[Manual on Benchmarking for Quality Improvement] 2012

MANUAL ON BENCHMARKING FOR

QUALITY IMPROVEMENT OF
HEALTH CARE SERVICES

Changes in Quality Indicators (QIs) Over Time

80

70

60

50
Percentage

40 1st Quarter
2nd Quarter
30
3rd Quarter
20

10

0
QI 1 QI 2 QI 3 QI 4

Quality Indicators

QUALITY ASSURANCE AND STANDARDIZATION DIVISION

MINISTRY OF HEALTH, BHUTAN
2012
 2012 [Manual on Benchmarking for Quality Improvement]

Manual on Benchmarking for Quality Improvement of Health Care Services

Quality Assurance and Standardization Division
Ministry of Health
Kawang Jangsa
Thimphu 11001
Bhutan

© Quality Assurance and Standardization Division (QASD), Ministry of

Health, 2012

Layout and cover design: QASD, MoH

Edited and compiled by:

1. Mr. Dechen Choiphel, Chief Program Officer, QASD
2. Mr. Kinley Wangchuk, Asst. Program Officer, QASD
3. Mr. Thinley Namgay K, Asst. Program Officer, QASD

1st Publication 2012

ISBN: 978-99936-919-3-8

All rights reserved. Publication of this guideline is available in the Ministry of

Health website (http://www.health.gov.bt/). Reproduction of this publication
for resale or other commercial purposes is prohibited without prior written
consent of the copyright holder.

This publication contains the collective view of various stakeholders from

Ministry of Health.
 [Manual on Benchmarking for Quality Improvement] 2012
TABLE OF CONTENTS
Contents Page No.
Table of contents..................................................................................................i
Acronyms........................................................................................................... ii
Acknowledgements........................................................................................... iii
Foreword............................................................................................................iv
1 Introduction................................................................................................ 1-5
1.2 How to use this manual..............................................................................2
1.3 What is continuous quality improvement............................................... 3-4
1.3.1 Ministry of Health (national level)..................................................... 4-5
1.3.2 Regional level..........................................................................................5
1.3.3 District & Geog level..............................................................................5
2 Quality indicators and benchmarking................................................... 6-10
2.1 What is a quality indicator..................................................................... 6-7
2.2 What is benchmarking.......................................................................... 7-10
3 Linked benchmarking system for monitoring quality indicators...... 10-19
3.1 What indicators should be covered by the benchmark system.................10
3.2 Data collection: how often, data forms, data collectors.......................... 11
3.3 Data entry and data analysis................................................................... 11
3.4 Purposes built excel spreadsheets...................................................... 12-16
3.5 Tailored excel spreadsheets......................................................................16
3.6 Reporting formats and frequencies.................................................... 16-18
3.7 A dashboard for national priorities for quality improvement..................18
4 References............................................................................................... 19-20
5 Annexure................................................................................................. 21-35
5.1 Annexure: Some key quality indicators from the HAMT KPI set.............21
5.2 Annexure: Defining the quality indicators for quality priorities....... 22-24
5.3 Annexure: Example of quality improvement tools & its range of steps...25
5.4 Annexure: Example of quality improvement tools & its uses............. 26-27
5.5 Annexure: Example of data entry format for indicators..........................27
5.6 Annexure: Example of formula reference sheet.......................................28
5.7 Annex: An example of Out-Patient department (OPD) exit survey
questionnaire.................................................................................... 29-30
5.8 Annex: An example of In-Patient department (IPD) exit survey
questionnaire.................................................................................... 30-32
5.9 Annex: An example of staff satisfaction survey.................................. 32-35

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ACRONYMS
BHU Basic Health Unit
BMHC Bhutan Medical and Health Council
CME Continuing Medical Education
CQI Continuous Quality Improvement
DHO District Health Officer
EQAS External Quality Assessment System
ER Emergency Room
FYP Five Year Plan
GNHC Gross National Happiness Commission
HAMT Hospital Administration and Management Transformation
HMIS Health Management and Information System
HMT Hospital Management Team
HTQC Health Technology and Quality Committee
IQAS Internal Quality Assessment System
KPI Key Performance Indicator
MDG Millennium Development Goal
MoH Ministry of Health
NEQAS National External Quality Assessment System
NITMS National Institute for Traditional Medicine Services
NRH National Referral Hospital
OPD Out-Patient Department
OT Operating Theatre
PHC Primary Health Care
QA Quality Assurance
QAG Quality Assurance Group
QA&S Quality Assurance and Standardisation
QASD Quality Assurance and Standardisation Division
QC Quality Control
QI Quality Improvement
QM Quality Management
RGOB Royal Government of Bhutan
RIHS Royal Institute for Health Sciences
SOP Standard Operating Procedure
STI Sexually transmitted infection
ToR Terms of Reference
ToT Training of Trainers

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ACKNOWLEDGEMENTS
These materials have been developed by the Quality Assurance and
Standardisation Division (QASD) Programme Personnel in consultation
with relevant stakeholders. The Ministry would like to expresses gratitude
to DANIDA for providing financial and technical assistance for drafting of
this document. The division would like to express our appreciation to all the
reviewers and colleagues for their time and valuable comments while preparing
this manual.

This handbook can be used in training or as reference guide for health facility
teams, administrators and program managers to improve the programmes and
activities that they currently deliver, with the ultimate aim of improving quality
of care for the end-users. This is in line with the overall thrust of the Tenth Plan
which aims to improve the quality of life of Bhutanese people within the overall
development philosophy of Gross National Happiness (GNH).

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FOREWORD
Benchmarking is a performance improvement method that has been used for
centuries. Recently, it has begun to be used in the healthcare industry where it
has the potential to improve significantly the efficiency, cost-effectiveness, and
quality of healthcare services. Performance measurement might seem strange to
some organizations, but the concept of measuring and monitoring performance is
not new to healthcare facilities. Requirements for public overview of healthcare
facilities demand that performance data be collected, analyzed, and monitored
for improvement measures, record keeping, and accreditation purposes. As
a result, most healthcare facilities already track key productivity indicators.
Healthcare facilities will be in better position to assess their performance and
share comparative information about performance and operations with other
facilities for mutual benefit. Indeed, the greatest value to be gained from all of
the performance data that healthcare facilities are gathering may well emerge
from the process of comparing that data. Healthcare facilities often are similar
in the complexity of their organizational structures, operational and clinical
services, and corporate missions. That similarity will benefit healthcare facilities
as they begin benchmarking efforts.

