computed.
Where the hospital concerned has characteristics that differ from the benchmark data base, suitable statistical adjustments using multivariate techniques can be used for adjustment before reaching conclusions.
After doing the gap analysis to identify differences between the internal and benchmark parameters, action plans are developed to cover the gap.
Effects of benchmarking
Feedback of benchmarking results has been shown to result in improvement of quality[50], reduction in the cost of labor[51], reduction of the operating budget[52]
1.3 Islamic basis for benchmarking
If we look at benchmarking as an exercising in comparing ourselves to the leaders in any endeavor, we can identify a lot of evidence for it in the Qur’an. The Qur’an has described in great detail behavior characteristics of the righteous, saalihiin, so that we may emulate them. It also has described the transgressors, dhaalimiin, so that we may avoid behaving like them.
The Qur’an is a book of moral guidance. It therefore gives models and examples of the righteous, salihiin, to be emulated as well as models of transgressor, dhalimin, to be avoided. It describes the thoughts, actions, and fate of the two groups in a historical perspective, a contemporary perspective, and a future perspective. It also provides intellectual arguments as well as makes pleas to humans to emulate the salihiin and to avoid the dhalimiin. I have made a partial compilation of such verses as an indication of how important this matter is.
Surat al Fatihat (S.1): 6-7; Surat al Takwir (S.81): 13-19; Surat al Mutafifiin (S.83): 4-17, 18-26; Surat al Inshiqaaq (S.84): 6-9, 10-15, 20-24, 25; Surat al Buruuj (S.85): 4-11, 12-20, 15-17; Surat al A’la (S.87): 11-13, 14-15; Surat al Ghashiyat (S.88): 1-7, 8-16, 23-26; Surat al Fajr (S.89): 6-14, 21-26, 27-30, 11-19, 20; Surat al Shams (S.91): 11-15, 4-7, 8-13, 13-16, 17-21; Surat al Sharh (S.94): 7-8, 6-19; Surat al Qadar (S.97): 1-6, 7-8, 6-7, 8; Surat al ‘Adiyat (S100): 6-8; Surat al Qari’at (S.101): 6-7, 8-11; Surat al Asr (S.103): 2, 3; Surat al Humazzat (S.104): 1-4; Surat al Fiil (S.105): 1-5; Surat Quraish (S.106): 1-7; Surat al Kafirun (S.109): 1-6; Surat al Masad (S.111): 1-4; Surat al Falaq (S.113): 1-2; Surat al Nas (S.114): 1-4; Surat al Jinn (S.72): 1-7, 11-15, 19, 23-24; Surat al Muzammil (S.73): 10-12, 16; Surat al Muddathir (S.74): 11-26; Surat al Qiyamat (S.75): 5-6, 20-21, and 22, 31-35; Surat Al Insan (S.76): 4, 5-22, 27-28; Surat al Mursalat (S.77): 15-19, 24, 28-40, 41-44, 45-50; Surat al Naba’ (S.78): 1-5, 21-30, 31-36; Surat al Saff (S.61): 5-6; Surat al Munafiqun (S.63): 1-8; Surat al Taghabun (S.64): 5-8, 16-17; Surat al Talaq (S.65): 8-11; Surat al Tahrim (S.66): 7, 9, 10, 11-12; Surat al Mulk (S.67): 6-11, 12, 28; Surat al Qalam (S.68): 17-33, and 24-41, 51-52; Surat al Haaqat (S.69): 11-12, 19-23, 24-37; Surat al Ma’arij (S.70): 19-21, 22-35, 36-44; Surat al hariyat (S.51): 10-14, 15-19, 24-46, 52-55, 59-60; Surat al Tur (S.52): 7-8, 11-16, 17-27, 29-47; Surat al Najm (S.53): 19-30, 31-32, 33-37; Surat al Qamar (S.54): 4-53, 54-55; Surat al Rahman (S.55): 46-78; Surat al Waqi’at (S.56): 10-40, 41-57; Surat al Hadid (S.57): 12, 13-15, 12-19; Surat al Hashr (S.59): 1-5, 11-17, 20; Surat ussilat (S.41): 1-8, 13-18, 25-29, 30-36, 40-46; Suurat al Shuura (S.42): 35, 36-43, 44-48; Surat al Zukhruf (S.43): 5-7, 15-67, 68-73, 74-83; Surat al Dukkhaan (S. 44): 9-29, 34-37, 40-50, 51-56, Surat al Jaathiyat (S.45): 7-11, 14-15, 21, 23-26, 27-35; Surat al Ahqaaf (S.46): 3-12, 13-19, 20-25, 27-28, 29-32, 34; Surat uhammad (S.47): 1-9, 12-38; Surat Luqman (S.31): 31:1-11, 31:20-24; Surat al Sajdat (S.32): 10-30; Surat al Ahzaab (S.33): 63-73; Surat Saba (S.34): 1-9, 20-54; Surat Fatir (S.35): 1-45; Surat Yasiin (S.36): 1-35, 45-83; Surat al Safaat (S.37): 12-74, 149; Surat Saad (S. 38): 1-17, 49-64; Surat al Zumar (S. 39): 7-75; Surat Ghaafir (S.40): 1-22, 69-85; Surat al Anbiya (S. 21): 1-47; Surat al Hajj (S.22): 1-25, 38-78; Surat al Muminuun (S.23): 23:51-118; Surat al Nuur (S.24): 24:46-57; Surat al Furqan (S.25): 1-44; Surat al Sha’ara (S.26): 26:92; Surat al Naml (S.27):27:59-93; Surat al Qisas (S.28): 28:51-75; Surat al ‘ankabuut (S. 29): 1-12, 41-69; Surat al Ruum (S.30): 1-16, 29-60; Surat Hud (S.11): 1-24, 104-123; Surat al Ra’ad (S.13): 19-43; Surat Ibrahim (S.14): 18-34, 42-52; Surat al Hijr (S.15): 1-11; Surat al Nahal (S.16): 19-64, 84-138; Surat al Isra (S.17): 1-22, 40-60, Surat al Kahf (S.18): 27-59, 18:99-110; Surat Maryam (S.19): 59-98; Surat Taha (S.20): 100-135; Surat al Taubat (S.9): 53-110; Surat al Taubat (S.9): 111-129; Surat Yunus (S.10): 10:7-70; Surat al A’araf (S.7): 31-53; Surat al an’aam (S.6): 1-73; Surat al Nisa (S.4): 105-126 ; Surat al Nisa (S.4): 131-152 ; Surat aal ‘Imraan (S.3): 187-200; Surat al Baqarat (S.2): 2:1-20; and 2:151-162;
So our approach to bench-marking should include looking for both good models and bad models of medical practice.
