Checking the Health of an Eye Hospital with a Patient Management Scorecard

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By Hemamalini Suresh and Mithun Raj

The changing environment of healthcare organizations -- which includes pressures to reduce costs, improve the quality of care and meet stringent guidelines -- has forced their staffs to examine how they evaluate their performance. The "Patient Management Scorecard" -- a customized form of the balanced scorecard -- that we discuss in this article provides a comprehensive framework to help managers define strategies, track performance and provide data on how well the hospital is performing in terms of its mission and values. This strategic management tool allows hospitals to check the health of their strategies and construct objectives to aid target setting and performance measurement.

First, we'll explain what the Patient Management Scorecard (PMS) is, and then we'll show how it was implemented in Aravind Eye Hospital in Coimbatore, India.

The Patient Management Scorecard

Thinking strategically, measuring performance, evaluating results, feedback -- these are fundamental concepts in management that have been around a long time and will continue to be here in the future. A PMS enables a hospital to clarify its strategic objectives, communicate short and long-range goals and apply a measurement system to performance improvement activities. The goal: to improve the overall healthcare quality of the hospital by spotlighting the patient perspective of the hospital.

Patient perspective focuses on the treatment and care offered to the hospital's patients, as well as the ability of the hospital to meet community expectations. It also extends to how well the hospital responds to physician needs. The PMS doesn't support patient interactions alone, but attempts to answer such questions as what does the patient want, and how well are we serving them?

It articulates what the organization must do to satisfy its patients in order to achieve its financial objectives. And it forces managers to identify the hospital's target market and clarify its patient care objectives.

Patient Care Strategy Mapping

Patient care strategy mapping enables a hospital to determine its goals and objectives and the means of achieving them. It does this by setting measures to assess performance and clarifying the linkages between drivers and strategic outcomes. It gives hospital managers specific routines to better link planning to the activities, responsibilities and managerial systems of operational units. The measures or indicators are linked as cause and effect. For example, reduction in service delay may increase customer satisfaction.

Strategy mapping can help in error detection by making inconsistencies and gaps in cause-and-effect linkages more visible. Periodic review of the strategy map will assist in error detection before related problems become a major issue. The graphical depiction of the strategy makes it more understandable to all levels of employees and, therefore, more likely to draw valuable input from a variety of sources.

The measures chosen for this scorecard should focus on the achievements of the hospital in reaching and satisfying its target market. Measures consist of two types: outcome (lagging indicator) and driver (leading indicator).

Outcome measures for this scorecard generally include patient satisfaction, marketshare, patient retention, patient profitability, etc. These outcome measures can be divided further into driver measures, such as measures relating to lead times, on-time delivery, product quality and product cost.

Driver measures chosen depend on what the patients in the chosen target market value. If patients place on-time delivery at a premium, then the hospital's ability to achieve on-time delivery will drive outcome measures such as the level of patient satisfaction and the level of patient retention. While the outcome measures may be similar across a large number of hospitals, the driver measures will be individually tailored for each hospital's product/market strategy.

A traffic-light system signals the hospital's performance at three levels: above average (green), average (amber), and below average (red).

The Scorecard Template

Patient care objectives	Measures	Values	Targets	Color code	Initiatives

The Patient Management Scorecard must define the following:

• Objectives: What tactics the hospital will try to achieve.
• Measures: How progress for that particular objective will be measured.
• Values: The current measure.
• Targets: The target value sought for each measure.
• Color Code: The color indicator with regards to measured values (such as green, amber and red).
• Initiatives: What will be done to facilitate the reaching of the target.

How PMS Was Implemented at Aravind Eye Hospital

Although a balanced scorecard is a wonderful idea in theory, we wanted to test out our thinking in practical terms. Thus it was that we enlisted Aravind Eye Hospital to become our "guinea pig." We educated its management on the concepts of the balanced scorecard, developed the system of measurement and implemented it for the hospital.

Aravind Eye Care System, founded in 1976, has become the world's largest eye care service provider. It consists of a vast network of hospitals, clinics and managed eye hospitals throughout India. Aravind combines modern technology and management practices with a measure of compassionate spirituality. Its mission: "To eradicate needless blindness by providing appropriate, compassionate and high quality eye care to all."

The hallmarks of the Aravind model are quality care and productivity at prices that everyone can afford. A core principle of Aravind is that the hospital must provide services to rich and poor alike, yet be financially self-supporting. This principle is achieved through high quality, large volume care and a well-organized system. With less than 1% of the country's ophthalmic manpower, Aravind accounts for 5% of the ophthalmic surgeries performed nationwide.

