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Sanigest Internacional White Paper

Benchmarking Hospital Performance in Health

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Benchmarking Hospital Performance in Health

Objective Efforts to assess and rank hospital Objective: 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.

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Benchmarking Hospital Performance in Health

Table of Contents
INTRODUCTION................................................................ ................................................................................................ ............................................................. 4 MEASUREMENT OF HOSPITAL PERFORMANCE IN T UNITED STATES, EUROPE AND LATIN AMERICA ........................ 5 TAL THE ROPE AMERI REVIEW OF HOSPITAL BENCHMARKING TOOLS ................................................................................................ ENCHMARKING ............................................. 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 ................................ ................................................................................................................................ ............................................................ 10 THOMSON & REUTERS TOP 100 HOSPITALS PROGRAM ................................................................................................ .............................................. 10 Scoring System ................................ ................................................................................................................................ ............................................................ 11 HEALTH CONSUMER POWERHOUSE ................................ ................................................................................................................................ ......................................... 11 Scoring System ................................ ................................................................................................................................ ............................................................ 11 NATIONAL HEALTH SERVICES CHOICES HOSPITAL SCORE CARD ................................................................................................ 12 ..................................... Scoring System ................................ ................................................................................................................................ ............................................................ 12 CHKS TOP HOSPITALS PROGRAM ................................ ................................................................................................................................ ........................................... 13 Scoring System ................................ ................................................................................................................................ ............................................................ 13 IASIST TOP 20 HOSPITALS ................................ ................................................................................................................................ .................................................... 13 Scoring System ................................ ................................................................................................................................ ............................................................ 13 WORLD HEALTH ORGANIZATION - PERFORMANCE ASSESSMENT TOOL FOR QUALITY IMPROVEMENT IN HOSPITALS (PATH ) .................... 14 Scoring System ................................ ................................................................................................................................ ............................................................ 14 INTERNATIONAL QUALITY INDICATOR PROGRAM (IQIP) ................................................................................................ .............................................. 14 Scoring System ................................ ................................................................................................................................ ............................................................ 15 LESSONS LEARNED ................................ ................................................................................................................................ ...................................................... 16 DATA ANALYSIS AND COMPOSITE INDEX ................................................................................................ MPOSITE .................................................... 19 QUALITY ASSURANCE ................................ ................................................................................................................................ ............................................................ 21 Background ................................................................ ................................................................................................ ................................................................. 21 Proposed Methodology for Quality Assurance ................................................................................................ ........................................... 22 ADDITIONAL CONSIDERATIONS ................................ ................................................................................................................................ 24 .................................. IMPLEMENTATION STRATEGY................................ ................................................................................................................................ .................................................. 24 SANIGEST INTERNATIONAL ................................ ................................................................................................................................ ..................................................... 25 ANNEX 1: INDICATORS USED BY VARIOUS HOSP HOSPITAL BENCHMARKING SYSTEMS ....................................................... 26 ................................

Tables
TABLE 1: LIST OF HOSPITAL BENCHMARKING INITIATIVES REVIEWED ................................................................ .................................................. 5 TABLE 2: PROPOSED INDICATORS FOR PILOT PROJECT BY CATEGORY ................................................................ ................................................. 18

Figure
FIGURE 1: STRUCTURE OF THE LATIN AMERICAN HOSPITAL BENCHMARKING TOOL .......................................................... 20 ................................
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Benchmarking Hospital Performance in Health

Introduction
Hospitals 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 countries, such as those found in many emerging markets, hospitals income 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 his disparities that exist in this region. There are four principal methods of measuring hospital performance: regulatory inspection, public satisfaction surveys, third-party assessment and comparison of statistical indicators. The majority of party assessment 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 third-party 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, many hospitals in the North America and Europe have undergone accreditation processes rmore, 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 Hospital 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 healthcar 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 to choose the most appropriate indicators for clinicians their healthcare system or hospital.

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How can hospital performance be measured and monitored? WHO Regional Office for Europe’s Health Evidence Network. August 2003.
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a measure of patient e experience/satisfaction is also commonly included in many of these instruments.sanigest.Page |5 Benchmarking Hospital Performance in Health Measurement of Hospital Performance in the United States. 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. In creating our proposed indicator set for hospital ranking and benchmarking. Table 1: List of Hospital Benchmarking Initia : Initiatives Reviewed PROJECT TITLE CHKS Top Hospitals Program Health Consumer Powerhouse HealthInsight National Rankings for Hospitals Hospital Compare IASIST Top 20 Hospitals International Quality Indicator Program Leapfrog Group COUNTRY/REGION United Kingdom European Union United States United States Spain International United States YEAR INITIATED 2001 2005 2004 2003 2000 1997 2001 © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest. we examined benchmarking systems from around the world that used statistical indicators to measure hospital tors performance (Table 2).com | Skype: sanigest .com | www. to assess hospital performance. The areas in which hospital performance can be assessed and the rationale for doing so are varied. Europe and Latin America Many governments. as such a tionale diverse range of instruments have emerged with varying indicator sets. some in partnership with each other. Benchmarking tools that have emerged in the United States and Europe have primarily focused on outcome and process of care measures. non-governmental institutions governmental and members of the private sector have initiated or engaged in projects.

com | www.Page |6 Benchmarking Hospital Performance in Health PROJECT TITLE Michigan Manufacturing Technology Center (MMTC) National Health Services (NHS) Choices Hospital Scorecard Thomson & Reuters Top 100 Hospitals US News & World Report World Health Organization Performance Assessment Tool for Quality Improvement in Hospitals (PATH) COUNTRY/REGION United States United Kingdom United States United States International YEAR INITIATED 2005 2008 1994 1990 2004 © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.sanigest.com | Skype: sanigest .

