Moving from KPI TO HDI

By Nashat Nafouri, PhD, Chair, Healthcare Interest Group, Executive Officer, Saudi Quality Council

At first impression, the reader might think the title is a rhyming poem for a song or a science fiction movie, but in fact, it is a true reflection of how the Key Performance Indicators (KPIs) at the work place impact positively or negatively the Human Development Index (HDI) in quality of life. The purpose of my article is to first explore the maturity of quality from just being a static idea to continually pumping quality as blood in the veins of all healthcare services over the last two decades to improve outcomes.  

Furthermore, the article aims to define the current crucial role of KPI  in driving the workforce performance enhancement, the HDI as global indicator of developed countries and how both are correlated in fostering better outcomes at the workplace, creating a healthy and productive work environment, increasing employees’ effectiveness and efficiency, and balancing between work, personal necessities and community prosperity.

A few years ago, I highlighted competitive marketing, high insurance rates, patients’ rights and knowledge, shortage of resources, information technology evolution, biotechnology and the high cost of risk management as the new challenges in healthcare industry, which were the driving forces behind quality and quality costs’ emergence during that period.

Over two decades, healthcare leaders focused their efforts on improving quality through accreditation as an approach to improve healthcare services and outcomes but gave trivial attention to the value behind dissecting the quality application and its costs. Therefore, there are tremendous number of lessons learned from adopting different modules of accreditations and their re-accreditation cycles, which helped the healthcare industry to re-invent itself, and advance the quality deployment from basic Quality Control (QC) to Continuous Quality Improvement (CQI) and finally, the organisational culture.

Healthcare has never been an easy science due to many factors, and also because it deals with human bodies and biological systems, which could alter suddenly or over years. For example, after the completion of the human genome project, doctors and researchers have only recently started to understand the genetics behind different syndromes and diseases, which used to be mysterious such as Alzheimer’s, autism, and metabolic disorders and they diagnose them properly with the aid of molecular biology testing. Nevertheless, many innovations are still in the pipeline, such as liquid samples testing for solid tumours. Even though it is promising to view and treat diseases at cellular level like stem cell applications, drugs interactions and their side effects still remain major challenges in the effectiveness of treatment plans.

In addition, with all these breakthroughs and technological leaps, medical and scientific associations are currently releasing different revolutionary guidelines on theories that have been practiced for decades in managing chronic diseases like diabetes and cholesterol, lipedema and heart diseases, amongst others.

On the other hand, the human body is a very complicated system, which can be affected by the surrounding environment. Its reaction and response to outside biological systems like emerging microorganisms is unpredictable. In my opinion, it would be a true horror movie if humanity gets hit by a superbug whether it is bacteria, fungi, biofilm or virus. Therefore, it would be very difficult to standardise the treatment efficacy from region to region, but the global community could standardise the approach to risk management of infectious diseases and its spread.

As the human body is continually changing, it is imperative that we should adopt lean thinking, evidence-based medicine, and agile processes for healthcare services rather than a robust standardised practice.

Several measures have been taken to improve the outcome of healthcare systems in the Middle East region including the health determinants model introduced in 2006 by the Organization for Economic Cooperation and Development (OECD), where public health is seen as the cornerstone with three main components of health protection, health promotion and diseases prevention that are key to drive a healthy lifestyle.

This is the integrated care model where the patient is the centre of care and all services from primary care to specialised services establish the sphere of the care system around the patient.

This is a paradigm shift from the industrial age medicine where the cost of primary care was discouraged to the information age healthcare where individual’s self-care costs are highly encouraged. This maturation was accompanied by progressive fast-based improvement of accrediting bodies by transforming standards into a culture that focuses on patient safety and has ultimately paved the road for the emergence of the “Just Culture” and high reliable organisation (HRO) concept. It is insane to keep the accreditation tool rolling and rolling, cycle after cycle, and expecting different results to satisfy patients, communities and other stakeholders. In my opinion, the healthcare industry has just recovered from the accreditation fever, which lasted for many years. It is clear now that human touch is vital and crucial in the healing process. Most importantly, quality should be embedded in all healthcare workers’ practice to apply different kinds of quality tools in their daily work to make informative decisions such as flow charting, 80/20 rule, root-cause-analysis (RCA), six sigma, balance score cards, Plan/DO/Check/Act (PDCA) cycle, etc. Along with the industry re-invention, the acceleration of digital technology – similar to the human genome discoveries – has helped in creating better healthcare outcomes and in 2020, disease prevention will be the prime focus.