Here are some key statistics regarding overall performance in 2005:

Outpatient visits
Paying: 234,935
Free (hospital-based and through rural camps): 217,928
Total outpatient visits: 452,863

Surgeries
Paying: 22,930
Free (hospital-based and through rural camps): 40,472
Total surgeries: 63,402
Camps: 382

Aravind Eye Hospital, Coimbatore, is recognized as a model for other developing hospitals. Much importance is given to ensure that all patients are accorded the same care and high quality service, regardless of their economic status. As a result of a unique fee system and effective management, Aravind is able to provide free eye care to two-thirds of its patients from the revenue generated from the other third, the paying patients. The hospital has experienced rapid growth in all aspects in a short period.

The hospital has defined its critical success factors as these:

• Mission Values
• Quality, Speed, Low cost, Familiarity, Patient satisfaction
• Team spirit
• Efficient technology

The corresponding objectives and measures are designed to evaluate hospital performance towards patients. They encompass three broad areas: the patient value proposition, technology and inter-department satisfaction.

The patient value proposition consists of the attributes that Aravind provides through their services to create loyalty and satisfaction for the patients. Attributes include: quality of service, speed, cost, the "image" of the hospital and satisfaction level.

Figure 1: The Aravind Eye Hospital strategy map.

Technical Support

As the backbone of every function in the hospital, information technology (IT) was something the hospital knew it must excel at. This indicator addresses the question of how well the employees are using technology to reach the patient objectives and create value for them.

Patient Satisfaction

This term is used to capture the idea of measuring how satisfied a hospital's patients are with the organization's efforts. Obtaining patient feedback in a timely and useable format helps ensure that the hospital is meeting and exceeding patient expectations and gives insight on where changes should be made to increase satisfaction and overall success. Reduction of service delay, affordable costs for service and a high level of patient perception drives patient satisfaction, a lagging indicator.

Patient Loyalty

A loyal patient develops a trusting relationship with the healthcare provider and is more interested in actively participating in a prescribed course of treatment. If a provider's service satisfies a patient, then the loyalty of that patient increases and leads to an increase in the hospital's image. This indicator can be boiled down to two questions:

1. Would you come to the hospital in future?
2. Would you recommend our service?

This indicator is led by patient satisfaction and patient partnership, the hospital's capacity to anticipate what a patient will need even before he or she knows it's needed.

Hospital Image

This indictor denotes what percentage of the public prefers Aravind's service for eye care treatment and also helps the hospital to understand what it is best known for.

Methodology

The overall objective of this project was to develop a PMS as a tool for process monitoring and performance enhancements of patient perspective for Aravind Eye Hospital.

The scorecard was implemented not just to know how the hospital was doing with its patients, but also to learn how well its services were being done (lagging indicators) and what it should expect to do in the future (leading indicators).

IT services (leading indicators) were one area of process where the hospital knew it must excel to achieve the patient objectives. So IT-related performance measures were designed and measured along with the patient perspective indicators.

Another question the hospital attempted to answer involved the number of service facilities required. If service facilities were to be increased, by how much? To answer that question, the hospital needed to know the number of patients waiting in a service counter. To obtain a measure, it adopted queuing theory.

This theory is based on the following assumptions:

• The arrivals follow Poisson distribution, with a mean arrival rate, A.
• The service time has exponential distribution, average service rate, S.
• Arrivals are infinite population.
• Patients are served on a first-in, first-out (FIFO) basis.

The evaluation of this model is as follows:

Expected number of patients in the system:
Ns = A / (S-A)

Expected number of patients in the queue:
Nq = A˛ / S(S-A)

Average waiting time in the system:
Ws = 1 / (S-A)

Average waiting time in the queue:
Wq = 1 / S(S-A)

To design this scorecard, we conducted various surveys. The following table explains the research methodology followed for those surveys.

Table 2. Patient Management Scorecard, Output
CSF	Objectives	Measurements	Values	Targets June 07	Initiatives
First choice of eye patients	Improve patient satisfaction level	Degree of out-patient satisfaction Degree of in-patient satisfaction No. of complaints No. of patient surveys	79.3% 82.4% 104 1	90% 90% -30% 4/year	Develop guidelines for optimal patient satisfaction Formulate a patient complaints procedure in all departments and execute routinely
Quality	Greater degree of trust from patients in the service provided Patient perceptionPatient partnership	Degree of patient loyalty Degree of perception over the facilities provided Degree of patients understanding discharge instructions No. of cooperative efforts No. of eye camps	100% 82% 91.4% 4 20/mo	100% 90% 100% 8 25/mo	Benchmark with regard to patient loyalty Conduct loyalty programs among the nurses and doctors Implement TQM principles Give training for the counselors about discharge instructions Conduct more outreach programs
Hospital image	Improve the familiarity level with public	Degree of public that knows about Aravind Degree of public that prefers Aravind for eye care treatment	91.4% 65%	100% 80%	Conduct more health awareness programs outside the hospital Provide good quality service
Low cost service provider	Provide service at an affordable cost	Degree of patients who feel that service is provided at affordable cost	72.9%	90%	Provide quality service to all with no regard to ability to pay
Pace of service	Reduce the service delays Increase the number of touch points	Service time and waiting time of patients in ODP department No. of patient contacts	Ns=8.3mins Nq=7.4mins Ws=26mins Wq=24mins 8	-10% 12	Set up patient help-desks wherever needed Cycle time optimization Increase service counter where greatest delays exist
Team spirit	Inter-department satisfaction	Degree of satisfaction - Reception - OPD - Specialty - EDP - Housekeeping - Laboratory - Management - Patient counselor - Store - Theater	88% 82% 84% 79% 83% 85% 80% 83% 72% 83%	90%	Execute inter-department satisfaction study between all the departments Organize meetings for the employees to enable communication between them