Page |7 Benchmarking Hospital Performance in Health Review of Hospital Benchmarking Tools Various methodologies have been employed to rank and benchmark hospital performance. An internet search was performed using search terms including hospital performance.hhs. and ranking hospitals.com | www. Scoring System Hospital Compare doesn’t rank hospitals. Publically available data from benchmarking and healthcare organizations were reviewed including but not limited to WHO reports on measuring ed hospital performance.gov © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest. A literature review was undertaken to learn from the diverse experiences of hospitals and organizations that have already undertaken ranking and benchmarking processes. rather it reports the percentage of patients for which a given indicator was performed/completed (i.e.hospitalcompare. discussion papers regarding the creation of the WHO Performance Assessment Tool for Quality Improvement in Hospitals and sample benchmarking reports from the Michigan Manufacturing Technology Center. Hospital Compare Hospital 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. benchmarking tools. Website: www.gov . Comparative graphs are also available in which the nationwide and state averages for all s hospitals reporting that indicator are displayed alongside the score for the specific hospital(s) chosen. The results of the literature review are presented below.sanigest.com | Skype: sanigest . The four areas in which hospital performance is measured four 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.hhs. hospital comparison. 98% of the time patient received prophylactic antibiotics prior to surgery).

The Leapfrog Group uses the following structural indicators to measure hospital per 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 om is welcome to participate). It uses publicly reported data from the Centers for Medicare & Medicaid Services (CMS) Hospital Compare website to conduct the hospital rankings. © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest. heart failure. they target hospitals predominantly in areas where their members have a large presence. Website: www. pneumonia and surgical infection prevention as set out by CMS.org 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.sanigest.com | www. Unlike Hospital Compare. here hospital performance is measured by using structural indicators instead of clinical ones to produce a composite index of hospital performance.Page |8 Benchmarking Hospital Performance in Health HealthInsight National Rankings for Hospitals HealthInsight is a private not-for-profit organization that conducts various health performance rakings profit including national rankings for hospitals. Scoring system Hospitals are ranked based on their overall success rate for performing the process of care measures for the above mentioned conditions. Leapfrog has a comprehensive incentive and rewards program to encourage and reward hospitals for participating in their program and implementing their quality/safety standards.com | Skype: sanigest . rankings are converted and reported as percentiles. Hospitals voluntarily submit data if they agree to participate in the program. home health agencies and nursing homes in an effort to improve healthcare systems in Nevada and Utah. Healthinsight measures hospital performance by examining the process of care measures for acute myocardial infarction.healthinsight.

. 12 of which are based on hard data while the remaining four are based on nominations by specialists that were surveyed. Website: http://www. Scoring System MMTC reports a hospital’s relative performance on each measure within a comparison group of similar hospitals.aspx US News & World Report Every year the US News & World Report releases a list of the best hospitals in the United States. oncology.g. © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.Page |9 Benchmarking Hospital Performance in Health Scoring System Leapfrog uses a scoring algorithm to come up with their ratings which fall into five categories.leapfroggroup.org Michigan Manufacturing Technology Center (MMTC) This benchmarking system uses 23 metrics to measure a hospital’s performance. The five categories are: • • • • • Declined to respond Willing to report Some Progress Substantial Progress Fully Meets Standards Website: www.com | Skype: sanigest . hospital percentile rankings range from 0 (worst in the group) to 100 (best in the group).org/hospital. It ranks hospitals based on 16 specialty areas (e. cardiology).com | www. 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. 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.sanigest.performancebenchmarking.

usnews. full-field image-guided full digital mammography) In addition to the above mentioned criteria. Scoring System A score from 0 – 100 is assigned based on three factors that are given equal weight: 1. technology. The organization-wide performance is then compared against national benchmarks.com | Skype: sanigest .P a g e | 10 Benchmarking Hospital Performance in Health To be considered for one of the 12 data driven specialties hospitals had to meet one of the following data-driven criteria: • • • Be a member of the Council of Teaching Hospitals and Health Systems Be affiliated with a medical school Have at least a certain number of key technologies (e. image guided radiation therapy. Reputation (random sample of 200 physicians from ABMS database) 2.sanigest.com | www.. hospital is measured including that of the Board. wide Hospitals 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 © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest. volume. patients Hospitals that meet all these criteria were then ranked.com/sections/health/best-hospitals Thomson & Reuters Top 100 Hospitals Program The primary goal of this program is to objectively identify US hospitals that have the best organization organizationwide performance and make this data publically available. hospitals also had to perform a minimum number of specified procedures (specialty dependent) on Medicare patients to qualify for ranking.com/sections/health/best http://health. executives and health care professionals. The performance of all members of the available.usnews. Website: http://health. Death rate (mortality index) 3.g. Care-related factors (nursing staff. patient services) related Hospitals with the 50 highest scores are subsequently ranked.

0 1.0 2.sanigest.P a g e | 11 Benchmarking Hospital Performance in Health Scoring System Statistical analyses of publically available data sources is carried out to rank hospitals.0 © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.com | Skype: sanigest . Website: http://www.5 2.com Health Consumer Powerhouse Health 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.0 1.100tophospitals.com | www. It examines indicators in the following 5 sub 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: discipline Sub discipline Patient rights and information Waiting time for treatment Outcomes “Generosity” Pharmaceuticals Relative weight 1. Hospitals are sources scored based on a set of weighted performance measures spanning the following 4 areas: • • • • Clinical excellence Operating efficiency Financial health Responsiveness to the community Hospitals are subsequently ranked relative to their comparison group. median and quartile values are ently reported.

sanigest. information is only compared. • • • • • • • • • • Wait time from referral to treatment Length of stay in hospital Risk of readmission (rated – lower than expected. These percentages are then multiplied by 133. higher than expected) er Experience of surgical department with specific procedure Patient rating of care received Patient experience during treatment (respect. feeling involved ) Survival rate for elective procedure (rated – better than. 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 discipline subsequently multiplied by the weight coefficients and added up to make the final country score. each indicator has a maximum possible score of 3. and rounded to a three digit integer. Hospitals are not ranked against each other. the maximum total score is 1000 indicating “the perfect healthcare system”. National Health Services Choices Hospital 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.P a g e | 12 Benchmarking Hospital Performance in Health Furthermore. 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).uk/ServiceDirectories/Pages/ServiceSearch.nhs.aspx © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest. expected. pending The following are the areas in which hospitals are assessed.com | www. fair (yellow) or weak (red). Website: https://www.com | Skype: sanigest . dignity.