The spirit that underlies any benchmarking initiative is the desire to learn from
and overcome the competition. Benchmarking is about comparing, learning
from the outcomes of such comparison, and consequently learning how to
do the job better. Its purpose is to help an organization by initiating changes
in performance. It consists of setting goals through an evaluation of past
performance and current need, and then going after those goals.

I am pleased to introduce and share this manual on benchmarking with all the
health workers. I would like to express my appreciation to all those involved
in publication of this manual. More so, I urge all the health care professionals
to use this manual to compare and improve upon the services that you deliver
in your health care facility. Lastly, I hope that this manual would contribute in
enhancing the productivity and efficiency of quality health care services to the
people of Bhutan.

(Nima Wangdi)
Secretary
Ministry of Health
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1. INTRODUCTION
1.1. Benchmarking in healthcare facilities
Business survival is increasingly difficult in the contemporary world. In order
to survive, organizations need a commitment to excellence and a means of
measuring that commitment and its results. Benchmarking provides one method
for doing this. Benchmarking is a performance improvement method that has
been used for centuries. Recently, it has begun to be used in the healthcare
industry where it has the potential to improve significantly the efficiency, cost-
effectiveness, and quality of healthcare services.

In the contemporary world, business survival is defined as long-term economic

viability achieved through excellent performance. To maintain the excellence
needed for survival, however, business enterprises must find a way of
consistently measuring and improving their performance.

Performance measurement might seem strange to some organizations, but the

concept of measuring and monitoring performance is not new to healthcare
facilities. Requirements for public overview of healthcare facilities demand
that performance data be collected, analyzed, and monitored for continual
improvement of services. As a result, most healthcare facilities already track key
productivity indicators. Healthcare facilities will be in an even better position to
assess their performance and share comparative information about performance
and operations with other facilities for mutual benefit. Indeed, the greatest
value to be gained from all of the performance data that healthcare facilities are
gathering may well emerge from the process of comparing that data. Healthcare
facilities often are similar in the complexity of their organizational structures,
operational and clinical services, and missions. That similarity will benefit
healthcare facilities as they begin benchmarking efforts.

The spirit that underlies any benchmarking initiative is the desire to learn from
and overcome the competition. Benchmarking is about comparing, learning
from the outcomes of such comparison, and consequently learning how to do
the job better. Its purpose is to help healthcare facility by initiating changes in
performance. Its goals are to make advances in performance so that a healthcare
facility performance better and thrives in a competitive environment. The
process is relatively simple. It consists of setting goals through an evaluation of
past performance and current need, and then going after those goals.
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The extensive measuring and comparing involved in the modern benchmarking

process focuses on a different battle, however, namely finding and closing
performance gaps and further improve in delivery of services. The potential
for performing better is in itself a prime motivator for change and urgency to
find solutions that speed delivery, increase access, decrease costs, and satisfy
customers has grown. Benchmarking within the healthcare facility offers the
opportunity for a quick response to that need.

1.2. How to use this manual

This manual explains how to undertake benchmarking of data on quality
indicators for monitoring Continuous Quality Improvement (CQI). It is aimed
at Quality Assurance Teams (QAT)/Hospital Administration and Management
Transformation (HAMT) teams at all levels of the healthcare services in Bhutan.

The process of benchmarking requires data collection by relevant health staff

and the entry of that data into spreadsheets so that the quality indicators can
be monitored on a regular basis as a means of assessing how effective are the
Action Plans for quality improvement.

The manual can be used by all staff to provide an overview of the process of
benchmarking for quality improvement. Appropriate section should be studied
by particular groups of staff who have specific responsibility for that activity.
For example the section on data collection & entry (3.2 and 3.3) should be
studied carefully by those staff who will be involved in entering data from
quality indicator collection into the EXCEL spreadsheets. The section (3.6) on
Reporting Formats and frequencies will be of special interest to the Regional
Quality Assurance, HAMT Cluster Focal person, Data Assistant and Medical
Record Technician (MRT). Section 3.7 describing a dashboard for National
Priorities for Quality Improvement will be of particular importance to the
senior managers with responsibility for improving quality and performance of
the healthcare services.

Anyone involved in health facility QA/HAMT teams would do well after

studying this manual.

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1.3. What is continuous quality improvement (CQI)?
The National Health Policy states that the aim of the health policy is “Every client
receives safe, appropriate, and effective quality care, and service provider’s
work together to contribute to a high-performing health system in line with
the national health policy ultimately realising the Gross National Happiness
(GNH)”. The overall thrust of the Tenth 5 Year Plan is to improve the quality of
life of the people within the overall development philosophy of GNH.

Quality means different things to different people. Many countries struggle in

their quest to improve quality in health care because they are unable to quantify
quality and identify the extent to which it is being met. This can only be achieved
by having:
• Appropriate definitions of quality in health care
• A range and adequacy of methods for measuring and improving quality
Evidence-based standards
• Strategies for implementing a programme to assure quality of service
delivery for its ultimate beneficiaries.

If a definition for quality of care is to be used by managers and professionals

to guide them in their QA activities or by patients to inform them of what to
expect, it should be simple, precise, explicit, scientific in nature and robust. The
definition of quality of health care in Bhutan is built on the following principles:
• Achievement of standards, indicators and targets
• Consideration of client needs and expectations
• Consideration of available resources (financial, human and time)
• Recognition that there is always room for improvement
• Regular review of quality levels, targets, indicators and standards
• Recognition of government policy
A fitting definition of quality of care provided by the Royal Government of
Bhutan’s (RGoB) health services is:
“The ability of our health service to meet the needs of our service users,
equitably and acceptably, within the resources available and in line with the
policies of the Royal Government of Bhutan”.
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Continuous Quality Improvement (CQI) is the systematic application of priority

setting, monitoring quality indicators and implementing Action Plans for quality
improvement. This requires that Quality Assurance and Quality improvement
are embedded into the whole of the Health Service from top to bottom.

