Journal of the Academy of Hospital Administration

Title: Benchmarking of Operation Theatre Processes - A Study

in a Corporate Hospital

Author(s): B. Krishna Reddy*, G.V.R.K. Acharyulu**

Vol. 17, No. 2 (2005-01 - 2005-12)

Key Words
Healthcare, Benchmarking, Operation Theatre, Process, Quality Improvement,
Performance Measurement, and Supply Chain

Key Messages

• Cost of surgery varies from discipline to discipline with Oncosurgery being most
expensive
• Medical equipments contribute to significant capital costs in OT

Abstract

Healthcare, by its nature, is an industry composed of numerous and complex processes.

Benchmarking is the continual and collaborative discipline of measuring and comparing
the results of key work processes with those of the best performers. Benchmarking ushers
in a new direction to the way activities are performed in hospitals, as there is no other
tool by which supply chain performance is measured in a reliable and comparable level.
It is learning how to adapt the best practices to achieve breakthrough in process
improvements and build healthier communities. With significant changes in the field of
medical science and technology, hospitals are competing neck- to- neck to attract patients
not only from the local areas but also from the Afro- Asian countries. Benchmarking is an
endeavor to push performance and capability to enormous levels and discover better
methods and quality standards. Those involved in continues improvement efforts rely on
benchmarking to formulate goals and targets for performance. This paper studies the
procedure times in operation theatres of a corporate hospital and their variability which
can help in setting benchmark for consistency in internal processes.

INTRODUCTION

In a competitive business environment, it is not enough for an organization to be doing

well. The performance has to be seen in comparison with its best competitors. It is
necessary to have a point of reference to know how well one is doing. Need for keeping a
constant watch on the competition is necessary for achieving and maintaining leadership
position. Benchmarking is an approach to identifying "quality" by comparing a service or
organization with another similar service or organization. In industry, this approach can
be highly competitive where companies attempt to emulate the performance of identified
high performers.(1)

Conceptually, the form of "benchmarking" is to the extent that an Organization or service

meets or exceeds all known standards of performance in all aspects. International best
practice is often adopted by managers as a term to signify organizational policy.
Continuous improvement is clearly an integral part of benchmarking, and is a vital
component in permitting flexibility for rapid response to opportunity. The philosophy of
benchmarking is to create a change - oriented workplace culture within which
'participative, people-driven approaches to benchmarking create outward looking,
cooperative, and responsive organisation'.(2) Companies use benchmarking to understand
better how outstanding companies do things so that they can improve their own
operations. Typical measures used in benchmarking include cost per unit, service upsets
(breakdowns) per customer, processing time per unit, customer retention rates, revenue
per unit, return on investment, and customer satisfaction levels.

Benchmarking firms must assess the strengths and weaknesses of their current work
processes, analyze critical cost components, consider customer complaints, spot areas for
improvement and cycle time reduction and find ways to reduce errors and defects or to
increase asset turns. Benchmarking firms must find out who is the best of the best. To
identify the best of the best, benchmarking firms must learn from leaders, uncover where
they are going, learn from the leader's superior practices and why they work, and emulate
the best practices. It is the process of measuring against best practice, similar products &
processing industry leaders and world class buisness.(3)

BENCHMARKING IN HEALTHCARE

In India, Hospitals gained the status of corporate sector in the year 1984. This has led to a
spurt, which is evident by the growing number of hospitals in the country. The opening
up of the General Insurance to Private companies has come up as a turning point and an
effort to make healthcare accessible to even a common man.

Benchmarking is one of the tools of Total Quality Management. The concept of seeking
best practices and implementing those practices within individual organizations can be
applied to any type of organization, including health care. The move towards
Benchmarking in health care is a relatively new concept.(1)

Benchmarking in health care is conceptually the same as benchmarking in other

industries. The difference is in the key processes selected for benchmarking in the health
care industry. Health care, by its nature, is an industry composed of numerous and
complex processes. Processes in health care typically are defined broadly as input,
processing and output, which are the same broad categories of production in industry.
Examples of these processes in a hospital setting are input activities of parking,
registration and admission; processing activities of taking a patient's history, serving
meals, answering call lights, administering medications, performing procedures and
providing education; and output activities of discharging or transferring patients. The
result of input, processing and output activities is the outcome of patient care. Examples
of outcome measurements are patient satisfaction, functional status, health status,
mortality rates, and complication rates. Input, processing and output activities and
outcomes can be measured and benchmarked.