iasist.chks.P a g e | 13 Benchmarking Hospital Performance in Health CHKS Top Hospitals Program CHKS is a healthcare benchmarking company that annually prepares a benchmarking repo on UK report hospitals using data from the National Health Care service.com/en/top--20 © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest. all indicators are equally weighted and summed once normalized.uk/ IASIST Top 20 Hospitals Top 20 Hospitals is a hospital assessment program that benchmarks public and private hospitals in Spain.co. however.com/en/top http://www.iasist. Top 20 hospitals use six indicators in the following three areas to carry out its benchmarking: to • • • Quality Functioning Clinical practice Scoring System It is not clear how the scoring and ranking system for IASIST works. Website: http://tophospitals. Website: http://www. Performance is based on 20 indicators in the following five areas: • • • • • Clinical effectiveness Health 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).com | Skype: sanigest . from these two values an index is derived and hospitals are subsequently ranked.com | www.sanigest.

com | www. Canada and Africa have participated in a pilot project using this assessment tool. It has a variety of performance metrics depending on s the type of health care institution as does the IQIP. The QIP collects data on quality of patient care and seeks to identify opportunities for improvement. 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.P a g e | 14 Benchmarking Hospital Performance in Health World Health Organization .Performance Assessment Tool for Quality Improvement in Hospitals (PATH ) In 2003. additional tailored indicators exists that can also be used. This tool was named Performance Assessment Tool for quality improvement in Hospitals (PATH). the World Health Organization (WHO) Regional Office for Europe initiated a project to develop a tool to measure hospital performance. the IQIP examines acute care process and outcome measures in the . 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 hospitals and resource availability. following areas: © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest. Hospitals in Europe.sanigest.com | Skype: sanigest . For acute care institutions. rather it reports the following comparative data: it • • • • • 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 Indicator Program (IQIP) dicator The International Quality Indicator Program is a branch of the Quality Indicator Program (QIP) that was first developed in the US over 20 years ago. Scoring System The PATH tool does not rank hospitals. IQIP is the only other international hospital assessment program aside from the WHO’s PATH program.

Website: http://www.com | Skype: sanigest . median. Pancreatic. minimum and maximum rates. 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. denominators. rather it produces an institution specific report for participants every institution-specific quarter. more narrowly user-defined peer group reports can also be obtained. Biliary Tract.P a g e | 15 Benchmarking Hospital Performance in Health Acute Myocardial Infarction Cardiac Surgery Colorectal Surgery Appendectomy Hysterectomies Maternity and Childbirth birth Patient Safety Infection Control Ambulatory Care Heart Failure Pneumonia Vascular Surgery Liver. analyze and compare their data.internationalqip. providing both historical and comparative data for each measure that data was submitted for. outcomes reported include numerators.com | www. or Gallbladder Surgery Hernia Surgery Orthopedic Surgery Emergency Care Intensive Care Units Internal Medicine Methyllin Resistant Staphylococcus Aureus (MRSA) s Over 180 health care organizations in 12 countries use IQIP and its indicators to collect. defined Depending on the nature of the data.sanigest. means (weighted and unweighted). standard deviation and q quartiles.com © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.

et al. San Francisco © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest. 20(3). expenditure and absenteeism. and how should we use it? Mehrotra A. The relevant 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. Groene O. Quality Health Care. The PATH project also stated that a lack of personnel. 20(3).sanigest. focusing particularly on indicators that may be relevant in the Latin American context. resource availability and cultural differences between regions and countries may be hurdles that have to be overcome when implementing a benchmarking tool. Frolich A. 2008. Intl J.com | www. challenges to implementation of such a tool and any other relevant lessons that surfaced . consideration of various stakeholder interests and technical support during data collection have all been sited as essential parts of a successful quality indicator program. 4 Hospital performance evaluation: What data do we want.P a g e | 16 Benchmarking Hospital Performance in Health Lessons Learned In developing the proposed ranking and benchmarking tool we reviewed and summarized 12 benchmarking systems. Intl J. it can be atient improved and collection of this type of data is inexpensive and most hospitals already gat gather this 4 type of information. 2008. Institute for Health Policy Studies University of California. RA Dudley. Different stages of development and organizational structures in institutions. • • • • • • 2 The World Health Organization Performance Assessment Tool for Quality Improvement in Hospitals (PATH): An analysis of the pilot implementation in 37 hospitals. surgical theatre use. the relevance of data is greater with process and outcome of care measures in regards to quality and performance measurement. Quality Health Care. in The institutional embedding of the performance measurement project at the regional/national level. 3 An international review of projects on hospital performance assessment. It is important to ensure that the selected indicators reflect measurement areas that are relevant to a broad range of institutions. however. how do we get it.com | Skype: sanigest . expertise an and 2 time for participating hospitals to collect data was an issue. resources. Groene O. Skau JK. The PATH project found that the burden of data collection was too PATH high for four of their indicators in particular – antibiotic use. Lee S. 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. 3 Patient experience appears to be a good indicator to include as it is measurable.

hospital policies and patient experience. Finally. Hospitals cannot function without resources 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. hospital clinical effectiveness and efficiency. Overall this component consists of the two sub components that attempt to gauge the ent sub-components readiness and ability of a hospital to serve its community. The Hospital 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 areas thus form the sub-components of this category. it is essential to ascertain the technological resources available to staff to carry out their duties. sub-component o Furthermore. facilities and technologies available are therefore the second and last sub sub-dimension of this category. infection and readmission assessed.com | www. diagnostics and the emergency department are considered to determine if services are being received in a timely manner. The Hospital 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. sub-components The Hospital Policies and Patient Experience component attempts to evaluate two important but s 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. wait times in a areas such as surgery. ded thus outcomes of care and process of care are the two sub components of this category.sanigest. it was decided that indicators for the proposed ranking and benchmarking tool would be selected based on the following criteria: osed • • • • 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. A effectiveness description of the reasoning behind each choice follows: The Hospital Infrastructure and Resources component was selected to capture information outlining both the technical and human resources available to hospitals.P a g e | 17 Benchmarking Hospital Performance in Health On the basis of the above review and subsequent lessons learned. These two sub-components will allow for the calculation of staff: patient ratios and provide a sense of components whether hospitals are operating under optimal staffing conditions. hospital volumes and wait times. components © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest. Not only are outcomes such as mortality. process of care measures are also included to determine if hospitals are employing current best practices in their clinical service provision.com | Skype: sanigest .

