Benchmarking as a Quality Improvement Tool in Healthcare

Você pode ler a versão em português aqui.

Puede leer la versión en español aquí. 

Benchmarking is the comparison of a healthcare organization´s performance against other organizations. Simply put, benchmarking is important for establishing a standard against which organizations can compare and find out if their performance is excellent, only average or poor on a particular indicator. In the context of quality improvement, it allows leaders and clinical teams to identify best practices and gaps in quality of care, patient outcomes and experience, and to realize what level of performance is possible to achieve while learning from the top performers. 

Ideally benchmarking should be an ongoing activity in order to capture improvements over time as organizations will be constantly moving forward with their improvement cycles. It should also be risk-adjusted as organizations should be compared with other similar organizations in terms of clinical context and patient case-mix and finally benchmarking reports should allow comparison against top performers and not the usual “average performance”. Being at average or slightly above average should be only an initial step and not a long-term goal organizations should pursue. Top performers are the ones who will teach us there is always room for improvement.

Goal setting

Typically, healthcare organizations set an annual dashboard of quality and safety indicators and define goals to be achieved based on one or a mix of the following: their own historical performance data, recommendations made by national and international societies or on published data from reference institutions. Only a minority report crude data to clinical practice registries that will collect and compile standardized data from different organizations and produce risk-adjusted benchmarking reports. Main reasons for this includes a limited number of clinical practice registries available, costs involved and infrastructure needed to collect, report and act upon the results obtained. 

The Einstein Case and the Action Registry

Back in 2013, when I still served as the Head of Cardiology at n Hospital Israelita Albert Einstei in São Paulo, Brazil, we decided to start participating in the American College of Cardiology National Cardiovascular Data Registry (NCDR ACTION Registry). Before that, our goal was to keep Door-to-balloon time, a key performance quality metric in the treatment of heart attacks, below the 90 minutes recommended by the American College of Cardiology/American Heart Association guidelines. Door-to-balloon time measures the time interval between patient´s arrival at the emergency department and the opening of the obstructed coronary artery in the cath lab.  Because there is a clear link between time to treatment and cardiac muscle damage (“Time is Muscle”), the lower the time the better the results in terms of mortality and limiting cardiac muscle damage.

Participating in the Action Registry would allow us to directly compare our practice on an ongoing basis. In other words, we were moving from pursuing a “static recommended goal” - that we had already achieved - to a “dynamic real-world evidence goal” from direct benchmarking with over 1,200 organizations reporting to the Action Registry.

I still can remember the feeling when we received the first report showing that our 82 minutes in DTB, well within the recommended goal of ≤ 90 minutes, was far from the 56 minutes achieved by other participants. First we were in shock but soon enough we were acting upon those findings as we could see from top performers that we could do better. We started by sharing the results throughout leadership and care teams and revisiting our care processes to find gaps and opportunities to improvement. 

The results of this experience have been recently published in the International Journal for Quality in Health Care  and they are very impressive. One year later our DTB was around 56 minutes and reached 47 minutes in 3 years. Other quality indicators also improved as the prescription of evidence-based medication and, most importantly, mortality decreased from 9% to 5,9%. 

Lessons Learned

Direct dynamic Benchmarking is a powerful but still an under-utilized management tool in healthcare. Setting goals based only on historical data or recommended goals may have a limited impact on quality improvement over time… if you don´t know how other organizations are performing, your current rate may be anywhere from poor to excellent performance and you may be missing opportunities to learn from top performers and to foster innovation within your organization.