The practical steps required to achieve this are:

1.3.1. Ministry of Health (National Level)
1.3.1.1. QAG (Quality Assurance Group) comprises of relevant
stakeholders, responsible for reviewing and focusing the
quality of healthcare services. It should be now integrated into
the management structure of the MoH such as the responsibility
of the High Level Committee (HLC) to make review of quality
as a focus of the meeting every three months
1.3.1.2. Make an Annual Plan for quality improvement
1.3.1.3. Select three quality issues as National Priorities for quality
improvement
1.3.1.4. Define quality indicators for each of these priorities that can be
measured at health facility level
1.3.1.5. Require Heath Facilities to make quality improvements on
these priorities and to monitor their own quality indicators
1.3.1.6. Monitor Quality Indicators every three months through a
“dashboard” of Quality Indicators. This can be done through
the HLC
1.3.1.7. Identify poorly performing health facility and support them in
extra efforts to improve the quality of their services
1.3.1.8. Require the QASD to produce an Annual Report on the Quality
of Healthcare service in Bhutan, which can form a section of
the Annual Health Report or news letter or news magazine, and
the Dashboard of Quality Indicators can be used in the National
Statistics Report section on Health

1.3.1.9. Disseminate information on quality of healthcare service to

health staff and the general public

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1.3.1.10. Identify an Annual Budget for QA and quality improvement
1.3.1.11. Engage in the International and Regional drive towards
Health Care quality improvement through membership of the
International Society for Quality in Health Care (ISQua) and
National Accreditation Board for Hospitals and Healthcare
Providers (NABH)

1.3.2. Regional health facility level

1.3.2.1. Make a Regional Annual Plan for quality improvement
following the MoH Annual Plan
1.3.2.2. Train health facility staff in QA and quality improvement in
line with the training they have received at the Training of
Trainers Workshop
1.3.2.3. Complete the “dashboard” of Quality Indicators every three
months for Health Facilities in their own Region
1.3.2.4. Use the Regional Dashboard to identify poorly performing
health facilities and support them in improving their
performance
1.3.2.5. Identify good practice in quality improvement in their Region
and disseminate to other health facilities
1.3.2.6. Produce an Annual Report on Quality of Health Care in their
own Region

1.3.3. District & Geog health facility level

1.3.3.1. Make a Facility Annual Plan for quality improvement following
the MoH and Regional Annual Plans
1.3.3.2. Train health facility staff in QA and quality improvement
1.3.3.3. Complete the “dashboard“ of Quality Indicators every three
months for their own Health Facility
1.3.3.4. Produce an Annual Report on Quality of Health Care in their
own health facility.
1.3.3.5. Identification of the local priority area
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2. QUALITY INDICATORS AND BENCHMARKING

2.1. What is a quality indicator?
A Quality Indicator is a simple tool for illustrating the level of quality achieved
by a service in regard to a particular aspect of quality. For example, we all
recognize that leaving patients waiting in Out Patient Department (OPD) clinics
causes inconvenience to them and is seen as poor quality. Hence any simple
measure of waiting time provides us with a way on monitoring quality of this
aspect of OPD service delivery. However it is important that we use indicators
that are accurate and reliable when comparing quality between facilities and
over time (from one quarter to the next). We also need the indicators to be
efficient so that staff don’t spend all their time gathering data on quality rather
than delivering a good quality service. Finally it’s important that staff can relate
the indicator to the aspect of quality it is designed to monitor, and therefore
can easily make use of it in their efforts to improve quality through quality
improvement Action Plans.
Good quality indicators are SMART!

“SMART INDICATORS”

 Specific

 Measurable

 Attainable

 Reliable

 Timely

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To be really useful for assisting the process of Continuous Quality Improvement,
quality indicators need to:
• Reflect quality issues that are of concern to both providers and users of
services
• Should be “Well defined”
• Measurable in a reliable way
• Truly reflect the aspect of quality that they refer to

Experience has shown that a single indicator is unlikely to capture all the
important features of a quality issue.

2.2. What is benchmarking?

Benchmarking is a process for finding, adapting, and consistently applying best
practices and implementing them to become the best of the best. The concept of
learning from others’ experience is perhaps as old as human society; however,
the first widely publicized use of the term “benchmarking” was by the Xerox
Corporation in Rochester, New York, USA in the 1970s. It was defined by
Xerox as “the continuous process of measuring products, services, and practices
against the company’s toughest competitors or those companies renowned as
industry leaders”. In general, the two key concepts in benchmarking are the
idea of systems or processes and the concept of “benchmarks.”

Perhaps the best way to understand this idea is to see Benchmarking as the
practice of being humble enough to admit that someone else is better at
something and being wise enough to try and learn how to match and even
surpass them at it.

2.3. The benchmarking process

Productive ideas and methods are not limited to a single industry. Cross-industry
benchmarking also can offer excellent opportunities for borrowing good
ideas and processes. But finding suitable partners with applicable ideas from
other industries can be time consuming and costly. For example, calling a fire
department to discuss the process of bringing both equipment and manpower
to an emergency site can generate a number of exciting ideas, but finding the

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“best performing” fire department would take long hours of research. Because
benchmarking is an ongoing effort, working first within the healthcare facility
for short- and medium-term solutions will help position a facility for later cross-
healthcare initiatives.

Information about the exact steps involved in the benchmarking process varies
its degree of detail depending on its source. However, the degree of detail in
the individual steps will not, in itself, add to the success of the benchmarking
effort. Success rests with the basics, and those basics are identified in the steps
listed below.

2.3.1. Planning
The planning phase of a benchmarking effort involves three steps. They are
(1) identifying exactly what will be benchmarked; (2) identifying the best
competitors as potential benchmarking partners, and (3) determining what
method will be used to collect data for comparison.

Success in benchmarking is primarily a function of these steps in the process,

which relate to obtaining and using the right comparative data. In fact, different
approaches to the benchmarking process can result as a function of just when
data enters the process chronologically. Bench markers either can determine
the health facilities and topics before sharing data and information, or they can
share data and information first in order to determine health facilities and topics.

When bench markers study and use internal data to determine benchmark topics
first, the whole process really begins with defining, measuring, and tracking
specific internal indicators. The healthcare facility can draw internal information
from its own quality assurance activities, financial management systems, budget
reports, productivity reports, pay-roll reports, or any other internal information
sources that maintain reliable records of performance. Most healthcare facilities
have already defined and currently track productivity indicators such as clinical,
quality, and functional indicators. Internal information allows bench markers
to understand a healthcare facility performance more completely, which then
makes possible a comparison with the performance of other healthcare facilities.