Staff (training) 3. Medical Facilities (availability) 1.Acute myocardial infarction (AMI) . Process of care measures . Surgery (wait times) 4. Hospital Needleless policy (whenever possible) (present or absent) 6. Cancer Treatment Wait Times (wait time from time requested to time of treatment) equested 1.readmission rates ( i. Patient satisfaction survey (overall satisfaction rating) Hospital Infrastructure and Resources Hospital Volumes and Wait Times Hospital Clinical Effectiveness and Best Practices Hospital Policies and Patient Experience © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest. Patient access to own medical records 3. Hospital No-lift policy (present or absent) lift 5.e. Diagnostic Tests (i.e.hospital wide survival/mortality rates . Medical Equipment (availability) 4. CHF.P a g e | 18 Benchmarking Hospital Performance in Health Table 2: Proposed Indicators for Pilot Project by Category : INDICATOR CATEGORY PROPOSED INDICATORS 1. Hospital Patient’s rights law (present or absent) 2. AMI.com | Skype: sanigest . Hospital Latex-free policy (present or absent) free 4. Emergency Department (wait times to see physician) 5. Outcome of care measures .Congestive heart failure (CHF) . CT scan. MRI) (wait times from time requested to performance of test) 6. Staff (volumes) 2.infection rates .length of stay (risk-adjusted – all adjusted discharges) . Patient (volumes) 2. Selected Procedures (volumes) 3. elective and emergency surgery) 2.com | www.Pneumonia 1.sanigest.

The normalization process is represented by Equation (1) where NVi. © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.5 will be 2. OVi.j the observed value for indicator i for hospital j and AVGi the average score for the indicator across hospitals: Equation (1): NVi.com | www. 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 multiplied by five. For example a hospital that receives a score of 7.j * 5 AVGi For the sub-components of the index.j represents the normalized score of indicator i for hospital j. for example components the average for all Volume related indicators in the Hospital Volumes and Wait Times componen will component be calculated and then weighted according to the corresponding weight of each sub sub-component.j = OVi. This will create results that are subsequently normalized to fall within a range of zero to ten and have a mean of five.sanigest. thus allowing for easier interpretation and comparison of results.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. this will create a sub index for each of the four components as outlined below that will sub-index then make up the overall benchmarking index (Figure 2 2). simple averages will be calculated for all indicators. Consequently.com | Skype: sanigest .P a g e | 19 Benchmarking Hospital Performance in Health Data Analysis and Composite Index Once data collection is complete and verified.

F10 Indicators G1. indicating no data or no action to 10. The majority of the selected indicators represent continuous data (83%) such that their values will either be percentages or absolute values.G5 Indicators H1 Hospital Infrastructure & Resources Index Hospital Volumes & Wait Times Index Hospital Clinical Effectiveness & Best Practices Index Hospital Policies & Patient Experience Index Latin American Hospital Performance Composite Index The scale for each indicator will range from zero. The four main components that comprise the composite index will be weighted equally (one-quarter (one each) to reflect the importance. Volumes D. Outcome of Care Measures F.D5 Indicators E1. Wait Times E. Process of Care Measures G. while a small percentage of the indicators produce binary data (17%).com | www. value and interdependence of all components in contributing to hospital performance. Hospital Staffing & Training B.E10 Indicators F1.P a g e | 20 Benchmarking Hospital Performance in Health Figure 1: Structure of the Latin American Hospital Benchmarking Tool : Hospital Infrastructure & Resources Component Hospital Volumes & Wait Times Component Hospital Clinical Effectiveness & Best Practices Component Hospital Policies & Patient Experience Component A. Patient Experience Indicators A1. Hospital Policies H. the eight sub-components however. Reporting no data for an indicator will result in a score of zero to encourage hospitals to systematically collect and report encourage the missing information.com | Skype: sanigest . indicating optimal performance in regards to achieving the highest standard for that indicator.B8 Indicators C1.A5 Indicators B1. Facilities & Technology Available C. penalizing hospitals for not reporting data will also ensure fairness in the final standings. will not necessarily be of equal weight. Binary data will be rescaled to continuous variables using a scale from 0 – 10.C4 Indicators D1.sanigest. The over components overall composite index is therefore represented by the following equation: © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.

