Benchmarking crucial for small, rural facilities with few resources

Tailor projects to your own community

For a large academic hospital or a major regional health system, using benchmarking as a tool to improve performance and determine strengths and weaknesses is practically second nature. But for small facilities in rural areas, getting on the data bandwagon has been less urgent and much less likely.

But according to Robert Gift, president of the consulting firm Systems Management Associates in Omaha, NE, being small isn’t a good excuse. "They probably need to do this more than the bigger places," he says. "Those large facilities may have more resources, and it might be hard to do with a three-person administrative staff, but small facilities can benefit more from understanding benchmarking and using it to improve processes, systems, and care." (For more on the benefits that can accrue for a small health care organization, see article, p. 51.)

Gift says there are three stages of development for benchmarking:

1. In the first stage, a hospital or health care system will look at task activities, such as buying under group purchasing contracts.

2. In the second stage, the organization looks at processes, such as the logistics system.

3. In the final stage, the hospital or system looks at systemwide issues, such as individual physician patterns of utilization.

But just getting to that first stage can be a trial, Gift admits. "One of the barriers to benchmarking is that people want to do’ benchmarking," he says. "When you work on your car, you don’t do a wrench; you solve a problem using a wrench as a tool. [With benchmarking], you improve patient satisfaction by using benchmarking as a tool, or you shorten days outstanding on accounts receivable by improving policies and procedures."

Another obstacle is a lack of enthusiasm among administrators, staff, and physicians to learn about benchmarking. "For it to work, there has to be a willingness to learn," he says. Gift recalls one situation where he was standing in front of a group of people who wanted to reduce cesarean rates in a particular state. "I talked about benchmarking and how it could help, and the person said, That might work in Omaha, but not here. We’re rural.’ My example at the time was from North Dakota."

Once you see an eagerness to learn about the topic, you must take advantage and provide opportunities for staff and managers to learn.

Make it a useful project

Often, those who start benchmarking give up because they don’t see it having a positive impact. Gift says that happens when people pick projects that don’t really have meaning to the particular organization.

"You have to choose something related to your overall strategic plan." Don’t assume that one project will solve all your problems, either, he adds. "No tool can deliver on the hype that surrounds it. You have to view it as one of an arsenal of tools that will help you meet your goals."

For instance, at VHA, an Irving, TX-based group of 1,900 health care organizations, one of the goals is to focus on various critical domains and key aspects of care every year. For 2000, those include stroke and acute myocardial infarction.

VHA started a benchmarking project on those two goals that is already yielding results.

"One thing we have learned is that you can unearth useful information from a diverse group of players," says Pat Houghton, RN, BSN, MHA, senior director of performance consulting at VHA, which includes both small rural hospitals and large academic facilities.

Often, administrators and staff at small facilities will complain they don’t have the internal resources to start benchmarking. Gift says those organizations should spring for the cost of hiring an expert the first time, but make sure the consultant imparts sufficient knowledge during the process so that the same project can be done internally the next time.

"If someone brings me in on a project, part of the specific agreement is that I’m going to be sure when I leave that they know how to do what I did. If they don’t, I’ve failed." Another option is to send one of your staff to a conference or seminar to learn the basics, collaborate with like facilities you can link with in your health system, or work through a professional organization, he explains.

"A small facility may not have all the technological advances and bells and whistles that the bigger hospitals have," Houghton says. "And they may not have progressed with benchmarking because they feel they don’t have the resources."

But they can take what they do have and do some simpler projects that are tailored to their community. "Simple isn’t a bad thing," she adds. "Start small. Don’t try to fix everything about acute myocardial infarction or stroke. Take one key aspect, one evidenced-based item that your institution can buy into, and do it."

You might not choose something clinical initially, such as the door-to-tPA times that VHA chose for its stroke program, Houghton continues. "Maybe choosing a particular process like documentation would work better for your institution. The important thing is not to try to devour the elephant at one sitting. Take a small bite, and don’t make it dependent on a hot new computer system."

You can collect data on every fifth or 10th patient as a start, then go on-line and hook up with similar hospitals. "Don’t spend money on site visits," she says. "Use the Internet; use the telephone. If you show a willingness to share your numbers, others will share with you."

Ben Hughes, MS, director of planning, marketing, and development at the 69-bed Punxsutawney (PA) Area Hospital was one of those administrators who thought benchmarking was just another dull chore he had to do when his hospital started getting involved in it about five years ago.

"Now it is truly part of our culture." He notes that each of the 40 departments in the hospital has benchmarking projects it is required to complete — whether they are clinical, statistical, or financial. The board of directors of the hospital, which has a primary market of 17,000, looks at the benchmarks and department goals monthly. "This is not something we report; this is something we do that is an inherent part of who we are," says Hughes.

Small facilities, small numbers

One of the obstacles Hughes continually struggles with is the inherent invalidity of the sample sizes. Punxsutawney brought in a statistician from an area university to calculate exactly how much the small sample size affected statistics.

"We also have a challenge relating our numbers to the national figures that are out there," he explains. "If you look at our service area to try to figure out how many radiology technicians we need, we have to compare it to facilities that might serve populations of 100,000. Maybe when you do the math and pare it down, that means we should have two technicians. Because we are small, we cross-train more than most larger facilities, and our techs are usually certified in ultrasound and nuclear medicine. Maybe they are busy doing other things part of the day. Maybe we need four or five technicians, not two. The data out there don’t address that."

One solution is to look at regional data, either on a formal or informal basis. Along with data from HCIA-Sachs of Baltimore and various national associations for specialties that Punxsutawney Area Hospital uses for benchmarking data, the facility obtains information from the Pennsylvania Mountain Healthcare Alliance — a three-year-old consortium of rural hospitals in its geographic area that Punxsutawney belongs to.

"We started out looking at safe issues like purchasing," says Hughes. "But based on the successes we had, our trust grew and we have been able to share data on other issues. Something like what we do might be harder in a city, where the hospitals seem to be more competitive."

There are also some data on rural hospitals available from the federal government and the Health Care Financing Administration, but not a lot, he adds.

Finding appropriate data is vital to getting your staff and clinicians to accept a benchmarking program, he points out. "There is a lot of concern that we are small, and our population, which is largely rural, somewhat impoverished, and includes a large Amish population, is different. But if you find good data to compare yourself to, that alone will overcome those objections. And we have used them to validate our efforts. We don’t necessarily use [the information] to look for problems or mistakes. We use it to prove how good we are."

Another reason to jump on the benchmarking bandwagon: It is easier to justify budget and staffing requests with data, rather than with gut reactions. "It is easier to validate what you do with numbers," Hughes says. "It answers the question, How are we doing?’ in a very concrete way."

[For more information, contact:

• Robert Gift, President, Systems Management Associates, Omaha, NE. Telephone: (402) 894-1927.

• Pat Houghton, RN, BSN, MHA, Senior Director of Performance Consulting, VHA Inc., Irving, TX. Telephone: (972) 830-0000.

• Ben Hughes, MS, Director of Planning, Marketing, and Development, Punxsutawney (PA) Area Hospital. Telephone: (814) 938-1826.]