Table 3. Technology Scorecard
CSF	Objectives	Measurements	Values	Targets by June 07	Initiatives
User-friendliness	Improve system user satisfaction level	Degree of system user satisfaction	84%	90%	Conduct surveys among IT users at least quarterly
Technology excellence	High integration of network High reversibility of software	Degree of completion Degree of sufficiency Degree of success Degree of simplicity Degree of security Degree of swiftness	75% 83% 83% 57.7% 57.7% 46.2%	90%	Provide cross-departmental network services Provide simulation software to solve typical errors
Response speed	Quickly resolve IT complaints	Response time of EDP - short time - reasonable time - long time	11.5% 50% 38.5%	70% 30% 0%	Response time optimization Form technology service team
Support	Educate on English to use IT service (e.g., email) Provide good help service at all time	% of English coaching given % of help-service provided whenever needed % of self-help inbuilt service provided	11.5% 61.5% 34.6%	100% 100% 100%	Educate on “English” to help nurses in email correspondence Create built-in help facility in HMS software

Conclusion

The patient management scorecard we describe in this article, although designed and implemented at Aravind Eye Hospital, is applicable to other hospitals as well. Its implementation in the patient care department has given Aravind a better understanding of how the patients evaluate its services, thereby enabling the hospital to achieve its primary goals and objectives. Those performance metrics that drive success for the hospital can be directly linked to objectives that will help drive long-term goals. It also enables the organization to make solid IT-related decisions, since they too must align with patient strategy.

Our final suggestion is that when you build your balanced scorecard, you include the other perspectives that we've touched on as well: learning and growth, internal and financial.

The authors wish to thank Dr. R. Nandagopal, Director, PSG Institute of Management, for his contributions to this article.

Useful Links

Aravind Eye Hospital
http://www.aravind.org/

PSG Institute of Management
http://www.psgim.ac.in/

Books

The Balanced Scorecard: Translating Strategy into Action by Robert S. Kaplan and David Norton (Harvard Business School Press, $35)
http://www.bpmenterprise.com/X5h

Total Performance Scorecard: Redefining Management to Achieve Performance with Integrity by Dr. Hubert K. Rampersad (Butterworth-Heinemann, $46.95)
http://www.bpmenterprise.com/swJ

Making Scorecards Actionable: Balancing Strategy and Control by Nils-Göran Olve, Carl-Johan Petri, Jan Roy and Sofie Roy (John Wiley and Sons, $55)
http://www.bpmenterprise.com/bgu

Journal Articles

"The Balanced Scorecard -- Measures that drive Performance" by Robert S. Kaplan and David Norton
http://www.bpmenterprise.com/SWc

"An integrated approach to determine hospital outpatient staffing needs" by Ping-Jung Hsieh
http://www.bpmenterprise.com/uyL

"University Health Services: Walk-In Clinic" by Shauna Doyle
http://www.bpmenterprise.com/59n

About the Authors:

Hemamalini Suresh is currently working as a member of the faculty at PSG Institute of Management, doing research on the balanced scorecard. She has over eight years of industrial experience in management and administration areas in industries ranging from manufacturing to software. She has a good knowledge and practical experience in business process re-engineering, enterprise resource planning, supply chain management and total quality management. She has published a number of articles online, including on these sites: stickyminds.com, ittoolbox.com, knowledgeboard.com, qualityoasis.com, providersedge.com and supplychainplanet.com. Contact Hemamalini Suresh at hemasanjana (at) yahoo.com.

Mithun Raj is an MBA student with marketing and systems specialization at PSG Institute of Management. He received his bachelor's degree in information technology. Areas of interest include enterprise resource planning, customer relationship management, brand management and strategic management. Contact Mithun Raj at mithunpepboy (at) gmail.com.

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