com | www. untimely data collection practices) Staging errors (i. made Various methodologies were consulted in developing this composite index including the OECD Handbook for Constructing Composite Indexes5and the World Bank Composite HIV/AIDS Response Index.e.P a g e | 21 Benchmarking Hospital Performance in Health Equation (2): Composite Index = 1 * HIRI + 1 * HVWI + 1 * HCEBPI + 1 * HPPEI 4 4 4 4 Hospitals will be separated into peer groups to make for fair comparisons. 6 World Bank. It has also been shown that the inclusion of fact. 2008.6 Quality Assurance Background Assuring the quality of the data submitted by hospitals is very important as the integrity of the results lity and the conclusions that can be drawn from them are based on this. monitor. Composite HIV/AIDS Response Index: Benchmarking Eastern Europe and Central Asia Country Performance in Response to HIV/AIDS 7 Berndt DJ. For example hospitals may be divided into categories of public or private institutions and then further sub divided by number of beds sub-divided or teaching status. Once the ranking is carried out. processed and warehoused the following five errors are guarded warehoused against.e.com | Skype: sanigest .7 5 Organisation for Economic Co-operation and Development. Handbook on Constructing Composite operation Indicators: Methodology and User Guide. Healthcare data warehousing and quality assurance.e.sanigest. improper data alignment) Query errors (i. incompatible units) Collection errors ( i. • • • • • Design or conformation errors (i. for easy rried interpretation of the overall performance index.e. Fisher JW. improper query formation) A quality assurance strategy for healthcare data must assess. data will be transformed into a visual representation. improper translation processes) Data integration (i.e. aggregate and dimensions filters inclusion can improve the quality of data collected to perform ranking and benchmarking. Indicator specific comparisons and data on the number of hospitals that participated and the number of cases involved will also be made available. Hevner AR and Studnicki J. and ultimately prevent these five types of data errors. Healthcare © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest. incorrectly recorded values. It is therefore important to ensure that when the data is being collected.

56-65.5 %) will be verified with original sources for all participating hospitals. as it is a comprehensive tool that enables them to Medicaid. December 2001.P a g e | 22 Benchmarking Hospital Performance in Health 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. 34(12). a random sampling of records (1 . Once data has been received from institutions and before it is processed. 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. it is important that the standard measures and benchmarking definitions that will be provided are understood by the participating institutions.sanigest. Only once these processes are complete are data included into the PATH database for further analysis. The health care institution reporting the data is responsible for the quality of the data being submitted. while the US Department of Health and Human Services tests data at the following levels to and 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. 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. as such training will be provided in regards to the indicator set and the standardized data collection pro procedures that will be employed.com | www. The application is available at no charge to hospitals or other organizations that seek to improve the quality of care in t following the clinical areas: • • • • Acute Myocardial Infarction (AMI) Heart Failure (HF) Pneumonia (PN) Surgical Care Improvement Project (SCIP) The US Department of Health and Human Services has a Data Integrity Verification Strategy that may prove useful. © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.com | Skype: sanigest . measures need to be embedded throughout various steps of the benchmarking process. An accuracy score will be assigned to each institution based on the following equation: Computer. conduct retrospective analyses and do real time reporting. First. collect data. 65.

com | www. source to post-processing target verification and transformation verification will be employed.com | Skype: sanigest . Furthermore.Number of inaccurate variables * 100 Total # of variables verified The minimally acceptable accuracy score is 80%. The feasibility of con conducting independent audits of the participating institutions will be considered for future versions of the benchmarking tool. values below this cutoff will not be included in the database for processing. Upon passing the data quality assessment. © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest. post processing measures such as source to target counts. Automated data edits will be built into the processing system such that missing or out of range into data will be identified.P a g e | 23 Benchmarking Hospital Performance in Health Equation (3): Accuracy Score = Total # of variables verified . data will be processed into the central database.sanigest.

com | Skype: sanigest .P a g e | 24 Benchmarking Hospital Performance in Health 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. • Seek out funders for initial ranking project.com | www.sanigest. define documentation procedure Establish time frame for data collection • • • • • • • • © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest. The following phase strategy seeks to establish a preliminary framework in which the ranking and benchmarking project will which be carried out. until the project becomes self-sustaining sustaining Assign project manager to be the contact person for hospitals that show interest and want hospitals further information or want to become involved. 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). potentially health insurers or drug companies. adjustments to indicator set will be made based on feedback from hospitals will Identify steps required to develop required information infrastructure. 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. 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.

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 by its ISO 9001:2008 certification. implement and deliver a high impact hospital ranking and benchmarking tool for Latin America.sanigest.P a g e | 25 Benchmarking Hospital Performance in Health Sanigest International Sanigest International is a healthcare consulting and management firm based out of San Jose. Sanigest’s experience spans the globe with extensive experience in the developing nations of Latin America such as Costa Rica. Belize. Ecuador. El Salvador such and Nicaragua. Sanigest is optimally suited and equipped to design.com | www. © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest. Colombia. In Slovakia. For over a decade. a health purchasing plan and implementing a management information system in Belize.com | Skype: sanigest . Sanigest created a hospital restructuring plan and defined provider payment mechanisms and a health insurance regulatory frame work. Some of Sanigest’s most evidenced recent success stories include successfully defining a National Health Insurance basic package of services. Costa Rica with additional offices in the United States and Europe.

com | Skype: sanigest .P a g e | 26 Benchmarking Hospital Performance in Health ANNEX 1: Indicators Used by Various Hospital 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 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 Hospital Compare 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 ients 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 postoperativ blood glucose postoperative 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 adjusted • • • Acute Myocardial Infarction Heart Failure Pneumonia Patient Satisfaction • Patient survey of Hospital Experience Acute Myocardial Infarction HealthInsight • • Aspirin at arrival Aspirin at discharge © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.com | www.sanigest.

P a g e | 27 Benchmarking Hospital Performance in Health 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 antib 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 ery Cardiac surgery patients with controlled 6 AM postoperative blood glucose Surgery patients with appropriate hair removal Structural indicators Leapfrog Group • • • • Computerized physician order entry (CPOE) system ICU staffing High risk treatments (evidence based hospital referral) Safe practice scores Hospital Policies • • • No lift policy (use lifts to raise patients to avoid staff and patient injury) Latex-free policy free 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 © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.com | www.sanigest.com | Skype: sanigest .

sanigest.com | Skype: sanigest . Case Case-Mix adjusted % of discharges made before noon Mean outpatient door door-to-door time (min) Mean Emergency Dept Door Door-to-Physician time (min) Mean Troponin Lab test turnaround time (min) Mean radiology order transcription time (hrs) order-to Clinical Outcomes and Services US News & World Report • • • • • • • Risk adjusted mortality Reputation Number of discharges Nurse staffing Nurse Magnet hospital Advanced technologies Patient services 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 Thomson & Reuters Top 100 Hospitals Program Heart Failure • • • Evaluation of left ventricular systolic (LVS) function ACE Inhibitor or Angiotensin Receptor Blocker for Left Ventricular Systolic Dysfunction Discharge instructions © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest. Productivity.com | www.P a g e | 28 Benchmarking Hospital Performance in Health BENCHMARKING SYSTEM INDICATORS INCLUDED Pneumonia • • • Oxygenation assessment Initial antibiotic timing (within 4hrs) Pneumococcal vaccination Clinical outcomes • • • • Hospital-wide Mortality Index wide % 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. Asset Utilization and Throughput • • • • • • • • • • • • • • • Operating (profit) margin Dollars of Expenses per Case Mix 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 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).

