Kingdom of Saudi Arabia Report

Performance improvement


By Dr Asaad Al-Asaad
PwC’s KSA Health Industries Leader and John Middleton,
PwC’s Middle East Health Industries Account Manager

The healthcare system in the Kingdom of Saudi Arabia (KSA) is undergoing major changes driven by the Government’s determination to improve the access, quality and cost effectiveness of health provision. The Ministry of Health is looking at a number of ways to meet the growing healthcare challenge, in particular managing the threat of long-term chronic diseases such as diabetes and hypertension, and ensuring that the capacity and capability of the system is fit to tackle them.

The MoH has embarked on a huge capacity expansion programme, with more than 120 new hospitals and five large medical cities to be developed. There are also plans to reform the current national health funding system, with signs that a form of health insurance is being looked at to provide a driving force towards access, quality and cost effectiveness across the sector.

Between these plans of capacity expansion and national payer reform, KSA is undoubtedly taking the required steps to address the intense change. However, there is one element that is often an afterthought, indeed across the GCC, of continuous performance improvement within the existing system. Performance improvement within current facilities can go some way towards meeting these shortcomings in the current system’s capacity and capability without requiring huge capital expenditure and large national reforms. Optimising the current system is just as important as expanding the system – it creates healthier organisations, focused on access, quality and cost effectiveness and as a result can have a huge aggregate impact at the national level.

Performance improvement initiatives can have a staggering impact in terms of freeing up capacity, lowering the cost of provision and improving service quality and patient satisfaction. A relevant example is the launch of region wide performance improvement schemes in Quebec, Canada to create capacity in the hospital system in 2008. The scheme was a great success leading to a 25% increase in the number of appropriate surgeries carried out a year across the region. The scheme has now been running for four years and health ministry officials believe that the increase in capacity has ensured that the region’s healthcare system will be sustainable for the next 20 years.

On the face of it, the scheme was very simple; each hospital recruited a team of engineers who measured everything – the steps, the delays and the time. This methodical mapping of the processes was then used to fuel a week of intensive brainstorming for a local multidisciplinary team of physicians, nurses, pharmacists, radiology technicians, attendants etc. Through these sessions, initiatives were originated and implemented that lead to the remarkable results across Quebec’s hospital system.

On a slightly smaller scale, but no less impressive, is the case study of the Narayana Hrudayalaya Hospital in Bangalore, India. This hospital stands as a remarkable example for the world to see of how a focus on continuous performance improvement can benefit the hospital, staff and patients. Their relentless drive towards process improvement has led to stunning results that have shocked cardiac hospitals across the world. Narayana Hrudayalaya Hospital is performing complex open heart surgeries at a fraction of the cost, achieving higher volumes and producing equivalent or better outcomes than the top US cardiac institutions. Driven by their charismatic chairman, Dr Devy Shetty, the hospital can perform open heart surgery for a mere US$1,700 and achieve equivalent, if not better, results than the top cardiac hospitals in the UK and US. To achieve these results, Narayana Hrudayalaya Hospital focuses on process improvement; the hospital standardises procedures and breaks down the processes into their component parts. For instance, highly paid senior surgeons perform only the main part of the operation; while more junior physicians open and close the chest. Prepping one infant for cardiac surgery – a process that takes up to two hours in the US – can be completed in 12 minutes in Narayana Hrudayalaya Hospital.

Undoubtedly, performance improvement done well can achieve quick and long lasting results. However, for every success story there are a number of failures. There are a number of key conditions that need to be created to drive and ensure the success of performance improvement. Firstly, efforts have to be organisation wide and continuous in nature. Narayana Hrudayalaya do not run short term and department focused performance improvement schemes; they focus on creating continuous change and improvement as a part of the organisation’s and clinical and non-clinical staffs’ culture. There are too many examples of short-term initiatives that promise much but quickly run out of steam when the organisation’s focus turns elsewhere. The challenge is to spread the cause of continuous improvement among clinical and non-clinical staff. A particularly important element of this engagement is securing the buy-in of physicians. Just like any other segment of an organisation’s staff, physicians who do not buy into the idea of continuous process improvement, can block any potential advances and improvements. However, more than any other staff, physicians can provide insight into the changes required to improve a particular clinical service and are key to their successful implementation. Performance improvement has to be ingrained in an organisation from the CEO and the physicians, right through to the support staff and cleaners.

There is also the danger of trying to drive performance improvement in a piecemeal fashion. Focusing all efforts on improving one department in a hospital while leaving others alone will not achieve anything – efforts need to be patient-centric rather than departmental and as a result need to apply to complete patient pathways from admission to discharge. Theatre efficiency is not going to dramatically improve through standardising operating rooms if the wards carrying out the pre-op and diagnostics are not efficient enough to support the through-flow. Performance improvement has to be implemented across an organisation, with different departments working together on a continuous basis focused on improving a patient’s journey through the organisation.

Performance improvement has to be supported by data collection and benchmarking. There is no point encouraging constant process improvement if you have no way of accurately measuring its impact or understanding what can be achieved. Indeed, there would be nothing more demoralising. Not only can performance related data show and encourage success it will also highlight the current failings in the systems, helping to explain why a certain hospital has low volumes of certain patients, why another hospital has a very high conversion rate of outpatients to inpatients and why another achieves relatively poor health outcomes. Collecting performance data provides fuel to driving continuous improvement.

Encouraging performance improvement within healthcare organisations in KSA should be a priority, just as it is to increase capacity through building new hospitals and to develop a more market-orientated national funding system. Continuous improvement within organisations will free up capacity, improve service quality and help to control the cost of provision. However, to achieve these improvements organisations need to develop a culture of performance improvement based on staff engagement, a focus on the patient and a solid understanding of the current performance and potential performance of the organisation through detailed data collection and benchmarking. Whatever the large national reforms or initiatives, performance improvement should be a mainstay of all healthcare organisations and as a result the vanguard force within the system to drive improvements and tackle the challenges facing the KSA system.

 Date of upload: 20th Nov 2012


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