Alternatively, bench markers can obtain and use external data to determine
benchmark topics and select benchmark health facilities. They begin by
compiling external information developed primarily from comparative
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databases and, secondarily, from studies, reports, publications, research, and
other published sources. The value of this approach is in the fact that those
who select the health facilities before studying comparative information may
discover that they have not selected the best performers for their benchmarking.

2.3.2. Analysis
The steps in the analysis phase of a benchmarking effort are (1) analyzing
collected data to identify competitive gaps, and (2) projecting future performance
levels and changes in the competitive gap based on those performance levels.

Reviewing internal and external information for comparative differences and

practices will allow bench markers to identify performance gaps and performance
drivers. In so doing, bench markers will discover the best opportunities for
improvement. The desirable process or function used by the best performer may
not be transferable, however. Only through a thorough understanding of their
own health facility will bench markers know what changes are appropriate or
feasible. After the appropriate goals and changes are identified, the process of
change can begin.

2.3.3. Integration
Once bench markers have identified the needed parameters of change for
their health facilities, they must integrate their findings into the health facility
organization. They can do this by (1) communicating their bench-marking
findings back to their health facilities, (2) writing a set of objectives to establish
functional goals for the health facility, and (3) developing an action plan to
reach the objectives and goals.

Once common objectives, goals, and action plans are in place, an health facility
can initiate the active process of change.

2.3.4. Action
The last phase of the benchmarking process involves initiating the desired
changes themselves. The steps include (1) implementing the action plans and
monitoring their progress, and (2) recalibrating benchmarking measurements.

Successful bench marking is establishing accountability and a specific time

frame for completion of the change process ensures success. Without them,
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change and its benefits can lag. If bench markers use reliable internal and
external information to develop their analysis and choose improvements,
then the change process has a sound basis and can move forward with less
resistance and greater chance for success. Further monitoring will ensure all of
the integrated change will bring anticipated improvements.

Nothing remains the same in a competitive environment, however, and

benchmarking efforts must continue if a health facility is to benefit fully
from them. In recalibrating their benchmarking efforts, health facility review
their benchmarking process to verify that they remain the best performer.
Alternatively, health facilities can seek another health facility and set new goals.

3. LINKED BENCHMARKING SYSTEM FOR

MONITORING QUALITY INDICATORS
3.1. What indicators should be covered by the benchmark system?
Collecting accurate and reliable data takes time and resources. Therefore the
number of indicators on which data should be collected each year should be
limited to those that are essential and critical for monitoring the quality of
services on the quality priorities selected in the Annual Planning Cycle. Given
what has been said above that “a single indicator is unlikely to capture all
the important features of a quality issue” then even for one quality priority
there may be four or five indicators required. It has been proposed that six
national priorities should be focused on each year. Therefore a minimum data
set of around 30 indicators will be required. The specific indicators should be
identified according to the criteria set in Annexure 5.2 (Defining the quality
indicators for quality priorities).

These criteria are:

A title for the Quality Indicator: This should reflect the quality concern being
monitored (e.g. Waiting time in OPD)

A definition of the indicator: How do we define waiting time in OPD (e.g. time
between the patient’s appointment and the patients seeing the Doctor)

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3.2. Data collection: how often, data forms, data collectors
The essence of health service quality monitoring is to obtain an accurate picture
of what changes are happening to aspects of the quality of service delivery. To
do this it is important that we use indicators that are accurate and reliable when
comparing quality between facilities and over time (from one quarter to the
next). We also need the indicators to be efficient so that staff don’t spend all their
time gathering data rather than delivering quality healthcare service. There are
many indicators that relate to quality in the HAMT Key Performance Indicators
(KPIs) set. Therefore these indicators can already be used for relevant aspect
of service quality. For example to get the patient’s perception of the service
quality and patient overall satisfaction, it is recommend that surveys be carried
out on patients’ experience of their use of the health facilities through In-patient
and Out-patient surveys. Example questionnaires for these Exit Surveys are
given in Annexure 5.7 & 5.8. It seems equally important that staff views on
quality and their satisfaction with the performance of the facilities should be
monitored. In order to undertake such a survey, example survey questionnaire
is provided in Annexure 5.9.

A quality indicator is only as good as the data it depends upon and for the data to
be of good quality requires good data collectors. Hence training in questionnaire
administration is vitally important for monitoring quality.

Finally it is important that staff who are delivering the services within the
facilities can relate the indicators which are monitored to aspects of quality of
the service they provide and therefore can easily make use of data collected in
their efforts to improve quality through quality improvement Action Plans.

3.3. Data entry and data analysis

Data entry is the process of typing data into the spreadsheet that will analyse
the indicators and provide the benchmarking graphs. Staff entering data into
these spreadsheets should be trained in EXCEL data entry, including checking
for errors by double entry. Section 3.4, the basic information is provided to
allow QA/HAMT teams, Data Assistant and MRT to construct their own
purpose built Excel spreadsheets for the collection entry and analysis of
specific indicator measures. In the next section 3.5 provides information on
tailor made spreadsheets for analysing data from patient surveys and from key
KPI indicators.
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3.4. Purpose built excel spreadsheets

Open a new EXCEL spreadsheet with a relevant name, for example “Central
Regional Referral Hospital (CRRH), Gyalegphu OPD chambers 2011”

On sheet 1 type the name of the KPI data that is being analysed in the first row of
the sheet. E.g. “CRRH, GAYLEGPHU DATA FOR CHAMBER 3 WAITING
TIMES 2011”

Step 1. On first sheet copy the data for the first chamber for each month that
data has been collected. For example in row 4 column B enter “July 2011”, in
row 4 column C enter “Aug 2011”, and in row 4 columns D enter “Sept 2011”

Copy the data from your KPI spreadsheets into the relevant columns under these
headings. This is what your spread sheet should look like now.

Step 2. Now for the data in each month’s column, calculate the percentage of
patients waiting less than the MoH recommended target (in minutes). To do this
we use the COUNTIF function available in EXCEL.

Let’s assume for the purpose of this example that the target is 30 minutes and
the data for July are contained in cells B5 to B69.
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Place the cursor in the cell at the bottom of the data column for July 2011, which
is cell B70, then press the function key “fx” and select COUNTIF function.