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 yr © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.com | Skype: sanigest .P a g e | 29 Benchmarking Hospital Performance in Health 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 surg 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 (case-mix and wage-adjusted) Cash to total debt ratio 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 Health Powerhouse Consumer Waiting Times • • • • • Family doctor same day service Direct access to specialist care Major non-acute operations Cancer.com | www.sanigest.

com | www.000 citizens (age adjusted) Infant 4-disease vaccination disease Kidney transplants per million population Is dental care a part of the offering from public healthcare system Pharmaceuticals • • • • Prescription subsidy % escription Layman-adapted pharmacopoeia adapted Speed of deployment of novel cancer drugs Access to new drugs Clinical Effectiveness and Safety National Health Services Choices Hospital Scorecard • • • • • • • • • 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 • • • • • • • Risk adjusted mortality (or mortality index) Rate of emergency readmission to hospital .000 MRSA Generosity of Public Healthcare Systems • • • • Cataract operation rates per 100.P a g e | 30 Benchmarking Hospital Performance in Health BENCHMARKING SYSTEM INDICATORS INCLUDED • • Avoidable deaths – potential years of life lost (PYLL)/ 100. difficile for patients ≥ 65 yrs CHKS Top Program Hospitals 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 op Pre-op length of stay for elective surgery op % elective in in-patient admission with no procedure Missed out out-patient appointments (1st attendance) Overall data quality Procedures not carried o (hospital decision) out Waiting times for common diagnostic procedures Clinical Effectiveness and Safety © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.com | Skype: sanigest .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.sanigest.

coronary artery bypass graft) bypass 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 Health care transitions Patient Centeredness Patient expectations Surgical Care Improvement Project International Quality Indicator 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 © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest. stroke.com | www. community acquired pneumonia.com | Skype: sanigest . hip fracture.sanigest.P a g e | 31 Benchmarking Hospital Performance in Health BENCHMARKING SYSTEM INDICATORS INCLUDED • • • • • • Risk adjusted mortality Risk adjusted complications index Risk adjusted length of stay Readmissions index (risk (risk-adjusted) Surgery index (without adjust incomes) adjusted Cost per unit of production IASIST Top 20 Hospitals Clinical Effectiveness and Safety World Health Organization .Performance Assessment Tool for Quality Improvement in Hospitals (PATH ) • • • • • • • Caesarean Section Prophylactic Antibiotic Use (surgery) Mortality (Acute myocardial infarction.

P a g e | 32 Benchmarking Hospital Performance in Health 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 sections Total C-sections sections Vaginal births after C C-sections Process of Care Measures • Active surveillance cultures for MRSA Clinical Effectiveness and Safety • • • • • • • • • • • • • • • • • • • • • Device-associated infections in ICU associated Device-associated infections in ICU due to MRSA associated 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 throm thromboembolism following surgery Multi-drug resistant organisms drug © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.sanigest.com | www.com | Skype: sanigest .

7 8.3 8.3 Efficiency Length of stay Surgical theatre use 2 1 16.3 1 8.3 1 2 1 1 1 8.3 8.sanigest. stroke. hip fracture.com | Skype: sanigest . coronary artery bypass graft) Readmission Day surgery for 8 tracers Admission after day surgery (same 8 tracers) Return to ICU WHO PATH Leapfrog Group Hospital Compare HealthInsight IASIST Top 20 Hospitals (Spain) Total Counts for Indicator 1 1 % of systems with indicator 8. community acquired pneumonia.3 8.3 Staff Orientation & Safety Training expenditure Absenteeism Working excessive hours 1 1 8.com | www.3 16.P a g e | 33 Benchmarking Hospital Performance in Health APPENDIX IV: MATRIX OF INDICATORS FROM REVIEWD HOSPITAL BENHCMAKRING SYSTEMS HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS Health Consumer Powerhouse MMTC Community Hospital Benchmarking Survey International Quality Indicator Project National Health Service ScoreCard (UK) CHKS 40 Top Hospitals (UK) US News & World Report Thomson & Reuters Top 100 Clinical Effectiveness & Safety Caesarean Section Prophylactic Antibiotic Use (surgery) Mortality (Acute myocardial infarction.3 © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.7 8.3 8.

3 8.3 1 1 8.3 8.P a g e | 34 Benchmarking Hospital Performance in Health HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS Health Consumer Powerhouse MMTC Community Hospital Benchmarking Survey International Quality Indicator Project National Health Service ScoreCard (UK) CHKS 40 Top Hospitals (UK) US News & World Report Thomson & Reuters Top 100 WHO PATH Leapfrog Group Hospital Compare HealthInsight IASIST Top 20 Hospitals (Spain) Total Counts for Indicator % 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 Health care transitions Patient Centeredness Patient expectations 1 1 8.com | Skype: sanigest .com | www.sanigest.3 Patient rights information & © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.3 1 8.3 1 8.3 8.3 1 1 8.