Indeed, in keeping with the tenets of the new knowledge economy, healthcare will utilise the innovation in smart applications and Artificial Intelligence. By that time, quality will move from its transitional phase as static standards become more dynamic with digital monitoring of processes and will be reflected in the form of KPI and Key Business Indicators (KBI) in making daily strategic decisions.

Leaders have now started monitoring KPIs on a daily basis and are relying on dashboards in making informative decisions. In the era of KPIs, leaders understood that a five-year period is required to reach international levels for an organisation of 500 or fewer employees and there is need for comparison on a larger scale than accreditation to attract new customers and investors, increase market share, and promote travel medicine. Hence, a global benchmarking based on KPIs became the framework of modern healthcare services.

To widen the scope of comparison of the healthcare industry in the Middle East region with other parts of the world or other industries regionally, the need for a unique evaluation model became evident. The European Foundation of Quality Management (EFQM) excellence model is a well-established and tested model based on eight excellence concepts that helped many manufacturing and service industries in Europe by evaluating organisations in meeting stakeholders’ needs with tangible results, and was adopted by leaders in the Gulf Region in the mid-nineties. In September 1997, His Highness Sheikh Mohammed bin Rashid Al Maktoum, Vice President and Prime Minister of the UAE and Ruler of Dubai, ordered the establishment of the Dubai Government Excellence Program, the first integrated programme for governmental excellence in the world, to be the driving force behind the development of the public sector in Dubai and enabled it to provide distinctive services for all customers and beneficiaries. After Dubai’s initiatives, many quality governing bodies in the Middle East started launching excellence awards with the primary aim of improving quality and excellence culture in different industries including healthcare such as Abu Dhabi Government Excellence Award as a mandatory programme, King Abdullah Quality Award in Jordan, King Abdulaziz Quality Award in Saudi Arabia, among others.

Excellence awards completely changed the bulk game from just meeting accreditation requirements to a strategic enterprise where the vision, mission, values, goals and objectives have defined KPIs with set targets, directional trends, and benchmarks to provide measurable and sustainable results. The majority of excellence models have five enablers’ criteria and four results criteria. The enablers’ criteria include leadership, strategy, people, partnerships and resources and processes while results criteria include people results, customer results, society results and business results. Effective and efficient enablers will lead to world-class results in excellent organisations and will increase the learning, innovation and creativity in organisations.

Spirit of Excellence

For many years, accreditation and re-accreditation drained healthcare organisations’ budgets in order to meet the accrediting bodies’ requirements. The costs and expenses of accreditation used to be a huge burden while accreditation cost by the definition of quality cost is just part of the appraisal costs. In excellent organisations, the large portion of quality cost would be spent on prevention costs. This concept was missed or abused during the accreditation fever era simply because financial dimension is not an integral part of any accreditation. Nowadays, leaders plan their organisations’ finance efficiently using the excellence model, with well-defined KPIs to improve the quality with special attention to cost analysis and reduction.

The spirit of all excellence models and the most important criterion that create excellent culture is people’s criteria. People can either make an organisation or break it. From this point of view, healthcare is not the most attractive work environment for people for many reasons. Human capital was ranked the number one global challenge in the Conference Board CEO Challenge Survey Report Findings in 2013. Stress was the first reason of why physicians, nurses, and other healthcare workers leave the healthcare industry (Watson Wyatt and ASHHRA in their Work Attitudes Research in 2008-2009). In the same research, base pay, length of commute, work/life balance, promotion opportunity, and trust/confidence in management were the top five ranked reasons among healthcare workers as well. In healthcare, despite these reasons, customers expect care givers to provide kindness, empathy, patience and warmth.