Benchmarking reveals key information as to which Practitioners perform most efficiently

given certain diagnoses; patterns and best practice for patient flow adjustment; flexible
staffing and patient satisfaction. If one can identify the optimal point of inflection - the
point at which facilities are operating efficiently and patients are happy with their care -
the industry will begin to make serious inroads toward the overall improvement of patient
care.

Benchmarking in Hospitals can be made in the following areas:

1. Managerial areas: Pricing, Utilization, Patient and payer mix, Productivity and
efficiency, Revenue, expenses, and profitability.
2. Clinical areas: Ambulatory care services, Anesthesia services, home care
services, Medical services, Obstetrical and newborn services, Pediatric services,
Post-anesthesia recovery services, Psychiatric services, Rehabilitation services,
Respiratory care services, Special care unit services, Surgical services,
Housekeeping services, Infection control program, and Laundry and linen
services.
3. Process areas in an operation theatre. The Process facilities are compared and
benchmarked with other participants in the peer group. Peer groups are
determined based on facility size, outpatient, inpatient, or combined services; and
teaching or non-teaching facilities available.
4. Some of the process areas where benchmarking can be undertaken are: Patient
Scheduling, Preoperative Screening, Day of Surgery, Management Information
Systems, Procedure Supply Preparation, Intra operative processes, Between Case
Processes, Materials Management, Review of Purchasing and Supply Chain
Performance and Measurement, Equipment Management, Facility Utilization,
Labor Utilization, Physical Facilities, Performance Improvement Monitoring,
Instrument Reprocessing, and Day of Surgery Flow Control.

NEED FOR BENCHMARKING IN HEALTHCARE

Healthcare has significantly changed in the last few decades. With rapid strides in the
field of medical science and technology, Hospitals are competing neck- to- neck to attract
patients not only from the local areas but also from the Afro-Asian countries. Increasing
costs and shrinking resources have created an increased focus on patient outcomes.
Executives engage in a constant and valiant struggle to master the fine art of juggling. In
health care, concurrent goals of high patient satisfaction must be balanced against
organizational efficiency and fiscal solvency. It's a fine line pushing hard to reduce costs.
The value of health care to the customer is the ratio of quality to cost. To increase the
value of health care, quality must increase more than cost or remain stable while cost
decreases. Quality is difficult to define. Currently, there are numerous performance
measurement systems that use different definitions for the same quality measure. This has
led to inconsistent measure sets across organizations that do not allow for comparison of
performance. Benchmarking ushers in a new direction to the way activities are performed
in Hospitals, as there is no other tool by which performance is measured in a reliable and
comparable level.

BENCHMARKING PROCESS

The benchmarking process is similar to the plan-do-checkact cycle in continuous

improvement, but benchmarking focuses on setting quantitative goals for continues
improvement. The process consists of four basic steps(4):

1. Planning: Identify the product, service, or process to be benchmarked and the

firm(s) to be used for comparision, determine the measures of performance for
analysis, and collect the data,
2. Analysis: Determine the gap between the firm's current performance and that of
the benchmark firm(s) and identify the causes of significant gaps,
3. Integration: Establish goals and obtain the support of managers who must
provide the resources for accomplishing the goals,
4. Action: Develop cross-functional teams of those most affected by the changes,
develop action plans and team assignments, implement the plans, monitor
progress, and recalibrate benchmarks as improvements are made. Simply, stated
Collect the data, analyse the data, set targets toachieve best processes, develop an
action plan, communicate, implement the action plan, remeasure benchmark in
the light of progress.

Figure 1: Benchmarking Process - Common Steps

LEVELS OF BENCHMARKING

There are four levels of benchmarking.

i. Internal benchmarking: Comparing similar processes performed in different parts

of the same Organization or service. This can be advantageous for firms that have
several business units or divisions.
 ii. Competitive benchmarking: Comparing the performance (or an aspect) of an
Organization with that of a competitor,
iii. Functional benchmarking: Comparison of performance of the same function for
all of those in the same sector,
iv. Generic benchmarking: Comparing functions at a generic level. This is often the
only approach available to Government organizations.