3 8.3 1 8.3 1 1 8.3 8.com | Skype: sanigest .3 8.sanigest.3 8.3 Direct access to specialist care Major non-acute operations Cancer.com | www. radiation/chemotherapy 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 100.3 © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.3 8.P a g e | 35 Benchmarking Hospital Performance in Health HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS Health Consumer Powerhous e MMTC Community Hospital Benchmarkin g Survey Internationa l Quality Indicator Project National Health Service ScoreCard (UK) CHKS 40 Top Hospitals (UK) US News & World Report Thomson & Reuters Top 100 WHO PATH Leapfrog Group Hospital Compare HealthInsigh t IASIST Top 20 Hospitals (Spain) Total Counts for Indicator 1 1 1 1 % of systems with indicator 8.3 8.000 citizens (age adjusted) 1 1 1 8.

3 .7 8.com | www.P a g e | 36 Benchmarking Hospital Performance in Health HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS Health Consumer Powerhouse MMTC Community Hospital Benchmarking Survey International Quality Indicator Project National Health Service ScoreCard (UK) CHKS 40 Top Hospitals (UK) US News & World Report Thomson & Reuters Top 100 WHO PATH Leapfrog Group Hospital Compare HealthInsight IASIST Top 20 Hospitals (Spain) Total Counts for Indicator % of systems with indicator Cataract operation rates per 100.3 1 8.3 1 8.3 Kidney transplants per million population Is dental care a part of the offering from public healthcare system Pharmaceuticals Prescription subsidy % 1 1 8.sanigest.3 Layman-adapted pharmacopoeia Speed of deployment of novel cancer drugs 1 2 16.3 1 8.com | Skype: sanigest 1 1 1 8.3 8.3 8.3 8.3 Access to new drugs Structural Indicators Computerized physician order entry (CPOE) system ICU staffing High risk treatments (evidence based hospital referral) © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.000 citizens (age adjusted) Infant 4-disease vaccination 1 8.

3 33.3 Safe practice scores Process of Care Measures 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 Beta Blocker at arrival 4 4 33.com | Skype: sanigest .0 © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.P a g e | 37 Benchmarking Hospital Performance in Health HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS Health Consumer Powerhouse MMTC Community Hospital Benchmarking Survey International Quality Indicator Project National Health Service ScoreCard (UK) CHKS 40 Top Hospitals (UK) US News & World Report Thomson & Reuters Top 100 WHO PATH Leapfrog Group Hospital Compare HealthInsight IASIST Top 20 Hospitals (Spain) Total Counts for Indicator 1 % of systems with indicator 8.3 33.com | www.3 25.0 25.0 3 3 3 25.3 4 4 3 33.0 25.sanigest.

3 25.0 25.P a g e | 38 Benchmarking Hospital Performance in Health HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS Health Consumer Powerhouse MMTC Community Hospital Benchmarking Survey International Quality Indicator Project National Health Service ScoreCard (UK) CHKS 40 Top Hospitals (UK) US News & World Report Thomson & Reuters Top 100 WHO PATH Leapfrog Group Hospital Compare HealthInsight IASIST Top 20 Hospitals (Spain) Total Counts for Indicator % 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 4 33.3 33.com | www.sanigest.0 © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.0 4 4 4 3 33.com | Skype: sanigest .0 3 25.3 4 3 3 33.3 25.3 33.

sanigest.P a g e | 39 Benchmarking Hospital Performance in Health HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS Health Consumer Powerhouse MMTC Community Hospital Benchmarking Survey International Quality Indicator Project National Health Service ScoreCard (UK) CHKS 40 Top Hospitals (UK) US News & World Report Thomson & Reuters Top 100 WHO PATH Leapfrog Group Hospital Compare HealthInsight IASIST Top 20 Hospitals (Spain) Total Counts for Indicator 3 3 % of systems with indicator 25.7 © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.0 25.7 3 25.0 2 2 16.3 25.com | www.3 4 3 33.0 2 16.com | Skype: sanigest .7 16.0 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 4 33.

3 1 1 1 8.3 8.3 © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.sanigest.3 8.com | www.3 8.3 8.com | Skype: sanigest .P a g e | 40 Benchmarking Hospital Performance in Health HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS Health Consumer Powerhouse MMTC Community Hospital Benchmarking Survey International Quality Indicator Project National Health Service ScoreCard (UK) CHKS 40 Top Hospitals (UK) US News & World Report Thomson & Reuters Top 100 WHO PATH Leapfrog Group Hospital Compare HealthInsight IASIST Top 20 Hospitals (Spain) Total Counts for Indicator % 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 1 8.3 8.3 Management of Labour Primary C-sections Repeat C-sections Total C-sections Vaginal births after Csections 1 1 1 1 8.3 1 8.

3 Heart Failure Pneumonia Patient survey of hospital experience (i.sanigest.3 30 day risk-adjusted mortality rate Acute Infarction Myocardial 1 1 1 8.com | www.P a g e | 41 Benchmarking Hospital Performance in Health HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS Health Consumer Powerhouse MMTC Community Hospital Benchmarking Survey International Quality Indicator Project National Health Service ScoreCard (UK) CHKS 40 Top Hospitals (UK) US News & World Report Thomson & Reuters Top 100 WHO PATH Leapfrog Group Hospital Compare HealthInsight IASIST Top 20 Hospitals (Spain) Total Counts for Indicator % of systems with indicator Other Process of Care Measures Active surveillance cultures for MRSA Outcome Measures of Care 1 8.3 8.3 1 © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.e.3 1 8.3 8.3 .com | Skype: sanigest 8. Consumer Assessment of Healthcare Providers & Systems (CHAPS)) Other clinical outcomes Hospital-wide Mortality Index % of cardiac patients with acute readmission within 31 days 1 8.

