Going beyond apples to apples’: How to get the most from your facility’s benchmarking efforts

Misunderstandings about benchmarking have limited use in hospitals

Benchmarking experts may differ somewhat on the whys, but they’re unanimous about the what. Hospital quality professionals are far from realizing the true potential of benchmarking. Instead of expanding their horizons beyond the health care world in a search for organizations to benchmark, hospitals are more inclined to narrow their focus in an attempt to identify facilities that are exactly the same as they are. This is referred to as the "apples-to-apples" myth.

"Some hospitals want to benchmark only with other hospitals in their system, but instead of spending time looking for benchmark partners who are identical, what you really want to do is find benchmark partners who aren’t identical," says Shelley Burns, MSE, MBA, director of knowledge management at the Healthcare Management Council Inc., a benchmarking and consulting firm in Needham, MA. "Caterpillar, for example, benchmarked against Marriott Hotels."

"This may be part of the paternalistic, We know what’s best’ history of hospitals," offers Sharon Lau, MS, a consultant with Los Angeles-based Medical Management Planning. "They have a very hard time thinking outside of the hospital box and comparing themselves to anybody that’s not exactly like them," Lau explains.

Another reason for the underutilization of benchmarking may be the sheer volume of options with which health care has been presented, says Robert G. Gift, MS, president of Systems Management Associates Inc., a consultant in performance and process management and benchmarking in health care in Omaha, NE. "I think the industry overall has been bombarded with advances in management methods," he says.

"As we get more tools we can utilize to improve effectiveness and performance, senior teams have a limited capacity to hold those tools in their heads. It gets to be a case of which one is the most recent, current fad, and what should we be doing?" Gift asks.

Hung up on details

In the benchmarking process, hospitals often get hung up on details that won’t significantly change their overall status, Burns says. "Our company does cost benchmarks," she notes. "We work very hard with hospitals to make them comparable, and we think we’re good at it. But they argue about the correctness of the data instead of looking at the big picture."

Gift agrees. "We tend to want to compare data and call that benchmarking, when in fact benchmarking is really all about the how’ of success, not the what’ of success," he asserts.

Burns recalls working with an environmental services manager. "Compared to other, similar hospital services, there was about $1 million of opportunity on the table for him," she says. "He was outraged; so instead of thinking about how he could chip away at it, he probably spent 30 to 40 hours of his valuable time at working on things we should include in the benchmark. I felt they were superfluous, but we reviewed our plan and came up with an $890,000 opportunity. The gap was still there," Burns adds.

"People utilize comparative data to help identify a gap in performance; that’s the what’ — someone else’s level of performance compared to ours," Gift adds. "Say you have medical record transcription costs of $10 an adjusted discharge. You utilize some comparative data and find hospitals that do this inexpensively are doing it at $8. That’s a what,’" he says. "What benchmarking is all about is finding how they achieve that number: What processes do they have in place? How do they operate? How are they structured? What you want to discover is the manner in which they go about achieving that performance," Gift explains.

Watch out for those apples

It’s possible that the apples-to-apples syndrome is the single biggest obstacle to optimization of benchmarking in health care because intuitively it feels right, but it’s really a myth, Burns insists. "Hospitals have taken benchmarking to mean they must be compared to hospitals that are just like them," she says. "If you think about it, it does not make sense, because they will have the same costs as you. There are going to be practice variations from hospital to hospital that will impact costs, but that’s the whole reason to benchmark — to fix costs."

One client who ran a cath lab sent Burns a note saying it wanted to be compared with other cath labs that performed overflow cases on Saturdays using their on-call staff. "Why would you do that?" Burns asks. "The whole point of benchmarking would be to discover whether there are things you should do with your scheduling to save time."

Lau, who is involved in a 21-facility children’s hospital benchmarking project, says Burns is absolutely correct. "As a consultant, we try to get them out of that mindset," she says. One technique she uses is sharing a real-world example. "There was a General Mills cereal plant in Lodi, CA, that took as long as three hours to retool its machines to change cereals, and the employees just sat around," Lau relates.

"They went to management and asked for help in making the wait time shorter and their work more productive. Do you know where they went for a model? Not to another cereal company, but to a NASCAR racetrack in Indio, CA," she continues. "They sat around and watched videos of cars coming into the pit for retooling. Then, they got their time down from three hours to 17 minutes. You talk about major improvement, from something that had no relation to cereal."