BENEFITS OF BENCHMARKING

i. Fresh thinking on meaningful comparisons by the industry,

ii. Establishment of a process, which the organization can maintain itself in the
future,
iii. Confidence building in the organisation, by setting appropriate Operation's
strategy performance targets,
iv. Enhanced understanding of the elements of competitiveness in the organization.

The present study provides an insight of Internal Benchmarking being put to a start in the
Hospital. A minimum of twenty cases of a procedure performed during the period of
study is considered. The Operation Theatre of a Corporate Hospital was selected as the
Study Area. The Operation Theatre has the Operation Rooms - OT1 , OT2, OT3, OT4,
OT5, OT6, OT7 , OT8 , OT9 , OT10.

METHODOLOGY

The data for the study was collected from the log data at the scheduling station of a
corporate hospital for a period of four consecutive months in the year i.e., from October
2004 to January 2005. The data consists of the Procedures performed in the Operation
Rooms by the Surgeons and the time taken for each procedure on a daily basis. There are
7 major and 3 minor Operation Rooms and for the sake of confidentiality they have been
named as Operation Rooms OT1 to OT10. Like wise the Surgeon's names are also
masked. The Surgeons who have performed less than 8 cases all through the period of the
study are not taken into consideration.

STATISTICAL DATA ON PROCEDURE TIMINGS

The following table gives the timings (in minutes) of procedures performed by various
specilists and Mean, Standard Deviation (SD) of the respective procedure.

Control Charts ( 3- sigma)

Table 1: Analysis of Procedure Timings

Procedure Number Mean S.D.
Number of Cases (Minutes) (Minutes)
1 30 81.96 22.96
2 116 159.02 23.25
3 52 145.21 27.64
4 25 72.20 24.47
5 22 20.54 4.55
6 35 119.68 17.65
7 40 107.30 9.35
8 20 69.35 11.77
9 72 113.73 11.35
10 48 77.87 10.72
11 25 48.32 4.51
12 44 116.36 7.30
13 35 30.82 2.33
14 32 108.71 28.69
15 48 50.12 17.47
16 36 10.11 4.09
17 48 185.20 21.58
18 20 53.40 16.67

Procedure 1: Cases 3,5,21,25,26 have

taken very low time in contrast 14,17,22,24
has taken very high time. There are cycles
present in the control chart. This indication
that there is a systematic difference in
procedure times. The reasons need to be
thoroughly probed in. Some of the
plausible reasons can be: experience and
skill of the specialist, complexity of the
case itself and skill of the supporting staff.
Procedure 2: Too large variation in
procedure times is noticed. But procedure
timing on the lower side of the central line
which are close to lower control limit need to
be thoroughly studied with the objective that
similar conditions should be created for
reducing the average procedure time. On the
other side, good number of procedure times
is also observed to be high. For achieving
managerial efficiency, these high procedure
times should be reduced so that better
benchmark can be set. This helps in effective
scheduling of OT's.

Procedure 3: Cyclic variation is noticed in

the procedure timings. Except the case
no.3, all other timings are within the
control limits. The cyclic variation can be
due to shift wise, day wise and weekly wise
observations.

Procedure 4: Though the procedure timings

are within the three-sigma control limits, lot
of variation is observed inherently. This may
be change in specialists, severity of the
patients and seasonality. Controllable causes
can be identified to bring the process under
internal consistency.
 Procedure 5: The variation in the
procedure times is stable but decreasing
trend is noticed. This indicates that
improvement in the process due to better
working conditions, equipment availability,
experienced specialists.

Procedure 6: Though the procedure timings

are under 3- sigma control, cyclic variation is
noticed. Almost equal number of procedures
is above the average line and below the
average line. The procedure times above the
average line need to be probed for possible
reduction in times after adopting changes
accordingly.

Procedure 7: Seven cases are found to be

very high times and only three are lower
times. On Overall basis, reasons for higher
times need to be carefully studied and
attempts are to be made for possible
reduction times.

Procedure 8: Except cases 3 and 8, all other

procedure times are stable having cyclic in
nature and having systematic variation. On
an average more number of timings are
below the central line compared to above the
central line. This indicates the procedure is
done efficiently most of the times.
 Procedure 9: Although systematic
variation noticed in the procedure times,
most number of cases observed to be
having lower procedure times. This
indicates the efficiency in the process. The
times above average lines need to be
probed in for possible reduction in time.