On the other hand, management expects workers to deliver the same state of care before, during and after accreditation with the same energy, enthusiasm, commitment, and cost constraint without considering work environment improvement. Of course, accreditation was instrumental in making medical errors reduction as top priority on each leadership agenda. Initially, medical errors were a maze that fired back on care providers until “To Err Is Human: Building a Safer Health System” report was issued in November 1999 by the U.S. Institute of Medicine that resulted in increased awareness of U.S. medical errors. Hospital Acquired Infections (HAI), infection prevention and control programmes and medications management in hospitals benefited tremendously from this report in demonstrating how infections can be reduced and costs can be saved from wrong medications, not like other complicated medical errors. That’s because it is much easier to utilise quality tools in these two fields.

Over decades, leadership in healthcare utilised data and other models like the Swiss Cheese Model and Failure Mode Effect Analysis (FMEA) to reduce medical errors untilit was realised that improving patient safety does not only mean reducing medical errors,but also reducing patient harm, empowering healthcare providers, fixing broken processesand improving work environment. Meanwhile, a common understanding of the impact of healthcare providers’ performancewas introduced by the Institute of Health Improvement (IHI). It lists limitations inperformance based on human psychology like fear, fatigue, frustration, illness etc., and limitations that are inherent in the work environment like distraction, noise, clutter, toomany handoffs, heat, unnatural workflow, etc.

The down side of accreditation on healthcare providers’ performance was increating an environment of reckless behaviour where the energy deteriorates after obtaining the accreditation and heats-up again when approaching the re-accreditation cycle. So, the norm became to stack paper as sets of evidence provided by the quality department rather than a true reflection of streamlined processes owned by every individual providing a service in healthcare. This scenario lasted for many years until today despite the fact that the accrediting bodies have changedthe strategy of assessment by looking at data analyses and its utilisation in improving service delivery and patient safety by competent healthcare providers.

But with the organisational excellence driven by governments to improve outcomesof the public sector and privatisation inthe horizon, investing in the human capitaldevelopment is now the number one priorityin both the public and private healthcaresectors. Excellent performance is the goaland KPIs are the measures used to rewardgood outcomes. Excellence models differ fromaccreditation by focusing on people capabilities, engagement, development, and empowerment from business blue print. It is an integral part ofthe organisational strategy with clear cascading of vision, mission, values and goals to balanced individual smart objectives that lead to clear career pathway, build organisational loyalty, foster productive and healthy work environment and finally achieve a set of KPIs and KBIs. Hence, when hiring an employee, leaders of excellent organisations nowadays would assess if he/she fits in the organisation culture along with the qualifications and if he/she has the right set of skills and whether or not the organisation has a clear career pathway for the hired employee.

In 2020, future workforce candidates of Generation Next need to acquire 10 top skills as per Future of Jobs Report of the World Economic Forum that include complex problemsolving, critical thinking, creativity, people management, coordinating with others, emotional intelligence, judgment and decision making, service orientation, negotiation, and cognitive flexibility, in addition to newly emerged specialised skills in healthcare like structured communication and team building. All these changes will be the components of a“Just Culture” and “Organisational Excellence”deployment in healthcare that will help achieve sustainable results for people, society, environment and business.

By doing this, there will be a paradigmshift in healthcare from retrospective review to prospective expectations in services delivery; and from evaluation by appraisal to proven deliverables driven by competent workforce. When this stage is reached, thenan index – as a composite of indicators that produces a single calculation – could be ranked and compared globally as part of HDI programme goals run by the United Nations Development Program (UNDP). Leadership of those excellent organisations who adopt the excellence model philosophy can easily demonstrate their organisations’contribution to the national economy since HDI is the best known composite index of social and economic well-being of a country.

In conclusion, I believe that the successof healthcare organisations in the next 10 to 20 years will be dependent on measures thatenable a culture of trust and empowermentthat allows healthcare professionals tomaximise their full potential through fillingand solving talent gaps, and by creating a systematic approach to innovation throughout the organisation in order to create distinctive value for stakeholders. Eventually, healthcare will be moving from KPI to HDI.