Lau asked her clients to think about the operating room and the turnaround time needed when one patient leaves before another comes in. "I asked them, Isn’t that like the pit?’" Lau says she gets an "aha moment," but then she hears a response that all too often flows from hospital benchmarking meetings: "But we’re different."

Focus on the differences

It’s precisely those differences you should be looking for, she explains. "By focusing on where there are differences, you are likely to get the performance you want; you may want to steal a part of what another hospital is doing." The perpetuation of the "but we’re different" attitude is extremely costly, Lau laments. "They lose incredible opportunity for improvement."

Burns agrees. "If you start ridding yourself of learning partners, you will have a smaller pool. Instead, say I can learn from anybody.’ Think about how ideas might work in your environment."

The apples-to-apples and but-we’re-different syndromes are two of what Lau calls the "deadly diseases" of benchmarking. A third is what she refers to as "the Nth decimal point." "We are so clinically trained for precision work, but in benchmarking it doesn’t matter," she explains. "If your benchmark information is off 5%, is there still a large gap between your performance and the best performer? If your data are off by 10%, is there still a gap? Absolutely. And a gap means there is opportunity for improvement. Benchmarking is not about the precise measurement; it’s looking at a gap in performance."

Last but not least, there are silos, Lau says. "Hospitals are the epitome of a silo organization," she says. "But benchmarking opportunities cross silos. If I’m looking at medication errors, do I send you to the pharmacist? The nurse? People are trained to be a part of a department, and as such, they may not take full advantage of benchmarking. This is a constant challenge."

The manager’s responsibility

It falls to the quality manager to overcome these obstacles. This includes thinking outside the box when looking for benchmarking partners, Burns says. "Go out; solicit ideas; find out what pieces of someone else’s best practices might work for you." Burns emphasizes "pieces" because whatever you borrow from another facility must be customized. "One hospital may have all those wonderful clinical pathways, but if you bring [them] over and you don’t have the physicians and nurses they require, it won’t work." 

"Analyze what goes on in your own process objectively, see what you need to work on, and go out and gather as many ideas as you can," she explains.

"We still don’t have a process focus in health care," Gift adds. "All that QI/TQM stuff teaches us all to work results from process. But people still don’t want to get down to the process level, which is one of the reasons benchmarking is not utilized effectively."

So how do you get at what Gift calls the how of benchmarking? "In most instances, you have to start ripping away at the layers," he says. "You have to get down to the people where the work really is — the medical records person or the person who heads up transcription, for example. Frankly, senior leaders don’t know that detail nor should they."

Can you get that kind of information? "It is difficult to get, but if you belong to an operational database service . . . it helps. Once you belong to those, you have access to other people who participate, so you can share information that way."

Gift also agrees with Burns on customization. "Adaptation is a really good point," he says. "Whatever you find from a successful practice standpoint has to be adapted before you can use it. Organizations continue to recognize and reward innovation much more readily than they do adaptation."

"The opportunities for hospitals are not in other hospitals but outside of health care," Lau reasserts. How can quality managers learn about potential benchmark partners outside their own field? "You can belong to a lot of groups, and there’s activity on the Internet," she says. "For example, I’m on a patient safety listserv for adult hospitals, and I shoot things over to my kids’ hospitals."

In terms of other industries, "We try to search our own networking groups, and that’s what hospitals can do," Lau says. "There should be somebody in quality whose job it is to go out and look: read Business Week, The Wall Street Journal, The New York Times. Read about things that work well in other industries, and see if they apply to you," she says.

For more information, contact:

Shelley Burns, MSE, MBA, The Healthcare Management Council Inc., Needham, MA. Telephone: (781) 449-5287. Web site: www.HMC-benchmarks.com.

Sharon Lau, MS, Consultant, Medical Management Planning, 2049 Balmer Drive, Los Angeles, CA 90239. Telephone: (323) 644-0056.

Robert G. Gift, MS, President, Systems Management Associates Inc., 4410 S. 176th St., Omaha, NE 68135. Telephone: (402) 894-1927. E-mail: bobgift@radiks.net.