3 8.3 Inpatient mortality Neonatal mortality Perioperative mortality Total unscheduled readmissions within 15 and 31 days Unscheduled admissions following ambulatory procedures Unscheduled returns to ICU 1 8.3 1 1 8.3 8.3 8.3 8.3 8.3 1 1 1 1 1 8.3 1 1 8.com | Skype: sanigest .3 8.com | www.P a g e | 42 Benchmarking Hospital Performance in Health HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS Health Consumer Powerhouse MMTC Community Hospital Benchmarking Survey International Quality Indicator Project National Health Service ScoreCard (UK) CHKS 40 Top Hospitals (UK) US News & World Report Thomson & Reuters Top 100 WHO PATH Leapfrog Group Hospital Compare HealthInsight IASIST Top 20 Hospitals (Spain) Total Counts for Indicator % of systems with indicator % of patients with unscheduled Inpatient returns to OR within same stay % of Inpatient admissions following unscheduled returns to Emergency Dept within 72 hrs Device-associated infections in ICU Device-associated infections in ICU due to MRSA Surgical infections site 1 8.sanigest.3 © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.

3 8.3 1 8.sanigest.3 1 8.3 .3 8.com | Skype: sanigest 8.3 1 1 8.3 1 8.3 8.3 1 © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.com | www.P a g e | 43 Benchmarking Hospital Performance in Health HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS Health Consumer Powerhouse MMTC Community Hospital Benchmarking Survey International Quality Indicator Project National Health Service ScoreCard (UK) CHKS 40 Top Hospitals (UK) US News & World Report Thomson & Reuters Top 100 WHO PATH Leapfrog Group Hospital Compare HealthInsight IASIST Top 20 Hospitals (Spain) Total Counts for Indicator 1 1 1 1 1 % of systems with indicator 8.3 8.3 Unscheduled OR returns to 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 1 8.3 8.

3 16.3 Rate of emergency readmission to hospital .3 1 8.7 8.28 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 Survival rate (elective surgery) Survival rate (emergency surgery) 1 8.3 1 1 8.7 8.3 16.com | Skype: sanigest 8.3 8.P a g e | 44 Benchmarking Hospital Performance in Health HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS Health Consumer Powerhouse MMTC Community Hospital Benchmarking Survey International Quality Indicator Project National Health Service ScoreCard (UK) CHKS 40 Top Hospitals (UK) US News & World Report Thomson & Reuters Top 100 WHO PATH Leapfrog Group Hospital Compare HealthInsight IASIST Top 20 Hospitals (Spain) Total Counts for Indicator % of systems with indicator Risk adjusted mortality (or mortality index) 4 33.com | www.3 1 8.3 .3 1 8.3 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) 2 1 2 1 1 © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.sanigest.

3 8.com | Skype: sanigest .7 1 1 8.3 1 8.3 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 MixAdjusted 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 2 16.3 1 8.7 2 16.com | www.3 1 8.3 1 8.3 1 8.3 © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.P a g e | 45 Benchmarking Hospital Performance in Health HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS Health Consumer Powerhouse MMTC Community Hospital Benchmarking Survey International Quality Indicator Project National Health Service ScoreCard (UK) CHKS 40 Top Hospitals (UK) US News & World Report Thomson & Reuters Top 100 WHO PATH Leapfrog Group Hospital Compare HealthInsight IASIST Top 20 Hospitals (Spain) Total Counts for Indicator 1 % of systems with indicator 8.sanigest.

3 Patients leaving Emergency room prior to completion of treatment 1 8.3 Occupancy beds rate.3 Cancellation of scheduled ambulatory procedures 1 8. staffed Avg days of receivables Avg days inventory Throughput Avg length of stay (days).3 8.com | www.3 1 8. 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) of on-hand 1 1 1 8.3 Length of Emergency (hrs) stay in department 1 8.3 8.3 8.3 1 8.3 8.sanigest.P a g e | 46 Benchmarking Hospital Performance in Health HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS Health Consumer Powerhouse MMTC Community Hospital Benchmarking Survey International Quality Indicator Project National Health Service ScoreCard (UK) CHKS 40 Top Hospitals (UK) US News & World Report Thomson & Reuters Top 100 WHO PATH Leapfrog Group Hospital Compare HealthInsight IASIST Top 20 Hospitals (Spain) Total Counts for Indicator 1 1 1 % of systems with indicator 8.com | Skype: sanigest .3 1 8.3 © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.

3 8.com | www.com | Skype: sanigest .3 1 8.7 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 1 1 1 1 1 8.3 1 1 8.3 8.3 1 8.3 8.3 8.3 8.P a g e | 47 Benchmarking Hospital Performance in Health HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS Health Consumer Powerhouse MMTC Community Hospital Benchmarking Survey International Quality Indicator Project National Health Service ScoreCard (UK) CHKS 40 Top Hospitals (UK) US News & World Report Thomson & Reuters Top 100 WHO PATH Leapfrog Group Hospital Compare HealthInsight IASIST Top 20 Hospitals (Spain) Total Counts for Indicator % of systems with indicator Patients leaving Emergency room prior to completion of treatment Time from treatment referral to 1 1 2 8.3 8.sanigest.3 16.3 © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.

3 8.hospital decision Waiting times for common diagnostic procedures Reputation Number of discharges Nurse staffing Nurse Magnet hospital Advanced technologies Patient services 1 1 1 1 1 1 1 8.3 8.3 8.3 8.3 8.3 Standardized admission ratio (SAR) Patient rating of overall care Cleanliness of hospital Overall data quality Procedures not carried out .3 8.com | www.3 8.3 8.com | Skype: sanigest .3 8.P a g e | 48 Benchmarking Hospital Performance in Health HOSPITAL PERFORMANCE DIMENSION BENCHMARKING SYSTEMS Health Consumer Powerhouse MMTC Community Hospital Benchmarking Survey International Quality Indicator Project National Health Service ScoreCard (UK) CHKS 40 Top Hospitals (UK) US News & World Report Thomson & Reuters Top 100 WHO PATH Leapfrog Group Hospital Compare HealthInsight IASIST Top 20 Hospitals (Spain) Total Counts for Indicator 1 1 1 1 1 % of systems with indicator 8.3 8.sanigest.3 © Copyright Sanigest Internacional Costa Rica Tel: (506) 2291-1200 | United States Tel: +1 (305) 600-4416 info@sanigest.