In the “Range argument” highlight the column of data for July 2011 and press
the “Enter” key

In the “Criteria argument” type “< 30”.

This will give the number of patients waiting less than 30 minutes in that column
of data.

Step 3. For the purpose of providing an indicator measure it is sensible to turn

this into a percentage of patients waiting less than 30 minutes. This we can do
by multiplying the number by 100 and dividing by the total number of patients
in that column.

For example if the data on waiting time are contained in cells 5 to 69 of column
B then we type =100*(COUNTIF (B5:B69,”<30”)/65), where 65 is the number
of patients in that column of data.

Step 4. Then in row 3 column G type “Percentage of patients waiting < 30

minutes.” Copy the month labels in row 4 columns B to D into row 4 columns
G to I. This is what the spreadsheet should like at this stage
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Step 5. Next, under each month label, copy the data from the last cell of the
corresponding relevant column of data in columns B, C and D. The simple
way to do this is to type “=” in the appropriate cell and click on the cell which
contains the value calculated in step 3, for example for July this cell B70. So the
entry for the cell under July 2011 in row 8 should look like this “=B70”.

Repeat this process for “Aug” and “Sept” columns.

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14 Quality Indicators
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This is what the spreadsheet should look like now:

Step 6. Now we are ready to draw the graph of waiting time for months July
to Sept 2011. From the menu at the top of the spreadsheet select the Insert
tab. Select the Column option and choose the first chart design which is 2D
clustered column.

Then select the range of cells that you wish to display, in this case these are G3
to I5. Press “ENTER” and the graph will automatically appear. As illustrated
here:
Percentage of patients waiting <30 mins A
Jul-11 Aug-11 Sep-11
76.9231 65.2174 45.122

% of patients waiting less than

30 mins in chamber 3

Series1

Jul-11 Aug-11 Sep-11

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You can drag this graph to anywhere in the worksheet and enlarge it as desired.

Now you can go on to develop more worksheets for other Indicators. Have fun
experimenting with the design of the charts (such as changing colours and in
fills, adding chart titles and text boxes, etc.).

3.5. Tailored excel spreadsheets

In order to facilitate the work of QA/HAMT teams, Data Assistant and MRT at
District and Regional levels in analysing the data from quality indicator data
collection, a number of tailor-made spreadsheets have been designed. These
cover:
• OPD Out-patient Exit Survey data
• Hospital In-patient Survey data
• Key KPI indicators from the HAMT which most directly reflect quality
concerns.

For these Excel spreadsheets the work of the QA/HAMT team is limited to
data entry of the raw data only. Internal links between the worksheets of the
Excel workbook will automatically produce the measure of the relevant quality
indicators, expressed as a percentage such that increases in the quality indicator
reflect increasing quality of service delivery.

These EXCEL files are available directly from QASD at MoH, and it is
anticipated that they will soon be available for downloading from the MoH
website – www.health.gov.bt .

3.6. Reporting formats and frequencies

Using the techniques described in this manual allows QA/HAMT teams to
report their data in a graphical fashion and makes the need for laborious written
reports superfluous. By graphing the data from each round of data collection
in a continuous way their reports will build an ongoing picture of the way in
which performance and quality are changing and will guide QA/HAMT teams
and their facility staff to prioritising those aspects of service delivery where
performance and quality are relatively poor.

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The following charts from CCRH, Gaylegphu provide a good illustration.

Percentage of patients waiting less than 30 mins by month

and chamber
100
80
Percentages

60
Chamber 2
40
Chamber 3
20
0 Chamber 4
Jul/11 Aug/11 Sep/11 Oct/11 Nov/11 Dec/11

Months
We can immediately see that waiting is becoming an increasing problem since
fewer patients are being seen within 30 minutes in succeeding months from
July to Sep 2011.

At the regional level the HAMT/QA team can collate the reports into a graph that
allows comparisons across all the regions hospitals and other health facilities.

OPD waiting time in Central Region

A 50
45
v
e M
40
June
r i
35

a n
30
August
25
g u 20
e t 15
e
10
i s 5
n 0
H ha hu ela ha sa -I -I -I -I 11
CRR umt amp gap lepts rong BHU BHU BHU BHU r 20
hu Bh D Da ebi T ng na
a kh
a ng t fo
legp Y
arpa Dag zing ngba arge
y S oi Pa T
Ga am
Lh
Hospital and BHU1

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Here we can see at a glance that the majority of facilities are improving and
meeting the national target, CRRH, Gaylegphu still needs to make greater
efforts if it is to meet the target. Needless to say it is more difficult for those
larger hospitals such as CRRH, Gaylegphu to reduce waiting time and this may
bring us to the conclusion that targets should be sensitive to workload at each
facility. It is only by using that data charted in such a way that these analyses of
the quality problems become possible. Again this demonstrates the importance
of using data to understand quality issues rather than concentrating solely on
data collection.

For the purpose of benchmarking it is better to collect good data on a

quarterly basis rather than unreliable data more frequently. All indicators of
organisational performance demonstrate random fluctuations from one week to
the next. Therefore, looking at trends in indicators on a weekly or monthly basis
may simply reflect these random variations rather than meaningful changes in
performance and quality.

3.7. A dashboard for national priorities for quality improvement

For those managers at the top of the MoH such as the Secretary of Health it
is difficult for them to keep up with a large number of charts on numerous
indicators as a means of keeping their finger on the pulse of quality improvement
and quality problems in the health services of Bhutan. The top level managers
require a simple way of seeing the levels of quality on key indicators across
the regions and overall across the nation. The simple dashboards are developed
from the data of the graphs for each Region. Such a dashboard gives a quick
snapshot of regional and national performance on a key indicator. In the diagram
below for example we can see the percentage of facilities meeting the target set
for waiting time by region and across the nation as a whole.

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% on target and missing target

4. REFERENCES
A modern paradigm for improving health care quality. Centre for human
services. (2002). Wisconsin Avenue, USA.

Ashton, J. (2001). Monitoring the quality of hospital care. Health Manager’s

Guide, Quality Assurance Project USAID USA [Electronic Version]. Retrieved
24 December, 2011 from http://www.hciproject.org/node/990

Batalden, P. B. & Davidoff, F. (2007). Quality and safety in health care: What
is “quality improvement” and how can it transform healthcare. British Medical
Journal 16(1), 2-3.