Procedure 10: The variation in procedure

times is higher even though the process is
under 3-sigma control. Internal reasons for
the cause of variation have to be identified. If
proper precautionary steps are adopted to
reduce variation, process can be stabilized
with minimum variation.

Procedure 11: The procedure timings are

under 3-sigma control. But there is a
systematic variation noticed for which the
causes need to identified to minimize the
variation
Procedure 12: 60 percent of the observations
fall under the central line and this shows the
efficiency of the process. But for the
remaining cases which are above the central
line need to be analyzed for possible
reduction in procedure times.

Procedure 13: The procedure timings are

within 3-sigma limits. The procedure is
having cyclic variation. The reasons for
this variation need to be identified.

Procedure 14: The variation is observed to

be systematic and the reasons for the
variation need to be further probed in.
 Procedure 15: Though the procedure
timings fall under 3- sigma limits, erratic
variation is notice. Some of the procedure
timings are very far from the central line
towards lower control limit, which is good
indication that the procedure is done
efficiently. Procedure timings, which took
higher timings, need to be probed in for
finding out the reasons.

Procedure 16: Except cases 7 and 30 all

other cases are having cyclic variation in
timings and within the control limits. The
reasons for the higher timings in the two
cases need to be identified and rectified.

Procedure 17: In one particular cycle, the

variations are noticed high and in other
cycle the variations are less. Case 33 is
touching upper control limit. The reasons
for the higher variations in cycles need to
be identified and possible efforts should be
put to minimize variations in the procedure
timings.

Procedure 18: Erratic variation observed in

the procedure timings. On Overall basis the
procedure is under control except case 2, 14
have higher procedure timings and very far
from central line towards upper control limit.
5.2 ANALYSIS

The basis for benchmarking of procedure timings is the control charts for studying the
variation. The reasons for the cause of variation can be attributed as two factors: 1)
Controllable - skill of the staff, equipment and material availability, medical attention,
coordination and communication, 2) Uncontrollable - sudden failure of equipment,
condition and severity of the patient, Age of the patient, technology, scarcity of material.
Benchmarking helps in reducing erratic variation in procedure timings and enable
internal consistency, which is crucial for organization for improving process
performance. Critical success factors can be identified for continuous improvement in
process. They include: i) Patient's physical (including complications) and psychological
condition, ii) Skill of the Surgeon based on the Qualification, Experience and Exposure,
iii) Type of anesthesia used, iv) Availability of state-of-the-art Equipment, v) A proper
and good maintenance schedule, vi) Coordinated effort of anesthetist, nursing staff and
supportive staff.

CONCLUSION

The intensive competition encountered in most markets has led to a new emphasis on
measuring performance not just in absolute terms, but also rather in terms relative to the
competition, and beyond that to 'best-practices'. The results of the benchmarking study
can be used to overcome and eliminate complacency within the organization. Hospitals
set up by the Government and the Corporate Hospitals constitute a large proportion of
healthcare providers in the country. In order to enhance performance, Internal
Benchmarking must be adopted for identifying the performance indicators of individual
hospitals. Some Key Performance Indicators can be: process timings, Length of Stay
(LOS), success rates in surgeries, supply chain process, equipment maintenance, Return
on Investment, Quality of service. In order to progress in the present competitive
environment, healthcare organisations need to adopt benchmarking practices for
continuous improvement in their operations and perform better than competitors for
improving their market share.

REFERENCES

1. Shridhara Bhat K, 2002, " Total Quality Management", Himalaya Publishing

House, Mumbai, pp.566-574.
2. Besterfield, D.H., et al, 2004, " Total Quality Management", Pearson Education
(Singapore) Pvt. Ltd, pp.207-210.
3. Mohanty, R.P. and Deshmukh, S.G., 2001, "Essentials of Supply Chain
Management", Phoenix Publishing House, New Delhi, p.269.
4. Lee J. Krajewski, Larry P.Ritzman.,2002, "Operations Management, Strategy and
Analysis", 6the edition, Pearson Education (Singapore) Pvt. Ltd, New Delhi,
pp.260.
5. Knod EM,Schonberrge RJ, Objects input 7e, 273page, Mc gracewill 2001.
* Associate Professor Department of Business Management Osmania University,
Hyderabad-500007
** Assistant Professor Apollo Institute of Hospital Administration Jubileehills,
Hyderabad-500033