Another characteristic of Islamic benchmarking is continuous improvement of performance. The prophet taught that he who has two consecutive days equal in performance is a loser, ‘man istawa yawmaahu fahuwa maghbuun. It should be a constant effort of Islamic hospitals to improve on a continuous basis.
2.0 ISSUES ON BENCHMARKING FOR ISLAMIC HOSPITALS
2.1 Identifying a hospital that is an industry leader
A central feature of benchmarking is ability to identify an industry leader against whose performance others can measure. This is a near-impossibility for Islamic hospitals for various reasons. The phenomenon of Islamic hospitals is quite new and there are few such hospitals and those that exist are small and are struggling to establish themselves. They are experimenting with various approaches and it will take time before they can develop their standard operating procedures fully. There are therefore no hospitals that can be clearly identified as leaders in this industry. Even those that may be identified will be the first to admit that they are still a long way from their own aspirations.
Using non-Islamic for-profit hospitals is also not a viable alternative because of the great differences in approach to health care. This is because Islamic hospitals aim at holistic care (physical, social, and spiritual modalities) within a tauhidi paradigm and in conformity with the Law (shari’at). They therefore have to expend more resources, human and material, in their care than general hospitals. The outcome measures for Islamic hospitals are also more holistic than general hospitals. Thus a for-profit hospital would not be a suitable benchmark for an Islamic hospital.
Using religious not-for-profit hospitals as a benchmark is also not a viable alternative. These hospitals may share compassion and help for the needy with Islamic hospitals. They however have standard operating procedures that are not distinguishable from standard for-profit hospitals. This is because, unlike Islamic hospitals, they do not have guiding principles akin to the Law, shari’at, that guide their operations and practices.
2.2 Financial benchmarking
There is a very dangerous tendency among not-for-profit hospitals to think of themselves as charitable institutions that have to operate far away from the financial concerns found in for-profit institutions. Some managers of not-for-profit institutions even consider fund-raising to support their operations because they cannot stand on their own. This type of thinking makes people relax regarding rigorous financial management.
I think that managers of Islamic hospitals must be more concerned about efficient financial performance more than managers of for-profit hospitals. This is because they expend more resources to provide holistic care but cannot charge very high hospital fees because their clientele is so far not from the richest strata of society. Secondly being in a precarious financial position Islamic hospitals have the thread of financial failure hanging over their heads. They cannot afford to fail financially because whatever else they do well, they will not be around to it if they fail financially. Islamic hospitals like Islamic banks, Islamic schools, and Islamic Universities are part of a larger ummatic civilizational project whose aim is to rebuild ummatic institutions destroyed by colonial invasion and occupation. Therefore failure of any hospital contributes to impairment of a larger ummatic project.
Islamic hospitals must set a basic benchmark to be able to generate revenue to cover their expenses and put aside some for growth or for the rainy day. This will require more efficient financial management than in the best for-profit hospital. The Islamic hospital is in other words being called upon to provide maximum services at the least cost. It will have to outperform the best for-profit institution in the industrially developed countries. Providing more for less will require serious re-engineering of clinical procedures[53], and management procedures (especially purchasing and control of waste).
2.3 Outcome benchmarking
Outcome benchmarking is quite easy. Rates of cure, morbidity, mortality, hospital stay etc are compared directly with those of the benchmark. If there are differences in the baseline characteristics between the internal and benchmark entities, some form of multivariate analysis is used to make adjustments.
2.4 Productivity benchmarks
Productivity is basically counting procedures done or units of work accomplished and comparing with the benchmark. Productivity is closely related to revenue. The hospital must make sure that it uses its human and material resources for maximal productivity.
2.5 Patient satisfaction
The most important issue for Islamic hospitals is patient satisfaction but is also the most difficult to measure. Finding a suitable benchmark is also difficult because Islamic hospitals provide holistic care not found in other institutions.
3.0 CONCLUSIONS
It seems to me that Islamic hospitals cannot benchmark against an industry leader because there are few suitable models. What will happen is that several Islamic hospitals shall meet and through discussion agree on a benchmark for each process. The benchmark should not be static; it can be reviewed regularly to keep up with developments in the hospital industry or just for the sake of improvement. Thus the role of benchmarking can be assigned to the Islamic Hospital Consortia. I think that regional consortium benchmarking will be more successful than international benchmarking because of the great diversity of medical practice at the international level. In terms of priority, Islamic hospitals should start with financial efficiency and patient satisfaction.
NOTES
* Paper first presented at the Islamic Hospital Management Workshop held in conjunction with the 3rd Federation of Islamic Medical Associations (FIMA) Scientific Convention held in Jogjakarta Indonesia on 21st July 2006
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