Bullivant, J. (1996). Benchmarking in the UK National Health Service,

International Journal of Health Care Quality Assurance 9(2), 9-14.

Ellis, J. (2000). Sharing the evidence: clinical practice benchmarking to improve

continuously the quality of care. Journal of advanced Nursing 32(1), 215 25.
Ellis, J. (2001). Introducing a method of benchmarking nursing practice,
Professional Nurse 16(7), 1202-03.

Ellis, J. (2001). Introducing a method of benchmarking nursing practice,

Professional Nurse 16(7), 1202-03.
Quality Assurance and Standardization Division, Ministry of Health | References
19
 2012 [Manual on Benchmarking for Quality Improvement]

Elmuti, D. & Kathawala, Y. (1997). An overview of benchmarking process: a

tool for continuous improvement and competitive advantage, Benchmarking
for Quality Management and Technology 4(4), 229-43.

Health Care Division, Health Department, Ministry of Health and Education,

Royal Government of Bhutan. (2002). National Policy Document, Quality
Assurance and Standardization in Healthcare. Thimphu, Bhutan: Ministry of
Health and Education, Royal Government of Bhutan.

Kelly E, Ashton J, Bornstein T. (2002). Applying Benchmarking in Health,

Quality Assurance Project USAID USA [Electronic Version]. Retrieved 22
December, 2011 from http://www.hciproject.org/node/543

Miller Franco et al. (2002). Sustaining Quality of Health Care: Institutionalization

of Quality Assurance, Quality Assurance Project USAID USA [Electronic
Version]. Retrieved 24 December, 2011 from http://www.hciproject.org/
node/697

Mckee, M. & James, P. (1997). Using routine data to evaluate quality of care in
British hospitals, Medical Care 35(10), 102-11.

Quality Assurance and Standardization Division, Ministry of Health, Royal

Government of Bhutan. (2007). Guideline on implementation of quality
assurance system in Health facilities. Thimphu, Bhutan: Ministry of Health,
Royal Government of Bhutan.

Sustaining quality of healthcare: Institutionalization of quality assurance.

(2002). Wisconsin Avenue, USA.

WHO. (2008). Guidance on developing quality and safety strategies with a

health system approach, WHO Europe [Electronic Version]. Retrieved 28
December, 2011 from http://www.euro.who.int/data/assets/pdffile/0011/96473/
E91317.pdf

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 [Manual on Benchmarking for Quality Improvement] 2012
5. ANNEXURE
5.1. Annexure: Some key quality indicators from the HAMT
KPI set
KPI code KPI (Assets) Definition
= Total cost of the consumables used
Cost of consumables across all the assets in the health facility/
A1
per patient Total number of patients attended
(inpatient + outpatient)
= Time gap between a patient’s entering
and leaving the health facility, monitored
Waiting time by time
OP1 in 3 parts depending upon the time of
of the day
entry: morning (9-11 am), noon (11 am-1
pm) and afternoon (1-3 pm)
= Number of instances when the health
facility is not able to serve an essential
Unavailability of drug to a patient, where instance is an
OP4
Essential drugs event when a patient has to go back
without even giving the substitute of the
out of stock drug
= (Number of patients not collecting a
OP8 Lab test wastage lab test report/ Total number of lab test
reports generated)x100
= (Number of survey forms that carry a
Percentage of
OP10 satisfactory rating from patients/ Total
patients satisfied
number of filled survey forms)x100
Hospital infection = Number of infections detected in the
W1
control swab lab tests
= Time gap between an emergency
Average emergency
patient’s reporting to the health facility
response time for
ER1 and him/ her seeing a consultant,
consultation during
monitored in 2 parts, during day (10 am-
day and night
12 am) and night (12 am-10 am)

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5.2. Annexure: Defining the Quality Indicators for Quality Priorities

 Indicators for Continuous Quality Improvement
 Name of indicator

 Definition
 How is the indicator defined?

 Indicator
 What data is required for monitoring this indicator?
 How is the data collected for this indicator?
 How often is the data collected?
 What should be the sample size?
 Who collects the data?

 Analysis
 How will data be analyzed? Normally this will be by calculating

a proportion (from a numerator and a denominator) and then
charted as a bar-graph with a baseline and Subsequent measures
indicated as Quarter 1 (Q1), Quarter 2 (Q2), and Quarter 3 (Q3)
etc.

Changes in QIs 2011

100

80
Percentages

60 Baseline
40 Q1
Q2
20
Q3
0
Indicator 1 Indicator 2 Indicator 3
Indicator

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 Interpret
 Comments on how to interpret the graphs. Are changes due to
quality improvement or other factors?

 Action
 What follow-up actions should now be taken?

 Responsible
 Who should be responsible for follow-up actions?

An Example of a Quality Indicator: Waiting Time in Hospital OPD

clinic

 Definition
 Waiting time A: Time between the patient’s appointment and the
patient actually seeing Doctor/Assistant Clinical Officer
 Waiting time B: Consultation time (time spent in the consultation
room with the Doctor/Assistant Clinical Officer).
 Waiting time C: The overall time that the patient spends in the
hospital

 Data
 Obtained from appointment slip/prescription.
 Hospitals sample size = 100 every month,

 Analysis
 Waiting A = Percentage of patients who are seen by Doctor/
Assistant Clinical Officer within 30 minutes of appointment.

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 Waiting B = % of patients spending 5-10 minutes in consultation

 Waiting C = % of patients spending < 2hrs in health facility

Changes in waiting time

80
70
Average in Minutes

60
50
Baseline
40
Q1
30
Q2
20
Q3
10
0
Waiting time A Waiting time B Waiting time c
Waiting time at different level

 Interpret
 The data indicate that all three indicators of waiting time are
showing improvement over the period of monitoring.

 Action
 Share the data on Waiting Time with the patients, staff and local
community

 Responsible
 HAMT teams/Health Facility Management committee.

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5.3. Annexure: Example of quality improvement tools and its
range of steps

Quality Improvement Step

Tool Step 4:
Step 1: Step 2: Step 3:
Test &
Identify Analyze Develop
Implement

Data Collection √ √ √ √

Brainstorming √ √ √

Creative thinking techniques √ √

Prioritization Tools
Voting √ √ √
Criteria Matrices √ √ √

Expert decision making √ √ √ √

Flow Chart √ √ √ √

Cause and Effect Analysis √

Statistical & data presentation

Bar and Pie Chart √ √ √
Run Chart √ √ √

Benchmarking √ √

QA Story Telling √ √ √ √

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5.4. Annexure: Example of quality improvement tools and its uses

Tools Use
- Identifying and analyzing problems
Data - Developing and testing, implementing solutions
collection - Demonstrate the effectiveness of interventions
- Maximizes the usefulness of QI tools
- A group process used to generate a large number of ideas about
specific issues in a nonjudgmental environment
Brainstorming - Generate ideas and insights
- Draw experiences of each member
- Creative ideas have been suppressed in the group
- A quick and efficient way to make a decision
Voting - When there are quite and dominant members
- There is an opportunity to follow up with team building exercise
- The core area for improvement has been identified but requires
further focus
Criteria Ma-
- The group agrees that a solution is needed but disagrees about
trix
where to start
- Resources for testing and implementation are scarce
- Understand process
- Consider ways to simplify process
- Recognize unnecessary steps in a process
Flowchart
- Determine areas for monitoring or data collection
- Identify who will be involved or affected by the improvement
process
Cause Effect - Use it at the beginning stage
Analysis - To broaden thinking about the possible reasons for a problem
Diagram - To develop hypothesis about the cause of the situation
(CEAD)
- To define or choose problems to work on
Bar and Pie-
- Analyzing problems, verifying causes or judge solutions
charts
- Present results that compares different groups
- Detect trend over time
Run Chart
- Determine if there is a change in a process
- The data are continuous, such as temperature, time or number
Histogram - There are large amount of data that are difficult to understand in
tables

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- Focus on areas of priority

Pareto Chart - Prioritize factors and put them in graphical form in a simple and
quick manner
- Develop plans to address needs for improvement
Benchmarking - Borrow and adapt successful ideas from others
- Understand what has already been tried
- Monitors the performance of a system
Control Chart - Distinguish between special and common cause of variation
- Discover and track variation in processes

5.5. Annexure: Example of data entry format for indicators

Hospital Name:

Month: Date:
Indicator Number Total Number Percentage
1. Patient told on ways to prevent
HIV transmission
2. Patient told on PMTCT

3. Patient examined

4. Told instructions about illness

6. Told if to return or not

7. Patients who had privacy

8. Received all drugs

9. Received all drugs (from records)

10. Drugs in stock (from records)

11. Staff attitude very good

12. Clinic very clean

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5.6. Annexure: Example of formula reference sheet

INDICATOR FORMULA
Proportion of patients who Number of patients saying they were given
were given information on information divided by Number of patients
HIV transmission interviewed multiplied by 100
Proportion of patients who
Number of patients saying they were informed on
were informed on ways to
PMTCT divided by Number of patients interviewed
prevent HIV transmission
multiplied by 100
from mother to child
Proportion of patients seen Number of patients saying they were seen without
without an unnecessary a delay divided by Number of patients interviewed
delay multiplied by 100
Proportion of patients Number of patients examined by the doctor/
examined by the doctor/ HCW divided by Number of patients interviewed
health care worker multiplied by 100
Proportion of patients told Number of patients told diagnosis divided by Number
the diagnosis of patients interviewed multiplied by 100
Proportion of patients given Number of patients given instructions by the doctor
instructions about how to divided by Number of patients interviewed multiplied
take their treatment by 100
Number of patients having privacy during
Proportion of patients having
consultation divided by Number of patients
privacy during consultation
interviewed multiplied by 100
Proportion of patients Number of patients who received all drugs prescribed
receiving all drugs divided by Number of patients interviewed multiplied
prescribed by 100
Proportion of patients Number of patients saying staff attitude is very good
perceiving staff attitude to divided by Number of patients interviewed multiplied
be very good by 100
Number of patients saying clinic is very clean
Proportion of patients divided by Number of patients interviewed
perceiving clinic to be clean multiplied by 100

Proportion of patients
Number of patients saying they were satisfied divided
feeling very satisfied with
by Number of patients interviewed multiplied by 100
their visit

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5.7. Annexure: OPD Exit Interview
We are conducting a survey with users of our facility to find out what you think
about our services. This will help us to improve quality services to future clients.
Your answers are strictly confidential and we thank you for your participation
and honesty.
Date: Region: Hospital: Sex: M/F No:

1. How long did you wait before you saw the doctor?
[ ] < 30mins [ ] 30mins–1hr [ ] 1-2hrs [ ] > 2hrs
2. Was there any unnecessary delay before you [ ] Yes [ ] No [ ] N/A
saw the doctor?
3. Did the doctor listen to you to describe your
[ ] Yes [ ] No [ ] N/A
concerns?
4. Did the doctor examine you? [ ] Yes [ ] No [ ] N/A
5. Did you have privacy during your consultation? [ ] Yes [ ] No [ ] N/A
6. Did the doctor tell you what is wrong with
[ ] Yes [ ] No [ ] N/A
you?
7. Did doctors tell you whether or not you need
[ ] Yes [ ] No [ ] N/A
to return?
8. Did you have laboratory test?
If yes....... [ ] Yes [ ] No [ ] N/A
Did you receive the laboratory test report?
9. Did you receive all the drugs that were
[ ] Yes [ ] No [ ] N/A
prescribed?
10. Were you given instructions about how to take
[ ] Yes [ ] No [ ] N/A
your treatment?
11. How long did you wait to receive your drugs
[ ] < 30mins [ ] 30mins–1hr [ ] 1-2hrs [ ] > 2hrs
12. Overall, what was the attitude of the staff to-
[ ] Very good [ ] Fair [ ] Poor
wards you?
13. What was the state of cleanliness of the hospital
[ ] Very good [ ] Fair [ ] Poor
and toilets?
14. Overall what did you think about the service
[ ] Very good [ ] Fair [ ] Poor
you received today?

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15. Are there any other special comments you wish to make?

Thank you for your time

5.8. Annexure: In-patient exit interview

We are conducting a survey with users of our facility to find out what you think
about our services. This will help us to improve quality services to future clients.
Your answers are strictly confidential and we thank you for your participation
and honesty.
Date: Region: Hospital: Sex: M/F No:

1. How long did it take for you to be admitted onto the ward, from arrival at the
hospital?
[ ] < 30mins [ ] 30mins–1hr [ ] 1-2hrs [ ] > 2hrs
2. When you had important questions to ask a
doctor, did you get answers that you could un- [ ] Yes [ ] No [ ] N/A
derstand?
3. When you had important questions to ask a
nurse, did you get answers that you could un- [ ] Yes [ ] No [ ] N/A
derstand?
4. Sometimes in a hospital, one doctor or nurse
will say one thing and another will say
[ ] Yes [ ] No [ ] N/A
something quite different. Did this happen to
you?
5. If you had any anxieties or fears about your
condition or treatment, did a doctor discuss [ ] Yes [ ] No [ ] N/A
them with you?

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6. Did doctors talk in front of you as if you

[ ] Yes [ ] No [ ] N/A
weren’t there?
7. Did you want to be more involved in decisions
[ ] Yes [ ] No [ ] N/A
made about your care and treatment?
8. If you had any anxieties or fears about your
condition or treatment did a nurse discuss them [ ] Yes [ ] No [ ] N/A
with you?
9. Were you ever in pain?
If yes............
[ ] Yes [ ] No [ ] N/A
Do you think the hospital staff did everything
they could to help control your pain?
10. If your family or someone else close to you
wanted to talk to a doctor, did they have enough [ ] Yes [ ] No [ ] N/A
opportunity to do so?
11. Did the doctors or nurses give your family or
someone close to you all the information they [ ] Yes [ ] No [ ] N/A
needed to help you recover?
12. Did a member of staff explain the purpose of
the medicines you were to take home in a way [ ] Yes [ ] No [ ] N/A
you could understand
13. Did a member of staff tell you about medication
[ ] Yes [ ] No [ ] N/A
side effects to watch for when you went home?
14. Did someone tell you about danger signals
regarding your illness or treatment to watch for [ ] Yes [ ] No [ ] N/A
after you went home?
15. Did you have privacy on the ward during your
[ ] Yes [ ] No [ ] N/A
hospital stay?
16. Overall, did you feel you were treated with
[ ] Yes [ ] No [ ] N/A
respect and dignity while you were in hospital?
17. What was the state of cleanliness of the ward
[ ] Yes [ ] No [ ] N/A
and toilets?
18. Overall, what was the attitude of the staff
[ ] Yes [ ] No [ ] N/A
towards you?
19. Overall what did you think about the service
[ ] Yes [ ] No [ ] N/A
you received in this hospital?

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20. Are there any other special comments you wish to make?

Thank you for your time

5.9. Annexure: Staff Satisfaction Survey

As a valuable member of the hospital, we seek your feedback to continue
improving the work environment and quality culture at Hospital.

It will take approximately 15-20 minutes to complete the survey. Your responses
will be confidential and you will not be individually identified.
Sl. 1- 5- Not
Advancing the Vision 2 3 4
No. Low High Applicable
I understand the vision of the
1
Hospital.
My CMO/MO/Manager/Head
2 provides a clear direction for the
organization’s future.
I know how my work contributes
3 to the Hospital’s overall vision and
mission.
I know how my work contributes
4 to the Hospital’s overall vision and
mission.
1- 5- Not
My Organization 2 3 4
Low High Applicable
Hospital provides opportunities for
5
growth and improvement.

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I am proud to say that I work at the

6
Hospital.
I understand how my work
7 contributes to the success of the
ward/unit & the organization.
I would recommend Hospital to my
8 friends and family as a good place
to work.
My unit has clearly defined
9
objectives
I know what is expected of me in
10
my job
Management encourages all staff
11 in my unit to identify and satisfy
customer needs
Management demonstrates
12
commitment in service excellence
1- 5- Not
My Job 2 3 4
Low High Applicable
My talents and abilities are used
13
well in my current position.
I am provided the resources I need
14
to be effective in my job.
I am motivated to go “above and
15 beyond” what is expected of me in
my job.
I am able to maintain an appropriate
16
work-life balance in my job.
1- 5- Not
My Career 2 3 4
Low High Applicable
I have annual objectives/goals on
17 which I am evaluated at the end of
the year.
I am encouraged to take initiative
18 in determining my own career
development.

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I am given the opportunity to

19
develop my skills at Hospital.
I view Hospital as my long term
20
career choice.
1- 5- Not
Quality Service 2 3 4
Low High Applicable
My ward/unit has a focus on
21
“Quality”.
My work environment supports
22
excellent customer service.
My ward/unit strives for quality
23
work/service for the Hospital.
1- 5- Not
Internal Operations 2 3 4
Low High Applicable
There are generic policies and
24 procedures to perform duties in the
hospital
There are policies and procedures
25
to perform duties in my ward/unit
I understand and able to interpret
26
policies and procedures
Are you encouraged to become
27 involved and committed to change
rather than being forced to comply
Conflict in my ward/ unit is dealt
28
with effectively and fairly
There is diversity tolerance in
29
Hospital
There is a free flow of information
30
and feedback within the hospital
1- 5- Not
My Supervisor 2 3 4
Low High Applicable
I receive appropriate guidance
31
from my supervisor.
My supervisor contributes towards
32
a positive work environment.

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My supervisor effectively resolves

33
interpersonal issues/conflicts.

I receive encouragement to come

34 up with new/creative ways of
doing things.

My supervisor gives me regular

35
feedback on how I am doing.

36 I get along with supervisor

My supervisor respects me and

37
listens to me

I am satisfied with the performance

38 review system through which my
annual performance is evaluated.

1- 5- Not
Team Work 2 3 4
Low High Applicable

Other team members from other

39 units are always within to give
assistance in my unit of crisis

I have good idea of functions

40 in other related unit within the
hospital
In my unit we discuss most of work
41 related problems and agree on an
action plan

42 In my unit we work as a team

I know the different roles of my

43
team members in my unit

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Additional Information (mandatory)

Regular
Temporary Unit:
___________________________________

Grade Age Gender Service at Hospital

Grade up to 8 18-29 Male Up to 1 year
Grade 9 to 13 30-44 Female Between 1 to 5 years
Grade 14 and above 45-55 More than 5 years
56 and above

Any other suggestions:

1. ..........................................................................................................................

2. ..........................................................................................................................

3. ..........................................................................................................................

4. ..........................................................................................................................

Thank you for your participation in this survey. Your feedback is extremely
valuable and we appreciate your participation in this process.

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